ISDS Consultation Duval County Health Department Jacksonville, FL August 20-21, 2007

1. ISDS Consultation Duval County Health Department Jacksonville, FL August 20-21, 2007

2. Background Identified that local systems that gather public health information were fragmented: Several public health organizations with multiple levels exist Several active and passive surveillance systems There is an overall need to provide “useable” information during an event response & subsequent situational awareness. To make quick and critical PH decisions Reduce health risks Reduce # of people exposed, prevent illness, reduce morbidity and mortality Many public health organizations and CDC have recognized that our “national” system to gather public health (PH) information is a fragmented patchwork of multiple systems [1]. The questions that are proposed to the panel member experts entailed addressing the possibility that SS data could be used effectively in amalgamation with other data sources. This would include its combination with a) BioWatch (environmental sampling data), to improve the public health utility of environmental pathogen monitoring [2], b) plume modeling, atmospheric data on weather conditions that foster disease spread to predict, rather than detect or explain, epidemics or the onset of seasonal disease [3], and c) veterinary data to better describe and predict interactions between animal and human health [4]. The topic is important to impede rapid detection of future health threats by combining syndromic surveillance data with other data sources. Many public health organizations and CDC have recognized that our “national” system to gather public health (PH) information is a fragmented patchwork of multiple systems [1]. The questions that are proposed to the panel member experts entailed addressing the possibility that SS data could be used effectively in amalgamation with other data sources. This would include its combination with a) BioWatch (environmental sampling data), to improve the public health utility of environmental pathogen monitoring [2], b) plume modeling, atmospheric data on weather conditions that foster disease spread to predict, rather than detect or explain, epidemics or the onset of seasonal disease [3], and c) veterinary data to better describe and predict interactions between animal and human health [4]. The topic is important to impede rapid detection of future health threats by combining syndromic surveillance data with other data sources.

3. Purpose Ten (10) panel members from a myriad of specialties Florida Department of Health Bureau of Epidemiology Bureau of Environmental Health Duval County Health Department, Jacksonville, FL Florida Bureau of Laboratories Florida Department of Emergency Preparedness Discuss several aspects of PH surveillance Situational Awareness Integration of multiple data streams Communication between agencies/organizations The purpose of this meeting is to develop recommendations for how to best use, alone and especially in combination, existing and emerging data sources in the Jacksonville area to maintain situational awareness with respect to population health in the case of a major event with public health implications. One feature of this definition is that it is NOT about event detection, but about situational awareness after initial event detection. In particular, we are interested in knowing how, in the event of a documented large-scale environmental release of a hazardous material, the science of plume modeling, syndromic surveillance for human health events, and veterinary health data could be used in tandem to predict or assess potential human health risks and consequences. In addition, we are interested in assessing whether and how animal health data could be used more effectively to detect or assess potential human health risks for zoonotic diseases. While the focus of this meeting is on how this could be done in one particular area (Duval County, FL), it is expected that the deliberations and recommendations from this meeting would be useful to public health epidemiologists in other local or state health departments who have similar interests in using such multiple information sources. The purpose of this meeting is to develop recommendations for how to best use, alone and especially in combination, existing and emerging data sources in the Jacksonville area to maintain situational awareness with respect to population health in the case of a major event with public health implications. One feature of this definition is that it is NOT about event detection, but about situational awareness after initial event detection. In particular, we are interested in knowing how, in the event of a documented large-scale environmental release of a hazardous material, the science of plume modeling, syndromic surveillance for human health events, and veterinary health data could be used in tandem to predict or assess potential human health risks and consequences. In addition, we are interested in assessing whether and how animal health data could be used more effectively to detect or assess potential human health risks for zoonotic diseases. While the focus of this meeting is on how this could be done in one particular area (Duval County, FL), it is expected that the deliberations and recommendations from this meeting would be useful to public health epidemiologists in other local or state health departments who have similar interests in using such multiple information sources.

