• Mark Casey

Leading Epidemiologist Talks COVID19

"Under the stern guidance of Alexander Langmuir, CDC’s chief epidemiologist, each cadre of novice EIS Officers was immersed in the principles and practice of investigative field epidemiology which transformed clinicians such as myself who had heretofore focused on the illnesses of single patients into public health physicians who worked to ensure the health of entire communities."

An Interview with:

William Schaffner, MD

Vanderbilt University

Professor of Preventive Medicine, Department of Health Policy

Professor of Medicine, Division of Infectious Diseases

Fun Facts:

· Grew up in West New York, New Jersey

· Went to college at Yale University

· Medical School at Cornell University Medical College

· Internship, Residency & Infectious Disease Fellowship at Vanderbilt University Hospital

· Epidemic Intelligence Service Officer at the CDC

· Medical Director of the National Foundation for Infectious Diseases

· International spokesman on epidemics

· On the Board of The Elephant Sanctuary-

About Dr Schaffner:

Since 1968, Dr Schaffner has held various positions at the Vanderbilt University Hospital, including Chief Medical Resident, Director of the Clinical Microbiology Laboratory and Hospital Epidemiologist. In parallel, he has been on the faculty of the Vanderbilt University School of Medicine, where he was Chairman of the Department of Preventive Medicine and now is Professor of Preventive Medicine in the Department of Health Policy as well as Professor of Medicine in the Division of Infectious Diseases.

Dr Schaffner’s work has focused on many aspects of infectious diseases, including epidemiology, infection control and immunization. He has worked extensively on the effective use of vaccines in both pediatric and adult populations. Beside his research, he has always had a passion for teaching, both to the professional community and to the public. He is a strong advocate for collaboration between academia and public health institutions. Dr Schaffner is an active member of numerous national and international committees and professional societies. He is the Medical Director of the National Foundation for Infectious Diseases.

His research has resulted in more than 370 original research papers and 215 invited chapters and reviews. During the course of his career, he has received many honors, among them the James D. Bruce Memorial Award in 2009 (American College of Physicans), the Sedgwick Memorial Medal in 2010 (American Public Health Association), as well as the Walter E. Stamm Mentor Award in 2011 and the DA Henderson Award for outstanding contributions to public health in 2018 (Infectious Diseases Society of America).

How did you get started in medicine?

I was born of German and Swiss immigrants and raised in an urban multi-ethnic lower middle-class neighborhood in northern New Jersey. From our family’s apartment window I could see the skyline of Manhattan, which was impressive in daylight and magical when illuminated at night. The boys I played with also were the sons or grandsons of immigrants and many families spoke English and another language (Italian, Polish, Hungarian, Yiddish, etc.) in their homes. I was entranced by Dr Tidwell, our family doctor whose office, smelling strongly of disinfectant, was on the ground floor and his home was upstairs. He made housecalls with his large black medical bag to our home and I decided about age 8 to become a doctor. The first in our family tree. With the help of a scholarship I was able to attend Yale College. Scholarship recipients were obliged to have a job at the university and I was assigned to shelve books and perform other mundane tasks at the Historical Medical Library at the medical school. The elegant oak-paneled environment contained, among others, the large historical collections of Harvey Cushing and John Farquhar Fulton, and I must admit that I spent much of my assigned time deep in the stacks reading these treasures rather than shelving them. I was particularly attracted to stories of contagion and infectious diseases. Actually, I am certain that the librarians were quite aware and were indulgent of this young pre-medical student. An appreciation of medical history remains with me to this day. Although I was focused on attending medical school, a professor of German literature suggested that I apply for a Fulbright Fellowship and so I postponed my entry into medical school when I received notice of the award which sent me to the Albert-Ludwigs University in Freiburg, Germany for a year.

