CDC Global Health

E-Brief

Responding to Global 

Public Health Emergencies

Third Quarter 2008

WELCOME to the third quarter Global Health 

E-Brief, designed to inform readers about key 

global health activities at the Centers for Disease 

Control and Prevention (CDC). Our third issue 

for 2008 highlights how CDC has responded 

to global public health emergencies. Whether 

natural disasters such as cyclones or earthquakes; 

deadly, recurrent disease outbreaks; or man-made 

emergencies arising from political unrest, CDC is 

committed to working with Ministries of Health 

and other partners to assess and respond to public 

health needs resulting from these critical events.

CDC Perseveres to Assess Public Health Needs 

After Cyclone Nargis

Nargis, a category 3 cyclone, made landfall May 2, 2008, 

on the southern edge of Burma (also known as Myanmar). 

Two months later, the official death toll was 84,537, another 

53,836 people were still missing, and 800,000 people were 

displaced. 

The worst natural disaster in the history of Burma, 

Cyclone Nargis was the most devastating cyclone to strike 

Asia since 1991. Nargis swept across the country with wind 

speeds of up to 200 kilometers per hour and heavy rain. 

When the storm subsided, there was near-total destruction 

of fields and shelter in the areas of direct impact.

In response to this global emergency, the United 

Nations (UN) deployed staff to the capital city of Yangon to 

provide informatics assistance and coordinate information 

for humanitarian response through the establishment of a 

Humanitarian Information Center (HIC). The Union of Burma, 

the UN, and the Association of Southeast Asian Nations 

(ASEAN) joined forces to coordinate relief activities. One of 

their first critical activities was to develop a joint assessment 

to analyze the extent of destruction and determine key 

recovery and humanitarian needs.

IN THIS ISSUE

1 CDC Perseveres to Assess Public Health Needs After 

Cyclone Nargis

2 Public Health Work Continued in Kenya Despite

Post-election Violence

3 CDC Foundation Donation of Mobile Technology Devices 

Helps Fight Disease in Earthquake-torn China

4 CDC Experts Work with Uganda Ministries of Health and 

Tourism to Protect Tourists from Deadly Marburg Virus

5 CDC and Partners Educate Kenyans about Simple Inter- vention to Ease Disruptive Cholera Outbreaks

Focus group conducting surveys to identify needs in special populations.

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CDC joined the relief efforts 

at the request of the Information 

Management and Mine Action 

Programs (iMMAP), a U.S.-based 

organization that works on the 

effective use of information 

management practices and principles 

in the service of humanitarian relief 

and development. iMMAP and CDC 

have a long history of setting up HICs 

around the world. CDC and iMMAP 

staff, including CDC informatics 

expert Carl Kincaide, were deployed 

to the UN to work on the assessment 

in Yangon. 

To rapidly assess the 

humanitarian needs of the 

extrordinarily large affected 

area—around 17,000 square 

miles—relief workers had to consider 

logistics, staffing, coordination and 

methodology. 

Kincaide helped survey individual 

households, teachers and representatives of special 

populations in the worst-affected townships. The survey 

included questions on health, food and nutrition, education, 

women and children, water and sanitation, agriculture, 

livelihood, temporary settlements, and emergency shelter. 

He and his colleagues collectively visited 291 villages, across 

30 townships, gathering almost 5,000 paper surveys over 10 

days in June. 

The logistics were one of the biggest challenges, 

according to Kincade. “When you try to survey villages 

that have been flooded or have no roads to get to them, it 

requires hours on small boats, walking, or helicopter to get 

the enumerators to the villages.”

“Then we had to bring 5,000 surveys back to Yangon to 

be analyzed.”

Despite the challenges of rapidly completing an 

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assessment of that magnitude, the data documented the 

devastation and the needs of people in affected villages. The 

devastation included entire villages levelled by the 12 foot 

storm surge, contaminated drinking water from ponds due 

to salination from the surge, dead livestock, and rice fields 

flooded with salt water. Public health issues that the Burma 

health system will need to be alert to for some time include 

stress, malnutrition from poor diets, and potential outbreaks 

of diarrhea because of poor sanitary conditions.

