EPIDEMIC INTELLIGENCE SERVICE

The Epidemic Intelligence Service (EIS) of the Centers for Disease Control and Prevention (CDC) is a training program that, since 1951, has trained over two thousand public health professionals in applied epidemiology. It has had a significant impact on the practice of epidemiology throughout the world.

In the 1940s, the U.S. Public Health Service (a uniformed service of the U.S. government) developed an Office of Malaria Control in War Areas, headquartered in Atlanta, Georgia, for the purpose of developing methods to control and prevent malaria among the armed forces located both in the United States and in areas of conflict— primarily in Southeast Asia. In 1946, the office had successfully met its mission in developing appropriate control and prevention measures, and it was no longer necessary to have approximately two thousand professionals working solely on malaria. Dr. Joseph W. Mountin, assistant U.S. Surgeon General, developed the concept of a Communicable Disease Center (the original name of the CDC) dedicated to investigating communicable diseases and developing appropriate control and prevention measures. Alexander D. Langmuir, a professor at Johns Hopkins University School of Hygiene and Public Health, was recruited as the senior epidemiologist at the newly designated CDC.

Langmuir recognized the need for a cadre of epidemiologists who could conduct investigations of the causes of epidemics from which control and prevention measures could be identified. At the same time, the Korean War raised concerns about biological warfare in the United States, and a major defense would be the availability of epidemiologists who could immediately investigate potential threats. The wisdom of developing such an applied epidemiology training program was recognized, and twenty-two physicians and one sanitary engineer began their training at EIS in July 1951.

From this initial endeavor the program has grown into an exemplary applied epidemiology training program. Today, EIS officers are selected from a large number of applicants for the sixty-five to seventy-five positions available each year. Approximately 80 percent of incoming officers are physicians, with the remaining being veterinarians, nurses, statisticians, demographers, biologists, microbiologists, dentists, sanitary engineers, behavioral social scientists, and other professionals. The incoming officers may have just completed their professional training, or they may have had one or several years of experience in their professional areas—which may have included work in public health.

The objectives of the EIS program are to train public health personnel in epidemiology, provide epidemiologic services to states and other municipalities, investigate disease and injury as they occur in communities, and develop and recommend appropriate control and prevention measures.

The two-year training course begins with a three-week course that includes discussions of the principles of epidemiology, biostatistics, public health surveillance, field investigations, and laboratory science; and of specific diseases prevalent throughout the United States and the world. A community survey is conducted and hands-on computer training is also included.

Following this classroom training, the EIS officers are assigned to a specific program either at CDC headquarters, in a field station, at another federal agency, or at a state (or large city) health department for their two-year commitment. The important criteria for an assignment is that the EIS officer will have close supervision from a trained field epidemiologist and opportunities to participate in epidemiological investigations.

The concept behind this applied, hands-on training is that epidemiology is best learned by working on epidemics in communities as they occur, initially with close supervision from an experienced epidemiologist. In addition to responsibilities for field investigations, the officers will have other ongoing responsibilities, such as working on public health surveillance, handling public inquiries, writing reports, training other personnel in epidemiology, and assisting in planning activities. During the two years in the EIS program, the officers will also participate in some specialized short training programs and in the annual one-week EIS Conference held every April.

EIS officers work on the full spectrum of public health problems, both domestically and internationally. Initially, the emphasis was on infectious diseases, but the focus has evolved to include all health conditions. Each year EIS officers conduct hundreds of disease investigations. Major contributions have been made in portraying the epidemiology of infectious diseases and identifying appropriate control and prevention measures for hospital-acquired infections, food-borne and waterborne diseases, respiratory diseases, and emerging or reemerging infections such as Legionnaire's disease, toxic shock syndrome, HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), sexually transmitted diseases, hantavirus pulmonary syndrome, and multi-drug-resistant tuberculosis. There has also been strong epidemiological input in reproductive health, environmental and occupational health problems, nutritional problems, chronic diseases, birth defects, unintentional injury, and violence.

EIS officers are on call twenty-four hours a day, seven days a week. Depending upon the situation, a multidisciplinary team can be rapidly assembled and dispatched, and may include statisticians, laboratorians, nurses, veterinarians, physicians, administrators, public-relations personnel, and secretaries from the EIS and other CDC programs. Additionally, any laboratory or other equipment not available in the field can be assembled by the team.

In all circumstances, approval has to be received from the appropriate governmental agency or foreign government before the CDC team can travel to the area in which the epidemic is occurring. The team will then remain in the field as long as necessary in order to meet the objectives of the investigation. Before departing a verbal report is given to the appropriate authorities, following which a written report is prepared and distributed to those with a need to know.

At the present time, there are approximately 2,500 alumni of the EIS program. Approximately 75 percent of EIS graduates work for federal, state, or local governments, or for international organizations in public health. Another 15 percent are on the staff of academic institutions, while most others are in a private hospital-based practice. Though these individuals are not working directly with public health, they serve as an important group of practicing professionals who have been trained in preventive medicine and who continue to stress prevention in their daily private practices.

The excellence of the EIS training has been recognized throughout the world, and each year several health professionals from other countries are selected to participate in the EIS program. However, the need for trained epidemiologists in other countries has been greater than can be satisfied through the EIS program. In 1979 the concept of a Field Epidemiology Training Program (FETP) was developed with strong support from the World Health Organization's Southeast Asia Regional office in Delhi, India. The first FETP was initiated in Thailand. In addition to increasing the opportunities to provide hands-on training of a country's own health professionals, the FETP makes it possible to train students in each nation using their own health problems and resources. In 2000 there were twenty FETP programs located throughout the world from which more than nine hundred individuals have graduated. These two-year training programs are patterned after the EIS program in the United States but modified to meet the epidemiologic needs of each specific country.

Another activity developed by the EIS program is an epidemiology elective for fourth-year medical and veterinary students. This is a one to two month experience in the EIS program and provides opportunities for the students to become familiar with field epidemiology. To date, 632 medical and veterinary students have rotated through this program, participating in field investigations, analyzing data, and attending meetings and conferences. Seventeen percent of the medical students have returned to join the EIS program and more than 8 percent of them have continued in a public health career after graduation.

Another aspect of the EIS program is a preventive medicine residency program. Officers who desire this additional training spend an extra year at CDC, and split their time between headquarters and field assignments.

The professional activities of EIS graduates demonstrate the significant contributions they make to the practice of public health. Approximately one hundred of them have been or are state epidemiologists, sixteen have been state health commissioners, and twelve have been deans of schools of public health. Others have had important positions at universities and colleges, such as chancellors, deans, and department chairs.

The concept of hands-on field experiences in the training of applied epidemiologists has resulted in strengthening the practice of epidemiology and public health in the United States as well as throughout the world. As the emphasis on healthy people continues, and with the increasing recognition of the importance of disease and injury prevention, the need for trained epidemiologists experienced in applied epidemiology is apparent. The EIS program helps satisfy this need.

Philip S. Brachman

(see also: Centers for Disease Control and Prevention; Epidemics; Epidemiologic Surveillance; Epidemiology; Langmuir, Alexander; Training for Public Health )