[MUSIC] In this module, we wanted to provide more recent examples of disease containment including some of the strategies that were used to accomplish this. Let's hear from Dr. Ali Khan about the Centers for Disease Control and Preventions epidemic intelligence service, or EIS. And the deployments that he had when he served in this capacity. >> CDC's EIS program is the premier applied field epidemiology program. There's now modeled worldwide within TEPHINET. So there's a network of these programs. They have different names for them depending on where they are. They're structured a little differently. But the premise is the same. Which is we bring people in for two years. And we put them in the middle of outbreaks and we help them understand how to investigate those outbreaks and put appropriate prevention measures in place. And then all the didactic components that come with trying to understand what public health is. CDCs model, you get two approaches. You either stay in Atlanta at CDC sort of becoming a deep subject matter expert or something, or you're placed out of the state. Or local health department where you get a wider experience and range of public health issues that you would deal with. So that's their general approach to EIS. To become an EIS officer you generally have to have a doctorate degree or be a health care provider with an MPH. So the majority of people probably have MDs or DBMs or PhDs. But they also have a significant number of people who may be a nurse or a respiratory therapist or another clinician who is very interested in public health and has an MPH. In addition and are passionate about these public health issues. So I've had the opportunity to respond to a number of outbreaks worldwide, both as an EIS officer and then as a employee at CDC. And actually since becoming Dean of the college of Public Health at the University of Nebraska medical center. During my EIS years most of the focus was on training to become a better public health practitioner needless to say. And some of the outbreaks that I responded to not just in then during EIS but subsequently Ebola or associated viral hemorrhagic fever outbreaks, like Fever or Congo-Crimean Hemorrhagic Fever. Now many of these, such as Congo-Crimean Hemorrhagic Fever, CCHF or Ebola have significant secondary public health effects. Because they cause person to person transmission mainly within healthcare settings. So the first Ebola outbreak that I had the opportunity to respond to was in Zaire in the mid 1990's when it sort of re-emerged after almost 20 years. So that was the thinking in those days about re-emergence we've learned a lot since then. But this was a large outbreak that occurred in Zaire. And my role there as essentially the newbie public health practitioner, young officer, was to try to understand how disease was being transmitted throughout the community. And so that's a lot about disease detection, which we've called surveillance. And how do you sort of keep track of every case and then try to understand who infected that case and who they exposed. So there's two pieces to this element. One is to try to understand where the disease came from, which was my job during that outbreak for the most part. But the more important job was to forward looking job which was if somebody had Ebola, who they did potentially expose? So that you could follow those people and make sure that they didn't get sick, or if they did get sick, immediately pull them out of the community so they didn't infect anybody else. And that is your primary job as a public health practitioner, nobody went into public health to count bodies or to be bean counters. We all went into public health to make a difference, and that's that prevention step. The secondary step, though, is to try to define what happened in the outbreak so that you can prevent future outbreaks. So when I showed up in that Zaire, there were a large number of cases already going throughout the community. And there was confusion about where did all these cases come from. We knew some were associated with transmission within hospitals which is well described but others just seemed to be community transmission with no links. And so, I had the opportunity to go back to these cases one by one, try to figure out from their family members for the most parts and many of the people who had already had Ebola had died. because it was a pretty fatal disease and then try to reconstruct what happened, and the interesting thing was from that reconstruction we could go back to a single person as the initial person, patient zero. For the whole outbreak, who likely got it in the forest, infected by a bat and then transmitted it to we do know, transmitted it to some family members. From there it went into a hospital setting, and then from the hospital setting that was like wildfire. Ebola in healthcare settings without infection control is absolutely wildfire and it transmitted from there. So that was some of what I did during the early outbreaks. And similar type of work in subsequent outbreaks, and from a series of these outbreaks we've sort of really understood how diseases such as Ebola occur and are transmitted. So there's probably cases going on all the time. Deep in the forest somebody gets infected, they may be unfortunate enough to infect a family member or somebody. But the outbreak will disappear at that point. Occasionally, what happens if somebody who gets infected moves to a bigger city? Or a very large city where there's healthcare workers. And then in a healthcare setting without infection control. It just gets transmitted by hand from family members or healthcare workers. From person to person the only protection in a healthcare setting depending on where it is. That often there's so little healthcare provided, that there's not a lot of opportunity to infect healthcare workers. And then it seeds once it see's a healthcare environment it can be transmitted widely. And some of the ways it seeds is the usual hand to hand transmission. But we had examples of the reuse of needles. Where you use the same needle on somebody who has had Ebola, then you use it on subsequent people without thorough sterilization, disinfection, and you can transmit the disease. So those are sort of how the disease gets transmitted. Now the reason you identify that as a public health practitioner is it helps you think about what does prevention look like in the community? What do preparedness efforts look like in the community. And so now we know what to do with these outbreaks base on how the disease is transmitted. So we now know that we follow context of individuals to make sure that they're not infected and then we pull them out of the community when they get infected. And what that does is that we know the high risk situation is when somebody's infected. So we want family members, if they have somebody who they think they are infected, to immediately call an ambulance to move them out of the household. The other prevention strategy we have is around corpse. So when your infected with Ebola, essentially your cells are hijacked by Ebola virus, and your cells stop doing the routine stuff, and they start making Ebola virus. And the amount of Ebola virus in your body just keeps going up and up and up. And you have, if you don't have an immune response, you obviously die. And depending on the type of Ebola, anywhere from 75 to 90% of people can die. And so you have the most amount of Ebola in your body when you die. So the worst time to interact with somebody is when they're dead. because there's all this virus in them and all around them and if your burial practices involve kissing the body, hugging the body, touching the body, washing the body. All of those practices can lead to a significant number of additional cases. So, that's what we do as public health practitioners. You figure it out how the diseases spread and those are the prevention measures you put in place to prevented next outbreak. [MUSIC]
