Bioterrorism

1. Dena M. Bravata, M.D., M.S.
Policy Analysis
MS&E 290
Bioterrorism:
The Use of Information Technologies and
Decision Support Systems

2. Case Presentation: Day 1 (11/16)
Ottilie Lundgren, a 94 year old widow, living in
Oxford, Connecticut presented with a 3-day
history of fever, cough, and myalgias.
Her physical examination showed an elderly
woman with a fever (102.3F), elevated heart
rate (118).
Her chest x-ray and initial laboratory tests were
all negative.
She was admitted to the hospital for dehydration
and an infection of the kidney tract.

3. Case Presentation: Days 2-4
Hospital Day 2-3 (11/17-11/18)
Labs: Bacteria found in her blood and urine but not
yet identified
Mrs. Lundgren had progressive respiratory distress
and confusion.
Repeat CXR: fluid around the left lung with the
suggestion of pneumonia
Hospital Day 4 (11/19)
A sample of fluid from around lung taken for culture.
The Connecticut Department of Public Health was
notified by the hospital laboratory of blood
culture results

4. Case Presentation: Day 5-6
Hospital Day 5 (11/19)
She was transferred to ICU on a ventilator
Blood culture isolates identified as Bacillus
anthracis at the State public health laboratory
Hospital Day 6 (11/21)
CDC confirms blood culture isolates as B. anthracis,
molecular typing and susceptibility patterns
identical to recent cases
Ottilie Lundgren’s condition continued to deteriorate
and she died.

5. Current Cases of Bioterrorism-related Anthrax
Confirmed Suspected
Cutaneous 7 5
Inhalational 10* 0
Total 17 5
* 4 Deaths associated with inhalational anthrax

6. Biothreat Agents
• Variola major (smallpox)
• Bacillus anthracis (anthrax)
• Yersinia pestis (plague)
• Clostridium botulinum toxin (botulism)
• Francisella tularensis (tularemia)
• Filoviruses (Ebola hemorrhagic fever and
Marburg hemorrhagic fever)
• Arenaviruses (Lassa fever, Junin/Argentine
hemorrhagic fever) and related viruses

7. The Project
The objective of our project was to synthesize
the evidence on information technologies and
decision support systems (IT/DSSs) that may
serve the information needs of clinicians and
public health officials in the event of a
bioterrorist attack.

8. Methodologic Challenges of this Project
• Conceptualizing the problem
– Complex topic, no single effect size
• Finding the literature
– Not limited to peer-reviewed medical literature
– Government documents
– Web-based sources
• Evaluating the quality of the evidence
– No single, published quality scale relevant

9. The Methodologic Approach
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence

10. The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence

11. 5 Key Questions
• What are the information needs of clinicians and
public health officials in the event of a
bioterrorist attack?
• What are the criteria by which IT/DSS should be
evaluated for usefulness in a bioterrorist event?
• What IT/DSSs are available for detection and
diagnosis, management, surveillance, and
communication?

12. 5 Key Questions Continued
• What is the quality of the evidence about
IT/DSS usefulness?
• If no existing IT/DSSs meet the information
needs of clinicians and public health
officials, what considerations are important
in the design of future IT/DSSs to support
response to bioterrorism events?

13. The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence

14. Structure of the Conceptual Framework
Time period: 1
Decision maker:
Clinicians
Events:
associated with
the initial cases
Time period: 2
Decision maker:
Public health
officials
Events:
associated with
the initial cases
Time period: 3
Decision maker:
Clinicians
Events:
associated with
subsequent cases

15. Diagram of the Conceptual Framework
Outbreak
Investigation
Surveillance
Alert
Epidemiologic
Control
Surveillance
Report
Diagnosis
Management
Prevention
Report
Exposure
Test Result
Susceptible
Infection Status
(unobserved)
Lives
Saved
Clinical
Syndrome
Diagnosis
Management
Prevention
Report
Exposure
Test Result
Susceptible
Infection Status
(unobserved)
Clinical
Syndrome
Surveillance
Alert
Lives
Saved
Time period 2 Time period 3
Time period 1

16. Healthcare provider
Reports
Outbreak
Investigation
Surveillance
Alert
Epidemiologic
Control
Surveillance
Report
Detector
Data
School/Work
Absenteeism
Data
Hospital
Discharge Data
EMT Data
Pharmacy
Sales Data
Coroner
Reports
Veterinarian
Reports
Laboratory
Reports
Lives
Saved
Time period 2: Surveillance Systems Detect Potential Events
Surveillance systems
receive data from a
variety of sources and
provide reports to public
health authorities.
Foodborne Disease
Reports

