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Raising our voices to improve health around the world.

My journey into Global Health: Dr. Pragna Patel

Categories: cardiovascular disease, HIV/AIDS

Dr. Patel at her family’s clinic in India where they provide health services to indigent communities.

Dr. Patel at her family’s clinic in India where they provide health services to indigent communities.

Dr. Pragna Patel says “Taking the road less travelled and working for CDC on HIV and NCD has been a worthwhile journey”

 Dr. Pragna Patel

Dr. Pragna Patel

As a young girl growing up in New York City, I would often help out at my father’s pediatric clinic in an indigent neighborhood of the Bronx.  My father was a caring and compassionate doctor whom I truly admired and wanted emulate by providing a service to society in a meaningful way.  At that time, I never imagined that I would follow in his footsteps and become a physician. Taking the road less travelled, joining the US Public Health Service (USPHS) and working with CDC has been a circuitous, but rewarding experience and well worth the journey.
Growing up as a daughter of immigrant parents from India, I always had a desire to return to their native country, and in some way, ‘give back’.  Years later while I was a medical student, I spent two months living and working in a village in India and saw things that I never imagined possible. One day, I was standing in the operating room and my only hope in that moment was that the fly buzzing around my head would not land in the open abdomen of the patient on the table. As I stood there wearing blood-stained flip flops and gloves that had been autoclaved for re-use, I began thinking about the conditions in India and the need to improve the country’s medical care system.  Seeing a ward full of beds occupied by two people and families providing nursing care for their loved ones was very sobering for me and sparked my interest in public health.

Kenya teaching hospital

The MOI Teaching & Referral Hospital in Kenya where Dr. Patel served as the attending physician on the adult male ward during her residency.

While serving as the attending physician on the adult male ward during my residency at a clinic in the Rift Valley in Kenya, my interest in public health was deepened even further.   The average age of my patients was 35 years old and all were dying of two diseases – tuberculosis and HIV.  My medication kit consisted of four antibiotics…none of which could treat these men and save their lives.  It was during that time that I got my ’aha moment’ and realized the importance of public health practices and policies. Right there and then,  I made a conscious decision to become an Epidemic Intelligence Service Officer  and work with CDC to improve the health of populations.

Joining the USPHS and CDC and leveraging the PEPFAR InfrastructureHIV red ribbon

Since joining the USPHS  and CDC in 2002, I’ve spent 13 years working on several important public health initiatives including acute HIV screening and  characterizing the natural history of HIV in the era of effective therapy, which largely consists of  chronic diseases.  In 2013, furthering my interest in global health issues,

I accepted a position with  CDC’s Global Noncommunicable Diseases (NCD) Unit .  While my main focus is hypertension management and control, I use my HIV background considerably and leverage the PEPFAR infrastructure to provide NCD management to HIV-infected patients.</p.

Managing the ‘Silent Killer’

I am no stranger to heart disease as my paternal grandfather died after three hearts attacks at age 56 and my cousin met his demise of a massive heart attack at age 32. I know that their premature deaths were likely preventable and not uncommon.  Cardiovascular disease is the number one killer in the world and each of us is touched by it.

Worldwide, by 2025, an estimated 1.56 billion people are expected to have high blood pressure, also referred to as hypertension. Each year, hypertension is estimated to cause 9 million preventable deaths.
Risk Hypertension Infographic

Hypertension is commonly referred to as the “silent killer” because it often has no warning signs or symptoms. Many patients being treated for hypertension either do not seek medical attention or adhere to treatment regimens because they don’t have symptoms,  and are unaware that they are at risk for cardiovascular disease and can without warning, suffer a stroke or heart attack.

Although hypertension can be life-threatening, the good thing is that it is fairly easy to treat.  There are effective, affordable medications that are not difficult to take but in some settings, these medications are not widely available.

Global Standardized Hypertension Treatment Project

In recognition of the need to meet the challenge of improving the control of hypertension worldwide, CDC in collaboration with the Pan American Health Organization (PAHO), launched the Global Standardized Hypertension Treatment Project (the Project).  The Project’s goal is to improve hypertension treatment and reduce associated morbidity and mortality by developing and implementing a framework for standardizing the pharmacologic treatment of hypertension globally.  The Project proposes a Framework that includes three key elements:

    1. Using a core set of medications for the treatment and control of hypertension
    2. Increasing the availability and affordability of these medications
    3. Strengthening health care delivery systems to improve controlled hypertension at a population level and sustain long-term control for every patient
Malawi-team_600px

Dr. Pragna Patel and Dr. Sonia Angell (2nd and 3rd from Left) working with team in Malawi on an hypertension control and management project. This project will determine if standardized hypertension care and treatment that has been incorporated into existing HIV care delivery settings can lead to significant improvements in blood pressure control rates among persons with HIV and hypertension. This work has the potential to create a sustainable, feasible model for hypertension control in clinical settings throughout Malawi.

