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Bioterrorism and Health System Preparedness, Issue Brief No. 5
The Agency for Healthcare Research and Quality is holding a series of Web-assisted conferences on bioterrorism and the health care system.
Archived online, each Web conference on bioterrorism is also distilled into an issue brief. This brief describes syndromic monitoring systems and how they are used to tack trends in patient populations and to establish early warning of disease outbreaks.
Select for the downloadable print version (PDF file 140 KB). PDF Help.
Understanding Syndromic Surveillance
Accelerating the Public Health Investigation Cycle
Developing a Standard Language
For More Information
In a time of increasing concern over
bioterrorist activity, early response to
disease outbreaks is a key public health
priority and an emerging field of research.
Early knowledge of a disease outbreak
can improve response time and health
outcomes. Recent public health
emergencies such as the severe acute
respiratory syndrome (SARS) outbreak
and the outbreak of monkeypox in the
Midwestern United States in the summer
of 2003 highlight the important role that
early detection plays in mobilizing rapid
While traditional disease surveillance
relies on often time-consuming laboratory
diagnosis, a new breed of syndromic
surveillance systems has the potential to
significantly speed up detection of disease
outbreaks. These new, computer-based
surveillance systems offer valuable and
timely information to hospitals as well as
to State, local, and Federal health officials.
This Issue Brief describes syndromic
monitoring systems and how they are
used to track trends within patient
populations and to establish early warning
of disease outbreaks, including potential
A Web-assisted audio
conference sponsored by the Agency for
Healthcare Research and Quality (AHRQ)
in October 2003 examined the role of
information technology and surveillance
systems in disease detection and
bioterrorism preparedness. Presentations
were made by the following
researchers and practitioners:
- Michael W. Shannon, M.D., M.P.H., Children's Hospital, Harvard Medical School, Boston, Massachusetts.
- Michael M. Wagner, M.D., Ph.D., University of Pittsburgh, Pittsburgh, Pennsylvania.
- John W. Loonsk, M.D., Centers for Disease Control and Prevention, Atlanta, Georgia.
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Syndromic surveillance is a relatively
new term in clinical medicine; it refers
to the active monitoring of a patient
population for disease outbreaks, said
Michael Shannon, M.D., Chief of the
Department of Emergency Services at
Children's Hospital at Harvard
surveillance systems monitor data that
are routinely collected—in emergency
rooms, for example. Based on
presenting complaints rather than final
diagnosis, these computerized systems
can provide an early signal of unusual
illnesses in a patient population—including symptoms resulting from
Disease detection and diagnosis once
relied solely on the astute clinician.
Now, with advances in information
technology, disease monitoring can be
done electronically using "real-time"
or instantaneous data analysis. While
the astute clinician remains critical to
early detection, this technology
reduces the burden on clinicians to
identify an unusual disease
occurrence. Automated decision-support
systems also offer an
important tool to clinicians who are
likely to be on the frontlines of
detecting a disease outbreak or
bioterrorist event. These systems
enable the clinician to use computer
programs to make a faster diagnosis.
Pediatric Disease Surveillance
The Center for Biopreparedness at
Children's Hospital Boston has
developed both syndromic and
automated decision-support tools for
early disease detection. The Center's
EDScope prototype is a syndromic
surveillance program that monitors
children's emergency department visits
and chief complaint patterns, signaling
when the number or type of visits is
outside the range expected.
EDScope, the Center reviewed 10
years worth of data on 500,000 visits
to the Children's Hospital Boston
emergency department. EDScope can
now predict—within 5 to 10 percent—the number of children who will visit
the hospital's emergency department
and their chief complaints.
Pediatric Disaster Preparedness—Areas of Need
- School preparedness.
- Surge capacity planning for pediatric casualties.
- Training of first responders in managing pediatric disaster victims.
- Development of national pediatric disaster response teams.
- Assessment tools to identify children with significant mental health issues resulting from a disaster.
The Center also developed the
Bioagent Diagnosis Program, which
can be used to detect possible bioagent
causes for presenting symptoms. An
automated decision-support tool, the
program allows clinicians to enter
information on a patient's chief
complaints into a computerized worksheet. The program then presents
information on possible bioagent
causes for the patient's symptoms.
