Epidemic Intelligence Service Research Articles

Fifty-Five Years of International Epidemic-Assistance Investigations Conducted by CDC's Disease Detectives

For more than 60 years, the Centers for Disease Control and Prevention (CDC) has used its scientific expertise to help people throughout the world live healthier, safer, longer lives through science-based health action. In 1951, CDC officially established the Epidemic Intelligence Service to help build public health capacity. During 1950–2005, CDC’s Epidemic Intelligence Service officers conducted 462 international epidemiologic field investigations in 131 foreign countries and 7 territories. Investigations have included responding to emerging infectious and noninfectious disease outbreaks, assisting in disaster response, and evaluating core components of public health programs worldwide. Approximately 81% of investigations were responses to infectious disease outbreaks, but the proportion of investigations related to chronic and other noninfectious conditions increased 7-fold (6%–45%). These investigations have contributed to detecting and characterizing new pathogens (e.g., severe acute respiratory syndrome–associated coronavirus) and conditions, provided insights regarding factors that cause or contribute to disease acquisition (e.g., Ebola hemorrhagic fever), led to development of new diagnostics and surveillance technologies, and provided information upon which global health policies and regulations can be based. CDC’s disease detectives will undoubtedly continue to play a critical role in global health and in responding to emerging global disease threats.

Epidemic Intelligence Service Investigations of Respiratory Illness, 1946-2005

Infectious respiratory pathogens were the suspected cause of 480 outbreaks investigated by the Centers for Disease Control and Prevention's Epidemic Intelligence Service officers during 1946-2005. All epidemic-assistance investigation reports and associated articles from scientific journals were reviewed. Investigations identified 25 different infectious respiratory pathogens including, most frequently, tuberculosis, influenza, and legionellosis. Other bacterial-, viral-, and fungal-related pathogens also were identified. Epidemic-assistance investigations were notable for first identifying Legionnaires disease and Pontiac fever, hantavirus pulmonary syndrome, and new strains of human and avian influenza, as well as emerging challenges (e.g., multidrug-resistant tuberculosis and pneumococcus). The investigations provided clinical insights into such diseases as pulmonary anthrax and identified high risks of serious respiratory illnesses for persons infected with human immunodeficiency virus, other immunocompromised persons, and persons with diabetes. They identified settings placing persons at high risk of acquiring disease, including nursing homes, prisons, homeless shelters, and hospitals. Travel also placed persons at risk. Key environmental factors related to spread of diseases and occupational risks for brucellosis and psittacosis were identified. The outbreak investigations constitute a wealth of prevention experience and provide the basis for recommendations to mitigate outbreaks and reduce future risks.

Health Care-Associated Infection Outbreak Investigations by the Centers for Disease Control and Prevention, 1946-2005

Since 1946, Centers for Disease Control and Prevention (CDC) personnel have investigated outbreaks of infections and adverse events associated with delivery of health care. CDC Epidemic Intelligence Service officers have led onsite investigations of these outbreaks by systematically applying epidemiology, statistics, and laboratory science. During 1946-2005, CDC Epidemic Intelligence Service officers conducted 531 outbreak investigations in facilities across the United States and abroad. Initially, the majority of outbreaks involved gastrointestinal tract infections; however, in later years, bloodstream, respiratory tract, and surgical wound infections predominated. Among pathogens implicated in CDC outbreak investigations, Staphylococcus aureus, Enterococcus species, Enterobacteriaceae, nonfermentative Gram-negative bacteria, or yeasts predominated, but unusual organisms (e.g., the atypical mycobacteria) were often included. Outbreak types varied and often were linked to transfer of colonized patients or health care personnel between facilities (multihospital outbreaks), national distribution of contaminated products, use of invasive medical devices, or variances in practices and procedures in health care environments (e.g., intensive care units, water reservoirs, or hemodialysis units). Through partnerships with health care facilities and local and state health departments, outbreaks were terminated and lives saved. Data from investigations invariably contributed to CDC-generated guidelines for prevention and control of health care-associated infections.

Epidemic Intelligence Service Officers by Class Year, 1951-2005

Epidemic Intelligence Service Officers by Class Year, 1951-2005

Vaccine-preventable Diseases, Immunizations, and the Epidemic Intelligence Service

During 1946-2005, vaccine-preventable diseases were the topic of approximately 20% of all epidemic-assistance investigations by the Centers for Disease Control and Prevention. Both in the United States and abroad, current and former Epidemic Intelligence Service officers have played a critical role in describing the epidemiology of vaccine-preventable diseases, contributing to development of immunization policies, participating in the implementation of immunization programs, and establishing effective means for assessing adverse events following immunization. As newer vaccines are developed and introduced, they will continue to play similar roles and most likely will be involved increasingly in investigations of the factors that affect people's willingness to accept vaccination for themselves or their children.

