Influenza Preparedness: Avian, Pandemic

On January 6, 2007, a 22-year-old female from Lagos, 

Nigeria, died of what is suspected to be a case of avian 

influenza. The mother of the 22-year-old died on January 

4, 2007, with similar symptoms. Preliminary tests on the 

samples from the 22-year-old were positive for influenza 

type A (H5N1). 

One of CDC’s most important roles is to protect the 

nation’s health from emerging health threats, such as the 

threat of an influenza pandemic. While a pandemic has not 

yet occurred, it is important that the United States and the 

world remain vigilant and be ready to respond. 

The circulation of avian influenza type A (H5N1) virus 

in domestic and wild birds is expected to continue. As a 

result, people with exposure to sick or dead birds remain at 

risk of being infected with H5N1 virus. In addition, as long 

as the virus continues to circulate, there is the possibility 

that it will undergo genetic changes that allow it to be 

easily transmitted from person-to-person.

To help prepare for a possible pandemic, CDC is 

carefully monitoring changes in the virus that might 

allow it to evolve into a strain that could result in a 

pandemic. CDC collaborates across the U.S. government 

under the leadership of the State Department and with 

global partners such as WHO and national ministries of 

health. This collaboration has proved to be an effective 

partnership and is playing an important role in the early 

identification of suspected cases of avian flu in Nigeria. 

Some key CDC activities in Africa include these:

Assisting the investigation of the H5N1 outbreak in 

poultry, in Nigeria (February 2006)

Training for influenza surveillance and laboratory 

testing in Uganda 

Rapid Response Team training in Kenya for Englishspeaking countries of Africa

Dispatching an EIS Officer from the Influenza Division 

to Nigeria in August 2006 to help the country develop 

a plan for avian influenza and seasonal influenza 

surveillance

Dispatching epidemiologists from the Global Disease 

Detection center in Kenya to investigate the recent 

human cases in Nigeria

Fortunately, there is no evidence of efficient human-tohuman transmission. CDC is also monitoring mutations in 

the H5N1 virus that could result in resistance to antiviral 

medications. For example, in January 2007 an Egyptian 

H5N1 virus indicated a small change in susceptibility to the 

antiretroviral medication oseltamivir. However, there is no 

widespread indication of resistance in Egypt or globally.

While monitoring the virus is critical, it is only 

half the battle. Emergency management and 

preparedness planning are among CDC’s most pressing 

responsibilities—both domestically and internationally. 

While CDC continues to improve preparedness within 

U.S. borders, CDC also assists other countries to develop 

national pandemic plans that will enhance systems to 

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First Quarter 2007

CDC Global Health 

E-Brief

-WELCOME to CDC’s first global health E-Brief, 

designed to educate and inform readers about 

key global health activities. The first issue focuses 

on the need to prepare for and respond to the 

unforeseen public health challenges from emerging 

infections – the urgent threats - while maintaining 

our commitment to the ongoing challenges posed 

by endemic infectious diseases, chronic disease, and 

injuries—the urgent realities.

IN THIS ISSUE

Influenza Preparedness: Avian, Pandemic

Rift Valley Fever 

XDR TB: Old Foe Poses New Threat

Mystery Illness in Panama Solved

Measles Initiative Surpasses Goal

President’s Malaria Initiative: A Call for Action

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Urgent Threats, Urgent Realities
detect and respond to new influenza viruses, and to 

identify and contain a pandemic at its earliest stage. For 

optimal response, an emerging influenza pandemic 

outbreak anywhere in the world must be recognized 

within 72 hours, investigated, and then confirmed within 

days. A successful response will require an unprecedented 

and well-coordinated containment effort involving dozens 

of trained teams, broadly disseminated public health 

messages, social-isolation and movement-restriction 

considerations, and the treatment of patients and 

potential contacts. 

Experts from CDC’s Influenza Division and Global 

Disease Detection (GDD) Centers are strengthening the 

agency’s resources on the ground by improving current 

surveillance systems, training and equipping rapidresponse teams in high-priority countries, supporting 

the expansion of the WHO Influenza Network, assisting 

countries with investigation of and response to outbreaks, 

and facilitating the availability of needed protective 

equipment and supplies for first responders to a potential 

pandemic. Much of the capacity that is being developed 

by CDC and its partners extends beyond the threat posed 

by avian influenza to help regions and countries to prepare 

for other emerging threats as well. 

