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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Center for Global Health

4th quarter 2009

E-Brief CDC Global Health

Revisiting Successful Integration of Public Health Interventions

Welcome to the fourth quarter 2009 

Global Health E-Brief, designed to inform 

readers about key global health activities 

at the Centers for Disease Control and 

Prevention (CDC). The end of 2009 marks 

the completion of the third year of the 

Global Health E-brief. To celebrate this 

milestone, this quarter’s e-brief showcases 

some of our past articles. In looking 

forward to the Obama Administration’s 

commitment to a holistic approach to 

global health, this issue revisits previously 

published articles highlighting CDC 

programs that have pioneered integrations 

of public health interventions, and crossprogram and -agency collaborations. 

Evidence-based integration of activities 

across disease-specific programs has 

been critical in helping CDC reach more 

people in need and use scarce resources 

efficiently. 

pg 2 CDC: Making Integration 

Work to Improve Health 

Impact

pg 2 Promoting Early 

Childhood Development 

for Orphans and 

Vulnerable Children

pg 4 CDC Research Leads 

to New Tools to Fight 

Malaria and Anemia in 

Pregnant Women

pg 5 Zambia’s Cervical Cancer 

Screening Program

pg 6 Routine Immunization 

Services: A Platform to 

Strengthen Systems

pg 7 Evidence-based 

Integration: Safe Water 

and HIV Interventions

pg 9 Newsbytes

In This Issue

CS208146

3-year Anniversary Edition

 Photo credit: CDC-Kenya
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4th CDC Global Health quarter 2009

CDC: Making Integration Work to Improve Health Impact

Program integration at CDC has led 

programs to work together in new and 

non-traditional ways to improve health 

outcomes, maximize efficiency, strengthen health systems and ownership in 

host countries, and tackle diseases 

that historically have not received large 

investments – such as maternal and child 

health, diarrheal diseases, and chronic 

disease. In addition, CDC’s technical 

expertise in operations research and 

monitoring and evaluation are critical to 

ensuring that integration of interventions 

is evidence based.

Because HIV/AIDS and malaria programs 

have extensive programmatic activities 

in the field, many CDC programs have 

sought to collaborate in those areas. For 

example, many of the groups featured 

in this e-brief have collaborated with 

groups serving HIV-positive or vulnerable populations. However, integration 

among CDC programs is not limited 

to HIV and malaria. CDC programs are 

integrating on multiple levels including 

combining health services during routine 

childhood immunizations, providing 

food supplements at antenatal clinics, 

and providing flu vaccinations to people 

with chronic diseases who are at greater 

risk of complications if they fall ill. 

These programs have seen the value of 

integration and are continually looking 

for innovative ways to build on their 

respective successes.

Integration of activities can also lessen 

the burden on health systems stressed 

from populations that have not yet 

addressed their infectious disease issues and are seeing the rise of chronic 

disease. Integration of infectious 

disease and chronic disease programs 

has shown that Ministries of Health 

can leverage limited resources to reach 

more people and affect multiple health 

outcomes at once. 

In short, integration has fulfilled 

many unmet health needs through 

the expansion of delivery of services 

that have the greatest health impact. 

Evidence-based integration of programs across agencies holds great 

promise to build on the tremendous 

reach and successes of U.S. health 

programs to achieve lasting and durable results. CDC looks forward to the 

challenge of expanding the evidence 

base for integration of public health 

programs that will expand access and 

improve efficiency. 

Photo credit: Camille Smith, CDC

Promoting Early Childhood Development for Orphans and 

Vulnerable Children (3rd Qtr 2007)

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, 

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.
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4th CDC Global Health quarter 2009

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. 

tious 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 a concentrated, costeffective manner. Partnerships have been 

formed with food programs and health 

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, where they 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 nutriAn Update:

Promoting Early Childhood Development for Orphans 

and Vulnerable Children

The Early Childhood Development Center (ECD) in Busia is still being well run by the St. Jude Health 

Center. Today, the project supports the mothers whose children are attending the center to start 

income generating activities. The mothers have since opened successful businesses. The probation 

office, where the child welfare officer works, has been included as part of the committee that oversees 

the running of the center. The mothers and children are thriving. The Center is supporting their health 

and developmental needs as well as protecting their rights. 

