Thency responsible for monitoring the Health Status of the american people. Stephen ostroff cdc functions as the doctor for the community or for the public at large, and so we monitor Health Status in a much broader sense. Our job is to watch the health of the american public, and when we see disturbances in the health of the american public, when we see diseases, our job is to try to figure out why they occur and how to both control them but more importantly, to prevent them. People often ask why this large Public Agency is located in atlanta instead of the nations capital. We are the only major Government Agency that is not headquartered in washington, dc, and both the fact that were not in washington as well as the date that we were established, tells you something about our history. In 1946, troops were returning home from europe and the pacific after world war ii. The joy of their return was tempered by Public Health concerns about what might be arriving with them. Would their homecoming also reintroduce diseases that had been erased from the National Scene . In the southeastern part of the United States, up until well into the 20th century, this was an area that had malaria. There was a lot of concern that as soldiers returned from areas, particularly in the pacific, which were highincidence areas for malaria, that as they came back to military bases in the southeast, that there was a possibility that they would reintroduce malaria into the mosquito populations around those military bases, and so a little unit was established in atlanta, being that it was the largest city in the southeast, to make sure that those mosquito populations were kept under control around the military bases, so that malaria wouldnt come back in this part of the country. And the way you control it, and the way we did in this country, was you got to get rid of the mosquito vector. That takes a sophisticated. Well, it takes an organized community effort. The chinese did that in southern china. Many places around the world have had malaria problems brazil that theyve brought under control. Not so in africa. Eradication efforts are erratic. Yellow fever is another mosquitotransmitted virus that the french encountered when they occupied west africa. So the way the french dealt with this was to conduct an ongoing everyfouryear campaign to vaccinate every person in every country they occupied. They had groups of doctors and nursesthats all they did. They just went from village to village on this four year cycle. That way, the most that could happen is youd have a group of susceptible children, but it would never get very big before youd be through vaccinating the next time around. That way, they kept yellow fever under control. Now, when those countries became independent, there wasnt money for those programs. And i got introduced to yellow fever in africa because, in 1965. Some seven or eight years after senegal got its independence, there was a big epidemic of yellow fever, and it was all in children under 10 years of age, because they hadnt been vaccinated. When we started off at cdc, a lot of emphasis was on Infectious Diseases. Thats really how cdc grew. But at the same time, i think there was a general feeling that Infectious Diseases were really conquered. It was really sort of a mopping up operation that we were about. The fact that malaria had disappeared from the United States, and we conquered smallpox in the americas in 1971 and worldwide in 1977, sort of lent us confidence that really, there wasnt much that we couldnt do. As a result, the center began to diversify, to broaden its focus. And so we expanded into chronic disease areas. The National Institute for Occupational Safety and health was incorporated into cdc in the early 1970s. Much more recently, weve gotten into areas surrounding injury control and prevention. And of course we realized in the last few years that the Infectious Disease agenda is not over. Certainly its not in the developing world where it still causes a very heavy burden. Apart from what aids is doing as probably the most egregious example that weve seen in our lifetimes, having surpassed malaria as the largest killer of people in africa, is tuberculosis, for which weve had good drugs, havent used them wisely or enough in years past to reduce some of the problems that were seeing today. And thats getting more and more serious now with multiply resistant strains of tuberculosis. Tuberculosis is the most common infectious agent worldwide, and that has not changed. That is, of course, particularly true in developing countries, and particularly in asia, where the burden ofuberculosis is heaviest. In a number of the industrialized countries and the United States is perhaps the best example weve had tremendous success in controlling tuberculosis and did so up until the sort of mid1980s, and then, due to a number of factors some complacency, declining resources directed at tuberculosis and other illnesses we assumed were going to disappear, lack of sort of attention by the Public Health Community Tuberculosis came back, and came back somewhat slowly, subtly, until we realized we had a serious problem. We were victims of our own success. We had all these wonderful antibiotics, we had wonderful, very safe and effective vaccines that took care of polio and that got rid of smallpox and that largely got rid of measles, and there sort of became a perception that, why do we need to spend all this money . Why do we need to have all these people to take care of problems that dont exist anymore . And so the resources got shifted away, both out of health but within Public Health, into other areas of Public Health. This was the period when the chronic disease activities were picking up. This was also the era of aids, and a lot of the resources that were being used for other Communicable Diseases got shifted over to try to deal with the aids problem. And so we watched the infrastructure erode to the point where the local and state Health Agencies couldnt do their normal baseline functions to monitor what we consider the essential role, which is to monitor the pulse of the health of their populations. David bennett in some marginalized populations and in people in jails and prisons, we found we had a big challenge on our hands, and there was a wake up call, a good response, and i think weve now turned the corner, but hopefully, weve learned our lessons, that