Ghana - Trip Notes

Ghanaian King in procession

Travel Dates - 23-27 April 2017

I traveled to Ghana for the purpose of exploring research opportunities for UNC Gillings faculty and practicum possibilities for students. Similar in size to the state of Oregon, Ghana is a West African country with an estimated population of 28 million (2016), about 48% of whom are under age 20 and a 2.15% population growth rate. The capital, Accra, is a port city of 2.27 million or 8% of the total population. Other major cities include Kumasi (1.5 million), Tamale (361,000), Takoradi (233,000), Achiaman (203,000), and Tema (156,000) through which the prime meridian passes at 0 degrees longitude. 

Oil and gas fields along Ghanaian coast

Economic Profile

Ghana is important to U.S. government interests, with U.S. 2016 overseas development assistance (ODA ) funding at $146 million[1], its rich natural resources, stable government (seven peaceful democratic transitions) and increasingly strong economic growth (8.7% GDP in 2012).

Developed in 1995, the "Ghana Vision 2020" plan intends for Ghana to be the first African nation to become a developed country by 2029 and a newly industrialized country by 2039. This would seem to be on track, according to the World Bank, as GNI per captia [2] in Ghana has increased 428% from $280 in 2002 to $1480 in 2015.

Currently, over 70% of Ghanaian exports come from crude oil (28%), gold (23%), and cocoa beans (23%) which together generated $7.4 billion in export revenue in 2014 [3].   Regarding cocoa, according to the Ghana Cocoa Board, the cultivation of this cash crop employees 800,000 farm families in six of the ten Ghanaian regions and produces about $2 billion in foreign exchange annually.

IMR 1960-2015 Ghana

Health Profile

According to UNICEF's most recent Multiple Indicator Cluster Surveys (MICS), Ghana has made very strong progress in basic health and economic indicators during the past two decades. For example, there has been a 39% and 44% decline in under-one and under-five mortality rates, respectively, between 1990 and 2012. Immunization rates in 2012 for DPT3 and Polio3 are at 92% and 91%, respectively, and the total fertility rate that has declined by 30% from 5.6 births per woman since 1990 to 3.9 births in 2012. About 34% of the population of reproductive age used modern contraceptives and adult HIV+ prevalence was 1.4% in 2012. These strong health indicators portend success for Ghana to become a developed nation in 12 years, following the Vision 2020 plan.

Research, Teaching, and Service

Ghana offers numerous research, training, and service opportunities that may be attractive to UNC school of public health faculty and students in an environment supportive of the UNC Gillings school mission to address “big public health problems with scalable solutions."

University of Ghana - Legon

The Noguchi Memorial Institute for Medical Research (NMIMR) was established in 1979 with
support from Japan as a semi-autonomous institute of the University of Ghana. As the major biomedical research facility in Ghana, the Institute is committed to research on

Ghanaian health priorities and training of biomedical scientists from Ghana and West Africa. I met with Institute Director, Professor Kwadwo A. Koram [email: KKoram@noguchi.ug.edu.gh], who indicated the Institute has enjoyed long-standing academic partnerships with Yale University (soil helminths research), University of Copenhagen (25 years joint training programs), the Swiss Tropical Institute (supports PhD training), the University of Sussex (implementation science, evidence to policy and practice, barriers to service delivery), and the WHO TDR Special Programme for Research and Training in Tropical Diseases (currently sponsors 6 post-doc Fellows ).

The Institute has traditionally focused on infectious diseases that were most prevalent in Ghana, e.g., malaria, HIV, the neglected tropical diseases (NTDs), and mycobacterial infections, and following traditional funding sources and international engagement in these areas. However, according to Director Koram, the Institute is now shifting its research efforts to reflect the epidemiological and demographic changes underway in Ghana. Increases in chronic diseases, such as diabetes, other kidney diseases, and breast, cervical, and prostate cancers are being observed in the Ghanaian population. The interface between infectious and non-communicable diseases complicates this dynamic. Given the rich flora of Ghana, the Institute is also increasingly focused on the area of medicinal plant research.

The Institute has departments of epidemiology, nutrition, histopathology, electron microscopy, parasitology, immunology,

Lab facilities at NMIMR

chemical pathology, virology and bacteriology. The main laboratory building hosts a biosafety level 3 facility for work with infectious agents, such as HIV and TB, and a separate building for laboratory animals. Routine studies include molecular biological experiments, PCR, plasmid cloning, DNA sequencing, and immunological studies, such as lymphocyte culture, immunofluorescence, EIA, ELISPOT, generation of monoclonal antibodies, and flow cytometry. The Institute has a multiplex assay system and the parasitology department maintains an insectary on site. The Institute’s genetic analysis platform has 11,000 sq ft of dedicated laboratory space. This permits genotyping and single-nucleotide polymorphism (SNP) discovery studies.

Professor Koram introduced me to Dr. Daniel Kojo Arhinfu [email: DArhinful@noguchi.ug.edu.gh], immediate past head, Dept of Epidemiology (2009-2013) at the Institute, whose research interests include social health insurance, access to medicines and health commodities, maternal and child health, health systems, and the chronic disease burden in African populations. Kojo shared with me a few of his recent publications including: Health Facilities Survey in Ghana, Household Survey to Measure Access to and Use of Medicines in Ghana, Knowledge, Attitudes, Behavior, and Practices study on Low Generics Prescribing in Ghana.

