Keeping the World Cup Healthy

The Skoll Global Threats Fund is supporting the debut of a mobile app at the FIFA World Cup in Brazil to help track people’s health over the course of the event. This builds on the participatory surveillance work we’ve done around Flu Near You here in the U.S.  The tool is now available for download free of charge at the Play Store (Android) and Apple Store (iPhone/iPad) in Portuguese, English and Spanish. The application is intended for both Brazilian and foreign visitors. The app has been developed by EpiTrack, a local partner in Brazil.

The risk of disease outbreak is always a concern at mass gatherings like the World Cup, in which millions of Brazilians and foreign tourists are in motion across 12 host cities. Via the app, fans report their daily health status (very good, good, ill or very ill). If a fan reports not being well, he/she is asked to indicate one or more symptoms from a list of ten, including fever, shortness of breath, nausea, vomiting and headache. The fan also reports if he/she has had contact or knows someone with any of the symptoms. If many fans in the same region report similar symptoms, surveillance teams can investigate. The Ministry of Health, in conjunction with state and local governments, can get an indicator of potential issues and adopt measures to inform and protect the public.

In addition to contributing to public health, with the Healthy Cup app fans have access to information such as the location of public and private hospitals, and nearby pharmacies, with maps. The app also includes information on health care and disease prevention, with direct access to the Twitter feed from the Ministry of Health and links to a Travelers’ Health Portal containing practical tips and essential information to help domestic and foreign tourists to protect their health during the trip.

This is a pilot project to explore the value of this kind of real-time reporting. If it proves successful, it could serve as a model for similar mass gathering events, such as the Hajj to Mecca or the Olympics.

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Public/Private Partnership in Pandemics Preparedness

Today, we announced a partnership with the U.S. Food and Drug Administration (FDA), the U.S. Centers for Disease Control and Prevention, the National Institutes of Health, the United States Pharmacopeial Convention (USP) and Corning to assess the utility and effectiveness of a new counterfeit detection device (CD-3) developed by the FDA to detect counterfeit medicines in the field. The USP Promoting the Quality of Medicines Program, with funds from USAID and the President’s Malaria Initiative, collaborates with the Ghanaian Food and Drug Authority to conduct drug surveillance programs at test sites in Ghana, and the new partnership will leverage this existing infrastructure to allow immediate testing of CD-3 in an area where malaria is endemic.

The FDA’s CD-3, already deployed for drug authentication in the U.S., is designed to work under real-world conditions for drugs in developing countries. The CD-3 device is based on sample illumination at specific wavelengths of light and visual comparison to a standard. It is a non-destructive, rapid, portable device that requires little training for effective use. The study in Ghana will allow for understanding of the capability of the CD-3 to discriminate between authentic and falsified medicines in the field in real time.  For the Skoll Global Threats Fund, we are testing the implementation of a technology that, if successful, will be in line for implementation at scale in other endemic malaria regions as well, including South East Asia.

FDA CD-3

We’re testing this out with malaria first as the real world crisis of counterfeit and substandard drugs threatens global health efforts to combat this illness. But we hope the technology can be proven effective for other drugs and other uses as well. It will help prevent ineffective or detrimental interventions on known diseases, such as malaria. But it could prove particularly useful in cases of sudden epidemic outbreaks, where desperate people could provide a ready market for unprincipled opportunists willing to sell fake drugs.  At a higher level, we see the ability to take these types of technologies effectively into the field as critical for tackling global health threats from infectious diseases. The ability to scan a medication is not too different technologically than the ability to scan, say, a blood or sputum sample for telltale signs of disease in a point of care diagnostic platform.This is what makes the CD-3 particularly interesting to us, because it can serve as a proof of concept of what might be possible for point of care diagnostic tools going forward.

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Flu Near You: Finally, a Way to Track (and Avoid) Getting Sick

(This was originally posted on TakePart.com)

It’s that time of year again: flu season. We’ve all had it. We have vaccines to prevent the flu, antivirals to help alleviate suffering, and control measures like hand washing and social distancing to reduce transmission. But, for a disease that hits every year, influenza retains many mysteries.