Syndromic surveillance systems can
also be used to improve public health
preparedness for children outside the
hospital. For example, used in the
school setting, syndromic surveillance
can identify a sudden change in
absentee rates or in illnesses among
children visiting the school nurse, both
of which may signal a disease
outbreak. "Children are not small
adults," says Shannon. "There is a real
challenge in being able to manage
children in the event of a disaster, and
it's going to require much more
training and education of first
Shannon points to five critical areas
that need greater attention and resources to prepare for a potential
public health emergency involving
children. In all these
areas, information technology has a
valuable role to play.
"Children are not small adults. There is a real challenge in
being able to manage children in the event of a disaster,
and it's going to require much more training and education
of first responders."
Michael Shannon, M.D., M.P.H.
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Accelerating the Public
The Realtime Outbreak and Disease
Surveillance Laboratory at the
University of Pittsburgh—known as
the RODS Lab—uses information
technology to improve detection of
disease outbreaks, either naturally
occurring or resulting from
bioterrorism. The Lab's signature
systems are the National Retail Data
Monitor (NRDM) and its RODS
system. "We're trying to accelerate the
basic public health investigation cycle
with the use of information
technology," said Michael Wagner,
M.D., director of the laboratory.
The Lab's NRDM system analyzes
sales of over-the-counter health care
products to detect disease outbreaks.
With the cooperation of seven national
pharmacy and grocery companies, the
NRDM gathers, evaluates, and
interprets massive amounts of sales
data routinely collected by the retail
industry on over-the-counter
medications. The standard coding
system for consumer products—the
12-digit Universal Product Code or
UPC printed on every package—enables collection of this data.
The NRDM receives data daily from
15,000 stores on sales of over-the-counter
health care products such as
cough syrup. This data provides
valuable information on medications
that may be purchased early during the
course of an illness. Computerized
algorithms monitor these data to
detect unusual patterns of sales. At
present, the NRDM captures 30
percent of the Nation's sales of over-the-counter health care products. The
lab aims to enlist enough additional
retail chains to reach 70 percent and
also hopes to decrease the data's time
latency to less than 24 hours.
public health official can obtain a free
account that provides access to the
NRDM by contacting email@example.com.
The first real-time public health
surveillance system for early detection
of disease outbreaks, the Lab's RODS
system examines hospital emergency
room data from across the country.
The RODS model analyzes and
integrates clinical data from
emergency departments within a
geographic region to provide an
instantaneous picture of symptoms
and an early warning of disease
outbreaks. The system monitors in real
time information such as chief
complaints that are routinely collected from patients visiting emergency
Used during the winter 2000 Olympics,
RODS currently operates in several
States, including Michigan, Ohio,
Pennsylvania, and Utah. For more
information about RODS, visit
In 2003, the
University of Pittsburgh made the
RODS software publicly available to
accelerate development of software for
disease outbreak surveillance. Source
code and information about RODS can
be found at the RODS Open Source
Project Web site at
Information Technology to Support Bioterrorism Preparedness
- Detection and monitoring systems support disease and threat surveillance and collect national health status indicators.
- Analytical systems facilitate real-time evaluation of live data feeds and turn data into information to identify disease outbreaks.
- Information resources and knowledge management systems provide reference information, distance learning, and decision support.
- Alerting and communications technologies transmit emergency alerts, facilitate routine professional discussions, and support collaborative activities.
- Response systems help manage vaccine distributions, track side effects, and disseminate public health information.
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Developing a Standard
Currently, many public health
surveillance systems generate data for
public health labs, the clinical
community, and State and local health
departments. Many of these systems
operate in isolation, however, and fail to
capitalize on the potential for electronic
data exchange. The current public
health investigation cycle—from the
first hint of trouble to managing a
disease outbreak—is lengthy and
frequently involves manual exchange of
data across many public health
organizations. For example, during the
anthrax attacks of fall 2001,
investigators communicated thousands
of environmental test results exclusively
by phone and fax.
Dr. John Loonsk, associate director of
the Information Resources
Management Office at the Centers for
Disease Control and Prevention,
explained that surveillance and
preparedness systems fall into several
categories ranging from detection
systems to response systems.
