of meningitis and 

severe pneumonia 

in children and 

because of concerns 

about vaccine 

cost. The good 

news is that the 

data we presented 

at this meeting 

about the burden 

of meningitis 

and pneumonia 

convinced the 

attendees to make the vaccine part of their countries’ 

standard immunization program. We must continue to 

share this information with other countries so that we take 

advantage of every opportunity to prevent deaths from Hib 

disease among children.” 

 -Dr. Rana Hajjeh, CDC scientist and 

 Director of the Hib Initiative

Haemophilus influenzae type b (Hib) is a bacterial 

disease that each year causes pneumonia and meningitis 

in young children, resulting in three million illnesses and 

WELCOME to the second quarter global health 

E-Brief, designed to inform readers about key global 

health activities at the CDC (Centers for Disease 

Control and Prevention). Our second issue for 2008 

spotlights the use of surveillance and research data 

to inform policies, and the life-saving power of these 

policy decisions - when implemented. For example, 

after a two-day meeting, 14 African countries made 

policy decisions that will impact over four million 

children -- with implementation, they will be eligible 

to receive a life-saving vaccine to prevent them from 

pneumonia and meningitis; and, CDC and the World 

Health Organization have developed a groundbreaking 

surveillance method to help prove the effectiveness of 

antiretroviroal treatment (ART) expansion programs.

Data Convince African Countries to Provide 

Life-Saving Vaccines that Prevent Meningitis 

“Last June I attended a meeting at the World Health 

Organization (WHO) headquarters for the African Region in 

Brazzaville, Congo. The journey there from the United States 

involved two 10-hour flights, an overnight stay in a run-down 

hotel in Kinshasa, the capital of the Democratic Republic of 

Congo, and an early morning boat ride the next day across 

the Congo river into Brazzaville. Representatives from 21 

African countries made the same river crossing to discuss 

introduction of new vaccines in their countries. As director 

of the Hib Initiative, an international consortium funded by 

the GAVI Alliance (formerly the Global Alliance for Vaccines 

and Immunisation), including CDC, WHO, the London School 

of Hygiene and Tropical Medicine, and the Johns Hopkins 

Bloomberg School of Public Health, my goal was to increase 

awareness about Hib vaccine-- a life saving childhood 

vaccine. Few of the representatives attending the Brazzaville 

meeting had considered the need for Hib vaccine, mainly 

because they were not aware of Hib as an important cause 

Second Quarter 2008

CDC Global Health 

E-Brief

Using Surveillance and Research Data to 

Inform Public Health Policies

IN THIS ISSUE

Data Convince African Countries to Provide Life-Saving 

 Vaccines that Prevent Meningitis

CDC Research leads to New Tools to Fight Malaria and 

Anemia in Pregnant Women

Innovative Threshold Survey Helps Preserve ART’s 

Life-saving Effects

The Plague - Fighting Pestilence with Persistence

Thailand Commits to Seasonal Flu Shots for Seniors

1

2

3

4

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Dr. Rana Hajjeh, CDC scientist and Director of the Hib Initiative
2

400,000 deaths. Bacterial meningitis alone kills more 

than 65,000 young children in the developing world 

each year. The United States has been able to virtually 

eliminate pediatric bacterial meningitis through several 

interventions including the introduction of Hib vaccines. 

A safe and effective vaccine has existed since the early 

1990s. However, Hib vaccines are still not used in many 

developing countries despite compelling evidence of the 

tremendous disease burden from Hib around the world, 

the tremendous potential to prevent this large disease 

burden, and WHO recommendations for every country to 

add Hib vaccine to their infant immunization programs.

The reluctance of many countries to use the Hib 

vaccine is because of lack of local data on the disease 

burden. Many of these countries have no or poor 

surveillance systems for bacterial diseases. The Hib 

Initiative and CDC are helping to fill this gap in Africa 

by strengthening systems such as the WHO-supported 

Pediatric Bacterial Meningitis Surveillance System (PBMS), 

run by the World Health Organization in Africa. PBMS is a 

22-country surveillance network that helps to accurately 

diagnose and record data on meningitis infections in 

young children who are seen at regional and national 

reference hospitals. The individual parts of the network 

then share the surveillance data with decision-makers at 

the country level. 

