Connecting the Dots: Creating a National Biosurveillance Capability

Jennifer Nuzzo

This article is part of Crossroads in Biosecurity: Steps to Strengthen U.S. Preparedness, published by the Center for Biosecurity September 8, 2011 to mark the 10th anniversery of the 2001 anthrax attacks. Full document | Printable PDF

                
In May 2011, Germany announced that a toxin-producing strain of Escherichia coli had infected thousands of people and killed dozens.[1] Health officials launched an investigation to identify the outbreak’s cause in hopes of preventing additional illnesses and deaths. Initially, they suspected that cucumbers from Spain might be to blame and cautioned the public not to consume raw produce.[2] But soon thereafter, authorities retracted that conclusion and began scrutinizing other possible sources.[3] Weeks later, after most of the German cases seemed to be on the decline, health officials announced with greater confidence that they had identified the source of the outbreak: raw sprouts produced at an organic farm.[4] By late June, though, hopes that the outbreak had been contained were dashed when a cluster of people in France fell ill with the same strain that was involved in the German outbreak.[5] Although the investigation is ongoing, genetic analysis of the clinical isolates, shoe-leather epidemiology, and an analysis of import and supply-chain information from the private sector now suggest that the outbreaks in France and Germany may have a common cause: fenugreek seeds imported to Europe in 2010.[6]

At the time of this writing, in early August, as many as 5,000 human E. coli cases have been reported from this outbreak, and European officials are predicting that it may be the most expensive one the EU has witnessed. Shortly after German officials spoke publicly about the outbreak, many countries around the world announced bans on produce from Germany and Spain.[7] Some countries, like Russia and Lebanon, opted to ban all produce from the EU, citing ongoing uncertainty about the true cause of the outbreak.[8] German retail sales in May fell by 2.8%, the fastest decline in 4 years.[9] To compensate those farmers whose crops were destroyed, EU officials are proposing an aid package of close to $300 million, which many experts fear falls far short of actual losses incurred.[10]

“A Wake-up Call”

In the words of U.S. Agriculture Secretary Tom Vilsack, “What’s happened in Europe is a wake-up call” for the United States.[11] Although the U.S. has worked hard since 2001 to improve biosurveillance capabilities across the nation, there are reasons to be concerned about how we would fare in a large-scale epidemic, in a foodborne outbreak, or worse, in a bioterrorist attack. Like Europe, the United States has also suffered losses as a result of a foodborne outbreak: in 2008, an outbreak of Salmonella Saintpaul sickened close to 1,500 people in 43 U.S. states and territories.[12] Although U.S. health officials eventually settled on the correct culprit (imported jalapenos), this pronouncement was made long after fingers initially pointed at tomatoes and the outbreak had peaked. The U.S. tomato industry suffered hundreds of millions of dollars in losses.

Achievable Improvements Within Reach

While an outbreak is unfolding, it is indeed a challenge to gather and assess the correct data quickly so that officials can accurately identify the source and contain an outbreak before additional people are affected. Recent experience suggests we might do better in the future if we start making some achievable improvements now. Specifically, U.S. biosurveillance systems could benefit greatly from adoption of new and better tools, greater and sustained support for existing programs, and improved integration of biosurveillance data across multiple agencies. These improvements should be prioritized given the nation’s reliance on its biosurveillance systems to minimize the spread of disease, prevent unnecessary sickness and death, and reduce the economic and social harm caused by outbreaks, epidemics, pandemics, and bioterrorist attacks.

Develop Better Surveillance Tools

When an outbreak occurs, whether from an infectious disease or foodborne pathogen, public health officials rely on patient data acquired from the doctors’ offices, hospitals, and laboratories where diagnosis occurs. Health authorities rely on these data to detect outbreaks, track down the source, identify how many people are infected, determine the severity of the disease, and make key decisions about which public health control measures are likely to work and how many resources are needed for responding. Those data also inform critical decisions regarding how to control the outbreak and allocate the resources needed for response. Even small delays in diagnosis and access to surveillance data can have significant consequences for the public’s health.

