Day 3(1/5/18) *Atlanta/CDC*

Our group with Melissa '06, our host!

Welcome to day 3! The number of things that we've done in these past 3 days is so great that I am surprised that it's only day 3-so many speakers, tours, experiences. I'm glad I'll be writing in this blog so I remember everything we do:) 

Speaker #1: Matthew Biggerstaff, ScD, MPH (Influenza forecasting/statistical modeling)

To start off the morning, we heard from Dr.Biggerstaff who works primarily in forecasting previous and future flu outbreaks. "How does one do that?" was my first thought. "I'm glad someone knows how to do that" was my second. It turns out that it's an incredibly complicated process, and that there are actually four different forecasting approaches that one can use to create a forecasting model: statistical(use historical data and info about external drivers), mechanistic(use knowledge about the infection process of the flu), machine learning(look at social media to track cases), and ensemble(run several trials of each and average them). So given that there are so many ways to do this, the CDC accepts forecasts from academic/student/professional groups(that have been approved by the CDC), and averages their findings. With the average, they create their official prediction of what will happen with the flu! The ultimate goal is to find the peak period for several regions across the US, since having accurate predictions could help with vaccine allocation timing, and it could impact school closures(if the schools knew when an outbreak might hit, they could close the school on that day in order to prevent children from getting sick). 

Speaker #2: John Omura, MD, MPH (Physical activity)

Dr.Omura was Canadian (and even was from Toronto, like me)! His work was also very interesting, as it dealt with the challenge of promoting physical activity in the US in order to prevent chronic disease. He told us that 70% of deaths in the US are due to chronic disease...which is often preventable! He then followed-up with the fact that physical activity is considered a "magic pill" when it comes to preventing chronic disease, and that inadequate physical activity causes $117billion in healthcare costs😟. Because of these scary statistics, he emphasized that it's very important to promote physical activity, and to maintain good surveillance systems. In order to do this, he showed us the steps that the CDC prefers: delivery of accessible exercise options and information, mobilization of proper resources, messaging of guidelines to communities across the US, training of community members in proper exercise regimens/guidelines, and development of new action plans and studies. An interesting note that he added was that when money was involved, decision-makers were more likely to support initiatives (walkways alongside streets were favored in new city designs because they'd promote local shopping, for example). Funny how money seems to be a recurring trend!

Speaker #3: Diane Morof, MD, MSc (Reproductive health and surveillance)

Before breaking for lunch, we heard from a third speaker, Dr. Morof, who was an extremely accomplished person. She had gone to medical school, graduate school, completed fellowships, started several public health projects, and served as an epidemic intelligence service officer at the CDC and all the while chose her own path to do what she wanted to do with her life (she only participated in one rotation in medical school that she didn't create herself!). Her advice to us was "look for loopholes in everything in order to accomplish exactly what it is that you want to do". Her work was mainly in reproductive health throughout her journey, specifically working with mothers in sub-saharan Africa in trying to determine mortality rates, maternal mortality causes, and monitoring any changes. She also was involved with a project that reduced maternal mortality in Uganda and Rwanda by 35% in its first year. In addition to her work on maternal mortality, Dr. Morof worked in investigations around global deaths of children under 5 years old. She found that too often the data was unreliable, often for cultural reasons of not wanting to report death or in not having access to proper death certificates. For this reason, she did know that over 50% of <5y/o deaths were thought to have been a result of undernutrition, but that more surveillance first needed to be done. Because of the cultural reasons for not documenting the childrens' deaths, however, she noted the great importance of teamwork with social-behavioral scientists in conducting such surveillance studies. After her talk, Dr.Morof and I chatted a little bit about my project with the pregnant incarcerated women, and she suggested I read "Jail Care" by Dr.Carolyn Sufrin (who is the doctor who lead the Pregnancy in Prison Statistics conference I got to attend last month-what a great coincidence!) in order to find out more about the incarcerated population and how these issues affect them. I cannot wait to read it as soon as I get back to Minnesota!

