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The Orlando Sentinel
ORLANDO, Fla. - Nearly two years after the Sept. 11 and anthrax attacks terrorized the nation, America remains far short of a national warning network to spot bioterrorism outbreaks early enough to prevent disaster.
Health officials nationwide are struggling to find better ways of detecting potential biological attacks in their earliest stages by tracking everything from sales of over-the-counter drugs to symptoms of emergency-room patients.
Yet few communities have managed to establish such a system, known as syndromic surveillance. A recent government report found that 34 surveillance systems are in various stages of testing, but their use is "piecemeal," with little uniformity between cities and states.
Health officials say patience is needed. The approach is in its infancy, they say, and the obstacles are significant. Lack of money is one problem. The sheer complexity of what's involved is another.
"Tremendous progress has been made. But when you consider how far behind public health was, we still have a long way to go," said Dr. Tracee Treadwell, an epidemiologist with the Centers for Disease Control and Prevention's bioterrorism-and-preparedness-response program. "We're talking about something that's never been done before."
Government health officials already track disease outbreaks and unusual illnesses with help from private doctors and hospitals. But the idea behind syndromic surveillance is to look for subtle clues that an outbreak is brewing - long before it becomes obvious.
One method is to monitor the prevalence of the initial symptoms of the viruses, bacteria and toxins that most likely would be used in a biological attack. Smallpox starts as the flu, as does inhalational anthrax and the plague. A nagging cough might mean Q fever or exposure to ricin.
But because such symptoms are common, it's difficult to pick out danger signs while simultaneously ignoring run-of-the-mill sniffles. A variety of data might be useful: school absenteeism; sales of nonprescription medications; total numbers of people seen in emergency rooms; or the kinds of symptoms being seen.
Timing is everything. With some illnesses, such as inhalational anthrax, people who were exposed can be protected by taking medication before they fall ill. Even when no treatment is available, health officials still need to identify contagious diseases quickly to quarantine sick people and reduce the spread of disease.
That's why the systems need to be sensitive - flagging the people in different towns who went to the same sporting event or particular theme park, then fell ill later with symptoms that might indicate a biological attack.
Quick recognition is even more important in tourist destinations such as the Orlando area, which had 40.8 million visitors in 2001, according to the Orlando/Orange County Convention and Visitors Bureau. The guests, including 3.1 million international visitors, flock to theme parks and elsewhere before boarding planes and returning to all corners of the country and the world.
"When you have 100 cases in a single location, you don't need a system to tell you that something's going on," said Dr. Georges Benjamin, executive director of the American Public Health Association in Washington, D.C. "When you have four or five spread out over a broad area, that's when you need help. The problem is we haven't figured out yet what data points to collect. There's hundreds of things you can look at, but we still don't know which are the right ones."
A May report from the U.S. General Accounting Office found serious deficiencies in the information technology needed to improve surveillance and support rapid response to biological threats. For example, technology used in one town may not be compatible with that in another, and there are no uniform standards to ensure quality.
As a result, the GAO found "disparate systems that cannot exchange data. This leads to information gaps, hindering the prompt and accurate identification of emerging biological threats and consequently, timely detection of major public health threats is limited."
In Florida, public-health officials are working on several fronts to improve surveillance.
At the state level, the Health Department is getting ready to launch an Internet-based system called EpiCom, which would allow health officials throughout Florida to share anything out of the ordinary.
Say a Tallahassee doctor notices a large number patients complaining of the flu during his or her emergency-room shift. He or she could log into the secure system and submit the details. The information will be reviewed 24 hours a day, seven days a week by a Health Department epidemiologist, who will decide whether it warrants further action.
If necessary, the findings can be posted on the site, which triggers automatic notification to participating doctors and health officials statewide. They get phoned and paged repeatedly with a recorded message until they log onto the EpiCom system and review the new information.
Elsewhere in Hillsborough County, officials first began experimenting with syndromic surveillance in preparation for the 2001 Super Bowl in Tampa. They temporarily monitored the symptoms of emergency-room patients in the weeks around the football game, then started permanent monitoring in late 2001. All nine of the county's hospital emergency departments submit data via computer on the complaints treated in their facilities.
One downside to such a system is the time required to feed it information. In Central Florida, Orlando Regional Medical Center dropped out of a similar program when it became too cumbersome to enter data on every patient seen in the bustling emergency department.
For now, there is only one ongoing effort to look for subtle trends in symptoms in Central Florida.
The University of South Florida's Center for Biological Defense in Tampa is overseeing a study that includes medical facilities at an undisclosed Florida military base, health clinics at Orlando-area theme parks and the emergency room at Florida Hospital Celebration Health in Osceola County.
The Department of Defense is funding the research, and some details of the project - such as which theme parks are participating - are not being released.
But since June 2002, Florida Hospital Celebration has been tracking emergency-room patients with complaints that fall into eight syndromes - including rash with fever, respiratory infection with fever, or influenzalike illness. For those patients only, the nurse or doctor runs through a short, written checklist of extra questions that includes the patient's ZIP code, the date when symptoms started and whether the patient visited any theme parks in the previous two weeks.
Every patient is given an identifying number - no names are used - and the details are sent via the Internet to be analyzed by a new program called BioDefend, developed by a company named DataSphere in conjunction with USF.
On any given day, the hospital expects to see a certain number of patients with flu symptoms and respiratory infections. The numbers fluctuate, depending on the time of year. If a significant number of additional cases are seen within one day, BioDefend sends an alert to Kristin Uhde, an epidemiologist at the Center for Biological Defense.
In turn, Uhde pages Michael Leon at Florida Hospital, who estimates he has gotten six warnings in the past year for potential problems. All of them turned out to be nothing serious. Yet the system has shown it can spot trends that normally would go unnoticed.
"When you're working a shift in the emergency room, you don't count up everything you've seen at the end of the day in your head and say, `Oh, I had two extra cases of the flu,' " said Leon, a registered nurse who is research coordinator for Florida Hospital Celebration. "You just know you had a busy day. But this (BioDefend program) can tell you something's going on."
An added benefit, Uhde said, is that the program also detects naturally occurring outbreaks, such as SARS or flu season. She said last year, BioDefend started picking up increased flu cases in October - two months before the state had enough data to say flu season had arrived.
Officials say programs such as this are critical for the nation's long-term protection.
"Surveillance systems are the future of bioterrorism recognition," said Richard Stilp, corporate director of safety for Orlando Regional Healthcare and author of two books on terrorism. "We all need to get online with surveillance. It's the only way we're going to get that early warning.
"My greatest fear is that we're going to be knee-deep into something before we realize it's going on."
(c) 2003, The Orlando Sentinel (Fla.). Distributed by Knight Ridder/Tribune News Service.