African Field Epidemiology Network: My Experience Attending the 2018 AFENET Conference in Maputo, Mozambique

I attended the African Field Epidemiology Network (AFENET) from November 12th-16th in Maputo, Mozambique. It was a great opportunity to hear about the on-the-ground public health work being conducted in 31 countries on the African continent and efforts being made to build field epidemiology capacity. The theme of the conference was, “Building Resilient and Sustainable Public Health Systems in Africa Through Field Epidemiology Training.” My first session to participate in was the preconference workshop, “Orientation to International Outbreak Response with WHO and Global Outbreak Alert and Response Network (GOARN) in the African Region.” Participants spent a full day learning about how to become involved in international public health deployments through the AFENET network, working through complex exercises in groups, and assessing our individual readiness to deploy if needed. Attendees from Zambia, Guinea, Cameroon, Nigeria, Uganda, and many other countries were represented at this session.

There were also great plenary sessions. My top three sessions (of those I had the opportunity to attend) included: 1) Implementation Science in Public Health (presentation given by Dr. Echezona Ezeanolue), 2) Transforming Public Health Surveillance – Proactive Measures for Prevention Detection and Response (presentation given by Dr. Scott JN McNabb), and 3) North-South Collaboration for Public Health Workforce Development: The Case of Washington University & University of Zimbabwe (Dr. Janet Baseman, Dr. Notion Gombe and Audrey Hu). All of these sessions either resonated with me or challenged me to think outside the box to take needed risks as a public health professional.

Now, the real reason I had the opportunity to attend the AFENET conference was to provide support and technical assistance to the Zambia Field Epidemiology Training Program (Zambia FETP). Zambia FETP had 6 residents present a mixture of poster and oral presentations over the course of 5 days. Our residents shined not only in the scientific sessions but also when it came time to share about the nation of Zambia during the International Night that was held towards the end of the week. Overall, I learned that providing support also meant helping showcase a popular Zambian dance, assisting with handing out small gifts and pamphlets to colleagues from other countries, and participating in insightful conversations about what true mentorship looks like.

Some highlights of the conference included catching up with two of my fellow PHI/CDC Global Health Fellows, having breakfast with my mentor, being near the beach, building relationships with our residents, meeting our points of contacts from CDC Atlanta, connecting with the Nigerian FETP and, of course, networking with a diverse array of public health leaders from the African continent. There were a few challenges as well. I was sick for the first few days of the conference. There were many hiccups that occurred prior to the conference which led to me only being able to attend last minute. Finally, the theme of the conference made me reflect on gaps I see in epidemiology capacity when I consider situations like the current Ebola outbreak in the Democratic Republic of the Congo (DRC) and wonder what, if any, impact I may be able to make during my time here.

Sophia Anyatonwu, MPH, CPH, CIC
Epidemiologist
Global Epidemiology Fellow | PHI/CDC Global Health Fellowship Program

 

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International Infection Prevention Week: Snapshot from the Field

 

During the last two weeks of September, I had the opportunity to participate in a week-long surveillance training and a week-long Ebola/Cholera Preparedness Training, respectively. Here at the CDC Zambia office I work with the Field Epidemiology Training Program. Our goal is to provide technical assistance and expertise in order to build local epidemiology capacity in Zambia. The surveillance training we conducted was geared towards surveillance officers that work in various districts throughout Zambia. These officers are accepted into a Frontline program as residents and trained on the public health surveillance cycle over the course of 3 months. The training is both classroom learning and hands-on application as residents are given projects that take them through the surveillance cycle and provide them with an opportunity to explore the data in their jurisdictions. My role during this first training was to lead excel trainings and assist with daily pre and post tests. I enjoyed the surveillance workshop so much that I feel a similar curriculum should be provided to all entry-level epidemiologists working in governmental public health in the states.

The Ebola/Cholera Preparedness Training was very intense. It was a collaboration between CDC Zambia, WHO, Zambia National Public Health Institute, local universities, and the Ministry of Health. Lectures and hands-on training were incorporated into this workshop as well. The participants consisted of surveillance officers, environmental health technicians, laboratory specialists, and health directors from various districts. These individuals make up a newly developed rapid response team that is being built in Zambia. During the Ebola preparedness portion of the training, participants were trained on triage, wearing proper PPE, lab specimen packing/shipping, setting up a treatment center, and transporting ill patients. The cholera preparedness portion consisted of a discussion about what went well and what didn’t go so well during last year’s cholera outbreak that lasted ~8 months. Participants walked through the process of investigating an outbreak and creating products such as epi curves and line lists. I could see the light bulbs going off for many people as they realized how efficient this was for ensuring data quality and tracking cases. Lightbulbs also went off during discussions about how to appropriately use the Incident Command System. My duties consisted of helping in the triage station, acting out scenarios, and helping with pre and post tests. Participants are now tasked with going back to their jurisdictions to train others.

Some interesting things to note is that we have built in “tea times” where you can take a coffee or tea break and grab a snack, someone is also asked to pray at the beginning and end of the day, and there are usually lengthy delays when it comes to gathering large groups together for training/workshops (but things come together at the end).