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.

Field Epidemiology and Laboratory Training Programs in sub-Saharan Africa from 2004 to 2010: need, the process, and prospects

As of 2010 sub-Saharan Africa had approximately 865 million inhabitants living with numerous public health challenges. Several public health initiatives [e.g., the United States (US) President's Emergency Plan for AIDS Relief and the US President's Malaria Initiative] have been very successful at reducing mortality from priority diseases. A competently trained public health workforce that can operate multi-disease surveillance and response systems is necessary to build upon and sustain these successes and to address other public health problems. Sub-Saharan Africa appears to have weathered the recent global economic downturn remarkably well and its increasing middle class may soon demand stronger public health systems to protect communities. The Epidemic Intelligence Service (EIS) program of the US Centers for Disease Control and Prevention (CDC) has been the backbone of public health surveillance and response in the US during its 60 years of existence. EIS has been adapted internationally to create the Field Epidemiology Training Program (FETP) in several countries. In the 1990s CDC and the Rockefeller Foundation collaborated with the Uganda and Zimbabwe ministries of health and local universities to create 2-year Public Health Schools Without Walls (PHSWOWs) which were based on the FETP model. In 2004 the FETP model was further adapted to create the Field Epidemiology and Laboratory Training Program (FELTP) in Kenya to conduct joint competency-based training for field epidemiologists and public health laboratory scientists providing a master's degree to participants upon completion. The FELTP model has been implemented in several additional countries in sub-Saharan Africa. By the end of 2010 these 10 FELTPs and two PHSWOWs covered 613 million of the 865 million people in sub-Saharan Africa and had enrolled 743 public health professionals. We describe the process that we used to develop 10 FELTPs covering 15 countries in sub-Saharan Africa from 2004 to 2010 as a strategy to develop a locally trained public health workforce that can operate multi-disease surveillance and response systems.

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.

Training the Global Public Health Workforce Through Applied Epidemiology Training Programs: CDC’s Experience, 1951–2011

The strengthening of health systems is becoming increasingly recognized as necessary for the achievement of many objectives promoted or supported by global public health initiatives. Key within the effort to strengthen health systems is the development of a well-prepared, skilled, and knowledgeable public health workforce. Over 60 years ago, the United States Centers for Disease Control and Prevention (CDC) began the first training program in applied epidemiology, the Epidemic Intelligence Service (EIS), a two-year, in-service training program in epidemiology and public health practice. Since 1951, the EIS has produced well-trained and highly qualified applied or field epidemiologists, many of whom later became leaders within the US public health system. In 1980, the CDC began assisting other countries to develop their own field epidemiology training programs (FETPs), modeling them after the highly successful EIS program. FETPs differ from other training programs in epidemiology in that: (1) they are positioned within Ministries of Health and the activities of the residents are designed to address the priority health issues of the Ministry; (2) they stress the principle of training through service; and (3) they provide close supervision and mentoring by trained field epidemiologists. While FETPs are designed to be adaptable to the needs of any given country, there exist many fundamental similarities in the skills and knowledge required by public health workers. Recognizing this, CDC developed a standard core FETP curriculum that can be adapted to any country’s needs. Countries can further customize FETP trainings to meet their specific needs by adding specialized “tracks” or by targeting different audiences and levels of the health system. Although FETPs require substantial investments in time and resources as well as significant commitment from ministries, CDC’s vision is that every country will have access to an FETP to help build its public health workforce and strengthen its public health systems.

Inside the outbreaks: the elite medical detectives of the Epidemic Intelligence Service