The data also help the humanitarian community make 

the case for responding to similar disasters in the future by 

showing the potential for continued suffering if the response 

is not effective. 

A unique challenge to CDC’s participation in the 

response is the current state of the US Government’s 

relationship with Burma, according to Mike Gerber, CDC’s 

lead for international emergency and refugee health. Due 

to Burma’s military leadership, visas were hard to obtain, 

especially for US government agencies.

“Because the US Government does not have diplomatic 

relations with Burma, CDC could not offer its typical support 

for this effort,” Gerber said. “Even so, through Carl Kinkade’s 

efforts as part of an international team, CDC made a 

substantial contribution to the rapid collection of information 

needed for effective emergency response.” 

The next phase of the assessment is evaluation and 

monitoring of the humanitarian effort to inform leaders 

of the relief efforts in progress. CDC continues to provide 

support through iMMAP to help the UN and Burma response 

to the current and ongoing health needs of Cyclone Nargis 

survivors.

The CDC Global Health E-Brief is produced quarterly by the Centers for Disease Control 

and Prevention’s (CDC) Coordinating Office for Global Health (COGH). To find out more 

about CDC and COGH, go to www.cdc.gov and www.cdc.gov/cogh.

CDC provided analysis of the collected data to identify areas of greatest need.
Public Health Work Continued in Kenya Despite 

Post-election Violence

More than 1,000 people were killed and another 300,000 

displaced as a result of violent protests when members 

of rival political parties contested the Kenyan presidential 

election in December 2007. During the following two 

months, CDC offices in Nairobi (including clinics in the Kibera 

informal settlement) and rural Kenya were closed periodically 

because of concerns for staff safety. Despite the upheaval, the 

public health work being done at CDC Kenya and its partner 

institution, the Kenya Medical Research Institute (KEMRI), 

continued throughout this chaotic period in Kenya. 

As others fled the violent regions, several heroic KEMRI/

CDC staff reported to work to provide the critical care and 

treatment on which so many Kenyans rely. When the violence 

began, Mary Agola, a nurse with KEMRI-CDC was at Lwak 

Mission Hospital in rural Kenya. Many of her colleagues had 

returned to their home districts to vote and could not return 

because of the violence. Realizing that hospital operations 

would stop if they left, Agola and other staff stayed. During 

the next two weeks, she and other KEMRI-CDC staff including 

health recorders Mary Pacho, Kennedy Jaramba, Judith 

Ongaro, and George Odhiambo; lab technologists Nicholas 

Omondi and Christine Awuor; and clinical officer Harun 

Chilaho, cared for the regular flow of people sick with malaria, 

pneumonia and HIV, in addition to the surge of patients 

injured during the post-election violence. In addition to the 

KEMRI-CDC clinical team, community workers also continued 

to visit households in the surveillance areas to collect data on 

health status.

Agola and the other KEMRI-CDC staff had the support of 

the community—which even staged mock demonstrations 

to keep troublemakers away—to keep the hospital running. 

“It’s true we were frightened, but we felt a responsibility to 

our work as well as to the people who were affected by the 

violence,” Agola said. “Other hospitals had closed and people 

were coming long distances for help.” Staff replacements 

began arriving the week of January 7, but the KEMRI-CDC 

staff continued working until January 20th to be sure that 

people who needed care received it. As a result, the Lwak 

Hospital never closed its doors.

KEMRI-CDC staff helped the community in other ways 

as well. The Kisumu Field Station in rural Kenya held a blood 

drive on January 11 and collected 32 pints of blood for 

use in community hospitals. In addition, the KEMRI-CDC 

collaboration joined Red Cross International and other 

partners in Nyanza Province to provide medical care. Through 

temporary medical camps, they provided drugs, medical care, 

psychosocial support, nutrition support, voluntary counseling 

and testing for HIV, food, and legal support. On February 2, 

more than 1,000 people attended one such camp. 

