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Tailing Disease

THE EPIDEMIC INTELLIGENCE SERVICE FINDS RENEWED SUPPORT FROM CONGRESS IN A BIOTERRORISM WORLD.

The New Physician September 2001
There are things that happen to you when you’re an Epidemic Intelligence Service (EIS) officer that you just don’t tell your mother. Mothers are worriers by nature, and so naturally, internist Daniel A. Singer didn’t tell his mom about his experience with that angry mob in India.


Working with the World Health Organization’s (WHO) global polio eradication program, Singer was traveling through the rather lawless area of Bihar when it happened. There are common-sense rules to follow when one sets out at night in this part of India with only a driver and a translator. Rule No. 1: If you get in an accident, just leave the scene. What would be considered a hit-and-run in the United States could very well save your life in Bihar.


Rule No. 1’s relevance was evident to Singer’s party as it encountered a roadblock: An angry crowd had gathered after a truck hit and killed a young girl. Sending his translator out to negotiate passage through the crowd, Singer knew this was a dangerous situation. So when the translator returned with a few of the marauders, he hoped they were climbing into his truck merely to guide it through the crowd.


No such luck. The men instructed his driver to go faster and faster, and Singer realized they were on a murderous search for the girl’s killer, and he was just along for the ride. “Now, to me, all Indian trucks look the same, but they see this truck ahead and make our driver speed ahead and force [the suspected hit-and-run driver] to pull over. The men get out to beat up the driver, and I said, ‘You know what? We have to get out of here.’”


They escaped the situation, but it was difficult for Singer to forget what happened. “I just felt horrible about it. I kept checking the papers [for a notice about the incident], but there never was.”


Now, Mother Singer, you might want to disregard what you just read. “I told my father, and he said, ‘Do not tell your mother,’” he says.


And there are lots of other people who are better off not knowing exactly what EIS officers are doing. Last fall, the housekeeping staff at the Washington, D.C., Holiday Inn was probably better off not knowing that behind a permanently hung “Do Not Disturb” sign was not a pair of frisky honeymooners or even just someone who needed a lot of naps, but the Centers for Disease Control and Prevention’s (CDC) Washington supply of anthrax vaccine—plus some for a few other nasty diseases, just in case.


And really, much of the nation is unaware of what EIS officers do, and this works to their advantage. It’s an aspect the program even promotes. Known as the CDC’s “disease detectives,” EIS officers seem clandestine—a Hollywood creation. But thanks to an unprecedented deployment in response to last fall’s terrorist attacks, more people now realize the EIS has been around for more than 50 years, identifying new diseases and quelling outbreaks worldwide, and lawmakers have shown their appreciation with an outpouring of cash.


In the beginning, there was Langmuir
The CDC created the EIS in 1951 as a two-year fellowship program in an attempt to train more epidemiologists to serve in state-level public health departments. At first, the EIS lacked federal support. “It was hard to persuade a lot of people 50 years ago there was a need for epidemiologists,” says Dr. J. Lyle Conrad, M.P.H., the retired former director of the CDC’s Division of Field Epidemiology. Luckily, though, Dr. Alexander Langmuir, M.P.H., the CDC’s chief epidemiologist at the time who founded the EIS, was a shrewd congressional lobbyist who knew how to squeeze lawmakers for cash. Pegging the program as a way to establish federal defenses against a Cold War bioterrorist attack, Langmuir won his funding.


Fifty years later, Langmuir’s legacy came true. The days after Sept. 11 found the EIS deploying the largest number of officers at one time to New York City, and many others were sent to find the source of the anthrax attacks. One hundred and thirty-six officers—just 10 shy of the total number of EIS officers employed by the CDC—were involved in the response in one form or another.


But for the past 50 years, EIS officers have spent most of their time doing more preventive and public health work—tracking disease outbreaks, rooting out the causes and reporting their findings back to the CDC. If botulism breaks out in Butte, meningitis menaces Michigan or cholera cripples Cancun, EIS officers are probably there, interviewing victims, taking samples and tracking microbe paths, practicing what is known as “shoe-leather epidemiology.” Along the way, the officers have fingered such previously unknown maladies as the Hantavirus and Legionnaires’ and Lyme diseases.


But EIS officers can’t investigate everything. The public health system in the United States is structured on the state level. Each state, and many municipalities, have their own public health departments that conduct surveillance and respond to outbreaks within their jurisdictions. The CDC doesn’t oversee these departments. It just aids them and those in foreign countries—when they ask.


