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Julius Global Health

University Medical Center Utrecht 1





Where we work




Reproductive & Child Health



Diabetes & Cardiovascular Diseases


Infectious Diseases


Environmental Health





Elevate Health - Online Academy

Capacity Building Staff

35 38

Project List







Dear colleagues and friends, Three years since the establishment of Julius Global Health, you are now looking at a summary of what our journey in the exciting and challenging world of international health sciences has brought us. We set out to explore how the Julius Center and related departments could invest and learn from major health challenges the globe is facing and how our strengths and competences could be used to help the world to become a better and healthier place. The problems affecting large parts of the world are beyond imagination and so are the solutions. Some of the problems are similar to what Western countries have experienced over a much longer period of time and clearly lessons were learned during that phase. These include changes in demography, nutrition and life style, urbanization, emerging chronic diseases and varying socio-economic changes. There are also major differences. The battle against heart disease and stroke is an uphill one, where preventive and therapeutic measures in Western countries were taken at a time the epidemic was nearing its end. Chronic diseases in low and middle-income countries are rising rapidly while infant mortality and infectious diseases remain common, creating a double burden. Persistent poverty and limited access to appropriate treatment and prevention in a setting of populations that is growing larger, older and more urbanized, place millions of people at health disadvantages that are spreading their shadows over decades to come. Truly concerted actions, seeking innovative solutions that are affordable, scalable and sensitive to ethnic and cultural difference, are needed to address these large and complex problems. In these actions, Western scientists are not only bringing in their knowledge and skills but will also find unique opportunities for research due to unprecedented disease dynamics and interactions. Sharing knowledge and combining forces among people, regions and disciplines are essential in starting to address some of these issues. Among this we, at the Julius Center, can only make modest contributions in a few areas in which we can provide some expertise. At the same time, crossing cultures and regions, experiencing the marked contrasts in risk and disease and finding approaches that also work in low resource settings is very rewarding, both personally and scientifically. In our efforts, we are privileged to be able to assemble a highly competent and committed team of junior and senior scientists in the Netherlands as well as in countries in Asia and Africa. Nelson Mandela said “Education is the most powerful weapon to change the world�. In addition to our international scientific collaborations, we are using the peaceful armory of teaching to educate new generations of researchers and health care workers across the globe. We do this primarily to give people the scientific tools to understand and combat the health care challenges their society is experiencing, but also, to build an international community of like-minded people fostering the health of populations and rising against inequalities.

Diederick E. Grobbee, MD, PhD Professor of Clinical Epidemiology Distinguished University Professor of International Health Sciences and Global Health Chair, Julius Global Health 5

Julius Global Health

Who we are

Our mission Julius Global Health contributes to global health through ground-breaking (clinical) epidemiologic research, innovations in health care technology and capacity building in health sciences. Our goals • To conduct high impact (clinical) epidemiologic research generating evidence to contribute to improved individual and population health; • To develop innovative health care technology solutions for the prevention and treatment of chronic diseases; • To educate new generations of researchers and health care workers.


Our values • Scientific rigor • Creativity • Transparency • Partnership

Julius Global Health carries out research and educational activities in the field of Global Health.

Historical overview Julius Global Health was founded in 2011 by Prof. Diederick Grobbee, with a two-fold focus: to conduct high impact (clinical) epidemiologic research that generates evidence contributing to improved individual and population health, and to educate new generations of researchers and health care workers across the globe.

Educational activities are closely linked to the research program and have expanded over the years to include courses in global health and offer research capacity training in international health sciences. Our latest development in this regard is Elevate Health, an e-learning platform offering worldwide online courses based on the health science expertise of the University Medical Center Utrecht and partner institutions.

Our global health research activities currently focus on Asia, Oceania and Africa, and draw on our expertise in (clinical) epidemiology in the areas of circulatory health, cancer, infectious disease, reproductive and child health, as well as environmental health at the Julius Center for Health Sciences and Primary Care in collaboration with our local and international partners.

Dr. Kerstin Klipstein-Grobusch has been a key character in setting up Julius Global Health. She joined the team as coordinating associate professor in March 2011 from the School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, while maintaining her academic appointment, research and educational

activities in Johannesburg. Her research capacity building expertise and African network have been a great asset to Julius Global Health. Since then, Julius Global Health has grown in size and expertise with Dr. Cuno Uiterwaal (early life origins of cardiovascular disease; clinical epidemiology), Dr. Lenny Verkooijen (cancer, clinical epidemiology), Dr. Ilonca Vaartjes (cardiovascular disease, data registries), Prof. Michiel Bots (atherosclerosis, hypertension, clinical trials), Prof. Roel Coutinho (infectious diseases, “One Health�), Prof. Mirjam Kretzschmar (mathematical modeling, infectious diseases), Prof. Irene Agyepong (health systems, public health) and Prof. Bert Brunekreef (environmental epidemiology).


Julius Global Health

Who we are



Projects Reproductive & Child Health Cancer Diabetes & Cardiovascular Disease Infectious Disease Environmental Health

* Projects all over the world

See project list on page 31 for description of corresponding projects. 9

Julius Global Health

Research - Reproductive & Child Health

REPRODUCTIVE & CHILD HEALTH Maternal and neonatal morbidity and mortality continue to be prominent public health issues in low and middle-income countries. They are two of the main priorities of the Millennium Development Goals of the United Nations. Reproductive health covers an array of topics including maternal health, safe pregnancy and childbirth, fertility, access to regulation of fertility and family planning, sexually transmitted diseases, and rights to reproductive health (services). Child health includes the wellbeing, and physical, emotional, mental, and social health of children and adolescents. Current projects in Ghana, Nigeria, Indonesia, and South Africa facilitate the application of best practice in clinical care and public health. They involve the strengthening of basic health systems directed at health care providers to enhance clinical decision-making skills through leadership development activities and mHealth support. They also aim to prevent pregnancy-related complications, such as hypertensive disorders of pregnancy. We offer educational support during pregnancy through text messaging and counseling on breastfeeding, thus contributing to the understanding of optimal maternal and infant feeding, thereby promoting child and adult health.

Julius Global Health research aims to promote reductions in maternal and infant mortality through prevention and intervention addressing: • Circulatory complications of pregnancy and its devastating consequences for mother and child. • Improving clinical decision-making support systems related to antenatal, delivery and postnatal care in health care facilities.




Julius Global Health

Research - Reproductive & Child Health

Improving reproductive health in Ghana Collaboration between Julius Global Health and the Ghana Health Service, Ghana, commenced in 2010 when Dr. Irene Agyepong, at that time director of the Greater Accra Region Health Service, was appointed to the Prince Claus Chair in Development and Equity at Utrecht University at the Julius Center. Given her expertise in health systems and health policy

research – in combination with the importance of reproductive health for the achievement of Millennium Development Goals 4 and 5 (reduction of child and maternal mortality) in Ghana – a research program to improve quality of care to pregnant women and their newborns was developed. The research program addresses both health care providers and pregnant women:



Enhance the use of clinical decision support systems to:

Reduce the burden of hypertensive disorders of pregnancy by:

Improve care to pregnant women

Detect complications in pregnancy

Prevent maternal and child morbidity/mortality

Identifying women at high risk of hypertensive disorders of pregnancy (HDP)

Enhancing care to women with HDP

Preventing pregnancy complications by the use of a supplementation strategy

Prof. Irene Agyepong elaborates: “Our activities are, first and foremost, directed at adaptations and changes in the health care system. How could healthcare workers, physicians and nurses in clinics change their daily practice in order to ensure better care to pregnant women?”


Studies conducted in collaboration between the Ghana Health Service and the School of Public Health at the University of Ghana, Legon, focus on the early detection of difficult pregnancies, consistent monitoring of pregnancy and follow-up, so that maternal and child morbidity/mortality can be prevented. For example, one of the research projects examines hypertensive disorders of pregnancy. These include many different forms of disease, all of which share a common characteristic: high blood pressure in pregnancy.

Prof. Irene Agyepong (MD, PhD) is a part-time faculty

As part of the project, the extent of the burden of hypertensive disorders of pregnancy was investigated and information on routine antenatal care was collected to predict hypertensive disorders and develop novel approaches to prevent them.

