Common use of Conclusions Clause in Contracts

Conclusions. This study finds no evidence indicating an association between nitrosamine exposure from condoms and incidence of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefits, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States By Xxxxxx XxXxxxxx Bachelor of Arts, Vassar College, 2013 Thesis Committee Chairs: Xxxxx Xxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements I would like to express sincere appreciation to my committee chairs Xxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support and advice during this process, as well as your good humor and very interesting conversations. I would like to thank Xxx X’Xxxxxx at the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).

Conclusions. This study finds no evidence indicating an association between nitrosamine exposure from condoms The U.S. needs a national mechanism to systematically identify survey reports and incidence to standardize measures and reporting for Campus Climate Surveys. FTFI and CASI elicited similar rates of cervical sexual violence disclosure, suggesting that colleges and colorectal canceruniversities can conduct robust assessments via CASI. Condoms provide substantial Nonsignificant findings that FTFI elicited more disclosures warrants further study. Colleges and measurable public health benefitsuniversities need to xxxxxx inclusive campus culture for students while implementing Campus Climate Surveys. Understanding the Disclosure of Sexual Violence among College Women By Xxxxxxxx Xxxxx Xxxxxx B.A., and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States By Xxxxxx XxXxxxxx Bachelor of Arts, Vassar Xxxxxxxx College, 2013 Thesis Committee Chairs2006 X.Xx. London School of Hygiene and Tropical Medicine, 2009 Advisor: Xxxxx Xxxxxxx X. Xxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS Ph.D. A thesis dissertation submitted to the Faculty of the Xxxxxxx Xxxxx X. Xxxxx School of Public Health Graduate Studies of Emory University in partial fulfillment of the requirements for the degree of Master Doctor of Public Philosophy in Behavioral Sciences and Health Education 2018 Acknowledgements There are many people to whom I’m grateful for supporting me in Global Epidemiology 2016 Acknowledgements I would like to express sincere appreciation this work. Thank you to my committee. Xxxxxxx Xxxxxx, thank you for helping me expand this idea into a dissertation through the proposal development class and for guiding me through the directed study on psychometric measurement. Xxxxxx Xxxxxxxxxx, thank you for encouraging me to pursue the systematic review of Campus Climate Surveys, for providing me with a directed study in structural equation modeling, and for letting me pop-in to your office on a frequent basis. Xxxxxxx Sales, thank you for selecting me to serve as the co-chair of the Campus Climate Survey Subcommittee in 2014, which gave me invaluable insight into these surveys and the practical experience with implementation and communication of results. Thank you for your support throughout my committee chairs work, in figuring out the logistics of this project, and the directed study in screening for experiences of violence, linkages to clinical care, and ethics. Finally, thank you to my advisor, Xxxxxxx Xxxxx. You pushed me to “think big” and prepared me to take on a project of this scope. You encouraged me to work independently while providing consistent support and guidance, removing barriers as I encountered them. It has been a pleasure to have you as my advisor, chair, and mentor. Thank you to the Department of Behavioral Sciences and Health Education for the excellent training that I have received. Thank you to both Director of Graduate Studies who served during my time; Xxx Xxxxx Xxxxxxx and Xxxxx Xxxxx Xxxxx. You both served as the anchor for agreeing to take on another thesis advisee despite their very busy schedulesthe doctoral students. Thank you so much to Xxxxxxx XxXxxxx for leading our department into a new era. Thank you to the faculty members who helped me navigate the world of teaching (you all served as wonderful role models); Xxxx Xxxxxx, Xxxxx Xxxx, and Xxxxx Xxxx. Thank you to Xxx Xxxxx Xxxxxxx, Xxxxx XxXxxxxxxx, and Xxxxxxxx Xxxxx for writing letters of support for my F31 grant. Thank you to all of the department faculty, who xxxxxx an environment of scientific rigor and genuine collegiality. It has made for a happy doctoral experience. I would never have completed this step, or any milestone in the program without the support of my doctoral student colleagues. Thank you to my cohort; Xxxxx Xxxxxxxxx, Xxxxx Xxxxx, Xxxxx Xxxxxxx, and Xxxxxx St. Xxxxx Xxxxxxxx; what a joy to have been through it all together. Thank you to my violence prevention colleagues, Xxxxxxxxx Xxxxxxx, Xxxxx Xxxx, Xxxxxx Xxxxxxx, and Xxxxx Xxxxxx; you inspire me each day through your support dedication to the movement. Thank you as well to my peer mentor Xxxxxxxx Hayley; you served as an unparalleled example for hard work and advice during this processgenerosity. Thank you to my officemates, who are aforementioned, as well as Xxxxx Xxxxxxx, and unofficial officemate Jing Xxxx Xx, for your good humor willingness to let me “run something by you real quick,” and very interesting conversationsfor all the laughter. I would like have a reason to thank Xxx X’Xxxxxx at each doctoral student in this department for a different reason; so again, thank you to all. Thank you to the department administrative staff; Xxxxxx Xxxxxx, Xxxxxxxx Xxxxx, Xxxxxx Xxxxxx, and Yenawa Xxxxxxxx. Our department would not function without you, and I thank you for making it all happen, from signing me up for classes and helping me manage my funding, to making me countless PDF packages, and planning our social gatherings. Thank you for serving as problem fixers and friends. I cannot wait to see what future opportunities await for my excellent research assistants Xxxxxxxx XxXxxxxxx, Xxxxxxxxx Xxxxxxxx, and Xxxxxxx Xxxxxxx. Your enthusiasm and talent kept me motivated throughout the past three years. You are all stars about to launch into the sky. Thank you. Thank you to the Respect Program; Xxxxx Xxxx, Jamechya Xxxxxx, and Xxxxxxx Passono. I see you as my partners in this work. I cannot help but be excited when we meet or collaborate on projects. Thank you for all that you have taught me and for all that you do for the Emory campus. Thank you especially, to Xxxxx, who has written me about six different letters of support for me to pursue funding for this work. Thank you to my colleagues at Emory University who have all contributed to making this work a reality: Xxxxxx Xxxx, Xxxxxx Xxxxxx, Xxxxxx Xxxxxx, Xxxxxx Xxxxx, and Xxxxxx Xxxxxxx. Thank you to my funders. Research reported in this dissertation was supported by National Institute of Child Health and Human Development of the National Institutes of Health under award number 1F31HD086964-01A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work was additionally supported by the Emory Injury Prevention Research Center and Xxxxx Graduate School Professional Development Support funds. Thank you to all of my friends who supported me throughout the applying to graduate school, moving to Atlanta, and finishing this degree. Thank you to my family for Digital Scholarship your love and support. Thank you to my parents, Xxxxx and Xxxxx. You have always encouraged me to follow my dreams and you have made achieving them possible by helping me get there. Thank you to my siblings, Xxxxxxx Xxxxxxxx at and Xxxxx. Spending a lifetime being known to teachers as “the Xxxxxxxx Health Science Center Library third Xxxxxx child” provided me with an endless motivation to live up to your brilliance. Thank you also to Bo, Molly, and Xxxxx. Thank you to my life partner and future husband, Xxxxxxx. Words fall short of all that you mean to me. Thank you for their helpinspiring me with your heart, including answering emails at 10pm on a Sunday your mind, and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) datayour cooking. Finally, all my love and gratitude thank you to my friends and family. To Student Advisory Board, my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs)participants, and family planningsurvivors. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015)You make this work worthwhile. Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference I am grateful for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of your willingness to use condoms (Xxxxxxx et al., 2012)participate in my study. Perceptions by Many students on campuses across the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include country act to create change on the belief issues that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal modelsmatter to them, including colon tumors sexual violence. I do this work in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et alhonor of you., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).

Conclusions. This study finds no evidence indicating an association between nitrosamine exposure from condoms In a population with prior positive TSTs, TST was more variable than QFT-GIT when pairs of each test were performed simultaneously. TSTs may trigger conversion of subsequent TST and incidence of cervical and colorectal cancerQFT-GIT. Condoms provide substantial and measurable public health benefitsThe Tuberculin Skin Test: Within-Subject Variability, Boosting, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between stateComparison with the QuantiFERON-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a crossTB Gold In-sectional study of the United States Tube Test By Xxxxxx XxXxxxxx Bachelor Xxxxxx-Xxxxxx DMD Medical University of Arts, Vassar College, 2013 Sofia 1982 Thesis Committee ChairsChair: Xxxxx XxxxxXxxxxx Xxxxxxx, PhDPhD Thesis Field Advisors: Xxxxxx Xxxxxxx, MD and Xxxxxxx X. Xxxxxxxxx, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements the Executive Master of Public Health Program, 2017 Acknowledgments I would like to express sincere appreciation my sincerest gratitude to my committee chairs Xxxxx chair, Xx. Xxxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedulesmy field advisors, Xx. Thank you so much for your support Xxxxxx Xxxxxxx and advice during this process, as well as your good humor and very interesting conversationsXx. Xxxxxxx Xxxxxxxxx. I would also like to thank Xxx X’Xxxxxx at express my gratitude to the Emory Center Centers for Digital Scholarship Disease Control and Xxxxxxx Xxxxxxxx at Prevention, Division of Tuberculosis Elimination’s Clinical Research Branch, with whom I had the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday honor and agreeing to meet frantic MPH students the very next dayprivilege of working and learning. I would also like to thank Xxxxx the students and faculty at Emory University and the Xxxxxxx School of Public Health – EMPH program for her expertise helping me and infectious enthusiasm providing me valuable knowledge and skills. I would finally like to thank my family for mapping their constant understanding, patience, and GISsupport. The findings and conclusions in this document are solely those of the author and do not necessarily represent the official views of the Centers for Disease Control and Prevention, as well as her encyclopedic knowledge in finding (free) dataThe U. S. Department of Defense, or the U. S. Air Force. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, Table of Contents CHAPTER I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents : INTRODUCTION 1 Nitrosamines INFECTION AND DISEASE DUE TO MYCOBACTERIUM TUBERCULOSIS 1 Historical Perspective 1 Epidemiology 2 Transmission 4 MYCOBACTERIUM TUBERCULOSIS INFECTION 5 Treatment and Control 6 Targeted Testing 7 IMMUNOLOGIC TESTS FOR MYCOBACTERIUM TUBERCULOSIS INFECTION 9 Tuberculin Skin Test (TST) 9 Interferon-Gamma Release Assay (IGRA) 11 Problems Addressed by this Research 14 Within-Subject TST Variability 14 TST – QFT Agreement 15 Boosting of Immunologic Responses as Measured by TST 15 Boosting of Immunologic Responses as Measured by QFT-GIT 17 Analysis Goals 18 CHAPTER II: LITERATURE REVIEW 19 Measures of Variability and Boosting Reported in food Prior Studies 19 WITHIN-SUBJECT TST VARIABILITY (WITHIN-SUBJECT COMPARISON OF TST RESULTS) 20 Within-Subject Comparison of TST and water 5 Occupational exposure QFT-GIT Results 22 TST Boosting 26 CHAPTER III: METHODS 28 Study Population 28 Analysis and Study Design 29 Test Methods 30 Statistical Analysis Methods 31 CHAPTER IV: RESULTS 32 Subject Characteristics 32 Test Results 33 Objective I: Assessment of Within-Subject XXX Xxxxxxxxxxx 00 Xxxxxxxxx XX: Assessment of TST - QFT-GIT Agreement 34 OBJECTIVE III: ASSESSMENT OF TST BOOSTING OF A SUBSEQUENT TST 34 OBJECTIVE IV: ASSESSMENT OF TST BOOSTING OF A SUBSEQUENT QFT-GIT 35 CHAPTER V: DISCUSSION 36 Introduction 36 Summary and Findings 37 Limitations 39 Implications 40 Recommendations for Future Studies 42 Conclusions 42 FIGURES 43 TABLES 47 REFERENCES 52 Chapter I: Introduction Infection and Disease Due to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 NonMycobacterium Tuberculosis Historical Perspective Tuberculosis (TB) is an infectious disease that has ravaged humanity for ages and continues to kill millions of people each year. TB usually affects the lungs and is transmitted from human-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual healthto-human through inhalation. The bacterium that is primarily responsible for causing TB, playing roles in human immunodeficiency virus Mycobacterium tuberculosis (HIV) prevention, prevention of sexually transmitted infections (STIsMTB), was first identified and family planningdescribed in 1882 by Xxxxxx Xxxx. There has been substantial investment Infections with MTB (MTBI) can be classified as either an active disease (referred to as TB) with clinical symptoms and pathological signs, or as an asymptomatic non-contagious state, often called “latent” TB infection (LTBI). People with TB may present with constitutional symptoms, such as weight loss, fever, chills, night sweats, and weakness, but may also present with symptoms associated with disease in specific organs. The lung is most often affected as evidence by local governmentssymptoms of cough, international health agencies sputum production, hemoptysis, and non- governmental organizations chest pain, that are typically accompanied by an abnormal chest x-ray. Pulmonary TB accounts for approximately 80% of newly diagnosed TB in the U. S. while 20% to 30% involves extra-pulmonary sites. Traditional methods used to diagnose TB rely primarily on sputum smear microscopy, bacteriological culture, and clinical examination, although newer and rapid molecular tests are being used with increasing frequency. A combination of sputum culture and clinical exam are considered the gold standard for definitive TB diagnosis. TB is curable with a standard six month course of four antimicrobial agents (NGOs) to increase supply isoniazid, rifampicin, pyrazinamide, and uptake ethambutol), but, if left untreated, 70% of condoms cases worldwide will not survive 10 years (Xxxxxx et al.World Health Organization, 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).

