Oxford Public Health Magazine Issue 2

The Magazine of the Oxford Public Health Global Network

December 2015

www.oxfordpublichealth.com

WELCOME MESSAGE

Disease Detective Diaries We are extremely lucky to also cover the stories of a few current and former EIS Officers, including Kaci Hickox, whose experience hit international headlines when she was quarantined after returning from West Africa during the Ebola epidemic.

Following the success of the first issue of the Oxford Public Health Magazine, I decided to publish another special issue, this time dedicated to the frontline of public health, the field epidemiologists, also known as ’intervention epidemiologists’ and ‘Disease Detectives’.

Field epidemiology is not limited to acute infectious disease and outbreak response. During my time in EIS, I also served with the team that followed up the population needs following the 2010 Gulf of Mexico oil spill. This same team has been involved with responding to natural disasters, such as hurricanes and other severe weather events. We include an article by Dr Tesfaye Bayleyegn, former EIS Officer and current team lead for the CDC’s Disaster Epidemiology and Response Team.

Early on in my epidemiology training, I knew that I wanted to apply my research skills to the practice of public health, similar to the historic ‘shoe-leather epidemiology’ investigations by John Snow. One of my former classmates, Dr Anil Panackal, described his experience of responding to the 9/11 World Trade Center attacks during his time as an Epidemic Intelligence Service (EIS) Officer at the United States Centers for Disease Control and Prevention (CDC).

I quickly read the book, Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service (http://markpendergrast.com/ inside-the-outbreaks) and became fascinated by the wide range of investigations conducted by EIS Officers. It didn’t take long before I applied and joined EIS, serving from 2011-13. The book’s front cover is the cover page of this special issue.

Similar to EIS, field epidemiology training programmes (FETP) exist worldwide (http://www.cdc.gov/ globalhealth/programs/fetp.htm). We interview the United Kingdom FETP Director, Dr Samantha Bracebridge, as well as a graduate of the European Programme for Intervention Epidemiology Training (EPIET) at the European Centre for Disease Prevention and Control (ECDC), Dr Michael Edelstein.

We kick off with an interview with Mark Pendergrast, author of the book that inspired me to join EIS. We then interview the new Chief of EIS, Dr Joshua Mott, describing the valuable contributions of EIS Officers since 1951. In support of World AIDS Day (1 December 2015), we highlight the work of Dr Harold Jaffe who in 1981, as an EIS Officer, investigated a new disease, soon to become known as AIDS.

I am also excited to share news about the launch of the Oxford Public Heath Global Consultancy Network, which matches organisations with independent consultants from any sector interested in offering services to support public health worldwide. For further information, please visit www.oxfordpublichealth.com.

Finally, if you wish to get involved with or to sponsor the Oxford Public Health Magazine, Masterclass or Innovation Mashup series, please contact us at: info@oxfordpublichealth.com.

I wish you a healthy & happy 2016!

Dr Behrooz Behbod, MB ChB MSc ScD MFPH Founder & Director, Oxford Public Health Ltd Copyright © 2015 Oxford Public Health Ltd

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In this issue...

Mark Pendergrast

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Author, Inside the Outbreaks

Dr. Joshua A. Mott

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Chief, Epidemic Intelligence Service (EIS)

Dr. Harold W. Jaffe

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EIS alumnus, Investigating AIDS

Kaci Hickox

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EIS alumna, Quarantine!

Dr. Seema Yasmin

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EIS alumna, Facing Your Deepest Fear

Dr. Angela Dunn

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Current EIS Officer, Ebola & Safe Burials

Dr. Tesfaye Bayleyegn

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EIS alumnus, Disaster Epidemiology in Action

Dr. Samantha Bracebridge

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Director, UK Field Epidemiology Training Programme (FETP)

Dr. Michael Edelstein

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European Programme in Intervention Epidemiology Training (EPIET) alumnus

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Are you: 

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An organisation seeking consultants from any sector for your public health service needs anywhere in the world?

Sectors include, but are not limited to, healthcare, academia, journalism, media, film, law, policy, economics, architecture, urban design, engineering, business and entrepreneurship.

An independent consultant in any sector searching for work in public health projects worldwide?

Looking for a way to supplement your full-time employment through independent consulting opportunities?

Interested in serving as an expert consultant supervising and coaching new, student, and trainee consultants?

A student, trainee, or new graduate interested in gaining consultancy experience?

The beauty of the Oxford Public Health Global Consultancy Network is that we connect and match organisations with consultants in all sectors worldwide, while providing opportunities to consultants at any level, ranging from new graduates to experienced professionals… and it’s free to join!

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In Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service, Mark Pendergrast takes readers on a riveting journey through the history of this remarkable organization, following Epidemic Intelligence Service (EIS) officers on their globetrotting quest to eliminate the most lethal and widespread threats 6 to the world’s health. Over the years they have successfully battled polio, cholera, smallpox, AIDS, and Ebola, and in recent years have turned to the epidemics killing us now — smoking, obesity, and violence among them.

Mark Pendergrast

Mark Pendergrast was born in Atlanta, GA, in 1948, the fourth of seven children. He earned a BA in English literature at Harvard and a masters in library science from Simmons College. He now lives in Vermont. He is the author of many books, including Inside the Outbreaks, Uncommon Grounds, For God, Country and Coca-Cola, and others.

See his website, www.markpendergrast.com for more details and to contact him.

“If you are interested in a career in public health, the two-year EIS program is the best entry you could get into the field, guaranteed to be fascinating & important. ”

Your book inspired me to apply to the Epidemic Intelligence Service (EIS) at the United States Centers for Disease Control and Prevention (CDC). But what inspired you to write your book?

Oh, and I also discovered that EIS officers are drilled in how to write clearly and logically, so we hopefully share that in common as well.

Did anything surprise you?

Another broad question. Just about everything surprised me, from the description of “honey buckets” (55-gallon drums used as toilets during the Korean War) to the simplicity of the Safe Water System that I saw in use in rural Kenyan schools. I was shocked and surprised by the way the U. S. Congress forbade the CDC to study gun control issues in the mid1990s. There were so many surprises from nature in the form of West Nile virus in New York City or the horrendous cholera epidemic in Goma following the Rwandan genocide, the first cases of Ebola and Legionnaires disease in 1976, the discovery that folic acid can prevent spina bifida, the extent of food-borne diseases, the early history of AIDS, the applicability of epidemiology to chronic diseases and behavioral issues, and so much more.

I enjoy writing books about important issues that help to educate people about the world in which they live and the issues that we face, big and small. I can truthfully say that one of the reasons I wrote the book is what you describe here – to inspire others to join the EIS and, more broadly, the fight for public health. My longtime friend Andy Vernon (we went to high school and college together) brought my attention to the topic and suggested I write a history of the Epidemic Intelligence Service. He had been an EIS officer and still works for the CDC, specializing in tuberculosis. I had never heard of this organization that had such an intriguing name. It sounded like a medical version of the CIA. In some ways, that’s true, although EIS exploits are generally not secretive.

Of all the stories you included in your book, which is your favourite and why?

What did you learn by covering the stories of EIS investigations?

Wow, that’s a rather broad question. I learned an incredible amount about infectious diseases, vectors, epidemic curves, resistant organisms, and investigative technique. I also learned how politics and cultural values of the time influence science and organizations, and how advances in technology can have a dramatic impact on public health. Mostly, I came to believe that it is individual initiative and intelligence that ultimately makes all the difference, even though teamwork is also important. I came to think of myself as a kind of literary EIS officer, because good journalists share many approaches with good epidemiologists – mining data, interviewing people, putting our feet on the ground, and coming up with reasonable hypotheses.

This is a very difficult question, like people who frequently ask what my favorite coffee is, since I wrote Uncommon Grounds, the history of coffee. There are so many great coffees from different origins, and so many great EIS stories. I guess I would have to pick EIS officer Karen Starko’s 1978-1979 investigation of an Arizona outbreak of Reye syndrome, a horrible, often fatal childhood disease. She did a case control study with only seven cases and sixteen controls, which implicated aspirin. At first, few would believe that this common childhood medicine could cause this lethal disease, but subsequent larger studies proved that 7

Are there any other types of public health articles or stories you have written?

aspirin was indeed the major culprit, and now there are only one or two cases of Reye syndrome per year in the United States. From 1979 until 1986, the aspirin industry successfully lobbied against a warning label on the product, during which time over 1,000 children contracted Reye syndrome.

Yes, I wrote a commentary about the movie Contagion, and I wrote an editorial cautioning against panicking in the face of the recent large Ebola epidemic. I have written other books that pertain to public health, such as Japan’s Tipping Point, about climate change and renewable energy, or my histories of coffee and Coca-Cola, both of which discuss the health impacts of caffeine and sugar.

Also, my book about quack psychotherapy, Victims of Memory, was also a kind of public health story, about an epidemic of false memories and allegations that occurred in the early 1990s.

What do you feel are the common characteristics of the EIS Officers you met and interviewed for your book?

Compassionate, analytical, hard-working, open-minded, smart, skeptical, and generally with a good sense of humor.

Since you wrote the book in 2010, have there been any EIS stories in the news you wish you could have included? Perhaps there's a sequel on the way?

Based on what you learned from researching the stories in your book, what advice would you give to:

Every time I hear about an outbreak of any kind, I wish I knew all about it. This was particularly true, of course, about the recent Ebola outbreaks in West Africa.