Research conducted at other project sites throughout sub-Saharan Africa has uncovered demand for 

solutions and a more complete package of services that addresses the health and developmental 

needs of young children. Creating a new program infrastructure is not sustainable, thus ECD interventions are being integrated into already existing platforms e.g. PMTCT, Maternal Child Health, Home 

based care, Virus Testing and Counseling, and Vaccination Programs.

CDC, CARE and Save the Children are co-facilitating a five-year process to formulate an Essential 

Package of critical services built off the design of the “5x5Model” for young orphans and vulnerable 

children (OVC) which utilizes qualitative, field based research, existing tools, standards and guides 

already used in OVC programs, and input from experts in the field of HIV/AIDS and early childhood. 

The package will propose frameworks for action and tools to improve child and caregiver outcomes. 

The goal is to empower volunteers, home based care providers and other paraprofessionals to offer a 

comprehensive range of services to enable children to reach their developmental potential. 

After an extensive literature review and field consultation, the project will develop a strategy for 

integrating quality standards to guide program design, and a tool kit to guide implementers to existing services. In addition, the center will develop and validate a research protocol in communities with 

documented high and low HIV prevalence.
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4th CDC Global Health quarter 2009

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 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 sub-Saharan 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: SP cannot be given to women 

who are taking cotrimoxazole; the drug 

HIV-positive pregnant women receive to 

prevent complications from their HIV; 

and the rates of HIV and malaria in many 

sub-Saharan African countries are very 

high and many individuals have both 

infections. This project and other CDC 

research will provide additional information about how to prevent malaria in 

HIV-positive pregnant women. 

CDC Research Leads to New Tools to Fight Malaria and 

Anemia in Pregnant Women (2nd Qtr 2008)

CDC’s Dr. Meghna Desai Working in Kenya Photo credit: Meghna Desai, CDC
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4th CDC Global Health quarter 2009

Zambia’s Cervical 

Cancer Screening 

Program (4th Qtr 

2007)

One of the key lessons learned from the 

United States’ efforts to improve global 

health is that many of the countries we 

assist provide opportunities for innovative approaches to the growing problem 

of chronic disease in less economically 

developed settings. CDC’s ability to offer 

innovative public health solutions in 

challenging global settings was utilized 

recently in Zambia, where life expectancy 

has dropped from 50 years of age in 1970 

to 38 years of age in 2007, and two thirds 

of the population lives on less than 

$1 per day. In May, a team from CDC’s 

National Center for Chronic Disease 

Prevention and Health Promotion visited 

Zambia’s Center for Infectious Disease 

Research’s (CIDRZ) Cervical Cancer See 

and Treat program in Lusaka.

CDC has begun to work hand in hand 

with this program, which is partially 

funded by CDC through the President’s 

Emergency Plan for AIDS Relief 

(PEPFAR). CDC plans to further See and 

Treat’s impact through technical and 

financial support to reduce the high 

incidence and mortality rates of cervical 

cancer in Zambia. CIDRZ initiated a 

cervical cancer prevention intervention 

that targets both HIV-positive and 

non-HIV infected female patients. 

Though HIV positive women live longer 

thanks to improved access to care and 

treatment programs targeting HIV/

AIDS, they continue to develop and die 

from serious chronic diseases - such as 

cervical cancer. Cervical Cancer rates 

have declined during the past decades 

for most of the developed world, but are 

increasing or unchanged, for women in 

Eastern Africa, Zambia and Swaziland. In 

these countries, the incidence of cervical 

cancer is up to ten times higher than in 

other parts of the developing world. 

The See and Treat Program is an 

outstanding example of CDC’s commitment to comprehensive, crosscutting 

global health issues and strategies, 

particularly the rising incidence of 

non-communicable disease in less 

economically developed countries. 

Based at the anti-retroviral clinics in 

Lusaka, Zambia, and spearheaded by Dr. 