The Institute has a strong Institutional Review Board (IRB), established in 2000, which is an independent body that ensures the protection of human subjects and ethical treatment of animals. The IRB serves the Institute, the school of nursing, the school of public health, the school of allied health, the medical school, and private organizations, on demand.

Historically, the Institute is named for Japanese scientist, Dr. Hideyo Noguchi, a bacteriologist who in 1911, while working for the Rockefeller Institute for Medical Research, discovered the spirochete bacterium Treponema pallidum as the infectious agent of syphilis.  In 1926, Noguchi joined the British Medical Research Institute in Accra, the Gold Coast, as a member of the Rockefeller Yellow Fever Commission in West Africa. Unfortunately, two years later, in 1928, Noguchi died at age 51 from yellow fever which he believed, incorrectly, was caused by a bacillus. It was Max Theiler, a South African, who determined in the 1930s that yellow fever was the result of a viral infection, a discovery for which Theiler was awarded the Nobel Prize in 1951 for his development of a yellow fever vaccine.

Ghana School of Public Health

I had the pleasure to meet with School of Public Health (SPH) Dean and Professor Richard Adanu [email: rmadanu@ug.edu.gh] who warmly welcomed me to his office to share ideas about research opportunities and student and faculty engagement from University of Ghana and UNC Chapel Hill. The Ghana

Ghana School of Public Health campus

SPH was established in 1994 and offers bachelors (36 months), masters (12 months), and doctoral degrees (48 months) in public health. The Ghana Health Service and Ministry of Health require all district health directors to have at least an MPH degree, as part of their job qualification requirements. This provides a steady flow of students seeking training one of the following masters degree concentrations:

1. Biological Basis of Public, Environmental and Occupational Health
2. Epidemiology and Disease Control
3. Health Policy, Planning and Management.
4. Population, Family and Reproductive Health
5. Social and Behavioral Sciences

Professor Adanu indicated the SPH has an on-going relationship with the University of Michigan which sends ~ 6 MPH students each summer for 6 week research projects with SPH faculty and students at field sites identified by local community NGOs in the greater Accra and Eastern District areas. The SPH also has an on-going partnership with NYU College of Global Public Health for a 2 year cross-continental MPH program. NYU also supports a strong undergraduate semester-long study aboard program with the University of Ghana called NYU Accra.

Institute for Statistical, Social, and Economic Research (ISSER)
In order to learn about local survey research opportunities in Ghana, I met with Dr. Issac Osei-Akoto [email: ioseiak@ug.edu.gh] Senior Research Fellow and Head, Statistics and Survey Division at ISSER. Issac has worked closely with UNC faculty, including Gillings Maternal and Child Health Department faculty member Kavita Singh on an evaluation of a maternal and newborn health project in Ghana, as well as with UNC School of Social Work's Gina Chowa on a youth savings project funded by the Mastercard Foundation.

ISSER facilities

Issac indicated that ISSER offers a strong and reliable platform for conducting complex economic, social, and statistical research in Ghana and the West African region. Research priorities include health system strengthening, health care financing and private insurance, HIV/AIDS, drug accountability and use, reproductive and women's health, NGOs and faith-based facilities service delivery, and malaria (a new malaria vaccine is currently being tested in Kumasi). Environmental health concerns in Ghana are also priorities for ISSER, including climate change, illegal mining, and electronic waste/dumping.

Electronic waste or e-waste may be of particular interest to students in environment sciences, health behavior, and health

Truck overloaded with E-waste

policy, as e-waste is serious issue in Ghana. E-waste is the dirty underside of electronics disposal that results from the world's love-fest with new smartphones, computers, and other e-gadgets, as described by the Basel Action Network. E-waste is a major threat to human health in low-income countries like Ghana, e.g., see this recent study on health seeking behavior by Ghanaian electronic waste workers. Examples of the e-waste disposal issue in Ghana can be found in this clip produced by the BBC and this slide show from Greenpeace.

As background on ISSER, the institute "was established in 1962 as the Institute of Statistics to provide a programme of teaching and research in statistics. In 1969, it was reorganized and renamed the Institute of Statistical, Social and Economic research with an expanded mandate to conduct research in the social sciences in order to generate solutions for national development. ISSER currently serves as the research wing under the College of Humanities, University of Ghana." ISSER also convenes the IRB for humanities studies and currently hosts 22 research fellows and has served as a consultant group to UNICEF and the Ghanaian Health Service, among others.

USAID and CDC

During my visit to Accra, I was warmly welcomed at the U.S. Embassy by Dr. Akua Kwateng-Addo [email: akwateng-addo@usaid.gov], USAID Health Office Director, and her colleagues, USAID Presidents Malaria Initiative (PMI) Resident Adviser, Mr. Sixte Zigirumugabe [email: szigirumugabe@usaid.gov], and CDC Country Director, Dan Baden, MD, [email: aix2@cdc.gov]. Overall, my takeaway from our discussion was all three Ghanaian institutions described above have been strong and reliable partners for the USG. Akua emphasized that Ghana also benefits from 4 excellent research centers located across the country, including the Kintampo Research Center, Navrongo Health Research Center, Dodowa Health Research Center, and Kumasi Centre for Collaborative Research. Ghana's strong national health insurance scheme has been in place for over 12 years and covers about 40% of Ghanaians. It is viewed as a model in sub-Saharan Africa and widely studied as a harbinger for other economically emergent Africa countries and attracts health economics researchers from across the globe.

