All posts by Bill Brieger

Mobile suitcase laboratory: A tool for the rapid detection of emerging and endemic infectious disease

Ahmed Abd El Wahed who is based at Georg-August University, Goettingen, Germany shares his experiences with development and use of field diagnostics that can fit in a suitcase. This work received support from the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland. He explains the concept here …

Laboratory diagnosis mainly depends on nucleic acid detection by real-time polymerase chain reaction (PCR), which is available in central laboratories and has a turnaround time of more than two hours. Since real-time RT-PCR assays are not suitable for on-site screening, samples collected from local hospitals, treatment center or at the site of an outbreak have to be sent to laboratories over long distances for testing.

In developing countries, the necessary equipment for diagnosis is only available in few central laboratories, which are not accessible and of limited capacity to test large numbers of incoming samples. Moreover, transport conditions of samples are inadequate and therefore lead to unreliable results.

lab-in-a-suitcaseFor decentralizing of the molecular diagnostics, there is a need for a simple molecular point-of-need test. We have developed a mobile suitcase laboratory (62+49+30 cm) containing all reagents and equipment for the detection of the nucleic acid of infectious agents using the recombinase polymerase amplification (RPA) technology. The RPA assay run at a constant temperature (42°C) for a maximum of 15 minutes.

Moreover, all reagents are cold-chain independent and the mobile laboratory is operated by a solar power battery. The nucleic acid extraction is performed by a magnetic bead based method, in which a simple fast lysis protocol is applied. In case of highly infectious agents such as Ebola virus, the inactivation step was performed in a glovebox.

The suitcase lab is designed to detect almost 30 pathogens such as Dengue, Zika, Chikungunya, Ebola, Coronaviruses as well as Tuberculosis, Leptospira, Salmonella typhi and paratyphi, malaria, avian influenza, and Leishmania.

The suitcase lab featured in a presentation at the 65th Annual Meeting of the American Society of Tropical Medicine in Atlanta under the title of “Novel Extraction Protocol and Recombinase Polymerase Amplification Assay for Detection of Leishmania Donovani In 30 Minutes.” Authors/presenters included Dinesh Mondal, Prakash Ghosh, Md. Anik Ashfaq Khan, Faria Hossain, Susanne Böhlken-Fascher, Greg Matlashewski, Axel Kroeger, Piero Olliaro, and Ahmed Abd El Wahed.

Their work highlighted Leishmania donovani (LD), a protozoan parasite transmitted to humans by sand flies, which causes Visceral Leishmaniasis (VL). Currently, diagnosis is based on presence of anti-LD antibodies and clinical symptoms. Molecular diagnosis would require real-time PCR, which is not easy to implement at field settings.

In this study, we report on the development and testing of a novel extraction protocol in combination with recombinase polymerase amplification (RPA) assay for the detection of LD. The LD RPA assay detected equivalent to one LD genomic DNA. The RPA assay was performed at constant temperature (42°C) and the total assay runtime including the extraction procedure was 30 minutes.

The RPA assay also detected other Leishmania species (L. major, L. aethiopica and L. infantum), but did not identify nucleic acid of other pathogens. Forty-eight samples from VL, asymptomatic and post-kala-azar dermal leishmaniasis subjects were detected positive and 48 LD negative samples were negative by both LD RPA and real-time PCR assays, which indicates 100% agreement.

To allow the use of the assay at field settings, a mobile suitcase laboratory (56+45.5+26.5 cm) was developed and operated at the local hospital in Mymensingh, Bangladesh by using a solar-powered battery. DNA extraction was performed by a novel magnetic bead based method, in which a simple fast lysis protocol was applied.

