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2
Epidemiological Investigation
OVERVIEW
Emerging infections continue to disrupt the health care system and are be-
coming increasingly complicated to detect and treat successfully. In addition, the
public health system is continually reminded of the challenges posed by the un-
expected, whether it is the next influenza pandemic or a bioterrorist act. In 1988
the Institute of Medicine (IOM) recommended that "every public health agency
regularly and systematically collect, assemble, analyze, and make available in-
formation on the health of the community, including statistics on health status,
community health needs, and epidemiologic and other studies of health prob-
lems" (IOM, 1988, p. 1419. Thus, one of the essential public health services is
the diagnosis and investigation of health hazards in the community. Health de-
partments at the federal, state, and local levels, often with the aid of the aca-
demic community, can perform these functions if they have the appropriate level
of resources, adequately trained personnel, and established systems of reporting
~ . .
and communication.
Each sector offers unique capabilities, and each sector faces some common
and uncommon challenges, but most infectious disease outbreak investigations
follow the same general approach: (1) identification of the circumstances that
indicate the need for an investigation (e.g., more than the expected number of
cases of a particular disease); (2) investigation; (3) determination of the cause
of the circumstances (i.e., the reason that the excess cases of disease occurred);
and (4) response, which usually includes the control of the outbreak, and rec-
ommendations and coordination of response—both public and private for the
prevention of further disease. Within each investigation are several components
which may include, but are not limited to epidemiological, laboratory, and en-
29
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30
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
vironmental assessments. Each component may also require coordination at
several levels, from the local to the state, private, and federal. In general, fed-
eral resources, through the Centers for Disease Control and Prevention (CDC)
and the U.S. Food and Drug Administration (FDA), are available to assist in
investigations, but they only do so if state and local public health agencies have
in place the infrastructure to detect and report unusual disease occurrences.
Concise and timely communication between each component is critical to a
good investigation.
NATIONAL PERSPECTIVE ON
OUTBREAK INVESTIGATIONS
Stephen M. Ostroff, M.D.
Associate Director for Epidemiologic Science, National Center for
Infectious Diseases, Centers for Disease Control and Prevention
Although the crises attendant with periodic infectious disease outbreaks
serve as a reminder of the importance of public health, media attention on the
successful investigation and control of outbreaks also contributes to the common
misconception that the infrastructure available to meet public health needs is
sufficient. However, although media attention has been instrumental in keeping
many infectious diseases in the forefront of public consciousness, such miscon-
ceptions about the sufficiency of the infrastructure contribute to greater expecta-
tions on the part of the public and those who control resources.
Investigations are more complex in nature because of a variety of new
pathogens and risk factors (e.g., travel, food imports, technological innovation)
increased public and media attention, their significant economic and political
consequences, and because they are more likely to cross state and international
jurisdictional boundaries. The ability to quickly recognize and respond to widely
dispersed disease outbreaks is a particular public health management challenge.
The tools available to recognize and respond to disease outbreaks have im-
proved in recent years. There are now computerized databases which allow out-
breaks to be more rapidly recognized, and electronic mail and the Internet allow
information to be more rapidly shared. As one example, CDC now develops and
shares with public health officials a weekly line listing of Escherichia cold
0157:H7 outbreaks that have been recognized. This allows seemingly disparate
outbreaks to be potentially linked. The development and dissemination of mo-
lecular fingerprinting has virtually revolutionized our understanding of the epi-
demiology of infectious diseases, and has been especially useful in outbreak
recognition and investigation. This technology allows laboratories to subtype
pathogens, and for foodborne pathogens, to electronically submit pattern analy-
sis to a centralized database maintained by CDC. Real-time analysis of submit-
ted data allows recognition of outbreaks when they are still small, and has al-
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EPIDEMIOLOGICAL INVESTIGATION
31
lowed us to recognize outbreaks which previously were unlikely to have been
identified. Early recognition and prompt investigation has likely led to preven-
tion of large numbers of illnesses, especially those related to foodborne disease.
