By Christopher Guadagnino, Ph.D.
The threat of future terrorist attacks on American soil has changed the ways in which the medical community thinks about response strategies. Naturally occurring disease outbreaks around the world have reinforced the seriousness of vigilant preparation, including an outbreak of severe acute respiratory syndrome (SARS) in mid-May that had effectively shut down Taiwan’s major teaching hospital when thousands of patients and more than 250 staff members, including at least 40 doctors and 68 nurses, were quarantined.
A combination of federal funding earmarked for bioterrorism preparedness and innovative research and development has brought important enhancements to Pennsylvania’s ability to detect and respond to mass casualty events.
As a corollary benefit, these developments also represent significant improvements in Pa.’s public health infrastructure and include a statewide smallpox response plan, new statewide electronic disease reporting capabilities, new systems of syndromic analysis programmed to detect outbreaks of specific pathogens, new resource utilization planning that optimizes responses to specific outbreaks, and enhanced response coordination efforts at the state, regional and institutional levels. Some of these systems have already proven their usefulness in bringing a rapid and effective response to outbreaks in Pa. of SARS and monkeypox, and can be equally effective for virtually all reportable infectious diseases.
Attempts to coordinate the efforts of Pa.’s 46,000 physicians – for any purpose – will never be completely successful, but increasingly abundant counter-terrorism training and education, and the availability of a stronger and more responsive public health infrastructure, bring to Pa. perhaps the strongest-ever bond between its public and private health care systems.
That bond is now more important than it has ever been before. Even with Pa.’s stronger public health capability, emergency experts agree that the window of opportunity for life saving lasts six hours, while significant state response will take at least four hours and significant federal response will take at least eight hours. It is the actions of physicians in an emergency that will determine the success of Pa.’s improved response capabilites to save patients’ lives – actions which depend upon physicians’ understanding of how best to interface with their improved public health system.
Using federal and state bioterrorism preparedness funding from the Centers for Disease Control (CDC), the Health Resource Services Administration (HRSA), and the Pennsylvania Emergency Management Agency (PEMA), the Pa. Health Department on July 1, 2002 launched an electronic disease reporting system that converted the department’s paper forms into a web-based application that allows hospitals, physicians and laboratories to report notifiable infectious and communicable diseases via a real-time, secure communications link. The Pennsylvania National Electronic Disease Surveillance System (PA-NEDSS) is now being used by every hospital in the state, 190 clinical microbiology labs and over 1,000 physicians, primarily infection control practitioners in hospitals who tend to report the largest number of cases per year, according to Joel Hersh, director of the Health Department’s Bureau of Epidemiology. As of this November, all physicians will be required to register with PA-NEDSS, which requires Internet access and at least a Windows 98 operating system, he adds.
PA-NEDSS allows a clinician to relay data about an unusual case to the Health Department – the system handled 100,000 disease reports last year – and the data is quickly re-transmitted to state and/or local public health investigators in the region from which the report originated, says Hersh.
The system is quick and adaptable to new diseases. The Health Department added SARS as a reportable condition to PA-NEDSS within one hour of identifying a case definition, says Hersh, noting that Pa. has had one probable case of SARS and 16 persons with some clinical symptoms. PA-NEDSS facilitated follow-up with local physicians and hospitals as needed, demonstrating its ability to coordinate state and local epidemiological investigations with speed and continuity superior to what is possible by the previous communication method of fax and email, Hersh adds. The one probable SARS case occurred in the Lehigh Valley region of the state and the patient is no longer contagious, while the 16 suspected cases are being monitored, says Hersh.
PA-NEDSS has also recently prompted an investigation of monkeypox, which has now been added to the system’s menu of reportable diseases, after the Health Department learned that some persons in Allegheny County had purchased prairie dogs, which spread the untreatable disease. A prompt investigation turned up no signs of the disease and further demonstrated the ability of NEDSS to coordinate intervention and morbidity reduction much more quickly than was possible in the past, says Hersh.
The Health Department has sent a letter to all licensed physicians in Pa. asking them to become registered users of PA-NEDSS to report notifiable diseases, which it said will ultimately better protect Pennsylvanians from outbreaks and bioterrorist attacks. The Department can also use PA-NEDSS instead of the traditional – and slower – fax and email messages to link physicians with the national Health Alert Network (HAN), which provides health advisories and updates, says Hersh.