Gaining an early start to IPTp through promotion of MIP at the community level in Kenya

posterA poster entitled “Community health: Improving start of IPTp early in second trimester through promotion of MIP at the community level in Kenya” was presented by Augustine Ngindu, Gathari Ndirangu, E Nyapada, David Omoit, and Mildred Mudany from Jhpiego’s Kenya Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

WHO policy recommends that pregnant women living in moderate to high malaria transmission areas start receiving intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine pyrimethamine (SP) early in second trimester to prevent malaria in pregnancy (MIP).

Training Community Health Volunteers in Bungoma

Training Community Health Volunteers in Bungoma

In Bungoma County, Kenya, 52% of pregnant women start IPTp in their third trimester. Between June and September 2015, 197 Community Health Assistants (CHAs) were trained, who in-turn trained 2,344 Community Health Volunteers (CHVs) in Bungoma County.

Following the training, CHVs  registered new pregnant women at their homes and encouraged them to seek antenatal care (ANC)  and start taking IPTp early in the second trimester. The CHVs also helped to identify previously registered women who were not attending ANC and refer them to ANC for MIP services.

The CHVs, with CHA supervision, reached 44,133 pregnant women with MIP messages on starting IPTp early in the second trimester and use of a net. Data from 70 health facility registers was collected biannually and showed a 12% increase (24%-36%) in the proportion of pregnant women starting ANC attendance ? 20 weeks of pregnancy between October 2014 and March 2016.

Community Health Volunteers Encourage ANC Attendance

Community Health Volunteers Encourage ANC Attendance

Although there was a decline in the proportion of women receiving IPTp-SP between October 2014 and January 2015 and between October 2015 and February 2016 due to SP stock-outs, this did not significantly affect ANC attendance. The 12% increase in early ANC attendance is likely associated with CHV efforts in sensitizing women to start IPTp early in the second trimester and indicates a positive change in health seeking behaviour that can be sustained over time provided the commodities are available.

The success with CHVs promoting MIP at the community level has led to it being replicated in three additional counties and it will be extended in phases in other malaria endemic counties.

Country Updates on Global Call to Action to Increase Coverage of Intermittent Preventive Treatment in Pregnancy

Symposium 87 at the 65th Annual Meeting of the American Society of Tropical Medicine and Hygiene focused on the Global Call to Action to Increase Coverage of Intermittent Preventive Treatment in Pregnancy: Progress and Lessons Learned. The original Global Call was initiated at a previous ASTMH meeting. Elaine Roman of Jhpiego chaired the session. Panelists included Julie Gutman of the US CDC,  Frank Chacky of the NMCP in Tanzania, Yacouba Savadogo of the NMCP in Burkina Faso and Fannie Kachale of the Reproductive Health Directorate in the Malawi MOH.

symp-tanzania-1The symposium speakers reviewed country progress in sub-Saharan Africa (SSA) in increasing intermittent preventative treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP). They described how Ministries of Health and donors and partners are working to increase IPTp-SP coverage to address malaria in pregnancy (MiP).

Following the release of the World Health Organization’s (WHO) 2012 updated policy on IPTp-SP, a number of global stakeholders came together through the Roll Back Malaria-Malaria in Pregnancy Working Group, to elaborate the Global Call to Action: To Increase National Coverage with IPTp of MiP for Immediate Impact. The Call to Action calls upon countries and partners to immediately scale up IPTp-SP to improve health outcomes for mothers and their newborns. Scaling up IPTp-SP across most countries in sub-Saharan Africa remains a critical weapon to prevent the devastating consequences of MiP.

symp-ipt-update-malawi

IPTp3+ has been started in Malawi following WHO recommendations

However, the low proportion of eligible pregnant women receiving at least one dose of IPTp-SP (52%) and IPTp3-SP (17%) in 2014 is unacceptable. Despite growing parasite resistance to SP in some areas, IPTp-SP remains Tuesday a highly cost-effective, life-saving strategy to prevent the adverse effects of MiP in the vast majority of SSA.