Value of the Hypertension Toolkit

The main objective of this toolkit is to provide health care providers and clinic administrators with the tools they need to improve blood pressure control among their clinic population. The materials provided include information on how to create registries to manage panels of patients and track indicators, as well as how to use standardized hypertension treatment protocols to improve the treatment and control of hypertension in clinical settings. Also included are educational materials for patients and providers as well as clinical tools for hypertension management and for improving medication adherence. The toolkit is available online at: http://www.cdc.gov/globalhealth/ncd/hypertension-toolkit.htm

These tools have been used successfully for the control of tuberculosis and for hypertension in the United States and can be leveraged for other diseases.

Partner Engagement

In low- and middle-income countries, a major challenge of controlling hypertension is medication availability and affordability.  Therefore, CDC is currently working with partners to improve access to antihypertensive medications.  For example, PAHO has included these medications on their list for the PAHO Strategic Fund to improve availability in the Latin American and Caribbean region: http://www.paho.org/hq/index.php?option=com_content&view=category&layout=blog&id=1159&Itemid=986&lang=en. The Barbados Drugs Service has done the same: http://drugservice.health.gov.bb/

While there have been many advances in electronic data collection, the technology necessary for electronic registries is not available in most low- and middle-income countries.  CDC and the Lighthouse Trust  are working with Baobab (http://baobabhealth.org/) in Malawi to develop hypertension modules to enhance local electronic medical record systems.  We hope this enhancement will be widely adopted in Malawi and will facilitate the scale-up of hypertension screening and treatment programs within the country.

Dr. Pragna Patel  team on hypertension project

Dr. Pragna Patel (front row left) with hypertension management and control team in Barbados.

CDC’s NCD Unit is also working with partners to stand up hypertension treatment programs by leveraging existing infrastructure, such as enhancing HIV care delivery at PEPFAR-funded sites to include hypertension screening, diagnosis, and treatment in Malawi.  In addition, CDC is  providing technical assistance to improve quality of care at clinical sites in Barbados, where many of the Project’s components are being implemented.  Health care institutions and other public health partners can help disseminate information about the project and engage ministries of health, academic institutions, and private organizations in adopting the components of the Project’s framework into their clinical care delivery sites.  Raising awareness about the disease and its associated complications is important as well.

For further information on the Global Standardized Hypertension Treatment Project , please contact Dr. Pragna Patel, at plp3@cdc.gov

Working Towards an Achievable Goal: A World without CRS

Categories: immunization, infectious disease, rubella

Rubella is generally a mild illness but when pregnant women become infected, there is a 90% chance of the fetus having congenital rubella syndrome (CRS). The baby can be born with multiple birth defects -- if he or she survives at all. Rubella vaccination prevents mothers from giving birth to babies with CRS and prevents life-long disability. 100,000 babies are born with CRS around the world each year.

Susan Reef, MD, Rubella Team Lead, Global Immunization Division

Susan Reef, MD, Rubella Team Lead, Global Immunization Division

When I started focusing on rubella in 1994, it was mainly recognized as a significant public health problem in high-income countries. When the public health community realized that rubella and congenital rubella syndrome (CRS) were actually significant public health issues in the entire region of the Americas, things took a turn and an elimination goal was set for 2010. In the pre-vaccine era, some 20,000 infants were born each year in the Americas region with CRS and one or more of its devastating birth defects. I look at our success in achieving the elimination goal —which occurred in 2009, a year before the target date—in terms of the lives it impacted: 20,000 of them, born free of CRS disabilities each year since then.

The Americas Region is rubella’s great success story. But unfortunately, that success isn’t always seen elsewhere; less than 55% of children live in countries with access to the rubella vaccine. In my decades of experience as a medical professional, I have seen my share of disease and the horrific impact it can have. But seeing infants with CRS has to be one of the most heartbreaking. Multiple defects, heart issues, cataracts, deafness all carry a significantly larger burden for families in low-income countries. They are often without extra resources, or access to services or facilities to help care for children born with CRS. Tiny babies starting their lives with a host of health issues that would challenge a full grown adult. Some infants even abandoned by their families because the costs and lifetime of dedication needed to care for them were too much to bear.

Between 1996 and 2014, the number of countries offering the rubella vaccine increased from 79 to 141 (73% of all countries). However, there are still 53 countries that have not yet introduced the vaccine. Most of these remaining countries are in the African and Eastern Mediterranean regions, but also in a few densely populated countries like India and Indonesia with substantial numbers of babies born with CRS each year. In an age where we have a safe and effective vaccine, 100,000 CRS babies are still born every year.

