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The Agency for Healthcare Research and Quality (AHRQ) convened a meeting of
experts on bioterrorism on February 18, 2000, to inform discussions on how the
Agency can contribute to the current state of bioterrorism research.
Center for Disease Control and
Office of Emergency
Other Ideas for Evidence
Helen Burstin, M.D., M.P.H., Director of the Center for Primary Care
Research, Agency for Healthcare Research and Quality (AHRQ), opened the meeting
and welcomed the participants. Five million dollars of the Agency's $205 million
fiscal year 2000 budget is allocated to addressing current issues relating to
bioterrorism research, prevention, and preparedness.
John Eisenberg, M.D., Director of AHRQ, gave a brief overview of AHRQ's
history and future goals. He stressed that AHRQ's focus is on health care within
the context of the general population, whereas agencies such as the Centers for
Disease Control and Prevention (CDC) are much more focused on public health.
However, there is significant overlap among government agencies and research
institutions with respect to bioterrorism initiatives.
AHRQ's overall research goals are as follows:
- To support improvement in health outcomes.
- To strengthen quality measurement and improvement.
- To identify strategies to improve health care access, foster appropriate
use of the health care system and reduce unnecessary expenditures.
Dr. Eisenberg encouraged meeting participants to identify priorities of
bioterrorism research within these goals.
Center for Disease Control and Prevention Presentation
Richard Spiegel, D.V.M., M.P.H., a medical epidemiologist within the
Bioterrorism Preparedness Response Program of the CDC, gave an overview of CDC's
role in responding to biological and chemical terrorism nationwide. CDC has been
designated by the Department of Health and Human Services (HHS) to coordinate
and lead the overall planning effort to upgrade public health capabilities in
response to bioterrorism.
A few of CDC's priority responsibilities and activities for the bioterrorism
- Conducting studies on health and bioterrorism events.
- Facilitating and supporting State and local bioterrorism preparedness and
- Enhancing Federal, State and local laboratory diagnostic capabilities.
- Strengthening State and local epidemiological and surveillance capacity.
- Establishing a national health alert network.
To successfully accomplish these goals, the following components of a
comprehensive public health program for bioterrorism preparedness and response
must be in place:
- Program planning and development.
- Detection of unusual events-surveillance.
- Rapid investigation and containment of real or potential
- Education and training.
- Coordination and communication.
- Practice, exercises and program evaluation.
Of the CDC's fiscal year 1999 budget, $121 million was allotted to
bioterrorism research. Of that amount, $28 million was spent on health alert
(communications) initiatives, $17 million was spent on surveillance and
epidemiology (response) systems and research, and $3 million was spent on
Dr. Spiegel predicts fiscal year 2000 expenditures will be roughly similar in
proportion. Priority initiatives for this fiscal year include enhancing outbreak
response, coordination and support, enhancing local-level epidemiology and
surveillance, and improving the use of information technology in the
Data flow is one area in which CDC would like to improve. News of a
recognized, unusual event spreads quickly to the right people using various
means of direct communication. An unrecognized, unusual event, however, is much
harder to detect. Efforts to develop surveillance systems which can monitor
unique circumstances and notify key personnel when a rare situation arises would
be highly beneficial.
Office of Emergency Preparedness Presentation
Robert Knouss, M.D. and Commander Kevin Tonat, Dr.P.H., M.P.H. presented an
overview of the Office of Emergency Preparedness (OEP) of HHS. The National
Disaster Medical System, within the OEP, focuses on emergency and disaster
assistance through planning, training, development, and response activities. A
systems development approach, concentrating on four key elements, strengthens
and enhances HHS's ability to prepare and respond to terrorist events.
The four elements are as follows:
- Enhancing the public health infrastructure.
- Strengthening medical response capabilities on national and local levels.
- Creating and maintaining a stockpile of pharmaceuticals and other
- Enhancing research, design, development, and approval of diagnostic
antibiotics/antivirals and vaccines.
In reviewing the response characteristics, Commander Tonat stressed the
bottom-up nature of a bioterrorism event. Therefore it is essential to implement
rapid and appropriate response systems, beginning with the first responder in
the community and working up through appropriate channels and ultimately
reaching the Federal level.
The main components of the response pathway are:
- Public health monitoring and surveillance.
- National/local data collection and analysis.
- Federal/local response operations.
- Federal recovery assistance.
One area of study the OEP would like to focus on is strengthening the links
along the response pathway. Law enforcement, emergency management, public
health, and medical personnel can all be involved in a single bioterrorism
event. Appropriate surveillance and communication measures which connect these
and other personnel are key components of effective public health decisionmaking
The group identified research activities in which AHRQ can utilize its
bioterrorism funding, with suggestions falling into the following
- Surveillance Systems.
