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WELCOME to the third quarter global 

health “e-brief,” designed to inform readers 

about key global health activities at the 

CDC (Centers for Disease Control and 

Prevention). Our third issue for 2007 is 

focused on child health and child survival. 

Globally, approximately 10.6 million 

children under age 5 will die in 2007 and 

about 4 million of these children die within 

their first month. CDC and its partners are 

committed to working around the world 

to improve health conditions and increase 

survival rates for children.

Violence Against Children in Swaziland

While only slightly larger than the state of Connecticut, 

Swaziland’s mountainous terrain and rural communities 

made implementing a nationwide household survey on 

violence against children more physically challenging than 

expected for epidemiologists Avid Reza, MD, MPH and 

Matthew Breiding, PhD.

“We were going where cars just couldn’t take us,” said 

Reza, who works as a medical epidemiologist in CDC’s 

National Center for Environmental Health (NCEH). “You 

could only drive to the base of mountains and walk from 

there. Often you couldn’t see from one house to the next. 

We sometimes relied on children in the village to guide us 

to the next house.”

The two researchers were in Swaziland after the 

United Nations Children’s Fund (UNICEF) requested the 

assistance of CDC researchers to conduct a national survey 

on violence against children, with an emphasis on sexual 

violence. 

Nearly 40% of adults in Swaziland are HIV-positive, 

the highest HIV prevalence rate in the world. AIDS 

has created a vicious cycle in Swaziland by breaking 

down the institution of the family. Orphans can fall into 

poverty, drop out of school, and become vulnerable to 

violence, rape, and abuse. Sexual abuse can be a route of 

transmission for HIV.

Understanding the scope of violence against children 

in Swaziland is difficult. Research on sexual violence 

against children in sub-Saharan Africa is limited. The 2006 

UN World Report on Violence Against Children called 

attention to this global health problem, but despite the 

scientific evidence this issue has not received adequate 

attention in many countries. 

Third Quarter 2007

CDC Global Health 

E-Brief

IN THIS ISSUE

Violence Against Children in Swaziland

Promoting Early Childhood Development for Orphans 

and Vulnerable Children

Integrating Child Health and Education

News Bytes

CDC’s Global AIDS Program: Helping to Pioneer 

Innovations in Early Infant HIV Diagnosis

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Improving the Health and 

Survival of Children Globally
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The household survey is the result of collaborative 

work between CDC, UNICEF, and the President’s 

Emergency Plan for AIDS Relief (PEPFAR), as well as several 

NGOs and government ministries in Swaziland. The survey, 

which was administered by a team of Swazi women, 

was designed to gather information to understand the 

magnitude of the problem, as well as identify risk and 

protective factors. It is hoped that responses will shed light 

on factors related to violence, particularly sexual violence, 

against children. 

“Countries cannot develop effective prevention strategies 

to address the problem of violence without reliable data,” 

said Reza. “This survey is an important step towards the 

prevention of violence against children in Swaziland. We 

hope the survey inspires other countries to take similar 

steps.” 

Promoting Early Childhood Development 

for Orphans and Vulnerable Children 

By 2010, 15 million children are predicted to have been 

orphaned by AIDS alone in sub Saharan Africa. AIDS, 

conflict, natural disasters, endemic diseases such as 

malaria and tuberculosis, and rising poverty are claiming 

the lives of millions of productive adults in Africa, leaving 

many more children orphaned and vulnerable. 

Research shows that as many as 200 million children 

worldwide fail to reach their full potential because 

of malnutrition, micronutrient deficiency, and lack of 

stimulation during early childhood. These findings are 

especially important for Africa, where 15 percent of 

all orphans, or about 6.5 million children, are younger 

than 5. Integrated interventions that address health and 

education as well as child rights, economic empowerment 

of families and improved community capacities are 

needed. 

Responding to this critical need, CDC is collaborating 

with CARE International in a program called “The 

5x5 Model”. This model was designed to deliver early 

childhood development interventions through community 

based child care centers catering to the 2-8 year old age 

group in Kenya, Uganda, Rwanda, and Zambia. The model 

represents an innovative, community-centered approach 

to Early Childhood Development programming. Key 

collaborators are Emory University, UNICEF, Hope for Africa 

Children’s Initiative, and the Bernard Van Leer Foundation. 

Five levels of intervention are addressed including 

the individual child, the caregiver or family, the child 

care settings, the community, and the wider policy 

environment. The 5x5 model has developed interventions 

for five critical areas: food and nutrition, child 

development, economic strengthening, health, and child 

protection. 

A great example of this work in action is a project in 

Uganda. In Busia, Uganda many young, poor women are 

brought to Uganda from other countries to be sex workers 

and find themselves pregnant, alone, and far from home. 