However, identification of outbreaks when they are small can prove a challenge
for investigators to identify the source and risk factors.
In the United States, outbreak investigation and control is the responsibility
of state and local health departments. When outbreaks are small and focal in
nature, as they usually were in the past, this arrangement is adequate. However,
it produces challenges in an era of a globalized food supply and international
travel when outbreaks cross jurisdictions. CDC's federal role is to support the
investigations conducted by the states and localities through the provision of
technical assistance and resources. The most intensive CDC support is through
the epidemic assistance (Epi-aid) mechanism where a team (including an Epi-
demic Intelligence Service epidemiological trainee) goes into the field to assist
the state; there are also international Epi-aids.
However, CDC provides lesser degrees of assistance to state and local ju-
risdictions in hundreds to thousands of other outbreak investigations annually.
This assistance can take a number of forms. One is provision of advice from
technical and disease experts, who may go into the field to provide assistance.
Another is through specialized diagnostic and laboratory investigations to de-
termine the cause of illness or to subtype or sequence pathogens. CDC can also
provide assistance in study and questionnaire design, and set up computer pro-
grams to enter data. CDC, in collaboration with the World Health Organization
has developed an integrated DOS-based (but Windows™-compatible) free soft-
ware package, Epi-Info, to assist in outbreak-related activities. The package al-
lows the user to design questionnaires, and receive assistance in epidemiological
study design, data analysis, and report writing. This software is used extensively
both in the United States and abroad.
Finally, CDC can also provide assistance in implementation of control
measures, including direct provision of materials such as vaccines or biologics.
For example, if there is an outbreak of hepatitis A or B and the local jurisdiction
has difficulty finding adequate supplies of immunoglobulins, CDC can help lo-
cate supplies in other parts of the country.
An increasingly important role at the federal level is outbreak coordination
and notification of other jurisdictions about an outbreak. It is no longer uncom-
mon for domestic outbreaks to involve 20 or more states, any one of which may
have too few cases of illness to conduct meaningful independent investigations.
Recent examples of such outbreaks include cyclosporiasis associated with im-
ported fresh raspberries, salmonellosis associated with contaminated cereal, and
listeriosis due to contaminated hot dogs. In such instances, consistent case defi-
nitions for illness must be applied, standard questionnaires must be employed,
selection of controls for case-control studies must be similar, specimen collec-
tion and disposition must be consistent, and data must be shared and pooled.
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32
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
Sister federal agencies also play a vital role in outbreak investigations, par-
ticularly the Department of Agriculture's public health agency, the Food Safety
and Inspection Service (FSIS) and the Department of Health and Human Serv-
ice's Food and Drug Administration (FDA). Both FSIS and FDA play a role in
foodborne outbreaks because of their regulatory oversight of all food products,
the former agency responsible for meat, poultry and egg products, and the latter
responsible for all other food products. In 1997, FSIS's Office of Public Health
and Science created the Epidemiology and Risk Assessment Division which
includes eight field epidemiologists who assist states, local jurisdictions, and
CDC with trace-back efforts during outbreaks where FSIS-regulated products
have been implicated. In recent years, FDA has tried to improve the coordina-
tion of its response to multi-state outbreaks with CDC and other federal agen-
cies. Because food-borne outbreaks frequently involve low-level sporadic con-
tamination of widely distributed foodstuffs, often in food from other countries,
FDA must deal with multiple federal agencies and jurisdictions. The FDA Divi-
sion of Federal-State Relations aims to conduct outreach and coordinate such
efforts.
