Face to Face
Figures Head
By Kate Ledger
As the state epidemiologist, Ruth Lynfield is the chief head counter when it comes to infectious disease outbreaks.
When a patient appeared at a clinic last spring in Slayton, Minnesota, showing the early flulike symptoms of hepatitis A, local health care workers didn’t know whether they were looking at an isolated case or the beginning of an outbreak. The picture emerged quickly, when they learned the man worked at a popular pizza restaurant. Because the liver-inflaming disease spreads swiftly by way of contaminated food, the single case suddenly presented a potential widespread threat.
Concern rippled through the western Minnesota towns near Slayton, but the events that unfolded the following week were reassuring to Ruth Lynfield, M.D., who was, at the time, acting state epidemiologist and medical director of infectious disease at the Minnesota Department of Health. In July, she was named officially to the post, where she continues to be responsible for managing the response to outbreaks of infectious disease and health emergencies.
When the call came in from Slayton on a Monday morning last April, community health officials and epidemiologists at the Minnesota Department of Health worked together to track down three additional cases of hepatitis A among food servers and a patron of the restaurant. The Department of Health ordered what Lynfield describes as “a massive shipment” of preventive immune globulin, enough for as many as 2,000 people who might have been exposed to the disease. By Friday, the township—using a plan established to respond to bioterrorism—set up two makeshift clinics and began giving shots.
In tracking communicable infections that strike the population, disease surveillance is the name of the game, and Lynfield’s job—an influential position in a health department that’s long stood out as a leader—is to keep tabs on the numbers. One fulminant, unexpected death in a healthy young man who just had knee surgery may signal donor-tissue contamination. Two infants from the same child care center turning up with a rare joint-inflaming bacterial infection may be the first sign of an emerging outbreak. Four cases of hepatitis A associated with eating or working at a restaurant may mean more will follow. Whether about disease borne by ticks and mosquitoes or passed through contaminated food, or about known scourges such as influenza or elusive ones, what an epidemiologist wants to know, Lynfield says, is whether the numbers are changing. Are they getting worse? Are they getting better?
Lynfield is quick to point out that charting the figures doesn’t itself have an effect on public health. “You can’t just take data,” she emphasizes. “You need to let people know what the data mean and use them to develop and assess prevention and control measures.” In fact, she takes seriously the role of communicator. She sees herself as the conduit between physicians who see patients and the federal agencies that track the course of disease nationally and internationally. Within the Department of Health, she orchestrates investigations, bringing in, for instance, a team to investigate why a group of workers suddenly developed acute severe respiratory symptoms at a sugar beet plant. And, when the public needs to know the risks associated with a disease outbreak and the steps that need to be taken to control it, she partners with the media to help convey that information without causing a scare.
“It’s a position of great consequence,” says Michael Osterholm, Ph.D., M.P.H., director of the Center for Infectious Disease Research and Policy at the University of Minnesota. Osterholm hired Lynfield when he was state epidemiologist from 1984 to 1999. “What gets counted gets acted upon, and what the state epidemiologist does impacts our lives daily.”
The Gumshoe Epidemiologist
For Lynfield, the fields of infectious disease and public health were always intertwined. She first became intrigued by the topics as a student at Cornell University Medical College. A native of New York and the daughter of two physicians, she spent a summer at a rural outpost in Brazil studying ways the parasitic infection leishmaniasis was transmitted. “It was real gumshoe epidemiology,” she recalls. In addition to Portuguese, she says, “I learned basic [public health] skills.” Going house to house, conducting surveys to count people with the disfiguring skin lesions associated with the disease, she was moved by the suffering she witnessed and compelled by the idea of intervening before people were infected. “What was clear was the importance of trying to understand the risk factors associated with the disease in order to prevent its occurrence,” she says. After a subsequent six-week stint at the Centers for Disease Control and Prevention (CDC), she knew her medical career would have a public health bent.
Specializing in pediatric infectious disease at Massachusetts General Hospital in Boston, Lynfield went on to practice there and teach at Harvard Medical School. “During those clinical years, I saw the damage that infectious diseases can do, and I really came to appreciate how profound it is to be able to develop and administer vaccines that can prevent some very severe diseases,” she says. Even as she rounded in the hospital, she kept a foot in epidemiology, working in the Massachusetts State Laboratory as the assistant director of the New England Newborn Screening Program, which tested infants for infections and congenital disorders. The research she did there led to a New England Journal of Medicine article in 1994 about the benefit of screening babies for congenital toxoplasmosis, a neurologically impairing disease that doesn’t often have obvious clinical signs at birth but can be stemmed with early treatment.
