Conference Reflections: Emergency Preparedness & International Health – Different Fields, Same Goals

Last week I was given the opportunity to attend the Preparedness Summit in Atlanta. This conference is the first and longest running national conference that discusses and revolves around the world of public health preparedness (think: natural disasters, medical countermeasures, flu, Zika and Ebola responses, biological threats and much more). There were many different opportunities to learn about preparedness activities including plenaries, small discussions, learning sessions and networking with local, state and federal partners. It was overwhelming, but in a good way!

As an epidemiologist, I have some experience and background in public health preparedness activities, but my main interests and time have always been spent with infectious diseases and global health initiatives. When I worked for the state health department, I actually was on a team that was half epidemiologists and half preparedness staff and we continually supported each other’s activities. Those experiences helped me with preparedness lingo and acronyms used during the conference so that things didn’t go completely over my head. However, I would not consider myself a preparedness expert by any means and soaked up as much as I could from the various sessions I attended.

One of the most exciting activities from the week was visiting the Emergency Operations Center (EOC) at the Centers for Disease Control and Prevention (CDC). This EOC is the center that gets activated in a public health emergency and where experts gather and get ready to respond. The main room of the EOC is spacious, with many computers, television screens and telephones set up and ready to be filled with points of contacts from different divisions and organizations. When there’s not an emergency response going on (like on our tour), it’s actually pretty quiet. However, staff are still on call working to monitor information and sift through potential threats. During a response, I’m sure the place is bustling with people, calls, information sharing and meetings. It was a neat experience to be in the center communication hub where past emergency responses like Hurricane Katrina in 2005 or the 2014 Ebola outbreaks took place.

I did some research after attending the summit and found that the EOC has become an integral part of meeting the goals of the “Global Health Security Agenda (GHSA)”. This agenda is focused on “accelerating progress toward a world safe and secure from infectious disease threats and to promote global health security as an international security priority.” Over 50 countries have joined in partnership with the U.S. to meet this objective and the CDC aims to activate the EOC and respond within 2 hours of any mandated public health emergency. There’s even a fellowship offered by the CDC called the “Public Health Emergency Management Fellowship” that provides an opportunity for public health workers to learn and train over a four-month course then go back to their respective countries and create their own local EOCs. Emergency management experts can also be sent to these countries and help guide and train responders in their own environment if needed.

This post-tour research made me start thinking about the importance of the EOC and preparedness in relation to international health. Public health threats (like pandemic flu, Zika, Ebola) of any degree can happen at any time at the local, state, national, or international level. Bill Gates recently spoke out about the necessity of being prepared for public health threats such as these at the Massachusetts Medical Society 2018. He stressed how unprepared we are for the next epidemic and the world’s need for a “global approach” with “better tools, an early detection system, and a global response system”. Gates’ is most likely alluding to the poor handling of the Ebola outbreaks in the recent past. These are a perfect example of why the field of preparedness is so important to global health. During Ebola, public health response was “too late” and there were too many “deaths that could have been prevented”. There were many disagreements among global health leaders over things like travel bans, how to handle public panic and how to best respond. The aftereffects of the outbreak point to the integral link between a strong preparedness field and international health that was lacking. Gates’ argues that we weren’t prepared to handle prior outbreaks, but we are capable and should spend time and money on planning and preparing for similar epidemics in the future.

Overall, these events – the conference, EOC tour and recent news and outbreaks – have helped hit home that these different public health fields, although working in slightly different capacities, are really aligned and influential on each other. Ultimately, preparedness and global health are working to reach the same goals of keeping our planet safe and healthy and we must first be prepared for any global threat in order to achieve these goals. Today, I feel refreshed in my perspective of the field and inspired and hopeful of future preparedness efforts. I no longer feel that preparedness and international health belong in the different boxes or divisions I’ve created in my mind, but as two parts to the same path.

I challenge other public health workers to also think about the important link between preparedness and global health and advocate for changes that strengthen this partnership. The Preparedness Summit conference is a great starting place and I encourage all fields of public health workers to look into it! I truly believe the more you learn, the more you see how everything is connected and the better you are able to achieve your public health goals … and maybe find some new teammates from other fields to help you along your journey, too.

 

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Is Zika still a thing? My experiences as a Zika Case Manager in the field (South Florida)

Zika was a hot topic, but now it seems like it is a thing of the past. People always ask me…”Is Zika still is a thing?” And my response is, “Of course! Just because it has declined, certainly does not mean that it isn’t still a public health threat.”

