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THe outbreak hunter

This man is predicting cholera before it appears. 

High above our planet, satellites are engaged in a floating ballet.

A few dance along Earth's orbit to track global weather systems. Some partner with locations on Earth to exchange television, GPS or phone data. And still others are choreographed to point into deep space to record other planets and distant galaxies.

A West Virginia University professor in a groundbreaking move is using satellite data to predict something much less celestial the outbreak of disease in order to save lives.

A Growing Disease

After nearly three years of war, Yemen is in the midst of what United Nations agencies have deemed the world’s "worst humanitarian crisis."

Ongoing hostilities, dilapidated infrastructure, famine and a crippled economy have plunged the war-torn country on the southern tip of the Arabian Peninsula into the largest cholera outbreak in history.

In December 2017, the International Committee of the Red Cross announced that the number of suspected cholera cases in Yemen had reached 1 million in less than nine months.

In contrast, Haiti, which suffered devastating levels of cholera after a 2010 earthquake that leveled the island nation, reached 700,000 cases over the course of three years.

"The escalation of the disease in Haiti, but especially in Yemen, is astonishing," said Antar Jutla, assistant professor in the Benjamin M. Statler College of Engineering and Mineral Resources, "particularly because cholera is an illness that is 100-percent preventable and treatable."

Jutla, a professor of civil and environmental engineering, studies hydroepidemiology, which he describes as the "nexus of hydroclimate, the environment and human health." He was recently awarded the prestigious CAREER award from the National Science Foundation to support this work.

Jutla became interested in this work as a doctoral student and National Oceanic and Atmospheric postdoctoral fellow at the University of Maryland. It was there that we began working with Rita Colwell, distinguished professor in Maryland’s cell biology and molecular genetics department.

Colwell, who is former director of the National Science Foundation and former president of the American Association for the Advancement of Science, is one of the foremost experts on cholera and pioneered work on the environmental factors that affect the spread of the disease.

As a researcher in Colwell’s lab, Jutla saw the impact that the work could have when viewed through the lens of civil engineering and infrastructure.

"Antar proved to be a brilliant research scientist with a capacity to absorb new information from diverse disciplinary fields, a talent that has allowed him to become an expert in climate-related infectious disease processes," Colwell said.

Although it remains a burgeoning field, Jutla recognizes the urgency of the work.

"There aren’t a lot of us doing this type of work yet," he said. "But we have an opportunity to understand how these different factors create conditions favorable for the proliferation of water-related diseases like cholera and what their impact will be on society.

"If we can ensure safe drinking water and sanitation facilities, we can control this disease."

Jutla

Antar Jutla uses The Cave to project maps on a large screen in his research to predict where cholera outbreaks will occur (SCOTT LITUCHY PHOTO).

The Worth of Water

For those living in industrialized nations, cholera may be recognized only as the disease that derailed a party of settlers on the Oregon Trail, the popular video game about migration to the Western United States.

But for millions of people around the world, cholera is not a pixelated game changer. It is a real, persistent and devastating illness.

Cholera is an acute infection in the intestine that causes diarrhea and can rapidly escalate to death from dehydration if left untreated. A waterborne illness, it is spread via water contaminated by fecal bacteria and becomes abundant in areas with inadequate sanitation systems and drinking water.

"When the British scientist John Snow discovered cholera in the 1800s, indications showed a strong association between the disease and the environment under certain circumstances," Jutla said. "I am looking at interactions between cholera bacteria and things like temperature, precipitation, organic matter and salinity in water through the lens of civil engineering."

Cholera outbreaks occur in two forms.

Endemic cholera happens along coastal regions on a seasonal basis. Environmental conditions such as warm temperatures and chlorophyll levels can spur the growth of bacteria already in existence in ocean waters. Often the disease is contained because communities are prepared for the regular pattern of outbreaks.

Epidemic cholera, like what happened in Yemen, is a sudden disease outbreak in inland regions with characteristic high mortality and morbidity rates. In these cases, communities are often unprepared to handle the outbreak.

"If the right conditions occur, the disease spreads quickly, and it is dangerous because communities are caught off guard," Jutla said. "On top of that, there is often a pre-existing breakdown in civil infrastructure or a new one caused by extreme events, which results in limited access to clean water, food, medical centers and treatments." 

Using sophisticated modeling, monitoring and surveillance tools combined with datasets and environmental and biological processes, Jutla and a team of researchers from the University of Maryland and University of Rhode Island developed predictive models for cholera outbreaks.

The only thing they needed was the empirical data to populate their algorithms.

Hello, NASA.

Cholera Water Drinker

A girl drinks water alleged to contain the bacterium Vibrio cholera on the outskirts of Sanaa, Yemen (ASSOCIATED PRESS PHOTO).

