The weakest link

The recent anthrax scare, and the specter of an outbreak of smallpox or another deadly disease, has lent new significance to an ongoing federal program to develop a nationwide communications system for public health officials at the federal, state and local levels.

Public health experts say the Health Alert Network has worked reasonably well during recent weeks, but they admit the network is incomplete and may prove ineffective if a more serious threat appears.

Spearheaded by the Centers for Disease Control and Prevention, HAN is intended to improve the government's ability to detect and respond to outbreaks by improving the flow of information between state and local public health offices and CDC. The faster CDC detects outbreaks and alerts health offices nationwide, the faster such outbreaks can be contained.

But according to several public health experts, about 10 percent of local public health departments do not have e-mail, and up to 40 percent do not have high-speed Internet access, with most gaps occurring in rural towns.

Those sparsely populated areas represent potentially dangerous blind spots in the nation's disease surveillance effort, and they could allow a contagion to spread widely before being detected.

"What happens in the rural area is just as important to the national health as what happens in the cities," said Edwin "Ted" Pratt, director of government relations for the National Association of Local Boards of Health (NALBOH). "Bioterrorism has changed the nature of the game."

In this new world in which a biological attack could spread through a community like a microbe through a body, public health experts, lawmakers and government officials are making a full-court press to have the public health information technology and telecommunications infrastructure strengthened and expanded.

More Than Alerts

CDC began developing HAN in 1999 to serve as a secure network through which it could send and receive information about emerging infectious diseases, environmental health dangers and potential bioterrorist attacks.

Because local public health agencies play a key role in combating bioterrorism — detecting outbreaks, providing treatment and disseminating information to the community and media — the HAN program includes funding to help those agencies buy new computer equipment and pay for high-speed Internet connectivity.

So far, CDC has provided about $90 million in funding and technical assistance to 37 state health agencies, three metropolitan health departments and three centers for public health preparedness. CDC representatives were unavailable to comment for this story.

In reality, the name Health Alert Network is something of a misnomer, said Rajesh Virkar, who heads the Health Informatics Branch in North Carolina's Department of Health and Human Services.

Everyone focuses on the "alert" part, Virkar said, but the network's main purpose is to be a two-way communication device to exchange surveillance, laboratory and other sensitive data between CDC and state and local public health agencies.

Besides computer equipment and high-speed Internet access, the program offers Internet- and satellite-based distance learning systems so health officials can stay updated on the latest developments in their field. It also provides a secure venue for laboratories to transmit sensitive data.

HAN also serves as the communications backbone for several key health-related applications. The Epidemic Information Exchange, known as Epi-X, enables federal, state and local epidemiologists to instantly notify others of urgent public health events, create reports and track information. They can also access a searchable database on outbreaks and unusual health events, and request assistance from CDC online.

The National Electronic Disease Surveillance System, meanwhile, ties together a wide variety of systems used to collect, access, analyze and transmit information about diseases.

"We want to spot an incident off the regular trend by regularly collecting surveillance data," Virkar said. "We don't want to have this as a white elephant on the side that's only called during an emergency. We want this to be part of a daily health office."

Not only could CDC spot unusual activity through quicker analysis of the data, but it could also map potential problems in certain geographic areas. Before, such data was mostly mailed through channels, which meant analysis would take longer. "We want to shorten this cycle," Virkar said.

Lawrence Gostin, director of the Center for Law and the Public's Health at Johns Hopkins and Georgetown universities, said information is the "lifeblood" of public health agencies, which have not been given the proper resources in the past. Center leaders recently drafted model legislation for states to adopt to facilitate bioterrorism preparedness.

"Many public health agencies are going to computerized records within the foreseeable future. They all should and must," Gostin said.

Along with technology, state and local governments need to look at laws to facilitate information between various agencies and across different levels of government. "At the moment, confidentiality laws thwart that vital info sharing," he said.

Preparing for the Worst

To judge by the recent anthrax scare, HAN is working well, health officials say, helping CDC spread the word about how to recognize and treat the disease (see box, Page 20). But anthrax is not necessarily a sufficient test.