- Education and Training.
- Decision Support.
- Other Ideas for Evidence Report.
Some participants suggested that AHRQ focus its efforts on making a
difference in outbreak detection or response in a concrete way in order to
increase bioterrorism funding in future years and give AHRQ more leverage in
health communities. To do so, AHRQ needs to articulate steps in detection and
response and offer solutions.
Many felt that determining the specific functions a surveillance system
should perform and the necessary sensitivity needed by such a system is a high
research priority. An effective surveillance system should link the public
health community, the health care provider, and Government agencies. If the
surveillance system serves as a routine organizational system that can be
altered to a different purpose during a bioterrorism event, clinicians will be
invested in using it every day. An appropriate system will build on current
electronic medical records and include multiple-source detection data and a
Suggestions for specific research activities include:
- Develop an algorithm which can be used to identify an emerging event.
- Monitor awareness and access of users and potential users.
- Determine what systems are already being used and how effective they are
in order to minimize development and use efforts.
- Implement a surveillance system which consists of a human interface with a
model framework. The ideal person/people will have public health training.
Computers are too slow and antiquated and there is little incentive for
hospitals to use them.
- Develop a way to link surveillance systems to poison control centers or
use them as models.
- Focus a study on the interface between bottom and top levels along the
- Research the different models and approaches to how an affordable linkage
system can visibly and quickly improve the interface communication.
Education and Training
Participants had opposing views on the effectiveness of bioterrorism
education programs targeting health care workers. Some believed that programs
designed to increase the awareness among those along the bioterrorism response
pathway would lead to a positive change in behavior. Others were unsure of whose
behavior is being targeted and what information they need to know. The main
objective of education initiatives was determined to be the identification of
the most effective educational interventions and dissemination of that
Research suggestions are as follows:
- Evaluate what is currently being done to educate health care providers and
determine if it is effective. Is it something the medical care community feels
a need for?
- Survey school training programs to determine the average baseline training
- Ask who is being trained. How are they being trained? Is "just-in-time"
- Study how awareness among health care workers is created and maintained.
How can accurate information be supplied to clinicians in a timely manner?
- Raise the index of suspicion by teaching professionals how to recognize an
outbreak rather than how to identify a particular agent.
- Find out how public health officials recognize and deal with false
- Document the current state of experience and knowledge about bioterrorism
Development of systems of decision support for physicians was another
suggested research topic. Studies should be designed to answer the following
- If clinicians are alerted to an unusual event, what do they do next?
- Who do they alert?
- How do they respond?
- Can a system be built to give physicians "just-in-time"
AHRQ should look at the feasibility of effectively answering these
Because simulations are effective in raising awareness and allow movement
into complex modes of interaction, participants suggested AHRQ focus its efforts
on assessing the objectivity and effectiveness of models and simulations.
However, it can be difficult to match an appropriate simulation to the level of
capacity of the clinician.
Key questions to consider and suggested research efforts on this topic
- With minimal data how does one detect and define the affected population
and assess models for predictive ability?
- How can one design simulations that will raise awareness and teach skills
to health care professionals?
- How can models remain current?
- How can simulations appropriately change to meet the needs of unique
Issues such as short- and long-term outcomes, costs, and quality indicators
were the subject of much discussion among participants. Various suggestions for
research topics include:
- Determine the impact of false alarms and hoaxes.
- Evaluate the psychiatric and physical burden among health care providers
and workers during a bioterrorism incident.
- Develop programs to treat community stress in order to keep the health
care community psychologically healthy.
- Determine where people get information during a health emergency. What
information do they trust?
- Form a joint information center to function as a readily available source
of authoritative information on bioterrorism events nationwide.
- Study how the public can be reassured during conditions of high
- Determine what risk communication tools are useful in bioterrorism
Other Ideas for Evidence Reports
- Study sensitivity/specificity of detection systems.
- Determine how prepared the health care community is to deal with an
outbreak and determine the economic impacts of such an event.
- Perform an evidence-based evaluation of protective gear (i.e., firemen's
masks, hospital masks).
- Conduct an evidence-based study of current response systems. How well
integrated are EMS command systems and hospitals?
Helen Burstin and Carolyn Clancy, Director of the Center for Outcomes and
Effectiveness Research, AHRQ, were pleased with the level of interest expressed
by the meeting participants and the amount of input given to this research
question. While keeping in mind the mission and goals of the Agency, they will
determine which research questions will benefit those groups handling
bioterrorist issues, and which will make the most impact with the level of
Current as of June 2000