Conclusions. This study finds no evidence indicating an association between nitrosamine exposure from condoms The results suggest that neither pre- nor post-deployment HIV training significantly improves comprehensive HIV knowledge among UN peacekeepers. If confirmed, our observations may have important implications for the current DPKO HIV training curriculum. HIV Knowledge and incidence Receipt of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefits, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between stateTargeted Training among UN Peacekeepers in a Post-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States Conflict Setting By Xxxxxx XxXxxxxx Bachelor of ArtsXxxx Sc.B., Vassar CollegeBrown University, 2013 2006 Thesis Committee ChairsChair: Xxxxx XxxxxDr. Xxxxxxx Xxxxxxx, PhDMD, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements 2011 Acknowledgements: I would like to express sincere my appreciation to my committee chairs academic instructor Dr. Xxxxxxx Xxxxxxx of the Emory University, and my field advisor Xx. Xxxxx Xxxxxxx of the International Emergency and Xxxxx Xxxxx Refugee Health Branch at the Centers for agreeing to take on another thesis advisee despite Disease Control and Prevention for their very busy scheduleshelp with various aspects of this project including development of the research question, analysis of the data, and presentation of results. Thank you so much Xx. Xxxxxxx for your support commitment to the project and advice during this process, as well as your good humor and very interesting conversationstechnical expertise. Thank you Xx. Xxxxxxx for the opportunity to work on such an important global issue. I would like very much look forward to thank Xxx X’Xxxxxx at our collaboration in the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next dayfuture. I would also like to thank Xxxxx Xx. Xxxxxx Xxxxxxx and Xxxx Xxxxxxxxxx for her expertise their technical and infectious enthusiasm analytical assistance throughout the course of the project. Thank you Xxxxxx for mapping your early work on the project and GIS, as well as her encyclopedic knowledge in finding (free) datayour invaluable statistical guidance navigating the treacherous waters of SAS and weighted logistic regression. Finally, all I would like to express my love and gratitude to my friends additional support at Emory and familyCDC, especially Branch Chief Xxxxxxx Xxxxxx, Dr. Xxxx Xxxxxxxx, and Xxxxx Xxxx for the opportunity to contribute to this remarkable area of public health research and your continued support and confidence in my achievements. To my Xxxxxxx friendsTable of Contents Introduction and Background 1 Methods 5 Survey Design and Data Collection 5 Questionnaire and Outcome Measures 6 Data analysis 7 Results 8 Discussion 10 Conclusions and Recommendations 14 References 15 Tables 20 Table 1. Associations between Comprehensive HIV Knowledge and Selected Demographic Variables 20 Table 2. Multivariable Analyses of Predictors of Comprehensive HIV Knowledge among UN Peacekeepers in Liberia, I could not have done it without you all—we’re 2005 21 Table 3. Multivariate Analyses of Effect of Pre- and Post-Deployment Training and other variables on Comprehensive HIV Knowledge 22 Table 4. Multivariate Analyses of Effect of Pre and Post-Deployment Training on Individual Components of HIV Knowledge 23 Appendix: IRB Approval and Study Questionnaire 24 Introduction and Background Armed conflict, natural disasters, and other emergencies resulting in mass displacement of people are referred to broadly as complex humanitarian emergencies (almost) done! To everyone elseCHEs). CHEs result in acute civic destabilization due to compromised national and local infrastructure, I’ll stop talking about this separation of families, interruption of health services, increased crowding conditions, decreased access to food and other essentials, and decline in opportunities for employment and income [1, 2]. These factors dramatically increase susceptibility to infectious disease and can result in very high mortality rates [3]. While the most critical need occurs in the period immediately following displacement, an additional host of health concerns become priorities in the post-emergency phase as the conflict progresses, conditions stabilize, and international aid and security are withdrawn. Displaced populations may experience a substantial increase in prevalence of health risk factors during the post-conflict stage. Awareness is growing that an increase in HIV transmission is of special importance in post-conflict settings. Although the literature suggests that the extreme level of disruption seen in the emergency phase may actually decrease opportunities for transmission, the risk of transmission may increase steeply during the post-emergency phase in populations affected by conflict and displacement [4-7]. These include interruption of testing and treatment services, the disruption of traditional family units, a rise in risk-taking behavior, food insecurity, and increased vulnerability of women and children leading to proliferation of contractual sex and sexual violence [1, 6-8]. These problems are exacerbated in areas with pre- existing high HIV prevalence, such as the Democratic Republic of the Congo [3, 8]. Conversely, transmission can also increase in post-conflict areas of low prevalence but with close contact with high-prevalence areas, as seen, for example, in Mozambique [6, 9, 10]. The risk of HIV transmission is an important issue because of its long-term effects on already destabilized populations. A higher prevalence of HIV among people of working age can undermine post- emergency efforts to rebuild infrastructure and return calls/emails to self-governance [11]. Special populations of concern regarding HIV transmission in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Nonpost-printed sources cited 53 Introduction Condoms conflict settings are one deployed members of the most important public health tools in sexual healthmilitary including UN peacekeepers. With high levels of mobility and generally young average age, playing roles in human immunodeficiency virus (HIV) prevention, prevention of these groups are at unique risk for acquiring and transmitting sexually transmitted infections (STIs) and HIV [8]. During deployments, military personnel are separated from their families and cultural social structures, are often under high amounts of stress, have frequent contact with local populations, and may be immersed in a culture that encourages risk-taking, all of which can lead to increases in risk behavior [1, 11]. These concerns are particularly relevant in light of reports of increases in contractual sex in communities that host UN peacekeepers and allegations of sexual violence perpetrated by peacekeepers [1, 6, 12]. When compared to civilian populations, military personnel in peacetime are up to five times more likely to have STIs and twice as likely to be infected with HIV, with similar data limited to African military contingents indicating an up to six-fold increase for HIV [13, 14]. This pattern clearly indicates that military groups should be considered as a high priority population for HIV interventions. Furthermore, interventions and education efforts focusing on soldiers may have especially high-impact due to the youth and mobility of the contingents and the military emphasis on discipline and hierarchy [8]. UN peacekeepers represent a particularly promising target for intervention and education. Peacekeepers, organized by the UN Department of Peacekeeping Operations (DPKO), are mostly national military and family planningpolice personnel seconded to the UN in organized units [15]. There As one of the most mobile populations in the world, peacekeepers have been identified as a unique potential vector for HIV transmission both in the country they are deployed and in their country of origin [11, 16]. This concern has been substantial investment highlighted as a potential security issue in recent years as peacekeepers have been reported to have HIV prevalence estimates double that of civilian populations[10, 17]. Studies have also indicated that the rate of infection correlates directly with duration of deployment. The on-mission incidence of HIV has been reported to increase by up to 5% per year of deployment [10]. Increases in HIV prevalence within a country under the auspices of the UN peacekeeping force can further weaken the disaster-affected region by exacerbating social and political instability and by impairing the country’s long-term reconstruction efforts. What is more, if peacekeepers are perceived to be spreading HIV in the region they are deployed, it could threaten local governmentstrust in the mission and reduce willingness of countries to host peacekeepers from high-prevalence countries [18, international 19]. Similarly, high HIV rates among military peacekeepers can have negative consequences in the soldiers’ countries of origin by undermining the military strength of the country and their ability to provide national security and maintain domestic stability [11]. This is confirmed in high reported rates of morbidity attributed to HIV among African militaries, some of which report that AIDS is implicated in more military deaths than combat [20, 21]. Furthermore, high HIV rates among military personnel have the potential to affect a large proportion of the country’s population in nations with mandated military service or high overall military involvement [11]. Overall, there is a concern that increasing HIV rates would divert large amounts of resources to the health agencies sector and non- governmental organizations lead to general state destabilization [17]. Due to these concerns, the UN Security Council passed Resolution 1308 in 2000, calling for an HIV training program for UN peacekeepers, and recommending countries that contribute contingents of peacekeepers (NGOsMember States) to increase supply develop their own HIV training programs and uptake voluntary counseling and testing services [22]. In response, DPKO developed standardized HIV training modules to be conducted in-country for all deployed UN peacekeepers. Voluntary testing and counseling (VCT) is also made available and is encouraged [23]. To date there has been no formal evaluation of condoms (Xxxxxx et al.the impact of the intervention or of the basic HIV knowledge among active peacekeepers following the training [24]. Furthermore, 2016; Xxxxxxx et al.although DPKO dissuades HIV-positive soldiers from deploying, 2008; Xxxxxxx et al.in order to conform to statues of nondiscrimination no mandatory testing is conducted at any time, 2016; Xxxxx et al.and Member States have varying policies on testing and deployment of HIV-positive individuals [23, 2015)24]. Increasing access This leads to condoms a lack of consistency on HIV policy among different peacekeeper contingents and presents difficulties for the development of a standardized education about STI program. With 15,880 peacekeepers on active duty in 2005, Liberia presented an ideal opportunity to assess HIV risk among peacekeepers and HIV prevention has to evaluate DPKO’s training program. Liberia is still in a state of post-conflict transition after more than a decade of civil war, which resulted in important gains large-scale infrastructural damage, massive population displacement, and widespread sexual violence [25]. Despite low estimates of HIV prevalence for the region (approximately 2%), Liberia has consistently had some of the worst development indicators in condom usethe world; it is currently ranked 162 out of 169 on the Human Development Index [26, especially 27]. Most recent data show an average of less than four years of school among adults, undernourishment in the population at almost 40%, and high levels of sexual risk-taking among youth [25, 26]. This combination of a high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al.undereducated population, 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Unionrelatively low HIV prevalence, and the US Environmental Protection Agency country’s continuing struggle for stability indicate that Liberia is at very high risk for an explosive increase in HIV incidence. With continuing presence of UN peacekeepers and the ongoing debate about associated HIV risk, Liberia is a key setting to evaluate DPKO’s educational programs and the HIV-related knowledge of the peacekeepers themselves. In order to accomplish this goal, DPKO, the Joint United Nations Program on HIV/AIDS (EPAUNAIDS) classify NDEA , and NDMA as probable or presumed human carcinogens the Centers for Disease Control and Prevention (Xxxxx, 2011)CDC) conducted an HIV knowledge attitude and practice survey in May-June 2005 in a representative sample of English speaking peacekeepers deployed in Liberia. The US Department purpose of Health the survey was to assess the levels of HIV awareness and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco productssexual practices among peacekeepers during deployment, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1to evaluate the HIV/AIDS program. The migration current report will focus on measures of nitrosamines from condoms to mucous membranes like HIV knowledge among the vagina peacekeepers and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).the factors influencing their understanding of HIV transmission and prevention. Methods