Flu is often underreported, so it’s difficult to really understand the full impact of the spread of flu, whether in communities or across the country. How many times have you had the flu, but not gone to the doctor?  Who “counts” you among those who got sick that year?

We don’t uniformly track who gets vaccinated and whether or not they get the flu that season. The science of vaccines assures us the flu shot is effective in warding off the flu.  But just how effective?  To measure such a question across the population would be a herculean task. To track the spread of flu across the United States each year, at the community level, would be impossible — until now.

Developed in partnership with HealthMap (an initiative of the Boston Children’s Hospital), the Skoll Global Threats Fund is launching Flu Near You this week after one year of testing with the American Public Health Association. Anyone living in the United States who’s 13 years of age or older can sign up at www.flunearyou.org. As a registered participant, each week you will be asked a pair of questions: “Do you have any of the following symptoms?” (with a checklist of 10 symptoms) and “Have you had the flu shot?”

Once you submit each week, a map pops up which shows how many people are feeling healthy or who might have the flu in your area (anonymously and privately, of course). The tool allows you to compare this self-reported data against Google Flu Trends and official CDC data. It also provides links to useful information about flu, including convenient locations to get vaccinated.

If it’s effective, Flu Near You will help us better understand how flu spreads and, importantly, engage the public directly in combatting this yearly plague. But Flu Near You as a proof of concept is equally important.  If people are willing to report symptoms on a regular basis, we can expand beyond flu to other diseases.  Moreover, we can move beyond the U.S. to the developing world where the challenges are significantly more complex. Participatory surveillance could become a crucial cornerstone of public health, helping us not only get a better handle on known diseases, but also catch novel diseases when they emerge anywhere on the planet.

It’s an exciting prospect. But it only works if we have extensive participation. So please join us now at www.fluenearyou.org. Do your part to help track and avoid the flu. Do you have it in you?

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Hantavirus in Yosemite: Why It Surfaced, and How We Can Stop It

(This post was first published on TakePart.com)

Seeing the news of a hantavirus outbreak in Yosemite, I was immediately transported back to work I did nearly 20 years ago, when a “mystery illness” killed three out of four of its victims in the Four Corners region of the United States in May 1993.

I was a member of the Arizona team of the hantavirus investigation group that included public health experts from Colorado, New Mexico, Utah, and the U.S. Centers for Disease Control and Prevention. Back then the headlines did not include the name of the pathogen. It took us weeks to determine the cause: a new hantavirus we eventually called Sin Nombre Virus—that which has no name.

Now, knowing hantavirus is the cause of the illness that has so far killed two people allows for quick action, including outreach to those potentially exposed. That’s what the Yosemite folks, assisted by health professionals and public health authorities, are doing.

The current list of preventive measures for hantavirus is nearly identical to the list we created 20 years ago. Hantavirus risk reduction still depends on avoiding contact with rodents or their urine and feces, and includes simple actions to reduce that likelihood. So while some things have not changed, the ability to rapidly communicate to people who have been exposed has certainly improved in 20 years.

If this particular campground in Yosemite bears out as a common point of exposure (as suggested in the early reports), then this will be a great stroke of luck, uncovering the outbreak’s origin when the total known cases can be counted on one hand.

Acting on this possible link early in the investigation will, at a minimum, inform a few thousand people who can be vigilant for symptoms, and, ideally, prevent others from future exposure through improved practices and awareness at the campground.

A bigger challenge is getting the word out to healthcare providers who may be seeing single cases of disease elsewhere in the United States or in other countries where travelers to this campground may have returned.

For epidemiologists, a cluster of illness or common exposure to a known pathogen is of much higher concern when the disease is able to spread from human to human. Thankfully, hantavirus has never spread from human to human, so this gives a little breathing room in tracking down those who might have been exposed. Since we know the source of hantavirus is the deer mouse, a cluster of illness from a common source like what we’re likely seeing in Yosemite begs the questions: why there and why now?

