NEW YORK - On Alert for Bioterrorism

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In New York, On Alert for Bioterrorism City's Tracking System Is Viewed as a Model

By Ceci Connolly Washington Post Staff Writer Saturday, November 24, 2001; Page A01

NEW YORK -- Just before noon on Nov. 13, Farzad Mostashari gazed down at his computer printout and wondered aloud if he was staring into the face of a biological attack.

In the previous 24 hours, ambulance calls and emergency room visits for respiratory distress had spiked in Queens. Mostashari, the city health department's epidemiologist, asked his medical detectives to check it out.

That afternoon and into the evening, teams of public health experts pored over patient charts at three Queens hospitals, looking for any sign that pulmonary anthrax was the cause of the respiratory cases. What they found instead was asthma, anxiety attacks and -- as Mostashari had suspected all along -- smoke inhalation from the crash of American Airlines Flight 587 on Nov. 12.

On the bioterrorism front, it was a false alarm, but the sort of false alarm that should give New Yorkers comfort. The city has what is widely regarded as the finest system in the country for monitoring public health problems and quickly detecting outbreaks of disease, including a biological assault.

"The events of the past couple months have made people get real serious about the need for surveillance systems with some sensitivity and some specificity," said Thomas Milne, executive director of the National Association of County and City Health Officials. "We need public health departments to get the information in as close to a real-time basis as possible."

The anthrax attacks that have struck Washington and four states -- Florida, New York, New Jersey and most recently Connecticut -- were relatively small and delivered in some cases with clear warning signs: white powder and threatening letters. But a future attack, such as smallpox released in a sports arena or anthrax spores introduced through air ducts, could be stealthy.

Treating the sick would be an unprecedented challenge for a generation of physicians who have no experience with such diseases, especially at a time when many state and local health departments have been starved for resources. Even more terrifying to many in the medical community is the notion that they might not know for some time that an attack had occurred.

New York's solution is an elaborate health surveillance system that tracks 911 calls, walk-in emergency room visits, pharmacy sales of anti-diarrhea medication and illnesses among city transit workers.

"One doctor working in one ER may not be able to see the forest for the trees," Mostashari said. "These systems are designed to detect the earliest signs of a massive, widespread bioterrorist attack."

Think of health surveillance as a set of medical smoke detectors, sounding the alarm before a deadly disease sweeps through an entire community, said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

"If a whole bunch of alarms go off, we may need to get to a large number of people with antibiotics or vaccine," he said. "We are not just here to record history, but to change history."

In some states, public health reporting is still done with "pencil, paper and snail mail," as one official put it. Milne's organization estimates that 40 percent of local health departments do not have high-speed Internet access. Detecting a biological attack in those communities could take days.

As part of a $3.3 billion emergency bioterrorism package, Congress is considering giving cities and states up to $425 million for "health surveillance." Still, public health experts say that would represent only a down payment on fixing what they describe as a woefully underfunded system.

For decades, the termhealth surveillance conjured up images of dusty annual reports cataloguing births, deaths and the occasional batch of spoiled eggs at a church social, said Margaret A. Hamburg,a bioterrorism expert and former assistant secretary at the U.S. Department of Health and Human Services. But in recent years, the AIDS epidemic and tuberculosis prompted New York health officials to take a more active role.

As New York City's health commissioner in the 1990s, Hamburg helped move from a "word of mouth" approach that relied on doctors and nurses to one that combines traditional disease reporting with high-tech tracking of symptoms, a system known as "syndromic surveillance."

The heart of that system is daily monitoring of every 911 call in the city, about 1 million a year. Each night, fire department logs are transferred electronically to the health department, where a sophisticated computer program helps spot anomalies. "It actually turns red on the graph," Mostashari said.

With the data coded by medical complaint and Zip code, health officials can track localized problems such as the smoke-filled air in Queens. It is the first department in the nation to apply spatial cluster maps to symptoms, said Commissioner Neal L. Cohen.