Conclusions. The associations between food insecurity and diabetes as well as the high prevalence of both conditions give evidence that food insecurity should be addressed in clinical settings. This study finds no evidence indicating an association between nitrosamine exposure from condoms and incidence makes the case that electronic medical records should include measures of cervical and colorectal cancerfood insecurity for appropriate referral. Condoms provide substantial and measurable public health benefitsMore research, and providers and healthcare organizations should especially longitudinal, is necessary to continue to recommend examining this association. Key words‌ Food security, nutrition, type 2 diabetes, hospital, electronic medical records Hunger is Health: The Association Between Food Insecurity and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of Diabetes in the United States Primary Care Center (PCC) at Xxxxx Hospital in Atlanta, GA By Xxxxxx XxXxxxxx Bachelor of ArtsBella A. Girovich B.A., Vassar CollegeAmerican University, 2013 2014 Emory University 2017 Thesis Committee ChairsChair: Xxxxx XxxxxXxx Xxxx-Xxxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements I would like not have been able to express sincere appreciation complete this thesis without the guidance of Xx. Xxx Xxxx- Girard. Thank you, Xxx, for helping me create and execute a project that I was truly passionate about, and supporting me through the (many) rounds of drafts! A huge thank you also goes to Xxx Xxxxx of Atlanta Community Food Bank for standing by me through every iteration of this project, from when it was just an idea in my committee chairs Xxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing head all the way to take on another thesis advisee despite their very busy schedulesthe finish line. Thank you so much for your to Xx. Xxxx Xxxxxx-Jones, without whom I would not have had the clinical nor hospital support and advice during to complete this process, as well as your good humor and very interesting conversationssurvey. I would like to thank Xxx X’Xxxxxx at the Emory Center am incredibly grateful for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my friends and familypeers, especially those in the nutrition department at Xxxxxxx, who encouraged me to keep moving forward even in the face of setbacks. Most of all, thank you to my parents, Xxxxx and Howie, for being my rocks throughout the entire journey that was graduate school. To my Xxxxxxx friendssay, “I could would not have done it be here without you all—we’re you” is a gross understatement. Chapter One: Introduction 1 Chapter Two: Review of the Literature 3 Chapter Three: Methodology 18 Chapter Four: Results 24 Chapter Five: Discussion 31 References 40 Appendices 43 List of Tables and Figures Table No. Description Page Table 1 Incidence and Prevalence of Type 2 Diabetes Across Various Racial/Ethnic Groups 6 Table 2 Descriptive Characteristics Overall and by Diabetes Diagnosis (almostPrediabetes + Diabetes) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear27 Box No. Contents INTRODUCTION Description Page Box 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 USDA Definition of Food Security 10 Box 2 Pillars of Food Security 11 Box 3 USDA Food Security Module 2-Item Screener 11 Figure No. Description Page Figure 1 34 Odds of Diabetes with Food Security for 323 Patients Attending the Primary Care Unit at Xxxxx Hospital from January-March 2017. Odds ratios and confidence intervals are estimated using logistic regression analysis. 28 Figure 2 35 2a Geographic Distribution to USDA 2-Item Screener First Question 29 Figure 3 36 2b Geographic Distribution to USDA 2-Item Screener Second Question 30 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 2c Geographic Distribution of Diabetes Status by Zip Code 31 Chapter One: Introduction Condoms are one As of 2014, type two diabetes touched the most important lives of 29.1% of Americans, giving it the status of a public health tools in sexual healthepidemic. While the United States spends millions of dollars on type two diabetes prevention every year, playing roles in human immunodeficiency virus (HIV) prevention, prevention the number of sexually transmitted infections (STIs), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs cases continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies grow. In that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).same year,

Conclusions. This study finds no evidence indicating project-based thesis presents an association between nitrosamine exposure from condoms and incidence innovative technique of cervical and colorectal cancer. Condoms provide substantial and measurable technical documentation developed in service of a complex global public health benefitssurveillance network that may offer a more comprehensive, versatile, and providers intelligible illustration technique to capture the flow of surveillance data, potentially disrupting conventional techniques within the industry. The data flow diagram was intentionally designed and healthcare organizations should continue honed to recommend communicate the appropriate ratio of operational/functional workflow specificity such that the document could inform the broadest audience of surveillance stakeholders, at the appropriate level magnification. If refined and promote them without hesitationmore broadly adopted, this data flow development methodology and the resulting artifacts could change how public health surveillance networks are designed, communicated, and comprehended. Lack Innovation and Application of ecological association between state-level cervical Data Flow Diagram to Inform Stakeholders, Validate Process, Align Operations, and colorectal cancer incidence Inform Systems Architecture for the Child Health and nitrosamine exposure from condom use for a cross-sectional study of the United States Mortality Prevention Surveillance (CHAMPS) Network By J. Xxxxxxx Xxxxxx XxXxxxxx Bachelor of Arts, Vassar College, 2013 Science University of Alabama 1997 Thesis Committee ChairsChair: J. Xxxx Xxxxx Xxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements Applied Public Health Informatics 2020 “A man who carries a cat by the tail learns something he can learn in no other way” - Xxxx Xxxxx My journey in public informatics started with a toe in the water as a non-degree seeking enrollee in an introductory class about applied public informatics. There an enthusiastic evangelist of systems thinking had my attention and later my commitment to enroll and go for it. I did not know what the next five years would have in store for me… I did not know that going for it would mean that two and half years of classes would need three and half years so that I could maintain my full-time job and try to manage being a husband and father. I did not know that I would like switch careers into global heath before I finished my degree and need put things on hold to express sincere appreciation help craft and implement an international multi-site surveillance network. There so many people from so many places that I am grateful to have met, learned from, and been inspired by during my committee chairs Xxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support and advice during this process, as well as your good humor and very interesting conversationspublic health quest. I would like to thank Xxx X’Xxxxxx the faculty and staff at the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their helpSchool of Public Health, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding my classmates (free) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIsacross few cohorts), and family planningcountless numbers people I have worked with through the CHAMPS program, a project like no other. There has been substantial investment by local governmentsI especially want to thank my committee members, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxx Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supplyXxx Xxxxxx, and policies that criminalize sex work (Xxxxx Xxxxxxxx et al.for their support, 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, genderguidance, and sex act: 24.7% encouragement. Your influence in my achievement of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines this milestone are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011)so much more than this paper. The World Health Organization (WHO), the European Union, most important acknowledgement of all goes to my wife and the US Environmental Protection Agency (EPA) classify NDEA sons who supported and NDMA as probable or presumed human carcinogens (Xxxxx, 2011)encouraged me to persevere. The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014)I think we did it. Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections I promise I will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is be a possible risk (Eisenbrand, 2005).lot more fun going forward… Chapter 1 Introduction 1

Conclusions. This study finds no evidence indicating an association between nitrosamine exposure from condoms and incidence of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefits, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States By Xxxxxx XxXxxxxx Bachelor of Arts, Vassar College, 2013 Thesis Committee Chairs: Xxxxx XxxxxGuest, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements I would like to express sincere appreciation to my committee chairs Xxxxx Xxxxxxx and Xxxxx Xxxxx Guest for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support and advice during this process, as well as your good humor and very interesting conversations. I would like to thank Xxx X’Xxxxxx at the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx Pienaar et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx Subramanian et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; XxxxJung, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; XxxxJung, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx Reece et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx Dong et al., 2015; Xxxxxxxx Altkofer et al., 2005; Xxxxxxxx Fritschi et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).

Conclusions. This study finds no evidence indicating The primary analysis did not support the hypothesis that NAFLD has an association with lower BMD. The secondary analysis suggested the possible relationship between nitrosamine exposure NAFLD and lower BMD among people with low to normal BMI. Mineral Density -- Results from condoms the Third National Health and incidence of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefits, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States Nutrition Examination Survey (NHANES III) By Xxxxxx XxXxxxxx Xxxxxxxxx Xxxxxxx Bachelor of ArtsMedicine, Vassar Collegethe University of Tokyo, 2013 2007 Doctor of Philosophy (Medicine), the University of Tokyo, 2014 Thesis Committee ChairsChair: Xxxxx XxxxxXxxxxxx XxXxxxxxx, PhDMD, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements I would like to express sincere appreciation to my committee chairs Xxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support and advice during this process, as well as your good humor and very interesting conversations. I would first like to thank Xxx X’Xxxxxx my thesis adviser Xx. Xxxxxxx XxXxxxxxx of Xxxxxxx School of Public Health at Emory University. He gave me important advices, and steered me in the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next dayright direction. I would also like to thank Xx. Xxxxxx Xxxxx Xxxxxxx of Centers for her expertise Disease Control and infectious enthusiasm for mapping and GIS, Prevention as well as her encyclopedic knowledge in finding (free) datathe second reader of this thesis. I appreciate his valuable comments on this thesis. Finally, all I must express my love and gratitude to my friends and family. To My wife, Xxxx Xxxxxxx, provided me with unfailing support and continuous encouragement throughout my Xxxxxxx friendsstudy period. I also would like to thank Xxxxxxxx Xxxxxxx, and Xxxxxx Xxxxxxx, who supported me to study in the United States. I really appreciate my father, Xxxxx Xxxxxxx, who endured through difficulties and raised me. This accomplishment would not have been possible without them. Thank you. Background/Literature Review 1 Methods 7 Results 17 Discussion 22 Future Directions 27 References 28 Tables 37 Figures and Figure Legends 45 Appendices 50 Supporting Information 50 SAS Source Codes 56 Background/Literature Review In this study, I could not focused on two chronic health conditions, low bone mineral density and nonalcoholic fatty liver (NAFLD). These days, chronic health conditions have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails been attracting more attentions in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles as the population lives longer and ages. Historically communicable diseases or infectious diseases were the main concerns, contributing to the mortality and morbidity. After the end of 19th century, developing the knowledge and treatments for infectious diseases has contributed to the steep declines in human immunodeficiency virus mortality from infectious diseases (HIV) prevention1). As a result people live longer but people became suffering from different diseases, prevention of sexually transmitted infections (STIs)such as cancers, heart diseases, diabetes, and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations dementia (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 20152). Increasing access Low bone mineral density and NAFLD are not directly related to condoms a life-threatening conditions, and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who they have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013)not attracted so much attention. However, condom usage among CSWs continues to face barriers including client preference for unprotected sexlow bone mineral density can increase the rate of bone fracture, inconsistent condom supplywhich decrease the patients’ quality of life. The number of people with NAFLD is increasing as obesity is becoming more prevalent. Therefore, these two factors can have a great impact on public health, and policies that criminalize sex work considering the association can give us a better strategy for prevention and therapy, and must be beneficial for the future researches. Bone Mineral Density Bone mineral density (Xxxxxxxx et al., 2016; Xxxx, 2013BMD) is widely used to diagnose osteoporosis (3). Among MSM populationsOsteoporosis is a disease “characterized by low bone mass, condom use is mediated deterioration of bone tissue and disruption of bone architecture, compromised bone strength and an increase in the risk of fracture.” (3) Xxxxxx reported 10.2 million Americans aged 50 years and older are affected by perceptions of risk and condom self-efficacy osteoporosis in 2013 (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 20134). National rates Maintaining BMD level is beneficial to protect against incidents of condom use bone fractures. Prospective cohort studies have demonstrated that people with low bone mineral density of femur (5, 6), lumber spine (5, 7), radius (6, 8) or forearm (9) have higher risk of bone fracture. Meta-analysis reported -1 S.D. BMD people have 1.5 to 2.6 times as high risk of bone fracture (10). In the industrialized countries, the number of people with osteoporosis or low bone mineral density is increasing, as population is aging. “It is anticipated that the number of fractures will grow proportionally.” (3) “Annually, two million fractures are attributed to osteoporosis, causing more than 432,000 hospital admissions, almost 2.5 million medical office visits and about 180,000 nursing home admissions in the US vary by raceU.S.” (3) Therefore, age, gender, keeping bone mineral density is also beneficial from the view of public health and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et alhealthcare economy., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).

