Epidemic Intelligence Service Officers Research Articles

Editorial: Epidemic-Assistance Investigations by the Centers for Disease Control and Prevention--The First 60 Years

In a supplement to this issue of the Journal, a series of papers describe the epidemic-assistance investigations (Epi-Aids) that the Centers for Disease Control and Prevention (CDC) conducted during the first 60 years of its existence (1946–2005). The vast majority of Epi-Aids were led by officers of the Epidemic Intelligence Service (EIS), the CDC’s renowned, 2-year field training program for epidemiologists initiated by Alexander Langmuir in 1951 to help address the CDC mission of providing US federal support to state and local health departments (1). In this supplement, a paper by Thacker et al. (2) reviews the types of health problems that were investigated by the CDC, as well as the progressively more sophisticated epidemiologic and statistical methods used in this work. Six papers focus on selected areas that together represent a large proportion of the investigations during this period. CDC was founded in 1946 as the Communicable Disease Center, and 4 papers focus on investigations of infectious disease outbreaks (vaccine-preventable diseases, foodborne/enteric disease outbreaks, respiratory illnesses, and infection outbreaks in health care settings) (3–6). Over time, CDC’s mandate broadened to include noninfectious public health problems, as reflected by a paper on environmental- and injury-related investigations (7) and one on maternal and child health investigations (8). For the most part, CDC provided this assistance to US state and local health departments, but the agency also responded to almost 500 international requests for assistance during this period. A paper by Rolle et al. (9) summarizes the nature of those investigations. The supplement also includes a paper summarizing 178 Epi-Aids that involved American Indian and Alaska Native populations (10). What can be learned from this 60-year history? The CDC is the world leader in field epidemiology, and this supplement chronicles this agency’s unparalleled experience in performing “shoe leather” epidemiology. This work also demonstrates the critical importance of a federal rapid epidemic-assistance program for addressing public health problems in the United States and worldwide. One measure of that importance is the demand for this service: the CDC conducted almost 4,500 Epi-Aids during this 60-year period. A second measure is the many important scientific and public health advances that resulted directly from CDC investigations, including the discovery of novel agents, transmission routes, and disease associations. In a very notable 1976 investigation, CDC became involved in an outbreak of pneumonia that resulted in 29 fatalities among attendees at an American Legion celebration of the US bicentennial in Philadelphia, Pennsylvania (11). This work led to the discovery of Legionella, a novel bacterial pathogen that CDC subsequently linked to previous respiratory disease outbreaks (12) and to the self-limited, influenza-like illness known as Pontiac fever (13). In 1981, investigations of Kaposi’s sarcoma and Pneumocystis carinii pneumonia among homosexual men in New York City and California provided the initial indication of the impending pandemic of human immunodeficiency virus (14, 15). CDC Epi-Aids also provide “surge capacity” for large-scale public health emergencies. In 2001, 126 EIS officers were deployed in response to the attack on the World Trade Center and the mailing of anthrax-containing letters soon thereafter (2). This supplement also demonstrates the value of CDC records as a window into the evolution of public health practice in the United States. To make this supplement possible, Thacker et al. (2) reviewed bound copies of all Epi-Aid reports for this period and other sources. They abstracted information on the nature of the health problems investigated, as well as information on dates, location, and participating CDC staff. Efforts are now under way at CDC to create an online version of the collection that will be available to the public, which should be a valuable resource for epidemiologists and other public health professionals. What will the next 60 years hold in terms of epidemic assistance by the CDC? As Yogi Berra, the Hall of Fame baseball player, once observed, “It’s tough to make predictions, especially about the future.” Globalization, climate change, technological intervention, and other less obvious factors will undoubtedly lead to public health problems that we cannot foresee, but rapid expert epidemiologic assistance by the CDC will be an essential component of the response to those challenges.

Bacteremia outbreak tied to improper filtration by compounding pharmacy

An improper filtration process let Serratia marcescens in tap water pass into two batches of pharmacy-prepared amino acid solution and then into hospital patients, a joint federal–state investigation has determined. The amino acid solution, said Neil Gupta, an epidemic intelligence service officer with the Centers for Disease Control and Prevention (CDC), had been prepared from scratch by a compounding pharmacy that he identified only as “Pharmacy A.” He said this pharmacy “sterilized” 80- to 100-L batches of 15% amino acid solution because of a national shortage of the manufacturer-provided product. The pharmacy then incorporated its amino acid solution into adult parenteral nutrient solutions for distribution in Alabama. In all, according to the state department of public health, the 2011 outbreak of S. marcescens bacteremia involved 19 patients at six hospitals in central Alabama: Cooper Green Mercy Hospital, Medical West, Prattville Baptist Hospital, Princeton Baptist Medical Center, Select Specialty Hospital—Birmingham, and Shelby Baptist Medical Center.

Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service

In this book, Mark Pendergrast, a journalist by training, tries to present a comprehensive history of the Epidemic Intelligence Service (EIS). He successfully tells the stories of the elite group, but in attempting to cover so many of the outbreaks in which they have been involved, he loses the essence of their story. Some of the outbreaks clearly have more detail than others. The story of the Cutter polio vaccine incident in 1955, the 1976 Ebola virus outbreak in Zaire, smallpox eradication, and the beginning of the AIDS epidemic in the United States are well documented. Unfortunately, even for these famous outbreaks, the stories are told better in other books singularly devoted to these topics rather than in this volume devoted to the role played by the EIS. Furthermore, most of the other outbreaks discussed in the book are covered in less than a page, and the author provides far too little detail. For example, the 1994 Salmonella enteritidis outbreak associated with Schwann’s ice cream that sickened >200,000 persons and was the largest common-source outbreak in the United States warranted only 2 paragraphs of coverage. The way in which Pendergrast describes the investigation—“He [Minnesota-based EIS officer Tom Hennessy] discovered that truck drivers were “back-hauling” liquid raw eggs on their return trip, and they were not cleaning their tankers sufficiently to prevent cross-contamination.”—makes the investigation seem simple and easy when it was, in fact, anything but simple and easy. Even though the individual outbreaks are well researched and written, the brevity with which each is portrayed makes light of the enormous effort involved in determining the source and controlling the outbreak. An outbreak investigation that may have taken weeks or months might be covered in the book in a mere 2 or 3 paragraphs, with little indication of how much the EIS officer(s) struggled to determine the etiologic agent and implement appropriate control measures. If taken as a story of the history of the EIS, rather than as a story of the outbreaks themselves, the book achieves its primary goal. However, how interesting the history of the EIS is to persons who were not EIS officers or who do not aspire to be one is questionable. On the other hand, given that the book has a retail price of $28.00, and Pendergrast interviewed such an impressive number of EIS alumni that any public health professional is bound to recognize at least 1 name, even with its flaws, the book is still a fast and entertaining read.

Interview: WHO Global Malaria Program: the road ahead

Robert D Newman became Head of the WHO Global Malaria Programme in 2009. Previously, Dr Newman was Deputy Chief for Science and Chief of the Program Implementation Unit in the Malaria Branch at the Centers for Disease Control and Prevention (CDC). Dr Newman also served as the CDC Team Lead for the President’s Malaria Initiative. Dr Newman originally joined CDC as an Epidemic Intelligence Service Officer in 2000. During his 9 years at CDC, Dr Newman was dedicated to advancing the science of preventing malaria during pregnancy and infancy in sub-Saharan Africa, and served as the principal investigator for numerous epidemiological studies and clinical trials. Dr Newman has served as a founding member of two large international research consortia, and has published more than 50 peer-reviewed articles on malaria and other infectious diseases.

Outbreak Investigations around the World: Case Studies in Infectious Disease Field Epidemiology

Outbreak investigations are fascinating stories. Mark S. Dworkin, Epidemic Intelligence Service (EIS) Class of 1994, has compiled 19 first-hand accounts of case studies in infectious disease epidemiology and presents them in chronological order. The first is Kenrad Nelson’s 1964 investigation of leptospirosis associated with swimming in an irrigation ditch in rural Washington; the last Patricia Quinlisk’s evaluation of a 2006 mumps epidemic in Iowa. In between are investigations involving 8 bacterial infections, 6 viruses, 1 helminth (Taenia solium), 1 protozoan (Cryptosporidium sp.), and a misdiagnosis of Entamoeba histolytica. Fourteen of the outbreaks occurred in the United States; of the remaining 5, one each occurred in Portugal, Israel, Egypt, Gabon, and Liberia. In general, the stories are told as first-person accounts, use an informal style, and include personal reflections. Many chapters, but not all, include epidemic curves, maps, tables, exhibits, and lessons learned. I especially enjoyed reading about Paul Blake’s experience with a cholera outbreak in Portugal, Charles Jennings and measles in Illinois, Daniel Bausch and Ebola in Gabon, and reading both chapters by Jeffrey Davis—toxic shock syndrome and cryptosporidiosis. As an instructor of epidemiology, I read the book seeking a complementary text for students. The informal style does make enjoyable reading but does not translate into an appropriate textbook. Several of the chapters are too long. One chapter is written by multiple authors, told from 4 points of view, and is very difficult to read. The lessons learned are organized chronologically, not by content. Some lessons are redundant; other areas of epidemiology are not adequately explored, e.g., sampling strategies, study design, questionnaire development and data analysis, population screening, and noninfectious diseases. However, I like the concept of first-hand accounts to supplement epidemiology textbooks. Could one format the chapters as unknowns like that of New England Journal of Medicine case studies? Could outbreak investigations be written in the style of Berton Roueche as medical mysteries, but supplemented with epidemic curves, maps, and lessons learned? I recommend this book to all infectious disease epidemiologists, EIS officers, and infectious diseases clinicians interested in the aura of outbreak investigations. I also encourage the editor to consider a reformatted second edition to enhance the book’s usefulness as a complementary text in epidemiology coursework.

