Tuesday, 6 April 2010

CDC Detectives - Dangerous Microbes

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April 5, 2010

An Elite Team of Sleuths, Saving Lives in Obscurity

Millions of people know what C.D.C. and F.D.A. stand for. Far fewer recognize E.I.S., though they may owe their lives to it.

The E.I.S. is the Epidemic Intelligence Service, an arm of the federal Centers for Disease Control and Prevention. Its cadre of 160 elite medical detectives — many of them young doctors at the start of their careers — serve two-year hitches that are part adventure, part drudgery.

Suitcases packed, they are poised to fly anywhere on short notice to investigate outbreaks of pneumonia, diarrhea, high fevers, mysterious rashes and many other health threats. Borrowing a term from news reporting, E.I.S. detectives like to call themselves “shoe-leather epidemiologists;” they also like to wear ties and lapel pins displaying their logo — a hole in the well-worn sole of a shoe over a map of the world.

Since its creation in 1951, the service has become a bulwark in the nation’s defense system against disease, often acting as the public’s emergency room. Its doctors have helped identify Legionnaires’ disease, Lyme disease, and toxic shock syndrome from superabsorbent tampons; stop outbreaks of diphtheria and other diseases before they could spread uncontrollably; discover the deadly Ebola and Lassa viruses; and trace paralyzing cases of polio to defective batches of the Salk vaccine. Other E.I.S. investigations have led the Food and Drug Administration to remove potentially lethal products from the market.

Indeed, the E.I.S. “may have saved your life, though you were probably unaware of it,” Mark Pendergrast writes in his new book, “Inside the Outbreaks,” the first history of the program, being published next week by Houghton Mifflin Harcourt.

I was among the 500 graduates of the service whom Mr. Pendergrast interviewed for the book. (He has no connection to the program.) The book describes a number of triumphs — and occasional roadblocks — told chronologically as vignettes, with bits of history interspersed.

Among them are examples of government officials’ suppressing critical health information — and a few surprises about the E.I.S.’s contributions to public health, including some that may come as news to the program’s more than 3,000 graduates.

For example, few colleagues I asked knew that an E.I.S. investigation of a 1953 outbreak of nervous-system damage in children led Chicago to create the nation’s first poison control center. Pediatricians had assumed the cause was viral encephalitis; a medical sleuth, visiting the children’s homes and neighborhood, discovered that many were eating paint chips containing lead and correctly linked the outbreak to lead poisoning.

The service had been founded two years earlier by Dr. Alexander D. Langmuir, a supremely self-confident epidemiologist who had gotten his start in the New York State Health Department and later taught at Johns Hopkins.

Seizing on a frightening outbreak of hemorrhagic fever that had killed 3,000 United Nations troops in Korea, Dr. Langmuir convinced federal officials that the nation needed a quick-response squadron of epidemiologists to investigate outbreaks. At the outset, E.I.S. recruits earned military credit; even today they sometimes wear uniforms and have military ranks. Many found the service a career-changing experience, because they realized they could help far more people through public health than they could in clinical practice.

Then and now, many graduates of the program stay for careers at the C.D.C., while others form the backbone of state and local health departments and become leaders in academic medical centers.

Tall, deep-voiced and domineering, Dr. Langmuir was a showman who delighted in hearing E.I.S. officers relate their adventures riding camels and exhuming bodies. But Mr. Pendergrast leaves no doubt that he was a genius and a visionary.

To colleagues who said that vaccines and antibiotics were making infectious diseases obsolete, he replied that the field still provided “a happy hunting ground for major discoveries and contributions.” The new service quickly took on his personality.

In the early 1950s, for example, an E.I.S. investigating team provided surprising evidence that malaria had virtually disappeared from the United States, overturning the conventional wisdom that it was still a leading cause of fever throughout the South.

At the same time, Dr. Langmuir made some decisions that would probably be condemned today. In 1955, the future of the new Salk polio vaccine was suddenly thrown into doubt when some recipients became paralyzed, apparently by a virus the vaccine maker had failed to kill.

