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NOTICE:
TIEMS Transportation Safety and Security Workshop January 28-29th 2003
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Welcome to
the
Institute for Crisis, Disaster, and Risk Management Crisis and Emergency Management
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| January 2003
Volume 3 - Number 4 |
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Links:
Current events
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Bioterrorism Mitigation: Infectious Disease Surveillance
What is Infectious Disease Surveillance? Infectious disease surveillance is the ongoing, systematic collection, analysis and interpretation of health data essential to planning, implementation and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. 1 Detection and containment of a disease outbreak entails three basic steps: 1. Recognition and diagnosis by primary health care practitioners. 2. Communication of surveillance information to public health authorities. 3. Epidemiological analysis of the raw surveillance data.2 Why Worry? Until recently, chemical and biological weapons have not been the focus of domestic planning, unlike our long-standing preparedness for a nuclear attack. However, the availability of Weapons of Mass Destruction (WMD), coupled with terrorists' willingness to use these deadly agents, has made the probability of a WMD incident greater than ever and threatens the United States and other countries with potentially devastating consequences, including widespread death and disease and destruction of societal infrastructure and possibly society itself.3 Why infectious disease surveillance is important Without early detection of biological terrorism and special preparation at the local and state levels, a large-scale attack could overwhelm the local and perhaps national public health infrastructure and cause mass panic. Furthermore, because some of the most deadly biological warfare agents, such as anthrax and plague, respond to antibiotics administered during the early phase of infection, prompt detection and treatment of an outbreak could save many lives. Rapid containment by isolation and vaccination could prevent further spread.4 Difference between chemical and bomb attacks and biological attack The first responders in a bioterrorist would be healthcare professionals. Unlike HAZMAT incidents, during which the response and initial treatment scene occurs away from the hospital, the scene for an incident involving intentional release of biological agents will be local emergency departments and clinics.5 This difference is a result of the different effects of the methods. Whereas the effects of chemical agents and bombings are usually immediate and obvious---thus eliciting immediate response from police, fire, and EMS personnel---attacks with biological agents, because of the incubation period, will not have an immediate impact. 6 The event would first be evident when people started to seek medical attention. By that time, days or even weeks may have passed since the event took place. Since 1995, there have been several key federal initiatives that deal with terrorism in general; however, until recently, most of them did not address the unique problems associated with bioterrorism. Problems With Infectious Disease Surveillance A critical and absolutely vital problem has been the need for specific training for healthcare personnel who must be able to recognize the signs and symptoms of a biological attack for the community and nation to respond quickly and successfully.7 Secondly, most laboratories have been lacking in the capacity or the expertise to detect and accurately and safely identify those biological agents classified as high priority. 8 A third problem has been the minimal involvement of health care facilities and health care professionals in WMD preparedness program. Health care facilities have not been integrated into the program because of lack of funds. The lack of involvement of physicians, nurses, and other health care professionals programs is also a concern.9 Inadequate reporting has been yet another problem. Practicing physicians rarely report unusual diseases to local public health officials, and public health officials don't have the ability to provide timely disease information to physicians working in clinics and hospitals. The process is “burdensome, inefficient and almost never gives anything back to the physician that is of relevance to the patient he or she is caring for."10 There also exists a lack of communication among different healthcare professionals, agencies and organizations, including disconnects between primary care providers and the public health system, the human and animal health communities (animals may present with symptoms more quickly than humans), and public health experts and intelligence analysts. It is essential to bridge such gaps that can seriously impede the nation's ability to detect and