key: cord-1047224-44knig6g
authors: Thacker, S.B.; Sencer, D.J.
title: Centers for Disease Control
date: 2008-08-26
journal: International Encyclopedia of Public Health
DOI: 10.1016/b978-012373960-5.00303-8
sha: 640c2ea2a72c86990088db9adb43d1b63b4a2217
doc_id: 1047224
cord_uid: 44knig6g

Emerging from a small, wartime government program with a regional focus on malaria in 1946, the Centers for Disease Control and Prevention (CDC) has become a global public health agency that addresses the entire scope of public health, with over 10 000 employees and contractors in nearly 200 occupations. The CDC's expertise has expanded in direct correlation with the expanding view of public health needs: it is recognized globally for its ability to respond to urgent threat related to disease epidemics and the health consequences of disaster and war. CDC programs have contributed significantly to the eradication and reduction of diseases such as smallpox, polio, and guinea worm, as well as the control of health problems such as human immunodeficiency virus (HIV), childhood lead poisoning, breast and cervical cancer, diabetes, violence, and unintentional injuries. CDC contributions in applied epidemiology, public health surveillance, risk factor reduction, and environmental risk assessment also have been critical to the practice of public health in the United States and around the world. The emerging concerns of the new century – genomics, globalization, the built environment, information technology, global warming, emerging infections, violence, and so forth – will require not only the traditional disciplines but also new expertise and new global partners, both public and private.

The history of the Centers for Disease Control and Prevention (CDC) began in 1942 with the establishment of the Malaria Control in War Areas (MCWA), under the U.S. Public Health Service (PHS). The U.S. military had suffered severely from malaria during World War I, and although the reported incidence had dropped during the 1930s, a cyclical 5-to 7-year pattern of disease raised concern. Because the disease had been endemic in the southern United States, concern was heightened because 600 military bases and more than 1000 essential war establishment facilities were located there. MCWA was the actualization of the vision of Joseph W. Mountin, MD (1891 -1952 , an assistant surgeon general in the PHS and director of the Bureau of State Services, who reported to the surgeon general of the PHS. The headquarters was located in Atlanta, Georgia, with close associations with 15 state health departments, Puerto Rico, and the Virgin Islands, as well as laboratory facilities and field stations in multiple states that worked with all the affected states and territories.

Although the PHS provided leadership for the new program, much of the expertise in malaria had been recruited by the military; therefore, substantial training became an essential component of the multifaceted approach taken by MCWA. Physicians assessed clinical malaria and parasitologists managed the laboratories; however, mosquito control was the emphasis, and engineers and entomologists dominated MCWA. Field staff from the recently terminated Works Progress Administration were recruited to continue their work of draining malaria breeding grounds and larviciding with diesel oil and insecticides (beginning with Paris Green but adding DDT in 1943, which substantially changed the approach to malaria control). State laboratory staff were trained to diagnose malaria by using the most effective techniques. The program's scope expanded to the civilian population and to other vector-borne diseases such as dengue and typhus. MWCA laboratory workers also responded to requests from states for assistance in epidemic investigations, a role previously left to the National Institute for Health (NIH) (now the National Institutes of Health). The MCWA program was regarded as highly successful, and even before the end of the war, Mountin and his staff were considering the future. With the support of Surgeon General Thomas Parran, Jr. (Surgeon General, 1936-48) , the Communicable Disease Center was established on July 1, 1946. At the time, CDC had 400 employees and a budget of $1.2 million ( Table 1) .

The legislation that created the CDC explicitly charged the new agency with responsibility for dealing directly with state health departments in the control of communicable diseases. This role was solidified in 1950 when the Association of State Health Officials and the American Public Health Association agreed that CDC take the lead in defining what diseases were of highest priority and should be reportable. The key figure in this expansion of the CDC role was Alexander D. Langmuir, MD (1910-93) , who was brought to the CDC in 1949 as Chief of the Epidemiology Division. Langmuir brought experience as a member of the Armed Forces Epidemiology Board, as a practicing epidemiologist at both the local and state health departments in New York, and as a professor teaching at the Johns Hopkins School of Hygiene and Public Health. He also brought vision and a strong personality that helped bring the role of the epidemiologist to prominence at the CDC and in public health practice throughout the country.

