CDC in Thailand: 30 years of partnership in improving health and preventing disease

CDC recently marked 30 years of collaboration with the Thailand Ministry of Public Health (MoPH). This partnership has created new disease prevention and intervention strategies that have saved lives and improved health in Thailand and across Southeast Asia and increased health security of the U.S.

CDC’s work in Thailand began in 1980, when CDC supported the MoPH in creating Thailand’s Field Epidemiology Training Program (FETP)—the first FETP outside of North America. Built on the model of CDC’s Epidemic Intelligence Service, FETP is a two-year program for public health professionals that helps them to develop expertise in epidemiology and response so that disease outbreaks can be detected locally and prevented from spreading. Since 1980, the Thailand FETP has graduated 214 Thais and 42 regional fellows in 32 cohorts. This program has developed a cadre of trained field epidemiologists and strengthened outbreak detection and response capacity in Thailand and the region. The Thailand FETP has become a model for its neighbors in investigating disease outbreaks, strengthening health security for Southeast Asia and the world. The Thailand FETP established a web-based journal, Outbreak, Surveillance & Investigative Reports.

Over the past 30 years, the CDC/Thailand collaboration has grown as a platform on which programs are built yielding global benefits.

Increased capacity for Thailand and the region

Collaborations between CDC and Thai partners have led to breakthroughs in research, and have strengthened laboratory and vaccine capacity in Thailand. These advances benefit not only Thailand, but in many cases, the region as well, and support Thailand’s sharing of expertise, lessons learned, and capacities.

CDC is conducting a study with Thai partners that has identified causes of infective endocarditis (inflammation of the inner tissue of the heart). Early results identified zoonotic pathogens (infectious agents transmitted from animals to humans) as among the most common causes. Initial findings contributed to efforts to build national laboratory capacity for zoonotic pathogens in the human and animal health sectors. A senior microbiologist from the Thailand National Institute of Health (Thai NIH) trained with CDC scientists to learn procedures for isolation, identification, and diagnostic reagent production for Coxiella burnetti, the pathogen causing Q fever. These techniques are being used as part of efforts to establish a National Q Fever Reference Laboratory in Thailand.

In addition to expanding laboratory capacity, CDC’s partnership with Thailand’s MoPH has led to increased influenza vaccine use in Thailand. CDC and the Thailand MoPH collected data on influenza incidence, cost and risk groups that were used to inform a decision to introduce influenza vaccine into Thailand’s National Vaccine Program in 2009. Vaccine use in the public sector increased from 520,000 doses in 2008 to 3.55 million doses in 2012. Increasing vaccination rates protects not only Thailand's population, but could also protect visitors to Thailand from around the world.

Collaborations with Thailand have implications for global health.

CDC is collaborating with Thai partners to test and improve interventions that have implications beyond Thailand.

In collaboration with the Bangkok Metropolitan Administration and the Thailand MoPH, CDC completed the Bangkok Tenofovir Study, the first trial examining prevention of HIV infection, using medication (“pre-exposure prohpylaxis”, or PReP) among people who inject drugs. This randomized, placebo controlled trial of 2,413 men and women in Bangkok, found that a daily dose of one pill, tenofovir, can reduce the risk of HIV infection 49 percent; among participants known to be taking tenofovir consistently, protection was 74 percent. These findings add to the mounting scientific evidence that PrEP may complement other available tools in a comprehensive approach to HIV prevention among people who inject drugs.

CDC works hand-in-hand with Thai national institutions to discover, evaluate, and scale-up more effective models for HIV prevention, surveillance, diagnosis, care and treatment. Achieving sustainability is a critical part of this work. For example, CDC built the capacity of Thai public health experts to design and employ innovative epidemiological techniques that scientifically demonstrated the public health and economic benefits of providing earlier access to antiretroviral therapy (ART) in Thailand, and then worked in partnership with Thailand’s Ministry of Public Health and National Health Security Office to use the evidence produced using these techniques to successfully advocate for a change in national policy that increased the number of people living with HIV that are eligible for ART in Thailand by 20%. At the same time, CDC leverages that same Thai expertise to help other national HIV programs in the region, such as by brokering TA from Thai laboratory experts to support the SLMTA (Strengthening Laboratory Management Towards Accreditation) process in Cambodia. TA from Thai MOPH and CDC/Thailand lab experts measurably improved HIV laboratory quality and competence: independent evaluations showed that the SLMTA performance increased from zero SLMTA stars in 2011 (out of a possible five) -- to three stars in 2013.

