Special MMWR issue commemorates 50th anniversary of the Epidemic Intelligence Service (EIS)
All articles authored by current or former EIS "disease detectives"
The April 20th edition of the MMWR commemorates 50 years of outbreak investigations by the Epidemic Intelligence Service, the Centers for Disease Control and Prevention training program for "disease detectives." The special MMWR issue precedes the annual EIS conference to be held April 23-27 in Atlanta and the first-ever alumni weekend, April 21-22.
During famine in Ethiopia, deaths due to infectious diseases as well as malnutrition
In 2000, successive years of drought resulted in a famine across parts of the Horn of Africa. Ethiopia was one of the worst affected countries with 10 million people at risk of starvation. The Somali region of Ethiopia, home to many pastoral clans, became the epicenter of the famine in Ethiopia. United Nations and non-government organizations began distributing food aid in April 2000 and many feeding centers were opened for the treatment of moderately and severely malnourished children. In June 2000, Peter Salama an EIS officer with CDC's international emergency and refugee health program, was seconded to the United Nations Children's Fund (UNICEF) in Ethiopia to assist in coordinating the famine relief response. In July 2000, in collaboration with UNICEF and a non-government organization, Save the Children US, CDC carried out a population-based assessment in the Somali region to gather important data on major causes of death and current prevalence rates of malnutrition. The humanitarian organizations were concerned that anecdotal evidence suggested that mortality rates were high despite more than three to four months of food distribution and they asked CDC to look into this.
The work in Ethiopia was very intense. According to Salama, a medical epidemiologist from Melbourne, Australia who previously was the Medical Coordinator for the humanitarian organization Concern Worldwide, "We traveled most days for four to five hours across isolated, desert paths and covered 24 villages in less than a week with six teams of field workers. It gave us an entirely different perspective on what the problems were and what needed to be done. What we found was that a large proportion of deaths were being caused by common infectious diseases such as measles and diarrhea, many of which were preventable with simple, cost-effective interventions such as mass measles vaccination campaigns. We also learned that more than one-quarter of measles deaths were in children five or older which meant that vaccination campaigns needed to extend coverage beyond the usual group of nine months to four years."
Death and severe liver injury a rare complication of new TB treatment regimen
This article reports the first known death associated with a new two-month drug regimen of rifampin and pyrazinamide for the treatment of latent tuberculosis infection. This regimen was recommended by the American Thoracic Society (ATS) and CDC in April 2000 as an alternative to isoniazid. In September 2000, a 53-year-old man in New York died from hepatitis after five weeks on this course of therapy. In December 2000, another severe case of hepatitis was reported, when a 59-year-old woman in Georgia was admitted to the hospital after taking the drug combination for seven weeks. Because both regimens recommended for treating latent TB infection have been associated with hepatitis previously, CDC continues to recommend health care providers educate their patients about the rare, but potentially severe, adverse effects of treatment and monitor their patients closely. Most importantly, patients should be reminded during each visit to their provider or at least monthly to stop taking their medication and contact their provider if symptoms, such as gastrointestinal pains, develop. CDC requests reports of severe hepatitis resulting from the treatment of latent TB infection be reported to CDC.
Author John Jereb joined CDC as an EIS officer in 1990, and he has worked in CDC's TB elimination program since then. Prior to that, he worked for the Indian Health Service in South Dakota.
According to Jereb, "In this type of investigation, health care workers find it unsettling to talk about their patients who have had adverse reactions to treatment, since they are trained to make people feel better."
