This week’s post is the second in our series of posts about Deadly Outbreaks, a book of real-life outbreak mystery stories. You can purchase a copy of Deadly Outbreaks by author Alexandra Levitt at amazon.com.

Epidemiologists who investigate outbreaks often use their findings not only to control disease but also to prevent future outbreaks once the immediate emergency is over. For example, in the aftermath of an outbreak that occurred at a Toronto hospital during the 1980s (described in Chapter 3 of Deadly Outbreaks), the investigators recommended extensive changes in how hospitals dispense drugs and how they use mortality data to monitor and improve hospital care. Although public health experts had been advocating these improvements for some time, the experience at the Toronto hospital—which involved drug overdoses and a long lag before a problem was recognized—demonstrated their importance in a dramatic and unequivocal way.

Here is what happened in the outbreak story entitled Sorrow and Statistics:

In 1981, thirty-four babies at the Hospital for Sick Children in Toronto died from apparent overdoses of the heart medication digoxin. Although a judge dismissed murder charges against a nurse who had been on duty during some (but not all) of the deaths, the police continued to claim that she was guilty, while the hospital’s doctors insisted the babies had died of natural causes.

With the hospital under a cloud of suspicion, the hospital authorities called in outside help, in the form of an Epidemic Intelligence Service (EIS) officer from CDC. On his arrival, officials from the Ontario Ministry of Health introduced the EIS officer —James Buehler—to two experienced Canadian colleagues who served as members of his investigative team.

“What could the medical detectives do that the…doctors and police had not already done? The doctors had focused on the details of each baby’s illness, finding a natural reason for each death. The police, on the other hand, had focused on a particular suspect, seeking legal evidence to build a case against her. The epidemiologists viewed the evidence from a different angle. Unlike the police or the doctors, they looked at all of the deaths at once, as part of a single mission, trying to figure out what all the cases had in common—somewhat like an FBI analyst examining deaths linked to a single serial killer. However, unlike the police or FBI, they were not concerned with legal issues or with questions about human guilt and motivation, and unlike the hospital staff, they bore no personal responsibility for the babies’ welfare. They did not interview the nurses or meeting with the victims’ parents. Thus, they were emotionally removed from the tiny victims and perhaps better able to analyze the data in a dispassionate way, using graphs and statistics—“people with the tears wiped away” as the EIS saying goes. Another way to say it is that they ignored the horror behind the numbers and plunged on, wherever the data would take them.”

Despite advances in healthcare, infectious microbes continue to be formidable adversaries to scientists and doctors. Deadly Outbreaks—a book of real-life outbreak mystery stories—recounts the scientific adventures of a special group of intrepid individuals who investigate disease outbreaks and figure out how to stop them.

Several upcoming blog posts will describe stories from Deadly Outbreaks, written by Alexandra Levitt. (You may recognize some of these outbreak or their causes, or you may know some of the epidemiologists. Read on to find out….) For example, this week’s post concerns an outbreak of a dangerous drug-resistant disease with the potential for international spread. Like today’s Ebola outbreak in West Africa, the dangers posed by this outbreak underscore the critical importance of maintaining local public health systems that do the day-to-day work of investigating outbreaks and stopping them at their source. We rarely know in advance which small outbreak or disease cluster will turn out to be something truly dangerous and devastating.

People stranded in refugee camps, displaced, impoverished, and malnourished, are at special risk for infectious diseases such as malaria, measles, and cholera that flourish in crowded and unsanitary living conditions. When infected refugees are moved to new holding sites, repatriated, or resettled in new countries, they can bring these diseases with them. As a result, public health officials like McConnon have overlapping and sometimes conflicting aims: to safeguard the health and welfare not only of the refugees themselves, but also of the people in countries that host refugee camps or accept refugees as permanent residents.

The spread of smallpox after the 1971 Pakistani civil war illustrates what can happen when a pathogen incubated in a refugee camp infects the wider population. Smallpox was carried to the newly established nation of Bangladesh by Bengali refugees returning home from India. According to public health lore, the presence of smallpox in the camps was detected by an epidemiologist in Atlanta, sitting in his living room watching TV, who noticed a man with a suspicious rash in a newsreel about a camp near Calcutta... The epidemiologist called the director of CDC, who called the director of the WHO Smallpox Vaccination Program, who called the Indian Ministry of Health. But it was already too late. Thousands of Bengalis had already left the camp, leading to widespread outbreaks in Bangladesh and making the last Asian country to eliminate smallpox.

• Informatics capacity continues to be a struggle, but we’re making progress. CSTE’s advocacy efforts educate policy makers to increase awareness and encourage funding. CSTE’s workforce development initiatives improve existing and new epidemiologists’ competencies in informatics skills. These continued efforts are important to sustain progress in this area.
• Developments in laboratory technology are just beginning to have a huge impact on public health surveillance. We will have to adapt to these changes to preserve our ability to do effective surveillance.
• Public health must align with the changes occurring in healthcare delivery and the focus on accountable care. Accountable care organizations (ACOs) are going to be responsible for the health of the populations in their care, not just their medical care. Public health epidemiologists should be the ones who are recognized as monitoring population health, identifying needs and holding ACOs truly accountable.
• Hepatitis C, as a public health challenge, is entering a whole new level of complexity. Literally millions of cases are diagnosed and being diagnosed. We are entering an era of cure with more easily tolerated, shorter course, highly effective, but expensive therapy. We will be called on to define the burden and monitor trends, but we have never had the needed resources.