The CDC expanded during those first years to include field stations in Missouri, Colorado, and Texas, and to conduct special studies in other states. Influential events and decisions in the 1950s, however, truly established the CDC as an agency with national recognition, and Mountin and Langmuir were forces behind the majority of these changes. In 1950, the Cold War set the tone in international affairs, and the Korean Conflict fueled a concern about the pointed use of biologic weapons there and in the United States. Langmuir successfully championed the concept of the Epidemic Intelligence Service (EIS), which would respond to disease outbreaks as part of a program of biologic warfare defense. The EIS program was established in 1951 with the recruitment of 23 men, including 22 physicians and a sanitary engineer. This first class became the disease detectives, the symbol of applied epidemiology practiced at the CDC and the core of epidemiologists who would come to lead the agency in future years. By 2006, more than 2700 men and women had graduated from the program, all with different backgrounds and experiences. Together they have conducted more than 10 000 investigations, not only in infectious disease but also in chronic diseases, injury, and the many other health areas that the CDC has engaged in during subsequent years ( Table 2) . EIS alumni have become public health leaders at the CDC, throughout the United States, and around the world.

The event that first brought national attention to the CDC came with poliomyelitis, the crippling childhood disease. In 1952, more than 50 000 cases were reported in the United States, and polio was the leading infectious cause of childhood death in the country. In 1954, the University of Michigan conducted a national randomized trial of the killed virus vaccine developed by Jonas Salk on more than 200 000 U.S. school children during a year when more than 38 000 cases had been reported. The positive results were announced on April 12, 1955, the tenth anniversary of the death of Franklin Delano Roosevelt, and the response was dramatic. Within hours, Surgeon General Leonard A. Scheele (Surgeon General, 1948-56) announced a national vaccination program.

Unfortunately, however, on April 25 of that year, a baby was reported to have contracted polio 9 days after vaccination; this proved to be the index case of an epidemic of vaccine-associated polio that led to a decision to shut down the program. Four days later, Langmuir was directed to establish the national polio surveillance unit he had been advocating, and he immediately directed the EIS officers to focus their efforts on this national emergency. Within less than a week, daily reports were produced by the epidemiologists in the unit. Rapid investigation in the field and in the laboratory clearly implicated one of the five vaccine manufacturers as the source of the epidemic (although a second manufacturer might have had problems as well). Weeks later Surgeon General Scheele was able to announce that the problem had been identified, safety standards had been instituted, and the vaccine was now safe to distribute. The CDC's role had been critical, and the importance of public health surveillance and of the EIS was recognized. National surveillance for Asian influenza in 1957-58, together with the work of CDC epidemiologists and laboratory staff, cemented the national role of the agency in disease control.

The second major event of the decade was less obvious to the public -the transfer of the PHS Venereal Disease Division (VDD) to the CDC in 1957. At the time the VDD had a larger budget than the CDC and certainly a longer history. However, the effect was more important than the budget. The VDD brought with it a grant program that distributed money to states and a program management function -the public health advisor. The grant program enhanced the agency's connection and collaboration with state health departments, and the public health advisor became the primary nonscientific manager of CDC programs and of the agency itself. Another program that came to the CDC with the VDD -unfortunately one that was highly negative -was the Tuskegee study of the complications of syphilis, which had begun in 1932 Table 1 Centers for Disease Control and Prevention (CDC) timeline among black men in rural Alabama. Although the gravity of this study was little recognized in 1957, the matter became public in 1972 and led to a formal apology by President William J. Clinton in 1997.

The CDC moved into new facilities adjacent to the Emory University campus in 1960. At the time, the CDC had more than 1000 employees and a budget of $20 million. The expansion of the agency mission was equally substantial. By the end of the decade, the budget had reached $45 million, and the CDC encompassed programs in immunization, hospital infection control, tuberculosis, and environmental health. The journal Morbidity and Mortality Weekly Report (MMWR) was brought from the National Office of Vital Statistics to the CDC by Langmuir in 1961. The publication rapidly became the agency's premier publication and the avenue for publishing concise, science-based articles of current events of public health interest such as epidemics, as well as current data regarding disease occurrence and death. The CDC increasingly was recognized for its responsiveness to epidemics of infectious diseases, including drug resistance among hospitalized patients, Salmonella in commercially produced chicken, polio associated with oral vaccine, and for its international work in smallpox eradication and disaster assistance. The CDC also maintained its lead federal role in disaster assistance, and staff studied the immediate and long-term health effects of such disasters as Hurricane Camille in 1969. Possibly, the most important event for the CDC during that decade, however, occurred in Geneva at the World Health Assembly in 1966 when the World Health Organization (WHO), under the joint leadership of the United States and the United Soviet Socialists Republic, endorsed the plan to eradicate smallpox. This political will, together with improved technology (e.g., the jet injector gun to deliver vaccine), was the impetus for an extraordinary global program. Donald A. Henderson, MD (EIS 1955) , was transferred to WHO to help lead the international effort. A global mass-vaccination strategy was undertaken, and active surveillance documented rapid decreases in illness and death. However, the program began to founder and eradication appeared out of reach. William H. Foege, MD, another EIS alumnus (1962) , demonstrated in West Africa that an active surveillance and containment strategy was an effective complement to the mass-vaccination strategy. In 1979, these efforts resulted in the first successful eradication of a human disease in history, 2 years after the last case of wild-strain smallpox in Somalia.

