Evidence-based Integration

Safe Water and HIV Interventions

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 USG-supported clinic, where 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 evidencebased, high-impact, and low-cost health interventions 

developed by CDC Global AIDS Program public health 

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. 

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 point-of-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 

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Second Quarter 2007

CDC Global Health 

E-Brief

-WELCOME to the second global health e-brief, 

designed to educate and inform readers about key 

global health activities at the Centers for Disease 

Control and Prevention (CDC). Our second issue 

is focused on global safe water and food. Over a 

billion people worldwide lack access to safe water. In 

addition, recent international foodborne outbreaks 

have caused considerable illness and made headline 

news through the world. Whether people get basic 

vitamins and minerals, or don’t, has an enormous 

impact on worldwide human health. For all of 

these reasons, CDC is committed to achieving core 

public health needs of safe and adequate water and 

nutrition.

IN THIS ISSUE

Safe Water and HIV Interventions

CDC’s Safe Water System Project in Kenya

CDC Launches Safe Water Project in Guyana 

Investigating Micronutrient Deficiencies in 

 Papua New Guinea

Food Fortification to Prevent Birth Defects

PulseNet International

WHO Global Salm-Surv

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Helping to Ensure Access to 

Safe Water and Food Globally
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.

Safe Water

CDC’s Safe Water System Project in Kenya:

Reaching at-risk populations through schools 

Nearly 2 million child deaths each year are attributed 

to diarrhea and other infectious diseases acquired from 

unsafe drinking water, inadequate sanitation, and poor 

hygiene. Diarrheal disease is one of the leading causes 

of child deaths in developing countries. These deaths 

are preventable with access to safe drinking water and 

hygiene. 

Globally, CDC works in collaboration with the social 

marketing, non-governmental organization Population 

Services International (PSI) to market a small bottle of 

dilute chlorine solution that is used to treat water in the 

household. The bottle holds a 4- to 6-week supply and 

costs a family only 25 US cents. 

The Safe Water System (SWS) has been proven to 

reduce diarrheal diseases in users by 22-84%. The SWS 

incorporates three main elements: 

Point-of-use water treatment by consumers with a 

locally manufactured, dilute sodium hypochlorite 

(bleach) solution.

Safe storage of treated water in containers designed to 

prevent recontamination.

Behavior change communications to improve water 

and food handling, sanitation, and hygiene practices in 

the home and in the community. 

Safe drinking water and hygiene are essential to 

reducing diarrheal disease in Kenya. In May 2005, CARE 

Kenya, CDC, and Emory University implemented a schoolbased safe drinking water and hygiene intervention 

in 45 rural primary schools in Nyanza Province, which 

is located in western Kenya. Each school received 

portable handwashing stations (pictured) and water 

storage containers, along with several months supply 

of WaterGuard solution for water treatment and soap 

for handwashing. 

Teachers in each 

school were trained 

to organize studentrun Safe Water 

clubs and to teach 

students to promote 

handwashing. 

An evaluation 

demonstrated a 

marked reduction 

in student 

absenteeism, 

improvements in 

student’s knowledge 

of correct water 

treatment and handwashing procedures, and transfer of 

the knowledge and practices to students’ families and 

homes. Funding for the pilot project, evaluation efforts, 

and an expansion of the program to 500 schools in Nyanza 

Province was provided by the Coca-Cola Africa Foundation, 

USAID, and the Gates Foundation. 

Besides the decrease in diarrheal episodes, Kenya 

benefits economically. Because the bottles of chlorine 

solution are produced locally and sold through existing 

distribution networks, jobs are created and manufacturers, 

distributors, wholesalers, retailers, and kiosk owners profit. 

This project shows that linking local community 

education mechanisms with existing health-beneficial 

products and messages can leverage funding to reach 

hundreds of thousands of students and their families.

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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. 

Two members of the safe water club at Sino SDA Primary 

School in Rachuonyo District, Nyanza Province in rural Kenya 

treating the school drinking water with WaterGuard®.

Simple interventions such as the provision of nutritional 

supplements, low-cost antibiotics andclean water can have 

significant impact in the quality of life for those living with 

HIV/AIDS.
CDC Launches Safe Water 

Project in Guyana 

Poor access to safe 

water continues to be a 

major threat to human 

health around the world. 

