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Conversations with the Director: Patrick Lammie

July 23, 2012

"We Don't Care Who Gets the Money as Long as the Work Goes Forward"

CDC Director Tom Frieden, MD, MPH, and Patrick Lammie, PhDCDC Director Tom Frieden, MD, MPH, and Patrick Lammie, PhD, biologist in the Parasitic Disease Branch, discussed Lymphatic Filariasis, one of the world's most disabling and economically costly tropical diseases. Photo by Kathleen Nellis Chastney

CDC Director Tom Frieden, MD, MPH, and Patrick Lammie, PhD, biologist in the Parasitic Disease Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, sat down recently during a Conversation with the Director about Lymphatic Filariasis (LF), one of the agency's winnable battles. Once a month, Frieden holds a one-on-one conversation with a CDC employee to discuss his or her public health work."For me, the fun part is just learning about you and your work," explained the director.

Lymphatic Filariasis (LF) is a disabling parasitic disease caused by microscopic, thread-like worms that are spread from person-to-person by the bite of infected mosquitoes. More than 120 million people are infected with LF, a disease that can be eliminated. CDC and its partners provide assistance to Ministries of Health to protect people from LF through community mobilization, distribution of effective drugs, and program monitoring and evaluation. The goal is to eliminate LF, first from the Americas and then, globally.

LF is considered a Neglected Tropical Disease, one of a group of parasitic and bacterial infections that cause tremendous morbidity, but little mortality. The adult worms only live in the human lymph system. The lymph system maintains the body's fluid balance and fights infections. People with the disease can suffer from lymphedema and elephantiasis and in men, swelling of the scrotum, called hydrocele. Lymphatic filariasis is a leading cause of permanent disability worldwide. Communities frequently shun and reject women and men disfigured by the disease. Affected people frequently are unable to work because of their disability, and this harms their families and their communities.
Patrick Lammie, PhD

Lammie said, "I think the essential CDC role here is we provide help to write the proposals; we don't care who gets the money as long as the work goes forward, and then we provide the technical input to make the program succeed. I think we're the glue that holds the partners together." Photo by Kathleen Nellis Chastney

Patrick Lammie, PhD

Lammie said, "I think the essential CDC role here is we provide help to write the proposals; we don't care who gets the money as long as the work goes forward, and then we provide the technical input to make the program succeed. I think we're the glue that holds the partners together." Photo by Kathleen Nellis Chastney

"Lymphatic Filariasis is one of the world's most disabling and economically costly tropical diseases," explained Frieden. "LF causes tremendous suffering to individuals in the form of chronic pain, severe and irreversible disfigurement, and social stigmatization. More than one-fifth of the global population is at risk of acquiring LF. We have identified eliminating LF as a key priority in global health. With additional effort and support for evidence-based, cost-effective strategies that we can implement now, we can have a major impact on LF elimination in the Americas."

In 1997, the World Health Assembly and World Health Organization called for the global elimination of LF by 2020. This initiative is driven by a two-fold, evidence-based strategy to:

stop the spread of infection through mass drug administration campaigns, and
reduce the suffering of people affected by filarial disease.

This strategy has already proven to be effective and the progress in Latin America is particularly promising. CDC has partnered with endemic countries and global experts to develop program strategies that can dramatically reduce the rates of LF worldwide. Today, 53 countries have ongoing programs to eliminate LF. In 2011, only Guyana, Haiti, and limited areas of Brazil and the Dominican Republic remained as regions in the Americas where transmission occurs and people are being newly infected. These four countries are all scaling-up their programs to reach the 2016 target date for elimination in the Americas.

"These elimination programs are critical to protect the health of more than 1.3 billion persons who are still at risk of becoming infected with LF," said Frieden. "CDC is strongly engaged in the elimination efforts, and CDC and its partners are committed to meeting the 2020 goal of elimination. With additional effort and support, we can win the battle of eliminating LF first from the Americas, and then the world."

While updating progress, Lammie described to Frieden the recent mass drug administration campaign in Haiti's capital city, Port au Prince. CDC provided technical and financial support. Early this year, more than 2.3 million people were treated in the six communes that comprise the metropolitan area.
Tracy Phan, Sonia Pelletreau and Jeff Priest. Not pictured are Delynn Moss, Kim Won, and Diana Martin.

Lammie (left) is shown in the lab with team DPDM and DFWED staff involved in the development and validation of the multiplex tool. They include Brook Goodhew (seated) and standing from (l-r): Tracy Phan, Sonia Pelletreau and Jeff Priest. Not pictured are Delynn Moss, Kim Won, and Diana Martin. Photo by Kathleen Nellis Chastney

Tracy Phan, Sonia Pelletreau and Jeff Priest. Not pictured are Delynn Moss, Kim Won, and Diana Martin.

Lammie (left) is shown in the lab with team DPDM and DFWED staff involved in the development and validation of the multiplex tool. They include Brook Goodhew (seated) and standing from (l-r): Tracy Phan, Sonia Pelletreau and Jeff Priest. Not pictured are Delynn Moss, Kim Won, and Diana Martin. Photo by Kathleen Nellis Chastney

"CDC is supporting a lot of activities in Haiti and one of those is the elimination of LF in Haiti," said Lammie. " It's a huge challenge in terms of delivering to a city of roughly 3 million people…many of whom are living still in the camps or living in slum areas. Post-cholera, we have a huge logistics challenge. What is this? Water-bags of water. We have to provide water distribution posts. One of the things that is really cool is the way people have really taken the message onboard. Five years ago if I put a bucket there, people would come with a cup and dip water out of it. Now, when people want the pills, they will not take the pills if they haven't washed their hands-so the cholera messages are definitely there."

