An Overview of CDC’s OCIIX BioPHusion Program

1. An Overview of CDC’sOCIIX BioPHusion Program Integrated Surveillance Seminar Series June 18, 2009 Henry Rolka, David Walker and Janet Heitgerd Office of Critical Information Integration and Exchange (OCIIX)

2. Outline • Background and Context: How did we get here? • Current Operations: What are we doing? • Future Directions: Where is this all going?

3. How did we get here? • Traditional Surveillance • Surveillance System Integration Project • “Syndromic” and multiple source surveillance • System Examples (data use complexity and challenges) • Summary of Data Analytic Issues • Information fusion concept

4. Biosurveillance Background • CDC Surveillance System Integration Project (1999) • Web-based public health information capabilities • 9-11-2001 • Syndromic Surveillance Conferences (Fall 2002) • DARPA BioAlirt Program (2002) • BioSense ‘rollout’ (Spring 2004) • National BioSurveillance Integration System (2004) • PL110-53 (2007) • Fusion Centers concept and BioPHusion Program (2007) • HSPD-21 (2007)

5. Public Health Surveillance Health Services Utilization Adverse event (to intervention exposure) Disease Drug Vaccine Syndromic Traditional Infectious disease Other Birth defect Injuries Etc. Conceptual Reporting Taxonomy

6. Public Health Surveillance Disease “News media-like” reporting Health Services Utilization Adverse event Syndromic Traditional Drug Vaccine Infectious disease Other Birth defect Injuries Etc. Conceptual Reporting Taxonomy

7. Post-event Event Timeline During event Multi- federal departments Clinic Hospital City County State Federal International Patient encounter Pre-event Stakeholder Level Highly aggregated Data Record Detail Granular detail Perspectives: System Stakeholder Information Requirements

8. CDC Surveillance System Integration Project(1999) Gave rise to …. • Traditional disease reporting standards • Web-based display/screen standards • Use of aberration detection algorithms • Implementation process: • Public Health Information Network (PHIN) • National Health Information Network (NHIN)

9. Application Context Themes • Local vs Regional vs National focus • Interoperability / Transportability • Interdisciplinary science and technology • Culturalism • Language • Social networks • Case/Adverse Event definitions • Information exchange • Leadership

10. More Application Context Themes • Standards • Timeliness for response potential • Data access • Data quality factors • Signal detection thresholds • Testing Methodologies • System Evaluation • Emphasis on rapid cycle data updating

11. What is Needed for ‘Rapid Cycle’ Event Detection? • Modular software • Flexible for local, regional and/or national use. • Interoperable for various systems, platforms and data structures. • Produces graphics for interdisciplinary communication. • Amenable to assisting with signal definition. • Organized with potential for automation. • Acceptable operating characteristics. • Staff prepared to use it!

12. Bio-ALIRT Program(Defense Advanced Research Projects Agency) • “Bio-event Advanced Leading Indicator Recognition Technology” • Goal: Identify Nontraditional Data Sources and Develop Advanced Algorithms for Early Detection of Disease Outbreaks • Large Geographical Testbeds with Real Data Needed for Credible Research and Technical Development • Provide Increased-Alerts to Public Health • CDC participation (early 2003)

13. LATER DETECTION EARLY DETECTION GOLD STANDARDS NON TRADITIONAL MEDICAL INTELLIGENCE BIOSENSORS Vets OTC Pharm ANIMALS HUMAN BEHAVIORS NON TRADITIONAL USES CLINICAL DATA Tests ordered Test Results Test Results Zoos Absenteeism Complaints Diagnosis Utilities Sentinel MD Agribusiness Poison Centers Influenza isolates Environmental Coughs 911 Calls Pollen counts Investi- gations Web Queries Medical Examiner Humidity Traffic EMS Runs Survey Temperature Nurse Calls Public Transport Wind Speed/ direct. ER Visits Cafeteria Prescriptions Allergy Index Video Surv Radiograph Reports Pollution Newsgroup Biosurveillance Data Space(Background ~2002-2004)

14. BioSense Vision • Provide local, state, and nationwide health situational awareness for suspect illness and cases of disease before, during, and after a health event • Help confirm or refute the existence of an event; monitor its size, location, and rate of spread Approach • Real-time delivery of healthcare data from hospitals, labs, ambulatory care settings, and other health data sources • Electronic “views,” analytics, and reports for national, state, and local public health, contributing healthcare organizations

15. Enables Public Health Access to Jurisdiction-Specific Data • Developing a nationwide capability for simultaneous access to biosurveillance data by all levels of public health • Able to provide cross-jurisdictional information during a public health threat event

16. BioSense ‘Rollout’ • Spring 2004 • Data: VA, DoD, Lab orders, OTC • Amplified need for … • Improved analytics • Visual data exploration methods • Statistical algorithms • Informed user guidance and support • Partnerships • More timely data

17. Main Factors Determining Analytical Priorities • Empirical nature of the data • Opportunistic, secondary use, spontaneously generated. • No sampling design • Multiple types and sources • Rare events of importance for detection (scarce data sets to ‘train on’) • ‘Dual Use’ for data system (traditional / syndromic) • New analytical models (rapid cycle surveillance) - experience is minimal.

