Notes from the field: ID Epi Students in their own Voice

Today, two of your class members speak out about their experiences working with H1N1 response. To hear from Guada, click on the link below. To hear from Merlene, read on.

Click HERE to hear from Guada Lopez-Marti about her experience working at Duke University.

From St. Lucia:

Hello, my name is Merlene Fredericks, a distance learning UNC Field Epidemiology student, and presently employed in the Ministry of Health, the central coordinating agency for health in St. Lucia.

St. Lucia is a 238 sq mile Caribbean island, with a population of ~170,000. Tourism is our main source of foreign exchange.

In this presentation, I will attempt to give you a global view of our preparations prior to this pandemic, and our present response to H1N1.

Coincidentally, on Thursday April 24, 2009, during a Caribbean Health Research Council (CHRC) Research conference in St. Lucia,

I presented a student paper entitled, “Health Care Workers Knowledge, Attitudes and Practices regarding PI in St. Lucia”. This resulted from work done to satisfy a MPH with USF.

The following day, Friday evening, April 25, we were informed by the National Epidemiologist, of an alert which she had received, regarding a new flu virus associated with an unusual number of deaths in Mexico.

We called up all partners to an emergency meeting which was held on Saturday morning, April 26 at the office of the National Emergency Management Organization. Heads from Health, agriculture, education, tourism, foreign affairs, security and immigration, air and sea ports authority, the private sector, emergency management organization and others, were present at this meeting.

In the days following, we were involved in many activities including regular press conferences, as we sought to activate out PI (Pandemic Influenza) plans, and allay the fears and concerns of the public.

Training received so far in this field epidemiology course proved very beneficial to me, as for the first two weeks after April 25, I was heading the Ministry of Health’s response as the chief was out on vacation…..in Mexico.

Please allow me to go back a bit, and give you an idea of what our preparations have been like, prior to April 2009.

Preparations for a possible influenza pandemic started as a PAHO (Pan American health Organization) initiative with the Ministry of health about 5 years ago. I joined the Ministry and the PI planning team in 2006, and by then we had made the decision to move the focus from Health, to a multi-sectoral approach…. which was handled very effectively by the head of the National Emergency Management organization, NEMO.

St. Lucia’s PI Plans can be viewed at www.tiny.cc/flu.

Prior to April 2009, we had also benefited from a number of training opportunities, held locally and abroad, and financed by PAHO, the United States Department of Defense, US SOUTHCOM and NORTHCOM, the Robert Wood Johnson Foundation among others.

We had also tested the plan via simulations and were evaluated by PAHO. Avian influenza was the focus then, and some of our simulations involved the actual culling of poultry.

This is an attempt at categorizing St. Lucia’s current response

Planning and Coordination

• National Level: NEMO (National Emergency Management Organization)
• Multi-sectoral Steering committee
• Guided by Health and other agencies
• Regular communication
• Activation of all Pandemic Influenza Plans

Situation Monitoring and Assessment

• Increase Surveillance for disease
• Health facilities: public and private
• Schools
• Hotels
• Ports of entry
• Increased Laboratory Capacity
• Rapid test for Influenza A is available locally.
• Confirmatory tests are done at the Caribbean Epidemiology Centre (CAREC) based in Trinidad, another Caribbean Island. We receive confirmation in 24 hrs.

Public Health Measures

• Public Education and Sensitization
• Radio and TV programmes
• Press releases
• Cough/hand-washing Posters
• Handouts: for travellers, transportation sector
• Quarantine- voluntary only
• Isolation-of ill at home or hospitals
• Social Distancing-This measure is not yet needed

Systems Response

• Sensitization of health care and front line workers
• Increase Infection Control: e.g.
• Health – e.g. triage procedures for respiratory cases
• Immigration/ports of entry -  sneeze guards erected
• Schools
• Hotels
• Increase medication & supplies (Tamiflu procured and supplies donated by PAHO and government of Mexico)
• Increase Protective Equipment- PAHOUpdate Clinical recommendations and Management

Communication

• Internal Communication
• Inter-agency Communication
• Public Communication
• Regional Communication
• Communication with International Agencies

Summary

• H1N1 response is a Multi-sectoral effort
• New Challenges e.g. H1N1 infected Cruise Ships
• Potential threats: Mass Crowd Events
• Need for Continued Public Education and Sensitization

New Addition:

On Friday June 26, 2009, St. Lucia confirmed its first case of H1N1 in a 32 yr old female who returned to the island after visiting the United Kingdom.

Stop that virus

As you know, H1N1 dominates the news – cases are being seen in new locations, and the tallies are increasing. You have probably heard that CDC estimates 1 million Americans could now have been infected with the virus, and in all countries the age of those affected is on the young side (average age estimated in the US population is 12 years).

Book Recommendation: The Coming Plague by Pulitzer-prize winning journalist Laurie Garrett.

