BioWatch and Public Health Surveillance Evaluating Systems for the Early Detection of Biological Threats: Abbreviated Version (2011) / Chapter Skim
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6 BioWatch and Enhanced National Biosurveillance Resources
6 BioWatch and Enhanced National Biosurveillance Resources
Pages 155-188
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From page 155... ...
Here the committee compares the BioWatch program to enhancing current surveillance practices in the public health and health care systems.1 EXPLORING THE EFFECTIVENESS OF BIOSURVEILLANCE RESOURCES Evaluating the effectiveness of the BioWatch program is problematic for several reasons. • Definitive information about the likelihood of a catastrophic bioterrorist attack of the kind that BioWatch is intended to detect and about the specific nature, costs, and effectiveness of an enhanced surveillance system implemented through the public health and health care systems is not available.
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From page 156... ...
• Biosurveillance within the public health system is composed of numerous separate systems, varying in maturity, whose integrated cost and performance is difficult to assess for detection of either natural disease outbreaks or bioterrorist events, whether alone or in conjunction with BioWatch. • Natural outbreaks are heterogeneous, differing in size, location, agent, and mechanism of spread, as are the capabilities of state and local public health departments to recognize and respond to outbreaks and the availability of health care resources to provide treatment.
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From page 157... ...
Generation 2 filters Decision makers receive Variable, by jurisdiction; in No experience yet with a positive BioWatch result and general, uncertain BAR later determined to other information sufficient result from a bioterror to promptly recognize a event BioWatch signal as indication Testimony from public health of a true bioterror event officials Effective prophylaxis or Depends on the agent Medical literature treatment exists Decision makers initiate Depends on the detected Experience from multiple prophylaxis or treatment agent, other available BARs, but response to a information, and BAR for anthrax may differ circumstances Testimony from public health officials Prophylaxis or treatment Depends on the agent, Modeling is carried out in time dose, time elapsed Exercises to reduce mortality and since human exposures, morbidity ability to define and target prophylaxis to the population exposed, and dispensing capabilities NOTE: BAR, BioWatch Actionable Result.
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From page 158... ...
(The committee notes that it heard testimony from public health officials in some of these jurisdictions, but it did not have the opportunity to review the information available to the public health authorities in each case.) However, as discussed in Chapter 3, several concerns about the BioWatch system's technical performance remain, including questions about sample collection, laboratory analysis, siting practices, and program priorities.
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From page 159... ...
The committee is most confident about the potential for early detection via BioWatch to reduce morbidity or mortality in the event of a massive aerosol attack using Bacillus anthracis spores, assuming an effective public health response capability is in place. This conclusion is based on evidence that includes the environmental stability of B
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From page 160... ...
, the effectiveness of public notification, and the resources available to set up distribution centers. Testimony to the committee suggests that, depending on the circumstances, some public health officials may be hesitant to launch a high-regret action that may cause unnecessary alarm or even harm, such as initiating the widespread distribution of prophylaxis or treatment, without confirmed cases of disease in humans or animals.
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From page 161... ...
With the specific challenges of rapid detection of bioterrorism and other serious infectious disease threats in mind, the committee framed 10 related performance features that could be used to evaluate the potential contributions of BioWatch or enhanced surveillance tools that may be integrated into the public health and health care systems. These performance features are: 1.
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From page 162... ...
With the current deployment in large urban areas, the BioWatch program has had the advantage of working with larger health departments that tend to have greater expertise and response capability than smaller health departments. Expanding BioWatch to more localities would require DHS to work with local health departments that are likely to need more federal interaction and support to be capable of analyzing and responding to a BAR.
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From page 163... ...
3 BIOWATCH ANd ENHANCEd NATIONAl BIOSuRVEIllANCE BOX 6-1 Potential Enhancements to Surveillance Through Public Health and Health Care Legally Mandated Disease Reporting Enhance electronic laboratory reporting systems Enhance notifiable disease reporting by clinicians (outreach, elec tronic reporting procedures, 24/7 call lines) Enhance electronic death reporting systems Automated Health Care Information Systems and Public Health Linkages Enhance/use clinical decision support tools for diagnosis, reporting, and management (e.g., triage, infection control, and treatment)
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From page 164... ...