EIS officers investigate outbreak of TB in Wichita, demonstrating importance of outbreak response systems
In January 2001, CDC EIS Officers were asked to assist in the investigation of an outbreak of tuberculosis (TB) among women who worked as exotic dancers in Wichita, Kansas. Within a four-month period, CDC, working with Wichita-Sedgwick County Department of Community Health and Kansas Department of Health and Environment, had linked 18 patients with active TB disease and 76 with latent infection to this outbreak. Patients with active disease included seven women who were exotic dancers, along with seven men, one woman, and three children who had been exposed to these individuals. The first patient was diagnosed in 1994, and the last five were diagnosed in 2000. This outbreak, which evolved over a six-year period, demonstrates the importance of maintaining local TB control systems capable of quickly identifying, containing, and curing TB, even in low incidence areas. Kansas routinely has a low incidence of TB (provisionally reporting only 77 active cases of TB in 2000) and has only two full-time and one-part time staff people dedicated to TB control. All states need outbreak response plans that describe how personnel, expertise, and resources will be mobilized quickly for outbreaks and during other times of increased demand.
EIS officer Reuben Varghese, a physician who worked for Harvard Pilgrim Health Care of New England in Rhode Island before joining the EIS, has made two trips to Wichita with fellow EIS officer Peter D. McElroy, working closely with Kansas public health officials to determine the extent of the TB outbreak and to recommend appropriate control measures to stem transmission.
"In Wichita, we uncovered how TB may be spreading in the community and helped state and local public health officials find solutions to control the disease, which ultimately may help eliminate TB from Kansas," said Varghese.
Outbreak of E. Coli among children associated with farm visits – CDC establishes guidelines for petting farms
In the fall of 2000, CDC EIS officers were asked to help investigate an outbreak of Escherichia coli O157:H7 in Pennsylvania among children who had visited a dairy farm. Fifty-one patients were identified by the local health department who developed diarrhea within 10 days of visiting the farm. CDC investigators conducted an environmental investigation and found that several dozen cattle on the farm were infected with an identical strain of E. coli found in a number of sick patients. The same strain was also isolated from a railing on the farm. While E. coli is most commonly transmitted by contaminated food or water, this investigation revealed that people can become infected with E. coli after touching farm animals or nearby environmental surfaces contaminated with animal feces and then putting their hands in their mouths. Following this outbreak and one similar to it in Washington, CDC developed strategies to reduce the risk in these settings, including petting farms.
EIS Officer John Crump was the lead investigator in Pennsylvania. A native of New Zealand, Crump grew up on a sheep farm and received his medical degree in New Zealand 1993. He received a degree in tropical medicine in London in 1995 and trained extensively in New Zealand and Australia before joining the EIS in 2000. Crump has participated in several outbreak investigations and finds the experience very exciting.
"Outbreaks are often emotionally charged and it can be challenging to try and bring order and apply science in such complex situations. They can be exhausting but are always rewarding," he said.
The EIS was established in 1951 following the start of the Korean War as an early-warning system against biological warfare and man-made epidemics. The program, comprising medical doctors, researchers and scientists who serve in two-year assignments, today has expanded into a surveillance and response unit for all types of epidemics, including chronic disease and injuries.
Influenza strains and recommendations for using the flu vaccine 2001–02
Every April, CDC releases recommendations from the Advisory Community on Immunization Practices (ACIP) on the use of influenza vaccine and antiviral drugs. The 2001–2002 trivalent vaccine virus strains are A/Moscow/10/99 (H3N2)-like, A/New Caledonia/20/99 (H1N1)-like, and B/Sichuan/379/99-like strains. The recommendations also includea information on the cost-effectiveness of influenza vaccination and the extension of the optimal time period for vaccination through November.
EIS Officer Carolyn Buxton Bridges received her medical degree from the University of Washington (Seattle) and was working for a private medical practice in Atlanta before joining the EIS in 1996. Buxton-Bridges is currently a medical epidemiologist in the CDC Influenza Branch. She was a member of the CDC team that investigated the very first outbreak of avian flu in Hong Kong in 1997. "Participating on the investigation of avian influenza A (H5N1) outbreak, an event with immediate global implications, was a true privilege, " said Buxton-Bridges, "This event crystalized for me the critical role of CDC in international public health collaborations and global disease prevention efforts."
For more information about EIS and the upcoming conference, see www.cdc.gov/eis. To attend the conference or arrange interviews, media can contact the CDC media relations office at (404) 639-3286.
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