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What is Rabies?

Categories: rabies

3 dogs

Healthy Animals, Healthy People

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ryan M. Wallace, US Centers for Disease Control and Prevention

Ryan M. Wallace, US Centers for Disease Control and Prevention

Most people in the United States know rabies as a rare and terrifying disease, ending in almost certain death. However, it’s not usually something they think about, except when the reminder card arrives from their veterinarian that their pet needs its rabies vaccine booster. Even then, they probably are not considering how important that shot is to not only keep their pet safe, but also as a barrier from exposure to rabid wildlife. In addition, that single shot is a critical tool in an international battle to prevent the tens of thousands of human deaths from this disease every year.

I occasionally hear stories from friends and family members who worry about rabies. I once talked to a woman who didn’t give rabies a second thought until she was deployed to Senegal as part of the Peace Corps. Her biggest fear was getting bitten by a stray dog and contracting a disease she might not be able to recover from.

Or consider the young professional who told me a story about traveling abroad and getting bitten by a stray dog on a beach. He panicked and didn’t know if that bite was his death sentence. Thanks to decades of public health interventions, canine rabies has been eliminated in the United States. However, what most people do not realize is that approximately three quarters of the world’s population currently lives in a country where rabies is an ever-present threat.

As the Veterinary Medical Officer for the CDC Rabies team, I’ve seen the toll rabies has taken on families around the world. In Taiwan, I had the difficult task of assessing a young puppy that was attacked by a wild ferret badger during a rabies outbreak. While there were no visible wounds, we could not rule out that the puppy had been exposed to rabies. The unfortunate recommendation was to either euthanize the puppy or quarantine it for six months. The family was poor, subsiding on a small farming plot; the cost for quarantine was seemingly out of reach. Yet the family scraped together the funds and paid for the quarantine. Unfortunately, four weeks later the puppy developed signs of rabies and was euthanized. The compassion this family showed for their puppy was amazing, but in the absence of qualified rabies control officials, the consequences could have been dire if the dog had remained at home.

CDC Veterinary Epidemiologist, Ryan Wallace, trains veterinarians at a spay/neuter clinic in Ethiopia. In many parts of the world standard veterinary services, an integral component of rabies control, are not present. CDC is collaborating with the Ethiopian government, Gondar University, and Ohio State University to help improve veterinary infrastructure to keep animals healthier, and prevent rabies.

CDC Veterinary Epidemiologist, Ryan Wallace, trains veterinarians at a spay/neuter clinic in Ethiopia. In many parts of the world standard veterinary services, an integral component of rabies control, are not present. CDC is collaborating with the Ethiopian government, Gondar University, and Ohio State University to help improve veterinary infrastructure to keep animals healthier, and prevent rabies.
Photo by Ally Sterman, OC Hubert Fellow, Ohio State University School of Veterinary Medicine

Earlier this year I was in Haiti helping the local government train veterinary staff on humane euthanasia of suspected rabid animals. During the training, a veterinarian received a call from a young man who was bitten by his dog. Like many dogs in Haiti, this family pet was allowed to roam freely around the community. Three months prior to the call, the pet came home with a bite wound to his back leg. The family thought nothing of it; dog fights are common, especially among young male dogs in the neighborhood. It was now three months later and the dog was in a full rage. When the young man opened his door on this particular morning his dog lunged at him, leaving two deep bite wounds in his hand. The family was trapped inside their house for several hours until we arrived to safely euthanize the animal. Even though this animal was obviously ill, and had bitten two people, the family was still distraught by the thought of losing their beloved pet.

In Ethiopia, while assisting with a rabies vaccination clinic for dogs, we saw that people had walked for hours to get their dogs vaccinated. In particular, two boys waited more than six hours to have their dogs protected from this deadly disease. In all of the places I have traveled, I have witnessed the same truth: the human-animal bond is deep and universal, but dog-transmitted rabies is a far too familiar story for those of us who work in this field.

So what is rabies? To people in the United States, it may be something that is rarely considered. To most of the world, it is likely something they have intimately experienced. In the public health world, rabies is defined as a neglected tropical disease (NTD). Why is this? How does it happen? Some NTDs don’t cause enough deaths to be a priority to many. Some NTDs are found only in poor parts of the world, where other public health issues take priority. Some NTDs, for various reasons, do not attract international attention. Those of us working on preventing NTDs often spend more time advocating for elimination of the disease than we do actually fighting it.

