Bioterrorism:
The Use of Information Technologies and
Decision Support Systems
Dena M. Bravata, M.D., M.S.
Policy Analysis
MS&E 290
Case Presentation: Day 1 (11/16)
Ottilie Lundgren, a 94 year old widow, living in
Oxford, Connecticut presented with a 3-day
history of fever, cough, and myalgias.
Her physical examination showed an elderly
woman with a fever (102.3F), elevated heart
rate (118).
Her chest x-ray and initial laboratory tests were
all negative.
She was admitted to the hospital for dehydration
and an infection of the kidney tract.
Case Presentation: Days 2-4
Hospital Day 2-3 (11/17-11/18)
Labs: Bacteria found in her blood and urine but not
yet identified
Mrs. Lundgren had progressive respiratory distress
and confusion.
Repeat CXR: fluid around the left lung with the
suggestion of pneumonia
Hospital Day 4 (11/19)
A sample of fluid from around lung taken for culture.
The Connecticut Department of Public Health was
notified by the hospital laboratory of blood
culture results
Case Presentation: Day 5-6
Hospital Day 5 (11/19)
She was transferred to ICU on a ventilator
Blood culture isolates identified as Bacillus
anthracis at the State public health laboratory
Hospital Day 6 (11/21)
CDC confirms blood culture isolates as B. anthracis,
molecular typing and susceptibility patterns
identical to recent cases
Ottilie Lundgren’s condition continued to deteriorate
and she died.
Current Cases of Bioterrorism-related Anthrax
Confirmed
Suspected
Cutaneous
7
5
Inhalational
10*
0
Total
17
5
*
4 Deaths associated with inhalational anthrax
Biothreat Agents
•
•
•
•
•
•
Variola major (smallpox)
Bacillus anthracis (anthrax)
Yersinia pestis (plague)
Clostridium botulinum toxin (botulism)
Francisella tularensis (tularemia)
Filoviruses (Ebola hemorrhagic fever and
Marburg hemorrhagic fever)
• Arenaviruses (Lassa fever, Junin/Argentine
hemorrhagic fever) and related viruses
The Project
The objective of our project was to synthesize
the evidence on information technologies and
decision support systems (IT/DSSs) that may
serve the information needs of clinicians and
public health officials in the event of a
bioterrorist attack.
Methodologic Challenges of this Project
• Conceptualizing the problem
– Complex topic, no single effect size
• Finding the literature
– Not limited to peer-reviewed medical literature
– Government documents
– Web-based sources
• Evaluating the quality of the evidence
– No single, published quality scale relevant
The Methodologic Approach
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence
The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence
5 Key Questions
• What are the information needs of clinicians and
public health officials in the event of a
bioterrorist attack?
• What are the criteria by which IT/DSS should be
evaluated for usefulness in a bioterrorist event?
• What IT/DSSs are available for detection and
diagnosis, management, surveillance, and
communication?
5 Key Questions Continued
• What is the quality of the evidence about
IT/DSS usefulness?
• If no existing IT/DSSs meet the information
needs of clinicians and public health
officials, what considerations are important
in the design of future IT/DSSs to support
response to bioterrorism events?
The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence
Structure of the Conceptual Framework
Time period: 1
Time period: 3
Decision maker:
Clinicians
Decision maker:
Clinicians
Events:
associated with
the initial cases
Time period: 2
Decision maker:
Public health
officials
Events:
associated with
the initial cases
Events:
associated with
subsequent cases
Diagram of the Conceptual Framework
Exposure
Clinical
Syndrome
Exposure
Infection Status
(unobserved)
Surveillance
Alert
Susceptible
Diagnosis
Susceptible
Diagnosis
Test Result
Lives
Saved
Management
Clinical
Syndrome
Infection Status
(unobserved)
Test Result
Lives
Saved
Management
Prevention
Prevention
Report
Report
Surveillance
Report
Outbreak
Investigation
Epidemiologic
Control
Surveillance
Alert
Time period 1
Time period 2
Time period 3
Time period 2: Surveillance Systems Detect Potential Events
Healthcare provider
Reports
Coroner
Reports
Foodborne Disease
Reports
Veterinarian
Reports
Laboratory
Reports
Surveillance
Report
Detector
Data
Outbreak
Investigation
School/Work
Absenteeism
Data
EMT Data
Pharmacy
Sales Data
Hospital
Discharge Data
Surveillance systems
receive data from a
variety of sources and
provide reports to public
health authorities.
Epidemiologic
Control
Surveillance
Alert
Lives
Saved
Role for Information Technologies and Decision Support
Exposure
Clinical
Syndrome
Exposure
Infection Status
(unobserved)
Surveillance
Alert
Susceptible
Diagnosis
Susceptible
Diagnosis
Test Result
Lives
Saved
Management
Clinical
Syndrome
Infection Status
(unobserved)
Test Result
Lives
Saved
Management
Prevention
Prevention
Report
Report
Surveillance
Report
Outbreak
Investigation
Epidemiologic
Control
Surveillance
Alert
Decisions marked in blue indicate those that can be affected by
decision support systems and arrows marked in blue indicate
processes in which information technologies could play a role.