For all the communication technologies available in this digital age, our biosurveillance approaches are, in many respects, still quite rudimentary. In many places, biosurveillance systems still rely on clinicians and laboratories to phone, fax, or mail in reports of important diseases.[13] If, upon receiving these reports, public health officials want to obtain additional information, they often must contact hospitals and clinicians one by one. Each of these time-consuming steps is subject to delay, and it can be difficult to keep up in the midst of a large-scale outbreak.

A major boost for biosurveillance could come from improving public health officials’ access to data from healthcare providers. As the nation builds a national framework for electronic health records (EHRs), we should seize the opportunity to develop critical connections between health care and public health. But current efforts to promote the use of EHRs across the nation do not adequately address the importance of these data for biosurveillance. For example, the current federal guidelines have not made it mandatory for providers to successfully report laboratory data—a critical biosurveillance information need—to public health agencies in order to receive incentive payments for using EHRs. Moreover, there has been little to no support for already cash- and personnel-strapped health departments to help them develop data systems to receive incoming EHR data. More than $18 billion in federal funds has been allocated for incentive payments for healthcare providers to promote adoption of EHRs. At least a modest portion of these funds should be used to support health departments to enable them to build and maintain strong and flexible digital connections with healthcare entities that adopt EHRs.[13]

We should also use our best efforts to design EHR systems that will significantly improve not just the quantity of data received by public health, but its quality and value for disease detection and response purposes. Specifically, HHS should expand future iterations of the guidelines for the use of EHRs by clinicians—the so-called Meaningful Use Criteria—to promote the development and adoption of EHRs that have the ability to evolve over time and allow for the addition of new features not currently envisioned, such as enabling public health departments to have remote, query-based access to patient records during outbreaks.

Another pressing need in surveillance is the development of technologies to improve the accuracy and speed with which we diagnose sick people, which is our best hope for detecting outbreaks early. Although 10 years have elapsed since the anthrax attacks, the diagnosis of this deadly disease is still dependent on assessing a patient’s symptoms (which can be imprecise) and/or by growing clinical specimens in the laboratory (which is time-consuming). Rapid, reliable, and cheap diagnostic tests for a range of diseases are within reach, but development is slow, and commercialization is difficult due to high costs, market failures, and other factors. Although U.S. agencies such as the Biomedical Research and Development Authority are authorized to develop and purchase the diagnostic tools that will be necessary to manage public health emergencies, progress in this area has been limited.[14] The USG should address this critical gap in our biosurveillance capabilities by making the development and acquisition of diagnostic tools a top national priority.

Preserve U.S. Biosurveillance Gains

Since 2001, federal support for state and local health departments has produced measurable improvements in national biosurveillance. Prior to the post-9/11 infusion of preparedness funds, most health departments lacked even the most basic surveillance infrastructure. For example, in 1999, more than 50% of public health departments did not have continuous access to high-speed internet or the ability to send broadcast faxes to alert clinicians about important outbreaks.[15] Bolstered by support from federal public health preparedness funds, most health departments now have those capacities along with more laboratories that can test for important diseases and more epidemiologists to review, investigate, and interpret disease reports. In fact, most public health departments now maintain 24/7 monitoring capabilities, something almost unheard of prior to 9/11. These are substantial gains.

However, recent declines in both federal preparedness funding and state and local financial resources are threatening those hard-won biosurveillance gains. For instance, federal funding for state and local public health preparedness programs has declined by 27% since 2005. That loss, combined with state budget cuts due to the economic downturn, has made it difficult for health departments to maintain newly developed information systems and analytical staff, which has threatened the viability of nascent biosurveillance programs. Worsening matters, local health departments have lost 15% of their workforce since 2008.[16] Significant personnel losses result in declines in capacity, as evidenced by reduced programs and services, including emergency preparedness efforts, in 40%of public health departments nationwide.[16]

To prevent the further erosion of the gains we have made since 2001, the U.S. should restore funding for these programs to at least their 2005 levels. Though money is scarce across all levels of government, this is a small but important investment relative to the substantial health and economic losses that can occur when outbreaks are not detected and contained in a timely manner because biosurveillance systems have been cut.

