A Program to Build Capacity to Address Emerging Infections in Africa

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A Program to Build Capacity to Address Emerging
Infectionsin Africa

• Dr. Robert F. Breiman
• Global Disease Detection Division
• KEMRI-CDC, Nairobi, Kenya

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CDC Kenya
CDC Kenya Director (acting) Bill Gallo
Kisumu Field Station Director Kayla Laserson
Global AIDS Program Director Lawrence Marum
Global Disease Detection Director Robert Breiman
WHO-Seconded CDC Staff
HIV Research
PMTCT
Surv/Blood Safety/ Strategic Info.
IEIP
S.Sudan/ Somalia
Malaria Research
Care and Treatment
Prevention
E. Africa
FELTP
GAP Kisumu
Laboratory
Refugee Health
TB / HIV
Data/Statistics
Data Mgmt
S. Sudan GAP
S. Sudan Surv. and Epi.Training
IEIP
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What is the CDC-Kenya Global Disease Detection
Division?

• Part of a global strategy to monitor for and
  respond to emerging infectious threats (local,
  regional, global)
• Establish diagnostic and epidemiologic capacity
  in Kenya to address diseases of epidemic
  potential
• Conduct public health research of national,
  regional, and global importance
• Contribute to development and widespread use of
  effective interventions to address high impact
  diseases

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Vision for a GDD-Response Center Network
Guatemala
China
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Program Cornerstones

• Surveillance
• Outbreak response
• Training/building local and regional capacity
• Applied research

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SurveillanceMajor Components

• Population-based
• Kisumu (rural, w. Kenya) (community)
• Nairobi Slum (Kibera) (community)
• Bondo District (hospital based)
• National reporting system
• Utilizing IDSR
• Refugee camp surveillance
• CDC-Kisumu health and demographic surveillance
  system

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Population-based SurveillanceObjectives

• Identify new or emerging pathogens
• Establish public health priorities in rural and
  urban settings
• Provide platform for evaluating impact of
  interventions to address leading causes of
  priority diseases

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Population-based SurveillanceApproach

• 55,000 people in two site (rural-23,000 and urban
  Kibera 32,000)
• Visit each household every two weeks
• Ask about episodes of pneumonia, diarrhea, fever,
  and jaundice
• Establish enhanced field clinic
• Free and high quality care
• Diagnostic and treatment algorithms
• Specimens obtained according to protocol and
  tested in the lab
• Define principal causes of priority diseases
• Pneumonia
• Diarrhea
• Fever
• Jaundice

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Characteristics of Urban Slum Site

• 87 of caretakers with no greater than primary
  school education
• 79 of heads of household have high school or
  higher education
• Only 4.4 of household heads unemployed
• 92 households have one room
• 97.5 get water from a sales person
• 72 store water in narrow mouth jerri-can
• 56 boil and 9 chlorinate water before use
• 91 use latrines (most privatewith walls)

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Care Sought from Kiosk, Dispensary or
Spiritual/Traditional HealerUrban Slum Site

• Febrile illness 38.5
• Diarrheal illness 47
• Cough/difficulty breathing 33

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Public Health Research

• Provide platforms for studies of
• New vaccine efficacy/effectiveness
• Rotavirus vaccine evaluation
• New diagnostic tests
• Avian influenza
• Rapid tests for typhoid, cholera, leptospirosis,
  Rift Valley Fever
• Impact of new interventions
• Zinc
• Safe water/hand washing
• Pneumococcal vaccine?
• Burden of disease/impact
• Gates enterics study
• Incidence
• Costs
• Risk factors

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Outbreak Investigation Assistance

• Aflatoxicosis
• Typhoid/leptospirosis
• Chikungunyamany locations
• Cholera
• Brucellosis
• Meningococcal Disease
• Avian influenza-Nigeria, S. Sudan
• Hepatitis Esouth Sudan

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An outbreak of Malaria in Lamu (July 2004)
A rise in the number of febrile illnesses in June
were felt to be due to malaria
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Lamu Outbreak of Febrile IllnessLooking for an
Etiology

• The District Medical officer was suspicious that
  these cases may not have been malaria
• 10 specimens from febrile patients from Lamu were
  sent to KEMRI
• IgM ELISAs done for Dengue, Yellow Fever, West
  Nile, RVF, Chikungunya, and Sindbis
• 3 specimens had IgM antibodies to Chikungunya
  virus

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Defining the Cause of Febrile Episodes in Lamu

• MoH, KEMRI, CDC, USAMRU-WRP sent team
• Established case definition
• Identified 130 patients (meeting case definition)
  seen in clinic over two days and collected
• clinical, demographic and epi information
• Blood
• Serum tested for IgM Abs to alphaviruses (Chik
  Ag) and PCR and virus isolation attempted on the
  antibody negatives

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Results of Testing

• IgM Antibodies against CHIK detected in 60 case
  sera
• Chikungunya isolated from 20 of 70 IgM negative
  specimens
• All twenty culture positive specimens were PCR
  positive, as were an additional 2 specimens
  (total PCR positive22)
• Thus, 82 of 130 cases screened had evidence of
  acute infection with CHIK virus
• Serosurvey suggested gt70 infection rate

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Movement of CHIK into Indian Ocean
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IEIP Labs

• Two new BSL3 Labs
• Dr. M. Kariuki Njenga, Head
• State-of-the-art laboratories in proximity to
  problems specific to the developing world
• Supports
• Training
• Outbreak investigations
• Surveillance (including IDSR)

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Building Epi and Lab CapacityField Epidemiology
and Laboratory Training Program

• Degree granting public health program for MoH
  staff
• MSc in applied epidemiology or lab management
• Currently in 3rd cohort
• Seven graduates of program back working for MoH
• 20 current residents from five countries
• Residents have been involved in almost every
  outbreak IEIP has undertaken including the AI
  outbreak in Nigeria

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Avian Influenza Activities

• Regional PCR training and lab assessments
• Regional rapid response team preparation
• Communication
• Ethnographic/behavioral investigations
• Local level sensitization
• Enhanced surveillance
• Building on population-based sites strengthening
  IDSR expanding sentinel/facility-based sites
• Infection control strengthening
• Outbreak support

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• Identify threats to health and well being
• Establish priorities for public health research
  and interventions
• Develop and evaluate safe, practical tools to
  contribute to the wellness of people in
  impoverished settings in Africa and
• developing countries elsewhere

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What is an Emerging Infection?

• A human infectious disease with gt1
  characteristic
• Newly appeared or is newly recognized
• Has become more
• Difficult to treat (i.e. drug resistance)
• Commonly occurring (increased incidence)
• Widely distributed geographically (i.e. West
  Nile) or demographically
• Severe/lethal
• New complication
• New mode of transmission
• Substantial epidemic potential (occurs in
  bursts)
• Threatens regional or global health