Then, in 1997, she and her husband Michael Sethna, M.D., a neurologist and Minnesota native, moved from Boston to Mendota Heights, when he was offered a job in a private practice. Lynfield’s reputation as a researcher and a public health advocate preceded her, and Osterholm quickly recruited her to the Department of Health. With three young children at home, she began working for the state part time in the emerging infections unit.
Ruth Lynfield at A Glance
Current position: State epidemiologist
Education: B.S., Cornell University, 1981
M.D., Cornell University Medical College, 1985
Internship and residency in pediatrics, Massachusetts General Hospital, 1985-1988
Fellowship in pediatric infectious diseases, Massachusetts General Hospital, 1988-1992
Leadership style: Lynfield has established herself as a leader who rolls up her sleeves and gets to work. She did so literally in 2000, when health care workers were offered the smallpox vaccine in an effort to protect the people who would be key responders in the event of a terrorism-related outbreak. Lynfield, then serving as medical director of the infectious disease division and supervisor of the emerging infections program, received hers in front of television cameras to set an example. “I felt it was important if we make recommendations that we do what we say,” she says.
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Right away, Lynfield made her mark investigating neonatal group B strep, a bacteria carried by 20 percent of pregnant women that can cause meningitis, blood stream infections, and pneumonia in newborns. Working with the CDC, Lynfield determined that screening women for the bacteria instead of waiting for the appearance of such risk factors as premature labor and fever during childbirth could cut down the incidence of disease. The work prompted the CDC in 2002 to revise guidelines for screening all women between weeks 35 and 37 of their pregnancies. Since then, Lynfield says, “early incidence of the disease in newborns has dropped.”
A Collaborator
At 46, Lynfield is petite with bright blue eyes and wavy, tousled hair that hangs past her shoulders. A fish-eating vegetarian who hikes and bikes, she has a casual, even artsy, demeanor. Her easy-going manner is a surprise, considering the life-or-death tension often involved in disease outbreaks. But it may well be part of what makes her successful, helping her to foster the relationships necessary to be effective in understanding and controlling disease. As she puts it, “Public health is a collaborative sport.”
She’s constantly mindful of the importance of building networks for effective disease control. “The better the networks,” Lynfield states, “the better the opportunities to solve problems.” In the case of SARS, she points out, “incredible collaborations” between the CDC, World Health Organization, and health officials in Hong Kong and Toronto enabled the public health community to identify the disease and contain it before it spread to more areas. But even during quieter crises, such connections are essential for getting a picture of what’s going on.
“When you have an outbreak of an unknown disease, you’re under a lot of pressure to find an answer quickly,” says Richard Danila, Ph.D., who was acting state epidemiologist after Osterholm moved on and is now deputy state epidemiologist. “Ruth is good at soliciting people’s scientific opinions and input, incorporating her own opinion, and gaining consensus.”
Four years ago, when a cluster of toddlers from a Minnesota day care center turned up infected with Kingella kingae, a bacteria that causes a joint-debilitating illness in isolated cases but was then unknown to present as a communicable disease, she consulted widely to figure out what was happening. Working with the CDC and an expert in Israel, interviewing parents and day care staff, and consulting with the state lab, which was asked to develop new assays to isolate and evaluate the unique bacterial strain, she led the epidemiology team to new understanding of the disease. Without delay, Lynfield gathered department members to craft new recommendations for managing the disease (advising that the children who were carrying the organism but not symptomatic also receive prophylactic treatment). The case was published in Pediatrics.
Such work has prompted public health experts to turn to Lynfield for assistance and advice. In 1997, Osterholm, who considers Lynfield “a superb researcher who also has the background of a clinician,” called on her to be the point person for Minnesota for the Active Bacterial Core surveillance (ABCs), a disease-tracking collaboration of the CDC and 10 areas in the United States. A joint academic and public health effort, ABCs has gathered information and isolates on life-threatening diseases such as meningococcal disease and multi-drug–resistant Streptococcus pneumoniae and helped assess treatment options. Minnesota is the only state in the Midwest represented.
Epidemiologist Henriette de Valk, at the Institut de Veille Sanitaire in Paris (the French version of the CDC), who knew of Lynfield’s wide-ranging publications, particularly those on invasive pneumococcal disease and listeriosis, has looked to Lynfield for practical advice about how to investigate unexplained infectious-disease–related deaths, including how to define such deaths, how to involve medical examiners and coroners in the investigations, and how to establish protocols for collecting and testing relevant specimens. When de Valk learned that Lynfield was co-editing a textbook, she was eager to get involved. Along with de Valk, Chris Van Beneden, M.D., M.P.H., of the CDC, and Nkuchia M’ikanatha, Ph.D., of the Pennsylvania Department of Health, Lynfield co-edited Infectious Disease Surveillance, the first on the topic. Published in October 2007 with more than 100 contributing authors, the book describes case studies such as the SARS epidemic and the West Nile outbreak in New York City in 1999 that killed seven people and details “lessons” epidemiologists learned from each of the incidents.