KEMRI-CDC staff also distributed malaria treatment 

and bednets, and several staff attended “alternatives to 

violence” workshops to discuss ways to bring peace to their 

own lives and to their communities. 

This violent episode illustrates 

how non-health issues, such as 

an election, can have a significant 

negative impact on the public 

health infrastructure of a country. 

CDC’s response shows the agency’s 

broad public health expertise that 

can be mobilized against violence 

and injury prevention as well as 

infectious diseases. In addition, the 

response shows CDC’s global reach 

is intentionally nimble to provide 

assistance in response to changing 

environments and public health 

needs. 

Today, the violence has subsided, 

but disruptions in food supply, 

immunizations, medications, and 

health services are expected to 

affect Kenyans’ health for some time. 

Looking forward, KEMRI-CDC will 

evaluate the public health impact 

of the post-election violence and 

respond to what may become lasting 

impacts on public health in Kenya.

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Tony Langat a pharmacist with KEMRI-CDC speaks to a patient .
CDC Foundation Donation of Mobile Technology 

Devices Helps Fight Disease in Earthquake-torn 

China

Six CDC scientists were scheduled to leave for China 

in just two days. Officials from China’s CDC were reporting 

that public health facilities in Sichuan province had been 

demolished by the May 2008 earthquake and that they had 

very limited capacity to assess the region’s health needs or 

monitor for potential disease outbreaks. The U.S. CDC experts 

were planning to work with their counterparts at China’s CDC 

to rapidly get a health surveillance system up and running by 

using mobile technology for data collection. 

Using mobile technology for surveillance is still an 

emerging idea in public health, and neither U.S. CDC nor 

China CDC had enough handheld computers to get the job 

done. Even if the U.S. team could work through the necessary 

government process to obtain the handheld PDA units they 

needed, they did not know how they would get them to 

China quickly enough through diplomatic channels. So, CDC 

asked the CDC Foundation for help.

The Foundation was ready to use funds from its Global 

Disaster Response Fund to help purchase the handheld 

units, but first reached out to partner organizations to see 

if the units might be secured through an in-kind gift. The 

Foundation immediately contacted corporate leaders at HP. 

HP had previously donated equipment to CDC through the 

Foundation to meet needs following the 2004 tsunami that 

devastated Southeast Asia. HP leaders quickly agreed to 

donate 500 HP iPAQ Travel Companions with GPS technology, 

valued at approximately $300,000, and ship them directly to 

China CDC in Beijing. The units arrived within one week of the 

U.S. CDC team, so they were able to begin helping Chinese 

scientists re-establish a health surveillance network almost 

immediately. 

“HP and its employees have a long history of helping 

those in need,” said Isaiah Cheung, vice president and general 

manager, Personal Systems Group, HP China and Hong Kong. 

“The public health surveillance system, supported by HP iPAQ 

GPS travel companions, will go a long way toward preventing 

Sichuan earthquake survivors from suffering additional pain 

due to disease.” 

Microsoft also donated handheld mobile devices directly 

to CDC China, and, working with the CDC Foundation, 

USGlobalSat, Inc., a subsidiary of GPS manufacturer GlobalSat 

Technology of Taiwan, provided wireless Bluetooth GPS 

receivers to ensure that the devices donated by Microsoft had 

the GPS capabilities health teams required.

Says Leslie A. Lenert, M.D., M.S., director of CDC’s National 

Center for Public Health Informatics, “With the new system 

we helped them design, and with equipment donations 

organized by the CDC Foundation, China CDC now is able 

to quickly collect public health data in earthquake-affected 

areas where communications capacity has been destroyed 

and send it to China CDC headquarters for analysis. This 

allows China CDC to rapidly get the right resources to the 

right places to save lives by preventing or reducing disease 

and injury.”

