Biological threats and recent epidemics have shown that local and national public health reporting and notification now require sophisticated information technology.
Until recently, this level would have been unattainable for many health departments, especially rural facilities that desperately need the most basic resources.
"We had some health departments that did not have the electrical capacity they would need for a fully functioning network," said Susan Griffith Chapman, director of operations at West Virginia's Office of Community and Rural Health Services.
Bioterrorism threats became a reality during the anthrax attacks that followed last year's Sept. 11 terrorist attacks. At the same time, public health centers tried to keep track of new, high-profile contagions, such as the West Nile virus.
The Centers for Disease Control and Prevention and the Health Resources and Services Administration (HRSA) directed more than $1 billion in funds earmarked for bioterrorism efforts to help long-neglected local departments handle new and existing public health threats.
One-third of that figure was set aside to fortify local public health information-sharing systems. The goal was to build on the progress of earlier public health IT grants and complete infrastructures needed by emergency workers, hospitals and medical care providers to respond to bioterrorist attacks.
By all accounts, the funding has been a windfall for the local health care community. "Public health has never seen the likes of this kind of funding," said John Loonsk, director of CDC's Information Resources Management Office.
Overall, the nation's more than 3,000 local health departments had inadequate IT systems until the late 1990s. Just three years ago, most facilities lacked the technical resources to react effectively to a major public health crisis of any kind.
According to a 1999 survey completed by the National Association of County and City Health Officials (NACCHO), more than half of all public health facilities had neither broadcast fax capabilities nor broadband access. One-third lacked e-mail and Internet connectivity entirely.
Those findings, however, predated CDC's ambitious Health Alert Network (HAN) initiative a grass-roots grant program begun in 1999 that aims to establish an integrated, national public health network.
HAN will host the distribution of health alerts, disseminate prevention guidelines and serve as the foundation for nationwide disease surveillance.
Even before Sept. 11, 2001, HAN was also viewed as a vehicle for CDC's bioterrorism and related preparedness efforts. But just as HAN was beginning to take hold and radically change the local IT landscape, the federal government piled on bioterrorism IT funds.
Now more than 90 percent of the nation's health departments have high-speed Internet access and claim to have adequate health alert reporting infrastructures in place or under way. "Things have changed dramatically," said Patrick Libbey, NACCHO executive director.
West Virginia was just one state in which local facilities needed second phone lines or electrical upgrades to support Internet connectivity and even air conditioning.
Despite those basic challenges, the state's local agencies have made much progress, largely through the $2.5 million West Virginia has received so far in federal funding.
"We began by building an infrastructure based on data sharing," Chapman said. "We took what we do every day floods and flu and looked for those information-sharing tools local jurisdictions could use to move to electronic communication vs. phone calls and faxes."
Now that most local departments have the basics they need to participate in West Virginia's HAN, the state is adding emergency response and state military and medical partners that could participate if a bioterrorism incident occurred.
"I tend to remove the words 'bioterrorism' and even 'health' when describing the effort," Chapman said. "We are adding partners to create an emergency alert system. You don't create a network with this much bandwidth without adding lots of partners and planning for continuing use."
"Bioterrorism has become a funny word in the health community, since it has been used to cover many rapidly emerging situations," said Seth Foldy, Milwaukee's health commissioner.
For instance, health alert systems fortified with bioterrorism funding in Milwaukee and elsewhere were instrumental in local governments' response to the spread of the West Nile virus.
"There has been a focus on the concept of dual use," Foldy said (see box, Page S24).
In New York City, the push for broad use of health information reporting infrastructures is strong. "We are not looking to utilize technology that we take out of the closet only when something really bad happens," said Ed Carubis, chief information officer for New York City's Department of Health and Mental Hygiene.
The city began its HAN efforts with IT infrastructures that were far more robust than those in rural areas. Still, the municipality has made good use of HAN funding, which has laid the groundwork for effective bioterrorism response, Carubis said.
"We have been fortunate, because we have had continuous high-speed Internet access at all 50 of our local department of health offices and clinics around the city," he said. "New York City hospitals are also entirely connected."
By using HAN funds to bolster capacity at local offices, the city was able to quickly delve into more advanced work. "We have been focused on building Web-based applications to provide for emergency communications," Carubis said.
In mid-November, New York officials planned to roll out the HAN Web site, which will eventually host much of the public health dialogue among emergency workers once city IT officials finish necessary authentication and security tasks, Carubis said.
New York City's site, however, will go much further. The city has used solutions such as Microsoft Corp.'s SharePoint software to set up an online conferencing component on the Web site that officials will use to swap information.
"We are looking at the HAN network as a communications alert system and a forum for discussion," Carubis said.
Down the line, other health data system efforts may be added to HAN, such as a syndromic surveillance system developed in part by software vendor iWay Software. The system is used to send information on epidemics, communicable diseases and other health events to CDC and other organizations.
Syndromic surveillance systems are used for analytical purposes, which is different from the HAN focus on more basic alert and notification efforts. CDC relies on such surveillance data to generate public health statistics and trends.
For the most part, individual state and local syndromic surveillance systems dovetail with CDC's National Electronic Disease Surveillance System initiative (see box, Page S26).
Although the CDC system and HAN initiatives are technically separate, they are building blocks of CDC's envisioned single nationwide network for disease reporting.
The need for such an infrastructure was made clear by the Sept. 11 terrorist attacks and the subsequent anthrax attacks. "We learned a lot last fall," said CDC's Loonsk.
"We are very convinced of the need to advocate a single public health network," Loonsk continued. "And we're making tremendous strides." l
Jones is a freelance writer based in Vienna, Va.
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