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Anyone considering EIS as a career?

If you are interested in a career in public health, the two-year EIS program is the best entry you could get into the field, guaranteed to be fascinating and important.

Yes, I would be interested in bringing the EIS story up to date at some point. But I would have to get a commission to do so. 

Current EIS Officers?

Keep your perspective, your energy, your idealism, and build on it in your future career.

What has been the impact of your book?

Well, it got you to apply for the EIS program! And I have heard from others who were also inspired by it. It’s always hard to know what impact a book has. I’d like to think that it has helped to educate many people about the work of public health, epidemiology, the CDC, World Health Organization, and many other important health issues. I will say that it probably would have had a wider impact if it had been turned into a television series, as it very nearly was. Sony TV optioned it, a pilot script was written, but then nothing happened. The scriptwriter consoled me by saying, “Well, this year they’re into supernatural stuff.”

Any final words?

I think that covers a lot. I’d be glad to hear from readers through my website with any other questions: www.markpendergrast.com.

I also may have made a mistake by insisting that the publisher, Houghton Mifflin Harcourt, change the cartoonish cover of the hardback edition and put a more academic-looking cover on the paperback (it features a listeria bacterium). I hoped that it would be more likely to be adopted as a supplementary textbook in medical schools and schools of public health. But you love the cartoon cover, and I must admit it has grown on me.

Credit: Mark Pendergrast

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Credit: Mark Pendergrast

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Dr. Joshua A. Mott

Joshua A. Mott, PhD, MA, EMT-P (CAPT, USPHS), is the branch chief of the Epidemiology Workforce Branch, Division of Scientific Education and Professional Development. In this role, he serves as chief of CDC’s iconic disease detective program, the Epidemic Intelligence Service (EIS), as well as other CDC training programs, such as the Hubert Global Health Workshop, the Epidemiology Elective Program, the Science Ambassador Program and the Laboratory Leadership Service.

“This fellowship will require your best efforts, sometimes in difficult and frustrating conditions.”

Congratulations on recently becoming the Chief of the Epidemic Intelligence Service (EIS) at the United States Centers for Disease Control and Prevention (CDC). How did EIS begin in the first place?

After one month of classroom training in the principles and techniques of field epidemiology, officers spend most of the rest of the two years learning through service under experienced supervisors, and by applying epidemiology through field assignments. They are assigned to work in local, state, and federal agencies, and at CDC. Worn out shoe leather with a prominent hole worn through is a motif of the EIS program, a reference to the practice of EIS officers personally investigating disease outbreaks at the local population level.

Alexander Langmuir, epidemiology branch director at what is now CDC, established the EIS program in 1951 in response to the threat of biological warfare during the Korean War. Since then, EIS—the world’s premier epidemiology training program—has successfully trained over 3500 “disease detectives,” as CDC’s EIS officers soon came to be known.

Over the course of a two-year fellowship, the officer responds to breaking or imminent local, national, or international serious public health threats. Multiple front-line experiences allow officers to face and address a variety of health challenges—good training for the diversity of crises they will inevitably encounter in their careers as epidemiologists.

What is the EIS program?

EIS is the only applied epidemiology training program of its kind in the United States. Since its inception, EIS officers have responded to outbreaks of diseases and urgent public health challenges by identifying the cause, rapidly implementing control measures, and using evidence-based decision making to recommend how to prevent similar events in the future. These activities help protect the public’s health.

What are some of the most famous EIS investigations to date?

Among the thousands of investigations since the program’s inception, many have flown under the public radar; however, some are more well-known. Just a few of the higher profile EIS investigations include identifying vaccine contamination as the cause of a polio outbreak in the 1950s; identifying the source of the 1976 Legionnaires’ disease outbreak in Philadelphia; tracing the cause of toxic shock syndrome among women in the early 1980s; arriving on hand immediately after the 2001 9/11 World Trade Center attacks (photo right) to assist local agencies; then later that year, tracking the first intentional release of anthrax to its source in Florida and subsequently investigating 22 other anthrax cases in multiple locations.

EIS officers are physicians, veterinarians, scientists, and other health professionals who are trained to become public health rapid responders, stepping up at a moment’s notice to investigate health threats in the United States and around the world. At least one team of EIS officers with complementary skills is available at all times, ready to deploy within 48 or fewer hours.

Officers gain admission to the two-year postgraduate fellowship through a highly competitive screening and interview process.

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How do you see EIS contributing to public health over the next 10 years?

Here, in a bit more detail are descriptions of four other “famous” EIS responses: EIS officers were on the scene in Africa as CDC began a worldwide smallpox eradication campaign in 1966. Over the next 13 years, EIS supported the campaign; then in 1980, WHO declared the world free of smallpox.

The core purpose of epidemiology will remain constant, but the knowledge, skills, and strategies required to carry out successful responses is evolving over time.

When needed, the EIS program adapts its training curriculum to prepare epidemiologists for the changing health threats they will encounter. For example, because people can travel across the globe in a few hours, infectious diseases can replicate and spread much more rapidly than in the past. This necessitates an adaptation of our strategies to interact appropriately with partners in the global context.

An EIS officer contributed to a Morbidity and Mortality Weekly Report (MMWR) article documenting an unusual number of Pneumocystis carinii pneumonia cases among young, previously healthy homosexual males. This 1981 article first called attention to the emerging HIV/AIDS pandemic.

EIS officers quickly responded following the 2005 landfall in the United States of Hurricanes Katrina, Rita, and Wilma. Many remained at disaster sites for weeks, assisting local health departments in identifying injuries, investigating disease outbreaks, and conducting needs assessments among displaced persons.

Another benefit to the public’s health overall involves expanding the application of the principles of epidemiology to include more chronic diseases or other conditions that contribute to a large global health burden. This also includes investigations of illness or injury associated with natural disasters, and exposure to chemical or other toxic agents, in addition to the traditional focus on infectious diseases. Also, more tools are becoming available for epidemiologists, which will hopefully help them to identify and head off outbreaks before they spread. The increasing complexity and quantity of data means that epidemiologists will need to collaborate to a greater extent with experts in prevention effectiveness (public health economics and decision sciences), informatics, and laboratory sciences.

More recently, all 158 EIS officers participated in the Ebola response in West Africa—the largest international outbreak response in CDC history. Their investigations revealed factors contributing to Ebola transmission in West Africa, and identified possible strategies to stop it.

They helped carry out several of these strategies, which included educating health care workers and communities about risks and prevention measures.

You, too, were an EIS Officer, back in 1998. What inspired you to join?

At that time I was finishing up a post-doctoral research position and was looking for a way to apply my skills that would make an impact in the world. In the process of searching for options, I learned about the EIS program. I met the eligibility standards, applied, and was fortunate enough to be accepted.

EIS Officer Nina Ahmad collects samples from a boa constrictor during a Salmonella outbreak in multiple US states. From: http://www.cdc.gov/eis

Which part of the CDC were you assigned to during EIS, and what types of projects were you involved in?

My experience prior to CDC had largely been in behavioral science, didactic epidemiology, and injury prevention. During the EIS Conference I was engaged with great interest by the environmental epidemiologists at the National Center for Environmental Health.

11 An EIS Officer investigates the impact of increasing bike share lanes in New York City. From: http://www.cdc.gov/eis

As a result I served in the Air Pollution and Respiratory Health Branch of the National at CDC for EIS. Over those two years, I investigated acute chemical exposures and undertook investigations and research on carbon monoxide poisoning. I also deployed to the Rift Valley Province of Kenya to help with global polio eradication and to the Northwest United States and Malaysia to study acute health effects from forest fires.

In 2011, I was able to bring my children to live in my own childhood home when I was subsequently appointed Director of the CDC Influenza Program in Nairobi, Kenya. Now, my journey has come full circle as I have become the Chief of the Epidemic Intelligence Service program. One motivation for my returning to lead the program was that much of what an officer learns in EIS, beyond that from the classroom and the field, comes from mentorship. The science and investigations are important—but just as important and satisfying is creating a strong future epidemiology workforce. One person towards whom I feel deep gratitude was my EIS supervisor in the Air Pollution and Respiratory Health Branch, Steve Redd, MD, who is now a Rear Admiral in the United States Public Health Service and Director of the CDC Office of Public Health Preparedness and Response. In my position in the EIS program, I try to emulate his integrity and his ability to lead a large program while providing meaningful individual mentorship.

What was your most memorable moment during EIS? Perhaps it wasn’t a moment, per se, but the deployment to Kenya was memorable, not just because of the epidemiologic challenge, but because it marked a return to a part of Africa where I had spent time during my childhood. In addition, I truly enjoyed living among and working with the local residents and public health and health care workers. That experience opened my eyes to the opportunities and challenges in international health and its relationship to the safety of U.S. populations. This truly shaped my subsequent career trajectory.

Who can apply to the EIS fellowship? Is it limited to medical doctors from the USA?

How did EIS prepare you for your public health career to date?

U.S. citizens who are medical doctors, PhD-level scientists, veterinarians, or from certain other healthcare professionals can apply, as can non–U.S. citizens who meet certain residency and professional requirements.

My public health career path has been formed by the intersection of my EIS experiences with needs arising from historical events. After serving in the Air Pollution and Respiratory Health Branch as an EIS officer, I became the Epidemiology Team Lead in the Branch.