The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence
Task Decomposition
• Formal framework for specifying, documenting, and
evaluating the data that should be contained within the
knowledge base of a DSS in order for it to serve its
purpose.
• Literature review to define tasks:
–
–
–
–
U.S. Offensive weapons program
Known bioterrorist events
Tabletop exercises
Infectious disease outbreaks
• 5 Tasks
–
–
–
–
–
Surveillance
Diagnosis and detection
Management
Prevention
Communication
Example: Task Decomposition: Surveillance
Subtask
Key Concepts
Data Requirement
Collect
surveillance
data
Continual, timely
collection of sensitive
and specific data from
multiple sources for
early detection of a
bioterrorist attack
•Environmental detectors
•Pharmacy sales data
•School & work absenteeism data
•Clinicians’ reports
•Laboratory reports
Analyze
surveillance
data
Timely analyses and
presentation to public
health decision makers
•Baseline information for each data
source to calculate expected trends
over time
•Threshold information for each
data source to know when an
outbreak has occurred
The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence
Literature Searches
• Literature Sources
– Peer-reviewed articles and government documents from
databases
• Medline, GrayLit, National Technical Information Service,
Catalog of U.S. Government Publications
– Government documents from websites
– Web-based information
• Search Strategies
– Professional librarians for peer-reviewed and
government documents
– Copernic 2001 metasearch engine for web-based
information
• Search Terms: same for our Government
document and Copernic searches
The Method
• Identify key research questions
• Develop a conceptual model
• Define the tasks IT/DSSs must perform to
meet the information needs of clinicians and
public health officials
• Perform literature searches
• Evaluate the evidence
Results of Literature Searches
• Reviewed 16,751 citations and 8,620 websites
• 251 articles and 41 websites met inclusion criteria
• Double abstractions (blinded to study author) for
all peer-reviewed articles and single abstractions
for web-based information
• Total of 204 systems
–
–
–
–
–
–
52 detection systems
23 diagnostic systems
14 management systems
88 surveillance systems
27 communication systems
7 systems that integrate surveillance, communication,
and command and control functions.
Results
• Generally: few clinically evaluated systems
• No IT/DSSs for Diagnosis or Management
have been developed specifically for
bioterrorism
• Systems for Detection, Surveillance, and
Communication have been developed for
bioterrorism
– Some show considerable promise but almost
none has been evaluated for its sensitivity,
specificity, or timeliness
Results
•
•
•
•
•
Detection Systems
General Diagnostic Systems
Management Systems
Surveillance Systems
Communication Systems
Results
•
•
•
•
•
Detection Systems
General Diagnostic Systems
Management Systems
Surveillance Systems
Communication Systems
Detection Systems: Overview
• Developed for Military need to be adapted to civilian
use
• Promising projects include:
– PROTECT (Program for the Response Options and
Technology Enhancements for Chemical/Biological
Terrorism)
• Detectors set up in subways, airports, government buildings
• Developing methods for signal-noise-processing
– LEADERS (Lightweight Epidemiology and Advanced
Detection and Emergency Response System)
• Integrates detector data with other surveillance data
• Particularly for event-based surveillance
Detection Systems: collection and identification
BioCaptureTM
• Only collection system clinically evaluated
• 50-125% collection efficiency of other devices
• Used by first responders
BioThreatAlert (BTA) Strips
• Antigen/Antibody system available for a
limited number of agents
• Sensitivity and Specificity not evaluated
• Used by first responders or clinicians
Conclusions: Systems have not been clinically evaluated, sensitivity
and specificity poorly characterized, can only test one sample at a
time, tests not available for many worrisome agents (e.g., smallpox)
Results
•
•
•
•
•
Detection Systems
General Diagnostic Systems
Management Systems
Surveillance Systems
Communication Systems
General Diagnostic Systems: Overview
• Purpose: Clinician enters patient information (usually
manually) and system provides a differential diagnosis
• Examples: DXplain, Iliad, QMR (newer handheld versions
now available)
• Clinical evaluations: the differential diagnoses provided
are highly dependent on descriptors entered
Conclusions: Have rarely been shown to improve patient
outcomes in general, none has been evaluated for diagnostic
capability for bioterrorism-related diseases
Results
•
•
•
•
•
Detection Systems
General Diagnostic Systems
Management Systems
Surveillance Systems
Communication Systems
Management Systems: Overview
• Generally: Depend on electronic medical
record to derive patient-specific
recommendations
• Most commonly for antibiotic
recommendations for hospitalized patients
Management Systems
Example: HELP system at LDS hospital in Salt Lake City
–When patients present to the ED, HELP’s databases are
queried every 10 minutes for any new clinical information on
the patient. Uses this information to calculate the probability of
pneumonia.