As efforts in China have 

shifted from emergency response 

to recovery, the health and 

well-being of an estimated 5 

million displaced persons and 

the rebuilding of health system 

infrastructure have become chief 

concerns. Mobile technology 

with geographic information 

systems (GIS), like the handheld 

units donated by HP and the 

components donated by 

USGlobalSat, Inc., can be used 

to collect data, map locations of 

clinics and shelters and transmit 

critical information for rapid 

analysis. CDC will continue to 

provide technical assistance 

and expertise as China works to 

prevent disease outbreaks and 

rebuild the public health system in 

Sichuan province. 

(This article was originally 

published in The Frontline 

Newsletter, Fall 2008, by the 

CDC Foundation: http://www.

cdcfoundation.org/frontline/2008/) CDC’s Dr. Ramesh Krishamurthy and Dr. Yu Wang, director of CDC China discuss the use of handheld computers to 

restore health surveillance activities following the earthquake.

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CDC Experts Work with 

Uganda Ministries of Health 

and Tourism to Protect Tourists from Deadly Marburg 

Virus

In July 2008, a Dutch tourist 

died of Marburg viral hemorrhagic 

fever following her return to the 

Netherlands from a vacation in 

Uganda. Marburg is a very rare but 

severe type of hemorrhagic fever 

caused by a virus similar to the 

group of Ebola viruses. During the 

trip, the Dutch tourist visited a cave 

near Queen Elizabeth National Park 

located in the western part of the 

country. After the diagnosis was 

confirmed, public health authorities 

in the Netherlands immediately 

notified others with whom she may 

have had contact. Fortunately, no 

one else was infected. 

Recognizing that other tourists 

could be at risk from similar 

exposures during visits to their 

country, the Uganda Ministry 

of Health requested assistance 

from CDC to help respond to the 

potential public health emergency. 

In early August, CDC sent a threeperson team to work with the 

Uganda Ministry of Health, the 

Uganda Wildlife Authority (UWA), and the Association of 

Uganda Tour Operators. Together, the group quickly created 

and distributed messages about safe and healthy travel to 

Uganda. The activities included: 

y Reaching out to Uganda and US-based African tour 

operators to describe the risks associated with exposure 

to bats and recommending that travelers not enter caves 

or other bat habitats; 

y Developing printed products, created by the CDC team 

with guidance and approval from the Ugandan public 

health and tourism authorities, for specific audiences:

þ A ‘Safe and Healthy Travel in Uganda’ brochure 

for distribution to international travelers. The 

brochure provides guidance on preventing disease 

during travel, as well as pre- and post-travel 

recommendations for travelers.

þ An ‘Ebola and Marburg 

Hemorrhagic Fevers’ 

brochure and a companion 

poster to educate residents 

and health providers 

in at-risk areas about 

precautions to prevent 

the two diseases and 

symptoms to watch for in 

the event of an exposure. 

y Posting a Travelers Health 

Notice on the CDC web site 

recommending that tourists 

and other visitors not enter 

caves or mines inhabited by 

bats.

To further investigate the 

ecology of Marburg virus in bats in 

Uganda, CDC sent a second team to 

collect and test bats from the cave 

for the Marburg virus. Tissue samples 

from the bats were initially examined 

at the Uganda Virus Research 

Institute in Entebbe. Additional 

analysis at CDC headquarters in 

Atlanta is expected to result in more 

information about the characteristics 

of the virus and lead to further public 

health recommendations to protect 

the public. 

This collaboration between CDC, the Ugandan 

Ministry of Health, Ugandan Wildlife Authority, and the 

tourism industry effectively used scientific inquiry to 

create messages to protect public health and prevent a 

potential public health crisis. The products created during 

the response—the first such collaboration by Uganda’s 

public health and tourism agencies—featured consistent 

messages to protect both the public’s health and the 

tourism industry that makes important contributions to 

Uganda’s economy. 