4. Objectives Develop recommendations for improved utilization of existing and emerging data sources to maintain situational awareness with respect to population health in case of a major event with public health implications. Provide generalizability across multiple localities and applications

5. Objectives The discussions focused on the uses of: Laboratory systems for environmental monitoring and human specimen testing Syndromic surveillance data Emergency department, Poison Control Center and 911/EMS data Reportable/notifiable case reporting Ad hoc active surveillance for specific health outcomes of interest Plume modeling to assess source and direction of environmental contaminant detected through environmental monitors Veterinary health data as a predictor of both animal and human health impacts

6. Objectives Desire for PH officials local, state and abroad: Have well defined protocols for accessing information from multiple sources over the course of an event Establish good communication flow across participating agencies and across county-state-federal levels Understand the type, characteristics, and potential utility of information from various data streams Assure the sustainability of maintaining data sources during an event Maintaining data sources Use systems and clarification of evolving needs for information Inform development of exercises: to promote and define strengths and weakness of data sources use capacities within local, regional, and/or state perspective

7. Panel Members Sa’ad Zaheer MD, MSPH Director of Epidemiology/ Bioterrorism Surveillance, FDOH/DCHD Sarah Winn, MPH DCHD Bioterrorism & Surveillance Epidemiologist Theresa Isaac RN, Director of Emergency Preparedness FDOH/DCHD Phil Lee Molecular Biology & Bioterrorism Defense Laboratory, FDOH BOL Iruvanti Sunitha PhD Microbiologist at Florida BOL - Defense Preparedness laboratory Guoyan Zhang, MD, MPH Senior Epidemiologist/ Coordinator, Miami-Dade County Health Department Carina Blackmore PhD, DVM State Public Health Veterinarian FDOH Mr. Ronald C. Burger FDOH, Division of Emergency Medical Operations Office of Emergency Operations Aaron Kite-Powell, MPH Surveillance Epidemiologist FDOH Mr. John Perry Developer of syndromic surveillance system BioDefend

8. Moderators/Discussion Leaders James Buehler, MD Research Professor in the Department of Epidemiology and a member of the Center for Public Health Preparedness and Research at the Rollins School of Public Health at Emory University. He also serves as a Consultant Epidemiologist at the Division of Public Health of the Georgia Department of Human Resources. Richard Hopkins, MD Medical Epidemiologist in the Florida Department of Health, Bureau of Epidemiology Assistant Chief for Science Section Administrator Previously with the CDC, in the division of Public Health Surveillance and Informatics

9. Jacksonville, FL City View Jacksonville is the largest city in the state of Florida and the county seat of Duval County As of the 2006 census, the city proper had an estimated population of 794,555 with a metropolitan population of more than 1.3 million. Jacksonville is a rail, air, and highway focal point and a busy port of entry, with Jacksonville International Airport and naval bases.

10. Scenario Interjection The discussion was based on consideration of a scenario involving a large-scale environmental release of BT agents, prompting participants to consider the applicability of various surveillance methodologies.

11. Laboratory capacity Issues addressed included: Capacity to test environmental monitoring specimens on a daily basis and 24/7/365 Ability to ramp up testing capacity in response to a crisis. Capacity to test for multiple agents in the event of a multi-agent BT attack Protocols for information flow from the laboratory to appropriate PH staff at local, state, and federal levels.

12. Laboratory capacity Concern was voiced: Procedures for transmitting information and for maintaining laboratory capacity beyond the acute event detection/ assessment phase Systems for communicating data from the state lab to CDC may be more clearly articulated and developed than systems and procedures for sharing information among public health officials in state, within or in addition to lines of communication articulated in an IC structure The existence of several different electronic reporting systems for environmental test results Negative results as important positives Access for people who need to know this information

13. The science of plume modeling In the event of an environmental detection of a biologic agent, the task of the plume modeler is to help determine: Where did it come from? e.g., what was the likely point of release Where is it going? Challenges include: Elevation at time of release and size of release will be unknown, These attributes of the release must be assumed Unknown whether exposure is ongoing or from multiple points environmental sampling and atmospheric data

14. The science of plume modeling Plume modeling would be unlikely to be a sole determining factor regarding decisions about evacuation or use of prophylactic agents Part of the mix of inputs in making such a decision. Its main advantage may be to inform where surveillance efforts should be focused.

