Operational Biosurveillance

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.

 

 

 

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.

 

 

The Academic-Operational Reality Gulf and the Debate of H5N1 Experimentation

We often see academics from many scientific discipline weighing in on health security issues.  Much of this opinion represents healthy discourse as the global community struggles with a challenging issue.  However, the transmission of memes may sometimes backfire and reveal assertions that are misleading or wrong.  Assertions that begin to circulate around the Internet.  During these times, the sometimes dramatic gulf between academia and operational reality becomes apparent. 

This ongoing debate is one example.  What is most impressive is the gap in understanding of the realities of biological event detection, recognition, and warning and the coupling of that information to response and understanding how vaccines are currently produced.

Social Media, Public Health Accountability, and The Positive Outcome

If one examines every CDC Flu Weekly report since the 1997-1998 season, one notices stretches of editorial errors and careless data transcription in the early years.  It is almost as if those filling out the reports intuitively knew most people didn't bother to read the deeper complexity of the information- specifically that describing antigenic testing and compatibility with vaccine strains.

After SARS, H5N1 emergence in Asia, and the 2009 H1N1 influenza pandemic, many more are paying attention to the information.   Here in Operational Biosurveillance and elsewhere people noticed the emergence of A/H3N2v being reported and viewed it as an opportunity to tell CDC "here's your chance to make right".  Indeed that appears to be happening, with seed stock being moved to the vaccine manufacturers and very quickly thereafter movement to clinical trials.  These are good measures of progress for an agency we've grown quite frustrated with over the years. 

We are pleased to finally see guidance for clinicians trying to make the difficult decision in the context of an economic recession whether to test for influenza in their patients (i.e. children):

Currently, while there are  low levels of circulating seasonal influenza viruses, CDC recommends increasing collection of specimens from patients with influenza-like illness (ILI) , and having these specimens sent to the state or local laboratory for prioritization for rRT-PCR testing. States should specifically consider increasing collection of specimens from patients presenting with ILI in the following high priority areas:

1. ILI outbreaks, particularly among children in child-care and school settings, since these have been the settings associated with human-to-human influenza A(H3N2)v virus transmission.
2. Unusual or severe presentations of ILI, especially among children.
3. Medically attended ILI and ARI in children under 18 years of age

Our only nit-pick with the recommendations (albeit an important one) is to suggest that pediatricians should at least test medically attended ILI and ARI in children under 18 years of age who were vaccinated for this season's influenza.  This is a loose call at this point given the low number of cases identified so far, however it may overcome social reluctance to test.

We have pinged several physician and pediatric social networks to raise this issue to their attention- that testing children with influenza-like illness may enable quicker decision-making for response.  That we have an opportunity to shorten the time delta to having a vaccine if we need it for our patients.  However we still see "pandemic fatigue" and desensitization to anything related to the word "pandemic".  And yes, with all the talk of healthcare spending cuts physicians do appear to hesitate to test for fear of denial of coverage by insurance.  In our patient population, we hesitate to test because our patients are at poverty level already, without insurance, without Medicaid, and may be paying in cash.  Often these are our sickest patients and the very ones we should test. 

But this entire phenomenon of holding public health accountable for faster reporting of A/H3N2v, transparency in the decision process to move vaccine through trials just in case, and enhanced media visibility to, let's face it, a bare few cases that would have escaped notice just a few short years ago.  Technology does make us more vulnerable because we don't have as much ignorance to be blissful about.  But social media holds us nevertheless responsible for this information and the actions implied by that information.  One only needs to see the hashtag "H3N2" on Twitter to see the wave of social sensitization. 

Here we are hopeful that the convergence of better laboratory diagnostics, risk communication, transparency in response operations, and the accountability provided by social media brings positive change in public health.  And positive change improves our nation's resilience in the face of infectious disease crises.

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.