Interesting enough, comments like “Is Zika still a thing” come from physicians and various public health professionals as well as individuals living in regions with active Zika transmission. Those that express more of a concern include individuals that have planned future travel to the state of Florida and are planning to conceive, or a close family member of someone who is currently pregnant.

What is Zika?

Perhaps you never heard of Zika, or still quite aren’t sure what Zika is exactly. Zika can be described as a virus that spreads to people primarily through the bite of an infected Aedes species mosquito. It is closely related to other flaviviruses such as Zika can also be transmitted sexually from a person that has Zika to their partner as well as from a pregnant woman to her developing fetus, which can result in serious birth defects. Want to learn more about Zika? Check out some other IH section blog posts about Zika here.

My role, criteria for testing, testing/funding limitations

I was hired as one of two Zika Case Managers within my local county health department through funding allocated to the state of Florida by the CDC. One of my duties is to coordinate the testing of suspected local, or travel cases, pregnant women, and any infant born to a potentially exposed pregnant woman. The testing criteria for pregnant women include those who traveled to a Zika-active transmission area, had sexual exposure during pregnancy, or 8 weeks prior regardless of the mother’s testing status, as well as those with any abnormal ultrasound results. Testing is also recommended if the mother was not previously tested. Just like other reportable infectious diseases, it takes effective communication between health professionals at all levels to get quality information across regarding Zika. In order to get the job done, we collaborate with infection control practitioners of local hospitals, nurses, physicians, and other public health clinicians to get samples of babies collected at birth for Zika testing while also making sure that a head ultrasound and hearing test are performed on the baby. This is very important because once the baby leaves the hospital it is almost impossible to get samples collected. A majority of the pediatric clinics don’t have the means to ship the specimens to the state laboratories. Some of the general responses we have received from these clinics include not knowing how to properly prepare the specimens for shipping, having the money to do so, and lack of knowledge about billing the patient’s insurance for the procedure. Although the county health department has the access and ability to ship specimens, it would be a liability for us to ship the specimens if another facility collected the samples.

As of March 2017, the department of health has conducted Zika virus testing for more than 13,020 people statewide. At Governor Scott’s direction, all county health departments were mandated to offer a free Zika risk assessment and testing to pregnant women. Unfortunately, due to a decline in cases, and federal funding allocated to state programs winding down, free testing is no longer accessible to the community, and is only provided on a case by case basis. Zika tests can be pretty expensive ranging anywhere from $200 – $400 when conducted at a commercial laboratory and even more in some cases.

State laboratories have just about depleted federal funds received for testing initiatives. If a patient does not meet testing criteria at our department of health, we recommend testing through affiliated commercial laboratories. In addition to the many changes in testing criteria including requiring patients to show proof of insurance, there has been issues with the insurance companies and patients’ have been incorrectly billed over $1000 for their Zika tests when in fact the test was free. This has been a big issue with tests conducted as far back as November and December which we have recently been made aware of. Mosquito control services specifically for Zika efforts provided by our county health department’s Environmental Health program has ended.

Management of Infants with confirmed, or possible Zika Infection

Currently, we have reached the stage where the pregnant women that are case managed have already given birth. We are now tasked with conducting 24 month active follow-ups of all infants exposed to a positive mother via in utero. We conduct follow-up of the infants exposed regardless of whether the infant tested negative, or positive. These infant follow-ups occur at 2, 6, 12, 18, and 24 months. This is because abnormalities can still occur during child development. A majority of our babies being followed are currently between the 12 and 18 month mark.

Out of all the babies we have tested, and are currently following, only one is confirmed to be microcephalic. Looking into the future, at the 18 month follow-up mark, the infants being followed will have to be re-tested in order to confirm if the antibodies are indeed negative or positive. Another complication with testing these babies will be whether the baby has traveled since it has been born. There is a possibility that the baby could have been infected during travel and not in utero. As of July 31st 2018, Zika contracts for our county health department will end and it is unsure who will take on the responsibility for maintaining the case management of these families.

Community Outreach

Best practices we have utilized as a county has been community outreach which we collaborate across the division of communicable diseases. I have been able to work closely with a CDC field assigned Zika Community outreach nurse to assemble and distribute Zika prevention and testing kits with a specific focus on obstetrician-gynecologist and pediatricians. We have been able to identify the gaps in testing and communication among our health department and local hospitals, clinics, and private physician offices. Additional community outreach activities of focus include visiting women, infant, and children (WIC) clinics throughout the county in order to conduct health education on Zika as well as community health fairs primarily within the Haitian population due to Haiti being one of the top countries which we get the most amount of travel related cases. Unfortunately, these outreach efforts will also end at the end of this summer due to the depletion of funds, and our CDC field assigned nurse’s contract ending.

