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Next we will be presenting, just flying in from Puerto Rico,
Dr. Michael Johansson a biologist
with CDC's Dengue Branch and a branch in San Juan,
who completed his PhD with Johns Hopkins and today he is talking
to us about bringing the public into public Health.
Dr. Johansson.
So I am going to talk about public health today.
Particularly, about the public part of public health.
I got started in public health, a number of years back,
getting my feet wet both literally and figuratively
in Acquisto, Peru, right here.
It's a city right on the Amazon River.
I went there to investigate leptospirosis.
Leptospirosis is a bacterial disease that is present
in a lot the bacteria's --
present in a lot of different animals.
They pass it through their urine
and they can contaminate different water sources
and if people come in contact
with that water they can become infected.
Now Acquisto is a place where there is a lot of water.
A lot of people living in close contact
with the water, and a lot of animals.
So we knew that it might be a problem there.
Leptospirosis is difficult because it's --
it can cause really severe disease in people
but it's also easily treatable via penicillin or any sort
of basic antibiotic like that; well certain ones.
However, you often don't recognize the disease until it's
in the later stages when it's difficult to treat.
So knowing whether or not this is a problem
in a certain community can be very helpful in terms
of treating these cases that are more severe.
So we knew that there had been a few cases there,
we knew they had the right risk factors,
but we didn't know how much disease was present.
So we went there to investigate it.
The first thing we found when we went
into this community was people.
The people we went and visited their houses,
talked to the people, told them about leptospirosis,
looked at the way they were living, risk factors
that were present or not present there and took blood samples
when they were willing to participate in our study
so that we could test them to see if they had been exposed.
It turns out that they had been exposed.
Over a quarter of the people had evidence
of exposure to leptospirosis.
Having been working in this community we knew what the
houses were like and we knew some
of the risk factors that might be there.
So we went back to the houses and started trapping rats
because we found that there were rats pretty much everywhere
in this community.
So we took a bunch of rats out of there, took the rats back
to the lab, tested the rats.
A bunch of the rats came up positive.
About 10% of them were actively infected
with leptospira, the bacteria.
So this was a really --
a sort of a small success story in public health.
That we were engaging the community by going
and visiting the people and trying
to understand the situation they were living in and by talking
to them and -- and doing our testing that we could find
out that they were having this problem there.
And we also found the source of the problem, which was the rats.
So this is a story of community engagement leading
to public health success.
And there's a lot of different ways
that community engagement could lead to public health success.
One of them is this and it's the first --
probably the first thing that I learned
and the most important thing I learned in Peru and it's
that public health problems are really not the problem
of a bacteria, or the problem of a virus, or the problem
of certain people, or a certain place.
Rather the problems that are created by an ecosystem
that includes all these things and other factors.
Here is another picture of Acquistos,
this part of Acquistos.
Here we have boats, we have the water, we have the houses
that are closely packed together, there is a lot
of trash up there that you can't really see very well
in this picture.
These are all things that are base in the tradition
and the history of this community.
And they make it a unique and special place
but they make it a really good place for leptospirosis.
You wouldn't really know that unless you go there.
So getting engaged with the community helps you understand
these problems and start to get a better grasp on them.
Community engagement is also really important
for public health success on the intervention side.
You know, going there and saying,
"Oh we have a big problem here," is just the first step.
We're doing that because we want to be able to do something
about it and improve people's health.
You can't really do that unless you also engage the community.
So whether your intervention is a vaccine, telling people
to wear boots when they are working in the water
in a community like this, or telling the people
to use bed nets to prevent malaria transmission,
you need to engage the community.
Whatever intervention that you have is not going
to work unless people are actually using it.
So we met with some success in Peru.
I mean this is fairly a small-scale thing.
Lots of people have done things like this.
We tried to think about ways
that we could make a bigger impact on the public
and then involving the public in public health.
So let's say for a minute now that I am not worried
about the people in Acquitos, I am worried
about the people here.
