How do you tonsil swab a wild African buffalo? More importantly, why? The answer is that buffaloes are reservoirs for certain “zoonotic” diseases, or diseases that can be passed from animals to humans. Many infectious diseases (such as rabies and Rift Valley Fever) are transmitted through animals, which is why tracking animal diseases that could potentially jump to humans is a crucial aspect of public health. Early detection means spotting these diseases in animals before they make people sick.

Tracking disease in a national park

Dr. Marietjie Venter of the Global Disease Detection program in South Africa, visited Kruger National Park along with Jumari Steyn, a PhD student from the University of Pretoria. As part of a wildlife surveillance program, a skilled group of veterinarians sampled 30 buffalo in three hours. They swabbed tonsils and collected blood, fecal, and stomach content to investigate foot and mouth disease (FMD), which can cause major outbreaks in cattle if they come into contact with infected buffalo.

While buffalo are natural reservoirs for FMD, they are also thought to carry Rift Valley Fever, bovine tuberculosis, and other bacteria and viruses that could potentially spread to humans. The University’s research unit will use the collected samples to investigate for these zoonotic diseases which have been detected in wildlife, farm animals and humans.

An expanded partnership between the Centers for Disease Control and Prevention (CDC) South Africa and the University’s research unit improves surveillance capacity to include priority zoonotic diseases in the region: anthrax, brucellosis, rodent- and bat-borne pathogens, and many others. It also adds additional data collection sites and enhances reporting.

Bridging animal health and human health

Tracking diseases in domestic animals and wildlife has been happening for a long time, but linking that information to humans who are sick or could become sick has not. South Africa has strong surveillance systems; CDC’s role has been to support and expand them through its One Health program.

While it makes sense to get human and animal experts together, this is not an easy task. The One Health initiative has programs all over the world and builds bridges between people who may not otherwise work together. The success of the program lies in the regularity of the exchanges. One Health programs explores connections between human health, animal health, and the environment, bringing together experts in fields as diverse as climate change, farming practices, and wildlife management. According to Dr. Wanda Markotter, the Principal Investigator for CDC’s original agreement with the University of Pretoria, “This new project will significantly enhance the collaboration between the Health and Veterinary faculties to develop joint surveillance and diagnostic programs on zoonotic disease in South Africa and provide feedback to the Ministries of Health and Agriculture in South Africa.”

So back to that buffalo. Are you curious about how those specimens are collected?

People think of their wedding day as the happiest day of their lives. In India, weddings often include several days of festivities with friends and family.  Symptoms like “abdominal pain,” and “vomiting” are unwanted guests, but they crashed one wedding party in Gujarat State.

Fortunately, India is committed to strengthening outbreak response and surveillance for acute diarrheal and foodborne diseases. Within 24 hours, four people were deployed to conduct an investigation to find the cause of the wedding outbreak. Two investigators were Indian EIS Officers and two were from the U.S. Centers for Disease Control and Prevention (CDC). Combining forces, they surveyed households to track down nearly 400 wedding guests from four villages to identify potential cases and get more information about foods the sick guests ate. Ninety-two people reported symptoms and eight were hospitalized.

Spoiled milk

The culprit? The team traced the likely source of the outbreak to basundi, a dessert made of condensed milk topped with dry fruit and served cold.  The officers discovered there was a 10-hour power outage two days before the wedding that affected the dairy where the milk was purchased.

Practice makes perfect

Solving foodborne outbreaks is not easy. It takes training, patience, practice, and many partners. Thanks to a longstanding scientific collaboration known as the Global Foodborne Infections Network, countries, including India, are getting the tools and relationships they need to solve outbreaks. Epidemiologists, microbiologists, lab technicians, and healthcare staff are trained and mentored on procedures for stool specimen collection, transport, laboratory testing, and reporting.

The key to cracking foodborne outbreaks is testing stool specimens from sick people. In two years, as part of a pilot project, over 30 outbreaks have been detected and reported in four districts; 2000 samples have been properly collected, transported, and tested. Clinical specimens were tested in 75% of those outbreaks—results that are on par with the best standards in the world.

Plans are being discussed to double the number of districts and add activities. With better ability to track, test for, and prevent foodborne illnesses, gatherings all over India could turn away uninvited bacterial guests.

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.”