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Expert Meeting on Bioterrorism

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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 Prevention Presentation
Office of Emergency Preparedness Presentation
Group Discussion
   Surveillance Systems
   Education and Training
   Decision Support
   Other Ideas for Evidence Reports
Next Steps


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 initiative include:

  • Conducting studies on health and bioterrorism events.
  • Facilitating and supporting State and local bioterrorism preparedness and response planning.
  • 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 threats-epidemiology.
  • 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 planning.

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 preparedness process.

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.

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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 materials.
  • 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 and response.

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Group Discussion

The group identified research activities in which AHRQ can utilize its bioterrorism funding, with suggestions falling into the following categories:

  • Surveillance Systems.
  • Education and Training.
  • Decision Support.
  • Models/Simulations.
  • Outcomes.
  • Other Ideas for Evidence Report.

Surveillance Systems

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 follow-up/feedback function.

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 response pathway.
  • 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 information.

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 level.
  • Ask who is being trained. How are they being trained? Is "just-in-time" training effective?
  • 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 positives.
  • Document the current state of experience and knowledge about bioterrorism events.

Decision Support

Development of systems of decision support for physicians was another suggested research topic. Studies should be designed to answer the following questions:

  • 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" information?

AHRQ should look at the feasibility of effectively answering these questions.


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 are:

  • 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 health events?


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 uncertainty.
  • Determine what risk communication tools are useful in bioterrorism events.

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?

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Next Steps

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 funding provided.

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Current as of June 2000

The information on this page is archived and provided for reference purposes only.


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