Conclusions. This study finds no evidence indicating an association between nitrosamine exposure from condoms In a population with prior positive TSTs, TST was more variable than QFT-GIT when pairs of each test were performed simultaneously. TSTs may trigger conversion of subsequent TST and incidence of cervical and colorectal cancerQFT-GIT. Condoms provide substantial and measurable public health benefitsThe Tuberculin Skin Test: Within-Subject Variability, Boosting, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between stateComparison with the QuantiFERON-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a crossTB Gold In-sectional study of the United States Tube Test By Xxxxxx XxXxxxxx Bachelor Xxxxxx-Xxxxxx DMD Medical University of Arts, Vassar College, 2013 Sofia 1982 Thesis Committee ChairsChair: Xxxxx XxxxxXxxxxx Xxxxxxx, PhDPhD Thesis Field Advisors: Xxxxxx Xxxxxxx, MD and Xxxxxxx X. Xxxxxxxxx, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements the Executive Master of Public Health Program, 2017 Acknowledgments I would like to express sincere appreciation my sincerest gratitude to my committee chairs Xxxxx chair, Xx. Xxxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedulesmy field advisors, Xx. Thank you so much for your support Xxxxxx Xxxxxxx and advice during this process, as well as your good humor and very interesting conversationsXx. Xxxxxxx Xxxxxxxxx. I would also like to thank Xxx X’Xxxxxx at express my gratitude to the Emory Center Centers for Digital Scholarship Disease Control and Xxxxxxx Xxxxxxxx at Prevention, Division of Tuberculosis Elimination’s Clinical Research Branch, with whom I had the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday honor and agreeing to meet frantic MPH students the very next dayprivilege of working and learning. I would also like to thank Xxxxx the students and faculty at Emory University and the Xxxxxxx School of Public Health – EMPH program for her expertise helping me and infectious enthusiasm providing me valuable knowledge and skills. I would finally like to thank my family for mapping their constant understanding, patience, and GISsupport. The findings and conclusions in this document are solely those of the author and do not necessarily represent the official views of the Centers for Disease Control and Prevention, as well as her encyclopedic knowledge in finding (free) dataThe U. S. Department of Defense, or the U. S. Air Force. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, Table of Contents CHAPTER I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents : INTRODUCTION 1 Nitrosamines in food INFECTION AND DISEASE DUE TO MYCOBACTERIUM TUBERCULOSIS 1 Historical Perspective 1 Epidemiology 2 Transmission 4 MYCOBACTERIUM TUBERCULOSIS INFECTION 5 Treatment and water 5 Occupational exposure Control 6 Targeted Testing 7 IMMUNOLOGIC TESTS FOR MYCOBACTERIUM TUBERCULOSIS INFECTION 9 Tuberculin Skin Test (TST) 9 Interferon-Gamma Release Assay (IGRA) 11 PROBLEMS ADDRESSED BY THIS RESEARCH 14 Within-Subject TST Variability 14 TST – QFT Agreement 15 Boosting of Immunologic Responses as Measured by TST 15 Boosting of Immunologic Responses as Measured by QFT-GIT 17 ANALYSIS GOALS CHAPTER II: LITERATURE REVIEW 19 MEASURES OF VARIABILITY AND BOOSTING REPORTED IN PRIOR STUDIES 19 WITHIN-SUBJECT TST VARIABILITY (WITHIN-SUBJECT COMPARISON OF TST RESULTS) 20 WITHIN-SUBJECT COMPARISON OF TST AND QFT-GIT RESULTS 22 TST BOOSTING CHAPTER III: METHODS 28 STUDY POPULATION 28 ANALYSIS AND STUDY DESIGN 29 TEST METHODS 30 STATISTICAL ANALYSIS METHODS 31 CHAPTER IV: RESULTS 32 SUBJECT CHARACTERISTICS TEST RESULTS 33 OBJECTIVE I: ASSESSMENT OF WITHIN-SUBJECT XXX XXXXXXXXXXX 00 XXXXXXXXX XX: ASSESSMENT OF TST - QFT-GIT AGREEMENT 34 OBJECTIVE III: ASSESSMENT OF TST BOOSTING OF A SUBSEQUENT TST OBJECTIVE IV: ASSESSMENT OF TST BOOSTING OF A SUBSEQUENT QFT-GIT 35 CHAPTER V: DISCUSSION 36 INTRODUCTION 36 SUMMARY AND FINDINGS 37 LIMITATIONS 39 IMPLICATIONS 40 RECOMMENDATIONS FOR FUTURE STUDIES 42 CONCLUSIONS 42 FIGURES 43 TABLES 47 REFERENCES 52 Chapter I: Introduction Infection and Disease Due to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 NonMycobacterium Tuberculosis Historical Perspective Tuberculosis (TB) is an infectious disease that has ravaged humanity for ages and continues to kill millions of people each year. TB usually affects the lungs and is transmitted from human-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual healthto-human through inhalation. The bacterium that is primarily responsible for causing TB, playing roles in human immunodeficiency virus Mycobacterium tuberculosis (HIV) prevention, prevention of sexually transmitted infections (STIsMTB), was first identified and family planningdescribed in 1882 by Xxxxxx Xxxx. There has been substantial investment Infections with MTB (MTBI) can be classified as either an active disease (referred to as TB) with clinical symptoms and pathological signs, or as an asymptomatic non-contagious state, often called “latent” TB infection (LTBI). People with TB may present with constitutional symptoms, such as weight loss, fever, chills, night sweats, and weakness, but may also present with symptoms associated with disease in specific organs. The lung is most often affected as evidence by local governmentssymptoms of cough, international health agencies sputum production, hemoptysis, and non- governmental organizations chest pain, that are typically accompanied by an abnormal chest x-ray. Pulmonary TB accounts for approximately 80% of newly diagnosed TB in the U. S. while 20% to 30% involves extra-pulmonary sites. Traditional methods used to diagnose TB rely primarily on sputum smear microscopy, bacteriological culture, and clinical examination, although newer and rapid molecular tests are being used with increasing frequency. A combination of sputum culture and clinical exam are considered the gold standard for definitive TB diagnosis. TB is curable with a standard six month course of four antimicrobial agents (NGOs) to increase supply isoniazid, rifampicin, pyrazinamide, and uptake ethambutol), but, if left untreated, 70% of condoms cases worldwide will not survive 10 years (Xxxxxx et al.World Health Organization, 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).

Conclusions. This Our study finds no evidence indicating points to an association between nitrosamine exposure from condoms maternal education and incidence breastfeeding duration after controlling for some important socio-demographic factors. Future studies should further explore how education, taken as a proxy for knowledge processing, is associated with breastfeeding, in a prospective analysis. Educational Level and Self- Reported Breastfeeding Duration among Primiparas in the National Survey of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefitsFamily Growth (NSFG) 2011 - 2013 BY Xxxxxx Xx M.P.H., and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States By Xxxxxx XxXxxxxx Bachelor of ArtsEmory University, Vassar College2016 D.V.M Universidad Peruana Xxxxxxxx Xxxxxxx, 2013 Thesis Committee ChairsChair: Xxxxx XxxxxXxxxxx Xxxxxxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS Ph.D A thesis submitted Thesis Submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for of the degree of Master of in Public Health in Global Epidemiology the Executive MPH program 2016 Acknowledgements ACKNOWLEDGEMENTS I would like want to express sincere appreciation thank Xx. Xxxxxx Xxxxxxxxx and Dr. Xxxxxxx Xxxxxx for their guidance and support during the Master in Public Health thesis development process. I was fortunate to be able to count on their vast expertise and knowledge in my committee chairs Xxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy scheduleschosen topic. Thank you so much for your support and advice during this processIn addition, as well as your good humor and very interesting conversations. I would like to thank Xxx X’Xxxxxx the Xxxxxxx School of Public Health at Emory University for providing me an outstanding opportunity and giving me the tools to develop a future career in the Public Health field. I’m very proud and honored to be considered a student at this prestigious school. Lastly, I certainly would not have been able to complete my graduate studies without the support of my family and friends. Special thanks to my husband, Xxxx Xxxxxx, who supported me not only financially but emotionally, generously providing me the opportunity to be able to develop my professional goals and aspirations. Table of contents Publication Cover Sheet… 1 Abstract for Publication 2 Expanded Introduction. 3 Introduction for Publication 8 Methods 13 Results… 16 Expanded Discussion. 18 Discussion 22 References 26 Figure 1… 30 Table 1 31 Table 1a 32 Table 2 33 Educational Level and Self- Reported Breastfeeding Duration among Primiparas in the National Survey of Family Growth (NSFG) 2011 - 2013 Xxxxxx Xx, MPH(c) Xxxxxx Xxxxxxxxx, Ph.D. Department of Epidemiology, Emory University Xxxxxxx School of Public Health, Atlanta, GA, USA Xxxxxxx Xxxxxx, Ph.D. Department of Epidemiology, Emory University Xxxxxxx School of Public Health, Atlanta, GA, USA Corresponding author: TBD Short title: Educational Level and Self- Reported Breastfeeding Duration The authors declare no competing financial interests. ABSTRACT BACKGROUND: Breastfeeding is vital for providing young infants with the nutrients they need for healthy growth and development; however, there are several socio-economic and health determinants that predict whether or not mothers are able to initiate and maintain it for the recommended duration. With changing demographics among first time mothers, we examined the current association between maternal education and self-reported breastfeeding duration in the U.S. METHODS: Utilizing national and population-based cross-sectional data from the 2011-2013 National Survey of Family Growth (NSFG), we examined the association between maternal education and self-reported breastfeeding duration among primiparas aged 15-44 years. Breastfeeding duration was examined as an ordinal variable. We estimated adjusted odds ratios and 95% confidence intervals using a multivariable ordinal logistic regression, while controlling for several potential confounders. RESULTS: Of the 2069 participants who were eligible for our analysis, 66.2% of first time mothers breastfed. 27.1% of them breastfed for less than a week to 8 weeks, 46.01% breastfed for 9 to 52 weeks and 15.12% breastfed for more than one-year-old and were still breastfeeding at the Emory Center time of interview. Maternal education was an independent risk factor for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge duration of breastfeeding among primiparas in finding (free) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIsour study sample), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference after controlling for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, genderrace and ethnicity, marital status, religious beliefs, employment status and sex act: 24.7% of men federal poverty level. Women with a college education and 21.8% of above were less likely to not breastfeed and to have shorter breastfeeding duration times. (aOR=0.59 CI= 0.47, 0.74) compared to women report condom use at last vaginal intercourse while 26.5% of insertive male partnerswith lower education. In addition, 44.1% of receptive male partners women with less than high school education, even though it was not statistically significant, also were less likely to not breastfeed and 10.8% of receptive female partners report condom use at last anal intercourse to have shorter breastfeeding duration times (Xxxxx et al.aOR=0.75 CI= 0.40, 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 20051.35).

Conclusions. The associations between food insecurity and diabetes as well as the high prevalence of both conditions give evidence that food insecurity should be addressed in clinical settings. This study finds no evidence indicating an association between nitrosamine exposure from condoms and incidence makes the case that electronic medical records should include measures of cervical and colorectal cancerfood insecurity for appropriate referral. Condoms provide substantial and measurable public health benefitsMore research, and providers and healthcare organizations should especially longitudinal, is necessary to continue to recommend examining this association. Key words‌ Food security, nutrition, type 2 diabetes, hospital, electronic medical records Hunger is Health: The Association Between Food Insecurity and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of Diabetes in the United States Primary Care Center (PCC) at Xxxxx Hospital in Atlanta, GA By Xxxxxx XxXxxxxx Bachelor of ArtsXxxxx X. Xxxxxxxx X.X., Vassar CollegeAmerican University, 2013 2014 Emory University 2017 Thesis Committee ChairsChair: Xxxxx XxxxxXxx Xxxx-Xxxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements I would like not have been able to express sincere appreciation complete this thesis without the guidance of Xx. Xxx Xxxx- Girard. Thank you, Xxx, for helping me create and execute a project that I was truly passionate about, and supporting me through the (many) rounds of drafts! A huge thank you also goes to Xxx Xxxxx of Atlanta Community Food Bank for standing by me through every iteration of this project, from when it was just an idea in my committee chairs Xxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing head all the way to take on another thesis advisee despite their very busy schedulesthe finish line. Thank you so much for your to Xx. Xxxx Xxxxxx-Jones, without whom I would not have had the clinical nor hospital support and advice during to complete this process, as well as your good humor and very interesting conversationssurvey. I would like to thank Xxx X’Xxxxxx at the Emory Center am incredibly grateful for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my friends and familypeers, especially those in the nutrition department at Xxxxxxx, who encouraged me to keep moving forward even in the face of setbacks. Most of all, thank you to my parents, Xxxxx and Xxxxx, for being my rocks throughout the entire journey that was graduate school. To my Xxxxxxx friendssay, “I could would not have done it be here without you all—we’re you” is a gross understatement. Chapter One: Introduction 1 Chapter Two: Review of the Literature 3 Chapter Three: Methodology 18 Chapter Four: Results 24 Chapter Five: Discussion 31 References 40 Appendices 43 List of Tables and Figures Table No. Description Page Table 1 Incidence and Prevalence of Type 2 Diabetes Across Various Racial/Ethnic Groups 6 Table 2 Descriptive Characteristics Overall and by Diabetes Diagnosis (almostPrediabetes + Diabetes) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear27 Box No. Contents INTRODUCTION Description Page Box 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 USDA Definition of Food Security 10 Box 2 Pillars of Food Security 11 Box 3 USDA Food Security Module 2-Item Screener 11 Figure No. Description Page Figure 1 34 Odds of Diabetes with Food Security for 323 Patients Attending the Primary Care Unit at Xxxxx Hospital from January-March 2017. Odds ratios and confidence intervals are estimated using logistic regression analysis. 28 Figure 2 35 2a Geographic Distribution to USDA 2-Item Screener First Question 29 Figure 3 36 2b Geographic Distribution to USDA 2-Item Screener Second Question 30 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 2c Geographic Distribution of Diabetes Status by Zip Code 31 Chapter One: Introduction Condoms are one As of 2014, type two diabetes touched the most important lives of 29.1% of Americans, giving it the status of a public health tools in sexual healthepidemic. While the United States spends millions of dollars on type two diabetes prevention every year, playing roles in human immunodeficiency virus (HIV) prevention, prevention the number of sexually transmitted infections (STIs), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs cases continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies grow. In that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).same year,

