Beijing huan ying ni (Beijing welcomes you!)

Greetings from the Immunization Group, back in style in Beijing!

We have had a very busy past few days! Yesterday, we visited DongLi County CDC, with our large entourage of Tianjin CDC EPI personnel. We were greeted by the director of the CDC and ushered into a beautiful conference room where we received a debriefing on the immunization logistics of this county. Next, we split into two groups and visited rural immunization clinics. One clinic was very crowded, filled with dozens of children and family members. We walked through the hectic immunization clinic from the registration room all the way to immunizations and observations. The other group did a similar thing, minus any babies. This clinic was completely devoid of any patients and/or any action that may have ensued.

Now let's talk about some important stuff: food! For lunch, we went to an extremely nice restaurant where our posse filled a 21 person table (it should be noted that our group consists only of 8 extremely good-looking SPH peeps... well, duh!). As if we hadn't tried enough interesting culinary masterpieces, our lunch began with pig ears, chicken feet, and eel!

After the deluge of dishes, the groups walked off their food by administering a small-scale survey in a rural developing village, allowing us once again to fit into our pants. Upon arrival, we were a spectacle for all of the villagers. A small crowd gathered as we traveled through the village, although children ran away in fear because they thought we were doctors there to give them shots. Luckily, we brought along some balloons to entertain the children, which quickly brought smiles to their faces. We conducted the survey to compare the parents' copy of the child's immunization record with that of the hospital as well as checking for up to date and proper timing of vaccination. We are unaware of any statistical implications that our findings may have, but grant proposals for further studies are pouring in.

Today, we analyzed the results of the survey and found that the two records were very comparable and that the vaccinations were given in a timely manner. Afterwards, we chatted with our new friends in the EPI department and learned more about their culture and lives. We were so sad to leave because we have grown very close to them in the past week and we now think of them as our good friends. Some of the members showed us pictures of their families and hometowns, which was really neat!

As a last little word, we would like to thank Dr. Liang and the staff of the EPI department for allowing us to infiltrate their division of the TJCDC and cause trouble all week. We are very grateful for all you have done for us, and we will never forget the dragon eyes (longen berries), er guo tou, mar huar, tian dur, and all the fun times that we have shared together. We hope to see you once again!

Before we leave China, we would like to say:

Wo-shi wan Tianjin! (aka- I Love Tianjin!)

- Team Friendlies (aka BeiBei, JingJing, HuanHuan, YingYing, NiNi, the famous olympic mascots that we have come to know and love!)

The Outbreak Round-Up

Well this constitutes our last night in China. It's a bit sad to think about leaving all the great friends behind that we've made, but home is never too far away. This week has been a great opportunity to validate our education at SPH and gave us the chance to further our knowledge in an area many clinically-trained physicans don't even get to learn.

While here, we've been able to take an active role in measles outbreak and surveillance. Our group traveled into district hospitals to learn the methods of disease control and how patients were treated. Over the next couple of days, we spent time in Tianjin districts conducting follow-up surveys within the homes of local residents. Some of the kids we met were absolutely hilarious. In one home, we met a three year old boy who put on a sweet kung-fu performance that absolutely compared to some of the best Asian kung-fu movies ever. Using the data we collected from our group foll0w-up, we were able to start seeing patterns and trends that related measles outbreaks to activity within communities and even more interesting, within the hospitals.

Upon assesing what little data we did have, we realized that many children were coming down with measles in the hospital for completely different reasons. Back home we're used to MRSA, VRE, and C-diff dominiating the scene and don't think of viruses being a major source of nosocomial infections. However, in China many children come for a plethora of small things and end up going home with a case of measles. This creates a huge problem in the public health system for China as the population numbers are very high and there is a shortage of vaccine to carry out a thourough vaccination program. While in the US, we see at most 7-10 cases per year, there was 27 cases in one province of China before lunch-time. That truly is astounding when you think about the fact that most US physicians will never even see a single case in their careers. We found that children were often not vaccinated properly even given immunization records. When you think about the sheer number of children to try and vaccinate, it's an astronomical task for the CDC to undertake, especially with a large float population.

It was interesting to dig deeper into the infrastructure of health-care from top to bottom in investigating and treating measles cases. It began with a village doctor who provided vaccinations and initial care to members of the community, but quickly traversed up the chain via real-time on-line surveillance reporting to alert the local, district, and national CDCs. Each link in the healthcare chain was integral in assuring that measles prevention could take place.