A worry also surfacing in the news, but well-known to those in local health – how do we get people vaccinated for seasonal flu as well as the novel H1N1? With a possible 4 flu shots for seasonal first-timers, the logistics get serious, especially considering staff cutbacks nearly across the board in state and local health departments. In addition, recommendations for who will get the H1N1 vaccine have not yet been determined, but they could vary from the recommendations for who gets the seasonal vaccine, adding to the difficult logistics and public communications challenges.

But, alas, I would like to get you thinking about something other than influenza. In our Module 2 Live Meeting, we discussed dengue. Because you already have access to details about this, this week’s disease of the week lists viral hemorrhagic fevers – these guys are always interesting. I wanted to bring to your attention one of this year’s Dengue outbreaks.

Book Recommendation: Virus Hunter by CDC great CJ Peters

Sri Lanka officials report a dengue outbreak has affected over 11,000.  A large concern is that dengue-3 is currently circulating, whereas dengue-1 and -2 are the strains more typically seen. As we discussed in the live meeting, with dengue re-infection with a different strain can cause the disease to be worse. See this ProMed posting (#9 in the list) to read more about officials’ concerns in May.  Currently, as health officials try to control dengue breeding places, they are requiring police assistance. Apparently some local citizens do not appreciate being told to dump out standing water sources. The Sri Lanka Daily News reports that the number of cases at the end of June is several times the number of cases normally expected for this time of year.

Adventures in Eating

Oh the decisions this week! The July issue of Lancet Infectious Diseases reports that you can get MRSA (methicillin-resistant Staph aureus) from man’s best friend. Accarding to the article, dog slobber hosts an array of pathogens, and dog-bites are an increasingly being found as a cause of MRSA infections, especially in children. Here is a news article on the topic; you can also access the journal article through the UNC Electronic Health Science Library. Dogs (and cats too!) can be carriers of the bacteria… and their most likely source of acquiring it in the first place? Their owners. What goes around comes around.

I would be remiss if I did not mention the cookie dough recall. Contaminated spinach or peanuts is one thing, but don’t mess with the cookie dough. Nestle cookie dough has been implicated after a months-long search for the culprit of E. coli O157:H7 infections, occurring mainly in young women. There’s a nice summary of the problem in this NY Times article. Exactly how the cookie dough was contaminated hasn’t yet been determined. Personally, I prefer to get my foodborne illness from homemade cookie dough, it is much preferred over store-bought illness. (This photo is one I took of my most recent batch!).

But this week’s winner is tapeworm. Now I do consider myself an adventurous eater, and I have willingly eaten specialties from a wide variety of cultures, including insects and several dishes where I decided I was better off not knowing what I was eating. But I do draw the line at raw fish, even though I feel chagrined every time I see a 5-year-old happily eating sushi while I resign myself to a noodle dish. But last week ABC news made me feel a lot better, when they published an extremely scientifically rigorous article about the the increase in parasites from raw fish, especially salmon tapeworm. So this week’s disease of the week: Tapeworm infection!

Tularemia Ditty

In homage to Module 1 and brains that are very tired from thinking about R-zero and transmission dynamics, this week is a light-hearted post. Just for fun, click HERE to hear a rousing song about tularemia by Tristan Israel.  Enjoy!

Because my favorite diseases run toward the vector-borne, this week’s disease of the week is Chagas, which afflicts tropical and subtropical regions of the Americas.  What is your favorite disease? Hop on over to the question of the week to give your vote.

Factoid Roundup

Influenza money

While swine-origin influenza A(H1N1) and other pandemic-potentialities threaten, in some ways, they are good for the economy. Of course Novavax is sitting pretty because of  H1N1 vaccine development, but the rubber-glove industry is also thriving just now. And some have done quite well for themselves in selling face-masks, particularly a Japanese entrepreneur who sold out of face-masks lined with ostrich antibodies. You read it correctly, ostrich antibodies. He harvests antibodies from ostriches, and affixes them to the face mask. This goes to show you why epidemiologists don’t double as entrepreneurs, we are entirely too practical. See today’s question of the week to answer the ostrich poll.

Boxing money

Sports-epidemiology may already be considered a sub-field of injury epidemiologists, but how about infectious disease? Sports can lead to some delightfully interesting (and gross) modes of transmission. This week’s winner: Hepatitis B among boxers. Perhaps you already know this story (boxing fans?), but here is an article about a match between 2 rivals, postponed because one has hepatitis and the other hasn’t been vaccinated (wouldn’t you think hepatitis vaccination would be required among boxers??).  Truth-finding on this one is tough – I think sports-writers have as much trouble writing about hepatitis as I have writing about sports.

Not for all the money

An article published in Pediatrics showed the results of a record linkage study to show just how risky not getting childhood pertussis vaccination can be. Here is a news story about the findings. Among my own friends and acquaintances, a surprising number are refusing or delaying vaccinations for their kids. Particularly epidemiologists, who understand that risks apply only to populations, not individuals. I respect personal choices, but my kid gets poked. If you need help convincing yourself or colleagues, listen to this link at doitforyourbaby.com.

Germ phobes, beware!