The success of this collaboration is attributable to 

CDC’s technical expertise and the willingness of Ugandan 

authorities, both public and private, to work together. The 

materials will be distributed broadly and authorities also 

plan to develop surveys to gather additional data from 

international travelers to Uganda, the Uganda Wildlife 

Authority staff, and the tourism industry about how to 

promote safe, healthy travel. 

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CDC communicators assisted the Uganda Public Health 

and Tourism authorities in developing materials to educate 

Ugandans and others about safe travel
CDC and Partners Educate Kenyans 

about Simple Intervention to Ease 

Disruptive Cholera Outbreaks

Teddy Malachi, CDC’s foot soldier in the 

battle against cholera in Nyanza Province, 

Kenya, has been busy lately. Seven times since 

March of this year he has traveled to rural 

villages or semi-urban slums to respond to 

outbreaks. In hospitals, clinics, schools, and 

at community meetings, Malachi has worked 

with local partners to give people the tools to 

protect themselves from cholera, an ancient 

disease that can cause explosive, potentially 

lethal epidemics of diarrhea. 

The tools are simple—disinfectant solution 

to kill cholera-causing germs in drinking water 

stored in the home, soap for washing hands, 

and counseling techniques to motivate people 

to use these products to prevent cholera and 

other waterborne diseases. 

Cholera is a disease that has defied efforts 

to keep it under control, and remains a 

serious problem throughout many parts of 

the world. From 1995 to 2005, there have 

been over 632 reported cholera outbreaks 

and 19,600 deaths related to those 632 

reports. In 2008 alone, there have been numerous outbreaks: 

1,200 infected and 60 dead in Kenya, 13 dead in Zimbabwe, 

90 infected in Benin, 35 dead in Nigeria, 36 infected and 5 

dead in Iraq. A large, on-going outbreak in Guinea-Bissau, 

to which CDC recently responded, jointly with the Brazilian 

Ministry of Health, has infected approximately 9,800 people 

(as of Oct. 6) and claimed 178 lives. 

While some countries have experienced long-lasting 

endemic cholera, a series of countries and sub-regions are 

regularly affected by disruptive outbreaks. Cholera has been 

particularly devastating in Africa, with 95% of cholera cases 

and 98% of cholera deaths occurring in sub-Saharan Africa. 

Cholera is a disease of poverty. It has persisted in 

sub-Saharan Africa because of lack of access to piped, 

treated water and sewage treatment systems. It is likely 

exacerbated by widespread malnutrition in that part of 

the world. Unfortunately, the obvious solution of building 

necessary water and sewage infrastructure will likely take 

billions of dollars and decades to achieve. The question is, 

in the meantime, what can be done to save lives and protect 

people’s health now.

CDC’s answer is development of simple, inexpensive, 

household interventions that are implemented locally. One 

such intervention is the Safe Water System (SWS), a water 

treatment technique that uses locally-produced bleach 

solution, safe water storage to prevent recontamination, 

and behavior change techniques - components that 

make the system effective, sustainable, and scalable. 

To learn more about SWS, please see CDC’s secondquarter 2007 e-brief (http://www.cdc.gov/washington/

EGlobalHealthEditions/2007_q2_ebrief.pdf). CDC also 

conducts public health research to understand the most 

effective hand-washing techniques and the most effective 

ways to motivate behavior change. 

When a SWS project is put in place, the response to 

cholera is simplified. Local health authorities and other 

partners can deliver an inexpensive, locally-available, and 

culturally familiar product to the site of the cholera outbreak 

and then develop communications campaigns to encourage 

the desired behavior change. In 2007 alone, Population 

Services International (PSI), a CDC partner, used the tools 

of the SWS to respond to cholera outbreaks in 14 countries. 

Malachi, who works with the Safe Water and AIDS Project, a 

Kenyan non-governmental organization that works closely 

with PSI, has himself responded to 14 outbreaks in Kenya in 

2007 and 2008. 

Solving the cholera problem will take more time and 

effort, but with a simple approach, and dedicated partners 

like PSI and individuals like Malachi, CDC is doing its part to 

respond to these disruptive, recurrent outbreaks and provide 

the tools for a healthier world. 

