Field epidemiology, 2nd edition

Field epidemiology, 2nd edition

Media Reviews and Reports Field Epidemiology, 2nd Edition Michael B. Gregg, MD, ed. New York, NY: Oxford University Press, 2002. 451 pp., $49.95. ISB...

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Media Reviews and Reports

Field Epidemiology, 2nd Edition Michael B. Gregg, MD, ed. New York, NY: Oxford University Press, 2002. 451 pp., $49.95. ISBN: 0-19-514259-4


mergency epidemiologic investigations of disease clusters have uncovered many new associations, including the association of super-absorbent tampons and toxic shock syndrome, L-tryptophan and eosinophilia myalgia syndrome, soybean dust and asthma epidemics in Barcelona, and molds and acute pulmonary hemorrhage among infants in Cleveland. Freshly minted, university-trained epidemiologists often find themselves ill prepared to handle emergency investigations because their training does not usually include experience with “honest-to-goodness” epidemiologic emergencies. In this book, Michael Gregg, who arrived in Atlanta in 1966 to join the Epidemic Intelligence Service (EIS), the Centers for Disease Control and Prevention’s (CDC) flagship training program for field epidemiologists, and subsequently served for 21 years as editor of the Morbidity and Mortality Weekly Report (MMWR), has described the conduct of field epidemiologic investigations for the novice. As he defines it, field epidemiology involves the application of epidemiology under the following set of general conditions: the problem is unexpected, a timely response may be demanded, public health epidemiologists must travel to and work in the field to solve the problem, and the extent of the investigation is likely to be limited because of the imperative for timely intervention. Field epidemiology is synonymous with “shoe-leather” epidemiology, so named because nailing down the cause of an epidemic can involve wearing out the leather on the bottom of the epidemiologist’s shoes (hence, the famous trademark of the EIS Officer, the shoe with the “holey” sole.) In many ways, the job of the field epidemiologist is like that of the specialist in emergency medicine. Both are charged with responding rapidly and effectively to unforeseen emergencies. The decisions made and actions taken can make the difference between life and death. For an anxious patient assisted by an emergency room physician, rapid evaluation and treatment may mean the difference between fulminating progression of disease and disease cure. For a worried community assisted by a field epidemiologist, quick evaluation and recommendations may mean the difference between an epidemic that careens out of control and one that is rapidly halted. In both cases, long-term follow-up of the problem is usually handled by another specialist (for

the individual patient, that may be a specialist in internal medicine; for the community, that specialist would, one hopes, be a specialist in preventive medicine). Dr. Gregg has enlisted 27 current and former CDC staff members to contribute 22 chapters covering many aspects of field epidemiology. The book contains 32 useful tables and 37 figures, many reprinted from the MMWR, that summarize and illustrate examples of data collected during field investigations. Four new chapters are included in the second edition to describe investigations of natural disasters, occupational disease and injury, investigations from the state and local health department perspective, and bioterrorism preparedness and response. A special bonus is the inclusion of an exercise based on an actual epidemic of foodborne illness which occurred in Oswego NY more than 50 years ago. In addition to being a great tabletop exercise, the Oswego story is of some historical importance because it has probably been used to train more field epidemiologists than any other. A little-known fact about field investigations is that the vast majority of the time when CDC epidemiologists are invited to do a field investigation, the local health officials already have a pretty good idea of the cause of the epidemic. Thus, the role of the field epidemiologist is often that of confirming the etiology and assisting with the prompt implementation of prevention measures. Although labeled “quick and dirty” studies, successful field investigations follow the prevailing CDC philosophy that “being roughly right is generally more useful than being precisely wrong.” The book wryly notes that “Clearly, the more signposts of a real causal association, the less astute need be the epidemiologist.” Because the ultimate goal of any field study is to implement control measures, the book suggests that an enormous effort should be made to contact and inform persons who can take effective preventive action. The book provides rare insight into the political realities faced by CDC field epidemiologists. The text describes the reluctance of industry to accept epidemiologic evidence, citing the well-known example of toxic shock syndrome. The author acknowledges that there are often many agendas playing off each other in an emergency and proceeds to caution the field epidemiologist that an investigation may subsequently be faulted as biased because of real or perceived alle-

Am J Prev Med 2003;24(4) © 2003 American Journal of Preventive Medicine • Published by Elsevier Inc.

0749-3797/03/$–see front matter doi:10.1016/S0749-3797(02)00597-4


giances. The book includes a warning to the naive epidemiologist that the performance of epidemiologic functions may be significantly compromised because of conflicting forces that can limit studies, muddy interpretation, and jeopardize valid conclusions. Although the book is generally comprehensive, there are a few notable gaps. For example, there is no chapter on environmental epidemiology, yet health officials across the nation are frequently faced with the need to use epidemiology to investigate health effects from environmental contamination. And although it is beyond the mission of this book to discuss the subtleties of


analytic epidemiology, more extensive references would be helpful for the practicing epidemiologist. In sum, the second edition of Field Epidemiology is outstanding and will surely become a classic in the field. Although less useful for the ivory-tower epidemiologist who rarely gets the dirt of the field under his or her fingernails, it is an indispensable reference for the practice of shoe-leather epidemiology. Reviewed by Ruth A. Etzel, MD, PhD, George Washington University School of Public Health and Health Services, Washington, DC. E-mail: [email protected]

American Journal of Preventive Medicine, Volume 24, Number 4