Conversations with the Director: Umesh Parashar

March 1, 2012

CDC Director Tom Frieden recently launched a new employee engagement initiative called Conversations with the Director. The first participant was Umesh Parashar. Photo by Kathy Nellis

"It's All About The Team"

CDC Director Tom Frieden, MD, MPH, kicked off his new Conversations with the Director series by discussing the rotavirus program with Umesh Parashar, who leads the Enteric Viruses Epidemiology Team within CDC’s National Center for Infectious and Respiratory Diseases.

Once a month, Frieden plans to meet with a CDC employee to discuss his or her public health work. “I get to learn more about the great work CDC scientists do,” said Frieden.

Staff are nominated by senior leadership to participate in Conversations with the Director. If you are interested, contact your senior leaders to submit your name or the name of someone else you think would be good for this series.

Reviewing Rotavirus

Rotavirus is the leading cause of severe diarrhea in infants and young children worldwide. The disease presents as severe watery diarrhea, often with vomiting, fever, and abdominal pain. In babies and young children, it can lead to dehydration that can be severe and fatal if not treated. Globally, rotavirus causes approximately half a million deaths each year in children younger than 5 years of age.

Rotavirus was also the leading cause of severe diarrhea in US infants and young children before the infant rotavirus vaccine was introduced in 2006. Prior to that, almost all children in the US were infected with rotavirus before their 5th birthday, causing about half a million primary care physician and emergency room visits and about 55,000-70,000 hospitalizations.

Frieden and Parashar explored complex issues concerning rotavirus and public health, including the economic implications. Commenting on CDC’s role, Parashar said, “Over the past three decades, CDC has been at the forefront of efforts to document the global burden of rotavirus disease and diversity of circulating rotavirus strains, together with key partners, including WHO, PATH, and the GAVI Alliance. As vaccines are being implemented globally, the focus has shifted to assessing the impact of vaccination and CDC has played a key role in such evaluations in many early adopter countries in the Americas. In addition, CDC is pursuing efforts to identify ways to improve the performance of rotavirus vaccines in challenging settings in developing countries, including alternative vaccine strategies that could be more effective.”

Frieden commented that several global partners had complimented him on their excellent collaborations with Parashar and his team and asked what were the keys to success in these partnerships? “I believe the key principles in such partnerships are simple: mutual respect, transparency, honesty, and good communication,” Parashar said. “As long as shared public health mission is the primary driver of a partnership, success is assured.”

Frieden and Parashar spent more than an hour discussing progress made by the Enteric Viruses Team in fighting this disease. Parashar’s team has 10 doctoral and master’s level epidemiologists who study the epidemiology, surveillance, research, and control and prevention strategies for gastroenteritis viruses, especially rotavirus and norovirus diseases.

Umesh Parashar. Photo by Kathy Nellis

A Global Problem

“Every year, about half a million children under 5 die from rotavirus, and more than 85 percent of those rotavirus-related deaths occur in developing countries of sub-Saharan Africa and south Asia,” Parashar said.

Parashar started at CDC in 1996 as an EIS officer, about 2 years before the first rotavirus vaccine was licensed in the US, so he got to be part of that work from the beginning. “I was involved in several projects to document rotavirus disease burden in US children and the potential health benefits of vaccination, and it was fascinating to be involved in the policy discussions around vaccine recommendations. It was a great experience.” These days Parashar is involved in assessing the impact, effectiveness, and monitoring the safety of the vaccine in the US and globally.

Parashar and Frieden met to chat just before Frieden was to visit India, Parashar’s birthplace and the country where he received his initial medical training. They exchanged information on a wide range of rotavirus issues. For example, Frieden asked, “What is the burden of rotavirus before vaccines in the US and globally?

Parashar answered, “In the US, we estimated about 55 to 70 thousand hospitalizations, about 200,000 to 250,000 emergency room visits and about half a million clinical visits, with about 20-60 deaths per year. Globally, of course, the picture is much different when it comes to mortality. The latest estimate is about 453,000 deaths per year.”

Parashar explained that rotavirus is responsible for 25–50 percent of all diarrheal hospitalizations in both developing and developed countries, and 23 million outpatient healthcare visits each year in young children. Most of those who die live in low-income countries and have suboptimal access to health care and hydration when they are severely ill. These people also experience greater rates of malnutrition and other co-existing illnesses overall, and a bout of rotavirus infection can set back a child’s growth and development by many months.

Frieden and Parashar went on to discuss the rotavirus vaccines. The World Health Organization now recommends that rotavirus vaccines be included in the national immunization programs of all countries. Two live, orally administered rotavirus vaccines are currently available for use.

“Clinical trials and post-licensure monitoring in high- and middle-income countries show rotavirus vaccines to be highly effective against rotavirus gastroenteritis, and demonstrate substantial public health impact,” Parashar explained. “While studies of rotavirus vaccines in low-income countries show moderate effectiveness, even a moderately effective vaccine will have substantial public health benefit in these settings because of the very high disease burden.

“The invitation to meet with Dr. Frieden came as a very pleasant surprise,” said Parashar. “I received a call from his office late Tuesday afternoon, asking if I was available to meet with him for an hour two days later. Of course I was available! It was a fantastic opportunity to brief the director about how CDC was contributing to the global public health effort to control rotavirus gastroenteritis, the leading cause of severe childhood diarrhea globally, and norovirus gastroenteritis, the leading cause of foodborne illness and outbreaks globally.”

Like the monthly Director Breakfasts that Frieden hosts with staff, the new Conversations with the Director series also provides him the opportunity to chat with staff about public health. The conversation format provides even greater depth, as Frieden has the chance to ask more complex, probing questions on a single topic.

“The conversation itself was absolutely delightful,” says Parashar. “Dr. Frieden was fully engaged – he listened attentively, asked very good questions, and made several insightful observations. We ended up speaking for about an hour and fifteen minutes without a specific agenda! It was most gratifying to share with him the many recent successes of our program and to solicit his feedback on future priorities and directions.”

It was a rewarding moment for Parashar, one of many in his career. “I joined the group just before the first rotavirus vaccine was launched in the United States in 1998,” he said. “However, this vaccine was withdrawn from the market within a year of introduction because it caused an uncommon but severe adverse event. The global health community overcame this abrupt and unanticipated setback, and we now have two new rotavirus vaccines that have been introduced in more than 30 high- and middle-income countries. In many of these countries, we have already seen marked reductions in hospitalizations and deaths from childhood diarrhea.

“These vaccines are now poised for introduction in developing countries of Africa and Asia where more than 90 percent of global rotavirus deaths occur, so we will soon reap their full life saving benefits,” Parashar added. “It is truly gratifying to be part of such an important public health mission that will benefit the health of children in the United States and worldwide. Moreover, I feel fortunate for the opportunity to work with an outstanding and dedicated group of public health professionals at CDC and our many wonderful outside partners and collaborators – it is truly a team effort.”

This Inside Story by Kathy Nellis