CDC has attempted to enhance the capacity of state and local partners to
conduct surveillance for disease outbreaks in a number of ways using resources
allocated for emerging infectious diseases. One is through improved in-house
laboratory and epidemiological expertise. The second is through provision of
resources to state health departments. One category of support is known as Epi-
demiology and Laboratory Capacity (ELC) cooperative agreements, which
states have used to build epidemiological capacity, improve laboratory infra-
structure, and electronically link local health departments. The second category
is the Emerging Infections Program (EIP) sites, which conduct more active dis-
ease surveillance and epidemiological studies, including the FoodNet system to
monitor the incidence of foodborne diseases. The third category is the develop-
ment of the PulseNet system for molecular fingerprinting of enteric pathogens.
Working with the Council of State and Territorial Epidemiologists (CSTE),
CDC has developed a number of strategies aimed at accomplishing multijuris-
dictional investigations while respecting state autonomy. These include devel-
opment of a coordination checklist, which allows state and local agencies to
determine when to inform others of an outbreak and when the outbreak may
have more widespread implications. CDC has also established a partnership with
state epidemiologists to review available data during an outbreak and make de-
terminations about the required public health response, as well as serve a quality
control function by reviewing the investigation once it is concluded. These de-
liberative groups, which are ad hoc, serve the important purpose of aiming to
balance local needs with national public health obligations. To allow better noti-
f~cation of potentially involved jurisdictions, CDC is developing a computer
program known as Epi-X, which will allow users to input data on outbreaks in
their jurisdiction into a centralized database, simultaneously informing other
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EPIDEMIOLOGICAL INVESTIGATION
33
public health officials of the occurrence. This should enhance information shar-
ing and notification, and allow the development of a database on disease out-
breaks, their risk factors, and control measures.
While these efforts have significantly improved the United States, ability to
recognize and respond to disease outbreaks, there is still substantial room for
improvement. Not all states currently participate in the ELC or PulseNet system,
and their capacity to conduct investigations is limited. The international capacity
for outbreak recognition and response is also spotty, although WHO is working
toward improvements in this area. In the outbreak setting, successful investiga-
tions require a coordinated, rapid response. To the degree that one of the in-
volved jurisdictions cannot meaningfully play their role, this goal cannot be
completely achieved.
STATE PERSPECTIVES ON
OUTBREAK INVESTIGATIONS
Patricia Quinlisk, M.D.
Iowa Department of Health, arid President.
Council of State and Territorial Epidemiologists
One of the essential public health services at the state level has been identi-
f~ed as the ability to diagnose and investigate health problems and health hazards
in the community. State health departments are often on the front line of out-
break investigations, and the information concerning potential outbreaks can
come from many sources, such as the medical care system, public agencies, or
other public health entities. At times, the recognition of potential outbreaks can
be coincidental and informal such as two physicians realizing that they had seen
patients with similar but unusual syndromes, as occurred with eosinophilia my-
algia syndrome. At other times, the identification of an outbreak occurs via es-
tablished public health surveillance systems. After the identification of a poten-
tial outbreak, the investigation starts to reveal the cause or causes of the
outbreak, and in the end, recommendations are made to stop the outbreak and to
prevent future illness.
Disease surveillance systems are usually population-based and can be either
active (e.g., calling hospitals to find cases of eosinophilia myalgia syndrome) or
passive (laboratories mailing reports of infectious diseases to the health depart-
ment). Although, active surveillance is expensive, it usually results in more ac-
curate data, but passive surveillance, even when only as few as 10 percent of
cases are reported, can be adequate for tracking disease trends. Sentinel surveil-
lance systems rely on reports of a few cases of disease whose occurrence sug-
gests that preventive or therapeutic care efforts need to be adjusted. For diseases
like influenza, sentinel surveillance can be relatively inexpensive and yet have
the ability to obtain timely and valuable information.
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34
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
A variety of diseases are made legally "reportable" to state health depart-
ments, a requirement that contributes greatly to the ability to track the health of
the population under surveillance. These reportable diseases include infectious,
occupational, chronic, and environmental diseases, as well as conditions such as
injuries, birth defects, and cancers. Most state public health systems also require
the reporting of outbreaks, unusual syndromes, and uncommon diseases, and
include a provision that allows "emergency" or research-related reporting in
special circumstances (e.g., to investigate the possible association between
Guillain-Barre syndrome and influenza vaccination in the early l990s).