Completion of the recommended three or more doses of IPTp-SP decreases the incidence of low birthweight (LBW) by 27%, severe maternal anemia by 40% and neonatal mortality by 38%. This symposium will feature presentations from WHO and the President’s Malaria Initiative on how they are prioritizing support to scale up MiP interventions including IPTp-SP across SSA.

Panelists from Burkina Faso, Malawi and Tanzania discussed how they were able to dramatically scale up IPTp-SP through a health systems approach that addresses MiP from community to district to national level.

symp-ipt-burkinaIn Burkina Faso, IPTp2-SP increased from 54.8% in 2013 to 82.3% nationally in 2015 and IPTp3-SP increased from 13.5% in 2014 to 41.2% nationally in 2015. Moving ahead Burkina Faso will Improve SP supply chain management, Pilot an IPTp distribution at the community level in three districts, Provide job aids throughout ANC clinics, and Provide support to district team for data review and analysis.

In Malawi, in targeted project sites across 15 districts, IPTp1 uptake increased from 44% in 2012 to 87% in 2015, while IPT2 increased from 16% to 61% over the same time period. Lessons learned from scale up include –

  • Consistent availability of SP for IPTp is critical to increasing coverage
  • A clear policy put in place to guide IPTp implementation is crucialsymp-building-blocks-malawi
  • A strong partnership between the Reproductive Health Directorate and National Malaria Control Programme is necessary
  • Intensification of information, education, and communication is crucial to increase uptake of ANC services
  • Strong collaboration, planning, and coordination between partners and other stakeholders improve ANC attendance
  • Antenatal clinics offers enormous opportunities for delivering the malaria prevention package, such as IPTp and insecticide-treated nets, to pregnant women

symp-ipt-tanzaniaIn Tanzania, IPTp2-SP increased from 34% in 2014 to 57% in 2015 and IPTp4-SP was reported at 22% in 225 facilities across 16 districts, in 2015. Program learning in Tanzania identified that consistent availability of commodities at facility level can complement Government’s and partners’ efforts to ensure provision of quality MiP services. Despite increased number of trained health care workers and regular supportive supervision and mentoring, increasing uptake of IPTp will continue to be a challenge unless malaria commodities such as mRDT and SP are available at health facilities. Redistribution of commodities among facilities could be crucial balancing the stock.

symp-tanzania-by-regionMoving forward Tanzania plans to use alternative funding to procure malaria commodities at health facility (e.g., Community Health Fund, National Health Insurance Fund, basket fund). Other efforts will include conducting onsite mentorship and coaching, data collection and interpretation, selecting sentinel sites for collecting IPTp3, working with Ministry of Health HMIS to revise HMIS tools when opportunity arises, and training Community Health Workers (CHWs) on maternal, neonatal and child health interventions including early booking of ANC services.

These three country examples demonstrate that progress is challenging but possible. The call to action for increased IPTp access and use is stronger today.

Improving IPTp uptake and mitigating Stock-outs in Bungoma County, Kenya

A poster entitled “Improving Pregnancy Outcomes: Alleviating Stock-Outs of Sulfadoxine-Pyrimethamine in Bungoma, Kenya” was presented by Augustine Ngindu, Gathari Ndirangu, Waqo Ejersa, David Omoit, and Mildred Mudany from Jhpiego’s Kenya Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

policyWHO recommends intermittent preventive treatment of malaria in pregnancy using sulfadoxine pyrimethamine (IPTp-SP) to be provided at antenatal care (ANC) clinic. The Malaria Policy in Kenya requires that All pregnant women in malaria-endemic areas receive free intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP), have access to free malaria diagnosis and treatment when presenting with fever, and have access to long-lasting insecticidal nets.