As a corollary to enhanced state-disseminated information, the CDC has greatly improved its timeliness in distributing information to physicians through its website and listserv to the Infectious Disease Specialty Society about SARS, compared to its performance during the anthrax outbreaks in late 2001, according to Matthew Levinson, M.D., professor of medicine and public health and an infectious disease specialist at Tenet’s MCP in Philadelphia. The CDC has been providing up-to-the minute information about SARS and quickly identified the agent that causes it, whereas physicians had to read the New York Times to get updates about the anthrax cases, he says.
The Health Department is also using HRSA funds to form a web-based hospital preparedness network to coordinate planning for surge capacity, patient isolation capacity and resource availability, according to Michael Huff, the Health Department’s Director of Community Health and Acting Director of the Office of Public Health Preparedness.
Another new statewide surveillance project overseen by the Health Department, the National Retail Data Monitor, is a software application that tracks over-the-counter retail drug sales and flags unusual purchase patterns as possible indications of a public health concern, says Hersh. The system was launched a few months ago and is linked to major pharmacy chains such as Walgreen’s, Rite Aid and CVS.
One weekend, the program detected a spike in the amount of fluid replacement for children being sold in a part of the state, which officials thought could have been linked to a higher-than-usual incidence of fever and diarrhea. The sales spike turned out to be caused by one particular pharmacy working as a middleman and selling the drug to other pharmacies, but the surveillance software worked in that it detected an unusual drug sale pattern and pinpointed its source, Hersh notes.
Another surveillance software system known as Real-time Outbreak Disease Surveillance System (RODSS), which was developed at the University of Pittsburgh and first piloted in western Pa., looks for syndromic patterns by analyzing hospital billing and medical record keeping data and comparing it to a five-to-six year baseline that is specific to medical condition, season, demographics, and other variables, explains Michael P. Allswede, D.O., section chief, special emergency response unit, Department of Emergency Medicine, University of Pittsburgh School of Medicine. The system can detect a number of conditions, such as gastroenteritis, respiratory failure, paralysis and flu-like syndromes and is now being used by some 40 hospitals in the state, while the Pa. Health Department, which has access to the data, hopes over the next three years to encourage every hospital ER in the state to link to the system.
Pa. has also used CDC bioterrorism funds to shore up its national pharmaceutical stockpile and to create a smallpox response plan, which the state initiated last December, according to Huff.
Pa.’s smallpox response plan spells out the logistics of pre-event and post-event vaccination, including what federal resources would be provided for vaccination clinics, how vaccines would be packaged and delivered, where vaccinations would be offered, which personnel would be vaccinated prior to beginning vaccination clinic activities, how medical screening for contraindications would be performed, where treatment of adverse reactions would be given, and which pre-designated sites would be used to evaluate symptomatic individuals to rule out smallpox.
The response plan also includes a Statewide Immunization Information System to track vaccine inventory within each participating clinic by vaccine name, doses on hand, lot number, expiration date and vaccine manufacturer. The system can monitor inventory doses within a clinic site to track redistribution of inventory at any time, and can document each immunization event with a provider and patient record. The system can also capture patients’ adverse events, which could then be reported to the CDC.
A system to enable the medical community to evaluate their best response to a bioterrorism attack is under development, whereby three factors of an attack – the size of the event, the timeline in which responders become aware of the event, and the characteristics of the pathogen – are analyzed as a matrix to determine how to save the most lives per dollars spent, says Allswede, the project’s primary investigator. The matrix analysis could help hospital systems to inventory their capabilities, decide which antibiotics to stockpile based on disease detection time and likely stage of disease presentation, and tailor a response after a biological event occurs, notes Allswede.
These preparedness tools are not limited to counter-terrorism uses. Because Pa. has taken an “all-hazards” approach to bioterrorism preparedness, the tools and improved statewide infrastructure will serve the entire public health spectrum, says Hersh. With the federal bioterrorism funding, the Health Department has also added ten new epidemiology positions at the state level and eight new positions at the county levels, and plans to add more in the future, Hersh notes.