On the fateful day of September 11, 2001, I happened to be in Missoula, Montana for a meeting on the health effects of forest fires. I knew at that moment that my career in Public Health would be impacted. Later in 2001, after volunteering as a responder to the anthrax crisis in the United States, I joined CDC’s Bioterrorism and Preparedness and Response Program as a Field Epidemiology Team Lead. This was my introduction to the world of infectious diseases, but by that time I realized that, in essence, “epidemiology is epidemiology” and sound evidence-based approaches are transferrable across multiple contexts. My time in the Bioterrorism Preparedness and Response Program had me leading teams of EIS Officers in New Orleans as we established rapid surveillance following Hurricanes Katrina and Rita. Later, when I moved to work in the CDC Influenza program, I trained EIS Officers to respond to avian and pandemic influenza.

What do you feel are the key attributes, knowledge, and skills of successful EIS Officers?

All applicants considered for a position in the EIS program are well-trained “high achievers” in their clinical, public health, or scientific professions. Their experiences and activities should demonstrate that EIS is a logical “next step” in their career progression and they should be committed to public service. There are, however, some other qualities that set apart those who will likely fit best considering the program’s demands.

First, candidates need a flexible attitude to be effective EIS officers, as they will often be operating in less-thanideal circumstances, and may have little control over certain conditions. This flexibility also extends to a willingness to apply epidemiology in multiple contexts.

Second, they must show leadership and sound interpersonal skills, because they often become the de facto leaders of epidemiologic investigations. Finally, candidates should demonstrate the resourcefulness needed to devise and lead an approach to an investigation based on limited data, as often happens.

In 2009, I agreed to serve as a CDC Technical Advisor to the World Health Organization’s Regional Office for Europe during that year’s influenza A (H1N1) pandemic.

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What’s your top advice for:

How can prospective applicants learn more about EIS?

Prospective EIS applicants?

If you are interested in EIS, go to CDC’s EIS website (http://www.cdc.gov/eis) to learn more about the program, to read about EIS officers’ experiences, to find out if you are eligible, and to learn how you can apply.

First of all you need to achieve at a high level in your studies and subsequent professional activities.

Along those same lines, it’s not enough to talk about your commitment to a career in public health service, you need to show it through your actions, such as volunteer activities.

In addition, I can think of two more interactive ways you for you to find out more about EIS. You can attend the EIS Conference, which is held annually, usually in late April or early May in Atlanta. At the EIS Conference, EIS officers present their epidemiologic activities. As EIS officers, their mentors, and EIS alumni attend, you should have a good opportunity, during breaks and over meals, to listen to first-hand accounts of experiences and to ask questions about the program.

Finally, to be a successful EIS Officer, you will need a real passion for public health, as this fellowship will require your best efforts, sometimes in difficult and frustrating conditions.

Current EIS Officers?

If you have been accepted as an EIS Officer, you have the qualities spelled out above. However, you will still have a lot to learn—both about the principles and techniques of epidemiology, and about developing the necessary attitude for thriving in the conditions you will undoubtedly encounter at times. The personal qualities that will serve you best include developing the ability to adapt quickly to unanticipated occurrences, be they in the office or the field, and recognizing that, in addition to the disparate conditions you can expect, you will likely be working with a variety of people from many different backgrounds and cultures.

Also, EIS alumni are everywhere. Assuming that you are already a practicing health professional, doing research, or studying in a public health or clinical health care setting, there’s a good chance that someone in your circle of contacts has an EIS background and would be willing to share their experiences with you.

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The Global Health Network aims to accelerate and streamline research.

It is an innovative digital platform facilitating collaboration and resource sharing in global health.

The Global Health Network has a steering committee comprised of:  Trudie Lang (University of Oxford)  Kevin Marsh (KEMRI-Wellcome Programme, Kenya)  Rosanna Peeling (London School of Hygiene and Tropical Medicine)  David Lalloo (Liverpool School of Tropical Medicine)  Tumani Corrah (MRC The Gambia)  Patricia J Garcia (Universidad Peruana Cayetano Heredia Peru)  Arthur Thomas (Oxford Internet Institute) Research Tools  Free, certified eLearning course  International regulatory information database  Site-Finder, a collaboration-finding tool for linking research sites and studies seeking sites  Professional Membership Scheme for tracking continued professional development  Process map to guide the set up of research studies Member areas Over 20 open-access, interlinked communities of practice containing:  Discussion groups and blogs  Up-to-date global health research news, events, and conference information  Grants and funding information from major global funders  ‘Ask an Expert’ and ‘Ask the Author’ panels  Information about scholarships and competitions from many sources  Guidance articles  Downloadable tools and resources Topics  Disease specific information portals, covering topics such as malaria, HIV and Influenza.

www.TheGlobalHealthNetwork.org 16

Dr. Harold W. Jaffe, MD, MA

Associate Director for Science at the Centers for Disease Control and Prevention (CDC). An internationally recognized scientist and public health leader, Dr. Jaffe previously served as Professor and Head of the Department of Public Health at the University of Oxford, UK. At Oxford, he established a new master’s degree program in Global Health Science.

“Connections made during EIS proved to be invaluable for a post-EIS career. ”

Having studied genetics and medicine in California, what made you decide to join the CDC as an EIS Officer?

Like many physicians who trained during the era of the Vietnam war, I was obligated to provide service to the military. As an alternative, I was allowed to join CDC as a United States Public Health Service Commissioned Officer. The program that I joined in 1974, the Venereal Disease Control Division, had no EIS Officers. However, after leaving CDC to complete training in infectious diseases at the University of Chicago, I was allowed to join EIS.

What were the professional backgrounds of your other team members?

My colleagues had very diverse backgrounds. Several were medical doctors, like me. But the team also included laboratorians, a medical sociologist, and administrative staff. We had access to statisticians, although they were not working with us full-time.

Your most famous EIS project was when you joined the CDC Task Force in 1981 to investigate a new disease, soon to become known as AIDS. How soon into your EIS fellowship did you join the Task Force? Did you feel adequately prepared?

What was your most memorable experience of the AIDS investigation?

There were many memorable moments. However, I think my strongest memories are of conducting the national case/control study by interviewing young gay men in hotel rooms. I was amazed by how open they were about the most intimate details of their lives.

I actually joined EIS at the time the CDC Task Force was being formed. At that point, I had four years of CDC experience, so serving on the Task Force didn’t seem too daunting. But of course, none of us knew what awaited us!

If you could go back in time, is there anything you would do differently?

Can you please describe the initial AIDS investigations, including what your role was?

Most of the opportunities I was given came about by chance. I was very fortunate to have the opportunity to work on such an important problem with so many excellent colleagues.

It took a while to organize ourselves as a Task Force, but after a few months I was asked to lead on our epidemiologic investigations. My first big project was to develop a national case/control study to look at risk factors for this new disease. The study began around October 1981 and was completed by the end of the year. Our findings pointed to a sexually transmitted infection as the cause of the epidemic.

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Your story inspired the book and movie, "And the Band Played On".

Were you involved in the script writing? How well do you feel the story accurately portrayed the investigations?

Were there any other projects you were involved in during your time in EIS?

Although I was interviewed by Randy Shilts for his book, I played no role in the script for the film. I think the film captured the most important moments in the early history of the epidemic, but distorted the roles that individuals played. I guess that creating “good guys” and “villains” is part of the movie business.

After EIS, you've had several leadership roles, including director of the CDC National Center for HIV, STD, and TB Prevention, Head of the Department of Public Health at the University of Oxford, and now as Associate Director of Science at the CDC. How did EIS prepare you for your public health career?

In your opinion, what can be done to promote the use of film as a tool for communicating public health stories and messages?

I’ve used clips from the film on many occasions as part of lectures to widely diverse audiences. I find the film to a very effective communication tool for audiences interested in the history of the epidemic as well as those wanting a better understanding of what field epidemiology is about.

Although I had some ongoing STI projects, I spent the vast majority of my time working on the epidemic.

EIS not only provides young public health professionals to work on the “front lines,” it also introduces them to a variety of partners, such as health departments, academia, and both national and international organizations. Connections made during EIS proved to be invaluable for a post-EIS career.

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Kaci Hickox, MSN/MPH, BSN, RN

Kaci started her career as an Emergency Department nurse in Dallas, Texas in 2002. She always had her eyes set on international humanitarian aid and first volunteered in Indonesia after the deadly tsunami in 2004. She fell in love with the work and gained further education on tropical disease at the London School of Hygiene and Tropical Medicine by obtaining a Diploma in Tropical Nursing. Over the next 4 years, she worked for Médecins Sans Frontières (MSF, also known as Doctors Without Borders) in Burma, Sudan, Nigeria, and Uganda. She received a dual Master of Science in Nursing and Master of Public Health from Johns Hopkins University in 2011. She then worked for the CDC as an Epidemic Intelligence Officer based at the Southern Nevada Health District in Las Vegas, Nevada, where she developed her skills in public health and epidemiology. In September 2014 she joined MSF in the fight against Ebola as a medical team lead in a treatment unit in Sierra Leone. She now lives in Eugene, Oregon and serves as Clinical Nurse Educator for a large healthcare system.

“A place where you are challenged to grow. ”

As an EIS Officer, what made you decide to travel to West Africa and join the fight against Ebola? Were you not afraid for your own safety and health?