Rift Valley Fever

At the request of the Kenya Ministry of Health, the Centers 

for Disease Control and Prevention (CDC) within the 

U.S. Department of Health and Human Services (HHS) 

is working closely with Kenyan health and veterinary 

officials in response to an outbreak of Rift Valley Fever 

(RVF) in Northeastern Kenya. As of January 25, 2007, the 

Kenyan Ministry of Health had reported 404 human cases 

(112 laboratory confirmed) and 115 deaths related to the 

outbreak. 

A viral disease, RVF causes sudden fever and, more 

rarely, serious complications including hemorrhagic fever, 

encephalitis, and blindness. While RVF primarily affects 

livestock, such as sheep and cattle, humans who are 

bitten by infected mosquitoes or other insects are also 

susceptible. Rift Valley Fever is generally found in regions 

of eastern and southern Africa. The United States has 

never experienced an outbreak of Rift Valley Fever, but 

the virus—like the West Nile virus—could reach the U.S., 

posing a threat to both human and animal health. 

The Centers for Disease Control and Prevention (CDC) 

within the U.S. Department of Health and Human Services 

(HHS) is leading the U.S. Government’s response to the 

outbreak. Other members of the USG team are the U.S. 

Army Medical Research Unit-Kenya, the Animal and Plant 

Health Inspection Service within the U.S. Department of 

Agriculture, and Naval Medical Research Unit-3. The World 

Health Organization (WHO) and its partners from the 

Global Outbreak Alert and Response Network (GOARN) are 

also actively engaged in the investigation and efforts to 

contain the outbreak. 

CDC is helping Kenya’s Ministry of Health to enhance 

its surveillance and response strategies, to revise standard 

case definitions to help accurately identify cases of 

suspected infections, to identify risk factors for disease 

transmission, and to craft health communications and 

media messages. CDC is also assisting the Ministry of 

Livestock and Fisheries Development with training 

and capacity building of veterinary labs, including the 

transfer of technology, and working with the Department 

of Veterinary Services within the Ministry of Livestock 

to improve their data management systems. Similar 

assistance has been provided in Tanzania.

In recent weeks, 18 experts from CDC’s Global Disease 

Detection (GDD) Center in Kenya and from the CDC’s 

offices in Atlanta, Georgia, and Ft. Collins, Colorado have 

helped investigate the outbreak in Nairobi and affected 

provinces. Also collaborating on the investigation are the 

current trainees and graduates of the Kenya CDC Field 

Epidemiology and Laboratory Training Program (FELTP) 

and representatives from the CDC-supported Kenya 

Medical Research Institute (KEMRI). KEMRI and the Kenya 

GDD Center have also provided laboratory support to 

confirm diagnosed cases. The improved detection of new 

cases and knowledge of how the virus is being spread will 

enable a swifter and more targeted response. 

CDC continues to play a strong role in identifying the 

source and patterns of transmission of Rift Valley in order 

to effectively control the current outbreak of RFV. This 

information will play an important role in the development 

of prevention and intervention strategies for Rift Valley 

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. 
Fever in endemic countries to limit the public health threat 

posed by RVF. For more information on the Rift Valley 

fever outbreak, please visit www.cdc.gov/mmwr/preview/

mmwrhtml/mm5604a3.htm?s_cid=mm5604a3_e . 

XDR TB: Old Foe Poses New Threat

CDC is actively engaged in addressing the emerging 

global concern stemming from reports of extensively 

drug-resistant tuberculosis (XDR TB), first described in the 

March 24, 2006 issue of the Morbidity and Mortality Weekly 

Report (MMWR). XDR TB is defined as M. tuberculosis strains 

which meet the definition for multidrug-resistant TB (MDR 

TB) with additional resistance to fluoroquinolones and at 

least one of the second-line injectable drugs (amikacin, 

kanamycin, or capreomycin). The loss of these additional 

drugs leaves most patients virtually untreatable with 

currently available drugs. 

Based on a joint CDC-WHO survey of 14 supranational 

reference labs, this MMWR provided an alert that XDR TB 

has emerged worldwide as a threat to public health and TB 

control.

The report documented the occurrence of XDR TB in 

47 countries on six continents, including the United States. 