Health care system The main focus of our work in the health care system is on the provision of efficient and high quality care to pregnant women, easy access to health facilities and efficient channeling through the system, thereby achieving high rates of antenatal care and counseling. One major area where improvements can be made is in delivery assisted by health care professionals. The work conducted is funded by the Netherlands Organisation for Scientific Research / WOTRO Science for Development and trains six West African PhD students in health policy, health systems research, anthropology, public health and clinical epidemiology in collaboration with the Ghana Health Service and the University of Wageningen. Julius Global Health affiliated PhD candidates Mary Amoakoh-Coleman and Gbenga Kayode are focusing on health care improvements, such as clinical decision support systems for health care personnel to reduce maternal and neonatal mortality in Ghana.

member in the Department of Health Policy, Planning and Management, School of Public Health, University of Ghana in Legon and Chair of the Board of Health Systems Global for 2012 – 2014.

Dr. Kerstin Klipstein-Grobusch (PhD) is Associate Professor of Global Health. Her expertise is in research capacity building, child health and chronic diseases in low and middle-income countries, such as South Africa

Dr. Kerstin Klipstein-Grobusch underlines how health system research is integrated into the local setting: “We want to build on what is already in place, thereby identifying and addressing areas that may require improvement.”

and Ghana.


Julius Global Health

Research - Reproductive & Child Health

How can hypertensive disorders in pregnancy be predicted and prevented? Predicting hypertensive disorders in pregnancy Edward Antwi (MD, MSc), a Ghanaian PhD student, developed a prediction model allowing identification of women at high risk of developing pregnancy-induced hypertension and associated complications. He obtained detailed pregnancy information about Ghanaian women from two provinces on which he based the development of a prediction model to be used in routine antenatal care. “This was the first time research was conducted on the prediction of hypertensive disorders in pregnancy in Ghana.” Because of the successful collaboration, the study could be extended to investigate the added value of biomarkers which have been shown in high-income countries to be of high predictive value in identifying women – in the early stages of their pregnancy – at high risk for pregnancy-related complications. For this, a cohort study of 1, 000 pregnant women was completed in December 2013, in conjunction with an on-going cohort study in Asia. This allows for comparison of predictors of pregnancy-induced hypertension and preeclampsia in both Asian and African settings and for subsequent wide application of research findings in low and middle-income countries.

Hypertensive disorders in pregnancy Joyce Browne (MD, MSc), PhD fellow at Julius Global Health, works closely with her Ghanaian PhD fellow colleague, Edward Antwi, on the prediction of hypertensive disorders in pregnancy. Her main focus is on how to prevent women from developing hypertensive disorders in pregnancy and to increase quality of care delivered to women with severe disease, such as preeclampsia and eclampsia. She is one of the young scientists selected by the Royal Netherlands Academy of Arts and Sciences (KNAW) for its ‘Faces of Science’ ( program to raise interest in scientific research among high school students. Joyce Browne explains: “We look at the quality of care delivered to pregnant women with preeclampsia and eclampsia, and we study how their babies are doing: do these women deliver healthy babies, or are these babies smaller or slightly younger?” Joyce Browne and her colleagues are currently conducting a project at Korle Bu Hospital in Accra to investigate severe bleeding after delivery, postpartum hemorrhage, which is another important cause of maternal mortality worldwide. “We examine whether certain steps to prevent bleeding can be safely performed by patients themselves, rather than midwives, who are often too few in number due to understaffing.” ↪


“People often think of research as an ivory tower where people work on topics only relevant to themselves or their small circle of colleagues. I think research can very well be focused on the real world and solutions for real world problems. This study is one of these projects where we identify the problem – hypertensive disorders in pregnancy as one of the major causes of maternal death worldwide – and we try to find solutions that improve health through research.” Joyce Browne


Julius Global Health

Research - Reproductive & child health

Local context Most of the research takes place in Ghana, where local and Utrechtbased researchers collaborate. Joyce Browne is partly based at both sites, which she considers an important principle in her work. “I think it is more interesting to set up a system that can work without your continued presence because sufficient local capacity is present. Additionally, by sharing responsibilities, local researchers and clinical staff are more involved, which is important for the future implementation of the findings.” Joyce Browne (MD, MSc) is


a PhD fellow at Julius Global

The first project on prediction of hypertensive disorders is almost complete. “We have collected information on 1.010 women from early pregnancy all the way to 6 weeks after delivery and we are currently in the process of analyzing the data.”

Health working on pregnancy induced hypertension and pre-eclampsia in Ghana.


The role of smart phones in delivering health messages in an urban, low socioeconomic status population, Soweto, South Africa Mobile health (mHealth) is evolving as a valuable tool in advancing health care access in areas with restricted resources to health services. Limited access is associated with poor antenatal care, as well as maternal and perinatal mortality. In the REACH-US (Reliable Equitable Access to Healthcare Utilizing SMS) project, post-doctoral researcher, Kim Lamont, Soweto Cardiovascular Research Unit, University of the Witwatersrand in collaboration with Dr. Kerstin Klipstein-Grobusch, Julius Global Health, is assessing cell phone-based antenatal care support in Soweto, South Africa. The study aims to increase awareness regarding risk factors adversely affecting pregnancy and to achieve sustainable behavioral changes through text messaging and internet-based educational material.

Markus Rijken (MD, PhD) is registrar in Obstetrics & Gynaecology. His research interest is in fetal growth development in relation to maternal malaria, which he investigates at the Shoklo Malaria Research Unit, Mahidol University, Thailand. 17

Julius Global Health

Research - Reproductive & Child Health

Optimizing breastfeeding in Indonesia While teaching clinical epidemiology in Indonesia, Julius Global Health researcher Dr. Cuno Uiterwaal made two interesting observations: firstly that Indonesia has very low breastfeeding rates and secondly that cardiovascular diseases are on the rise. These two observations combined the interest of local researchers and his previous work on early causes for cardiovascular diseases later in life. As a result, the BReastfeeding Attitude and Volume Optimization (BRAVO) trial was designed. Dr. Cuno Uiterwaal (MD, PhD) is Associate Professor of Clinical Epidemiology working on early life causes of later life chronic disease in Asia and in the Netherlands.

BRAVO is a randomized controlled clinical trial that aims to optimize breastfeeding habits of the substantial group of Indonesian women who plan little or no breastfeeding during pregnancy. 1,000 women are randomly allocated to an intensive breastfeeding optimization program or to support as usual. The intervention is focused on reducing both private and professional limitations for breastfeeding. The breastfeeding program includes counseling sessions, special support during labor, home visits and support for the working breastfeeding mothers. Nikmah Salamia Idris, principal researcher, explains: “We teach the women how to express breast milk and how to store it; we also provide a breastfeeding pump.” The primary goal is to assess whether the rate of breastfeeding in the intervention group increases as compared to care as usual. Secondarily, the health consequences for the newborn children will be studied with special attention to cardiovascular development, pulmonary development, and infectious disease vulnerability.

Nikmah Salamia Idris (MD, MSc) is a pediatrician, working on her PhD research on breastfeeding and HIV in

“For children, the first ‘1000’ days, including the time of the mother’s pregnancy and the first two years, are considered of utmost importance for resilience to chronic disease in adult life.”

relation to early cardiovascular risk in children in Indonesia.

Nikmah Salamia Idris


Principal local investigators: Nikmah Salamia Idris and Wahyuni Indawati

560 women and child pairs included; target 1000 women

• Low breastfeading rates in Indonesian women (WHO)


Rise in cardiovascular diseases

Evaluate breastfeeding attitudes of mothers and the health of their offspring after breastfeeding optimization programme

Importance and results “The trial itself is beneficial for the health of the children and their mothers , who are now more confident about breastfeeding.” Nikmah Salamia Idris provides additional support by cell phone. Mothers can call or text in case of questions and will receive a response educating them on maternal and child health. Once the measure has been proven to be effective, it can be recommended to the Indonesian government, but also to those in the region who face similar challenges. One important asset of the study is its customization to local circumstances. “The recommendations we use come from the World Health Organization, but we slightly modified them for easier implementation in low socio-economic groups.”

Challenges “One of the challenges is to get working mothers to breastfeed their infants. The milk should be stored in a refrigerator, which can be difficult if they do not possess one or if there is no electricity.” For this reason it is necessary to modify the intervention to fit the local circumstances. The researchers have solved this by providing the women with a bag and ice. They teach the mothers how to buy ice for a low price from local vendors in order to store the milk properly.

The follow-up of the study participants is a challenge. Nikmah Salamia Idris explains: “Indonesian people are not used to being trial participants. Sometimes they relocate without notifying us. Most of our efforts concentrate on keeping them on track and following them up.”

Spin-offs More research questions have been added to the BRAVO trial. “We now also look at the relationship between breastfeeding and lung development, and the effect of bacterial colonization in the throat after birth.”