Sophia Anyatonwu, MPH, CPH, CIC
Epidemiologist
Global Epidemiology Fellow | PHI/CDC Global Health Fellowship Program

 

 

 

Health in All Policies Faculty Development Workshop-June 18-20 in Washington, DC

The World Health Organization (WHO) in collaboration with the Association of Schools and Programs of Public Health (ASPPH) and the National Environmental Health Association (NEHA) invites you to attend a Health in All Policies (HiAP) skill-building workshop from June 18-20 in Washington, DC to build education/training and practice approaches that move policy in support of both health and the environment. Air pollution will be used to provide case examples throughout the workshop.

The deadline for applications is April 25, 2018. To apply online, please visit the ASPPH page here. The WHO site provides more background here.

 

National Public Health Week is Here!

National Public Health Week (NPHW) is a great opportunity for public health professionals to rally together and raise awareness about work that is being carried out around the nation. NPHW will take place from April 2nd to April 6th this year. It specifically highlights, “Generation Public Health,” a movement focused on creating the healthiest nation in one generation by supporting initiatives and policies that improve social and environmental factors which impact health. No matter what stage you are at in your public health career, you can get involved this week!

The theme of NPHW 2018 is Changing Our Future together. The key focus is to:

Additionally, daily themes will be highlighted in order to focus on one public health topic a day.

 

 

Ways To Get Involved

 

Feel free to also highlight and share social media posts of events that are being held in local neighborhoods, schools, workplaces, and public health organizations near you! Make sure to include the following hashtags with your pictures and social media posts: #NPHW, #1BillionSteps, @ih_section, #ih_section!

 

NPHW 2018: Healthiest Nation Poem/Song

We want to be the healthiest nation
in one generation
for communities to have a solid foundation
where safety is the norm and we can all be free
to live life to the fullest and pursue our dreams
as we breathe clean air while we sleep, work, and play
our youth go to school and graduate
Our jobs lead to wealth, health, and have meaning
but there are services in place “for the time being” 
when we reach those moments that we fall through the cracks
or fall on hard times and it’s hard to come back
our nation truly practices justice for all
communities are well informed to sound the call
for various needs like fresh water and meals
or access to sidewalks for bicycle wheels
healthcare and prevention go hand in hand
so that unhealthy practices have low demand
Yes, the healthiest nation 
is what we aim to be 
in one generation is when we hope to see
public health infrastructure and improved capacity
to truly serve our nation and support communities

Listen here: https://soundcloud.com/sophianyatonwu/nphw-healthiest-nation

Sophia Anyatonwu, MPH, CPH, CIC
Epidemiologist II

 

Maternal Mortality in the United States: A More Comprehensive Picture to Advocate for Changes that Save Lives

In 2014, I had the opportunity to work with the Health Resources and Services Administration (HRSA) Graduate Student Epidemiology Program (GSEP). My project was focused on evaluating the maternal mortality review committee process in Georgia. Early on, most of my work consisted of becoming familiar with the global burden of maternal mortality (starting with the 2010 Amnesty International special report on maternal health care in the United States– This report criticized estimated maternal mortality ratios that gave the United States (U.S.) a subpar global ranking based on data published by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNPF), and Word Bank in 2005– despite the U.S spending more than any other country on health care), becoming acquainted with appropriate case definitions for surveillance, and reviewing various maternal mortality review data sources to gain situational awareness of the distribution and determinants of maternal mortality in the United States. Ultimately, this led me to realize that, although maternal mortality was seemingly rare and largely preventable in the U.S, the disparities that existed based on race, socioeconomic status, and quality of care were concerning.

 

As the heart of my project took off, I learned about key aspects of Georgia’s maternal mortality review committee. The committee, like others similar to it, was tasked with identifying maternal deaths using multiple data sources, reviewing medical records and death certificates to classify cases accurately (i.e. not a case, pregnancy-related, or pregnancy-associated), and evaluating which deaths were truly preventable. The process evaluation that I conducted assessed whether the review process was taking place as intended, best practices were being employed, and pregnancy-related deaths were accurately being classified. The evaluation also provided action points and recommendations that included tracking and reporting dissemination efforts intended to inform provider care, having a unified voice on the topic of maternal mortality in the state (due to conflicting local news headlines or statements made), defining process indicators, and developing a feedback loop for policy and educational changes.

 

After returning to my home state of Texas and joining the public health workforce, I remained interested in maternal mortality and learned that work was being done here too- in the form of a Maternal Mortality and Morbidity Taskforce. That was about a year and a half ago. More recently, there has been renewed media interest concerning how maternal outcomes (including maternal mortality and severe maternal morbidity) in the U.S. compares to other countries. A visit to the Centers for Disease Control and Prevention (CDC) website provided me with some background on how the CDC tracks severe maternal morbidity in the U.S. and highlighted the main risk factors or indicators for complications during pregnancy. According to the CDC, recent trends show an increase in maternal morbidity rates from 1993 to 2014 for the following indicators:

 

  • Blood transfusions at 399%.
  • Acute myocardial infarction or aneurysm at 300%.
  • Acute renal failure at 300%.
  • Adult respiratory distress syndrome at 205%.
  • Cardiac arrest, fibrillation, or conversion of cardiac rhythm at 175%.
  • Shock at 173%.
  • Ventilation/temporary tracheostomy at 93%.
  • Sepsis at 75%.
  • Hysterectomy at 55%.