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Teddy Malachi (right) and Jamal Ahmed (center) testing water during a response to a cholera outbreak at 

Dadaab Refugee Camp in Kenya.
CDC identifies new arenavirus as 

cause of unusual cases of acute febrile 

syndrome in Africa

The results of tests conducted at CDC 

in Atlanta and at the National Institute 

for Communicable Diseases (NICD) 

of the National Health Laboratory 

Service in Johannesburg, South Africa, 

provide preliminary evidence that the 

causative agent of the disease which 

has resulted in the recent deaths of 4 

people in hospitals in Johannesburg, 

has been preliminarily identified as 

an Old World arenavirus related to 

the Lassa fever virus of West Africa. 

Arenaviruses cause chronic infection 

in wild rodents (multimammate mice) 

with excretion of virus in urine, which 

can contaminate human food or house 

dust.

Within three weeks of the first 

reports, the new arenavirus was 

identified by immunohistochemical 

tests performed at CDC in Atlanta on 

autopsy liver and skin samples taken 

with biopsy needles and skin punches 

in the Special Pathogens Unit of the 

National Institute for Communicable 

Diseases, South Africa.

Other tests further confirm that the 

infections were caused by a virus 

which is different from lymphocytic 

choriomeningitis virus (LCMV), Lassa 

fever virus (LASV), and other known 

Old World arenaviruses. Successful 

isolation of the causative agent means 

that more detailed characterization, 

including full genome sequencing and 

electron microscopy, can now take place. 

This outbreak represents a cluster of 

cases confined to individuals with 

very close contact in a health-care 

setting. Monitoring of contacts, active 

case finding and investigation and 

management of suspected cases will 

continue as needed. Collection of 

additional clinical, epidemiological 

and laboratory data is ongoing and 

data will be updated accordingly.

CDC, the NICD, and the World Health 

Organization continue to monitor 

persons who had close contact with 

persons who became ill for new cases. 

Analysis continues at the NICD and 

CDC in order to characterize this virus 

more fully. CDC and NICD are technical 

partners in the Global Outbreak Alert 

and Response Network (GOARN), a 

technical collaboration based at the 

World Health Organization. 

CDC – Thailand Collaborates with 

Regional Partners to Convene Expert 

Forum on Hand, Foot, and Mouth 

Disease in the Asia-Pacific Region

Hand, foot, and mouth disease 

(HFMD) is usually a mild illness, most 

frequently reported in young children. 

HFMD can be caused by a number 

of different enteroviruses. Over the 

past decade, however, HFMD caused 

by enterovirus (EV) 71 has caused 

large outbreaks associated with a 

disproportionately high percentage 

of severe and fatal HFMD cases in the 

Asia-Pacific region. During 2008 alone, 

HFMD outbreaks linked to EV71 

affected tens of thousands of children, 

with more than 45 reported deaths in 

China, Taiwan, Singapore, Malaysia, 

and Thailand. 

In response to these recent outbreaks, 

CDC emerging infectious disease 

experts in Thailand collaborated 

with regional partners, including 

the Regional Emerging Diseases 

Intervention (REDI) Centre and the 

Singapore Ministry of Health, to 

convene a meeting of experts in 

HFMD and EV71. The late August 

meeting enabled scientists to share 

and compare experiences, review 

the state of knowledge regarding 

the diagnosis, causes, treatment, 

control, and prevention of the 

disease, and identify priority areas 

around which future collaborative 

research and intervention project 

could be conducted to strengthen 

prevention, control, and management 

of HFMD. The forum brought together 

CDC scientists and approximately 

80 scientific experts from several 

countries in the region, including 

Australia, Burma, Brunei, Indonesia, 

Malaysia ,People’s Republic of 

China, Singapore, Thailand, and 

Vietnam. Meeting proceedings and 

recommendations are currently being 

compiled and will be available later 

this year. Additional publications 

summarizing scientific data and 

presentations from the forum are also 

planned.

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