Kenya’s Strategic Direction between 2014–2018 was revised to reflect the following:

  • All pregnant women in the 14 malaria-endemic counties shall receive at least three doses of IPTp-SP
  • Annual quantification of SP based on consumption to ensure adequate supplies
  • Training, retraining and supervision of health care workers
  • Dissemination of appropriate IPTp messages and materials

coverageMinistry of Health (MOH) used to procure SP until 2013 when health services were devolved to counties and procurement of became the responsibility of county governments. This presented a major challenge as counties had not factored SP in their budgets. Consequently, counties experienced SP stock-outs from October 2014. In Bungoma County the number of pregnant women receiving IPTp dropped by 51% from 7,845 in October 2014 to 3,865 in February 2015.

To alleviate the situation (MOH) at national level requested counties to procure SP. Advocacy efforts with Bungoma County by the Maternal and Child Survival Program focused on prioritization of SP procurement at least once every quarter. As a result of this intervention, Bungoma County procured SP from February to July 2015.

core-indicatorsThe county advised health facilities to procure additional SP doses if the supplied stocks ran out. The procurement led to a 117% increase in the number of pregnant women receiving IPTp; from 3,865 in February to 8,404 in July 2015.

The fiscal year ended in June 2015 and no funds were available to procure additional SP until October 2015. This contributed to a 33% decrease in the number of pregnant women receiving IPTp from 8,404 in July to 5,672 in October 2015. As a response to support counties, MOH at national level procured 2.24 million SP doses in November/December for 14 MIP-focus counties which were received at health facilities in February 2016.

In conclusion, Bungoma County applied feasible mitigation measures including county level procurement of SP, supplemented by additional procurement at health facility and national levels. This is a practice which is replicable in other counties to ensure continued availability of SP to protect pregnant women from effects of malaria in pregnancy.

Joint efforts, a key to success for the Malaria in Pregnancy Program in Luanda, Angola

A poster entitled “Joint efforts, a key to success for the Malaria in Pregnancy Program in Luanda, Angola” was presented by Jhony Juarez, Adolfo Sampaio, William R. Brieger, and Domingos F. Gueve from Jhpiego’s Angola Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

sbmr-visit-baia-farta-dscn0523Angola, in response to WHO’s 2012 updated guidance on Intermittent Preventive Treatment in pregnancy (IPTp), revised its national malaria protocol to better address the fact that 25% of maternal mortality is caused by the disease. The new protocol was a collaborative effort of a national technical working group assisting the National Malaria Control Program (NMCP) including the National Reproductive Health Program, the national AIDS Institute, WHO, UNICEF, UNFPA and implementing partners of the U.S. Presidents Malaria Initiative (PMI).

The updated Prevention and Treatment Manual for Malaria in Pregnancy, based on the revised protocol, was approved in 2014, and efforts continued with reviewing and updating training modules, job aids and monitoring tools that would reflect the additional doses of IPTp. The Ministry of Health, with support from partners, then disseminated these materials in the provinces and municipalities where they worked. USAID’s ForçaSaúde program, with support from PMI, worked with the Provincial Health Directorate of Luanda to build capacity of 297 health professionals to implement the new guidance in 78 health facilities of four municipalities, Belas, Cazenga, Cacuaco and Viana, with a combined population of 4.3 million.

ipt-1234Comparing the IPTp data from the four municipalities between 2014 and 2015, one can see that the new guidance has started to take effect. In both years approximately 70,000 pregnant women received the first dose or around 60% of women registering for antenatal care (ANC). For the new third dose there was an increase of 85% (from 12,490 women to 23,046), and receipt of the fourth dose rose by 164% (3,345 to 8,839).

Two major challenges remain: increasing ANC registration and addressing missed opportunities to provide ANC doses for those who do attend including ensuring regular supplies of sulfadoxine-pyrimethamine for IPTp. Future progress requires continued inter-departmental collaboration among NMCP, Reproductive Health and the AIDs Institute, on-the-job training, enhanced statistical capacity, and supervision.