Where we are now

As of right now, Florida still does not have any identified areas with ongoing, active Zika transmission. Florida is a hotspot for vacationers, especially the counties of Miami-Dade and Broward. Since the local transmission of Zika in 2016 in both counties, it seems that very few individuals consider Zika as being a major concern. Very few physicians’ are screening for Zika. Some still aren’t sure what it is exactly, and how it can affect an unborn fetus. Congenital Zika infection is still a global health threat to pregnant women and their infants. Zika is still a fairly new infectious disease, and we are learning as we go, especially the risks after pregnancy. The reality is that Zika is here to stay. Funding for zika prevention and treatment should be a top priority in order to aid in the health and wellbeing of children and families across the United States.

World TB Day 2018

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Tuberculosis is caused by Mycobacterium (seen in the image), a genus postulated  to have originated some 150 million years ago! The first written records about TB from India and China, date back to 3300 and 2300 years ago respectively.

Hippocrates accurately defined symptoms of “Pthisis” (Greek for TB) and described it as a fatal disease. There is also plenty of historical evidence about tuberculosis and its impact on human culture. From being identified as a “romantic disease” to being associated with poetic and artistic qualities, TB has had its fair share of time in the limelight.

All this history aside, the fact is, if untreated, TB can be fatal.  Effective treatment became available about 50 years after Robert Koch showed that TB was caused by an infectious agent in 1882Soldier TB 2. Isolation in sanitariums and surgical interventions were all part of treatment until the advent of streptomycin in 1944. BCG vaccine has also been in use since 1921. Several public health campaigns (such as the one seen here) were also conducted to raise awareness once TB was established as a contagious disease.

Unfortunately even to this day, TB is still a major public health concern in many parts of the world and is among the top 10 leading causes of death worldwide.  Seven countries account for two-thirds of total TB cases with India leading the count.

The disease typically affects the lungs and is spread in the air when a person infected with TB coughs or sneezes. Sadly the cost of having TB goes beyond the damage it does to one’s health. Recent studies show that economic impact TB can have people; TB can lead to a downward spiral into poverty and for the poor a TB diagnosis can prolong the cycle of poverty they already live in.

TB3March 24th is World TB Day. The theme for World TB Day 2018 is “Wanted: Leaders for a TB-free World”.

TB rate spike due to the humanitarian crisis in Venezuela, poor TB infection control in South African clinics and jail time for doctors who fail to report TB cases in India, have all been in the news leading up to World TB day. Clearly these news reports show the need for stepping up global action, if we hope to end TB by 2030.

The message about greater commitment and better leadership comes ahead of the UN General Assembly High Level Meeting on TB in September 2018. Given the surge in multiple drug-resistant TB, it is imperative that leaders at all levels work together to end TB. End TB strategy adopted in 2014 outlines interventions that fall under three key pillars that include integrated, patient-centered care and prevention, policies and supportive systems and research and innovation.

But as public health professionals, community leaders and residents, we all can take small steps to make sure we put an end to TB. The path to ending TB will hopefully improve the lives of most vulnerable people world-wide.

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Antimicrobial Resistance Workshop

You are invited to attend the International Global Health & Antimicrobial Resistance Workshop organized by the World Federation of Public Health Associations to be held on May 23rd in Geneva, Switzerland as a side event to the 71st World Health AssemblyThe workshop will provide guidance and insights to face the growing threats from antimicrobial resistance through the sharing of knowledge and development of innovative ideas.  The aims of the event are to create a win-win situation by highlighting all of the actors from multiple sectors that are playing a major role in the public’s health.  The event will consist of high-level keynote speakers, interactive discussions, and small group activities under the theme.

This workshop will be held on May 23rd, 2018 in Geneva, Switzerland. Participation in the workshop is free but registration is mandatory as space is limited.  For more information and to register, please visit the website.

The 9th TEPHINET Global Scientific Conference: Ending Pandemics in our Lifetime Initiative

From August 7th-11th, The Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET) held its 9th Global Scientific Conference and the 23rd National Epidemiology Seminar in Chiang Mai, Thailand. I had the opportunity to listen to a panel presentation on Global Influenza Surveillance as well as the following presentation on Ending Pandemics. The overview I have provided below summarizes Mark Smolinski’s (Director of Global Health Threats at Skoll Global Threat Funds) presentation on innovations in surveillance for personal, national, and global health security. Feel free to listen to the entire presentation (1:17:00-2:16:28)!

