Technologies to Enable Autonomous Detection for BioWatch Ensuring Timely and Accurate Information for Public Health Officials: Workshop Summary (2014) / Chapter Skim
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3 Public Health's Perspective on the Role of BioWatch in the Decision-Making Process
3 Public Health's Perspective on the Role of BioWatch in the Decision-Making Process
Pages 23-40
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From page 23... ...
Session moderator Suzet McKinney, deputy commissioner of the Bureau of Public Health Preparedness and Emergency Response in the Chicago Department of Public Health, said that the panelists had been asked to consider two questions when they prepared their remarks: 1. What factors related to BioWatch autonomous detection will af fect decision-making response actions after a BAR is reported?
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From page 24... ...
INFORMATION NEEDED FOR DECISION MAKING In her overview of BioWatch as it relates to public health, Sandra Smole stressed that BioWatch is viewed in the public health community as a surveillance tool that is used in conjunction with other tools, such as syndromic surveillance, for detecting the presence of an infectious agent or toxin of public health significance. In that respect, information from BioWatch contributes to and is interpreted within the context of the larger surveillance picture.
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From page 25... ...
Concerning the information needed to determine a BAR from a new autonomous detector, Smole said that the public health laboratory director or designee will need prior knowledge of parameters such as sensitivity, specificity, reproducibility, robustness, and inherent limitations that will be critical for interpreting test results. Once an instrument provides a positive signal, the public health laboratory director or designee will need access to instrument performance indicators, positive and negative controls, threshold settings, and historical data from the detectors.
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From page 26... ...
It should be assumed that the new technology must perform equal to or better than the current technology before it is adopted." As a final comment, Smole added that, in her experience, public health is supportive and poised for adoption and implementation of new technologies to protect the nation's health. FOUR REGIONAL PERSPECTIVES Houston, Texas, and Surrounding Harris County Two of the strengths that public health agencies bring to the table are their versatility and their ability to make decisions even when sufficient information is not available, said David Persse, emergency medical system physician director in the City of Houston's Public Health Authority, who serves as the BioWatch Advisory Committee (BAC)
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From page 27... ...
located in their community. A Ct value indicates that a certain DNA sequence (representing a target organism)
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Shah, executive director of the Local Health Authority, Harris County (Texas) Public Health and Environmental Services, stated that although the workshop was focused on the science of biodetection, he wanted to address the art of decision making.
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For example, a decreased investment in the technologies that enable syndromic surveillance and automated disease reporting, combined with decreased staffing for surveillance, is diminishing response capabilities, which in turn makes the decision on how to respond to a BAR even more art than science. Shah concluded his remarks by offering some considerations for those in the audience who are involved in developing and deciding on Generation 3 or other future BioWatch technologies.
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From page 30... ...
One unusual feature of the Bay Area is that the regional BioWatch laboratory is the California state laboratory, which is not in the Bay Area region. Furthermore, while San Francisco does not have any indoor detectors, San Francisco International Airport does, and a representative of the airport is also a member of the advisory committee.
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From page 31... ...
presence of positive environmental surface swipe samples, recent outbreaks of human or animal disease in the region, overt unusual or adversarial activity consistent with a threat, evidence of a weaponized or genetically modified agent, a recent bioterrorism incident or credible threat in the United States, or an FBI-designated special event near the positive collector. Decision making is aided by a detailed list of organism-specific criteria that account for factors such as incubation period, transmissibility between humans, past incidence of human disease, the likelihood of natural environmental occurrence in the region, and the potential risk to public health.
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From page 32... ...
She noted that her committee has decided that the distribution of postexposure prophylaxis will take priority, and it has worked closely with the Bay Area Mass Prophylaxis Working Group to create a unified screening algorithm for all of the region's points of distribution and also an associated website that would go live immediately after a release event was confirmed. Thoughts on Future Technology Regarding the impact of newer technology, Pan reiterated earlier remarks that it will be essential to build confidence in the results that is at least equal to the comfort level that public health has developed with the current technology.
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From page 33... ...
In New York City, only 40 percent of the BioWatch portable detection units are outdoors, with the remaining 60 percent in indoor locations. Another unusual feature of the New York City BioWatch network is that it is administered by the New York City Police Department, with the Department of Health and Mental Hygiene serving as the lead scientific agency responsible for testing, environmental sampling strategies, disease surveillance, and implementing
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From page 34... ...
In this scenario, which he characterized as the one that is most likely to present him and his colleagues with the necessity of making an immediate, potentially high-regret decision, the public health laboratory reports a BAR for a biological threat agent from an indoor detector in a major transit hub. At that point, a number of things are known: the number of detectors reporting a BAR, the location of the detector or detectors reporting a BAR, the Ct values, the sample period range for each detector, the performance of the detectors in terms of sensitivity and specificity, and syndromic surveillance data from the previous day.
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From page 35... ...
How can the stakeholder group target the available public health interventions to protect the greatest number of potentially at-risk people? Answering the first question, Stimmler said, leads to the default hypothesis upon which all other actions will be based, but given the limited information available at that moment, he said, "all of our actions are potentially high-regret and are instantly public." The unique challenge of having an indoor program is that there will have to be a decision about closing the facility in which the signaling detector is located, Stimmler said.
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From page 36... ...
Because of the scale of the New York City BioWatch network, even a 0.01 percent failure rate -- which Stimmler said would translate to two false-positive BARs per year -- would be unacceptable, given the consequences. Moving into the realm of what he acknowledged might be science fiction, Stimmler provided a public health wish list for Generation 3 or autonomous detection technology that was very similar to the list Pan presented.
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PUBLIC HEALTH'S PERSPECTIVE 37 FIGURE 3-2 The CTA rail map. SOURCE: Chicago Transit Authority.
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Stimmler said it would be most helpful if the time frame was minutes rather than hours because that determination affects the decision to release medical countermeasures and trigger procedures to prevent the spread of an infectious agent.
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From page 39... ...
Shah agreed with that comment and added that such information allows public health to make a more nuanced decision in a timely manner. Session rapporteur Beth Maldin Morgenthau, assistant commissioner for the Bureau of Policy, Community Resilience and Response within the Office of Emergency Preparedness and Response at the New York City Department of Health and Mental Hygiene, voiced her concern that a system that produces results every few hours could strain what are already limited and diminishing public health resources and said that the BioWatch program needs to keep that in mind as it contemplates rolling out the next version of this technology.
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From page 40... ...
However, assuming that state and local officials have more input and information as future programs are deployed, he said he is looking forward to the autonomous detection system. He noted that people need to view it in the context of all the tools available in the surveillance toolkit and also recognize that resources are limited.
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