In Memoriam: George Martin Baer (1936–2009)

George Martin Baer, DVM, MPH, who for many years was chief of the Rabies Laboratory in the Division of Viral and Rickettsial Diseases at the Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA, died suddenly at his home in Mexico City on June 2, 2009, at the age of 73. He was an eminent veterinary virologist whose book, The Natural History of Rabies, the second edition of which was published in 1991, is the major reference work in the field. He has been widely acclaimed as “the father of oral rabies vaccination” as a result of his discovery of a strain of rabies virus (SAD strain) that immunizes foxes when given into the mouth cavity. His intensive work on the development of baits for vaccine administration to canines paved the way for successful mass fox vaccination campaigns conducted in Switzerland, several other European countries, and Canada. Dr Baer was born in London in 1936, but after the outbreak of World War II his family moved to the United States, and he was brought up in New York. He attended Cornell University in Ithaca, New York, and received a bachelor of science degree in agricultural sciences in 1954 and a Doctor of Veterinary Medicine degree in 1959. In 1961, he earned a Master of Public Health degree from the University of Michigan at Ann Arbor. He then came to CDC as an Epidemic Intelligence Service Officer, initially assigned to the New York State Health Department in Albany, where he first became interested in rabies. He subsequently joined the CDC Southwest Rabies Investigations Laboratory in Las Cruces, New Mexico, and from 1966 through 1969 was a consultant for the Pan American Health Organization in Mexico. He returned to CDC in Atlanta in 1969 to become chief of the Rabies Laboratory and served until his retirement in August 1991. He and his family then moved to Mexico City, where he founded a diagnostic laboratory and continued to use his expertise on rabies as a member of the Mexican International Steering Committee for the Rabies in the Americas Conference. Dr Baer was a valued supporter of and reviewer for Emerging Infectious Diseases and will be greatly missed. We offer our condolences to his wife, Maria Olga, and daughters, Katherine, Alexandra, and Isabella, as well as to his 4 granddaughters.

10th Annual Conference on New and Re-emerging Infectious Diseases

10th Annual Conference on New and Re-emerging Infectious Diseases

U.S. Military Officer Participation in the Centers for Disease Control and Prevention's Epidemic Intelligence Service (1951–2001)

The Epidemic Intelligence Service (EIS) was created in 1951 to provide epidemiologists to investigate natural and intentional disease epidemics. From an initial class of 23 U.S. citizens, the program has evolved into a globally recognized, hands-on learning experience, accepting approximately 65 to 75 new officers each year. The first U.S. military epidemic intelligence service officer (EISO) was accepted into the program in 1994. Since that time, 12 such officers have completed, or have begun, EIS training. They have comprised 2.1% of all EISOs from 1994 to 2001 and 0.47% of all EISOs. This total has included nine Air Force veterinarians, one Army veterinarian, one Army physician, and one Navy physician. Each military EISO had the opportunity to lead investigations of significant public health events (e.g., Ebola, monkeypox, malaria, Nipah virus, West Nile fever, and anthrax outbreaks). All graduates from the military returned to active duty assignments in operational medical units, research institutes, or the intelligence community.

Converging issues in veterinary and public health.

Converging issues in veterinary and public health.