Regarding the future of overseas development assistance (ODA) in Ghana, in concert with the Vision 2020 plan and the current and projected GDP growth, Ghana is likely to see fewer bilateral donors in the next decade. That being said, increased private investment and government funding of public health programs will need to offset reduced ODA, thus changing the donor landscape in the emerging economy of Ghana.

UNC Gillings Faculty Active in Ghana

Gillings has a number of faculty with research experience in Ghana, including Clare Barrington, Rohit Ramamswamy, Heidi Reynolds, and Ilene Speizer. A snapshot of their work is available from the Elsiever REACH NC mapping product by selecting Ghana on the map, as shown on this screenshot below.

REACH NC map

Akwaaba (Welcome) to Ghana!


Jim



[1] http://beta.foreignassistance.gov/explore
[2] GNI is calculated using the Atlas method https://datahelpdesk.worldbank.org/knowledgebase/articles/378832-the-world-bank-atlas-method-detailed-methodology
[3] http://atlas.cid.harvard.edu/explore/tree_map/export/gha/all/show/2014/

Côte d'Ivoire - Trip Notes

Travel Dates - 18 - 22 April 2017


I traveled to Côte d'Ivoire for the purpose of exploring research opportunities for UNC Gillings faculty and practicum opportunities for students.  Early in my global public health career I worked in Côte d'Ivoire for the U.S. CDC, based in the Office of Statistics within the Ministry of Public Health and Hygiene.  I still have a number of professional contacts there with whom I connected for this trip.

Briefly, Côte d'Ivoire is a West African country similar in size to the state of New Mexico with an estimated population of 23 million (2016), about 50% of whom are under age 20. About 5.1 million Ivoirians (23%)  live in Abidjan, a port city and defacto business capital located between lovely lagoons along the southeastern coast of the country. 

Downtown Abidjan

Economic Profile

Côte d'Ivoire is important to U.S. government interests, with 2016 overseas development assistance (ODA ) funding at $144 million[1], its rich natural resources (cocoa, cashews, coffee, oil, gas, minerals, etc.) and stable government and increasingly strong economic growth (9% GDP in 2015).

Côte d'Ivoire offers several research, training, and service opportunities that may be attractive to UNC school of public health faculty and students in an environment supportive of the school's mission to address “big public health problems with scalable solutions.” 

While still an economy largely dependent on rural agriculture, Côte d'Ivoire is crossing the tipping point to become a middle income country[2], given gross national income (GNI) growth per captia has increased 64% from $942 in 2005 to $1546 in 2014.  According to The World Bank, Côte d’Ivoire is the largest economy in the West African Economic and Monetary Union, as the world’s top exporter of cocoa and raw cashew nuts, a net exporter of oil, and with a significant and emerging manufacturing sector. 

Health Profile

According to UNICEF's most recent Multiple Indicator Cluster Surveys (MICS), Côte d'Ivoire has made steady and positive progress in basic health and economic indicators between 1990 and 2012.  For example, there has been a 27% and 29% decline in under-one and under-five mortality rates, respectively, DPT3 and Polio3 immunization rates at nearly 95% in 2012, and total fertility rate that has declined by 23% from 6.4 births per woman in 1990 to 4.9 births in 2012.  About 18% of the population of reproductive age used modern contraceptives and adult HIV+ prevalence was 3.2% in 2012. 

Ministry of Health and Public Hygiene (MOPH) Ministère de la Santé et de l'Hygiène Publique

L-R: Drs YEO, ADOURI, NIANGUE, HERRINGTON

, and KOUAME

I met with Dr. NIANGUE Joseph, Director of Cabinet, MOPH, with whom I worked in the late 1980s on the CDC Africa Child Survival Initiative - Combatting Childhood Communicable Diseases Project when Dr. NIANGUE was a District Medical Officer in Aboisso department.  Dr. NIANGUE assembled the following group of his colleagues, including Dr. KOUAME Desires, Director of NGO Services,  Prof ADOURI Innocent, Director of Cancer, and Dr. YEO Ali Frederick, Institute for Public Health, who investigates falsified medicines, for our discussion.  All were enthusiastic about UNC interest in engagement with Côte d'Ivoire.


There are several national research institutes within the MOPH worth consideration by UNC public health researchers, particularly those interested in the following areas:

• National Institue for Public Hygiene (INHP): endemic diseases (les grandes endémies), led by Dr. TIEMBRE Issaka, Assistant Director for Vaccinology, [email: itiembre@yahoo.fr]; medical entomology, led by Dr. KONAN Yao Lucien, Chief of Research and Medical Entomologist, [email: lucien_konan@yahoo.fr or lucienkonan5@gmail.com].  Dr. KONAN is actively studying the population dynamics and geo-spatial distribution of mosquito vectors in Cote d'Ivoire, including vectors of dengue, chikungunya, yellow fever, and Zika viruses, and Culex quinquefasciatus insecticide sensitivity. 
• National Public Health Reference Laboratory (LNSP): Assistant Director of Laboratories Dr. TOURE Aisseta [email: sakinalamtou@yahoo.fr] who was featured in a recent France24 interview regarding the problem of falsified and substandard medicines in Côte d'Ivoire.
• National Institute for Public Health (Institut National de la Santé Publique- IHSP): Director General, Professor DINARD Kouassi who was recently interviewed by the International Association of National Public Health Institutes and seeks to build a strong, national operations research cadre of professionals in Côte d'Ivoire.

