Biosurveillance Targeting And Critical Information Requirements

Previously we discussed the difference between detection, recognition (which included prioritization of threat), and warning.

In this case, let's use the example of ProMED, which certainly delves more into the recognition aspect of the detection-warning cycle.  Here you have subject matter experts curating information from the firehose of input available on the internet on a daily basis.  They often provide excellent context and background information, forming collaborative partnerships with such terrific groups as GIDEON.  GIDEON is essentially a "living textbook" of information on infectious disease  worldwide.

But ProMED has had its detractors over the years, having adopted a now-archaic (by social media standards) form of community dialog.  ProMED is heavily moderated, which is a good thing when considering all the potential garbage that could hit the system.  However, it does introduce substantial time delays, which relegates the system to a forensic, after the fact operational posture.  Further, you will often see bias exhibited in displaying "what's hot and sexy" versus a particular subject matter expert's interest.  In other words, it is a mish-mash of things happening around the world without a clear sense of what is truly relevant and important.

But how does one establish relevance?  That is indeed the question, and the same one we dealt with in the DHS National Biosurveillance Integration Center (NBIC).  During that time, we observed that many agencies actually did not even have a prioritized list of issues they monitored on a daily basis.  The concept of critical information requirements from the military operational environment had not permeated the analyst watch cells we interacted with.  Of course, this created tremendous confusion regarding what to warn about on the back end.  ... And it took hours and hours of discussion for people to arrive at an integrated agreement on what pathogens take priority, particularly when having this discussion among physicians, veterinarians, public health officers, etc.

We would see CDC, for instance, obsess about an isolated outbreak of Ebola in Africa that was hundreds of clicks from the nearest airport and completely ignore reports of an unusual respiratory disease in southern China.  When dealing with limited ground verification resources, this poses quite the conundrum when our stateside first responders may encounter the infectious agent in question before warning is issued by a national authority, as what happened during the 2009 H1N1 influenza pandemic.  Certainly Ebola is far more "sexy" than influenza... but one is clearly more acutely and broadly disruptive to a society than the other.

So let's examine some examples:

• Anthrax in Argentina.  In this particular report, it is unclear why the outbreak was brought to the entire world's attention.  Does this outbreak exhibit unusual epidemiological features?  Does it exhibit any suspicious features?  Is it reflective of a concerning long term trend?  It would seem this kind of report should be tagged as a "routine event".
• Oseltamivir-Resistant Pandemic H1N1.  Now this is of casual interest, albeit not at the top of our list.  It is of course good for clinicians to know where we are in terms of drug resistance, but certainly not an unexpected phenomenon.
• NDM-1 Enterobacteriaceae In India's Water Supply.  This is a slow-moving threat of high impact, highlighting the challenge of prioritizing fast-moving, potentially acutely disruptive threats versus slow-moving insidious phenomena.  This is clearly an important warning to the world, however certainly of far greater immediate relevance to the people of New Delhi than here in the United States.  Of course, the definition of a crisis depends entirely on perspective.
• Influenza A/H3N2v In The United States.  This particular issue is at the top of our monitoring list.  But it is an interesting example because we likely would never have noticed this phenomenon just a few short years ago thanks to technology.  This would be an example of the odd dichotomy of better technology yielding greater social vulnerability to anxiety as a result of being able to percieve more threats.  The phrase "ignorance is bliss" of course is relevant here.  But that said, this is a top issue because of the opportunity to explore shortening of the time delta between detection / recognition / warning and response.  While we in the United States are singularly concerned with this issue, the people of Haiti would probably not see this as particularly concerning because they are still dealing with cholera and the myriad of other more morbid and mortal infectious disease endemic to their country.  Again the problem of perspective.

ProMED certainly has a problem trying to be all things to all people, with is a tar pit operationally.  In recent years we have seen multiple appeals for funding vis a vie the Jimmy Wales / Wikipedia Syndrome of proving a great service to the world, creating an expectation for that service, but not establishing a business plan to sustain that service before creating the social expectation in the first place.

Use of prioritized information requirements to structure the outputs is important, as it does create some degree of an edge to the reporting scheme.  It also tightens the screws on the plate of accountability, where issues detected, recognized, prioritized, and warned are more visibly displayed to the international community for their consideration.  But this kind of process requires another level of analysis by moderators and indeed, the user community.  This is ultimately important because we as a global community simply cannot react to all things all the time.