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Last Updated

28 Mar 2003

Source: Washington Post, March 28, 2003

Strategic Tracking of Sniffles

Scientists on Alert for Terrorism Monitor Area Health Factors

By Avram Goldstein, Washington Post Staff Writer

Every morning, scientists gather in a secure war room in Howard County to gauge how people in the Washington region are feeling.

Are people buying lots of flu or diarrhea medicine? What are patients complaining about in doctors' offices and emergency rooms? Are doctors ordering more lab tests? How many people are calling 911? How many children missed school? What about animals -- are governments picking up more carcasses?

At the Johns Hopkins University Applied Physics Laboratory in Scaggsville, a 30-mile drive from the White House, researchers believe quick answers to those questions could save huge numbers of people in a biological attack.

Experts say outbreaks of highly contagious smallpox, starting with only 3,000 infected people in three states, could lead to 1 million deaths if not promptly contained by rapid public health measures. A cloud of anthrax spores released over a congested urban area could cause 120,000 deaths unless antibiotics were distributed at once, according to a computer model released last week. Al Qaeda leaders have obtained materials to weaponize botulinum and salmonella and the chemical poison cyanide, according to U.S. officials, and are close to a feasible production plan for anthrax.

Scientists, though, think they have found a way to use the two or more days it takes a bacterium or virus to incubate, saying their computerized surveillance could alert government officials that antibiotics, vaccines or quarantines might be necessary.

Otherwise, many could become sick before scattered physicians discerned a pattern.

"If tens of thousands were infected and we were able to detect it [early], and the health departments have an effective response, I would think the majority of the people infected could be rescued," said Joe Lombardo, the project's lead researcher. "I hate to say this, but I think all this terrorism is the future. We have to be prepared. . . . We can only hope that others see that need."

Many pathogens that might be used by terrorists are known to cause early symptoms that mimic flu, so a key indicator watched by Lombardo's team is the sale of nonprescription drugs to treat flu and respiratory problems, as well as gastrointestinal and skin conditions.

The project, which involves doctors, epidemiologists, biostatisticians and even a meteorologist, was launched as a national security measure after the Pentagon attack.

It is called ESSENCE, for Electronic Surveillance System for the Early Notification of Community-based Epidemics. It enables participating health departments to use a secure Web site to review and compare pre-diagnostic data with neighboring jurisdictions. The health departments would notify federal officials of suspicions.

The ESSENCE staff collects daily reports from hospital emergency rooms, drugstore cash registers, physicians, school systems, animal control agencies, veterinarians, emergency medical services, emergency dispatchers, clinical laboratories and weather forecasters. They even check into physician chat rooms on the Internet. Patient identities are stripped out of all information used, Lombardo says.

The system can be "tuned" to watch for recently arrived diseases such as West Nile virus and malaria, Lombardo says, or completely new maladies such as severe acute respiratory syndrome, which surfaced recently. ESSENCE has flagged various types of outbreaks in populations as small as a nursing home, he says.

So far, the project has been funded with more $6 million from the Defense Department and $1 million from Maryland. It could become a permanent public health tool, but some are withholding endorsements. ESSENCE surveys 12 counties in Maryland and Virginia, plus the District and Baltimore, and the number of data sources has grown steadily. The only major information provider that has not formally joined is the Virginia Department of Health, the gatekeeper for daily emergency room and 911 data in that state.

Diane Woolard, chief of surveillance for the Virginia department, has been talking with Lombardo about working with ESSENCE in the same way that health officials in Maryland and the District do, but no arrangement has been struck yet.

"I'm just not sure this is really efficient," Woolard said. "I believe the best way for us to detect an unusual disease event is by a physician alerting the health department rather than by combing through data files. That is what's worked from the beginning of public health."

But Lynn Frank, chief of Montgomery County's public health agency and chair of a regional committee of health directors, said waiting could be dangerous.

"Some are uneasy with ESSENCE because it doesn't have the traditional [confirmed] disease reporting mechanism," she said. "I would rather act out of an abundance of caution than lose anyone to a biological attack. . . . There's no [experimental] control group here. We're it."

Since Sept. 12, 2001, hospitals in Virginia, Maryland and the District have shared daily emergency room logs with epidemiologists, who look for patterns.

ESSENCE goes beyond that. It began collecting automated data from military and civilian health care providers in central Maryland, the District and Virginia that Sept. 12, and it has steadily added data sources since then. They include diagnoses reported to insurance companies by doctors' offices and precise counts of how many bottles of cough medicine are sold in each Zip code.

If an agreement is reached with Virginia, as Woolard expects despite her concerns, figures from Fairfax, Arlington, Loudoun and Prince William counties and Alexandria also would flow to ESSENCE. Lombardo said ESSENCE bio-surveillance might be extended to the rest of Virginia as well.

Similar systems are being developed or enhanced in other metropolitan areas, including Pittsburgh, New York and Boston.

"If you're dealing with a virulent pathogen, even a lead time of a day or two can reduce mortality up to sevenfold," said Kenneth Mandl, a Harvard medical school associate professor working on a monitoring system for Massachusetts.

But Georges C. Benjamin, the Maryland health secretary who steered program funding to the Hopkins lab before becoming executive director of the American Public Health Association, said an isolated jump in rashes or drug purchases could be misleading.

"You have to tell emergency planners and elected leadership who might see those numbers that this is not knowledge -- it's just a number that's begging to be understood," he said.

The biggest supporters of ESSENCE are in Montgomery and the District, where 13 hospitals pump daily reports into the system.

"It gives us the ability to really function as a region, as a county, as an area for public health issues whether from natural causes or not," said Susan Glover, quality assurance chief of Shady Grove Adventist and Washington Adventist hospitals.

Frank, the Montgomery health chief, suspects that the program represents the future of public health, though she knows it may be some time before anyone proves it.

"I'd love to study this for five years," she said. "But we have no time. You just have to go with what you have and continually improve it."