17. Role for Information Technologies and Decision Support
Decisions marked in blue indicate those that can be affected by
decision support systems and arrows marked in blue indicate
processes in which information technologies could play a role.
Outbreak
Investigation
Surveillance
Alert
Epidemiologic
Control
Surveillance
Report
Diagnosis
Management
Prevention
Report
Exposure
Test Result
Susceptible
Infection Status
(unobserved)
Lives
Saved
Clinical
Syndrome
Diagnosis
Management
Prevention
Report
Exposure
Test Result
Susceptible
Infection Status
(unobserved)
Clinical
Syndrome
Surveillance
Alert
Lives
Saved

18. The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence

19. Task Decomposition
• Formal framework for specifying, documenting, and
evaluating the data that should be contained within the
knowledge base of a DSS in order for it to serve its
purpose.
• Literature review to define tasks:
– U.S. Offensive weapons program
– Known bioterrorist events
– Tabletop exercises
– Infectious disease outbreaks
• 5 Tasks
– Surveillance
– Diagnosis and detection
– Management
– Prevention
– Communication

20. Example: Task Decomposition: Surveillance
Subtask Key Concepts Data Requirement
Collect
surveillance
data
Continual, timely
collection of sensitive
and specific data from
multiple sources for
early detection of a
bioterrorist attack
•Environmental detectors
•Pharmacy sales data
•School & work absenteeism data
•Clinicians’ reports
•Laboratory reports
Analyze
surveillance
data
Timely analyses and
presentation to public
health decision makers
•Baseline information for each data
source to calculate expected trends
over time
•Threshold information for each
data source to know when an
outbreak has occurred

21. The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence

22. Literature Searches
• Literature Sources
– Peer-reviewed articles and government documents from
databases
• Medline, GrayLit, National Technical Information Service,
Catalog of U.S. Government Publications
– Government documents from websites
– Web-based information
• Search Strategies
– Professional librarians for peer-reviewed and
government documents
– Copernic 2001 metasearch engine for web-based
information
• Search Terms: same for our Government
document and Copernic searches

23. The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence

24. Results of Literature Searches
• Reviewed 16,751 citations and 8,620 websites
• 251 articles and 41 websites met inclusion criteria
• Double abstractions (blinded to study author) for
all peer-reviewed articles and single abstractions
for web-based information
• Total of 204 systems
– 52 detection systems
– 23 diagnostic systems
– 14 management systems
– 88 surveillance systems
– 27 communication systems
– 7 systems that integrate surveillance, communication,
and command and control functions.

25. Results
• Generally: few clinically evaluated systems
• No IT/DSSs for Diagnosis or Management
have been developed specifically for
bioterrorism
• Systems for Detection, Surveillance, and
Communication have been developed for
bioterrorism
– Some show considerable promise but almost
none has been evaluated for its sensitivity,
specificity, or timeliness

26. Results
• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

27. Results
• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

28. Detection Systems: Overview
• Developed for Military need to be adapted to civilian
use
• Promising projects include:
– PROTECT (Program for the Response Options and
Technology Enhancements for Chemical/Biological
Terrorism)
• Detectors set up in subways, airports, government buildings
• Developing methods for signal-noise-processing
– LEADERS (Lightweight Epidemiology and Advanced
Detection and Emergency Response System)
• Integrates detector data with other surveillance data
• Particularly for event-based surveillance

29. Detection Systems: collection and identification
BioThreatAlert (BTA) Strips
• Antigen/Antibody system available for a
limited number of agents
• Sensitivity and Specificity not evaluated
• Used by first responders or clinicians
BioCaptureTM
• Only collection system clinically evaluated
• 50-125% collection efficiency of other devices
• Used by first responders
Conclusions: Systems have not been clinically evaluated, sensitivity
and specificity poorly characterized, can only test one sample at a
time, tests not available for many worrisome agents (e.g., smallpox)

30. Results
• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

31. General Diagnostic Systems: Overview
• Purpose: Clinician enters patient information (usually
manually) and system provides a differential diagnosis
• Examples: DXplain, Iliad, QMR (newer handheld versions
now available)
• Clinical evaluations: the differential diagnoses provided
are highly dependent on descriptors entered
Conclusions: Have rarely been shown to improve patient
outcomes in general, none has been evaluated for diagnostic
capability for bioterrorism-related diseases

32. Results
• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

33. Management Systems: Overview
• Generally: Depend on electronic medical
record to derive patient-specific
recommendations
• Most commonly for antibiotic
recommendations for hospitalized patients

34. Management Systems
Example: HELP system at LDS hospital in Salt Lake City
–When patients present to the ED, HELP’s databases are
queried every 10 minutes for any new clinical information on
the patient. Uses this information to calculate the probability of
pneumonia.
–Specificity 92%, PPV 15.1%, NPV 99.9%
Conclusions: No evidence for their usefulness in a bioterrorist
event; would have to incorporate new guidelines for biothreat
agent diagnosis and management; typically require EMR.