The CDC's global role in disease control was founded on its active role in smallpox eradication. Two future CDC directors, Foege and Jeffrey P. Koplan, MD, who had served as an EIS officer (1972) in the program, and dozens of future public health leaders and hundreds of public health workers domestically and internationally were trained in this effort. The critical role of epidemiology and public health surveillance was now recognized by a much broader audience, and the importance of international, cross-disciplinary, and cross-cultural collaboration was appreciable.

The 1970s brought further change to the CDC and initiated its programmatic expansion to broader areas of public health, including environmental health, additional chronic diseases, occupational safety and health, and injury prevention and control. The CDC's expansion in part came from the transfer of programs in these areas, notably the National Institute for Occupational Safety and Health, which was transferred in 1972. Other expansions resulted from calls for assistance from states or other federal agencies. Childhood lead poisoning was being reported as a result of industrial pollution or from parents bringing lead home on their work clothing. Vinyl chloride-associated liver cancer was demonstrated in population studies. Investigating the short-and long-term effects of exposure to radiation after the incident at the nuclear reactor at Three Mile Island in Pennsylvania was initiated at the end of the decade. A collaborative study with the National Cancer Institute was conducted to investigate the association of cancer with both oral contraception and estrogen therapy. All these changes provided background for major organizational changes that occurred at the end of the decade.

Meanwhile, the CDC continued to have active engagement in infectious diseases. The identification of Salmonella among pet turtles altered that industry, as did discovery of the contamination of commercial intravenous preparations with bacteria and the subsequent documentation of a nationwide epidemic leading to a product recall. The Study of the Efficacy of Nosocomial Infection Control (SENIC) confirmed the effectiveness of hospital infection-control practices. Internationally, the CDC was involved in documenting the threat of hemorrhagic fever viruses -first the Marburg virus in Germany, and subsequently the Lassa and Ebola viruses in Sierra Leone, Zaire, and Sudan.

Two events in 1976, the agency's 30th year, however, might have had the most enduring impact. In spring 1976, an outbreak of influenza at a military base in New Jersey was identified as being caused by a new strain of influenza A, a strain that was quite different than the strain (A/Hong Kong/H3N2) circulating since 1968. The new strain (H sw 1N1) had demonstrated pathogenicity among humans and its ability to be transmitted person to person, circumstances that were believed to always lead to pandemics. As important, this strain was believed to be closely related to the influenza virus that had led to a pandemic in 1918-19, which had killed 500 000 U.S. residents and an estimated 25 million persons globally, affecting particularly young adults. With the CDC in the lead, scientific experts were engaged during the following months to study the problem. They ultimately recommended the policy that led to the National Influenza Immunization Program, which targeted the entire U.S. population. Vigorous efforts by the president, Congress, the vaccine manufacturers, and the public health system enabled the program to begin in October 1976. Within weeks, the CDC's national surveillance program, in collaboration with the states, uncovered an increased reporting of Guillain-Barré syndrome among persons who had been vaccinated during the program. Subsequently, the program was suspended and no epidemic occurred. An association was confirmed in a national case-control study conducted by the agency; the agency was criticized harshly, and other vaccination programs were called into question.

In early August 1976, a report from Pennsylvania of possible swine influenza led to an investigation of fatal pneumonias among veterans and their families who had attended a statewide convention of the American Legion in Philadelphia during the third week of July. The legionnaires' disease epidemic eventually brought 25 EIS officers and many other staff to Pennsylvania and stayed on the front pages for weeks during this bicentennial year. By the end of August, the field team had identified more than 200 cases -laboratory staff had ruled out all known human pathogens -and together they had investigated multiple leads in an effort to determine a toxin. Terrorism was considered, and external experts were called in. However, the strongest association identified was with the hotel that had housed the conventioneers and had hosted major business and social activities. The team returned to Atlanta without a definitive answer, and in the context of the mounting criticism around the swine influenza program, continued its work. Finally, in December, Joseph E. McDade, PhD (1940-) , in the CDC's Rickettsial Diseases Laboratory, identified the Gram-negative rod that proved to be the bacterium that caused the epidemic. Legionella pneumophila became the first new human bacterial pathogen identified in decades, and McDade and his coworkers linked it to two previously unsolved epidemics in 1965 and 1968.

