Philosophical Underpinnings for Blank Slate: Bioterrorism and Field Epidemiology

1
Philosophical Underpinnings for Blank Slate
Bioterrorism and Field Epidemiology
Paul Bartlett, DVM, MPH, PhD Michigan State
University
2

• Do you believe in Field Epidemiology? Outbreak
  investigation?
• Field epidemiology can still be sexy.
• The data may be messy and dirty,
• But the song can usually be heard through all
  the noise.
• It still works

John Snow Pub
3
Syndromic Surveillance
The primordial soup of epidemiology
Dr. John Snow, September, 1854
4
Would John Snow get NIH funding today to study
Cholera? Imagine the critique!

• Drinking water at work? Neighbors?
• Some people dont know their water company?
• Water companies too defensive to share data?
• Confidentiality?
• Liability?

5

• No adjustment for confounders.
• No statistics.
• Poor case definition (no laboratory confirmation)
• Nevertheless Classic outbreak investigation
  still works!

6
Convincing others of the importance of field
epidemiology is (strangely) a difficult task?

• No sophisticated statistics or laboratory genus
  to impress your peers.

7
Field Epidemiology Disease Control

• Just basic risk factor identification based on 2
  by 2 tables and common sense.
• Yet these methods have been used to control the
  latest emerging infectious agents.
• Look at how the last 8 new public health diseases
  were controlled.

8
Field Epidemiology

• Field epidemiology and working syndromic case
  definitions have been used to control the
• Latest emerging infectious agents.
• Legionnaires Disease
• TSS
• Hanta Virus Pulmonary Syndrome rodents
• WNV
• EHEC (E. coli O157H7) - hamburger
• HIV/AIDS Risk factor determination
• BSE (Case-control study identified rendered beef
  products as likely cause.)
• Bovine TB in deer.

9
Bioterrorism Defense
For a biological or chemical attack, there is not
much you can do with guns or hoses.
10
It is doubtful that terrorists will feel
compelled to select their biological agents from
the list NIAID provides them.Our defenses must
therefore be flexible and prepared for the
unexpected.
11
Bioterrorism Defense

• The epidemiological puzzle will probably be more
  complex than naturally occurring outbreaks.
• Potato salad in Cincinnati with agent 1?
• Tylenol in Detroit with agent 2?
• Pork in Chicago with agent 3?
• The puzzle will need to be solved very rapidly!
• Will require a very speedy outbreak investigation
  (classic descriptive field epidemiology and risk
  factor analysis )
• How many are sick?
• Where are the sick located?
• What is the likely source or early risk factors?
  
• What products or activities need to be avoided?

12
Blank Slate is designed to provide the flexible
component to your network of surveillance
systems.

13
Flexibility Are we preparing to fight the last
war? Or the next?

• Prior to 2002, the US postal Service was not
  listed as one of the routes of transmission for
  Anthrax.
• We should expect novel agents delivered in
  totally unexpected manners.

Blank Slate is designed to provide the flexible
component.
14
What do you do when panic sets in?
NYC, 9/11/2002
Go back to First Principles. Go back to the
basics of Epi 101
15
EPI 101 Steps in Outbreak Investigation

• Verify Diagnosis
• Develop a working case definition based on early
  syndromic data (Blank Slate)
• Confirm epidemic
• Based on early syndromic data (Blank Slate)
• Identify and count cases
• Line listing (Blank Slate)
• Refine case definition

16
Steps in Outbreak Investigation

• Tabulate and orient data based on basic
  descriptive variables
• Time, Place, Person factors (Blank Slate)
• Take immediate control measures (Can e-mail
  instructions to large numbers of people who visit
  Blank Slate.)

17
Steps in Outbreak Investigation

• Formulate and test hypothesis regarding early
  suspected risk factors
• Plan additional studies (Blank Slate)
• Implement and evaluate control measures
• Initiate surveillance (Drop in SS w/ Blank Slate)
• Communicate findings

18
Syndromic Surveillance and Bioterrorism

• Early mitigation of an outbreak (agro-terrorism,
  bio-terrorism, chemical terrorism, etc.) may be
  more important and effective (save more lives)
  than attempts at total prevention.
• While not politically attractive, limiting an
  outbreak to 3,000 instead of 30,000 may be be the
  most effective investment of our resources.
• Blank Slate can be a tool used for early
  mitigation.

19
A word about laboratory-based Surveillance

• We cant be afraid to go it alone without
  laboratory support.
• Requires faith in the value of old fashioned
  field epidemiology!
• Consider that virtually all new public health
  agents have been managed and successfully
  controlled with syndromic case definitions .
• Look at the emerging diseases of the last 30
  years.
• All were controlled by field epidemiology using
  syndromic case definitions
• long before laboratory support was available.

20
Round up the usual suspects
Casablanca
Laboratories can only find agents for which they
look, and they only look for what they expect to
find. A serious problem for defense against
terrorism.
21
Limits of Laboratory-based surveillance

• Reliance on laboratory confirmation often results
  in a low rate of reporting.
• Less than 1 for foodborne diseases
• FoodNet .14 of cases reported
• Medical attention not always sought.
• Diagnosis may not be possible for a new
  bioterrorist or new natural agent.
• Lab confirmation is not needed on every case in a
  massive epidemic.

22
Bioterrorism
Blank Slate enables Drop-in Syndromic
Surveillance.

• Laboratory confirmation would be
• Redundant
• What percent of 2 Million cases need to be
  laboratory-confirmed?)

23
Drop-in Syndromic Surveillance is pre-laboratory.
It is not anti-laboratory.
24
A Word about the (proverbial) astute clinician
for detecting outbreaks? Is that one case
Or the tip of an Iceberg?
An isolated Snow Flake?
Distinguishing the astute clinicians from the
isolated flakes can be another problem.
Source John Tilden
25
But

• From their location, the astute clinician can not
  see the extent of the problem.
• Which is probably why they called you in the
  first place.
• Is the problem just in his/her town? County?
  State?
• Is it 5 people? 50? 500? 5,000? 5 million?

26
From their location amongst the trees, the astute
clinician cant see the forest. Hence the need
for syndromic surveillance
27
In Summary

• Knowing the lab diagnosis does not solve the
  public health problem if thousands or millions
  are sick. Syndromic surveillance can help manage
  the public health emergency.
• Need fast descriptive information regarding the
  size and location of the outbreak and early
  data regarding suspected risk factors.
• Blank Slate is a tool for this purpose

28
The Role of Syndromic Surveillance in Biodefense

• Only Syndromic Surveillance can solve
  epidemiologic puzzle with sufficient speed.
• Yet most of our biodefense money is going into
  molecular research on the NIAD Category A list of
  priority pathogens
• and the guys with the guns and hoses.

29
Syndromic Surveillance State of the Art

• CDC has several SS projects underway.
• Emergency Departments
• Nurse hotlines
• Poison Control
• Over the Counter drug sales
• School absentees
• Blank Slate is designed as the flexible component
  to supplement these other SS programs.

30
Thank You!

• Paul Bartlett or Holly Wethington
• 165 Food Safety Tox Bldg
• National Food Safety
• Toxicology Center
• Michigan State University
• East Lansing, MI 48824
• P 517-432-3100 x128
• Email ffmod_at_cvm.msu.edu
  bartlett_at_cvm.msu.edu