Between the food, the sightseeing, and soaking up as much new information as we could handle, the week flew by quicker than we ever expected. We leave China tomorrow with a new appreciation for the public health system here, the surveillance methods, and all the new friends we've made at the Tianjin CDC. We are sad to leave, but are thankful for the chance we've had and the memories of a lifetime!!!

Kickin Back with PHAST and the Tianjin CDC Director

The PHAST group taking a minute out of their EXTREMELY busy day to pose with General Director Professor Wang Xiexiu of Tianjin CDC.

photo courtesy of Tianjin CDC

http://cdctj.com.cn

Imagine...

...you are a clinician in a friendly neighborhood where 17 teams of retired people (over 60) meet regularly in parks to get exercise and some social time by practicing tai chi routines to music (and sword dances, and fan dances, and more). You've brought some visiting foreigners (rarely seen Americans) to watch the practice, to show how your society finds a wonderful way to encourage older folks to exercise. This is the sort of activity you yourself enjoy, and are quite adept at. It's a sunny afternoon, and everyone is feeling lighthearted. The spirit moves you to join in the practice. So you do.

That's the sort of thing that happens in Tianjin, China, where people don't seem too terribly inhibited... which is a lovely thing, in this case. (Watch sword dance video below.)

Home visits

Some of the groups have ventured into rural areas surrounding Tianjin, even getting opportunities to visit family homes--to talk about how a child has recovered from measles or the status of drinking water or other health issues of everyday life. The families are wonderfully gracious to the curious students. The homes are modest from the outside, but they are usually attractive and immaculate inside, often with an open courtyard.

No bother

The immunization team visited the Hongqiao District of Tianjin today. We traveled to the district hospital and two "street level community clinics" in order to observe and evaluate the immunization delivery program (Extended Program for Immunizations, EPI). This program includes 9 vaccines covering 11 diseases (e.g. MMR, BCG, HBV, DPT etc.).

Upon arrival we strolled down the red carpet they had rolled out for us, signed a few autographs, smiled for the Paparazzi, kissed a few babies, shook a few hands and proceeded into an alleyway one might associate with a four year olds graffiti artwork (think panda bears and pink cartoon rats). Just kidding....but seriously. Then we were were greeted by an entourage of medical staff cloaked in white lab coats and smiles of curiosity. They escorted us into rooms full of adorable vehicles of transmission (children) receiving essential immunizations. We made the children laugh...everyone likes foreigners. Then we watched them cry...no one likes shots. Someone should alert Amnesty International, they are giving these kids shots and are NOT giving out the obligatory lollipops. Immunization history is kept using a standardized red booklet which details time, date, dosage, vaccine lot, etc. Detailed records are also kept on Cold Chain maintenance of vaccines. Electronic immunization records that can be accessed by any provider are also kept. Overall we believe the Chinese EPI system is far superior to that of the United States (eg. where is your immunization card?).

After going through the immunization clinic we continued to tour the rest of the hospital, met with various staff, and spent some time observing acupuncture and learning about traditional Chinese medicine. We then watched the pharmacist fill a prescription of 20 herbs, roots and animal bits to treat Chronic Pulmonary Obstructive Disease (COPD). Anyone interested in some turtle shell tea? And then we ate.

Not the turtle shell.

-Immunization Team (Team Martin, Team Xei Xei, Team No Bother, Team Unix, Team Corange, stay tuned for future name alterations)

P.S. we also saw a floating baby...

We, the health education group, have gone through the second day of our field experience in Tianjin, and it has been an incredible experience so far.

This morning we started at Hexi Maternity Hospital where we were thrilled to observe the pioneering foot massage technique which helps to stimulate the flow of breastfeeding. This hospital has been instrumental in disseminating this practice throughout Tianjin, and the practitioners have published several articles in scholarly journals promoting the efficacy of these methods. We had the amazing opportunity to witness the massage technique on a new mother who had given birth 3 days previously. This method of massage is something we would recommend bringing back to the U.S. to incorporate with the post-partum maternal standard of care. This hospital prides itself on being "baby friendly" and strives to have the newborn baby with the mother within 30 minutes of a natural delivery, and as soon as possible with other methods of delivery.

