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Testimony
Before
the Committee on Energy and Commerce, Subcommittee on Oversight
and Investigations
United States House
of Representatives
Bioterrorism
Preparedness: CDC's Public Health Surveillance Activities
Statement of
Claire
Broome, M.D.
Senior
Advisor to the Director
Centers
for Disease Control and Prevention
Department
of Health and Human Services
For Release on Delivery
Expected
at 9:00 am
on
Thursday, November 1, 2001
Good morning, Mr. Chairman
and Members of the Subcommittee. I am Dr. Claire Broome,
Senior Advisor to the Director for Integrated Health Information
Systems at the Centers for Disease Control and Prevention
(CDC). Thank you for the invitation to update you on CDC's
public health surveillance activities. I will describe the
function of our current surveillance systems, update you
on recent efforts to build surveillance capacity in state
and local health departments, and discuss the status of
the National Electronic Disease Surveillance System.
As the nation's disease prevention
and control agency, CDC has the responsibility on behalf
of the Department of Health and Human Services (HHS) to
provide national leadership in the public health and medical
communities to detect, diagnose, respond to, and prevent
illnesses, including those that occur as a result of a deliberate
release of biological agents. This task is an integral part
of CDC's overall mission to monitor and protect the health
of the U.S. population.
Much has been in the news
lately about the disease detective function of CDC and its
epidemiologists, including Epidemic Intelligence Service
Officers. What has not been often emphasized is the need
for continued watchfulness to first detect problems that
our disease detectives then investigate. We refer to this
function-- this constant state of alert-- as public health
surveillance.
Public health surveillance
is a crucial monitoring function for CDC and its partners.
It is these ongoing data collection activities that help
us detect threats to the health of the public. Without our
public health surveillance systems, we might not identify
outbreaks or other important problems in time to prevent
the further spread of disease. We cannot investigate problems,
identify their causes, and implement control measures if
we have not detected them. Recent events have underscored
this essential role of public health surveillance, as well
as the integral role of health care providers in the overall
public health system. For most of our surveillance data,
the original source of information is the health care provider;
the Florida physician's ability to recognize a suspected
case of anthrax and his awareness of his role in reporting
it to the local health department was critical to our initial
recognition of the current bioterrorist events. Indeed,
identification of subsequent anthrax cases has also relied
on heightened awareness among health care professionals
that the wounds and respiratory syndromes they were seeing
were actually cutaneous and inhalation anthrax, not merely
spider bites and pneumonia.
Current Surveillance
Systems
The best initial defense against
any threats to the health of the public, whether naturally
occurring or deliberately caused, continues to be accurate,
timely recognition of a problem. Key elements of our current
surveillance systems include awareness and diagnosis of
a condition of public health importance, whether by a clinician
or laboratory, with subsequent notification of the local
health department, which in turn reports to the state health
department, which shares information with CDC. We work with
our public health partners to define conditions that should
be reported to public health departments; health departments
share these definitions and guidelines with health care
providers, infection control practitioners, emergency department
physicians, laboratorians, and other members of the health
care system. A timely example of such guidelines was included
in the October 19, 2001, issue of the Morbidity and
Mortality Weekly Report (MMWR), in the report
that dealt with "Recognition of Illness Associated with
the Intentional Release of a Biologic Agent." Copies of
the MMWR have been provided to the Subcommittee.
The traditional operation
of our surveillance systems generally consists of paper
or facsimile reporting by providers to health departments.
If a case of illness is particularly unusual or severe (such
as a case of anthrax or rabies), the provider will call
the local health department immediately. As mentioned, health
care provider recognition of the illness and awareness that
certain health events require immediate notification of
public health authorities, is critical to our ability to
detect problems and mount a public health response. It was
another alert clinician in 1993, a pediatric gastroenterologist,
who provided the early warning about a potential diarrheal
disease outbreak to the Washington State Department of Health.
Within one week, the Health Department identified hamburgers
from Jack-in-the-Box as the cause of the outbreak, and the
fast-food chain voluntarily recalled all hamburger meat
from their restaurants in the state. However, for routine
public health surveillance, this largely paper-based system
is burdensome both to providers and health departments,
and therefore reports are often incomplete and not timely.