Speaker #4: Mark Weng, MD, MSc (Antimicrobial resistance)

Dr. Weng's talk was quite worrisome-it discussed the global issue of antimicrobial resistance. His work was mainly in finding the root causes for antimicrobial resistance, and setting up surveillance in areas to determine location-specific resistance. The official term for this is “point prevalence surveys”. He had learned that surgeries, chronic disease, organ transplantation, dialysis, cancer, and childbirth all contribute to compromised immune systems(if only temporarily) and thus require the use of antibiotics. In these cases, among others, he emphasized the importance of learning about the specific bacteria in order to treat them with the proper antibiotic, and to monitor closely that they antibiotics were not being misused(prescription not taken for the entire assigned time) or unnecessarily prescribed. 

This past summer at HCMC, when I was shadowing the public health workers, I remember speaking to a certain homeless patient (we’ll call him “Aaron”) who wasn’t feeling well so he took an antibiotic pill that his friend on the street had given him. I asked Dr.Weng what he though about this, and whether it was of great concern that people who couldn’t afford to buy antibiotics were doing this. In fact, I remember in middle and high school (even in college) that some of my peers would share their antibiotics because they could be expensive. Dr.Weng’s response was that since this isn’t a great portion of the population that’s doing that, it’s likely not to contribute to the overall antimicrobial resistance evolution….but I thought that the homeless population is very large and growing, and that underinsurance is growing in the US. So wouldn’t it actually be a very contributing factor to antimicrobial resistance if this large population was all not taking the antibiotics correctly? Is it possible that I misheard him? I’ll be emailing him to follow-up about this question.

Case study: Norovirus in Virginia

To finish off the day, we completed a case study on Norovirus-an EIS officer lead us through it, and we were able to be in the shoes of epidemiologists again, just like yesterday! We learned that a group of children had become sick because their was norovirus in the community swimming pool where they had attended a birthday party. Then, we were able to propose investigations and further steps to preventing future outbreaks! 

Our leader(a pediatrician :) ) was super entertaining, and shared lots of fun facts with us about public health….such as:

-big fountains located in town squares and such are often recycled water, and therefore spray whatever contaminants in them(often urine and bacteria…) into to the air around them!!

-the chlorine smell at pools is actually the smell of a chemical that is made once chlorine has combined with contaminants in pool water—so if you smell chlorine at a pool and think that means it’s super clean, it actually means that there is lots of pee in that pool!

-there’s an amoeba found in warm water that infects one’s brain if it comes in contact with it…so cliff divers and people who use neti pots often put themselves at great risk of coming in contact with these amoebas…so be careful next time you are in a warm lake or get warm water up your nose!

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After today, I had many take-aways. I learned to take data with a grain of salt (Dr.Morof, for example, said that much of the data they collected was through “verbal autopsies”, and that global proportions are often not representative of every location across the world, such as maternal mortality, which occurs 62% of the time in sub-saharan Africa). Additionally, I learned about the benefit of holding an MD/MPH as opposed to just an MPH-that the MD informs the clinical aspect of studies, and has a more informed knowledge of the nature of the illness in question. Lastly, I learned to remember that in the CDC, even though they’re dealing with large-scale populations, it’s important to treat everyone as humans, rather than just cases. The CDC coming into a community can have a great impact on local business, and is often times quite stressful for business owners-therefore, the goal of the CDC is not to shut down the business, but rather to prevent an outbreak from occurring again there. It’s interesting that this is their model, because the US government’s(which runs the CDC) criminal justice system seems to be set up differently…to punish rather than to rehabilitate prisoners to be sent back into the word to contribute to the overall wellness of the world. Hmm….interesting.

After a greatly interesting day, I'm again super tired (but, as my mom says, it's the "good tired")! Looking forward to tomorrow because it's a work day so I'm going to go work on my project and my group's project in a coffee shop somewhere in downtown Atlanta-which will also be a great opportunity to people-watch here :) Then for part of the day I'll explore Atlanta with a few of my classmates-maybe we'll check out a museum or a park or something....either way I'm sure it'll be fun. 

Goodnight!

-Anna