WHO estimates that 

1.1 billion people lack 

access to improved water 

supplies. In January 

of 2007, CDC, the National Oceanic and Atmospheric 

Administration, the U.S. Geological Survey, the Pan 

American Health Organization, and CARICOM’s Caribbean 

Environmental Health Institute selected Linden, Guyana, as 

a demonstration site for an exciting water safety project to 

protect drinking water for thousands of people. 

This pilot project will assess how to lower land-based 

sources of pollution by protecting the watershed with a 

Water Safety Plan (WSP)—a risk-reducing approach to 

improving drinking water quality. As a result of the project, 

it is expected that 35,000 residents of Linden, Guyana, 

will have access to cleaner drinking water and watershed 

management will improve.

The first workshop to kick-off the WSP Project was 

recently held in Linden, Guyana, to train key stakeholders 

in the process and to lay the groundwork for developing a 

National Program of Action. The demonstration project will 

be showcased at World Water Week in Stockholm, Sweden, 

in August. When the project is completed in Fall 2007, 

other countries in the region will be trained to undertake 

similar activities within their borders.

Improving Global Health 

by Fortifying Foods

Investigating Micronutrient Deficiencies in Papua 

New Guinea: From Data to Intervention

After enduring three months of rough seas and a nearfatal shipwreck, a team of field workers landed on Bali (an 

outlying island of Papua New Guinea) in July 2005. The 

team of Papua New Guinean natives, supported by CDC 

and UNICEF, was conducting a national survey to assess 

the presence of micronutrient deficiencies including iron, 

anemia, and vitamin A in women of reproductive age and 

children aged 6-59 months. This survey offered the team 

members an opportunity to travel beyond their home 

provinces to collect, for the first time, information about 

the nutritional status of some of the world’s most isolated 

people. 

Vitamin and mineral deficiencies can lead to premature 

death, poor health, blindness, growth stunting, mental 

retardation, learning disabilities, and low work capacity. 

For example, iron deficiency reduces capacity for learning 

and the ability to work in 4 to 5 billion people. In addition, 

approximately 30% of the world’s population is anemic. 

Vitamin A deficiency is associated with 2.5 million annual 

deaths in children. 

The International Micronutrient Malnutrition 

Prevention and Control (IMMPaCt) program, launched by 

CDC in 2000, is committed to advancing global efforts to 

eliminate vitamin and mineral deficiencies. This program 

is a global effort that includes partners such as United 

Nations Children’s Fund (UNICEF), WHO, and USAID. 

Water Treatment Plant in Linden, Guyana.

An outbreak of an illness 

characterized by rash, conjunctivitis 

and joint pain has recently been 

described in Yap (an island in the 

Caroline Islands of the western Pacific 

Ocean, the westernmost state of 

the Federated States of Micronesia). 

Scientists from CDC’s Division of 

Vector-Borne Infectious Diseases 

(DVBID) in Fort Collins, Colorado 

have determined that this illness is 

caused by Zika virus. Zika virus is 

a mosquito-transmitted flavivirus 

with transmission epidemiology 

that is similar to dengue viruses. 

Outbreaks of Zika virus illness have 

been described in Africa and Asia but 

have not been previously detected 

in Micronesia. CDC’s Global Disease 

Detection (GDD) program is providing 

support for a team of epidemiologists 

and entomologists from DVBID to 

assist the Micronesia authorities 

in the investigation and control 

activities. For more information, 

please see the press release at www.

fsmgov.org/press/pr06260a.htm 

China has made substantial progress 

in implementing universal, timely 

hepatitis B vaccination for infants 

and reducing disparities in coverage. 

During 2003--2006, approximately 42 

million children nationwide received 

hepatitis B vaccine. More information 

can be found in the May 11 issues of 

the Morbidity and Mortality Weekly 

Report [56(18) 441-445] www.cdc.

gov/mmwr/PDF/wk/mm5618.pdf. 

Laos is now a full participant in 

the global influenza surveillance 

network. The Lao national influenza 

laboratory (established with onsite assistance from CDC) is up and 

running. In March 2007 the Lao 

laboratory identified a human case 

of H5N1 without outside assistance 

and sent the specimen to a WHO 

Collaborating Center for confirmatory 

testing. This is a major milestone 

in the development of capacity for 

pandemic influenza detection and 

response in a priority country likely to 

be critical in detecting and therefore 

controlling an early pandemic.