When an outbreak is discovered,
systems must be in place to manage the
response by tracking vaccine side
effects, disseminating public health
alerts, and treating cases of the disease.
A unifying framework is needed to
better monitor data streams from
different public health entities to ensure
a successful response. "These systems
need to work together to share data and
use technology approaches that will
allow them to exchange data more
efficiently," said Dr. Loonsk.
The CDC's Public Health Information
Network (PHIN) will provide a
framework to unify data streams from
different organizations to ensure early
detection and an efficient response to
health emergencies. PHIN is currently
under development as an umbrella
system that is building on the
technologies of existing CDC systems
such as the National Electronic Disease
Surveillance System, the Health Alert
Network, and the Epidemic Information
Major Components of CDC's PHIN Initiative
The BioSense Initiative—Supports early detection activities
associated with possible bioterrorist threats. This CDC
initiative monitors regional health data—combined with
clinical data from the Department of Defense and
Department of Veterans Affairs—to identify trends related to
a possible bioterrorist attack.
The National Electronic Disease Surveillance System
(NEDSS)—Promotes the use of data
and information system standards to advance the
development of efficient and integrated surveillance systems
at the Federal, State, and local levels. Go to http://www.cdc.gov/nedss/
The Epidemic Information Exchange (Epi-X)—Is the
CDC's secure, Web-based communications network that
serves as a communication exchange between CDC, State
and local health departments, poison control centers, and
other public health professionals. The system provides rapid
reporting, immediate notification, and coordination of health
The Health Alert Network (HAN)—Ensures communications capacity
at all local and State health departments to broadcast and
receive public health alerts. The initiative also ensures local
capacity to receive distance learning offerings from CDC. Go to http://www2a.cdc.gov/han/Index.asp
PHIN aims to transform the public
health community with information
systems that enable real-time data flow,
computer-assisted analysis, and rapid
dissemination of information. PHIN
includes five key components that
correspond to the information
detection and monitoring, data analysis,
information dissemination, alerting,
In the event of a disease outbreak,
PHIN will ensure consistent exchange
of information between public health
organizations through uniform data and
vocabulary standards. The Federal
government has moved aggressively to
standardize data exchange through the
Consolidated Health Informatics, an
initiative to establish a portfolio of
clinical vocabularies and messaging
standards that would ensure compatible
health data systems across Federal
agencies. Key to this activity is the use
of Health Level 7, or HL7, and Logical
Observation Identifiers Names and
Codes, or LOINC. HL7 is a standards-based
protocol for formatting,
transmitting, and receiving data in a
health care environment. LOINC codes
are universal identifiers or names for
laboratory and other clinical
observations. PHIN is incorporating the
codes used in HL7 and LOINC, both of
which are independent, non-governmental
PHIN is also a process, explains
Loonsk. The initiative requires a
commitment from the public health
community to use its standards and a
commitment to participate in the
development and implementation of
electronic specifications. In fact, the
PHIN technical requirements—both
data and systems specifications—are
included in over $2 billion in
cooperative agreement funds awarded
in 2002 and 2003 by CDC and the
Health Resources and Services
Administration. These agreements are
designed to upgrade the preparedness
of the nation's public health care system
to respond to bioterrorism, infectious
disease outbreaks, and other public
health threats and emergencies.
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For More Information
For the most current information on
PHIN, including data and technical
specifications, please visit http://www.cdc.gov/phin/.
The PHIN Web site
also provides contact information for
technical assistance offered by the CDC
to support PHIN.
The complete audioconference on The
Role of Information Technology and
Surveillance Systems in Bioterrorism
Readiness is available as a streaming
presentation and as a text transcript on
the AHRQ Web site at http://www.ahrq.gov/prep/.
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|This issue brief was prepared for AHRQ by AcademyHealth under
contract No. 290-98-0003.
AHRQ Publication No. 05-0072
Current as of March 2005
The Role of Information Technology
and Surveillance Systems in
Bioterrorism Readiness. Bioterrorism and Health System Preparedness, Issue Brief No. 5. AHRQ Publication No. 05-0072, March 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/btbriefs/btbrief5.htm