–Specificity 92%, PPV 15.1%, NPV 99.9%
Conclusions: No evidence for their usefulness in a bioterrorist
event; would have to incorporate new guidelines for biothreat
agent diagnosis and management; typically require EMR.
Results
•
•
•
•
•
Detection Systems
General Diagnostic Systems
Management Systems
Surveillance Systems
Communication Systems
Data Sources for Biosurveillance
Earlier Detection Data
Later Detection Data
School & Work
Absenteeism
Phone Triage
Nurses
Sentinel
Physicians
Pharmacies (Rx)
Pharmacies (OTC)
Environmental
detectors
Emergency
Department
911 Calls
Laboratory
Hospital
admissions &
discharge
Surveillance Systems
•
•
•
•
•
•
•
•
Syndromal surveillance reports (7)
Reports from clinicians (6)
Influenza-related data (10)
Systems for laboratory and antimicrobial
resistance data (23)
Systems for nosocomial infections (15)
Food-borne illnesses (10)
Zoonotic illnesses (5)
Other types of surveillance data (12)
Syndromal Surveillance
• Syndromes associated with biothreat agents
–
–
–
–
–
–
Flu-like illness
Acute respiratory distress
Gastrointestinal symptoms
Febrile, hemorrhagic syndromes
Fever and rash
Fever and mental status change
®
HealthBuddy
ESSENCE
Integrated Systems
Data Analysis and
Presentation
Results
•
•
•
•
•
Detection Systems
General Diagnostic Systems
Management Systems
Surveillance Systems
Communication Systems
Communication Systems: Overview
• Email systems for communication between
patients and clinicians
• Web-based secure networks linking
branches of the public health
• Radio/Microwave-based systems for linking
emergency personnel in the field with EDs
• Alert systems to notify clinicians of
abnormal laboratory tests
Communication Systems for Bioterrorism
Local Public Health
Communication Systems for Bioterrorism
WHO
CDC
State Public Health
Local Public Health
Communication Systems for Bioterrorism
WHO
CDC
FBI
Zoo
State Public Health
Food Inspectors
Schools
HazMat
Local Public Health
Pharmacies
Police
Laboratories
Fire
Hospitals &
Nursing Facilities
The Public
Clinicians
Coroner &
Medical Examiner
The Media
Communication Systems for Bioterrorism
WHO
CDC
FBI
*
Zoo
State Public Health
Food Inspectors
Schools
*
HazMat
Pharmacies
Local Public Health
*
Police
Laboratories
Fire
*
*
The Public
*
*
Hospitals &
Nursing Facilities
Clinicians
Coroner &
Medical Examiner
The Media
*
*
Communication Systems for Bioterrorism
WHO
CDC
FBI
*
Zoo
State Public Health
Food Inspectors
S
*
HazMat
Schools
S
Pharmacies
Local Public Health
Police
*
S
Laboratories
Fire
S
*
*
The Public
*
*
Hospitals &
Nursing Facilities
Clinicians
Coroner &
Medical Examiner
The Media
*
*
Communication Systems for Bioterrorism
WHO
CDC
FBI
*
Zoo
State Public Health
Food Inspectors
S
*
HazMat
Schools
S
Pharmacies
Local Public Health
Police
*
S
Laboratories
Fire
S
*
*
The Public
*
*
Hospitals &
Nursing Facilities
Clinicians
Coroner &
Medical Examiner
The Media
*
*
Conclusions
• Overall: IT/DSSs have not be subjected to critical evaluations
• Detection Systems:
–
–
–
–
Rapid
Portable
Sensitive and Specific
Can test for more of the worrisome biothreat agents
• General Diagnostic Systems:
– Link to EMR
• Management systems:
– Utilize available bioterrorism guidelines
• Surveillance systems:
– Greater integration
– Early warning data
– Methods for the determination for what constitutes an outbreak
• Communication systems:
– Single system for public health officers at various levels
– Public health  media
Future analysis
• Models of natural history of disease processes of
biothreat agents
• Cost-effectiveness analyses of surveillance
systems using different sources of data
• Cost-effectiveness of prevention and management
strategies for the most worrisome biothreat agents
• Analyses of the adequacies of current capacity of
hospitals, law-enforcement, and public health to
respond to a bioterrorist attack.
Collaborators
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•
•
•
•
•
•
•
Douglas K. Owens
Kathryn McDonald
Wendy Smith
Chara Rydzak
Herbert Szeto
Corinna Haberland
David Buckeridge
Mark Schleinitz
•
•
•
•
•
•
•
•
•
Dean Wilkening
Mark Musen
Bahman Nouri
Bradford W. Duncan
Mariana B. Dangiolo
Hau Liu
Scott Shofer
Justin Graham
Sheryl Davies