Pasteur Institute in Côte d'Ivoire (Institut Pasteur en Côte d'Ivoire - IPCI)
Established in Côte d'Ivoire in 1972, IPCI is under the jurisdiction of the Ministry of Higher Education and Scientific Research (Ministère de l’Éducation Supérieur et de la Recherche Scientifique) and has been part of the Institut Pasteur worldwide network of 33 national research sites since 1978. The IPCI mission is to "provide scientific research in the service of humanity."

I had the pleasure to meet with Professor DOSSO Mirielle [email: mireilledosso@pasteur.ci] and her team at IPCI and visit their labs in Adiopodoume (west of Abidjan) where the Institute has created a cryobiology room of 480 square meters with a capacity for twenty 1000 liter cryotanks that will hold over 7 million specimens.   The establishment a biobank in Côte d'Ivoire represents smart and strategic long-term thinking, as it would strengthen and enable African scientists to carry out proteomic and genomic studies to develop vaccines and other intervention tools against Ebola, Zika, Lassa and other infectious diseases, as well as studies to address non-communicable diseases, such as cervical and breast cancers, diabetes, and cardiovascular illnesses that are becoming increasingly prevalent in West Africa, as life expetancy increases and the epidemiologic transition occurs in the region.   There have been published calls for establishment of biobanks in low-resource countries as an "alternate paradigm of biomedical research that relies on human biobanks [that] is not dependent on ‘a priori’ hypotheses, because it can simply apply rigorous statistical methods to search for apparent associations [see NIH genome-side association studies - GWAS data sharing] between thousands or millions of variables that were measured simultaneously in a very

https://www.whi.org/

large sample of participants, using exceptionally precise (and increasingly inexpensive) measurement tools, while correcting for and discarding false-positive results expected due to multiple testing [3]."  To this end, a cadre of Ivorian biostatisicans will be necessary for such research to be accomplished locally, an expressed desire by Director DOSSO, who is a professor of microbiology.

Student Practica
The U.S. Embassy in Abidjan is eager to support U.S. students studying in Côte d'Ivoire, per Nina R. Toyo, EducationUSA Advisor,  [tel. (225) 22 49 41 45 / 22 49 42 16, https://www.facebook.com/EducationUSA RCI Toyo and http://www.educationusa.state.gov], and creating study abroad/exchange programs between UNC Chapel Hill and institutions in Côte d’Ivoire.

  

The International University of Grand Bassam (IUGB) is a four-year English-only undergraduate private institution located about 30 min south of Abidjan.  Started with support from former U.S. Ambassador to the United Nations, Andrew Young, "IUGB is an independent, not-for profit, American-style institution whose focus is to produce workforce-ready innovative, entrepreneurial, and socially responsible leaders."  I met with Vice Provost for Academic Affairs, Dr. Ahmed LEGROURI, who explained that IUGB awards undergraduate degrees in Business Administration, Political Science, Mathematics, Computer Science, Computer Information System and Mechanical Engineering Technology with options in petroleum or manufacturing technology.  Students can also minor in International Relations, Accounting, Finance,

Economics, Marketing, Management, Computer Information Systems, Mathematics, and Computer Science.  Dr. LEGROURI indicated that IUGB is seeking accreditation from The Commission on Institutions of Higher Education (CIHE) of the New England Association of Schools and Colleges (NEASC) and intends to meet the standards and requirements for undergraduate programs per ABET or AACSB guidelines.  IUGB currently has on-going partnerships with the Georgia State University, Minnesota State Mankato, University of Arkansas, University of Alabama at Birmingham, and the University of Houston.  Dr. LEGROURI indicated IUGB would be delighted to consider a study aboard partnership with UNC Chapel Hill. 

In sum,

I would encourage UNC students, particularly those who are francophones, to let me know if you are interested in research opportunities in Côte d'Ivoire and I'd be happy to make relevant connections with CDC, USAID, and the MOPH.

Bonne arrivée,

Jim





[1] http://beta.foreignassistance.gov/explore
[2] https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups 
For the current 2017 fiscal year, low-income economies are defined as those with a GNI per capita, calculated using the World Bank Atlas method, of $1,025 or less in 2015; lower middle-income economies are those with a GNI per capita between $1,026 and $4,035; upper middle-income economies are those with a GNI per capita between $4,036 and $12,475; high-income economies are those with a GNI per capita of $12,476 or more.
[3] "Developing biobanks in developing countries" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484738/ 

 

DDT, the Environment, and the Law of Unintended Consequences

Spraying DDT against the body louse, WWII.

Rachel Carson warned the world in the early 1960s, through her now classic book "Silent Spring", about the dangers of single use pesticides, specifically Dichlorodiphenyltrichloroethane (DDT).