Although I completed the EIS fellowship with the CDC in June 2014. Through this experience I learned how to collect, analyze, and interpret information at the population level and apply the results to local public health programs and policies in Las Vegas. Among the public health issues I helped investigate were teen pregnancy, pedestrian and homeless pedestrian deaths, and exposure and outbreaks of diseases including rabies, tuberculosis, and salmonella. During this time I was closely following news of the Ebola outbreak and MSF’s efforts to combat the disease. So, when they emailed me and other former volunteers calling for help, my heart ached. I knew there was nowhere else I needed or wanted to be than in West Africa. It was around a campfire in Northern Maine that I asked my then partner (now husband) Ted, “how would you feel if I went to Sierra Leone?” His response: “I would be scared, but you have to go. This is what you were trained for. This is what you love.” I emailed MSF as soon as we returned from our camping trip and I was on a plane to West Africa a week later.

Drying gloves

Credit: Kaci Hickox

I think we need to consider what ‘being afraid’ means in a different context. The fear-driven response of the general public to this Ebola outbreak resulted in hatred, discrimination, and poor decision-making. Instead of combatting Ebola, what if I asked you to rewire the electrical system in my house? How comfortable would you feel doing this?

I can tell you that I would be very afraid to work with electricity because I do not have the knowledge, training, or skills to take the appropriate precautions and keep myself safe. If you are an electrician you have a healthy respect for electricity, just like I have a healthy respect for Ebola. But an electrician also has the knowledge and skills to take the proper precautions. I have the knowledge and training to take the proper precautions with an infectious disease like Ebola. There is no such thing as 100% safe, for me or an electrician, but I knew people were suffering and I had the skills to care for them. It is not very different from you needing electricity and knowing someone is trained and willing to help you!

To put it into further context, before this outbreak MSF had responded to dozens of Ebola outbreaks and never had an international staff member become infected with Ebola. It is a testament to our ability to mobilize appropriate supplies, prepare staff, and implement strong infection control measures. With these measures in place, I was able to focus on what we know about Ebola and perform my role.

The first time I stepped into the high-risk area to care for Ebola patients I felt even more at ease. The personal protective equipment (PPE) was cumbersome but comforting. I was completely covered and protected. Then I stepped into the doffing area where I was sprayed with strong chlorine water, washing my hands between each step of removing the PPE. I felt safe.

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Sierra Leone

Credit: Kaci Hickox

What were your roles and responsibilities while in West Africa?

I was the medical team lead of a 30+ bed Ebola treatment unit in Bo, Sierra Leone. Our team of international and national staff triaged patients, tested patients, and cared for patients diagnosed with Ebola. We had three shifts of healthcare workers taking care of patients around the clock.

Aside from the nursing staff, our amazing team was multidisciplinary. It included finance staff who ensured our national staff were paid and could support their families so they could continue to care for patients. The logisticians ensured we had the PPE and medications we needed, and spent hours setting up tents so that we could treat more patients and protect communities. We had psycho-social support for staff, patients, and families to try to meet the indescribable emotional needs. A CDC lab provided Ebola testing with same day results. And, as a nurse in the Ebola Unit, I was most thankful for our amazing water and sanitation colleagues. These men and women kept my coworkers and I safe and supported medical activities by ensuring patients had clean water, were able to perform basic hygiene, and ensuring the unit was clean to promote healing. In addition they performed the most difficult of jobs – spraying off the bodies of those who lost their lives to Ebola and starting the process of ensuring a safe burial.

It is a job I would not wish on anyone, yet a vital job to control the Ebola outbreak.

What were the most memorable moments?

I arrived just a few days after the ETU opened in Bo, Sierra Leone and I will never forget watching a patient being discharged from the Ebola Unit. It was the quintessential West African celebration, vibrant with singing, dancing, and praising the life before us.

Other memories are less joyful. I cannot forget my Sierra Leonean colleagues telling me that they were being discriminated against because they were working in the Ebola Unit. Some of their landlords wanted them to leave their homes because they might bring Ebola in, and their money was not accepted in the local market because their communities said ‘your money has Ebola on it.’ It broke my heart to hear these things about my valiant colleagues who were working so hard under such perilous conditions to stop this outbreak by offering care for those who were suffering.

I also remember the first morning that our international psychosocial worker arrived in the unit. He hardly had time to get his feet on the ground when all of a sudden I heard this beautiful sound coming from the tent next to me. The counsellors initiated a morning song and soon the entire staff were singing, their harmony filling the entire compound. I am embarrassed to say that singing was not an activity that I would have prioritized, yet is it one of the things that I remember most and something that we all needed.

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So now we get to the story which many are familiar with... what happened when you returned home to the USA? Let’s back up a few steps. When I look back on finishing my assignment in Sierra Leone, I remember knowing that I wanted to return to West Africa as soon as possible to continue to care for patients and support my colleagues. I flew back for debriefing with MSF in Brussels, Belgium and I felt completely overwhelmed by the love and support they showed me. I was greeted with hugs and displays of concern because they purposefully wanted to show me that I was loved, appreciated, and supported. Every debriefing with an MSF staff started with a simple sentiment like this, ‘I know you have had a difficult month. How are you doing? Is there anything I can do for you?’ It was simple yet soothing. It was the support I needed.

Returning to the U.S. was a stark contrast that I will never forget. When I landed at Newark International I never could have predicted how I would be treated. I had seen dozens of my patients die, lost 15 pounds, and I wanted more than anything to see my partner and to rest so that I could return to fight Ebola again. Those plans were shattered in 6 hours [unclear, is “the first 6 hours on American soil” correct?] when I was treated like an enemy in my own country. I was questioned over and over again about my experiences in Sierra Leone, as if my answers might change if I were asked enough times. I was eventually taken in an ambulance followed by 7 or 8 police cars with lights and sirens blaring to an isolation unit at University Hospital.

It was so drastically different from the welcome I had received in Brussels. I had read and reread the CDC recommendations for those returning from West Africa prior to my return. I understood those recommendations from a public health perspective and completely agreed to follow necessary monitoring, but I never imagined that I would face such draconian measures introduced not by health experts for reasons of protecting the public, but by politicians and for political reasons.

I was held in isolation in New Jersey for approximately 80 hours without due process and without legal representation. I was provided only paper clothing by the hospital. MSF coworkers in New York brought me warm clothes to sleep in and my previous Johns Hopkins classmates brought me care packages, but no one was allowed to see me. My partner in Maine and my family in Texas were ready to book flights to at least see me and talk to me through the plastic windows of the tent, but I was told the NJ Department of Health would not allow me to have visitors. This concerned me. If the medical staff were allowed to talk to me through the plastic windows wearing normal clothes, why couldn’t my family? Finally, on Sunday my lawyers insisted and succeeding in gaining access to speak to me through those plastic windows. These were red flags that made me realize the importance of speaking out not only for myself but for everyone returning home from West Africa. No one should be treated in such a way. It is important that we treat people with compassion and protect their basic civil rights so that we can succeed in fighting against real public health threats in the US and around the world.

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Kaci in quarantine

Credit: Kaci Hickox

through training, supplies, and procedures for infection control. These needs remain critical today, not because of Ebola, but because the next infectious disease outbreak may be easily transmitted through respiratory means.

Wasn't being quarantined the safe thing to do to protect the health of the public? What would have been the right course of action in your opinion?

I have been asked many times, “Why didn’t you just agree to stay home for three weeks” with regards to my quarantine order in Maine. It is simple. First, I knew that the policies being implemented, including my quarantine, did not protect the public, were not scientific, and were not constitutional. Second, I believe that we cannot be apathetic about fighting for what is right, especially when our civil rights are being abused by politicians who believe they are above the law.

I watched the dangerous combination of fear and misinformation about Ebola spread rapidly across the US and result in discrimination against returning healthcare workers and travelers from West Africa. Discrimination must not be tolerated because it hurts individuals and hinders our ability as a nation to respond to public health concerns. We must create a culture of compassion and support for those most at risk by prioritizing consistent and science-based public education, sound public health policies, and an intolerance of discrimination.

Let us look to the facts regarding Ebola and this outbreak response. A person with Ebola is not contagious until they develop symptoms, therefore someone who is asymptomatic does not require home quarantine. There has been no community transmission of Ebola in the US. None of Thomas Eric Duncan’s close contacts developed Ebola, even though they were in direct contact with him while he was ill at home. None of Craig Spencer’s close contacts contracted Ebola. The two nurses who contracted Ebola while caring for Duncan did not spread the disease to their close contacts. Finally, the healthcareacquired transmission of Ebola to the two nurses taking care of Duncan in Dallas indicates the urgent need for a different focus. Instead of focusing on quarantine policies that do not protect the public, our leaders should have been focusing on supporting US healthcare facilities

We need to look at the evidence and use it in our favor, instead of hiding behind false claims of protecting the public at the expense of those most willing to combat global outbreaks. The process of active or direct/active monitoring has proven to be effective for Ebola and thus represents the least restrictive public health action, a basic principle in public health policy and quarantine law. In fact, the actions of several states and politicians put West Africans and Americans in danger by dissuading our medical professionals from responding. We have to defend our constitutional principles that have allowed our country to become what it is today.

How did you pass your time while in quarantine?

How I passed the time seems like an insignificant question in the face of the Ebola outbreak. I was calling family, writing an op-ed to bring attention to the situation, and eventually contacting my lawyers, Norman Siegel and Steve Hyman. There was little else for me to do beside stare at the walls of the tent. I was essentially in a prison cell.

