60 Years of Public Health Science at CDC

Supplement December 22 2006 Vol 55

depardepardepardepardepartment of health and human sertment of health and human sertment of health and human sertment of health and human sertment of health and human servicesvicesvicesvicesvicesCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and Prevention

Morbidity and Mortality Weekly Report

60 Years of Public Health Science at CDC

MMWR

The MMWR series of publications is published by the CoordinatingCenter for Health Information and Service Centers for DiseaseControl and Prevention (CDC) US Department of Health andHuman Services Atlanta GA 30333

Suggested Citation Centers for Disease Control and Prevention[Title] MMWR 200655(Suppl)[inclusive page numbers]

Editorial BoardWilliam L Roper MD MPH Chapel Hill NC Chairman

Virginia A Caine MD Indianapolis INDavid W Fleming MD Seattle WA

William E Halperin MD DrPH MPH Newark NJMargaret A Hamburg MD Washington DC

King K Holmes MD PhD Seattle WADeborah Holtzman PhD Atlanta GA

John K Iglehart Bethesda MDDennis G Maki MD Madison WI

Sue Mallonee MPH Oklahoma City OKStanley A Plotkin MD Doylestown PA

Patricia Quinlisk MD MPH Des Moines IAPatrick L Remington MD MPH Madison WI

Barbara K Rimer DrPH Chapel Hill NCJohn V Rullan MD MPH San Juan PR

Anne Schuchat MD Atlanta GADixie E Snider MD MPH Atlanta GA

John W Ward MD Atlanta GA

Centers for Disease Control and PreventionJulie L Gerberding MD MPH

Director

Tanja Popovic MD PhD(Acting) Chief Science Officer

James W Stephens PhD(Acting) Associate Director for Science

Steven L Solomon MDDirector Coordinating Center for Health Information and Service

Jay M Bernhardt PhD MPHDirector National Center for Health Marketing

Judith R Aguilar(Acting) Director Division of Health Information Dissemination (Proposed)

Editorial and Production StaffJohn S Moran MD MPH

(Acting) Editor MMWR Series

Suzanne M Hewitt MPAManaging Editor MMWR Series

Teresa F RutledgeLead Technical Writer-Editor

Karen L Foster MAProject Editor

Beverly J HollandLead Visual Information Specialist

Lynda G CupellMalbea A LaPete

Visual Information Specialists

Quang M Doan MBAErica R Shaver

Information Technology Specialists

On the cover Clockwise Tom Harkin Global Communications Center atCDC (built in 2006) In 1946 the Communicable Disease Center or CDCopened in the old Office of Malaria Control in war areas in downtownAtlanta Georgia Locks at the Pacific Ocean end of the Panama Canal wherepublic health officials instituted sanitation measures that eliminated the yellowfever and malaria carrying mosquitoes which made building the canalpossible A child washing his hands after handling a pet turtle An adultreceiving a vaccination with a jet injector during the swine flu nationwidevaccination campaign Two CDC veterinarians administering a rabiesvaccination to a dog A CDC microbiologist examining reconstructed 1918Pandemic Influenza Virus inside a specimen vial containing a supernatantculture medium Photomicrograph of Streptococcus pyogenes bacteria

CONTENTS

Preface 1

Epidemiology and Public Health at CDCStephen B Thacker 3

Laboratory Science and Public Health at CDCKaren K Steinberg J Nicholson 5

Veterinary Medicine and Public Health at CDCLonnie J King 7

Engineering and Public Health at CDCG Scott Earnest Laurence D Reed D Conover C EstillC Gjessing M Gressel R Hall S Hudock H HudsonC Kardous J Sheehy J Topmiller D TroutM Woebkenberg A Amendola H Hsiao P KeaneD Weissman G Finfinger S Tadolini E ThimonsE Cullen M Jenkins R McKibbin G ConwayB Husberg J Lincoln S Rodenbeck D LantagneJ Cardarelli 10

Behavioral and Social Sciences and Public Health at CDCDeborah Holtzman M Neumann E SumartojoA Lansky 14

Economics and Public Health at CDCMark L Messonnier 17

Genomics and Public Health at CDCMarta Gwinn M Bowen M Khoury 20

Statistics and Public Health at CDCWilliam K Sieber T Green G D Williamson 22

Informatics and Public Health at CDCScott J McNabb D Koo R Pinner J Seligman 25

Law and Public Health at CDCRichard A Goodman A Moulton G MatthewsF Shaw P Kocher G Mensah S Zaza R Besser 29

Urban Planning and Public Health at CDCChris S Kochtitzky H Frumkin R RodriguezA Dannenberg J Rayman K Rose R Gillig T Kanter 34

Vol 55 Supplement MMWR 1

Preface 60 Years of Public Health Science at CDC

In 2006 CDC celebrates its 60th anniversary From theagencyrsquos relatively humble beginnings in 1946 as a malaria-control agency through its rapid growth in mission andexpansion of staff and public health partnerships by 2006science has been the foundation for everything CDC doesPublic health science comprises numerous disciplines thatcombined are more than simply the addition of their partsThis synergy is public healthrsquos unique scientific strength

Public healthrsquos ldquopatientrdquo is the community CDCrsquos mandateto protect the community has broadened as scientists havelearned about what constitutes health and how they can posi-tively affect health outcomes in the ldquopatientrdquo CDCrsquos healthprotection goals formally adopted in 2005 capture theessence and spirit of the agencyrsquos charge healthy people inevery stage of life healthy people in healthy places peopleprepared for emerging health threats and healthy people in ahealthy world

Accomplishment of these goals requires close collaborationacross scientific disciplines a multidisciplinary approach topublic health problems and highly coordinated efforts toimplement solutions The increasing complexity of factors thatcontribute to health requires use of the full spectrum of scien-

tific disciplines and expansion of scientific disciplines at CDChas been impressive From the entomologists and engineersdominating CDCrsquos scientific ranks in the 1940s to the addi-tion of epidemiologists veterinarians microbiologists andmedical officers through the 1970s to the latest addition ofeconomists behavioral and social scientists molecular biolo-gists statisticians urban planners informaticians and otherscientists current CDC staff represent approximately 25 sci-entific disciplines

This supplemental issue of MMWR celebrates CDCrsquos sci-entific strength and diversity by describing the public healthcontributions of 11 disciplines It begins with the fundamen-tal cross-cutting disciplines of laboratory sciences and epide-miology then focuses on disciplines new to public health yetessential to CDCrsquos success Although this supplement onlypartially illustrates the variety of disciplines contributing topublic health the 11 articles provide a flavor of public healthrsquosscientific diversity and strength They highlight contributionsof many disciplines to each of CDCrsquos health protection goalsand emphasize how synthesizing scientific information is es-sential to impact health and maximize scientific investments

Lisa M Lee PhDTanja Popovic MD PhDOffice of the Chief Science Officer CDC


Epidemiology and Public Health at CDCStephen B Thacker MD

Office of Workplace and Career Development Office of the Director

Corresponding author Stephen B Thacker MD Office of Workplace and Career Development Office of the Director CDC MS E-94 Atlanta GA 30329 Telephone404-498-6010 Fax 404-498-6365 E-mail sbt1cdcgov

Epidemiology is the study of the distribution and determi-nants of health-related states or events in specified popula-tions and the application of this study to control healthproblems (1) However in public health the terms ldquofieldepidemiologyrdquo (2) and ldquoapplied epidemiologyrdquo (3)mdashwhichemphasize use of results in public health settingsmdashdefine thepractice of epidemiology at CDC Epidemiology has beencharacterized as the basic science of public health (2) and itspractice at CDC has shaped the agencyrsquos development andwill contribute to its future success

Epidemiology at CDCEpidemiology at CDC began with Dr Alexander Langmuir

and his extraordinary contributions to CDC and to publichealth Hired in 1949 Langmuir served as first Chief Epide-miologist at CDC and remained in that position until 1970(4) In 1952 he convened the first Conference of State andTerritorial Epidemiologists which became the organizationrepresenting the approximately 2500 epidemiologists work-ing today in states Langmuir defined disease surveillance atCDC (5) and this model since has become an establishedglobal public health practice In 1961 Langmuir helped bringthe MMWR to CDC to disseminate timely public health sur-veillance data and to communicate the results of public healthinvestigations He was an international consultant in epide-miology at the Winnipeg flood disaster of 1950 the radiationstudies that followed the bombings at Hiroshima and NagasakiJapan the global smallpox-eradication program and otherinternational issues of public health importance

During the 1960s CDC epidemiologists continued to workin infectious diseases domestically especially drug-resistancein hospitals and Salmonella in commercial chicken productsA 1961 study of leukemia in Niles Illinois (6) marked thefirst of several investigations of cancer clusters and the intro-duction of chronic disease epidemiology to CDC Langmuirextended the scope of CDC epidemiology by initiating a familyplanning activity in 1963 and 4 years later he established theMetropolitan Atlanta Congenital Defects Program

Possibly Langmuirrsquos most recognized contribution was theEpidemic Intelligence Service (EIS) a combined training andservice program formed initially in response to the threat ofbioterrorism (7) Since 1951 approximately 2700 EIS

officers have provided CDC and the states with a rapid-response capacity for any public health need in an estimated10000 investigations domestically and internationally (8)EIS-trained epidemiologists remain at CDC in leadershippositions others occupy prominent positions in other gov-ernment agencies academia and international organizations

One investigation put CDC and applied epidemiology inthe public eye for the first time On April 12 1955 (the anni-versary of the death of Franklin Roosevelt) the favorableresults of the field trial of inactivated poliovirus vaccine wereannounced 5 days later a massive national vaccination cam-paign was initiated However within a week paralytic poliowas diagnosed in a child who had received the vaccine and asnew cases emerged Langmuir was called on to investigateA surveillance unit was set up and began issuing daily reportsOn May 8 the US Surgeon General declared a moratoriumon the program Using all the EIS officers and working withthe states CDC established the association with two lots ofvaccine from one manufacturer cleared the other four manu-facturers and persuaded public authorities by June 1 torestart the program (9)

The 1970s saw an expanding role for epidemiology at CDCCDC epidemiologists identified contaminated bottles ofintravenous fluid leading to a national recall linked liver can-cer in certain workers with exposure to vinyl chloride playeda pivotal role in the global eradication of smallpox identifiedEbola virus in Zaire and the Sudan identified toxic-shocksyndrome and uncovered the association between aspirin useand Reye syndrome The Cancer and Steroid Hormone Studyconducted in collaboration with the National Cancer Insti-tute and the Study of the Efficacy of Nosocomial InfectionControl were important not only for their findings but alsofor the introduction of large numbers of analytic epidemiolo-gists and statisticians to CDC The 1976 investigation ofLegionnaires disease in Pennsylvania highlighted collabora-tion between laboratory scientists and epidemiologists in thediscovery of new and important pathogens (10) Field epide-miology training programs established in Canada and Thai-land were the first of now 34 EIS-like programs around theworld (11)

Acquired immunodeficiency syndrome dominated the1980s and together with expansion of agency programs innoninfectious diseases added behavioral and social scientists

4 MMWR December 22 2006

to CDCrsquos team of epidemiologists statisticians and labora-tory scientists Infectious diseasesmdashnotably Escherichia coliO157H7 associated with hemorrhagic diarrhea andhemolytic-uremic syndromemdashremained important Howeverstudies of chronic diseases violence disasters refugees andtoxic exposures to both environmental and commercial prod-ucts such as cooking oil medications diet supplements andpaint engaged increasing numbers of epidemiologists

Since 1990 CDC epidemiologists have collaborated withan expanding array of partners around the world to tacklenoninfectious diseases and injuries as well as emerging infec-tions such as hantavirus cryptosporidiosis West Nile virussevere acute respiratory syndrome and the threat of pandemicinfluenza Global eradication programs in polio and dracun-culiasis (guinea worm disease) engage a global network of epi-demiologists with the World Health Organizationinternational governments and the private sector Preventioneffectiveness and informatics have been added to theepidemiologistrsquos toolkit Hundreds of epidemiologists weredeployed to address disasters at the World Trade Center andthe anthrax poisonings in 2001 and hurricanes Katrina andRita in 2005

The Role of the Epidemiologistin the Future

CDC epidemiologists will continue to respond to emer-gent events be they newly emerging infections natural disas-ters or terrorism and will continue to study public healthproblems such as unintentional injuries environmentalexposures cardiovascular disease obesity tobacco use and vio-lence domestically and internationally (12) Public and pri-vate partners on the public health team will expand to include

new disciplines The analytic tools and technologies availablewill increase and CDC epidemiologists will maintain a criti-cal role in capacity building Finally CDC epidemiologistsmust maintain the scientific integrity the agency has estab-lished by remaining rigorous yet adaptable to the challengesnew global realities bring to public health

References1 Last JM ed A dictionary of epidemiology 4th ed New York NY

Oxford University Press 20002 Gregg MB ed Field epidemiology 2nd ed New York NY Oxford

University Press 20013 Brownson RC Petitti DB Applied epidemiology theory to practice

2nd ed New York NY Oxford University Press 20064 Thacker SB Brachman PS eds A tribute to Alexander D Langmuir

Am J Epidemiol 1996144(Suppl)S1ndashS785 Langmuir AD The surveillance of communicable diseases of national

importance N Engl J Med 1963268182ndash926 Heath CW Jr Hasterlik RJ Leukemia among children in a suburban

community Am J Med 196334796ndash8127 Langmuir AD Andrews JM Biological warfare defense 2 The Epi-

demic Intelligence Service of the Communicable Disease Center AmJ Public Health 195242235ndash8

8 Thacker SB Dannenberg AL Hamilton DH Epidemic IntelligenceService of the Centers for Disease Control and Prevention 50 years oftraining and service in applied epidemiology Am J Epidemiol2001154985ndash92

9 Nathanson N Langmuir AD The Cutter incident poliomyelitis fol-lowing formaldehyde-inactivated poliovirus vaccination in the UnitedStates during the spring of 1955 Am J Hyg 19647816ndash81

10 Fraser DW Tsai TR Orenstein W et al Legionnairersquos disease descrip-tion of an epidemic of pneumonia N Engl J Med 19772971189ndash97

11 White ME McDonnell SM Werker DH Cardenas VM Thacker SBPartnerships in international applied epidemiology training and ser-vice 1975ndash2001 Am J Epidemiol 2001154993ndash9

12 Koplan JP Thacker SB Epilogue public health at the dawn of thetwenty-first century In Ward JW Warren C eds Silent victories thehistory and practice of public health in twentieth-century AmericaNew York NY Oxford University Press 2006457ndash63


Laboratory Science and Public Health at CDCKaren K Steinberg PhD1 J Nicholson PhD2

1Office of the Director Coordinating Center for Health Promotion2Office of the Director Coordinating Center for Infectious Diseases

Corresponding author Karen K Steinberg PhD Office of the Director Coordianting Center for Health Promotion CDC 2877 Brandywine Rd Koger Center MS K-88Chamblee GA 30341 Telephone 770-488-6067 Fax 770-488-6448 E-mail kks1cdcgov

in China and within weeks affected people in approximately30 countries Scientists from about a dozen countries aroundthe world held daily teleconferences to compare findings fromspecimens they had received CDC obtained blood from aWorld Health Organization physician caring for patientswhom we now know had SARS tested it by standard tech-niques including tissue culture and discovered a cytopatho-genic effect in one of the tissue culture cell lines Thesupernatants from the cells were examined by electronmicroscopy and a coronavirus was identified Patient speci-mens then were examined for antibody reactions to the iso-lated virus Virus-infected cells and cell extracts were used todevelop an antibody assay Then taking clues from partialRNA sequences of the coronavirus a molecular assay also wasdeveloped and in record time CDC had assays to deploy tothe state public health laboratories to detect both antibodyand antigen Three weeks after initial identification of SARS-CoV the complete sequence was determined and comparedwith other coronaviruses (3)

Role of the Laboratoryin Chronic Diseases

and Environmental HealthCDCrsquos experience in environmental health and chronic dis-

ease is more recent than its work in infectious disease StillCDC laboratories dedicated to these important public healthdisciplines provide vital expertise for accomplishing the CDCmission to protect public health

Smoking and exposure to secondhand smoke (SHS) areresponsible for a substantial proportion of death and diseasein the United States and worldwide The Surgeon Generalrsquosrecent report The Health Consequences of Involuntary Expo-sure to Tobacco Smoke showed that exposure to SHS increasesthe risk for developing heart disease by 25ndash30 and lungcancer by 20ndash30 (4) The CDC Environmental HealthLaboratory contributed to understanding the risks from SHSThis work included the first national estimate of nonsmokersrsquoexposure to SHS in the US population (5) and documenta-tion of a substantial decrease in SHS exposure using cotinine(a marker in the blood for exposure to nicotine) measures

Laboratory technology is as essential to public health prac-titioners for monitoring threats to public health as it is toclinical practitioners who depend on laboratory technologyto diagnose and monitor disease in individuals Laboratorytechnology provides essential information for effective publichealth interventions whether monitoring emerging infectiousdiseases such as avian influenza globally identifying patho-gens such as Escherichia coli in the US food supply and pin-pointing its source screening newborns for devastatingdisorders such as phenylketonuria that can be prevented byearly intervention or developing the capacity to quickly screenfor exposure to chemical and biologic agents

Role of the Laboratoryin Infectious Diseases

CDC was founded to address infectious diseases importantin the post-World War II era Today combating infectiousdiseases remains a vital part of the CDC mission includinginvestigating new outbreaks caused by infectious agents anddetecting characterizing and devising methods for preven-tion The laboratory also has been instrumental in identifyingnewly recognized or reemerging microbes that caused out-breaks including Legionella hantavirus West Nile virus andsevere acute respiratory syndrome-associated coronavirus(SARS-CoV) CDCrsquos ability to identify new pathogens hasimproved over time as laboratory technologies have advancedas illustrated by Legionella in 1977 (1) and SARS-CoV in 2003(2) Legionella a bacterium was discovered after many monthsof extensive laboratory testing when a scientist inoculatedguinea pigs with lung tissue from a patient and caused afebrile illness Spleen suspensions from the guinea pigs wereinoculated into embryonated eggs and a bacterium grewSerum from 101 of 111 patients whose illness met the clinicalcriteria for Legionnaires disease showed diagnostic increasesin antibody titers The laboratory tools used to describe thisnew bacterium were state-of-the-art in the 1970s althoughby todayrsquos standards they are rudimentary

Contrast laboratory techniques used to identify Legionellawith those used 3 decades later to identify another neworganism the SARS-CoV The SARS outbreak began in 2003


from the Third National Health and Nutrition ExaminationSurvey (NHANES III [1998ndash1991]) (6) Earlier studies usedless reliable estimates based on self-report or questions relatedto lifestyle rather than to laboratory measurements of SHSexposure