The fact that we can protect children everywhere from rubella and CRS motivates me to eliminate these viruses from the earth. Fortunately, the global health community is working hard to make this goal a reality. Over the last two years, there have been 10 countries that have introduced rubella vaccine and several more countries will be introducing rubella vaccine in 2015. It is so important to reach people with rubella vaccine when they are young, both male and female, to ensure rubella is eliminated in all regions where it is endemic. That is why conducting wide-age range vaccination campaigns are essential when introducing rubella vaccines into national immunization systems – we can protect more than one generation at a time: children and their future children.

Progress is slow and steady, but is gaining momentum thanks to the advocacy and activities of the Measles & Rubella Initiative. It is a global partnership committed to ensuring no child dies from measles or rubella, or is born with congenital rubella syndrome. As a founding member, CDC provides scientific and financial support to partners and countries to protect against rubella and CRS. Our efforts have been strengthened with significant assistance since 2013 through Gavi, the Vaccine Alliance. Since 2013, Gavi supports catch up campaigns for measles-rubella for countries self-financing the introduction of the measles-rubella vaccine in their routine immunization programmes. This means that by 2020, more than 600 million children in 49 countries between 9 months and 14 years are expected to be immunized against measles and rubella.

Even with this excellent progress, there are too many infants being born with CRS simply because of lack of access to the vaccine. As a global community, we need to prioritize getting life-saving vaccines to children in even the hardest-to-reach places. We call them “vaccine-preventable” because immunization truly does prevent these devastating diseases from spreading. By working to ensure that safe, effective vaccines reach every remaining corner of the world, we will give babies around the world a chance to live healthier lives, free from the scourge of CRS.

 

 

Why I Care about Cancer in Developing Countries

Categories: cancer

Being treated for cancer in a lonely hospital room in Guatemala City.

Being treated for cancer in a lonely hospital room in Guatemala City.

Jeff Glenn

Jeff Glenn, Public Health Advisor, Office of Noncommunicable Diseases, Injury and Environmental Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

I’m 30 years old and have already had cancer three times. If I lived in a developing country I likely would have died from my testicular cancer, or from my melanoma, or almost surely from my recurrence of melanoma that spread to the liver and brain. Fortunately for me, I have the opportunity to access an extraordinarily high level of care that has kept me alive and hopefully will continue to do so. Unfortunately for billions of people around the world, the same cancers that are largely preventable or treatable in countries with access to good-quality care can still be devastatingly deadly for them. Even in 2015, whether you survive cancer still depends very much on where you live.

As a public health advisor in CDC’s Office of International Cancer Control, for the past four years I’ve been working to develop programs that increase access to cancer prevention and treatment services in low- and middle-income countries. While traveling for my job I’ve often reflected on my ongoing personal experience with cancer and how different things would be for me if I had been born somewhere without access to good-quality cancer care. I feel a powerful connection to the cancer survivors and public health professionals I meet. My experiences have given me a unique perspective on cancer disparities that exist between countries and the importance of international collaboration to address them.

Health Systems

Cervical cancer ward in Vietnamese hospital

Crowded beds in the cervical cancer ward in a Vietnamese hospital. (Photo courtesy of Carolyn Taylor)

One area where health disparities are apparent is in the availability of specialized cancer care. I’ve always had access to the care I need, but sometimes I wait at the clinic for what seems like a long time to see my oncologist. Once I waited for four hours and even wondered if I should take my business elsewhere. It wasn’t until I traveled to Vietnam, where I met patients at the main cancer hospitals who had been waiting for hours and even days in crowded waiting rooms, stairwells, and outside in the smothering heat and humidity, that I realized how trivial the concerns about my wait time actually were.

In Vietnam and many other countries, wait times are a symptom of much larger health systems challenges. Many countries lack sufficient cancer treatment and prevention services, while some countries have no specialized cancer care at all. Even if treatment is available, it may be too expensive for most people, or they may have to travel for days to arrive at a cancer center, making it less likely that patients will receive the care they need to survive.

I recently met an elderly woman in Guatemala City who had melanoma and had traveled a long way from her rural village to receive treatment. She spoke only her indigenous language, and because of the distance, nobody had been able to travel with her. After meeting her, I felt especially fortunate to have had my family by my side throughout my treatment.

Stigma

The overwhelming support I’ve received from my family, friends, colleagues, and even strangers has been an absolutely critical part of my care. I can’t express how comforting it is to know that so many people would do anything they could to help me. Never have I felt embarrassed or ashamed about having cancer; rather, I’ve been encouraged to share my experience to help others who are going through similar things and to raise awareness about melanoma prevention.

Blue wristbands showing family support

My family showing their support by wearing their blue wristbands that say, “Just4Jeff”.

