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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.

Chikungunya’s reach has been rapidly expanding for eight years. From its origins in Africa, it’s been detected throughout tropical Asia, in Italy and France, and since December, 2013, in the Caribbean, including in the U.S. territories of Puerto Rico and the U.S. Virgin Islands. Today, the Pan American Health Organization (PAHO) reports more than 300,000 suspected cases of chikungunya have been identified across the Caribbean, Central, and South America.

Investigation in Comoros in 2005

Investigation in Comoros in 2005.

And while it hasn’t taken root yet in the United State yet there are cases in travelers. On average, several dozen cases have been introduced each of the last five years into the U.S., all from people coming from countries with active transmission.

More than one-third of the United States has the warm to moderate climate necessary for the mosquito vectors, which are known to be “aggressive daytime biters.” Since the virus has largely been absent from the United States, there’s a huge population with little to no immunity. But a large-scale outbreak in the mainland U.S. will not be easy to achieve. There has to be a perfect convergence of enough mosquitoes and infected people as well as timing. Mosquitoes become infected when they feed on a person recently infected (within the first few days of illness onset) with the virus.  That infected mosquito can bite another person who may then become infected with the virus.  Outbreaks occur when multiple mosquitoes and humans get infected.

The potential, however, for limited transmission is real and it’s the reason CDC has been actively working to curb the virus and the threat it poses to humans.  There is no vaccine and in most cases the best medical response is using over-the-counter medication such as acetaminophen or ibuprofen to treat fever and aches.

Much of CDC’s work is with regional partners. Since 2010 for example, CDC has joined with the Pan American Health Organization to craft a regional surveillance and response plan for the Americas. CDC has also developed, evaluated, and published diagnostic testing protocols, produced and distributed diagnostic test reagents and positive controls and developed notices with specific information for health departments, health care providers, and travelers, among other acts.

Other work is with state and local health departments, including in Puerto Rico and the U.S. Virgin Islands. My colleagues and I are educating public health officials and physicians about the disease and the need to consider using laboratory testing to confirm the virus, particularly with samples from areas not previously affected. Getting accurate chikungunya surveillance data is challenging because the disease is not a “nationally notifiable disease” in the United States.

Even harder are the demands of the groundwork which often requires labor-intensive efforts to trap and count mosquitoes; getting an accurate census of the distribution and type of mosquitoes is critical to predicting chikungunya’s threat. Even in places like Florida and Texas where the mosquito vectors thrive and where the threat is real, tight budgets in local and state public health agencies can make it difficult to find partners.

The science is just as challenging. The virus, like all viruses is ever changing, subject to mutations that can affect its potency and how it’s treated.  And yet, progress has been realized. In the 15 years public awareness of the virus has grown. People understand that preventing mosquito bites by covering as much skin as possible, using insect repellent and convincing local governments to more aggressively combat mosquitoes remain the best defense.

Refining surveillance data along with a deeper understanding of the biology and clinical aspects of chikungunya has also prompted pharmaceutical companies to work on a potential vaccine. Several show promise and the pace will accelerate as comprehensive data better defines CDC’s capability to  predict chikungunya’ s reach, where it may be heading, and what populations are most at risk. All of it means that a reasonable goal is that 10 years from now chikungunya will be on the decline because we will better understand the virus and have more effective control options widely available.

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.

The tablet-based system and the Epi Info software driving it are seen as an important advance in disease surveillance that gives users the ability to identify outbreaks earlier and with more precision. That ability is especially important in “mass gatherings” such as the World Cup and other major events which is why this disease detection system is being tested this month.

The tablet-based system and the Epi Info software driving it are seen as an important advance in disease surveillance that gives users the ability to identify outbreaks earlier and with more precision.

The tablet-based system and the Epi Info software driving it are seen as an important advance in disease surveillance that gives users the ability to identify outbreaks earlier and with more precision.

The effort also highlights something else – the long and deep relationship between CDC and Brazilian health authorities.

In this case, CDC developed the tools and helped train Brazilian officials to use the technology. Many of the officials trained to use the software are graduates of the Brazil MOH’s FETP, a highly successful program that has taught scores of “disease detectives.”

The roles are clear and distinct. The technology and all the data collected during the mass gatherings, for example, are controlled entirely by Brazilian health authorities and not shared with CDC or any other outside entity. The same is true for where the system is used; the decisions rest solely with the Ministry of Health.

Mass gatherings like the World Cup represent ideal opportunities because they are planned events, fixed in time allowing us to be more prepared for use of this new technology in an unpredictable event such as a natural disaster, said Victor Caceres of CDC’s FETP Branch.

The effort, two years in the making, is being put to the test in the current “mass gathering” of fans, players, and others at the World Cup. It is the first large-scale (both numerically and geographically) system designed to collect, then stream data seamlessly in real time to a central location where public health officials will have access to a comprehensive set of data.

That goal is achieved through a surveillance system that collects real time health data and displays this information in a centrally located dashboard for analysis and response. And by using a popular tech gadget – a computer tablet.