With Port au Prince's campaign complete, Haiti has achieved full national coverage with its mass drug administration program for LF. According to World Health Organization guidelines, a total of four to six years of mass drug administration is recommended to interrupt transmission of the disease.

Lammie continued, "Haiti now has full country coverage. From this school year, from last September to June, 8.7 million people were treated, and I would call that the largest public health program ever in Haiti. We are in the situation now where we can absolutely touch every community and basically every household."

In order to do that on an annual basis, the Ministry of Health and partners are training or retraining 28,000 people per year, an enormous public health resource.

Frieden and Lammie discussed many issues concerning LF, including types of mosquito transmission, the possibility of accelerating the program through twice-a-year treatments, bed nets, and much more, as well as other health concerns in Haiti, such as iodine deficiency. They talked about the critical role of partnerships, USAID and the Bill & Melinda Gates Foundation and private funding now being raised by partners from Notre Dame.

Lammie said, "I think the essential CDC role here is we provide help to write the proposals; we don't care who gets the money as long as the work goes forward, and then we provide the technical input to make the program succeed. I think we're the glue that holds the partners together." Given the challenges Haiti has faced over the past decade, with civil strife and a devastating earthquake and cholera outbreak, full national coverage constitutes a major success in the drive to eliminate this disabling and preventable disease.

As the two discussed the disease, Frieden also talked with Lammie about Lammie's time at CDC. Lammie said, "I came almost by chance in 1989 and the intent was really to be here for five years and then to get back in the academic arena. But I liked the platform; I liked the fact you could do things here that really have a global impact, and we're in a position where we can influence policy on a scale that you just can't imagine."
Patrick Lammie, PhD

Lammie received his PhD from Tulane University in 1983 following doctoral research on Lymphatic Filariasis. After a post-doctoral fellowship at the University of Pennsylvania, he was a faculty member at LSU Medical Center in New Orleans before moving to CDC. He also is an adjunct professor at both Emory University and the University of Georgia. Photo by Kathleen Nellis Chastney

Patrick Lammie, PhD

Lammie received his PhD from Tulane University in 1983 following doctoral research on Lymphatic Filariasis. After a post-doctoral fellowship at the University of Pennsylvania, he was a faculty member at LSU Medical Center in New Orleans before moving to CDC. He also is an adjunct professor at both Emory University and the University of Georgia. Photo by Kathleen Nellis Chastney

Lammie said he's enjoyed the opportunity to go from bench to field. "One week I can focus on laboratory issues; next week get out into the field looking at programmatic issues." Lammie told Frieden he was fascinated when he got into field work. "The field work, well it has to be the same for you in the clinical arena. Once you have that first taste of the impact of the disease on people, something clicks."

The two discussed the challenges with LF globally. Lammie noted, "We don't really have a validated surveillance strategy, so from the laboratory side we are absolutely engaged in the development of new tools that can be used for surveillance for filariasis and other neglected tropical diseases. One of the take-aways in the world of neglected tropical diseases is that nobody is going to pay for surveillance. So our strategy is to develop a multiplex surveillance tool: We'll generate data for vaccination programs, malaria programs, water and other programs and we'll also get the data we want." This effort, a collaboration with Jeff Priest and Delynn Moss of CDC's Division of Foodborne, Waterborne, and Environmental Diseases, is attracting a great deal of interest from partners outside CDC.

Lammie explained that CDC is working with NIH and others to validate new antibody tests for filariasis that hopefully will be the basis of a new surveillance system. "But who is going to pay for it? I am not a defeatist. So what have we done? We've said we're going to build a multiplex that we can convince other people to use. And what do I need to have in that multiplex? I need to be able to monitor vaccine coverage, I need to be able to monitor malaria programs. I need to be able to monitor WASH programs. You name it, we can do it."

He explained that multiplex represents huge potential cost savings. For example, you don't have to pay a technician to run only one test when you can do 25 or more at the same time. "The pitch is getting others on board, collaboration, looking for opportunities where platforms can generate data across multiple diseases. It makes sense to get people into the mindset that this is a cultural expectation, where we have multi-disease surveillance to reduce demand on people and costs to countries."

The hour passed quickly as the two engaged in lively conversation. At the end, Frieden asked, "What can I do to better support your work? Sorry, we're out of time!" After they finished laughing, Lammie said, "I would say two things. One is that you're the champion for getting people to work across centers; that's a situation, that dynamic has changed a lot during your tenure here, so I give you credit for that. I think the second thing I think I will mention out of allegiance to my lab people is that I think in some areas the labs are struggling. I came to CDC many years ago and the labs were really the drivers, really the center of the institution. And I think that it is absolutely fair and safe for me to say that our support for the labs has eroded over the years, and I think we're less able to contribute than we once were. It doesn't mean we're not contributing. I think we are still the idea generators, but I'm a little bit anxious about losing some of that capacity. We appreciate the fact that you are a champion for global health. This is a real thrill, I think, for us to have a director that is so engaged in the activities, and I think it's also great to have somebody that likes to get into the weeds."

This Inside Story by Kathleen Nellis Chastney.

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