BARRY WILLIAMS/Special

Mark Simmerman, an epidemiologist with the Centers for Disease Control and Prevention, poses outside the World Health Organization in Hanoi, Vietnam. Simmerman is on assignment with the WHO to help health officials identify early groups of respiratory disease outbreaks, including avian flu.

As a Centers for Disease Control and Prevention epidemiologist working with the World Health Organization, Mark Simmerman has just moved to the hot spot for avian flu. Vietnam has had the highest number of human cases of the dreaded disease, and no one knows exactly why.

Simmerman, a public health nurse who has worked with migrant and Indian populations, delivered health care as a nurse practitioner to remote villages in Alaska and worked with the national immunization program in New Orleans. Sometimes,
during his globe-trotting, he wonders, "How on earth did I get here?"

In his heart, he knows. Simmerman, Ph.D., RN, FNP, is an influenza expert and has worked internationally for five years. He was part of the CDC's International Emerging Infections Program in Bangkok and was researching the burden of disease from human influences in Thailand when the bird flu re-emerged.

"When that happened, about 80 percent of my research time was spent on avian flu," he said.

Simmerman's job in Vietnam involves a lot less research and a lot more management of the resources and efforts by various
countries and health organizations that have come to this high-priority location to help local health officials. The goal is
to better detect avian and other influenza cases and respond quickly to their spread.

He took over a mountain of paperwork, budgets and reports and has been working 10- to 14-hour days since his arrival.

"We now have a Vietnamese physician who is working with me, and other countries are sending staff and funding, " Simmerman said. "We're working with the various health care ministries of Vietnam, which is a large country with a diverse political structure, to put systems in place that will let us, first, detect quickly when there are clusters of patients with acute respiratory symptoms and secondly, determine if there is a critical change in the virus and initiate an immediate response to slow its spread through isolation and infection control measures."

Simmerman's job is both tough and important.

"There is good reason to be concerned about the H5N1 avian flu virus, but there is a fine line between concern and hysteria," he said. "As public health officials, our job is to inform the public and keep them aware of the proper response to this disease. People need to know that we have a situation with an influenza virus whose combined characteristics are capable of causing severe disease in humans because we are not immune to it."

The virus has spread rapidly through the poultry population and now is affecting the human population in Southeast Asia, Iraq and Turkey. "We could be seeing the early stages of a pandemic strain, but we are in a unique position historically to do the necessary lab work and epidemiologic research to respond rapidly," Simmerman said.

A global system of influenza labs set up in different countries is capable of collecting samples of the virus and sharing information quickly.

"In Turkey, we saw a substantial response and investigation within hours," Simmerman said.

There's an electronic nerve system of surveillance monitoring the virus constantly, and health care workers are doing a remarkable job of putting interventions into place, Simmerman said.

"We need to be vigilant, but in the last three months no humans or poultry have contracted the disease in Vietnam, so we hope we're having an impact. It's a complex problem with dozens of possible solutions, so finding the right mix of solutions is challenging," he added.

Public health posters inform Vietnamese people about the importance of hand-washing and safe ways to handle poultry in order to avoid avian flu.

Resources to monitor and prevent the spread of avian influenza provide an opportunity to create a long-term benefit for Vietnam. Simmerman is always thinking of ways to apply the resources so that they have a sustained effect on the country's health care system.

"In patient care, you often see the immediate impact of your work, and that's very gratifying," he said. "When you work in public health in a developing country, it might take years for your labors to bear fruit. It takes a lot of patience, but the personal and professional relationships you develop [while] working with your counterparts in other countries results in productive outcomes. I focus on that every day."