CDC Issues Pandemic Systems Plan

By Doug Bartholomew  |  Posted 2008-03-11

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.

Change in Plans
Because BioSense failed to catch on (only 441 of the nation’s more than 5,600 hospitals are currently participating), its effectiveness as a nationwide flu-detection system was limited. But instead of giving up on BioSense, the CDC has adopted a new approach to make the system work.

After investing an estimated $100 million on hospital recruitment and technology for BioSense in 2005 and 2006, the CDC decided last year to work with state and local public health care systems, rather than competing with them. The agency will continue to use BioSense in its limited geographic form, while simultaneously pursuing other initiatives to gather early pandemic data.

The new approach is designed to foster a cooperative, information-sharing initiative with state health departments. “We want to get surveillance without the states having to move their data into a national repository,” the CDC’s Dr. Lenert explains. The states that participate in the new initiative would keep their patients’ data, but would share the aggregate analysis.

“We would like to find a way to federate existing state databases so that we can share the analysis of that data,” he adds. “But it involves more than just sharing the results: We have to be able to look across state borders to recognize patterns.” 

To that end, the CDC has begun enlisting state health departments to send their data into BioSense to try to create this national system. To seed the growth of this new initiative, the CDC will soon begin providing grants to state and regional health care agencies to develop systems that accomplish these goals of patient data sharing and pattern analysis. Dr. Lenert notes that Indiana and North Carolina have already agreed to participate, adding, “They are forwarding to us anonymized individual-level case data.”

The jury is still out on precisely what the new initiative will look like and how it will work, according to Dr. Lenert. “We are piloting different strategies for this in order to fund the best approach,” he says. “We will provide five years of grants, with $8.5 million in funding to start for this year. We know we can’t do the whole country at one time.”

Simultaneously, the CDC is focusing efforts on a variety of different systems that could be deployed when an early outbreak of a flu pandemic was identified. For example, the federal agency enlisted CIBER, a systems integrator, to build an alerting system to electronically notify state and regional public health care officials and agencies when and where an outbreak is taking place. Previously, the CDC had to contact state health officials by e-mail or telephone.

The CDC Alerting Service (CDCAS) is part of the agency’s four-year effort to develop the Public Health Information Network (PHIN), a set of functional and technical standards that lay out minimum IT capabilities and interoperability requirements for local and state health agencies.

“Working with CIBER, we’ve developed both an alerting service and a directory service on which we can build all our programs and specific applications in order to get all the benefits of a service-oriented architecture,” says Robb Chapman, the CDC IT program director who oversees the CIBER implementation. “This was all spawned by the events of 2001. A lot of people point to 9/11, but even more than that, it was the anthrax scare—along with concerns about things like bird flu—that made it clear we needed to improve the way public health agencies work together.”

Officials from five states helped craft CDCAS’ cascade reporting protocol, so the CDC can use the PHIN to rapidly alert officials across jurisdictional boundaries without stepping on political toes, according to Richard Draut, account manager for CIBER’s federal health practice.

The PHIN system is currently running in Michigan and Indiana, and public health agencies in New York and Minnesota are in the latter stages of adoption, according to Chapman. CDC officials expect to have the majority of states on board within two years, he says.

Mixed Bag of Systems
Because BioSense is used only on a limited basis around the country, the CDC continues to rely on a mixed bag of different systems—some completed, some not—to uncover a major pandemic in the making. Chief among these is the Influenza Sentinel Provider Surveillance System, which depends on some 2,200 volunteer physicians to collect information from patients who exhibit flu-like symptoms. The CDC also uses the World Health Organization’s FluNet system, a database that epidemiologists and other researchers can query to learn about flu-related activity in other countries.

Laboratory data can provide yet another indicator of unusual flu activity. “We are looking to recognize cases early on by using laboratory data and to report that data automatically to public health authorities and the CDC at the same time,” the CDC’s Dr. Lenert says. The CDC depends on the Laboratory Response Network, which connects it with state health department laboratories and other laboratories that have special training to perform influenza research.

Pandemics are monitored using a system called the Health Alert Network. “We use this system to communicate to physicians and health departments about how to report cases, what to look for and other information about specific cases,” says Dr. Steve Redd, a CDC epidemiologist.

Another system, FluFinder, was begun in 2004 during a shortage of flu vaccine. The system allows health officials to locate vaccine supplies.

With all these systems—and others—in the works, the CDC must consolidate its information systems in order to provide more timely data to its own staff and to health care professionals in the field.