Four Decades of Academia: A Personal Perspective

Marvin Turck, M.D., M.A.C.P, received his medical degree from the University of Illinois in Chicago in 1959 and completed his residency in Internal Medicine at the University of Illinois, where he also served as Chief Resident at Cook County Hospital in 1963. In addition, he served as an Epidemic Intelligence Service (EIS) Officer for the Centers for Disease Control and Prevention (CDC) and completed his fellowship in Infectious Diseases at the University of Washington in Seattle from 1960 to 1962. Dr. Turck joined the faculty at the University of Washington in 1964 and has remained there in various academic positions, including Division Chief of Infectious Diseases, Vice-Chairman and Chief of Medicine, and Associate Dean of the Medical School, for the past 37 years. Dr. Turck’s significant contribution to the field of infectious diseases has focused on Gram-negative infections, particularly urinary tract infections (UTI’s). In addition, he has been Chief Editor of the Journal of Infectious Diseases since 1989 and has served on the editorial boards of numerous other journals. Dr. Turck is a member of various scientific and academic organizations, including the American College of Physicians where he served as Governor and Regent, the Western Society for Clinical Investigation where he served as President, the Infectious Diseases Society of America where he served as Councillor, and the American Board of Internal Medicine where he served as Secretary-Treasurer. Dr. Turck has received many teaching awards throughout his impressive career at the University of Washington. In 1999, he was awarded the Distinguished Teacher Award from the American College of Physicians and American Society of Internal Medicine.

Surveillance, foundation for the future: A historical overview and evolution of methodologies

As a new Epidemic Intelligence Service (EIS) officer of the Communicable Disease Center in Atlanta (now the Centers for Disease Control and Prevention, or CDC), I at tended a required EIS course in general epidemiology and biostatistics in July 1968. I was the fourth EIS officer assigned to the new Hospital Infections Unit, which was begun in 1966. One of the principal functions of the course was to teach us what to do when assigned to assess an epidemic, the six steps of which are listed in Box 1. The course is now the basis for an excellent book, 1 and those six steps also form the basis for the long-held Eleventh Commandment of the CDC, Thou shalt do surveillance when evaluating any epidemic or even endemic problem. The purpose of this report is to provide an overview of how the surveillance of nosocomial infections has developed and been refined through the years. I will do this by using my own communi ty teaching hospital and CDC experiences as illustrations and case histories.

Level 4: Virus Hunters of the CDC

The Centers for Disease Control and Prevention (CDC) celebrates its 50th anniversary this year. What started as a malaria control agency has blossomed into an institution renowned for its excellence in the field of epidemiology. The first class of Epidemic Intelligence Service (EIS) officers graduated in 1951. These "disease detectives," so wonderfully depicted in the January 1991 issue of the National Geographic magazine by Peter Jaret, have blazed a trail of success and glory worldwide. "The CDC says" has become a common refrain for sweaty-palmed hospital infection control officers prior to the inevitable visit by the Joint Commission on Accreditation of Healthcare Organizations when they wish to provide legitimacy to their infection control ventures. EIS officers have been involved in global programs for the eradication of infectious diseases ranging from poliomyelitis to dracunculiasis. They have investigated and defined the scope of such new diseases as legionnaire disease, toxic shock syndrome,

Training field epidemiologists: Alexander D. Langmuir and the epidemic intelligence service.

In 1966, both of us came to the Communicable Disease Center (now the Centers for Disease Control and Prevention (CDC» as newly commissioned officers in the US Public Health Service. We were initiated into the Epidemic Intelligence Service (EIS) and immediately were immersed in the EIS course, which facilitated our metamorphosis from bedside clinicians into enthusiastic, if inexperienced, epidemiologists. During the subsequent 2 years, one of us (W.S.) was assigned to work as a generalist in a state health department (Rhode Island) while the other (F.M.L.) had a more specialized position (bacterial diseases) at CDC. Nevertheless, both of us went repeatedly into the field on epidemiologic investigations. Somewhere along the way, we assimilated the defining concept that populations, as distinguished from individual patients, were important. As a consequence, our careers, as with those of many other EIS officers, were irrevocably changed.

Contributions of Alexander D. Langmuir to the epidemiologic study of population change and family planning.

