Dana Haberling and Jodi Vanden Eng

Getting to Zero

Dana Haberling

Dana Haberling is a statistician in the Prion and Public Health Office in the Division of High-Consequence Pathogens and Pathology at the Centers for Disease Control and Prevention in Atlanta, Georgia. In January 2015, she spent a month working in Sierra Leone as part of the ongoing Ebola emergency response. She earned her MSPH in biostatistics from Emory University School of Public Health.

As statisticians, we don’t often get opportunities to get out in the field. But hey, I work for the Centers for Disease Control and Prevention (CDC), too! I love public heath, too! And I think it sounds “fun” to go out, too! So as soon as I could, I put my name in for a deployment to West Africa to be part of the Ebola response.

In real life, I am a “health statistician” and I tend to act something like a consultant to my group at CDC. My division covers many diseases, and so I see many types of data and studies. We’re heavily slanted toward epidemiology, but the job really requires a statistician’s thinking and a statistical programmer’s capabilities. I knew there were a lot of data going around in West Africa and figured I would have something to offer that others did not. That said, for an outbreak, you know going in that you have to be flexible.

The amount of time and effort it takes to get any one person out the door is staggering. On top of my typical week and preparing to have my current projects under control, I needed the following:

• Official permission from my boss
• Training for personal and health safety
• A visa for Sierra Leone
• Plane tickets
• Budgeting paperwork
• Clothing that washes well in the sink and can air dry
• Food, soap, and whatever else I might need
• Any number of arrangements for the life I was leaving behind for 29 days

This is all done with the help of CDCers in Atlanta volunteering to work Ebola administration roles. Two days after Christmas, I boarded a plane for Freetown, Sierra Leone.

Everyone from CDC working in Freetown lived and worked (we took over a conference room for an emergency operations center) in the same hotel. The average day felt a bit like being a freshman again: roll out of bed, load up on a buffet breakfast, walk down the hall, stick my head in a laptop, take quick breaks for ramen or coffee, maybe join happy hour with colleagues (including laptops, work phones, and usually talk of Ebola), have a quick Skype with loved ones, and then work in my room until it was late/early enough to get some sleep in preparation for the next day. Repeat 28 times. The days were long. But, because I was so into the work and on the go, it was a week before I realized just how close to the beach I was.

I ended up as the country data manager and statistician. In many ways, you can imagine what it was like: getting new data, trying to understand and clean it both for regular and ad-hoc analysis, trying to figure out what had been done previously, interpreting hand-me-down code, and wondering how I might be able to improve anything for the next person.

In the beginning, it was a little intimidating to step into the middle of a big production that seemed to be going along just fine without me. But much like being a freshman, I quickly found my place. I got to know other CDC people (some from my own building in Atlanta and others from international offices), the Sierra Leone Ministry of Health staff, and others from different organizations or NGOs.

It eventually became normal to see the doorway guards with bleach water and a thermometer, signing up for a driver if I needed to go out, feeling comfortable with road blocks and check points, getting dinner or takeout before the city-wide curfew of 6 p.m. (thereby avoiding another hotel dinner), and navigating new buildings and meeting protocols.

Several days of my week were spent working at the Ministry of Health. My main task there was pushing to streamline the data acquisition from various districts, each with their own data manager, and helping get a weekly national data set published. We provided both analytical and technical support for their daily count reports; others from our epidemiology team taught the staff how to use mapping software to reproduce what the CDC had been providing.

Statistical work on the ground in Sierra Leone was like working with the cartoon angel and devil on my shoulders: The angel wanted me to examine my data, follow assumptions, and produce organized and beautiful graphics; the devil nagged me to rush and just get something out the door! Professionally, this was the biggest challenge. And everything required patience—patience with myself for not working fast enough, patience with my co-workers who needed data/graphs/tables/p-values/something shiny right now for a presentation in five minutes(!), patience learning how partner organizations worked and how to fit in with that, patience learning the needs and abilities of the Ministry of Health staff, patience waiting for data updates. Patience. My biggest lesson learned was that when you aren’t afforded the time to double-check everything, you still always do your best work. However, you do your best by keeping it simple and trusting your abilities and statistical intuition.

Finally, I must also acknowledge the constant and real interaction with people who were suffering with and dying from Ebola every day. By the time I arrived, the epidemic had been going on for months without a break, and no one knew when it might slow down. The entire region suffered horribly, and many thousands lost their lives or family. But what I consistently saw were people who were grateful for our presence, patient with our questions, and always welcoming and gracious.

Those who volunteered to work on the ground—in any capacity—may have had different motivations for going to West Africa, but there was comfort in knowing we were all there for the same reason: to get to zero.

