Stemming the tide
Alumna travels globe with CDC to control tuberculosis outbreaks
Sapna Bamrah, MD ’99, examines a boy with tuberculosis during one of her trips to Chuuk in Micronesia.
It’s a drought year in Ethiopia, and the dearth of hydroelectricity is causing power outages every other day. Clean water is scarce, and malnutrition is on the rise. Sapna Bamrah, MD ’99, is back in Africa. It had been almost a year, but when you travel as often as she, time compresses and the memories rush back with clarity.
Dr. Bamrah is working in Tigray, the northern region of a country that experiences more than 150,000 cases of tuberculosis a year, and that is what brings the infectious diseases specialist here this summer. She is a medical officer and epidemiologist on the Division of Tuberculosis Elimination Outbreak Investigations Team, within the Surveillance, Epidemiology and Outbreak Investigations Branch of the Centers for Disease Control and Prevention (CDC). Her primary responsibility is to respond to local and state TB control program requests for assistance.
In a full investigation such as this, Dr. Bamrah is challenged to identify active cases of TB and understand the transmission chain between patients using contact investigations, molecular epidemiology and social mapping. Managing the public health concerns can be difficult with complicated health systems, she said, and local staff tend to interpret the assistance of a federal agency like the CDC as evidence of their shortcomings. This is usually furthest from the truth, she said.
While on the Micronesian island of Chuuk in January, Sapna Bamrah, MD ’99, visited with a patient who was being treated for drug-resistant tuberculosis.
“The majority of local programs do a phenomenal job of case identification, prevention of further transmission and contact investigations,” Dr. Bamrah said. “It is often the resources that they are lacking to go a step further to understand the outbreak and work toward reducing and eventually eliminating TB in their area.”
A member of the TB outbreak team since July 2008, Dr. Bamrah first joined the CDC as en epidemic intelligence service officer with the International Emergency and Refugee Health Branch in the National Center for Environmental Health in 2006. It was in this role that she traveled to Swaziland in May 2007 to assist her branch and the United Nations Children’s Fund (UNICEF) with conducting a national survey on sexual violence. It turned out to be one of the most meaningful experiences of her career among many.
Swaziland has the second highest prevalence of HIV in the world, estimated between 27 and 35 percent. Experts predict that by 2010, there will be 100,000 orphans in the country due to HIV/AIDS. UNICEF set out to address the risks faced by young women and children as sexual violence against them increased as age-appropriate wives and partners were dying from the disease.
“Unfortunately, laws against sexual violence have not been very well defined – although rape was illegal technically, punishments were rarely enforced if guilt could even be proven,” she said. “To allocate the funds and help the government advocate for these children and new laws to protect them, the problem had to be defined.”
Dr. Bamrah assisted with staff training and monitoring as well as data management for the survey team, which hired 40 Swazi women to work as team leaders and interviewers. They went from randomly selected house to house, talking with one randomly selected girl age 13-24 from each.
Dr. Bamrah’s CDC team made house calls during their recent response to an ongoing tuberculosis outbreak in the Federated States of Micronesia.
“I consider myself extremely fortunate that I get to travel off the beaten path and see some of the realities of the countries I travel to, both beautiful and tragic,” Dr. Bamrah said. “In addition, I am given the opportunity to work with and often befriend such amazing individuals. In Swaziland, this was true more than any other trip on which I had been.”
The participation of the women resulted in the country passing new laws and bringing more attention to the problem of sexual violence, she said. Within a few months, programs were initiated to educate the population, provide services to victims and enforce punishment of offenders. Shortly after a regional meeting where the study was presented by Dr. Bamrah’s Swazi colleagues, three other countries asked for the study to begin designing their own.
Success stories in Dr. Bamrah’s line of work are not necessarily happy endings, but often positive beginnings. One locale in which she has spent considerable time is the island of Chuuk in the Federated States of Micronesia. Her visits have focused on an outbreak of multidrug-resistant tuberculosis. In its initial visit, the CDC team identified cases of multidrug-resistant TB as well as exposed individuals after four people died from the disease. They were able to quarantine and treat infected patients and administer preventive therapy for others.
Dr. Bamrah has returned twice to the island to follow the patients. Among them, no additional deaths have occurred from the disease, and no one receiving preventive therapy advanced to active TB.
On the map
Locations Dr. Bamrah’s work with the CDC has taken her:
(UNHCR HQ, 2)
Federated States of Micronesia (3)
Las Vegas, Nev.
“Without a doubt, the most important outcome in all of this was the absolute improvement of the Chuuk TB program,” she said. “They have gone from a struggling control program, without the resources to provide care up to standards, to one of the most efficient, successful TB programs.”
The daughter of physicians, Dr. Bamrah had early aspirations to follow her parents into medicine. While she did become a doctor, she followed her own path – majoring in social work, minoring in Spanish, and studying post-apartheid development in South Africa and Namibia her senior year of college. She came home from Africa wanting to volunteer for a year, but she was already accepted at The Medical College of Wisconsin, and her parents convinced her to matriculate.