3. If only clinical case finding operates, to estimate the incremental benefit of adding syndromic surveillance, environmental sampling, or both.
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From page 165... ...
The analytic approach provides exact values of outputs of interest and facilitates the use of sensitivity analyses to understand how assumptions and input parameters affect these outputs. Results of the Modeling Analyses The analyses indicate that, under highly favorable scenarios, BioWatch environmental sampling has the potential to lead to dispensing of antibiotics 2 to 3 days sooner after an aerosolized anthrax release than does syndromic surveillance or clinical case finding.
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From page 166... ...
to determine that distribution of antibiotic prophylaxis is an appropriate response. It is also uncertain whether public health officials would be able to provide antibiotic prophylaxis to hundreds of thousands, if not several million, people within 48 hours of determining that a large-scale aerosol attack with anthrax spores has occurred -- the time frame that CDC has recommended as the planning target in its Cities Readiness Initiative.
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From page 167... ...
For example, BioWatch may show greater benefit if a pathogen causing a contagious disease is detected and effective quarantine and isolation procedures can be implemented to limit the spread of the disease. With pathogens having longer incubation periods, the interval between detection by environmental sampling and clinical case finding or syndromic surveillance could be greater than it is for anthrax, giving public health officials more time to implement their response.
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From page 168... ...
, to aid in understanding and comparing the relative benefits of environmental sampling, syndromic surveillance, and improved clinical case finding.2 Although rapid implementation of the BioWatch program was judged necessary in 2003, at this stage in the life of the program, DHS should be using available information and analytic tools to shape the program in a way that maximizes its potential benefits. This includes developing models that are more detailed to address the questions assessed in the modeling exercise described here.
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From page 169... ...
The explicit federal program costs for BioWatch since 2003 can be tracked in the aggregate through DHS budget documents, but as discussed in previous chapters, the costs of other surveillance activities across federal, state, and local levels and the public and private sectors are much harder to document (Hebert et al., 2007; GAO, 2008a; Franco, 2009)
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From page 170... ...
To illustrate, an action that reduces the annual mortality risk by 1/100,000 for each member of a population of 100,000 saves 1 statistical life over a year (Robinson, 2008)
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From page 171... ...
The calculations also assume $6.3 million for a VSL, a 7 percent real discount rate as used in the cost analysis in Chapter 2, and income growth of 3 percent per year. To "break even" with an annual probability of attack of .1 per year, or 1 attack expected in 10 years, BioWatch Generation 2 would need to save 134 additional lives if an attack occurs; Generation 3 (configured according to the proposed acquisition and deployment plans)
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From page 172... ...
Two factors appear to be fueling this skepticism. First, local and state public health departments are under increasing budgetary and staffing pressure.
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From page 173... ...
Such information may include which pathogen is detected, the number of BioWatch collectors producing alerts, whether the pathogen detected is known to be endemic to the area, or whether there is relevant intelligence information indicating the potential for an attack. Although the absence of a signal from BioWatch collectors cannot be taken as firm evidence that no release has occurred, positive signals from multiple collectors in a single jurisdiction, or information that collectors in other jurisdictions have produced BARs, could influence interpretation of the significance of a signal and decisions regarding the speed and scope of the public health response.
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From page 174... ...
Situational Biosur veillance Awareness and Monitoring and Response Intelligence Decision Suppor t Detection Syndromic Mail Surveillance Rooms FIGURE 6-1 A schematic illustration of the relation between the BioWatch program and other sources of information needed for infectious disease surveillance in the public health and health care igure 6-1.eps Fsystems. SOURCE: Adapted from Hooks (2008)
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From page 175... ...