The decline in exposure to lead in the United States hasbeen called one of the most important recent accomplishmentsof public health (7) Most of the decline in blood lead levelsoccurred during the 1970s and 1980s paralleling removal oflead from gasoline (8) Understanding of this relation can beattributed to the accurate and precise blood lead measure-ments of the CDC Environmental Health Laboratory whichused atomic absorption spectrometric methods to measure leadlevels for NHANES III Analytical results indicated a dra-matic decrease in blood lead levels for the population Inaddition the percentage of children with blood lead levelsgt10 microgdL also decreased sharply from 89 in NHANES II(1976ndash1980) to 89 in NHANES III

ConclusionFrom CDCrsquos beginnings its expertise in laboratory science

has played a vital role in accomplishing its public health mis-sion both domestically and internationally That role contin-ues to grow as advances in laboratory technology are developedand used in the service of promoting the nationrsquos health andquality of life

References1 McDade JE Shepard CC Fraser DW Tsai TR Redus MA Dowdle WR

Legionnairesrsquo disease isolation of a bacterium and demonstration of itsrole in other respiratory disease N Engl J Med 19772971197ndash203

2 Ksiazek TG Erdman D Goldsmith CS et al A novel Coronavirusassociated with severe acute respiratory syndrome N Engl J Med20033481953ndash66

3 Rota P Oberste MS Monroe SS et al Characterization of a novelcoronavirus associated with severe acute respiratory syndrome Science20033001394ndash9

4 CDC The health consequences of involuntary exposure to tobacco smokea report of the Surgeon General Atlanta GA US Department of Healthand Human Services CDC Coordinating Center for Health PromotionNational Center for Chronic Disease Prevention and Health PromotionOffice on Smoking and Health 2006 Available at httpwwwsurgeongeneralgovlibrarysecondhandsmoke

5 Pirkle JL Flegal KM Bernert JT Brody DJ Etzel RA Maurer KRExposure of the US population to environmental tobacco smoke TheThird National Health and Nutrition Examination Survey 1988 to1991 JAMA 1996751233ndash40

6 Pirkle JL Bernert JT Caudill SP Sosnoff CS Pechacek TF Trends inthe exposure of nonsmokers in the US population to secondhand smoke1988ndash2002 Environ Health Perspect 2006114853ndash8

7 Bellinger DC Bellinger AM Childhood lead poisoning the torturouspath from science to policy J Clin Invest 2006116853ndash7

8 Pirkle JL Kaufman RB Brody DJ Hickman T Gunter EW PaschalDC Exposure of the US population to lead 1991ndash1994 Environ HealthPersepct 199811745ndash50


Veterinary Medicine and Public Health at CDCLonnie J King DVM

Office of the Director National Center for Zoonotic Vector-Borne and Enteric Diseases (proposed)

Corresponding author Lonnie J King DVM National Center for Zoonotic Vector-Borne and Enteric Diseases (proposed) CDC 1600 Clifton Rd NE MS D-76Atlanta GA 30333 Telephone 404-639-7380 Fax 404-639-7369 E-mail ljk8cdcgov

other countries pay three or four times more (7) Althoughthis achievement is recognized to have added billions of dol-lars to other parts of the US economy its success in allowingthe US public access to a nutritious affordable and sustain-able food supplymdashalso important for the publicrsquos health andwell-beingmdashis far less appreciated The success of the nationalbrucellosis and tuberculosis elimination campaigns has ben-efited not only the US livestock industries but also humanhealth by substantially reducing these zoonotic threats in ani-mals Additional public health contributions can be attrib-uted to the Food Safety and Inspection Service of the USDepartment of Agriculture (USDA) which has substantiallyreduced the burden of foodborne illnesses improved foodsafety and eliminated other zoonotic threats Over the yearsCDC has worked closely with USDA and the Food and DrugAdministration to improve the safety of US foods andreduce antimicrobial resistance in pathogens that infect bothhumans and animals

ResearchResearch in veterinary science is critical to understanding and

improving human health (8) In 1858 Rudolph Virchow thefather of comparative medicine stated ldquoBetween animal andhuman medicine there are no dividing linesmdashnor should therebe The object is different but the experience obtained consti-tutes the basis of all medicinerdquo (9) Today comparative andinterdisciplinary research is critical to translating scientific ad-vances from one discipline or species to another and providingnew insights into human health problems Scientific fields suchas laboratory animal medicine pathology and toxicology whencombined with veterinary medicine have proven especiallyrelevant to success in biomedical research (10)

Zoonoses in Companion AnimalsVeterinarians also have contributed to public health through

the care of companion animals Fifty-seven percent of all UShouseholds own a dog cat or both In addition millions ofexotic animals birds and reptiles are kept as pets (11)Although pets enrich the lives of humans they also poten-tially can threaten public health Veterinarians help educatethe public about prevention of zoonoses vaccinate large num-

IntroductionPeople readily associate the role of veterinarians with pri-

vate veterinary practice focused on pets and farm animalsbut the true dimensions and contributions of veterinary medi-cine are much broader and reflect expanding societal needsand contemporary challenges to animal and human healthand to the environment (1) Veterinary medicine has respon-sibilities in biomedical research ecosystem management pub-lic health food and agricultural systems and care ofcompanion animals wildlife exotic animals and food ani-mals The expanding role of veterinarians at CDC reflects anappreciation for this variety of contributions

Veterinariansrsquo educational background in basic biomedicaland clinical sciences compare with that of physicians How-ever unlike their counterparts in human medicine veterinar-ians must be familiar with multiple species and their trainingemphasizes comparative medicine Veterinarians are compe-tent in preventive medicine population health parasitologyzoonoses and epidemiology which serve them well forcareers in public health The history and tradition of the pro-fession always have focused on protecting and improving bothanimal health and human health (2)

Veterinary Contributionsto Public Health

The veterinary profession contributes to improvement ofhuman and public health by improving agriculture and foodsystems advancing biomedical and comparative medicalresearch preventing and addressing zoonotic diseases enhanc-ing environmental and ecosystem health and helping man-age 21st century public health challenges (34)

Bridging Agriculture and MedicineSince 1892 a total of 14 diseases have been eliminated from

equine poultry and livestock populations in the United States(5) The elimination of these livestock diseases along withoutstanding research in animal health is key to the remark-able gains in the efficiency of US animal production Partlyas a consequence US residents spend only approximately10 of their disposable income on food whereas residents in


bers of pets for zoonotic diseases such as rabies and leptospiro-sis and reduce the level of ecoparasites that can transmithuman diseases and intestinal worms such as roundwormsand hookworms which can cause serious health problems inhumans The 60000 private-practice veterinarians in theUnited States form a valuable front line for detecting adversehealth events reducing zoonotic diseases and deliveringpublic health education (7)

Environmental HealthBecause veterinarians work at the interface of human ani-

mal and environmental health they are uniquely positionedto view this dynamic through the lens of public health impactSignificant changes in land use expansion of large and inten-sified animal-production units and microbial and chemicalpollution of land and water sources have created new threatsto the health of both animals and humans (12) Because ani-mals share human environment food and water they areeffective sentinels for environmental human and public healthproblems including bioterrorism

Concerns are increasing about antimicrobial resistance ofpathogens waste and nutrient management and potentialrunoffs into streams rivers and oceans Food animal and wild-life populations are inextricably linked to some environmen-tal problems Together these have led to creation of a newscientific discipline called ecosystem health and veterinariansare assuming a leadership role in the field (13)

Contemporary ChallengesConvergence of Animal and Human

Health in a New EraSeveral decades ago special factors came together to create

a new epidemiologic era characterized by increases in emerg-ing and reemerging zoonoses (14) Humans animals andanimal products now move rapidly around the world andpathogens are adapting finding new niches and jumpingacross species into new hosts In 2005 approximately 21 bil-lion food animals were produced to help feed a world popula-tion of 65 billion persons the United Nationsrsquo Food andAgriculture Organization estimates that demand for animalprotein will increase by 50 by 2020 especially in develop-ing countries (15)

The lessons learned from severe acute respiratory syndromeWest Nile virus monkeypox and avian influenza are remind-ers of the need to view diseases globally integrate animal andpublic health surveillance epidemiology and laboratory sys-tems and create new strategic partnerships among animal

human and public health professions (1617) Veterinariansare essential to the detection and diagnosis of and response tothese threats and are integral to first-line defense and surveil-lance for bioterrorism agents

Veterinary Contributionsand the Changing Emphasis at CDCJust as CDC has expanded its role scope and influence in

public health since its inception in 1946 so has the veterinaryprofession (D Satcher CDC personal communicationOctober 21 1996) Early in the history of CDC veterinarians inthe US Public Health Service and the CDC Veterinary PublicHealth Division helped reduce zoonotic diseases especiallyrabies and foodborne illnesses (18) Today 89 veterinarians servethroughout CDC in positions that address not only infectiousdiseases but also the entire spectrum of public health challengesenvironmental health chronic diseases human immunodeficiencyvirus infection and acquired immunodeficiency syndrome inju-ries immunizations laboratory animal medicine global healthmigration and quarantine health education and bioterrorismVeterinarians contribute as epidemiologists laboratory scientistspolicymakers researchers and surveillance experts and inenvironmental and disease prevention and control programsboth domestically and globally

At CDC 228 veterinarians have participated in the Epi-demic Intelligence Service since 1951 (19) Forty-one statesnow have State Veterinary Public Health officials In 2005almost 300 students and faculty attended the first veterinarystudent day at CDC in April 2007 CDC will co-host aninaugural conference with the Association of Schools of Pub-lic Health and Association of American Veterinary MedicalColleges In addition CDC has been recognized as a WorldAssociation for Animal Health Collaborating Center forEmerging and Re-Emerging Zoonoses The CDC publica-tion Emerging Infectious Diseases has highlighted zoonoticdiseases in nearly every issue to zoonotic diseases and hasdevoted an annual issue in each of the previous 2 years ThusCDC has provided an important scientific forum for zoonoticdisease research and programs both domestically and globally

The convergence of human and animal health drove cre-ation of the newly proposed National Center for ZoonoticVector-Borne and Enteric Diseases Plans are being completedto establish several multidisciplinary state-level zoonosisresearch and development centers The veterinary professionat CDC has evolved in prominence as a member of the healthprofessions and has established its importance and usefulnessto human and public health Because their education is basedon the concept of multiple determinants of health in popula-


tions veterinarians are well suited to help define and achievethe new CDC health protection goals and to continue to con-tribute to the CDC mission in ways more important diverseand profound than ever before

References1 Hoblet KM McCabe AT Heider L Veterinarians in population health

and public practice meeting critical national needs J Vet Med Educ200330287ndash94

2 Schwabe CW Cattle priests and progress in medicine MinneapolisMN University of Minnesota Press 1978

3 Walsh DA Murphy FA Osburn BI King L Kelly AM An agenda foraction veterinary medicinersquos crucial role in public health and biodefenseand the obligation of academic veterinary medicine to respond J VetMed Educ 20033092ndash5

4 Noah DL Grayson JK Caudle LC 3rd Ten great veterinary publichealthpreventive medicine achievements in the United States 1901to 2000 J Am Vet Med Assoc 20002171834ndash6

5 Dunlop RH Williams DJ Veterinary medicine an illustrated historySt Louis MO Mosby 1996

6 Steele JH The history of public health and veterinary public serviceJ Am Vet Med Assoc 20002171813ndash21

7 Committee on Assessing the Nationrsquos Framework for Addressing Ani-mal Diseases National Research Council Animal health at the cross-roads preventing detecting and diagnosing animal diseasesWashington DC National Academies Press 2005

8 Committee on the National Needs for Research in Veterinary ScienceNational Research Council Critical needs for research in veterinaryscience Washington DC National Academies Press 2005

9 Schwabe CW Veterinary medicine and human health 3rd ed Balti-more MD Williams amp Wilkins 1984

10 Committee on Increasing Veterinary Involvement in BiomedicalResearch National Research Council National need and priorities forveterinarians in biomedical research Washington DC National Acad-emies Press 2004

11 Brown JP Silverman JD The current and future market for veterinar-ians and veterinary medical services in the United States J Am VetMed Assoc 1999215161ndash83

12 Zinsstag J Schelling E Wyss K Mahamat MB Potential of coopera-tion between human and animal health to strengthen health systemsLancet 20053361242ndash5

13 King LJ ed Emerging zoonoses and pathogens of public health con-cern Scientific and Technical Review 200423(2)

14 Smolinski MS Hamburg MA Lederberg J eds Microbial threats tohealth emergence detection and response Washington DC NationalAcademies Press 2003

15 Delgado C Rosegrant M Steinfeld H Ehui S Courbois C Livestockto 2020 the next food revolution Food agriculture and the environ-ment discussion paper 28 Washington DC International Food PolicyResearch Institute 199920ndash3

16 Knobler S Mahmoud A Lemon S Mack A Sivitz L Oberholtzer Keds Learning from SARS preparing for the next disease outbreakWorkshop summary Washington DC National Academies Press2004

17 Kahn LH Confronting zoonoses linking human and veterinary medi-cine Emerg Infect Dis 200612556ndash61

18 Steele JH Blackwell MJ Andres CR The 50th anniversary of theVeterinary Medical Corps Officers of the US Public Health ServiceJ Am Vet Med Assoc 1998212952ndash4

19 Pappioanou M Garbe PL Glynn MK Thacker SB Veterinarians andpublic health the Epidemic Intelligence Service of the Centers forDisease Control and Prevention 1951ndash2002 J Vet Med Educ200330383ndash91


Engineering and Public Health at CDCG Scott Earnest PhD1 Laurence D Reed MS2 D Conover PhD1 C Estill MS2 C Gjessing MS1 M Gressel PhD1

R Hall MS1 S Hudock PhD1 H Hudson MPH1 C Kardous MS1 J Sheehy PhD1 J Topmiller MS1

D Trout MD2 M Woebkenberg PhD1 A Amendola PhD3 H Hsiao PhD3 P Keane MBA3 D Weissman MD4

G Finfinger PhD5S Tadolini PhD5 E Thimons MS5 E Cullen PhD6 M Jenkins MS6 R McKibbin6 G Conway MD7

B Husberg MPH7 J Lincoln PhD7 S Rodenbeck PhD6 D Lantagne MS7 J Cardarelli II PhD81Division of Applied Research and Technology National Institute for Occupational Safety and Health CDC

2Division of Surveillance Hazard Evaluations and Field Studies National Institute for Occupational Safety and Health CDC3Division of Safety Research National Institute for Occupational Safety and Health CDC

4Division of Respiratory Disease Studies National Institute for Occupational Safety and Health CDC5Pittsburgh Research Laboratory National Institute for Occupational Safety and Health CDC6Spokane Research Laboratory National Institute for Occupational Safety and Health CDC

7Spokane Research Laboratory Alaska Field Station National Institute for Occupational Safety and Health CDC8Division of Health Assessment and Consultation Agency for Toxic Substances and Disease Registry

Corresponding author G Scott Earnest PhD Division of Applied Research and Technology National Institute for Occupational Safety and Health CDC 4676 ColumbiaParkway Cincinnati OH 45226 Telephone 513-841-4539 Fax 513-841-4506 E-mail gearnestcdcgov

Key Engineering Contributionsto Public Health

Air ContaminantsCDC engineers at NIOSH Hamilton Laboratories have

worked in industrial ventilation isolation and containmentcontaminant control indoor environmental quality and com-putational fluid dynamic modeling Successful engineering-control studies have led to advancements for 1) controllingair contaminants such as asphalt fumes silica and lead2) developing strategies under national emergency prepared-ness to protect buildings from attacks by chemical biologicor radiologic agents (3) 3) preventing transmission of infec-tious diseases in occupational settings (45) and 4) control-ling carbon monoxide on recreational boats (6)

CDC engineering work has focused on innovative solutionsfor controlling air contaminants During the mid-1990sNIOSH engineers working with paving equipment manu-facturers designed a control that reduced worker exposure toasphalt fumes by 80 (Figure 1) (7) NIOSH engineers havestudied control of respirable silica dust in nearly a dozenindustriesmdashin one example employee exposure to respirablesilica dust was reduced approximately 87 after a china manu-facturing plant implemented its dust-control recommenda-tions CDC engineers at NIOSH also have designed studiedand had installed ventilated booths for radiator repair shopsreducing blood lead levels of workers in those shops by 70

Lung-Function TestingCDC engineers have contributed substantially to the prac-

tice of lung-function testing Accomplishments includedevelopment of the standard approaches to testing lung-function equipment international leadership in developing

IntroductionEngineering is the application of scientific and technical

knowledge to solve human problems Using imagination judg-ment and reasoning to apply science technology mathemat-ics and practical experience engineers develop the designproduction and operation of useful objects or processes Dur-ing the 1940s engineers dominated the ranks of CDC scien-tists In fact the first CDC director Assistant Surgeon GeneralMark Hollis was an engineer CDC engineers were involvedin malaria control through the elimination of standing waterEventually the CDC mission expanded to include preventionand control of dengue typhus and other communicable dis-eases The development of chlorination water filtration andsewage treatment were crucial to preventing waterborne ill-ness Beginning in the 1950s CDC engineers began their workto improve public health while developing the fields of envi-ronmental health industrial hygiene and control of air pol-lution (1) Engineering disciplines represented at CDC todayinclude biomedical civil chemical electrical industrialmechanical mining and safety engineering Most CDCengineers are located in the National Institute for Occupa-tional Safety and Health (NIOSH) and the Agency for ToxicSubstances and Disease Registry (ATSDR)

Engineering research at CDC has a broad stakeholder baseWith the cooperation of industry labor trade associationsand other stakeholders and partners current work includesstudies of air contaminants mining safety physical agentsergonomics and environmental hazards Engineering solu-tions remain a cornerstone of the traditional ldquohierarchy ofcontrolsrdquo approach to reducing public health hazards (2)


and disseminating lung-function testing standards and col-laborations with epidemiologists in studies of occupationaland general populations A notable collaboration betweenNIOSH and the CDC National Center for Health Statisticsled to development of a commonly used set of reference val-ues for evaluating spirometry in the United States (8)

MiningMining presents a challenging work environment concerns

include excessive noise levels dust exposures explosive andtoxic gases and massive equipment in near-constant motionThe NIOSH mining research program developed engineer-ing controls for surface and underground mining to improveminersrsquo health and safety Successful controls adopted withinthe mining industry include water-jet sprays for dust controlnoise reductions on conveyors and drill units roof and struc-tural support systems designs for improved ventilation mine-escape operations and improved materials-handling systems