35. Results
• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

36. Data Sources for Biosurveillance
School & Work
Absenteeism
Phone Triage
Nurses
Pharmacies (OTC)
Environmental
detectors
Sentinel
Physicians
Pharmacies (Rx)
Emergency
Department
911 Calls
Laboratory
Hospital
admissions &
discharge
Earlier Detection Data Later Detection Data

37. Surveillance Systems
• Syndromal surveillance reports (7)
• Reports from clinicians (6)
• Influenza-related data (10)
• Systems for laboratory and antimicrobial
resistance data (23)
• Systems for nosocomial infections (15)
• Food-borne illnesses (10)
• Zoonotic illnesses (5)
• Other types of surveillance data (12)

38. Syndromal Surveillance
• Syndromes associated with biothreat agents
– Flu-like illness
– Acute respiratory distress
– Gastrointestinal symptoms
– Febrile, hemorrhagic syndromes
– Fever and rash
– Fever and mental status change

39. HealthBuddy®

40. ESSENCE

41. Integrated Systems
Data Analysis and
Presentation

42. Results
• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

43. Communication Systems: Overview
• Email systems for communication between
patients and clinicians
• Web-based secure networks linking
branches of the public health
• Radio/Microwave-based systems for linking
emergency personnel in the field with EDs
• Alert systems to notify clinicians of
abnormal laboratory tests

44. Communication Systems for Bioterrorism
Local Public Health

45. Communication Systems for Bioterrorism
CDC
State Public Health
Local Public Health
WHO

46. Communication Systems for Bioterrorism
CDC
State Public Health
HazMat
Police
Local Public Health
Fire
Pharmacies
Coroner &
Medical Examiner
Laboratories
Clinicians
The Public
The Media
Schools
Zoo
Food Inspectors
Hospitals &
Nursing Facilities
WHO
FBI

47. CDC
State Public Health
HazMat
Police
Local Public Health
Fire
Pharmacies
Coroner &
Medical Examiner
Laboratories
Clinicians
The Public
The Media
Schools
Zoo
Food Inspectors
Hospitals &
Nursing Facilities
WHO
FBI
*
*
*
*
*
*
*
*
*
Communication Systems for Bioterrorism

48. CDC
State Public Health
HazMat
Police
Local Public Health
Fire
Pharmacies
Coroner &
Medical Examiner
Laboratories
Clinicians
The Public
The Media
Schools
Zoo
Food Inspectors
Hospitals &
Nursing Facilities
WHO
FBI
*
*
*
*
*
*
*
*
S
S
S
S
*
Communication Systems for Bioterrorism

49. CDC
State Public Health
HazMat
Police
Local Public Health
Fire
Pharmacies
Coroner &
Medical Examiner
Laboratories
Clinicians
The Public
The Media
Schools
Zoo
Food Inspectors
Hospitals &
Nursing Facilities
WHO
FBI
*
*
*
*
*
*
*
*
S
S
S
S
*
Communication Systems for Bioterrorism

50. Conclusions
• Overall: IT/DSSs have not be subjected to critical evaluations
• Detection Systems:
– Rapid
– Portable
– Sensitive and Specific
– Can test for more of the worrisome biothreat agents
• General Diagnostic Systems:
– Link to EMR
• Management systems:
– Utilize available bioterrorism guidelines
• Surveillance systems:
– Greater integration
– Early warning data
– Methods for the determination for what constitutes an outbreak
• Communication systems:
– Single system for public health officers at various levels
– Public health  media

51. Future analysis
• Models of natural history of disease processes of
biothreat agents
• Cost-effectiveness analyses of surveillance
systems using different sources of data
• Cost-effectiveness of prevention and management
strategies for the most worrisome biothreat agents
• Analyses of the adequacies of current capacity of
hospitals, law-enforcement, and public health to
respond to a bioterrorist attack.

52. Collaborators
• Douglas K. Owens
• Kathryn McDonald
• Wendy Smith
• Chara Rydzak
• Herbert Szeto
• Corinna Haberland
• David Buckeridge
• Mark Schleinitz
• Dean Wilkening
• Mark Musen
• Bahman Nouri
• Bradford W. Duncan
• Mariana B. Dangiolo
• Hau Liu
• Scott Shofer
• Justin Graham
• Sheryl Davies