Skeptics such as Osterholm say they are waiting for evidence that syndromic tracking -- which costs New York about $1.5 million a year -- works better or faster than highly trained doctors and nurses.

"The New York experiment is worth watching, but it's subject to a lot of random variations" such as bad weather triggering more 911 calls, said Alan P. Zelicoff,senior scientist at the Center for National Security and Arms Control at Sandia National Laboratory in Albuquerque. He has developed a touch-screen program for doctors that he said has the virtue of "capturing physician judgment about the severity of illness."

In the diverse city of 8 million, New York's system is already paying dividends as the "eyes and ears" of the health department, Cohen said. For the past three winters, the computer announced the start of flu season two to three weeks before traditional reporting by health care professionals.

The early warning can save lives, said Gregg Husk,chairman of emergency medicine at Beth Israel Medical Center.

"If I were a medical director at a nursing home and heard of a flu outbreak, that would light a candle under me to get people vaccinated," he said. Similarly, health department alerts about syphilis outbreaks tip doctors off to ask the right questions and perform extra tests, he said.

After some 300,000 Milwaukee residents were infected in 1993 with cryptosporidium, a parasite that can cause severe intestinal illness, New York added a diarrhea surveillance program that tracks lab results and pharmacy sales. The first clue in Milwaukee, said Marcelle Layton, assistant commissioner of health in New York, was an uptick in purchases of Kaopectate.

One Monday morning a few winters ago, Layton's team arrived at work to see a similar increase in sales of Imodium, another anti-diarrheal medication.

"It turns out Imodium had been a sponsor of the Super Bowl that weekend," Layton said, laughing in retrospect. "I now know more about pharmaceutical marketing than I ever expected."

Still, Layton said it is easier to weed out false leads than not to have any data. She hopes to expand the pharmacy surveillance program to include popular flu medications, since many people try them before visiting a doctor.

After the Sept. 11 hijackings, health officials broadened their surveillance to hospitals, asking emergency workers to fill out an extra form on every patient. Epidemiologists from the Centers for Disease Control and Prevention were stationed round the clock in hospitals to assist, but when they left for a brief period, compliance plummeted, Layton said.

Within a few weeks, the process was computerized. Now, 28 hospitals in the five New York boroughs ship a daily log to the health department. The system is still "clunky," said Husk, who each morning excises confidential patient information by hand before sending the report to the health department. But he expects the technical glitches to be smoothed out.

Often, the real value of surveillance is ruling things out. After New York hospital worker Kathy T. Nguyen was initially diagnosed with inhalation anthrax on Oct. 29, Layton's team watched the computer charts, waiting to see if her case foreshadowed a new wave of attacks. "We especially wanted to see if there were clusters around where she lived or worked," she said.

As three, four and five days went by without a blip on the graphs, health officials began to breathe easier. "It was very reassuring," Layton said.

More than most, New York health officials are keenly aware of the strengths and weaknesses of syndromic surveillance. An astute doctor -- not syndromic surveillance -- first alerted Layton to a possible outbreak of West Nile virus in 1999. Yet city doctors had hospitalized 15 people with the disease, cases that were never reported.

A computerized chart doesn't lie, but it also doesn't tell the whole story, Mostashari said.

"It's just one arrow in the quiver," he said. "But if this adds a 20 percent chance of giving us 24 hours earlier notice of a massive bioterrorist attack, I'm sure people would say it was worth it."

-- Anonymous, November 24, 2001

Answers

Good article Old Git, thanks for posting it. The part below, had me shaking my head:

"In some states, public health reporting is still done with "pencil, paper and snail mail," as one official put it. Milne's organization estimates that 40 percent of local health departments do not have high-speed Internet access. Detecting a biological attack in those communities could take days."

-- Anonymous, November 24, 2001


I am thinking the whole country is on Bio-alerts, only we are not being told!!! but anyone that can read, hear, or think...knows this!

Good Article, Git

-- Anonymous, November 25, 2001


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