Centres for Disease Control and Prevention (CDC), International Emergency and Refugee Health Branch (IEHRB)

The ENN recently conducted an agency profile interview with Leisel Talley and Carlos Navarro-Colorado from CDC’s International Emergency and Refugee Health Branch (IEHRB). CDC is a US federal agency dedicated to the prevention and control of disease, injury and disability. Leisel has worked for CDC for 11 years while Carlos is new to the branch, with a little over a year’s time at CDC. The IEHRB branch has approximately 35 staff who cover a range of disciplines including infectious disease, malaria, child protection, war related injuries, WASH, immunisation , mental health, reproductive health, survey and surveillance methodologies and statistics. Oleg Bilukha (who couldn’t make the interview and has worked for CDC for 11 years), Leisel and Carlos are the three individuals who spend most of their time working on nutrition in this multidisciplinary team.

Leisel explained that IEHRB activities vary year to year depending on the number and type of emergencies. Their work may encompass direct support in emergencies, operational research and development of programmatic tools, providing technical advice, participating in technical forums and teaching (in universities, US government, US agencies or UN agencies). In order to provide direct support, CDC has to be invited into a country to work, i.e. by the US government, national Ministry of Health (MoH), international non-governmental organizations (INGOs) or UN agencies. Staff from the branch may be seconded during emergencies to agencies with whom CDC has agreements, especially at the beginning of an emergency before agencies can identify and recruit longer-term staff. Often, a senior epidemiologist is deployed together with an Epidemic Intelligence Service Officer (EISO) for mentoring purposes while strengthening CDC’s response capacity. Since CDC is a US government agency, staff are provided as in-kind technical assistance to agencies and programmes.

Operational research is always conducted in partnership with other agencies. A current example is the ongoing evaluation of a blanket supplementary feeding programme in Turkana and Wajir, northern Kenya in partnership with WFP and several field partners. This involves following a cohort of children to determine the impact of the intervention and, through a casecontrol study, the determinants of malnutrition while enrolled in the programme. The IEHRB may be approached by agencies to conduct research or individuals in the branch may proactively approach agencies for a specific research project. For example, UNICEF recently approached IERHB to work with them on assessing the impact of Plumpy’doz in a Darfur feeding programme. IERHB is also working closely with the ENN on a study of defaulting from emergency supplementary feeding programmes. The branch is currently working on a funding announcement that will allow a substantial volume of operational research on acute malnutrition. IERHB is hoping to use this opportunity to strengthen existing partnerships and forge new ones.

Leisel recalled that when she started working in the branch there were only seven staff, which made it difficult to respond to emergencies. Now that the branch has grown to more than 30 staff members, it has been able to expand into other areas like operational research, teaching and development of programmatic tools. It also means that they can be much more proactive about work and participate in relevant expert groups and discussions in most key areas of emergency public health.

Carlos explained how branch members have a solid understanding of public health principles and emergency relief, no matter what their professional background. Any of the three individuals mentioned may therefore find themselves working in areas outside of nutrition. For example, Leisel recently worked on sampling aspects of a survey of violence against children in Tanzania. Oleg routinely works on war-related injuries and Carlos has been involved in disease outbreak investigations in South Sudan and Kenya. The multi-disciplinary nature of the team means that everyone learns from everyone else. Carlos also felt that working in this type of multi-discipline team helps with professional development and leads to strong technical support, as well as locating nutrition under a broader public health umbrella.

At this point in the interview I remembered something that had always perplexed me about CDC. Why was it located in Atlanta in the state of Georgia? Leisel explained that when CDC was established early in the last century, malaria was still a substantial problem in the southern United States. SInce Atlanta was the largest city with the best transportation in the region, it was viewed as the most appropriate location.

We then moved onto a discussion about the branch’s role in the current Horn of Africa crisis, both in the field and from Atlanta. Leisel recounted how the Food Security and Nutrition Analysis Unit - Somalia (FSNAU) had contacted CDC in July 2011 asking for support to improve the quality of their nutrition data from Somalia and to validate the findings. Oleg has been involved in SMART training in Ethiopia for a number of humanitarian agency staff. Carlos was sent to the region fairly early on in the crisis and worked in the Dadaab camps in Kenya, mostly supporting the UNHCR public health office with nutrition and public health advice. He also helped remotely from Atlanta with the design of a nutrition survey in Dolo camp in Ethiopia, as well as supporting analysis of community based management of acute malnutrition data in order to improve reporting and response. The whole branch has generally been very involved in the region supporting a number of activities, like measles and cholera surveillance, in coordination with in country CDC offices and programmes. However, the difficult and fluctuating security situation in the region has meant that a number of surveys that CDC was planning have had to be cancelled.

We also spoke about challenges that the branch faces. As with most agencies in the humanitarian sector, the current global financial crisis is cause for concern. CDC’s budget is determined on an annual basis and the current economic situation may result in reduced budgets across the US government. This situation has not seriously affected the branch, though. There are also technical challenges such as trying to keep the right balance between methodological rigour of surveys, surveillance and impact assessment and the reality of what is needed and possible on the ground during emergencies. Another challenge, not unique to CDC, relates to how to evaluate programme outcomes when in most situations, randomised controlled trials are simply not viable. There is a spectrum of opinion within the branch about other means of proving impact and outcomes and a strong engagement in helping evolve epidemiological methods in emergencies. The high level of verification and quality control within CDC required to formally release results can be lengthy at times but ensures a very high quality of work.

I asked Carlos and Leisel where they hoped or expected the branch and in particular nutrition activities in the branch, to be in five years time. While there isn’t a specific five-year plan, there is the hope that the new funding announcement will allow the branch to partner with a number of agencies to conduct operational research to improve the evidence base for nutrition-related interventions, thereby improving intervention effectiveness. This should contribute to the continuous development of the evidence base, building on CDC’s unique combination of methodological expertise and public health applied work. In addition to this, they expect to build a critical mass of emergency trained epidemiologist within CDC that will facilitate responding to field requests.

What seemed obvious from talking with Leisel and Carlos was that the nutrition team have consistently high demands and expectations placed upon them and have to react rapidly to requests from partner agencies with no way of knowing when these requests will be made. It therefore seemed like a bit of intended understatement when Leisel concluded our interview by saying that "we were certainly very pleased with the recent expansion of the branch".