Sadly, due to the stigma around cancer that still exists in many countries, cancer patients are often discouraged from speaking openly about their disease, even among close family and friends. This can be detrimental to the psychological well-being of cancer patients and interfere with their ability to get the medical care they need. A friend of mine, Carolyn Taylor, a cancer survivor and photographer who founded the nonprofit organization Global Focus on Cancer, tells the story of a woman she met at a hospital in India who was waiting to receive treatment for breast cancer. As this woman cautiously opened up, she told Carolyn that the only other person who knew she had cancer was her husband, who had asked her not to speak to anyone else about it since it could be seen as a source of shame for the family. Unfortunately, stories like this are not uncommon, especially in places with lower levels of awareness about cancer.

Cancer is scary for anyone, but especially for those who think there’s no way to survive it. After spending a few days visiting the top cancer hospitals in Vietnam, I asked two Vietnamese women, both highly educated physicians who had been with me throughout the trip, where they would go to for treatment if they learned they had breast cancer. I was surprised when they both responded that they probably wouldn’t go anywhere. Perhaps they truly believed cancer was incurable, or maybe they felt like it wasn’t worth the pain and discomfort to get care at one of the overcrowded hospitals we’d visited where patients often slept on the floor or shared beds with as many as three other people, but the fact that they had no hope of being cured strikes me, a cancer survivor and public health professional, as an important indicator that we need to do something about this.

Vietnam cancer hospital

Patients wait for appointments at a cancer hospital in Vietnam.

A Global Response

It’s past time to stop ignoring the impact of cancer on poverty and health systems while expecting impressive results from economic development and global health programs. They are inextricably linked and need to be tackled together to have the desired outcome. Reducing the cancer burden worldwide contributes significantly to the success of other global health and development efforts.

The growing cancer burden places an enormous load on already strained health systems, making it more difficult for countries to manage other health challenges. Since a health system strong enough to prevent and control cancer is also better equipped to deal with other important causes of death and disability, such as Ebola and AIDS, strengthening country health systems to control cancer also contributes to building a safer world.

If the global cancer crisis is not addressed now, it will become even more difficult and costly to deal with in the future after millions of lives have been avoidably lost. Fortunately, technology already exists that can prevent millions of cancer deaths every year. Low-cost yet effective approaches to cancer prevention and treatment are already being implemented in many countries throughout the world, but the work is obviously far from finished.

2014: A pivotal year for the HIV response in Malawi

Categories: HIV/AIDS, Malawi

How we refined and refocused programs using a data-driven approach

Beth A. Tippett Barr, DrPH Chief of Health Services, CDC Malawi

Beth A. Tippett Barr, DrPH Chief of Health Services, CDC Malawi

The appointment of Dr. Deborah Birx as the new Global AIDS Coordinator in May 2014 heralded an enormous change in the PEPFAR world:  Within the span of a few weeks, the focus changed from the newly-cemented PEPFAR vocabulary around ‘sustainability’ and ‘country ownership’ to language more targeted at maximizing resources for ‘epidemic control’.  As Dr. Birx said at the PEPFAR Annual meeting in Durban in June 2014, “We cannot sustain an uncontrolled epidemic”.  Although there has been enormous success in globally scaling up access to HIV testing and counseling (HTC) and anti-retroviral therapy (ART), the point Dr. Birx has continually reiterated in her six months in office, is that we need to find those places and populations in which the epidemic is least-controlled and respond accordingly.

To successfully do this, data is required:  Data on locating those who have never been tested and those at highest risk of acquiring HIV, and data that identifies which programs work best at reducing new infections and caring for those already infected.  The wide variation in new and existing HIV infections between urban and rural, male and female, and between age groups has long been established;  however, the use of this and other data to maximize the entire spectrum of our HIV prevention, care and treatment interventions in a coordinated effort to control the epidemic, has not been maximized.  With this challenge ringing in our ears, and a mandate from the Office of the U.S. Global AIDS Coordinator (OGAC) to revise our 2014 annual plan (COP), CDC and the other US Government (USG) agencies utilizing PEPFAR funding in Malawi, sat down to plan how to better work with the Ministry of Health and gain control over the HIV epidemic. As a result of these meetings, the following has been endorsed or adopted.