What is often frustrating for those of us who are passionate about preventing NTDs like rabies is that, unlike many NTDs, rabies is vaccine-preventable. In fact, there are over 20 different approved rabies vaccines for more than six animal species (and people too!). In addition to those vaccines, there are also step-by-step recommendations developed by world experts that have been proven, when followed, to successfully eliminate canine rabies. Yet despite the existence of effective vaccines and proven successful interventions, more than 55,000 people die each year from an easily preventable disease. 95% of these deaths can be attributed to a bite from a rabid dog. All of these deaths at the jaws of rabid dogs, even though in most parts of the world it costs less than one U.S. dollar to protect a dog against rabies.

World Rabies Day was created in 2007 as a way to raise awareness for this NTD. As a veterinarian working in the public health field, I cannot imagine a more rewarding NTD to fight against and advocate for prevention. I am fortunate enough to have the opportunity to travel the world, not only to save human lives, but also to advocate for healthier, happier animals. In my travels, I am reminded of how important and loved animals are to the families with whom they share homes.

So this Word Rabies Day please take a moment to thank all of the hard-working people who spend every day to prevent you and your pets from catching this fatal disease. Thank your veterinarian for keeping your pets healthy. Thank your local animal control officer, who just tussled with that rabid fox in your backyard. Thank that doctor who reminded you to get those rabies shots before your vacation to any one of the 150 rabies-endemic countries. Hug your dogs if they are vaccinated, and get them vaccinated if they are not! (Then hug them.)

Finally, in honor of World Rabies Day, I’d like to highlight some of the many great stories about how the rabies work of CDC and our collaborators impacts the lives of families around the world:

 

What it’s REALLY like fighting Ebola in Liberia

Categories: Ebola, global health security, infectious disease

 

This blog was originally posted on the ONE.org on September 11, 2014.

 

A Médecins Sans Frontières/Doctors Without Borders (MSF) staff member ties the face mask of Dr. Jordan Tappero, CDC, before Dr. Tappero enters the Ebola treatment unit (ETU), ELWA 3. MSF operates the ELWA 3 ETU, which opened on August 17.

A Médecins Sans Frontières/Doctors Without Borders (MSF) staff member ties the face mask of Dr. Jordan Tappero, CDC, before Dr. Tappero enters the Ebola treatment unit (ETU), ELWA 3. MSF operates the ELWA 3 ETU, which opened on August 17.

Jordan W. Tappero, MD, MPH

Jordan W. Tappero, MD, MPH

During my time in Liberia, I have tried not to provide much detail to my family about the day-to-day work we are doing.

I don’t want to cause alarm or propagate fear; conditions in Monrovia can at times be deeply troubling.

I have spent the past month working to help control the Ebola outbreak in Liberia as part of the United States Government’s Disaster Assistance Response Team, or DART.

Our work here has been nonstop and it doesn’t appear that the end of the epidemic will be anytime soon. There are days when there is palpable tension in the air, especially when a new community experiences Ebola virus transmission for the first time, or experiences a second or third wave of disease.

I have seen what needs to be done to stop Ebola from spreading – find patients quickly, isolate and treat them, identify their contacts and safely bury those that die. But the scale of this Ebola outbreak is unprecedented.

The systems currently in place to identify, refer, isolate and treat Ebola cases are overwhelmed. Knowledge of how the disease is spread varies from community to community, and unsafe burial practices continue to take place far and wide.

In addition, the international response has not been enough. This is in part due to fear that is fostered by ongoing transmission of infection among health care workers with inadequate supplies of personal protective equipment, soap and clean water, and incomplete understanding of required infection control practices, or both.

As part of the DART, our goals are to help partners find people with the virus in the community, get them into Ebola treatment centers and improve infection control practices to prevent the spread of the virus to health care workers and burial teams.

I have worked with many Liberians, our CDC team, and partners in the field who are at the front of the response, and I’m amazed by their dedication in this challenging environment.

As just one example, Dr. Mohammed Sankoh, Director of the Ministry of Health and Social Welfare’s Redemption Hospital in Monrovia is now managing a primary care facility that is being overrun by suspected Ebola patients.

He has lost many of his staff (doctors, nurses, a physician assistant and a midwife) to Ebola. His remaining staff are fearful of coming to work, and his community is increasingly afraid of coming to the hospital, with many preferring to die at home.