Added value Research conducted in Indonesia is closely linked to the different disease and exposure levels present in Indonesia as compared to the Netherlands. Dr. Cuno Uiterwaal: “By conducting research abroad, we can investigate issues that cannot be studied here. For example, we randomize with breastfeeding, which is impossible in the Netherlands.”

Future “People in Indonesia support the idea that childhood is an important period for later life disease. If we improve children’s health now it will pay off in the future. This is particularly true for populations that have limited access to healthcare.”


Julius Global Health

Research - Cancer

CANCER Cancer is a major leading cause of death, with the majority of cancer occurring in low and middle-income countries. The number of persons with cancer is increasing considerably due to growing and aging populations, changes in lifestyle factors and improved diagnostic facilities. Recent work by Julius Global Health researchers in Singapore and Malaysia showed that Asian women with breast cancer show different symptoms and disease outcomes compared to Caucasian women.

Diagnosing and treating breast cancer in Singapore and Malaysia The Singapore-Malaysia Breast cancer-working group set up a cohort of breast cancer patients from five hospitals in Kuala Lumpur (Malaysia) and Singapore. Dr. Lenny Verkooijen (MD, PhD) was involved from the start. She elaborates: “In this cohort, we look at ethnic differences in breast cancer risk, breast cancer presentation and breast cancer outcome. It is one of the few Asian breast cancer cohorts. The population in South-East Asia consists of Malay, Chinese and Indian ethnicities.�

Unique setting Singapore and Malaysia are multi-ethnic societies which include Chinese, Malays and Indians all living together. However, each ethnic group has its own culture, lifestyle, genetic background and even diet, which make Malaysia and Singapore interesting study populations. An additional reason to study breast cancer in South East Asia is the rapid economic development that is taking place. Singapore has transformed over a period of 30 years from a rural area into a highly developed, affluent city-state. Lifestyle has changed accordingly over time: the average number of children per woman has decreased from 7 to less than 1.5 within 20 years.


“It is becoming increasingly clear that breast cancer in Asia is, in many ways, different from breast cancer in Western, Caucasian women.” Lenny Verkooijen

“The main outcome measure we are looking at is survival. The cohort examines determinants of survival in South-East Asian women, between ethnic groups, and compares this with survival of breast cancer in Caucasian women. “We see that breast cancer survival in certain Asian groups is worse compared to survival in Western settings. Potential explanations include late presentation and less adequate treatment. Interestingly, survival is also different between the ethnic groups within Asia. Malay women, in particular, have worse outcomes compared to other ethnic groups.”


Relevance of studying breast cancer in Asia


The majority of breast cancers occur in Asia – mainly India and China – and not in Europe or the USA. Yet, practically all knowledge about breast cancer is generated via Caucasian women. Since it is becoming increasingly clear that we cannot simply apply Western knowledge to other settings, studying breast cancer in ethnicities with the highest burden of cancer, i.e. in Chinese and Indian women, is important.

Oncologists frequently use online tools for prognostication of breast cancer. Dr. Verkooijen and her colleagues validated one of these prognostic tools in Malaysia and showed that it offers an overoptimistic perspective. “In South East Asia, more women with breast cancer already have distant metastases at diagnosis: 1020%, compared <5% in the Netherlands. Since prognostic models for women in this group perform poorly in Asian settings, one of our PhD students is currently building an Asian prognostic model for breast cancer.”

The National University of Singapore is one of the strategic partner universities of the UMC Utrecht. Both parties have recently agreed on a collaborative PhD program, where six PhD students will be trained in clinical epidemiology and work together on projects in the field of cardiovascular diseases and cancer.

Dr. Lenny Verkooijen (MD, PhD), Associate Professor, has lived in Singapore and worked at the School of Public Health of the National University Singapore (NUS). Her main focus of research is breast cancer epidemiology.

“In Singapore and Malaysia, we have the opportunity to do research in a wellorganized environment. Our findings can be extrapolated and applied to China and India, where this knowledge is particularly needed. Some etiologic determinants of breast cancer are universal and can be applied anywhere. However, prognostication and diagnostics are setting-specific. In these cases, we should study the occurrence relationships in a setting where the knowledge is applied and needed.” 21

Julius Global Health

Research - Diabetes & Cardiovasular Diseases

DIABETES & CARDIOVASCULAR DISEASES Morbidity and mortality of non-communicable diseases, in particular diabetes and cardiovascular diseases (CVD) are on the rise, especially in low and middle-income countries. This increase has been attributed to population aging and trends towards unhealthy diets, smoking and sedentary lifestyles, in part related to increasing urbanization and globalization.

Prof. Michiel Bots (MD, PhD) is Professor of Epidemiology of Cardiovascular Disease,

Julius Global Health researchers are involved in multi-center international studies on common cardiovascular risk factors and disease outcomes and clinical trials to test the effectiveness and the global impact of low-cost medication (Red Heart Pill) to reduce cardiovascular morbidity and mortality in high-risk patients. They are participating in the UMPIRE trial (Use of a Multidrug Pill in Reducing Cardiovascular Events) and are members of the worldwide network of researchers in the SPACE (Single Pill to Avert Cardiovascular Events) Collaboration (

with a particular focus on the development, risk factors and consequences of atherosclerosis.

Further research aims to develop primary and secondary prevention models that are most cost-effective in reducing the burden of cardiovascular diseases and diabetes. “The MedChamps (Mediterranean Studies of Cardiovascular Disease and Hyperglycemia: Analytical Modeling of Population Socio-Economic Transitions) project, for example, aims to make recommendations about policy initiatives” explains Dr. Ilonca Vaartjes (PhD), who is involved in the six country project in European, North African and Middle Eastern countries. With colleagues from the Amsterdam Medical Center, she also investigates the relationship between ethnicity and cardiovascular disease in various first and secondgeneration ethnic minorities in the Netherlands. In Asia, cardiovascular disease research conducted by Julius Global Health is taking place in Malaysia, Indonesia, India and China.

Julius Global Health Cardiovascular Research focuses on: Dr. Ilonca Vaartjes (PhD) is a post-doctoral researcher in Cardiovascular Disease Epidemiology. Her main research focus is the use of nationwide register data for cardiovascular disease research. This includes trend analysis and prognosis after admission for cardiovascular disease.


• Studies investigating the influence of early life development on adult health; • International comparison of diabetes and cardiovascular disease rates and their risk factors; • Novel approaches to the prevention of diabetes and cardiovascular disease in high and low income settings.

In Malaysia, Julius Global Health is collaborating with the Clinical Research Centre, Ministry of Health. Dr. Sharmini Selvarajah PhD is working on the causes, consequences, and prevention of cardiovascular diseases and has recently expanded his work to include studies on risk factors, management and quality of care for stroke victims in order to provide an evidence base to help tackle the increasing burden of CVD in Malaysia. Given the importance of early life experience for resistance to chronic disease in adult life, a further focus of Julius Global Health cardiovascular disease research is on optimal fetal, infant and child development.

use during routine health assessment in primary health care facilities. This would then identify those at greatest risk for diabetes in order to provide adequate medical care. Xin Wang, PhD fellow at the Julius Center, is writing her dissertation on similarities and differences of cardiovascular risk factors between China and the Netherlands. She is using two health-screen survey databases conducted in Changchun and Dehui, Jilin Province, China and is comparing these with their Dutch counterpart, the Utrecht Health Project (UHP) cohort. She is doing this in close collaboration with the George Institute in Beijing. ↪

Umpire Utrecht-Shanghai Cancer & Cardiovascular Disease Collaboration In May 2013, the Utrecht-Shanghai Cancer & Cardiovascular Disease Collaboration was launched, a new research and capacity-building partnership on cancer, metabolic and cardiovascular disease. The Center for Disease Control in Shanghai, China, is responsible for the prevention and disease control of a population of 23 million people living in the Shanghai area. Comprehensive disease surveillance is complemented by routine risk factor surveys providing the evidence needed for preventive strategies aiming at enhanced health and quality of life. As diabetes in Chinese populations has been increasing considerably over the last years, current joint work between CDC Shanghai and Julius Global Health researchers aims to develop diabetes risk prediction models for easy

For low-cost and effective prevention of cardiovascular disease (CVD), the UMPIRE trial (Use of a Multidrug Pill in Reducing Cardiovascular Events) tests a combination of low-dose aspirin, a statin and two blood pressurelowering medicines in a low-cost single polypill (Red Heart Pill) in those who are at high risk of heart attack and stroke in India, Ireland, The Netherlands and the UK. Between July 2010-July 2011, more than 2000 participants with established CVD – or at risk of CVD – were enrolled and randomly assigned to polypill or usual care. They were then monitored through July 2012. Results showed that the polypill strategy improved medication adherence and lowered systolic blood pressure and LDL-cholesterol, thereby indicating the potential of the polypill to impact the reduction of global cardiovascular morbidity and mortality.


