NIEHS Dual-Degree Predoctoral Fellowships for Training Clinician–Scientists

lic, and public sentiment that environmental causes are responsible and must be investigated is widely prevalent. More than a decade ago, the Centers for Disease Control and Prevention (CDC) recognized the need to develop operating procedures for response to public concern about disease clusters. The National Conference on Clustering of Health Events was held 15–16 February 1989 in Atlanta, Georgia; the proceedings were published (Rothenberg et al. 1990a); and the CDC released the “Guidelines for Investigating Clusters of Health Events” (CDC 1990) in which a four-stage process was presented: a) an initial response to gather source information, b) an assessment of the occurrence of the health event, c) a feasibility study, and d) an epidemiologic investigation. During the last 15 years, these guidelines have provided a framework that most state health departments have adopted, modifying it for their specific situations and available resources. The states have the primary responsibility for response to cancer cluster concerns within their domain. The CDC guidelines emphasize the need for health agencies to develop an approach that maintains community relations while responding to clusters efficiently; the approaches vary among states as well as according to the nature of the cluster and the availability of case and comparison data. The orientation of each state-based inquiry response and investigation plan is shaped by state philosophy and experience with previous clusters. The purpose of this article is not to revise the CDC guidelines; they retain their usefulness and validity. However, in the past 15 years, numerous cluster studies [Agency for Toxic Substances and Disease Registry (ATSDR) 2006; Cochise County Health Department (CCHD) 2005; Heath 2005; Massachusetts Department of Public Health (MDPH) 2005; National Cancer Institute (NCI) 2005; New Jersey Department of Health and Senior Services (NJDHSS) 2004; Rubin et al. 2007] as well as scientific and technologic developments have affected cluster science and response. Thus, we offer an addendum for use with the original document. Included in this list of significant developments are improvements in cancer registries, a federal initiative in environmental public health tracking (EPHT), refinement of biomarker technology, new cluster identification and geographic information systems (GIS) software, and the emergence of the Internet. These developments have shaped the approach of the CDC National Center for Environmental Health (NCEH) for public health response to cancer clusters.