15. Surveillance for human health events: SS, ad hoc active surveillance Issues included: In the early stage of an event, there is likely to be intense interest in carefully evaluating individual cases. Later, if the event proves to be large, less detailed information about cases would be necessary for situational awareness. The relative use of ad hoc active case reporting and SS will evolve over these stages of an event Ability to modify current systems for outcome of interest? SS is likely to be useful in providing trend analyses across geographic areas

16. Surveillance for human health events: SS, ad hoc active surveillance Issues continued: Discussion considered the potential role of SS in supporting active case reporting and in "casting a net" for potential cases that should be investigated more thoroughly. Boundary between SS and active case finding and the role of automated systems versus the role of hospital staff in identifying potential cases of interest in an active case-finding stage.

17. Veterinary Health Data Private clinics dedicated to pet care may be optimally positioned to report data to public health, but pets may not be the population of animals most vulnerable to a BT attack. Morbidity information for pets more likely useful than mortality information. Stray or feral animals may be most vulnerable due to poorer underlying health status and greater exposures to outdoor environmental exposures, There is apt to be less information available Consideration of animal control and dead animal complaints as a source of information Local vets and PH officials are not presently prepared to collaborate in conducting animal health surveillance and reporting. Sentinel bird surveillance through state and Florida WildlifeLocal vets and PH officials are not presently prepared to collaborate in conducting animal health surveillance and reporting. Sentinel bird surveillance through state and Florida Wildlife

18. Veterinary Health Data Agricultural herds may be affected depending on nature of attack and direction of plume from urban to rural areas Knowledge of locale-specific endemic animal infections will be critical to assessing environmental biological sampling positives. Key question will be: Is an agent detected in environmental biologic sampling likely to be from a naturally-occurring local source, or is it possibly from an exogenous BT attack? Hindrance: Veterinary data are heterogeneous and information would currently be difficult to assemble for quick analysis.

19. Discussion of recent wildfire Role of Public Health versus Environmental Health agency in issuing public advisories Primary source of information to inform public was air quality data (not human health data) ED SS system in Duval did not detect an increase in respiratory disease Designed to focus on infectious diseases No increase seen in respiratory disease category (although focus on ID) Anecdotal reports from physicians suggested some increases in visits Efforts at post-event data collection from hospitals had mixed success Now planning post-event assessment using state's hospital/ED discharge registry

20. Implications for the future For Duval Co, other counties, and state Address gaps in preparedness capacity to integrate information from multiple sources Communicate information across government levels Maintain information sources during potential transition from acute detection/assessment phase of an event to longer-term stages from days to weeks following an event. Especially if exposures are ongoing.

21. Implications for the future Consultation demonstrated the utility of bringing together groups from multiple localities, multiple disciplines and various levels of state government. Participants have engaged in more in-depth consultations or exercises within their domains of responsibility or expertise A cross-section of representation for surveillance and assessment had not been previously assembled Discussion format may be useful to others localities and states

22. Implications for the future Highlighted that much of preparedness focus has been on event detection, initial assessment and response. Longer-term follow-up, response, and need for situational awareness capacity over the entire course of a major crisis. Need for criteria to assess the situational awareness utility of various information sources. This is an attribute of this consultation that other areas may benefit from modeling

23. Acknowledgments ISDS for sponsoring the event Duval County Health Department Florida Department of Health Bureau of Epidemiology Bureau of Environmental Health Bureau of Laboratories Moderators Dr. James Buehler Dr. Richard Hopkins

24. References [1] Teutsch SM, Churchill RE, Principles and Practice of Public Health Surveillance. Activities in the Public Health Arena (4th ed., pp 89 – 90). New York, NY: Oxford. [2] “The BioWatch Program: Detection of Bioterrorism”, Congressional Research Service Report No. RL 32152, November 19, 2003. Retrieved July 18, 2007 from the World Wide Web: http://www.fas.org/sgp/crs/terror/RL32152.html [3] “Emergency Response System: Real-time Operational Models: NARAC. Retrieved July 18, 2007 from the World Wide Web: https://narac.iinl.gove/modeling.php. [4] Stark KDC, et al (2006). Concepts for risk-based surveillance in the field of veterinary medicine and veterinary public health: Review of current approaches. BMC Health Service Research, 6, 20. Retrieved July 18, 2007 from the World Wide Web: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1409776.

25. Questions