U.S. patients with XDR TB are 64% more likely to die during 

treatment than patients with multidrug-resistant (MDR) 

TB. Additionally, reports from a province in South Africa 

describe a recent outbreak of XDR TB in an HIV-infected 

population, characterized by alarmingly high death 

rates. Of 536 patients with TB, 221 (41.2%) had multidrug resistant (MDR) TB and, of these, 53 had extensive 

drug-resistant (XDR) TB. Nearly all (98%) of the individuals 

with XDR TB died—1/2 of them within 16 days and 70% 

within one month. Forty-four of these persons were 

tested for HIV; all were positive and had been receiving 

antiretroviral drugs. These data likely represent the “tip 

of the iceberg” of highly drug-resistant TB predominantly 

affecting HIV-infected individuals in that country and 

other regions of the world. The harrowing implication 

of these highly resistant strains of TB spreading among 

clients accessing HIV care and treatment services, such as 

those spearheaded by the President’s Emergency Plan for 

AIDS Relief (PEPFAR), has necessitated concerted and swift 

responses. 

CDC, in collaboration with WHO and the South Africa 

Medical Research Council (MRC), convened an Expert 

Consultation on Drug Resistant TB in the African Region 

in Johannesburg in September 2006. CDC demonstrated 

expertise in rapid response, surveillance, building 

laboratory capacity and infection control helped inform 

discussion at this meeting. 

On-going activities supported by PEPFAR have also 

been accelerated in the context of overall TB program 

strengthening as the critical element to prevent drugresistance. Staff 

from CDC work 

with their PEPFARimplementing 

colleagues in other 

U.S. Government 

Agencies and those 

in WHO, MRC, and 

other international 

partners to 

provide technical 

assistance and 

mobilize financial and 

technical resources to respond to XDR TB.

The U.S. Government has convened a U.S. Federal 

TB Task Force to discuss a domestic and international 

response plan for U.S. Government agencies on XDRTB. The White House is also planning to convene an 

interagency meeting in the next few weeks to ensure 

a unified strategic approach. The U.S. Government also 

participates in the WHO Global XDR-TB Task Force which is 

finalizing a global plan to respond to XDR-TB.  

Mystery Illness in Panama Solved

On October 2, 2006, the Gorgas Memorial Institute of 

Health Research (GMIHR) in Panama City asked the Centers 

for Disease Control and Prevention (CDC) to join the 

Ministry of Health and Pan American Health Organization 

(PAHO) for assistance in tracking down an unknown 

killer. A mysterious illness, producing acute renal failure 

and weakness in adults, had appeared in 21 seriously ill 

patients in the Latin American nation, leading to death in 

more than half of them.

A team with expertise in epidemiology, medical 

toxicology, neurology and infectious disease was 

assembled by CDC Atlanta as well as staff from CDC’s 

regional office in Guatemala. The team hit the ground 

running in Panama, quickly distributing supplies and 

equipment to gather medical data and diagnostic 

samples from patients—as well as gathering samples 

from suspected sources of the possible poisoning—and 

returning them to Atlanta’s laboratories. The rapid 

delivery of supplies to Panama and return transportation 

of diagnostic samples for testing by CDC and FDA was 

facilitated through use of CDC’s leased airplane. 
CDC and United States Food and Drug Administration 

(FDA) laboratories conducted several comprehensive and 

exhaustive analyses for a wide variety of both chemical 

and infectious agents in biologic specimens as well as 

reviewed kidney and nerve tissue specimens for evidence 

of infectious diseases. CDC and FDA laboratories also 

collaborated to assess the purity of various medications 

associated with case-patients and conducted targeted 

testing for specific agents in these medications suspected 

of causing this illness. In just nine days, CDC scientists 

working with numerous international partners were able 

to identify the cause of this disease.

Diethylene glycol (DEG) somehow was introduced into 

several locally produced medications including a sugarless 

cough syrup. DEG is a water-soluble, clear liquid commonly 

found in brake fluids, antifreeze, and fuel additives that can 

cause potent kidney and nervous system damage when 

ingested by humans.

Once the contaminant was identified, Panamanian 

health authorities quickly withdrew the contaminated 

medications from clinics, and began a national public 

health prevention and risk communication program. 

They notified people through the media as well as 

through door-to-door visits to not use these products. 

Thanks to this remarkable scientific detective work, it 

is likely that many lives were saved. CDC will translate 

lessons learned during this experience to prevent further 

poisonings. 

Measles Initiative Surpasses Goal

Measles deaths have fallen by 60% worldwide, from an 

estimated 873,000 deaths in 1999 to 345,000 in 2005—a 

major public health success. This exceeds the United 

Nation’s goal to halve measles deaths by 2005, and is 

largely due to an unprecedented decline in measles deaths 

in the African region. 

In Africa, measles deaths fell by 75%, from an estimated 

506,000 to 126,000. This announcement was made on 

January 18, 2007, by partners in the Measles Initiative: the 

American Red Cross, CDC, the United Nations Foundation, 

UNICEF, and the World Health Organization. The data was 

published in the January 20 edition of the Lancet. The 75% 

reduction in measles deaths in Africa is due to the firm 

commitment and resources of national governments and 

support from the Measles Initiative.