the fact that were now seeing a decline in tuberculosis doesnt give us any guarantees for the future. Another thing that haunts me is, now, there are other much more common problems such as measles and some of these other ones for which, in the case of measles, weve had a perfectly good intervention now for more than 30 years and have not used it. Were using it more and more now to help reduce it, but there are several other problems. Measles, polio, mumps, and chicken pox. The vaccinepreventable diseases of childhood are rarely seen in the industrialized nations of the world because of the immunization programs that exist. David bennett measles is still a serious disease in many developing countries, especially in africa and in many countries in asia. Even in healthy populations, measles will kill on an average of one per thousand children who are infected with measles, and if you dont immunize, every child would eventually get measles. Its even more serious in african populations where one has other illnesses and malnutrition at the same time, and that means children are quite likely to die, even 10 of children who get measles. In the next few years, the world Health Community will be targeting measles for eradication. It is next in line after polio. We need to approach diseases individually, where we have specially selected diseases that are amenable to a concentrated attack, to bring them to eradication. Theres no substitute for that. The cost benefit of getting rid of a disease is very high, often infinite, depending on how far you want to calculate it out. The issue of Disease Eradication is a very interesting one. The only example that we currently have is smallpox, where we know that the only reservoir in nature for smallpox was humans. And so, if you could break the chain of transmission in humans and it wasnt a latent infection in humans, and so it caused an acute disease, and then it disappeared if you could break the chain of transmission in humans, you could eradicate the disease. There hasnt been a case of smallpox thats occurred anywhere in the world since 1977, and so were now more than 20 years out, and so i think we have a fair degree of confidence that we have eradicated the disease in nature. The only known repositories of the smallpox virus are here at the centers for Disease Control and prevention, and also in equivalent institutions in russia. Of course, one of the more active discussions thats gone on over the last couple of years has been whether or not those stocks should be destroyed in order to ensure that any opportunity for this to break out of those laboratories and get back into the population is reduced to zero as much as conceivably could be. The counterarguments to that, of course, is number one youd be destroying a living species. The other is that you never know when you may need the live virus to be able to do research. One of the interesting things about smallpox is you dont need the virus to make the vaccine. The vaccine is a different virus. Its cowpox. And so you can produce lots of smallpox vaccine without needing the virus itself. The other interesting component of the smallpox story is that the fact that the disease has been eradicated and the fact that we stopped vaccinating the populations has made it a potentially very desirable bioterrorism agent. Its a highly transmissible illness. The levels of immunity in the population, not only of the United States but everywhere else in the world, is quite low. The World Community will face similar questions once polio and measles are eradicated. With measles and with polio, the story is much more complicated, because you do need the viruses to make the vaccine. In recent years, a strike force of deadly microbes has taken aim at the world. Because these bacteria and viruses multiply quickly, they evolve rapidly into even more aggressive strains. Most people, when they think of these emerging Infectious Diseases, think about them happening in sudan, or in the middle of africa, or in the middle of the remotest parts of asia or wherever, and we have to realize that if we look down the list of diseases and pathogens that weve discovered over the last 20 to 25 years, just as many of them have been found right here in the United States as has been found elsewhere in the world. Often a new pathogen is discovered when there are simultaneous outbreaks of an illness that cant be explained. This is a red flag to the centers for Disease Control. And e. Coli 157 actually fits into that mold. When there were nearsimultaneous outbreaks, one of them in southern oregon, the other one in. The upper part of the lower peninsula of michigan. There were suddenly a large number of people in relatively small communities with very severe, bloody, diarrheal illness. And when these people went to their Health Care Providers, the Health Care Providers took specimens, tested them for the bugs that they knew caused that type of bloody diarrhea and came up with nothing. They turned first to the local, then to the state Public Health department, and when that didnt turn up any answers, the state asked the cdc for assistance. And so in circumstances where people cant come up with the causative agent, those specimens can then come into our laboratories, and we can run tests for a variety of Different Things that are both known and unknown. And thats what we did in that particular situation. And one of the things that we noticed is that we found that there were unusual e. Coli in several of the specimens that were submitted to us from both oregon and from michigan. Now, everyone normally has e. Coli in their g. I. Tract. Its a normal inhabitant, and you need it to break down certain foodstuffs to be able to absorb them, and this was not an e. Coli that was recognized to be one of the bad ones. We further tested it, and we discovered that it had some unusual features that hadnt been seen before. With many of the emerging Infectious Diseases that weve seen, we can tell retrospectively that theyre not really new. Theyre just newly recognized. The cdc and its counterparts in canada and Great Britain describe themselves as pack rats when it comes to specimens. We save erything, and if you go around our laboratories and you look in the frzers, youll find all kinds of stuff that weve collected over the last 50 years. And we went back into our inventories, looking to see if we had old ones