1Introduction

Background Information

The nation's capacity to respond to biothreat agents depends on the ability of first responders, clinicians, and public health officials to detect, manage, and communicate during a bioterrorist event.^2-6 These first responders (e.g., emergency medical technicians, firemen, policemen, and hazard materials professionals), clinicians (e.g., physicians, nurses, nurse practitioners and respiratory therapists), and public health officials (local, state, national and international) will require substantial resources as well as appropriate information technologies and decision support systems (IT/DSSs) to perform their jobs effectively in response to a bioterrorist attack.^2-6

The morbidity and mortality that may result from a poorly prepared health care system responding to a bioterrorist attack have been well described.^{7, 8} In 2 recent simulations, ⁹ and perhaps most dramatically in the descriptions of 2 actual vulnerability tests performed during the U.S. offensive bioweapons program, ¹⁰ the need for ITs for detection, diagnosis, management, prevention, surveillance, reporting, and communication during a bioterrorism event was deemed paramount.

An exercise called TOPOFF, designed to test the readiness of top officials of the government to respond to terrorist attacks, was conducted by the U.S. Department of Justice in response to a request by the U.S. Congress to "assess the Nation's crisis and consequence management capacity under extraordinarily stressful conditions." ⁹ The exercise, which took place in May 2000 at a cost of $3 million, simulated a chemical weapons event in Portsmouth, New Hampshire, a radiological event in the Washington, D.C. area, and a release of an aerosol of Yersinia pestis in Denver, Colorado. ⁹ The officials participating in this exercise included: county, state, and federal public health officials; emergency physicians; emergency management professionals; and infection control professionals. ⁹ Significant difficulties were experienced during the exercise including clear identification of the crisis management leaders and decision makers, distribution of resources such as antibiotics from the National Pharmaceutical Stockpile, determination of best methods for the prevention of the spread of disease, and inadequate management of crisis situations that resulted from hospitals running out of beds, supplies, and personnel. ⁹ The primary means of communication during the exercise was via conference calls. ⁹ At times nearly 100 people, many of whom had no prior working relationships, were on the conference calls trying to participate in the decision-making process. ⁹ ITs would have facilitated many of the decision-making processes during this exercise. In particular, IT/DSSs could have been used for the rapid diagnosis of people seeking medical attention; for the management of cases including isolation, treatment, and maintenance of personal safety among clinicians; and for communication among all participating organizations.

In the Dark Winter exercise, held at Andrews Air Force Base on June 22-23, 2001, former senior government officials played the roles of National Security Council members and representatives from the media portrayed journalists during a response to an evolving smallpox epidemic. ¹¹ The scenario presented in this exercise culminated in the infection of thousands of patients, death of hundreds, and generalized civil disorder. ¹¹ The Dark Winter exercise emphasized the lack of surge capability in U.S. hospitals, public health systems, and vaccine and pharmaceutical industries. ¹¹ Additionally, Dark Winter highlighted the lack of adequate communication systems among clinicians, public health organizations, and the media. The resulting poor communication contributed to the chaos and perception that public health officials had lost control of the situation. ¹¹ Ideally, public health officials would have predicted the information needs of clinicians, first responders, and the public, and utilized existing relationships with the media to communicate critical information in a timely manner. Instead, the media, with a 24-hour news cycle, provided ongoing coverage of the outbreak in a manner fairly disconnected from public health officials. ¹¹

In 1950, several dissemination experiments were carried out in the San Francisco Bay area. ¹² In one experiment, a naval vessel sprayed Bacillus globigii (a harmless simulant commonly used in bioterrorism experiments because of its morphologic similarity to Bacillus anthracis) in a 2-mile long line, approximately 2 miles offshore. ¹² Collection devices in downtown San Francisco demonstrated concentrations of more than 10,000 spores per liter, sufficient to have caused infections among more than 60 percent of the population. ¹² The Berkeley area was also contaminated, but at a much lower level. ¹²

