Emily R. Smith

COVID-19

Dr. Smith is the principle investigator for the Perinatal COVID-19 Sequential Prospective Meta-Analysis Project (sPMA) funded by the Bill & Melinda Gates Foundation.  While many national registries, health facilities, and research groups are collecting data about SARS-CoV-2 infection during pregnancy and in the newborn period, the sPMA is a collaborative and methodologically appropriate effort to pool and analyze this data. More than 100 investigators and stakeholders working in 41 countries are participating in the project with an aim of rapidly answering high priority questions about COVID-19. The public protocol is available here. The study confirmed that COVID-19 in pregnancy increases the risk for maternal morbidity and mortality and identified pregnancies that are at higher risk during SARS-CoV-2 infection.

Dr. Smith is the founder and editor-in-chief of COVID-101.org. She launched this project on March 15, 2020, in response to the need for COVID information that is accessible and rooted in science. The project workflow looks like this: readers ask COVID-19 questions, our doctors rapidly review the scientific evidence, and the team delivers simple answers to an array of platforms (Facebook, Twitter, Instagram, and the web).  More than 25 volunteers contribute to COVID-101, including epidemiologists and infectious disease physicians from a dozen colleges and universities (University of Washington, Columbia, Johns Hopkins, Harvard, George Washington University, and more). 

Dr. Smith is an investigator for a collaborative meta-analysis that aims to use data from all available randomized clinical trials, including unpublished and ongoing trials, to understand the potential benefits of convalescent plasma as treatment for COVID-19. The protocol is available via the Open Science Framework here. Based on data accrued to date, there is no benefit of convalescent plasma in reducing mortality, based primarily on randomized trials among hospitalized patients (Janiaud et al. JAMA. 2021; Axfors et al. BMC infectious diseases. 2021).

Dr. Smith collaborated with the Africa Research, Implementation Science and Education (ARISE) Network to complete a series of surveys to assess drivers of vaccine acceptance and the health, nutritional, and socioeconomic impacts of the pandemic over time among adults, adolescents and healthcare providers in Ethiopia, Ghana, Tanzania, Nigeria, and Burkina Faso. The work has been published in PLOS Global Public Health,

Comprehensive Multivitamins in Pregnancy Improve Birth Outcomes

Dr. Smith led the pooling and analysis for an individual patient data meta-analysis intended to inform policy surrounding multiple micronutrient supplementation (MMS) in pregnancy (Smith et al. Lancet Global Health. 2017). Despite concerns about potential health risks raised in the World Health Organization (WHO) 2016 Antenatal Care Guidlines, the meta-analysis and a second study published in the Journal of Nutrition (Smith & Sudfeld. 2019) finds clear evidence that MMS containing iron and folic acid is safe and superior to iron and folic acid alone. MMS in pregnancy reduces the risk of low birth weight, preterm birth, and being born small-for-gestational-age. Further, MMS reduces the risk of neonatal and infant mortality for girls, and there was no evidence of increased risk among the 26 subgroups examined. Dr. Smith has participated in the Taskforce on Maternal Micronutrient Supplementation in Pregnancy hosted by the New York Academy of Sciences and is an advocate for improving evidence-based maternal nutrition services during pregnancy.

To address specific research questions related to the optimal amount of iron to include in prenatal vitamins (MMS), Dr. Smith and colleagues are conducting an individually randomized controlled trial to assess the effect of MMS containing 60 and 45 mg iron as compared to MMS that contains 30 mg of iron (standard iron dose in UNIMAP MMS formulation) on maternal anemia and other important maternal and newborn health outcomes. The MMS-MAP trial will be conducted in Dar es Salaam, Tanzania, in collaboration with colleagues at Ifakara Health Institute, Africa Academy of Public Health, Muhimbili University of Health and Allied Sciences, and Harvard TH Chan School of Public Health. This study will help inform countries like Tanzania (that currently use IFA containing 60 mg of iron) as they transition to using MMS.