The 1980s was dominated by the epidemic caused by HIV, but the CDC was also to undergo another major organizational change that reflected a new direction for the agency. However, the decade opened with two investigations of a more traditional nature that brought national visibility to the agency and brought lawyers into the public health policy arena in a dramatic fashion. In the summer of 1980, a report from Arizona in the MMWR linked Reye's syndrome with using aspirin. That report was followed by similar data from Ohio and Michigan, which led the CDC to conclude that the association might be real. The aspirin industry aggressively attacked, but the CDC held firm and recommended that aspirin be avoided for children with chickenpox and during influenza epidemics. Surgeon General Julius B. Richmond (1977-81) soon followed with a similar recommendation. The struggle with industry did not stop, but national data demonstrated a noticeable decrease in Reye's syndrome during the next few years. Meanwhile, the CDC was responding rapidly to the national epidemic of toxic shock syndrome among women. Within 6 months, the disease was linked to use of tampons and by the end of 1980, specifically to the use of the Rely tampon, made by Proctor and Gamble. After the manufacturer voluntarily withdrew the product, the epidemic abated dramatically.

Major change was continuing to happen in public health, and the CDC was involved in measuring the health effects of the radiation release from the nuclear reactor at Three Mile Island in Pennsylvania, the toxic effects of dioxin at Love Canal (New York) and among Vietnam War veterans, and the volcanic eruption at Mount Saint Helens (Washington state). The chemical release in Bhopal, India, and the investigation of toxic oil syndrome in Spain reflected the international recognition of the CDC in environmental health. In 1982, the agency announced a reorganization to reflect these new public health concerns and environmental health, chronic diseases, occupational health, unintentional injuries, violence, and maternal and child health, while maintaining excellence in the prevention of infectious diseases. This reorganization enabled the programmatic growth for the next two decades.

However, a brief report of an unusual pneumonia among five homosexual men in a June 1981 issue of the MMWR changed health practice at the CDC and around the world. The pandemic of acquired immunodeficiency syndrome (AIDS) caused by HIV crept slowly into public consciousness, but by the end of the decade, no health problem in the world generated more interest and controversy. The CDC was at the center of both. During those years, more than a third of the agency's budget was directed toward researching this illness and the virus that causes it. The agency's budget grew to approximately $1 billion by the end of the decade. Its constituency grew with the budget, and both domestic and global partnerships expanded considerably. At the CDC, behavioral and social scientists rapidly developed an important niche, and the move of the National Center for Health Statistics in 1987 to what was now the Centers for Disease Control brought a wealth of data and enhanced the role of the statistician at the CDC and in public health practice.

The last decade of the twentieth century was marked by expansion of programs and budget in the newly defined priority areas at CDC, especially chronic diseases. In 1993, the CDC's name changed to reflect its broadened mission, and it became the Centers for Disease Control and Prevention. By 2000, the CDC budget had exceeded $3 billion. The chronic disease budget was $660 million that year and was dedicated primarily to development of programs for preventing breast and cervical cancer. In addition, routine data collection was being established at the state level through the Behavioral Risk Factor Surveillance System, and state-based cancer registries were implemented to provide a data baseline for defining problems and evaluating program effectiveness. Emerging infections (e.g., Escherichia coli O157:H7, the hantavirus, and West Nile virus) and reemerging infections (e.g., antibiotic and drug resistance for bacteria, tuberculosis, and malaria), together with an increasing number of effective vaccines, underscored the continuing importance of infectious diseases. By the end of the century, ten major programs (then termed centers, institute, and offices) were located at the CDC, the last focusing on unintentional injuries and violence. An 11th center was created a year later. Global health programs related to HIV and other worldwide public health concerns continued to grow. By 2000, a global network of more than 30 Field Epidemiology Training Programs modeled on the EIS was established. On any give day, the CDC had more than 200 persons stationed internationally on long-term assignments. Nationally and globally, the science and services of the CDC were in great demand. The MMWR was available on the Internet and in 2006 received 1.2 million hits.