The real question regards those who suffered from Ebola in West Africa and how they dealt with the most difficult of circumstances. I celebrated with children who had survived Ebola but were then banned from returning to their villages. I met a woman who survived Ebola and explained to me, “I have lost a husband and two children from this disease, but I want to return to take care of my two living children.” Today many of these people still face discrimination in their own countries. There are reports of Ebola survivors whose landlords are raising their rents because it is easy to take advantage of survivors. Some of these families are now facing homelessness. They have lost so much, and yet their battle is not over. Our poor leadership and the US Ebola quarantines only fuel the flames of misinformation and fear. We succumbed to this stigma and missed the opportunity to lead a strong and understanding response instead.

It is estimated that over 500 healthcare workers died of Ebola in West Africa, in countries where healthcare workers are already in short supply. How many of them died alone, with no media coverage detailing their sacrifices? The image I want to leave with you is the way they and many of their countrymen spent their last hours. My fight against illegal and unnecessary quarantine was fought to support them. We must respond to global threats with strength, science, and commitment. Unnecessary quarantine of healthcare workers willing to respond to this effort only undermines our ability to fight infectious diseases today and tomorrow.

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Had you returned home to any other country, would you have been treated any differently?

Yes. There are obviously both good and bad examples of public health policies throughout the world. The European CDC showed positive leadership during the Ebola outbreak by creating policies for returning healthcare workers and other travelers from West Africa that were clear and evidence-based. Their public health and political leaders chose to combat the fear and misunderstanding of the disease with education and science-based policies for monitoring instead of manipulating those fears. On the other hand, the Canadian and Australian governments took a shameful approach, banning all incoming visitors from countries battling the outbreak.

Most concerning is the major discrepancy in responses of US states. States like New York, New Jersey, Connecticut, and Maine tried to enforce home quarantine for all healthcare workers and sometimes all travelers from Ebola -affected countries. This was against the recommendations made by the CDC, public health, and infectious disease experts. Thankfully, there were other states who showed great leadership. For example, Michigan’s Dr. Matthew Davis, the MDCH’s chief medical executive said in an interview, “Here in Michigan, we have an approach to Ebola that is based on the fundamentals of public health. … What we hope we can find here in Michigan is a balance between good, solid, effective public health care principles and also encouraging health workers to follow their humanitarian goals.” (http://woodtv.com/2014/10/27/ mandatory-ebola-quarantine-unlikely-in-michigan/ ) In light of these discrepancies, we need to consider the need for protection against political decisions to quarantine by ensuring timely due process for quarantine orders.

Every state has legal requirements regarding quarantine and isolation decisions, and many of these requirements do not include due process when making the decision to take away someone’s liberty. When politicians are involved in public health decisions, ignoring science and believing there will be no recourse, public health loses credibility and we become more vulnerable to public health threats. When poor public health decisions are made, this results in public misunderstanding and discrimination instead of the support and protection needed for those most at risk. We must not allow politicians to make the same mistakes that were made during the HIV outbreak in the early 1980s.

How are you using your experience to make a positive change to the perspectives and choices of the public, politicians, media, and key decision makers?

Yes. I am and will always remain an advocate for our civil liberties and evidence-based public health policies. I won my court case against an unnecessary home quarantine order in Maine and I believe this ruling is a big step in my support for science-based quarantine policies. Since then, I have continued to promote public health by speaking in conferences and at medical and public health schools, as well as writing articles to ensure this issue is not forgotten.

One such article was published in the Journal of Health and Biomedical Law (http://www.suffolk.edu/documents/ LawJournals/Kaci_Hickox_Suffolk_Law_JHBL.pdf ). My current lawsuit against Governor Christie and other New Jersey officials is another attempt to hold decision makers accountable for their actions, prevent politicians from making public health decisions, and ensure the constitutionally protected rights of healthcare workers and patients are upheld.

Would you still recommend EIS to anyone considering to apply?

YES! EIS is a training program where you have the opportunity to learn from experts in the field regarding any topic, not just the issue you are working on. This is invaluable. Not only does the program provide a supportive environment where everyone has the same goal, to increase the wellness of populations, but it is also a place where you are challenged to grow. Honestly, it was the knowledge and experience I gained from professors at the School of Public Health at Johns Hopkins as well as my mentors in the EIS program that gave me the tools and strength to stand up to politicians and their poor policies, to stand up for science and compassion. I would highly recommend EIS to anyone interested in taking a more global, population level approach to today’s public health problems.

What's your advice to anyone who may be in your shoes in the future?

I think we have to demand good leadership today so that no one has to ever be in my shoes in the future. Good leadership means basing decisions on facts instead of fears, science instead of politics. Good leadership means listening to public health experts and creating public health policies that will support those most at-risk. It means leading the effort to inform and educate the public, instead of stoking the fires of discrimination. President Obama hugged the nurses taking care of Ebola patients in Atlanta. The ACT UP Campaign, an AIDS activist group in New York, protested from Bellevue Hospital where nurses reported being stigmatized by Governor Cuomo’s office to advocate against discrimination. Many public health leaders stood up against these unscientific quarantine policies, and now we must follow through and continue to demand that public health decisions be left to public health experts and not politicians.

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Dr. Seema Yasmin

Dr. Seema Yasmin is a public health doctor, professor and journalist. She is a staff writer at The Dallas Morning News, a professor of public health at The University of Texas at Dallas and a Medical Analyst for CNN. Dr. Yasmin trained in medicine at the University of Cambridge in England and in journalism at the University of Toronto. She served as an officer in the Epidemic Intelligence Service at the Centers for Disease Control and Prevention where she investigated epidemics in maximum-security prisons, American Indian reservations and healthcare facilities. Her research interests focus on disparities in health and epidemic preparedness and response. Dr. Yasmin's work has appeared in peer-reviewed medical journals as well as the popular press including the Huffington Post and Scientific American.

Facing Your Deepest Fear “It’s not just pathogens and vectors that we discover during outbreaks; sometimes it’s ourselves.”

How pathetic. But I hoped the $50 award (reduced from $100 because of budget cuts) would come in handy for the deserving recipient.

Learn shoe-leather epidemiology, design case-control studies, and investigate deadly outbreaks . . . that’s what the EIS brochure promised. There was no mention of “face your deepest fear,” but that’s exactly what happened during my transformative time as an EIS officer.

Deciding it more professional and definitely less embarrassing to keep quiet about my fear of becoming a dog’s dinner, I focused instead on the difficult task of driving from Phoenix to San Carlos on the wrong side of the road. It was my first time driving in America, and I’d landed the role of team driver. The prospect of not arriving at the reservation in one piece seemed less scary than having to approach stray dogs.

Like everyone who signs up to be a disease detective, I thought I was fearless and ready to jump on any outbreak. Crawling through cells in a maximum-security prison and interviewing hundreds of inmates during a botulism outbreak couldn’t deter me; neither could examining specimens during a fatal outbreak of necrotizing fasciitis in the simmering heat of the Arizona desert. It was my very first field trip — investigating outbreaks of Rocky Mountain spotted fever (RMSF) on American Indian reservations that made me want to board a plane back to England.

Our team was a formidable mix of experienced tribal health workers, field epidemiologists, veterinarians, and physicians. I took on the task of setting up carbon dioxide tick traps in the hopes of avoiding any interaction with dogs. But then Jennifer H. McQuiston, DVM, MS (EIS ’98), Epidemiology Activity Leader at the Rickettsial Zoonoses Branch and world expert on RMSF, joined us for a day, and I felt the need to demonstrate that I was a worthy EIS officer. That didn’t go as planned. Instead, Jenny watched as I ran as fast as I could from a ravenous, barking, possibly rabid, black dog. “You must never run away from a dog!” shouted the world expert as I kicked up my heels even higher. “Yeah, right,” I thought. “Like that was going to happen!” However, I was inspired by Jenny’s determination to see the field trip succeed. One day, she crawled so far under a house to retrieve a litter of puppies that only her feet were sticking out. I wanted to be that brave, but I was still petrified.

It wasn’t the blood-sucking, bacteria-laden ticks that are the vectors for RMSF that scared me. It was the fact that we’d be picking the ticks off dogs. And I was petrified of dogs! It got worse. As the folks at the Rickettsial Zoonoses Branch briefed me on the investigation, it dawned on me that we wouldn’t be approaching the kind of cuddly, pampered, pristinely coiffed pooches that I see walking near my Manhattan home every day on their way to doggy spas. We would be pulling engorged ticks off the faces, abdomens, and paws of strays.

My imagination ran as wild as a pack of feral dogs. I pictured myself being chased across the reservation by rabid beasts, foaming at the mouth, as esteemed epidemiologists and unimpressed locals observed the hapless English doctor who would last only 1 week as an EIS officer. Perhaps I could grab a few ticks off one dog while another mauled me? I had to make this work somehow. Maybe they’d name an award after me: in tribute to the EIS officer who died of dog bites.

Everything changed halfway through the field trip when a tribe member put her dog in my hands and uttered two words, “Help her.” “I’m a doctor for humans,” I replied, trying to look away, “I can't help animals.” But even with my capacity to treat only one species, I could tell that the dog was hypovolemic and very sick. She stared at me with sad, shrunken eyes and my 24

irrational and unfounded fear of dogs dissipated into the desert sky. I could do nothing to help in that moment — no veterinary clinic on the reservation was available, and the woman said that even if a clinic were available, she didn’t have money to pay for treatment. However, I promised myself that I would do something to help in the future.