This article traces the influence of Dr. Alexander Langmuir on the application of epidemiological methods to the study of population change and family planning. In the 1960s, global population growth had become a major issue but the role of public health professionals in meeting the challenge was unclear. By 1967, Langmuir had assigned eight Epidemic Intelligence Service (EIS) Officers to family planning (FP) evaluation, capitalizing on support from the Centers for Disease Control (CDC) and securing funding from many sources. In 1970, the year Title X of the Public Health Service Act designated funds for population activities with none of the funds designated for the CDC, Langmuir retired. EIS officers trained by Langmuir issued surveillance reports on abortion (in 1969) and sexual sterilization (the report defined the risk of morbidity from sterilization for women) and conducted studies of the safety and effectiveness of IUDs, (which led to association of the Dalkon Shield with high rates of pelvic inflammatory disease and with septic spontaneous abortion deaths) and the association of oral contraceptive use with various cancers. Epidemiologic evaluation procedures were applied to FP programs and evaluation training, to adolescent pregnancy, to international studies, to international contraceptive prevalence surveys, and to demographic studies. By mid-1993, 118 EIS officers had worked in FP evaluation. These EIS officers and alumni continue to work in the fields of reproductive health or public health throughout the world.

Informing Physicians About Promising New Treatments for Severe Disease

To the Editor.— We agree with Drs Steinbrook and Lo 1 that increasing the detailed information in unconventional communications indeed can provide timely and useful information to physicians. Our experience shows that diagnostic information may be transmitted quickly. In January 1990, Epidemic Intelligence Service Officer Kelly J. Henning, MD, identified practitioners' need for additional clinical information on the newly recognized tryptophan-associated eosinophilia-myalgia syndrome. The decision was made to publish an emergency alert issue of City Health Information , the monthly epidemiologic bulletin of the New York City Department of Health. We were at press within 24 hours with an issue that described clinical, laboratory, and roentgenographic findings in the first 96 cases of eosinolphilia-myalgia syndrome in New York State. Copies were mailed to New York City's 24 000 physicians and to 8000 other health care providers within the next 2 weeks. In addition, the department's public health advisers hand carried the

EIS Officers: Medical Detectives

WHEN LISTERIOSIS struck the neonatal unit in a Costa Rican hospital about a year ago, the CDC sent Anne Schuckit, MD, to find out why. The young Epidemic Intelligence Service (EIS) officer had investigated one other major outbreak at the time, but it offered little direct guidance for how to approach the new problem. Yet she knew what to do, and no more infants in that hospital became ill. Tackling outbreaks of diseases as diverse as Schuckit's first encounter with a rapidly transmitted pathogen—which turned out to be sporotrichosis, a fungal infection—and her second, theListeriabacterium, is par for the EIS course. Founding the EIS in 1951, Alexander Langmuir, MD, set up a 2-year training and service program designed to accomplish three objectives: (1) to help the CDC implement its mission to prevent and control communicable diseases, (2) to increase the number of field-trained epidemiologists in the United States,

New Fishbein Fellow

Bruce B. Dan, MD, has been chosen the fifth recipient of the Dr Morris Fishbein Fellowship in Medical Journalism at the American Medical Association. The one-year fellowship begins this month. Dan completed a two-year stint as an Epidemic Intelligence Service Officer at the Centers for Disease Control in Atlanta last month. He had served as deputy chief of the Toxic Shock Syndrome Task Force. A 1968 graduate of the Massachusetts Institute of Technology (MIT), Cambridge, Mass, Dan received a bachelor's degree in space systems engineering and did graduate work in that field at Purdue University, West Lafayette, Ind, and at MIT before turning to medicine. He received his MD degree from Vanderbilt University School of Medicine, Nashville, in 1974. Dan remained in Nashville to serve his internship and residency in internal medicine at Vanderbilt University Hospital. Now board-certified in internal medicine, he has completed two post-doctoral fellowships: in computerized medicine

Maternal methimazole and congenital defects in children

TeratologyVolume 5, Issue 1 p. 125-125 Letter Maternal methimazole and congenital defects in children Samuel Milham Jr., Samuel Milham Jr. Washington State Department of Social and Health Services, Division of Health Services, Olympia, Washington 98501Search for more papers by this authorWilliam Elledge, William Elledge Washington State Department of Social and Health Services, Division of Health Services, Olympia, Washington 98501 Epidemic Intelligence Service Officer, Center for Disease Control, assigned to the Washington State Department of Social and Health Services.Search for more papers by this author Samuel Milham Jr., Samuel Milham Jr. Washington State Department of Social and Health Services, Division of Health Services, Olympia, Washington 98501Search for more papers by this authorWilliam Elledge, William Elledge Washington State Department of Social and Health Services, Division of Health Services, Olympia, Washington 98501 Epidemic Intelligence Service Officer, Center for Disease Control, assigned to the Washington State Department of Social and Health Services.Search for more papers by this author First published: February 1972 https://doi.org/10.1002/tera.1420050117Citations: 102 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume5, Issue1February 1972Pages 125-125 RelatedInformation