Accelerating IPTp uptake through updated WHO IPTp guidance in Malawi

A poster entitled “Building Capacity to accelerate IPTp uptake through the adoption of 2012 WHO IPTp guidance in Malawi” was presented by John Munthali, Lolade Oseni, Dan Wendo, Kabango Malewezi, and Tambudzai Rashidi from Jhpiego’s Malawi Team at the

Community activities encourage IPTp uptake in Malawi

Community activities encourage IPTp uptake in Malawi

65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

Malawi adopted the World Health Organization’s updated guidance on intermittent preventive treatment in pregnancy (IPTp) in 2013. Support from the US President’s Malaria Initiative through USAID funded health projects, enabled collaboration between the National Malaria Control Program (NMCP) and the Reproductive Health Directorate (RHD) of the Ministry of Health, to build capacity from national to district to frontline health facility levels to implement the updated IPTp policy.

iptpaccessThese partners updated IPTp policy in the National Malaria Treatment Guidelines, and developed appropriate training manuals. All 5708 health workers from the 304 facilities in the 15 project districts were trained on the IPTp policy and guidelines. Post-training test scores of health staff increased over pre-test by an average of 40 percentage points.

The community action cycle approach engages community volunteers and local community based organizations to identify and solve local problems and was used to encourage pregnant women to attend antenatal care (ANC) and receive IPTp and long lasting insecticide-treated nets.

Sample page from ANC register showing delivery of IPTp3 and 4, but these data are not yet recorded on summary HMIS forms

Sample page from ANC register showing delivery of IPTp3 and 4, but these data are not yet recorded on summary HMIS forms

Health information system data from the 15 Districts were used to compare ANC and IPTp coverage for 2012 and 2015 fiscal years (Oct.-Sept.). ANC registration in the project area rose from 113,683 to 394,116. IPTp1 as a proportion of ANC registration rose from 52% to 87%, and IPTp2 increased from 17% to 62%. While IPTp3 doses were recorded in the ANC registers, reporting forms in 2015 still did not include space to enter this IPTp3.

Observations at clinics showed IPTp3 and 4 were provided. Malawi’s experience shows that collaboration between NMCP and RHD as well as between clinics and communities not only disseminated knowledge of the new policy, but resulted in increased uptake of services and protection of pregnant women from malaria.

Towards Malaria Pre-Elimination in Rwanda: Active Case Investigation in a Low Endemic District

A poster entitled “Towards Malaria Pre-Elimination in Rwanda: Active Case Investigation in a Low Endemic District” was presented by members of Jhpiego’s Rwanda Team and colleagues:

Noella Umulisa, Angelique Mugirente, Veneranda Umubyeyi, Beata Mukarugwiro, Stephen Mutwiwa, Jean Pierre Habimana, and Corrine Karema, at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

case-detectionRwanda has seen an increase in malaria cases recently with an increase from 514,173 cases in 2012 to 1,957,402 cases in 2015. This change can be attributed to an increase in temperature, rainfall, and resistance to insecticides.

Despite this setback, Rwanda is aiming to reach the pre-elimination phase by 2018. In January 2015, 11 health facilities in Rubavu, a low endemic district, started implementing reactive active case detection after training 55 health care providers and 11 lab technicians on the topic. This strategy involves screening and treating individuals living in close proximity to passively detected cases, also known as index cases. Index cases can be used to identify population groups that are sources of infection.

cases-confirmed-investigatedFrom January 2015 to December 2015, 16,434 cases of Malaria were detected and treated at 11 health facilities in Rubavu District. Among these cases, 2,917(17.8%) index cases were investigated and 4,943 individuals (between 1 and 2 contacts for each index case) living in proximity of index cases were tested using rapid diagnostic tests by health care providers. Of these, 508 (10.3%) tested positive for malaria and were treated according to national guidelines.

These data shows that the number of investigated cases is still lower than the national guidelines of screening 5 individuals residing between 100 to 500 meters of every confirmed case. This low rate could be due to the increase of malaria cases in Rwanda which has placed a burden on health care providers and health facilities in areas like Rubavu which used to be low endemic malaria areas. Additionally, data gathered through supervision activities has indicated a need for additional training on screening investigations in order to adhere to national guidelines and conduct the investigations more efficiently.