This disease, deadly as it is, is not contagious, so occurrences are limited to individuals exposed to spores. Smallpox, on the other hand, spreads very quickly, and any delay in treatment can mean lost lives.

Public health experts say that although HAN has been effective up to this point, it cannot continue to exist in its current capacity.

"Since not everybody is connected, [HAN is] not very effective," said Mohammad Akhter, executive director of the American Public Health Association. "If only 50 percent are connected, it hasn't done its job. Monitoring of the health is very, very critical and critical in times of national crisis, and we are way behind the times."

It's fortunate that 75 percent to 80 percent of Americans live near public health agencies that have full-time staff and IT capacity, said Tom Milne, executive director of the National Association of County and City Health Officials (NACCHO). But "the defense of the country in terms of a communicable disease is as strong as the weakest link," he said.

The message seems to be getting through.

"I think in some of the hearings we're [having] on the Hill right now, clearly the public health infrastructure needs to be enhanced and cannot effectively address a large-scale bioterrorist attack," said Janet Marchibroda, chief executive officer of the eHealth Initiative, a nonprofit consortium of more than 50 health care companies.

CDC officials are aware of the problem. In a March report, the agency said the public health infrastructure — the network of trained people, information and data systems, and interagency coordination — is "fragile and has been under stress for decades." NACCHO has recommended $835 million for improving the public health infrastructure.

Calls for strengthening the existing communications system are coming from both the public and private sectors.

Last week, the eHealth Initiative was expected to release a blueprint for using IT and Internet-based communications to ensure a fast and effective response to bioterrorism during the next six months. "Our sense is speed is required. Our nation is under threat now, and speed is important," Marchibroda said.

She said a private/public collaboration is needed to close the gaps, especially at the state and local public health agency levels. The effort should emphasize preparing and educating the first responders — the physicians, hospitals and clinics — in an emerging health crisis or bioterrorist attack.

The consortium also will recommend improving disease surveillance and detection through more real-time data communication and analysis among hospitals, state and local public health authorities, and CDC, she said.

Rather than starting from scratch, the public community should take advantage of the many well-established private information systems that link thousands of doctors and hospitals, integrating these into HAN, Marchibroda said. "How well-connected are the existing systems to the CDC? They're not," she said.

Marchibroda, like other public health experts, said federal funding is likely needed to bolster the entire communications network. In Congress, appropriations bills for fiscal 2002 increase funding to combat bioterrorism, but just how much is earmarked to strengthen the IT and telecommunications components is unclear.

The Senate version of the appropriations bill gives the Department of Health and Human Services more than $338 million, an increase of more than $48 million from last year, while the House bill recommends more than $393 million to counter bioterrorism and improve preparedness.

The House bill also gives more than $4 billion directly to CDC and taps an additional $232 million for activities related to bioterrorism preparedness. Overall CDC funding is about $4.3 billion, or $264 million above the fiscal 2001 level.

Sens. Bill Frist (R-Tenn.) and Edward Kennedy (D-Mass.) were expected to introduce a bioterrorism bill last week that will address, in part, the Health Alert Network, said Margaret Camp, Frist's press secretary. She said she was unsure of the bill's provisions or how much money it sought.

The State Bioterrorism Preparedness Act, unveiled last month by Sen. Evan Bayh (D-Ind.), would provide multi.million-dollar annual grants to states for bioterrorism preparation and response. The bill also specifies improving the communications systems for better information exchange and rapid dissemination of information. Grants are also available for states to carry out tabletop and computer-based biological or chemical attack simulations. A similar bill was also introduced in the House.

Health experts say that providing hardware, software and connectivity is not really the problem. That is doable. What is needed is more bioterrorism planning and coordination within and among the different levels of government.

"There has to be a well-organized plan in place in how state and federal authorities and law enforcement in particular are going to interface with public health," NALBOH's Pratt said.

North Carolina's Virkar said the real work is planning and preparing for the variety of threats out there for both biological and chemical weapons. "A lot has to be done and a lot has been done. Both are true," he said. "We still are a few months away from having everything function just the way we like it. But you have to realize this is new for everybody."

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