Operational Biosurveillance

Operational Forecasting of Antimicrobial Resistance

We now have the ability to provide operational forecasts for antimicrobial resistance.  This is going live at the Black Canyon Infectious Disease Forecasting Station soon.

Forecasting Influenza Vaccine Mismatches Is Now LIVE

We are now providing accurate operational forecasting of seasonal influenza vaccine mismatches.  This information is now being used clinically. 

A Gap in Situational Awareness: A/H3N2v in the United States

The last public update from CDC regarding the status of A/H3N2v in the United States was January 6, referring to information end-dated (and originally posted) on December 23rd (exactly one month ago).  This update did not reflect test results for the Marin County suspect case.  The January 6th MMWR Editorial Note stated:

Human infections with the influenza viruses currently circulating among swine are rare. Since 2005, only 35 cases have been reported in the United States, but the frequency with which they have been detected increased in 2011. When different influenza viruses simultaneously infect a single host (e.g., a human or swine), exchange of genetic material can occur, resulting in a new influenza virus. Depending on the antigenic distance between the new virus and recently circulating seasonal viruses, little or no immunity might exist in the human population.

Despite this apparent concern, situational awareness has been scant, with substantial time deltas between detection and warning noted.  The latest Flu Weekly provides no information on A/H3N2v antigenic characterization.  There is no indication of "samples received for testing" versus "samples actually tested".  Therefore the lab processing backlog is in question.

Put another way:

 

"What is the status of A/H3N2v in the United States???"

 

 

 

 

The Operational Biosurveillance Version of the "Arab Spring"

Recently we released documentation provided to the US government regarding the world's first operational National Weather Service-inspired infectious disease forecasting center and the first such station in the United States. 

One scientist from a US national laboratory called this the "SPRING REVOLUTION OF BIOSURVEILLANCE", with reference to the social media-facilitated Arab Spring, one of the biggest social events of the decade.  We tend to agree (albeit with obvious bias), for we now view clinical medicine in an entirely different light. 

I was recently at a Beacon Community conference, where Farzad Mostashari was present as a keynote speaker.  With a bit of mischief in mind, I walked up to him, introduced myself with a small bit of operational background thrown in, and proceeded to tell him the first infectious disease forecasting station in US history was just activated in a Beacon Community participating clinic.  Needless to say that got a few stares. 

We engaged in a back and forth about what one would do with a forecast for asthma exacerbation (which, for some children, is triggered by infectious disease activity).  He suggested a friendly call to the parent to remind them to use their inhaled steroid.  I told him it may be even more compelling than that- in the most brittle asthmatics we may be looking at the prescription of oral steroids before the exacerbation has even begun.  He said, "Prove the case."

 

Fair 'nuff.  The Biosurveillance Spring has arrived.

 

 

 

Official Documentation of the World's First Infectious Disease Forecasting Center

This report was submitted to the US Government in September 2010 for internal publication.  This was official documentation of the existence of the world's first infectious disease forecasting center. 

Disaster Conditions Declared in Pestel, Grand Anse, Haiti

The Haiti Epidemic Advisory System (HEAS) is scrambling now to issue an Emergency Appeal, as cholera has most certainly reared its head yet again, this time in Grand Anse with 445 cases and 59 fatalities.

The Local Infectious Disease Forecasting Station: "Partly Cloudy With A Chance Of Vomiting"

"Game On": we are now in a new era of operational biosurveillance, specifically the routinization or socialization of infectious disease forecasting such that local communities around the world become used to, and expect, access to highly detailed infectious disease forecasting information.

The intent of this blog is to promote a vision for the world.  The vision of infectious disease forecasting and promotion of better situational awareness that is relevant to the daily public.  Certainly we discuss controversial world issues such as biodefense, biological warfare, bioterrorism, genetic engineering, and so on, but at the end of the day people continue to lead their daily lives as they should.  This is not to say these high level issues are not worthy of costing a few analysts' their sleep, but national security begins at the local community level with the promotion of resilience.