Cornell University Medical College in New York City provided a wonderful milieu for students, permitting them to explore their own interests, particularly in research. I had had no previous research experience, but, once again, an opportunity presented itself. B.H. Kean, a vivid tropical medicine specialist, was recruiting students to work on a project in Mexico City during the two-month summer hiatus and I talked myself into a job. Thus began a series of research projects that extended throughout my time in medical school. The most memorable was a double-blind trial of two non-absorbable antibiotics to prevent diarrhea among travelers to Mexico. The two antibiotics and a placebo had been formulated by a pharmacy in New York into identical—appearing large pink capsules. The coded bottles into which they were to be placed were, however, in Mexico, so we had to get the study drugs into that country. No formal arrangement with the Mexican customs authorities had been made and we had three very large transparent plastic bags, each filled with vivid pink capsules to get to Mexico City. It was decided to transport the study drugs into Mexico “informally”, that is, hidden in the team leader’s (my) suitcase covered by my assorted clothes. The deception was successful and to this day, I claim to be the only person who has smuggled drugs across the US-Mexican border in a north-to-south direction. The research project also was successful and resulted in my first contribution to the medical literature. These experiences ignited my interest in research, particularly in applying methods of disease prevention to populations.

How did you become an expert on epidemics?

I just had completed two years of an internal medicine residency as well as two years of clinical and research training in infectious diseases at Vanderbilt University Medical Center. Now it was time to fulfill my national service obligation (Selective Service—“the draft”) that all young men had back in the 1960s. Because of my interest in infectious diseases, it had been suggested that, rather than serving in the Army, I apply for a Commission in the US Public Health Service. To my delight and considerable surprise I was accepted and I reported for training and further assignment to the Communicable Disease Center in Atlanta (now the Centers for Disease Control and Prevention—CDC) as a newly minted Epidemic Intelligence Service (EIS) Officer. Under the stern guidance of Alexander Langmuir, CDC’s chief epidemiologist, each cadre of novice EIS Officers was immersed in the principles and practice of investigative field epidemiology which transformed clinicians such as myself who had heretofore focused on the illnesses of single patients into public health physicians who worked to ensure the health of entire communities. The six-week instruction period was both demanding and inspiring. It instilled an esprit de corps; and at the completion of our training we were eager to undertake our new roles as “disease detectives” in our duty assignments. Mine was to be at the state health department in Rhode Island. Which is where I encountered measles and measles vaccine. Through our work there proof of principle was established: comprehensive measles immunization could create solid population immunity over a substantial geographic area and the results gave further impetus to the national goal of measles elimination. Thus it was that an internist who had been trained in the treatment of individual bacterial illness became fascinated with the population-based prevention of a pediatric viral infection. I determined that I would continue my association with public health and specifically with the implementation of vaccines on my return to Vanderbilt where an invitation to join the faculty awaited me.

How have you been involved with the Tennessee Department of Health?

Returning to Vanderbilt after my rewarding experience as an EIS Officer, I was determined to continue my interest in public health and vaccine-preventable diseases so I pursued a consultative role with the Tennessee Department of Health. This was an atypical ambition for a young faculty member, but over time both institutions have been generously supportive and the relationship has resulted in productive collaborations in teaching and research. To this mix should be added a third institution, the CDC, which assigned young EIS Officers to the Tennessee Department of Health where I became a co-supervisor of their investigations.

Tell us about your involvement with The Elephant Sanctuary:

Who would have ever thought that there would be 2700 acres in Hohenwald, Tennessee devoted to being a sanctuary for elephants? It is a refuge for old, abused, unwanted or ill elephants who come from the circus, zoos or even private owners. My wife took me to a meeting about the elephant sanctuary years ago and I was drawn in and now I am a member of the Board. We have accepted some 25 or so elephants through the years. One of the things that I have learned from these elephants is that they are susceptible to acquiring tuberculosis from humans. This has been an area where I have been able to contribute to understanding the spread of this disease among elephants. It has been an unexpected joy to be a part of this organization.


How has your experience prepared you for the times that we face today with COVID19?

I have spent virtually my whole career with one foot in clinical medicine in academia and the other foot in public health. I've had a very long association (over 40 years) with the TN Department of Health and the CDC. Much of my academic work involves public health and communicable disease control. I have assisted public health in investigating many outbreaks of communicable diseases.