The book describes the history of the EIS in 3 segments, including the ‘‘Grand Adventures of Dr. Langmuir’s Boys,’’ covering the inception of the program through 1970; the ‘‘Golden Age of Epidemiology,’’ dealing with changes in the organization and presenting short histories of some of the outbreaks that EIS officers evaluated through 1982; and ‘‘Complex Challenges,’’ covering more recent events in the program’s history from 1983 to the present. Short chapters in each section focus primarily on the facts of various epidemics, the geopolitical climates that influenced the investigations, and the reporting of the investigations. The quotes included from the field officers give the stories a fictional and dramatic character and draw readers into the accounts of the outbreaks. Although I read most of the book in 2 sessions, this text could be read in segments without critical loss of flow. Each of the short chapters stands alone and provides interesting factual reading and substantial entertainment for fans of field epidemiology. Chapter 21, ‘‘Into the Twenty-first Century’’ briefly summarizes many of the public health challenges that society faces today, and that EIS officers are engaged in worldwide—in addition to comments on the political backgrounds that influence the prevention of some of these contemporary diseases. The book is a valuable addition to the ever-lengthier literature on epidemics. Most chapters offer multiple brief, but fascinating accounts of epidemiologic investigations. The vignettes are not closely tied to one another, except perhaps for the temporal associations related to the book’s organization into 3 time periods. Consequently, within any chapter, the author might give attention to an enteric pathogenassociated outbreak, followed by a chronic disease example or a behavioral health example (such as a cluster of suicides) and also supply information on the unfolding history of the EIS program at that particular time. The examples provided were all informative to read, and, from my first- (or at least second-) hand knowledge of many of the outbreaks, few errors in fact appear in the accounts of the various epidemics covered. The author deserves congratulations on the extensive sleuthing that he undertook in writing this book: he conducted hundreds of interviews with EIS officers and outbreak-related personnel, and he researched numerous textbooks, articles, archives, and government documents that are difficult to access. He lists these useful sources at the book’s end and provides a full bibliography online. He surprisingly includes his e-mail address so interested readers can contact him, presumably to correct errors or provide other feedback.

"A wild and wondrous ride": CDC field epidemiologists in the east Pakistan smallpox and cholera epidemics of 1958

In mid-April of 1958 the Government of Pakistan summoned the press to announce a grave need for international aid to cope with smallpox and cholera epidemics in East Pakistan. In response, and with the backing of the US State Department, Dr. Alexander D. Langmuir, chief epidemiologist of the CDC, led a team of epidemiologists to assist authorities in Dacca strengthen their immunization programs. Langmuir's superiors hoped for a Cold War advantage, but he saw an opportunity for trainees in the Epidemic Intelligence Service to learn about public health in a developing country. Langmuir later described the episode as a "wild and wondrous ride," but it had been more like a nightmare: the East Pakistan health department had collapsed; a popular movement had taken over vaccination and squandered vaccine supplies; hostile journalists had questioned the Americans' deeper motives; and a professional rivalry opened between the Americans and a British epidemiologist named Aidan Cockburn. By the time the epidemic subsided in July 1958, 30 million Bengalis had been vaccinated for smallpox but another 20,000 had succumbed to the disease. This episode was CDC's first sustained foreign intervention, a precursor to its extensive role in the 1970s helping WHO eradicate smallpox from Bangladesh.

Interview With Dr. Lee Riley

I nterview with L ee R iley Mike Moses, Alex Gagnon, Jennifer Cherone, John Domingo, Felicia Linn, Hannes Prescher, Pryanka Murali Dr. Lee Riley, M.D., is a UC Berkeley professor of Epidemiology and Infectious Diseases. Dr. Riley earned his B.A. in philosophy at Stanford University, and completed medical school at the University of California, San Francisco. After medical school he obtained an internship and residency at Columbia Presbyterian Medical Center in internal medicine. Riley then joined the Epidemic Intelligence Service of the Enteric Diseases Branch of the Centers for Disease Control and Prevention (CDC), where he spent three years. He also served as Laboratory Project Manager with the India Biomedical Support Project, organized by the World Health Organization, after which he joined the Cornell University Medical College as a professor of medicine in 1990. He became a tenured professor of medicine in 1994, and in 1996 came to the University of California, Berkeley to be professor of epidemiology and infectious disease. He also serves as Chair of the UC Berkeley School of Public Health Division of Infectious Diseases and Vaccinology. Berkeley Scientific Journal had the opportunity to meet with Dr. Lee Riley and talk about his work in Brazil and India. at some possible projects we could do. Cornell has been involved in Brazil for about 45 years now, so I joined the faculty as an assistant professor and they wanted me to do a project there as well, so I started on a diarrheal disease project, focusing on kids with diarrhea. It turns out most of the kids with severe diarrhea were kids from slums, and of course I sort of knew that already but didn’t pay much attention. We were interested in looking at different kinds of infectious agents that cause diarrhea. As we were doing the project, nobody seemed to really care about what happens to kids because for one, kids don’t really contribute economically to these communities, so it was kind of frustrating even though it was intellectually satisfying. So we started working on another disease, called leptospirosis. Leptospirosis is a type of bacterial infection that is transmitted by rat urine, and we were seeing all of these severe cases of leptospirosis. The clinical manifestation of leptospirosis is initial flu- like symptoms, followed by liver failure, and kidney failure. And the people die because of kidney failure, the kidneys just shut down. About 15% of them die, so it’s a pretty bad disease, and what was interesting was it predominantly affected young adult males. This is something that the government really paid attention to. BSJ: Because they are the most productive members of the economy. Riley: Exactly. Young adult males are the main income earners, and they are the ones that contribute to the economy. And it turns out that more than 95% of these cases came from the slums. This was all done in Salvador, Brazil. Salvador is the third largest city in Brazil. So the first study we did was to look at risk factors for death; why some people die from this disease and others don’t. When we reported our finding in The Lancet, the government really paid attention. It’s a major international journal, and I think the Brazilian government was embarrassed that they had this problem. Brazil is one of the richest countries in the world, economically it’s a very rich country, and yet they had this disease in their backyard, something you see in some of the poorest countries of the world. So they were embarrassed, but instead of kicking us out they became interested and asked us to set up similar surveillance in other cities, and the local government actually came into the city we were working in to try to implement some sanitation measures and other things. BSJ: So they really cared. Riley: Yes, they really cared, so we were lucky. And the B S J Dr. Lee Riley, M.D. teaches Epidemiology and Infectious Diseases at UC Berkeley. BSJ: Can you begin by telling us how you became interested in slum settlements and diseases in slums? Riley: Sure. I’ve been working abroad for many years, since the early 90’s when I was a faculty member at Cornell. When I joined the faculty at Cornell, at the school of medicine, I was then sent on to Brazil to look 28 • B erkeley S cientific J ournal • I nfectious D isease • F all 2010 • V olume 14 • I ssue 1