An experience that all of us thoroughly enjoyed was the floating baby. In this practice, the newborn is placed in a warm pool of water (body temperature), being comfortably supported by a musical flotation device. For ten minutes, the baby is comforted by the simulated feeling of being in the mother's womb. The attending nurse also assisted the baby's limbs in gentle exercise movements.

Overall, our experience with the host country's interpreters and CDC and hospital staff have been spectacular. We have received a warm welcome as they have shared their cultural practices and professional expertise. We're looking forward to the remainder of our stay with them!

Is water a right or a privilege?

After two days of learning about the Tianjin water system the Environmental Group was left to wonder: should all people (in both rural and urban settings) be provided with access to treated water? From our collective points of view we take water for granted - regardless of where we go in the U.S. we can get water either out of our home faucets or from our local grocer. In the plains of rural Tianjin, however, treated drinking water is hard to come by. With underground reservoirs being the norm this means untreated, unfluoridated water is the primary supply available. If residents want treated, healthier options they have to purchase water coolers and make their own arrangements to get barrels of water. When cleaner water is better for one's health, what measures should and can be taken to make sure that everyone has access to defluoridated H2O?

Water World!

Nee Hao! This morning the Environmental Health group journeyed southwest of Tianjin to the rural Jinghai district. Lots of sunshine and warm temperatures today! Here we are learning about the importance of water defluoridation and the new strategies being implemented in Tianjin to provide treated water to the residents of rural Tianjin. We've had so much fun and learned a tremendous amount after only two days of touring water treatment facilities and collecting terminal water samples from all over Tianjin. Friday we'll get to help test the water samples we've collected!

Outbreak group visits 5th Central Hospital in Tianjin

On its first day in the field, the outbreak group had the good fortune of visiting a showcase hospital in Tianjin. They watched as the CDC communicable disease staff administered a questionnaire about measles to 5th Central physicians who had diagnosed a handful of 640 measles cases diagnosed in the city of 11 million thus far in 2008. SPH students had worked with the CDC staff on a couple of new questions for the survey in the morning, in a long discussion about possible reasons for the 600-percent increase for winter-onset measles cases the city is currently experiencing. Having a chance to walk through a Chinese hospital's emergency room and pediatric wards was an incredible opportunity. The nurses and doctors were willing to take time to talk about what they do, how they report diagnosis of infectious disease (twice a day via the Internet), how they decide to refer patients to the stand-alone infectious disease hospital not far away.

A word about traffic, cars and bikes...

Yikes.

Country roads, take me home... to China!

So, you're probably all wondering what the heck we've been doing in Tianjin... Well, we, the immunization group, started our first day of work today at the Tianjin CDC. After our breakfast, we were escorted to the CDC, and by escorted, we mean we had to dodge oncoming cars and bicycle herds. I guess to give those who have never been to China a better perspective on what this means: picture Ann Arbor, on State Street, during the first week of school, times 14. After our arrival at the TJCDC, we listened to several presentations on the immunization program in China. While our lectures were interesting and very informative, the most exciting part of the day was the "exchange of cultural information." For example, we asked what stereotypes many Chinese people might have of Americans, to which they responded saying we are honest, open minded, a melting pot, and that we tend to not save very much money. We also asked them what kind of music they like to listen to, and, to our surprise, the most popular American song in China is "Take Me Home, Country Roads" by John Denver. Because a few Americans didn't know the song, Kraig decided to sing a few lines, and one of the CDC doctors, who had said only a few words beforehand, joined in and finished the song in perfect English with a sweet solo!

After a very informative day, tomorrow we are looking forward to a day in the field at the Hongqiao District CDC, where we will be viewing immunization procedures in an urban health care setting. Later, we will be administering immunization coverage surveys in the Dongli County Health Stations. Keep checking back for updates!!!

Zai jian!

- The Immunization Group

On to Tianjin...

Today marked the second day in Tianjin for the PHAST group. Yesterday the group checked out of the hotel in Beijing and traveled directly to the National CDC to hear a series of talks about the varied and important functions of the CDC network. Among the highlights was a virtual tour of the CDC's online disease surveillance and reporting system - an impressive database containing information from health centers nationwide.

We then traveled to Tianjin. A quick windshield tour revealed countless gleaming high-rise apartment buildings and offices, with countless more in various stages of construction. Tianjin is certainly a city on the rise! The group spent the afternoon in the Tianjin CDC office. Introductions to the staff were made and the group was given a tour of the impressive new building.

