The Babies Are Dying
by Marcus A. Horwitz, MD; Carole Novick; and Lloyd F. Novick, MD, MPH
Dr. Marcus A. Horwitz, newly minted EIS (Epidemic Intelligence Service) officer, had been at his post in the Bacterial Diseases Division at CDC for barely 3 months when he got the call to investigate three infant deaths reported at a rural West Virginia hospital. It was only his second assignment and he thought he was a curious choice. Normal protocol would have assigned someone from the Hospital Infections Branch, not someone who was assigned to the Enteric Diseases Branch that focused primarily on food borne illnesses. But he did not question the command further. He went home to pack, not really knowing how long he would be away. He flew from his home base in Atlanta to West Virginia, rented a car and drove straight to Elkins, took a room at a small motel within walking distance of the hospital and set about to find out why the babies were dying.
It was September 17, 1974, when Herbert L. Eckert, MD, made the first call to the Hospital Infections Branch of CDC. Eckert was an associate professor of pediatrics and community medicine at the University Hospital in Morgantown, West Virginia. The Medical Center had treated 5 infants with necrotizing enterocolitis (NEC) during the past 3 months and Eckert wanted to obtain information about the possible etiologic role of Escherichia coli in NEC in neonates since this organism had been grown from the blood or peritoneum of all 5 cases. (1)(2) Four of these cases had been referred from a rural hospital 70 miles from the medical center in Elkins, WV. The infants presented with abdominal distension and apparent peritonitis 18-36 hours after birth. Three of the infants had free air in the abdominal cavity but none had a recognized site of bowel perforation. Three of the infants had died. (1) (See Table 1 for Chronology of Outbreak.)
In response to Dr. Eckert’s call, Dr. Allen Steere of the CDC Hospital Infections Branch called the Chair of Pediatrics at West Virginia University Medical Center to discuss the cases. Pneumotosis intestinalis, a characteristic of NEC, was not evident in any of the infants. CDC did not investigate the outbreak at that time, but requested a call if any more cases occurred. (2)
Between October 3 and 8th, 5 additional cases occurred in neonates from the same small hospital in Elkins, all in critical condition. This prompted a call on October 9, 1974, by N.H. Dyer, MD, Director of Health for the West Virginia State Department of Health to John V. Bennett, MD, Director, Bacterial Diseases Division, Bureau of Epidemiology at CDC. He asked CDC to participate in an investigation of the outbreak. And Marcus A. Horwitz, MD, assigned to the Enteric Diseases Branch, Bacterial Diseases Division, Bureau of Epidemiology of CDC departed for Elkins on October 10, 1974. (1) (2)
The outbreak occurred in the small town of Elkins in northern West Virginia. Founders of the town were involved with coal mining and timbering businesses and developed railroad lines. At the time of the outbreak, there was a population of 8,800. The community had two hospitals including a private hospital, Memorial General Hospital, where the outbreak occurred, and a second hospital, Davis Memorial, one-quarter mile distant. The private institution was the main referral hospital for the surrounding population of about 100,000 people.
The nursery at Memorial General had closed by the time Horwitz arrived due to the mysterious infant deaths. Expectant mothers and newborn infants were all referred to Davis Memorial. Townspeople referred to the cause of the deaths as the “mysterious disease,” local doctors dubbed it “spontaneous pneumoperitoneum” and tentatively diagnosed it as necrotizing enterocolitis (NEC). (2)
On October 11, 1974, the front page of the Intermountain News contained the headline “Mysterious Disease Sweeps Nursery… Stricken Babies Die in Recent Months.” (3) The article describes experts from the CDC arriving in an attempt to help local and state medical authorities track down a rare mysterious disease “spontaneous pneumoperitoneum.” The article disclosed that 3 of the stricken infants were rushed to the West Virginia University Medical Center. “Hospital authorities declined to comment on the prognosis for the infants due to the lack of knowledge about the illness which has infiltrated the hospital nursery.” (3) Obstetricians at Memorial General obtained emergency admitting privileges at Davis Memorial.