 

 

Biosurveillance: The Difference Between Detection, Signal Recognition, and Warning

For the last 15 or so years, we have seen an explosion of different electronic disease surveillance systems emerge.  Everything from laboratory diagnostics and reporting systems to syndromic surveillance to using the internet for so-called "event-based surveillance".  And there has been a virtual orgy of academic frenzy around the "bright lights and shiny object" effect of the technology.  This is representative of billions of taxpayer dollars over these years dispensed from a variety of federal mechanisms.

Yet, with all of this expenditure (much of which is ongoing), we have still so very little proof of operational value.  The "research and development ice cream cone" continues to lick itself without any apparent metric held by the funders for the operational "so what".  Arthur Reingold's challenge points from 2003 still appear to be unanswered ten years later.  Below, his points have been adjusted to fit a more broad consideration of the topic:

1. Demonstrating that [x, y, z type of] surveillance reduces morbidity and / or mortality following [an infectious disease crisis / disaster].
2. Types of [infectious disease crises / disasters] that [x, y, z type of] surveillance is likely to detect.
3. Response to apparent increases in illnesses signaled by [x, y, z type of] surveillance.
4. Plausibility that [x, y, z type of] surveillance can yield more timely identification of the population at risk in [an infectious disease crisis / disaster].
5. Likelihood that [x, y, z type of] surveillance will produce useful information about naturally occurring infectious diseases.
6. Circumstances under which [x, y, z type of] surveillance is likely to strengthen local and state health departments.

Certainly Reingold was not the only person during the heyday of syndromic surveillance to raise questions about the validity of the approach, but the gist of the above challenges were echoed several times in the literature.  But the academics lept onward undeterred, and the marketing associated with their programs grew to astounding levels of claimed accomplishments.

One such claim was that made by John Brownstein of HealthMap on Aug 3rd at an IARPA OSI Program Proposer's Day, who stated (paraphrased) that HealthMap was "the first surveillance system in the world to detect and publicly report the 2009 H1N1 influenza pandemic".  This impressive claim invokes scrutiny into the defintion of detection and how it applies to evaluating any disease surveillance system... and of course, the taxpayer funds associated with that program.

Merriam Webster defines the word detect as

1. to discover the true character of;
2. to discover or determine the existence, presence, or fact of
   

Webster's definition of recognize goes deeper than detect, however:

1. to acknowledge formally;
2. to acknowledge or take notice of in some definite way;
3. to perceive to be something or someone previously known

However it is the word's Latin origin, cognoscere that brings this point into focus.  Cognoscere means to know.  Of course the word know implies that a human being's mental processes have been engaged.  Which implies 1) there is a human being looking at the data and thinking about it. 

The definition of warning is provided by Webster as:

1. to give notice to beforehand especially of danger or evil
2. to give adminishing advice to
3. to call to one's attention

So this implies a human being, having thought about the data, has recognized and prioritized a concern... and communicated that specific concern to others.

The analytic team that warned the senior health intelligence officer in CDC's Director's Emergency Operations Center (DEOC) noted at the time that HealthMap's information was 1) not posted on their website as fast as the original Mexican source posting 2) was not highlighted in any unusual way to call singular attention to the information among dozens (hundreds?) of other colored pins on their map, and 3) where was no transfer of information to ProMED or CDC from HealthMap evident to suggest that human beings had communicated about the information during early to mid April 2009.  Therefore, the following may be concluded:

1. The first point of detection was actually the Mexican journalist who wrote the first article on the La Gloria situation.  HealthMap simply functioned as a Google News parser- a function anyone could have performed using Google Alerts.  If you happened to click that one pin on the map, you would have 'seen' the report, albeit then you would have to understand whether what was being reported was unusual...
   
2. Human beings were required to recognize unusual indicator patterns in the initial reports (n=1 to 3), not through recognition of simply volume of reporting as captured by HealthMap's Heat Index. 
3. Human to human communication clearly had to occur to push the warning through, as information provided via pull websites and push email notifications were inadequate due to daily information overload at WHO and CDC.