Active case investigation could be improved by training and involving more health care providers such as community health workers who could reduce the burden on health center staff. The additional support for case investigation activities and improved training can help to achieve higher coverage of individuals located near index cases.

A Pilot to Use Malaria RDTs at the Community Level in Burkina Faso

A poster entitled “The Improving Malaria Care (IMC) Project’s Contribution to follow up a Pilot to Use Rapid Diagnostic Tests (RDTs) at the Community Level in Burkina Faso” was presented by members of Jhpiego’s Burkina Faso Team: Ousmane Badolo, Stanislas P. Nebie, Moumouni Bonkoungou, Mathurin Dodo, Rachel Waxman, Danielle Burke, William Brieger at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

CHWs provide malaria testing, treatment and health education

CHWs provide malaria testing, treatment and health education

Early and correct case management of malaria in health facilities and at the community level is among the priorities of Burkina Faso’s National Malaria Control Program (NMCP). In line with this initiative, the NMCP piloted use of Rapid Diagnostic Tests (RDTs) by Community Health Workers (CHWs) to confirm malaria cases in the three health districts of Kaya, Saponé and Nouna between 2013 and 2015. With PMI support, follow-up visits were organized to document best practices, as well as challenges, on RDT use by CHWs that could serve as lessons learned for scale-up.

During follow-up visits, malaria commodities management (supply, storage and use) at the community level was examined, use of RDTs was assessed, and implementation at the community stockoutlevel was discussed with all actors at regional, district, health facilities, and community levels. The team examined the monitoring/supervision processes at all levels, used a check list on malaria commodities management, and employed a questionnaire for each type of actor. Both qualitative and quantitative data have been collected. A total of 108 persons were contacted including 32 CHWs, 42 community leaders and 34 health care providers and managers.

chw-drug-kitFindings revealed frequent stock-outs of RDTs and artemisinin-based combination therapies, non-payment of stipends to CHWs (a demotivator) and insufficient supervision of CHW by health teams. From the community perspective, 66% of community leaders were satisfied with their CHW’s work (diagnosis and treatment of uncomplicated malaria concernsand referral of severe cases to health facilities). However, 46% of community leaders complained of frequent stock-outs and unanimously agreed on the importance of regular payment of premiums to CHW.

Follow up of the pilot was valuable in obtaining community, CHW and health worker perspectives for improving the program. While the community finds the program acceptable, its sustainability will require that solutions be found for stock-outs, non-payment, and insufficient supervision before scale up takes place.

The Challenge of Reducing Malaria in Angola – High Transmission Provinces

Below is an abstract of a poster presentation today at the American Society of tropical Medicine 65th Annual meeting in Atlanta. The presentation was prepared by Jhpiego’s Angola team including Jhony Juarez, Margarita Gurdian-Sandoval, Julio Bonillo, and William R. Brieger. Please join us at the Late-breaker’s session at noon.

CONTEXTmap

  • Angola has three major belts of malaria transmission
  • The north is high transmission and borders on the heavy burden country of the Democratic Republic of the Congo
  • The mid-section of the country is meso-endemic
  • The south is considered low endemic
  • This low endemic area brings Angola into the Southern African Elimination 8 countries.

METHODS: Field visits were made to six northern high burden provinces. Health information system (HIS) data were collected from each provincial health department. Supplementary HIS information was collected from the national malaria control program

northFINDINGS: Data from the six high burden provinces reveal an overall upward trend in confirmed malaria. Cases from 2011, but with a jump of over 130,000 confirmed cases from 2014 to 2015. This occurred despite support from government and major malaria partners over the past decade. Overall cases in the country have risen from 2.73m in 2011 to 3.25m in 2015

NATIONAL MALARIA EFFORTS

  • Between 2012 and 2015 2 million Long Lasting insecticide treated nets were distributed to a population of approximately 5 million in the 6 provinces
  • This exceeded the desired 2 people per net ratio
  • netsIntermittent preventive treatment in pregnancy reached only 59% of women registering for antenatal care in 2015
  • Only 44% and 18% of women received the second and third IPTp doses respectively.