The mining community has successfully implemented prod-ucts resulting from engineering research These productsinclude several programs that helped improve roof floor andsidewall stability and prevent the likelihood of roof collapseand major causes of death and injuries (9) Coal pillar recov-ery guidelines and mobile roof supports have made pillarrecovery safer (10) Guidelines for designing deep-cover minesto prevent coal bumps (violent failures of highly stressed coal)contributed to 7 consecutive years without fatalities Aresearch and education campaign on rock-fall injuries and useof surface controls in coal mines has reduced rock-fall injuryrates by approximately 25

SafetyCDC engineers at NIOSH conduct safety engineering

research to prevent occupational injuries by developing prac-tical products and interventions in areas such as fall preven-tion machine safety and equipment safety research Examplesof engineering-control research include improved lock-outdevices for paper balers and rollover protective structures fortractors equipment responsible for numerous deaths andinjuries More rigorous standards have been examined formachine safeguarding to better match international standards(11) Other projects include improving the safety of roof-bracket assemblies to protect roofers and construction work-ers from disabling or deadly falls (12) and developing improvedwork practices and computer modeling on scissor-lift tip-overcontrols to prevent fatalities NIOSH safety engineers alsostudy personal protective equipment for workers exposed tofall-from-elevation hazards (13) Research on the interfacebetween the human body machinery and protective equip-ment represents an advancing area of safety engineering Thesepractices have provided the basis in developing injury-controlinnovations and moved many safety engineering technologiesto product-design practices standardization and commercial-ization

NIOSH engineers and epidemiologists worked together inAlaska after deck machinery on commercial fishing vessels wasidentified as the cause of 40 of injuries requiring hospital-ization in one of the countryrsquos most dangerous industriesEngineering researchers developed a solution to prevententanglements from a capstan-style deck winch Fisher-men praised the device as a safety and productivity improve-ment that reduces injuries and work stoppages (14)

Physical Agents Noise Heatand Radiation

Hearing loss prevention engineers at CDC study the effectsof noise-induced hearing loss that affects an estimated 30million US workers Engineers design and develop instru-ments and methods to assess and characterize hazardous noiseexposures NIOSH engineers have an international reputa-tion for their work on hearing protection devices controllingexposure to impulsive noise and novel engineering noise-control research They developed and patented EarTalkTM ahearing-protection and communication system that enablesworkers to communicate in noisy environments (Figure 2)They also developed a novel system for characterizing expo-sure to impulsive noise and applied for US and internationalpatents (1516)

FIGURE 1 Asphalt paver before (left) and after installationof an engineering control to reduce exposures to asphaltfumes

Before AfterPhotoCDC


Engineering assessments have shown that workers areexposed to ionizing radiation from technologies recentlydeveloped to improve homeland security These technologies(many of which were introduced to market after the terroristattacks of September 11 2001) use X-rays to screen checkedbaggage at every major airport throughout the world forexplosive materials or use gamma radiation to screen cargocontainers for illegal contraband NIOSH engineers charac-terized unnecessary exposures from these technologies and rec-ommended measures to prevent or reduce these exposures (17)

ErgonomicsEngineers support the NIOSH program to reduce work-

related musculoskeletal disorders and contribute to the designof new or improved exposure-assessment techniques tools andequipment According to the Bureau of Labor Statisticsapproximately 32 of lost workdays result from overexertionor repetitive motion CDC engineers developed an exposure-assessment technique to quantify risk factors associated withworkplace postures and job tasks Workers using nonpoweredhand tools have been studied using force sensor technology toidentify the portion of the work cycle resulting in the greatest

forces to the hand Effective interventions and solutions thatreduced repetitive motion injuries have been applied to theagriculture shipyard mining and construction industries(Figure 3) NIOSH also conducted an intervention trial that dem-onstrated a strategically designed patient-lifting program canmarkedly reduce musculoskeletal injuries to nursing staff inhealth-care facilities CDC engineers at NIOSH worked to pro-duce patentable devices to address specific concerns when com-mercially available interventions were not available (18ndash20)

EnvironmentEngineers at ATSDR are involved in determining through

engineering interpretation of environmental investigations andsampling results how the public could be exposed to hazard-ous materials in the environment In addition situation-specific sampling methodologies have been developed todetermine how exposures have occurred to hazardous materi-als Cutting-edge environmental modeling techniques are usedto reconstruct past exposures from contaminated drinkingwater supplies These remodeling techniques permit moreaccurate determination of adverse health impacts and reducethe exposure misclassification bias in ATSDR epidemiologicstudies During emergency response situations ATSDR engi-neers analyzed community infrastructures to help determinewhen the public could safely return home (2122)

Water quality is a public health concern worldwide CDCengineers at the National Center for Infectious Diseases work-ing with epidemiologists have conducted water quality test-ing developed standardized chlorine-dosing regimens and

FIGURE 2 NIOSH-developed and -patented EarTalktrade hearingprotection and communication system which uses miniaturemicrophones built into custom-molded earplugs to capturespeech signals from the ear canal and transmit it usingportable radios

FIGURE 3 Construction worker being evaluated by engineersfor musculoskeletal disorder risk factors

PhotoCDC


collaborated to develop regional safe-water systems that areinexpensive and easy to transport and have the appropriatechlorine dosing Engineering design has increased the impactof this program by making the chlorine solution available atlower cost to more persons in developing countries Last year8 billion liters of water were treated in 15 countries through-out Africa and Asia

ConclusionsFor decades CDC engineers have played a key role in

enhancing US and international public health by focusingon CDC goals concerning healthy communities workplaceshomes and schools CDC engineers are meeting public healthchallenges by conducting laboratory and field studies over-seeing research and development that result in solutions-basedproducts conducting disaster relief and emergency responseand engaging in public health program management Engi-neers are an integral part of the public health team that helpsdefine what is possible identify existing limitations and shapeworkable solutions Their efforts have contributed immenselyto reducing disease and preventing injury in the United Statesand around the world

References1 Engineer Professional Advisory Committee US Public Health Service

Engineerrsquos career planning handbook (January 2003) Available athttpwwwusphsengineersorghandbook

2 Plog BA Niland J Quinlan PJ Plogg H eds Fundamentals of indus-trial hygiene 5th ed Itasca IL National Safety Council 2002

3 NIOSH Guidance for filtration and air-cleaning systems to protectbuilding environments from airborne chemical biological or radio-logical attacks Cincinnati OH US Department of Health andHuman Services CDC National Institute for Occupational Safety andHealth 2003 NIOSH publication no 2003-139

4 Lin C Horstman RH Ahlers MF et al Numerical simulation ofairflow and airborne pathogen transport in aircraft cabinsmdashpart 1numerical simulation of the flow field ASHRAE Trans 2005111(Part I)755ndash63

5 CDC Guidelines for preventing the transmission of Mycobacteriumtuberculosis in health-care settings MMWR 200554(No RR-17)

6 Earnest GS Dunn KH Hall RM McCleery RE McCammon JBAn evaluation of an engineering control to prevent carbon monoxidepoisonings of individuals on and around houseboats AIHA J200263361ndash9

7 Mead KR Mickelsen RL Brumagin TE Factory performance evalua-tions of engineering controls for asphalt paving equipment Appl OccupEnviron Hyg 199914565ndash73

8 Hankinson JL Odencrantz JR Fedan KB Spirometric reference val-ues from a sample of the general US population Am J Respir CritCare Med 1999159179ndash87

9 Barczak TM Updating the NIOSH Support Technology Optimiza-tion Program (STOP) with new support technologies and additionaldesign features In Peng SS Mark C Khair AW eds Proceedings ofthe 20th International Conference on Ground Control in MiningMorgantown WV West Virginia University 2001337ndash46

10 Mark C Chase FE Pappas DM Reducing the risk of ground falls dur-ing pillar recovery In Yernberg WR ed Transactions of Society forMining Metallurgy and Explorations Inc Vol 314 Littleton COSociety for Mining Metallurgy and Exploration Inc 2003153ndash60

11 Etherton J Taubitz M Raafat H Russell J Roudebush C Machineryrisk assessment for risk reduction Human and Ecological Risk Assess-ment 200171787ndash99

12 Bobick TG McKenzie EA Jr Using guardrail systems to prevent fallsthrough roof and floor holes In Proceedings of the 2005 ASSE Pro-fessional Development Conference June 12ndash15 2005 New OrleansLouisiana Des Plaines IL American Society of Safety Engineers 2005Session 601

13 Hsiao H Bradtmiller B Whitestone J Sizing and fit of fall-protectionharnesses Ergonomics 2003461233ndash58

14 Thomas TK Lincoln JM Husberg BJ Conway GA Is it safe on deckFatal and non-fatal workplace injuries among Alaskan commercial fish-ermen Am J Ind Med 200140693ndash702

15 NIOSH Criteria for a recommended standard occupational noiseexposure revised criteria 1998 Cincinnati OH US Department ofHealth and Human Services Public Health Service CDC NationalInstitute for Occupational Safety and Health 1998 DHHS (NIOSH)publication no 98-126

16 Kardous CA Willson RD Murphy WJ Noise dosimeter for monitoringexposure to impulse noise Applied Acoustics Journal 200566974ndash85

17 CDC X-ray exposures from airport screening machines Available athttpwwwcdcgovnioshtopicsairportscreener

18 Albers JT Estill CF MacDonald LA Identification of ergonomicsinterventions used to reduce musculoskeletal loading for building in-stallation tasks Appl Ergon 200536427ndash39

19 Estill CF McGlothlin JD Hagedorn RT Flesch JP Hazard controlscontrolling the ergonomic hazards of wiring tasks for household appli-ances Appl Occup Environ Hyg 199914289ndash91

20 Lowe BD Wurzelbacher SJ Shulman SA Hudock SD Electromyo-graphic and discomfort analysis of confined-space shipyard weldingprocesses Appl Ergon 200132255ndash69

21 New York City Department of Health and Mental Hygiene ATSDRAmbient and indoor sampling for public health evaluations of resi-dential areas near World Trade Center New York New York samplingprotocol Atlanta GA US Department of Health and Human Ser-vices ATSDR 2001

22 Maslia ML Aral MM Analytical contaminant transport analysis sys-tem (ACTS)mdashmultimedia environmental fate and transport PracticePeriodical of Hazardous Toxic and Radioactive Waste Management20048181ndash98


Behavioral and Social Sciences and Public Health at CDCDeborah Holtzman PhD1 M Neumann PhD2 E Sumartojo PhD3 A Lansky PhD4

1Office of Scientific Regulatory Services Office of the Chief Science Officer Office of the Director2Division of HIVAIDS PreventionmdashIntervention Research and Support National Center for HIVAIDS Viral Hepatitis STD and TB Prevention (proposed)

3Office of the Director National Center on Birth Defects and Developmental Disabilities4Division of HIVAIDS Prevention National Center for HIVAIDS Viral Hepatitis STD and TB Prevention (proposed)

Corresponding author Deborah Holtzman PhD Office of Scientific Regulatory Services Office of the Chief Science Officer CDC MS D-50 Atlanta GA 30333Telephone 404-639-7262 Fax 404-639-7341 E-mail dxh4cdcgov

these disciplines contribute most to applied public healththrough intervention research program evaluation and policyanalysis

Development and testing of new interventions that arebehaviorally and socially based or that include behavioral andsocial components have been active areas of study at CDCespecially with regard to the acquired immunodeficiency syn-drome (AIDS) epidemic During the 1980s and 1990snumerous interventions were developed and tested to reducethe risk for human immunodeficiency virus (HIV) infection(1) For example using experimental or quasi-experimentaldesigns many studies examined the impact of psychosocial fac-tors on sex- or drug-related outcomes among clinic or drug-treatment populations In addition social and behavioralscientists have evaluated many of these interventionsmdashthosedeveloped not only for reduction of HIV infection (2) but alsofor other areas of public health significance such as violenceprevention (3) and occupational safety and health (4)

Another contribution to CDC and public health is themonitoring of key behavioral outcomes through surveillancesystems to assess policy impact For example in one studyusing data from the US Behavioral Risk Factor SurveillanceSystem and a quasi-experimental approach the prevalence ofdrinking and driving behavior was examined before and afterenactment of a new state policy The authors found a statisti-cally significant decrease in drinking and driving after lawswere passed and enforced to both lower the blood alcohol levelconsidered to be prima facie evidence of intoxication and tosuspend the driversrsquo licenses of persons found guilty of driv-ing while intoxicated (5)

The contributions of behavioral and social scientists to theCDC mission span the breadth and depth of public healthresearch and study Within CDC behavioral and social scien-tists have conducted research in the areas of AIDSHIV infec-tion (16) chronic diseases (78) intentional and unintentionalinjury (39) occupational safety and health (410) healtheducation and promotion (11) reproductive health (12) birthdefects and developmental disabilities (13) and environmen-tal health (1415) For example behavioral and social scien-tists applied social cognitive theory to data from the Family

IntroductionAlthough the history of CDC spans 60 years only during

the last 2 decades of the 20th century did the agency come torecognize and better understand the importance of thebehavioral and social sciences to its overall mission This rec-ognition was a consequence of several events notably thegrowing public awareness of the many conditions and dis-eases linked to unhealthy behavior and the creation of threenew organizational units at CDCmdashthe National Center forChronic Disease Prevention and Health Promotion in 1988the National Center for Injury Prevention and Control in1992 and the National Center for HIV STD and TB Pre-vention in 1993mdashthat focused on conditions diseases andinjuries with clear behavioral risks Accordingly the relativelysmall number of CDC behavioral and social scientists wereinitially concentrated in these three centers In 1995 to raiseawareness of behavioral and social sciences at CDC and tointegrate these fields into CDC-conducted and -supportedresearch and practice activities the agencyrsquos behavioral andsocial scientists established the Behavioral and Social SciencesWorking Group (BSSWG) The application of the behavioraland social science disciplines to public health attests to thesuccess of the working group Today BSSWG continues as aformal organization sponsored by the Office of the ChiefScience Officer within the CDC Office of the Director

Contributions of Behavioraland Social Science to CDC

The behavioral and social sciences incorporate a number ofdisciplines and each brings a variety of theoretical perspec-tives and methodologic approaches to its particular areas ofstudy At CDC these sciences are represented primarily bypsychology sociology anthropology and economics Armedwith their unique frameworks scientists from these fields canuse qualitative quantitative or multiple methods to explorethe effects of behavioral social and cultural factors on publichealth problems As with all research at CDC behavioral andsocial science research ranges from basic to applied however


Adolescent Risk Behavior and Communications Study toexamine the influence of multiple social factors on sexualbehavior among adolescents (12) They used a similar theo-retical framework to explore the impact of parental commu-nication on adolescent risk behavior for HIV infection (16)Others at CDC have emphasized the need for behavioral andsocial scientists to systematically examine economic socialpolitical and organizational factors to learn about behaviorsimportant to disease prevention (17) Recently behavioral andsocial scientists have directed their attention toward environ-mental health They are uniquely suited to uncover the socialforces affecting the environment that could create a healthdisadvantage to persons who inhabit that environment (14)

Furthermore behavioral and social scientists are well trainedto study the effects of not only attitudes and behaviors on thepublicrsquos health but also social factorsmdashsuch as class familystructure and community integrationmdashthat affect it Theinfluence of race and ethnicity on health and illness has beenimportant to investigations by behavioral and social scientists(18) and critical to the CDC goals of identifying understand-ing and reducing health disparities

The application of innovative approaches such as meta-analyses and translational research to public health problemsalso has been an important contribution by behavioral andsocial scientists (23) These contributions are especiallyapparent in the CDC Guide to Community Preventive Services(19) where systematic reviews of evidence for the effective-ness of prevention programs and interventions have been con-ducted for key programmatic areas throughout the agency

The Behavioral and SocialSciences Working Group

The successful integration of behavioral and social scienceinto CDCrsquos work can be attributed in large part to BSSWGand the commitment of its members The group has achievedits goals through major initiatives that include an annualspeaker series and support for BSSWG member attendance atrelevant professional conferences which helps identify newscientists who may be interested in public health and employ-ment at CDC New in 2006 was an annual award for out-standing behavioral or social science research Theseachievements have resulted in substantial increases in the num-ber of such scientists and expansion of their roles at CDC

From only a handful of behavioral and social scientists in afew parts of the agency just 15 years ago CDC today employsapproximately 300 behavioral and social scientists who workwith epidemiologists and biomedical researchers throughoutthe agency and collaborate with other federal agencies and

with nongovernment partners on a myriad of public healthconcerns Moreover behavioral and social scientists haveincreasingly competed successfully for positions in traditionalpublic health training programs such as the Epidemic Intelli-gence Service and participated actively in outbreak investiga-tions and emergency responses The behavioral and socialsciences are expected to continue to contribute to public healthat CDC in areas not already reached by these disciplines andthrough greater participation in areas of traditional publichealth such as infectious diseases (20)

As CDC has grown over the past 60 years its workforce hasbecome increasingly multidisciplinary The influence of theseworkforce changes reaches far into CDCrsquos extensive networkof public health partners Behavioral and social science per-spectives and approaches to public health extend to collabo-rative activities with state and local partners other federalpartners and other public and private organizations bothdomestically and globally Public health research and practicehave been strengthened by the disciplines represented amongthe behavioral and social sciences disciplines that have cometo play a vital role at CDC as it carries out its mission to makepeople safer and healthier

References1 Semaan S Kay L Strouse D et al A profile of US-based trials of

behavioral and social interventions for HIV risk reduction J AcquirImmune Defic Syndr 200230(Suppl 1)S30ndashS50

2 Semaan S Des Jarlais DC Sogolow E et al A meta-analysis of theeffects of HIV prevention interventions on the sex behaviors of drugusers in the United States J Acquir Immune Defic Syndr 200230(Suppl 1)S73ndashS93

3 Hahn RA Bilukha O Lowy J et al The effectiveness of therapeuticfoster care for the prevention of violence a systematic review Am JPrev Med 200528(2 Suppl 1)72ndash90

4 Israel BA Baker EA Goldenhar LM Heaney CA Schurman SJOccupational stress safety and health conceptual framework and prin-ciples for effective prevention interventions J Occup Health Psychol19961261ndash86

5 Campostrini S Holtzman D McQueen DV Boaretto E Evaluating theeffectiveness of health promotion policy changes in the law on drinkingand driving in California Health Promot Int 200621130ndash5

6 Holtzman D Bland SD Lansky A Mack KA HIV-related behaviorsand perceptions among adults in 25 states Am J Public Health 2001911882ndash8

7 Jack L Jr Liburd L Vinicor F Brody G Murray GM Influence of theenvironmental context on diabetes self-management a rationale fordeveloping a new research paradigm in diabetes education DiabetesEduc 199925775ndash7 779ndash80 782