At the meeting attended by Dr. Hajjeh, country, regional 

and global level surveillance data gathered with the PBMS 

network for bacterial meningitis and pneumonia were 

presented. Convinced by the data, every country who had 

not yet introduced the Hib vaccine committed to adding 

it to their country’s national immunization program. With 

the implementation of this new policy decision, more than 

four million children are now eligible for this life-saving 

vaccine.

CDC Research Leads to New Tools to Fight 

Malaria and Anemia in Pregnant Women 

Dr. Meghna Desai, one of CDC’s lead malaria researchers, 

was treating a Kenyan child for anemia, when she noticed 

the child’s mother was very pale and looked pregnant. Dr. 

Desai knew if the mother was pregnant and had anemia 

(a common consequence of malaria), her pregnancy could 

be threatened. The experience sparked her interest in 

studying the effects of malaria during pregnancy, in the 

hopes of making health system changes that would help 

mothers like this one – and ultimately ensure that their 

babies were born healthy.

Each year approximately 50 million women living in 

regions with high rates of malaria – 25 million of whom are 

in Africa – become pregnant and are at risk from malaria 

and its particularly harmful effects during pregnancy. 

During pregnancy, women lose some of the immunity to 

malaria they have acquired from living in high-risk areas. 

If they acquire malaria and develop anemia, their children 

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. 

Bacterial Meningitis Surveillance in Uganda

Despite an ongoing 20-year conflict between rebel and 

government forces, CDC has helped implement a pediatric 

bacterial meningitis surveillance system in Uganda’s Gulu 

District.

 Charles Anywar, who grew up in this region, holds 

two jobs, one as a nurse in one of the busiest hospitals 

in northern Uganda, and the other as the PBMS data 

manager. He works with Dr. Robert Iriso, pediatrician and 

PBMS coordinator at the hospital, to record information 

on new cases of suspected meningitis, track patients’ lab 

results, and follow up with patients and their physicians 

to determine survival rates. After collecting and entering 

the data into the PBMS database, Charles forwards 

the information to Dr. Annet Kisakye, the National 

Surveillance Officer for the Ugandan Expanded Program on 

Immunizations with the Ministry of Health, to be combined 

with data from the other hospitals. 

Uganda introduced Hib vaccine in June 2002 with funding provided by the GAVI Alliance (formerly the Global Alliance 

for Vaccines and Immunization). PBMS data demonstrated that the Hib vaccine is highly protective and each year prevents 

almost 30,000 cases of severe Hib disease (both meningitis and pneumonia) and more than 5,000 deaths among children 

younger than five. These data convinced the government of Uganda to commit national resources to use the Hib vaccine.

 Charles Anywar pilot tests the new data management module for pediatric bacteria 

meningitis surveillance.
are more likely to be born small – and are more likely to 

be sick or die. In Africa, low birth weight associated with 

malaria in pregnancy is estimated to contribute to 100,000 

infant deaths each year.

CDC malaria research plays a critical role in ensuring 

that the tools we have to combat malaria in all those 

affected by the disease can be implemented with greatest 

impact both by researching the most effective way to 

implement an intervention, and by monitoring and 

evaluating its impact. Findings from studies conducted 

by CDC experts like Dr. Desai are the foundation for the 

way malaria in pregnant women is treated and prevented 

today and are reflected in the World Health Organization’s 

guidelines and recommendations 

for preventing and controlling 

malaria in pregnant women, 

especially in countries in subSaharan Africa with high malaria 

transmission. 

Key CDC research findings 

that are preventing illness and 

saving lives are these:

• intermittent preventive 

treatment of malaria during 

pregnancy (IPTp)—delivery 

of the right dose of effective 

antimalarial drugs as part of 

routine pre-natal care—reduced 

the risk that malaria-infected pregnant 

women would have babies with low 

birth weight and the associated high 

risks for infant death; 

• insecticide-treated nets (ITNs) help reduce malaria 

infections and associated ill effects in pregnancy. When 

pregnant women in a study area in Kenya slept under 

ITNs, severe malarial anemia was reduced by 47% and the 

delivery of low-birth-weight infants decreased by 28%; and

• To benefit from treatment, pregnant women who 

are HIV-positive need more doses of IPTp with the drug 

sulfadoxine-pyrimethamine (SP) or, in some cases, a 

different drug. 