Although each investigation is unique, most state-level investigations re-
quire basic components to ensure a timely and appropriate conclusion:
1. Epidemiological component. The determination of a cause of an out-
break usually requires the use of accurate epidemiological methods to ensure the
collection of unbiased data, the use of appropriate statistical methods in the
analysis of the data (often with the use of computer software such as Epi-Info
[computer software developed by CDC]), and the correct interpretation of the
analysis results.
2. Laboratory component. The ability to collect specimens, whether clini-
cal specimens from patients, environmental specimens from food or water, or
targeted specimens (such as the filter of a whirlpool associated with cases of
Legionnaires' Disease), is a critical component of the investigation. The ability
to have these specimens appropriately analyzed is often critical, particularly if
regulatory authority needs to be invoked, for example, to recall food products on
the market.
3. Environmental component. The information provided by the environ-
mental health engineer's investigation is instrumental for determining what en-
vironmental risks were present. For example, the engineer's information can
determine if the chlorination unit at the municipal water supply was working
correctly or if the oven used to bake the casserole at a local restaurant was hot
enough to kill all pathogenic bacteria.
4. Effective communication. The final and often most critical component is
effective communication. The results of the investigation must be communicated
and the appropriate individuals must be educated about the actions needed to
reduce the risk of further illnesses.
Frequently, an incident that begins at the state or local level requires na-
tional response as it becomes evident that the outbreak has crossed state borders.
An example of this occurred in the summer of 1996 when members of the Na-
tional Guard from Iowa became ill after returning from 2 weeks of training at
Camp Chaffee, Arkansas. When medical officials at the National Guard became
aware of the situation, they contacted the Iowa Department of Public Health to
report a possible outbreak, to solicit help in appropriate laboratory testing of
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EPIDEMIOLOGICAL INVESTIGA TION
35
blood specimens, and to seek epidemiological advice. The symptoms reported
by the members of the Guard were consistent with those of tick-borne illnesses,
such as ehrlichiosis or Rocky Mountain spotted fever, both of which are known
to occur in Arkansas but which occur only rarely in Iowa. The situation was
complicated by the fact that many members of the Guard had donated blood
after being exposed to the ticks, but before becoming ill, thus potentially
spreading the disease to the blood recipients.
After the Iowa Department of Public Health confirmed that the illness was a
tick-borne disease, CDC was contacted for assistance, since it became apparent
that the Guard members from other states were also attending training sessions
and the blood recipients, who resided in many states, were at risk of developing
disease. CDC played an essential role by coordinating and assisting the investi-
gations in several states and took primary responsibility for recalling and deter-
mining the safety of the donated blood. This investigation involved several
states and CDC as well as other national entities such as the National Guard, the
Red Cross, and other organizations concerned with the safety of the blood sup-
ply. The epidemiological investigation included interviewing ill and well mem-
bers of the guard, obtaining blood specimens, and tracing donated blood units.
The environmental investigation involved inspection of the Fort Chaffee site for
the presence of ticks and other risk factors and the retrieval of ticks for identifi-
cation and testing. The laboratory component involved testing of blood speci-
mens from members of the guard, blood recipients, and ticks.
The results of the combined investigations were recommendations to the
National Guard and Fort Chaffee on methods for reducing the risk of transmis-
sion of tick-borne diseases and obtaining a better understanding of the risks of
transmission of tick-borne diseases via blood transfusion. This one investigation,
however, tapped all available epidemiological resources in Iowa for its duration.
It illustrates how outbreaks within an individual state can quickly become a
challenge at the national level as well.