CHALLENGES

  • A dual challenge makes performance of malaria indicators difficult
  • The Global Fund grant had expired for more than a year
  • The oil-based economy also suffered from the major global drop in prices

THE WAY FORWARD

  • Angola requires concerted efforts by government and partners to scale up malaria control interventions
  • Universal coverage targets must be sustained if these high burden northern provinces are to begin seeing a decline in the disease

PAHO Head Reflects on Zika, Obscurity to Crisis, during 65th ASTMH Keynote

The Following blog from the 65th American Society of Tropical Medicine and Hygiene Annual Meeting opening keynote address has been re-posted here.

20161113_174950From moving quickly to train heads of state in risk communications, to making major decisions based on limited evidence, to sitting with Zika victims whose children had just been diagnosed with microcephaly, the head of the Pan American Health Organization (PAHO) offered a detailed assessment Sunday night of her experience with the sudden explosion of the Zika virus in the Americas.

In her keynote address to a packed hall at opening of ASTMH 2016 Annual Meeting, PAHO Director Dr. Carissa F. Etienne, MBBS, MSc, described the extraordinary experience and lessons learned from encounters with a once-obscure disease that now has been documented in 48 countries and territories in the Americas—and 67 globally.

20161113_180235Dr. Etienne credited “vigilant, astute, front-line health care workers” with first noting the unusual clusters of rash disease in Brazil in late 2014 that turned out to be an early indication that Zika virus had arrived. She noted it was also front-line health workers who first noted the spike in cases of microcephaly and Guillain-Barré Syndrome and connected them to the Zika virus.

Dr. Etienne said their “astute” observations have re-enforced her conviction that, when it comes to protecting the public from infectious disease, there is no substitute for “good clinical judgment and alertness for atypical events.”

Dr. Etienne recalled how quickly the situation escalated and the challenges this presented on a day-to-day basis. For example, heads of state wanted to take charge of discussing the emergency in radio and television appearances. So PAHO moved quickly to provide technical information along with training in risk communications.

There was also the fact that Zika was first discovered while many countries in the Americas were in the middle of preparing for potential Ebola infections and responding to outbreaks of chikungunya. Yet despite this confusing swirl of activity, she said health officials had to move 20161113_180647swiftly to declare Zika an emergency, even though they lacked a complete picture of the true extent of the threat.

“Determination of causality needs to run its course, but PAHO cannot wait until the final verdict of the scientific community,” Dr. Etienne said. “We must be willing to make decisions based on incomplete evidence.”

Dr. Etienne said her experience with the Zika response has reminded her of the many ways infectious diseases take their toll on people, communities and countries. She said Zika has been particularly hard on countries in the Americas that already were suffering economically. And she said it was profoundly moving to spend time with parents whose children have been diagnosed with microcephaly linked to Zika.

“It was quite emotional,” she said. “Here are mothers and fathers loving their child and caring for their child but recognizing that this child’s life will probably be marked by disability.”

Dr. Etienne said that given limitations with diagnostic tests and disease surveillance, the current case count probably underestimates the true magnitude of Zika infections in the Americas. She also believes that “microcephaly is merely the tip of the iceberg” and it will take years to assess the full impact of Zika on children whose mothers were infected with Zika during pregnancy.

Among other things, Dr. Etienne said the experience with the Zika outbreak should prompt a re-thinking “of our approach to reproductive health services.”

“There is still a long way to go with Zika,” she said. “This is not going to be a 100 meter dash. This is a marathon in which science and public health must work hand in hand.”