CDC’s research on the usefulness of insecticide-treated 

nets and IPTp strongly influenced the strategies being 

implemented in the President’s Malaria Initiative (PMI), a 

$1.2 billion 5-year plan to reduce deaths due to malaria 

by 50 percent in 15 African countries). PMI provides IPTp, 

to pregnant women and their babies. To date, PMI has 

procured SP for IPTp for more than 1.3 million women. 

Additionally more than 5,000 health care workers have 

been trained to administer IPTp. In addition to IPTp, 

African countries are adopting policies on the use of 

insecticide-treated bed nets and the effective treatment of 

malaria illness with antimalarial drugs to mitigate malaria’s 

ill effects in pregnant women. 

CDC, with Dr. Desai as principal investigator, is currently 

helping to plan a study in Kenya on another drug, 

mefloquine, for use in IPTp among HIV-infected pregnant 

women. The study is important for two reasons: 1) SP 

cannot be given to women who are taking cotrimoxazole, 

the drug HIV-positive pregnant women receive to prevent 

complications from their HIV; and 2) the rates of HIV and 

malaria in many sub-Saharan African countries are very 

high and the two infections overlap considerably. This 

project and other CDC research will provide additional 

information about how to prevent malaria in HIV-positive 

pregnant women. 

Innovative Threshold Survey Helps 

Preserve ART’s Life-saving Effects

Right now, over 33.2 million people are living with HIV/

AIDS – an epidemic that has long 

been one of global proportions. 

Ninety-five percent of people 

living with HIV/AIDS reside in 

developing countries. Fortunately, 

these countries are benefiting 

from significant expansion of 

antiretroviral treatment (ART), 

the main treatment for HIV/AIDS. 

While not a cure, it can prevent 

progression and symptoms of the 

disease in an individual for many 

years.

ART is dramatically improving 

the health and extending the lives 

of people who have HIV/AIDS – further 

contributing to the economic and 

social well-being of resource-poor countries. However, 

ART can lead to HIV ART drug resistance (HIVDR) if 

delivery programs are poorly designed and not enough 

drugs are available. The Centers for Disease Control and 

Prevention (CDC), as part of the President’s Emergency 

Plan for AIDS Relief (PEPFAR), is leading efforts to provide 

HIVDR surveillance in resource-limited settings, thereby 

preserving ART’s life-saving effects. These critical 

surveillance data help guide public health policies to 

reduce occurrences of HIVDR and inform the selection 

of future drug regimens that will be effective for specific 

populations, without draining resources from other 

activities, such as higher-priority treatment, prevention 

and laboratory expansion. 

In partnership with the World Health Organization 

(WHO), CDC has developed a groundbreaking threshold 

survey that provides Ministries of Health with a relatively 

simple, rapid, and inexpensive method to estimate levels 

of HIVDR in areas where ART is being delivered. The 

method builds on well-established surveillance systems 

and uses blood specimens that are already being gathered 

as part of a country’s routine antenatal clinic (ANC) 

surveillance. 

The scientists test a few dozen randomly selected 

specimens from eligible HIV-infected persons for viral 

genetic mutations that reduce the virus’ susceptibility to 

ART. “Then we basically provided a cheat sheet,” explains 

3

 CDC’s Dr. Meghna Desai Working in Kenya
4

Keith Sabin, a CDC expert in global HIV/AIDS surveillance, 

“requiring only check marks to simply and easily classify 

levels of resistance into one of three categories: low, 

medium, or high.” 

The “cheat sheet” is simple, but provides vital 

information to guide programs. Those localities testing 

“low” should repeat the survey in two years; those areas 

testing “high” should expand the number of HIVDR testing 

sites, analyze program monitoring data, strengthen 

program implementation, and consider changes in 

standard ART regimens. 

