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Medicine

Accurate clinical assessment of dehydration is critical to improving the quality of care and epidemiologic research. We began in 2005 developing the Cholera Outbreak Training and Shigellosis (COTS) program to export the medical, scientific and public expertise on the management of large-scale diarrheal-disease outbreaks from Dhaka Bangladesh to unexpected sites globally. This work was championed by Dr. David Sack, MD at both Johns Hopkins University and the International Centre for Diarrhoeal Disease Research, Bangladesh and funded by USAID. COTS was successfully deployed internationally with partners at the WHO and CDC (USA), however it did have limitations. These limitations related to drawbacks with paper-based tools (e.g. unable to update, difficult to print, difficult to maintain). In response, we have established an international team of clinicians and software developers to adapt the paper-based guidelines onto smartphones. These tools have been piloted and now are being scaled to larger validation studies in Bangladesh and Haiti. So far, we have found that these tools can normalize the assessment of dehydration and encourage more prudent use of IV fluids and antibiotics. The improved assessment also enables epidemiologists to better track and report outbreaks based on clinical presentation (syndromic surveillance).

Science

We are rooted by the quote “nothing in biology makes sense except in the light of evolution” by Theodor Dobhzansky. We believe that to best stop pathogen transmission we must first understand the selective pressures that drive pathogens through their life history. To do this we study the relationship between Vibrio cholerae, its human host, and the aquatic environment. We happen to focus on the selective pressures of antibiotic and lytic phage predation because these forces tend to naturally dominate our field studies. The challenge we face is how to reproduce these dynamics in the lab, or develop tools to better study them in remote outbreak settings. We collaborate with field teams in Bangladesh and Haiti to improve point of care diagnostics for cholera and methods to better preserve samples when no cold-chain exists. When samples do arrive from the field, we have developed both quantitative PCR, Next Generation sequencing and mass spectrometry techniques that are high-throughout yet lower cost. The combination of improving research capacity along the field and laboratory spectrum is providing unanticipated insight on how better to respond to outbreaks.

Technology

Paper reporting forms are outpaced by fast moving diseases like cholera. We began asking how we might bring mobile software into outbreak settings during the 2010 cholera outbreak in Haiti. We have subsequently built a point-of-care decision support calculator for both bedside clinical support but also improved syndromic surveillance. In parallel we have built a platform called Outbreak Responder for both bedside management and outbreak surveillance. These tools have been piloted in Bangladesh and are now being scaled to operate with population coverage of greater than 1 million person communities. We rely on a method called human centered design to assure that what we build meets community needs and is sustainable. This design method requires listening to communities to understand the problems they face, allowing communities to vocalize solutions, and then prototyping and testing these community inspired solutions in real-life scenarios. We view the rehydration calculator and data collection platform as two additional tools that responders can use during outbreaks. Future endeavors involve improving access to care early in disease and developing methods for communities to better report public health problems.