Additional notable public health events marked the early years of the twenty-first century -the terrorist attacks on the World Trade Center and the Pentagon (and the downing of a fourth airliner in a field in Pennsylvania) and the deliberate anthrax poisonings in 2001. Those two major events were followed in 2005 by Hurricanes Katrina and Rita occurring in rapid succession. All of these crises had an extraordinary effect on the country and on the CDC. The emergence of a major change in influenza made real the threat of another pandemic, and this also played out markedly at the agency. Two important themes emerged from these events. First, the nation and the CDC needed to adapt their approach to public health emergencies. Although the traditional approaches worked, improvement was needed. The impact on the public health system was significant and long-lasting. Second, the CDC received substantial additional funding, most of which was provided to traditional partners in state and local health departments to strengthen public health system infrastructures and to adapt to new demands. More than 9000 staff are now employed at the CDC, and the budget in 2006 exceeded $9 billion, $6 billion of which was shared with state and local governmental partners and with nonprofit organizations.

The new era stimulated a major examination of the agency and its future, and in 2003 led to a major reorganization that focused both on adaptation and response to crises but also greater collaboration across the major programs. The intent was to focus on major public health goals and not necessarily specific disease or injury programs, except in support of these goals. As with the reorganization two decades earlier, this process will take years to finalize and to assess the impact.

Beginning with a regional focus on a single parasite, the CDC has become the premier public health agency in the world, and its expertise has expanded in direct correlation with the expanding view of public health needs. The emerging concerns of the new century -genomics, globalization, the built environment, information technology, global warming, emerging infections, violence, and so onwill require not only the traditional disciplines but also new expertise and new global partners, both public and private. What will remain the same at the CDC is the dedication to its mission in global public health and its adherence to the core values of accountability, integrity, and respect. The new century has already proven challenging and exciting, a situation that CDC anticipates eagerly.

Ohio) and provides epidemiologic assistance to Canada during the Winnipeg flood 1951 -Epidemic Intelligence Service (EIS) established 1953 -CDC reports first case of bat rabies in United States 1955 -CDC establishes Polio Surveillance Unit during national investigation of contaminated vaccine 1957 -Asian influenza pandemic; Venereal Disease Division (VDD) transferred to CDC 1958 -First assistance to southeast Asia in response to cholera and smallpox epidemics 1960 -Permanent facilities open on property adjacent to Emory University campus; tuberculosis program transferred to CDC 1961 -Morbidity and Mortality Weekly Report (MMWR) moves to CDC; Cooperative Cholesterol Standardization Program established 1967 -Foreign Quarantine Service joins CDC

Control; smallpox eradicated in West Africa 1972 -National Institute for Occupational Safety and Health moves to CDC 1973 -MMWR reports that lead emissions in residential area are a public health threat 1975 -First Field Epidemiology Training Program established in Canada 1977 -Global smallpox eradication achieved (eradication certified by the World Health Organization in 1980) 1978 -First outbreak of multidrug-resistant tuberculosis (Mississippi) reported 1979 -Publication of Healthy People established measurable public health goals for the United States for 1990 1980 -Agency for Toxic Substances and Disease Registry established; MMWR publishes first report of toxic shock syndrome associated with tampon use 1981 -MMWR publishes first report of fatal disease eventually called acquired immunodeficiency syndrome (AIDS) 1982 -CDC reorganized with new centers for infectious diseases

CDC established Violence Epidemiology Branch 1986 -Office on Smoking and Health moves to CDC 1987 -National Center for Health Statistics moves to CDC 1988 -National Center for Chronic Disease Prevention and Health Promotion established 1991 -PHS recommends that all women of childbearing age consume 400 mg of folic acid daily to reduce risk for spina bifida and anencephaly 1992 -National Center for Injury Prevention and Control established 1993 -CDC's prevention mission is recognized, and it becomes the Centers for Disease Control and Prevention 1994 -Polio elimination certified in the Americas 1996 -CDC reports measurable levels of serum cotinine in blood of 88% of nonsmokers in United States 1997 -CDC participates in presidential apology for the Tuskegee study of syphilis treatment among black men 1999 -CDC's Laboratory Response Network established 2001 -National Center for Birth Defects and Developmental Disabilities established 2002 -Director's Emergency Operations Center opened 2003 -CDC provides global assistance for surveillance and clinical and laboratory evaluation regarding severe acute respiratory syndrome (SARS)

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