Julius Global Health

Research - Diabetes & Cardiovasular Diseases

Gender differences in the effects of common cardiovascular risk factors and disease outcomes

Dr. Sanne Peters (PhD) completed her PhD at the Julius Center and is currently a research fellow in Epidemiology at University of Oxford and the George Institute for Global Health.

While there are major anatomical, physiological and behavioral differences between men and women, it is commonly assumed in medicine that the effects of risk factors on disease outcomes are the same for both men and women. There is increasing evidence, however, to suggest that the effects of some risk factors â&#x20AC;&#x201C; such as diabetes and smoking â&#x20AC;&#x201C; on vascular outcomes, and possibly cancer, are different between the sexes, most often to the detriment of women. Julius Global Health researcher, Dr. Sanne Peters (PhD), in collaboration with the University of Oxford and Sydney, is currently running a series of systematic reviews and meta-analyses to quantify potential gender differences in the association between vascular risk factors and vascular disease and to determine which biological, behavioral or social mechanisms may explain such differences. Determining whether there are clinically meaningful gender differences in the association between risk factors and disease endpoints is important, not solely for the understanding of the etiology of CVD, but also from a population and public health perspective. Moreover, information on important gender differences may be used to provide an added impetus for targeted interventions aimed at the treatment and management of these risk factors in both sexes.

Research on Obesity and Diabetes among African Migrants (RODAM) Sub-Saharan populations in Europe have increased substantially over the last few decades. Evidence suggests that the risk of type II diabetes and obesity is higher in these populations than in European host populations. At the same time, the prevalence of type II diabetes and obesity has been observed to be increasing in Sub-Saharan Africa. The RODAM (Research on Obesity and Diabetes among African Migrants) study aims to understand the complex interplay between environment and genetics in the development of type II diabetes and obesity. It does so by comparing Ghanaians living in rural and urban Ghana to their compatriots in metropolitan European centers, namely Amsterdam, London and Berlin. In doing this, they allow for the consideration of transitional changes occurring not only in Ghana, but also in relation to diverse living environments in various European societies. Dr. Kerstin Klipstein-Grobusch is a co-investigator on the project. The study is coordinated by the Department of Public Health, Amsterdam Medical Center, The Netherlands.


Research - Infectious Diseases

Julius Global Health

INFECTIOUS DISEASES Most low and middle-income countries face a double burden of disease: non-communicable diseases are on the rise, while traditional communicable diseases, particularly malaria, tuberculosis and HIV, are persisting. For those infected with HIV, the use of effective antiviral treatment has resulted in increases in life expectancy, almost up to the level of non-infected people. However, there is evidence that the constant activation of the (successfully treated) HIV patients’ immune system leads to a higher risk of developing cardiovascular diseases (CVD), chronic diseases such as diabetes, or diseases of the nervous system. The regular use of antivirals might also play a role in this increased risk.

Prof. Mirjam Kretzschmar (PhD) is Professor of Dynamics of Infectious Diseases and uses mathematical modeling

Julius Global Health researchers are investigating the interaction of HIV and non-communicable diseases – particularly cardiometabolic disease in children and adults – for better prevention of non-communicable disease and better treatment of HIV. This is mainly being done in (South) Africa, one of the countries with the highest HIV burden in the world. In addition, Julius Global Health researchers, Dr. Cuno Uiterwaal and PhD fellow Nikmah Salamia Idris, are undertaking work in Jakarta, Indonesia, addressing cardiovascular health in infants and children infected through HIV transmission from mother to child.

to study the relationship between risk behavior and the transmission of infections.

Southeast Asia is a hotspot for emerging infectious diseases, including those with pandemic potential. For important respiratory pathogens, such as influenza, SARS and tuberculosis, spatial proximity between social contacts is a major determinant in the transmission process. To understand the dynamics of transmission of pathogens through a population, information on contact patterns is needed. Prof. Mirjam Kretzschmar (PhD), in collaboration with the Faculty of Public Health of the Mahidol University in Bangkok (Thailand) and the Karolinska Institute (Sweden), is conducting research in Thailand to find new ways to reach internet-using individuals in order to learn more about the spread of pathogens in populations.


Julius Global Health

Research - Infectious Diseases

Ndlovu Research Consortium in South Africa Julius Global Health is conducting research in collaboration with the Ndlovu Care Group in Elandsdoorn, where thousands of HIV patients are being treated in a well-equipped specialized clinic. Prof. Roel Coutinho explains: “We will follow a group of 1,000 HIV-infected patients and a group of 1,000 non-infected people over a period of several years, collecting samples, conducting interviews and collecting medical data. The core study will focus on the interaction between HIV and CVD/chronic diseases, with some additional studies benefiting from the collected information as well, leading to a unique multidisciplinary set-up which includes social sciences, virology and immunology.” Prof. Roel Coutinho (MD, PhD) is Professor of ‘Epidemiology and the Prevention of Infectious Diseases in the VeterinaryHuman Domain’ and Scientific Coordinator of the Ndlovu Research Consortium.

Ndlovu Research Consortium The Ndlovu Research Consortium is a collaboration among the Julius Center, responsible for the project coordination, the Departments of Internal Medicine & Infectious Diseases and Virology and Immunology, the Faculty of Behavioral and Social Sciences at Utrecht University, the Ndlovu Care Group and the University of the Witwatersrand, Johannesburg. Dr. Hugo Tempelman’s team at the Ndlovu Care Group will conduct the core study together with two postdoctoral researchers working in South Africa. The participation of South African researchers will be ensured by the involvement of colleagues from the Reproductive Health and HIV Research Institute (WHRI), University of the Witwatersrand, Johannesburg, South Africa. Additional studies will involve Master and PhD students from Dutch and South African faculties, including Alinda Vos, PhD fellow at Julius Global Health studying the relation between HIV, inflammation, immune activation and cardiovascular disease. Thus far, the Ndlovu Research Consortium is being funded by the UMC Utrecht, the Dutch Aids Fund and the Dioraphte Foundation.

Hugo Tempelman (MD, MA) founder and CEO of the Ndlovu Care Group, a multi-award winning social enterprise devoted to community health care and community development in rural South


Africa. •

Multidisciplinary research on HIV in rural South Africa

Core investigation: interaction between HIV and cardiovascular diseases


1,000 HIV negative and 1000 HIV positive participants

2012: first discussions

August 2013: kick-off

June 2014: ethics approval for research protocol

October 2014: enrollment of first study participants

Focus The multidisciplinary research program concentrates on the prevention, prognosis and management of HIV and the interaction with chronic diseases, such as diabetes and cardiovascular diseases. “We would like to understand the impact of HIV (both treated and untreated) on CVD as a driving factor. Such clues could help understanding what is driving CVD in general” explains Prof. Roel Coutinho. In addition to the clinical aspects, special attention is paid to social, economic and demographic determinants of disease and disease outcomes. Other research activities deal with translational viro-immunology. This is complementary work to research conducted by Dr. Kerstin KlipsteinGrobusch with colleagues from the Medical Research Council / Wits Rural Public Health and Health Transitions

Unit in the Agincourt Health and SocioDemographic Surveillance System located in rural northeast Africa, close to the Mozambiquan border. They conducted a population-based cross-sectional survey in more than 4500 men and women from 15 to 80 years of age and observed intersecting high prevalence of HIV and hypertension. More than half of the adult population requires long-term care for at least one of the conditions of HIV, hypertension or diabetes, suggesting serious implications for the South African health care system with regard to provision of chronic care. In response to the high burden of chronic diseases, South Africa, as part of its reengineering of the primary health care system, has initated integrated chronic disease management (ICDM), currently

being piloted in several districts in the country. “Research in public health facilities, in the Agincourt Health Socio-Demographic Surveillance System area on quality of care for HIV, hypertension and diabetes and patient outcomes in the new ICDM, will shed light on the quality and effectiveness of the ICDM to manage chronic disease” says Dr. Kerstin Klipstein-Grobusch. ↪

“A truly unique multidisciplinary set-up that is not seen anywhere else” Anne Wensing


Julius Global Health

Research - Infectious Diseases

Global health relevance What makes the research activities unique is that the interaction between HIV and CVD in rural settings is being examined in both population-based and clinical research, as opposed to urban areas where it usually takes place. In addition, in contrast to the majority of ongoing studies in industrialized countries that investigate the interaction between HIV and CVD, research is being conducted among both men and women, as the general population is at risk for HIV in South Africa, which is not the case in Western countries.