CDC staff member David McQueen 

recently co-edited a book entitled 

Global Perspectives on Health 

Promotion Effectiveness. This 

document was specifically developed 

for public health practitioners 

and researchers to implement 

international health programs. Dr. 

McQueen is the Associate Director 

for Global Health Promotion at the 

National Center for Chronic Disease 

Prevention and Health Promotion. 

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IMMPaCt staff have worked in more than 50 countries 

to develop national capacity to assess and monitor 

micronutrient status; conduct epidemiological research; 

and develop, monitor and evaluate national interventions 

to eliminate micronutrient deficiencies. 

Results from the Papua New Guinea survey have led to 

several new or planned nutrition interventions. Planned 

interventions include fortifying flour and flour products 

with iron and folic acid, oil with vitamin A, and sugar 

with vitamin A. Similarly, the findings motivated health 

officials to improve existing nutritional interventions, 

such as greater vitamin A supplementation for infants and 

lactating mothers. Expansion of the national salt iodization 

program is also becoming a top priority. IMMPaCt is 

working with local partners to design novel ways to 

increase exposure to iodized salt. 

Given the difficulty in reaching people in remote 

areas of the country, approaches that focus on access 

and purchasing power are particularly important. Such 

interventions offer great promise for improving the 

nutrition and health status of Papua New Guineans.

Food Fortification to Prevent Birth Defects: 

Improving the health of infants and children

The high prevalence of neural tube defects (NTDs) related 

to folic acid deficiency is a major global health problem. 

Food fortification, as has been implemented in the U.S., is 

one way to reduce that problem.

For almost three decades, CDC researchers in the 

National Center on Birth Defects and Developmental 

Disabilities (NCBDDD) have been investigating the role of 

folic acid in preventing birth defects. In 1993, China and 

CDC collaborated on a large-scale intervention assessing 

the effects of consuming 400 micrograms of folic acid 

daily before and during early pregnancy on the prevention 

of (NTDs). This study showed that folic acid can prevent 

a large number of NTDs and alleviated concerns about 

possible links between folic acid and miscarriage or 

multiple births.

Today, Central America suffers an especially high 

burden of NTDs related to folic acid deficiencies in 

women. As many as 10 in 1,000 infants are born with an 

NTD despite having wheat flour fortification policies in 

place since 2003. Unfortunately, these policies are not 

enforced. Last year, CDC began working closely with the 

governments of Belize, Costa Rica, El Salvador, Guatemala, 

Honduras, Nicaragua, and Panama to promote a regional 

approach that focuses on multiple nutrients to prevent 

micronutrient deficiency. The program is funded through 

a competitive grant to Central America by the InterAmerican Developmental Bank, a regional arm of the 

World Bank.

This collaboration is working to fortify foods with 

key micronutrients—iron, folic acid, B complex vitamins, 

zinc, vitamin A, and iodine—to reduce pregnancy 

complications, anemia, and serious birth defects that 

cause death and severe disability.

Countries will agree as a region on minimum levels 

of fortification for staple foods such as corn flour, rice, 

milk, and juice. Each country will then select the staples 

to be fortified. By having common standards and legal 

requirements for food fortification, these regions will 

be identified as valuable 

customers in the global 

market for fortified foods. 

Other expected benefits to 

the region include economies 

of scale in carrying out the 

fortification, uniformity and 

compliance in enforcing 

fortification standards, and 

an opportunity for countries 

to work together to develop 

and test strategies to reach 

populations with less 

access to fortified foods, 

micronutrient supplements, 

or vitamin pills.

Safe Food

PulseNet International: Tracking Foodborne 

Disease Outbreaks throughout the World

In February 2007, millions of Americans heard news 

reports about a large multi-state outbreak of Salmonella 

traced to peanut butter produced in Georgia. Because 

foodborne disease outbreaks do not respect borders, 

and with increasing international trade of food, CDC’s 

PulseNet program was also working closely with federal 

and international partners to ensure global detection of 

the outbreak. 

PulseNet USA is the national surveillance network for 

foodborne infections. Members of PulseNet USA include 

public health and food regulatory agency laboratories that 

perform DNA “fingerprinting” on bacteria that may spread 

through food. Network members identify and label each 

Papua New Guinea National Micronutrient survey

Food fortification in several Central 

American countries has potential to reduce 

birth defects.
“fingerprint” pattern for rapid comparison through an 

electronic database maintained at CDC. This helps identify 

and track particular strains of bacteria that are harmful to 

human health. 

