Booting up global connections A new international fellowship program has been established at the Rollins School of Public Health (RSPH) in honor of William Foege, the Presidential Distinguished Professor of International Health and senior adviser to the Bill & Melinda Gates Foundation. The William H. Foege Fellowships in Global Health will bring four Foege fellows from developing countries to study at RSPH each year, beginning in the fall of 2003.

The fellows will be mid-career professionals who will work with mentors at public health agencies in Atlanta, including Emory, the Centers for Disease Control and Prevention (CDC), The Carter Center, and CARE. Fellows will receive a laptop computer when they begin the program, and they will be encouraged to take it with them when they leave. The goal is to help public health leaders in the developing world plug into the global network of knowledge and expertise and stay connected.

The Gates Foundation gave the RSPH a $5 million endowment gift to establish the program in Foege's honor. “Bill Foege has devoted his life to ensuring that others can enjoy full and healthy lives,” says Bill Gates, Sr. “I can think of no better way to honor him than to encourage and train others to continue the work he pioneered.”

Foege was one of the masterminds behind the smallpox eradication campaign and has served as director of the CDC, executive director of The Carter Center, a member of the CARE board, and a faculty member at RSPH.

In addition, the O.C. Hubert Charitable Trust has granted RSPH $1.4 million to establish the William H. Foege Chair in Global Health. An Emory commitment brings the total endowment for that chair to $2 million. The recipient of the chair will direct the Foege fellowship program as well as the O.C. Hubert Fellowships in International Health, which help support international field research experiences for students each year.

Every day in the developing world, people die deaths that could have been prevented by appropriate medicines. But in some of the world’s poorest countries, essential medicines are too expensive or are no longer produced by drug companies. Available drugs are often ineffective or highly toxic. Doctors Without Borders has launched the Access to Essential Medicines Campaign to heighten awareness of this problem. The Rollins School of Public Health helped bring the traveling exhibit to the Emory campus during Human Rights Week this past April, and Dean James Curran toured the exhibit along with several RSPH faculty members.

If a suicidal terrorist with contagious smallpox were to amble down a crowded city street, run through a residential neighborhood, or pass through the busiest airport in the world, random chance would have much to do with how many others that person might infect and how many new infections they, in turn, would pass on, and so on down the line.

The National Institutes of Health contracted with biostatisticians at the Rollins School of Public Health (RSPH) to statistically model the potential spread of smallpox if it were unleashed in the United States. Their findings, published in the November 15 issue of Science, should help government officials plan immunization strategies in the event of a bioterrorist attack. For months, government officials have debated whether mass vaccination of the American population or targeted vaccination of close contacts of those infected with smallpox would be more effective. The current smallpox vaccine carries a high rate of adverse reactions, including death.

RSPH faculty members Ira Longini, Elizabeth Halloran, Azhar Nizam, and Yang Yang, are the principal investigators. They found that targeted vaccination of close contacts could rival the effectiveness of mass vaccination, given enough previous immunity among the population from vaccination of first responders, voluntary vaccinations, and residual immunity from vaccinations before 1972.

Their statistical model takes the structure of the population into account, following individuals as they move through the day—in their households, neighborhoods, schools, and places of work. After crunching the numbers, a computer program offers a scenario of how an outbreak would progress before it reaches a peak and then tapers off.

RSPH researchers have used this statistical method for years to help the Centers for Disease Control and Prevention plan vaccination strategies for influenza. “The results could be used like a playbook in a smallpox simulation, where various public health agencies would compete against the computer,” says Longini. “In past exercises like Dark Winter, which simulated US reaction to the deliberate introduction of smallpox, the spread of disease was calculated on the back of an envelope. Our model yields much more precise results. Good data will give us a much better chance of containing an outbreak before it mushrooms into an epidemic.”

Future models will explore different possibilities regarding the spread of smallpox, such as the interconnectedness of communities and different ways smallpox might be introduced. It will also explore whether targeted vaccination should focus on where epidemics occur rather than mass vaccinations throughout the country.

Biostatistician Ira Longini has statistically modeled outbreaks of infectious diseases like influenza for many years. Along with Professor Elizabeth Halloran, he is now turning his attention to smallpox, one of the most feared agents of bioterrorism.

Research institutions and public health programs throughout the southeastern United States recently joined forces to create the Southeastern Center for Emerging Biologic Threats (SECEBT). Emory University’s Robert W. Woodruff Health Sciences Center, which includes the Rollins School of Public Health, is a key initiating partner.