Improve Data Integration

The next important goal is integration of data across multiple sectors, a goal that may be more difficult to achieve but that is worth attempting. The more we can integrate healthcare and public health data with data from intelligence, law enforcement, and private sector sources, the better off we will be. Data integration could shave precious time from the weeks or even months that it can take now to identify the source of an outbreak, develop a successful control strategy, and prevent unnecessary illness and death.

During the 2011 E. coli outbreak in Europe and the 2008 Salmonella outbreak in the U.S., it was private sector supply chain and shipping data that proved most useful in identifying the contaminated sources responsible for those foodborne outbreaks.[17] In a biological attack, information from law enforcement and intelligence will be critical, as was the case in 1984, following an outbreak of salmonellosis in Oregon. It was a law enforcement investigation that traced the source of that outbreak to a cult seeking to influence the outcome of an election by perpetrating a biological attack.[18] Before the source was definitively identified, a public health investigation had concluded that the outbreak was likely caused by poor hygiene among food handlers at local salad bars.[19]

Unfortunately, in many places communication between public health agencies and other entities that might play an important role in biosurveillance happens largely on an ad hoc, relationship-driven basis. Congress tried to address this problem in 2007 with passage of the “Implementing the Recommendations of the 9/11 Commission” bill, which calls on the Department of Homeland Security to develop a National Biosurveillance Integration Center (NBIC) to coordinate biosurveillance across the federal government.[20] Whether NBIC will continue to have this mission remains to be seen, but the USG should work to integrate the information that exists across federal agencies.

What would be worth exploring now is creation of a dedicated interagency process for conducting joint analyses of biosurveillance information on a routine basis and during national emergencies. Any such process would have to be clearly defined, have a clear governance structure, and include provisions for sharing analyses with state and local partners that contribute data to federal biosurveillance programs.

Preparing for the Next One

Although the number of new human cases in Europe appears to be on the decline, the fallout from the outbreak is just beginning. Many of those who survived their E. coli infection will likely require expensive, life-altering, long-term treatments, such as dialysis. This is expected to place additional strain on hospitals, which are already struggling from budget cuts following Europe’s economic troubles.

U.S. outbreaks and Europe’s recent experience are reminders of the significant consequences of not being able to connect the dots in order to efficiently contain outbreaks. While we may not be able to prevent future outbreaks, we can mitigate their effects by developing better biosurveillance tools, shoring up state and local surveillance programs, and improving integration of biosurveillance data.

References

  1. Frank C, Faber MS, Askar M, et al; HUS investigation team. Large and ongoing outbreak of haemolytic uraemic syndrome, Germany. Eurosurveillance 2011;16(21):1-3.

  2. Kupferschmidt K. Cucumbers may be culprit in massive E. coli outbreak in Germany. Science Insider May 26, 2011. http:// news.sciencemag.org/scienceinsider/2011/05/cucumbers-may-be-culprit-in-mass.html. Accessed July 28, 2011.

  3. Tremlett G, Pidd H. Germany admits Spanish cucumbers are not to blame for E coli outbreak. guardian.co.uk May 31, 2011.http://www.guardian.co.uk/uk/2011/may/31/e-coli-deaths-16- germany-sweden. Accessed July 28, 2011.

  4. Cowell A. Germany says bean sprouts are likely E. coli source. New York Times June 20, 2011. http://www.nytimes. com/2011/06/11/world/europe/11ecoli.html. Accessed July 28, 2011.

  5. Kanter J. French E. coli episode seems isolated, officials say. New York Times June 26, 2011. http://www.nytimes. com/2011/06/27/world/europe/27ecoli.html. Accessed July 28, 2011.