This CDC/CARE collaboration established a comprehensive 

Early Childhood Development (ECD) center providing the 

children of these mothers a stimulating and healthy child 

care environment and nutritious daily meals. The project 

informs the community about child nutrition, parenting 

skills, and child rights through radio programming. A local 

Catholic health center provides prevention and medical 

treatment services. The ECD is linked with a government 

child welfare officer to address issues related to child rights 

violations. 

The ECD centers deliver health services to children in 

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. 
a concentrated, cost-effective manner. Partnerships have 

been formed with food programs and health centers so 

that children also receive immunizations, deworming, 

growth monitoring, vitamin supplementation, and 

treatment of minor respiratory infections and ringworm. 

Partnerships are being established with the Ministries of 

Health and Education to strengthen relationships between 

the ECD centers and schools and community programs. 

Pilot projects in challenging and resource-constrained 

environments have shown that the approach can be 

adapted within a variety of settings. 

Integrating Child Health and Education

Rose Odhiambo was an AIDS widow from a rural village in 

western Kenya who received her main support from five 

other widows in her neighborhood. The women barely got 

by, but did what they could by pooling their money and 

taking turns using it for household needs. In July 2005, the 

group heard about a unique program serving people like 

them called the Safe Water and AIDS Project (SWAP). SWAP, 

sponsored by a Kenyan non-governmental organization 

(NGO), taught them about diarrhea prevention, nutrition, 

malaria prevention, and other diseases and offered them 

health interventions-

-such as water 

treatment solution, 

insecticide treated 

bednets, protein 

fortified flour-- to 

purchase at wholesale, 

sell at retail, and keep 

the difference. 

SWAP also 

encouraged the 

women to participate 

in a support group 

sponsored by CDC. 

CDC staff taught them 

about home based care, HIV counseling, HIV treatment, 

and the importance of using safe water to take their 

antiretroviral medicines. SWAP provided a kiosk for selling 

their products and their product sales increased. Soon 

there were 60 members in their group. Beyond the gains 

in income, the women have become valued members of 

their community. 

Until recently, there were no products that contained 

Beginning in August 2007, CDC’s 

Global Disease Detection (GDD) 

Operations Center began tracking 

reports of unexplained death in the 

Democratic Republic of Congo (DRC). 

In September, this outbreak was 

confirmed as Ebola, after specimen 

testing performed at CDC and in 

Gabon. As part of the ongoing 

response, CDC continues to work 

closely with the Ministry of Health, 

the World Health Organization and 

other partners to conduct outbreak 

response activities as suspected 

cases continue to emerge. Updated 

information about this outbreak can 

be found at the WHO website: www.

who.int/csr/don/2007_09_20/en/

index.html

Through February 2007, an outbreak 

of HIV in Southern Kazakhstan has 

infected 101 children and 13 mothers 

with HIV. CDC participated in an 

epidemiological investigation of the 

HIV outbreak among children. 

When global eradication of 

dracunculiasis, or Guinea worm 

disease (GWD), is achieved, it will 

mark the first worldwide elimination 

of a parasitic disease and the first time 

a disease has been eradicated without 

benefit of a vaccine. As of May 2007, 

GWD is still endemic in nine countries 

(Burkina Faso, Côte d’Ivoire, Ethiopia, 

Ghana, Mali, Niger, Nigeria, Sudan, 

and Togo) with an eradication target 

date of 2009. The eradication effort 

has received generous support 

from the Carter Center, the Bill & 

Melinda Gates Foundation, CDC, and 

other donors. For more information 

on CDC’s involvement in GWD 

eradication see: wwwdev.cdc.gov/

ncidod/dpd/parasites/dracunculiasis/

default.htm

Between April 2 and June 29, 2007, 

there were 288 cases of cholera 

including four deaths in Dadaab 

refugee camps in Kenya. CDC sent a 

team to the camp in May to carry out 

a rapid assessment, assess potential 

sources, and make recommendations 

for next response steps. In addition, 

from June 26 to August 15, 2007, at 

least 90 confirmed or suspect cases of 

cholera including three deaths were 

reported from the Mae La Refugee 

Camp in Thailand. CDC’s investigation 

into these outbreaks is continuing. To 

date, no cases of cholera have been 

imported into the United States from 

either outbreak.

CDC scientists and their collaborators 

have for the first time successfully 

identified Marburg virus infection in 

a common species of African fruit bat 

(Rousettus aegyptiacus). Bats have 

been suspected of carrying the virus, 

but until now, virus infection in bats 

had not been detected. This is the first 

study to definitively document the 

evidence of the virus in wild nonprimates. It is also the first study to 

document the existence of Marburg 

virus in the Central African country of 

Gabon. 

In May 2007, DRH released the final 

product of the Reproductive Health 

Assessment (RHA) Toolkit specifically 

for Conflict-Affected Women. This 

updated RHA Toolkit provides 

user-friendly tools to assess the 

reproductive health needs of women 

aged 15–49. It enables field staff 

with limited experience to collect 

data to inform program planning, 

monitoring, and evaluation. 