On Oct. 12, 1974, the InterMountain News front-page story on the outbreak ran under the headline: “Davis Memorial Takes Steps to Prevent Newborn Disease; Community Problem.” Among other measures, the administrator of the hospital announced that “absolutely nobody except the fathers” would be allowed to visit mothers of newborn infants. Fathers were allowed to view the babies in the newborn nursery but not to touch them. Physicians from Memorial General Hospital were not allowed to deliver babies at Davis Memorial until they were cultured and cleared as non-contagious. (4) Pediatricians from Memorial General were allowed to supervise the care of infants at Davis Memorial. Fathers were not allowed to hold their babies in the nursery. All linen from Davis Memorial, normally sent to Memorial General for laundering, was now sent to another hospital 25 miles distant. The administrator of Davis Memorial remarked, “Most of the mothers are taking this thing very calmly. They realize we are watching all newborn babies very very closely…” (4)
When Horwitz arrived in Elkins the community was well aware of the “mysterious disease.” He made his way to Memorial General Hospital where the infants had been born and their conditions diagnosed and met with the hospital administrator and the head nurse. The head nurse was to become a vital partner in the investigation. Horwitz remembers that everyone was very accommodating to him, although the sadness over the unexplained deaths was palpable.
Much of his work centered on a review of hospital records. His motel room became a de facto office, and he spent long hours poring over the data. He found that 9 cases of NEC occurred between June 16, 1974, and October 9, 1974. All were newborns, one premature and the others not, with an onset of vomiting and rapid abdominal distension, 18-48 hours after birth. Three infants were asymptomatic. In all 9, radiography showed the presence of free air under the diaphragm. Eight of the 9 underwent surgery and were found to have exudative fluid in the abdomen. Only 1 had a gangrenous infection of the bowel. As previously stated, 3 of the infants died. Notably of the last 7 infants born at the hospital, 5 had this syndrome. (5) Pneumoperitoneum or abnormal presence of air in the abdominal cavity in the newborn is uncommon and usually sporadic. Until this time, Horwitz found that no similar outbreaks had ever been reported. (6)
About 30 infants a month were born at Memorial General Hospital, where the outbreak occurred. The first 2 cases occurred sporadically: 1 in June and 1 in July. The next 2 were in infants born consecutively in early September. Then 5 of 7 babies born between October 3 and 8 became ill with the same syndrome. Seven of the infants were transferred for treatment to West Virginia Medical Center in Morgantown. The deaths occurred in the second, third and fourth infants.
After the 5 new cases occurred at Memorial General Hospital, the nursery was immediately closed and patients were sent to another hospital in the community less than a mile away, Davis Memorial. No cases of NEC were reported from Davis Memorial Hospital.
In the first few days of the investigation, Horwitz focused on establishing the clinical syndrome and identifying additional cases. His initial investigation revealed that the syndrome was not consistent with NEC but was consistent with bowel perforation.
In establishing the clinical syndrome, he noted that all 9 ill infants had similar clinical courses. All but 1 were full-term and all were in good condition in the first hours of life. Then, unexpectedly, they fell ill. The first signs of illness were noted from 17 to 77 hours after birth. The illness was characterized by abdominal distension, peritonitis, Escherichia coli sepsis, and, in 8 of 9 infants, pneumoperitoneum. An outbreak of pneumoperitoneum had never been reported before.
E. coli organisms with different serotypes and antibiograms were cultured from the peritoneum of 7 infants and the blood or peritoneum of all 9. The isolates were neither enterotoxigenic nor invasive. This indicated that a new pathogen was unlikely to be the source of the outbreak. In all 5 infants who underwent surgery, physicians found abdominal exudates, but no evidence of gastrointestinal perforation. The autopsy findings on the 1 autopsied infant were nonspecific; there was no report on the condition of the rectum or recto sigmoid.