  • Epi curves generally focus on human disease but human disease and animal outbreaks coincide or trigger one another. Additionally, bioterrorism can play a role in outbreaks and should be included in epi curves.
  • There are six main opportunities for epidemiologists/public health practitioners to intervene and reduce risk from pandemic threat:
    • Stop the threat in the animal population
    • Reduce the epi curve in the animal population
    • Find the first human cases (quickly)
    • Limit human infections and stop the epi curve in the animal population
    • Ensure strong surveillance/warning systems are in every country so disease doesn’t spread beyond country borders
    • Know and work directly with neighbors across borders so that regional security exists to stop any outbreak/prevent pandemics
  • It costs 3.4 billion dollars to prevent a pandemic by ensuring that developing countries have baseline capacity/public health systems that meet international standards. The return of investment is 10 fold. We are currently at ~450 million dollars.
  • Innovations in Surveillance – Researchers in tech as well as universities are involved in innovative surveillance methods, not necessarily epidemiologists/public health practitioners:
    • Google Flu Trends –predictive of flu and comparable to CDC flu reports (visits to providers), which were delayed by two weeks (80% of ill individuals did not visit a provider)
    • Twitter – University of Rochester developed an algorithm that can predict flu with 90% accuracy and gives an 8-day notice of when someone will get the flu (based off of tweets of others in your community/social circle)
    • HealthMap/Flu Near You – Participatory surveillance system that allows people to check off symptoms, see results on a map, and find where the closest vaccines are; correlates very well with the CDC influenza-like illness surveillance (over 5 years)
    • Epi Hacks – the idea is to bring together human, animal, and environmental health experts for one week to work with developers to come up with open source products for countries to use (for surveillance purposes); at least one has been conducted on each continent
    • PODD – uses a One Health approach as people in villages are tasked with helping find outbreaks quickly and reporting animal morbidity/mortality in real-time
    • KIDENGA – CDC and the University of Arizona are working together on vector-borne surveillance on the U.S/Mexico border, an epi hack will take place to see if they can create a sustainable way to address vector-borne diseases
    • Guardians of Health app – asked attendees to report health issues or symptoms during the World Cup, attendees received health information and program updates/information in return
    • EPICORE – retrospective analysis of public health information related to outbreaks; an automated system that epidemiologists follow-up on (after requests for information have been sent out)
  • When there are no outbreaks, public health gets no credit…
  • All countries cannot meet the International Health Regulations, even if they agree that they SHOULD be met
  • Skoll Global Threats Fund teamed up with Google and examined publicly available data at the World Health Organization (WHO) to determine how long it takes to detect, report, and respond to outbreaks; found that the global community is improving but has plateaued (due to limited data)
  • Research Paper – Finding Outbreaks Faster – Smolinski MS, Crawley AW, Olsen JM. Finding Outbreaks Faster. Health Security. 2017;15(2):215-220. doi:10.1089/hs.2016.0069.
    • There are epidemiologists in 28 countries looking at data from each outbreak to determine 6 metrics that all countries can follow (over past 5-10 years)
    • Countries had never looked closely at this issue and were able to see their strengths and weaknesses in investigating different types of outbreaks
    • Hot Spots of Emerging Infectious Disease – CORDS
      • Build friendship and trust across borders
      • Helps regional disease investigation networks share best practices, scale innovations, optimize informal networks
      • South Asia and West Africa are the most concerning for emerging infectious diseases, in a few years they may have stronger regional networks
  • Ending Pandemics Collective
    • 14 foundations and leaders of companies concerned about social responsibility want to invest in global health, share ideas, coordinate funding for projects, break down barriers in the foundation world
      • Smithsonian Museum of Natural History wants to do a 2-year exhibit called outbreaks, collectively a great chance to improve the knowledge base of people that visit the exhibit (~7 million people)
      • In 10 years the collective sees a world where:
        • Every outbreak is detected within 3 incubations periods of the index case or cluster
        • Every country’s Emergency Operations Center is utilizing an integrated, event-based detection system being used simultaneously by the WHO and G20
        • Human, animal, and environmental health volunteers are verifying rumors or suspected threats within 24 -48 hours through EpiCore
        • Participatory surveillance is engaging communities directly to detect and respond to outbreaks in every disease hotspot across the globe
        • Field epidemiologists in every country are using the latest technology to detect, verify, and respond to outbreaks faster
  • At the end of the day, pandemics can be prevented because “no community is too hard to reach, no community is too poor to innovate, and curiosity outshines fear!”