By Doug Bartholomew and Chris Gonsalves  

Are the nation’s systems ready to support an all-out fight against a pandemic influenza such as the avian flu?

The just-released Influenza Pandemic Plan from the Centers for Disease Control and Prevention (CDC) lists 13 different systems for identifying, alerting, responding to and tracking a potential pandemic flu outbreak. Most of these systems—some are completed, while others are under development—are designed to perform specific tasks, but the CDC continues to struggle with its centerpiece, the fledgling $100 million BioSense network.

If avian flu were to suddenly make the biological leap to a form that could be transmitted among humans, U.S. hospitals and physicians’ offices would be overwhelmed. An estimated 18 million patients would need immediate care, 300,000 to 800,000 of them would require hospitalization and 90,000 to 200,000 people could die.

Nor is the avian flu, known as H5N1, the only potential virus that could develop into a pandemic. During the 20th century, there were three influenza pandemics. The so-called Spanish influenza pandemic of 1918 killed more than half a million people in the United States, with a global mortality estimated at 20 million to 40 million people. The 1957 Asian flu caused an estimated 80,000 deaths in the United States, while the Hong Kong pandemic of 1968-69 affected 51 million Americans, resulting in an estimated 30,000 deaths in this country.  

The possibility of an influenza pandemic—defined by the CDC as a novel virus that is readily transmissible and causes disease in humans—is so serious that Uncle Sam is setting up a host of systems to detect and support a nationwide response should an outbreak occur. Since 2002, the CDC has spent more than $5 billion to improve public health preparedness and response.

Early Warning System
The CDC’s primary nationwide hospital network-based defensive system, the BioSense Network (see Baseline, March 2006), was designed to provide early warning of a potential avian flu or other massive influenza outbreak. Originally conceived as a nationwide alarm system that would enlist thousands of hospitals on a network that would automatically “sniff out” every flu-like diagnosis, BioSense was to provide CDC with what, in effect, would have been a national stethoscope capable of gauging the health of the population. Urban, statewide, regional and even national outbreaks of any illness displaying flu-like symptoms would have been detected very early, enabling local, state and federal health agencies to respond quickly.

BioSense was designed to sit atop participating hospitals’ existing systems, gathering and analyzing their data in real time. The network was intended to provide a constantly refreshed flow—updated every 15 minutes—of patient information from the field. Using this information, CDC epidemiologists would be able to immediately detect the early signs of an outbreak of any flu-like disease. The hope was that by providing early detection, BioSense would help the CDC focus its resources on controlling an outbreak.

Unfortunately, in 2006 and 2007, BioSense encountered significant resistance from wary physicians and hospital administrators around the country. “Our approach turned out to be much more difficult than anticipated,” says Dr. Leslie Lenert, director of the CDC’s National Center for Public Health Informatics, who is responsible for managing the application of information technology in all health care settings. “We got a lot of pushback on BioSense.”

Part of the problem was that BioSense required health care facilities to recode patient and medical records so the CDC’s custom-built software could monitor the hospital’s network and identify relevant data about patients. Many hospitals were unwilling to take on such a complicated technology project, given their limited IT staffs and resources.

“We found that the process was very human-dependent,” Dr. Lenert explains. “Getting a public health technician inside a hospital requires close collaboration with the hospital’s CIO, as well as trust that’s based on personal relationships.”

In addition to the technological hurdle of having to standardize patient data, many physicians and state health department epidemiologists expressed concern over the federal government’s move to usurp what they saw as their role in protecting the public’s health. Part of the problem, according to Dr. Lenert, resulted from the federal government ignoring state, regional and local health care agencies. In addition, some hospital administrators were wary of transmitting local health care data electronically to the federal government.

“BioSense was very controversial, and there was a question about its usefulness,” says Dr. Erica Pan, director of the Bioterrorism and Infectious Disease Emergencies Unit at the San Francisco Department of Public Health. The medical community was skeptical of the need for such a system, believing that it is their responsibility, along with community and state health department officials, to identify and act on a disease outbreak. “You really need people on the local level to ask the right epidemiological questions,” she explains.