Grant money from the federal Department of Homeland Security’s Office for Domestic Preparedness is being disbursed through PEMA to each of nine regional counter-terrorism task forces throughout the state. According to the Pennsylvania Office of Homeland Security, the regional task forces were the result of a PEMA effort launched in 1998 to organize an effective coordinated response to a growing threat of the use of weapons of mass destruction by allowing counties to form their own partnership groupings, including emergency management agencies, law enforcement, fire/rescue, emergency medical service, hazardous material response teams, district attorneys and coroners. The aggregated county groups forming these regional task forces are augmented by state and federal officials from the respective regions, including the Federal Bureau of Investigation; Bureau of Alcohol, Tobacco and Firearms; Pennsylvania State Police; National Guard; Environmental Protection; and various health and medical organizations.
The task forces are working to integrate a federal, state and county response to a terrorist attack, to coordinate mutual aid in the region, to establish standing regional response groups and to encourage regional networking. Among the working assumptions of the task forces are that formal mutual aid in Pa. is not highly structured, that emergency responsibility lies at the municipal level, and that the window of opportunity for life saving lasts six hours, while significant state response will take at least four hours and significant federal response will take at least eight hours.
In order to qualify for HRSA emergency preparedness grants, hospitals are required to attend their region’s task force meetings and to sign mutual aid agreements with other hospitals pledging to share bed space, decontamination equipment and staffing in the event of a terrorist attack, according to Cheri Rinehart, vice president for integrated delivery systems, Hospital & Healthsystem Association of Pennsylvania. The agreements include accepting other hospitals’ credentialing of medical personnel, she notes.
Integrating hospitals’ disaster planning with that of their county and region represents a major enhancement in preparedness. In the past, EMS, fire and law enforcement agencies have done emergency planning on their own and hospitals were rarely involved in discussions of what their role would be in an emergency, says Rinehart.
Cooperation between hospitals has also been taken to a new level as institutions realize that “these events are bigger than any of us,” says Thomas Grace, R.N., Ph.D., corporate director of emergency and safety management for the University of Pennsylvania Health System. “Many of the artificial lines of resistance that existed before have been broken down to where we’ve been working at the operational level across the corporate boundaries and competition boundaries,” he notes.
The regional task forces meet monthly to perform risk analyses and identify assets and resources among the various entities. Since the task forces are conceived and organized as “bottom-up” organizations, coordinating the efforts of such an assortment of agencies and participants is a challenge, and several sources interviewed mentioned the need for improved communication within and between the task forces, and perhaps stronger state oversight to structure their activities more efficiently.
Although hospital involvement in the task forces is strong, local communities and local physicians do not yet have an adequate understanding of the task forces, which need to do more to educate citizens about what role they should play in an emergency, according to David Pipozar, executive director, Center for Public Health Preparedness, University of Pittsburgh School of Public Health, and former chair of Region 13’s Metropolitan Medical Response System (MMRS) Working Group.
If hospitals become overwhelmed during an emergency, community physicians will have to provide preventive and subacute care, and Pipozar is promoting the concept that outpatient practices should form neighborhood emergency health centers as a venue to provide first aid and sheltering. He urges private physicians to contact their county emergency planning coordinators and get on their email lists to become better integrated into regional disaster planning.
These criticisms aside, the task forces are producing results, such as coordinating emergency drills across large regions – something that nearly every source interviewed said there should be more of. The task force for the southwestern Pa. region, which includes 13 counties, is planning a major disaster exercise on Sept. 14 which, for the first time, will include participation of all 64 hospitals in the region, according to Victor Tucci, M.D., bioterrorism coordinator for the Allegheny County Health Department and current head of Region 13 MMRS, which is the medical branch of the task force. The drill will test the region’s ability to coordinate a large-scale response to a chemical, biological or radiological release on a Sunday.
The southwestern region task force is also seeking funding to develop and distribute a Smart Card for every first responder volunteer that would contain their credentials, and is working with the state Health Department to try to get it implemented statewide. The task force is also developing a “Risk Team” database of volunteers, which will include a Medical Reserve Corps. of physicians and other medical personnel, says Tucci.