Now if I am worried about your health the traditional thing
that we would do
in epidemiological disease surveillance is that we assume
that sort of the doctor knows best.
So we go and ask doctors about people.
And we have the doctor's report on their patients who are sick
and then they have certain diseases that are reportable,
and we get them in the surveillance system and we find
out what diseases are maybe going around in their community.
Well this is a perfectly reasonable way to do it
and it works quite well.
But there's another way we could do it.
Instead of asking doctors
if people are sick we could start asking people
if people are sick.
So we call this Participatory Surveillance.
If I wanted to do this right now I could go around
and ask everyone in this room if they were sick.
It might take me a little while
but I probably could get some decent data out of you guys
if someone has had illness in the last week or two weeks.
Another way that I could do it is just to ask you
to raise your hand if you've have had a fever
in the last month.
I could -- that would make it go faster.
You know, I could just count it up.
There would be maybe some reliability issues.
Maybe my counting is not that good; maybe you don't want
to admit you had a fever yesterday.
There is another way that I could do this though.
That I could get input from all of you anonymously,
pretty much simultaneously and then share that data with you.
We could do that if we did it all digitally.
So there is different ways that you could do this.
We -- the way I am going to talk
about it now is called Internet Based
Participatory Surveillance.
So in that -- this case we are just using the internet
to collect data from people about whether they're sick
or not and it can be entered anonymously
and then it can be shared, broadly, immediately.
This is the system we use
in Puerto Rico its called Salo Boricua.
People get an email every week.
You sign up for the system,
then people who are participating get an email
every week.
I know most of you probably can't read this.
This is just a list of symptoms.
So the person goes into the website every week,
clicks on any symptoms that they had or they click
that they didn't have any symptoms that week.
This takes 10 or 15 seconds
after you've done it the first time or two and that's it.
That's all you have to do to participate in this system.
This system grew out of another system called Flu Near You
that some of you may have heard of that is present
in the United States looking at influenza.
Immediately after answering this, which only takes that 10
to 15 seconds, you get to look at this map and this is a map
of Puerto Rico and it shows
where people are reporting illness.
So these red dots there are places where at least one person
in the zip code is reporting having the symptoms
of having Dengue.
So we know that there is some problems in those areas.
Now this is kind of a nifty public health tool, right?
But can it really like have an influence on a larger scale?
Let's think about what surveillance --
what we really try to get out of surveillance data.
One of the most important things is
that we want to capture disease.
So in the traditional surveillance system we capture
disease by capturing clinical cases of disease; people who go
and seek medical care.
And then the doctor if they diagnose a case
of a certain kind of syndrome they might report
that to a system and -- to the surveillance system
and you will get reporting going up the chain.
Eventually reports get aggregated
and a report comes out.
In a participatory surveillance system you can actually capture
more disease because you can capture people who get sick
and maybe don't go to the doctor.
Maybe I have a sore throat and a fever for a few days but I have
so many things to do at work that I --
you know, I try to work from home instead
of getting people sick at work but I don't go to the doctor
because I don't want to sit in a waiting room for 10 hours
when I could be doing something else or resting
in trying to get better.
Another thing that we look for in a surveillance system is
that it's timely, right?
We're trying to collect data on diseases because we want
to do something about it.
It doesn't really help that much if we know
that something happened three or four months ago.
We'd really like to know what is happening now.
In the participatory surveillance system this data
is immediate.
So as soon as the data is entered it is there
and people can see it.
Not just the public health authorities but anyone.
The public can see it so they can start reacting
if there is disease in their community.
We also would like a system that is inexpensive.
Now creating these systems isn't that easy, you know we are still
in the early stages of it.
But basically once you have it you need --
you need to maintain your servers and you need
to have some developers on hand but it's pretty easy
to run compared to a traditional system.
Where you have different levels of reporting, and involvement
with clinicians, laboratory testing, etcetera.
You also want a system that's scalable.