After reviewing the evidence, the first surprise of the outbreak investigation was revealed: the presumptive diagnosis of NEC did not hold up. Why did Horwitz come to that conclusion? NEC is mostly found in infants born premature; however, aside from the first case, all of the infants were full-term and healthy at birth. The onset of NEC is typically gradual, but these infants became ill very rapidly. They also lacked other signs of NEC, such as pneumotosis intestinalis (gas cysts in the bowel wall), and the 5 infants that had surgery lacked segmental bowel necrosis and bowel discoloration. Hence the syndrome was not consistent with NEC by epidemiologic, radiologic, and clinical criteria.
The symptoms were consistent with a rare syndrome, bowel perforation. Consistent with this diagnosis, the infants were initially well and then suddenly became ill, usually in the first day of life. They also had the characteristic findings of abdominal distension and peritonitis. Not surprisingly, in the 5 infants who went to surgery, abdominal exudates were observed, but no bowel perforations were identified – these can be difficult to detect. The presence of rectal perforation was not specifically investigated.
With respect to case finding, Horwitz defined a case as 1) abdominal distension and 2) peritonitis or pneumoperitoneum. To compile the clinical data, he reviewed the following: 1) Memorial General Hospital’s charts, newborn and nursery records, x-rays and laboratory records on the 9 cases; 2) University Medical Center’s hospital records on the 7 infants transferred there; 3) interviews of the nurses, pediatricians and surgeons who had attended these infants and 4) examination of the results of the 1 autopsy performed. To search for additional cases, Horwitz reviewed the charts of all infants born at Memorial General Hospital between May 1 and October 9, 1974. This exhaustive review of the hospital records identified no new cases during the outbreak period. (6)
Case Control Studies
Horwitz then undertook case control studies to examine the host and therapeutic variables and to determine if there was any association of the illnesses with personnel. He needed to determine if any of the ill infants had any characteristics that distinguished them from other neonates born at about the same time. He believed a case control study was the best method to determine this.
Horwitz made comparisons for a multitude of host and therapeutic variables covering all phases of infant hospitalization. The 9 cases were compared with 19 infants born within 1 week of the cases. He found no statistically significant differences in a large number of host and infant variables such as parents’ ethnicity, number of vaginal exams in labor, duration of total labor and its stages, infant weight, and Apgar score.
Association of Illness with Personnel
He then looked for an association between an employee and ill infants by assessing the exposures of ill infants and controls to labor and delivery room personnel, pediatricians, and the nursing staff. He did this by assessing the number of ill infants and controls exposed or not exposed to labor and delivery room personnel, pediatricians and the 20 nursing staff assigned to the OB-GYN floor. (6) Horwitz compared 3 different time periods for the infants’ stay in the nursery, examining the total duration; the first 3 shifts in the nursery; and the last 3 shifts before illness.
Eleven nursing employees had attended at least 1 of the 9 infants. However, only 2 of the 11, Employees 1 and 3, both nurses’ aides, had attended more than 3 of the 9 ill infants: Employee 1 had attended 8 while Employee 3 had attended all 9. When the exposure of all 9 infants and controls to nursing employees was compared, only the association with Employee 3 was statistically significant, (p = 0.033).
The Eureka Moment
This was a very intensive outbreak investigation, and Horwitz worked around the clock on it for weeks, so it was not unusual for him to be up most of the night working on it.It was 3 am and Horwitz was just about to turn in when the critical answer to the mystery hit him. When he undertook the case control studies, he uncovered a preliminary association between Employee 3 and the 9 ill infants, but he was not really expecting it to amount to anything significant. However, as all the data swirled together, he suddenly realized that the association was very significant. Horwitz still recalls his surprise and fright when this association flashed concretely through his mind: there had to be a direct cause and effect connection between Employee 3 and the 9 ill infants.