A View From Above

Jutla’s team was interested in monitoring cholera "trigger conditions" to observe the risk of the disease in regions like Yemen.

"We are linking satellite information with microbiological information and disease data to analyze conditions that are favorable for cholera," Jutla said. "The result is a comprehensive database and validations that can be used to produce risk maps at least four weeks in advance, enough time for countries to mobilize resources."

To do this, the team had to collect specific variables on things like population density and migration, but in Yemen they were faced with a particular challenge: the team had little to no access to the country’s population data.

With the ongoing volatility in the country and increased level of instability in the infrastructure, the datasets in question were in constant flux. Even if the team could have obtained the appropriate data, there was no guarantee that it would have been accurate.

"The use of NASA satellite data was especially important in Yemen since we didn’t have boots on the ground," Jutla said. 

The team collected observation data such as temperature, precipitation, water availability and land from satellites that keep watch over Earth.

Using the algorithms that they had previously built and validated with data collected from parts of South Asia and Africa, the team processed the satellite data from Yemen and calculated the risk of outbreak.

They predicted that the western regions of Yemen had a high risk of cholera outbreak in large part due to sudden wet conditions that preceded warm temperatures.

When these two environmental conditions fall in sequence, then the hydrological risk of growth of bacteria increases dramatically. If you add a condition under which humans interact with water, such as a natural disaster or civil unrest, an outbreak could occur.

While Jutla and his graduate student, Rakibul Khan, checked their models, the World Health Organization reported a major outbreak that closely mirrored the research team’s predictions.

"At that point, we decided to take a deeper look into the data from Yemen, because as a scientist, your first reaction is that there is a flaw in your algorithm," Jutla said.

But as he and Khan combed through their work, they found that risk of cholera was, in fact, high.

"On the scientific side of what we do, we were pleasantly surprised at the predictive power of the model," Jutla said. 

"But on the human side, we were very concerned about the impact of this infection on children and elderly in Yemen. We knew if the infection had triggered, then transmission was going to follow given societal conditions in the country."

That interest pushes the team to improve their models. Their primary focus is to refine and validate the product so that the information can inform decision-making. 

Currently the team is using NASA resources and funds from the West Virginia Space Grant Consortium to gather, process and analyze data for public use. Eventually they would like to have simulation tools robust enough to mimic the ease and clarity of pollen counts in weather predictions.

Cholera sewage swamp

A boy walks beside a sewage swamp covered with waste tires near a well in Sanaa, Yemen (ASSOCIATED PRESS PHOTO).

The Power of Prediction

In the case of cholera, which can ravage the body in a matter of hours, preparation can mean the difference between saving a life and sobering statistics.

For Jutla, the ultimate objective is to produce "actionable knowledge" that will reduce the incidence of water-related disease and death.

"Ultimately, you want to get the information in the hands of decision-makers — government agencies, local authorities, foundations and humanitarian aid organizations," Jutla said.

With timely and accurate notification, cities can deploy educational campaigns about safe drinking and sanitation habits, stock up on and distribute oral rehydration treatments and antibiotics (particularly pediatric antibiotics), mobilize health professionals, and inform policy and intervention strategies related to sanitation infrastructure and access to clean drinking water in vulnerable regions.

Yemen is still in dire need of humanitarian aid. The extreme events from war in the country have been major contributors to the spread of cholera, highlighting the critical need for stable infrastructure for water and health in order to stop the spread of the disease.

But government and aid groups report that nearly all those with the disease who have access to healthcare services survive. Cholera is easily treatable by treating those affected with an oral rehydration solution, a combination of sugar and salts mixed with water. Antibiotics and vaccines are also available.

Hope is on the horizon.

As Jutla and the team continue to refine their algorithms and datasets, they know that it is a race to beat the next cholera outbreak.

"Africa is the new homeland of cholera," Jutla said. "Many countries on the continent endure frequent extreme events, mass migration of human population and stresses on availability of safe water."

As seen in Yemen, these are the ingredients for a new epidemic.

Jutla also continues to help lead the growth of the field. In fall 2017, he and his colleagues completed a workshop in Bangladesh — the first of its kind — to develop a cholera warning system using remote sensing data from satellites.

"This was the flagship program," Jutla said. "The goal was to promote the use of these observations in public health decisions, from improving prevention efforts and raising disease awareness to water and sanitation management."

In addition, Jutla has been asked to speak at national and international conferences and other academic institutions that are looking to establish similar programs.

There is a great opportunity at hand — development of a unique and innovative civil infrastructure — which is directly tied to the mission of civil and environmental engineering.

"When I began this work, I realized it was about how engineers think about disease," Jutla said. "But it is larger than that. It is engineering, computer science, microbiology, medicine, public health and policy rolled into one.

"All of it is necessary to solve the biggest challenges facing the world today." 

Line drawing of a microscope with a small lightning bolt.

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