“Without an authorization from a city or state, authorities from the CDC can’t go anywhere,” Conrad says. (The exception is cruise ships.) And that includes the EIS, which, as a part of the CDC, is an agency of the U.S. Public Health Service. “We actually think that’s a very healthy way to have it,” Conrad says, adding that Washington’s inside-the-Beltway public health bureaucracy necessitates the decentralized system. “The states know they’re on their own, but right from the start we put [EIS] officers in the state health departments.”


The CDC accepts about 73 officers each year—this year there were 89, thanks to an influx of funds from the bioterrorism response legislation in Congress. They take two-year posts based either at a CDC research center or directly with a state health department. More than just physicians, officers—about 60 percent women and 40 percent men—hail from a host of allied health fields: veterinarians, pharmacists, nurses and dentists. About 65 percent of the officers are physicians, who must complete at least their intern year of residency before joining the EIS, and about half of them have their M.P.H. The U.S. military and Department of Agriculture also sponsor their own officers in the program. Most EIS officers choose to enter the program through the Commissioned Corps and are assigned a military rank, which determines their pay, usually between $30,000 and $80,000.


Singer, for example, was based in Atlanta during his 1999–2001 EIS stint with the Division of Global Migration and Quarantine, which meant he was sent to outbreaks dealing with disease in immigrants, travelers and refugees. From their home bases, officers can be asked to go anywhere to do anything—and they may only have an hour to pack before the plane takes off.


THE STUFF OF MOVIES


Dr. Marc Traeger was in rural Madison County, Florida—far from any airport—on Oct. 4, 2001, searching for West Nile virus when he got a call. As a state-based EIS officer, Traeger had been working all summer on the first cases of West Nile virus to appear in Florida, and he had just returned to the field a few days earlier, having spent 10 days in New York City assisting with bioterrorist surveillance at Ground Zero. “I’m getting pages, but I’m in a cell-phone dead zone,” he says.


His boss’ secretary finally got through with a cryptic message: “Go to the airport and get on a plane.” With a shoddy cellular connection, Dr. Stephen Wiersma, Florida’s state epidemiologist, was finally able to give him a little more information: There’s a confirmed case of inhalation anthrax in Palm Beach County. Wiersma reiterated his secretary’s message—the plane to Palm Beach was leaving in an hour, and Traeger needed to be on it.


Racing down 50 miles of backcountry roads, Traeger made that plane—and a little history—as he became the first EIS officer on the scene in Boca Raton where anthrax first appeared in October.


“I called my wife on the phone and said, ‘I’m going to Palm Beach County, and I can’t say why, but if it’s what I think it is, it will be on the news tonight,’” he says.


That first night, public health officials met for a briefing. “Anthrax was always at the top of the list [for a possible bioterrorist attack]…but here we had just one case—it wasn’t like someone had sprayed a football stadium with it,” he says.


So the epidemiologist began looking for natural sources, such as animal skins, the victim, Bob Stevens, might have come into contact with. “We basically traced his steps of everywhere he had been for the past 60 days.” In the meantime, Traeger began establishing a surveillance system in the county’s hospitals, looking for other cases. “And actually, in three days we had an answer.”


The detectives broke the case when a co-worker’s nasal swab for anthrax spores and a desk sample at Steven’s office, American Media, tested positive on the same day. Traeger says basic shoe-leather epidemiology teaches you to look closely at the workplace and family any time there’s an outbreak.


From then on, the EPI-AID, as the CDC calls EIS deployments, was linked to a criminal investigation. “The No. 1 public health measure in this instance was catching the bad guy, because that will ultimately stop the outbreak. And we’re still working on that,” he says. Two days later, officials knew the spores came to the workplace via the mail, and from that point on, Traeger was primarily responsible for processing the American Media workers, conducting nasal swab tests, finding out where in the building each one worked and supplying antibiotics to those who needed them. By now, there were dozens of other CDC and law enforcement officials on the scene, but “since it was my state, it was clear that I was there for the long run,” Traeger says.


Turns out, he was in Boca Raton for about two weeks, although even in June he was still tying up loose ends. A family man himself, Wiersma had sent him home before all the anthrax activity died down. Traeger had spent only several days at home since the summer, when he and his wife adopted a baby.


This kind of personal sacrifice is common among EIS officers. They miss celebrations and family events—one nearly missed her own wedding—but the work is worth it, they say. Traeger says even with little George waiting for him at home, it was hard to tear himself away from all the action. “Seeing the U.S. president discuss it and the secretary of health discuss it and realizing that it’s what you’re working on…was just amazing.”