The Canadian Environment and Plastics Industry Council publicized the results of a study last week showing that reusable shopping bags make a happy dwelling place for yeast, mold, and bacteria including coliforms. You can read the news story here. A little moisture gets trapped, meat and unwashed veggies go in and out of the bags, checkers handle one set of bags after another, spreading everything around… ew!

Does the scenario sound a bit familiar? A couple years ago, an article in the Journal of Environmental Health related finding 25 different species of bacteria on restaurant beverage lemon slices. In reaction to that news, one of our ID Epi students at the time said that her science students had done a project that found high levels of bacterial growth on restaurant soda machines.

This is all an example of us interacting with our environment and the agents there to create potential new modes of disease transmission. The epidemiologic importance, however, at this point is limited, and begs a few questions. Are the bugs colonizing these items, be they lemons or grocery bags, pathogenic? And if they are pathogenic, is anyone ever getting sick?

I’ve yet to read about a restaurant-lemon outbreak, but if you’ve seen one, let me know. In the mean time, wash out your reusable grocery bags every once in a while.

The lure of the dark side

Epidemiologists have a complex relationship with the diseases we study. We love to study them, figure out why and how they do what they do, and then we love to destroy them. There is a lure, like the study of the occult, learning what makes the ‘dark side’ tick. Whether it’s catastrophic or just plain scary, we are strangely attracted pandemic strains of influenza (H5N1), agents of bioterrorism (tularemia, anthrax), newly emerged and uncharacterized viruses (SARS), or infections with alarming fatality rates (Ebola).

This week’s disease of the week is anthrax. As you learned in lecture, normal transmission of this bug relies on agent-host(s)-environment interaction. Because of its spore-forming ability, it is also a nice candidate for an agent of bioterrorism.

Bioterrorism and pandemic preparedness and funding for  public health programs  aims to prepare us to deal with the possibility of a high-profile lethal event; in the case of bioterrorism in particular, the likelihood of the event is extremely small. This funding is wisely used by public health agencies to train and expand public health capacity that can respond to any event, not just a bioterrorism event.

What tickles the back of my brain, is this question: What are the real threats to biosecurity in the US and worldwide? I’m invested in possibility of pandemic influenza. But what about HIV in the developing world? Are we and can we do enough to keep the HIV pandemic from eroding basic societal structures? In many cases the situation is already beyond this, and the question is how can societies be rebuilt?

The H1N1 Back-story

Today WHO reports over 8800 cases of influenza A (H1N1) occurring globally, with most of the new cases stemming from continuing transmission in Mexico and a growing epidemic in Japan. WHO also reports 74 deaths; 4 of these occurred in the US, but this is not inclusive of the death of a New York school principal reported today.

“Swine flu” has actually been around for quite some time — H1N1 emerged to cause the 1918 influenza pandemic. Over time, the virus adapted to its host, and now circulates as a less virulent seasonal strain among humans.

Agent-Host interaction

Why would a virus adapt  to become less virulent? The selection process is crafty. A virus or other pathogen that is too virulent will kill off its host before it has the chance to be transmitted to enough other hosts to maintain circulation in the population. A virus that becomes less virulent (this can happen through small genetic changes during virus replication) enables itself to reproduce in the host and also allows the host survive and share the pathogen with his or her contacts. Over time, this is a natural selection process that can allow the less virulent strain to dominate.

What’s different about H1N1 now?

Influenza viruses have a segmented genome. As the genome replicates inside a host cell, each virion is packed with the requisite gene segments. Imagine, however, if the same cell in the same host were infected with two completely different influenza viruses.  As the viruses replicate themselves, the gene segments can be mixed up, or re-assorted, using the host as a mixing vessel. This results in a dramatically different strain of influenza. It happens that swine are particularly good as influenza mixing vessels. In the 1990’s, surveillance in the US began to see a new influenza virus infecting herds of pigs. This virus was a triple reassortant, combining genes from swine, avian, and human viruses. Sporadic human cases were of the triple reassortant were observed in the US, and you can read about the epidemiology of recent cases in this New England Journal of Medicine article.

The novel H1N1 virus currently circulating around the world, known in the literature as S-OIV (swine-origin influenza A (H1N1) virus), is the essentially a quadruple reassortant – the triple reassortant with an additional Eurasian swine influenza virus reassortment. But it still has it’s roots in the 1918 strain.  Read about the current epidemiology of US cases of S-OIV in this article, Emergence of a Novel Swine-Origin Influenza A (H1N1)Virus in Humans, and be sure to catch the daily updates on case tallies on US cases from the CDC at http://www.cdc.gov/h1n1flu/ and global cases from WHO.

I can’t believe I watched the whole thing

As this Spring’s H1N1 scare has reminded us, the easy, individual measures we take can be just as important in preventing disease transmission as government pandemic preparedness plans and antiviral stockpiles.  If you’ve never seen this video, Why don’t we do it in our sleeves?, then you must check it out. It’s an entertaining and surprisingly engaging reminder about cough and sneeze hygiene. I sent it around to friends and family a few weeks ago – as one friend of mine, who is a pediatric counselor, said, “I get it, but I can’t believe I watched the whole thing!”