This was the lesson we learned in Haiti, where engagement of local Haitians provided awareness of the introduction of cholera, which was later labeled by the Haitian government as a national security issue.  Either way it could be argued such an accident might have eventually occurred anyway given the flow of humanitarian traffic to this extremely vulnerable area of the world.  The point is if forecasts hadn't been issued by the HEAS, and a social network representative of an invested community that included local Haitians hadn't rallied together around those forecasts and situational awareness, they would not have been primed to recognize non-routine infectious disease activity.  ...And display such incredibly rapid response convergence around that information.  This experience changed many of the responders' lives, including my own, and left us with an extremely strong sense of devotion to the concept of local community resilience. 

This of course sounds like an entirely different world than our current reality of forecasting routine endemic infectious disease in a rural community.  But it isn't.  What is happening is we have a tremendous demand from our patients to have access to the forecasts- down to a highly granular level of information.  Similar to the public demand for access to temperature, humidity, and air pressure readings in meteorology.  Personally, I do not fully understand the relationship between high and low barometric readings on the news and usually igore it.  I'm far more interested in whether it will rain or snow.  But we have air plane pilots, for instance, that do care about that information. 

In the world of local community infectious disease forecasting, we have the same kind of variation in patient interest in the information: 

• I have parents that want me to sit down with them and review the forecast but then want me to "keep them posted", content that their physician understands their local "health intelligence" at such a granular level and is prepared to inform them of emerging risk. 
• I also have parents who have a brittle asthmatic child whose triggers for a severe asthmatic exacerbation include respiratory viral infection and agricultural burning or forest fire smoke.  These children are so sensitive, they can rapidly require hospitalization, admission to the intensive care unit, intubation and ventilation, or transfer to a major critical care center.  We track near-real time satellite imagery so that we are able to give these parents a "heads up" with several days' advance notice of wildfire smoke that may be vectoring into the area.  This is in collaboration with the US National Oceanic and Atmospheric Administration (NOAA), and we are profoundly thankful to them for their hard work.  We also share the infectious disease forecast which multiple infectious agents we know are capable of triggering an asthmatic into exacerbation.  One of these families told me that hospitalization of their child (who is extremely sensitive to agricultural burning and wildfire smoke) is so incredibly disruptive to their family and expensive, they were inclined to pack the family into the car and leave the area until smoke had cleared if they were given a 3-day forecast.  This is of course an extreme example, but indicative of the impact these forecastable health conditions are to our clientele.
• Then I have another family that has had a horrid time with plantar warts.  All three of their kids were infected, two of whom had warts as large as 1 cm in diameter.  They came in about every two weeks to have these warts sanded and scraped down with a scapel, cryofrozen, and treated with canthacur.  It took multiple treatments, each about 30 minutes in the clinic.  This seemingly insignificant example was, however, quite significant to this family who had certainly better things to do with their time and wanted to avoid another occurence.  So they asked about a forecast for plantar warts along with guidance for how to avoid exposure, which we provided.
• And then we have yet another family whose child is immunocompromised and runs around with face mask on.  They worry about taking her to the local grocery store or the movies when there is high infectious disease activity.  So they are keenly interested in the detailed, line by line forecast.

I often reflect on Haiti and the heartbreaking misery and heart-warming joy of the people there and remember my time with them as we move forward in rural America.

Anthrax in Rhodesia During the Front War (1978-82): A Suspected Act of Biological Warfare

Exerpt from an upcoming publication:

From 1978-82, an epizootic of anthrax appeared in Rhodesia in the context of the Front War, where the minority European-controlled government fought a losing engagement against Maoist- and Soviet- backed African forces.  Ultimately, they lost but not before South African-supported Selous Scouts engaged in biological and chemical weapons development.  It is believed these activities in Rhodesia and similar incidents in Namibia were a research and development prelude to the South African Project Coast.

A documented 10,700+ human cases and an untold tens of thousands of cattle deaths were documented in Rhodesia at the time covering an estimated 200,000 km².  There were of course multiple unusual, non-routine epidemiological features documented at the time, not the least of which consideration of the prior baseline of case reporting in Rhodesia:

Figure 1.  National level baseline reporting of human anthrax cases in Rhodesia from 1926-1977.