He recognized the potential legal implications of his suspicions and knew he had to make an extensive effort to further evaluate and confirm the association of Employee 3 to the mysterious disease. He telephoned Dr. John V. Bennett, Director, Bacterial Diseases Division, CDC to alert him of the new findings and to strategize. A new control group was selected consisting of 20 infants selected randomly from among all 122 well infants born in the hospital during the span of the outbreak. Employee 3’s association with the mysterious illness became even stronger with further analysis. For example, she was the only employee significantly associated with ill infants during the entire time period that they were in the hospital, and the odds of her association occurring by chance were 3 in 100. He looked at exposure of ill infants to personnel only during the first 3 shifts the babies were in the nursery and found that Employee 3’s association with ill infants was very high; the odds that her association during this period occurred by chance was less than 1 in 10,000. Similarly, when exposure of ill infants to personnel only during the last 3 shifts the babies were in the nursery was considered (for control infants, 3 randomly selected consecutive shifts were used for this comparison), her association was also very strong – the odds of her association occurring by chance were only 2 in 1000. (6)
The fact that Employee 3 had worked at the hospital for only a short time but one spanning the entire outbreak, and that Employee 3 did not work as often as many of the other employees but was nevertheless associated with illnesses lent credence to the finding, as did the finding of a negative association with an employee that worked the same shift as Employee 3 but on different days.
Since Employee 1 was associated with 8 of the 9 infants, Horwitz undertook another case-control study using a more comprehensive comparison between Employee 1 and Employee 3, this time using as the control group all 122 of the well infants. He found that Employee 1, who had worked at the hospital for many years, was not significantly associated with illness while Employee 3 was strongly associated. (6)
Since the illnesses occurred in the infants so rapidly after birth, it was postulated that the incubation period was short. Horwitz further reasoned that if the first exposure to a nursing employee was highly associated with an illness that had a short incubation, then there should be a relationship between the time the infants were first exposed to the employee and the time they became ill. The later an infant was exposed to the associated employee, the later the illness would be expected to begin. The data showed a striking temporal relationship to the presence of Employee 3. There was no relationship between the temporal exposure of Employee 1 and time of onset of infant illness. (6)
The Baby Doll Exercise
Finding a strong epidemiologic association between Employee 3 and an illness clinically compatible with gastrointestinal perforation prompted an investigation of hospital practices that might have led to bowel perforation. No nasogastric suction, gavage feedings, or therapeutic or diagnostic enemas were administered to any of the 9 ill infants. However, rectal temperatures were routinely taken in the nursery each shift. This was the only practice identified that was possibly linked to bowel perforation. This led to the potential etiologic role of rectal thermometers.
The realization that rectal thermometer use was routine in the nursery and was a potential cause of the outbreak prompted an effort to seek more information on how the thermometers were used. Since the nursery had been closed, Horwitz could not observe nursing procedures under normal conditions.
He discussed his suspicions with the head nurse and together they developed a way to observe the nurses. She remembered that her daughter had an anatomically correct doll that she played with constantly. It was sold commercially as Baby Alive®. Hence, each nurse and aide on the OB-GYN service was asked to take part in a general examination of nursing skills using a life-like baby doll that had a gastrointestinal tract complete with anus. The doll was purchased by the head nurse and Horwitz reimbursed her for the cost: $12.36.
The examination was sprung on the staff by surprise and conducted in such a way that there was essentially no opportunity for a staff member to inform another staff member about it in advance of taking the test. Each nursing employee was instructed to admit the newborn in her usual fashion which meant scrubbing and weighing the baby, carrying and supporting her, tending to the umbilical cord and taking the rectal temperature. Horwitz and the head nurse were the observers.
While the employee took the doll’s rectal temperature, the length of the exposed part of the thermometer was measured and the depth of insertion calculated. At the end of the routine admitting procedure, the nursing employee was interrupted and she was told that the doctor had just walked in and said, “I think the baby is septic. Please get a reliable temperature right away.” In response to this request, all nursing personnel took another rectal temperature. Thus two readings were obtained on each employee. (6) Evidential photos were taken of each measurement.