There’s also geographic diversity. The World Cup is being played in 12 locations across Brazil with dramatically different climate and even health profiles of the population.

Analysis of results

Analysis of results

In fact, the system was tested prior to the World Cup in three small events in Brazil that confirmed the design and the promise of the technology. The first test-run was in January at Aparecida, São Paolo when 250,000 people came to the national shrine. The focus was to test the mobile survey tool’s ability and reliability to collect data in real time and observe data collection on a dashboard in the operations center in real time.

“In this partnership, beyond the improvement of these new features of Epi Info, we have the opportunity to enhance surveillance in mass events and to understand the use of data collection in real time in response to public health emergencies,” said Dr. Wanderson Oliveira, Director of Surveillance and Emergency Response for Brazil’s MOH. “The Ministry of Health intends to adopt this strategy to increase the speed in investigations of outbreaks and other emergencies.”

The next trial came in February and March for carnival in the city of Fortaleza where more than 2 million people converged. The final test came in May during a gay pride event in São Paolo attended by 4 million people. The added feature in this trial was that, in addition to providing surveillance at hospitals and clinics the system was also used in major transportation hubs such as airports and rail stations.

The software is the key. Tablets are pre-loaded with specialized CDC developed software known as Epi Info that allows field deployed epidemiologists to collect data for a wide array of categories and indicators. The data is stored offline until Internet connectivity is available, at which point it is sent to “cloud” computer storage for aggregation. At a “home base” that is often an emergency operations center the data can then be viewed on a dashboard that is continuously updated with statistical results, charts, and maps.

The capability will allow outbreaks to be detected far quicker than with previous technology. That ability is important at any time but even more crucial at mass gatherings such as the World Cup or Olympics or in natural disasters where disease can spread faster and in less predictable ways.

Staff responsible for the technologyIlanit Kateb, a public health advisor for the Center for Global Health was deeply involved in developing the project and helping Brazilian officials use it, said Brazil was the perfect collaborative environment. She cited CDC’s long and close relationship with the Ministry of Health and fact that the country’s FETP program is thriving and that Brazil has a long and successful history in public health.

“Brazil is a high-capacity partner,” she said, “and it openly accepted this program and our collaboration.”

This system, Kateb said, shows how FETP is adapting and evolving, using new technology and techniques for a new generation of disease detectives.

With the system functioning well after the first two weeks of the World Cup, Asad Islam, CDC’s Epi Info team lead, said that it is conceivable to take the lessons learned there and apply them to other public health surveillance and response activities related to outbreaks, natural disasters or humanitarian crises.

That remains in the future, however. As successful as the World Cup experience has been to date, Kateb emphasized the system is still in pilot stage. More tests and evaluation are needed before it can be released into wide use by FETP “disease detectives” globally.

No one doubts, however, that that goal will be reached. The only question, they say, is, when?

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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.

CDC Staffers Take No Refuge From Helping Refugees Around the World

Categories: infectious disease, refugee health

A child plays with a kite in a tent camp after the earthquake, Port-au-Prince, Haiti, 2010.

A child plays with a kite in a tent camp after the earthquake, Port-au-Prince, Haiti, 2010.

For anybody wondering why CDC has a branch dedicated to helping refugees or why the United Nations has formally recognized World Refugee Day every year since it was created in 2001, the answer can be found in a single, stark statistic: In 2013, a person became a new refugee or internally displaced person every 4.1 seconds.

Michelle Dynes, PhD, MPH, MSN, CNM, RN, EIS Officer/Epidemiologist, CDC Emergency Response and Recovery Branch

Michelle Dynes, PhD, MPH, MSN, CNM, RN, EIS Officer/Epidemiologist, CDC Emergency Response and Recovery Branch

Cyrus Shahpar, MD, MBA, MPH, Medical Epidemiologist, CDC Emergency Response and Recovery Branch

Cyrus Shahpar, MD, MBA, MPH, Medical Epidemiologist, CDC Emergency Response and Recovery Branch

That translates to “a population of concern” of nearly 40 million refugees or internally displaced people worldwide every year, according to the United Nations.

It also translates to a lot of illnesses and suffering. And that’s the reason Cyrus Shahpar, Michelle Dynes and approximately 50 other staff in CDC’s Emergency Response and Recovery Branch (Division of Global Health Protection) have their bags packed and are constantly ready to deploy to the field.

Communication Matters in Global Health Deployments

Categories: global health security, infectious disease

During the simulation exercise, ECN trainees deployed to the site of a mock disaster in Avully, Switzerland.

During the simulation exercise, ECN trainees deployed to the site of a mock disaster in Avully, Switzerland.

Communication matters.

Gaya Gamhewage, MD, Coordinator, WHO Communication Capacity Building Team; Founder, WHO Emergency Communication Network

Gaya Gamhewage, MD, Coordinator, WHO Communication Capacity Building Team; Founder, WHO Emergency Communication Network

That’s not a new idea. Many of us have learned this the hard way. This concept is being applied in a new, more comprehensive way for a key purpose—to help the World Health Organization (WHO) communicate more effectively, with more clarity and purpose during humanitarian and public health emergencies.