8 Mercer SL Kettel Khan L Green LW et al Drawing possible lessonsfor obesity control from the tobacco control experience In CrawfordD Jeffery RW eds Obesity prevention in the 21st century publichealth approaches to tackle the obesity pandemic New York NYOxford University Press 2005


9 Dodge AC McLoughlin E Saltzman LE et al Improving intimatepartner violence protocols for emergency departments an assessmenttool and findings Violence Against Women 20028320ndash38

10 Thomas TK Bensyl DM Manwaring JC Conway GA Controlledflight into terrain accidents among commuter and air taxi operators inAlaska Aviat Space Environ Med 2000711098ndash103

11 Kann L Brener ND Allensworth DD Health education results fromthe School Health Policies and Programs Study 2000 J School Health200171266ndash78

12 Fasula AM Miller KS African-American and Hispanic adolescentsrsquointentions to delay first intercourse parental communication as a bufferfor sexually active peers J Adolesc Health 200638193ndash200

13 Ingersoll K Floyd L Sobell M Velasquez MM Project CHOICESIntervention Research Group Reducing the risk of alcohol-exposedpregnancies a study of a motivational intervention in community set-tings Pediatrics 20031111131ndash5

14 Howze EH Baldwin GT Kegler MC Environmental health promo-tion bridging traditional environmental health and health promotionHealth Educ Behav 200431429ndash40

15 Mott JA Wolfe MI Alverson CJ et al National vehicle emissionspolicies and practices and declining US carbon monoxide-related mor-tality JAMA 2002288988ndash95

16 Holtzman D Rubinson R Parent and peer communication on AIDS-related behavior among US high school students Fam Plan Perspect199527235ndash40 268

17 Sumartojo E Structural factors in HIV prevention concepts examplesand implications for research AIDS 200014(Suppl 1)S3ndashS10

18 Denny CH Holtzman D Goins RT Croft JB Disparities in chronicdisease risk factors and health status between American Indian AlaskaNative and white elders findings from a telephone survey 2001 and2002 Am J Public Health 200595825ndash7

19 Anderson LM Brownson RC Fullilove MT et al Evidence-basedpublic health policy and practice promises and limits Am J Prev Med200528226ndash30

20 Sumartojo E When tuberculosis treatment fails a social behavioralaccount of patient adherence Am Rev Respir Dis 19931471311ndash20


Economics and Public Health at CDCMark L Messonnier PhD

Immunization Services Division National Center for Immunization and Respiratory Diseases (proposed)

Corresponding author Mark L Messonnier PhD National Center for Immunization and Respiratory Diseases (proposed) CDC 1600 Clifton Road NE MS E-52Atlanta GA 30029 Telephone 404-639-8218 Fax 404-639-8614 E-mail qzm3cdcgov

vaccine on the basis of the results of an economic evaluationACIP makes recommendations on vaccines and immuniza-tion practices but it influences both government and privatepolicy decisions When ACIP votes to include vaccines in theVaccines for Children (VFC) program the decision is codi-fied as a VFC resolution A VFC resolution usually takeseffect after a CDC contract is established for purchase of thatvaccine Hence ACIP decisions on VFC have budgetary con-sequences Recommendations also are often followed by pri-vate health-care providers and affect third-party payers

Program Priority Setting and AnalysisIn 2002 the National Center for Injury Prevention and

Control (NCIPC) developed its Injury Research Agenda withinput from its academic research centers national nonprofitorganizations and other federal agencies with a stake ininjury prevention (16) The agenda was intended to guideresearch in key areas of injury prevention and control Amongthe criteria for including a topic area among the NCIPCresearch priorities were economic and social cost measures ofpublic health burden As a result cost-of-illness studies wereconducted in injury topic areas Such studies are importantnecessary starting points for subsequent economic evaluationsused to finalize intervention implementation priorities

Recent work at the National Center for Immunization andRespiratory Diseases (proposed) (formerly the NationalImmunization Program) illustrates program economic analy-sis that goes beyond cost analysis and economic evaluationEconomists there are studying the economics of vaccine sup-ply to understand the costs of vaccine development produc-tion and pricing Although manufacturers consider thisinformation proprietary it can be estimated and used by fed-eral government negotiators to evaluate their negotiation strat-egies for vaccines purchased for the VFC program

Practical ImpactEconomic evaluation has proven influential at the public

health practice level when alternative means exist of achievinga specific health goal Different therapies different popula-tions and different timing of interventions have been exam-

What is Economics ReallyEconomics is the study of decisionsmdashthe incentives that

lead to them and the consequences that result from themmdashasthey relate to present and future production distribution andconsumption of goods and services when resources are lim-ited and have alternative uses (1) At CDC economics is usedto systematically identify measure value and compare thecosts and consequences of alternative prevention strategiesCosts and consequences in public health can be measured invarious ways including incidence or prevalence of diseasenumbers of adverse events utility measures such as quality-adjusted life years and monetary values Because it deals withbehavior economics is not really about money at all Moneyis just a convenient way to measure incentives and conse-quences

Contributions of Economics to CDCand Public Health Research

Health economics has developed as a subdiscipline of eco-nomics and led to consideration of public health economicsas its own field (2) Its developmental history is evident inmilestone disciplinary publications (3ndash11) A few applied con-tributions illustrate the breadth to which economics has beenused at CDC and in public health a more expansive review ofapplied economic evaluation in public health (including meth-ods) and the ways economic studies have affected decisions isavailable elsewhere (12)

Policy AnalysisUseful at various levels of decision-making responsibility

applied economic studies have been conducted to evaluatein-place policies and public health programs and practices Atthe policy level examples include the effects of tobacco excisetaxes on cigarette consumption (13) and the effects of liquortaxes on rates of sexually transmitted diseases (14) Both stud-ies found that increases in taxes result in decreases in undesir-able health outcomes Cost-benefit and cost-effectivenessanalyses of vaccines are explicitly considered by the AdvisoryCommittee on Immunization Practices (ACIP) when it makesrecommendations (15) although ACIP has never rejected a


ined to determine the best use of resources An analysis ofdrug therapy options for treating Chlamydia trachomatisinfections in women indicated that a more costly more effec-tive drug than was in current use could be cost-saving whenconsidered from a broad perspective (17) Use of the drugresulted in a net cost however when the more limited per-spective of the budget of a publicly funded clinic was consid-ered Results of the analysis were used to negotiate a lowerprice for the more effective drug so clinics could consideradopting it for treatment

Compilations of recommendations of clinical and commu-nity preventive services have used economic evaluations to vary-ing degrees The US Preventive Services Task Force (18) andthe Task Force on Community Preventive Services (19) makeevidence-based recommendations on the use of preventive ser-vices Both include economic information in their recommen-dations but neither incorporates it as a criterion on which tobase recommendations Conversely the National Commissionon Prevention Priorities published a ranking of US PreventiveServices Task Force-recommended clinical preventive servicesbased in part on cost effectiveness evidence (20)

Economics and Public HealthGrowing Together

Although the application of economics to health and pub-lic health issues did not begin at CDC its use at the agencyno doubt has accelerated its development and maturity in thefield Economics was introduced to public health researchbecause of a desire to make transparent and fair decisions onthe basis of the best tools and data possible Beginning in thelate 1970s the Office of Program Planning and Evaluationwas the agencyrsquos focus of economic evaluation and decisionanalysis Economic expertise was brought to CDC under short-term interagency personnel agreements and economic stud-ies were conducted through contracts

Interest increased throughout the 1980s and in the early1990s economics began to be formally incorporated at CDCbeginning as an allied discipline with decision sciences underthe rubric of prevention effectiveness It continues in that roleto this day although one is more likely now to encounter theterm ldquoeconomicsrdquo than ldquoprevention effectivenessrdquo as moreeconomists are embedded throughout CDC A training coursein prevention effectiveness methods was developed for theEpidemic Intelligence Service starting in 1992 and then forCDC staff Thus far these courses have attracted well over2000 attendees The Prevention Effectiveness Fellowship Pro-gram (subsequently renamed in honor of Steven M Teutschfor his contributions) welcomed its first class of five post-

doctoral fellows in 1995 (httpwwwcdcgovepofellowhtm)Since then approximately 80 fellows have participated in theprogram and nearly 50 have been employed throughout CDCFellows and alumni have published nearly 300 peer-reviewedarticles Initially the analytic tools employed proved satisfac-tory however as more of the early basic questions have beenanswered research problems and topics have grown more com-plicated Economists at CDC participate in the developmentand adaptation of methods and measures to meet newchallenges

The need for better tools for decision making recognizedearly on has not disappeared and may even have intensifiedCDCrsquos economists face no shortage of research opportuni-ties Public health policymakers and managers know they needto demonstrate the value of interventions when budgets arehighly scrutinized and must be justified in detail They alsoneed to make decisions about resource use and understandthat economics can help make more efficient use of resourcesRecognizing the concept of opportunity cost policymakersand managers also have come to understand that resourcesemployed in one activity cannot be used in another

The integration of economics into public health researchhas provided decision makers with a valuable tool Econom-ics cannot provide the answer to all decisions because allaspects of a decision cannot be quantified However a sys-tematic transparent analysis can demonstrate value and helpmake decisions that improve efficiency in providing publichealth services

References1 Wetzstein ME Microeconomic theory concepts amp connections

Mason OH ThomsonSouth-Western 20052ndash32 Carande-Kulis VG Getzen TE Thacker SB Public goods and exter-

nalities a research agenda for public health economics J Public HealthManag Pract In press

3 Mushkin S Toward a definition of health economics Public HealthRep 195873785ndash93

4 Arrow KJ Uncertainty and the welfare economics of medical careAmerican Economic Review 196353141ndash9

5 Grossman M On the concept of health capital and the demand forhealth Journal of Political Economy 197280223ndash55

6 Cochrane AL Effectiveness and efficiency random reflections on healthservices London Nuffield Provincial Hospitals Trust 1972

7 Thacker SB Koplan JP Taylor WR Hinman AR Katz MF RoperWL Assessing prevention effectiveness using data to drive programdecisions Public Health Rep 1994109187ndash94

8 CDC A framework for assessing the effectiveness of disease andinjury prevention MMWR 199241(No RR-3)1ndash15

9 Gold MR Siegel JE Russell LB Weinstein MC eds Cost-effectiveness in health and medicine New York NY OxfordUniversity Press 1996

10 Drummond MF OrsquoBrien B Stoddart GL Torrance GW Methods forthe economic evaluation of health care programmes 2nd ed OxfordOxford University Press 1997


11 Haddix AC Teutsch SM Corso PS eds Prevention effectiveness aguide to decision analysis and economic evaluation 2nd ed New YorkNY Oxford University 2003

12 Grosse SD Teutsch SM Haddix AC Lessons from cost-effectivenessresearch for United States public health policy Annu Rev Public HealthIn press

13 Farrelly MC Bray JW Pechacek T Woollery T Response by adults toincreases in cigarette prices by sociodemographic characteristics South-ern Economic Journal 200168156ndash65

14 Chesson H Harrison P Kassler WJ Sex under the influence the effectof alcohol policy on sexually transmitted disease rates in the US Jour-nal of Law and Economics 200043215ndash38

15 National Immunization Program CDC ACIP Advisory Committeeon Immunization Practices [Internet] [updated 2006 Aug 29 cited2006 Aug 29] Available at httpwwwcdcgovnipACIPdefaulthtm

16 National Center for Injury Prevention and Control CDC injuryresearch agenda Atlanta GA US Department of Health and HumanServices CDC 2002 Available at httpwwwcdcgovncipcpub-resresearch_agendaagendahtm

17 Haddix AC Hillia SD Kassler WJ The cost effectiveness ofazithromycin for Chlamydia trachomatis infections in women SexTransm Dis 199522274ndash80

18 US Preventive Services Task Force Guide to clinical preventive ser-vices 2005 recommendations of the US Preventive Services Task ForceRockville MD US Department of Health and Human Services Agencyfor Healthcare Research and Quality 2005

19 Zaza S Briss PA Harris KW eds The guide to community preventiveservices What works to promote health New York NY Oxford Uni-versity Press 2005

20 Maciosek MV Coffield AB Edwards NM Goodman MJ FlottemeschTJ Solberg LI Priorities among effective clinical preventive servicesresults of a systematic review and analysis Am J Prev Med 20063152ndash61


Genomics and Public Health at CDCMarta Gwinn MD M Bowen MPH M Khoury MD PhD

National Office of Public Health Genomics

Corresponding author Marta Gwinn MD National Office of Public Health Genomics CDC 4770 Buford Hwy MS K-89 Atlanta GA 30342 Telephone 770-488-8433Fax 770-488-8336 E-mail mgwinncdcgov

Genomics is the study of the entire genome including allgenes and their interactions with each other and with theenvironment (1) The scope of public health genomics is evenbroader encompassing genetic variation in populations bothhuman and microbial Molecular typing of pathogensmdashamainstay of infectious disease surveillance prevention andcontrolmdashalready is used to trace epidemics (2) provideinformation for vaccine development (3) and monitor drugresistance (4) Now genomic research is producing powerfulnew tools for public health for example a newly describedmicrochip-based method promises to diagnose influenzainfection distinguish among viruses of human or animalorigin and detect mutations that suggest increasingvirulencemdashall in a matter of hours (56)

Until recently public health applications of human genet-ics were limited largely to state-mandated programs thatscreened newborn infants and ensured access to genetic ser-vices for affected children and families Now genomic researchand technology have generated new molecular targets and newtests for newborn screening kindling renewed debate on theirrelative benefits risks and costs (7) Public health investiga-tions of diseases with infectious and environmental causes alsoare beginning to evaluate the contribution of human geneticvariation to susceptibility and natural history (8)

Most population-based research in genetic epidemiology hasfocused on common chronic diseases as reflected in approxi-mately 22000 scientific publications during the last 5 years(9) The results point to complex interactions among mul-tiple genes and environmental factors which remain poorlyunderstood However small successes in translation illustratethe potential for public health genomics in three areas strati-fying risk to guide multilevel interventions understandingenvironmental causes of disease and identifying new oppor-tunities for prevention

Family health history which captures information aboutshared inherited and environmental factors is a simple andinexpensive genomic tool for identifying persons and familiesat high risk (10) For example a Utah study indicated that the14 of families with positive family histories for coronaryheart disease (CHD) accounted for 48 of all persons withCHD and for 72 of CHD events occurring before age55 years (11) Population-based data and careful cost-

effectiveness analysis are needed to determine whether com-bining traditional population-level prevention strategies withmore intensive interventions for families at increased risk willimprove the return on investment in prevention (12)

Public health interventions are based on understanding andmodifying environmental risk factors For example recogni-tion of inadequate folate status as a cause of neural tubedefects led to an effective public health intervention to in-crease folic acid intake among reproductive-aged women (13)A systematic review of epidemiologic data on birth defects inrelation to folic acid intake and variation in the methylen-etetrahydrofolate reductase (MTHFR) gene illustrates ldquoMende-lian randomizationrdquo (14) in which the effects of specificenvironmental exposures such as dietary elements drugs ortoxins are either accentuated or mitigated in persons withdifferent variants of genes involved in physiologic responseBecause genotype is ldquorandomizedrdquo at birth biologic informa-tion thus can strengthen evidence obtained from traditionalenvironmental risk factor studies and provide a less biasedframework for interpreting data on gene-environment inter-actions (15)

Public health genomics can provide information about popu-lation-level interventions that do not depend on knowledgeof individual genotypes For example a study in Mexico ofchildren with asthma found that supplementation with theantioxidant vitamins C and E improved lung function inchildren with a common polymorphism of glutathioneS-transferase M1 (GSTM1) who are exposed to ozone (16) Ifconfirmed by other studies this finding might suggest a simpleinterventionmdashantioxidant vitamin supplementationmdashforchildren with asthma who are exposed to ozone Without geno-type-specific analysis a potentially important population-levelintervention could have been overlooked

Just as genomics will enhance the knowledge base for pub-lic health research and practice public health principles andmethods can provide information for genomics research andtranslation Rigorous application of population-based meth-ods for collecting evaluating and interpreting the evidenceon genetic variation in relation to health and disease willimprove research quality promote knowledge synthesis andhelp identify research gaps By keeping the focus on popula-tion-level implications the public health perspective helps


ensure the entire population benefits from public investmentin genomics research

References1 Committee on Genomics and the Publicrsquos Health in the 21st Century

Institute of Medicine Implications of genomics for public healthworkshop summary Washington DC National Academies Press 2005

2 Parker AA Staggs W Dayan GH et al Implications of a 2005 measlesoutbreak in Indiana for sustained elimination of measles in the UnitedStates N Engl J Med 2006355447ndash55

3 Pai R Gertz RE Whitney CG Beall B Active Bacterial Core Surveil-lance Team Clonal association between Streptococcus pneumoniaeserotype 23A circulating within the United States and an internation-ally dispersed clone of serotype 23F J Clin Microbiol 2005435440ndash4

4 Tenover FC McDougal LK Goering RV et al Characterization of astrain of community-associated methicillin-resistant Staphylococcusaureus widely disseminated in the United States J Clin Microbiol200644108ndash18

5 Mehlmann M Dawson ED Townsend MB et al Robust sequenceselection method used to develop the FluChip diagnostic microarrayfor influenza virus J Clin Microbiol 2006442857ndash62

6 Townsend MB Dawson ED Mehlmann M et al Experimental evalu-ation of the FluChip diagnostic microarray for influenza virus surveil-lance J Clin Microbiol 2006442863ndash71

7 CDC Newborn screening for cystic fibrosis evaluation of benefitsand risks and recommendations for state newborn screening programsMMWR 200453(No RR-13)

8 Lingappa J Kuffner T Tappero J et al HLA-DQ6 and ingestion ofcontaminated water possible gene-environment interaction in an out-break of leptospirosis Genes Immun 20045197ndash202

9 Lin BK Clyne M Walsh M et al Tracking the epidemiology ofhuman genes in the literature the HuGE published literature data-base Am J Epidemiol 20061641ndash4 Available at httpwwwcdcgovgenomicssearchaboutHPLDhtm

10 Yoon PW Scheuner MT Khoury MJ Research priorities for evaluat-ing family history in the prevention of common chronic diseases AmJ Prev Med 200324128ndash35

11 Hunt SC Gwinn M Adams TD Family history assessment strategies forprevention of cardiovascular disease Am J Prev Med 200324136ndash42

12 Ramsey SD Burke W Pinsky L Clarke L Newcomb P Khoury MJFamily history assessment to detect increased risk for colorectal can-cer conceptual considerations and a preliminary economic analysisCancer Epidemiol Biomarkers Prev 2005142494ndash500

13 CDC Use of vitamins containing folic acid among women of child-bearing agemdashUnited States 2004 MMWR 200453847ndash50

