International Emergency and Refugee Health Branch in CDC

By Jeremy Shoham

Most people have heard of the Centre for Disease Control and Prevention - known as CDC. Based in Atlanta, Georgia, CDC is part of the Department of Health and Human Services in the US government and deals with matters of public health. CDC's work mainly involves public health in the US (more than 95% of CDC funding). The International Emergency and Refugee Health Branch (IERHB) within the CDC is less of a household name. Formed within the last three years, this branch has now become the formal centre of CDC humanitarian emergency activities overseas. The focal person for IERHB nutrition activities within IERHB is Bradley Woodruff. Up until 1996 he worked in the CDC Hepatitis Branch but joined the unit dealing with humanitarian emergencies (a precursor to IERHB) in 1996. Field Exchange interviewed Bradley by phone.

Bradley recalled that CDC's involvement in emergency work overseas began with the Biafran crisis at the end of the 1960s. This introduction to international emergency work was marked by the tragic death of a CDC staff member who was killed in a plane crash while on mission. In the late 1970s CDC sent various staff to assist with epidemiological work in the Kmer refugee camps in Thailand. The first staff member to be employed specifically for full-time work in humanitarian emergencies was Mike Toole in the mid 1980s. Mike's extensive experience of refugee and other emergency programmes made this appointment a coup for CDC. Mike worked alone until the early 1990s. The appointment of additional full-time 'humanitarian emergency' staff resulted in the coalescing of their activities into a unit (1994). Staff from this unit assisted UNHCR and UNICEF in their responses to the refugee crisis in Zaire following the genocide in Rwanda. CDC staff realised that NGOs were relatively ill-prepared to respond to such a large emergency. As a result, OFDA funded training of staff from US PVOs (US NGOs). CDC were involved in writing curriculum and evaluating the pilot training. The formal formation of a branch within CDC dealing with humanitarian emergencies - IERHB, only occurred in 1998

IERHB now has 9 full-time staff including 5 medical epidemiologists, a statistician/epidemiologist, a public health assistant, and administrative support. The branch has access to all CDC staff which ensures wide-ranging technical expertise and laboratory support.

Focus of activities

The main areas of IERHB activity are:

• Emergency response
• Training and Capacity Development
• Operational Research
• Programme Evaluation
• Information Dissemination

Bradley explained that IERHB works with organisations that need epidemiological or public health expertise and provides technical assistance upon request. Collaborating organisations include branches of the US government (OFDA, USAID etc.), UN agencies, international and local NGOs and governments. Most of the NGOs are US NGOs "as European NGOs tend to have more 'in-house' epidemiological expertise" - although Bradley felt that this was changing.

The types of work undertaken by IERHB include

• epidemiological surveillance
• rapid health assessment
• health and nutrition assessment surveys
• outbreak investigations
• disease control programmes
• training in public health and epidemiology
• evaluation of health services

IERHB and nutrition

All IERHB staff have nutritional epidemiological expertise and can undertake or advise on nutritional assessments. Staff tend to work overseas for 4-12 week periods. Bradley acknowledged that "this makes it difficult to get involved in long term problem solving".

Bradley explained that IERHB do not get very involved in assessing food security leaving approaches like household food economy and livelihood analysis to other agencies with greater expertise. He did however admit to a sense within IERHB that there is a need to start thinking about how to better integrate food security and anthropometric assessment information.

The branch is also asked to undertake epidemiological work on micro-nutrient deficiency outbreaks. They were asked by UNHCR and WFP to investigate the riboflavin deficiency outbreak amongst the Bhutanese refugees. The excellent laboratory back-up of CDC makes IERHB ideal for this type of work.

Bradley affirmed that being involved in nutritional surveys and assessments can place IERHB in politically sensitive situations as "results may not always be what agencies want to hear". However, "CDC/IERHB's reputation and track-record is such that most agencies trust the objectivity of findings".

IERHB is a WHO collaborating centre for emergency preparedness and response which means that WHO can theoretically call them up at any time for help. IERHB also assist in training staff from the US government, UN agencies, INGOs, universities, and ministries of health in foreign governments. Staff also attend scientific meetings and assist in curriculum design. In the nutrition field, training is limited to epidemiology and assessment. IERHB are not involved on the nutritional intervention side.

Research activities of IERHB

A number of nutrition related research programmes have been completed by IERHB. One study in Tanzanian refugee camps found that iron dosages three times a week were effective in treating moderate and severe anaemia.

There has also been research into optimal anthropometric measures of malnutrition in adolescents. This research came about following the reported high levels of severe anaemia and malnutrition in adolescents in Kakuma refugee camp. A study in Kakuma and three Dadaab camps in Kenya found that, using WHO anthropometric criteria, prevalence of wasting amongst adolescents was very high whereas under five wasting and mortality levels were low. At the same time food security in the camps appeared to be adequate. There were similar findings amongst Bhutanese refugees. This led IERHB to question the applicability of the WHO guidelines on anthropometric assessment of adolescents and to IERHB's involvement in the recent SCN publication on optimal ways to measure nutritional status of adolescents (see this edition of Field Exchange).

Another study completed by IERHB has involved looking at outcome indicators (mortality and morbidity) in 52 camps in stable situations (after emergency related mortality has stabilised) in relation to nutrition and health indicators. The aim of this study is to determine which variables lead to best outcome. Results are soon to be published.

On-going research in the branch includes developing field-friendly techniques for measuring iron, vitamin A and iodine status. A recent survey conducted by IERHB found a 4% prevalence of bitot spots amongst adolescents but when blood samples were taken back to CDC prevalence of low serum vitamin A was over 30%. Bradley felt that this showed how important it is to develop field techniques for serum assays as clinical diagnosis can be so problematic. "Basically, we need to develop something like a haemocue but for Vitamin A."

IERHB are also hoping to conduct research into standardising case definitions of scurvy. As many as three case definitions have been used by the same agency. Bradley is hoping for an opportunity to conduct simultaneous clinical and biochemical assessment.

IERHB wish to expand their R & E activities and are currently talking with Epicentre in France and two US universities about potential collaboration.

It appears that other parts of CDC may be more susceptible to political pressures than IERHB. For example, CDC efforts to conduct research into needle exchange programmes to prevent spread of HIV in the US and epidemiological studies of the effectiveness of gun control programmes were resisted in the past for political reasons. Bradley could only think of two reasons why IERHB activities might be curtailed: conflict with US foreign policy and security concerns. As examples, "Travel to Iran was not allowed due to foreign policy towards Iran while work in Burundi has been disallowed in the past for security reasons". However, the fact that CDC's main constituency are state health departments, which have a great influence on CDC's overall operation, means that CDC generally have a fair degree of autonomy over what they do while IERHB have even less political interference because their work is based overseas and therefore rarely poses a threat to political interests. CDC has no legal regulatory authority, either within the US or overseas.

Bradley believes that there is still limited understanding internationally of CDC's work and that "CDC provides a unique centralised repository of epidemiological expertise". Only a few other countries, such as Canada and France, have similar centres and these centres may not have the same degree of involvement in overseas work. Bradley also believes that increasing awareness of CDC and its work is stimulating other countries to think about developing similar in-house government epidemiological expertise and that this can only be a good thing.