Los roles del ambiente, de la higiene, de la epidemiología y de las vacunas en el desafío de las enfermedades infecciosas

This commentary uses a recent article in the press about the failure of the Gates Foundation's plans to eradicate poliomyelitis in Asia and Africa as a basis for discussing the often limited historical role that vaccines have played in controlling many infectious diseases when compared to increases in living standards. A recent book on the Epidemic Intelligence Service of the Centers for Disease Control and Prevention, USA, is used to illustrate the importance of epidemiological surveillance and public health laboratories in past and present efforts to control infectious diseases. On the basis of these publications, the author discusses and proposes solutions for some of the shortcomings of the Chilean sanitary services demonstrated when dealing with a recent epidemic of more than 26, 000 cases of acute diarrhea in the Northern Chilean city of Antofagasta.

The roles that the environment, the sanitary conditions, the epidemiology and vaccines play in the challenge of infectious diseases

This commentary uses a recent article in the press about the failure of the Gates Foundation's plans to eradicate poliomyelitis in Asia and Africa as a basis for discussing the often limited historical role that vaccines have played in controlling many infectious diseases when compared to increases in living standards. A recent book on the Epidemic Intelligence Service of the Centers for Disease Control and Prevention, USA, is used to illustrate the importance of epidemiological surveillance and public health laboratories in past and present efforts to control infectious diseases. On the basis of these publications, the author discusses and proposes solutions for some of the shortcomings of the Chilean sanitary services demonstrated when dealing with a recent epidemic of more than 26, 000 cases of acute diarrhea in the Northern Chilean city of Antofagasta.

In Snow's Footsteps: Commentary on Shoe-Leather and Applied Epidemiology

The term shoe-leather epidemiology is often synonymous with field epidemiology or intervention epidemiology. All 3 terms imply investigations initiated in response to urgent public health problems and for which the investigative team does much of its work in the field (i.e., outside the office or laboratory). Alexander D. Langmuir is credited with articulating the concept of disease surveillance as it is applied to populations rather than individuals. He also founded the Epidemic Intelligence Service (EIS) Program in 1951, a 2-year training experience in applied epidemiology that places professionals in the field, domestically and internationally, in real-life situations. Today, 70-90 EIS officers are assigned each year to Centers for Disease Control and Prevention programs and to state and local health departments to meet the broad spectrum of challenges in chronic disease, injury prevention, violence, environmental health, occupational safety and health, and maternal and child health, as well as infectious diseases. Throughout their assignments, EIS officers are encouraged to strive for analytic rigor as well as public health consequence, which requires technical competence blended with good judgment and awareness of context. Effective applied epidemiologists must have skills beyond just epidemiology to improve a population's health; the field of applied epidemiology requires multiple team members, all having different but complementary skills, to be effective.

