Carnegie Reporter, Vol. 1, No. 4 | Preventing “Dark Winter”— The Public Health System’s Role in Strengthening National Security, page 4 (low bandwidth)

In the event of a bioterror attack, Stimson Center researchers Smithson and Levy reported, doctors would be unable to make a diagnosis in patients with vague, flu-like symptoms. Early detection would depend upon a doctor's suspicion followed up by laboratory diagnosis by technicians in the nation's 158,000 state and local public health and private laboratories. It helps if the labs have some idea of what they're looking for: few laboratory technicians have ever seen the organisms that might be used in bioterror attacks, and they may not be familiar with the tests to identify them. Furthermore, they may be overwhelmed by an enormous number of samples to test, as happened in the anthrax scare. There would be delays before the illness was identified, and during that time the bioterror disease would spread widely.

"A surveillance network is the key. We need nationwide reporting in real time," says microbiologist Nancy Connell, director of the Center for Biodefense at the University of Medicine and Dentistry of New Jersey, which is located a few miles from the postal center where the anthrax letters were mailed. She heads a university lab that could have helped in diagnosis but was not connected as a backup to the state's overwhelmed public health labs. "Bioterror moves so fast," she says. "In the first 12 hours you would be absolutely alone." Her lab has now made arrangements to link with the New Jersey Department of Health labs so they can be of assistance in the event of future bioterrorism attacks.

Dr. Akhter of APHA voices similar concerns. "We still do not have an early warning system," he says. "We react rather than act. We need information in real time from hospitals and from emergency medical service people so we can immediately identify what we're dealing with. In the case of anthrax, botulism, tularemia and smallpox, we have only one or two days after the onset of disease to treat and save lives." As an example, he explains that the Washington, D.C. area has a regional system connecting information from hospitals. During the anthrax outbreak, several infected patients were brought to facilities linked up by the system. Two people died, but two others lived because staff at Inova Fairfax Hospital in Virginia, realizing their patients worked at postal facilities, quickly suspected anthrax, called the D.C. authorities and provided appropriate treatment. However, Dr. Akhter warns that healthcare workers in the Washington, D.C. area communicate with each other and with the health departments involved by telephone, which means that they experience delays when someone is not available and must call back. Most metropolitan healthcare systems work this way, which Dr. Akhter believes is a mistake; they should all have computerized communications and work in real time.

New York City, with probably the nation's best public health system, set up a syndrome surveillance system four years ago, using the 911 emergency system. It monitors calls that suggest the person has flu, for example, and enters that information, together with information from other sources, into a computerized system. Dr. Neil Cohen, who recently left as health commissioner to join a regional early-warning system, explains that these procedures have made a significant difference. "We got a jump of two to four weeks on a flu outbreak, compared to national reporting," he says. The New York system is exploring new ways to incorporate information from HMOs, nurse-advocate hotlines, commercial lab reporting, and sales of flu medications and anti-diarrheal agents from large retail drugstores, particularly using online technology and collecting information by day, night and on weekends.

Dr. Akhter wants to see the establishment of regional systems that are computerized from the moment someone calls 911 or when a healthcare person first sees the patient. If somebody calls 911 because of difficulty breathing-an early sign of many serious problems-the 911 system should note that and automatically enter it into a computerized system organized by zip code. If there are an unusually high number of similar cases in the zip code, the system should sound an alarm.

Ideally, the system should connect the police and fire departments, the Department of Justice, the Federal Emergency Management Agency, the Department of Health and Human Services, CDC, the National Institutes of Health and military hospitals in real time so that they can monitor information. When an emergency medical technician reaches the patient with breathing difficulty, for example, the technician would enter the patient's vital signs into the system while en route to the hospital. Once the patient arrived in the emergency room, healthcare workers would enter further information and transmit the information to the health department. As the hospital's laboratory provided test results, they too would be reported. The health department, monitoring incoming information 24 hours a day, might suggest further tests if the case seemed suspicious and these results would also be entered. A similar system would enable physicians to communicate information about a suspicious case. Every hospital would have an individual designated and trained to investigate a possible bioterrorist attack. Although there are not enough epidemiologists-often called disease detectives-to staff every one of the nation's 3,000 health departments, four or five counties could get together in a regional organization and hire one, Dr. Akhter suggests.

On the positive side, some advances have been made in educating providers and first responders that may contribute to early detection of disease outbreaks. Since September 11th, many medical schools, teaching hospitals and medical societies have added courses, updates and lectures on bioterrorism to their curricula. The web sites of many professional organizations now include comprehensive information on diagnosing and treating disorders that were previously considered to be exotic.

Next page: Real-Time Communications

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