To define evidence-based strategies for TB case finding in people living with HIV/AIDS, CDC and partners conducted a research study in Thailand, Cambodia, and Vietnam to identify a more sensitive step-by-step procedure for screening for TB in people living with HIV/AIDS (PLHA). The findings have changed national policies in the region and contributed to a change in global screening guidelines.

Another study used active TB case finding in patients who were hospitalized with pneumonia symptoms. The approach increased detection of smear-positive TB cases from 2.7-4.4%. Quickly finding and treating these cases is critical to preventing further spread in hospitals.

CDC is a key implementing partner with USAID for the US government’s President’s Malaria Initiative (PMI) which aims to reduce the impact of malaria. Southeast Asia, PMI’s paramount priority is to reduce the impact of drug resistant malaria. PMI, as an inter-agency effort, leverages CDC’s traditional strengths in epidemiology, surveillance and monitoring/evaluation to prevent and control malaria. Additionally, because the spread of drug resistance could severely turn back the successes of malaria control during the last decade, CDC-PMI ensures the conduct of high-quality standardized drug resistance surveillance to monitor the possible spread of drug resistance and provide the best possible evidence to support national treatment policies. Because of the regional nature of the drug resistance problem in Southeast Asia, CDC-PMI works in six countries in the Greater Mekong Subregion, fostering connectivity between national malaria control programs and emphasizing interventions in mobile, migrant and other malaria-vulnerable populations. As worldwide efforts to control and ultimately eliminate malaria proceed, CDC-PMI conducts programmatically relevant operations research to develop new tools and approaches towards prevention measures, characterize malaria-related practices and preferences in key populations, and evaluate the safety and efficacy of new malaria interventions.

Non communicable diseases (NCDs) are a high priority of the Thailand MoPH, and CDC has helped the Thailand MoPH design an intervention for reducing salt and fat in Thai food. The intervention being considered includes public education, food reformulation, and clear labeling. The results of the MoPH NCD intervention will have the potential for informing strategies in other countries where NCDs are leading causes of sickness, disability and death, including the U.S.

CDC’s partnership with Thailand focuses on refugee health, improving the health of refugees before they leave Thailand and people in nations of their final destinations, including the US.

Mae La camp, on the Thailand-Burma border, shelters about 45,000 mostly Karen refugees who have been persecuted by the Burmese military regime. The camp has experienced four cholera outbreaks in the last eight years. To complement water and sanitation, CDC led a collaboration including improvements with preventative immunization using a new, less expensive oral cholera vaccine. The collaboration included Thai MoPH, Première Urgence - Aide Médicale Internationale (the healthcare NGO in Mae La), and Bill and Melinda Gates Foundation. More than 36,000 (84%) refugees living in Mae La received at least one dose of the oral cholera vaccine. With partners, CDC will evaluate and describe the feasibility of such mass campaigns, the impact of vaccination on pregnancy outcomes, and vaccine effectiveness (if cases appear). [See http://www.cdc.gov/ncezid/dgmq/afp-fact-sheet.html]

In addition, CDC recently launched a voluntary testing and treatment program for certain medical conditions in pre-departure medical examinations for U.S.-bound refugees. Included among the voluntary tests were procedures to identify intestinal parasites, anemia, and chronic hepatitis B virus infection. The voluntary tests were in addition to current mandatory testing/treatment. This pilot program seeks to identify opportunities to improve refugee health during the time between exam and resettlement. More than 1,000 refugees were enrolled as of May 31, 2013. Preliminary results suggest that measures addressing intestinal parasites and iron-deficiency anemia produce measurable benefits.

As CDC’s work with Thailand partners has expanded from FETP in 1980 to include additional programs such as HIV/STD research, global HIV/AIDS, tuberculosis, global disease detection, influenza, quarantine and migration, non communicable disease interventions, laboratory strengthening, and the President’s Malaria Initiative, the benefits of our collaboration are clear. The research we conduct with partners in Thailand benefits us in the U.S. The public health actions that protect refugees in Southeast Asia improve their health and prevent importation of disease into the U.S. The higher the skills of Thailand’s public health workforce, the more protected the region and the world will be from infectious diseases and other health threats.