That opportunity arrived in my second year, when I joined a team of Indian Health Service workers and fellow Arizona EIS officer, Laura Adams, DVM (EIS ’12), an accomplished veterinarian, to offer free dog vaccination clinics on a different reservation. As the dogs were vaccinated, we collected serum specimens to study the prevalence of RMSF. I took blood from dogs with the help of Laura’s expert tutoring, and survived without a scratch!

Not only did I overcome my deepest fear, but my canine encounters as an EISO led to a full-fledged love for dogs. On March 2, after months of research and planning, my husband and I took the A Train to Animal Haven in downtown New York City and adopted Lily, a 3-month-old pit bull-boxer mix that could win over any soul with her brown eyes and freckly nose.

Her fear conquered, Seema rescued Lily, a pit bull-boxer mix.

[Who rescued whom?]

Credit: Seema Yasmin

That incredible transformation is a testament to the growth I experienced during EIS. It’s not just pathogens and vectors that we discover during outbreaks; sometimes it’s ourselves. In my case, I discovered a love for dogs and found my way to Lily.

I am still incredulous that I am nibbled by a teething pit bull puppy every day, and that Lily's penchant for my feet invokes laughter and not screams.

Article originally published in the CDC EIS Bulletin, April 2014

25 Seema Yasmin (left) takes blood from a dog on the Yavapai Apache Reservation to test for RMSF. She is being assisted by a veterinarian from the U.S. Department of Agriculture.

Credit: Seema Yasmin

Dr. Ayan Panja

Dr. Ayan Panja followed his family tradition of becoming a doctor and is a GP partner in a NHS practice in St Albans.

He began health broadcasting in 2006 when he was the expert presenter on BBC 1’s Street Doctors. More recently, Ayan has featured as a medical expert in Celebrity Quitters (FIVE), Squeamish (Discovery) and Bang Goes the Theory (BBC1). He also appeared as a GP panellist on Channel 4’s Health Freaks, where traditional home remedies were scientifically analysed by the doctors. He is currently the resident doctor on Health Check on BBC World News, presenting a monthly overview of global health stories. In 2005, Ayan’s first book was published, An Essential Medical Miscellany which is a collection of amusing medical titbits. Ayan has written features for various publications including The Guardian, The Huffington Post and Men’s Health.

Credit: Angela Dunn

Dr. Angela Dunn, MD MPH

Stories From the Field: Infection Prevention & Control Sierra Leone

Epidemic Intelligence Service Officer, U.S. Centers for Disease Control and Prevention

Article originally published by the CDC, available at: http://www.cdc.gov/vhf/ebola/hcp/stories-angela-dunn.html In a remote village in central Sierra Leone, a 38-yearold businessman went to his village clinic complaining of stomach pain and hiccups. He had recently returned from a business trip to Freetown and was enjoying time with his wife and two children. The clinic nurse knew the man well. He had been diagnosed and treated for peptic ulcer disease in the past. She examined the man by taking his temperature and pushing on his abdomen.

Apart from some mild abdominal discomfort, the examination was fairly normal. The nurse gave the man Tylenol and antibiotics, which had relieved his peptic ulcer disease in the past, and sent him home to rest.

The next morning, the man died.

Someone had alerted health authorities of an illegal burial. In Sierra Leone, all deaths must be treated as potential Ebola cases and buried by the government’s safe burial teams. The village chief, however, did not allow the health authorities to take the body and demanded the visitors leave the village immediately.

The deceased man’s family hid his body in an unfinished village house. While the village chief did not appreciate the health authorities’ approach, he did agree that a safe burial was warranted. The chief negotiated with the family and health authorities.

Accordingly, the family would not continue with the traditional burial; however, the safe burial team would conduct the burial in the village, rather than bringing the deceased to a mass graveyard inaccessible to the family. The next morning, the safe burial team arrived in the village. An 8-foot deep grave was dug in the land behind the deceased’s home. The burial team donned bright yellow suits— any expressions of compassion hidden by their protective masks.

Assuming her husband had died from peptic ulcer disease, the wife began washing his body following their traditional burial practice. The children helped their mother dress their deceased father in his best clothes.

As the family was grieving, a large white SUV arrived at the village.

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A swab was taken of the corpse’s mouth to test for Ebola. They took the body from the unfinished house and put it into the double body bag while the entire village looked on. The wife alternated between singing and crying as she watched her husband’s body being handled by five burial team members. The burial team carried the body from the house to the grave approximately 100 yards away. Inevitably, the body sagged to the ground, barely avoiding being dragged in the dirt. No one followed the burial team.

It is common belief that keeping traditional burial practices not only allows the deceased to pass on to a greater existence, but it also ensures that the village will be protected from hardships. It is believed that if the burial practices are disregarded, the deceased will be forced to wander the Earth tormenting the village with misfortunes.

Fortunately, the response from the international community has greatly evolved over the course of the epidemic. Efforts have been made to work within Sierra Leone’s cultural beliefs. Village and religious leaders have now been involved in developing safe burial practices. Burials are allowed to take place within the villages so that the families can observe them and visit the grave. Family members may give the safe burial team a symbolic object that will accompany the deceased in the body bag. This provides the family a bit of peace.

The villagers sat on their porches in silence, everyone stoic except for the wife who grieved while her husband’s burial was made very public. Results came back the next day: positive. This was the first case of Ebola in this village. The virus had spread once again.

The wife and children who washed and dressed the body would likely contract Ebola, as the deceased man’s body was full of the Ebola virus. However, because the body ultimately received a safe burial, it prevented many other exposures of people in the village.

Although safe burial practices are difficult and different from traditional burials, Sierra Leoneans are dedicated to stopping Ebola and have had to break from cultural traditions to honor the deceased. These efforts are monumental, though painful, and have resulted in most burials becoming safe burials in Sierra Leone—an essential and critical step to containing the epidemic.

Infection prevention and control is crucial in containing the Ebola epidemic; however, to be effective, the local culture needs to be considered. Burial practices in Sierra Leone are mostly determined by religion, local traditions, and secret societies. Fear of the consequences of not following these customs can be more powerful than the fear of Ebola.

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Credit: Angela Dunn

Drivers of Disease leads high-level One Health symposium A high-level symposium, ‘One Health in the Real Word: zoonoses, ecosystems and wellbeing’, is being co-organised by the ESPA-funded Dynamic Drivers of Disease in Africa Consortium. The symposium, to be held at the Zoological Society of London (ZSL) 17-18 March 2016, is bringing together leading experts from different fields in the natural and social sciences to discuss ‘healthy ecosystems, healthy people’.

Co-organised by ZSL, in partnership with the Royal Society, the event will present new interdisciplinary frameworks for a One Health approach to zoonotic diseases (those passed from vertebrate animals to people). One Health rests on the principle that the health of humans, animals and ecosystems are interdependent.

However, there is little integration in understanding the relationships between these sectors. Often research is divided between those who focus on environmental change and ecosystem services; those who address socio-economic, poverty and wellbeing issues; and those who consider health and disease, leading to fragmented understandings and inadequate responses.

The symposium will also highlight evidence from field-based settings, including those in Ghana, Kenya, Sierra Leone, Zambia and Zimbabwe where Drivers of Disease researchers have been working.

Importantly, it will also debate implications of a One Health approach for policy and practice.

Agreed speakers to date include Dr David Nabarro, who organised the UN’s response to the recent Ebola crisis, Professor Jeremy Farrar, Director of the Wellcome Trust, Professor Chris Dye, Director of Strategy at WHO, and Dr Peter Daszak, President of EcoHealth Alliance.

The Drivers of Disease consortium has been working for more than three years to deliver much-needed, cutting-edge science on the relationships between ecosystems, zoonoses, health and wellbeing, with the objective of moving people out of poverty and promoting social justice.

To find out more about the symposium or to register to attend or to present a poster: www.zsl.org/science/whats-on/one-health-for-the-real-world-zoonoses-ecosystems-and-wellbeing To find out more about the Dynamic Drivers of Disease in Africa Consortium: www.driversofdisease.org 28

Dr. Tesfaye Bayleyegn

Dr. Tesfaye Bayleyegn, MD, is an epidemiologist. He is a team lead for Disaster Epidemiology and Response Team at the CDC National Center for Environmental Health. Dr Bayleyegn, trained in medicine at the Higher Institute of Medical Science Santiago de Cuba, Cuba and specialized in Anesthesiology in Addis Ababa University Medical Faculty, Ethiopia. While he was in Ethiopia, 1993-2004, he initiated and advocated for Emergency Medicine development. He was the first appointee officer for violence and injury prevention surveillance in WHO country office in Addis Ababa, Ethiopia.

In 2004 he joined the Epidemic Intelligence Service Officer (EIS’ 2004) where he investigated several disaster-related morbidity and mortality during hurricanes (e.g., Hurricane Ivan, Katrina, Ike) and conducted field investigations and evaluation to respond effectively to disaster. His research interest focuses on environmental health, disaster preparedness and response both for natural or human-induced disasters. Dr. Bayleyegn has authored or co-authored several peer -reviewed articles, guidelines, tools, factsheets and disaster-related training materials.