Today the PHAST members met for the first time as smaller groups in order to begin the week's work. The morning was mainly devoted to introductory lectures about the CDC's role in outbreak investigation, immunization services, environmental health sciences, and maternal and child health. In the afternoon, some of the smaller groups set off into the field. Tomorrow the smaller groups will scatter across Tianjin in order to investigate their topics and work on their field assignments.

State welcome

Students and staff enjoyed gracious welcomes Monday, first at the China national CDC in Beijing in the morning, where they met with several epidemiology division officials and watched a real-time Internet report on hundreds of new measles cases in the area they were headed to, Tianjin. Arriving there at that provincial CDC in the afternoon, SPH staff were given a state welcome and seated at a table with division heads to hear about projects students would be assigned to for the rest of the week: visiting children who have recovered from measles in their homes, visiting hospitals, monitoring rural drinking water, engaging in health education sessions with rural mothers, and working on immunization programs.

A Whirlwhind Tour of Beijing

As PHAST members have already mentioned, today was our first full day in China. We certainly made the most of it!

After an early breakfast at the hotel, we hopped a bus and traveled to the Great Wall of China. Although the weather was chilly, the group gladly spent an hour or so wandering down a small section of the 6,800 km passageway. The enormity of the structure was shocking - it is almost impossible to imagine the amount of work that must have gone into its construction (and later reconstruction).

After being mobbed by vendors on the way back to our cozy tour bus, we headed back into the city for a delicious meal and a tour of the Forbidden City. Built during the Ming and Qing Dynasties, the Imperial Palace is truly a work of art. The palace grounds seem to stretch on forever, with a total of 9,999 and a half rooms. The group was able to view some of the most respected and fiercely guarded buildings in Chinese history, including the Emperor's bedroom (with its ten beds), the Empress's living quarters (a beautiful display of red silk and embroidery), and the celebration or meeting hall.

Following the Imperial Palace, we took a tour through a local community in bicycle-powered rickshaws. Despite a few minor crashes and a temporary mechanical malfunction, the group made it through the narrow, winding streets of the Hutong. It was quite a contrast to see how the rest of the population was living outside of the palace walls! The houses were usually smaller but looked comfortable and well lived-in. Residents, for the most part, did not have bathrooms in their homes but instead used communal, public bathrooms. The younger generation has begun to move from these neighborhoods and into high-rise buildings, but a strong-knit older community remains in these courtyards, living in the homes that had been passed on generation to generation.

Finally, we trekked over to the Tian'anmen Square to watch the official flag lowering ceremony. By then, it had become bitterly cold, and the group was eager to find its way into a heated building. We took refuge in the King Roast Duck restaurant and had our second huge but delicious meal of the day before heading back to the hotel for the night. Tomorrow morning the group will travel to the National CDC and then on to Tianjin!

Forbidden City, friendly city

Here's a pic of most of the students outside the gate to the massive Imperial Palace. Our guide was enthusiastic about the meaning of colors, numbers, etc. Pretty interesting. Also learned a lot about the eunuchs' role in ancient times... Bitter cold today but we ate enough to make up for the calories expended. The city of Beijing is a contrast in opulence and sooty tiredness--a tour of the old courtyard-style multi-family hutongs actually put us in residents' century-old living rooms, with a gracious host. Every one has been nice.

First day in China!

Right now it is the end of the day on Sunday, 9:30 at night we had our fun sightseeing day today--we walked on the Great Wall, went to the Forbidden City, rode in a bicycle-pulled rickshaw cart, saw the national flag ceremony in Tiananmen Square, and ate TONS of food (Stephanie and Kristen at lunch, right). It was really interesting, but freezing cold, so a hard day to be outside all day. We'll see the CDCs tomorrow and begin our projects. As for now, off to bed...

Last minute details...

We are just over 24 hours away from beginning our journey to China. At this point, I can still think of a million things I need to do before we leave. But really all I am thinking about is the trip and getting ready. Doing laundry, writing lists, making phone calls, sending emails, rounding up my homework, and paying bills. It all gets taken care of somehow. By this time tomorrow, I'll be ready to relax on the plane for a good 12 or 13 hours. :)

The destination

In less than 3 weeks, the PHAST students will take a 14-hour flight to China. After a stop in Tokyo, first destination in Beijing. Tianjin is the seaport, just to the southeast.