“It was not an easy decision for me, but at the end of the day, I truly thought I could contribute more to addressing poverty, could affect more change as a physician,” said Dr. Bamrah, who completed her internal medicine residency at Case Western Reserve University and an infectious diseases fellowship at Cleveland Clinic.
At the Medical College, Dr. Bamrah found favor in strong mentors and in an institutional culture that supported her efforts to seek out and even create new experiences that coincided with her educational and professional goals.
“As I was never the best academic student, my success is in large part due to faculty and staff members valuing me for the things I did bring to medicine as opposed to constantly focusing on my shortcomings,” she said. “At the Medical College, the faculty and staff allowed me to define what being a good doctor meant to me – which included learning about the poverty-stricken, the abused, the underserved.”
Choosing a career or even an occasional experience in global health requires some self evaluation. It is important, Dr. Bamrah said, for interested students or young physicians to take every opportunity to discover if the work feeds their passion or drains it. One should also consider their potential role – clinical work, epidemiology, improving electronic medical records systems, disease eradication, for example. The work that is sustainable has the highest value.
A Coptic priest Dr. Bamrah met in Ethiopia this summer walks three hours each way, twice a week, to the clinic to obtain TB medication for himself and his congregation.
“The goal is not necessarily to go and provide services that cannot be replaced by the capacity of those who live and work in that country,” Dr. Bamrah said. “The goal, I believe, is to contribute to what people are already doing or provide them the ability to do more.”
To address the largest scale problems, Dr. Bamrah engages in the most personal of interactions, and the people she encounters seldom leave her thoughts. In Ethiopia, she meets a Coptic priest with TB who walks three hours to the clinic, two times a week. He picks up medication not only for himself but patients in his congregation and helps distribute the medication at church.
Many in the country are still waiting for medication. Two years ago, Ethiopia identified 273 cases of multidrug-resistant TB in a pilot study and applied for World Health Organization drug support. They were approved one year ago and are still awaiting shipment of the meds, which, even then, will only be enough for 50 people.
With TB clinics overburdened, Dr. Bamrah sees so much work still unfinished, yet she has, at least, helped give people some tools to succeed. Of course, the outbreak investigations team is needed elsewhere. Sapna Bamrah is back in Africa, but by the time you read this, she’ll be gone.
My second day on the job
After joining the Division of Tuberculosis Elimination, I was asked to assist in responding to an outbreak of multidrug-resistant tuberculosis (MDR TB) in the Federated States of Micronesia (FSM). Truth be told, I had no idea where FSM was, and had little idea what it would be like to work there. In December 2007, the Chuuk TB program was notified of their first MDR TB case on island. FSM, like most developing countries, have neither stockpiles nor access to second line medications to treat TB. Within weeks of the diagnosis, the patient died. Subsequently, over the next five months, four more patients were diagnosed with MDR TB, three of whom also died. Over the course of those months, FSM requested assistance from CDC to address this problem.
FSM used to be a U.S. territory under a trust agreement established post World War II. In the late 1980s, FSM entered a compact of free association with the U.S., which made them an independent nation; however, there is a strong affiliation that remains with the U.S. The citizens are also able to freely work, attend school and serve in the military in the US. We also provide assistance to specific aspects of their health care system, e.g. the tuberculosis control program. Given this relationship, FSM requested our assistance, and CDC was happy to provide a team to help control the situation.
Medications were procured through the managing bodies of the Compact of Free Association, and a team from CDC arrived to help investigate potential transmission and identify any additional cases. We also wanted to understand the number of people who had been exposed and could potentially become sick due to MDR TB. Over the three weeks there, we were able to identify six additional cases and 124 exposed individuals. Over the next few weeks to months, we were able to assist in opening a quarantine unit to house infectious patients and initiate the patients on therapy. On a subsequent visit to evaluate the progress of patients and evaluate those who had been exposed, we found 10 more patients with active TB. On that same visit, we were able to initiate preventive therapy for approximately 100 patients.
Although the loss of patients (five out of six patients with confirmed MDR TB) was tragic (another death occurred in a 4-year-old boy after the investigation), zero of 16 additional patients have died since the procurement and initiation of therapy. Of equal importance, zero patients on preventive therapy have progressed to having active TB.
Without a doubt, the most important outcome in all of this was the absolute improvement of the Chuuk TB program. The accomplishments are theirs. The Health Officers (primarily Dr. Dorina Fred), and the RNs as well as the workers delivering medications daily to 160 patients deserve all of the credit. They have gone from a struggling control program, without the resources to provide care up to standards to one of the most efficient, successful TB programs within the US. I have been fortunate to go back on two occasions and see all of the patients and continue to work with the Chuuk TB program.
It is amazing to be able to go back and see what they have accomplished. I have gained (and learned) so much from this experience; it is difficult to even articulate. Nonetheless, I hope to have more of these success stories as MDR TB is an emerging infectious illness that has not yet reached its peak.
View the entire fall 2009 issue of Alumni News. (opens as a pdf)
Read & React
We welcome your comments about this article and also invite you to share your own experiences. Comments are subject to editorial approval. The Medical College reserves the right to edit comments for length, grammar, clarity and appropriateness.
Alumni, please include your degree(s) and year(s) of graduation along with your name. Your e-mail address will not be published.