CDC Global Health

E-Brief

Strengthening Health Systems Globally

Fourth Quarter 2008

WELCOME to the fourth quarter E-Brief, 

designed to inform readers about key global 

health activities at the Centers for Disease 

Control and Prevention (CDC). Our last issue 

of the year focuses on the agency’s continued 

efforts to help strengthen health systems 

around the world. Unprecedented levels of 

funding for global health, coupled with the 

strong U.S. Government commitment to global 

health, demonstrated by major initiatives 

such as the President’s Emergency Plan for 

AIDS Relief (PEPFAR) and the President’s 

Malaria Initiative (PMI), represent tremendous 

opportunities to improve health systems 

and promote the delivery of adequate and 

equitable health services. CDC is committed 

to empowering our host country government 

partners to establish capacity to address their 

own health priorities. The current issue offers 

a snapshot of how CDC has shared its core 

expertise to help strengthen health systems 

and improve the world’s health. 

Investment in Human Capacity Strengthens 

Public Health Expertise in Cote d’Ivoire 

Since the first public health agreement between the 

United States and Cote d’Ivoire in 1987, CDC has worked 

side by side with Ivoirian scientists and the Ministry 

of Health (MOH) to build top-notch infrastructure and 

expertise to shape a national response to HIV. In those 

20-plus years, the CDC Retrovirus Cote d’Ivoire (CDC 

Retro-CI) project in Abidjan has answered some of the 

most important questions about HIV worldwide, while 

strengthening the country’s overall health system and 

workforce. 

Cote d’Ivoire’s history of political instability 

and random violence, coupled with the highest HIV 

prevalence in West Africa, created a challenging 

environment for leaders and public health workers. From 

the beginning of the program, CDC understood that the 

IN THIS ISSUE

1 Investment in Human Capacity Strengthens Public 

Health Expertise in Cote d’Ivoire

2 Enhancing Surveillance and Outbreak Response 

Capacity in Pakistan

3 Routine Immunization Services: A Platform to 

Strengthen Systems

4 Building Laboratory Capacity: Accurate, Timely Lab 

Results Are Essential to Safeguarding the World from 

Infectious Disease Threats

5 WHO Global Salm-Surv Network Strengthens 

Foodborne Disease Outbreak Detection and Response

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Coordinating Office for Global Health

www.cdc.gov

www.cdc.gov/cogh

CS123664
country’s capacity to sustain HIV prevention and control 

activities would require a national cadre of Ivoirian 

public health, laboratory, and medical providers to 

implement national HIV/AIDS services. To meet the need, 

CDC established a comprehensive training program 

and close mentorship of Ivoirian students, medical 

professionals, and MOH staff in public health, laboratory 

and behavioral sciences, epidemiology, clinical services, 

and research. 

“Before CDC came to Cote d’Ivoire, our response 

to HIV was disorder, chaos. We didn’t have HIV testing. 

But CDC Retro-CI helped us organize ourselves (into) 

a national fight against HIV,” according to one Public 

Health official. 

The program began with the recruitment of four 

Ivoirian doctoral candidates in Europe, who were asked 

to return to their home country to provide technical 

leadership in the CDC Retro-CI laboratory. Their 

leadership helped CDC Retro-CI support routine training 

of hundreds of laboratory technicians throughout the 

country and region in HIV, TB, and STD diagnostics; 

virology; immunology; and biosafety. At the same 

time, CDC supported the strengthening of the Retro-CI 

laboratory to become a world-class facility—and the 

first lab with its level of capacity in sub-Saharan Africa. 

CDC Retro-CI soon became a regional Center of 

Excellence, and laboratory technicians from Mali, 

Senegal, Ghana, and other countries made regular 

trips to Abidjan for training. Laboratory staff from CDC 

Retro-CI also provided expert technical assistance to lab 

professionals from other countries, conducted regional 

training, and offered 3- to 4-month details for advanced 

training. The lab currently also serves as a teaching 

laboratory for medical students pursuing doctoral-level 

coursework in microbiology and related sciences. 