Most employees took the temperature with the baby in the supine position but some took it with the baby prone or on its side. The depth of insertion of the rectal thermometer for 34 readings from the 17 nursing employees ranged from 0.8 to 5.9 cm. The median depth of insertion was 3.5 cm for all employees and 3.2 cm for the 6 nurses’ aides who regularly worked in the nursery.
Employee 3 registered the second and fourth highest depths of insertion. Her average depth of insertion, 5.4 cm, was second highest and was exceeded only by that of Employee 14, who had little contact with the nursery. Employee 1, on the other hand, tied for the second lowest average depth of insertion, and hers were the lowest of the 6 nurses’ aides who regularly worked in the nursery.
On completing her exercise, Employee 3 was asked to take 3 more rectal temperatures. The mean depth of insertion for her 5 readings was 5.8 cm, somewhat higher than the mean of her initial 2 readings.
Implication of the Exercise
Rectal thermometers should not be inserted further than 1 or 2 cm. The angulation of the colon is such that insertion to a depth of more than 3 cm makes the risk of perforation great. Employee 3 inserted the thermometer to nearly twice that depth. Moreover, she took temperatures with the doll in the supine position, which the literature suggests is more hazardous than the prone or side positions. The general consistency of the 2 measurements by any 1 employee and of the 5 measurements by Employee 3 suggested that the demonstrated depth of insertion was the result of habit rather than chance.
Recommendation that the 3 Deceased Infants Be Exhumed
The report on the outbreak investigation ended with a recommendation to exhume the bodies of the 3 infants who had died for an examination of their rectums for perforation. It was believed that this was the only potential approach to confirming the hypothesis that the cause of the outbreak was rectal perforation. For whatever reasons, the state health department rejected this recommendation.
Because rectal temperature taking may be hazardous, many authors consider it an ill-advised procedure. Fifteen cases of rectal perforation had at the time been reported in the world literature with a fatality rate of 47% due to thermometers. (6) If rectal temperatures are taken at all, the maximum depths of insertion into the rectum of the thermometers should be less than 3 cm to avoid rectal perforation. The CDC report on this outbreak agreed with those that advocate axillary temperature taking under routine procedures. (1)
Horwitz and Bennett in their report of November 18, 1974, did conclude that the most likely diagnosis of the outbreak at Memorial General Hospital was perforation of the distal gastrointestinal tract. The etiologic hypothesis was that the mechanism of perforation was taking of temperatures with rectal thermometers. Horwitz and his colleagues at CDC thought that the most likely and perhaps only way to directly confirm this strongly suspected etiology would be exhumation of the 3 deceased infants and their examination by a pediatric pathologist for evidence of perforation. Horwitz and Bennett’s report recommended that the exhumations and autopsies be done without delay. It was felt that without this step, the safety of the nursery, at that time closed, if reopened could not be established. “Nor is it possible to fairly and responsibly establish the basis for Employee 3’s strong association with the illness.”(1).