HIV and chronic diseases Assessing cardiovascular disease risk in children with HIV in Indonesia Nikmah Salamia Idris: “We would like to see the effect of HIV infection (with or without treatment) on cardiovascular risk. I recruit HIV positive children and take measurements of their cardiovascular development, such as a heart echo and vascular measurements. All patients between 0-18 years are included. Most of the HIV-infected Indonesian children are between 3-5 years old. HIV is transmitted during pregnancy through the placenta, during labor or via breast milk. It is a problem that most pregnant women do not know their HIV status. Sometimes children are diagnosed before their parents.” The reason for conducting research in HIV is explained by Dr. Cuno Uiterwaal: “In Indonesia, we can examine cardiovascular risk of children with HIV who have not received treatment until the moment they enroll in the study. That allows us to distinguish between cardiovascular effects of HIV infection and of its treatment, some of which itself has cardiovascular consequences.”



Julius Global Health

Research - Environmental Health

ENVIRONMENTAL HEALTH IRAS - The Institute for Risk Assessment Sciences The Institute for Risk Assessment Sciences is a research institute linked to the Faculties of Veterinary Medicine, Medicine and Sciences of Utrecht University. IRAS provides education and research on the human health risks associated with exposure to potentially harmful agents in the environment, at the workplace and through the food chain.

Prof. Bert Brunekreef is Professor of Environmental Epidemiology and Director of the Institute for Risk Assessment Sciences, University Utrecht.

Global Burden of Disease Study 2010 Prof. Bert Brunekreef was part of the team that evaluated the impact of air pollution for the 2010 Global Burden of Disease (GBD) study: a study estimating the prevalence of diseases and the risk factors accounting for health loss in terms of estimated deaths and disability-adjusted life years (DALYs) globally. Currently, the team is working on the estimates for 2013. By documenting exposure distributions for different years, regions, gender and ages, the burden of disease attributable to each risk factor can be estimated. A shift has occurred; non-communicable diseases rather than infectious diseases are now the main conditions contributing to morbidity and mortality in most parts of the world. With regard to air pollution, thus far, study findings from countries with low pollution levels were used to make estimates for regions with high exposure levels. In the future, more studies need to be conducted in countries with higher levels of pollution to better estimate the health risk associated with air pollution, particularly in lower and middle-income countries.


Air pollution and prevalence of asthma In the International Study of Asthma and Allergies in Childhood (ISAAC), the association between asthma and the use of cooking fuels and truck traffic around the world was investigated. Between 1999 and 2004, with the use of questionnaires, data was collected. More than 500,000 children from 108 centers in 47 countries were included. It was found that the use of open fire for cooking and exposure to truck traffic on the street of residence are important risk factors for health outcomes such as asthma, rhinitis and eczema. Bert Brunekreef explains: â&#x20AC;&#x153;As a result, the suggestion was made to switch to cleaner electric or gas stoves. These recommendations are, however, difficult to implement because people who need them are poor and tend to stick to traditional ways of cooking. This makes it an interesting challenge for policymakers to make this work.â&#x20AC;?

Indoor air pollution - Burning solid fuels in rural China The combustion of coal, biomass and other solid fuels is a significant cause of household air pollution in China. Women burn coal when cooking indoors, thereby contributing to high incidence rates of lung cancer. Research is being carried out to measure the exposure to polluted air of women living in rural China. Lower levels of pollution and reduced risk of lung disease are achieved when using vented stoves and/or clean alternatives such as bottled gas and electricity. Indoor air quality remains a considerable problem, in particular, because it primarily affects women and children and half of the worldâ&#x20AC;&#x2122;s population lives in rural areas where traditional indoor cooking still takes place.

Jakarta Indonesia - Air pollution and infant health Nikmah Salamia Idris, PhD fellow, is investigating the effect of air pollution on the health of neonates and infants in Jakarta. This is being done in collaboration with IRAS and UMCU-based colleagues and is funded by the PEER-Health Indonesia program of USAIDS. Exposure assessment techniques from Europe will be adapted to the local situation in Jakarta to estimate exposure of these vulnerable populations to air pollution in Jakarta. Scientific insight and the evidence generated could be useful for local policy in setting out to address air pollution more efficiently. Solutions to reduce air pollution have been implemented, for instance in China where, in 2008, motorcycles with combustion engines were replaced by electric bicycles during and after the Olympics in Beijing.



Educational activities at Julius Global Health are closely linked to the research program and have been expanding over the years to include courses in global health and research capacity training in international health sciences. Most of our educational activities are aimed at postgraduates, with a strong focus on health sciences, particularly epidemiology and clinical epidemiology, epidemiology of chronic diseases and environmental epidemiology. Julius Global Health contributes to the Master of Epidemiology program ( and PhD Epidemiology program at Utrecht University and conducts courses with international partners around the globe. International capacity-building activities were and are being developed based on best practice. One such program is AsiaLink, funded by the European Union to improve clinical epidemiology teaching and research in Indonesia and Malaysia and is supported through the UMC Utrecht Global Health Support Program, providing PhD study opportunities to excellent PhD candidates from low and middle income countries.

Julius Global Health offers a wide range of educational activities ranging from: • Master and PhD-level epidemiology training • Short courses offered in collaboration with the University Utrecht Summer School • Distance learning via Elevate Health • Internship and PhD fellowship opportunities


Julius Global Health

Education - Elevate Health

ELEVATE HEALTH – ONLINE ACADEMY Elevate Health ( is an online academy for international health professionals to enhance professional knowledge in medical sciences and thereby contribute to the improvement of health worldwide. Elevate was founded in 2011 as a project based in the Julius Center and has developed over a short period of time into a professional social enterprise.

Elevate for international health science education Elevate offers a comprehensive range of courses in medical and veterinary sciences on behalf of renowned partner institutes, with a specific focus on global health. These courses may be taken exclusively online, or in the form of blended learning: a mix of face-to-face sessions in addition to distance learning. Hylke Faber, business developer at Elevate explains: “We want to make sure that education can be reached by anyone anywhere in the world. We hope to reach people and educate them: to make sure that they become better doctors, researchers, global health professionals or veterinary scientists and that they share their knowledge to improve healthcare worldwide.”

Elevate stands for: • • • • • •

The provision of better access to good quality health care worldwide Focus on life sciences and health care E-learning expertise and solutions Reliable platform Personalized learning with interaction & support International academic knowledge, networks and partners

Online Epidemiology Master Starting in February 2015, Elevate, in collaboration with the MSc Epidemiology, will offer a full Masters Degree Programme in Epidemiology accredited by Utrecht University and the University Medical Center Utrecht. More information can be found on

Are you interested in platform services or partnership opportunities? Do you want to know what Elevate Health can offer you? Contact one of our managers: • • Hylke Faber: • Maggy Ovaa:


1000+OBGYN Project The 1000+OBGYN consortium aims to substantially reduce maternal and neonatal morbidity in Sub-Saharan Africa by training 1000 new obstetricians and gynecologists. It brings together obstetricians from academic institutions in both high and low resource countries in Sub-Saharan Africa, professional support organizations, policy makers and funders to strengthen the obstetric capacity in this region. Elevate Health and the University of Michigan were recently awarded a World Bank grant to develop a pilot project for the 1000+OBYN Consortium. Elevate Health will facilitate the development of the online course “Hypertensive disorders in pregnancy as part of the pilot.”

Education - Capacity Building

Julius Global Health

CAPACITY BUILDING Asialink - Building local capacity in Asia through education AsiaLink, a highly successful collaboration between the Rumah Sakit Cipto Mangunkusomo hospital in Jakarta (Indonesia), the Faculty of Medicine, University of Malaya in Kuala Lumpur (Malaysia), the University of Oxford (UK) and the University Medical Center Utrecht, aims at durable improvement in clinical epidemiological teaching and research in Indonesia and Malaysia. AsiaLink enables medical students, medical doctors, clinical researchers and other health care professionals to enroll in educational programs. As a result of the collaboration, six PhD fellowships have been granted and Clinical Epidemiology & Evidence-Based Medicine Units in Jakarta and Kuala Lumpur have been developed. A direct spin-off of the European Union sponsored AsiaLink consortium has been the setup of local academic units for clinical epidemiology. The organizers realized that, for academic medical research to thrive, local high-quality clinical epidemiological research capacity is indispensable. Local partners had recognized this and founded units, in collaboration with the Julius Center for Health Sciences and Primary Care at University Medical Center Utrecht, in Jakarta, Indonesia and Kuala Lumpur, Malaysia.