From its first days, CDC Retro-CI hired lab and 

research staff and provided on-the-job training to 

develop Ivoirian professionals who could conduct 

the expanding CDC-supported research and program 

activities. As former Retro-CI Director Dr. Stefan Wiktor 

points out, “very few expatriate staff were resident incountry, so Retro-CI was a product of Ivoirian staff, of 

their professional evolution from medical students to 

directors of world-class research trials, which we helped 

to support.” For more than two decades, CDC Retro-CI 

directors have personally mentored and trained dozens 

of Ivoirian medical providers and researchers to manage 

clinical research, collect and analyze data, and produce 

scientific publications. 

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As part of a long-term strategy, CDC Retro-CI 

partnered with the Ivoirian MOH to regularly sponsor 

Ivoirian medical doctors for 2-year, on-the-job trainings 

in epidemiology and public health. The program has 

also worked with the U.S. National Institutes of Health’s 

Fogarty International Center to support one or two 

Ivoirian MOH professionals each year in their pursuit of 

advanced degrees in public health, epidemiology, and 

biostatistics at University of California Berkeley and (with 

Belgian assistance) at the Antwerp Institute of Tropical 

Medicine. 

Many former trainees and employees of CDC Retro-CI 

credit the project’s investment in Cote d’Ivoire’s workforce 

and establishment of a public health approach in the 

country with having transformed their personal careers. 

“I felt very fortunate to be among the few that received 

graduate training abroad,” said one graduate. “We don’t 

have these opportunities in my country. It opened doors.”

Developing a competent and skilled public health 

workforce is the keystone of CDC Retro-CI-supported HIV/

AIDS activities in the country. CDC Retro-CI’s commitment 

and comprehensive approach to developing health 

workforce capacity has resulted in a large cadre of public 

health professionals in Cote d’Ivoire and the surrounding 

region. These professionals apply the training and 

expertise they received to their work at the MOH, 

multilateral organizations, and civil society. The close 

network formed among the participants of CDC Retro-CI 

is a visible legacy. 

Laboratory technicians in Cote d’Ivoire and other countries in the region have 

been trained at CDC Retro-CI’s world-class laboratory facility in Abidjan.
Enhancing Surveillance and Outbreak Response 

Capacity in Pakistan

In December 2007, a suspected cluster of human 

avian influenza cases was identified in a family living in 

the northwest region of Pakistan. Laboratory testing later 

confirmed four of the family members had influenza type A 

H5N1 avian influenza; additional evidence indicated another 

family member was a probable case. An investigation of 

the outbreak found transmission of the virus among close 

household contacts of the family member with confirmed 

avian influenza.

Events like this spurred the Government of Pakistan, 

with the help of CDC, to improve the country’s outbreak 

detection and response system. Trainees in the first 

class of Pakistan’s Field Epidemiology and Laboratory 

Training Program (FELTP), a two year in-service program 

developed by the Ministry of Health with support from CDC, 

investigated the outbreak. FELTPs, which are modeled after 

the CDC’s highly respected Epidemic Intelligence Service 

(EIS), help developing countries strengthen their public 

health capacity, primarily by training of epidemiologists and 

laboratory scientists. 

Since it began in September 2006, the Pakistan FELTP 

has become a well-known and valuable asset to the 

country’s Ministry of Health (MOH). The Federal Secretary 

of Health, Khushnood Lashari, stated “the work that has 

been initiated will serve Pakistan for a very long time.” The 

Government of Pakistan has requested more training in 

surveillance and outbreak response and has assigned FELTP 

graduates to leadership roles in the MOH. For example, 

two graduates have been appointed to head Epidemic 

Intelligence Cells, surveillance and response units located 

within the MOH at the national and provincial levels. 

Besides assisting with outbreak investigations, FELTP 

fellows have also conducted studies to determine the 

burden of diarrhea and typhoid fever, and evaluated polio 

vaccination rates, all priorities for provincial and districtlevel Departments of Health. 

The two year training program is just one component 

of a broader CDC effort to strengthen Pakistan’s disease 

surveillance and response capacity. The FELTP is also 

helping to implement the Pakistan National Plan of Action 

for Surveillance, focusing on the country’s self-identified 

priority diseases such as influenza, hepatitis, and polio. 