Everyone who looked carefully at this outbreak, including the physicians at Memorial General Hospital and Davis Memorial Hospital, with one possible exception, accepted the hypothesis that the cause of the outbreak was rectal perforation following insertion of rectal thermometers. The exception was Dr. William Cook, from the disease control branch of the West Virginia Health Department. Dr. Cook found that Dr. Horwitz’s report was inconclusive and thought the thermometer hypothesis unlikely; he did not recommend autopsies because he did not think they would yield conclusive evidence. (7)
Acceptance of the Horwitz hypothesis was firm enough that the nursery reopened on November 22, 1974, with temperatures being taken by the axillary route; rectal temperatures were reserved for very special situations. The employment of Employee 3 was terminated by Memorial General Hospital effectively before the nursery reopened but officially not until May 1, 1975. In February, an arbitration hearing was held to settle the dispute between Memorial General Hospital and the union representing Employee 3. The grievance by the employee was denied on October 28, 1976, when the arbitrator ruled in favor of the hospital. (2)
The attorney for Memorial General Hospital stated that he expected settlements would be reached out of court between the hospital and the parents of the 3 deceased infants. The parents of 1 deceased child filed an additional lawsuit. The mother had a tubal ligation after giving birth but before the infant fell ill, and the hospital was sued for her loss in ability to give birth subsequently. A summary judgment in favor of Memorial General Hospital was rendered on October 23, 1980. (2)
Grand Jury Convened
On October 26, 1974, Dr. David Sencer, Director of CDC, notified Dr. N.H. Dyer, Director, West Virginia Department of Health, of the conclusions of the Horwitz report. He strongly urged that the 3 deceased infants be exhumed. In November, the head of Memorial General Hospital and the chair of a committee formed by the hospital Board of Directors to oversee matters related to the outbreak, both concurred that the deceased infants should be exhumed and examined.
But in February a phone conversation with the county prosecuting attorney revealed that although the attorney had initially favored exhumation of the bodies, he subsequently decided to let a Grand Jury decide whether to do so. This effectively changed the intent of the exhumation from confirming the hypothesis of rectal perforation to finding sufficient evidence to convict someone of the deaths. The prosecuting attorney was concerned that even if the autopsy showed perforation, he was not certain that he could satisfy a jury “That a wanton and gross act had occurred.” (2)
On February 26, 1975, the Intermountain News had a front-page story with the headline “Homicide Eyed in Baby Deaths.” Plans were to place the evidence before the Grand Jury in April. The prosecuting attorney pointed out that homicide does not necessarily mean felonious homicide. Quoting Black’s Law Dictionary “The term homicide is neutral; while it describes an act it pronounces no judgment, no moral and legal quality.” (6) Further he stated that there were no plans for exhumation.
The father of the first baby to die commented that he wanted some kind of reasonable explanation of why his baby had died. (8) The director of Memorial General Hospital pledged cooperation in the baby deaths’ inquiry but remarked that neither the hospital nor CDC had the authority to order an exhumation. On March 1, 1975, the county sheriff served a “gag order” in reference to the criminal investigation of the infant deaths. This order was approved by a county judge. This pertained to the release of information by any of the grand jurors or dissemination of documents. (9) The purpose of the order was to protect the rights of any defendant in the case. An editorial in the Intermountain News, “The Public’s Right to Know” was published on March 3, 1975, recounting the newspapers role in bringing facts to the public about the deaths of the 3 infants. The editorial stated that they were not upset by the court order, understanding the judicial process and not wishing to prejudice the judicial proceeding. At the same time, the editorial emphasized the role of the free press and plans to continue to pursue the story. (10)
At the conclusion of the hearing, the prosecuting attorney informed Horwitz and the others who testified “that the Grand Jury has decided not to hand down any indictments in this case and not to ask for exhumation of the 3 deceased infants.” (2)
What are the current recommendations for obtaining temperatures of neonates? The American Academy of Pediatrics recommends rectal thermometers as the gold standard for children under 3. Parents are advised to gently insert the lubricated end only 1-half to 1 inch just past the anal sphincter. However, in 2017, axillary thermometry was found to have outperformed rectal thermometry in 205 newborns aged 12-72 hours in a study conducted at the University of North Carolina at Chapel Hill. (10)
The Langmuir Prize
On April 21, 1976, Dr. Marcus A. Horwitz, Epidemic Intelligence Service (EIS 1974) received the Annual Alexander D. Langmuir Prize Manuscript Award in recognition of his investigation and the scientific article he first-authored documenting the events, which was subsequently published. Horwitz was selected, according Paul Wehrle (EIS 1951), because of the article’s great significance heralding epidemiology of the future, which would often be in a hospital setting. (25) The prize consisted of a $100 cash award, a case of Watney’s ale, a desk plaque and an inscription on the permanent plague at CDC. (11)
Why Watney’s Ale you might ask? Watney’s has been made by a leading London brewery since 1837. In 1854, a cholera epidemic struck London and was investigated by Dr. John Snow, father of epidemiology. Many were affected in the area of the Broad Street pump save those employed by a local brewery. Later Watney’s Ale was served at the John Snow Pub in London. The famous pump from which Dr. Snow removed the handle stood next to the pub on what was then the corner of Broad Street and Cambridge, streets now renamed Broadwick and Lexington. CDC adopted the bottle of Watney’s Ale as a symbol of epidemiology along with the shoe sole with a hole in it where the ball of the foot would be (shoe leather epidemiology). The plaque for the Langmuir Prize depicts the shoe sole with the hole in it.
