REPORT BRIEF OCTOBER 2010

Advising the nation / Improving health

For more information visit www.iom.edu/biowatch

BioWatch and Public Health Surveillance Evaluating Systems for the Early Detection of Biological Threats Abbreviated Version

Concern about acts of and infectious disease epidemics following the attacks of September 11, 2001, and the letters increased interest in developing ways to detect biological threats as quickly as possible. In response, in 2003, the Department of Homeland Security (DHS) introduced the BioWatch program—a federal monitoring system intended to speed detec- tion of specific biological agents that could be released in aerosolized form during a biological attack. In 2008, at the direction of Congress, DHS asked the Institute of Medicine and the National Research Council to convene a committee to evaluate the . . . the committee concludes that costs and merits of both the current BioWatch program and the plans for a the current BioWatch system new generation of BioWatch devices, to examine infectious disease surveil- requires better testing to establish lance through hospitals and public health agencies in the , and its effectiveness and better to consider whether BioWatch and traditional infectious disease surveillance collaboration with public health are redundant or complementary. systems to improve its usefulness. In its report, BioWatch and Public Health Surveillance: Evaluating Sys- tems for the Early Detection of Biological Threats, the committee concludes that the current BioWatch system requires better testing to establish its effec- tiveness and better collaboration with public health systems to improve its usefulness.

The BioWatch System BioWatch air sampling devices are deployed in more than 30 major U.S. cities. The air samples typically are tested daily for signs of the particular biologi- cal agents being monitored. The current BioWatch system generates a signal when laboratory testing confirms the presence • Pursue opportunities to advance future bio- of genetic material consistent with one of the detection systems: DHS should work with biological agents that the system monitors. This other agencies in support of research and signal is known as a BioWatch Actionable Result development needed to achieve goals such (BAR), but the committee finds the term mislead- as lowering the cost of biodetection and ing because it sees a BAR alone as unlikely to be a improving the knowledge base for inter- sufficient basis for public health action. preting surveillance results. While DHS is responsible for the BioWatch • Make BioWatch planning risk-based and program, the program operates as part of a broader responsive to user needs: DHS should system. DHS works in collaboration with the states emphasize using the BioWatch system to and localities in which BioWatch air samplers are aid a timely response to a biological attack, deployed, and with other federal agencies, includ- not just successfully detecting genetic ing the Department of Health and Human Ser- material that may indicate a terrorist event. vices (HHS). In making its recommendations, the BioWatch planning and evaluation should committee assumed that the current BioWatch include a careful analysis of both the risks of system can be shown through operational testing an airborne biological attack and the most to provide useful information. However, the com- effective ways to manage these risks. DHS mittee identified several concerns about the pro- and HHS should collaborate in the contin- gram’s management and priorities and about the ued development of the BioWatch system, system’s technical performance. To address these with advice from an independent panel of concerns, the committee recommends that DHS external stakeholders and subject-matter and other federal agencies take steps to: experts. • Strengthen the relationship between Bio- Watch and the state and local jurisdictions in which it operates: Public health offi- BioWatch and Public Health cials need greater assistance in developing Surveillance the necessary capabilities to interpret and In principle, BioWatch and infectious disease sur- respond to BARs. Detection of DNA consis- veillance through the public health and health tent with that of a bioterrorism agent does care systems are complementary. Yet while Bio- not automatically mean that an attack has Watch has the potential to provide a more timely occurred or that people have been exposed. alert than the public health and health care sys- In addition, the BioWatch program should tems, the promise remains theoretical. Warnings reimburse cities and states for their from BioWatch would only be more timely under financial and in-kind costs to support its specific circumstances: if a large-scale aerosol operation. attack were to use certain biological agents and • Conduct systematic testing and evaluation of occur where BioWatch is deployed, and if Bio- current and planned technology: DHS needs Watch successfully detects the . to thoroughly test the BioWatch system to While surveillance through the public health establish a more systematic, scientifically and health care systems needs improvement, it is sound, and stakeholder-approved approach an integral part of daily public health activities to technology acquisition, development, across the country at the local, state, and federal testing, and deployment than was possible levels. These surveillance activities are broader when the BioWatch program began. and more flexible than BioWatch, permitting

2 Warnings from BioWatch would only be more timely under specific circumstances: if a large-scale aerosol attack were to use certain biological agents and occur where BioWatch is deployed, and if BioWatch successfully detects the biological agent.