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

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

Inside the outbreaks

If there’s something strange in your neighborhood, who you gonna call? EIS! In the early 1950s, Alexander Langmuir, an epidemiologist for the Communicable Disease Center (CDC) in Atlanta, Georgia, warned that pathogenic microbes could be used as agents of biological warfare. To counter the threat, he advised the federal government to establish a ready response team at CDC. This advice was prescient: when Korean hemorrhagic fever virus infected 25,000 American troops in June 1951, killing 3,000, funding was provided to establish the Epidemic Intelligence Service (EIS). The two-year program trained young epidemiologists not only to look out for biological warfare, but to respond quickly to unintentional epidemics. Despite the success of EIS in producing the world’s disease detectives, the history of the organization has never been told. Neither does Mark Pendergrast tell the history of EIS in Inside the Outbreaks — although it is a compelling collection of dozens of vignettes that cover many of the most interesting disease outbreaks of the past 60 years. If you are a microbe geek like I am, you will love reading about how EIS officers travel the world to quell lethal threats to global health. All of the well-known infectious disease stories are here: pandemic influenza, the eradication of smallpox, the “Cutter incident” involving contaminated polio vaccine, and the first outbreak of Legionnaires’ disease in Philadelphia, to name just a few. But there are many other less well-known incidents that established disease etiologies. An example is the finding by the EIS in 1955 of the importance of Staphylococcus aureus in hospital-acquired infections. Inside the Outbreaks is divided into three sections: “The Grand Adventures of Dr. Langmuir’s Boys” covers 1951–1970; “The Golden Age of Epi” continues to 1982; and “Complex Challenges” takes us to the present. Each section is composed of individual chapters that are further broken down into outbreak stories, such as “Mystery in Tuba City,” “Profuse Diaphoresis in Infants,” and “An Exhausting Disease.” While I found this approach appealing, it does have weak points. Because of the focus on outbreaks, there is no overall view of the history of the EIS. Furthermore, character development is minimal: there are few memorable individuals, with the exception of Dr. Langmuir. This book is about outbreaks, not people. While EIS officers obviously play important roles in each story, we quickly forget them as we move on to the next problem. There are so many riveting stories in Inside the Outbreaks that I had difficulty identifying one that conveyed the book’s atmosphere. One of my favorites is “Health-Conscious Sprout Eaters,” which describes outbreaks with Salmonella or E. coli O157:H7 caused by alfalfa sprouts. The sprouts, consumed uncooked, are difficult to sterilize because the bacteria may be internalized in the inner plant tissues. Sprouts contaminated with E. coli O157:H7 were tracked to Idaho farms, where deer droppings may have been the source of the bacteria. EIS officer Roger Shapiro concluded, “Raw sprouts are inherently dangerous. They are the only food I stopped eating as a result of my EIS experience.” I finished Inside the Outbreaks while traveling, and as I looked for a snack in the airport, I had difficulty identifying food that would be safe. The yogurt looked terrific, but it contained berries, and I had just read about outbreaks of infections in Texas and Florida with the parasite Cyclospora, caused by raspberries from Guatemala. There were also lovely sandwiches, but who knew what lurked in the salad greens — perhaps E. coli O157:H7, which caused gastroenteritis in Illinois when it contaminated mesclun from California. Reading Inside the Outbreaks will cause you to suspect nearly every food or food supplement, as well you should. The global economy and the demand for fresh food throughout the year have led to many opportunities for traveling microbes. The list of former EIS officers is a Who’s Who of significant figures in science and medicine. Some individuals I was surprised to find in this program include D.A. Henderson and William Foege, architects of the smallpox eradication program; Neal Nathanson, a prominent virologist; current CDC Director Tom Frieden; former CDC Director Julie Gerberding; and WHO Assistant Director-General Keiji Fukuda. Neither had I known that Lawrence Altman, the well-known New York Times science writer, had been an EIS officer. You’ll have to read Inside the Outbreaks to learn how an EIS trainee learns the craft of disease epidemiology. Perhaps Alexander Langmuir’s approach is the most informative: he would send only one or two EIS officers to an outbreak. “We’ll get them on an epidemic as fast as we can. Throw them overboard. See if they can swim, and if they can’t, throw them a life ring; pull them out and throw them in again.”

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.

A Review of Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Serivce; PendergrastMark; ( 2010). Houghton Mifflin Harcourt. Boston. 432 pages.

Review of: Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Serivce ; Mark Pendergrast; (2010). Hough-ton Mifflin Harcourt. Boston. 432 pages.

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.