Even without a national tragedy, there are always loads of high-profile epidemiology to be done. “The fact is that every few years a big new investigation comes up that EIS is going to be a part of,” Traeger says.


Singer learned just how interesting new diseases are to the media. In addition to being sent to India to help find and vaccinate polio cases for the WHO, which frequently recruits the EIS’ help, he spent about four weeks in the summer of 1999 helping the New York City health department track down the first American cases of West Nile virus. Based in a tiny outpost health department in Queens, Singer spent his early days of the EPI-AID looking at maps and targeting neighborhoods for potential victims. The plan was to conduct a door-to-door search, taking interviews and blood samples. But Singer hadn’t counted on just how piqued the notoriously aggressive New York City media would be at the idea of a new disease emerging within its city limits.


“When we came out [of the health department], there was this bank of cameras,” he says. He knew he couldn’t conduct interviews with a pack of journalists in tow—it’s bad enough when a government agent shows up at your door asking health questions and drawing blood. So, officials sent out decoy teams who drove around for 20 minutes “until the media figured out they weren’t going anywhere.


“The best part about EIS is you learn basic epidemiology techniques, but you learn them with a political component,” Singer says. But that doesn’t mean EIS officers get mired in political wrangling about money, overseas spending or public health priorities. “Politics do happen, but…these decisions are made for you,” he says.


That’s the best way for officers to learn, says Jim Hayslett, a doctor of pharmacy with an M.P.H. who was with the EIS from 2000 to 2002. “There’s stuff that had to get done, and you didn’t want to get sidetracked by some political bullshit. I think it worked really well.” He understands the need for autonomy, having spent four months in Washington, D.C., investigating anthrax. He says he grew used to concern coming from a multitude of interested parties.


Hayslett spent the bulk of his October-to-February tour of duty in the nation’s capital communicating facts about anthrax and its treatments to postal workers. “I got here and the first thing I did was I ended up spending two weeks in an office in the back of the Capitol with half a dozen other people on the intervention team, and we transitioned out of there to the Brentwood post office for three days before it closed. And we all walked the floor and looked at the machines and did everything else. So all of us that were in there got 60 days of antibiotics, just like the rest of the workers. I stood right in front of the No. 17 machine that sorted that mail [at Brentwood].” And while Hayslett says he wasn’t scared—“It’s all personality”—he does admit that “my mother was a little freaked out.”


Communication was key for the CDC in the anthrax investigation, Hayslett says. It was also one aspect of the agency’s response that was criticized both in the media and by government officials. But for Hayslett, it was all about the postal workers. He traveled to 21 city post offices to talk about anthrax, the antibiotics to treat it and the vaccine, which the CDC was providing to those who wanted it. “If [workers] feel like they are a part of this intervention, then they may actually take 60 days of antibiotics,” he says. “If they feel like they’re just on the fringe, they don’t have any control anyway, so what’s the point of taking them now? So by making sure you have good communication with these people, you minimize the chance of any delayed case popping up and encumbering the system all over again—because it was stressed.”


JUST GOOD PUBLIC HEALTH


But not everything is as high-profile as bioterrorism. When they’re not on an EPI-AID, most officers are often running outbreak analyses or designing surveillance systems to monitor an area for disease or injuries. “Depending on your supervisor, there are supervisors who think you’re just a data monkey, that your goal is to put data in,” Hayslett says. “And that’s part of the gig, there’s no doubt about that.”


Dr. F. Douglas Scutchfield, an EIS officer from 1967 to 1969, spent all of his fellowship at Emory University focusing on family planning and obstetrical epidemiology. “This was a new idea,” he says. “Until then, EIS had been all about infectious diseases.”


Scutchfield ran clinical trials on then-new contraceptive technology, such as Depo-Provera and what would be the beginning of emergency contraception. His one EPI-AID didn’t even take him away from Emory: When the EIS was asked to investigate the cause of a series of perforated uteruses in women using IUDs at Emory, the program knew just who to send—even if it was from just down the hall.


Orthopedic surgeon Sandra Berrios-Torres also found a way to incorporate her clinical interests with epidemiology during the two years she spent with the EIS. The bulk of her assignments focused on developing a surveillance system and training manual for physicians in Central American countries to use when seeing patients with injuries. Far from a more traditional EPI-AID, this type of work is an important function of the CDC’s public health purpose, because by establishing systems to track disease causes, communities can then begin to prevent them altogether, she says.