The method has multiple advantages:

• the process for specimen collection already exists, 

minimizing implementation costs;

• only a small number of specimens are required;

•the results determine whether or not regimens are 

appropriate; and

• the results provide critical information on prevention 

failures.

“[This method] helps countries use their resources 

wisely, only spending additional resources on more 

intensive program monitoring if it’s needed. Then they can 

focus the funding on treating people, training workforce, 

ensuring adequate drug supply, and other essential 

program activities,” Sabin explains.

To date, CDC has helped nine countries conduct the 

threshold surveys (Tanzania, Vietnam, Malawi, Kenya, 

Ethiopia, China, Thailand, Botswana and Namibia). 

Five new countries are scheduled to conduct HIVDR 

surveillance within the year. So far, no significant drug 

resistance has been found. According to Sabin, “this 

simple and efficient method is showing the world that our 

remarkable ART expansion programs are working – and it 

is allowing us to ensure that they keep working.”

The Plague – Fighting Pestilence 

with Persistence

Does the plague still exist? While it is an ancient disease, 

it is certainly not gone. The plague still persists with 

approximately 1,000 to 3,000 cases worldwide each year, 

including five to 15 cases each year in the western United 

States, according to the World Health Organization. There 

is no vaccine for this persistent disease. However, today’s 

antibiotics can treat the disease and prevent death, which 

occurs in 50% to 90% of untreated victims.

Yersinia pestis – the plague bacteria – causes swollen, 

tender lymph glands called buboes in bubonic plague, 

and fever, weakness, and pneumonia in pneumonic 

plague. People get the bubonic plague from flea bites. 

Fleas become infected when they feed on rodents with 

the bacteria. People are infected with pneumonic plague 

through airborne transmission, that is, by inhaling Yersinia 

pestis particles.

Most Americans today don’t worry about the 

plague, but health care and emergency preparedness 

professionals do. They worry because aerosolized Yersinia 

pestis could be used in a bioterrorist aerosol attack 

spreading the pneumonic form 

of plague. Once people have 

the disease, the bacteria can 

spread to others who have close 

contact with them. Because 

people don’t get sick right after 

exposure to the bacteria, they 

could travel over long distances 

and potentially infect many 

others. Controlling the disease 

at this later stage is much more 

challenging. For all of these 

reasons, public health and 

preparedness experts recognize 

the need for continued plague 

research and preparedness, and 

control activities. The more we 

understand about plague and 

how it spreads, the greater our 

ability to control it —whether 

it strikes naturally or is released 

intentionally. 

CDC is conducting research in Uganda where 

approximately 2,000 cases of plague have been reported 

since 1999. Efforts by the Ministry of Health to control 

the disease have had limited success because laboratory 

capacity, case follow-up, and data on the animal carriers 

of plague are essentially non-existent. Without these 

resources and information, public health professionals 

have been unable to develop policies and interventions to 

control plague and reduce associated illness and death. 

To help build regional capacity, CDC established a 

field laboratory in the Arua province of northwestern 

Uganda (near the border with Democratic Republic of the 

Congo). Staffed by CDC and local experts in laboratory, 

epidemiology, and clinical medicine, the program is 

helping to understand risk factors for plague, evaluate 

interventions targeting rodents, develop methods for 

improved diagnostics, and understand obstacles to 

treatment. Already the laboratory has identified key ways 

in which plague is transmitted, confirmed a human plague 

case for the first time locally, and evaluated an intervention 

based on a novel method of flea and rodent control to 

ensure its efficacy in controlling plague.

These efforts represent the first steps in a longterm collaboration that will greatly contribute to the 

understanding of plague and the development of 

policies and interventions to reduce its impact in Uganda. 

Additionally, research in Uganda provides an opportunity 

to increase CDC’s global emergency preparedness 

capabilities. 

Thailand Commits to Seasonal 

Flu Shots for Seniors

Asian cultures are generally known for commitment 

to their older adult population. An example of this 

commitment is Thailand’s bold step in February 2008 
5

to fund flu shots for seniors with chronic disease. This 

evidence-based policy decision is notable because it 

required Thailand –a middle income nation—to make a 

large government investment. The government moved 

forward because of the significant health impact this 

decision will have. More than five million people living 

in Thailand are over the age 

of 65 and many have serious 

conditions such as bronchitis, 

emphysema, asthma, heart 

disease, renal disease, diabetes, 

and hypertension. Without 

seasonal flu shots, they 

would be at risk for severe 

complications due to influenza 

infection. 