Malawi has recently endorsed the UNAIDS ‘90-90-90’ goals for 2030, which include:

  • 90% of People Living with HIV (PLHIV) are tested and know their status
  • 90% of known PLHIV are initiated on Anti-retroviral Therapy (ART)
  • 90% of ART patients are retained in care at one year

To reach these ambitious goals we will actively pursue progress by matching the appropriate amount of funding with similar outputs of effort, targeted to the right places and the right populations.  The first 90% is the gateway to the subsequent 90’s for the 2030 goals; if we don’t find those already living with HIV, we won’t be able to start them on treatment or keep them in care.  To find 90% of people living with HIV (PLHIV), we have to know where to look, and although our national survey data isn’t current, there is enough available information to rethink our overall strategy.  Of immediate importance is ensuring we get the highest ‘yield’ for HIV Testing and Counseling (HTC); the highest likelihood of identifying an HIV-positive individual with every test used.  This is a recent departure from the last few years in which HTC had become a way to identify those who were negative and provide counseling on staying HIV-negative.  Fortunately, thinking has now come full circle, and the role of HIV testing is rapidly regaining its priority as the most important gateway to treatment, survival and epidemic control.  This has had the immediate effect of highlighting the importance of testing in health facilities, particularly in settings where HIV prevalence may be higher than the national average, including STI clinics, TB clinics and in-patient wards.

HIV prevention in the new millennium

The emphasis on reaching the 90-90-90 targets mandates that the targeted behaviors for change be HIV testing, accepting treatment, taking one’s medication, and keeping appointments.  Should these behavior change and treatment agendas truly align to support each other, the 90’s can be achieved in Malawi.  If this happened, then 73% of the approximately one million PLHIV would lower the amount of HIV in their blood so they essentially do not transmit the virus, reducing new infections nationally to 0.2 per 100 individuals per year.  This is a staggering 78,000 adult infections and 75,000 pediatric infections prevented in the next five years, a massive impact on HIV prevention in Malawi, the likes of which has never been seen before.

 

Reviewing our data from a new perspective

Districts in Malawi are made up of anywhere from 100,000 to 1,000,000 people, and HIV prevalence in antenatal (prenatal) clinics within a district can vary from 0.2% to 33%.  When reviewing variation in HIV prevalence in the Demographic and Health Survey (DHS) 2010 at the cluster level, it rapidly became clear that the epidemic needs a targeted response at the lowest possible geographic unit, certainly well below the typical approach of district level.  All health facilities in Malawi are assigned ‘catchment areas’, an uneven radius around each facility which provides an approximation for the population each health center is responsible for serving.  Because the entire population of the country can also be divided into these catchment areas, and because HIV service delivery data is available at the facility level and provides a proxy measure for community coverage, the use of facility and catchment areas to define our refocused response was the most appropriate choice for geographic refining of our programs.

 

Refining site-level focus

While funding cannot provide support to every ART site in Malawi, our data shows intensive HIV program support isn’t needed in every facility.  This has enabled us to rethink how every dollar invested in HIV can produce maximum impact.  Several measures for the prioritization of health facilities were considered, and after discussing the pros and cons of each measure with the Ministry of Health Department of HIV and AIDS, we utilized a combination of measures to identify those health facility catchment areas which altogether would provide 90% population coverage based on three priority criteria:

  1. Number of current ART patients of treatment
  2. Expected number of HIV-positive pregnancies registering at the ANC clinic
  3. Number of PLHIV in the health facility catchment area

The last measure was important, as it gives us an estimated program need outside of documented facility services.  In each of the measures, we sorted the health facilities in the country in order of size from largest to smallest, and identified which sites would enable us to reach 90% of the population.  We then displayed the results visually, via Venn diagram, to show the overlap between the criteria and the health centers.  venn_diagramMalawi_HIV

We found that we could reach 90% of the HIV-positive population by prioritizing support to 50% of the health facilities in the country. The majority of health centers which were to become ‘priority sites’ met two or more criteria, but 99 sites met only one of the three criteria, which emphasizes the importance of knowing priorities when targeting programs for impact.

 

Conclusion

We now have at hand all of the tools we need to fight the HIV epidemic – and win.  We have the program science, the ARVs, trained staff in the health centers, the experience at national, district and site levels, and organizations to support the program in every district in Malawi.  And now, we have the data.  We’ve mapped out the country’s population, reduced the programs at every site to numbers, and we have a logical approach to moving forward.  We have the ability to now intensively target our response within each facility, addressing challenges systematically, and monitoring results.  The data is complex and the road ahead still difficult, but for the first time in more than three decades, a clear end to the HIV epidemic is in sight.

 

 

A Life Dedicated to Public Health Service

Categories: HIV/AIDS, infectious disease

Ellen Wan, Division of Healthcare Quality Promotion

Ellen Wan, Division of Healthcare Quality Promotion

In January 2010, Diane Caves was on a 3-week assignment from CDC to improve HIV/AIDS programs in Haiti when the massive 7.0 earthquake struck, killing her and 230,000 others on the island. She was 31 years old and the only CDC employee to die in the tragedy. Diane’s reasons for going to Haiti were typical of her deep commitment to helping others. Her sharp intellect, optimism, adventurous spirit, and infectious smile touched all who met her. I count myself lucky to have been her colleague and friend, and her spirit continues to influence my approach to life and work.