Julius Center, Kuala Lumpur, Malaysia In 2008, a unit named the Julius Center was established in close conjunction with the Department of Social and Preventive Medicine (current chair: Associate Professor Noran N. Hairi, at the University of Malaya Medical Center (UMMC) in Kuala Lumpur, Malaysia. It was named after the Julius Center for Health Sciences and Primary Care in Utrecht and it seeks to fulfill a similar role. It is situated on the campus of UMMC; its staff includes senior epidemiologists who had received their Master of Science in Clinical Epidemiology and PhD training at the Julius Center in Utrecht. The Julius Center at UMMC and Julius Global Health work together intensively in various areas of research, specifically in cardiovascular disease research and (breast) cancer research. The Julius Center at UMMC has been of critical importance for shared research within the National Heart Disease Registry of Malaysia, which has led to successful PhD tracks for both Malaysian and Dutch candidates. It also plays a pivotal role in South East Asian breast cancer research, pooling Malaysian and Singaporean data in a single registry. Shared research activities are expanding and the exchange of senior and junior staff is expected to intensify. From the Julius Global Health perspective, the Julius Center at UMMC is a very important research affiliation and one of the main pillars of research in the South East Asian region. â&#x2020;Ş


Julius Global Health

Education - Capacity Building

Clinical Epidemiology and Evidence-Based Medicine, Jakarta, Indonesia In 2010, a unit called Clinical Epidemiology and Evidence-Based Medicine (CEEBM) was officially opened by Prof. Rick Grobbee and Prof. Sudigdo Sastroasmoro, pediatrician (chair), as a full department of the Cipto Mangunkusumo Hospital in Jakarta, Indonesia. It was the first of its kind in Indonesia. From its inception, CEEBM has aimed to play a growing role in clinical research collaborations in and outside the hospital. It is staffed by dedicated personnel with expertise in clinical epidemiology, health technology assessment, data-management and analysis and evidence-based medicine and it features a medical library. CEEBM has been quite successful in achieving its objectives and is recognized for its expertise – not only locally, but in Indonesia at large – mainly through its intensive teaching activities. Julius Global Health in Utrecht closely collaborates with CEEBM in research and in research capacity building. As a result, there is a rapid expansion of shared research projects and substantial exchange of senior staff and of students at various career levels. CEEBM has, within the short time span of its existence, grown to be an important research hub for Julius Global Health, not only serving a high demand for local needs but also serving international collaboration dedicated to global health objectives. 36

“By joining the program, I truly learned how to conduct good research. I hope to spread the knowledge and skills that I acquire by teaching others how to conduct research.” Nikmah Salamia Idris, PhD fellow

Successful two-way exchange Dr. Cuno Uiterwaal: “One of the critical factors that have led to the success of the Utrecht-Indonesia collaboration is the intensive training and tutoring through PhD fellowships, including one-year training in Utrecht. Both Dutch and Indonesian PhD students gain a lot by participating in this exchange. It is important to be present locally, meet people and teach courses. Remote cooperation alone is not sufficient; we need to show commitment to a common cause. Shared activities are taking place in Jakarta and Kuala Lumpur: together we gather people with skills, enthusiasm and the ability to help out clinicians to do proper research, thereby creating a shared purpose.”

Short courses Short courses in global health at Julius Global Health are offered as introductory and advanced international summer courses in collaboration with the MSc Epidemiology, the Utrecht Summer School ( and online learning courses via Elevate ( As part of the Utrecht Summer School, we also offer an international course on mathematical modeling on infectious diseases and, with the MSc Epidemiology, a course on cardiovascular disease epidemiology. In addition, Julius Global Health colleagues are involved in international teaching activities in Asia and Africa, such as courses in clinical epidemiology in Singapore and Malaysia, environmental epidemiology in China and chronic disease epidemiology in South Africa.

Research Capacity Building in Africa Dr. Kerstin Klipstein-Grobusch is focusing on research capacity building in Sub-Saharan Africa (SSA). “This is an area I have been working on extensively over the past years, as Academic Head of the Master of Science in Epidemiology program at the Wits School of Public Health, in collaboration with the INDEPTH Network, a Network of Health and Demographic Surveillance Sites, mainly in Africa and Asia, and as a Principal Investigator of the ‘Wits Non-communicable Disease Research Leadership Training Program.’” This is a cross-disciplinary program aimed at nurturing future leaders in noncommunicable disease research within the African continent. Epidemiology and, particularly, clinical epidemiology are still scarce skills in most African countries. Thus, post-graduate level training to develop research capacity is of major importance to generate the evidence needed to improve population and individual health.”

“Julius Global Health offers educational activities to enhance the local capacity in (clinical) epidemiology and public health.” Kerstin Klipstein-Grobusch


Julius Global Health


STAFF Scientific

Irene Agyepong

Michiel Bots

Bert Brunekreef

Roel Coutinho

Rick Grobbee

Kerstin KlipsteinGrobusch

Mirjam Kretzschmar

Sanne Peters

Marcus Rijken

Cuno Uiterwaal

Ilonca Vaartjes

Lenny Verkooijen

Edward Antwi

Joyce Browne

Sofie Gernaat

Wahyuni Indawati

Ary Indriana Savitri

Nikmah Salamia Idris

Alinda Vos

Xin Wang

Renée Filius

Maggy Ovaa

PhD fellows

Mary Amoakoh-Coleman

Gbenga Kayode

Elevate Health

Hylke Faber


Mélanie Péro 38


Giene de Vries

Linsey van Bennekom

Noortje Mutsaerts

Project List

Julius Global Health

PROJECT LIST Reproductive & Child Health

6. Prediction, management and prevention of hypertensive disorders in a low resource setting

1. Accelerating progress towards attainment of MDG4 and 5 in

Investigators: J.L. Browne, K. Klipstein-Grobusch, D.E. Grobbee

Ghana through basic health systems functioning strengthening

Timeframe: 2013-2015

Investigators: I.A. Agyepong, H van Dijk, E. Ansah, D. Arhinful,

Partners: Ghana Health Service, Ghana

D.E. Grobbee, K. Klipstein-Grobusch

Funding: UMC Utrecht

Timeframe: 2011-2015 Partners: Greater Ghana Health Service, Accra, Ghana; University of

7. Breast feeding optimization and child health

Wageningen, Netherlands

Investigators: N. Salamia Idris, D.E. Grobbee, C.S.P. Uiterwaal

Funding: NWO/WOTRO

Timeframe: 2010-2014 Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia

2. Reducing maternal morbidity and mortality through enhanced

Funding: Nutricia Indonesia Research Fund; Indonesian National

Clinical Decision Making Support Systems (CDMSS) for frontline

Agency for Research and Development; Utrecht Developing World PhD

providers of care in the Greater Accra Region of Ghana

Support Program (DWS program)

Investigators: M. Amoakoh-Coleman, I.A. Agyepong, E. Ansah, K. Klipstein-Grobusch, D.E. Grobbee

8. Breast feeding and cardiovascular disease risk

Timeframe: 2011-2015

Investigators: N. Salamia Idris, C.S.P. Uiterwaal, S. Sastroasmoro

Partners: Greater Ghana Health Service, Accra, Ghana

Timeframe: 2010-ongoing

Funding: NWO/WOTRO; Utrecht Developing World PhD Support

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Program (DWS program)

Funding: Nutricia Indonesia (unrestricted)

3. Accelerating progress to reduce neonatal mortality through

9. Reliable Equitable Access to Healthcare Utilising SMS

quality improvement in health care in Ghana

Investigators: K. Lamont, K. Sliwa, S. Stewart, K. Klipstein-Grobusch








Timeframe: 2013-2015

K. Klipstein-Grobusch, D.E. Grobbee

Partners: Soweto Cardiovascular Research Unit, University of the

Timeframe: 2011-2015

Witwatersrand, South Africa; Hatter Institute for Cardiovascular Disease

Partners: Greater Ghana Health Service, Accra, Ghana

Research in Africa, University of Cape Town, South Africa; Baker IDI Heart

Funding: NWO/WOTRO; Utrecht Developing World PhD Support

and Diabetes Institute, Melbourne, Australia

Program (DWS program)

Funding: NIH; Medtronics Foundation USA

4. Predicting Neonatal Survival among pre-term infants in Niger

10. Malaria in pregnancy: ultrasound studies of fetal growth

State, Nigeria

Investigator: M. Rijken

Investigators: G.A. Kayode, K. Klipstein-Grobusch, D.E. Grobbee

Timeframe: 2006-2012

Timeframe: 2011-2015

Partners: Shoklo Malaria Research Unit (part of the Mahidol Oxford

Partners: Greater Ghana Health Service, Accra, Ghana

Tropical Medicine Research Unit) UK; Mahidol University, Thailand; The

Funding: NWO/WOTRO; Utrecht Developing World PhD Support

Nuffield Department of Obstetrics & Gynaecology, Oxford University,

Program (DWS program)