In his own words “When we had our civil war, we knew who we were fighting, but with Ebola, the enemy is invisible, and it is taking us in increasing numbers.”

We simply need more people to step up to help supply, train and equip Liberian nationals to take on the epidemic.

The work is challenging, yet highly rewarding. The United States’ effort in Liberia is but one cog in a larger wheel of the response that is striving to save lives. However, I am certain that the epidemic would be even worse without our presence.

I am grateful to be able to contribute to the fight against this scourge.  And the Liberian people are thankful that the U.S. has not abandoned them.

We need others to join in the fight against Ebola. But let’s not stop there.

To prevent such public health events, all countries need to have the capability to prevent the spread of infectious disease threats quickly, detect them accurately, and respond to them effectively.

It is heartbreaking to see countries like Guinea, Sierra Leone and Liberia trying to tackle this epidemic with inadequate public health infrastructure and trained public health and medical workforce that could have averted it with modest investment.

It is a global health security imperative to contain Ebola in West Africa and to prevent its spread across the continent and beyond.

An Important Partnership in Central America

Categories: health systems strengthening

 

Central America

On the streets of Tegucigalpa or San Salvador or Santo Domingo or in the capitals of five other Central American countries, few people would be able to provide an answer to this question: What is the Council of Ministers of Health of Central America’s (COMISCA)?

Dr. Nelson Arboleda, CDC Central American Regional Office Director

Dr. Nelson Arboleda, CDC Central American Regional Office Director

Despite the understandable lack of awareness, COMISCA has emerged as an important—and effective—mechanism for improving public health across the region. It has unified eight disparate nations into a singular force in the fight against leading causes of death and illness. CDC is one of COMISCA’s prime partners.

COMISCA’s mandate and reason for existence, in fact, is both straightforward and crucial: improve public health in a part of the world beset by health challenges, strained budgets, and technical limitations by joining forces and combining resources. The idea is that by locking arms, sharing data and logistics, and agreeing on a public health blueprint, people in every country will be better protected from illness.

That is good news for the member countries: Belize, Costa Rica, Guatemala, El Salvador, Honduras, Nicaragua, Panama, and the Dominican Republic. COMISCA is led by ministers of health from the countries with the Council’s chair rotating every 6 months.

Since its creation in 1991, COMISCA has shown promise almost from the start. Results, in fact, can already be found in each of the member countries. The ethos is captured in the title of a 2009 document outlining the goals and targets for 2010–2015: “United for the Health of Our People.”

Some of the goals are obvious. Consolidating national surveillance systems and sentinel integrated viral and bacterial diseases is one. Joining forces in a unified and comprehensive way in battle against HIV/AIDS is another. Refining the system for detecting influenza and other infectious diseases to make it more sensitive, accurate, and universal is yet another legitimate aspiration.

Its potential for success and capacity to join forces are the main reasons why CDC not only recognizes COMISCA’s promise but why CDC has fully embraced the organization by offering both financial and technical support, becoming CDC’s most important strategic partner.

CDC, in fact, is currently COMISCA’s largest funding partner, providing approximately $1.3 million per year. Laboratories and disease surveillance are two of the major focuses in the partnership. That emphasis is underscored by CDC’s five-year cooperative agreement with COMISCA designed to develop a regional public health surveillance and laboratory network in the region.

The agreement, which was finalized in 2010, provides funding and technical guidance necessary to create a more robust and effective surveillance network and an upgraded laboratory system. It also includes tools to improve emergency preparedness for Central America and the Dominican Republic while enhancing regional cooperation.

At its core, the goal is to build a more comprehensive surveillance platform that can effortlessly share public health information while also supporting the regional implementation of WHO/PAHO International Health Regulations.

Those are lofty but sufficiently vague goals. In real-life, on-the-ground terms, COMISCA has, in recent years, been a conduit for

  • Providing and orchestrating technical assistance and training to better detect and respond to the influenza pandemic in Central America. As part of that effort, it developed the “Guide to Respiratory Disease Surveillance of Nicaragua”; provided critical supplies and inputs to the National Laboratory of Honduras; and produced newsletters and other materials with product information and influenza surveillance results.
  • Working to integrate and harmonize the assortment of surveillance systems for HIV/AIDS used across the region. A key element of this effort is identifying gaps and needs in the surveillance network.
  • Creating a web portal to make it easier to share information.
  • Working broadly to meet International Health Regulations including upgrading tools and systems for detecting disease. These improved early warning tools “allow the use of historical data and…algorithms tailored to the country…[and to] issue alarms on abnormal behaviors of different diseases monitored by the information systems of the country.”
  • Developing protocols and guidelines for updating, strengthening, and standardizing laboratories across the region. A key element is sharing experiences to strengthen the entire systems. For example, Dominican health officials would share their experience and lessons learned in the diagnosis of cholera.