An astounding shift in epidemiological pattern upon the onset of this infectious disease disaster (i.e. an IDIS Cat 5), where the above statistics were recorded at the national level.  The below was recorded at the provincial level and at a single hospital, respectively.

Figure 2.  Midlands Province, Rhodesia: documentation of human anthrax cases.

Figure 3.  Number of hospitalizations and fatalities due to anthrax, Beatrice Road Infectious Diseases Hospital.

The transmission intensity at Beatrice Road was such that they saw all clinical forms of anthrax: cutaneous, inhalational, gastroenteric, septic, and meningitic.  These are photographs of some of the victims (credit: JCA Davies):

Many notable anthrax experts provided their opinion of this event being a "perfectly natural" epizootic in the context of a collapsed veterinary infrastructure during the Front War.  We disagree.  Details to follow in an upcoming publication.

One of the strongly suspected perpetrators who worked with the Selous Scouts- a man we interviewed on several occasions- was bludgeoned to death this year by unidentified assailants.

 

 

The First National Weather Service-Inspired Infectious Disease Forecast Station in US History

To our knowledge, this has not been done before- activation of a comprehensive, integrated infectious disease forecasting station in the United States.  The precidence was the Haiti Epidemic Advisory System (HEAS), which was the first operational comprehensive infectious disease forecasting center in the world.  Here is one output of the station: the Delta County Memorial Hospital "Kids Wellcast^TM", expressed in language the local community is able to understand. This is the barest thumbnail of the full forecasting power of the station.

Enter 21st century medicine, where patients are now empowered with information to anticipate dozens of infectious diseases... forecasted like the weather.  We use these forecasts in daily clinical care for our pediatric patients. 

 

... Game on.

 

 

 

GAO: Nonfederal Capabilities Should Be Considered in Creating a National Biosurveillance Strategy

We were reminded by one of our readers of the Oct 31, 2011 GAO report titled Nonfederal Capabilities Should Be Considered in Creating a National Biosurveillance Strategy, which is a somewhat misleading title.  One might think they finally "got it", but then fell short:

 In order to help build and maintain a national biosurveillance capability in a manner that accounts for the particular challenges and opportunities of reliance on state and local partnerships, the Homeland Security Council should direct the National Security Staff to ensure that the national biosurveillance strategy

(1) incorporates a means to leverage existing efforts that support nonfederal biosurveillance capabilities,

(2) considers challenges that nonfederal jurisdictions face in building and maintaining biosurveillance capabilities, and

(3) includes a framework to develop a baseline and gap assessment of nonfederal jurisdictions' biosurveillance capabilities as part of its implementation of our previous recommendation for a national biosurveillance strategy.

The GAO staff state the obvious: that local capacity, coupled to state capacity, is the base of the pyramid of support for a national capacity for integrated biosurveillance within the official hierarchical chain of bureaucracies.  However the insular Beltway bias continues to be directed along the axes of official bureaucracies, ignoring the reality of integrated operational biosurveillance: that a significant proportion of capabilities and capacities resides outside the federal, state, AND local official bureaucracies.

This should have been apparent when we provided ironically prophetic Congressional testimony directed specifically at the DHS National Biosurveillance Integration Center, which was of course ignored.  Then came the 2009 H1N1 influenza pandemic, for which NBIC was essentially impotent save for after-the-fact situational awareness.  It is unfortunate we were unable to provide them with assistance when it was offered.  At this time, analytic competency resided outside of the federal, state, and local governments.

Then we had Haiti.  Needless to say, it took a 1,000-member "village" to manage detection / recognition / warning / emergency response operations in Haiti via the Haiti Epidemic Advisory System (HEAS).  This too was another example of expertise residing outside of the federal, state, and local governments.  Let it be said that the official bureaucracies performed less than optimally in Haiti.  The HEAS provided a significant role in the initial detection of cholera in Haiti, recognition of the likely source of cholera, and multiple forecasts for multiple infectious disease events that guided responders to saving entire villages with enough precision to guide helo drops. 

Time for the GAO to understand a broader reality.  More "surprises" to come in the very near future that will further emphasize this point.