respond rapidly to unusual outbreaks of disease.11 Furthermore, there is no set incident management system in place to help coordinate the many disparate actors and activities pertinent to bioterrorism preparedness and response. Another critical element that is needed to ensure quick and effective surveillance has been the capacity to provide early warning of an attack. Traditional laboratory-based surveillance is simply too slow. What’s been done to address these problems CDC established a Bioterrorism Preparedness and Response Program to ensure the rapid development of federal, state, and local capacity to address potential bioterrorism events. The program integrates planning and training to facilitate the development of core capacities in the primary elements of public health preparedness, including surveillance. A nationwide, integrated information, communications, and training network, consisting of the Health Alert Network (HAN) and the Epidemic Information Exchange (Epi-X), proved to be an invaluable mechanism for rapid dissemination of information.12 The Public Health Security and Bioterrorism Preparedness and Response Act The 107th Congress passed the Public Health Security and Bioterrorism Preparedness and Response Act in May 2002 (see References: Public Law 107-188: Public Health Security and Bioterrorism Response Act). The purpose of the Act is to improve national public health preparedness. A key component of this legislation was the authorization of more than $1.5 billion in grants to help states, local governments, and healthcare facilities to improve their planning and preparedness, enhance lab capacity, and train personnel, and to develop new drugs and vaccines. It also provides for support for the areas of surveillance, laboratory capacity, the training an education of healthcare professionals and the Health Alert Network (HAN)/ Communications and information technology to support exchange of key information and training by linking public health and private partners.13 The Homeland Security Act of 2002 In November 2002, the 107th Congress passed the Homeland Security Act of 2002; the President signed the Act into law on November 25, 2002 (see References: Whitehouse: Homeland Security Act of 2002). Section 303 requires the Secretary of Homeland Security to carry our civilian human health activities in conjunction with the Department of Health and Human Services and gives him the right to carry out other projects with DHHS as he sees fit. Dept of Homeland Security: responsibilities include securing people, infrastructure for acts of terrorism involving biological weapons, supporting research and procurement of technology for detecting, conducting a national scientific research and development program including efforts to counter these types of terrorist (likely to be done via agreements with DHHS)14 What still needs to be done While training has received much more funding and attention in the last year, there is still much work to be done in this area. A comprehensive training and education program involving all aspects of the healthcare community is needed to ensure timely and accurate recognition and treatment of disease. Laboratories must have the equipment necessary for identifying the pathogens likely to be used in a biological attack and lab technicians must be trained to recognize these pathogens. Furthermore they must have the ability to share information throughout the country to ensure that multiple location outbreaks are recognized quickly. The healthcare community must be fully integrated into the planning and response. While the integration of the healthcare community has become increasingly prominent in the emergency response system, it remains to be seen exactly how much influence it will have in the activities and decisions of the Office of Homeland Security. Communication Systems must be upgraded. U.S. ability to mitigate the public health consequences of biological and chemical terrorism depends on the coordinated activities of well-trained health-care and public health personnel throughout the United States who have access to up-to-the minute emergency information.15 Sophisticated surveillance systems must be in place and must be integrated with the existing public health infrastructure, including emergency departments. The CDC currently maintains more than 100 surveillance and health information systems, but they are largely independent of one another.17 A national electronic network to monitor reports of unusual medical events will provide real-time valid information critical to early detection and identification. This too has been addressed to some extent but there is still much work to do. A tool for reporting is needed that will establish and maintain communication between overworked clinicians and out-of-reach public health officers, as well as a tool that is easy and intuitive to use, fast, responsive, and cost-effective.17 A syndomric surveillance system, especially