of this e. Coli 157 in our collections. The canadians did the same things, the british did the same things in their inventories. In the case of this e. Coli, it genuinely appears to us to be a new one. It looks like its a bug, its been around for some period of time. It sort of got together in the wrong neighborhood with some other bad players and picked up some of its bad habits. Basically, what happened is that some of what we call virulence factors got picked up by this bug from other bugs and then turned what was probably a faly harmless e. Coli into one that causes a fairly severe illness not only the bloody diarrhea, but also some complications with affecting kidneys, particularly in very young children. The risk factor for the disease, discovered in both the oregon and michigan outbreaks, was a large cheeseburger that people had ordered from the same fast food chain. We then continued to search, because at that point, it wasnt clear to us whether this was just a very unusual occurrence and we werent going to see this again, or whether or not we were genuinely looking at sort of a new major emerging disease in north america. And so we searched very diligently over the next couple of years for outbreaks. We found a small number of sporadic for us, sporadic means a case here and a case there but not part of a larger, recognized outbreak and we actually did investigate one or two other outbreaks. There was one that was in nebraska, in a nursing home, where it turned out hamburgers were also implicated. But then, in the 1990s, a major outbreak did occur. Stephen ostroff and that of course was a very large outbreak that occurred in the Pacific Northwest linked to jack in the box which involved somewhere in the range of 700800 people with a number of deaths, and for want of a better term, it sort of put this bug on the map. Weve learned over the years that primarily th is a bug that lives normally in the gastrointestinal tract of cows and is quite happy there and doesnt cause any disease. And so many of the problems that weve seen with this have been related to both Dairy Products as well as ground beef. But in addition to that, its sort of spectrum of implicated food items has expanded over the years, particularly into fruits and vegetables. As we look at this, it seems to be related to farming techniques that might allow access of cow manure into things where we would think that it shouldnt be. We have worked very closy with the regulatory agencies that are responsible for trying to reduce the occurrence of this in both Meat Products as well as other items the food and Drug Administration and the department of agriculture to implement measures that we believe would work to reduce its presence in the Food Products in the country. The detective work required to identify and counteract a new disease agent like e. Coli 157 demands enormous cooperation, not only between the public and private sectors, but among the nations of the world. To do our job, to recognize. The patterns of disease and to recognize anomalies from the normal patterns of disease because anomalies from the normal pattern of disease are basically what the definition of an outbreak is that requires a very tight partnership and working relationship between the clinical community, the Health Care Providers themselves, as well as the laboratories that see the specimens and make the diagnoses. In addition, it requires having robust investigative capacity at mostly the local level, but also at the state level, because by and large, thats where most of the action occurs. It is very, very important, particularly for people in the United States and other relatively wealthy countries to understand that this is one small boat. And we may be in the more affluent part of the boat, but were still in the same boat, and its in our interest to help everybody understand their health and deal with their health problems, especially the Infectious Disease problems. The importance of International Awareness and coopation even extends to our food supply. One of the things thats happened over the last couple of decades is the significant globalization of our food supply. You know, if you go to basically any nice restaurant in the country and have a several course meal, you could probably count up the number of continents that the various foods on your plate may have come from. The distribution of pathogens that might occur in. Peru, or that may occur in. Costa rica, is significantly different than might occur in california or in michigan. And so we have to be aware that there are potentially different. Risks in terms of those foods. The other is that weve figured out a way to mass produce and mass distribute foods in a volume that weve never been able to do re. And we have a variety of new Food Products prepackaged salads and while in general these products are quite safe, the problem is that if something does go wrong, it can go wrong on a very largescale basis. The traditional outbreak that we think about the bad potato salad at the church supper, you know still does occur, but what we see more and more of is we see very low levels of contamination in a product that may be distributed very widely in a large number of states. In order to get a handle on these widely dispersed cases, the cdc is turning to technology. One of the ways that weve been doing that is similar to what the fbi does in terms to having a National Database of fingerprints of criminals. Anytime one of those bugs is isolated, either from a human stool sample or from a food product, what happens is it goes into a network of laboratories that are capable of performing the fingerprints, using standardized methodology. Changes in how food is grown and handled, increased international travel, people crammed togethe in unsanitary nditions all contribute to the emergence of these new and deadlier microbes, but there is another critical factor. David bennett we now have the threat that our major tools, the antibiotics that we can treat bacterial infections, are being compromised. Theres a lot of resistance to antibiotics, both in hospitals and communities, so were very worried about what will happen there. And this means increased cost, and it also means in some cases we cant effectively treat some infections, or its much more difficult to treat. Stephen ostroff so rapidly we have watched one after the next after the next of the