 

Diane Caves and friend in Haiti before the earthquake. Ellen Wan (Division of Healthcare Quality Promotion) and Diane Caves were colleagues in the Office of Public Health Preparedness and Response.

Diane Caves and friend in Haiti before the earthquake. Ellen Wan (Division of Healthcare Quality Promotion) and Diane Caves were colleagues in the Office of Public Health Preparedness and Response.

Diane left an enduring legacy of public health service for CDC and the community at large. Shortly after her passing, CDC established an award in Diane’s honor to recognize early career CDC employees who inspire others in the public health community through collaboration, resourcefulness, and perseverance. Rice University, Diane’s alma mater, supports undergraduate scholarships in her memory, and Georgia State University’s School of Public Health, where Diane was completing her second master’s degree, established an award to recognize students who best exemplify her selflessness and dedication to public health.

Today, I know Diane would be right there working alongside the many CDC staff who risk their personal safety and well-being to create healthier and safer communities throughout the world, from the ongoing CDC Ebola response in West Africa to public health efforts closer to home. Through their own dedication to public health service, CDC staff honor Diane’s memory and continue her legacy every day.

Fulfilling the Decade of Vaccines Vision

Categories: Ebola, HIV/AIDS, immunization, infectious disease, malaria


Dr Rebecca MartinAs 2014 draws to a close, one theme that has been continuously present is the importance of a strong public health infrastructure in a country to effectively protect against vaccine-preventable diseases (VPDs).  Universal access to immunization is the Decade of Vaccines vision, and in order to achieve this, more efforts are needed to build upon the existing infrastructure developed for immunization programmes and other health interventions, such as for HIV prevention and treatment and malaria control and elimination.  With the importation of Ebola virus disease into Nigeria, we saw the country use its Emergency Operations Centre built to support polio eradication to quickly respond to the outbreak supporting case investigation, contact tracing, and bringing government together with national and international partners to stop the outbreak.  The infrastructure built in Uganda to collect samples from individuals at the community level for HIV testing and get them to a laboratory for testing in minimal time, can be used to quickly identify cases of epidemic-prone VPDs.  We should continue to build upon and use the experiences to save more lives and achieve global goals that have been delayed.  The coming year, 2015, marks the halfway point of the Decade of Vaccines—let us use this moment to accelerate efforts by ensuring the public health infrastructure is there to reach every individual with lifesaving vaccines.

 

A Day in Liberia — John Logan Town

Categories: Ebola

On the trip back from John Logan Town, we were stopped for nearly two hours while a new bridge was built.  I was observing the construction since this was really a once in a lifetime opportunity.

On the trip back from John Logan Town, we were stopped for nearly two hours while a new bridge was built. I was observing the construction since this was really a once in a lifetime opportunity.

Justin Williams, Health Communications Specialist, Division of Global Health Protection

Justin Williams, Health Communications Specialist, Division of Global Health Protection

I am not a morning person. In a typical week, it takes a long shower and a cup or two of coffee before I hit my stride. This was not the case for me on October 30th. I sprung out of bed at 5:00am and was ready to start the day’s mission. We were heading to John Logan Town in Grand Bassa County, Liberia to investigate if there was active transmission of Ebola. John Logan Town, which is not directly accessible by road, is home to 20,000 people. It is locally called the “City in the Jungle”.

I was in Liberia as part of the health promotion team to help interrupt transmission of Ebola through community engagement and education. My role was to provide training on social mobilization to volunteers in John Logan Town.

Dr. Meghan Weinberg, EIS Officer, introducing the CDC team to the residents of John Logan Town, Grand Bassa County, Liberia.  Dr. Pearce also provided a training on infection prevention and control during the visit.

Dr. Meghan Weinberg, EIS Officer, introducing the CDC team to the residents of John Logan Town, Grand Bassa County, Liberia. Dr. Pearce also provided a training on infection prevention and control during the visit.

We got on the road by 5:30 am and met with our colleagues from the Liberian Ministry of Health, the World Health Organization (WHO), the UN Children’s Fund (UNICEF), Concern Worldwide, Global Communities and Ehealth Africa. We were a multi-disciplinary team organized to handle the key areas of the Ebola response including case identification, contact tracing, infection prevention and control, safe burial, and of course education.

It was critical to have all elements of the team in place for the visit to John Logan Town because they had recently had a number of unexplained deaths in the community and had at least one laboratory confirmed case of Ebola in the prior weeks.

The journey to John Logan Town was an arduous one. Although the roads were wide, there were many sections of deep mud which often trapped at least one of our seven vehicles. In true team spirit, our caravan would not progress until all vehicles were freed from the mud. We crossed several handmade bridges of boards and fallen trees. We even had to ford a river to reach our final destination.