Perhaps most important, Lynfield has established strong relationships with local physicians. Since they’re the ones who see patients, they’re ultimately the key to effective disease surveillance. Even though physicians are required by state law to report cases of certain infectious diseases within one working day, “doctors are busy. They don’t get around to the paperwork,” says Greg Filice, M.D., head of the infectious disease section at the Veterans Affairs Medical Center in Minneapolis and a professor of medicine at the University of Minnesota. And clinicians’ attitudes toward a health department—whether they perceive the information will be put to good use—can interfere with their reporting.
To win physicians’ confidence and to connect them with the Department of Health, Lynfield faithfully attends the weekly Intercity Infectious Disease Conference that Filice hosts at the VA for Twin Cities-area physicians and fellows. She’s also presented on topics such as the adverse effects of the smallpox vaccine, preparing for SARS, pandemic influenza, and other public health threats. “It’s important to relay the data back to physicians to keep them informed about what we’ve learned,” she says. Those connections with physicians have expanded her network: “When I need input on guidelines or want to establish a working group, I can count on people from the ID community to help,” she says. And as for whether her Tuesday morning attendance improves disease-reporting, she says, “Absolutely. People pick up the phone and call me directly.”
Staying on Task
Lynfield will clearly need to use her people skills to set her strong-but-troubled department on a better course. She comes to her position on the wave of two very public and embattled resignations. Her predecessor, Harry Hull, M.D., made press for angry, threatening outbursts in the office and resigned in December. At the end of August, Health Commissioner Dianne Mandernach submitted her resignation to Gov. Tim Pawlenty following criticism that she’d withheld information about the cancer deaths of 35 miners.
For her part, Lynfield hasn’t let such departures steer her attention from her priority issues, one of which is the overuse of antibiotics. “Many infections are now resistant to first-line antibiotics,” she says. The challenge has been to get the word out to physicians and to the public to change how antibiotics are being used to treat viral infections. “The general public believed they got better with [antibiotics]. Clinicians thought they might prevent bacterial disease—antibiotics might not help, but they wouldn’t hurt. In fact, they did hurt,” she says.
In 1999, Lynfield headed a team at the Department of Health that developed a Minnesota “antibiogram,” a statewide look at antibiotic susceptibility. The information can help physicians select appropriate drugs for infections that are getting increasingly hard to treat. “Susceptibilities vary geographically, so it’s useful to have an idea about what’s going on in your area,” she notes. (She knows the list is being used because physicians call regularly to request the latest version.)
To help change prescribing patterns, she’s been part of an effort to provide physicians with ready responses for patients who pressure them for an unnecessary antibiotic prescription. “I’m hopeful clinicians will take a greater role if we give them tools they can use to sit with patients and say, ‘This is a reason why an antibiotic is not a good idea.’” And to compel the public to think differently about antibiotics, the department is working with child care centers to alter long-held policies that have required sick children to be on antibiotics in order to return to the facility. She’s also collaborating with other infectious disease experts to recommend minimizing antibiotic use in animals, which is contributing to the rise of resistant strains. “Antibiotics should be treated like a natural resource and used judiciously,” Lynfield states.
Perhaps her biggest challenge is making sure the state is prepared in the event of pandemic influenza or widespread bioterrorism—public health crises that could affect thousands. She’s working with hospitals, offering guidance about how to handle scores of sick patients when the beds become filled and what sort of medical equipment to stockpile. “We’re developing lists of health care providers who are retired who could come back if we need additional workers,” she says. She’s also working with local public health officials to determine how to provide medication to homebound individuals and how children who are dependent on meals at school would get food if the schools are forced to close. To the question, Are we ready? she responds: “With every day we’re getting more and more ready.”
During day-to-day operations at the collegiate-looking Freeman Building down the hill from the state Capitol in St. Paul, Lynfield seems to take each new problem she encounters in stride. Whether dealing with disaster preparations, antibiotic abuse, or a hepatitis outbreak, she views each twist and turn of her new job as an unfolding mystery. As she says, “I never know when I come to work what’s going to happen.” MM
Kate Ledger is a St. Louis Park freelance writer.