Being Prepared for Bioterrorism

James E. Rohrer, Ph.D., Professor and Chair, Department of Health Services, Research and Management, Texas Tech University Health Sciences Center, Lubbock, Texas

Disease surveillance and outbreak investigation are the highest bioterrorism priorities, according to the Centers for Disease Control and Prevention. These are related but distinct activities. Disease surveillance is a continuous activity that involves routine reporting of potential threats, such as single cases of communicable diseases. Through the timely accumulation of data, surveillance permits the early identification of outbreaks that require epidemiological investigation. Epidemiologists will interview persons suffering from the disease in question and their contacts with the goal of determining the source of the disease and its means of transmission.

Unfortunately, local public agencies lack the capacity for real-time surveillance and immediate response to outbreaks caused by terrorists. Our system of reporting diseases that might warn us of emerging epidemics is antiquated and ineffective. Many clinicians do not bother to report diseases even when they are legally obligated to do so. Clinicians are busy and, besides, patient privacy is an issue. Having a public health investigator show up at your patient's door to ask about sexual partners is an example of what can happen when diseases are reported. And, of course, this kind of investigation is indeed necessary. If a quickly spreading disease outbreak is triggered by terrorists, public health officials must be able to track down the source if they are to stop the epidemic. Treating victims after the disease has become a disaster is like locking the barn after the horse is gone. In actual fact, epidemics are not stopped by treating the sick, but by preventing exposure.

The best system would involve reporting all cases of infectious disease, even if we do not immediately suspect that bioterrorism is involved. After all, if you are not expecting to see anthrax, you might call it flu. But if there is a sudden outbreak of flu, public health officials might begin to put two and two together right away.

Unfortunately, our system of collecting and analyzing new cases of infectious disease is very slow and cumbersome. Even if all cases were reported, local health officials may not receive the information soon enough to permit mapping and charting and other analytical activities that will reveal the level of danger we might be facing. This is the computer age, but local health agencies are not equipped with the latest machines or software for this purpose. They also lack the staff - trained epidemiologists - to investigate the outbreaks. Epidemiologists are "disease detectives" who lead a team into the field to search out causes and stop the epidemic before it gets out of control. A nasty epidemic is likely to result in a report being made to the Centers for Disease Control and Prevention in Atlanta, which will then send a team to investigate. This system has worked well enough in the past, but imagine what the result will be if a dozen outbreaks occur at once and are scattered across the country.

We would not send out to Atlanta for a pizza, because it would take too long. And we sure don't want to send out to Atlanta when people are getting sick all around us. We want to be able to handle epidemics with regional health departments.

Additional epidemiologists must be trained and placed in regional health agencies. New systems for capturing cases and relevant information about those cases must be developed and tested. These systems must be very easy to use, so that busy clinicians won't be burdened. Instantaneous transmission of clinical information to the regional public health agency must occur. Privacy may suffer, but how important, really, is secrecy about our health problems if that secrecy causes an epidemic to get out of control? The terrorists would be delighted if our concern about privacy crippled our public health defenses.