Dr. Smith is further evaluating optimal nutrition during pregnancy through the Molecular Methods for Maternal Nutrition (MM4MN) study, focusing on vitamin B12. This project aims to enhance understanding of the bioavailability of vitamin B12 during pregnancy in patients with sufficient and insufficient baseline B12 status. Further, this study aims to identify the priority dose regimens of vitamin B12 in pregnancy to be investigated in future phase clinical trials & identify novel biomarkers of vitamin B12 intake that are suitable for pregnancy. This study is conducted alongside colleagues at Penn State University, Baylor College of Medicine, University of Maryland School of Pharmacy, Ifakara Health Institute, and Muhimbili University of Health & Allied Sciences. 

The Effect of Neonatal Vitamin A Supplementation on Infant Mortality

Dr. Smith led field operations for implementation of a large, neonatal vitamin A supplementation (NVAS) randomized control trial in Tanzania funded by the Bill & Melinda Gates Foundation, in collaboration with colleagues at the Harvard T.H. Chan School of Public Health (HSPH), Ifakara Health Institute (IHI), and the World Health Organization (WHO). This was the largest NVAS trial ever conducted in sub-Saharan Africa; the team enrolled 32,000 neonates and tracked them throughout their first year of life. To inform global policy, other teams conducted parallel trials in India and Ghana; the three trials found conflicting results. The India trial—consistent with previous trials in the region—found that supplementation reduced the risk of infant death. But the trials in Tanzania and Ghana found no effect of supplementation (Masanja and Smith et al Lancet 2015). Dr. Smith published a study that explored potential reasons for these conflicting results; this work provided the first evidence—based on individual data—that indicated maternal micronutrient status may explain the heterogenous effects of NVAS (Smith et al International Journal of Epidemiology 2016). Dr. Smith was part of the WHO working group that pooled and analyzed individual patient data from all prior NVAS trials. This work has informed WHO guidelines for NVAS; those guidelines are expected to be released this year.

The Effect of Early Breastfeeding Initiation on Infant Morbidity and Mortality

Dr. Smith has published several papers showing a link between breastfeeding initiation time and infant morbidity and mortality (Smith et al The Journal of Pediatrics 2107; Smith et al PloS one 2017; Neovita Study Group Lancet Global Health 2016). However, the mechanism through which early newborn nutrition has a long-term health impact is not known. Some have hypothesized that early breastfeeding may decrease the risk of microbial translocation, accelerate intestinal maturation, promote resistance to and epithelial recovery from infection, and protect against environmental enteric dysfunction (EED). But there is limited data about these potential mechanisms. Dr. Smith and colleagues recently completed a study among a cohort of children enrolled in a micronutrient trial in Tanzania; both delayed breastfeeding initiation and prelacteal feeding were associated with elevated biomarkers of poor gut function later in infancy. Dr. Smith led four systematic reviews to support development of the 2022 WHO Recommendations on care and feeding of low birthweight and preterm infants. Dr. Smith and GW Colleagues also conducted a study to understand mothers’ experiences during the 2022 infant formula shortage in Washington DC.

Immunology, Epidemiology, and Burden of Viral Diarrhea

Dr. Smith has worked on a number of studies related to immunology and epidemiology of norovirus and rotavirus. While at Emory University, she worked on several randomized, human-challenge trials to assess the effectiveness of new technology to inactivate norovirus. Prior to introduction of the rotavirus vaccine in Bolivia, Dr. Smith worked with Universidad Mayor de San Andrés and the Pan American Health Organization to conduct national, sentinel rotavirus surveillance. In parallel, she led costing studies to assess the cost-effectiveness of the new vaccine from both the caregiver and state perspectives.

PUBH 6047 - Synthesizing Evidence (Systematic Reviews)
PUBH 6565 - Global Child Health
PUBH 8473 - Advance Topics in Global Child Health