With each new outbreak, medical sleuth is on case

CHESAPEAKE

By the time headlines revealed that the state’s first death related to swine flu happened in Chesapeake last week, Lisa Engle had already logged four days on the case .

As the city health department’s epidemiologist, she is on the front line of outbreaks and part of a global network of disease detectives whose job it is to keep viruses and bacteria at bay.

These investigators – there’s an epidemiologist in every health district – are often behind the scenes of the day’s biggest stories:

“Salmonella linked to three deaths in Virginia.”

“E. coli sickens 15 at Boy Scout camp.”

“Governor orders hospitals to track superbug cases.”

From anthrax threats to potato-salad poisonings, from a nurse’s tuberculosis to a vomiting outbreak on a cruise ship, medical sleuths such as Engle track sources and causes of such illnesses and work to keep them from spreading.

The phone call that began the latest headline maker for Engle came May 30, a Saturday, as she looked for iTunes cards with her children at Target.

She was standing in a shopping aisle when an emergency-room doctor on the other end of the phone line told her five residents from the Southeastern Virginia Training Center, a state facility for the mentally disabled, had been admitted with flulike symptoms.

The scenario had all the elements for concern – a vulnerable population, a cluster of them hospitalized, a new strain of flu called the H1N1 virus. And that would set the schedule for Engle’s next four days:

Lining up an emergency courier to take flu samples to the state lab in Richmond for testing.

Fielding middle-of-the-night calls from hospital workers asking about infection control protocol.

Meeting with Training Center officials and family members of people who had the H1N1 flu, more commonly known as swine flu, and advising precautions such as anti-virals for those in the same cottage and masks for visitors and staff.

Answering questions at a Tuesday news conference with Chesapeake Health Director Nancy Welch, who announced the death of one of the Training Center’s residents, 34-year-old April Wilson. The others were hospitalized, three with the swine flu and one with regular flu.

That news conference, in turn, would kick off a new barrage of calls for Engle that ranged from doctors asking about flu specimens to citizens with more mundane queries:

“I drove by the Chesapeake hospital last week, am I at risk?”

The field of epidemiology stretches back to 1854, when London physician John Snow suggested removing the handle from a water pump after noting victims of a cholera outbreak had used it.

His theory put to rest the prevailing notion that evil spirits caused the disease.

Modern epidemiologists use some of the same techniques:

Observing. Asking questions. Making connections.

At their disposal, though, are new technological tools.

Databases, for instance, that collect reports overnight from emergency rooms and urgent care centers, on illnesses such as fevers, rashes, intestinal problems, lesions. Global communication that links doctors in West Africa to nurses in Suffolk in minutes. Advances in science that parse the strains that sicken.

“It may seem like there are more salmonella cases, when actually our ability to genetically match salmonella and associate it with a food source has improved,” said Norfolk epidemiologist John Monroe.

Diane Woolard, the epidemiologist who directs the state Health Department’s surveillance and investigations division, said the field received a major boost after the Sept. 11, 2001, terrorist attacks, with federal funding for bioterrorism prevention and emergency planning.

That’s bolstered their work force, and epidemiologists now work in each of the state’s 35 health districts, in six regional offices, and in the state office.

At the center of their work is the state’s reportable disease list, which includes the common – flu and norovirus – the not-so-common – West Nile virus, tuberculosis, meningitis – and the rarely seen – yellow fever, the plague, monkey pox.

“It’s exciting – that’s what’s kept me in the field,” said Ana Colon, regional epidemiologist for the eastern part of Virginia. “It’s something I can’t get tired of, because it’s always different. Every time the pager goes off, you never know what you’ll get.”

Their job is not just to stem the illness of the moment but to look ahead at opportunities for public awareness campaigns. A rash of carbon monoxide poisonings around the time of a hurricane, for instance, led to a public warning about the dangers of generators and chain saws.

According to the Bureau of Labor Statistics, there were 4,100 epidemiologists employed in 2006, working in hospitals, government, industry and research. The field is projected to grow by 14 percent in the next decade, with the greatest growth in local government.

“They have a curiosity about how things happen,” said Dr. David Matson, director of the master’s of public health degree at Eastern Virginia Medical School and Old Dominion University, which graduates about 15 epidemiologists a year. “They’re philosophers of nature.”

Long after the headlines die down, Engle will be working on the case that garnered attention across the state last week.

She’ll continue to track the Training Center residents with flu and see if more people develop symptoms. She’ll talk with the center’s officials about whether they should consider a more stringent policy about taking residents out in the community.

The source of the H1N1 is impossible to pinpoint. The center has open visitation, and residents often go into the community, to go to the mall and other activities. And it’s clear the virus is spreading throughout Hampton Roads, which led to a recommendation that staff and visitors wear masks.

“They are a very fragile population, even more so than the elderly,” she said.

Right now, the H1N1 flu is mild for most people, even more so than seasonal flu. But new viruses sometimes arise late in spring, morph during the summer, and come back in the fall in a more virulent, severe strain.

Flu surveillance is usually suspended during the summer in Virginia, but this year it will continue in order to track the strains and severity through both lab reports and physician observation.

Epidemiologists across the globe will try to answer: Is the strain changing? Is it becoming more virulent? Is it becoming resistant to the anti-viral Tamiflu, as seasonal flu has? Who is getting sick? What’s the distribution by age?

And that’s just a piece of the work that Engle tackles.

In the past year, she’s fielded Chinese-drywall questions, tested well water for fly-ash contamination, and tracked methicillin-resistant Staphylococcus aureus, or MRSA, in school athletic teams.

“You’re constantly researching and learning,” Engle said. “You have to learn quickly. It’s like being a detective. You’re always looking for answers. You have to think on your feet.”

Most of the time, the public doesn’t even hear about what she investigates. There are a lot of dead ends, she said, noting a vehicle that spreads faster than flesh-eating bacteria: rumors.

Each one must be tracked down.

She also has to balance the public’s need to know about a health threat with a person’s right to health privacy, and figure out how to deal with questions from reporters.

In the most recent high-profile case, she was glad the infection protocols taken by the facilities were highlighted in the media but wishes there had been more focus on the dangers of regular flu, more attention to tips that some journalists may consider old hat by now:

Hand washing, good coughing practices, staying home if sick.

“People find it shocking that someone died of the swine flu, but every year, 36,000 people in this country die from seasonal flu,” she said in her never-ending public awareness spiel. “We’re trying to get that message out.”

Elizabeth Simpson, (757) 446-2635, elizabeth.simpson@pilotonline.com