In addition, the volume of paper reports and the need to
enter the information collected into various information
systems leads to errors and duplication of efforts.
These shortfalls influence
more than our ability to detect an event; surveillance also
plays a pivotal role in event management. Surveillance data
help us to determine where cases are occurring and who is
affected (e.g., particular age groups or occupations such
as children or postal workers), when cases are occurring
(i.e., are cases still occurring; are the numbers increasing
or decreasing with time?), and matching such information
to the laboratory data about the particular agent, to trace
its origin as well as to identify whether cases in different
geographic locations might have resulted from the same source.
Such information is vital to directing our investigation
and control efforts, but it requires a well-designed system
to input and analyze the voluminous data required, such
as the thousands of swabs tested for anthrax.
Given the crucial function
of public health surveillance, we have recognized the need
to take advantage of recent information technology advances
to bring our surveillance systems into the 21st
century. First I will describe the overall direction that
we are headed to transform our public health surveillance
systems, and then I will describe some of our short-term
efforts to enhance current surveillance systems in the aftermath
of September 11, as described in the MMWR report mentioned
previously.
Integrated, Electronic
Surveillance Information Systems
CDC and its partners have
recognized the need to build more timely, comprehensive
surveillance information systems that are less burdensome
to data providers. Several years ago, we initiated the development
of the National Electronic Disease Surveillance System (NEDSS).
The ultimate goal of NEDSS is the electronic, real-time
reporting of information for public health action. NEDSS
will include direct electronic linkages with the health
care system; for example, medical information about important
diagnostic tests can be shared electronically with public
health as soon as a clinical laboratory receives a specimen,
or makes a diagnosis. In the future, NEDSS coupled with
a computer-based vital statistics system and computerized
medical records, not only in hospitals but also in ambulatory
care offices, could facilitate immediate awareness of unusual
illnesses such as anthrax or smallpox, as well as our ability
to detect more subtle problems that may be dispersed across
the country.
NEDSS emphasizes a standards-based
approach, relying on the use of standards for data, information
architecture, security, and information technology (de facto
industry standards). This reliance on standards will ensure
that data need only be entered once, at the point of care
for a patient, without a need for re-entry of data by our
local and state partners. Use of standards is critical to
ensure that our public health partners can use technology
more effectively and collaboratively. As we build NEDSS
we are ensuring that the data standards we use are compatible
with those used in health care systems, so that we can make
sense of health-related data and therefore detect potentially
related cases across the country. In addition, a standard
information architecture and appropriate, high level security
will enable public health partners to share data in a secure
fashion, which is critical for identifying problems that
cross jurisdictional boundaries. And finally, the reliance
on de facto industry standards for information technology
ensures the availability of multiple commercial products
to meet the needs of our public health partners, including
state-of-the-art analytic tools and geographic information
system capacity.
CDC has worked with our state
and local partners on the development of NEDSS. We have
provided funding and support to all 50 states for activities
related to NEDSS planning and development. NEDSS is an ambitious
project; defining appropriate standards and ensuring appropriate
data sharing among the myriad health care systems, over
2000 local health departments, 50 state health departments,
and numerous federal public health agencies is a complex
process. As a start, a NEDSS Base System that incorporates
the standards and functions mentioned will be deployed in
at least 20 states during 2002. This project will ensure
our ability to capture data efficiently, electronically,
and to use it effectively for public health response. And
a public health surveillance system that spans the nation
will help detect threats to the public, wherever they might
occur.
Indeed, 2 related projects
also provide a key part of the effort to ensure the development
of the public health communications infrastructure. Health
Alert Network (HAN) is a nationwide program, the goals of
which include provision of Internet connectivity and rapid
communications capability among local and state health departments,
which will also facilitate linkage of local health departments
and health care providers. This connectivity will be crucial
for rapid sharing of surveillance data among public health
agencies. In addition, the Epidemic Information Exchange,
or Epi-X, provides
secure, high-speed, Web-based communication about outbreaks
and other acute or emerging health events among public health
officials from CDC, state and local health departments and
the military. One of the unique features of Epi-X is
the ability to provide a forum for secure communications
for state epidemiologists to post information on surveillance
and response activities for approximately 500 public health
officials around the country, including the U.S. military.
