To stop a disease in its tracks, you need to get ahead of it. Sometimes this means going off the beaten path, into remote villages where your GPS doesn’t work, into people’s homes and businesses. Sometimes the people there speak your language, sometimes they don’t. But when the disease you’re tracking doesn’t know any boundaries, neither can you.

In the country of Georgia, the culprit is Hepatitis C (HCV). HCV is a serious viral infection that, over time, can cause liver damage and even liver cancer. Almost 7% of Georgia’s population is affected by this disease — the third highest rate in the world. As part of an ongoing collaboration, epidemiologist Dr. Stephanie Salyer, who is based at the Centers for Disease Control and Prevention (CDC) in Atlanta, and her team have been in the field conducting a door-to-door survey to find out how HCV is spreading.

A unique set of challenges

Particularly in the country of Georgia, language barriers can present a challenge. In some areas, Georgian citizens speak Armenian and Azerbaijani languages, but little to no Georgian. To address this, a diverse group of 45 field staff from Georgia’s National Center for Disease Control (NCDC), joined by Field Epidemiology Training Program residents from Georgia, Armenia and Azerbaijan, were selected and trained to conduct the survey.

Each team surveyed 25 households per day, which is harder than it sounds. Teams used GPS units and Google maps to locate homes to survey, but, particularly in rural areas, navigation proved challenging. More than once, teams – which included interviewers, nurses, and drivers — ended up hiking in the middle of nowhere past abandoned houses. The teams worked long hours and became “like a family,” said Salyer.

Perhaps the most difficult challenge was “hearing heartbreaking stories from people in the field with Hepatitis C. A lot of team members personally knew people impacted by this disease. That is why we were so invested in this project. This really highlights the tragedy of Hepatitis C in Georgia: it has touched almost everybody in the country,” said Salyer.

Putting data to work

Teams in the field used smart phone technology to enter the survey responses, automatically uploading the data into the cloud. Survey participants benefited by learning their HCV status, receiving health education materials in their preferred language, and getting their BMI and blood pressure measured. Public health nurses on the survey teams referred participants to local health care facilities and national information hotlines if needed.

Survey results are already informing national strategy. Experts assumed that HCV in Georgia could be traced back to intravenous drug use, reusing syringes, or being previously incarcerated. New information may indicate that transmission could also be associated with lack of infection control surrounding medical and dental procedures, and even tattoo parlors and manicure salons. Data is making researchers look in a new direction.

A strong commitment

The results from this survey will inform where to target prevention messages and who can benefit from treatment and screening. A remarkable public-private partnership with pharmaceutical manufacturer Gilead Sciences is supporting the program by providing 5,000 courses of the medication Sovaldi for the initial phase, followed by 20,000 courses of Harvoni free annually.

Several factors make HCV elimination a possibility in Georgia: the availability of effective diagnostics and treatment; the country’s small size and population; experience with HIV prevention and control programs; and strong political will and public support. Despite this, limitations exist in Georgia’s ability to track cases, reduce transmission, and provide care and treatment. Most infected people remain untested and unaware of their infection.

The principal investigator and one of the team’s phlebotomists even appeared on a local talk show to educate the public about Hepatitis C and encourage survey participation in cities.

Salyer recalls the commitment of the survey teams: “They went above and beyond. I would have to force them to come back at the end of the day.”