The government’s 

decision was influenced by 

high-quality data collected 

through collaboration with 

the Centers for Disease 

Control and Prevention (CDC) 

and the Thailand Ministry 

of Public Health (MOPH). 

“What’s great about this 

recent announcement is the 

opportunity to see our scientific work translated into 

public health policy,” says Mark Simmerman, Ph.D., chief of 

CDC’s Influenza Section in Thailand. In collaboration with 

Thai health officials, the CDC team has conducted active 

surveillance since 2003 and has presented data on the 

incidence, cost, risk factors, and seasonality of influenza 

since 2003. 

Thailand is no stranger to initiating policy decisions 

based on scientific evidence to protect the public’s health. 

The country organized a major vaccine campaign against 

Japanese encephalitis in 1998 and has given influenza 

vaccine to some health care workers and government 

veterinary workers for several years. 

“We have to look for the groups that will benefit 

most,” says Dr. Piyanit Tharmapornpilas, who manages 

the Expanded Program on Immunization for the MOPH. 

Research from other countries provides guidance about 

which groups those might be, but clear information 

specific to Thailand is available 

only from the populationbased studies conducted by 

the MOPH-CDC collaboration, 

according to Dr. Piyanit. 

The studies used to 

support the policy decision 

demonstrated that the disease 

and cost burden of influenza 

in Thailand were substantially 

greater than had previously 

been believed. They identified 

young and advanced age, 

and underlying chronic 

disease—especially those with 

cardiopulmonary disease and 

previous hospitalization within 

the last year—as risk factors 

for severe complications from 

influenza infection.

In 2008 alone, the number of government-provided flu 

shots will nearly double to around 600,000. Those shots 

are expected to cover about 50% of the Thais who are 65 

or older and have chronic disease. According to Thai MOPH 

plans, a new government plant to manufacture flu shots 

locally will be operational by 2011, and will eventually 

have the capacity to produce more than 10 million doses 

annually. This is one of several steps that Thailand is taking 

to prepare for an influenza pandemic, and represents how 

Thailand, with assistance from CDC, has been able to turn 

surveillance data into sound public health policy with the 

promise of prolonging the lives of its seniors. 

The US CDC is assisting the Chinese 

Center for Disease Control and 

Prevention (China CDC), with 

support from private technology 

companies and the CDC Foundation, 

to strengthen China CDC’s health 

informatics capacities. This timely 

partnership will be used for rapid 

public health assessments in 

Sichuan province’s post-earthquake 

environment. CDC experts in 

informatics, mobile computing, 

and natural disaster epidemiologic 

surveillance were deployed to 

Beijing to help design and develop 

a platform of data collection and 

management which is based on PDA 

and mobile technology systems and 

tools. As efforts in the affected areas 

shift from emergency response to 

recovery, the health and well-being of 

the approximately 5 million displaced 

persons and the re-building of health 

systems are chief concerns. “With 

the new system and equipment, 

China CDC will collect public health 

data in earthquake-affected areas 

where communications capacity 

has been destroyed and send it to 

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,” said Dr. Leslie A. 

Lenert, Director of CDC’s National 

Center for Public Health Informatics. 

US CDC informatics experts will 

continue to provide guidance to 

China CDC in coming weeks on how 

to use the donated technology in a 

systematic and sustainable way to 

best manage disease control and 

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Thai government officials look on as Minister of Commerce Mingkwan Saengsuwan 

helps kick off a campaign to promote flu shots among senior citizens. 
6

 

prevention while the Sichuan public 

health system is rebuilt. 

The press release is available on the 

US Embassy Beijing website at: http://

beijing.usembassy-china.org.

cn/070208p.html

Update to 2008 first qaurter e-brief: 

CDC is continuing to monitor yellow 

fever outbreak in South America in 

three countries: Brazil, Argentina, and 

Paraguay. As of June 26, 78 cases and 

34 deaths have been confirmed. 