One of the vehicles in the caravan from Concern Worldwide stuck in the mud in route to John Logan Town.

One of the vehicles in the caravan from Concern Worldwide stuck in the mud in route to John Logan Town.

In John Logan Town, we did not find evidence of active Ebola cases, but we found a community thirsty for information on Ebola and how to protect themselves and their loved ones. During the 2 hour social mobilization training, we taught a group of 15 men and women, both Christian and Muslim, how to prepare their community for Ebola.

At least an additional 20 people stood and observed the training and hopefully learned more about Ebola in the process.

We discussed the signs and symptoms, ways to prevent spread of Ebola such as notifying town leadership of any sick persons, and what as social mobilizers they should accomplish by raising awareness and further educating the community.

Although there are many aspects of the response, one of the best ways to beat Ebola is to arm people with information about how they can prevent family members and health care workers from exposing themselves to Ebola. As I settled into the SUV for the rugged ride back to the hotel, I pictured the many hopeful faces who we had helped that day. And I realized that the next morning’s shower and coffee would never quite measure up to this day’s wake up call.

 

World AIDS Day 2014: Closer to an AIDS-Free Generation

Categories: HIV/AIDS

Shannon Hader, MD, MPH

Shannon Hader, MD, MPHDirector, CDC’s Division of Global HIV/AIDS

On December 1, people throughout the world observe World AIDS Day to raise awareness of the global impact of HIV/AIDS, to honor those affected by it, and—ever so importantly—to recommit to achieving more in the upcoming year. An estimated 35 million people are living with HIV/AIDS worldwide. The theme for World AIDS Day 2014 – “Focus, Partner, Achieve: An AIDS-Free Generation” – reflects the drive to focus on interventions proven to work and to partner with a broad range of stakeholders to achievecontrol of the HIV epidemic and, ultimately, an AIDS-free generation.

CDC plays a key role in fighting the epidemic. We provide scientific and technical support to more than 60 countries through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to combat a single disease. Daily, our teams are working to support Ministries of Health, community organizations, and other stakeholders to strengthen their systems to detect, manage, and respond to the epidemic; to deliver quality HIV services; and to be ready to shift as the epidemic shifts so as to ensure continued progress.

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CDC activities are grounded in science and critical to saving lives and preventing new HIV infections. Core efforts include preventing mother-to-child HIV transmission, antiretroviral treatment, and voluntary medical male circumcision. We are also helping countries build and enhance the resources they need to achieve and sustain epidemic control, including accurate, reliable laboratories and a trained healthcare workforce. Innovative programs developed and led by CDC scientists are now being used by countries to collect more detailed data that allow them to target HIV treatment services to where they are needed most and to reduce the cost of delivering services. Besides reaching more people in need, these data-driven activities support greater accountability for the use of U.S. government funds.

No single entity can do it alone. We work closely with key partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria — to which the United States is the largest contributor—to ensure maximum impact for our investments.

Together, we are making great progress: AIDS-related deaths fell by 35% since the peak in 2005 to 1.5 million, and new HIV infections decreased 38% since 2001 to 2.1 million. But millions more around the globe are waiting for access to lifesaving antiretroviral drugs, including 40 percent of eligible adults and 75 percent of eligible children. We must continue to work to reach those affected by this devastating disease, including children, adolescent girls, and other neglected and hard-to-reach groups.

The United States has made an unwavering commitment to work with partner governments and other stakeholders to turn the tide on HIV/AIDS. Working together, I know we can achieve this.

 

Tom Frieden: What I’m Thankful For

Categories: Ebola

 

This blog was originally posted on Time.com on November 20, 2014

 

CDC Director Dr. Tom Frieden

CDC Director Dr. Tom Frieden

This Thanksgiving Day, 170 CDC disease detectives, public health experts, and communication specialists will not be home celebrating with loved ones. They’ll be in West Africa, working to contain the Ebola epidemic.

Some of them are deep in remote areas, far from the home comforts we take for granted. Some are traveling on dangerous roads, by helicopter, and in dugout canoes to help stop outbreaks of Ebola. They do many critical things such as trace contacts so they can be isolated, and treated if necessary, to improve their survival and prevent spread of the epidemic. Others swelter in personal protective equipment to prepare blood samples for Ebola testing in mobile labs. Still others stay up late into the night poring over epidemiologic data to see where teams will need to be sent the next day.

Our workers on the front lines are supported by hundreds of equally hard-working staff back in Atlanta who keep CDC’s Emergency Operations Center running 24/7. They’ve been working at full speed for more than four months, and will keep going until the job is done. Thousands of other equally dedicated CDC workers continue to protect Americans from other health threats, ranging from influenza to drug-resistant infections and more. And there are teams to jump in at a moment’s notice in the event there is another case of Ebola here in the United States.