This product won the 1948 Noble Prize for its developer, Paul Hermann Müller, given its successful use against arthropods, including by U.S. Allies in WWII to reduce exposure of military troops to debilitating louse-borne typhus and mosquito-borne illnesses, like malaria and dengue fever.

DDT also became popular in the 1950s and 60s as an agricultural pesticide, with tens of thousands of tons of product sprayed on crops for human consumption.  This was because DDT is a lipophilic persistent organic pesticide, which means it bio-accumulates in fatty tissue of animals and moves up the food chain, is found in human breast milk, and also bio-concentrates in the soil, being present for 15+ years.  Carson also warned that DDT was decimating bird populations due to its effect of weakening the egg shell.  In essence see foresaw a "silent spring" coming if DDT continued to be used as an agricultural pesticide.

She also warned, prophetically, that reliance on a single strong pesticide would disrupt ecological systems and have unintended consequences.  Many countries, including the U.S. in 1972, banned the agricultural use of DDT, at the same time the World Health Organization was having initial success in eradicating malaria with the use of DDT.  To date, DDT has been banned in 34 countries and severely restricted in 34 others.

See this NY Times Video clip for an in-depth discussion of this issue.

Take care,

Jim

Fall 2016

Welcome New and Continuing Students! 

A warm welcome to new and continuing students at the Gillings School of Global Public Health this fall semester 2016.

This is Jim Herrington and I have the humble honor of leading the Gillings Global Gateway™team here at the School. The mission of the Gillings Global Gateway™is to promote and facilitate the global public health activities of the School by connecting faculty and students with research, teaching, and service opportunities in global public health, both domestically and overseas.   Naya Villarreal, Program Coordinator, oversees the Global Health Certificate, Global Internships and Funding, and Student International Travel requirements, among other programs in the Gillings Global Gateway™and is a great resource for you.  Dr. Dilshad Jaff, is a Kurdish physician who worked previously for the International Committee of the Red Cross (ICRC) and serves as an Advisor to the Gillings Global Gateway™ on Conflict Prevention and Disaster Preparedness research and programs.  Elisia Black is our administrative assistant who will make you feel welcome when you stop by our offices in 104 Rosenau Hall to seek advice, ask questions, or share your ideas about our global public health.  Also, be sure to check out the Student Global Health Committee (SGHC), led by Christine Pettitt-Schieber, which is "committed to creating awareness and understanding of global health issues among the UNC community through education, advocacy, and service."

A few SGHC members plus Jim and Naya (in glasses)

I came to UNC about a year and a half ago from a 27 year career as a public health practitioner with CDC and the NIH (read my personal story here).  My goal is to use the Gillings Global Gateway™ to build a strong global public health platform with the fantastic students, faculty, and staff at UNC.  This global public health effort at UNC has been long in the making with the School's Associate Dean for Global Health, Peggy Bentley, at the vanguard for over a decade in promoting global public health at UNC with the mantra that "global health is local health."

What's in a Name?

So, what's in a name? What does it mean to you as a student that UNC Chapel Hill is the only public health school in the US (and the world) with "global" in its name?

For starters, just consider the fact that there are over 100,000 daily commercial international flights around the world and over 29,000 daily domestic commercial flights in the US alone. According to the World Bank, air transport carried almost half the world's population or 3.44 billion passengers in 2015.  As you will learn, "person, place, and time" are central tenets to understanding how a disease is distributed in a family, community, or nation.  We have all three when considering air transport.

"Breakbone Fever"

https://en.wikipedia.org/wiki/Aedes

Let's use the dengue virus to illustrate the effect of globalization and why this is important to you as a student at Gillings. A recent article in the Lancet by researchers at Brandeis and Univ of Washington estimates that in 2013 there were a total of 58 million symptomatic dengue virus infections, including 13,586 fatal cases, in the world at a total annual global cost of $8 - 9 billion.   How is it that a little mosquito can wreak such havoc?    In a word: "globalization."

USS North Carolina (1941-1947) had a complement of 2,339 men.

Earlier in my career, I worked at the CDC vector-borne disease lab under Duane Gubler, a dengue expert who taught me much about this pernicious disease. Here are a few important facts that explain, in part, why the dengue burden is so large.

There are five dengue virus serotypes and they are all transmitted in a human-mosquito-human cycle, primarily by the daytime biting, anthrophilic, female Aedes aegypti mosquito, also a vector of Zika virus (a disease with very similar symptoms).

Dengue illness typically presents 4-7 days after infection (indicating rapid viral replication) as a severe fever with muscle and joint aches (hence the nickname “breakbone fever”) and, less frequently, as fatal dengue hemorrhage fever (mainly in children and adolescents), a result of low blood platelets and blood plasma loss. The physiopathology for this shock syndrome is poorly understood.

Discarded containers favored by female Aedes aegypti. Photo: CNN

The spread of dengue increased dramatically during and after WWII, as military troops and troop transport vessels facilitated the movement of the virus and vector, respectively, from southeast Asia to the Pacific Islands, Central and South America, and the Caribbean Islands.  Beginning in June 1945, "Operation Magic Carpet" transported millions of soldiers, marines, and sailors back home, with a peak of 700,000 troops returning in December 1945 from the Pacific theater.   Some researchers suggest that dengue's distribution continued during and after the Vietnam War and other military operations, "From the 1960s into the 1990s, dengue often occurred in US troops in Vietnam, the Philippines, Somalia, and Haiti. We found attack rates as high as 80% and periods of convalescence up to 3-1/2 weeks beyond the acute illness."