Please share your thoughts on COVID19 where we stand today:

There isn't any doubt that this is a pandemic, and it is a pandemic that rivals any others that I have seen... Hong Kong Flu, Swine Flu, and Zika. It also has overtones of HIV when it first burst onto the scene because it has caused so much anxiety. The spread of HIV, while not as rapid as COVID19, certainly became a worldwide phenomenon. COVID19 has evoked a similar level of anxiety because initially very little was known about how it was transmitted. COVID19 has had a greater impact on the entire society than anything that I have experienced in the past.

Is there anything we can compare it to historically?

There is a temptation to go back to 1918, the most enormous influenza pandemic that the world has ever experienced. I certainly hope that COVID19 doesn't reach anything near that magnitude, but given international travel, the rapidity with which this virus has spread to virtually all the continents of the world is just stunning.

As a leading Epidemiologist, what are your concerns about COVID19 for the future?

I have a whole assessment of concerns. One is the public health concern. How widely is it spreading & will COVID19 return again next Fall? That assumes that we are going to get some reduction in transmission during the Summer as we have with other respiratory illnesses. What will be the eventual penetrance of the virus in our population? Another concern is the management of the large number of very ill patients that are coming to hospitals all across the country and indeed around the world. How many patients are we going to lose? That is just very very sobering.

Where are we in the "curve"?

The pandemic is taking various forms in different countries. Here in the US (as of the interview April 3) COVID19 has moved past the beginning and has reached what I would think is the middle phase where it is on the upsweep in many metropolitan cities in the US and it is moving out into the suburbs and into the rural areas. So it is still on the rise here.

Can we trust the numbers?

It depends on what you are counting. The best number we have at present is the number of patients admitted into the hospital with laboratory confirmed COVID19 infection. When that number begins to come down that will make us all smile.

What concerns do you have for the medical professionals dealing with this illness?

I am clearly concerned for the welfare of the healthcare team because COVID19 is the sort of infection that can be readily acquired during the course of providing medical care. We hope that everyone will have available all the necessary personal protective equipment so that they can use it appropriately. I would suggest that medical providers slow down, use their protective equipment appropriately, use hand hygiene at all times and take care of themselves.

What do you think are some of the biggest lessons we learn from this pandemic?

The first lesson is one we should have already learned from the past. Most of us in public health and infectious diseases would put at the top of the list- clear, honest, sustained communication. It is imperative for informing both the general population as well as health care providers. When the messages become confused, uncertainty and anxiety increase among providers and the public and they lose confidence in governmental public health.

The second lesson is that we need strong national leadership... probably a special unit with someone in charge to coordinate all the national governmental organizations as well as to reach out and coordinate the private sector. We have had precedence from hurricane Katrina as well as when Ebola threatened the US. When you have that kind of firm organized leadership, things work better.

Another lesson we should learn is that we can't keep cutting the budgets of our public health agencies. The world is not as large as it used to be. When a new infectious agent arises in a far-away place that many of us think of as exotic (such as central China), it can be here within a matter of days or weeks, and can cause much illness here. So we need to be aware of what is going on throughout the world. In order to do that we need a strong federal health agency, strong state health departments and strong local public health departments. Budget cuts to health departments have been happening for years. We need to restore some of the strength of our public health infrastructure in this country. That will enable us to do better pandemic preparedness. COVID19 was an emerging infection. There will be other emerging infections. What we can't tell you is which infection it will be, where it will originate or when it will occur... but we can promise you that there will be other emerging infectious diseases. We need to be better prepared for them than we are now.

How well do you think the hospitals in the US are prepared.

The short answer is- somewhat. Every hospital in America has a pandemic preparedness plan. It is usually in several stages (small problem- medium problem- big problem). All of these have been rehearsed. That certainly is the case here at Vanderbilt. That gave every institution a head start, but the nature of the COVID19 demand is such that it has nonetheless stressed hospitals and the entire system of medical care.

Given your expertise, what specifically do you want physicians on the front lines of COVID19 to know?

What I would like them to know is what they already know... that your next patient, even though they do not complain about any respiratory symptoms, could have this viral infection. So please, on every occasion take appropriate infection control precautions so that you spare yourself, your family, and everyone else on your team. We need you to help take care of patients, so please take care of yourselves.

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