Initially, the FELTP is helping revise the legal framework 

for surveillance, demonstrating best practices in surveillance 

methodologies, developing an electronic information 

management system, and establishing quality laboratory 

testing for hepatitis and influenza. These systems and the 

lessons learned will then be expanded to address other 

priority diseases. 

In the future, the Government of Pakistan envisions 

the health care community using standard definitions and 

reporting mechanisms (including electronic) to immediately 

alert the public health system of any disease outbreak in the 

country. Graduates of the FELTP will respond, investigate, 

and make timely evidence-based recommendations that 

will influence overall public health programs and policy. The 

FELTP is ultimately training the future public health leaders 

in Pakistan and strengthening the surveillance and response 

systems in which they will work.  

Routine Immunization Services: A Platform to 

Strengthen Systems

Few can argue that, on many indicators, the health 

of people in the developing world remains unacceptably 

poor. The primary reason is that existing health systems 

cannot ensure that health services are widely available and 

accessible across society. An exception has been routine 

immunizations for children. 

Public health professionals in immunization 

programs have long recognized that investing in health 

systems infrastructure is vital to achieve and sustain high 

immunization coverage, which protects populations from 

vaccine-preventable diseases. By building on the platform of 

immunizations to increase coverage of other essential health 

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Pakistan FELTP trainee conducting a survey to estimate the prevalence of 

diarrhea in children younger than 5 years in the town of Murree.
services, there is a tremendous opportunity to improve 

health systems overall.

Because immunization services are a proven entry 

point into the health system, other health interventions, 

with sufficient additional human and logistical resources, 

can be integrated with immunization service delivery. This 

leveraging of health interventions includes the following 

benefits:

1) health services match communities’ needs and 

expectations, 

2) the number of people receiving services increases, 

maximizing the impact of resources invested, 

3) services reach those most in need, and 

4) people’s health improves because multiple needs are 

addressed. 

For example, routine immunization sessions for young 

children present opportunities to provide advice on growth 

monitoring and nutrition, deliver Vitamin A supplements and 

mosquito nets to prevent malaria and other vector-borne 

diseases, and to assess and treat other medical conditions 

from which children may be suffering. Mothers who bring 

their children to immunization sessions can also receive 

reproductive and sexual health care and counseling. 

To improve on synergies realized to date, CDC is working 

with global partners to evaluate and identify the best ways in 

which additional health services can be effectively integrated 

with routine immunizations. The information will provide 

evidence to determine the optimal types of services to 

integrate, and at what point combining too many services 

fails to produce the desired health benefits. 

In Malawi, CDC supported a pilot study to determine the 

feasibility of distributing insecticide-treated mosquito nets 

through routine immunization services. Bed nets typically 

cost up to $5 in this country, which has an estimated average 

annual income of $160. In two districts, free nets were 

given to children when they had completed their routine 

vaccinations by 12 months of age. For comparison, another 

district offered the immunizations without the nets. In the 

two districts receiving the integrated services, the percentage 

of children aged 12-23 months who were both fully 

vaccinated by 12 months and who had slept under a net the 

night before their mothers were interviewed was four times 

higher (increasing from 10-14% to 40-44%). 

Now, the Malawian Ministry of Health has begun to 

distribute free nets at ante-natal clinics and under-5 clinics 

nationwide. 

CDC supported similar research on the integration of 

vaccine services with bed net distribution in Indonesia. A 

mother who received a net there said, “I am very happy that 

they gave me a free net. I would still have gotten my child 

vaccinated, but with the net I can protect my baby from 

malaria.” A vaccination worker in Indonesia observed, “More 

children are coming to [the vaccination session] because the 

mothers know that if they complete their immunizations, 

they will get a net, so they come more regularly.” 

Other studies in the works include evaluating the 

integration of routine immunizations with safe water solution 

and hygiene products, as well as with family planning 

services. A comprehensive multi-country study will explore 

community and health-worker preferences about integrated 

services and estimate the timeframes and personnel required. 

Findings from all of these studies will provide insight 

and evidence on how integrated services can best be 

implemented in a variety of settings around the world. 

As countries strive to reduce unnecessary morbidity and 

mortality, the synergy created by integrating other health 

services with routine immunization programs can help to 

strengthen health system capacity, optimize use of local 

resources, maximize the efficiency of public health services—

and ultimately save lives. 