Conclusions. This study finds no evidence indicating project-based thesis presents an association between nitrosamine exposure from condoms and incidence innovative technique of cervical and colorectal cancer. Condoms provide substantial and measurable technical documentation developed in service of a complex global public health benefitssurveillance network that may offer a more comprehensive, versatile, and providers intelligible illustration technique to capture the flow of surveillance data, potentially disrupting conventional techniques within the industry. The data flow diagram was intentionally designed and healthcare organizations should continue honed to recommend communicate the appropriate ratio of operational/functional workflow specificity such that the document could inform the broadest audience of surveillance stakeholders, at the appropriate level magnification. If refined and promote them without hesitationmore broadly adopted, this data flow development methodology and the resulting artifacts could change how public health surveillance networks are designed, communicated, and comprehended. Lack Innovation and Application of ecological association between state-level cervical Data Flow Diagram to Inform Stakeholders, Validate Process, Align Operations, and colorectal cancer incidence Inform Systems Architecture for the Child Health and nitrosamine exposure from condom use for a cross-sectional study of the United States Mortality Prevention Surveillance (CHAMPS) Network By X. Xxxxxxx Xxxxxx XxXxxxxx Bachelor of Arts, Vassar College, 2013 Science University of Alabama 1997 Thesis Committee ChairsChair: X. Xxxx Xxxxx Xxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements Applied Public Health Informatics 2020 “A man who carries a cat by the tail learns something he can learn in no other way” - Xxxx Xxxxx My journey in public informatics started with a toe in the water as a non-degree seeking enrollee in an introductory class about applied public informatics. There an enthusiastic evangelist of systems thinking had my attention and later my commitment to enroll and go for it. I did not know what the next five years would have in store for me… I did not know that going for it would mean that two and half years of classes would need three and half years so that I could maintain my full-time job and try to manage being a husband and father. I did not know that I would like switch careers into global heath before I finished my degree and need put things on hold to express sincere appreciation help craft and implement an international multi-site surveillance network. There so many people from so many places that I am grateful to have met, learned from, and been inspired by during my committee chairs Xxxxx Xxxxxxx and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support and advice during this process, as well as your good humor and very interesting conversationspublic health quest. I would like to thank Xxx X’Xxxxxx the faculty and staff at the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their helpSchool of Public Health, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding my classmates (free) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIsacross few cohorts), and family planningcountless numbers people I have worked with through the CHAMPS program, a project like no other. There has been substantial investment by local governmentsI especially want to thank my committee members, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxx Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supplyXxx Xxxxxx, and policies that criminalize sex work (Xxxxx Xxxxxxxx et al.for their support, 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, genderguidance, and sex act: 24.7% encouragement. Your influence in my achievement of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines this milestone are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011)so much more than this paper. The World Health Organization (WHO), the European Union, most important acknowledgement of all goes to my wife and the US Environmental Protection Agency (EPA) classify NDEA sons who supported and NDMA as probable or presumed human carcinogens (Xxxxx, 2011)encouraged me to persevere. The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014)I think we did it. Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections I promise I will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is be a possible risk (Eisenbrand, 2005).lot more fun going forward… Chapter 1 Introduction 1

Conclusions. HDP was associated with higher rates of adverse maternal and neonatal outcomes in one hospital with possibly better reporting of maternal complications than other hospitals in Haiti. This study finds no evidence indicating an association between nitrosamine exposure from condoms finding is comparable to studies of HDP conducted in high- income countries. The Associations of Hypertensive Disorders in Pregnancy with Maternal and incidence of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefits, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States Neonatal Outcomes in Haiti By Xxxxxx XxXxxxxx Xxxxxxx Xxxxxxxx Bachelor of Arts, Vassar College, 2013 Science Clemson University 2011 Thesis Committee ChairsChair: Xxxxx XxxxxXxxxxxx Xxxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS Ph.D. A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 Acknowledgements I would like to express sincere appreciation to my committee chairs Xxxxx Xxxxxxx thank the Centers for Disease Control and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support Prevention and advice during the Emergency Response and Recovery Branch, who made this process, as well as your good humor project and very interesting conversationsexperience possible. I would like to extend a special thank Xxx X’Xxxxxx at you to Xx. Xxxxxx Xxxxxxx, who allowed me access to the Emory Center for Digital Scholarship ePOSS project and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next dayHaiti data. I would also like to thank Xxxxx Xxxxxxx for her expertise Xx. Xxxxxxxx Xxxxx, whose expertise, guidance, and infectious enthusiasm for mapping support allowed me to grow and GIS, as well as her encyclopedic knowledge in finding (free) datalearn throughout this process. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friendsAdditionally, I could not have done it without you all—we’re (almost) done! To everyone elsewould like to thank Xxxx Xxxxxxx, who was instrumental in helping with data cleaning and management. I sincerely thank Xx. Xxxxxxx Xxxxxx and Xx. Xxxxx Xxxxx for the time they put into helping me with this project. I greatly appreciate all their wisdom and feedback, which challenged me to expand my project and enhance my scientific writing. I would also like to acknowledge my family and friends who provided me with the much- needed support throughout the last two years. Glossary i Chapter I’ll stop talking about this and return calls/emails : Literature Review 1 Hypertensive Disorders in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSIONPregnancy: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure A Global Problem 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use HDP Research in the US vary Developed World 4 Health System in Haiti 6 Health Complications Faced by race, age, gender, and sex actHaitian Women 8 Hypertensive Disorders in Pregnancy Research in Haiti 9 Challenges in Health Statistics in Haiti 11 Conclusion 12 Chapter II: 24.7% Manuscript 13 Abstract 13 Introduction 14 Methods 16 Results 19 Discussion 22 Tables 28 Table 1: Prevalence of men and 21.8% hypertensive disorders in pregnancy in 4 hospitals by 6-month intervals 28 Table 2: Comparison of clinical presentation of women report condom use at last vaginal intercourse while 26.5% 4 hospitals in Haiti 29 Table 3: Clinical presentation of insertive male partnerswomen with and without stillbirth at HAS, 44.1% of receptive male partners by entire cohort and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).HDP mothers only 30

Conclusions. This study finds no evidence indicating an association between nitrosamine exposure from condoms Diabetes specialty care delivered via telemedicine to veterans in rural Alabama and incidence of cervical Georgia was safe and colorectal cancernon-inferior to in-person care. Condoms provide substantial and measurable public health benefitsTelemedicine is also associated with time-savings, cost-savings, high appointment adherence rates, and providers and healthcare organizations high patient satisfaction. Our findings suggest that the Veterans Health Administration should continue to recommend and promote them without hesitationimplement telemedicine on a broader scale. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States By Xxxxxx XxXxxxxx Bachelor of Arts, Vassar College, 2013 Thesis Committee Chairs: Xxxxx Xxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS Xxxxxxx Xx Xxxx Xxxx Adviser A thesis submitted to the Faculty of the Xxxxxxx School Emory College of Public Health Arts and Sciences of Emory University in partial fulfillment of the requirements for of the degree of Master Bachelor of Public Health in Global Epidemiology 2016 Acknowledgements Sciences with Honors Department of Biology 2017 I would like am sincerely thankful to express sincere appreciation Xx. Xxxx Xxxx for her invaluable mentorship throughout the past two years. I am also grateful to my committee chairs Xx. Xxxxxx Xxxxxx and Dr. Xxxxx Xxxxxxx Xxxxxx for their support with this project’s data collection and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedulesanalysis. Thank you so much for your support and advice during this processLastly, as well as your good humor and very interesting conversations. I would like to thank Xxx X’Xxxxxx at Xx. Xxxxx Xxxxxxxxxx and Xx. Xxxxxx Xxxxxxx for their mentorship and advice. This research was supported by the Emory Atlanta Clinical and Translational Science Institute and the National Center for Digital Scholarship Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454. Table of Contents Introduction 1 Background 1 Specific Aims… 3 Hypotheses 3 Methods 4 Atlanta Veterans Affairs Medical Center Endocrinology Telehealth Clinic Structure 4 Study Design 5 Diabetes Management, Clinical Outcomes, and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Glycemic Control 5 Veterans Health Science Center Library for their help, including answering emails at 10pm on a Sunday Administration Cost-Saving and agreeing Patient Time-Saving 6 Patient Adherence to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise Telehealth Appointments 7 Patient Satisfaction with Telemedicine 7 Statistical Analysis 8 Results 8 Demographics 8 Diabetes Outcomes and infectious enthusiasm for mapping Glycemic Control 9 Patient Time-Saving and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products Veterans Health Administration Cost-Saving 10 Telehealth Appointment Adherence 11 Patient Satisfaction with Telemedicine 11 Discussion 11 Limitations 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Strengths 14 Conclusion 15 Figures 16 Figure 1 34 16 Figure 2 35 17 Figure 3 36 18 Figure 4 37 19 Figure 5 38 20 Figure 6 39 21 Figure 7 40 22 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).23 References 24 Introduction

Conclusions. This study finds no evidence indicating an association BMI appeared to have a stronger influence on young adult SBP and pre-hypertension / hypertension than all measures of SES, but significant moderation and mediation was observed between nitrosamine exposure from condoms BMI and incidence various measures of cervical SES. Further research is needed into the role of BMI as a mediator or moderator on SES and colorectal cancer. Condoms provide substantial and measurable public health benefitsyoung adult blood pressure, and providers to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and healthcare organizations should continue Body Composition on Young Adult Blood Pressure: The Birth to recommend and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the United States Twenty Cohort By Xxxxxx XxXxxxxx Bachelor of Arts, Vassar College, 2013 Chloe W. Eng B.S. Northeastern University 2014 Thesis Committee ChairsChair: Xxxxx X. Xxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Global Epidemiology 2016 Acknowledgements I would like to express sincere extend my sincerest thanks and appreciation to my committee chairs to: Xxxxx Xxxxxxx and Xxxxx Xxxxx X. Xxxxx, for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support and advice during allowing me this processlearning opportunity, as well as your good humor his insight, support, and very interesting conversationsongoing patience whenever I veer off topic. I would like to thank Xxx X’Xxxxxx Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRU, and University of the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library Witwatersrand, for their helpefforts towards the continuation of Birth to Twenty, including answering emails at 10pm for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on a Sunday you for cell phone access and agreeing to meet frantic MPH students the very next daytransportation while abroad. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my My friends and familyfellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. To And finally, my Xxxxxxx friendsparents, I could not have done it without you all—we’re for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (almostNCD) done! To everyone elsehas begun to replace communicable, I’ll stop talking about or infectious, disease as the major contributor to mortality.1 One example of this and return calls/emails epidemiologic shift seen in South Africa, a timely manner now, I swearmiddle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The AIDs crisis.2 Nationally representative World Health Organization (WHO)) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the European Unionhighest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the US Environmental Protection Agency highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (EPASAGE) classify NDEA compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and NDMA as probable or presumed human carcinogens South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (Xxxxxthough significance in South Africa data alone was only significant in the 60 – 79 year age group, 2011with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). The US Department Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of Health hypertension, and Human Services released income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the 13th Report Birth to Twenty Cohort to investigate the effect of socioeconomic status on Carcinogens blood pressure in 2014young adults from South Africa, which included 15 listings an age group that remains underrepresented in the study of nitrosamines classified hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as “known or reasonably anticipated” carcinogens (NTPthe longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, 2014)the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. Nitrosamines are linked with This cohort is the development first to allow for tracking of multiple different types of cancer health throughout early life in many different animal modelsSouth Africa, and past findings have contributed to nation-wide policies, including colon tumors regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco productsthe young adult data collection wave, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et alto assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).