This eclectic group will combat emerging infectious disease threats and will consolidate resources in basic research, vaccine development, pathogen surveillance, biomedical engineering, pharmacology, veterinary medicine, food safety, and clinical recognition and treatment. The center will also develop new ways to detect, combat, and prevent biologic threats, both naturally occurring or stemming from bioterrorism. Along with Emory and the Rollins Center for Public Health Preparedness and Research, Georgia Institute of Technology, Medical College of Georgia, Morehouse School of Medicine, University of Florida, University of Georgia, Medical University of South Carolina, Mercer University, University of Mississippi Medical Center, and others have joined the partnership. The center will also work closely with state and federal health agencies, including the CDC, and the state health departments of Florida, Georgia, Kentucky, Mississippi, and South Carolina.

Jeffrey Koplan, vice president for academic health affairs at the Woodruff Health Sciences Center and former director of the CDC, is senior adviser to the center.

A winter storm approached ominously the evening of January 2, 2002, and by dawn, metro Atlanta was blanketed in 4.6 inches of snow. At Hartsfield International Airport, thousands of stranded travelers waited as crews de-iced the planes lined up outside. Hours later, the planes were ready for take-off, but close by and out of sight, a clogged drainage pipe caused as much as 180,000 gallons of de-icing fluid to bypass the treatment system and empty into the Flint River, a key source of drinking water for south Fayette County. More than three months later, Howard Frumkin, chair of the RSPH Department of Environmental and Occupational Health, addressed concerned citizens at the Peachtree City Library. Pregnant women and nursing mothers who had been drinking Fayette County water had been calling him at Emory’s Pediatric Environmental Health Specialty Unit, worried that the de-icing fluid might have harmed their babies.

Pregnant women and nursing mothers in Peachtree City were anxious and concerned when they realized their drinking water was contaminated with airplane de-icing fluid, which can lead to birth defects.

“With a situation like this, there are no easy answers. You can’t say, ‘There’s no danger,’ and you can’t say, ‘You’re certain to have a birth defect,’” Frumkin says. “It’s a question of odds.”

Peachtree City residents like Patty Culjak were frustrated with state and local water departments and environmental agencies. Three months pregnant at the time of the spill, Culjak had noticed an odd smell to her drinking water and called the water department and state environmental officials. She had heard nothing about the spill.

“The water had a stench,” she says. “Some people described it as syrup smell, but my immediate thought was antifreeze.”

Finally, at the end of January, the Flint River was tested and found contaminated with traces of the de-icing chemicals propylene glycol and ethylene glycol, which can cause birth defects. Frumkin suggested careful diagnostic testing for infants before and after birth.

“Universities should provide public health information to the community, especially when there’s a level of anxiety and a legitimate basis for concern,” Frumkin says. “It’s an important part of our school’s mission to provide service to the community when we can.”

A new version of a pneumococcal vaccine reduced the incidence of pneumonia in 40,000 children in a clinical trial in Soweto, South Africa, by more than 20%, concluded researchers from the Rollins School of Public Health (RSPH) and the University of Witwatersrand in South Africa.

Keith Klugman (second from right) with the first child included in his clinical trial of a new pneumococcal vaccine.

The vaccine reduced the incidence of invasive disease—pneumococcal bacteria in the bloodstream—by more than 80% in children not infected with HIV and by more than 50% in HIV-infected children. Keith P. Klugman, professor of International Health at RSPH, was principal investigator of the study. The World Health Organization, the Medical Research Council of South Africa, and Wyeth Pharmaceuticals, which developed the vaccine, were collaborators.

Pneumonia is the leading cause of death in children worldwide and is responsible for approximately 4 million deaths a year, mostly in developing countries. Although pneumonia has many different causes, the pneumococcal bacterium is the primary source. Until recently, no vaccine was available to prevent pneumococcal disease in young children.

“With this reduction in the incidence of pneumonia, we could potentially save more than 500,000 lives each year in the developing world,” says Klugman. “In addition, no vaccine has previously been documented to prevent pneumococcal disease in HIV-infected children, and our study showed a 50% reduction in this group. In an era in which there is little to offer children with HIV, we can clearly reduce invasive disease.”

Best-selling science writer Richard Preston, author of The Hot Zone, held an Emory crowd spellbound this past October as he described his many years of research on man’s tumultuous relationship with smallpox. His newest book, The Demon in the Freezer, is a gripping account of emerging bioterrorist threats, the smallpox eradication program, and the biowarfare programs of the United States and the former Soviet Union.

Preston spoke as part of the Triangle Club lecture series, sponsored by the Center for Public Health Preparedness and Research at the Rollins School of Public Health. This monthly event brings together Atlanta professionals in public health, health care, and academia who are working on issues related to bioterrorism preparedness. Sam Nunn, former US senator and co-chair of the Nunn-Turner Nuclear Threat Initiative, gave the first Triangle Club lecture this past September.