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SWAP basket filled with various health products
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micronutrients in the SWAP basket, a critical omission in a 

region where childhood anemia exceeds 60%. Through the 

efforts of CDC, the Heinz Corporation made a new product, 

called Sprinkles, available for field testing in Kenya. Field 

trials showed that Sprinkles reduced anemia in children 

while providing essential micronutrients like Vitamin A, 

folate, zinc, and Vitamin C. What was missing was a vehicle 

for delivering the product. CDC and SWAP were ready to 

provide that vehicle. This was the genesis of the Nyando 

Integrated Child Health Education (NICHE) project. This 

project is a collaboration between CDC, SWAP, the private 

sector, and people living with HIV/AIDS in the Nyando 

region of Kenya. 

Initial interest in SWAP, which ultimately led to the 

creation of NICHE, was started by the Atlanta Rotary Club 

with support of the President of the CDC Foundation and a 

former CDC Director, both of whom were Rotary members. 

The SWAP baskets include over 20 health products such 

as WaterGuard water treatment solution, PuR water 

purifier (a Procter & Gamble product that was developed 

in collaboration with CDC), insecticide-treated bednets, 

condoms, protein- fortified flour, and antiseptic solution 

for wound treatment. 

NICHE is training community leaders, schoolteachers, 

nurses, religious leaders, and SWAP groups about the 

health products in SWAP’s basket of goods. The SWAP 

groups are the “Avon Ladies” for health, promoting healthy 

behavior change and selling low-cost health products 

to their neighbors while earning money to support their 

families. CDC is collecting data to measure the health 

impact of NICHE. In the future, project partners hope to 

take this model and occupy a similar “niche” in other parts 

of Kenya and beyond.

CDC’s Global AIDS Program: Helping to Pioneer 

Innovations in Early Infant HIV Diagnosis

In Botswana, a country with one of the highest rates of 

HIV/AIDS infection in the world, one in three pregnant 

women is HIV positive. Without intervention, 35-40 percent 

of children born to HIV-positive mothers will become HIVinfected during pregnancy, delivery, or breastfeeding. With 

the right interventions, however, the rates of infection can 

be reduced to between 1-20 percent. In 1999 Botswana 

was the first country in Africa to launch a free national 

program for prevention of mother-to-child transmission 

(PMTCT) of HIV.

PMTCT programs require data to assess their impact 

and to make critical policy and program decisions. Early 

infant HIV diagnosis (EID) can help provide this vital data. 

The CDC Global AIDS Program (GAP) provides essential 

support to expand EID services in Botswana, as well as in 

other resource-limited settings all over the world.

Early infant diagnosis also offers HIV-infected infants 

early access to appropriate care and treatment, often 

before the onset of disease progression If not identified or 

treated, as many as 50-60% of HIV-infected infants die by 

age two. EID requires, 

however, complex 

and expensive tests, 

as well as blood 

refrigeration and 

transportation. These 

tests are often not 

possible outside of the 

developed world. 

Fortunately, the 

collection of infant 

blood by the dried 

blood spot (DBS) 

method is expanding 

opportunities for infant diagnosis in resource-limited 

settings. With the simple prick of an infant’s heel, toe, or 

finger, whole blood is placed on a card to dry, creating 

samples that are simple to transport and stable for 

relatively long periods without refrigeration. 

Following a successful pilot program, the Botswana 

Ministry of Health (MOH), with CDC support, has expanded 

DBS collection nationwide. EID are now provided to 

approximately 13,300 HIV-exposed infants born in 

Botswana each year.

In 2005, with support from the CDC through the US 

President’s Emergency Plan for AIDS Relief, the Botswana 

MOH published a report on the effectiveness of Botswana’s 

program. Analyses showed that the program has been 

remarkably effective. Only 7% of infants with HIV-positive 

mothers were HIV-infected, an 80% reduction from the 

expected number of infections if no PMTCT program were 

available. CDC and the Botswana MOH estimated there 

were 930 infant infections in Botswana in 2005; without 

the PMTCT program, as many as 4650 infections would 

have been expected. 

The success of Botswana’s program has given hope 

to other under-resourced countries that both PMTCT 

and infant diagnosis programs can be successful in their 

settings.

On September 27, 2007, 

the CDC and the University of North Carolina 

School of Public Health 

launched a global health 

case study. “Public 

Health is Global Health: 

An Innovative Approach 

to Fighting Disease in 

Uganda” spotlights on 

innovative intervention to 

improve health—The Basic 

Care Package, which was developed with funding from PEPFAR 

and through a collaborative effort of CDC and other partners. The 

webcast is free and available for replay. Go to www.publichealthgrandrounds.unc.edu