Dena M. Bravata, M.D., M.S.

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Bioterrorism The Use of Information
Technologies and Decision Support Systems

• Dena M. Bravata, M.D., M.S.
• Policy Analysis
• MSE 290

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Case Presentation Day 1 (11/16)

• Ottilie Lundgren, a 94 year old widow, living in
  Oxford, Connecticut presented with a 3-day
  history of fever, cough, and myalgias.
• Her physical examination showed an elderly woman
  with a fever (102.3F), elevated heart rate (118).
• Her chest x-ray and initial laboratory tests were
  all negative.
• She was admitted to the hospital for dehydration
  and an infection of the kidney tract.

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Case Presentation Days 2-4

• Hospital Day 2-3 (11/17-11/18)
• Labs Bacteria found in her blood and urine but
  not yet identified
• Mrs. Lundgren had progressive respiratory
  distress and confusion.
• Repeat CXR fluid around the left lung with the
  suggestion of pneumonia
• Hospital Day 4 (11/19)
• A sample of fluid from around lung taken for
  culture.
• The Connecticut Department of Public Health was
  notified by the hospital laboratory of blood
  culture results

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Case Presentation Day 5-6

• Hospital Day 5 (11/19)
• She was transferred to ICU on a ventilator
• Blood culture isolates identified as Bacillus
  anthracis at the State public health laboratory
• Hospital Day 6 (11/21)
• CDC confirms blood culture isolates as B.
  anthracis, molecular typing and susceptibility
  patterns identical to recent cases
• Ottilie Lundgrens condition continued to
  deteriorate and she died.

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Current Cases of Bioterrorism-related Anthrax
Confirmed Suspected
Cutaneous 7 5
Inhalational 10 0
Total 17 5
4 Deaths associated with inhalational anthrax
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Biothreat Agents

• Variola major (smallpox)
• Bacillus anthracis (anthrax)
• Yersinia pestis (plague)
• Clostridium botulinum toxin (botulism)
• Francisella tularensis (tularemia)
• Filoviruses (Ebola hemorrhagic fever and Marburg
  hemorrhagic fever)
• Arenaviruses (Lassa fever, Junin/Argentine
  hemorrhagic fever) and related viruses

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The Project

• The objective of our project was to synthesize
  the evidence on information technologies and
  decision support systems (IT/DSSs) that may serve
  the information needs of clinicians and public
  health officials in the event of a bioterrorist
  attack.

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Methodologic Challenges of this Project

• Conceptualizing the problem
• Complex topic, no single effect size
• Finding the literature
• Not limited to peer-reviewed medical literature
• Government documents
• Web-based sources
• Evaluating the quality of the evidence
• No single, published quality scale relevant

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The Methodologic Approach

• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to meet the
  information needs of clinicians and public health
  officials
• Perform literature searches
• Evaluate the evidence

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The Method

• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to meet the
  information needs of clinicians and public health
  officials
• Perform literature searches
• Evaluate the evidence

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5 Key Questions

• What are the information needs of clinicians and
  public health officials in the event of a
  bioterrorist attack?
• What are the criteria by which IT/DSS should be
  evaluated for usefulness in a bioterrorist event?
• What IT/DSSs are available for detection and
  diagnosis, management, surveillance, and
  communication?

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5 Key Questions Continued

• What is the quality of the evidence about IT/DSS
  usefulness?
• If no existing IT/DSSs meet the information needs
  of clinicians and public health officials, what
  considerations are important in the design of
  future IT/DSSs to support response to
  bioterrorism events?

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The Method

• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to meet the
  information needs of clinicians and public health
  officials
• Perform literature searches
• Evaluate the evidence

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Structure of the Conceptual Framework
Time period 1 Decision maker Clinicians Events
associated with the initial cases
Time period 3 Decision maker Clinicians Events
associated with subsequent cases
Time period 2 Decision maker Public health
officials Events associated with the initial
cases
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Diagram of the Conceptual Framework
Exposure
Exposure
Infection Status (unobserved)
Infection Status (unobserved)
Clinical Syndrome
Clinical Syndrome
Surveillance Alert
Susceptible
Susceptible
Diagnosis
Diagnosis
Test Result
Test Result
Lives Saved
Lives Saved
Management
Management
Prevention
Prevention
Report
Report
Surveillance Report
Epidemiologic Control
Outbreak Investigation
Surveillance Alert
Time period 2
Time period 3
Time period 1
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Time period 2 Surveillance Systems Detect
Potential Events
Surveillance systems receive data from a variety
of sources and provide reports to public health
authorities.
Foodborne Disease Reports
Healthcare provider Reports
Veterinarian Reports
Coroner Reports
Laboratory Reports
Surveillance Report
Epidemiologic Control
Detector Data
Lives Saved
Outbreak Investigation
Surveillance Alert
School/Work Absenteeism Data
Pharmacy Sales Data
Hospital Discharge Data
EMT Data
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Role for Information Technologies and Decision
Support
Exposure
Exposure
Infection Status (unobserved)
Infection Status (unobserved)
Clinical Syndrome
Clinical Syndrome
Surveillance Alert
Susceptible
Susceptible
Diagnosis
Diagnosis
Test Result
Test Result
Lives Saved
Lives Saved
Management
Management
Prevention
Prevention
Report
Report
Surveillance Report
Epidemiologic Control
Outbreak Investigation
Surveillance Alert
Decisions marked in blue indicate those that can
be affected by decision support systems and
arrows marked in blue indicate processes in which
information technologies could play a role.
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The Method

• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to meet the
  information needs of clinicians and public health
  officials
• Perform literature searches
• Evaluate the evidence

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Task Decomposition

• Formal framework for specifying, documenting, and
  evaluating the data that should be contained
  within the knowledge base of a DSS in order for
  it to serve its purpose.
• Literature review to define tasks
• U.S. Offensive weapons program
• Known bioterrorist events
• Tabletop exercises
• Infectious disease outbreaks
• 5 Tasks
• Surveillance
• Diagnosis and detection
• Management
• Prevention
• Communication

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Example Task Decomposition Surveillance
Subtask Key Concepts Data Requirement
Collect surveillance data Continual, timely collection of sensitive and specific data from multiple sources for early detection of a bioterrorist attack Environmental detectors Pharmacy sales data School work absenteeism data Clinicians reports Laboratory reports
Analyze surveillance data Timely analyses and presentation to public health decision makers Baseline information for each data source to calculate expected trends over time Threshold information for each data source to know when an outbreak has occurred
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The Method

• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to meet the
  information needs of clinicians and public health
  officials
• Perform literature searches
• Evaluate the evidence

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Literature Searches

• Literature Sources
• Peer-reviewed articles and government documents
  from databases
• Medline, GrayLit, National Technical Information
  Service, Catalog of U.S. Government Publications
• Government documents from websites
• Web-based information
• Search Strategies
• Professional librarians for peer-reviewed and
  government documents
• Copernic 2001 metasearch engine for web-based
  information
• Search Terms same for our Government document
  and Copernic searches

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The Method

• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to meet the
  information needs of clinicians and public health
  officials
• Perform literature searches
• Evaluate the evidence

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Results of Literature Searches

• Reviewed 16,751 citations and 8,620 websites
• 251 articles and 41 websites met inclusion
  criteria
• Double abstractions (blinded to study author) for
  all peer-reviewed articles and single
  abstractions for web-based information
• Total of 204 systems
• 52 detection systems
• 23 diagnostic systems
• 14 management systems
• 88 surveillance systems
• 27 communication systems
• 7 systems that integrate surveillance,
  communication, and command and control functions.

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Results

• Generally few clinically evaluated systems
• No IT/DSSs for Diagnosis or Management have been
  developed specifically for bioterrorism
• Systems for Detection, Surveillance, and
  Communication have been developed for
  bioterrorism
• Some show considerable promise but almost none
  has been evaluated for its sensitivity,
  specificity, or timeliness

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Results

• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

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Results

• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

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Detection Systems Overview

• Developed for Military need to be adapted to
  civilian use
• Promising projects include
• PROTECT (Program for the Response Options and
  Technology Enhancements for Chemical/Biological
  Terrorism)
• Detectors set up in subways, airports, government
  buildings
• Developing methods for signal-noise-processing
• LEADERS (Lightweight Epidemiology and Advanced
  Detection and Emergency Response System)
• Integrates detector data with other surveillance
  data
• Particularly for event-based surveillance

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Detection Systems collection and identification

• BioCaptureTM
• Only collection system clinically evaluated
• 50-125 collection efficiency of other devices
• Used by first responders

• BioThreatAlert (BTA) Strips
• Antigen/Antibody system available for a limited
  number of agents
• Sensitivity and Specificity not evaluated
• Used by first responders or clinicians

Conclusions Systems have not been clinically
evaluated, sensitivity and specificity poorly
characterized, can only test one sample at a
time, tests not available for many worrisome
agents (e.g., smallpox)
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Results

• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

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General Diagnostic Systems Overview

• Purpose Clinician enters patient information
  (usually manually) and system provides a
  differential diagnosis
• Examples DXplain, Iliad, QMR (newer handheld
  versions now available)
• Clinical evaluations the differential diagnoses
  provided are highly dependent on descriptors
  entered

Conclusions Have rarely been shown to improve
patient outcomes in general, none has been
evaluated for diagnostic capability for
bioterrorism-related diseases
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Results

• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

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Management Systems Overview

• Generally Depend on electronic medical record to
  derive patient-specific recommendations
• Most commonly for antibiotic recommendations for
  hospitalized patients

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Management Systems

• Example HELP system at LDS hospital in Salt
  Lake City
• When patients present to the ED, HELPs databases
  are queried every 10 minutes for any new clinical
  information on the patient. Uses this information
  to calculate the probability of pneumonia.
• Specificity 92, PPV 15.1, NPV 99.9

Conclusions No evidence for their usefulness in
a bioterrorist event would have to incorporate
new guidelines for biothreat agent diagnosis and
management typically require EMR.
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Results

• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

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Data Sources for Biosurveillance
Earlier Detection Data Later Detection Data
School Work Absenteeism Phone Triage
Nurses Pharmacies (OTC) Environmental detectors
Emergency Department 911 Calls Laboratory Hospi
tal admissions discharge
Sentinel Physicians Pharmacies (Rx)
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Surveillance Systems

• Syndromal surveillance reports (7)
• Reports from clinicians (6)
• Influenza-related data (10)
• Systems for laboratory and antimicrobial
  resistance data (23)
• Systems for nosocomial infections (15)
• Food-borne illnesses (10)
• Zoonotic illnesses (5)
• Other types of surveillance data (12)

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Syndromal Surveillance

• Syndromes associated with biothreat agents
• Flu-like illness
• Acute respiratory distress
• Gastrointestinal symptoms
• Febrile, hemorrhagic syndromes
• Fever and rash
• Fever and mental status change

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HealthBuddy
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ESSENCE
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Integrated Systems
Data Analysis and Presentation
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Results

• Detection Systems
• General Diagnostic Systems
• Management Systems
• Surveillance Systems
• Communication Systems

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Communication Systems Overview

• Email systems for communication between patients
  and clinicians
• Web-based secure networks linking branches of the
  public health
• Radio/Microwave-based systems for linking
  emergency personnel in the field with EDs
• Alert systems to notify clinicians of abnormal
  laboratory tests

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Communication Systems for Bioterrorism
Local Public Health
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Communication Systems for Bioterrorism
WHO
CDC
State Public Health
Local Public Health
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Communication Systems for Bioterrorism
WHO
CDC
FBI
Zoo
State Public Health
Food Inspectors
Schools
HazMat
Local Public Health
Pharmacies
Police
Laboratories
Fire
Hospitals Nursing Facilities
The Public
Clinicians
Coroner Medical Examiner
The Media
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Communication Systems for Bioterrorism
WHO
CDC
FBI

Zoo
State Public Health
Food Inspectors
Schools

HazMat
Local Public Health
Pharmacies

Police
Laboratories
Fire


Hospitals Nursing Facilities


The Public
Clinicians

Coroner Medical Examiner
The Media

48
Communication Systems for Bioterrorism
WHO
CDC
FBI

Zoo
State Public Health
Food Inspectors
S
Schools

HazMat
S
Local Public Health
Pharmacies

Police
S
Laboratories
Fire

S

Hospitals Nursing Facilities


The Public
Clinicians

Coroner Medical Examiner
The Media

49
Communication Systems for Bioterrorism
WHO
CDC
FBI

Zoo
State Public Health
Food Inspectors
S
Schools

HazMat
S
Local Public Health
Pharmacies

Police
S
Laboratories
Fire

S

Hospitals Nursing Facilities


The Public
Clinicians

Coroner Medical Examiner
The Media

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Conclusions

• Overall IT/DSSs have not be subjected to
  critical evaluations
• Detection Systems
• Rapid
• Portable
• Sensitive and Specific
• Can test for more of the worrisome biothreat
  agents
• General Diagnostic Systems
• Link to EMR
• Management systems
• Utilize available bioterrorism guidelines
• Surveillance systems
• Greater integration
• Early warning data
• Methods for the determination for what
  constitutes an outbreak
• Communication systems
• Single system for public health officers at
  various levels
• Public health ? media

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Future analysis

• Models of natural history of disease processes of
  biothreat agents
• Cost-effectiveness analyses of surveillance
  systems using different sources of data
• Cost-effectiveness of prevention and management
  strategies for the most worrisome biothreat
  agents
• Analyses of the adequacies of current capacity of
  hospitals, law-enforcement, and public health to
  respond to a bioterrorist attack.

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Collaborators

• Douglas K. Owens
• Kathryn McDonald
• Wendy Smith
• Chara Rydzak
• Herbert Szeto
• Corinna Haberland
• David Buckeridge
• Mark Schleinitz

• Dean Wilkening
• Mark Musen
• Bahman Nouri
• Bradford W. Duncan
• Mariana B. Dangiolo
• Hau Liu
• Scott Shofer
• Justin Graham
• Sheryl Davies