Since February 2008, CDC has been 

involved in the detection, verification, 

and investigation of a monkeypox 

outbreak in the Democratic 

Republic of Congo. CDC supported 

deployment of a 9-person team to the 

affected area. The team engaged in 

epidemiologic investigations, health 

care worker education, ecologic 

survey activities and patient care. 

The CDC team helped train health 

care workers from across the affected 

area in monkeypox recognition, 

specimen collection, reporting, 

patient care and proper infection 

control practices. Surveillance data 

were reviewed to determine the 

extent and duration of the suspected 

epidemic, and information about 

interactions between people and 

wildlife was gathered to learn more 

about how the virus is transmitted 

from animals to people. As a result of 

the assistance, CDC and the Ministry 

of Health have strengthened their 

collaborations on orthopoxvirus 

research and disease detection and 

control.

The presidential elections in Kenya 

conducted on December 

27, 2007, were contested, 

and shortly after violence 

erupted in multiple locations 

throughout the country. 

More than 1,000 people 

were killed and 350,000 

people displaced. There were 

disruptions in availability of 

food and fuel, and there was 

displacement of some CDC 

staff, including an authorized 

departure from Kisumu to 

Nairoibi for USG employees. 

On February 28, a widely 

accepted power-sharing 

agreement between 

the Kenya Government and the 

opposition was signed, and threats of 

political demonstrations and violence 

have dropped dramatically. As a 

result, the US Embassy cancelled the 

authorized departure for Kisumu and 

surrounding areas, and CDC staff and 

their families have been allowed to 

return. Although the power-sharing 

agreement has eased tension and 

reduced unrest, the conflict affected 

CDC-Kenya’s programmatic, research, 

and administrative activities.

Throughout the weeks of unrest, 

CDC-Kenya staff proved themselves 

to be resourceful, caring, competent 

and hard working. Through long 

hours, strategic planning, and regular 

communications, staff at CDC-Kenya, 

including employees of the KEMRICDC collaboration in Kisumu, ensured 

the continuity and quality of public 

health activities, including these: 

 * HIV programs that provide 

prevention services, care, and 

antiretroviral treatment to tens of 

thousands of people with HIV; 

 * more than 40 public health 

studies, and 

 * intensive community-based 

disease surveillance. 

Although the violence has subsided, 

the impacts on public health in Kenya 

may extend for years to come. These 

may include increases in mental illness, 

substance abuse, and unemployment 

and disruptions in food supply, 

immunizations, medications, and 

health services. Besides resuming their 

normal public health operations, the 

CDC-KEMRI collaboration is evaluating 

the public health impact of the 

post-election violence to identify and 

respond to any lasting public health 

problems in Kenya. These activities 

are described in a Letter to the editor 

to the American Journal of Tropical 

Medicine and Hygiene (May 2008). 

The WHO cites delays in tuberculosis 

diagnosis as the leading risk factor for 

tuberculosis (TB) transmission within 

health care facilities. A recent study 

conducted by CDC-Thailand and the 

Thailand Ministry of Public Health 

found that almost 75% of patients 

hospitalized with clinical pneumonia 

were not adequately evaluated for 

TB. High rates of TB in Thailand 

and frequent diagnostic delays 

coupled with these data suggest that 

interventions should be implemented 

to ensure that hospital clinicians in 

Thailand consider performing a TB 

laboratory evaluation for all adults 

hospitalized with clinical pneumonia. 

Early screening interventions have 

the potential to prevent infection and 

devastating hospital outbreaks of TB, 

including drug-resistant TB. The full 

study can be found in the July issue 

of Infection Control and Hospital 

Epidemiology. 

http://www.journals.uchicago.edu/

doi/full/10.1086/588684

COGH is pleased to bring you this 

podcast of the recent visit to CDC by 

United Nations Secretary General Ban 

Ki-Moon: http://www2a.cdc.gov/

podcasts/player.asp?f=9305. The 

link also includes a transcript. 

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Fredrick Miruka a Clinical Officer at KEMRI-CDC speaks to a patient during the 

medical camp.