  6. European Food Safety Authority. Tracing seeds, in particular fenugreek (Trigonella foenum-graecum) seeds, in relation to the Shiga toxin-producing E. coli (STEC) O104:H4 2011 outbreaks in Germany and France. EFSA/ECDC Joint Rapid Risk Assessment June 29, 2011. http://ecdc.europa.eu/en/publications/ Publications/2011June29_RA_JOINT_EFSA_STEC_France.pdf. Accessed July 28, 2011.

  7. Goodman A. Warning lifted against Spanish cucumbers suspected in E. coli outbreak. CNN June 1, 2011. http://www. cnn.com/2011/WORLD/europe/06/01/spain.germany.e.coli/ index.html. Accessed July 28, 2011.

  8. Norman L. E.coli row could overshadow EU-Russia summit. Wall Street Journal June 9, 2011. http://online.wsj.com/article/ SB10001424052702304392704576373720030940058. html?mod=googlenews_wsj. Accessed July 28, 2011.

  9. E. coli outbreak hits German retail sales in May. Reuters June 30, 2011. http://in.reuters.com/article/2011/06/30/ idINIndia-58006420110630. Accessed July 28, 2011.

  10. Willis A. EU agrees compensation deal for bacteria-hit farmers. EUObserver June 15, 2011 http://euobserver.com/9/32490. Accessed July 28, 2011.

  11. Peterson M, Bjerga A. FDA seeks $1.4 billion for food-safety law as budget faces cuts. Bloomberg July 6, 2011. http://www. bloomberg.com/news/2011-07-06/fda-seeks-1-4-billion-for-food-safety-law-as-budget-faces-cuts.html. Accessed July 28, 2011.

  12. U.S. Centers for Disease Control and Prevention. Investigation of outbreak of infections caused by Salmonella Saintpaul. August 28, 2008. http://www.cdc.gov/Salmonella/saintpaul/jalapeno/. Accessed July 28, 2011.

  13. Toner E, Nuzzo J, Watson M, et al. Biosurveillance where it happens: state and local capabilities and needs. Biosecur Bioterror 2011;9(4).

  14. National Biosurveillance Advisory Subcommitee. Improving the Nation’s Ability to Detect and Respond to 21st Century Urgent Health Threats: First Report of the National Biosurveillance Advisory Subcommittee. April 2009. http://www.avma.org/ atwork/NBASreport072209.pdf. Accessed July 24, 2011.

  15. U.S. Centers for Disease Control and Prevention. Public Health Preparedness: Mobilizing State by State. February 2008. http:// www.bt.cdc.gov/publications/feb08phprep/pdf/feb08phprep. pdf. Accessed August 8, 2011.

  16. National Association of County and City Health Officials. Local health department job losses and program cuts: findings from January/February 2010 survey. Research Brief. May 2010. http://www.naccho.org/topics/infrastructure/lhdbudget/upload/ Job-Losses-and-Program-Cuts-5-10.pdf. Accessed August 8, 2011.

  17. Pew Charitable Trusts’ Produce Safety Project. Lessons to Be Learned from the 2008 Salmonella Saintpaul Outbreak. November 17, 2008. http://www.pewtrusts.org/uploadedFiles/ wwwpewtrustsorg/Reports/Produce_Safety_Project/produce_ safety_Salmonella.pdf. Accessed July 24, 2011.

  18. Carus S. Working Paper: Bioterrorism and biocrimes: the illicit use of biological agents since 1900. February 2001. http:// www.dtic.mil/dtic/tr/fulltext/u2/a402108.pdf. Accessed July 24, 2011.

  19. Ill handlers suspected in Oregon food poisonings. New York Times October 21, 1984. http://www.nytimes. com/1984/10/21/us/ill-handlers-suspected-in-oregon-food-poisonings.html. Accessed July 24, 2011.

  20. Implementing Recommendations of the 9/11 Commission Act of 2007 (9/11 Commission Act). Pub. L. 110-53.