So with a system like this we can easily go
from a thousand people to 10,000 people.
You just need more server capacity basically.
But you also need people with internet access
which is not true everywhere but it's also increasing globally.
This is -- in fact Salo Boricua is a good example of this
because we didn't have a system in Puerto Rico
and we didn't have the money --
the resources to put together a system.
So luckily we found our partners at Boston Children's Hospital
in the Health Map Group who had developed this Flu Near You,
which is very similar system.
And so we just worked with them to modify their system
so that it was suit our needs in Puerto Rico.
So very easily we came up with a system
so we have this whole new system that we created basically
with a little bit of collaboration and that was it.
Lastly to get back to this point;
we want to engage to the public.
So this is a way that we can very easily get people involved
with public health.
People can come in and they can report
and they can also see the data in real time.
The maps are interactive
and there are some different features in there.
We also provide information on the diseases,
ways to prevent the diseases,
and some information about vaccination.
Salo Boricua and Flu Near You aren't the first systems.
They're some of the more recent ones.
The first systems came out in 2003 in Europe
and it's been expanding.
There are a few new systems each year.
It's nice to have all these systems out there
because we started to accumulate some data that can show
that these systems can actually work.
So here is one example of one of these systems,
this is from the Netherlands in 2007,
and these are influenza like illness curves.
So these are people who are reporting influenza
like illness.
One of these curves is from a traditional surveillance system
where people go to the doctor and it's reported.
It is called a sentinel surveillance system
and then the doctor's report in the cases.
The other is a participatory surveillance system.
You can see that they both perform pretty well
and pretty similarly.
So one of them -- they're both capturing the --
the increase in incidents at about the same time
and they're capturing the peak of incidents at the same time.
Now they look very similar but remember that one
of these systems is a heck of a lot cheaper
and it is also getting you the data a week or two weeks faster.
That is the participatory surveillance system.
So you are getting some of the same data
but you are getting it faster and at less expense.
Now there is another thing that is different
between these two things and now that I have put up the axis here
so you can see this is the -- these are actually estimates
of the incidents rates in the overall population.
So their estimates of numbers of cases per 100,000 people
and you can see that the participatory surveillance
system is actually much more sensitive.
So they are capturing a lot more disease and this is true
of the other systems as well in the other countries.
It's not always 10 times as much
as what we are seeing here sometimes it's a little more
sometimes a little less but basically,
you're capturing a lot of these people who are sick
but don't go to the doctor.
Or they go to the doctor and the doctor thinks it's some other
disease; maybe doesn't report that it is influenza.
So there's a lot to be gained potentially here in sensitivity
as well, of what the true burden of disease it.
Here's another example, this is from the Flu Near You website,
so on there there's a question
about vaccination in the weekly survey.
So we are asking people if they had a flu vaccine
in the previous -- since the last time that they reported.
There's also this tool that helps people find places
where they can get vaccinated.
So you enter your zip code and it spits
out the closest vaccination centers.
Now what's interesting about this in particular is
that this summer they did a survey of their users and out
of all the people who got flu vaccines with --
and responded to the survey, last year --
so this is the 2012-2013 season,
5% of those people said they got the vaccine
because of Flu Near You.
Now this is kind of remarkable, it's -- 5% is not a huge number
but think about what it really means.
These people are participating online in a surveillance system
and it's actually influencing what they're doing
in their daily life and that they're taking a public health
action that is very positive,
just due to their participation in here.
And so there is even a perceived benefit and a real benefit
because these people are getting vaccinated.
So these systems there still --
they're still sort of in their infancy even though some
of them have been around for 10 years.
There's a whole lot of room for expansion, both geographically
and getting more participants.
There's room for improving the quality
and the quantity of the data.
There's a lot that can be done here
and we're just seeing the beginning.
So to improve public health we can really engage the public,
we can ask people if they are sick, we can do it digitally,
and we can bring the public into public health
in a really meaningful way.
Thanks.
[ Applause ]