None of these extraordinarily dedicated women and men are strangers to work on holidays, weekends, or after-hours. They aren’t doing it to get rich or famous. And they won’t get thank-you letters from the millions of Americans and others around the world who won’t get sick or injured because of their work. Public health successes are usually invisible – the “dog that doesn’t bark in the night.”

Please join me in recognizing them on this day of Thanksgiving. Epidemiologists, lab scientists, public health specialists, world experts in every aspect of public health, and so many more – we all owe them thanks for the work they do at home and abroad to keep us safe and healthy.

 

Implications of Latrines on Women’s and Girls’ Safety

Categories: Emergency Response and Recovery, toilet, water, women's/maternal health

Michelle Hynes and Michelle Dynes are epidemiologists in CDC’s Emergency Response and Recovery Branch.

Michelle Hynes and Michelle Dynes are epidemiologists in CDC’s Emergency Response and Recovery Branch.

Michelle Hynes and Michelle Dynes are epidemiologists in CDC’s Emergency Response and Recovery Branch. They took a moment out of their hectic schedules to talk about their work related to World Toilet Day. Dr. Hynes and Dr. Dynes have been involved in public health activities linking the safety of women and girls to the locations and privacy of latrines in humanitarian settings.

Michelle Dynes, EIS Officer/Epidemiologist, PhD, MPH, MSN, CNM, RN

Michelle Dynes, EIS Officer/Epidemiologist, PhD, MPH, MSN, CNM, RN

During CDC’s response following the Haiti earthquake, my team worked with the International Rescue Committee and the USAID Office of Foreign Disaster assistance to address the needs of women and girls in internally displaced persons’ camps in Port au Prince. Our team evaluated the use of handheld solar lights by women and girls. We wanted to better understand women and girls’ sense of safety in the camps and to know if the solar lights were acceptable, useful, and durable.

We found that one of the primary reasons women and girls left their shelters at night was to use latrines. In focus group discussions, women identified the latrines and the paths leading to the latrines as areas where they felt the least safe. Women and girls spokes about men hanging around the latrines and nearby paths. They described lack of proper lighting in the area. They also described latrines without privacy or doors to close the latrines, with men positioning themselves so they could see inside the facilities.

After the baseline surveys, the team distributed handheld solar lights to each household and followed up every other month to explore their impact. It turned out that the lights were extremely beloved, even precious. Women reported using them at least once a day, if not more often. They used them for going to latrine, to navigate dark pathways, and kids used them for homework at night.

The intervention was successful. We know these lights had high durability and were used often. Women and girls maintained the ability to use the lights when they needed them. We think, because the lights were introduced into the household in the context of safety for women and girls, that men and boys in the family respected their rights to use the devices.

The handheld solar light project is important for women and girls. Having access to lighting is critical. Think about how many times a day you turn a light on. Here in the U.S., you expect to be able to see in the parking lot or to turn on a light when you walk into the house after dark. Giving women and girls in displacement camps access to lighting also gives them control. This is a huge change for women and girls who feel like they have little control in their lives. As an intervention, it is easy to do.

Michelle Hynes, Epidemiologist, sexual and reproductive health lead for CDC’s Emergency Response and Recovery Branch

Michelle Hynes, Epidemiologist, sexual and reproductive health lead for CDC’s Emergency Response and Recovery Branch

The project that my colleague, Michelle Dynes, described is a great example of the ways in which violence against women and girls can be prevented or reduced in humanitarian settings. The location and lighting of public latrines is only one of the safety issues in displacement camps. As part of an inter-agency task team led by UNICEF and UNFPA, I have been working on the revision of guidelines for the integration of gender based violence (GBV) interventions in humanitarian settings. Many different sectors work in humanitarian settings, such as the Water, Sanitation and Hygiene Sector. These sectors aren’t necessarily aware of actions they can take to increase the safety of women and girls or other at-risk groups, or feel confident in their ability to do so. Woman and girls who must walk into isolated areas to bathe, go to the bathroom, or get water are vulnerable to rape and other violent acts. The guidelines provide suggested actions the sector can take to reduce these risks. For example, those who are at risk can be included in the planning process for the location of the latrines and aspects of the construction such as lighting and privacy. Similar guidance will be given for all sectors working in humanitarian settings. By providing specific ways in which each sector can include GBV prevention and response activities into their normal tasks, the humanitarian field as a whole will have increased capacity to respond to and prevent this type of violence. We expect the revision of the GBV Guidelines to be completed by the end of 2014 with the official launch in 2015.

 

 

 

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