The idea is to better integrate communications specialists from WHO, CDC, ministries of health and a wide array of other humanitarian and global health organizations into a cohesive, specially trained team that can be dispatched on short notice when public health or humanitarian emergencies occur.

The logic is based on the idea that communications is part and parcel of emergency health response. Communicating in a crisis not only provides the public and policy maker clear and critical information, it also can help the technical side of the response. It connects those affected with those willing to help and can make sure that resources are aligned to the most important needs.

Voices from the Central African Republic: FELTP residents remain committed to strengthening disease surveillance and outbreak response in CAR

Categories: child health, immunization, infectious disease, refugee health

CAR refugees forced from their homes by rebels

CAR refugees forced from their homes by rebels

Dr. Els Mathieu, Resident Advisor, CAR- FELTP

Dr. Els Mathieu, Resident Advisor, CAR- FELTP

The Central African Republic (CAR) is a landlocked country in Central Africa, bordered by Chad in the north, Sudan in the northeast, South Sudan in the east, the Democratic Republic of the Congo and the Republic of the Congo in the south and Cameroon in the west.  CAR is one of the world’s least developed nations and has experienced several periods of political instability, as well as deadly attacks and violence by rebels that have forced nearly 1 million people from their homes in search of refuge.  With so many civilians fleeing to refugee camps in the capital, Bangui, and the provinces, there is an increased need to strengthen disease surveillance and response.

A Call for Action: Responding to the Tobacco Epidemic and the Price of Cigarettes

Categories: cancer, cardiovascular disease, noncommunicable diseases (NCDs), tobacco

Woman smoking tobacco

“Raising taxes to increase the price of tobacco products is the most effective means to reduce tobacco use and encourage smokers to quit.” – WHO Report on the Global Tobacco Epidemic, 2013

Samira Asma, DDS, MPH - Chief, CDC Global Tobacco Control Branch

Samira Asma, DDS, MPH - Chief, CDC Global Tobacco Control Branch

Real People, Real Stories

Mehmet Nuhoğlu started smoking when he was in middle school at the age of 12 after hearing that real men smoke. Little did he know that 45 years later his two pack a day addiction would lead to a heart attack and then cancer. “I never thought it would happen to me. I still can’t believe it,” he says.

Featured in national ads similar to the US Tips campaign, Mehmet was one of the real-life people featured in Turkey’s anti-tobacco mass media campaign that was launched in the later part of 2011. He tells of his experience with cigarettes and what daily smoking ended up costing him- his voice and his health. Now speaking with the help of an electrolarynx (a device that helps users who have lost their voice box produce clearer speech), he confesses that he regrets smoking.

Public Health Informatics in Action in Malawi: Making life easier for healthcare workers and patients while improving quality through an innovative national Electronic Medical Record System

Categories: HIV/AIDS, child health, global health security, women's/maternal health

Instituting an Electronic Medical Record System reduces the need to manage and store growing volumes of patient charts, a major challenge in resource-limited settings.

Instituting an Electronic Medical Record System reduces the need to manage and store growing volumes of patient charts, a major challenge in resource-limited settings.

Denise Giles, M.P.H., Health Scientist, CDC-Malawi

Denise Giles, M.P.H., Health Scientist, CDC-Malawi

Keeping track of even one patient undergoing treatment for HIV/AIDS can be complicated enough.

Doing it for over 472,865 patients when you’re a low income country coping with high demand and a sputtering economy magnifies the complexity.

Which is why Malawi’s story – and its solution – is attracting attention and praise. It’s a story of how Electronic Medical Record System (EMRS) technology is being used and the foresight needed to bring it to reality.

You don’t have to look far to see the positive results.

CDC Protects Families: My favorite stories

Categories: child health, malaria, tuberculosis (TB), women's/maternal health

Terri Still-LeMelle

Terri Still-LeMelle

As we celebrate families on Mother’s Day, May 11, and the International Day of Families, May 15, I am especially proud to work in CDC’s Center for Global Health.  As one of the Center’s  health communication specialists, I have the privilege to write or edit many stories about how CDC’s programs impact the lives of families around the world.  In honor of this season, I’d like to highlight a few of my favorite accounts about brave mothers, determined families, and CDC’s global health programs.

 
 
 
 

FETP Work in South Sudan Benefits the Whole World

Categories: global health security, health systems strengthening

I’ve been with the Field Epidemiology Training Program (FETP) for 2.5 years now, where I am currently the resident advisor (RA) in South Sudan. My epidemiology training has provided me with the opportunity to gain a wide variety of experiences; prior to joining FETP, I served as an epidemiologist with Médecins Sans Frontières-Switzerland (MSF-CH), working in the refugee camp in Dadaab, Kenya, and have also worked in Dawei (Tavoy), Burma . I am glad to be able to pass on my knowledge about epidemiology to future leaders in the field. As an RA I assist with basic FETP implementation for county and state surveillance officers as well as immunization managers and supervisors. I also advise on outbreak response for priority diseases as well as assist with cascade training for the health facility staff who provide immunization services.

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