The point of the above is not to singularly criticize HealthMap but to make a point: collection of data is insufficient, by itself, to generate operational impact.  This was a very hard lesson learned by the syndromic surveillance community as well.  And if you are fighting an embedded, decades-old professional culture imbued with a "not invented here" bias (i.e. public health), it is unlikely the data will be exploited properly.

So let's give Brownstein a break for a minute and focus on one of his collaborators: the Canadian Global Public Health Network (GPHIN).  Brownstein's claim at the IARPA meeting was a duplication of GPHIN's claim to the world of having been the first public health system to detect SARS (see attached manuscript, Figure 1). However there was unverified rumor at the time that the web-harvested Chinese media article published on Nov 27, 2002 went unnoticed by GPHIN's staff for some time due to lack of machine translation for Chinese (unverified) and lack of a Chinese linguist.  Even if these rumors were false, and GPHIN's system immediately punched a warning out to its customers, there is no evidence anyone was paying attention.  In the multiple manuscripts and powerpoints given by GPHIN staff, not one contains copies of emails or phone records to indicate human beings had 1) recognized the problem, 2) prioritized the problem (out of the dozens of other reports for the day), and 3) communicated directly with the Canadian PHAC, the US CDC, or WHO specifically about this prioritized problem.  This is concerning when considering how much information was actually missed at the time (see attached report by Polyak et al).

The analogy is football: it's like being thrilled you threw a "Hail Mary" pass, but unawares that 1) no one caught the ball and 2) ran it to the end zone... 3) and thus you lost the game in the process.  Sound familiar?  It should.  These are very similar issues to those in the original 9/11 Commission Report.

Currently the federal government continues to chase its tail, spending more funds on biosurveillance research: the self-licking ice cream cone.  Billions of dollars and 10-15 years later, we still are not holding these systems' collective feet to the fire asking "show me don't tell me".  We continue to reach for the bright lights and shiney objects represented by the latest fad technology ("social media" being the current one) without thinking about how to promote the human process of understanding the data, accumulating knowledge, and using that knowledge to impact the potential outcome of the threat.

These are lessons currently highlighted in the recent IOM report on the DHS National Biosurveillance Integration Center (NBIC), however the problem is far bigger than just NBIC, DHS, or the people funded by DHS.  This is a biosurveillance community-wide problem that affects the credibility of the entire field. 

And if we do not fix it, the funding and public support may eventually disappear.

Download GPHIN Manuscript

Download Emergence of SARS in 2002

 

 

 

False Alarms: A Standard to Strive For

Recently the Germans issued an alarm of what would have been the first publicly recognized translocation of a human Rift Valley fever (RVF) infection from endemic areas in Africa to a temperate zone country.  We applaud them for their proactive release of this information, regardless of it being a false alarm. 

This alarm brought contemplation of the potential impact RVF would have if introduced in a country with transmission-competent mosquitoes and an immunologically naive cloven-hoofed animal and human population.  Many in the agricultural industry consider RVF to be every bit as potentially devastating to livestock exporting country's economy as hoof and mouth disease (FMD) if that country was previously RVF and FMD-free.

It is notable there was not a strong negative reaction (in fact, we have not seen any) to the false alarm.  This is an excellent outcome.  We do not want to get into the habit of penalizing or discouraging reporting if it is later found to be a false alarm.  As general surgeons know, it is good to maintain a 10% rate of normal appendix removals so that none infected are missed.  Same principle here: we cannot afford to miss an introduction of RVF or be slow to react if an introduction is suspected.  Better to react and be wrong than to be slow to respond or hesitate and invoke serious damage to a national economy.