Since forming just nine months ago, the center has forged new partnerships with government and academic experts in bioterrorism and established new programs to prepare students and public health professionals for this new emphasis in public health. Some noteworthy accomplishments include the following:

• Establishment of a Centers for Disease Control and Prevention (CDC)-sponsored public health preparedness program to focus on training public health professionals throughout Georgia about bioterrorism preparedness. Associate Dean for Applied Public Health Kathleen Miner is principal investigator.
• A new course called Public Health Preparedness and Bioterrorism. Ruth Berkelman, the Rollins Professor of Public Health Preparedness and director of the center, and Philip Brachman, anthrax expert and Professor of International Health, are co-directing the course.
• A new course called Crisis Communications and Public Health, developed and taught by Melissa Shepherd, a visiting communications associate from the CDC.
• Ongoing research involving the development and evaluation of early-detection systems for epidemics and changes in health care utilization after a terrorist event.
• A Student Outbreak Response Team, formed in collaboration with the DeKalb County Board of Health. This voluntary group allows students to gain experience working in a local public health department. The students are also on call to help the country during emergency situations.

An Internet-based version of a health economics software program developed by researchers at the Rollins School of Public Health (RSPH) and the Centers for Disease Control and Prevention (CDC) allows users to calculate the direct and indirect costs of cigarette smoking for adults and newborn children within and across states.

By first estimating the number of smoking-related deaths in the current year, the software can estimate the economic costs associated with the years of productive life lost for adults. It also estimates annual medical expenses for smoking-related conditions for adults and infants.

The original software program, called the Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC), has been used extensively for many years. This new release is the first web-based version and the first to include a maternal and child health component. This aspect of the program allows users to estimate the number of infant deaths associated with maternal smoking, years of potential life lost for these infants, and neonatal medical expenditures linked to active maternal smoking. Smoking while pregnant has been associated with reduced birth weight, sudden infant death syndrome, and respiratory conditions in infants.

Emory researchers have found that nearly 9% of insured women are hospitalized during their pregnancies, with the majority of hospitalizations among younger women, women with multiple gestations, and women in the northeastern United States. The findings were published in the July 1 issue of Obstetrics and Gynecology.

Researchers at the Emory Center on Health Outcomes and Quality analyzed data from Aetna, Inc. the largest managed care organization in the United States, using information gathered from 46,179 pregnant women who had a live birth or pregnancy loss. Overall, 8.7 % of these women were hospitalized during pregnancy. The primary causes for hospitalization were hypertension, nausea, premature rupture of membranes, and pre-term labor. Costs for these hospitalizations topped $36 million.

Julie Gazmararian, a professor in the Department of Health Policy and Management at the Rollins School of Public Health (RSPH) and lead investigator for the study, suggested several ways to reduce pregnancy-related hospitalizations. “Certain conditions, such as hypertension, may be treated more effectively in an outpatient setting,” she says. "If high-risk patients are better educated on warning signs and certain conditions, hospitalization might be prevented." Further study may identify specific reasons for these hospitalizations, determine whether they can be prevented, and hopefully lower maternal and fetal illness, Gazmararian concluded.

The study is the first to use data from a large national managed care population to monitor inpatient care received by women during pregnancy. Consequently, the study does not include uninsured and other vulnerable populations. The Emory Center on Health Outcomes and Quality—a multi-school, multi- disciplinary group within The Robert W. Woodruff Health Sciences Center at Emory—conducts research aimed at improving quality-of-care measurements and designing interventions to improve health outcomes. It works with consumers, physicians, and insurers to evaluate and implement new approaches for improving quality of care.

Epidemiologist David Kleinbaum has harnessed the latest cutting-edge technology to develop a revolutionary new teaching tool called ActivEpi, an interactive electronic textbook on the fundamentals of epidemiology. This book on CD-ROM uses innovative learning tools such as video clips, animation, narration, interactive exercises, Internet links, and a point-and-click glossary, index, and appendices. Built-in software also allows students to practice analyzing data sets.

During his many years as an award- winning professor at the Rollins School of Public Health (RSPH), Kleinbaum has always sought the best new ways to reach students. He is internationally known as the author of some of the most widely used textbooks on epidemiology and biostatistics.

With the help of Data Description Inc., an educational multimedia development firm, Kleinbaum developed this electronic textbook to bring epidemiology to a wider range of students. “ActivEpi is appropriate for people at all levels of experience,” he says. “Public health and medical students, public health professionals, and medical researchers all can benefit from the interactive methods ActivEpi uses to teach epidemiologic concepts.”

The ActivEpi CD-ROM and its companion hard-copy text can be used in on-campus courses, distance learning programs, or for self-paced learning. It could be particularly useful for public health professionals in the developing world.