14 Botto LD Yang Q 510-Methylenetetrahydrofolate reductase (MTHFR)gene variants and congenital anomalies a HuGE review Am JEpidemiol 2000151862ndash77

15 Smith GD Ebrahim S Mendelian randomization prospects poten-tials and limitations Int J Epidemiol 20043330ndash42

16 Romieu I Sienra-Monge JJ Ramirez-Aguilar M et al Genetic poly-morphism of GSTM1 and antioxidant supplementation influence lungfunction in relation to ozone exposure in asthmatic children in MexicoCity Thorax 2004598ndash10


Statistics and Public Health at CDCWilliam K Sieber Jr PhD1 T Green PhD2 G D Williamson PhD3

1National Institute for Occupational Safety and Health2National Center for HIVAIDS Viral Hepatitis STD and TB Prevention (proposed)

3Agency for Toxic Substances and Disease Registry

Corresponding author William K Sieber Jr PhD National Institute for Occupational Safety and Health 4676 Columbia Parkway Cincinnati OH 45226 Telephone513-841-4231 Fax 513-841-4489 E-mail wsiebercdcgov

systems detection algorithms and scan statistics to documenthealth trends and identify emerging health issues and modeldevelopment to project disease incidence and injury or num-bers of cases prevented through treatment and public healthmeasures during an outbreak For example new methods havebeen developed to enable comparisons of population charac-teristics across data-collection programs and over time whendata-collection methods change (7) and to quantify dispari-ties in health and health care (8) Methodologic work also hasaddressed high levels of nonresponse on central variables suchas income (9) Reliance on data for policy and programmaticuse and the growing number and diversity of users haverequired ongoing research and innovative approaches to pro-tect the confidentiality and security of data while offering thewidest possible access to data (10)

The CDC National Center for Health Statistics (NCHS) isthe nationrsquos principal health statistics agency and has broadresponsibilities to monitor the health of the United States Inaddition to conducting a data-collection program that encom-passes vital statistics interview surveys examination surveysand provider surveys NCHS prepares the annual report HealthUnited States (11) which the Secretary of Health and Human

Have you ever wondered how an association between expo-sure and disease is evaluated For example how does theseverity of salmonellosis depend on ingested dose of egg prod-ucts (1) Or how is the relation between blood lead levels andgasoline lead levels determined (2) Each of these studiesinvolves statistical analysis

Since CDCrsquos inception an important function of the agencyhas been the compilation analysis and interpretation of sta-tistical information to guide actions and policies to improvehealth Sources of data include vital statistics records medicalrecords personal interviews telephone and mail surveys physi-cal examinations and laboratory testing Public health sur-veillance data have been used to characterize the magnitudeand distribution of illness and injury to track health trendsand to develop standard curves such as growth chartsBeyond the development of appropriate program studydesigns and analytic methodologies statisticians have playedroles in the development of public health data-collection sys-tems and software to analyze collected data CDCATSDRemploys approximately 330 mathematical and health statisti-cians They work in each of the four coordinating centerstwo coordinating offices and the National Institute forOccupational Safety and Health

Statistics and ResearchThe integration of statistics and analytic techniques into

public health research is a critical asset to the agency (Figure 1)and has resulted in important applications in various disci-plines such as epidemiology economics and the behavioraland social sciences Examples include economic determina-tions contributing to folic acid supplementation of foods todecrease birth defects (3) behavioral science methods leadingto the development of strategies for preventing humanimmunodeficiency virus infection and acquired immuno-deficiency syndrome (4) quantitative epidemiologic analysesleading to understanding the relation between radon and lungcancer in coal miners (5) and evaluations of the effectivenessof using back belts to reduce back injury claims and back pain(6) Other areas of continuing statistical contribution includesurvey planning and analytic methodology data-collection

FIGURE 1 Statistician in the field collecting data for a studyon asphalt milling in Rapid City South Dakota

PhotoCDC


Services submits to the President and Congress Health UnitedStates presents a comprehensive profile of health in the UnitedStates and tracks key health indicators and trends NCHS alsois responsible for advancing the field of health statistics throughresearch into statistical and analytic methods The NationalLaboratory for Collaborative Research in Cognition and Sur-vey Measurement an NCHS program applies cognitive meth-ods to questionnaire design research and testing ofdata-collection instruments to improve data quality (12)

Recent CDC activities presenting new analytic and statisti-cal challenges include emergency preparedness and emerginginfectious diseases CDC statistical programs have contrib-uted to development of syndromic surveillance methods evalu-ation of different civilian smallpox vaccination proposalscharacterization of emerging infectious diseases such assevere acute respiratory syndrome and development of na-tional health report cards

The anthrax investigations of SeptemberndashDecember 2001spurred development of multiple analytic techniques Theseincluded maps linking analytic sampling activity with ana-lytic results developed to better understand the spread anddeposition of spore-containing particles and analyses of envi-ronmental sampling information (CDC unpublished data2002) Stochastic simulation has been used to optimizepatient flow-through in clinics dispensing oral antibioticsafter a bioterrorism attack (13)

Aberration detection in public health data representsanother area of statistical contribution For example CDCrsquosSmallpox Preparedness and Response Activity receives vacci-nation and adverse event data from several sources Thesesources employ both active and passive data collection andprovide registry contraindication and adverse events infor-mation

The CDCATSDRStatistical Advisory Group

The CDCATSDR Statistical Advisory Group (SAG) ascientific workgroup sponsored by the Office of the ChiefScience Officer (14) coordinates statistical activities through-out the agency SAG was established in 1989 to act in anadvisory capacity to the Office of the Director to facilitateand address statistical issues problems and opportunities thatinfluence the quality and integrity of science at CDC and tocoordinate agencywide statistical activities and increase com-munication across organizational components

SAG activities illustrate the breadth of statistical activitythroughout CDCATSDR Since 1989 biennial symposiahave been held on topics of interest to the public health com-

munity such as surveillance (15) and study design and deci-sion making (16) Each year SAG recognizes outstanding sta-tistical papers published during the previous year with theCDCATSDR Statistical Science Awards The most recentwinners included manuscripts on capture-recapture analysis(17) and genetic studies (18) SAG is responsible for advancedstatisticalepidemiologic training at CDCATSDR and main-tains a listserv and intranet site

Other SAG statistical activities include participation instatisticalprotocol review and institutional review boards andleadership in the development procurement and installationof statistical software available for use by researchers in theCDCATSDR community SAG has provided review andadvice on complex statistical and broad scientific issues suchas validation of the statistical design of the Vietnam Experi-ence Study of the health of Vietnam veterans and codevelopedan evaluation of recruitment and retention policies at CDCATSDR Other special requests such as for development oftraining materials or requests for interagency collaboration andsentation also frequently are handled through SAG Since1990 SAG has sponsored an exhibit booth highlightingstatistical activities at CDCATSDR that has been displayedat the Joint Statistical Meetings and other conferences forinformational and recruiting purposes

Future Directions for Statisticsat CDCATSDR

The critical role of statistics in accomplishing the missionof CDCATSDR will become even more apparent as theagency begins to align its activities around its overarchinghealth protection goals The assessment of burden effective-ness of interventions cost considerations and evaluationframeworks all will require rigorous attention to methods ofdata-ollection study design and analytic technique The abilityof statisticians to ensure the most effective use of quantitativescience in research and analysis and in meeting new challengesin the evolving public health mission of CDCATSDR willrequire reexamination of statistical skills and contributions Amultidisciplinary approach to investigation of public healthproblems such as emergency preparedness and obesity alreadyis being realized Continued valuable statistical input will bekey to efficient use of new technologies such as in informaticsWeb-based query systems geographic information systemsand survey data collection methodologies Advances in thefield of relational databases for example and its coupling withWeb-based technology have facilitated improvements in theefficiency of data collection and increases in size and com-pleteness of data available for analysis The developing BioSense


program (19) initiated at CDC and operational throughoutthe United States uses existing health-care information fromhospitals ambulatory-care clinics and commercial laborato-ries for early event detection and health situational awarenessUse of multisource data and further development of recordlinkage techniques to extract maximal information fromexisting data sources also will require addressing privacy andconfidentiality concerns as well as appropriate methods ofcommunication of important public health findings to thenation

AcknowledgementThe authors appreciate the assistance of Dr Jennifer Madans for

her help in preparing this description of statistical activitiesthroughout CDCATSDR

References1 Mintz ED Cartter ML Hadler JL Wassell JT Zingeser JA Tauxe RV

Dose-response effects in an outbreak of Salmonella enteritidis EpidemiolInfect 199411213ndash23

2 Annest JL Pirkle JL Makuc D Neese JW Bayse DD Kovar MGChronological trend in blood lead levels between 1976 and 1980N Engl J Med 19833081373ndash7

3 Kelly AE Haddix AC Scanlon KS Helmick CG Mulinare J Cost-effectiveness of strategies to prevent neural tube defects In Gold MRSiegel JE Russell LB Weinstein MC eds Cost-effectiveness in healthand medicine New York NY Oxford University Press 1996313ndash48

4 Kamb ML Fishbein M Douglas JM Jr et al Efficacy of risk-reduction counseling to prevent human immunodeficiency virus andsexually transmitted diseases JAMA 19982801161ndash7

5 Hornung RW Meinhardt TJ Quantitative risk assessment of lungcancer in US uranium miners Health Phys 198752417ndash30

6 Wassell JT Gardner LI Landsittel DP Johnston JJ Johnston JMA prospective study of back belts for prevention of back pain andinjury JAMA 20002842727ndash32

7 Schenker N Parker JD From single-race reporting to multiple-racereporting using imputation methods to bridge the transition Stat Med2003221571ndash87

8 Keppel KG Pearcy JN Klein RJ Measuring progress in Healthy People2010 Healthy People 2010 statistical notes no 25 Hyattsville MDUS Department of Health and Human Services CDC National Cen-ter for Health Statistics 2004 Available at httpwwwcdcgovnchsdatastatntstatnt25pdf

9 Schenker N Raghunathan TG Chiu P Makuc DM Zhang G CohenAJ Multiple imputation of family income and personal earnings inthe National Health Interview Survey Hyattsville MD US Depart-ment of Health and Human Services CDC National Center for HealthStatistics 2004

10 Cox LH Disclosure risk for tabular economic data In Doyle P LaneJ Theeuwes J Zayatz L eds Confidentiality disclosure and dataaccess theory and practical applications for statistical agencies NewYork NY Elsevier 2002167ndash83

11 National Center for Health Statistics Health United States 2004with chartbook on trends in the health of Americans Hyattsville MDUS Department of Health and Human Services CDC National Cen-ter for Health Statistics 2004 Available at httpwwwcdcgovnchsdatahushus04pdf

12 National Center for Health Statistics Cognitive methods Workingpaper series Available at httpwwwcdcgovnchsproductspubsworkpapworkpaphtm

13 Washington ML Mason J Meltzer MI Maxi-Vac a tool to assist inplanning mass smallpox vaccination clinics J Public Health ManagPract 200511542ndash7 Software available at httpwwwbtcdcgovagentsmallpoxvaccinationmaxi-vac

14 Williamson GD Snider DE Speers MA Facilitating use of analyticmethods at a Federal agency Am J Prev Med 200019(Suppl 1)40ndash6

15 Symposium on statistics in surveillance Stat Med 19898251ndash40016 Lipman H Cadwell BL Kerkering JC Lin LS Sieber WK eds Study

design and decision making in public health Proceedings of the 9thBiennial US Centers for Disease ControlAgency for Toxic Substancesand Disease Registry (CDCATSDR) symposium on Statistical Meth-ods January 27ndash29 2003 Atlanta Georgia USA Stat Med200524491ndash669

17 Cadwell BL Smith PJ Baughman AL Methods for capture-recaptureanalysis when cases lack personal identifiers Stat Med 2005242041ndash51

18 Allen AS Satten GA Tsiatis AA Locally-efficient robust estimation ofhaplotype disease association in family-based studies Biometrika200592559ndash71

19 Bradley CA Rolka H Walker D Loonsk J BioSense implementationof a national early situational awareness system MMWR 200554(Suppl 1)11ndash9


Informatics and Public Health at CDCScott J N McNabb PhD1 D Koo MD2 R Pinner MD3 J Seligman MS4

1Division of Integrated Surveillance Systems and Services National Center for Public Health Informatics2Career Development Division Office of Workforce and Career Development Office of the Director

3Office of Surveillance Office of the Director National Center for Prevention Detection and Control of Infectious Diseases (proposed)4Office of the Chief Information Officer Office of the Director

Corresponding author Scott J N McNabb PhD Division of Integrated Surveillance Systems and Services National Center for Public Health Informatics CDC 2500Century Parkway MS E-91 Atlanta GA 30345 Telephone 404-498-6427 Fax 404-498-6144 E-mail smcnabbcdcgov

In 1990 CDC released the Wide-ranging OnLine Data forEpidemiologic Research (WONDER) (910) This tool pro-vided access to data on the CDC mainframe for analyses byCDC epidemiologists WONDERPCmdashreleased to thebroader public health community in 1992mdashincluded accessto e-mail for practitioners from local and state health depart-ments private bulletin boards and searchable CDC docu-ment libraries plus the capability to download data in CDCsurveillance programs while maintaining data security andpatient confidentiality

PHI CrossroadsBy the early 1990s CDC and its partners recognized both

the costliness of systems specific to categorical diseases andhealth conditions and the capability of the Internet to permitmore efficient approaches to data collection and analyses In1993 CDC launched a plan with partners to conceive anddevelop integrated surveillance (11) Furthermore in 1993the Information Network for Public Health Officials (INPHO)initiative began to enhance broader access to CDC informa-tion technology networking and software systems by users(1213) These initiatives marked a PHI milestone for CDCmovement from stand-alone solutions for individual prob-lems to networked integrated solutions and standards-baseddata exchange Six current CDC PHI initiatives reflect thisvision and highlight the critical role of PHI in transformingpublic health practice PulseNet USA (14) the National Elec-tronic Disease Surveillance System (NEDSS) (15) the Epi-demic Information Exchange (Epi-X) the Health AlertNetwork (HAN) (1617) BioSense (18) and the Public HealthInformation Network (PHIN) (19)

In 1993 a large outbreak of foodborne illness occurred inthe western United States (20) Laboratory scientists performedDNA ldquofingerprintingrdquo and determined the strain of Escheri-chia coli O157H7 found in patients had the same pattern asthat found in hamburger patties served at a large chain ofregional fast-food restaurants Prompt recognition of this out-break and its cause might have prevented as many as 800 ill-nesses As a result CDC created PulseNet USA the molecularsurveillance network for foodborne infections in the United

Since CDC acquired its first mainframe computer in 1964the use of information technology in public health practicehas grown steadily and during the past 2 decades dramati-cally (Table 1) Public health informatics (PHI) arrived onthe scene during the 1990s after medical informatics (inter-secting information technology medicine and health care)and bioinformatics (intersecting mathematics statistics com-puter science and molecular biology) Similarly PHI mergedthe disciplines of information science and computer scienceto public health practice research and learning (2ndash5) Usingstrategies and standards practitioners employ PHI tools andtraining to maximize health impacts at local state andnational levels They develop and deploy information tech-nology solutions that provide accurate timely and secureinformation to guide public health action

Early PHI ApplicationsAdvances in PHI resulted in public health innovations and

added value to interventions by providing the capability formore timely detection of health threats and more completeand efficient health communications Early PHI initiatives atCDC assisted the collection and analysis of data Epi Infotradeshowed that combining questionnaire development with database creation and specialized analytic tools gave greater facil-ity during surveillance and outbreak investigations (67) WhenInternet use became common the CDC PHI initiatives linkedusers and incorporated integrative and open-networkedarchitecture In this new integrated environment CDC PHIinitiatives shifted to serve the broader public health commu-nity through development of enterprise architecture standardssystems and interoperability

Evolving from the Enhanced Surveillance Project in four statesthe National Electronic Telecommunications System for Sur-veillance (NETSS) began in 1990 (8) NETSS (which supportsthe National Notifiable Diseases Surveillance System) provideda standard record and variables for reporting all individual casesof disease without requiring a specific software solution Earlyon NETSS data were communicated by dial-up modem eachweek from state health departments to CDC This improvedthe timeliness of public health surveillance


States and an indispensable tool for early detection offoodborne disease outbreaks (14)

In 1999 CDC launched NEDSS With the goal of inte-grating public health surveillance through case reporting ofapproximately 100 diseases using a standards-based datainterchange NEDSS enabled new electronic data feeds fromclinical laboratories and substantially reduced the latency ofdata transmission improved completeness of reporting anddecreased data-reporting burdens (15)

Created in 2000 Epi-X is the CDC secure communicationssolution for practitioners to access and share informationRecently an epidemiologist in Colorado noted an unusualbacterial infection Burkholderia cepacia in patients who hadsinus surgery This information was posted on Epi-X Afterfurther investigation a common epidemiologic link was foundthe use of a particular nasal spray of the same lot made by thesame company Epi-Xrsquos notice informed officials that this lotmost likely was contaminated and through this alert the Food

TABLE 1 Evolutionary milestones in public health informatics at CDC 1976ndash2006MilestoneldquoGale Reportrdquo released calling for coordinatedsurveillance

Enhanced Surveillance Project (later to becomethe National Electronic TelecommunicationSystem for Surveillance [NETSS]) released

Epi Infotrade developed

NETSS initiated

Wide-ranging OnLine Data for EpidemiologicResearch (WONDER) released

WONDERPC released

Report on Public Health Information andSurveillance System Development released

Information Network for Public Health Officials(INPHO) begun

PulseNet USA created

Public Health Informatics fellowship programbegun

National Electronic Disease SurveillanceSystem (NEDSS) launched

Secure Data Network goes into production

Epidemic Information Exchange (Epi-X)launched

Health Alert Network (HAN) launched

National Environmental Public Health TrackingProgram

BioSense launched

Public Health Information Network (PHIN)initiated

Public Health Laboratory Interoperability Projectbegun

National Center for Public Health Informaticsformed

Year1976

1984

1985

1990

1990

1992

1993

1993

1996

1996

1999

1999

2000

2000

2002

2003

2004

2005

2005

References1

67

8

910

11

1213

14

15

1617

18

19

Stakeholder

Four state epidemiologists

Epidemiologists

State epidemiologists

Public health practitioners



Public health laboratorians

Public health informaticians


CDC electronic data providersand external users of CDC-hosted systems

Public health officialsdesignated by health agencies


Researchers policymakersand public health practitioners




URL

httpwwwcdcgovepiinfo

httpwwwcdcgovepodphsinetsshtm

httpwondercdcgovWelcomeAhtml

httpwwwcdcgovpulsenet

httpwwwcdcgovphtraininformaticshtml

httpwwwcdcgovnedss

httpwwwcdcgovepix

httpwww2acdcgovhanIndexasp

httpwwwcdcgovncehtracking

httpwwwcdcgovphincomponent-initiativesbiosenseindexhtml


httpwwwcdcgovncphi


and Drug Administration and the company intervened to re-call that lot of nasal spray