Groesbeck Parham from the University of 

Alabama-Birmingham School of Medicine, and Dr. Mulindi Mwanahamuntu 

from the University Teaching Hospital in 

Zambia, the See and Treat program is a 

low-cost, innovative approach to detecting cervical cancer. The protocol begins 

with visual inspections by trained nurses. 

If abnormal cells are found, the nurse 

provides basic treatment and digital 

images, or makes a referral for further 

histologic evaluation by Drs. Parham or 

Mwanahamuntu. 

The See and Treat program, is the first 

free, public health-based cervical cancer 

prevention program in Zambia. Since 

its beginning in November 2005, more 

than 10,000 women have been screened, 

13 nurse-midwives and 3 gynecologists 

have been trained, nine cervical cancer 

prevention clinics have been developed, 

and one cervical cancer peer educator for 

each clinic has been trained and hired.

CDC’s collaboration with CIDRZ will enhance the See and Treat clinical program 

in Zambia through the development 

of a Management Information System 

to track the disease burden; human 

papillomavirus (HPV) vaccine research; 

digital pathology/consultation; and HPV 

laboratory capacity and evaluation. Plans 

are also underway to develop and implement an arrangement to sustain this 

activity in Zambia through a student and 

professional exchange program with U.S. 

medical and graduate schools, a Health 

Promotion/Health Education program, 

cervical cancer nurse certification, peer 

educator training, and a micro-credit 

lending program. 

Through its careful approach to addressing one chronic disease – cervical 

cancer – the See and Treat screening 

program is a model for other countries. It 

creates needed community infrastructure 

for chronic disease prevention and 

enhances opportunities for on-going 

professional development. This program 

leverages CDC’s technical and scientific 

assets and shows that partnership is 

essential to solving global public health 

disease problems, particularly the rising 

burden of chronic disease in developing 

countries. 

Photo credit: Mary Hall, CDC
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4th CDC Global Health quarter 2009

Routine Immunization Services: A Platform 

to Strengthen Systems (4th Qtr 2008)

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 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:

•	 Health services match communities’ 

needs and expectations,

•	 The number of people receiving 

services increases, maximizing the 

impact of resources invested,

•	 Services reach those most in need, and

•	 People’s health improves because 

multiple needs are addressed. Photo credit: Steven Stewart, CDC

An Update:

Online Training Program Designed to Build Capacity of 

Zambia’s Healthcare Providers

Since 2005, trained nurses and physicians with the Center for Infectious Disease Research in Zambia 

(CIDRZ) Cervical Cancer Prevention Program (CCPP) have successfully screened and treated more than 

27,000 HIV-positive and non-HIV-infected women in Zambia. The nurses are primary health care providers and routinely perform visual inspection and acetic acid (VIA) digital cervicography. Cryotherapy is 

provided during the same visit after visual examination, ensuring appropriate follow-up.

To build capacity among the Cervical Cancer Prevention Program healthcare professionals, the CDC 

Division of Adult and Community Health provided resources for a Professional Development and 

Exchange Program (PDEP). A CDC epidemiology fellow in Zambia developed an online training 

program for healthcare providers. The PDEP includes several competency-based learning modules: 

epidemiology and natural history of cervical cancer, cervical cancer screening method--Cytology, VIA, 

Digital cervicography, HPV DNA testing, HPV vaccine, and how to educate the community about 

cervical cancer screening. Post-training assessments will be incorporated into each training module to 

ensure comprehension and retention of the information.

Long-term objectives of this online program are to facilitate more rapid, comprehensive, and efficient 

training of the CCPP nurses and doctors and to provide easy access to the CCPP Zambia training 

materials among other countries in the region. 
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4th CDC Global Health quarter 2009

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 

Evidence-based Integration: Safe Water 

and HIV Interventions (2nd Qtr 2007)

Jemima is a woman living with HIV in 

rural western Kenya, where rates of HIV 

are among the highest in the world. 

Nearly one in five adults is infected, and 

nearly 20% of children are orphaned. 

Jemima became a leader in her community by founding a group that provides 

emotional support and small loans to 

HIV-affected families in her home area. 