Conclusions. This study finds no evidence indicating an association The specificity of QFT-GIT was high and similar to TST at either cutoff. Test discordance observed in recruits with increased risk may be due to lower TST specificity, lower QFT-GIT sensitivity, or both. Negative QFT-GIT results for recruits born in countries with high–TB prevalence and whose TST is > 15mm suggest that QFT-GIT may be less sensitive than TST. Additional studies are needed to determine the risk of developing TB when TST and QFT-GIT results are discordant. Assessing specificity and discordance between nitrosamine exposure from condoms the tuberculin skin test and incidence a whole-blood interferon-γ release assay for the detection of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefits, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of the Mycobacterium tuberculosis infection among United States Navy recruits. By Xxxxxx XxXxxxxx Xxxxx Xxxxxxx Xxxxx Bachelor of ArtsScience in Biology Bachelor of Science in Anthropology University of Utah 2007 Thesis Faculty Advisor: Xxxx X. XxXxxxx, Vassar CollegeXx., 2013 Thesis Committee ChairsM.D. Field Advisor: Xxxxx Xxxxx, PhD, MPH Xxxxx Xxxxxx X. Xxxxxxx, PhD, MHS M.D. A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Global Epidemiology 2016 2011 Acknowledgements I would like to express sincere appreciation to my committee chairs Xxxxx thank Xx. Xxxxxxx and Xx. XxXxxxx for their efforts in advising and mentoring me through the processes of the thesis and my professional development while at Emory University and with the CDC; the staff at CDC, DTBE, especially Xxxxx Xxxxxxx, Xxxxxx Xxxxx, Kit Xxxxxxxxx, Xxxxxxx Xxxxxxxx and Xxxxx Xxxxxxx, for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support including me in the branch’s activities and advice during this process, as well as your good humor assisting in innumerable ways with my analysis and very interesting conversations. I would like to thank Xxx X’Xxxxxx manuscript; my professors at the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their helpSchool of Public Health, including answering emails at 10pm particularly Xx. Xxxxxxxxx, who provided council on a Sunday and agreeing to meet frantic MPH students the very next day. I would my statistical analyses; also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my friends and familycolleagues at in the Epidemiology and Behavioral Science and Health Education departments, who have helped make my time in Atlanta a rich experience; my parents, Xxxxxx and Xxxxxxx, for their unwavering love and support; and Xxxxxxx Xxxxx, who has endured the hardships of education with me and has given me such support and freedom, that I may never truly repay her gifts and sacrifices. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Table of Contents INTRODUCTION 1 Nitrosamines CHAPTER I: BACKGROUND 4 EPIDEMIOLOGY OF TUBERCULOSIS 4 PATHOGENESIS OF MYCOBACTERIUM TUBERCULOSIS INFECTION 6 DIAGNOSTICS FOR MYCOBACTERIUM TUBERCULOSIS INFECTION 11 THE TUBERCULIN SKIN TEST 14 INTERFERON-GAMMA RELEASE ASSAYS 19 WHOLE-BLOOD INTERFERON-GAMMA RELEASE ASSAYS 22 DISCORDANCE IN RESULTS FOR THE DETECTION OF M. TUBERCULOSIS INFECTION 29 LIMITATIONS TO INTERFERON-GAMMA RELEASE ASSAYS 36 TUBERCULOSIS AND THE UNITED STATES NAVY 40 LATENT TUBERCULOSIS INFECTION IN MILITARY RECRUITS 45 CHAPTER II: MANUSCRIPT 52 TITLE PAGE 52 INTRODUCTION 53 MATERIALS AND METHODS 58 RESULTS 64 DISCUSSION 70 LIMITATIONS AND STRENGTHS 83 CONCLUSION 87 REFERENCE LIST 89 TABLES 115 FIGURES 122 CHAPTER III: PUBLIC HEALTH IMPLICATIONS 124 SUMMARY 124 APPLICATIONS OF THE QUANTIFERON-TB GOLD IN-TUBE ASSAY 126 FUTURE DIRECTIONS 128 REFERENCES 131 APPENDICES 173 MILITARY HISTORY FORM FROM STUDY PROTOCOL 173 LINK TO XXXXXXX ET AL. – M. TUBERCULOSIS INFECTION IN NAVY RECRUITS, 2007 175 Tables and Figures TABLE 1. CHARACTERISTICS OF US NAVY RECRUITS 115 TABLE 2. OUTCOMES OF THE TUBERCULIN SKIN TEST VERSUS THE QUANTIFERON®-TB GOLD IN-TUBE ASSAY 116 TABLE 3. OUTCOMES OF THE QUANTIFERON®-TB GOLD ASSAY VERSUS THE QUANTIFERON®-TB GOLD IN-TUBE ASSAY 117 TABLE 4. UNIVARIATE ASSOCIATION OF SUBJECT CHARACTERISTICS WITH TUBERCULIN SKIN TEST OR QUANTIFERON®-TB GOLD IN-TUBE ASSAY RESULTS 118 TABLE 5. UNIVARIATE ASSOCIATION OF SUBJECT CHARACTERISTICS WITH DISCORDANT RESULTS BETWEEN THE QUANTIFERON®-TB GOLD IN-TUBE ASSAY AND THE TUBERCULIN SKIN TEST, USING A 10 MM CUTOFF 119 TABLE 6. UNIVARIATE ASSOCIATION OF SUBJECT CHARACTERISTICS WITH DISCORDANT RESULTS BETWEEN THE QUANTIFERON®-TB GOLD IN-TUBE ASSAY AND THE TUBERCULIN SKIN TEST, USING A 15 MM CUTOFF 120 TABLE 7. MULTIVARIATE ANALYSIS EXAMINING DISCORDANCE BETWEEN NEGATIVE QUANTIFERON®-TB GOLD IN-TUBE ASSAY RESULTS AND TUBERCULIN SKIN TEST RESULTS USING A 15 MM OR A 10 MM CUTOFF 121 FIGURE 1. DIAGRAM OF STUDY PARTICIPATION AND TESTING 122 FIGURE 2. COMPARISON OF TUBERCULIN SKIN TEST RESULTS TO INTERFERON-GAMMA RELEASE ASSAY INTERPRETATIONS, STRATIFIED BY RISK OF INFECTION 123 Introduction Tuberculosis (TB) is a leading cause of death and illness worldwide. The causative agent of TB is the Mycobacterium tuberculosis bacillus. Mycobacterium tuberculosis infection (MTBI) occurs in food humans, who act as its primary reservoir. Approximately 2 billion people worldwide have quiescent or latent M. tuberculosis infection (LTBI) and water 5 Occupational exposure are at risk of developing TB (1). Due to nitrosamines 9 Nitrosamines effective treatment and control measures, TB incidence and prevalence rates are declining in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one the United States (US) and most developed regions of the most important public health tools in sexual healthworld (2, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs), and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 20133). However, condom usage among CSWs continues elimination of TB remains elusive, even in high-resource countries because of continued transmission in groups at high risk of MTBI and progression to face barriers including client preference for unprotected sexTB, inconsistent condom supplydifficulties in detecting MTBI, and policies that criminalize sex work programmatic complacency (Xxxxxxxx et al., 2016; Xxxx, 20134). Among MSM populationsAround 4% of the US population is thought to have LTBI, condom use and is mediated by perceptions of risk a constant source for future TB and condom self-efficacy MTBI transmission (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 20135). National rates There is continued pressure to improve diagnostic and screening methods for detecting MTBI, including LTBI and infection manifesting as TB (6-8). Identifying and treating LTBI among those at high risk of condom use in the US vary by race, age, gender, developing TB is an important component for TB control and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the barriers to condom usage elimination in low-income countries is negative perception or rumors about condoms TB incidence regions, such as the US and Canada (Xxxxxxx et al.9, 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 201210). Perceptions by No method exists for accurately detecting LTBI. Historically, the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs only way to diagnose LTBI was the tuberculin skin test (Xxxxx et al.TST), 2014; Xxxxxxx et al., 2012which involved measuring immunologic delayed hypersensitivity to an intradermal injection of purified protein derivatives (PPD) made from M. tuberculosis (tuberculin PPD) (11). Negative beliefs about condoms include The TST has limitations in detecting LTBI in some settings. For example, where the belief prevalence of LTBI is low, the positive predictive value (PPV) of TST is hindered by cross reactions induced by sensitization to other mycobacteria (11). The development of interferon-gamma release assays (IGRA) offered an alternative to the TST and addressed some limitations in the TST (12, 13). MTBI typically induces an immune T-lymphocyte response which produces the cytokine interferon gamma (INF-γ) when the T-cells encounter mycobacterial antigens (13). Whole-blood IGRAs such as the 2nd generation, QuantiFERON®-TB Gold test (QFT-G) (Cellestis Limited, Xxxxxxxx, Xxxxxxxx, Australia) measure the amount of INF-γ released when blood is stimulated with specific Mycobacterium antigens (14). In 2007, the US Food and Drug Administration (FDA) approved the 3rd generation of IGRA for the detection of MTBI, the QuantiFERON®-TB Gold In-Tube test (QFT-GIT) (Cellestis Limited, Xxxxxxxx, Xxxxxxxx, Australia) (15). Like the TST, positive QFT-GIT results are highly associated with factors that condoms cause cancer historically contribute to MTBI (Xxxxxxx et al.15, 201216). However, QFT-GIT can exhibit discordance when compared to TST results and other IGRAs (15, 17-19). Absence of a “gold standard” to confirm MTBI limits IGRA assessments of accuracy and allows only estimates of sensitivity and specificity (15, 16). Approximations of sensitivity have been achieved by comparing the results of diagnostic tests to culture-confirmed cases of TB (15). Previous studies have assessed IGRAs among “assumed negative” populations at low-risk of MTBI, to better approximate specificity, with some consideration of test discordance (20- 22). Further research has been suggested to understand the factors associated with discordant test results (6, 15, 23). In light of the need for more research to understand IGRA accuracy and discordance, this study on QFT-GIT is part of a series of IGRA studies (21, 24- 26). This is actually study was conducted to add to the current discourse on the interpretation of LTBI screening results among low-risk populations when considering multiple testing methods. The analysis of cross-sectional data obtained from US Navy recruits in 2004 will quantify QFT-GIT specificity for a concern among some condom manufacturers —specificallypopulation at low-risk for MTBI. Additionally, this study will identify recruit characteristics and estimate their associations to discordant results between the release of nitrosamines from condoms QFT-GIT and TST. Results for QFT-GIT will also be compared to other IGRA results, performed at the same time (ISO/TC 157, 201521). Nitrosamines are a class of carcinogenic compounds that can be produced in the manufacturing process of rubber products. Formed by the reaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Union, and the US Environmental Protection Agency (EPA) classify NDEA and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).Chapter I