detection of a wider range of infectious diseases in partnership with state and local public and disease resulting from sources of exposure health agencies, should coordinate research, that BioWatch is not designed to detect. State and development, and evaluation of improved local authorities have legal responsibilities as well public health surveillance methods. as knowledge of endemic health risks that make • Develop and evaluate decision support for them essential and valuable partners not only in clinical case recognition and reporting by the BioWatch program but also in broader national health care providers: Early detection of a and emergency preparedness bioterrorism event or other serious dis- efforts. ease outbreak may depend on astute clini- cians’ ability to recognize suspicious cases. HHS should promote the development, Enhancing National Surveillance testing, and evaluation of technologies that Capacity and Resources strengthen the accuracy, timeliness, con- The public health and health care systems face sistency, and completeness of clinical diag- many challenges in meeting preparedness goals, nosis of significant infectious diseases, and which include improving the effectiveness of that facilitate timely reporting to public their infectious disease surveillance and develop- health authorities. ing better capabilities for analysis and exchange • Improve information sharing and situational of information. The differences in capabilities awareness: The current geographic and pro- across local and state health departments con- grammatic compartmentalization of infor- tribute to inefficiencies and to the potential for mation generated by health care providers, surveillance gaps. Although emergency prepared- laboratories, and health departments can ness has improved since 2001, further improve- impede detection and ongoing manage- ments are needed, and federal funding covering ment of natural and bioterrorism-related all aspects of preparedness has declined since the infectious disease outbreaks. DHS and HHS initial post-2001 increases. The committee recom- should facilitate the development of an mends several actions by HHS and others: interoperable, secure, bidirectional, nation- • Develop and evaluate new opportunities in wide health information-sharing infrastruc- infectious disease surveillance and detection: ture and ensure that local and state health Detecting and responding to infectious dis- officials have ready access to the system. ease threats is a core function for the pub- • Build and sustain capacity to detect and lic health and health care systems. HHS, respond to health emergencies: Despite tar-

3 Committee on Effectiveness of National Biosurveillance geted funding for emergency preparedness, Systems: BioWatch and the Public Health System* Bernard D. Goldstein (Chair) Marcelle Layton investment in the basic public health infra- University of Pittsburgh Gradu- Bureau of Communicable ate School of Public Health Disease, Depart- structure has been more limited. HHS and Joseph M. DeSimone (Vice ment of Health and Mental DHS should give high priority to building Chair) University of North Hygiene Carolina at Chapel Hill, and Eva K. Lee and sustaining sufficient public health work- North Carolina State University School of Industrial & Systems force strength and competencies, along with Michael S. Ascher Engineering, Georgia Institute California Emergency Manage- of Technology, associated laboratory and information man- ment Agency, and School of Shane D. Mayor Veterinary Medicine, University Department of Geological and agement capacities, needed by all states and of California, Davis Environmental Sciences, Cali- James W. Buehler fornia State University, Chico communities to detect a bioterrorism attack Rollins School of Public Health, Timothy F. Moshier Emory University, Atlanta, GA Environmental Science Center, or other public health emergency. Karen S. Cook Syracuse Research Corpora- Department of Sociology, tion, NY Stanford University, CA Frederick A. Murphy Norman Crouch Department of Pathology, The Health Protection Bureau, University of Texas Medical Conclusion Minnesota Department of Branch at Galveston Health, St. Paul (Retired) Royce Murray The enhancements DHS has proposed to the Bio- Francis J. Doyle III Department of Chemistry, Department of Chemical University of North Carolina at Watch system to make testing automated and more Engineering, University of Chapel Hill California, Santa Barbara Douglas K. Owens frequent are appropriate, but because they are very Seth Foldy VA Palo Alto Healthcare ambitious, they will be possible only if significant Division of Public Health, State System, and Stanford of Wisconsin University, CA and long-standing scientific and technical chal- Elin A. Gursky Stephen M. Pollock ANSER/Analytic Services, Inc., Industrial and Operations Engi- lenges can be overcome. The committee also sees Arlington, VA neering Department, University of Michigan a need for evaluation and improvement of infec- Sandra Hoffman Resources for the Future, I. Gary Resnick tious disease surveillance and disease detection Washington, DC Los Alamos National Labora- tory, NM Calvin Johnson resources in both the public health and health care Temple University Health R. Paul Schaudies System, , PA GenArraytion, Inc., Rockville, systems. Together with the BioWatch system, these MD Paul Keim resources should be better linked to a broader and Northern Arizona University, Jerome S. Schultz and The Translational Department of Bioengineer- more effective national biosurveillance framework Genomics Resarch Institute ing, University of California, Riverside Arthur L. Kellermann that will help provide state and local public health Emory University School of Medicine, Atlanta, GA authorities and the health care system with the Kenneth P. Kleinman information needed to determine the appropriate Department of Ambulatory Care and Prevention, Harvard response to biological threats. f Medical School, , MA

* Affiliations at the time the committee concluded its work in August 2009.

Study Staff

Lois Joellenbeck Donna Randall Study Director Financial Associate Jane Durch Jessica Pullen Senior Program Officer Administrative Assistant Michael McGeary Andrew Pope Senior Program Officer Director, Board on Health Kathryn Hughes Sciences Policy Program Officer Frances Sharples Director, Board on Life Ericka McGowan Program Officer Sciences Dorothy Zolandz Susan McCutchen Director, Board on Chemical Advising the nation / Improving health Senior Program Associate Sciences and Technology Jon Q. Sanders Program Associate 500 Fifth Street, NW Washington, DC 20001 Study Sponsor TEL 202.334.2352 The Department of Homeland Security FAX 202.334.1412 www.iom.edu

The Institute of Medicine serves as adviser to the nation to improve health. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policy makers, health professionals, the private sector, and the public. Copyright 2010 by the National Academy of Sciences. All rights reserved.