However, Jemima’s own HIV disease 

continued to progress. She grew ill with 

diarrhea and wasted to a low of 77 lbs. A 

local volunteer found Jemima at home, 

bedridden, weak, and with oral thrush 

and skin infections.

The volunteer brought Jemima, her 

husband, and her sick grandchild to a 

U.S. Government-supported clinic, where 

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. 

staff provided the family a “Basic Care 

Package” to treat their symptoms and 

to prevent further illness. Developed in 

2002, the ‘Basic Care Package’ is a bundle 

of evidence-based, high-impact, and lowcost health interventions developed by 

CDC Global AIDS Program’s researchers 

in Uganda (in partnership with other CDC 

scientists) to prevent the most debilitating opportunistic infections among 

people living with HIV. With suppressed 

immune systems, Jemima and others 

living with HIV are more vulnerable to 

opportunistic illnesses, such as those 

transmitted through contaminated 

water. These illnesses can be costly and 

difficult to treat in settings with limited 

resources. 

Photo credit: Rob Quick, CDC

Simple interventions such as the provision of 

nutritional supplements, low-cost antibiotics 

and clean water can have significant impact 

in the quality of life for those living with HIV/

AIDS.
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4th CDC Global Health quarter 2009

The elements of the Basic Care 

Package are designed to be simple to 

implement, so they can be delivered 

at primary health care centers. The 

essential elements—delivered together 

or separately—include cotrimoxazole (a 

powerful antibiotic), insecticide- treated 

bed nets to prevent malaria, screening 

and management of STDs, Prevention of 

Mother to Child Transmission (PMTCT) 

services, and counseling (e.g., condom 

use and family planning), and pointof-use safe water systems. The safe 

water system of the Basic Care Package 

includes education as well as:

•	 Use of household-based water treatment methods and water storage in 

containers that limit hand contact 

(e.g., plastic containers with spigots 

and dilute chlorine tablets)

•	 Proper disposal of human or animal 

feces

•	 Promotion of hand washing with soap 

after handling human or animal feces, 

before food preparation, and before 

eating, along with the provision of soap

Each intervention has been shown to 

improve health outcomes while remaining cost effective. Alone, the Safe Water 

System has been documented to reduce 

diarrhea among persons with HIV by 25-

35%, at a cost to $10 per family per year. 

Combining the safe water system with 

cotrimoxazole reduces diarrhea episodes 

among people living with HIV by 77% and 

days of work or school lost to diarrhea by 

47%, at a cost of roughly $15 per family, 

per year. Because of these successes, the 

integrated Basic Care Package is now being scaled up under the U.S. President’s 

Emergency Plan for AIDS Relief.

After receiving her Basic Care Package, 

Jemima’s condition improved dramatically, and she regained a healthy weight 

of 132 lbs. She now promotes health 

interventions in her community and 

sells health products to help support the 

eight sick and orphaned children she has 

adopted. Jemima is a fervent advocate 

for the U.S. government-supported 

clinic and has referred more than 100 

HIV-infected men, women, and children 

to receive care at the facility. 

An Update:

Distribution of Basic Care Package Expands in and 

beyond Africa

As of December 2009, five countries have expanded distribution of Basic Care Package programs: 

Uganda, Kenya, Nigeria, Ivory Coast, and Ethiopia. Four additional countries are integrating household 

drinking water treatment products with HIV services: Viet Nam, Rwanda, Zambia, and Malawi. In 2010, 

a national basic care package program will be launched in Mozambique. Eight years after its development, hundreds of thousands of people living with HIV are benefitting from the program.
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4th CDC Global Health quarter 2009

Newsbytes

CDC Part of First Response to 

Haitian Earthquake

CDC staff members on duty in Haiti were 

among the first to respond following 

the devastating earthquake on January 

12, 2010 providing first aid at the U.S. 

Embassy in Port-au-Prince and supporting USG and Haitian colleagues 

affected by the 7.0 magnitude temblor. 