It’s a strong record with numerous and demonstrable achievements. But the challenges are also large and demonstrable which means the work of COMISCA and its partners, including CDC, is far from finished.

Indonesia Takes a Leadership Position in the Global Health Security Agenda

Categories: global health security

Maluku mom and kid with mosquito bed net (Photo courtesy of Edi Purnomo, UNICEF)

Photo courtesy of Edi Purnomo, UNICEF

Dr. William Hawley, Country Director for CDC-Indonesia

Dr. William Hawley, Country Director for CDC-Indonesia

As the world’s fourth most populated country, Indonesia plays an important strategic role in protecting the global community from infectious disease threats. As one of the early countries to take a leadership role in the Global Health Security (GHS) Agenda, the Government of Indonesia will welcome senior health and agricultural leaders from 36 countries and 12 international organizations for the next commitment meeting August 20-21. The meeting, “Building Global Commitment to Multisectoral Approaches to Manage Emerging Zoonotic Diseases in Support of the Global Health Security Agenda within the Framework of Public Health”, demonstrates the progress and growing momentum of the GHS Agenda.

The High Stakes in Fighting Ebola: Leave One Burning Ember and the Epidemic Could Re-Ignite

Categories: Ebola, global disease detection, global health security, health systems strengthening, infectious disease

 

This blog was originally posted on the Huffington Post on August 7, 2014.

 

A banner encouraging people suffering from Ebola to go immediately to a health center for treatment is seen on a sidewalk in the city of Freetown, Sierra Leone, Thursday, Aug. 7, 2014. While the Ebola virus outbreak has now reached four countries, Liberia and Sierra Leone account for more than 60 percent of the deaths, according to the World Health Organization. The outbreak that emerged in March has claimed at least 932 lives. (AP Photo/Michael Duff)

(AP Photo/Michael Duff)

CDC and our partners are currently fighting the biggest and most complex outbreak of Ebola virus disease ever recorded.

CDC Director Dr. Tom Frieden

CDC Director Dr. Tom Frieden

There are hundreds of cases in West Africa and now a new cluster of cases in Nigeria is very concerning. The spread of Ebola shows what happens if we don’t have meticulous infection control, contact tracing, and proper isolation of those with symptoms of the disease.

There are two things that are very important to understand about how Ebola spreads.

The evidence suggests that Ebola only spreads from sick people—not from people who have been exposed to the disease but haven’t yet become sick from it. The illness has an average 8-10 day incubation period, although in rare instances the incubation period may be as short as two days or as long as 21 days, which is why we recommend monitoring for 21 days after any potential exposure.

Global Health Security in Africa: Collaborations Between CDC and African Partners

Categories: global health security

2012 investigation of Ebola virus in Uganda

2012 investigation of Ebola virus in Uganda

Thomas Kenyon, MD MPH, Director of CDC Center for Global Health

Thomas Kenyon, MD MPH, Director of CDC Center for Global Health

The ambition and scope of the Global Health Security Agenda are clear. Its reach can be discerned from the very first word: global. The Agenda’s overarching goal is just as expansive—making the world safer and more secure by preventing epidemics and outbreaks, detecting them more rapidly, and responding effectively to lessen the health, economic, and societal consequences from disease threats.

Less obvious, but no less true, is that African ownership will be central and fundamental in shaping the way the Global Health Security Agenda evolves worldwide, the way it is enacted and refined, and to a large extent, how it succeeds.

CDC and African nations have been close and successful partners for many decades in the battle to protect and improve public health. In many ways, the concepts, practices, and tools that are central to the Global Health Security Agenda are drawn from experiences honed with our partners in Africa over many years.