Disaster Epidemiology in Action “The Health Studies Branch at CDC welcomes the opportunity to work with and help communities with their needs by conducting CASPERs in response to natural or human induced disasters or in preparation for environmental disasters ”

procedure to assess the community’s needs following a disaster or to assess household preparedness for emergencies. The first stage includes selecting a sample of 30 clusters (e.g., census blocks) with probability proportional size (i.e., estimated number of housing units in each cluster). In the second stage, 7 households are systematically selected in each of the 30 clusters.

Following any type of environmental disaster, public health and emergency management professionals must be prepared to respond to the needs of people who have been affected. But without accurate information on the health status and needs of the affected community, they may make decisions based on impressions, opinions, or limited knowledge.

To make informed choices, health scientists use epidemiology to assess the short- and long-term adverse health effects of the disaster. Disaster epidemiologists use rapid needs assessment, morbidity and mortality surveillance, health tracking, research, field investigations, and evaluation to respond effectively to the current disaster and to predict consequences of future disasters.

The CASPER methodology estimates needs for the entire population affected. The advantage of this methodology is that each household has an equal chance of being selected. CASPER data can be used to guide authorities in determining appropriate response and recovery activities throughout affected areas. The CASPER methodology is modeled after the World Health Organization’s (WHO; Geneva, Switzerland) Expanded Program on Immunization, which was designed in the 1970s to estimate immunization coverage.

The Center for Disease Control and Prevention (CDC), National Center for Environmental Health (NCEH), Health Studies Branch (HSB) has promoted disaster epidemiology and been involved in needs assessment and disaster-related morbidity and mortality surveillance since the early 1990s. In addition, HSB developed a needs assessment tool that can be used during natural or human-induced disaster events.

Although the CASPER was originally used for disaster response, the assessment has been increasingly used for non-disaster assessments such as measuring community preparedness and conducting health impact assessments. Health impact assessments are systematic processes that help evaluate the potential health effects of a plan, project, or policy before it is built or implemented.

The Community Assessment for Public Health Emergency Response (CASPER) is a rapid needs assessment approach that uses a two-staged sampling 29

To make CASPER more accessible, HSB developed an online CASPER toolkit to assist the public health community in conducting CASPERs. The toolkit provides guidelines on data collection tool development, methodology, sample selection, training, data collection, analysis, and report writing.

Over a 10-year period (2003 – 2012), CDC assisted public health authorities in conducting 53 CASPERs in United States. The number of CASPERs conducted has steadily increased since 2003. These assessments include responses to natural disasters (e.g., hurricane, earthquake, and tsunami) and human-induced disasters (e.g., Gulf of Mexico Oil Spill), as well as preparedness CASPERs.

Ekta Choudhary, PhD, providing training to American Samoa Department of Health staff on CASPER, October, 2009.

Credit: Tesfaye Bayleygn

CDC’s Response to a Natural Disaster: Tsunami in American Samoa, 2009 At 6:48 a.m. local time on September 29, 2009, four successive tsunami waves, each 15 to 20 feet high, hit the small Pacific island of American Samoa. The surge reached up to a mile inland. Minutes before, the Pacific Tsunami Warning Centre reported an earthquake in the Pacific Ocean measuring a magnitude of 8.1 on Richter scale and lasting more than five minutes. Although the epicenter of the quake was 20 miles below the ocean floor and 120 miles southwest of American Samoa, the resulting tsunami brought death, injury, and extensive damage to the Territory.

The CDC team of (from left); Michelle Murti, MD, MPH, and Mawuli Nyaku, DrPH, MPH, conducting a household interview during CASPER. Credit: Tesfaye Bayleygn

American Samoa’s largest island, Tutuila, the capital city of Pago Pago, and the western population center of Leone were hit particularly hard. In addition to fatalities and injuries, the tsunami damaged public utilities, resulting in a widespread loss of water, electricity, and sanitation services and displacing many families from their homes.

CDC’s National Center for Environmental Health (NCEH) was part of the immediate emergency response and assisted the American Samoa Department of Health in conducting an initial CASPER within a week. A month after the tsunami, with the objective of evaluating the response efforts, CDC and the American Samoa Department of Health conducted a follow-up CASPER.

CDC’s Response to a Human-induced Disaster: Deepwater Horizon Explosion, Gulf of Mexico, 2012 On April 20, 2010, the Deepwater Horizon oil drilling platform exploded in the Gulf of Mexico, 40 miles from the Louisiana coast.

The explosion resulted in 11 deaths, 17 injuries, and the largest marine petroleum release in history. The oil well’s proximity to the fishing industry; coastal attractions; and estuarine, marsh and protected ecosystems of the Gulf States of Louisiana, Alabama, and Mississippi placed these resources, as well as the fishing industry and coastal attractions, in jeopardy of destruction.

The initial CASPER results provided the American Samoa Department of Health with information on the most pressing public health concerns, including lack of access to clean drinking water, lack of medications, and injuries associated with clean-up. The follow-up CASPER evaluated whether the post-disaster public health recovery activities were successful and identified a significant increase in mental health conditions since the initial CASPER.

In the days and weeks following the explosion, oil leaked from the damaged well, posing potential health hazards for those exposed to or affected by the spill. In addition, businesses and industries along the Gulf Coast suffered financial losses.

To assess the recovery efforts, CDC assisted the states of Alabama and Mississippi in conducting CASPERs. The goals of these assessments were to determine the general and mental

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The CDC team of (from left) Tesfaye Bayleyegn, MD; Sara Vagi, PhD; Amy Schnall, MPH; and Danielle Buttke, DVM, PhD, MPH, feverishly analyze data collected by the CASPER interview teams to send to states within 48 hours. Credit: Behrooz Behbod

In September 2012, the Oakland County Health Division (OCHD), the Michigan Department of Community Health (MDCH), and the CDC conducted a CASPER survey of residents in Oakland. Because Michigan had experienced severe weather events (storm or flood) during 2008-2012, the primary objective of the CASPER was to assess general emergency preparedness. The survey asked for information about household emergency supplies, households with additional needs (e.g., medical requirements or pet ownership), and the preferred sources of information during a disaster. In addition because Oakland County is located 50 miles from nuclear power plant, the survey included questions about preparedness and emergency response plan to a radiation emergency.

The CASPER results showed most households reported having basic supplies to last three days in an emergency including non-perishable food (85.4%), water (1 gallon/ person/day) (64.7%), and a way to cook food without utilities (76.4%). In households where at least one person took daily medication, 96.9% had a seven-day supply, and in households with a pet, 88.7% had a three-day supply of food and water for their pet. Half of all households had at least one pet (48.8%), and the majority of households (88.0%) said they would take their pet with them during an evacuation.

Michelle Murti, MD, MPH, presenting preliminary result of the assessment to stakeholders.

Credit: Tesfaye Bayleygn

health needs of communities following the oil spill, and to provide the state and local public health officials with information to guide responses and allocate resources. The interviews, analysis, and report were all completed within 48 hours.

The survey results revealed evidence of the mental and social effects of the oil spill on individuals, families, and the community.

The proportion of respondents reporting negative mental health effects (e.g., depressive symptoms, anxiety disorder) in the affected Alabama and Mississippi coastal communities was higher than the proportion reported in the 2008 and 2009 state reports of Behavioral Risk Factor Surveillance System.

The states of Alabama and Mississippi used the CASPER results to focus interventions and outreach services. For example, Alabama hired additional mental health personnel, created crisis response teams, and formed the Gulf Coast Resiliency Coalition to better understand and address the needs of the communities.

CDC’s Response to a Non-disaster Event (Preparedness) CASPER: Assessing Radiation Emergency Preparedness, Oakland, Michigan, 2012

Households in Oakland County reported a very high willingness to follow instructions from officials in the event of the release of radioactive material that could affect their community. Most households also indicated their willingness to go to a radiation screening center (93.3%), evacuate (96.0%), and shelter-in-place (91.8%) if told to do so by officials.

CASPER data regarding how residents might react during a radiation emergency provided objective and quantifiable information that will be used to develop Oakland County's radiation emergency preparedness plans. Survey results demonstrate the feasibility and usefulness of CASPER methodology for radiation emergency preparedness planning.

CDC’s CASPER Helps Public Health and Emergency Managers The use of the CASPER has continued to expand over the past two decades. Public health authorities have used CASPER methodology to accurately assess communities’ public health needs following disasters. In addition, CASPER results, both in disaster and non-disaster settings, are being used to support evidence-based public health decisionmaking. Using CASPER provides public health professionals the opportunity and the means to be involved in acute problem-solving situations before, during, and following disasters. For more information, email Dr Bayleyegn at bvy7@cdc.gov or contact us at +1-770.488.3410.

Website: http://www.cdc.gov/nceh/hsb/disaster/casper.htm 31

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Dr. Samantha Bracebridge

I have worked as the UK Field Epidemiology Training Programme (FETP) Director since September 2010, initially developing and implementing the new programme, and now mainly supervising FETP fellows and facilitating at training modules.

I qualified from the Royal London Hospital Medical School in 1992, and first trained in General Practice before specialising in Public Health Medicine. I was appointed as Consultant Regional Epidemiologist in the East of England in 2004, and was seconded within the former Health Protection Agency to lead on the international surveillance of pandemic influenza in 2009.

I have been involved in the operation aspects of several major incidents including SARS, the largest European fire since the Second World War, the 2009 influenza pandemic, and more recently I was deployed to Sierra Leone to work alongside the Ministry of Health to assist with the development of the surveillance systems for Ebola. I have always had a keen interest in developing others, and have been actively involved in training during my entire career. I have a Professional Certificate in Higher Education.