During the Salmonella outbreak, PulseNet 

International, a global network modeled after U.S. 

PulseNet, informed network countries that the 

contaminated product had been exported to many 

countries. Suspect cases were reported in several 

European countries, but tests ultimately showed none had 

the “fingerprint” identified in the U.S. outbreak. 

PulseNet International has confirmed global cases in 

other outbreaks. One example is an outbreak of shigellosis 

that was associated with air travel from Hawaii in 2004. By 

sharing DNA fingerprints from the bacterial strains isolated 

from patients, public health officials confirmed cases in the 

United States, Canada and Japan. 

Today, 67 countries/regions are members of the 

PulseNet International network. Goals for PulseNet 

International include:

Developing partnerships between public health 

laboratories throughout the world

Establishing efficient communication systems between 

the networks

Building capacity for molecular surveillance of 

foodborne infections

 Today, PulseNet USA and PulseNet Canada are sharing 

data in real-time through direct connection between their 

respective databases. This real-time communication is 

also planned with the other PulseNet networks. PulseNet 

International is currently exploring the possibility of 

establishing PulseNet networks in Africa and the former 

Soviet Union. This work is done in cooperation with WHO’s 

Global Salmonella Surveillance program (WHO GSS). These 

expanded collaborations are expected to further improve 

global surveillance and control of foodborne diseases, 

which in turn will lead to fewer people being affected by 

foodborne infection worldwide.

WHO Global Salm-Surv: Providing Tools for Foodborne 

Illness Surveillance and Outbreaks Globally

The WHO Global Salmonella-Surveillance program 

(WHO Global Salm-Surv) recently conducted two major 

international trainings in advanced foodborne illness 

surveillance. From March 19-23, WHO Global Salm-Surv 

conducted a training in Guatemala City, Guatemala. 

Hosted by the Universidad del Valle, this training brought 

epidemiologists and microbiologists from numerous 

countries and organizations in the region to learn about 

foodborne outbreak investigation and the impact of 

these illnesses on a community. A second recent training 

was held from March 25-29 in Cairo, Egypt. Thirty-nine 

participants attended, representing countries such as 

Egypt, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia, 

Sudan, Syria, and Yemen. 

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These trainings are vital due to the fact that foodborne 

illness cost U.S. companies and consumers millions of 

dollars in medical and labor costs and impact developing 

countries in a far, far greater way. For example, in the 

developing world foodborne illness outbreaks go 

undetected, cases of foodborne illness are not reported, 

and death can occur due to lack of training and 

communication between scientists working within the 

human, animal, and food sectors. WHO Global Salm-Surv is 

working to reverse this trend.

WHO Global Salm-Surv is a World Health Organization 

network of institutions and individuals which train public 

health and food safety microbiologists, epidemiologists, 

environmental health officers and managers to conduct 

foodborne illness surveillance and outbreak investigations. 

CDC participates in the global Steering Committee, along 

with the Food and Drug Administration (FDA), and other 

international institutions. The Steering Committee works 

in close partnership with WHO Regional Food Safety 

Advisors, the Training Programs in Epidemiology and 

Public Health Interventions Network Inc (TEPHINET), and 

PulseNet International.

The main activity of WHO Global Salm-Surv is 

training courses, such as those mentioned in Guatemala 

and Egypt. WHO Global Salm-Surv has conducted 45 

International Training Courses and Workshops in English, 

Spanish, French, Portuguese, Chinese, Arabic and Russian 

for more than 600 public health microbiologists and 

epidemiologists from more than 100 countries. 

Participants in the WHO Global Salm-Surv classes have 

remarked on the educational as well as the networking 

benefits of the trainings. “It was a meeting of ideas and 

dreams of different [countries] in one space of time,” 

remarked a participant at the 2007 Training Course for 

the Middle East. Cherae’ L. Robinson of the CDC explains 

that “.the microbiologists and epidemiologists had the 

opportunity to talk, some of them for the first time, and 

even plan projects for their countries. The course was 

an excellent example of how important collaboration is 

to public health.” Indeed, it is these activities like these 

that equip countries and regions with critical scientific 

and public health tools so that they can carry out disease 

detection in their respective countries.

WHO Global Salm-Surv has conducted 43 International Training 

Courses and Workshops in more than 100 countries.