A lot of what an officer does depends on what post she accepts, for the CDC doesn’t assign them to a specific position. New officers select their posts at an EIS conference every April. There are more positions than officers, and red tags on name badges identify new recruits. Singer calls it the closest thing to sorority rush week that he’s ever been to. “People would start talking to you about how great their division is and how much fun it is to work on, say, viral diarrhea,” he says jokingly. “At the end of the week you want to hide your little red ribbon.”


Personality types affect where officers go. Some don’t want to be sent on EPI-AIDs, perhaps because of family needs. They often end up in Atlanta or Washington, D.C., working in one of the CDC’s more statistic- and research-based centers. Those who want to be on the road all the time might go to the National Center for Infectious Diseases (NCID). Hayslett wanted the EPI-AID experience, but he also wanted to take charge of his own destiny, so he took a state-based position at the Texas Department of Health. State officers get first dibs on any EPI-AID within their borders, but they don’t have to take an assignment if they don’t want to. “I wanted a position where, when they came downstairs and said, ‘We’ve got a cluster of hepatitis A up in Paris, Texas… —and hepatitis A is pretty boring—I could turn that down. [But] if I worked for [NCID], I’d be up there. So when they came down and said, ‘Botulism,’ I said, ‘Sure!’ I traveled because I like to travel, [but] places I want to go.


“And you’re going to these places where…I mean, some of them are just wild. Just wild outbreaks. There were outbreaks in Kansas—was it hepatitis or tuberculosis—of strippers. I mean, that would be a cool one,” he says, jokingly. “And that’s not flashy public health. It takes the right person in the right place.”


Dr. Scott Harper was one of those officers in the right place. Having spent years abroad practicing internal medicine, he didn’t mind constant travel and joined the NCID, focusing on viral and rickettsial ailments. After working for a few months in the influenza branch, Harper got word in the fall of 2000 that he was needed in Uganda to investigate an Ebola outbreak. “I didn’t come here with the inclination to be a virus hunter,” he says. “I just happened to be in the right place at the right time.


“That was a difficult outbreak. It was my first. People wanted information in a hurry, and it had to be accurate information, and [the multilevel political hurdles of international work] make it more difficult.”


His job—finding and stopping the cause of this most recent Ebola flare-up—was made more challenging by the loss of a colleague. EIS officers will tell you they’re rarely afraid of their work. They take every precaution for themselves and at most come home with nothing more than exhaustion from working 14- to 20-hour days. But when local physician Matthew Lukwiya, who first realized the Gulu outbreak was Ebola, died of the disease, it hit the entire response team hard, Harper says. “There’s a trench mentality on outbreaks,” he says. “The work is reasonably dangerous, and you make friends fast. The loss was difficult.”


It can also be tough for physicians like Harper to work on an EPI-AID only as epidemiologists, leaving the doctoring to others. “Knowing what your role is is very important,” he says. “The main point is to control the outbreak, [but] it’s actually a two-way street. You have to know what your priorities are.”


But in the midst of all the suffering, the maverick personalities the EIS attracts also manage to find humor in almost every situation, and their stories become yarns for the ages. Hayslett’s best comes from working on a botulism outbreak in Dallas.


“You couldn’t have asked for a sweeter group of people. The woman who cooked the food put four of her sons on ventilators and her granddaughter and her great-grandson on ventilators. Can you imagine being a 75-year-old woman and just about killing half your family?


“So we go looking for…[any cases] that got misdiagnosed. And it turned out that this was a case where they thought this woman had a stroke, but it turned out she had a minor case of botulism.


“Well, obviously one of the things we need is a stool sample.” The older black woman was in her hospital bed, and “her wig is twisted off. She looks…like Don King’s mother. So [my colleague] says, ‘I wonder if I could get some poop from you.’ And the lady goes, ‘Oh lordy, I done give that to the city of Dallas.’ And so [my colleague] says, ‘Do you remember who you gave it to?’ and [the patient] goes, ‘Oh no, lordy, I gave that to ’em yesterday.’ And I said, ‘Megan, Megan, she’s trying to tell you she went to the bathroom.’ I said, ‘Ma’am, did you go to the bathroom yesterday and give it to the city of Dallas by the sewage system?’ And she says, ‘Oh, yeah.’”


AFTER THE EIS


After two years of traveling to and investigating outbreaks, the CDC hopes officers will take their on-the-job training and apply it to the many state and municipal health departments. Conrad says Langmuir’s experiment worked. “You can go to a state health department and about 50 percent [of the state epidemiologists] have come through the EIS.”