Influenza in Los Angeles County, 1968-69

T HE LAST SIGNIFICANT epidemic of A2 influenza in Los Angeles County had occurred in early 1966, with its estimated peak around February 20. Although the remainder of the nation experienced epidemic influenza in the 1967-68 winter season, California, including Los Angeles, did not (1) . In July 1968 the World Health Organization received reports of an influenza epidemic in Ho,ng Kong. The agent isolated from patients in this outbreak was found to differ antigenically from recent A2 strains, and it was labeled influenza A2/Hong Kong/68 (2). Because of the magnitude of the antigenic drift, the Surgeon General's Advisory Committee revised its statement of June 1968 (3). Their original forecast had mentioned little or no influenza activity for most of the nation in the 1968-69 season. The revised statement and recommendatio,ns proved to be correct, as the entire country experienced epidemic activity by January 1969. This report describes the epidemic in Los Angeles County and the surveillance methods used to monitor it. Surveillance Methods Daily reporting of absenteeism from city schools. Beginning in September 1968, all Los Angeles city schools with more than 10 percent absenteeism reported by telephone to a central administrative office that in turn informed the health department on a daily basis. This surveillance included 576 public schools-130 senior and junior high schools and 446 elementary schools. Weekly reporting of school absenteeism. A sample of approximately 30 city, county, and parochial schools reported absenteeism by mail on a weekly The authors are with the County of Los Angeles Health Department. Dr. Matlof is an epidemic intelligence service officer from the Public Health Service's Center for Disease Control, Atlanta, Ga., and he is assigned to the county health department's Acute Communicable Disease Control Division. Mr. Murray is epidemiology analyst, and Dr. Kamei is chief of the division. Dr. Heidbreder is the county health officer. Tearsheet requests to Harvey Matlof, M.D., 220 North Broadway, Los Angeles, Calif. 90012.

Aseptic Meningitis Epidemic Involving ECHO 4 and Coxsackie B5 Viruses

THE FIRST ATTEMPT to characterize aseptic meningitis as a distinct entity was made by 'Wallgren (1) in 1925. Although his criteria are still useful today, improved laboratory diagnostic techniques now make it possible to demonstrate that what he originally assumed to be a single disease may occur in the course of infection due to a number of different etiological agents. The enteroviruses, other than the poliovirus, which have been associated with the aseptic meningitis syndrome in epidemic form include ECHO 4,6,9,11,16, and 30 (2), as well as Coxsackie A2, 4, 7, 9, 10, 16, and B1-B6 (3). The other types most frequently implicated, in addition to ECHO 9, are ECHO 4 and Coxsackie B5. The first reported outbreak of aseptic meningitis associated with ECHO 4 occurred in Marshalltown, Iowa, in 1955 (4, 5); the first reported epidemic of aseptic meningitis associated with Coxsackie B5 was in Cerro Gordo County, Iowa, in 1956(6). In a search of the U.S. literature, however, we found no reports of a well-defined epidemic of aseptic meningitis in which two enteroviruses, excluding poliovirus, played major etiological roles. Such an epidemic did occur in Baltimore, Md., in 1967. Baltimoire, in central Maryland, is surrounded by, but is politically distinct from, Baltimore County. According to estimates by the bureau of vital statistics of the Baltimore City Health Department, the population as of July 1, 1966, was 914,000. Approximately 41 percent of the population is nonwhite. Thirty-nine percent of the inhabitants are less than 20 years old. In 1967, epidemiologists of the Maryland State Department of Health, after being notified of an increased number of cases of aseptic meningitis in one Baltimore hospital, undertook a telephone survey of hospitals and offices olf selected pediatricians to assess the possibility of an outbreak in the city. When an increased incidence was confirmed by a number of these sources, letters were sent to all Maryland physicians alerting them to the pattern of symptoms and the laboratory results. Specimens of blood and spinal fluid, stool or rectal swabs, and throat swabs or washings were requested for laboratory study. Most of the reported cases were among the Dr. Garber, Dr. Glick, and Dr. Dupont are epidemic intelligence service officers with the National Communicable Disease Center, Public Health Service. Dr. Garber is assigned to the Maryland State Department of Health in Baltimore, Dr. Glick to NCDC in Atlanta, Ga., and Dr. Dupont to the University of Maryland School of Medicine in Baltimore. Dr. Joseph is assistant director, bureau of laboratories, Maryland State Department of Health, and Mr. Eichler is head of the virus isolation laboratory of that bureau.