In 1993, months of substantial rainfall in the Southwestern part of the United States led to increased local vegetation that produced pinion nuts—a food source for the local mice. Increased mice meant more mice droppings that filled cabins closed for the winter, empty seasonal camp grounds, and houseboats left in storage.

Normal activities like sweeping out a cabin may have aerosolized the invisible microbes from the mice urine and feces on the floor and led to human illness and death. Epidemiologists will no doubt be looking at similar factors to try to understand the Yosemite outbreak.

Zoonotic diseases are those spread from animals to humans. Hantavirus, though rare, is just one of many infections that can be transmitted from rodents. Another zoonitic disease, West Nile virus, is currently in the headlines as well. Introduced to the United States in 1999 (many speculate it came via mosquitoes in stagnant water in wheel wells of aircraft or as a “passenger” inside the cabin), it is now endemic throughout the country. We can expect periodic disease outbreaks when vectors like mosquitoes are part of our ecosystem—just like the mice that carry hantavirus.

Insects, rodents, bats, birds, and animals in general each carry disease risks. Sometimes these manifest in ways that give us warning. We can get signals like bird deaths from West Nile virus, or bird flu in chickens and ducks that can be a warning to humans. But often a microbe lives silently and benignly within another creature, like hantavirus in mice, and we only learn of its presence when we see outbreaks in humans, like the one in Yosemite.

Visitors to rural areas, national parks, and wildlife preserves should understand that contact with any wildlife carries some risk. In many cases, including hantavirus, risks can be reduced, as long as we’re aware there’s a threat. Keep informed, protect yourself and others by following the recommendations of public health and medical experts, and remember that we are all connected together from a health perspective—human, animals, and the complex ecosystem of our planet.

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Flu Near You – DIY Surveillance

In addition to supporting the good work of others, we also aspire to identify areas where gaps exist in solutions to the threats we work on and create projects ourselves. Such is the case with Flu Near You. Developed in partnership with HealthMap and the American Public Health Association, Flu Near You is an effort to track the spread of flu on a national level, potentially unlocking hidden secrets about this viral mystery.

As a medical epidemiologist at Google.org, I had the pleasure of working with a team of Google engineers to answer a very specific question: “Can we find flu faster?” With Google Flu Trends, the engineers built a tool that finds flu up to two weeks earlier than the traditional sentinel laboratory-based system used in public health today. Researchers have demonstrated similar success looking at Yahoo search terms related to flu. While this two weeks advanced warning surprised some, we suspected that people would search the Internet for information about their symptoms before visiting a health care provider. This seems to be the case.

Many in public health are trying to explore the use of social networks – what you write on your “wall”, what you SMS each day – anything that might provide valuable information for even earlier warning of flu. Seems to me we may have been too timid to try what really matters:  simply asking people. Theoretically, the earliest sign of spread in a community could come from tracking the flu via self-reporting of symptoms.

Evidence suggests self-reported flu surveillance indeed works. Craig Dalton and colleagues, for example, successfully implemented FluTracking in 2004 with partners in Australia. Now tracking 10,000 people online every week, they have demonstrated vaccine efficacy and are providing guidance on addressing pockets of need in communities with high rates of self-reported illness. More importantly, they have retained – indeed, even grown – participation in the program through the simplicity of the system. Ten countries in Europe currently collaborate on Influenzanet, with thousands of online volunteers responding to a similar weekly survey via email.

Inspired by these early pioneers, we have engaged the APHA as the leading public health organization in the U.S. to build a pool of voluntary ‘sentinels’ of flu in the United States. We are asking volunteers to complete a short survey that takes 5-10 seconds once a week. Your shared data is anonymous and contributes to the Flu Near You platform, built by HealthMap.

The openly available data set can help everyone better understand flu, including policy makers, healthcare providers, researchers, educators and the public.  Reporting no symptoms of flu may prove as useful as reporting symptoms—hence the weekly survey.

With APHA’s help, we are putting the public into pubic health surveillance in a direct, active way.  We have asked APHA members to reach out through their social networks, engage with community partners, schools and workplaces, and share among their family and friends. We hope everyone will explore Flu Near You.