CDC experts were also part of the first 

HHS Disaster Medical Assistance Team 

supporting the overall U.S. response in 

Haiti, which is being coordinated by the 

U.S. Agency for International Development, 

and the public health efforts of the World 

Health Organization (WHO) and the Pan 

American Health Organization (PAHO). CDC 

also coordinated closely with international 

and national governmental organizations 

and non-governmental organizations 

(e.g., International Red Cross, World 

Food Programme, UNICEF, and CARE). 

During the response, CDC’s primary 

role is to support surveillance and help 

address food and water safety and the 

prevention and treatment of infectious 

diseases. CDC public health information 

on earthquakes and updated information 

about our response to the Haiti earthquake 

are posted on the CDC website.

CDC staff head out to Haiti on January 18, 

2010. Their mission includes helping to prevent 

tropical diseases, airborne and waterborne, 

from spreading through the population.

Nodding Disease affecting 

Children in Northern Uganda

In December 2009, CDC was asked by the 

Ugandan Ministry of Health to assist with 

a multidisciplinary field investigation of an 

outbreak of “nodding disease” in Kitgum 

District, Uganda. The disease affects children 

aged 5 to 15 years, and it is characterized 

by episodes of head nodding, often with 

other neurologic problems such as seizures, 

psychoses, and mental deterioration. 

Hundreds of children have been reported 

to be affected, many in internally displaced 

population camps, and in Uganda, Sudan, 

and Tanzania. Findings from preliminary 

investigations have been inconclusive, 

there is no known treatment or cure, and 

no patients are known to have recovered.

CDC deployed a team of experts representing 

infectious disease, environmental health, 

neurology, and nutrition to Uganda to consult on the outbreak and its causes. Partners 

in the response included the Ugandan 

Ministry of Health, CDC-Uganda, the World 

Health Organization (WHO), and the African 

Field Epidemiology Network (AFENET). Data 

analyses are in the initial stages. Over the 

course of two weeks, the team surveyed 180 

children who met the case definition and 

conducted a range of evaluations: psychiatric 

and neurologic examinations; testing of 

blood, urine, skin snips, spinal fluid; and 

electroencephalograms. Interviews with 

community members found that villagers 

thought the disease might be caused by 

spirits, onchocerciasis (a parasitic infection 

that can lead to blindness), or contaminated 

food, but in general were perplexed about 

the disease’s cause and discouraged by its effects on their community. CDC investigators 

documented significant abnormal brain wave 

activity on EEG and are currently evaluating 

possible causes. It is hoped that the data 

analyzed thus far, combined with findings 

from various biometric recordings, will help 

yield a definitive etiology in the near future.

Thailand First to Release 

Results of the Global Adult 

Tobacco Survey 

In November 2009, Thailand became the 

first of 14 low- and middle-income countries 

(Bangladesh, Brazil, China, Egypt, India, 

Mexico, Philippines, Poland, Russian 

Federation, Thailand, Turkey, Ukraine, 

Uruguay and Vietnam) to release results of 

the Global Adult Tobacco Survey (GATS)

The country report states: that, “Among 

12.5 million current smokers, almost half of 

them (49.8 %) made an attempt to quit in 

the last 12 months. Among current smokers 

and recent quitters (<12 months) who 

visited any health facility, 60.2% were asked 

about their history of tobacco smoking 

while 51.9% were advised to quit smoking.” 

Representatives from Thailand’s Ministry of 

Public Health, CDC, CDC Foundation, WHO, 

Campaign for Tobacco-Free Kids, and various 

Thailand GATS partners after the release of 

the survey results.

CDC Investigates One of the 

Largest Outbreaks of Hepatitis E

CDC’s investigation of the outbreak of 

hepatitis E virus in the Kitgum district in 

northern Uganda appears in the January 

Emerging Infectious Diseases Journal. 

The district outbreak is part of one of 

the largest outbreaks to date impacting 

northern Uganda. In Kitgum over 10,000 

people became ill and almost 200 died. 

There was particularly high morbidity among women, especially pregnant 

women, and children (infants to 2 years). 