To ensure that state-level responses to outbreaks of illness are adequate, ap-
propriate, timely, and efficient, surveillance systems for diseases of public
health importance must be in place. There need to be adequate resources at the
local, state, national, and, occasionally, international levels to respond to and
investigate these outbreaks. The needed resources include both adequately
trained personnel and resources such as computers, laboratory testing reagents,
and environmental monitors. When all of these components come together, the
state can be assured that it has the best ability to identify, investigate, and ad-
dress problems affecting the public's health.
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36
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
COUNTY-LEVEL PERSPECTIVE ON
OUTBREAK INVESTIGATIONS
Catherine Slemp, M.D., M.P.H.
Director, Infectious Disease Epidemiology Program,
West Virginia Bureau for Public Health
The local public health department's role in an outbreak investigation is vi-
tal. It is most often the agency charged with maintaining surveillance systems
that detects outbreaks and that receives the first call for a response when an out-
break occurs. In most outbreaks, the best opportunity for collection of epidemi-
ological data and laboratory specimens as well as for applicable environmental
investigations is in the first few hours to days of the outbreak. These become
critical roles of the local health department, for on-site state and federal in-
volvement is often, at a minimum, 1 to 2 days away.
Nevertheless, many barriers to the appropriate accomplishment of this es-
sential public health service exist. Detection and reporting systems remain in-
adequate in many locales. Many local public health agencies cover small juris-
dictions (often jurisdictions with populations under 15,000 to 20,000) and are
staffed by a nurse, a sanitarian, a clerk, and a part-time health officer. Thus, a
limited number of staff members are available for outbreak investigations be-
cause they meanwhile are needed to maintain other critical functions. In addi-
tion, it is difficult to develop and maintain the skills required to conduct an in-
vestigation given the infrequency of outbreaks' occurrence. Finally, a low
administrative priority is often given to outbreak investigations since little
funding or planning is dedicated to what is often a rare and intermittent event.
As a bare minimum, local health officials need basic investigational skills in
questionnaire design, interviewing techniques, and collection of environmental
and clinical specimens. They need computer, media, communications, and coor-
dination skills. Importantly, they need to extend these skills beyond classic food-
borne outbreak investigations, because they are increasingly being called to in-
vestigate respiratory illnesses in school systems, occupational exposures, noso-
comial infections, day care center outbreaks, and so on. Electronic communica-
tions systems need to be strengthened so that information about outbreaks can be
shared and resources for use during the outbreak can be obtained. Finally, many
core-capacity documents, grants, and so on, explicitly define system expecta-
tions to the state level only (or combine the expectations for the state and local
levels). There is a need to better define expectations about local health depart-
ment capacities in outbreak investigations.
In sum, local health departments, which are often the first to be called when
an outbreak occurs, are often the least equipped to respond. Current inadequa-
cies can be overcome with the assistance and guidance of state and federal agen-
cies and with enhanced collaborations with local agencies. General principles
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EPIDEMIOLOGICAL INVESTIGA TION
37
that should be kept in mind when developing solutions to these issues include
the following: (1) Local health departments want to and must remain involved
with outbreaks in their jurisdictions. In most, the legal authority for outbreak
investigations rests at the local level. (2) Training must be designed to maintain
as well as develop these skills, and training must be long-distance accessible. (3)
Most local health departments already have working relationships with states
(although they may be administratively autonomous). (4) Local health depart-
ment staff members are open to guidance, direction, and development of new
skills but want clear expectations and adequate resources to accomplish them.
(5) Building and maintaining the local capacity to detect and respond to an out-
break can dramatically strengthen the public health system's ability to respond
to larger epidemics (e.g., a flu pandemic or a bioterrorist attack).
PERSPECTIVES OF PHYSICIANS' COMMUNITY
Larry Strausbaugh, M.D.