 

At the same time, rates decreased or remained the same for the following indicators from 1993 to 2014:

 

  • Disseminated intravascular coagulation.
  • Air and thrombotic embolism.
  • Amniotic fluid embolism.
  • Acute congestive heart failure or pulmonary edema.
  • Puerperal cerebrovascular disorders.
  • Heart failure or arrest during surgery or procedure.
  • Eclampsia
  • Severe anesthesia complications

 

The data collected by the CDC suggests that women who are giving birth later in life or were obese before becoming pregnant/have other underlying health issues may be contributing to increases in maternal morbidity due to not being as healthy as the typical population of women that would be giving birth in the U.S. Cesarean sections are also being performed more frequently which greatly increases the risks of complications for women. On November 14th, 2017, the CDC hosted a Grand Rounds session titled, “Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States“.  William M. Callaghan presented data from the National Vital Statistics Registry which showed an increase from 1999 to 2014 in the maternal mortality rate (MMR) in the U.S (from 9.8 to 21.5 maternal deaths per 100,000 live births). America’s Health Rankings indicates that the U.S. had a rate of 19.9 maternal deaths per 100,000 live births in 2016. There was great variation across states, however, ranging from 5.8-40.7 maternal deaths per 100,000 live births.

 

Vital statistics collected by the National Center for Health Statistics (NCHS) are only one measure of maternal mortality and are limited in their ability to accurately identify cases. The Pregnancy Mortality Surveillance System (PMSS) enhances NCHS data by adding a pregnancy checkbox to maternal death certificates so that epidemiologists can link them to birth or fetal death certificates. PMSS also includes all maternal deaths occurring during pregnancy or within one year of the end of pregnancy, instead of only those that occur during pregnancy or within 42 days of the end of pregnancy. PMSS uses clinical relevance, rather than Cause of Death codes, to classify cases and the Pregnancy-related Mortality Ratio (PRMR) as its unit of measurement- MMR and PRMR have the same denominator. When comparing the MMR (which is calculated using vital statistics data) to the PRMR, there is an increase in maternal mortality but the increase is not as steep (13.2 to 17.3 as opposed to 9.8 to 21.5) and seems to be leveling off over the past few years. PRMR is more comparable to MMR when restricted to maternal deaths occurring during pregnancy or within 42 days of termination. Once this adjustment is made, maternal mortality appears to be relatively flat from 1999 to 2014. Since the PRMR incorporates clinically relevant elements, specific changes in trends can be observed. For example, between 1987 and 2013, there was a decrease in maternal deaths due to hemorrhaging and hypertension as well as an increase in maternal deaths due to heart conditions. Additional data from PMSS indicates that state maternal mortality rates ranged from ~7 to 33 maternal deaths per 100,000 live births from 2006-2013 (again showing an increase that is lower than maternal mortality rates calculated using vital statistics data). At the same, it shows that some states have 3-4 times the number of maternal deaths than other states. These differences are similar when comparing mortality across race/ethnicity- Non-Hispanic Blacks and American Indian/Alaska Natives have 3-4 times more maternal deaths than other groups. Ultimately, this paints a picture of state-level and racial/ethnic disparities that are occurring throughout the U.S.

 

Review committees and task forces like the one I evaluated in 2014 have been established in different states in order to review cases of maternal death and/or severe morbidity. However, while individual states have a better ability to implement quality improvement initiatives that are relevant to their specific needs and risk factors, it takes significant political and social motivation to pass legislation that establishes these committees. The CDC provides technical assistance to jurisdictions that desire to establish maternal mortality review committees and identify preventable deaths as well as highlight interventions that can save lives. In fact, it is information from these reviews that have led to the realization that 20%-59% of maternal deaths are preventable. The Maternal Mortality Review Information Application (MMRIA) has more recently been established to create a standardized set of best practices that have been gleaned from maternal mortality review committees across the nation.

 

So, what’s the point? My evaluation in 2014, the surveillance data that is being collected by the CDC, the committees that are being established, best practices that are being compiled, and media stories that are being written should result in the implementation of evidence-based interventions that save lives. Here are some good examples:

 

  • Earlier this year, California was celebrated as being a state that has seen a 55% decrease in maternal deaths between 2006 and 2013 due to the development of the California Maternal Quality Care Collaborative. The collaborative is a product of the review process and has put in place various toolkits, research articles, and collaborative outreach materials to improve the health of mothers.
  • A 2016 report from Saving Mothers Giving Lives, an international collaborative, has shown that countries such as Zambia and Uganda are on track to meet their 5-year goal of reducing maternal mortality by 50%

 

At the end of the day, even one preventable maternal death is one too many.