Dengue is now endemic in most tropical latitudes around the globe where Aedes aegypti mosquitoes are present. The female Aedes aegypti mosquito can lay eggs in small containers, such as discarded bottle caps, tin cans, and tires.  She is more common in urban tropical environments, given her preference for humans as blood meals (blood protein is necessary for egg production).

Environmental control and health behavior are the primary keys to preventing dengue infection, given there is no treatment for the illness nor a vaccine against the virus, though Drs. Ralph Baric and Doug Widman, UNC Department of Epidemiology, are actively conducting research for a suitable vaccine candidate.

So, I hope using dengue and the Aedes aegypti mosquito help illustrate what "global" means in terms of person, place, and time, and why this is important to you as a student of "global" public health, whether you are working in Sampson County, North Carolina, or  Sédhiou, Senegal.


Very best wishes for a successful year at Gillings!

Jim

Senegal - Trip Notes

Travel Dates: 28 May - 4 June 2016

Senegal offers several research, training, and service opportunities that may be attractive to UNC school of public health faculty and students in an environment that would be supportive of the school's mission to address “big public health problems with scalable solutions.”

Senegal is important to US government interests, with ODA funding at $140 million[1] (FY12), its geographic location and history of peaceful, democratic transitions since independence from colonial France in 1960.

Research

Senegal is home to highly skilled biomedical researchers[2], who are proficient in English, and lead well-equipped university laboratories at the Le Dantec and Fann teaching hospitals[3]. There is also a field research station at Keur Socé, Kaolack Department, with affordable lodging and meals to accommodate guest researchers.

The Pasteur Institute of Dakar research facility was established in 1913 and serves as a primary laboratory reference center and one of only four worldwide yellow fever (YF) vaccine manufacturers, producing 10 millions doses per year (<$1 per dose) of the attenuated live YF 17D vaccine strain, derived from a wild-type YF virus (the Asibi strain) isolated in Ghana in 1927, for sub-Saharan Africa. In 2009, the Pasteur Institute of Dakar became the Pasteur Institute of Dakar Foundation, under Senegalese law, and is led by Dr. Amadou SALL, PhD in virology, who is proficient in English and well known for his work on HIV-2, and more recently on Ebola and Zika virus disease research.

The Pasteur Institute of Dakar welcomes graduate and post-graduate trainees and offers them access to affordable accommodations on the Pasteur Institute of Dakar campus. The majority of the Pasteur Institute of Dakar professional staff are proficient in English. The Pasteur Institute of Dakar is a national and international collaborating reference center for enterobacteria, poliomyelitis, arboviruses and hemorrhagic fever viruses, influenza, and rabies. There is a strong mathematical modelling, genome wide-association studies (GWAS) effort by Pasteur Institute of Dakar researchers, led by Dr. Cheikh LOUCOUBAR, e.g., “Better understanding of whether these or other variants interact leading to differential risk compared with individual marker effects will increase our understanding of the genetic architecture of disease, which may be investigated using the family-based study design.”

Ministère de la santé publique et l'action sociale

The Ministry of Public Health and Social Action (MOH) is led by a dynamic Minister, Dr. Awa Marie COLL SECK, who was previously the Executive Director, Roll Back Malaria Partnership, WHO.  Minister COLL SECK has been widely lauded for her transparent leadership in addressing the Ebola crisis in Senegal.  Dr. COLL SECK invited me to meet with her and Dr. Sambacor SARR, MOH Research Manager and national IRB coordinator. During our 20 min session, the Minister fully endorsed my presence to Dr. SARR, stating she has full confidence in my representing the UNC Gillings School of Global Public Health, based on my having served on her Board of Directors for 5 years when she led the Roll Back Malaria Partnership at WHO during which time we collaborated on the "Africa Live: Roll Back Malaria Concert" with Grammy-award winning Senegalese musician and humanitarian, Youssou Ndour.

The Minister suggested an MOU between UNC and the MOH would allow our two institutions to establish a basis for collaboration and would be very helpful to UNC in engaging with universities, local and international NGOs, bi-lateral, and UN organizations in Senegal. This was, in fact, confirmed by Elizabeth Williams, Health Officer, USAID/Senegal, who said UNC would be well served by having an MOU with the MOH, as the USAID health office works uniquely with MOH and, as such, an MOU between UNC and the MOH would allow access to funding from USAID/Senegal, based on this established relationship of collaboration with the MOH. CDC also has a field office in Dakar that is focusing on the "One Health Workforce" (the human-animal disease interface) to address emerging pandemic threats and the Global Health Security Agenda (GHSA) to prevent, detect, and respond to future infectious disease outbreaks. Senegal is one of 17 GHSA partner countries where the US government intents to invest more than $1 billion in total resources.