an electric one, would meet most of these needs. The majority of infectious disease surveillance in this country is laboratory based, which is reliable and precise, but it's not always timely. Syndromic surveillance is a method that works as a screening device by tracking the emergence of clusters of symptoms associated with certain illnesses. It provides for rapid identification of and prophylaxis but does not diagnose a precise disease. CDC is currently working with state and local health departments and information system contractors to develop real-time special event syndromic surveillance and analytical methods.18 Electronic systems would greatly enhance the ability to share and analyze information quickly. Such systems could facilitate the electronic transfer of appropriate information from clinical information systems in the health care industry to public health departments and reduce provider burden in the provision of information. Monitoring of non-traditional public health data sources (e.g., pharmacy and lab data) may be yet another way to improve early detection efforts.19 There is speculation that monitoring things such as the sale of Kleenex or orange juice, or monitoring the number of hits received by online healthcare sites may be helpful in detecting health trends. This method would detect those who choose not to seek medical attention until the symptoms become extreme. In order for these systems to be effective, the further-reaching problem arising from the lack of a clear managerial hierarchy in the healthcare community must be addressed. 16 A clear-cut incident management system such as MaHIM proposed by Dr. Barbera and Dr. McIntyre at the George Washington University would be greatly beneficial to ensuring effective mitigation. In the event of a bioterrorist attack, the spread of disease would be logarithmic. Quick detection is of the essence. Continued refinement of methods for detecting emerging public health threats and for supporting local and state public health staff in applying these methods will enable more timely recognition of disease outbreaks, allowing for the timely implementation of effective interventions that would minimize the devastation and panic that would likely occur in the wake of a bioterrorism event. 1 Infection Control Today. “Disease Surveillance Goes High-Tech.” Available at http://www.infectioncontroltoday.com/articles/211feat2.htmlfectious as of 11/14/02 2 CNS – CBW. “Improving Infectiious Disease Surbeillance to Combat Bioterrorism and Natural Emerging Infections.” Available at http://cns.miis.edu/research/cbw/testtuck.htm as of 11/14/02 3 JAMA. “Domestic Preparedness for Events Involving weapons of Mass destruction.” Available at http://jama.ama-assn.org/issues/v283n2/ffull/jed90095.html as of 11/25/02 4 Monterey Institute of International Studies Chemical & Biological Weapons Resource PageImproving Infectious Disease Surveillance to Combat Bioterrorism and Natural Emerging Infections.” Available at http://cns.miis.edu/research/cbw/testtuck.htm. As of 11/14/02. 5 JAMA. “Domestic Preparedness for Events Involving weapons of Mass destruction.” Available at http://jama.ama-assn.org/issues/v283n2/ffull/jed90095.html as of 11/25/02 6 Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response: Recommendations of the CDC Strategic Planning Workgroup.” Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rra1.htm as of 11/25/02 7 JAMA. “Domestic Preparedness for Events Involving weapons of Mass destruction.” Available at http://jama.ama-assn.org/issues/v283n2/ffull/jed90095.html as of 11/25/02 8 American Society for Microbiology. “Bioterrorism: Frontline Response, Evaluating U.S. Preparedness.” Available at http://222.asmusa.org/pasrc/bioterrorismdef.htm as of 11/25/02 9 Infection control Today. “Disease Surveillance Goes High-Tech.” Available at http://www.infectioncontroltoday.com/articles/211feat2.htmlfectious as of 11/14/02 10 ibid. 11 CNS – CBW. “Improving Infectiious Disease Surbeillance to Combat Bioterrorism and Natural Emerging Infections.” Available at http://cns.miis.edu/research/cbw/testtuck.htm as of 11/14/02 12 CDC Programs in Brief. “Bioterrorism.” Available at http://www.cdc.gov/programs/bio1.htm as of 11/12/02 13 Centers for Infectious Disease Control. “Bioterrorism Preparedness, Planning, and Response. “ Available at http://www1.umn.edu/cidrap/content/bt/bioprep/planning/be-prep-planning.html as of 11/28/02 14 ibid. 15 Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response: Recommendations of the CDC Strategic Planning Workgroup.” Available at http://222.cdc.gov/mmwe/preview/mmwrhtml/rr4904a1.htm as of 11/15/02. 16 Infection control Today. “Disease Surveillance Goes High-Tech.” 17 Infection control Today. “Disease Surveillance Goes High-Tech.” 18 CDC. “Enhanced Surveillance Project(ESP).” Available at http://www.bt.cdc.gov/episurv/ESP.asp as 11/14/02 19 CDC: Programs in Brief. “Outbreak Detection Using Public Health Surveillance Data.” |