1. Public Health Service-CDC EPI-75-52-2, November 18, 1974. 2. Personal communication. Dr. Marcus Horwitz, “How the Story Started 2/28/19. 3. “Mysterious Disease Sweeps Nursery at Memorial General; 3 Stricken Babies Die in Recent Months” The Inter-Mountain News, October 11, 1974. 4. “Davis Memorial Takes Steps to Prevent Newborn Disease; Community Problem” The Inter-Mountain News, October 12, 1974. 5. Public Health Service-CDC EPI-75-52-1, October 10, 1974. 6. Horwitz, MA, Bennett, JV, “Nursery Outbreak of Peritonitis with Pneumoperitoneum Probably Caused By Thermometer-Induced Rectal Perforation. American Journal of Epidemiology, 104:6, 632-644. 7. Transcript of News Report from WVU TV, December 4, 1975. 8. “MG Pledges Cooperation in Baby Deaths Inquiry” The Inter-Mountain News, February 28, 1975. 9. “Gag Order Served in Baby Deaths Case” The Inter-Mountain News, February 15, 1975. 10. “Axillary thermometry is the best choice for newborns” Pediatric News, August 24, 2017. 11. “Horwitz Lands Langmuir Prize”, Memo, Department of Health Education and Welfare, Center for Disease Control, April 21, 1976.
- The method of analysis for the etiologic agent was the case-control study. Comment on the suitability of this type of epidemiologic study. What are the advantages and limitations of a case-control study?
- Was the cause of the outbreak established? Guidelines for judging whether an association is causal include (a) temporal relationship; (b) strength of the association; (c) dose-response relationship; (d) replication of the findings; (e) biologic plausibility; (f) consideration of alternate explanations; (g) cessation of exposure; (h) consistency with other knowledge; and (i) specificity of the association (34). List those causal factors that were identified in this investigation.
- Comment on the different intent of the CDC and the prosecuting attorney in this case. What were their respective objectives?
- The CDC and the hospital recommended exhumation. The County Prosecuting Attorney decided against exhumation. What would your recommendation have been? Please describe the advantages and disadvantages of exhumation.
- What recommendations will you make in training personnel to avoid these types of misadventures?
ABOUT THE AUTHORS
Marcus A. Horwitz, MD, is a professor of Medicine and Microbiology, Immunology & Molecular Genetics at UCLA School of Medicine. At the time of this case, he served as an Epidemic Intelligence Officer (EIS) for the Centers for Disease Control and Prevention.
Carole Novick is an editor and writer residing in Stamford, Connecticut. She was associate vice chancellor for Health Sciences Development and Alumni at East Carolina University from 2005 to 2011.
Lloyd F. Novick, MD, MPH, is the Founding Editor and Editor-in-Chief of the Journal of Public Health Management and Practice. He is also editor of five books, including Public Health Administration: Principles for Population-Based Management; Public Health Issues in DisasterPreparedness; Community-Based Prevention Programs that Work; Public Health Leaders Tell Their Stories; and Health Problems in the Prison Setting. [Full bio]
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