An imprecise but relevant comparison is the example of Vancouver's proactive response to situational awareness during SARS versus Toronto in 2003.  Another example was presented to me just this week where I interviewed an adult infectious disease specialist whose differential diagnosis and index of suspicion was altered to consider West Nile virus as he monitored the westward spread of the virus through the southern states.  He was subsequently the first person to diagnose a case of West Nile in the county in a patient with an unusual presentation of encephalitis.  Presensitization is a key component to successful detection of an index case arriving at the recipient end of a translocation.

This then raises the question of the relevancy of informing local communities in non-endemic countries such as the United States about RVF in South Africa.  When should a local medical or veterinary community be aware of such outbreaks?  Presensitization is key to successful rapid detection of exotic cases.  Therefore, decision points to inform should be biased to inform rather than not.    

As demonstrated during the 2009 influenza pandemic, the introductions of HIV/AIDS, West Nile virus, and several other key infectious disease translocation events, the social reaction to perceived withholding of information is far more severe than the issuance of a false alarm.  This has long been an observation of the disaster sociology community, a point public health after so many decades should internalize and embrace as a standard of practice.

Biosurveillance: A Vehicle for Accountability

As discussed previously, biosurveillance outputs become a vehicle for accountability.  We believe this is a major reason for resistance by bureaucratic organizations.  A more extreme consideration of this problem may be seen in closed societies, where one of the key information sectors controlled by totalitarian regimes is public health surveillance data. 

When considering a national security perspective, there was a time when meteorological data was classified because of wartime concerns about informing the enemy of perfect conditions for a bombing run or chemical weapon deployment.  Of course, one of the key objectives of biosurveillance is a comprehensive understanding of the multi-faceted baseline of infectious disease.  This baseline must be understood pan-species, with a full understanding of the entire expanded taxonomy of indicators and how they differ by season, culture, disease, and other contexts.  Only then may the unusual or non-routine events be flagged for closer time-sensitive scrutiny.  It is not difficult to understand when biosurveillance information becomes sensitive given the context.

The public health perspective is driven heavily by direct interaction with the public and all the politics that surrounds that interaction.  For most countries, the public health apparatus is driven towards gold-standard epidemiological investigation and laboratory confirmation prior to communication with the public.  The persistent misconception the public will "panic" upon receipt of health threat information remains a global problem.  The multitude of peer-reviewed literature from the disaster and warning sociology communities remains largely unincorporated in public health.  With this forensic, risk adverse posture, public health becomes the analogy of the pathologist placed in charge of an emergency room.  The very nature of warning is a tolerance of false positive information and an embrace of uncertainty- with effective and timely communication of that uncertainty to the public.  This overlaps heavily with the basic tenets of risk communication.  As readily observed during the 2009 influenza pandemic, effective risk communication relates directly to public health credibility with the public.  This hesitation in issuing warning information plays right into an erosion of public trust.  As mentioned before, we are dealing with active resistance to implementing the Haiti Epidemic Advisory System, the world's first infectious disease forecasting system.

Recently InterAction, a select group of the world's largest NGOs, responded to allegations of donor money withholding and failure to execute proper response on the ground in Haiti.  They declared, "NGOs are part of the solution, not the problem".  As the executive director of an NGO, I am circumspect enough to say, "Perhaps". 

But I sit in a unique position of facilitating operationally sensitive information sharing to save lives.  Specifically in the case of Haiti, children's lives.  The stakes are imminent and high, and I have seen many of the InterAction partners flatly deny sharing information about infectious disease prevalence with the responder community.  How it is done currently is each organization separately send data in a spreadsheet once per week to the Haitian Ministry of Health where over the course of a week, it is analyzed, and presented as aggregated to the city level.  Each organization rarely talks with each in the course of the week to highlight abrupt changes in the disease baseline that may herald the beginning of an epidemic the entire responder community should be aware of as soon as possible.  We have made some degree of progress with this problem in the Haiti Epidemic Advisory System, where three of the major NGOs on the ground in Haiti have shared critically important information about infectious disease prevalence they have documented in their clinics.  They are to be strongly commended for this, and it is our hope we are witnessing a new era in NGO information sharing.