Conclusions. This pilot study finds no evidence indicating an association between nitrosamine exposure from condoms and incidence of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefits, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between stateoffers the first regional-level cervical characterization of PLWH proceeding through the early steps of transplantation. PLWH were less likely to traverse the steps of kidney transplant compared with those HIV negative, highlighting the need for targeted interventions to improve access to kidney transplant for PLWH. Identifying the barriers and colorectal cancer incidence disparities for referral to kidney transplantation faced by person living with HIV and nitrosamine exposure from condom use for a cross-sectional study end stage renal disease By Xxxx X. Xxxxxxxx ScB, Monmouth University, 2009 MD, Xxxxxx Xxxxxxxxxx University School of the United States By Xxxxxx XxXxxxxx Bachelor of Arts, Vassar CollegeHealth Sciences, 2013 Thesis Committee ChairsAdvisor: Xxxxx Xxxxxx X. Xxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS MD A thesis submitted to the Faculty of the Xxxxxxx Xxxxx X. Xxxxx School of Public Health Graduate Studies of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health Science in Global Epidemiology 2016 Acknowledgements Clinical Research 2020 I would like to express sincere appreciation to thank Xx. Xxxxxx Xxxxx and Xx. Xxxxxx Xxxxxx for serving as research mentors. Their assistance in honing my committee chairs Xxxxx Xxxxxxx ideas and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your interests, providing me with the necessary support and advice during guidance to complete my MSCR application, and informative discussions regarding the implications of this processwork, not only tremendously developed this work, but helped me to grow as well a junior investigator. I am thankful for the help of Dr. Zhensheng (AKA Xxxxx) Wang who assisted me with the analysis and served as your good humor my reader and very interesting conversationsadditionally and Xx. Xxxxxxxxx for reviewing the drafts of this thesis. I would like to thank Xxx X’Xxxxxx at Xx. Xxxxxxx Xxxxx for being instrumental in obtaining the Emory Center data for Digital Scholarship this project and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing being so accommodating to meet frantic MPH students the very next dayadditional data requests. I am also appreciative of Dr. Xxxxx Xxxxxxxxx who has been a fearless leader and program director, and the main reason why I applied to the MSCR program. Lastly, I would also like to thank Xxxxx Xxxxxxx my husband Xxxxxx Xxxxxxxxx for her expertise his patience, love, support, and infectious enthusiasm SAS consultations. TABLE OF CONTENTS INTRODUCTION 1 BACKGROUND 3 METHODS 8 RESULTS 19 DISCUSSION 24 CONCLUSIONS 33 REFERENCES 34 INTRODUCTION‌ End-stage renal disease (ESRD) has increased by 1000% in the past 3 decades, proving to be a significant health concern in the United Sates. In 1980, there were 60,000 persons with ESRD though in 2018 there were over 700,000 Americans living with ESRD (1). The expense of Chronic Kidney Disease (CKD) and ESRD has a significant impact on the United States economy and in 2018, CKD and ESRD accounted for mapping approximately 7% of Medicare expenditure, equating to $114 billion per year (2,3). It is well established that kidney transplantation is the optimal therapy for ESRD as it provides increased survival, better quality of life, and GISis less costly when compared with conventional dialysis (4–7). Since the advent of effective antiretroviral therapy, persons living with HIV (PLWH) are surviving longer and accumulating comorbidities. While HIV specific mortality has decreased, unfortunately, there continues to be a growing HIV epidemic, particularly in the southeastern United States. In 2017, the south accounted for 52% of the 38,739 new HIV diagnoses (8). As the HIV population ages, ESRD has emerged as a significant cause of morbidity and mortality, with PLWH being three times more likely to develop ESRD compared with the general population and is thought to compromise approximately 1.5% of the dialysis population (9,10). Additionally, compared with HIV- negative counterparts, PLWH experience a lower one- and five- year survival on dialysis (11). Despite this, there is growing evidence that PLWH are less likely to be placed on the organ waitlist and 47% less likely to receive a living donor kidney transplant (12). In order to improve survival and increase transplant rates among PLWH, it is critical to better understand the barriers to achieving a kidney transplant in this high-risk population. The objective of this thesis project was to identify and describe the HIV positive dialysis population in ESRD Network 6, the region with the lowest rates of kidney transplantation in the nation. Additionally, to compare their progression through the early steps (referral, evaluation, and waitlisting) of kidney transplantation to general dialysis population, and highlight patient and dialysis level characteristics that may influence access to kidney transplantation. This was accomplished through creating a novel HIV-ESRD dataset that identifies PLWH as well as her encyclopedic knowledge in finding those who proceeded through the early steps of transplantation. BACKGROUND‌ PLWH have increasing rates of ESRD. HIV-associated nephropathy (freeHIVAN) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are was previously one of the most important public health tools in sexual healthleading causes of renal failure among PLWH. The widespread use of affective antiretroviral therapy (ART) has decreased the prevalence of HIV-associated nephropathies (13,14), playing roles in human immunodeficiency however, PLWH are still developing CKD and ESRD faster than HIV negative counterparts. This is largely due to co-morbidities (diabetes mellitus, cardiovascular disease, hypertension, and metabolic syndrome), co- infection with hepatitis C virus (HIV) prevention, prevention of sexually transmitted infections (STIsHCV), medication induced injury, and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations accelerated aging seeing in chronic HIV infection (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 20159,15,16). Increasing PLWH of black race are especially at risk for progression from CKD to ESRD. A study performed in Baltimore, Maryland revealed that African-Americans were at an increased risk for incident CKD and developed ESRD markedly faster than white subjects (HR, 17.7 [95% CI 2.5-127.0]) (17). ESRD among PLWH is particularly present in the southeast. In 2000, ESRD Network 6 had the 4th highest percentage of PLWH on dialysis at a proportion of 1.9% compared to an national average of 1.5%(10). Unfortunately, the southeastern region of the US continues to have the highest burden of CKD and ESRD with Georgia, North Carolina and South Carolina being states with some of the highest age-standardized CKD disability-adjusted life years (18,19). This coupled by the ongoing HIV epidemic in the southeast makes ESRD Network 6 a unique region to study the coexistence of ESRD and access to condoms kidney transplantation among PLWH. With significant risk of progression from CKD to ESRD, it is imperative to understand access to transplantation among this vulnerable patient population. Renal transplantation is a feasible treatment option for PLWH with ESRD. In the 1980’s, HIV infection was considered a contraindication for transplantation and education about STI and US legal code was amended to make it a federal crime to transplant tissue from HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers positive donors (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 201320). HoweverIt was theorized that the effect of immunosuppression would contribute to progression of HIV disease, condom usage among CSWs continues lead to face barriers including client preference for unprotected sexmore episodes of infection and increased rate of death; making it an inappropriate allocation of an organ. Between 1987 to 1997, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use there were 32 kidney transplants performed in the US vary in PLWH (mostly unintentional transplantation), with reported 3-year graft survival of 53% and patient survival 83% (21,22). These transplants though were prior to significant improvement in medications used to treat PLWH. In 2003, Stock et al published promising outcomes on 14 HIV-positive patients who underwent transplantation. At a mean follow up of 480 days, 10 out of 10 (100%) of patients who received kidney transplants were alive with functioning grafts. There was no evidence of HIV disease progression and HIV did not seem to have an impact on graft survival (23). Around the same time, driven out of lack of access to dialysis, colleagues in South Africa performed the first kidney transplants from HIV-positive organ donors to HIV-positive recipients, showing that transplantation among PLWH was safe and feasible (24). With revived interest in transplanting PLWH, there have been a number of single center studies and a large multicenter study of 150 HIV-positive renal transplant recipients which all reported transplant outcomes for PLWH that were similar to the general transplant population 19(25–28). With better HIV care and improved understanding of medication interactions, PLWH in the United States are not only eligible for HIV-negative organs, but HIV-positive organs as well. In 2013, the HIV Organ Procurement Equity (HOPE) Act was signed into law, reversing the 1988 amendment, allowing HIV positive organs to be transplanted into HIV positive recipients. This policy change is estimated to increase the donor pool by race300-500 organs, ageproviding a unique opportunity to increase utilization of these organs and increase rates of kidney transplantation in HIV positive individuals 20(29). The transplant evaluation process is a multifaceted and complex process with the southeastern region performing the least transplants. Though it is possible for patients to be referred for kidney transplant prior to starting dialysis, genderthe majority of ESRD patients start on dialysis before they are referred to a transplant center. Within 60 days of starting dialysis, patients are required by law to be educated on the risks and benefits of transplantation and if eligible, are referred by a dialysis provider to a transplant center. The transplant center then decides on their waitlist candidacy through conducting thorough medical evaluations (often inclusive of multiple studies and specialty evaluations), performing a psychosocial evaluation, assessing their social support network and financial ability to fund kidney transplantation. When this step is completed, the patient can be waitlisted with the eventual hope of receiving a living or deceased donor kidney transplant. To better understand how well dialysis facilities were performing in referring patients to kidney transplant, Xx. Xxxxxx Xxxxxx (co-I; Department of Surgery & Department of Epidemiology) and team reported in 2014 that ESRD Network 6 has the lowest rates of kidney transplantation in the nation, and sex actthat Georgia had the lowest of all 50 states (18,30,31) (Figure 1). Factors associated with decreased access to transplant include demographic differences in the southeast, racial disparities, socioeconomic influences, distance to transplant center, provider knowledge and awareness of transplantation (18,32,33). Because no national surveillance data exist on steps prior to waitlisting, the Southeastern Kidney Transplant Coalition developed a novel data registry for referral and evaluation for transplantation among all 9 transplant centers in Xxxxxxx, Xxxxx Xxxxxxxx xxx Xxxxx Xxxxxxxx (X00XX000000, PI: 24.7Xxxxxx). They found substantial variability in transplant access at the dialysis facility level where some facilities referred 0% of men patients and 21.8others referred 76% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 201034). One Dialysis facility variability in transplant rates for HIV patients have not been described because currently no data exists linking HIV and ESRD care within a state or region. Factors influencing referral to kidney transplantation in PLWH have yet to be described in ESRD Network 6 and will direct construction of future interventions. Identifying PLWH who are on dialysis is difficult to do. Since 2005, there are scarce data on the barriers to condom usage incidence and prevalence of PLWH requiring dialysis. As part of a condition of participation in lowthe ESRD Medicare program, Centers for Medicare and Medicaid Services (CMS) medical evidence form (CMS 2728 form) is completed on every ESRD patient upon initiation of dialysis. CMS funds dialysis for ESRD patient and the surgical procedure and immunosuppressants for those who undergo kidney transplantation. The medical evidence form provides evidence of an ESRD condition, registers patients into a national renal registry, documents medical co-income countries is negative perception or rumors about condoms morbidities and other clinical data in dialysis patients, and ensures quality care for ERSD patients (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 201235). Perceptions by In 2005, HIV serostatus was removed as an ESRD-related condition on the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs medical evidence form due to concerns regarding disclosure of HIV status (Xxxxx et al., 2014; Xxxxxxx et al., 201236). Negative beliefs about condoms include the belief that condoms cause cancer Presently, in order to identity PLWH on dialysis, HIV status is inferred through pharmacy prescription data (Xxxxxxx et al., 201212). This ascertainment method is actually a concern among some condom manufacturers —specificallysuboptimal, as it may misclassify patients on pre-exposure prophylaxis as being on ART, may fail to identify PLWH not engaged in HIV care, and lacks patient-level epidemiologic and clinical data. Nonetheless, pharmacy prescription data is the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds only currently available method that can be produced used. In this study, Medicare prescription part D claims data was used to identify PLWH on dialysis. In 2016, there was 81% participation of Medicare part D among hemodialysis patients, suggestive that majority of the HIV population is captured in this study (37). METHODS‌ Hypothesis: Persons living with HIV in ESRD Network 6 are less likely to traverse through the multistep process of kidney transplantation compared to HIV-negative counterparts in the manufacturing process setting of rubber productsESRD. Formed by Specific Aims Aim 1: To identify and describe the reaction characteristics of nitrites with secondary or tertiary aminesPLWH and ESRD in ESRD Network 6. Aim 2: To describe the distribution and timing of early steps of kidney transplant inclusive of referral, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Unionevaluation, and the US Environmental Protection Agency (EPA) classify NDEA waitlisting among PLWH compared with HIV negative individuals with ESRD in Network 6. Aim 3: To identify patient-level and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health dialysis facility-level factors that are associated with time to referral and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et altime to waitlisting., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).