Also launched in 2000 HAN was developed to improvepublic health interconnectivity through a statewide and anational alert system In response to the increased threat ofbioterrorism in 2003 CDC launched BioSense to improvethe nationrsquos capabilities for real-time biosurveillance and situ-ational awareness BioSense maintains patient confidentialityand uses secure methods to receive health data from sourcessuch as hospitals and health-care systems in major metropoli-tan areas BioSense connects existing health information topublic health and will enable simultaneous access to data ana-lytic and visualization tools by authorized users at all jurisdic-tional levels

Balanced with secure protection from misuse CDCrsquos visionfor interoperable and integrated networking is embodied inPHIN Initiated in 2004 PHIN promotes standards and insome cases software solutions to enable real-time data flowcomputer-assisted analyses decision support professional col-laboration and rapid dissemination of information (Box)

These PHI initiatives and others reflect CDCrsquos ongoingcommitment to make evidence-based decisions and maximizehealth impacts They support PHI tools that will effectivelymonitor the health of communities identify causes of dis-ease and provide the tracking and management capabilitiesnecessary to respond to and contain outbreaks They also helpevaluate the performance and measure the costs of healthinformation systems (21) Furthermore they connect publichealth systems to clinical-care systems (eg electronic medi-cal records)

PHI Training at CDCAlthough a workforce trained in PHI is essential the sup-

ply of informaticians is not sufficient to meet national needs(17) To address this CDC initiated a 2-year PHI fellowshipprogram in 1996 which has graduated 51 fellows These fel-lows have contributed to standards development enabledagencywide knowledge management and performed researchDuring the responses to hurricanes Katrina and Rita in 2005three PHI fellows deployed to Texas and Louisiana to supportintegration of surveillance and develop electronic-based sur-veillance tools and two were assigned to the CDC DirectorrsquosEmergency Operations Center to manage surveillance dataCDC recently initiated a plan to define competencies for publichealth informaticians

The Future of PHIRecognizing the growing importance of PHI across the

agency CDC created the National Center for Public HealthInformatics (NCPHI) in 2005 to provide leadership andcoordination of shared systems and services NCPHIrsquos mis-sion is to protect and improve the publicrsquos health throughPHI discovery innovation and service NCPHI is develop-ing a national PHI research agenda and advancing the state-of-the-science through a grant program with academicinstitutions and state and local health departments NCPHIhas funded five Centers of Excellence in PHI and has awardedadditional research grants to support the BioSense programto further the science of early detection and analyses Collec-tively these projects reflect CDCrsquos ongoing efforts to build

BOX Public Health Information Network (PHIN) preparedness functional areas and corresponding software solutions

Functional area Software solutionsEarly event detection and situational awareness BioSenseCall triage services

Surveillance National Electronic Disease Surveillance System (NEDSS)

Outbreak management Outbreak Management System (OMS)

Connecting laboratory systems Laboratory Response Network Results Messenger systems(LRN Results Messenger)

CountermeasureResponse Countermeasure and Response Administration system

Partner communications and alerting Public Health Information Network (PHIN) directoryHealth Alert Network (HAN)Epidemic Information Exchange (Epi-X)Partner Alerting Services

Cross-functional area PHIN Vocabulary Access and Distribution System (PHIN-VADS)PHIN Messaging System (PHIN-MS)


and support a national network of integrated standards-basedand interoperable public health information systems that willenhance its partnersrsquo capabilities to detect register confirmreport analyze provide feedback and alerts and communi-cate to drive evidence-based decisions that make healthimpacts

One challenge now facing PHI is to facilitate the develop-ment of electronic medical and personal health records thatboth protect patient privacy and confidentiality and servelegitimate clinical and public health needs With US health-care costs steadily risingmdashnow representing approximately16 of the gross domestic productmdashand the increase of acuteand chronic health threats PHI must help meet these chal-lenges through more efficient and effective disease prevention(eg better detection communication public health actionand health protection) These benefits combined with theincreasing expectation of (and requirements for) instantaneousaccess to public health data make the potential contributionof PHI to public health practice even more promising andurgent PHI is now positioned to accelerate building fromthe substantial increase in information technology invested inhealth care and capitalizing on major trends toward electronicmedical and personal health records Future PHI systems willinclude innovative solutions extending the reach of publichealth practice to more efficiently and effectively impact health

AcknowledgmentsThe authors thank the following personsmdashlisted in alphabetic

ordermdashfor their contribution to this article Andrew Autry PhDClaire Broome MD Scott Danos MPH Sigrid Economou RobertFagan Lynn Gibbs Scharf MPH Mary Lerchen DrPh TimothyMorris Tony Moulton PhD Dale Nordenberg MD Joseph ReidPhD Barry Rhodes PhD Henry Rolka MS David Ross ScDThomas Savel MD Jerome Tokars MD Herman Tolentino MDand John Ward MD

References1 Gale JL Surveillance data quality use and effect on public health

divisions in local and state health departments pilot study of aninstrument to collect this information and a proposed method of analy-sis of data collected nation-wide Atlanta GA US Department ofHealth Education and Welfare Center for Disease Control 1976(Final report for CDC contract 200-76-0671 P)

2 Yasnoff WA OrsquoCarroll PW Koo D Linkins RW Kilbourne EM Pub-lic health informatics improving and transforming public health inthe information age J Public Health Manag Pract 2000667ndash75

3 Ross DA Hinman AR Saarlas K Foege WH Public health informaticsand information systems New York NY Springer 2002

4 Walker J Pan E Johnston D Adler-Milstein J Bates DW MiddletonB The value of health care information exchange and interoperabilityHealth Aff (Millwood) 2005(Suppl Web Exclusive)W5-10ndash18

5 Friede A Blum HL McDonald M Public health informatics howinformation-age technology can strengthen public health Annu RevPublic Health 199516239ndash52

6 Burton AH Dean JA Dean AG Software for data management andanalysis in epidemiology World Health Forum 19901175ndash7

7 Dean AG Dean JA Burton AH Dicker RC Epi Infotrade a general-purpose microcomputer program for health information systems Am J Prev Med 19917178ndash82

8 CDC National Electronic Telecommunications System for Surveil-lancemdashUnited States 1990ndash1991 MMWR 199140502ndash3

9 Friede A Rosen DH Reid JA CDC WONDER a cooperative pro-cessing architecture for public health J Am Med Inform Assoc19941303ndash12

10 Friede A OrsquoCarroll PW CDC and ATSDR electronic informationresources for health officers J Pub Health Manag Pract 1996210ndash24

11 CDC Integrating public health information and surveillance systemsA report and recommendations from the CDCATSDR Steering Com-mittee on Public Health Information and Surveillance System Devel-opment Atlanta GA US Department of Health and Human ServicesPublic Health Service CDC 1995 Available at httpwwwcdcgovnedssArchivekatzpdf

12 Baker EL Melton RJ Stange PV et al Health reform and the healthof the public forging community health partnerships [special com-munication] JAMA 19942721276ndash82

13 Baker EL Friede A Moulton AD Ross DA CDCrsquos Information Net-work for Public Health Officials (INPHO) a framework for integratedpublic health information and practice J Public Health Manag Pract1995143ndash7

14 Gerner-Smidt P Hise K Kincaid J et al PulseNet USA a five-yearupdate Foodborne Pathog Dis 200639ndash19

15 CDC Progress in improving state and local disease surveillancemdashUnited States 2000ndash2005 MMWR 200554822ndash5

16 Rotz LD Koo D OrsquoCarroll PW Kellogg RB Sage MJ Lillibridge SRBioterrorism preparedness planning for the future J Public HealthManag Pract 2000645ndash9

17 Institute of Medicine The future of the publicrsquos health in the 21stcentury Washington DC National Academies Press 2003

18 CDC BioSensemdasha national initiative for early detection and quanti-fication of public health emergencies MMWR 200454(Suppl)53ndash5

19 Loonsk JW McGarvey SR Conn LA Johnson J The Public HealthInformation Network (PHIN) Preparedness Initiative J Am Med In-form Assoc 2006131ndash4

20 Bell BP Goldoft M Griffin PM et al A multistate outbreak ofEscherichia coli O157H7-associated bloody diarrhea and hemolyticuremic syndrome from hamburgers The Washington experienceJAMA 19942721349ndash53

21 McNabb SJN Surdo A Redmond A et al Applying a new conceptualframework to evaluate tuberculosis surveillance and action performanceand measure the costs Hillsborough County Florida 2002 AnnEpidemiol 200414640ndash5


Law and Public Health at CDCRichard A Goodman MD JD1 A Moulton PhD1 G Matthews JD2 F Shaw MD JD1

P Kocher JD3 G Mensah MD4 S Zaza MD5 R Besser MD51Public Health Law Program Office of the Chief of Public Health Practice CDC

2University of North Carolina School of Public Health Chapel Hill North Carolina3Office of the General Counsel CDC 4National Center for Chronic Disease Prevention and Health Promotion CDC

5Office of the Director Coordinating Office for Terrorism Preparedness and Emergency Response CDC

Corresponding author Richard A Goodman MD JD Public Health Law Program CDC MS D-30 Atlanta GA 30333 Telephone 404-639-4625 Fax 404-639-7121E-mail rag4cdcgov

Health officers must be familiar not only with the extent of their powers and duties but alsowith the limitations imposed upon them by law With such knowledge available and widelyapplied by health authorities public health will not remain static but will progress

mdashJames A Tobey 1947 (1)

legal powers and duties of government to ensure public healthand limitations on government powers to constrain the pro-tected liberties of individuals

Integration of Public Health LawWithin CDC and StatePublic Health Practice

Public health law at CDC and at many of its partner organi-zations has earned explicit recognition only recently DuringCDC-sponsored workshops on public health law in 1999ndash2000major public health stakeholders including health officers epi-demiologists public health lawyers educators and legislatorscalled for strengthening the legal foundation for public healthpractice These stakeholders concluded that public health wouldbenefit by adding legal skills and scientific knowledge aboutthe impact of law on public health to the toolkits of publichealth practitioners CDC consequently established its PublicHealth Law Program (PHLP) in 2000 with a mission forimproving the publicrsquos health through law (8)

Primary goals of PHLP are to enhance the public healthsystemrsquos legal preparedness to address emerging threats chronicdiseases and other national public health priorities and toimprove use of law to support program activities PHLPfocuses on these goals by 1) strengthening the competenciesof public health professionals attorneys and other practitio-ners to apply law to public health 2) stimulating appliedresearch about the effectiveness of laws in public health 3)fostering partnerships among organizations and professionalsworking in public health and law and 4) developing and dis-seminating authoritative information about public health lawto public health practice policy and other communities (8)PHLP does not provide legal advice to CDC programs thatremains the separate responsibility of the Office of the Gen-eral Counsel of the US Department of Health and HumanServices

IntroductionPublic health law is an emerging field in US public health

practice The 20th century proved the indispensability of lawto public health as demonstrated by the contribution of lawto each of the centuryrsquos 10 great public health achievements(Table 1) (23) Former CDC Director Dr William Foege hassuggested that law along with epidemiology is an essentialtool in public health practice (4)

Public health laws are any laws that have important conse-quences for the health of defined populations They derivefrom federal and state constitutions statutes and other legis-lative enactments agency rules and regulations judicial rul-ings and case law and policies of public bodies Governmentagencies that apply public health laws include agencies offi-cially designated as ldquopublic health agenciesrdquo as well as health-care environmental protection education and lawenforcement agencies among others

Scope of Public Health LawLaw is foundational to US public health practice Laws

establish and delineate the missions of public health agenciesauthorize and delimit public health functions and appropri-ate essential funds The concept of public health law gainedmomentum early in the 20th century in James Tobeyrsquos semi-nal volumes (1) Frank Gradrsquos practical guide The Public HealthLaw Manual (5) and Lawrence Gostinrsquos treatment of publichealth law under the US constitutional design followed (6)A CDC-related contribution to this literature emphasized theinterdisciplinary relation between law and public healthpractice (7)

The concept of public health law has evolved into overlap-ping paradigms One paradigm frames public health practicein relation to multiple sources of law (eg statutes and regu-lations) and to fields of law (eg constitutional and environ-mental law) The other a more scholarly view focuses on the


State and local partners also are strengthening public healthlegal preparedness CDC has stimulated this in part throughinitiatives such as ldquoPublic Health Emergency Lawrdquo a coursedelivered nationally in state and local health departments (8)In some states grassroots activities are increasing competenciesof practitioners to use law and strengthening legal preparednesscapacities of public health systems For example in California

the Public Health Law Work Group (comprising representa-tives of county counsel and city attorney offices) drafted alegally annotated health officer practice guide for communi-cable disease control (9) Related activities in California includea 2006 conference on legal preparedness for pandemic influ-enza and a series of forensic epidemiology joint training pro-grams for public health and law enforcement agencies

TABLE 1 Ten great public health achievements and selected supportive laws and legal tools mdash United States 1900ndash1999

Public health Selected supportive laws and legal toolsachievement Local State Federal

Authority to conduct disease surveillancerequire disease reports and investigateoutbreaks regulation of drinking water andwaste disposal regulation of food supplieslicensure of health professionals

Seat-belt child-safety-seat and motorcycle-helmet laws vehicle inspections driverlicensing and graduated drivers licensesystems authorization to conduct sobrietycheckpoints zero tolerance for alcoholamong drivers under age 21 yearsprohibition on alcohol sales to minors008 blood alcohol content per se lawsspeed limits

Legislation authorizing fluoridation courtrulings upholding fluoridation

Excise taxes restrictions on retail salepractices clean indoor air laws funding forpublic antismoking education lawsuitsleading to the Master Settlement Agreementof 1998

Court rulings supporting mandatoryvaccination school entry admission laws

Tobacco-control laws education andinformation programs

Mandated niacin enrichment of bread andflour standards for and inspection of foodsat the producer level limits on chemicalcontamination of crops

Establishment of maternal and child healthclinics licensure of obstetrics health-careprofessionals mandated milk pasteurizationfunding for Medicaid services

Authorization to provide birth controlservices authority to provide prenatal andpostnatal care to indigent mothers

Laws to inspect and regulate workplacesafety practices including toxic exposurescriminal penalties for grossly negligentworker injury or death

Public Health Service Act of 1944 Safe Drinking WaterAct of 1974 National Environmental Protection Act of1976

Performance and crash standards for motor vehiclesstandards for road and highway construction safety-belt use in some commercial vehicles financialassistance to states to promote and enforce highwaysafety initiatives airbag warning labels creation of stateoffices of highway safety federal court ruling upholdingmotorcycle-helmet use

Federal court rulings upholding fluoridation of publicdrinking water supplies Environmental ProtectionAgency caps on fluoride levels

Excise tax mandated warning labels prohibition ofadvertising on radio and television penalties on statesnot outlawing sale to persons under aged lt18 yearsfinancial assistance to state and local tobacco-controlprograms Department of Justice lawsuit to recoverhealth-care costs

Court rulings supporting mandatory vaccinationlicensure of vaccines financial aid to state vaccinationprograms

Food-labeling laws Department of Transportationfunding for bikeways and walking paths National HighBlood Pressure Education Program

Pure Food and Drug Act of 1906 and later enactmentsto regulate foods and prescription drugs mandated folicacid fortification of cereal grain products limits onchemical contamination of crops food stamps theWomen Infants and Children program school meals

Drinking water quality standards creation of theChildrenrsquos Bureau (1912) with education and serviceprograms licensure of sulfa drugs and antibioticscreation of the Medicaid program the Infant FormulaAct of 1980

Family Planning Services and Population Research ActSupreme Court rulings on contraceptive use

Minimum safety standards for federal contractorsinspection and regulation of mine safety mandates onstates to adopt minimum workplace safety standardsOccupational Safety and Health Act of 1970

Control of infectiousdiseases

Motor vehicle safety

Fluoridation of drinkingwater

Recognition of tobaccouse as a health hazard

Vaccination

Decline in deaths fromcoronary heart diseaseand stroke

Safer and healthier foods

Healthier mothers andbabies

Family planning

Safer workplaces

Sanitary codes and drinkingwater standards quarantine andisolation authority zoningordinances and building codesmosquito- and rodent-controlprograms inspection of foodestablishments

Speed limits limitation on liquor-store hours penalties for servinginebriated bar patrons

Ordinances authorizingfluoridation referenda andinitiatives authorizing fluoridation

Excise taxes restrictions onretail sale to minors clean indoorair laws

School board enforcement ofschool entry vaccinationrequirements

Education for and informationprograms

Standards for and inspectionof retail food establishments

Sewage and refuse ordinancesdrinking water codes milkpasteurization

Funding for family planningclinics

Authority to inspect for unsafeconditions building and firesafety codes

Adapted from CDC Ten great public health achievementsmdashUnited States 1900ndash1999 MMWR 199948241ndash3 and from Moulton AD Goodman RA Parmet WE Perspectivelaw and great public health achievements In Goodman RA Hoffman RE Lopez W Rothstein MA Foster KL eds Law in public health practice 2nd ed New York NY OxfordUniversity Press 20073ndash21


Role of Public Health Lawin Addressing High Priorities

in Public HealthThe indispensable role of law is evident across the entire

history of US public healthmdashfrom early colonialistsrsquo needsto defend against infectious threats to todayrsquos innovative law-based approaches to preventing chronic diseases injuries andother problems (Table 2) The US experience with smallpoxillustrates how at some points in history law-based interven-tions were implemented even before science elucidated thenature of the public health threat and the basis of the inter-vention The legal-epidemiologic strategy of quarantine toprevent the spread of smallpox was employed on Long Islandas early as 1662 (10) Smallpox prevention also was at theroot of the 1905 landmark decision in Jacobson v Massachu-setts in which the US Supreme Court upheld the Massachu-setts statutory requirement for smallpox vaccination (11)

Public health is examining law-based countermeasures tothe use of smallpox virus and other infectious pathogens asbiologic weapons In its program of grants supporting statesrsquodevelopment of capacity to address public health emergen-cies CDC expects states to attain legal preparedness for such

emergencies in the wake of the 2001 anthrax attacks thesevere acute respiratory syndrome epidemic in 2003 the 2005hurricane disasters and the specter of an A(H5N1) influenzapandemic Response to these threats has spawned new andinnovative resources such as the draft Model State EmergencyHealth Powers Act the CDC forensic epidemiology coursefor joint training of public health and law enforcement offi-cials community public health legal preparedness workshopsfor hospital and public health attorneys public health lawldquobench booksrdquo for the judiciary and the CDC Public HealthEmergency Legal Preparedness Clearinghouse (8)

