Disease surveillance and the academic, clinical, and public health communities - Synopses

Emerging Infectious Diseases, July, 2003 by Robert W. Pinner, Catherine A. Rebmann, Anne Schuchat, James M. Hughes

The Emerging Infections Programs (EIPs), a population-based network involving 10 state health departments and the Centers for Disease Control and Prevention, complement and support local, regional, and national surveillance and research efforts. EIPs depend on collaboration between public health agencies and clinical and academic institutions to perform active, population-based surveillance for infectious diseases; conduct applied epidemiologic and laboratory research; implement and evaluate pilot prevention and intervention projects; and provide capacity for flexible public health response. Recent EIP work has included monitoring the impact of a new conjugate vaccine on the epidemiology of invasive pneumococcal disease, providing the evidence base used to derive new recommendations to prevent neonatal group B streptococcal disease, measuring the impact of foodborne diseases in the United States, and developing a systematic, integrated laboratory and epidemiologic method for syndrome-based surveillance.

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During the 1980s, clinicians added newly recognized infectious diseases, such as toxic shock syndrome and AIDS, to their differential diagnoses when evaluating previously healthy young adults with severe illness. More recently, clinicians in the United States found themselves considering the possibility of inhalational anthrax among patients with influenzalike illnesses and adding West Nile virus infection to their workup of posttransfusion fevers (1-3). The existence of these and dozens of other emerging and reemerging infectious diseases, naturally or intentionally transmitted, has removed any doubt about the interdependence of clinical medicine and public health. Clinicians are sentinels for detection of new or reemerging diseases and may benefit from information acquired through public health surveillance and research projects, which helps to place the quantitative risks of these new diseases in perspective amidst the media attention that often accompanies the latest medical mysteries.

In 1992, the Institute of Medicine (IOM) articulated the concept of emerging infections, discarding the naive view that infectious diseases were problems of the past and cautioning against complacency about public health preparedness for infectious diseases (4). By defining emerging infectious diseases as "new, reemerging, or drug-resistant infections whose incidence in humans has increased within the past two decades or whose incidence threatens to increase in the near future," IOM recognized the broad scope of these diseases. The IOM report also cited factors that influence the emergence of infectious diseases: changes in human demographics and behavior; advances in technology and changes in industry practices; economic development and change in land-use patterns; increased volume and speed of international travel and commerce; microbial adaptation and change; and breakdown of public health capacity at the local, national, and global levels. The intentional release of anthrax in the United States in 2001 emphasized the need to add intentionally inflicted harm to the list of factors that influence the emergence of infectious diseases and to suspect the unexpected.

In response to the IOM report, Addressing Emerging Infectious Disease Threats to Health: A Prevention Strategy for the United States was developed by the Centers for Disease Control and Prevention (CDC) (5). A key recommendation of the plan called for establishing population-based centers to complement and support local, regional, and national surveillance and research efforts. This concept was realized through Emerging Infections Programs (EIPs), a network of state health departments (Figure 1) coordinated by CDC. EIPs are intended to be a national resource for surveillance and epidemiologic research by conducting work that goes beyond the routine public health department functions; by fostering collaborations between the public health, academic, and clinical communities; and by maintaining an infrastructure flexible enough to address new infectious diseases challenges as they emerge. An updated plan released in 1998 described the important role assumed by EIPs in addressing emerging infections and identified several high-priority target areas (6), which include: antimicrobial drug resistance, foodborne and waterborne diseases, vector-borne and zoonotic diseases, chronic diseases caused by infectious agents, diseases transmitted through blood transfusions or products, vaccine development and use, diseases of pregnant women and newborns, diseases of persons with impaired host defenses, and diseases of travelers, immigrants, and refugees. We describe EIP accomplishments and future directions.

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EIP Methods

The principal functions of EIPs are to perform active, population-based surveillance for infectious diseases; conduct applied epidemiologic and laboratory research; implement and evaluate pilot prevention and intervention projects; and provide capacity for flexible public health response. EIPs also develop and evaluate public health practice and transfer what is learned to the public health and medical communities.