Conclusions. This pilot study finds no evidence indicating an association between nitrosamine exposure from condoms and incidence of cervical and colorectal cancer. Condoms provide substantial and measurable public health benefits, and providers and healthcare organizations should continue to recommend and promote them without hesitation. Lack of ecological association between stateoffers the first regional-level cervical characterization of PLWH proceeding through the early steps of transplantation. PLWH were less likely to traverse the steps of kidney transplant compared with those HIV negative, highlighting the need for targeted interventions to improve access to kidney transplant for PLWH. Identifying the barriers and colorectal cancer incidence disparities for referral to kidney transplantation faced by person living with HIV and nitrosamine exposure from condom use for a cross-sectional study end stage renal disease By Xxxx X. Xxxxxxxx ScB, Monmouth University, 2009 MD, Xxxxxx Xxxxxxxxxx University School of the United States By Xxxxxx XxXxxxxx Bachelor of Arts, Vassar CollegeHealth Sciences, 2013 Thesis Committee ChairsAdvisor: Xxxxx Xxxxxx X. Xxxxx, PhD, MPH Xxxxx Xxxxxxx, PhD, MHS MD A thesis submitted to the Faculty of the Xxxxxxx Xxxxx X. Xxxxx School of Public Health Graduate Studies of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health Science in Global Epidemiology 2016 Acknowledgements Clinical Research 2020 I would like to express sincere appreciation to thank Xx. Xxxxxx Xxxxx and Xx. Xxxxxx Xxxxxx for serving as research mentors. Their assistance in honing my committee chairs Xxxxx Xxxxxxx ideas and Xxxxx Xxxxx for agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your interests, providing me with the necessary support and advice during guidance to complete my MSCR application, and informative discussions regarding the implications of this processwork, not only tremendously developed this work, but helped me to grow as well a junior investigator. I am thankful for the help of Dr. Xxxxxxxxx (AKA Xxxxx) Xxxx who assisted me with the analysis and served as your good humor my reader and very interesting conversationsadditionally and Xx. Xxxxxxxxx for reviewing the drafts of this thesis. I would like to thank Xxx X’Xxxxxx at Xx. Xxxxxxx Xxxxx for being instrumental in obtaining the Emory Center data for Digital Scholarship this project and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, including answering emails at 10pm on a Sunday and agreeing being so accommodating to meet frantic MPH students the very next dayadditional data requests. I am also appreciative of Dr. Xxxxx Xxxxxxxxx who has been a fearless leader and program director, and the main reason why I applied to the MSCR program. Lastly, I would also like to thank Xxxxx Xxxxxxx my husband Xxxxxx Xxxxxxxxx for her expertise his patience, love, support, and infectious enthusiasm SAS consultations. TABLE OF CONTENTS INTRODUCTION 1 BACKGROUND 3 METHODS 8 RESULTS 19 DISCUSSION 24 CONCLUSIONS 33 REFERENCES 34 INTRODUCTION‌ End-stage renal disease (ESRD) has increased by 1000% in the past 3 decades, proving to be a significant health concern in the United Sates. In 1980, there were 60,000 persons with ESRD though in 2018 there were over 700,000 Americans living with ESRD (1). The expense of Chronic Kidney Disease (CKD) and ESRD has a significant impact on the United States economy and in 2018, CKD and ESRD accounted for mapping approximately 7% of Medicare expenditure, equating to $114 billion per year (2,3). It is well established that kidney transplantation is the optimal therapy for ESRD as it provides increased survival, better quality of life, and GISis less costly when compared with conventional dialysis (4–7). Since the advent of effective antiretroviral therapy, persons living with HIV (PLWH) are surviving longer and accumulating comorbidities. While HIV specific mortality has decreased, unfortunately, there continues to be a growing HIV epidemic, particularly in the southeastern United States. In 2017, the south accounted for 52% of the 38,739 new HIV diagnoses (8). As the HIV population ages, ESRD has emerged as a significant cause of morbidity and mortality, with PLWH being three times more likely to develop ESRD compared with the general population and is thought to compromise approximately 1.5% of the dialysis population (9,10). Additionally, compared with HIV- negative counterparts, PLWH experience a lower one- and five- year survival on dialysis (11). Despite this, there is growing evidence that PLWH are less likely to be placed on the organ waitlist and 47% less likely to receive a living donor kidney transplant (12). In order to improve survival and increase transplant rates among PLWH, it is critical to better understand the barriers to achieving a kidney transplant in this high-risk population. The objective of this thesis project was to identify and describe the HIV positive dialysis population in ESRD Network 6, the region with the lowest rates of kidney transplantation in the nation. Additionally, to compare their progression through the early steps (referral, evaluation, and waitlisting) of kidney transplantation to general dialysis population, and highlight patient and dialysis level characteristics that may influence access to kidney transplantation. This was accomplished through creating a novel HIV-ESRD dataset that identifies PLWH as well as her encyclopedic knowledge in finding those who proceeded through the early steps of transplantation. BACKGROUND‌ PLWH have increasing rates of ESRD. HIV-associated nephropathy (freeHIVAN) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are was previously one of the most important public health tools in sexual healthleading causes of renal failure among PLWH. The widespread use of affective antiretroviral therapy (ART) has decreased the prevalence of HIV-associated nephropathies (13,14), playing roles in human immunodeficiency however, PLWH are still developing CKD and ESRD faster than HIV negative counterparts. This is largely due to co-morbidities (diabetes mellitus, cardiovascular disease, hypertension, and metabolic syndrome), co- infection with hepatitis C virus (HIV) prevention, prevention of sexually transmitted infections (STIsHCV), medication induced injury, and family planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations accelerated aging seeing in chronic HIV infection (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx et al., 20159,15,16). Increasing PLWH of black race are especially at risk for progression from CKD to ESRD. A study performed in Baltimore, Maryland revealed that African-Americans were at an increased risk for incident CKD and developed ESRD markedly faster than white subjects (HR, 17.7 [95% CI 2.5-127.0]) (17). ESRD among PLWH is particularly present in the southeast. In 2000, ESRD Network 6 had the 4th highest percentage of PLWH on dialysis at a proportion of 1.9% compared to an national average of 1.5%(10). Unfortunately, the southeastern region of the US continues to have the highest burden of CKD and ESRD with Georgia, North Carolina and South Carolina being states with some of the highest age-standardized CKD disability-adjusted life years (18,19). This coupled by the ongoing HIV epidemic in the southeast makes ESRD Network 6 a unique region to study the coexistence of ESRD and access to condoms kidney transplantation among PLWH. With significant risk of progression from CKD to ESRD, it is imperative to understand access to transplantation among this vulnerable patient population. Renal transplantation is a feasible treatment option for PLWH with ESRD. In the 1980’s, HIV infection was considered a contraindication for transplantation and education about STI and US legal code was amended to make it a federal crime to transplant tissue from HIV prevention has resulted in important gains in condom use, especially among high-risk populations like commercial sex workers positive donors (CSW) and men who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 201320). HoweverIt was theorized that the effect of immunosuppression would contribute to progression of HIV disease, condom usage among CSWs continues lead to face barriers including client preference for unprotected sexmore episodes of infection and increased rate of death; making it an inappropriate allocation of an organ. Between 1987 to 1997, inconsistent condom supply, and policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use there were 32 kidney transplants performed in the US vary in PLWH (mostly unintentional transplantation), with reported 3-year graft survival of 53% and patient survival 83% (21,22). These transplants though were prior to significant improvement in medications used to treat PLWH. In 2003, Xxxxx et al published promising outcomes on 14 HIV-positive patients who underwent transplantation. At a mean follow up of 480 days, 10 out of 10 (100%) of patients who received kidney transplants were alive with functioning grafts. There was no evidence of HIV disease progression and HIV did not seem to have an impact on graft survival (23). Around the same time, driven out of lack of access to dialysis, colleagues in South Africa performed the first kidney transplants from HIV-positive organ donors to HIV-positive recipients, showing that transplantation among PLWH was safe and feasible (24). With revived interest in transplanting PLWH, there have been a number of single center studies and a large multicenter study of 150 HIV-positive renal transplant recipients which all reported transplant outcomes for PLWH that were similar to the general transplant population 19(25–28). With better HIV care and improved understanding of medication interactions, PLWH in the United States are not only eligible for HIV-negative organs, but HIV-positive organs as well. In 2013, the HIV Organ Procurement Equity (HOPE) Act was signed into law, reversing the 1988 amendment, allowing HIV positive organs to be transplanted into HIV positive recipients. This policy change is estimated to increase the donor pool by race300-500 organs, ageproviding a unique opportunity to increase utilization of these organs and increase rates of kidney transplantation in HIV positive individuals 20(29). The transplant evaluation process is a multifaceted and complex process with the southeastern region performing the least transplants. Though it is possible for patients to be referred for kidney transplant prior to starting dialysis, genderthe majority of ESRD patients start on dialysis before they are referred to a transplant center. Within 60 days of starting dialysis, patients are required by law to be educated on the risks and benefits of transplantation and if eligible, are referred by a dialysis provider to a transplant center. The transplant center then decides on their waitlist candidacy through conducting thorough medical evaluations (often inclusive of multiple studies and specialty evaluations), performing a psychosocial evaluation, assessing their social support network and financial ability to fund kidney transplantation. When this step is completed, the patient can be waitlisted with the eventual hope of receiving a living or deceased donor kidney transplant. To better understand how well dialysis facilities were performing in referring patients to kidney transplant, Xx. Xxxxxx Xxxxxx (co-I; Department of Surgery & Department of Epidemiology) and team reported in 2014 that ESRD Network 6 has the lowest rates of kidney transplantation in the nation, and sex actthat Georgia had the lowest of all 50 states (18,30,31) (Figure 1). Factors associated with decreased access to transplant include demographic differences in the southeast, racial disparities, socioeconomic influences, distance to transplant center, provider knowledge and awareness of transplantation (18,32,33). Because no national surveillance data exist on steps prior to waitlisting, the Southeastern Kidney Transplant Coalition developed a novel data registry for referral and evaluation for transplantation among all 9 transplant centers in Xxxxxxx, Xxxxx Xxxxxxxx xxx Xxxxx Xxxxxxxx (X00XX000000, PI: 24.7Xxxxxx). They found substantial variability in transplant access at the dialysis facility level where some facilities referred 0% of men patients and 21.8others referred 76% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 201034). One Dialysis facility variability in transplant rates for HIV patients have not been described because currently no data exists linking HIV and ESRD care within a state or region. Factors influencing referral to kidney transplantation in PLWH have yet to be described in ESRD Network 6 and will direct construction of future interventions. Identifying PLWH who are on dialysis is difficult to do. Since 2005, there are scarce data on the barriers to condom usage incidence and prevalence of PLWH requiring dialysis. As part of a condition of participation in lowthe ESRD Medicare program, Centers for Medicare and Medicaid Services (CMS) medical evidence form (CMS 2728 form) is completed on every ESRD patient upon initiation of dialysis. CMS funds dialysis for ESRD patient and the surgical procedure and immunosuppressants for those who undergo kidney transplantation. The medical evidence form provides evidence of an ESRD condition, registers patients into a national renal registry, documents medical co-income countries is negative perception or rumors about condoms morbidities and other clinical data in dialysis patients, and ensures quality care for ERSD patients (Xxxxxxx et al., 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 201235). Perceptions by In 2005, HIV serostatus was removed as an ESRD-related condition on the public about condom safety and efficacy directly affect their use and thus can adversely affect sexual and reproductive health programs medical evidence form due to concerns regarding disclosure of HIV status (Xxxxx et al., 2014; Xxxxxxx et al., 201236). Negative beliefs about condoms include the belief that condoms cause cancer Presently, in order to identity PLWH on dialysis, HIV status is inferred through pharmacy prescription data (Xxxxxxx et al., 201212). This ascertainment method is actually a concern among some condom manufacturers —specificallysuboptimal, as it may misclassify patients on pre-exposure prophylaxis as being on ART, may fail to identify PLWH not engaged in HIV care, and lacks patient-level epidemiologic and clinical data. Nonetheless, pharmacy prescription data is the release of nitrosamines from condoms (ISO/TC 157, 2015). Nitrosamines are a class of carcinogenic compounds only currently available method that can be produced used. In this study, Medicare prescription part D claims data was used to identify PLWH on dialysis. In 2016, there was 81% participation of Medicare part D among hemodialysis patients, suggestive that majority of the HIV population is captured in this study (37). METHODS‌ Hypothesis: Persons living with HIV in ESRD Network 6 are less likely to traverse through the multistep process of kidney transplantation compared to HIV-negative counterparts in the manufacturing process setting of rubber productsESRD. Formed by Specific Aims Aim 1: To identify and describe the reaction characteristics of nitrites with secondary or tertiary aminesPLWH and ESRD in ESRD Network 6. Aim 2: To describe the distribution and timing of early steps of kidney transplant inclusive of referral, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and N- nitrosodimethylamine (NDMA), often used as indicators of nitrosamine presence (Xxxxx, 2011). The World Health Organization (WHO), the European Unionevaluation, and the US Environmental Protection Agency (EPA) classify NDEA waitlisting among PLWH compared with HIV negative individuals with ESRD in Network 6. Aim 3: To identify patient-level and NDMA as probable or presumed human carcinogens (Xxxxx, 2011). The US Department of Health dialysis facility-level factors that are associated with time to referral and Human Services released the 13th Report on Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (NTP, 2014). Nitrosamines have been found in food, cosmetics, tobacco products, and rubber goods such as balloons, pacifiers, baby bottle teats, and also condoms (NTP, 2007; Xxxx et altime to waitlisting., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as well as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a possible risk (Eisenbrand, 2005).