A four-component strategy has been the key to 

ensuring the massive global decrease in measles deaths. 

The strategy calls for

The provision of one dose of measles vaccine for all 

infants, via routine health services

A second opportunity for measles immunization 

for all children, generally through mass vaccination 

campaigns

Effective surveillance for measles

Enhanced care, including provision of supplemental 

Vitamin A

As a result of this strategy, between 1999 and 2005, 

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global measles immunization coverage with the first 

routine dose increased from 71% to 77%, and more than 

360 million children aged 9 months to 15 years received 

measles vaccine through immunization campaigns.

In addition, measles vaccination campaigns are 

contributing to the reduction of child deaths from other 

causes. They have become a channel for the delivery of 

other life-saving interventions, such as

Bed nets to protect against malaria

De-worming medicine

Vitamin A supplements

In 2006 alone, an estimated 18 million bed nets were 

provided to families in nine African countries during 

Measles Initiative-supported campaigns. Combining 

measles immunization with other health interventions 

is a contribution to the achievement of the Millennium 

Development Goal to reach a two thirds reduction in child 

deaths between 1999 and 2015. There is still some way to 

go in the fight against one of the world’s most contagious 

diseases. Of the estimated 345,000 measles deaths in 2005, 

90% were among children under the age of 5—many 

dying as a result of complications related to severe 

diarrhea, pneumonia, and encephalitis.

CDC’s Global Immunization Division (GID) contributes 

funds and technical assistance to partner activities in 

priority countries around the world. GID’s technical 

assistance supports the implementation of high-quality 

measles campaigns to strengthen field and laboratory 

surveillance for measles virus detection and for efforts 

to strengthen national routine immunization systems in 

priority countries. 

Since 2001, CDC has contributed more than $50 

million for the purchase of bundled measles vaccine 

(more than 280 million doses) to the UN Foundation. 

This contribution has generated matching funds of more 

than $16 million in support of measles surveillance and 

routine immunizations helping to sustain the gains made 

through this innovative partnership on reducing measles 

mortality and morbidity in priority countries supported by 

the partnership. CDC’s response to measles highlights the 

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agency’s ability to respond to public health threats, and its 

ability to expand the focus of a public health intervention 

strategically to prevent other emergent public health 

threats. 

President’s Malaria Initiative: A 

Call for Action

The global toll of malaria is high: an estimated one million 

people die each year, most of them young children in 

Africa. Malaria’s impact extends beyond the infected 

individual. It also weakens economies by leaving adults 

too sick to work for days each year and requiring large 

expenditures by ministries of health and families. Malariarelated illness and mortality are estimated to cost Africa’s 

economy $12 billion per year. 

In June 2005 President Bush announced the $1.2 

billion President’s Malaria Initiative (PMI) with the goal to 

cut malaria deaths in half in targeted African countries. 

PMI assists national governments in delivering a 

comprehensive package of proven, effective interventions 

to a majority (85%) of people at greatest risk—pregnant 

women and children less than 5 years old. 

From PMI’s inception, CDC has worked closely with 

USAID to design the initiative. CDC has helped conceive 

and lead implementation of the plan for evaluating PMI’s 

impact in achieving its goal. In support of PMI activities, 

CDC provides assistance with implementation of scale 

up activities and leadership in formulating strategies and 

conducting activities to monitor and evaluate program 

outcomes and impacts. USAID and CDC work with host 

Ministries of Health, other U.S. agencies (National Institutes 

of Health, U.S. Department of State); the Global Fund to 

Fight AIDS, TB, and Malaria; the World Bank; Roll Back 

Malaria; U.N. Children’s Foundation (UNICEF); and other 

organizations to achieve the President’s goal. 

Within 6 months of the President’s announcement, 

work was under way in the first 3 (fiscal year 2006) 

countries targeted: Angola, Tanzania, and Uganda. In 

November 2006, PMI began work in the next 4 (fiscal year 

2007) targeted countries—Malawi, Mozambique, Rwanda, 

and Senegal. 

The final 8 countries targeted for the initiative 

were named at the White House Summit on Malaria, 

December 14, 2006–Benin, Ethiopia, Ghana, Kenya, Liberia, 

Madagascar, Mali, and Zambia. Activities in these countries 

are scheduled to begin in fiscal year 2008. To date, PMI has 

provided life-saving interventions to more than 6 million 

people. 