When 29 people mysteriously died and another 150 fell ill after attending the American Legion Convention in Philadelphia last July, the job of tracking down the cause fell to Dr. Philip Brachman. As director of the Bureau of Epidemiology for the U.S. Center for Disease Control in Atlanta, he has been the nation’s top microbe hunter for the past 16 years. Brachman heads a staff of some 150 public health service experts who keep a nationwide watch for epidemics and move quickly to halt their spread when they occur. Another of Brachman’s current projects is participating in the nationwide swine flu vaccination program. It was prompted by an outbreak of the flu at Fort Dix in New Jersey earlier this year which killed one soldier. Brachman discussed the epidemiologist’s war against disease with Joyce Leviton for PEOPLE.
How does the Philadelphia situation rate in the annals of plagues and disease?
It is one of the most complex problems we’ve ever had to meet. We’ve had outbreaks in which more people have been involved, but with 29 deaths this is one of the most serious. The fact that we have been unable to identify the cause and how it was spread makes it more perplexing than any we’ve ever been called upon to investigate.
Where does an epidemiologist begin to find the answers?
The first thing we do in any investigation is confirm the fact that a disease occurred. So we sent a crew up to Pennsylvania, interviewed people who were ill and their physicians, and looked at hospital records and autopsy reports. We developed a questionnaire that was aimed at identifying what all these people had in common in the way of exposure to a possible cause. As we interviewed more people, we developed some new leads. Soon it was obvious to us that one of the criteria was that a victim was either a Legionnaire who had been in Philadelphia or was related to some of the events the Legionnaires participated in. We feel fairly confident that we can place almost all of the people who were ill with this disease in the Bellevue Stratford Hotel.
Where did you go from there?
We looked at their agenda. The Legionnaires had an election, and they had six other events—all but one at the Bellevue. They also had a certain number of hospitality hours where drinks and food were served. And there were many informal get-togethers. But in looking at all the cases, we discovered that there was not one of the six main events or hospitality hours that the majority of those who became ill attended. There were several cases of people who came into the hotel, went up to the second floor to watch the parade and then went out and later developed the disease. One lady came in, went to the women’s room and left. She developed the disease. Another gentleman came in to use the telephone. He developed it.
What are some possible causes you considered?
You name it and it’s been suggested. Anything. From the beginning people have said, “It’s the food,” “It’s the water,” “It’s something in the air.” Some people have suggested that it was a deliberate attempt to poison people on the part of some group. It was suggested that the ink on the programs was the answer, but there was no common program. Some say it was the metal in the Legionnaires’ badges. We read each letter that comes in suggesting an answer, and we answer every phone call. Right now, since these people did not eat and drink the same things, we feel it was something carried in the air—though we don’t know precisely what.
Has the publicity hurt the Bellevue?
Yes, the hotel has suffered and that is unfortunate. But nobody can claim that the hotel was negligent. Many of our officers stayed at the Bellevue Stratford while investigating this case. I stayed there and ate breakfast in the hotel’s cafeteria.
Are some conventioneers being shunned?
Yes, but there is no danger to others from these Legionnaires, because there has been no secondary spread of the disease. Nobody has caught it from somebody else. You had to have been there at the time.
Is the Philadelphia epidemic over?
Yes, it is over. There are no new cases. We are still getting reports of people who were ill last February who think they had the disease. But they didn’t; they had something else. The criteria of fever, chills, headache, muscle aches, pains and tiredness are general symptoms of pneumonia.
Is there any danger to your staff in investigating epidemics?
If we’re dealing with a disease that’s infectious and if the source of infection is still present, yes there is a risk. If we send out a team to investigate an epidemic that is still going on, we are always concerned about them. Four years ago we sent a team of 10 or 15 people to Pontiac, Mich., to look into a respiratory epidemic, and about half of them developed the disease. We still don’t know what the disease was. In the Philadelphia investigation, we took precautions. When people were interviewed in hospitals, for example, we followed strict isolation procedures.
What is the “hot lab”?
It is a high-security laboratory in which selected infectious agents in an epidemic are worked on behind glass and under negative pressure, so that if a leak develops the air goes into the glass case rather than out of it. That way, there is essentially no danger to the people working on it. Lassa fever, for instance, is highly infectious and there have been several laboratory-acquired cases of it. Now anything we do with Lassa fever is handled in a hot lab because we know that it demands the highest security. Initially all materials from the Philadelphia outbreak were worked with in the hot lab until we determined that nothing as highly infectious as Lassa fever was involved.
What are the most important advances in epidemiology in recent years?
Basically, we know a lot more about laboratory investigation of disease. There are a lot more lab techniques available, particularly the electron microscope with which we can identify viruses, bacteria and fungi.
Do you think mass inoculation for swine flu is necessary?
Yes. Our past surveillance suggests to us that this new influenza virus may show some spread within this next year. We have not said definitely there will be an epidemic, only that there is a possibility. When you have a susceptible population, you can expect an increased incidence of influenza. And then you can expect increased deaths. To the extent that we have enough time to make a vaccine and get it distributed, people should be protected.
Will it be 100 percent effective?
No, but the vaccine is 90 to 95 percent effective for people above the age of 25.
Who will be most likely to develop an adverse reaction?
The vaccine is made in chicken eggs and there are people who are sensitive to the protein of eggs. The worst reaction they could get would be anaphylactic shock, which can be fatal. So anyone who is sensitive to egg protein should be vaccinated only by a physician who is aware of the sensitivity. In addition, a very small percentage of people will get some local pain and redness around the site of the inoculation, a little bit of a fever or some achiness. The majority will have absolutely no reaction.
Besides people who are allergic to eggs, who should not receive the vaccination?
The very, very young. Children under the age of 3 should not be vaccinated. And anyone with a fever or an illness should wait for it to pass before being vaccinated, since the flu shot might complicate things.
Is the vaccine safe for pregnant women?
Yes, perfectly safe, and I advise pregnant women to be vaccinated.
What about older people?
They should definitely be vaccinated, because they generally present more serious risks of developing complications from influenza.
Some states are resisting the vaccination program. What about that?
They are saying the vaccine should be stockpiled but not used unless there is evidence of an epidemic. We think that’s too late. Once sporadic outbreaks occur, the flu spreads very rapidly. By then we will not have time to get the vaccine into everybody who should be immunized.
What does the future hold for microbe hunters like you?
The name of the game is prevention. It’s tough, exhausting and sometimes frustrating detective work. When lives are at stake, it’s well worth it.