On the other hand, the committee was unable to obtain information that would allow a determination of the costs of infectious disease surveillance for significant biological threats, or specifically for bioterrorism threats. These costs cannot be readily separated from other health surveillance programs, and as discussed in Chapter 5, the costs of the broader surveillance activities in the public health and health care systems are also difficult to estimate because current budgeting and accounting systems at the local, state, and federal levels do not use classifications that provide this information.
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From page 176... ...
Generation 2, with goal of including additional agents; environmental presence of airborne pathogens Public Health and Health Care Systems Disease recognition All human health Entire country, Not readily quantified; and reporting hazards (e.g., reports of varies by disease, by health care biologic, chemical, uneven quality provider, location, providers and environmental) submitted to reporting system, laboratories that result nearly 3,000 local epidemiologic to health in clinically and state health expertise, and other departments recognized disease departments resources or injury
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From page 177... ...
changes not must be overcome included to achieve desired system capabilities May depend Provide ongoing Unknown; data Need for additional on disease, detection of necessary to integration and skill of health intentional estimate costs information sharing care provider, and naturally of disease across federal, state, availability of occurring surveillance and local levels; appropriate outbreaks for systems or need for evaluation analysis tools, prevention or marginal cost and incorporation of scale of pathogen treatment of surveillance new techniques exposure, for significant reporting system; infectious disease depends on threats not evidence of available infection, so not likely to detect before environmental surveillance continued
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From page 178... ...
In addition, innovative methods may be needed for assessing the impacts of a multifaceted and multipurpose public health infrastructure such as infectious disease surveillance. INCORPORATING BIOWATCH INTO AN ENHANCED NATIONAL SURVEILLANCE SYSTEM The nation lacks a clear, overarching architecture of interlocking interagency goals, metrics, and accountability to support a seamless process from detection of biological threats through response and recovery.
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From page 179... ...
Some of the challenges of integrating BioWatch functions into surveillance and decision making carried out by the public health community may stem in part from its superimposition onto existing systems that serve other important priorities. Local and state public health departments have diverse responsibilities that include both routine and outbreak surveillance activities, independent of the responsibilities that come with participation in the BioWatch program.
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From page 180... ...
Although the deployment of the BioWatch system has been somewhat rocky in terms of coordination and integration with local public health officials, there is a continuing national effort to achieve a more integrated system from the multitude of local and state systems for infectious disease surveillance. All told, the BioWatch system needs to be better integrated into local surveillance systems that themselves are ultimately better integrated into a whole that resembles more of a national biosurveillance system.
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From page 181... ...
In the committee's view, a national biosurveillance system should aid in protecting the nation from significant, time-critical biological threats of all types, whether intentionally released (i.e., bioterrorism) , accidentally dispersed, or naturally arising (i.e., emerging or re-emerging infectious disease)
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From page 182... ...
Improved methods for Infectious disease Surveillance Surveillance is an essential public health practice, but it has long rested on multiple independent data collection activities, often constrained by limited resources and narrow programmatic requirements. As information and communication technologies have evolved and become more accessible to health departments and health care providers, they are making it possible to improve the collection, integration, and analysis of surveillance data.
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From page 183... ...
At the federal level, activities in both DHS and HHS are aimed at more effective integration of information to improve situational awareness. In DHS, the National Biosurveillance Integration Center (NBIC)
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From page 184... ...
Because the potential for BioWatch to help limit morbidity and mortality depends so heavily on the ability of health departments and the health care system to analyze the nature of the threat and take quick and decisive action, it is essential that the operation and management of BioWatch be well integrated with the jurisdictions in which it operates. State and local authorities, whose knowledge of endemic health risks and available resources cannot be replicated at the federal level, need to be recognized as essential and valuable partners not only in the BioWatch program but also in broader national biosurveillance and biodefense efforts.
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From page 185... ...
Emerging Infectious diseases 12:1942–1949. CDC (Centers for Disease Control and Prevention)
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From page 186... ...
Emerging Infectious diseases 7(6)
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From page 187... ...
2008. Modeling the incubation period of inhalational anthrax.
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