We must arrive at a point where we observe the basic human right of providing an environment of uninhibited access to health information for those we serve.  Let us continue to walk this road, and walk like we have a purpose.

Observations Regarding the Implementation of the Haiti Epidemic Advisory System

We have successfully triggered a social network to support reporting of disease events in Haiti called the Haiti Epidemic Advisory System (HEAS). We now have 150 members with representatives from nearly every major NGO, smaller NGOs, unaffiliated clinicians, and key Haitian authorities. What we have executed is a system that mirrors a basic sociological process we have seen in many other operating environments to support warning functions such as:

• The World Health Organization IHR reporting system (official, publicly visible) versus ProMED, the Global Outbreak Alert and Response Network (GOARN), and the now-defunct World Health Organization Outbreak Verification List (OVL) systems (unofficial, offline).
• The National Biosurveillance Integration Center (official) versus the BIWAC/Wildfire system (unofficial, offline) In other words, we continue to observe a very important sociological phenomenon that relates to the process of getting people to routinely report information- specifically, important public health information – that would not be reported under formal networks.

We are still in crisis mode in Haiti.  As such, the challenges for effective formal medical surveillance remain.  Others have published outlining the need for alternative reporting systems for disease events, again highlighting a basic sociological phenomenon.

Especially as it pertains to emerging crises, we have found over our 12-year career that “tip” information regarding infectious disease events is often received through trusted one-to-one communications. When this one-to-one communications are coupled with well-architected, intelligent social networks, a new, more robust type of situational awareness and collective intelligence emerges that can drive agile, proactive, rapid response in emergent situations.

This is absolutely a complimentary process to formal public health reporting, as currently facilitated by the Haitian Ministry of Health, PAHO, and CDC in Haiti.  Metrics for success when constructing a warning system are always so difficult to define. But we do have two important ones:

• People are reporting disease events in a way that supplements reporting in the formal medical surveillance system.
• Several of the major NGOs have proactively moved medical countermeasures and logistics into position in anticipation of a possible infectious disease crisis – as a result of advisories sent to them from the HEAS community effort.

We are currently in emergency mode monitoring for a potential crisis of pediatric diarrheal disease.  Unfortunately, the same cultural resistance to change in the public health community is present in our attempts to properly fund and maintain the capability: 

"[thanks for your] detailed follow-up message, which has been reviewed by the... health teams in Haiti. They appreciate the interest but, for now, find the current procedures satisfactory to their objectives."

As mentioned before, this same sociological process delayed public benefit of weather forecasting by decades.  In the case of Haiti, it is actively impeding our attempts to mitigate large scale child mortality with the advent of the rains.  Unfortunately in this case, the risk relates not only to the tragedy of children dying in Haiti after there was a major loss of life due to the earthquake, but also represents an important contributing factor to destabilizing the region.  We have seen in other cultures that unexpected fatalities involving children- particularly if perceived to be preventable- is a key trigger for social outcry.  In the context of the current situation in Haiti, where the public is already aware of a mismatch between donations and ground implementation of those monies, there is a very real possibility of civil unrest.

Warning systems are contentious constructs.  The reaction two nights ago at the UN Health Cluster to a recent posting of an HEAS advisory related to malaria is revealing.  Comments by public health professionals were indignant, saying "we already knew that".  The disconnect is the translation of awareness to proactive action.  In the case of malaria, there have been robust discussions with the MENTOR Initiative about malaria surveillance, control, and emergency preparedness.  MENTOR is an excellent effort that has been proactively engaged in dialog with the HEAS community, very much to their credit and to the benefit of the community.  However, pediatric diarrheal disease is more likely to abruptly overwhelm the already fragile medical infrastructure and therefore more likely to fall in the range of being labeled a crisis or disaster.  It is therefore more likely to contribute to social destabilization.  