UK; Utrecht University Netherlands Funding: Wellcome Trust; Christophe et Rodolphe Merieux Foundation

5. Variation in incidence and prediction of pregnancy-induced


hypertension in Ghana Investigators: E. Antwi, D.E. Grobbee, K. Klipstein-Grobusch,

11. Active management of the Third Stage of Labour: Uterine

I.A. Agyepong, K Koram

Tonus Assessment by Midwife versus Patient Self-Assessment-

Timeframe: 2012-2015

(UTAMP) Trial

Partners: Ghana Health Service, Accra, Ghana

Investigators: J.L. Browne, N.K.R. Damale, T.R. Raams, E.L. Van der Linden,

Funding: Greater Accra Health Service, UMC Utrecht; Utrecht Developing

E.T. Maya, E. Ansah, R. Doe, M. Rijken, R. Adanu, D.E. Grobbee, A. Franx,

World PhD Support Program (DWS program)

K. Klipstein-Grobusch Time frame: March 2014 â&#x20AC;&#x201C; April 2015 Partners: University Medical Center Utrecht, Korle Bu Teaching Hospital, 39

Julius Global Health

Project List

6. Prediction of cardiovascular events in women treated for

University of Ghana School of Public Health Funding:






(Geboortecentrum), Korle Bu Teaching Hospital

breastcancer Investigators: H.M. Verkooijen Timeframe: 2014-ongoing

Cancer 1. Singapore/Malaysia Breast Cancer Cohort: breast cancer risk factors and outcome: a global perspective

Partners: National University Singapore, Singapore Funding: NUS – UMC strategic partnership programme

Diabetes & Cardiovascular Disease

Investigators: H.M. Verkooijen, M. Hartman, S.C. Lee, N. Bhoo Pathy, C.H. Yip, C. van Gils, P. Peeters, Y. van der Graaf

1. Early life famine exposure and adult cardiovascular disease: The

Timeframe: 2008-ongoing

Dutch hungerwinter experience

Partners: National University of Singapore, Singapore; University of

Investigators: A. van Abeelen, C.S.P. Uiterwaal, T. Roseboom,

Malaysia, Kuala Lumpur, Malaysia

D.E. Grobbee, P. Bossuyt

Funding: EU AsiaLink; High Impact Research (HIR) grant Malaysia

Timeframe: 2011-2013 Partners: AMC Amsterdam, Netherlands

2. International population-based cancer registry studies

Funding: AMC Amsterdam; UMC Utrecht

Investigators: H.M. Verkooijen, M. Hartman, K. Czene, K.S. Chia, C. Bouchardy

2. Type 2 diabetes and obesity among sub-Saharan African

Timeframe: 2008-ongoing

native and migrant populations: dissection of environment and

Partners: National University Singapore, Singapore; Karolinska Institute,

endogenous predisposition (RODAM)

Stockholm, Sweden; Geneva Cancer Registry Switzerland

Investigators: C. Agyemang, E. Beune, K. Meeks, M. Nicolaou,

Funding: NMRC start up grant

K. Klipstein-Grobusch, E. Owusu-Dabo, P. Agyei-Baffour, A. de-Graft Aikins, F. Dodoo, L. Smeeth, J. Addo, F.P. Mockenhaupt, S.K. Amoah,

3. Estimating and understanding social and biological factors

M.B Schulze, I. Danquah, J. Spranger, ,T. Burr, P. Henneman, M.M. Mannens,

contributing to the burden of disease due to breast cancer in

J.P van Straalen, S. Bahendeka, A.H. Zwinderman, A. E. Kunst, K. Stronks

South-East Asia

Timeframe: 2012-2015

Investigators: M. Hartman, H.M. Verkooijen, C.H. Yip, J.N.W. Lim,

Partners: AMC Amsterdam, The Netherlands; Kwame Nkrumah

N.A.M. Taib, M. Dahlui, H. Ga Sze, T.-C. Aw

University of Science and Technology, Kumasi, Ghana; Charité,

Timeframe: 2011-ongoing

Universitätsmedizin Berlin, Germany; LSHTM, UK; DlFE, Potsdam,

Partners: SSH School of Public Health National University of Singapore,

Germany; University of Ghana, Accra, Ghana; IMaGenes, Berlin, Germany;

Singapore; University Malaya Medical Centre, Malaysia; University of

International Diabetes Federation Africa, Uganda

Leeds, UK; KK Women’s and Children’s Hospital Singapore, Singapore;

Funding: FP7 European Commission

United Arab Emirates University, Arab Emirates University, Arab Emirates Funding: Global Asia Institute Research Grant

3. Wits Non-Communicable Disease Leadership Training Programme Investigators: M. Ramsay, N. Crowther, K. Klipstein-Grobusch,

4. Ethnicity, reproductive history and the risk of breast cancer

K. Sliwa-Haehnle

Investigators: H.M. Verkooijen, M. Hartman, K.S. Chia

Timeframe: 2010-2015

Timeframe: 2009-2012

Partners: Division of Human Genetics, National Health Laboratory Service,

Partners: National University Singapore, Singapore

Johannesburg, South Africa; Division of Chemical Pathology, National

Funding: National Medical Research Council Singapore

Health Laboratory Service, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa;

5. Impact of genetic and familial factors on breast and other

Soweto Cardiovascular Research Heart Unit, University of Witwatersrand,

cancers occurrence, treatment and outcomes. Studies from

Johannesburg, South Africa

the first population-based Familial Breast Cancer Registry in

Funding: NIH, USA

Switzerland Investigators: C. Bouchardy, S. Benhamou, H.M. Verkooijen, P. Chappuis,

4. Validation of Western derived prognostic scores for acute

G. Vlastos, E. Rapiti

coronary syndromes in Indonesian patients admitted with acute

Timeframe: 2003-ongoing

coronary syndromes

Partners: Université de Genève, Switzerland; Hôpitaux Universitaire de

Investigators: E. Dewiasti, C.S.P. Uiterwaal, A. Hoes, Y. van der Graaf

Genève, Switzerland; Imaging Division

Timeframe: terminated

Funding: Ligue Suisse contre le Cancer

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia


Project List

Funding: EU AsiaLink; Universitas Indonesia

Julius Global Health

UK; London School of Hygiene and Tropical Medicine, London, UK; Trinity College, Dublin University, Ireland; Department of Public

5. Malaysian Cardiovascular Disease Registry Development,

Healht, School of Medicine, Dokuz Eylul University Izmir, Turkey; Syrian

Improvement and Optimisation (MyCaRDIO)

Center for Tobacco Studies, Allepo, Syria; CVD Epidemiology and

Investigators: N. Bhoo Pathy, M.L. Bots, A. Bulgiba, I. Vaartjes

Prevention Research Laboratory, Tunis, Tunisia.

Timeframe: 2011-ongoing

Funding: FP7: European Union

Partners: University of Malaysia, Kuala Lumpur, Malaysia Funding: Malaysian government







Collaboration 6. Cardiovascular analyses of the Asia-Pacific Cohorts collaboration

Investigators: K. Klipstein-Grobusch, X. Li, Y. Li, D. Yuan, C.S.P. Uiterwaal,

Investigators: S.A.E. Peters, M.L. Bots, D.E. Grobbee, M. Woodward,

P. Bao, H. Yu, H.M. Verkooijen, D.E. Grobbee, W. Zhong, F. Wu

T.H. Lam, Xianghua Fang, Il Suh, H. Ueshema, A.J. Dobson, R.R. Huxley

Timeframe: 2013 - ongoing

Timeframe: 2012-2014

Partners: CDC Shanghai, China

Partners: The George Institute for Global Health, University of Sydney,

Funding: CDC Shanghai, UMCU Utrecht

Australia; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; School of Public Health, The University of Hong Kong, Hong Kong; Xuanwu Hospital Capital Medical University, China;

Infectious Disease

Yonsei University College of Medicine, Seoul, Korea; Shiga University of Medical Science, Shiga, Japan; School of Population Health, University of

1. A multidisciplinary cohort study comparing HIV-positive

Queensland, Australia; Division of Epidemiology & Community Health,

and HIV-negative subjects to investigate the epidemiology,

University of Minnesota, Minneapolis, USA

pathogenesis and social factors determining the interaction

Funding: Pfizer; AstraZeneca; UMC Utrecht

between HIV and (lifestyle-related) chronic conditions, with a special focus on cardiovascular disease