A mother receives an insecticide treated mosquito net 

after her child was fully vaccinated in Malawi.

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Building Laboratory Capacity: Accurate, Timely 

Lab Results Are Essential to Safeguarding the 

World from Infectious Disease Threats

Misidentification of a virus can lead to deadly delays 

in detecting and containing an epidemic, as was the case 

when severe acute respiratory syndrome (SARS) threatened 

the world’s health in 2003. Initial delays in identifying what 

was later determined to be a new coronavirus significantly 

increased the spread of SARS and had a devastating 

economic impact on the affected countries. 

Then and today, Chinese laboratories are part of a 

global network dedicated to quickly identifying existing or 

new pathogens before they spread globally.

Even before SARS, China CDC—China’s lead public 

health agency and a counterpart to U.S. CDC—had 

committed substantial resources to strengthening its 

network of public health laboratories. Beginning in 2005, 

U.S. CDC collaborated with China to integrate elements of 

U.S. CDC’s training in quality management systems (QMS) 

into the Chinese network of public health laboratories. The 

goal has been to improve China’s laboratory system and 

overall laboratory services. 

In recent train-the-trainer QMS workshops led by U.S. 

CDC, participants focused on reducing laboratory errors 

and producing consistent, timely, reliable test results that 

can be replicated in multiple laboratories. Graduates of the 

workshops serve as the quality assurance leaders for China’s 

public health laboratories and as faculty who conduct QMS 

training at the local level.

“Reliable, timely laboratory results are essential to a 

rapid response during a public health emergency, and 

they are a cornerstone of the revised International Health 

Regulations (IHR),” explains U.S. CDC Health Scientist Dr. Xin 

Liu. The regulations provide guidance to help World Health 

Organization member countries prevent and respond to 

serious threats to public health, including SARS, new flu 

pandemics, and other emerging infections. 

According to Dr. Liu, strengthening the laboratory 

network with QMS tools ensures that laboratory bench work 

is integrated with all of the processes required to detect 

and respond effectively to emerging infectious diseases. 

Epidemiologists must have accurate laboratory data to 

identify and contain outbreaks that pose threats to the 

public’s health. 

“This training is expected to have long-lasting impact 

because the participants will be the leaders for quality 

assurance in China’s public health laboratories,” adds Dr. Wu 

Guizhen, Director of China CDC’s Laboratory Management 

Division. “QMS and its systematic approach have given 

participants a broader knowledge of quality management 

and its impact on public health.”

Now that training is complete, implementation of QMS 

is moving forward. U.S. CDC is collaborating with China 

on a pilot survey in the Guangdong province to assess the 

laboratory network’s capacity to support infectious disease 

surveillance and preparedness and to serve as reference 

laboratories for clinical diagnosis. The newly acquired QMS 

tools will be directly applied to the surveillance activities of 

the International Emerging Infections Program in China. 

WHO Global Salm-Surv Network Strengthens 

Foodborne Disease Outbreak Detection and 

Response

Frustrated by a lack of adequate laboratory supplies 

and dated laboratory facilities, Dr. Raufu Ibrahim, a highly 

trained Salmonella researcher in Maiduguri, Nigeria, was 

unable to confirm his suspicion about a new strain of 

Salmonella. Undeterred, Dr. Ibrahim contacted several 

international reference laboratories for assistance and 

received a response from Rene Hendriksen, a steering 

committee member of WHO Global Salm-Surv. WHO Global 

Salm-Surv is an international network of institutions and 

individuals committed to enhancing the capacity of national 

ministries of health and agriculture and national reference 

laboratories to detect, respond and prevent foodborne and 

other infectious, enteric diseases.

WHO, CDC, and the Danish Institute for Food and 

Veterinary Research founded WHO Global Salm-Surv in 

January 2000 in response to the heavy burden and public 

health importance of foodborne disease, particularly 5

Representatives of clinical and public health laboratories in China participate in 

an evaluation to assess their capacity to support infectious disease surveillance 

and preparedness and to serve as reference laboratories for clinical diagnosis.
Salmonella, and the need to enhance 

capacity for laboratory-based surveillance 

in many countries. Today, the program has 

close to 1,100 members from 153 WHO 

Member States and provides training for 

other pathogens in addition to Salmonella

such as Shigella, Vibrio cholerae, E. coli 

O157, and Campylobacter. CDC is a Steering 

Committee Partner and contributor of 

scientific expertise. 