Translation to action is a difficult process.  The issuance of a warning is an important step in sensitizing a community who internalize that information, cross-check the validity of the warning, and then decide whether the information is relevant to their operations or not (i.e. confirmatory behavior).  Another way to view confirmatory behavior is to consider it a part of active surveillance.  We often see the "all is clear" type reporting through this process, which enables detection of negative as well as positive signature patterns.  Proof of successful translation to action was demonstrated by the above-mentioned metrics for success:

• People are reporting disease events in a way that supplements reporting in the formal medical surveillance system.
• Several of the major NGOs have proactively moved medical countermeasures and logistics into position in anticipation of a possible infectious disease crisis – as a result of advisories sent to them from the HEAS community effort.

The more troublesome aspect of situational awareness-driven warning systems is they promote transparency.  In other words, it is a vehicle for accountability.  Receipt of a warning automatically places the recipient in a position of accountability.  If they act to mitigate a crisis before it happens, then the recipient and those they server are pleased if the crisis indeed manifests (or no social outcry is observed that challenges the credibility of the recipient organization).  If the recipient does not act, and a crisis occurs when their receipt of the information was known broadly, then the question of "why did you do nothing" appears.  For a bureaucrat, this places them directly in the line of sight, a most difficult position to be in when risk-averse.

Commentary- The 2009 H1N1 Experience: Policy Implications for Future Infectious Disease Emergencies

There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.

-Niccolo Machiavelli

Recently, the University of Pittsburgh Medical Center (UPMC) Center for Biosecurity hosted an invitation-only conference titled The 2009 H1N1 Experience: Policy Implications for Future Infectious Disease Emergencies.  Cited key conclusions were the following:

1. The prioritization and distribution of vaccine in future influenza pandemics should be reexamined.
2. Improvements are needed in the healthcare response to a large-scale bioterrorism attack.
3. The role of disease containment measures in the response to a SARS-like emerging infectious disease should be reconsidered.

Unfortunately, there was no focus on the front-end piece, the one piece essential to response: an effective biological threat detection and warning system. 

As one of the original group of individuals who called for the creation of the National Biosurveillance Integration Center (then called the "National Biosurveillance Integration System") under HSPD-7, -9, -10, NSPD-33, and Public Law 110-53, it is disheartening to see criticism of a key component of our nation's security apparatus without engaging in open discussion with those who have professional experience in operational biosurveillance:

"The problem is there is no strategy," said Tara O'Toole of the University of Pittsburgh's Center for Biosecurity.  "They wanted to build a national hurricane watch for public health emergencies.  But just as we saw with Hurricane Katrina, just watching the hurricane coming is not enough." [August 10, 2007]

The National Biosurveillance Integration System, which is supposed to bring together federal agencies to improve the detection and characterization of biological agents, has been criticized by GAO and the Homeland Security Department's inspector general as being ineffective and under-resourced.

Tara O'Toole, the department's new undersecretary for science and technology, told a House panel last week the effort had been suspended. But the department clarified her remarks this week, saying the effort is being reworked under the leadership of Alexander Garza, DHS chief medical officer.

No time line was given for when decisions about the program would be made. [March 3, 2010]

Indeed. We certainly do need effective leadership.

What is also required is an effective operational bridge between early warning and response.  When we briefed ASPR/HHS several months before the 2009 H1N1 influenza pandemic, Dr. Vanderwagen admitted (paraphrased), "even if we had credible warning of an influenza pandemic, we wouldn't know what to do with it."  I respected him greatly for his candor.  It is unfortunate we made no further progress in the dialog in the months before the pandemic.

There actually was a strategy to NBIC, and one that was vetted with every federal agency with an operational stake in biodefense at the original Concept Design Review meetings.  But there was minimal support inside DHS to implement the program properly and other federal agencies refused to share information with the nascent center.  It was a sociological problem first and foremost.  And Machiavellian.  Nearly identical challenges and contention in implementing this concept as the idea of storm forecasting in the 1800s.  Same kind of bickering and fighting among academics, politicians, and bureaucrats over control of operationalization of the concept that winds up delaying effective realization of a public benefit by decades. 