And to be sure, a quick survey of a handful of state epidemiologists proves that most of them did come through the EIS. But the same can be said for the CDC headquarters in Atlanta—hundreds of CDC employees have also come from the EIS. And both Traeger and Singer have left the EIS to apply their newly found epidemiological know-how in various areas of the federal government—Traeger at the Indian Health Service in Arizona and Singer in the Office of the U.S. Surgeon General in Washington, D.C.


About 35 percent of the officers go on to federal service, and 11 percent land at a state or local health department. Another 25 percent go back to private practice, 15 percent end up as university faculty, as Scutchfield did, 7 percent work for international health organizations and 6 percent work in some other area of the health-care industry.


But even though Conrad is satisfied with the program, these statistics don’t sit well with Stephen Wiersma, Traeger’s supervisor in Florida. As the chief of the state’s Bureau of Epidemiology, he says the federal EIS program isn’t building state-level infrastructure as it was intended to because officers take more comfortable positions at the CDC.


In a response to the need so clearly identified in the Florida anthrax investigation—the state had only one EIS officer to call, although the CDC sent others—Florida Gov. Jeb Bush authorized $350,000 in state funds to create a state-based EIS program. Until then, California had the only other state-based EIS program. The first six Florida officers began work in April and have been investigating outbreaks around the state.


The program differs little in structure from its federal counterpart: Officers sign on for a two-year, on-the-job training fellowship in exchange for a modest salary and benefits. State officials hope that by integrating officers into the state career system from the beginning, they will be more apt to stay on at the end of two years.


The program is scheduled to double its number of officers next April, and the increase in staff is part of a post-anthrax trend in Florida. “I was scheduled to take a five-person cut,” Wiersma says. Those positions—his five best epidemiologists—have since been restored.


PAYING THE PIPER


Florida is not the only public-health funding winner in anthrax’s wake. The CDC can give thanks for its additional 16 officers this year to stepped-up congressional interest in the wake of Sept. 11. “Folks have recognized the value of EIS officers—they’re trained epidemiologists when they finish,” says Dr. Doug Hamilton, the EIS program’s director. “There has been an increase in Washington in recognizing the importance of EIS. In many ways, EIS officers were the tip of the spear.” Hamilton is referring to the 36 officers flown to New York City on an Australian Air Force C-130—that just happened to be in Atlanta on Sept. 11—“on a day when only two nonmilitary planes were in the air: the president’s and this one.”


The program’s numbers have steadily grown since 1951 when 23 officers joined up. Congress gave $11.8 million to fund the EIS in FY 2001 and provided $11 million this year. Counter-bioterrorism spending provided an additional $8 million to the program.


But Hamilton says the boon to the EIS could mean hard times for other areas of public health, which could result in more work for the EIS in the future. “Priorities can change quickly. My impression is that other areas of CDC are being hit hard by cuts in funding.”


Each member of the federal government has his own priorities about where funding should go, and U.S. Health and Human Services Secretary Tommy Thompson is no exception. An early supporter of the EIS in the post-Sept. 11 scramble for money, Thompson began by publicly stating he wanted an EIS officer in every state. Until this year, about 20 states secured officers each year. Changing his mind, he then said he wanted an EIS-trained epidemiologist in each state to act as a resource. So the majority of this year’s additional officers didn’t go through the traditional match process at the EIS conference and instead were accepted into the program for a specific state or municipality. Hamilton says not every state can support an officer; a lack of available funds or a permanent epidemiological infrastructure can preclude some states from taking one on. In those cases, the program sends a team of about 10 EIS-trained CDC officials to build up a state’s capacity to train an officer.


But the increasing strength
in state programs is evident to Hamilton in the decreasing number of requests for aid. In Langmuir’s day, it was between 200 and 300; today that number is between 80 and 100. “State health departments are much better now at dealing with these investigations,” he says. But, he adds, the continued need for the EIS is evident in the officers’ busy days and many states’ incapacity for training.


Conrad thinks there is room for even more officers—as many as twice the number the CDC employs—which would cost around $100,000 per officer for salary and support, he says. “For my entire career…we’ve been screaming to Washington for more bodies.”


If more funding comes, it shouldn’t be difficult to fill the new positions, from the way Singer talks. “As far as public health goes, the most exciting work is EIS.”
Jennifer Zeigler is a senior writer with The New Physician.