CLICK HERE FOR USAID Interactive Project Map

Ethical Evaluation - A Pillar of Senegal's National Research Program

Under the aegis of the National Ethics Committee (NEC), the national research ethics evaluation system is an important pillar of the health research system in Senegal.  Established by law on 09 March 2009, the NEC is based at the Ministry of Health (MOH) and coordinated by Dr. Sambacor SARR.  The NEC is the only body authorized to give ethical approval for research conducted in Senegal.  There is an institutional review committee (similar to an institutional review board) at The University of Cheikh Anta Diop (UCAD; see more below), of which Dr. SARR is a member.  But its radius of jurisdiction is limited to field protocols developed as part of training at Senegal's graduate schools. There are also additional institutional research centers working with the MOH and universities in Senegal, including the Institutional Research for Development (IRD) program which has four Demographic Health Observatories in Senegal, implemented in the villages of Niakhar, Bandafassi, Mlomp, and Dielmo-Ndiop.  Senegalese, other Africans, and Europeans have been trained at these sites, which are also used for clinical trials.  For neglected tropical diseases, Senegal has a specialized health research laboratory based in Saint Louis "Espoir pour la santé (EPLS)."   

In summary, Senegal hosts 41 health research centers and NGOs, authorized by and registered in the MOH database, to conduct health research, including 1,500 senior health researchers, 2,500 junior, 3,500 support staff, and about 7,500 temporary staff per year. The MOH has established a knowledge translation system in order to transform the lessons learned and relevant health research results into policy and health practices.  The MOH is also developing, with support from the West Africa Health Organization (WAHO), a health information and research for health database that will support the MOH's knowledge management programs. 

Programs - IntraHealth International

Senegal health facility staff. Photo: IntraHealth International

IntraHealth International is an 30+ year old international NGO based in Chapel Hill with operations in 98 countries, including Senegal where it has been actively supporting MOH and local NGO and private sector efforts in malaria, reproductive health services, health worker training, and health services delivery, among many other programs, for more than a decade.

Led by Babacar GUEYE, IntraHealth/Senegal hosts several projects funded by the Bill and Melinda Gates Foundation (BMGF), the William and Flora Hewlett Foundation, Pfizer, the Global Fund, Merck for Mothers, Capital for Good for the Global Health Advocacy Fund, and USAID.

"Stockouts" in public clinic health facilities are a perennial problem in many low-resource countries due to poor logistical management and commodities tracking.  In 2012, with funding from the BMGF and Merck for Mothers, IntraHealth/Senegal contracted with the private sector to use electronic information technology tools to assess facilities' needs for contraceptives and usage trends that would allow them to anticipate the quantity of new commodities needed to always maintain an adequate supply on-hand in the clinic.   This "Informed Push Model" has reduced stockouts from over 80% to less than 2% nationally, giving Senegalese women assurance that they can expect their contraceptive of choice to be available when needed.

Partnerships established by IntraHealth/Senegal with the private sector support MOH goals to increase contraceptive prevalence from 16% to 30% in the near future and lead to further improvement in Senegal's health indicators.  
  

Baobab tree, south of Kaolack, Senegal

Study Abroad

Study abroad programs in Senegal have long been popular with US universities, including George Mason, University of Minnesota, Boston University, and Harvard, among others, due to the proximity to the US (4 hour time zone difference), positive security situation, political stability, cultural tradition of hospitality “Teranga”, low cost RT airfare ~$1300 direct Washington, DC, - Dakar, low cost - high speed Internet and cellular service throughout the country, and a strong popular arts and cultural environment (music, dance, fabrics, painting, languages).


The Africa Consultants International (ACI) Baobab Center is a well-known NGO based in Dakar that has successfully hosted undergraduate and graduate study abroad, language training, health, social justice, and cross-cultural training programs for over 30 years. Based on my initial discussions with Ms. Rama SOW NIANG, Study Abroad Program Coordinator (who grew up in Arlington, VA), the ACI Baobab Center is quite flexible and could craft a program that would suit UNC student interests, based on ACI’s long history of coordinating study aboard for over 20 US universities, including public health-related service learning programs. I shared ACI Baobab Center’s promotional literature with the Dept of Health, Policy, and Management BSPH Director, Dr. Karl Umble. He is particularly interested in exploring internship/service learning programs in Senegal, as the BSPH undergraduates have a required 10-week service learning experience between their junior and senior years.

Université de Cheikh Anta Diop

L-R: Mireille Djenno,
Emily Burrill, self,
Barbara Anderson

My visit to Senegal was conjoint with the UNC Africa Studies Center (Dr. Emily Burrill, Director, and Dr. Barbara Anderson, Associate Director) and UNC Africa and African American and Diaspora Library (Mireille Djenno, librarian).  We were hosted by the University of Cheikh Anta Diop (UCAD), which was established in 1918 and renamed in 1987 to honor the Senegalese philosopher and anthropologist, Cheikh Anta Diop.  During this trip, UNC renewed with UCAD their 5-year MOU that is signed by Chancellor Folt and Rector

Parasitology lab of Prof Omar GAYE, UCAD

Ibrahima THIOUB.

[Note: some of you may recall that Professor THIOUB, Dr. Fatimata LY, Head, Faculty of Medicine, UCAD, and linguist researcher Mamarame SECK visited UNC in January 2016.]