Evidemiologist, Portland Veterans Affairs Medical Center
Historically, clinicians have played a central role in outbreak investigations
and surveillance. Long before the causative agents for infectious disease were
known, the observations of medical practitioners served to alert the community to
unusual occurrences. Even after the etiologies of infectious diseases have been
unraveled and laboratory tests made available, clinicians still play an essential
role in providing cases for study and assisting in some epidemiological investiga-
tions. Often, however, physicians are not sure when and where to report suspi-
cious cases of disease, are unaware of the need to collect and forward specimens
for laboratory analysis, and may not be educated regarding the criteria used to
launch a public health investigation. Often, there is lack a of communication
among public health agencies and community physicians.
To bring these two sectors together, a number of obstacles need to be over-
come, including addressing the historical biases that each group holds about the
other, improving communications channels, providing public health offices with
the financial resources they need to establish and maintain professional working
relationships with the physician community, and educating physicians about the
need to interact with public health agencies.
In 1995 CDC announced the Cooperative Agreement Program for Provider-
Based Emerging Infections Sentinel Networks in support of an approach that
aims to overcome some of the obstacles that impede practitioner involvement in
the epidemiological investigation process. The program had its origin in a CDC
plan that addressed emerging infectious disease threats; listed under a disease
surveillance goal was the aim of establishing two physician-based sentinel sur-
veillance networks to detect and monitor emerging infectious diseases. In 1995
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38
o
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
i
i~ ,
/
o'er
ILL ~
~ ..
' ·::
moo
.
~ :
.
·~4
~--!~.':
V 74......
·~
::: ~ Lit=
\~ (630 Members, 10/9/98)
PR
FIGURE 2-1. Geographical distribution of Emerging Infections Network members.
Source: Infectious Diseases Society of America, 1998. SOURCE: IDSA Emerging Infec-
tions Network, unpublished data.
CDC made awards to (1) the Infectious Diseases Society of America (IDSA),
which has 4,700 active members, half of whom are clinical consultants in infec-
tious diseases; (2) EMERGEncy ID NET, a group of academic emergency de-
partment physicians; and (3) GeoSentinel (funded in 1996), a group of travel
medicine physicians, including some outside the United States, who joined to-
gether to report on phenomena related to emerging infectious diseases.
In 1996, the IDSA created the Emerging Infections Network (EIN), which
now has more than 700 active members. The strength of KIN lies in its members,
who have trained in internal medicine or pediatrics, have completed 2 or more
years of subspecialty training in infectious diseases, and serve a varied patient
population. KIN members are geographically dispersed and communicate regu-
larly with clinical microbiologists and pharmacists, who help them determine
which antibiotics are being used in health care facilities and why (see Figure 2-14.
KIN aims to (1) detect unusual clinical events (2) assist in the identification
of possible cases and outbreaks being investigated by CDC and other public
health authorities, (3) acquire knowledge about the use of diagnostic tests for
specific syndromes in different parts of the country and provide preliminary
estimates about morbidity and mortality, (4) collaborate in research with CDC
and other public health agencies, and (5) educate and communicate with health
care professionals through periodic and ongoing requests for information on a
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EPIDEMIOLOGICAL INVESTIGATION
39
specific topic. Sometimes KIN makes urgent queries and requests assistance
with outbreak investigations, for example, by requesting a 24-hour response on
experiences with febrile reactions after once-a-day gentamicin use related to
possible endotoxin contamination. When appropriate, KIN sends its initial ob-
servations to CDC and to state health departments. It also sends preliminary
reports back to its members within a month of issuing the query. Results of que-
ries are published on the World Wide Web (http://www.idsociety.org).
PUBLIC HEALTH PRACTICE AND THE ROLE OF
ACADEMIC PUBLIC HEALTH*
William Roper, M.D., M.P.H.
Dean, School of Public Health, University of North Carolina at
Chapel Hill
Academic public health institutions are a vital component of the global re-
sponse to emerging infections. The roles that these institutions play flow directly
from their core missions of education, research, and public health practice.