7. UMPIRE: A randomized controlled open-label trial of a fixed-

Investigators: R. Coutinho, H. Tempelman, D.E. Grobbee, R. Barth,

dose combination polypill medication and usual care in those at

A. Wensing, T. Knijn, M. Kretzschmar, K. Klipstein-Grobusch, (M. Slabbert),

high risk of cardiovascular disease

A. Hoepelman, C.S.P. Uiterwaal, F. Venter

Investigators: D.E. Grobbee, M.L. Bots, M. Lafeber, S. Thom, N. Poulter,

Timeframe: 2013-ongoing

A. Stanton, S. Reddy

Partners: Ndlovu Care Group, Elandsdoorn, South Africa; University of

Timeframe: 2010-2014

Utrecht, Netherlands; University of the Witwatersrand, Johannesburg,

Partners: Imperial College, London, UK; Royal College of Surgeons,

South Africa

Ireland; Public Health Association of India, Hyderabad, India

Funding: Dioraphte Foundation; Aids Fonds; De Grote Onderneming;

Funding: EU, FP7

UMC Utrecht; University of Utrecht

8. Origins of premature acute coronary syndrome in Indonesia:

2. Non-communicable disease risk and HIV in rural South Africa

a case-control study in Makassar

Investigators: S. Tollman, J. Menken, K. Klipstein-Grobusch, G .Williams,

Investigators: B. de Mol, Y. van der Graaf, C.S.P Uiterwaal

F.X. Gómez-Olivé, N. Angotti, B. Houle, C. Kabudula, S. Clark

Timeframe: 2011-2015

Timeframe: 2010-2013

Partners: Cardiology General Hospital Makassar Indonesia

Partners: School of Public Health, University of the Witwatersrand,

Funding: AMC Amsterdam

Johannesburg, South Africa; MRC / WITS Rural Public Health and Health Transitions Research Unit, Johannesburg, South Africa; University of

9. Ethnicity and its relation with risk of cardiovascular disease

Colorado, Boulders, USA; University of Washington, Seattle, USA

Investigators: L. van Oeffelen, I. Vaartjes, C. Agyemang, K. Stronks,

Funding: National Institute of Aging (USA); National Institutes of Health

M. Bots

(USA); Wellcome Trust (UK); William and Flora Hewlett Foundation (USA);

Timeframe: 2010-2014

Anglo American Chairman’s Fund (South Africa)

Partners: Department of Social Medicine, AMC, Netherlands Funding: Hartstichting

3. Assessment of health system’s response to chronic disease burden in South Africa


Investigators: S. Ameh, K. Klipstein-Grobusch, F.X. Gómez-Olivé,

Investigators: I. Vaartjes, S. Capewell, M O’Flaherty, J. Critchley,

S. Tollman

K. Bennet, B. Unal, F. Fouad, H. Ben Romdhane

Timeframe: 2011-2015

Timeframe: 2010-2014

Partners: School of Public Health, University of the Witwatersrand,

Partners: Department of Public Health, Liverpool University,

Johannesburg, South Africa; MRC/WITS Rural Public Health and Health 41

Julius Global Health

Project List

Transitions Research Unit, Johannesburg, South Africa

Environmental Health

Funding: NIH/Fogarty Millennium Promise Awards Programme (USA); African Doctoral Dissertation Fellowship Programme, Nairobi,

1. Land use regression models for estimating individual NOx and

Kenya; Faculty of Health Sciences University of the Witwatersrand,

NOâ&#x201A;&#x201A; exposures in a metropolis with a high density of traffic roads

Johannesburg, South Africa

and population Investigators: B Brunekreef

4. HIV, inflammation, immune activation and cardiovascular

Timeframe: 2007-2012


Partners: IRAS; RIVM; GGD, City of Utrecht

Investigators: A. Vos, K. Klipstein-Grobusch, R. Barth, D.E. Grobbee

Funding: VROM

Timeframe: 2014-2016 Partners: Ndlovu Research Consortium; Wits Reproductive Health

2. Effects of air pollution on lung function and symptoms of

and HIV Institute, University of the Witwatersrand, Johannesburg,

asthma, rhinitis and eczema in primary school children

South Africa

Investigators: B. Brunekreef

Funding: UMC Utrecht

Timeframe: 2008-2011 Partners: IRAS; Ministry of Foreign Affairs

5. Clinical epidemiology of HIV infected Indonesian children

Funding: Royal Haskoning

Investigators: N. Salamia Idris, C.S.P. Uiterwaal Timeframe: 2011-ongoing

3. Cooking fuels and prevalence of asthma: a global analysis of

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia

phase three of the International Study of Asthma and Allergies in

Funding: Universitas Indonesia; DWS; Julius Global Health, UMC Utrecht,

Childhood (ISAAC)


Investigators: B.Brunekreef, ISAAC Phase 3 Study Group Timeframe: ongoing

6. Epidemiology of Dengue infection

Partners: IRAS; ISAAC Consortium

Investigators: M.R. Karyanti, C.S.P. Uiterwaal, A.W. Hoes, H. Heesterbeek,

Funding: Glaxo Wellcome International Medical Affairs

P. Bruijning-Verhagen Timeframe: 2011-2016

4. A comparative risk assessment of burden of disease and injury

Partners: Cipto Mangunkusumo Hospital, Jakarta, Indonesia

attributable to 67 risk factors and risk factor clusters in 21 regions,

Funding: EU AsiaLink

1990-2010: a systematic analysis for the Global Burden of Disease Study 2010

7. Evaluation of an intensified treatment monitoring strategy

Investigators: B. Brunekreef, GBD Consortium

to prevent accumulation and spread of HIV-1 drug resistance in

Timeframe: 2010-2013

resource-limited settings; the ITREMA project

Partners: Institute for Health Metrics and Evaluation; WHO; IRAS

Investigators: A.M Wensing, R. Schuurman, M.J.M. Bonten, D.M. Burger,

Funding: Bill and Melinda Gates Foundation

G.C.M. Knijn, M.E.E. Kretzschmar, M. Nijhuis, H.A. Tempelman, F.W. Venter Timeframe: 2014-2016

5. Acute respiratory inflammation in children and black carbon in

Partners: Department of Virology, UMC Utrecht, Netherlands; Radboud

ambient air before and during the 2008 Beijing Olympics

UMC, Nijmegen, Netherlands; Faculty of Social Sciences, University

Investigators: B Brunekreef

Utrecht, Netherlands; Ndlovu Care Group, South Africa, University of the

Timeframe: 2010-2012

Witwatersrand, Johannesburg, South Africa

Partners: IRAS

Funding: ZonMw/WOTRO

Funding: IRAS Foundation

8. Using respondent driven sampling to study contact patterns

6. Effects of air pollution in early life on infant and maternal health

relevant for the spread of close-contact pathogens


Investigators: M.E.E. Kretzschmar

K. Klipstein-Grobusch, S. Sastroasmoro, D.E. Grobbee, G. Hoek,

Timeframe: 2010-2014

A. Prayitno, N. Dwi Putri, B. Wiweko

Partners: Faculty of Public Health, Mahidol University, Bangkok,

Timeframe: 2014 - 2017

Thailand; Karolinska Institute, Sweden; Utrecht Center for Infection


Dynamics, UMC Utrecht, Netherlands

IRAS, University of Utrecht, The Netherlands

Funding: Focus & Massa Epidemiology

Funding: USAID; PEER Health / Indonesia













COLOPHON ©2014 This is a publication of the UMC Utrecht Julius Center, Julius Global Health Design and Production Photography Samuel Fidder, Geerte Hollander, Kerstin Klipstein-Grobusch, Noortje Mutsaerts, Ndlovu Care Group, Cuno Uiterwaal, Lenny Verkooijen, Marijn de Wit Photography, Matthias G. Ziegler/, UN Photo/Kibae Park /, UN Photo/UNICEF/Marco Dormino /, © UNICEF/NYHQ2006-1367/Pirozzi, © UNICEF/IDSA2010-00115/Purnomo, © UNICEF/NETH2010-00012/Schoonewille, © UNICEF/NYHQ2008-1290/Estey, © UNICEF NL2010/0171/Schoonewille, © UNICEF/NETH2010-00020/Schoonewille, © UNICEF/NETH201000014/Schoonewille, © UNICEF/NYHQ2008-0459/Dean, © UNICEF/NYHQ2012-1024/Pirozzi, © UNICEF/NYHQ2008-1291/Estey, © UNICEF/NYHQ2013-0465/Esiebo


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