WHO Global Salm-Surv promotes 

the integration of foodborne disease 

surveillance with appropriate laboratory 

diagnostic practices and fosters a 

multidisciplinary approach among 

human health, veterinary, and foodrelated disciplines. The network supports 

international training courses, the global Salmonella

country databank with data from more than 380 institutions 

worldwide, the external quality assurance system, the 

electronic discussion group to facilitate communication 

among members, and reference testing services. Since its 

inception, WHO Global Salm-Surv has brought together 

Dr. Raufu Ibrahim, a highly trained 

Salmonella researcher in Nigeria

KEMRI/CDC Participates in the First 

Late-Stage Clinical Evaluation of a 

Candidate Malaria Vaccine

In collaboration with the Kenya 

Medical Research Institute (KEMRI), 

CDC will be participating in the world’s 

first late-stage clinical evaluation of 

a candidate malaria vaccine at the 

KEMRI/CDC Field Station in western 

Kenya. Based on successful earlier 

phase 2 trials in Africa, GlaxoSmithKline 

and the Malaria Vaccine Initiative (MVI) 

are sponsoring this large phase 3 trial 

in infants and young children in 7 

African countries, including Kenya. 

Reductions in Measles Deaths 

On December 4, 2008, CDC Director 

Dr. Julie Gerberding joined leaders 

from CDC Measles Initiative partners; 

the American Red Cross, the United 

Nations Foundation, United Nations 

Children’s Fund (UNICEF), and the 

World Health Organization (WHO) 

to announce the remarkable 

74% reduction in global measles 

deaths since 2000 and specific 

accomplishments in measles 

reductions in the WHO regions. 

Partners also discussed the future 

goals and challenges for reducing 

measles deaths globally as much work 

remains. 

CDC Responds to Cholera Outbreak 

in Zimbabwe

Since late October, CDC has been 

assisting in the response to a large 

cholera outbreak in Zimbabwe. As 

of January 4, 2009, there have been 

33,579 including 1,671 deaths as 

reported by WHO Zimbabwe. Cholera 

cases in refugees from Zimbabwe 

have been reported in South Africa 

and Botswana, and are likely to 

appear in Zambia and Mozambique, 

as well. CDC is working with WHO, 

who is leading the response, 

providing technical assistance in 

an epidemiologic investigation 

of the outbreak and making 

recommendations how to control the 

outbreak. 

CDC Investigates Suspected 

Diethylene Glycol Poisoning (DEG) 

in Nigeria

CDC staff in Nigeria reported clusters 

of deaths as a result of acute renal 

failure among children reported 

at three main health facilities. The 

Nigerian Field Epidemiology and 

Laboratory Training Program (FELTP), 

a program started and managed 

by CDC, is investigating. The 

suspected agent is an acetaminophen 

(paracetamol)-based teething syrup for 

children that has been contaminated 

with DEG. The first case was reported 

on November 24, 2008, and as of 

December 10, 2008, a total of 65 cases 

have been reported with 59 deaths 

(i.e., 91% of all cases reported have 

died). Reported cases are aged 3 – 36 

months.

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microbiologists and epidemiologists from 

more than 130 countries at 57 training 

courses at 15 regional sites. 

With support from WHO Global SalmSurv, Dr. Ibrahim was able to identify in 

his laboratory a new type of Salmonella—

Salmonella serotype Hiddudify. Further 

investigation showed that Salmonella

Hiduddify is prevalent in Nigerian chickens 

and in the local environment. Because of 

the threat to the health of Nigerians and 

possible negative effects on the national 

economy, Dr. Ibrahim is keen to learn more 

so that Nigeria can be better prepared in the 

event of an outbreak. 