Public health law also helps address high priorities otherthan infectious diseases and emergencies as illustrated by theroles of law and legal strategies in tobacco control (12) CDCand others are exploring the role of law in preventing chronicdiseases (13) including development of legal frameworks foraddressing cardiovascular disease (14) and obesity (15) andfor fostering healthy built environments (16) Injury preven-tion has benefited from litigation laws requiring preventivemeasures and other legal interventions (1718)

In 2002 a rich multidisciplinary public health law com-munity began taking shape at the first national public healthlaw conference which CDC convened This community com-

TABLE 2 Selected laws for the prevention of chronic diseases and injuriesLaw

Smoking bans or restrictions

Tobacco excise taxes

Required coverage ofcessation services costs

Zoning and land-use policies

Child safety-seatndashuse laws

Safety-beltndashuse laws

Blood alcohol concentrationlimit of 008 for operators ofmotor vehicles

Sobriety checkpoints for motorvehicle operators

Fluoridation of communitywater supplies

Food fortification

Public health issue addressedExposure to environmentaltobacco smoke

Tobacco initiation and use

Tobacco use

Physical inactivity

Unintentional injuries of children

Unintentional injuries of olderchildren adolescents andadults



Dental caries

Nutritional deficiencies

EffectivenessStrong evidence

Strong evidence

Sufficient evidence

Sufficient evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence

How it worksRequires behavioral change to change the environment

Applies a financial disincentive to evoke behavior change

Requires organizational change that promotesbehavioral change

Requires environmental change to facilitate behavioralchange

Directly requires behavioral change


Primarily provides powerful psychological deterrentto evoke behavioral change also provides disincentiveto evoke behavioral change through fines and otherpenalties

Provides psychological deterrent to evoke behavioralchange

Directly changes the physical environment requiring noaction on the part of the target population


Adapted from Mensa GA Goodman RA Zaza S et al Law as a tool for preventing chronic diseases expanding the range of effective public healthstrategies Prev Chronic Dis 20041A13


TABLE 3 Core elements of public health legal preparedness and illustrative functions tools and activitiesIllustrative functions tools and activities

Core element Functions Tools and activitiesbull Public health surveillance and epidemiologic

investigationsbull Interventions to contain disease spread

(eg quarantine and isolation)bull Restrictions on indoor smokingbull Zoning standards to promote physical activity

bull Assessment of existing public health laws andordinances

bull Recommendations to elected officials about neededimprovements in existing laws

bull Application of laws that are effective and consistentwith protections for personal liberty and private property

bull Response to public health emergencies by multiplestates and diverse disciplines

bull Collaboration by multiple sectors (eg public healthland use transportation and housing) to design healthycommunities

bull Scientific findings about effective public health lawsbull Current or recent changes in public health lawbull Best practices and innovations in application of legal

authorities to public health priorities

Essential legal authorities

Competencies to apply laws

Coordination acrossjurisdictions and sectors

Information about publichealth law best practices

bull Draft Model State Emergency Health Powers Actbull Turning Point Model State Public Health Act (20)

bull CDC ldquoPublic Health Emergency Lawrdquo curriculumbull CDC ldquoCommunity Public Health Legal Preparednessrdquo

curriculumbull ldquoIndiana Public Health Law Bench Bookrdquo for state

judges

bull The Emergency Management Assistance Compactbull The ldquoHealthy Communitiesrdquo initiatives of CDC the

American Planning Association and the NationalConference of State Legislatures

bull Planning and operational exercises such as TOPOFF

bull Recommendations of the Task Force for CommunityPreventive Services (see also Table 2)

bull The weekly ldquoCDC Public Health Law Newsrdquobull The ldquoCDC Public Health and the Law in the 21st

Centuryrdquo national conference series

prises practitioners trained in the classical disciplines of pub-lic health attorneys in the public and private sectors increas-ing numbers of professionals trained and experienced in bothpublic health and law elected officials emergency manage-ment and law enforcement professionals judges educatorsresearchers and others The more than 7000 current sub-scribers to the weekly CDC Public Health Law News (8) attestto the size of the community

Requirements for AchievingFull Public Health LegalPreparedness to Support

the Mission of Public HealthEffective responses to emerging threats and attainment of pub-

lic health goals require CDC partner organizations and com-munities to achieve full public health legal preparedness (1319)Public health legal preparedness a subset of public health pre-paredness is the attainment by a public health system of speci-fied legal benchmarks or standards essential to preparedness ofthe public health system (19) The elements of public healthlegal preparedness (Table 3) include requirements to

bull Ensure the presence of effective legal authorities tocarry out essential public health services US com-munities states and the nation as a whole should havepublic health legal authorities consistent with modernjurisprudence

bull Establish and sustain the competencies of public healthprofessionals to apply those laws Public health offi-cials their staff and legal counsel judges and others shouldhave access to training to achieve competencies in publichealth law and be skilled in applying essential legalauthorities

bull Provide for coordination of law-based efforts acrossjurisdictions and sectors Law-based measures to pro-tect communities and promote health must be coordi-nated effectively across the local-state-federal-internationaldimension and among multiple public and private sectorentities (ie disciplines officials and organizations hav-ing diverse missions and enabling legal authorities)

bull Develop and make accessible information about pub-lic health law best practices Public health agenciespolicymakers and lawmakers and others must haveaccess to science-based knowledge about effective publichealth laws

CDC increasingly envisions public health law as an integralelement in the armamentarium of each of its programs and inthe competencies of its professionals CDC and its partnersare working vigorously toward full legal preparedness through-out the public health system developing and deploying newlegal tools that policymakers and front-line practitioners willapply to the entire spectrum of 21st-century public healthchallenges and opportunities


References1 Tobey JA Public health law 3rd ed New York NY The Common-

wealth Fund 19472 CDC Ten great public health achievementsmdashUnited States 1900ndash

1999 MMWR 199948241ndash33 Moulton AD Goodman RA Parmet WE Perspective law and great

public health achievements In Goodman RA Hoffman RE LopezW Rothstein MA Foster KL eds Law in public health practice 2nded New York NY Oxford University Press 20073ndash21

4 Foege WH Redefining public health J Law Med Ethics 200432(Suppl 4)23ndash6

5 Grad F The public health law manual 3rd ed Washington DC Ameri-can Public Health Association 2004

6 Gostin LO Public health law power duty restraint Berkeley CAUniversity of California Press 2000

7 Goodman RA Rothstein MA Hoffman RE Lopez W Matthews GWeds Law in public health practice New York NY Oxford UniversityPress 2003

8 CDC Public Health Law Program Available at httpwwwcdcgovphlp9 Public Health Law Work Group Health officer practice guide for com-

municable disease control in California Available at httpwwwdhscagovpsdcdcpdfDec201420Practice20Guidepdf

10 Hopkins DR Princes and peasants smallpox in history Chicago ILUniversity of Chicago Press 1983

11 Jacobson v Massachusetts 197 US 11 (1905)12 Daynard RA Gottlieb MA Kline RL Sweda EL Davis RM Tobacco

prevention and control In Goodman RA Rothstein MA HoffmanRE Lopez W Matthews GW eds Law in public health practice NewYork NY Oxford University Press 2003323ndash47

13 Mensah GA Goodman RA Zaza S et al Law as a tool for preventingchronic diseases expanding the range of effective public health strate-gies Prev Chronic Dis [serial online] 200411ndash8 [Erratum in PrevChronic Dis 20041A13]

14 Perdue WC Mensah GH Goodman RA Moulton AD A legal frame-work for preventing cardiovascular disease Am J Prev Med200529(Suppl 1)139ndash45

15 Mello MM Studdert DM Brennan TA Obesitymdashthe new frontier ofpublic health law N Engl J Med 20063542601ndash10

16 Perdue WC Stone LA Gostin LO The built environment and itsrelationship to the publicrsquos health the legal framework Am J PublicHealth 2003931390ndash4

17 Vernick JS Mair JS Teret SP Sapsin JW Role of litigation in prevent-ing product-related injuries Epidemiol Rev 20032590ndash8

18 Shaw FE Ogolla CP Law behavior and injury prevention In GielenAC Sleet DA DiClemente RJ eds Injury and violence preventionbehavioral science theories methods and applications San FranciscoCA Jossey-Bass 2006442ndash66

19 Moulton AD Gottfried RN Goodman RA Murphy AM RawsonRD What is public health legal preparedness J Law Med Ethics200331372ndash83

20 Turning Point Model State Public Health Act a tool for assessing publichealth laws Available at httpwwwturningpointprogramorgPagespdfsstatute_modMSPHAfinalpdf


Urban Planning and Public Health at CDCChris S Kochtitzky MSP1 H Frumkin MD DrPH2 R Rodriguez MA2 A L Dannenberg MD2

J Rayman MPH2 K Rose MPA2 R Gillig MCP2 T Kanter MURP31Office of the Director Coordinating Center for Environmental Health and Injury Prevention2National Center for Environmental HealthAgency for Toxic Substances and Disease Registry

3National Center on Birth Defects and Developmental Disabilities

Corresponding author Chris S Kochtitzky MSP Office of the Director Coordinating Center for Environmental Health and Injury Prevention 1600 Clifton Road NEMS E-28 Atlanta GA 30333 Telephone 404-498-0668 Fax 404-498-0083 E-mail csk3cdcgov

designing hundreds of places including New Yorkrsquos CentralPark By 1872 the disciplines were so aligned that two of theseven founders of the American Public Health Association wereurban designers (an architect and a housing specialist) (3) In1926 the US Supreme Court in validating zoning and land-use law as a legal government authority in Village of Euclidv Ambler Realty cited the protection of public health as partof its justification (45) Other connections have included 1)pioneering urbanist Jane Jacobs who during the 1960s calledfor community design that offered safe and convenientoptions for walking biking and impromptu social interac-tion and 2) the Healthy Cities movement which began inEurope and the United States during the 1980s and nowincludes projects in approximately 1000 cities that in variousways highlight the role of health as much more than the pres-ence of medical care (6)

Contributions of Urban Planningto Public Health

During the 19th and early 20th centuries the synergiesbetween urban planning and public health were evident in atleast three areas creation of green space to promote physicalactivity social integration and better mental health preven-tion of infectious diseases through community infrastructuresuch as drinking water and sewage systems and protection ofpersons from hazardous industrial exposures and injury risksthrough land-use and zoning ordinances During the middleof the 20th century the disciplines drifted apart to a certainextent because of their success in limiting health and safetyrisks caused by inappropriate mixing of land uses

The disciplines recently have begun to reintegrate Duringthe last 20 years shared concerns have included transporta-tion planning to improve air quality encourage physicalactivity prevent injuries and promote wellness In additionsome original crossover ideas such as the potential for parksand recreational facilities to contribute to physical activity andmental health have reemerged Relatively recently urban plan-ning has focused on the effects of community design onenergy use and greenhouse gas emissions to affect the growing

IntroductionUrban planning also called city and regional planning is a

multidisciplinary field in which professionals work to improvethe welfare of persons and communities by creating more con-venient equitable healthful efficient and attractive placesnow and for the future The centerpiece of urban planningactivities is a ldquomaster planrdquo which can take many formsincluding comprehensive plans neighborhood plans commu-nity action plans regulatory and incentive strategies economicdevelopment plans and disaster preparedness plans (1) Tra-ditionally these plans include assessing and planning for com-munity needs in some or all of the following areastransportation housing commercialoffice buildings natu-ral resource utilization environmental protection and health-care infrastructure

Urban planning and public health share common missionsand perspectives Both aim to improve human well-beingemphasize needs assessment and service delivery manage com-plex social systems focus at the population level and rely oncommunity-based participatory methods Both fields focuson the needs of vulnerable populations Throughout theirdevelopment both fields have broadened their perspectivesInitially public health most often used a biomedical model(examining normalabnormal functioning of the humanorganism) and urban planning often relied on a geographicmodel (analysis of human needs or interactions in a spatialcontext) However both fields have expanded their tools andperspectives in part because of the influence of the other

Urban planning and public health have been intertwinedfor most of their histories In 1854 British physician JohnSnow used geographic mapping of an outbreak of cholera inLondon to identify a public water pump as the outbreakrsquossource Geographic analysis is a key planning tool shared byurban planning and public health In the mid-1800s plan-ners such as Frederick Law Olmsted bridged the gap betweenthe fields by advancing the concept that community designcontributes to physical and mental health serving as Presi-dent Lincolnrsquos US Sanitary Commission Secretary (2) and


public health concern of climate change Finally emergencypreparedness (eg community infrastructure assurance evacu-ation planning) and access to health care (eg assurance ofaccessibility and adequacy of facilities) are topics importantto both disciplines

Recent contributions to the public health knowledge-baseby urban planners and other community designers such asarchitects and engineers are important A recent tabulationof the 50 most-readmost-cited articles within the AmericanJournal of Public Health (AJPH) (as of October 1 2006)included topics of interest to both urban planning and publichealth professionals such as social capital neighborhood-leveleffects on health housing and health and clustering of fast-food establishments around schools (7) Examples of cross-discipline collaborations (Table 1) from publications such asJAMA and AJPH address such diverse CDC program areas asaging studies air pollution and respiratory diseases disabilityand health unintentional injury and nutrition and physicalactivity

As individual collaborations have increased calls for broadprofession-level integrations also have increased (Table 2) Thusfar CDC has employed only a few urban planners either tem-porarily or permanently Urban planners for instance haveworked within the ATSDR Policy Office Division of HealthAssessment and Consultation and Office of Tribal Affairswithin the National Center for Environmental Health PolicyOffice and Division of Emergency and Environmental HealthServices within the National Center on Birth Defects andDevelopmental Disabilities Division of Human Developmentand Disability and within the National Center for ChronicDisease Prevention and Health Promotion Division of Nutri-tion and Physical Activity Although these urban planners haveconducted some research their primary role has been to bridgethe broader urban planning academic and practitioner worlds

Specific Findings Activitiesand Contributions

The interdependence of urban planning and public healthin both research and intervention activities is evident in manyareas For example to increase physical activity persons needsafe and accessible areas development of these areas can beaided by determining the environmental barriers and facilita-tors that affect activity levels designing constructing andmaintaining community environments to help ensure safetyand accessibility and developing programs to encourage peopleto use improved community environments to increase theiractivity levels Without the contributions of both disciplines

the odds of substantial increases in community physical activ-ity decrease considerably

Pedestrian and bicycle safety programs also illustrate theinterdependence of public health and urban planning Trans-portation planners are charged with creating streets and inter-sections on which all modes of transportation can safely coexistHowever considerable morbidity and mortality occur annu-ally because of injuries related to interactions between motor-ists bicyclists and pedestrians indicating that manycommunities have failed to truly balance choices of transpor-tation modes

Examples of recent successful cross-discipline activitiesinclude chronic disease prevention injury prevention healthpromotion for older adults and persons with disabilities andair- and water-quality assurance Reviews of research studiesconducted by cross-disciplinary teams on behalf of the Guideto Community Preventive Services have documented that street-scale urban design and land-use policies affect levels of physi-cal activity and result in recommendations for widerimplementation of such policies (8) Similarly research hasdocumented the potential for design choices to reduce bothunintentional (910) and intentional (1112) injuries

Research has described some of the impacts of physicalenvironments on the health and quality of life of persons withdisabilities (13) residents of low-income housing projects (14)and older adults (15) In environmental health data analysisof waterborne-disease outbreaks and extreme weather eventsindicates potential interaction between land-use patterns andrisk for waterborne diseases (16) In an equally important areaof environmental healthmdashair quality and respiratory healthmdashCDC staff used the unique ldquonatural experimentrdquo of theAtlanta Olympics to document a 42 decrease in acute asthmaevents among children that were attributable to reductions inautomobile traffic and associated air pollution (17) Otherimpacts of the interdependence of urban planning and publichealth also have been demonstrated (Table 3)

Urban planning in particular and the array of communitydesign professions in general historically have played major rolesin public health and public health disciplines have playedmajor roles in urban planning In recent years as reintegrationbetween the two professions has accelerated academia hasresponded by offering cross-cutting courses and in at least fiveschools joint graduate degrees in urban planning and publichealth At the federal level CDC leadership selected seven ldquoplace-relatedrdquo goals reflecting this reintegration (18) many of whichare impacted by urban planning CDC scientifically andprogramatically addresses all factors associated with the inter-action between people and their natural and human-madeenvironments and promotes design and construction of placesthat improve both physical and social environments


(httpwwwcdcgovhealthyplaces) Providing safe and healthyplaces in which to live work and play is more likely to succeedif urban planning and public health work togetherFuture integration of and collaborations between the disciplinescan serve as a cornerstone for the immediate and long-termsuccess of the Healthy Places goals (19) A long-term blendingof the responsibilities tools and eventually perspectives of publichealth and urban planning can result in many positive out-comes including the following

TABLE 1 Selected examples of cross-disciplinary publications that link urban planning and public healthCategory Citation examplePublications in the urban planning literature (often by public health professionals)Overview of links betweenpublic health and urbanplanning

Research review

Empirical research

Program evaluation

Policy analysis

Practice guidelines

bull Greenberg M Popper F West B Krueckeberg D Linking city planning and public health in the United StatesJournal of Planning Literature 19948235ndash9

bull Spielman SE Golembeski CA Northridge ME et al Interdisciplinary planning for healthier communities findingsfrom the Harlem Childrenrsquos Zone Asthma Initiative J Am Plann Assoc 200672100ndash8

bull Lee C Moudon AV Physical activity and environment research in the health field implications for urban andtransportation planning practice and research Journal of Planning Literature 200419147ndash81

bull Frank LD Engelke PO The built environment and human activity patterns exploring the impacts of urban form onpublic health Journal of Planning Literature 200116202ndash18

bull Boarnet MG Day K Anderson C McMillan T Alfonso M Californiarsquos safe routes to school program impacts onwalking bicycling and pedestrian safety J Am Plann Assoc 200571301ndash17

bull Wernstedt K Devolving Superfund to Main Street avenues local community involvement J Am Plann Assoc200167293ndash313

bull Takahashi LM Smutny G Community planning for HIVAIDS prevention in Orange County California J AmPlann Assoc 199864441ndash56

bull Rodriguez DA Khattak AJ Evenson KR Can new urbanism encourage physical activity Comparing a newurbanist neighborhood with conventional suburbs J Am Plann Assoc 20067243ndash54

bull Kochtitzky CS Duncan RC Universal design community design public health and people with a disability InMorris M ed Planning and universal design in integrating planning and public health tools and strategies tocreate healthy places Chicago IL American Planning Association 200651ndash64 (APA Planning Advisory ServiceReport 539540)