Seeing the Big Picture

Jodi Vanden Eng

Jodi Vanden Eng is a statistician in the Division of Parasitic Diseases and Malaria at the Centers for Disease Control and Prevention in Atlanta, Georgia. She spent six weeks working in Sierra Leone as part of the ongoing Ebola emergency response. She earned her MPH in epidemiology from Yale University School of Public Health and MS in biostatistics from the University of Michigan Ann Arbor School of Public Health.

As a mathematical statistician at CDC, I consider myself a statistical programmer and consultant for epidemiologists. I’ve had the opportunity to work internationally many times while working in the Division of Parasitic Diseases and Malaria, which has a large international component. In addition to statistical analysis, much of my fieldwork has involved developing tools and training ministry of health staff on the use of mobile data collection, specifically using PDAs and smartphones to improve data collection for national household surveys, surveillance, and other research projects.

I have traveled to West Africa several times. In fact, I had been to Sierra Leone four times previously to work on malaria prevention activities before being deployed for the Ebola response. I thought I was well prepared. I was used to the late night ferry crossing when you arrive at the airport; I was prepared for the hot harmattan weather (a dry, dusty wind); I was familiar with the geography, bumpy roads, traffic bottlenecks, and dilapidated government buildings; and I already knew some of the local customs, greetings, and not-too-distant history of civil war. Moreover, I had experience working in two other emergency deployments—one in 2005 after the tsunami in Indonesia and one in 2010 after the earthquake in Haiti.

Time Magazine had just released its Person of the Year edition, so I bought it at the airport and read it on the plane. I was heartened to read accounts from Ebola fighters, nurses, and doctors—the heroes on the front lines risking their lives to treat patients with a deadly and devastating virus. It was exciting to see a full profile picture and comment from CDC Director Tom Frieden at the end of the article, and it was sobering to have a sense of security because I thought the closest exposure I would have to someone with Ebola was analyzing his or her data.

I thought I was prepared, but when I arrived in Sierra Leone on December 21, 2014, for a six-week deployment, the epidemic was at its peak. About 500 new cases were being reported every week and it seemed no end was in sight.

The differences from my previous visits were immediately apparent. Instead of people holding hands and hugging in general social situations, there were nods and faint smiles. Curfews at night prevented social gatherings. Roadblocks with hand-washing stations and fever checks had become routine. And drivers yielded to ambulances and any vehicle with EBOLA RESPONDER on the windshield.

During an emergency, flexibility and resourcefulness are important. I thought I would be supporting data management and analysis, but a colleague and I were given the task of assessing the surveillance process and data flow for the country’s Ebola response. This seemed insurmountable. How do you describe the surveillance and information systems of a newly introduced disease for an entire country? How do you account for the variation between districts, partners, and nongovernmental organizations? Despite the obstacles, it had to be done, so we developed a small standardized set of questions to determine the data inputs, uses, and outputs during the stages of an Ebola response.

We visited Ebola response centers in several districts and assessed the data flow from beginning to end from the patient’s perspective, including alerts (like 911), ambulances, case management, labs, quarantine, holding and treatment centers, contact tracing, and burials. At each of these stages, we attempted to identify variations among districts and potential data gaps and their causes. We assessed information technology infrastructure and resources. Most importantly, we obtained this information by meeting with key individuals without interrupting their primary response efforts.

During this assessment, I sometimes had mixed feelings about my work. Data collection and statistical analyses in emergency response seem like a catch-22. Data collection is often an extremely low priority—and rightfully so. Health centers need supplies; patients need beds, care, and transport; lab specimens need testing; potential contacts need tracing and monitoring to stop the chain of transmission; and families need closure for the loss of their loved ones. When people are dying, data are secondary.

Data are collected in the way they are most useful. In treatment centers without electricity, this means in a logbook and on a whiteboard. In urban areas with more resources, it means smartphones and geographic information systems. At the national level, it means reconciling and integrating all the data sources to make meaningful interpretations.

This can get chaotic. Nobody is thinking, “This may be better in a standardized relational database on the cloud.” Nonetheless, real-time data during an outbreak are invaluable for coordinating response efforts. Not only do data describe the epidemiology of the disease, but they also identify areas with the greatest needs and allow donors to direct aid and resources efficiently and cost effectively.

I saw public health workers tirelessly visiting every health center to train and retrain staff on standard infection control procedures and survivors staying at treatment centers to provide care for other patients. Special unplanned meetings were held to figure out where to place newly orphaned children or how to care for a pregnant woman going into labor while in quarantine. A volunteer set up a village hotline to enable families to get feedback about their ill loved ones. Although these types of efforts cannot be measured with data, they are just as significant and crucial in a response.

Working on this data assessment allowed me to see the big picture of the outbreak. In doing so, I realized how much the little things matter. From well-wish letters sent by U.S. school children to encourage us to care packages sent by CDC colleagues and family members during the holidays, from the warm greetings and smiles of gratitude shared with the Sierra Leoneans to the waving hands of small children, we were reminded often that we had so much to work for and protect.