In another dissemination experiment in1965, light bulbs filled with B. globigii were dropped from the back of New York City subway trains onto the tracks. ¹² The trains ran over the organisms, creating aerosols that were carried throughout the subway system. ¹² Collection devices demonstrated B. globigii in "high concentration for 60 to 90 minutes in all trains tested." ¹² Given that the average subway user in 1965 spent 8 minutes on the trains during rush hour, it is estimated that 80 to 90 percent of the passengers would have become infected. ¹²

Unlike the TOPOFF and Dark Winter exercises, in which the release of a biothreat agent was known, these latter 2 dissemination experiments simulated a covert bioterrorist attack. They emphasized the need for environmental detection systems in locations thought to be possible targets (e.g., subways, airports, government buildings, and large entertainment venues). They also highlighted the need for robust surveillance systems capable of timely detection of a bioterrorist attack. The bioterrorism exercises and the dissemination experiments demonstrated the potential vulnerabilities of the civilian population to a bioterrorist attack and emphasized the necessity for thoughtful preparedness and response planning for both covert and announced release of biothreat agents.

The Purpose of the Evidence Report

This Evidence Report details the methodology, results, and conclusions of a literature search on IT/DSSs that could serve the information needs of clinicians and public health officials in the event of a bioterrorism attack. We evaluated IT/DSSs that serve 1 or more of 4 main categories of information needs of clinicians and public health officers: detection and diagnosis, management and prevention, surveillance, and reporting and communication. The information presented is intended to assist clinicians and public health officials improve bioterrorism preparedness and response capabilities. We anticipate the report will be valuable to policymakers requiring evidence for informed decision making regarding the implementation of IT/DSSs for bioterrorism preparedness and response planning.

Scope of Work

The focus of our analysis was on IT/DSSs required by clinicians and public health officials. Therefore, systems designed for other decision makers (e.g., hazardous materials personnel or incident commanders) that could not also be used by clinicians or public health officials were omitted. Additionally, our focus was preparation for and response to bioterrorism events. We included those IT/DSSs designed for other purposes (such as the management of naturally occurring outbreaks) if such systems are potentially useful for a bioterrorist response (i.e., "dual use" systems), or related public health functions (e.g., food safety and animal health). Similarly, we did not include those IT/DSSs for response to chemical or nuclear weapons unless they could also be of use against biothreat agents.

We considered first responders to be all personnel responsible for the direct management of a bioterrorism event in the field. These include, but are not limited to, emergency medical technicians, firemen, policemen, and hazard materials professionals. We considered clinicians to be all personnel who would be directly involved in the care of patients with bioterrorism-related illness in a clinic or hospital. These include physicians, nurses, nurse practitioners and respiratory therapists. We use the term public health official (unless otherwise specified) to refer to all professionals at the local, state, national and international levels responsible for preparing for and responding to acts of bioterrorism to ensure the public health.

We evaluated IT/DSSs that affect 1 or more of 4 main categories of information needs of clinicians and public health officers: detection and diagnosis, management and prevention, surveillance, and reporting and communication. We defined ITs and DSSs according to the definitions provided by Friedman and Wyatt: A DSS (also called decision-aid, decision-assistance system, decision-making system) is a "system that compares patient characteristics with a knowledge base and then guides a health provider by offering patient-specific and situation-specific advice. Such systems, by definition, offer more than a summary of the patient data." ¹³ An IT (also called information resource) is a system "typically consisting of computer hardware and/or software that facilitate the collection, processing, and dissemination of information." ¹³

IT/DSSs described by articles included in the Evidence Report include the use of 1 or more computers for the purpose of collecting, managing, analyzing, or communicating medical information. Because our search strategies were designed to capture all systems for a given purpose (such as detection), this Report does include some relevant technologies that are neither ITs nor DSSs. For example, we describe assays used in the field by first responders to make the rapid detection of B. anthracis spores. Because the information from these types of assays can be transferred via wireless or other connections to a data analysis system or to decision makers, we have included them.