The five-county southeastern Pa. region task force has formed four mutual assistance areas within which hospitals and other agencies have coordinated their emergency response capacities, according to John Domzalski, commissioner of the Philadelphia County Health Department. The task force has run several joint “tabletop planning” exercises involving the hospital community, the state’s Homeland Security Office, local and state police, the FBI, and public health officials from the federal, state and local levels, Domzalski notes.
Philadelphia also has continuous air sampling technology know as Biowatch, which monitors for biotoxins and, together with meteorological plume modeling software, permits a rapid and location-specific emergency and epidemiological response, says Domzalski.
The northwestern Pa. region task force, which encompasses five counties, has assembled a team of 50 clinicians in Erie County who would be first responders to a smallpox incident, and is trying to expand the team to the remaining four counties, according to Richard Brzuz, medical committee chairperson of the task force and CEO of Erie’s Shriners Hospital for Children. The task force also hopes to have a plan in place by the end of summer for how its region will coordinate the use of the national pharmaceutical stockpile, and is testing its emergency radio system for use in mountainous areas to overcome the challenge of communication among emergency personnel in rural areas, says Brzuz.
The task forces are also helping to coordinate local participation with other Pa. Health Department initiatives, such as the Facility Resources Emergency Database (FRED), an online system based in hospital emergency departments which captures information about bed space and health personnel availability for regional allocation planning when a disaster occurs, according to Scott Bitting, medical committee chairperson of the east central Pa. task force – which encompasses seven counties – and manager of security services for the Geisinger Health System. Every hospital in his region is expected to be part of that system by late July, says Bitting.
Individual Hospital Preparedness
Pa.’s hospitals have received some federal funding, proportional to their Emergency Department volume, to purchase decontamination gear and triage tents, to make capital improvements and to enhance training programs in order to protect hospital employees and upgrade hospitals’ capacity to deal with mass casualties after a terrorist attack.
UPMC Presbyterian, for example, spent several hundred thousand dollars in October to install a 1,000 person/hour decontamination system at the entrance to its Emergency Department, says Allswede. The hospital is developing non-contiguous staff training for disaster preparation, which will include about eight types of training so that every staff member in the hospital will be trained in the specific types of skills required by their job description during disaster drills.
Many Pa. hospitals have begun to put together post-event response teams in the event of a serious bioterrorism attack. Reading Hospital, for example, has educated its entire staff about protection against smallpox and hopes to assemble a cadre of about 50 staff members from different areas of expertise within the hospital who would be responsible for caring for the first cases of smallpox, according to Kenneth J. DeBenedictis, M.D., Reading Hospital’s director of epidemiology and infection control. These individuals would volunteer to be vaccinated first on the same day of the event, and would include ER workers, security personnel, infectious disease specialists, dermatologists, admissions staff, surgeons, obstetricians, anesthesiologists, intensivists and respiratory therapists.
Some 15 to 20 persons have volunteered to be in that first responder team so far, while the hospital will also train its own team of about six personnel to administer the vaccine to the entire hospital staff after an event, says DeBenedictis. He notes the best defense would be to vaccinate everyone up front, but the morbidity and mortality of the vaccine, together with the nebulous threat level of a possible attack, makes the state’s post-event response plan preferable. According to the state Health Department, 229 Pennsylvanians have received a recent smallpox vaccination as of June 10, 2003.
The University of Pennsylvania Health System has recently made a number of upgrades in its emergency response and decontamination capabilities, including updating its command center, expanding its training beyond emergency room staff to other hospital staff, upgrading infrastructure and performing emergency drills every two or three months, according to Grace.
Although hospitals have received federal funding for emergency preparedness upgrades, the grants cover only five to ten percent of their costs, with hospitals kicking in the rest from their operations budget, according to Rinehart. Pa. hospitals spent $8.3 million on emergency preparedness in FY01-02, and are projected to spend $24.6 million in FY02-03, she adds.
Aside from bringing major improvements to Pa.’s public health infrastructure, many of Pa.’s counter-terrorism preparedness enhancements, particularly hospital upgrades, are “all-hazards” oriented, and would prove worthwhile for natural disasters as well as terrorist attacks. How worthwhile they are for the latter alone depends on the perception of the threat, says Allswede, who notes that the U.S. spent billions of dollars during the Cold War for armed conflict that never came – perhaps because we made our Mutual Assured Destruction posture too expensive for those who posed a threat.