easytouse, cheap, effective antibiotics sort of get thrown by the wayside because of the way that we have indiscriminately and inappropriately used them to the point now where as we speak, penicillin basically treats almost nothing. And so my message is in terms of emerging Infectious Diseases that the public at large should do what they can do to reduce the likelihood that we will continue to see the spread of antibiotic resistance by only taking those antibiotics when its appropriate to do so, to not seek antibiotics from your Health Care Provider when you have sort of the usual cold or viral infection that wont be responsive to them. Importantly as well, if the doctor tells you to take three tablets a day for seven days or for ten days, and you start feeling better after a day or two, then dont go down to two a day and then dont go down to one a day and then stop taking them after three or four days because you feel all better because thats how you leave behind the resistant bugs. In an effort to stay at least one step ahead of the bugs, the centers for Disease Control and prevention have started what they call the unexplained deaths project. Instead of waiting for a doctor to report an illness to the Health Department, the Health Department actually goes out and looks for the occurrence of deaths or very severe illnesses where the clinicians think that these are somehow related to some Infectious Disease but cant figure out what the cause is. And what we do is we collect specimens, both those that are available before the person died, and then postmortem, we also take what specimens are available, and we run them through a variety of different laboratories, not only here at cdc but also in various Academic Centers around the country, using the most uptodate razzledazzle technology to see if we can pick up something that is unexpected, that we didnt know was there. For example, the hantavirus, a severe illness that kills four of every ten of its victims, occurred so infrequently that no one picked it up. We know that those cases were going on for decades, and nobody ever pieced it together because they were so sporadic and they were so spread out over a Geographic Area that nobody recognized the patterns. We think that if we had been doing a project like this in 1993, that we wouldve picked up the existence of the hantavirus before it found us by producing an outbreak. So this is our opportunity to try to get sort of a little bit ahead of the curve and find the pathogens before they come and find us. Awareness is important, but just how much time should the public at large worry about e. Coli 157 or hantavirus or any of the other deadly pathogens that may emerge . If i was joe public, i wouldnt lose sleep worrying about being the victim of ebola, sitting in kansas city, missouri. I like to say that there are emerging Infectious Disease problems that we have right here in the United States, that you as the public can actually do something about, by taking the necessary prevention and control measures to reduce your individual risk of being the victim of one of these diseases. The types of things that we think about are the vaccinepreventable diseases. We know that a large proportion of the populations that we target to get the flu vaccine and we know that influenza kills many more people in the United States than will ever have been recognized with ebola in the world up to this point every single year, and yet we have a very simple preventative, such as the flu vaccine over half of the people that are targeted to receive it dont get it. Thsame itrue of theneumonia vcine which prevents illness due to a pathogen thats called the pneumococcus. And one of the problems that weve had over the last several years is that this bug has very rapidly developed resistance to many of the common antibiotics that are used to treat it. We have a very good vaccine against this particular organism, and yet in the targeted populations in elderly individuals and people with chronic lung disease and people with chronic Heart Disease in some of these populations, less than one in five who should get this vaccine and you only have to get it once actually get it, and so thats a very simple preventative measure that one can take to reduce their risk of being the victim of one of these emerging Infectious Diseases. Similarly, in the whole area of foodborne illness, we know that there are very simple things that one can do, such as kitchen hygiene, such as refrigeration, such as properly cooking your foods and properly washing your foods, which would reduce your individual risk of being the victim of the e. Coli bug, and yet its very hard to get that message across to people. Similarly, outdoor activities. You know, insect repellents. We just had this big outbreak in the new york city metropolitan area related to this virus that wed never se befor in the western hemisphere, known as the west nile virus. There were very simple preventative measures that people could take to reduce their risk of being the victim not only of that one but other mosquitoborne diseases, the same with tickborne diseases. And so, in your own personal campaign against marauding germs and microbes, the advice is clear. Concentrate on the things you can do something about, and try not to wry about the rest. The human condition is a 26part series about health and wellness. For more information on this program, and accompanyingaterials, call or, visit us online at [. ] female announcer some dreams are universal. Dreams that inspire us. Multiple sclerosis is a devastating disease that changes lives forever. The National Ms Society does more for people with ms than any organization in the world. But we cant do it alone. To get involved, visit us online at nationalmssociety. Org or call 1800fight ms. This is why were here. Because nobody dreams of having multiple sclerosis. Pl to aids in this country, in our borders, than all of our world wars. Death was a constant in my life for many years. I was sitting by deathbeds day by day, watching people die om the se thing i d. No matter how effectively we work to kill h. I. V. , to get r of it, to vaccinate against it, unle we look hard and carefully at our sexual behaviors and at the entire issue of drug abuse in the world, we will not be over this problem. There will be another epidemic, and another, and another
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