The path toward improved biosurveillance

In April 2009, following an experimental protocol, staff members at a Navy lab in San Diego tested specimens from two patients using a new diagnostic device. Both tested positive for influenza, but, oddly, neither specimen matched the influenza A subtypes that are known to infect humans. This finding raised suspicions, and so the samples were sent to the US Centers for Disease Control and Prevention (CDC). Further tests would reveal that these two patients were the first reported cases of a novel H1N1 influenza virus that would cause a global pandemic in 2009.

In many respects, the Navy lab’s discovery of H1N1 is a success story for US efforts to boost its biosurveillance capabilities. Working together to improve influenza surveillance, the CDC and the Defense Department helped to develop the diagnostic tool that led to the detection of a novel virus. Had such a partnership not existed, it’s likely that the pandemic strain would have circulated in the community for weeks before it was detected. 

But the events of 2009 also shined a light on holes in US biosurveillance capabilities. Shortly after the discovery of H1N1, leaders were faced with many questions about how the US government should respond. How many people would likely get sick? How many would die? Was the virus so lethal that officials recommend closing schools to prevent spread? Who should get priority access to limited supplies of vaccines and antivirals? Existing biosurveillance systems, largely designed to provide early warning of an outbreak or to study long-term disease trends, were not equipped to aid in real-time decision-making. As a result, leaders had to take action based on highly uncertain assumptions.

To address these gaps, in 2012 the White House released the National Strategy for Biosurveillance, which sets out a fundamental goal of national biosurveillance efforts: saving lives by ensuring that leaders have the right information to make timely decisions during a public health emergency. The strategy calls on federal agencies to work with the private sector, international, state, local, and tribal governments, and nongovernmental organizations to build a national biosurveillance enterprise.

To advance the strategy, the White House Office of Science and Technology Policy released the National Biosurveillance Science and Technology Roadmap in June. Developed by an interagency working group, the roadmap outlines research and development needs in four core areas: the detection of aberrations from baseline biological conditions; the anticipation of risks posed by a natural or intentional biological incident; the identification and characterization of bio-threats; and the sharing, integration, and analysis of biosurveillance information with decision makers, including responders and health care providers. For each of these areas, the roadmap describes current programs and “capability needs,” or areas where additional efforts are needed.

Though far from complete, the roadmap’s list of a vast number of existing biosurveillance agencies and projects is instructive and goes some way toward addressing the National Biosurveillance Advisory Subcommittee’s concern about duplication among the hundreds of biosurveillance efforts underway across the federal government.

In terms of capability needs, the roadmap articulates specific areas where additional technical research is still needed. But it does not describe any new initiatives to undertake that research. Many of the current programs listed in the roadmap, in fact, predate issuance of the National Biosurveillance Strategy. For example, the US Agency for International Development PREDICT program—which aims to monitor “hot spots” around the world to detect emerging infectious diseases in animals—has been underway since 2009.  And despite its name, the roadmap is missing key details that would make it a complete “map” that makes specific recommendations for bridging gapsin biosurveillance capability. There is no mention of which agencies or other entities would be tasked with new research needed in the biosurveillance arena, or what funds (if any) would be made available to support such work. In the absence of this information, it is difficult to see how the additional research would be accomplished, particularly in the face of seemingly perpetual budget decreases.

The document also does not prioritize among the capability needs identified in each of the four areas. There are clearly some aspects of biosurveillance that warrant attention above others. If you ask the people who have the primary responsibility for detecting and responding to outbreaks what sorts of biosurveillance capabilities they’d like to see developed, chances are you’ll hear the same short-list over and over again: better diagnostic tests; interoperable electronic health records; faster electronic reporting from clinical laboratories; and better-trained and more-experienced analysts who can review and act upon data. By failing to emphasize these—or any other—capabilities, the roadmap released last month makes it unlikely that any will receive the support they need to be effective.

Following a roadmap takes money. Even if the federal government is successful in developing enhanced technologies for biosurveillance as outlined in the roadmap, two critical issues will have to be addressed if there is to be meaningful improvement in the availability of information to support decision making during bio-emergencies. First, much of the data that populate existing federal biosurveillance systems are provided by state and local health departments.  And so, as a matter of priority, the US government should consider developing tools that can be adopted by state and local health departments to facilitate their work. But resource shortages at state and local health departments may complicate this task. For example, the federal government is trying to roll out electronic health records across the nation, but many states point out that they lack sufficient information technology capacity to store and analyze data from those records.

Second, even though better technology can help improve the collection and analysis of biosurveillance data, it still takes a skilled analyst to review the available information and to determine when it is appropriate to take action. Unfortunately, there is a shortage of skilled biosurveillance analysts across all levels of government. This problem has been exacerbated by sustained budget cuts that have resulted in the loss of nearly 40,000 jobs at state and local health departments.

The National Biosurveillance Strategy and its roadmap represent important first steps toward improving the focus and coordination of US biosurveillance investments. Whether these high-level policy statements will meaningfully improve decision making during public health emergencies will ultimately depend on implementation. With a national commitment and interagency cooperation, it is possible to make big improvements in surveillance.  One hopes the White House will provide additional details toward that end when it releases the Implementation plan for the National Biosurveillance Strategy—a document that, according to the strategy, should have been issued last year.