Another unique feature of Epi-X is emergency notification
by telephone and/or pager to defined groups of public health
officials.
Support to date for these
important national projects has strengthened our public
health infrastructure for detection of events of concern
and subsequent communication to ensure appropriate public
health response.
Near Term Surveillance
Efforts
Recognizing the need for near
term increased capacity
while NEDSS is implemented, CDC and its public health partners
initiated various activities to improve their ability to
detect events of importance to the health of the public.
For example, with the first CDC funding for countering bioterrorist
activities, in Fiscal Year 1999, many state health departments
were able to purchase the most advanced pattern recognition
analytic capacity available today - - a trained human being:
an epidemiologist whose duties included coordinating bioterrorism
surveillance and rapid response activities. The activities
range from enhancing communications (between state and local
health departments and between public health agencies and
health-care providers) to conducting special surveillance
projects. These special projects have included active surveillance
for changes in the number of emergency medical system/911
calls, hospital admissions, emergency department visits,
and occurrence of specific syndromes. After September 11,
these systems were explicitly called on to provide heightened
surveillance information. CDC is undertaking a critical
review of these activities to identify the most useful and
practical approaches that may be implemented on a national
basis. One key question to address is the feasibility of
capturing medically relevant data in a timely and appropriately
representative fashion, since we do not know when or where
the next event might occur. Furthermore, what effort do
proposed systems require from health care providers to report,
or enter data in the systems? Can the systems be used in
geographic areas beyond those where they were developed?
In addition, given the substantial burden of investigating
potentially concerning events, we are evaluating mechanisms
for minimizing the proportion of alerts generated by the
system that are false alarms.
Other related activities useful
for early detection of emerging infections or other critical
biological agents include CDC's Emerging
Infections Programs (EIP). CDC funds EIP cooperative agreements
with state and local health departments to conduct population-based
surveillance and research that goes beyond the routine functions
of health departments, and often involve partnerships among
public health agencies and academic medical centers. In
addition, CDC has established other networks
of clinicians-- whether infectious disease or travel medicine
specialists, or emergency department physicians-- whose
functions are to serve as "early
warning systems" for public health by providing information
about unusual cases encountered in the clinical practices
of its members. The guidance provided in the October 19
MMWR is intended to heighten awareness among these clinical
partners about what to watch for, and what to report to
public health. It is important to note that these relationships,
particularly between health care providers and local health
departments, are the foundation
on which our surveillance systems operate.
The local health department
is the front-line of defense for the public health system.
Many other projects and proposals for rapid surveillance
omit the vital connection to public health, especially the
local public health agency, which is responsible for the
initial public health response.
Conclusion
In conclusion, CDC is
committed to working with other federal agencies and partners
as well as state and local public health departments to
ensure the health and medical care of our citizens. The
best public health strategy to protect the health of civilians
against illness, regardless of cause, is the development,
organization, and enhancement of public health prevention
systems and tools.
Our public health surveillance
systems provide a critical piece of the public health infrastructure
for recognizing and controlling deliberate bioterrorist
threats as well as naturally occurring new or re-emerging
infectious diseases. We
have made substantial
progress to date in enhancing the nation's capability to
detect and respond to problems that threaten the public's
health. Recognizing that there is no simple solution for
our surveillance needs, we have supported
augmenting the
staff in state and local
health departments, as well as special projects to explore
the usefulness of various clinical data sources. We are
undertaking a critical review of current efforts to determine
what would be feasible and useful to implement more broadly
in coming weeks. We are implementing the National Electronic
Disease Surveillance System, which will provide direct linkages
with the health care system in 2002, improving the timeliness,
efficiency, and usefulness of our surveillance efforts.
These cross-cutting efforts to build the surveillance infrastructure
will be useful to detect any problem, not just potential
bioterrorist events; the ongoing use of this surveillance
infrastructure will assure that it is familiar and functional
should bioterrorist events continue to occur. A strong and
flexible public health infrastructure is the best defense
against any disease outbreak.
Thank you very much for your
attention. I will be happy to answer any questions you may
have.
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Last revised: November 1, 2001