Strengthening Vaccination Systems – how it STARTs

Categories: immunization

On the road to Bukwo District (photo courtesy of George Momanyi)

On the road to Bukwo District (photo courtesy of George Momanyi)

George Momanyi, Public Health Nurse, START Consultant

George Momanyi, Public Health Nurse, START Consultant

George Momanyi, a public health nurse from Kenya, has twice served as a consultant with CDC’s Strengthening Technical Assistance for Routine Immunization Training (START) project in Uganda.  START, funded through a grant from the Bill & Melinda Gates Foundation, provides mentoring and on-the-job training to district-level immunization officers and service providers in areas with high numbers of unimmunized children. START consultants make regular visits to district health officers and service providers, delivering training and reinforcing the application of practical job skills.  START’s objective is to build the capacity of program staff and thereby strengthen the overall immunization system. 

As a START consultant, George worked in eastern Uganda from July-December 2013, and in northern Uganda from February-June 2014. As he was ending his service on the 2nd START team in June, he sent us this blog about his experience.

CDC Scientist Fights Chikungunya

Categories: chikungunya, mosquito-borne disease

investigation in Comoros in 2005.

Investigation in Comoros in 2005.

Ann Powers, Ph.D., Research Microbiologist and Chief of the Alphavirus Laboratory in CDC’s Division of Vector-Borne Diseases

Ann Powers, Ph.D., Research Microbiologist and Chief of the Alphavirus Laboratory in CDC’s Division of Vector-Borne Diseases

One of the most telling signs of the complexity surrounding chikungunya is that educating people on pronouncing the name correctly is perhaps the easiest challenge.

I’m exposed to that truth more than most.  And for the record, it’s pronounced chick-un-goon-ya.

As a research microbiologist for CDC’s National Center for Emerging Zoonotic and Infectious Diseases, my job is to better understand and occasionally chase (literally) an often overlooked, mosquito-borne, threat to public health; one that holds the potential to spread sickness and misery in the United States.

Chikungunya is viral disease that is transmitted to people by two species of mosquitoes that are present in the United States. Aedes aegypti and Aedes albopictus, often called the Asian tiger mosquito, can be found in about a third of the U.S.  They are the same mosquito species that transmit dengue in much of the tropics.  And while chikungunya does not kill people, the toll it inflicts ranks high on the misery index; it hits fast and hard and with almost no subtlety. People infected with chikungunya typically experience high fever and severe joint pain soon after they are exposed. Sometimes those problems are long-lasting.

World Cup serving as real-world test for new disease detection technology

Categories: global disease detection, global health security, health systems strengthening, infectious disease

 

World Cup soccer ball

 

With the World Cup underway in all its frenzied glory, you can be forgiven for missing another major effort currently underway in Brazil that represents the first large scale, real-life, real-world test of important new technology.

And no, it’s not the goal-line technology that’s being used for the first time at soccer’s biggest competition.

This technology uses computer tablets, sophisticated software designed by CDC and public health experts from Brazil’s Ministry of Health (MOH) trained in the Field Epidemiological Training Program (FETP) to provide the most complete, detailed and timely information about disease threats and other public health concerns.

Polio Eradication, Microplanning and GIS

Categories: child health, immunization, polio

A Bugagi child travels by camel near Lake Chad in Borno State, Nigeria. Photo courtesy of Thomas Moran/WHO.

A Bugagi child travels by camel near Lake Chad in Borno State, Nigeria. Photo courtesy of Thomas Moran/WHO.

Victoria Gammino, PhD, MPH, Epidemiologist, CDC Global Immunization Division

Victoria Gammino, PhD, MPH, Epidemiologist, CDC Global Immunization Division

Geospatial data have been used in public health since John Snow mapped cholera cases around the Broad Street water pump during the London cholera epidemic of 1854.  And, while global positioning system technologies (GPS) are so ubiquitous in the United States that virtually all new smartphones, tablets and cars have this technology embedded, in many areas of the world, health care workers in the field are often without the most basic two-dimensional paper maps.

So what do maps and map literacy have to do with polio?  Polio is a crippling and potentially fatal infectious disease. There is no cure, but there are safe and effective vaccines. Therefore, the strategy to eradicate polio is based on preventing infection by immunizing every child to stop transmission of the virus that causes polio, and ultimately make the world polio free.   The four pillars of polio eradication all rely on “microplans”— detailed logistical blueprints that guide the planning and implementation of vaccination campaigns, routine immunization outreach, and surveillance for polio cases by providing critical data on the size and location of the target population in a given geographic area.  These target population numbers determine the amount of vaccine required, the number of health care workers and supervisors to deliver the vaccine, and the cost of transportation to get the vaccine and health care workers where they need to go.

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