In a recent testimony by Dr. Alex Garza, NBIC "provided critical biosurveillance information... on the 2009 H1N1 influenza pandemic".  It would be helpful to understand the definition of "critical" along with a full review of what early warning information was recognized by NBIC analysts and conveyed to decision makers in the form of a warning. 

Much to CDC and Dr. Besser's credit, the issue of effective communication of threat information was addressed in an open forum.  The facilitator spoke much truth in her guidance for effective risk communication.  The contention around the warning of the 2009 H1N1 influenza pandemic was nearly identical to the public's anger about perceived withholding of tornado warning information in the 1940s and 1950s.  The bottom line is the public now knows warning information is out there, and they have a right to seeing threat information as quickly as possible- even in an atmosphere of uncertainty.

Our experience during the pandemic was quite revealing.  The timeliness issues with CDC have already been discussed here.  The broader public health community generally did not promote informal surveillance processes to share information.  With but two notable exceptions, none of the federally-funded public health and healthcare professional organizations we engaged (and we approached all of them) shared situational awareness information during the pandemic.  Federal, state, and local authorities pleaded for access to our information but wound up rarely ever sharing information or answering questions about reports in their areas of responsibility.  The public would be quite surprised to see the email transcripts during the early days of the crisis of us admonishing public health organizations to share information. 

Those that rose to the occasion were individual healthcare providers, and they were heroic in their efforts to be appropriately transparent about medical grid loading and strain, anxiety levels of staff, and unusual clinical findings without compromising patient privacy.  This is how we were able to detect events and event features more quickly than official communication channels.  Indeed, during the emergence of the pandemic, conversation with public health officials became operationally irrelevant.

We are observing a similar phenomenon in Haiti, where the major multi-million dollar NGOs are not readily engaging in informal information sharing about disease incidence.  However, smaller more agile humanitarian groups and individual responders are. 

Our conclusion from these experiences is the bigger and more complex the organization, the less able it is to share critical information in a timely fashion during crises and disasters. 

Our team has demonstrated the feasibility of issuing timely warning information for biological events such as:

- Near-real time operational biosurveillance support to the 2004 tsunami disaster response theater

- Detection of SARS laboratory accident in Taiwan (2004)

- Detection of Marburg hemorrhagic fever in Angola for the first time in history (2005)

- Detection of streptococcus suis in swine and humans in China (2005)

- Detection of PRRS in swine in China with subsequent impact on global heparin production (2005)

- The spread of H5N1 avian influenza in Asia, Europe, and Africa (2005 and 2006)

- Detection of Ebola hemorrhagic fever outbreaks in Africa

- First forecast and detection of Rift Valley fever in East Africa (2006)

- Detection of hoof and mouth disease laboratory accident at Pirbright, UK (2007)

- Detection of melamine-contaminated baby formula via reporting of unusual renal disease in babies in China

- Detection of Reston filovirus (and Ebola relative) in the Philippines with subsequent impact on pork futures (2008)

- Detection and warning of vaccine-drifted A/H3N2 in 2007

- Detection and warning of the Mexico crisis, later found to be the beginning of the 2009 H1N1 influenza pandemic

- Warning of H1N1 resurgence in the United States (summer 2009)

- Warning of adverse health outcomes involving H1N1 infection in indigenous peoples (worldwide)

- Warning of medical care demand for pulmonary bypass (ECMO) during the H1N1 pandemic

- Provision of operational biosurveillance support to the Haiti disaster response effort (2010)

Improvements in biological threat warning have actually occurred, and a professional discipline has now been present for several years now.  We openly invite decision makers to engage people with operational experience dealing with these issues as soon as possible before the next infectious disease crisis presents itself.