“Field epidemiology is a vocation: it takes passion to do the job well.�

How did the Field Epidemiology Training Programme (FETP) begin in England?

The FETP was set up in 2011 in response to an externally commissioned review of epidemiology in the former Health Protection Agency. The review identified gaps in the depth of skills across some subject areas, and the lack of planning for the next generation of national and international epidemiology experts, thus recommended that a Field Epidemiology Programme should be developed. We are really fortunate to run the programme in collaboration with the European Programme for Intervention Epidemiology Training (EPIET), so our fellows learn from, and belong to, a very strong network of epidemiologists.

What are some of the most famous or successful FETP investigations to date?

I think that all of the investigations that have been done by fellows have been successful in achieving public health action – which is what it is all about. Fellows spend the majority of their time investigating outbreaks, evaluating surveillance systems or conducting applied research to add to the body of evidence. Most fellows have the opportunity to deploy overseas to help network building, and to strengthen global health capacity.

How do you see FETP contributing to public health over the next 10 years?

In addition to building our national epidemiological capability, I think the FETP will become more involved in global health system strengthening.

What has been your training and experience to date, and how did you get involved with leading FETP in England?

I trained in public health, focussing on health protection, and have District offices in East Java, Indonesia. We were asked to evaluate the surveillance system and vaccination coverage for diphtheria after conducting a seroprevalence study.

Credit: Samantha Bracebridge

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worked as an epidemiologist since I qualified. I was initially seconded from my Regional Epidemiology post to set up the FETP, and then was successful in becoming the permanent director of the programme.

Yes there are many other programmes across the world. Many belong to the Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET). Their website includes some of the affiliated programmes and is a good place to look: http://library.tephinet.org/programs

What has been your most memorable moment to date as part of your work with FETP?

What do you feel are the key attributes, knowledge, and skills of successful FETP Fellows?

Seeing the first cohort through the programme and successfully graduate!

A thirst for learning, flexibility and good communication skills are key attributes for successful fellows. Fellows need a good basic understanding of epidemiology in the public health context.

What do you feel you have learned from your leadership experience with FETP?

Where have FETP alumni gone after completing the 2-year fellowship?

That collaboration and networking are the key elements for a successful programme. The FETP would not be possible without the wonderful input of our training site supervisors.

We have been very privileged to work with the European Programme for Intervention Epidemiology Training (EPIET), to share resources and best practice.

Generally fellows have either stayed in Public Health England, or continue with their public health training programme with the aim of applying for an epidemiology post when they graduate. We have had one vet through the programme who is now a lecturer in veterinary public health at the Royal Veterinary College.

What's your top advice for prospective FETP applicants?

Who can apply to the FETP fellowship? Is it limited to medical doctors from England?

Read the application form well and make sure you evidence all of the essential criteria in the person specification of the Job Description! Recruitment to the FETP is a very competitive process.

The 2 year programme is aimed at medical, nursing, scientific, or veterinary professionals who wish to have a career involving field investigation and epidemiology.

Any final words?

Are there FETP programmes in other parts of the world? How can prospective applicants learn about these programmes closer to home in their respective nations?

Field epidemiology is a vocation: it takes passion to do the job well. The career is extremely rewarding and varied, and has the potential to really improve the health of the population. I would recommend it without hesitation!

35 Visiting contacts of an Ebola case in a quarantined home in Tonkolili district, Sierra Leone, to ensure they are all well and getting the support they need.

A week after this photo was made, their family member was discharged from the ETU, returned home and no further contacts became ill.

Credit: Samantha Bracebridge

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Dr. Michael Edelstein

Michael Edelstein is a medical doctor specialised in public health and field epidemiology. He graduated from Birmingham University medical School in 2006, holds an MPH from London School of Hygiene and Tropical Medicine and is an alumnus of the European Programme in Intervention Epidemiology Training (EPIET).

He currently works as an epidemiologist at Public Health England and as a research fellow for the Centre on Global health Security, Chatham House. He has worked in both routine and emergency contexts for national public health agencies and international public health organisations in Europe, Africa and Southeast Asia.

“Good field epidemiologists are in high demand and there is something for everyone!�

You've been involved in the field epidemiology response to several incidents that have made the headlines; the 2013 Typhoon Haiyan (Yolanda) that hit the Philippines, the 2014-15 Ebola outbreak in Liberia, and the 2015 earthquake in Nepal, to name a few.

Let's go back to the start... what made you decide to become a field epidemiologist in the first place?

What were your roles and responsibilities in these field investigations?

Emergencies are by nature chaotic and unpredictable. One important skill when responding to such emergencies is flexibility - one must be ready to get outside of his/her comfort zone quite regularly. I have had both technical and coordination roles in the field- doing things such as setting up an early warning system to detect outbreaks, investigating outbreaks or organizing the response to an emergency in partnership with several agencies.

This requires technical skills such as analysing and interpreting data using statistical or GIS software, as well as leadership skills, when managing stakeholders from other agencies or from the government. The ability to take difficult decisions rapidly based on incomplete information is another skill you develop.

You also end up undertaking very unexpected tasks- such as tracing a spare part for a truck, negotiating helicopter use with the army or hiring a group of machete-equipped locals to clear a patch of jungle!

I graduated from medical school in 2006, and from my elective experience of looking at the impact of antenatal care on pregnancy outcomes in Bangladesh, I understood the potential impact of public health compared with clinical medicine and knew I wanted to become a public health doctor. As part of my public health training, I was fortunate to be placed at the Health protection Agency (now Public Health England) and got a taste of disease surveillance and outbreak investigations, which I really enjoyed- I geared my training towards communicable disease control, and realised that surveillance and outbreak investigations required a specific set of skills, and those skills were those of a field epidemiologist- so after acquiring some experience, both nationally in England and internationally, working on the polio eradication programme in Burkina Faso, I went onto the European field epidemiology training programme (EPIET). During the 2 year fellowship, I learnt the technical skills that would prepare me for field investigations, as well as epidemiology work in Europe- at a leadership level. EPIET was a great opportunity to investigate outbreaks, set up and evaluate surveillance systems while pursuing my research interests- as well as taking part in international missions.

How did you prepare ahead of your deployment?

I generally try to get as much information as I can about the country I am going to, liaise with people already in the field to get the most up to date information. I also make sure my immunization status is up to date - the days before deployment are quite manic and there can be quite a lot of paperwork such a sorting flights, accommodation, insurance etc‌ Once there, one of the most important lessons I have learnt from short term deployments is to very rapidly gauge the situation once in the field, identify the most crucial gaps, focus on one or two key objectives and deliver them, rather than trying to solve the whole crisis.

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Who else was in your team for the field epidemiology investigations?

Obviously being far away from family and friends, sometimes in dangerous situation with limited ability to communicate is stressful for those back home as well- it’s important to consider that too.

It is generally a mix of backgrounds- water and hygiene specialists, engineers, clinicians, communication expertsbut the most crucial person is the logistician- ensuring you can get safely where you need to, with the equipment you require. Increasingly, sociologists and anthropologists are also deployed- an extremely valuable addition to field teams, to help understand the local context and culture, which is essential for a successful delivery of any public health intervention

Do you now wish you could have done anything differently?

One important thing is to understand your own limits and to accept some things are outside of your control- in large emergencies sometimes you feel a little powerless, you feel you are not contributing anything positive. I have now learnt to focus on specific objectives and to make sure I hand over properly to the next person- each individual in the field makes his/her contribution to the larger response.

What worked well and why?

In my experience things work well when everyone is clear about their role, has the right skills and is ready to go the extra mile. There is not a huge amount of time for training or adaptation. If the team bonds well, generally things go well- and you can have a good time and deliver what you need to deliver. These deployments are also a great opportunity to build local capacity- you identify key local staff, you teach them to do what you do- and you improve things on the long run.

How can readers learn more about EPIET? Go to the webpage (http://ecdc.europa.eu/en/epiet/Pages/ HomeEpiet.aspx) or speak to an EPIET alumnus.

What's your top advice for prospective EPIET applicants or field epidemiologists?

Were there any challenges, and how did you overcome them?

Make sure by the time you apply for EPIET or an FETP, you are clear on how it fits with your career objectives and how you will benefit from the programme- speak to several alumni to make sure this is for you. Prior to applying, I think having a little bit of experience to demonstrate your commitment to the field helps.

There are many challenges- the first one is that you have to work very hard- at the very beginning of an emergency, I have had 18-20 h days for several weeks in a row- it is very tiring. The second one is that you can have pretty rough living conditions- I have had to share a tiny room with no water or electricity for a couple of weeks in very hot and humid conditions- it’s difficult to operate at your best in those conditions. You also work and stay with the same people 24/7- you get no free time and little privacy.

As a result people burn out. Personally, the way I overcome this is by telling myself I am here for a very specific purpose, for a limited time and that I need to make a difference- that motivates me to give 100%.

Any final words?

While I have mainly discussed emergency response, field epidemiology is quite varied and while some of us work full times as emergency responders or in rapid response teams, a large proportion work in more stable environments such as public health agencies, academic institutions, NGOs or the private sector- good field epidemiologists are in high demand and there is something for everyone!

38 En route to investigate and respond to an outbreak, Philippines 2013 Credit: Michael Edelstein

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