Dr. Fred Angulo, a CDC expert in enteric 

disease epidemiology, is enthusiastic about the mutually 

beneficial aspects of the program. “WHO Global Salm-Surv 

helps nations better detect and respond to foodborne 

disease and work together; it has [also] facilitated several 

new partnerships that allow CDC to better perform our 

public health mission.” 
CDC Participates in China -US 

Workshop on Food Safety 

A China – US Workshop on food 

safety was held in Beijing, China, in 

November 2008. CDC participated, as 

part of a Health and Human Services 

(HHS) team led by Secretary Mike 

Leavitt, with Chinese counterparts 

about research and policy related 

to general food safety, including 

melamine-contaminated milk 

products, a major source of food 

safety concern in China after two 

well publicized contamination 

incidents in baby formula and pet 

food. The discussions resulted in 

an increased understanding of 

the melamine situation, and other 

food safety issues, and an increased 

cooperation and coordination on the 

work needed to address the issue of 

melamine in the food supply.

CDC Assists with Unknown Chronic 

Liver Disease Outbreak in Ethiopia

In August 2007, the Ethiopian 

Ministry of Health (MOH) requested 

CDC assistance in investigating 

an outbreak of chronic, fatal, liver 

disease of unknown cause occurring 

in the Tigray region of Ethiopia, and 

CDC immediately responded. The 

initial CDC investigation helped 

public health officials learn more 

about the disease, but its cause 

remains unknown. Ethiopian officials 

now believe that the numbers of 

affected people and geographic 

areas have increased. CDC 

investigators returned to Ethiopia 

on December 3, 2008, and with the 

Ethiopian MOH increased disease 

surveillance in the region; looked 

for new cases; and interviewed 

people in one of the most affected 

villages. The investigation included 

testing human and environmental 

samples for contaminants or other 

agents that may be causing the 

disease. CDC Director Dr. Julie 

Gerberding also traveled to Ethiopia 

during December to reaffirm 

CDC’s commitment to helping the 

Ethiopian government resolve the 

outbreak.

President’s Emergency Plan for 

AIDS Relief (PEPFAR) Results 

Released

December 1, 2008, was the 20th 

anniversary of World AIDS Day-- a 

day in the past that was often spent 

in remembrance of lives lost to the 

epidemic. While we continue to 

remember the lives lost, CDC was 

able to embrace the World AIDS Day 

theme “Celebrate Life!” as President 

George W. Bush announced that the 

President’s Emergency Plan for AIDS 

Relief (PEPFAR) had fulfilled ahead 

of schedule its commitment to 

support treatment for two million 

people. As of September 30, 2008, 

through PEPFAR, CDC has supported:

y Life-saving antiretroviral 

treatment for more than 2.1 

million men, women and 

children living with HIV/AIDS 

around the world. 

y Nearly 9.7 million people 

affected by HIV/AIDS in 

PEPFAR’s 15 focus countries 

had received compassionate 

care, including nearly 4 million 

orphans and vulnerable 

children. 

y Prevention of Mother-to-Child 

HIV Transmission programs 

that resulted in nearly 240,000 

babies being born free of HIV.

Through its unique capabilities 

(health systems strengthening, 

treatment, prevention, laboratory 

capacity building, surveillance, and 

human capacity development ), CDC 

looks forward to helping the U.S. 

Government meet the new PEPFAR 

10-year goals: treatment for at least 

3 million people, the prevention of 

12 million new infections, and care 

for 12 million people, including 5 

million orphans and vulnerable 

children. 

CDC Support for Global Blood 

Safety Highlighted in CDC 

Morbidity and Mortality Weekly 

Report

Through PEPFAR, CDC works in 

partnership with countries to 

strengthen laboratory capacity, 

epidemiology, surveillance, public 

health evaluation, workforce 

capacity, and prevention 

initiatives—essential components 

for strong sustainable public health 

systems. A key part of CDC’s health 

systems strengthening activities 

has been five years of support to 

improve national blood transfusion 

services in 14 countries in Africa 

and the Caribbean. In recognition 

of World AIDS Day, the progress 

made by these CDC-supported 

nations toward delivering an 

adequate supply of safe blood is 

highlighted in the November 28th, 

2008 CDC Morbidity and Mortality 

Weekly Report. To view this issue 

of the CDC Morbidity and Mortality 

Weekly Report go to: http://www.cdc.

gov/mmwr/preview/mmwrhtml/

mm5747a2.htm

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