Publications in the public health literature (often by urban planners or allied professionals)bull Corburn J Confronting the challenges in reconnecting urban planning and public health Am J Public Health

200494541ndash6

bull Zimring C Joseph A Nicoll GL Tsepas S Influences of building design and site design on physical activityresearch and intervention opportunities Am J Prev Med 200528(Suppl 2)185ndash93

bull Boarnet MG Day K Alfonzo M Forsyth A Oakes M The IrvinendashMinnesota Inventory to measure built environ-ments reliability tests Am J Prev Med 200630153ndash9

bull Koepsell T McCloskey L Wolf M et al Crosswalk markings and the risk of pedestrian motor vehicle collisions inolder pedestrians JAMA 20022882136ndash43

bull Tester JM Rutherford GW Wald Z Rutherford MW A matched casendashcontrol study evaluating the effectivenessof speed humps in reducing child pedestrian injuries Am J Public Health 200494646ndash50

bull Lopez R Urban sprawl and risk for being overweight or obese Am J Public Health 2004941574ndash9

bull Boarnet MG Anderson CL Day K McMillan T Alfonzo M Evaluation of the California Safe Routes to Schoollegislation urban form changes and childrenrsquos active transportation to school Am J Prev Med 200528(2 Suppl 2)134ndash40

bull Dannenberg AL Jackson RJ Frumkin H et al The impact of community design and land-use choices on publichealth a scientific research agenda Am J Public Health 2003931500ndash8

Overview of links betweenpublic health and urbanplanning

Research review

Methods development

Empirical research

Policy analysis

Research framework

Cross-disciplinary overviews bull Frumkin H Frank L Jackson RJ Urban sprawl and public health designing planning and building for healthycommunities Washington DC Island Press 2004

bull Frank LD Engelke PO Schmid TL Health and community design the impact of the built environment on physicalactivity Washington DC Island Press 2003

bull Public health explicitly recognizing the importance ofplace-based approaches and the leverage these provide foraddressing public health opportunities and threats

bull Public health and urban planning professionals increas-ingly drawing on tools and processes developed by theother field Key examples are geographic information sys-tems (20) health impact assessment (21) and commu-nity assessment tools such as the Protocol for AssessingCommunity Excellence in Environmental Health (22)


TABLE 2 Examples of professional association policies and recommendations on issues involving urban planning and publichealthTopics of organizational American Planning US Green American Public National Association of Countypolicy or recommendations Association Building Council Health Association and City Health OfficialsHousing X X X XSmart growth XLand use X X XSurface transportation X XEnergy X XAir quality X XWater resources management X XHealthy community design X X X XHealth impact assessment XSustainability XSolid and hazardous waste X XEnvironmental justice X XDisability issues X X

TABLE 3 Sample of public health projects with significant contributions from urban planningProject leadTitle Project description

Promotes walking and bicycling and development of accessible recreation facilities Developed inresponse to public health urban design and transportation planning data suggesting communitycharacteristics such as proximity of facilities street design density of housing availability of publictransit and of pedestrian and bicycle facilities play an important role on physical activity Available athttpwwwcdcgovnccdphpdnpaphysicalhealth_professionalsactive_environments

Creates a community environment in which persons with disabilities have opportunities to participate inevery aspect of community life equal to those of persons without disabilities This project works closelywith the Public Works Department to plan improvements to streets sidewalks mechanisms of trafficcontrol and other aspects of the urban plan Available at httpwwwo3aorgDASHhtm

Pilot study to develop and pilot test a research audit instrument to collect data on the street-scalefactors associated with physical activity in several older adult populations (ie persons aged gt65years with an emphasis on those with special needs such as wheelchairs or oxygen tanks) acrossmultiple settings (eg urbanrural areas colderwarmer climates presenceabsence of diverse racialand economic groups residentialcommercial and flathilly areas) Available at httpdeptswashingtoneduharnpublicationsengaging_olderpps

Encourages children to walk or bike to and from school by for example advocating for communities tocreate an environment that supports walking or bicycling safely to school Benefits include 1) increasedlevels of daily physical activity for children 2) increased likelihood that children and adults will chooseto walk or bike for other trips 3) improved neighborhood safety 4) fewer cars traveling through theneighborhood and 5) friendlier neighborhoods as people get out and interact with each otherAvailable at httpwwwcdcgovnccdphpdnpakidswalk

Recommendations for encouraging children to explore their environments by walking while reducingtheir risk for pedestrian injury Key strategies include encouraging 1) revised laws and practices topromote construction of sidewalks and traffic-calming measures 2) consideration of pedestriansafetymdashparticularly for children and persons with disabilitiesmdashwhen designing new communities ormodifying existing ones and 3) enhancement of pedestrian accessibility and safety when buildingremodeling schools parks and businesses Available at httpwwwcdcgovncipcpedestrian

Encourages persons to make small behavior changes to reduce the burden of some of the leadingcauses of death Communities are taking steps to implement community environmental and policyinterventions in school community health-care and workplace settings to 1) engage communitymembers in assessing planning delivering and evaluating intervention activities 2) create supportiveenvironments to sustain individual efforts 3) provide social support for healthy choices and 4) improveaccess to and use of quality health-care services Available at httpwwwcdcgovsteps

Assesses how land use relates to travel choice vehicle emissions and physical activity Its goal is todevelop a framework for assessing land use and transportation policies that have the greatest potentialfor reducing the level of automobile dependence and vehicle emissions in the Atlanta metropolitan areawhile sustaining the economic vitality and environmental health of the region Available at httpwwwact-transubccasmartraqpageshome2htm

CDC National Center for Chronic DiseasePrevention and Health Promotion(NCCDPHP) Division of Nutrition andPhysical Activity

Active Community Environments Initiative

Washington State Department of HealthJefferson County Wash (CDC-supported)

Disability Awareness Starts Here (DASH)Program

Prevention Research Center Healthy AgingResearch Network (CDC-supported)

Healthy Aging Network Built Environmentand Physical Activity in Older Adults AuditTool Development

CDC NCCDPHP Division of Nutrition andPhysical Activity

KidsWalk-to-School Initiative

CDC National Center for Injury Preventionand Control Division of Unintentional InjuryPrevention

National Strategies for Advancing ChildPedestrian Safety

CDC NCCDPHPSteps to a Healthier US Program

Georgia Institute of TechnologyUniversity of British Columbia(CDC-supported)

Strategies for Metropolitan AtlantarsquosRegional Transportation and AirQuality (SMARTRAQ)


bull Public health professionals increasingly engaging in theurban planning arena participating in zoning decisionsand serving on urban planning boards and incorporat-ing health into urban planning decision-making

bull Urban planning professionals increasingly engaging in thepublic health arena participating in campaigns promot-ing physical activity and pedestrian injury prevention andserving on boards of health and incorporating design intopublic health decision-making

This renewed integration is essential in restoring andenhancing the health and vitality of the nationrsquos places and people

References1 American Planning Association Available at httpwwwplanningorg2 Jackson RJ What Olmsted knew Western City 2001(March)12ndash153 Glasser J Back to the future [transcript] Presented at Global public

health issues and strategies for Hawairsquoi and the Pacific June 12ndash132002 Available at httpwwwhawaiieduglobalprojects_activitiesPastGlasserXscript2pdf

4 Jacobson v Massachusetts 197 US 11 (1905)5 Village of Euclid v Ambler Realty Co 272 US 365 (1926)6 International Healthy Cities Foundation Available at httpwww

healthycitiesorgoverviewhtml7 American Journal of Public Health Articles in demand Available at

httpwwwajphorg8 CDC Guide to community preventive services Physical activity Avail-

able at httpwwwthecommunityguideorgpa9 Retting RA Ferguson SA McCartt AT A review of evidence-based

traffic engineering measures designed to reduce pedestrianndashmotorvehicle crashes Am J Public Health 2003931456ndash63

10 Elvik R Area-wide urban traffic calming schemes a meta-analysis ofsafety effects Accid Anal Prev 200133327ndash36

11 Carter SP Carter SL Dannenberg AL Zoning out crime and improv-ing community health in Sarasota Florida ldquoCrime Prevention ThroughEnvironmental Designrdquo Am J Public Health 2003931442ndash5

12 Casteel C Peek-Asa C Effectiveness of crime prevention throughenvironmental design (CPTED) in reducing robberies [review] Am JPrev Med 200018(4 Suppl)99ndash115

13 Whiteneck GG Gerhart KA Cusick CP Identifying environmentalfactors that influence the outcomes of people with traumatic braininjury J Head Trauma Rehabil 200419191ndash204

14 Kuo FE Sullivan WC Aggression and violence in the inner cityeffects of environment via mental fatigue Environment and Behavior200133543ndash71

15 Koepsell T McCloskey L Wolf M et al Crosswalk markings and therisk of pedestrianndashmotor vehicle collisions in older pedestrians JAMA20022882136ndash43

16 Curriero FC Patz JA Rose JB Allele S The association betweenextreme precipitation and waterborne disease outbreaks in the UnitedStates 1948ndash1994 Am J Public Health 2001911194ndash9

17 Friedman MS Powell KE Hutwagner L Graham LM Teague WGImpact of changes in transportation and commuting behaviors duringthe 1996 Summer Olympic games in Atlanta on air quality and child-hood asthma JAMA 2001285897ndash905

18 CDC Healthy people in healthy places Available at httpwwwcdcgovosigoalsplaceshtml

19 CDC About CDC health protection goals Available at httpwwwcdcgovaboutgoalsgoalshtm

20 Waller LA Gotway CA Applied spatial statistics for public health dataHoboken NJ John Wiley amp Sons 2004

21 Dannenberg AL Bhatia R Cole BL et al Growing the field of healthimpact assessment in the United States an agenda for research andpractice Am J Public Health 200696262ndash70

22 National Association of County and City Health Officials Protocolfor Assessing Community Excellence in Environmental Health Avail-able at httppacenacchoorg

TABLE 3 (Continued) Sample of public health projects with significant contributions from urban planningProject leadTitle Project description

Uses geographic information systems (GIS) for public health applications GIS techniques andapplications developed in urban planning have direct implications for public health The tracking andmanagement of city infrastructure such as water and sewage have implications for environmentalhealth GIS is used to look at green space and sidewalks in the city and the impact on physical activityand health Population data can overlay land-usefacility data to examine the context in which publichealth events occur Available at httpwwwatsdrcdcgovgis

Developed model zoning codes designed to promote healthy walkable communities Available athttpwwwplanningorgsmartgrowthcodespdfsection48pdf

Produced the LEED-ND Public Health Report that comprehensively summarized the relation betweencommunity designmdashland use design character transportation system and densitymdashand public healthoutcomes such as physical activity traffic crashes respiratory health and mental health This reportis used as part of the foundation for the LEED-ND Rating System currently in draft which integratesthe principles of smart growth urbanism and green building into the first national standard forneighborhood design Available at httpswwwusgbcorgDisplayPageaspxCMSPageID=148report

ATSDR Division of Health StudiesGeospatial Research Analysisamp Services Program (GRASP)

American Planning AssociationModel Zoning Codes Project (supportedby the Environmental Protection Agency[EPA] and CDC National Center forEnvironmental Health [NCEH] Divisionof Emergency and Environmental HealthServices)

US Green Building CouncilLEED-ND Public Health Report(supported by EPA and CDC NCEH Division of Emergency andEnvironmental Health Services)

MMWR

The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of chargein electronic format To receive an electronic copy each week send an e-mail message to listservlistservcdcgov The body content should read SUBscribe mmwr-toc Electronic copy also is available from CDCrsquos Internet server at httpwwwcdcgovmmwr or from CDCrsquos file transfer protocol server at ftpftpcdcgovpubpublicationsmmwr Paper copy subscriptions are available through the Superintendent of Documents US Government Printing Office Washington DC20402 telephone 202-512-1800

Data in the weekly MMWR are provisional based on weekly reports to CDC by state health departments The reporting week concludes at close of business onFriday compiled data on a national basis are officially released to the public on the following Friday Data are compiled in the National Center for Public HealthInformatics Division of Integrated Surveillance Systems and Services Address all inquiries about the MMWR Series including material to be considered forpublication to Editor MMWR Series Mailstop E-90 CDC 1600 Clifton Rd NE Atlanta GA 30333 or to wwwmmwrqcdcgov

All material in the MMWR Series is in the public domain and may be used and reprinted without permission citation as to source however is appreciated

Use of trade names and commercial sources is for identification only and does not imply endorsement by the US Department of Health and Human Services

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations ortheir programs by CDC or the US Department of Health and Human Services CDC is not responsible for the content of these sites URL addresses listed inMMWR were current as of the date of publication

US Government Printing Office 2007-623-03840095 Region IV ISSN 1546-0738

MMWR

The MMWR series of publications is published by the CoordinatingCenter for Health Information and Service Centers for DiseaseControl and Prevention (CDC) US Department of Health andHuman Services Atlanta GA 30333

Suggested Citation Centers for Disease Control and Prevention[Title] MMWR 200655(Suppl)[inclusive page numbers]

Editorial BoardWilliam L Roper MD MPH Chapel Hill NC Chairman

Virginia A Caine MD Indianapolis INDavid W Fleming MD Seattle WA

William E Halperin MD DrPH MPH Newark NJMargaret A Hamburg MD Washington DC

King K Holmes MD PhD Seattle WADeborah Holtzman PhD Atlanta GA

John K Iglehart Bethesda MDDennis G Maki MD Madison WI

Sue Mallonee MPH Oklahoma City OKStanley A Plotkin MD Doylestown PA

Patricia Quinlisk MD MPH Des Moines IAPatrick L Remington MD MPH Madison WI

Barbara K Rimer DrPH Chapel Hill NCJohn V Rullan MD MPH San Juan PR

Anne Schuchat MD Atlanta GADixie E Snider MD MPH Atlanta GA

John W Ward MD Atlanta GA

Centers for Disease Control and PreventionJulie L Gerberding MD MPH

Director

Tanja Popovic MD PhD(Acting) Chief Science Officer

James W Stephens PhD(Acting) Associate Director for Science

Steven L Solomon MDDirector Coordinating Center for Health Information and Service

Jay M Bernhardt PhD MPHDirector National Center for Health Marketing

Judith R Aguilar(Acting) Director Division of Health Information Dissemination (Proposed)

Editorial and Production StaffJohn S Moran MD MPH

(Acting) Editor MMWR Series

Suzanne M Hewitt MPAManaging Editor MMWR Series

Teresa F RutledgeLead Technical Writer-Editor

Karen L Foster MAProject Editor

Beverly J HollandLead Visual Information Specialist

Lynda G CupellMalbea A LaPete

Visual Information Specialists

Quang M Doan MBAErica R Shaver

Information Technology Specialists

On the cover Clockwise Tom Harkin Global Communications Center atCDC (built in 2006) In 1946 the Communicable Disease Center or CDCopened in the old Office of Malaria Control in war areas in downtownAtlanta Georgia Locks at the Pacific Ocean end of the Panama Canal wherepublic health officials instituted sanitation measures that eliminated the yellowfever and malaria carrying mosquitoes which made building the canalpossible A child washing his hands after handling a pet turtle An adultreceiving a vaccination with a jet injector during the swine flu nationwidevaccination campaign Two CDC veterinarians administering a rabiesvaccination to a dog A CDC microbiologist examining reconstructed 1918Pandemic Influenza Virus inside a specimen vial containing a supernatantculture medium Photomicrograph of Streptococcus pyogenes bacteria

CONTENTS

Preface 1

Epidemiology and Public Health at CDCStephen B Thacker 3

Laboratory Science and Public Health at CDCKaren K Steinberg J Nicholson 5

Veterinary Medicine and Public Health at CDCLonnie J King 7

Engineering and Public Health at CDCG Scott Earnest Laurence D Reed D Conover C EstillC Gjessing M Gressel R Hall S Hudock H HudsonC Kardous J Sheehy J Topmiller D TroutM Woebkenberg A Amendola H Hsiao P KeaneD Weissman G Finfinger S Tadolini E ThimonsE Cullen M Jenkins R McKibbin G ConwayB Husberg J Lincoln S Rodenbeck D LantagneJ Cardarelli 10

Behavioral and Social Sciences and Public Health at CDCDeborah Holtzman M Neumann E SumartojoA Lansky 14

Economics and Public Health at CDCMark L Messonnier 17

Genomics and Public Health at CDCMarta Gwinn M Bowen M Khoury 20

Statistics and Public Health at CDCWilliam K Sieber T Green G D Williamson 22

Informatics and Public Health at CDCScott J McNabb D Koo R Pinner J Seligman 25

Law and Public Health at CDCRichard A Goodman A Moulton G MatthewsF Shaw P Kocher G Mensah S Zaza R Besser 29

Urban Planning and Public Health at CDCChris S Kochtitzky H Frumkin R RodriguezA Dannenberg J Rayman K Rose R Gillig T Kanter 34

































































































































































PhotoCDC


































































































































































PhotoCDC

























































NETSS initiated


WONDERPC released










BioSense launched




Year1976

1984

1985

1990

1990

1992

1993

1993

1996

1996

1999

1999

2000

2000

2002

2003

2004

2005

2005

References1

67

8

910

11

1213

14

15

1617

18

19

Stakeholder


Epidemiologists















URL






httpwwwcdcgovnedss

httpwwwcdcgovepix





httpwwwcdcgovncphi




























































































Vaccination




Family planning

Safer workplaces






























Food fortification



Tobacco use

Physical inactivity





Dental caries



Strong evidence

Sufficient evidence

Sufficient evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence































judges

































































Research review

Empirical research

Program evaluation

Policy analysis

Practice guidelines











200494541ndash6









Research review

Methods development

Empirical research

Policy analysis

Research framework



























































MMWR







































































































































































PhotoCDC


































































































































































PhotoCDC

























































NETSS initiated


WONDERPC released










BioSense launched




Year1976

1984

1985

1990

1990

1992

1993

1993

1996

1996

1999

1999

2000

2000

2002

2003

2004

2005

2005

References1

67

8

910

11

1213

14

15

1617

18

19

Stakeholder


Epidemiologists















URL






httpwwwcdcgovnedss

httpwwwcdcgovepix





httpwwwcdcgovncphi




























































































Vaccination




Family planning

Safer workplaces






























Food fortification



Tobacco use

Physical inactivity





Dental caries



Strong evidence

Sufficient evidence

Sufficient evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence

Strong evidence































judges

































































Research review

Empirical research

Program evaluation

Policy analysis

Practice guidelines











200494541ndash6









Research review

Methods development

Empirical research

Policy analysis

Research framework



























































MMWR







60 Years of Public Health Science at CDC

Documents

Transcript of 60 Years of Public Health Science at CDC