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Diverse and disjointed, the nation’s public health and clinical settings have education needs and communication gaps that must be bridged if the system is to improve its response to bioterrorism, a group of consultants recently told the Atlanta-based Centers for Disease Control and Prevention (CDC). The CDC’s national center for infectious diseases is holding a series of meetings to assess the lessons of last year’s anthrax attacks and begin to close the long-standing breach between public health and clinical medicine.
The gap may stem from differences between the private and public health care systems, both of which are fragmented and highly variable by geography and urban vs. rural settings, according to a CDC draft summary of the Jan. 7, 2002, consultants’ meeting, which was obtained by Bioterrorism Watch.
"There was lot of [discussion] about the gap between public health, private practices, and hospitals and how to bridge that gap and make things more collaborative," said William Scheckler, MD, a consultant at the meeting and hospital epidemiologist at St. Mary’s Hospital in Madison, WI. "[We need] to reduce some of the redundancies in the systems both in terms of preparing and education." Scheckler also is a member of the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC), which met Feb. 25-26, 2002, in Atlanta.
Scheckler gave a report on the consultants’ meeting, telling HICPAC members that the CDC had input from a broad range of bioterrorism groups and clinical specialties. There is a wealth of information scattered among these groups and on numerous web sites, he noted. For example, a dermatology group at the meeting has photographs of skin lesions that could be a good resource in an investigation of cutaneous anthrax. "When an outbreak occurs, the same questions [arise]: What do people need to know? What is the best way to get out the information?" he said. "There should be one best-practices web page that you can go to."
The CDC currently operates several different clearinghouses for information as well as different public inquiry numbers. The agency now is considering the possibility of centralizing its clearinghouses and public inquiry services, the CDC report states. "During the anthrax crisis, the CDC public inquiry system was overwhelmed, and therefore the agency set up a new system during the outbreak," the CDC report continues. In addition, the CDC found that "during the attacks, the amount of information on anthrax increased from virtually nothing to an overwhelming number of e-mails, web sites, printed documents, and other materials. Much of this information and work was duplicative."
The consultants suggested that the CDC devise a strategy to centralize information development activities and then distribute the product, rather than having so many individuals working independently.
Regarding public health and clinical partnerships, a relatively simple system of linking health departments with hospital emergency departments (ED) was described by HICPAC member Alfred DeMaria Jr., MD, state epidemiologist at the Massachusetts Department of Public Health in Jamaica Plain. Under the program, participating hospitals in the Boston area report their daily number of ED visits to the health department. The numbers are compared against emergency visits a week earlier and on the same date a year prior to detect surges that might suggest a bioterrorism event, he said.
The information is easily obtainable by the hospitals and can be submitted electronically to the health department without extra work. That is important because bioterrorism surveillance systems that are labor-intensive will likely falter as vigilance inevitably wanes, DeMaria noted. The system has provided the secondary gain of improving communication between public health and clinical sectors. The threshold for investigation occurs at two orders of magnitude above baseline, which thus far has occurred with influenza ED visits and those associated with a large trauma event such as a bus crash, he said.
Sometimes, the threshold will be reached simply out of random chance, as ED visits increase for no single reason. "The question is, we don’t know how big an event has to happen [to be detected]," DeMaria said.
The CDC is interested in such bioterrorism surveillance systems, and also may seek to apply its existing hospital sentinel networks, including the National Nosocomial Infections Surveillance system, said Steve Solomon, MD, chief of special studies activity in the CDC division of healthcare quality promotion. National concerns about patient safety and bioterrorism have created a "tsunami of money" to address such issues, Solomon told HICPAC members. "We have a lot of concerns about the surveillance and response needs," he said. "We are seeking a small trickle of that tidal wave of funds."
Ultimately, the CDC may help shape a national system or contribute to a "mosaic" of systems that track surrogate markers such as severity of illness in "real time," he said. The research and development needs for such a system are in the ballpark of $120 million to $180 million, which may be available in the current climate over the next four or five years, he said. There is considerable interest being expressed from health care-related industries in partnering with the CDC on such efforts. "They are standing in line," Solomon told HICPAC members. "The phone is ringing off the hook. We are trying to figure out who is the best partner."