During our meeting at UCAD, presentations were given by the Faculty of Medicine, Heads of Department, during a ½ day meeting (I have copies of these which I can share).   The strong suit of UCAD Faculty of Medicine researchers has traditionally been infectious disease training and research (parasitology, TB, and HIV/AIDS).  However, there is a strong expressed interest in health systems research (HPV screening and immunization; hepatitis B immunization),

http://www.who.int/nmh/countries/sen_en.pdf

epidemiology, public health behavior, nutrition (obesity and diabetes), and the environment (air and water pollution).  UCAD would like to explore faculty and student exchanges and research opportunities with UNC in these areas, among others. This keen interest in non-communicable disease (NCDs) acknowledges the need to build research and teaching capacity within the UCAD and the other four public universities in Senegal to address modifiable risk factors leading to increased

morbidity and mortality being experienced in Senegal from conditions such as cancers, hypertension, obesity, and type 2 diabetes.

In terms of English competency, it is worth noting that about one-quarter of the faculty and over one-third of the students with whom we met demonstrated basic English language skills and desired to become more proficient, given, as one professor said, "English is the language of science."  Many Senegalese researchers publish in English-language journals.

Hepatitis B and Human Papilloma Viruses

HPV anti-cancer vaccine. Photo credit: Unicef.

I was invited to attend the 1st Joint Meeting on Hepatitis B and Schistosomiasis, held in St. Louis, Senegal (3.5 hours by road north of Dakar) and organized by the research and training units of the 5 principal public universities in Senegal. Hepatitis B is a serious, endemic, and silent problem in Senegal, according to Dr. Muriel VRAY, reseacher at the Pasteur Institute of Dakar, who indicates there are about 2 million people in Senegal (15% of the population), including 350,000 chronic carriers, who have hepatitis B, with about 25% of children < 5 yrs old testing positive for surface antigen for Hep B virus, a prevalence en par with China and Thailand. This silent problem can result in fatal liver cancer during the most productive years of life. The MOH is striving to provide Hep B immunizations to newborns within 24 hrs of birth. Even still, treatment costs are high and the country is challenged with a lack of universal screening to curb transmission.

Cervical cancer and other cancers caused by human papilloma virus (HPV) infection continue to be preventable health problems in Senegal. Recent research has demonstrated that new quadrivalent HPV vaccination was well tolerated when administered in a 3-dose regimen, a 98% seroconversion rate for each vaccine HPV type, and all subjects seroconverted by 4 weeks post-dose 3 after a seven month, double-blind study that enrolled 250 healthy, human immunodeficiency virus (HIV)-uninfected females, ages 9-26, residing in Ghana, Kenya, and Senegal. The MOH is demonstrating the effectiveness of providing HPV immunization to 9-11 yr old girls in an urban school setting in Dakar, with funding from GAVI.

Next Steps

I will be reaching out to UNC faculty members to follow up on this visit and share additional details regarding possible opportunities for training, service, and collaboration with Senegalese researchers.

Jim


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[1] http://us-foreign-aid.insidegov.com/

[2] Notably: Professor Souleymane MBOUP, PhD, Head, Laboratory of Bacteriology and Virology at Le Dantec Hospital in Dakar; Professor Omar GAYE, PhD, Head, Parasitology Dept, Faculty of Medicine, University of Cheikh Anta Diop; Professor Moussa SEYDI, MD, Head, Infectious Diseases Unit, University Hospital Fann in Dakar;

[3] Equipment such as RT-PCR sequencers, bioMérieux NucliSENS® EasyQ system, Luminex readers, LightSwitch assays, BSL-3 hoods, liquid nitrogen tanks, ultra-low freezers (minus 86 deg C), etc.

99% effective, lasts a lifetime, costs <$1, and can save > 70,000 lives - What is it?

The Answer: A vaccine that for over 70 years has protected 99% of vaccinees against yellow fever, a deadly hemorrhagic viral infection spread by Aedes aegypti and Aedes albopictus female mosquitoes (males do not seek a bloodmeal, unlike females which need the blood protein for egg production).

Aedes aegypti female. Photo credit: James Gathany, CDC.

The Problem:  In case you are not aware, there is a yellow fever (YF) vaccine shortage problem in the DRC and Angola (and likely expanding elsewhere), and the on-going YF outbreak in the Africa region (see below).

Aedes albopictus female.
Photo credit: James Gathany, CDC.

One key objective in “implementation science” is to “…investigate and address major bottlenecks (e.g., social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact.”

The YF vaccine shortage offers a prime example of an intervention that is ~99% percent effective, likely producing lifelong immunity, fairly cheap at < $1 per dose in Africa, yet is not accessible to populations that need it, resulting in >70,000 unnecessary deaths annually.  

I recently spoke with Institute Pasteur of Dakar leadership a few weeks ago during my visit to Dakar.  

They are at max YF vaccine production capacity (10 million doses per year) with their current facility (one of 4 in the world) which will need to shut down for several months for renovations to build a newer production unit.

Meantime, the YF shortage continues which Jack Woodall, retired virologist formerly with CDC and WHO, says, “I hate being alarmist, but this is something I’m really panicking about.”

The Solution: This implementation problem should give one pause when an Ebola or Zika vaccine is a “proposed solution” to prevent these devastating diseases, and yet the YF “known solution” cannot meet current demand, even with a diluted 1/5 dose in the interim. 

Considered as an opportunity, this YF implementation science issue would make for a really interesting and usesful thesis or dissertation topic for a UNC student!

Any takers?

Jim