Academic public health institutions maintain primary responsibility for pro-
ducing a public health workforce that is skilled in responding to emerging infec-
tions. This requires (1) fostering an awareness of emerging infections and their
public health importance among students in schools of public health, (2) training
students in the most advanced concepts and methods for disease surveillance
and epidemiological investigation, and (3) ensuring student exposure to and un-
derstanding of real-world issues in the prevention, detection, treatment, and
control of emerging infections through targeted field experiences and collabora-
tion with public health organizations.
Academic institutions must also assume a primary role in keeping practic-
ing health professionals informed of new knowledge, practices, and technologies
that can be used to respond to emerging infections. Schools must capitalize on
new technologies in continuing education, distance learning, and executive
training that make use of the Internet, wide-area computer networks, and satel-
lite communications. To be effective, these activities must be carried out in close
partnership with national, state, and local public health organizations.
Academic public health institutions play central roles in strengthening and
expanding the scientific base to identify and respond to emerging infections.
This is done through laboratory research, in partnership with researchers in the
basic medical sciences, especially microbiology, to develop an understanding of
the basic biology of emerging pathogens. Epidemiological research identifies
emerging infections in populations to discover the mechanisms of transmission,
with the eventual goal being to develop interventions for the prevention, detec-
Delivered in absentia.
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40
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
lion, treatment, and control of the infections. This area of research includes the
development of new surveillance methods and the use of biostatistical models in
predicting disease progression and transmission.
Clinical research further elucidates the clinical practices and technologies
that are most effective in preventing, diagnosing, and treating emerging infec-
tions. Primarily academic medical schools lead these efforts, often with close
collaboration from epidemiologists and biostatisticians in schools of public
health.
Behavioral research interprets the roles of human decision making and in-
teractions in the prevention, treatment, and control of emerging infections. Aca-
demic public health institutions can bring together the concepts and methods
from a variety of behavioral science disciplines including psychology, sociol-
ogy, economics, demography, and geography and apply them to the study of
emerging infections.
Health services research, operations research, and program evaluations
identify the most effective ways of communicating information, exchanging
data, and coordinating efforts in disease prevention, treatment, and control
across organizations. This research is critically important as the health system
grows more complex, with public- and private-sector organizations sharing re-
sponsibilities in disease control and prevention.
Public health policy research informs the policy decisions faced by national,
state, and local public health officials in addressing emerging infections. This
research can help to answer questions about the public benefits and risks of poli-
cies, such as those affecting the privatization of laboratory services, the reporting
requirements for public- and private-sector health care providers, and the privacy
and confidentiality concerns of patient health and health care information.
It is imperative that academic public health institutions carry out all these
research activities in close collaboration with academic medical institutions and
that both entities share the knowledge and expertise in emerging infections that
each brings to bear. For example, epidemiologists in schools of public health
must work closely with colleagues in medical school divisions of infectious dis-
ease to elucidate biological pathways and transmission mechanisms.
Academic public health institutions also have important roles to play in
providing technical assistance, advice, and consultation to the organizations in-
volved in responding to emerging infections. These activities ensure that find-
ings from scientific research are disseminated, adopted, and implemented within
these organizations. Key activities include the following:
. assisting in the design and operation of governmental surveillance and
early-warning systems,
. coordinating surveillance and reporting systems across governmental
boundaries,
. supporting the adoption and use of new surveillance techniques,
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EPIDEMIOLOGICAL INVESTIGA TION
41
. assessing the preparedness of health care providers to identify and report
on emerging infections at the local level, and
. advising organizations on how best to respond to changes in the organi-
zation and to changes in the financing of health services and the effects of these
changes on disease surveillance capacities.
Traditionally, schools of public health have worked most extensively with
state and local health departments, and the entities are natural partners in public
health education, research, and practice. A much broader array of organizations
is now involved in the practice of public health generally and in the response to
emerging infections more specifically. Academic institutions must find ways in
which they can work more effectively with this broader array of organizations,
including commercial laboratories, managed care plans, hospitals, and private
. . .
pnys~c~ans.
Representative terms from entire chapter:
outbreak investigations
