Technology Tapped to Battle Bioterror
By LAURENCE DARMIENTO
Staff Reporter
The investigators at L.A. County’s Acute Communicable Disease Control unit recently noticed a worrisome development: The emergency room at a local hospital had received three times the number of patients it normally did with rashes.
Since rashes can be a sign of bioterrorism agents, including smallpox, doctors and nurses responded quickly to find possible links among the cases.
What they discovered alleviated their concerns: The rashes had unrelated, natural causes. It was a statistical fluke. But the exercise was, in a sense, a success anyway.
It had demonstrated the power of a pilot program in which emergency room personnel electronically transmit patient symptoms to the communicable disease control unit for review. The idea is to find trends that busy ER doctors might overlook, using data that the county didn’t have timely access to in the past.
“We are looking at it with a different set of eyes,” said Dr. Jessica Jones, the communicable disease control unit’s assistant director for bioterrorism preparedness and response.
The unit is part of a nationwide network of local disease reporting programs that collects outbreak information ultimately deposited at the Centers for Disease Control and Prevention in Atlanta. There are wide variances in the thoroughness of the information, but generally it’s been viewed with more urgency since the Sept. 11, 2001 terrorist attacks.
New York’s system is the most advanced. It already tracks data such as emergency room visits and over-the-counter drug sales, and analyzes it by computer in an attempt to detect possible disease clusters.
Over the last few years, Los Angeles has launched its own series of programs aimed at utilizing high-tech tools.
“We have people coming and going daily from all over the world,” said RN Rita Bagby, a public health nurse who is assigned to investigate outbreaks of deadly diseases. “We may be warriors but we are also sentinels.”
Leap to the future
The unit is trying out a number of techniques at a time of heightened concern that’s been driven by SARS and other emerging diseases, as well as by threats of bioterrorism. These new programs have not yet been tested by any significant outbreak indeed, the county has reported only a handful of suspected SARS cases that have yet to be confirmed. But public health officials are recognizing the importance of consolidating data in an efficient and time-sensitive manner.
Not long ago, the county’s communicable disease control unit seemed stuck in another age.
Under law, doctors, lab personnel, school administrators and others are required to report some 80 listed, infectious diseases. The list includes everything from sexually transmitted diseases to food-borne illnesses to some of the most dangerous pathogens on the planet, including Ebola and the West Nile virus.
Until recently, reports were collected using an antiquated computer system that did not even allow epidemiologists to track the progress of cases as they were investigated in the field.
“We didn’t hear about cases for six weeks, until the time they went through all the channels,” said Dr. Laurene Mascola, director of the county unit.
Using a CDC grant, the county purchased an electronic reporting system a few years ago that allows doctors to both monitor cases and manipulate data to discover possible disease clusters.
That move has been followed by a series of newer programs aimed at getting a more timely view of possible outbreaks.
The program finally got off the ground last year at Kaiser Permanente, the largest HMO in the region with an integrated hospital system. Kaiser’s regional medical lab in North Hollywood conducts 14 million tests annually for patients from Bakersfield to San Diego, resulting in 300 cases a week being reported to Los Angeles County.
The results used be printed out, faxed and then entered into the county system. Now they are electronically transmitted.
“It’s a time and error saver on both ends,” said Dr. Ann Vannier, a Kaiser microbiologist who overseas lab operations.
What makes the effort more valuable to infectious disease specialists is the ability to view the data alongside other information to rapidly create a picture of an emerging epidemic.
The automation also helps minimize under-reporting, a problem that plagues communicable disease programs nationwide and results in by some estimates only a 50 percent rate of reporting communicable diseases by hospitals.
“Everybody thinks everybody else is supposed to be reporting it,” Mascola said.
Multiple eyes
Within the last year or so the county unit has started several other promising initiatives, including the pilot emergency room surveillance program and a similar program with the Los Angeles County Coroner.
The unit now receives daily e-mails from the coroner detailing the primary symptoms that a person experienced prior to an unexpected, non-violent death. (The coroner has jurisdiction over such cases when a physician doesn’t sign the death certificate.)
The symptoms are broken out into four main categories fever and rash, gastrointestinal, neurological and upper respiratory each of which could be a sign of a specific communicable disease or bioterrorism agent.
Dr. Lakshmanan Sathyavagiswaran, the county’s chief medical examiner, said that while his office tries to keep an eye out for unexpected death patterns, it is not always easy to do when they are focused on handling some 4,200 natural deaths last year.
Last month, the unit also began receiving localized data that the CDC collects from major national drug store chains. It shows sales of fever reducers, cough syrups and other over-the-counter products people might take when first coming down with a potentially serious disease.
“It’s questionable how useful each of these systems is by itself,” said Jones. “But if we see an increase in cough syrup sales, an increase in upper respiratory infections in the emergency room and an increase in death from the coroner, that is concerning.”
Since September 2001, the federal government has ramped up funding and support nationwide for communicable disease surveillance.
Locally, what started out as a few million dollars in federal funding turned into a $24 million grant to the county unit this past year. That has helped fund the recent initiatives, which could expand to more emergency rooms.
Three years ago when Los Angeles hosted the Democratic National Convention, the unit got a taste of how sophisticated disease surveillance could be on a generous budget.
The CDC, seeking to spot any possible bioterrorism outbreak, assisted the unit in setting up a temporary network of computers in hospitals near the Staples Center.
Hospital workers, coaxed by round-the-clock supplies of doughnuts, were instructed to input detailed emergency room information into the system. But having the system proved time consuming even though it only operated for a few weeks.
“It took a lot of positive stroking,” Mascola said.