Dr. Langmuir swiftly set up an investigative team that found that the defective vaccine came from Cutter Laboratories, one of six drug companies licensed to make and distribute vaccine. The five other manufacturers were allowed to resume production and sales.

But cases also occurred among recipients of the polio vaccine made by Wyeth Laboratories. In a little-known attempt to salvage the overall program, Dr. Langmuir suppressed reports of these cases.

In 1962, Dr. Langmuir publicly supported the Sabin oral polio vaccine despite evidence that it had led to eight cases of paralysis. He buried the data in a paper published two years later.

Dr. Langmuir retired from the service in 1970, but its propensity for secrecy lived on. In 1985, after a baffling outbreak of salmonellosis linked to salad bars in Oregon, E.I.S. investigators found a vial of salmonella with the same bacterial fingerprints in the laboratory of a nurse who had worked for the cult leader Bhagwan Shree Rajneesh. the service refused to report its investigation for years, on the ground that it would provoke copycat attacks.

The service’s reputation was bolstered after the 9/11 attacks, when it played a leading role in the investigation of the deliberate release of anthrax spores through the postal system. But its accomplishments are generally based on strengthening the nation’s system to report common and unusual diseases, and then discerning patterns of infection and spread.

Gradually, the E.I.S. expanded to include veterinarians, nurses, dentists, statisticians, social workers, even lawyers. Depending on the nature of the outbreak, its detectives may conduct door-to-door interviews and surveys, mapping cases and venturing abroad.

When I was a member of the service, in 1963-65, for instance, two of my colleagues went to Bolivia to investigate a plague outbreak and bring back a sample of the causative bacterium. To get it, they had to exhume a body to remove a finger and isolate the bacterium from the marrow. The specimen eventually became part of the collection of potential agents at the government’s biological warfare center at in Maryland.

Despite his penchant for secrecy, Dr. Langmuir knew the value of publicity, and his subordinates learned from his example. During an outbreak of hepatitis from raw shellfish taken from Raritan Bay in New Jersey in 1961, Dr. D. A. Henderson, an E.I.S. graduate then working at the C.D.C., likened the risk to “playing Russian roulette on the half shell.” His pithy comment, widely reported in the news media, earned a mild reprimand from his superiors. (Dr. Henderson later led the W.H.O. team that eradicatedsmallpox, and after 9/11 he advised the United States government on bioterrorism.)

The E.I.S. was Alexander Langmuir’s family. He demanded full loyalty and was upset when one of his “boys” left.

When Dr. E. Russell Alexander announced that he was leaving to join the faculty at the University of Washington, Dr. Langmuir told him he would “never make it in academia.” (The prediction proved wrong.) And when Dr. Henderson began organizing the team that eventually eradicated smallpox, Dr. Langmuir opposed involving the E.I.S. and told his subordinate to take what he wanted and get out. The two later reconciled.

I, too, was a victim. When I joined the E.I.S. in 1963, Dr. Langmuir appointed me editor of The Morbidity and Mortality Weekly Report, over which he had won control in a bureaucratic battle with another agency. He wanted to change its emphasis on vital statistics, which he said made for dull reading, and he preached the importance of promptly feeding information to the public on a “need-to-know basis.” So I included many reports of current outbreaks, in effect making the report a weekly newspaper.

In those days, doctors were not required to report cases of rubella, even though it can lead to severe birth defects in the babies of pregnant women who contract it. So I played journalist, calling epidemiologists in many states to track the disease’s spread and obstetricians to learn that some were performing first-trimester abortions.

My accounts unnerved and angered Dr. Langmuir, and he contradicted his early statements by insisting that the weekly report stick to its archive function. He sent me packing to help run a measles immunization program in Africa. I accepted the punishment enthusiastically, never expecting that my African adventures would eventually make me part of the Henderson team that eradicated smallpox.

By the time of his death, in 1993, Dr. Langmuir had soured on the service he created, saying it had outlived its usefulness and should be abolished. Yet as other countries have adopted smaller versions of the E.I.S., his contributions to global health have outlived him, and so has his formidable legacy as a giant of public health.

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