Photo credit: Samira Asma, CDC

Photo credit: CDC
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4th CDC Global Health quarter 2009

High morbidity may be due to the lack of 

preexisting immunity since this was the 

first reported epidemic in Uganda. Safe 

drinking water, adequate sanitation and 

personal hygiene are the most important 

public health interventions to prevent 

hepatitis E. Despite availability of preventive measures and the rapid spread and 

long incubation of the disease, efforts 

to develop a vaccine are imperative.

3rd Annual Report to 

Congress on The Assistance 

for Orphans and Other 

Vulnerable Children in 

Developing Countries Act of 

2005 (Public Law (PL) 109-95)

PL 109-95 was passed in 2005 with the aim 

of ensuring that the U.S. Government’s 

assistance to Orphans and Other Vulnerable 

Children in Developing Countries is coordinated, comprehensive, and effective. In 

FY 2008 CDC expended approximately $5.5 

million, including PEPFAR funds, on global 

health activities directly targeted to the 

needs of approximately 27,000 vulnerable 

children and young women. An additional 

$141million was invested in infectious 

disease prevention and control in ways that 

also contribute substantially to the needs 

of the children: providing immunizations, 

vitamin A, and bednets, among other proven 

interventions. More than 300 million doses 

of polio vaccine were provided in 2008 in 

the push to end the disabling disease. 

The report details CDC accomplishments 

including preventing mother-to-child 

transmission of HIV, reducing infant 

abandonment, identifying and linking HIVinfected orphans and street youth to clinical 

care and support, and increasing the use of 

modern contraception among HIV-infected 

women wishing to avoid pregnancy.

CDC’s Global AIDS Program 

Director Addresses Rome 

Conference on Partnerships 

among Governments and 

Faith-Based Organizations

At the request of Ambassador Goosby 

(Office of the Global AIDS Coordinator), Dr. 

Deborah Birx, director of the Global AIDS 

Program at CDC participated in a conference 

in Rome on creating partnerships among 

governments and faith-based organizations in the global fight against HIV/AIDS, 

particularly the effects of the disease on 

children. The October conference brought 

together physicians, members of religious 

orders, heads of Catholic-sponsored AIDS 

projects, professors of theology, and representatives from the pharmaceutical industry. 

Partnerships between the U.S. Government 

and faith-based organizations are critical; 

the US is the largest source of foreign 

assistance and the Catholic Church is the 

world’s largest aid-delivery organization. 

UNAIDS Executive Director Michel Sidibé discusses HIV/AIDS partnerships with Dr Deborah 

Birx, director of the Global AIDS Program, 

CDC; Dr Georges Tiendrebeogo, Royal Tropical 

Institute, Cordaid; and Dr Miguel H. Diaz, U.S. 

ambassador to the Holy See. 

Release of Latest State of 

the World’s Vaccines and 

Immunization

On October 21, 2009, the World Health 

Organization (WHO), the United Children’s 

Fund (UNICEF), and the World Bank 

released the third edition of the 

report State of the World’s Vaccines 

and Immunization (SOWVI). The report 

evaluates the Global Immunization Vision 

and Strategy (GIVS) established in 2005 by 

WHO and UNICEF to expand global vaccine 

coverage and development through the integration of immunization with other health 

systems, global interdependence and new 

technologies. Among the successes identified in the report was the unprecedented 

immunization of 106 million infants in 2008. 

The report also acknowledges a funding gap 

that must be addressed before the remaining 24 million children are immunized. 

Pan American Health 

Organizations Names Jon Kim 

Andrus Deputy Director 

Dr. Jon Kim Andrus has been named 

deputy director of the Pan American Health 

Organization, Regional Office for the 

Americas of the World Health Organization 

(PAHO/WHO). Before the announcement, 

Dr. Andrus served as lead senior technical 

advisor for PAHO’s immunization program, 

where he has been a forceful advocate for 

spreading the benefits of vaccination. He is 

also the director of the George Washington 

University’s Global Health MPH Program 

and holds adjunct faculty appointments at 

the University of California at San Francisco 

School of Medicine and the Johns Hopkins 

Bloomberg School of Public Health.

Photo credit: Bobbie Person, CDC

 Photo credit: US embassy to the Holy See