18. Data Use-related Issues • Messaging/Data Challenges • Scalability and Capacity Challenges • Analysis and Visualization Challenges • Perception/concerns of privacy, confidentiality issues

19. National BioSurveillance Integration System(Dept of Homeland Security) • Planned and designed in 2004 • Involves multiple agencies and their respective domain information • Described in detail to House Subcommittee on Prevention of Nuclear and Biological Attack • May of 2006 • “Creating a Nation-wide, Integrated Bio-surveillance Network” • PL 110-53 assigns NBIC to DHS for full operational capacity by end of FY08.

20. NBIS Mission • Recognize biological events, including disease outbreaks and the use of biological agents, which present a risk to the nation, its infrastructure, and key assets • Collate, integrate, and analyze information from existing surveillance systems focused on human disease, food, agriculture, water, meteorology, and the environment, as well as other relevant threat information • Disseminate this all-source information to appropriate Federal departments and agencies and provide timely bio-situational awareness to support decision-making

21. Domain Detection Thresholds 72 hrs Agency A Detection Time 48 hrs Agency B Single domain threshold Agency C reached informs all members 24 hrs NBIS Detection Window Event Time NBIS Objectives Multi - domain cueing can reduce detection • Improved info sharing threshold below independent domain thresholds • Reduced detection time 7 Enhanced Surveillance

22. Summary of Data Analytic Issues • Modern biosurveillance is a ‘fast moving target’ • High volume across heterogeneity • Multiple outcomes of relevance within a record within a data source • Multiple data sources • Complex data setting • Hospitals, labs, emergency response etc. • Local, State and Federal public health • Diverse variety of potential data uses and types of queries • Maturity of system (related to available knowledge about the data)

23. Multiple Horizontal and Vertical Interdependent and Overlapping Activities • BioSense, BioWatch, BioShield • DHHS, DHS and DoD all receive directives to develop “bioIntelligence centers”. (2003) • DoD, DHS and DHHS Executive Officials challenged to provide “a unified system enabling the assessment of the health status of any community in the US when needed in real time”. (2005)

24. Pandemic and All-Hazards Preparedness Act • Signed into law in December 2006 • Public Law 109-417 • Further emphasis on public health preparedness including coordination

25. PL110-53: “Implementing Recommendations of the 9/11 Commission Act of 2007” • Authorized DHS to establish, enhance, and staff State, local, and regional fusion centers that comply with the guidelines established under section 210A(i). • Promotes information sharing in general • Promotes integration across subject matter domains • CDC used the same guidelines as a template to get our own ‘information house in order’ (as this law was under development in early 2007).

26. CDC BioPHusion Center • Inception discussed throughout 2007 • Office of Critical Information Integration and Exchange (FR Vol. 73, No. 96, p. 28483. May 16, 2008) • Designed to serve as an information exchange unit • Develop standard operating procedures for information exchange and communication • Provide ‘common operating picture’ and ‘situational awareness’ – actionable information

27. Homeland Security Presidential Directive - 21 • October 18, 2007 • 20+ Implementation Actions • Integration of all vertical levels of government and horizontal community components • Discipline of Disaster Health • CDC Biosurveillance Coordination Unit

28. BioPHusion Current Operations:What are we doing? Collaborative Partnerships Information Source Details Analysis Processes and Report Production

29. BioPHusionMission Statement To provide a CDC wide resource that facilitates the exchange, integration, and visualization of relevant information from a variety of sources to enhance Agency and programmatic situational awareness for decision making and early event detection

30. BioPHusion: Purpose • Integration or ‘Fusion’ of public health information from existing CDC programs / external partners / other sources to: • Increase situation awareness • Improve early event detection • Support decision-making to protect the public’s health • Sharing timely and actionable information to public health programs and leaders at the national, state, local, tribal, and global levels

31. National Biosurveillance e.g. National Biosurveillance Integration System International Biosurveillance e.g. World Health Organization CDC: BioPHusion: Common Operating Picture CDC: BioSense Electronic Health Information Exchange CDC: Reporting National Reporting Systems (e.g., Nationally Notifiable Disease Surveillance System, BioWatch, Laboratory Response Network) CDC: Programs Pathogen and Exposure Surveillance Systems Outbreak Reporting Relationships and Contacts CDC: Global Disease Detection Building capacity & connectivity for international information exchange Local, State, Tribal, Territorial, Federal, Global Health-Related Data and Information Source: Biosurveillance Coordination Unit Strategic Planning Presentations Coordination of Global Biosurveillance for Human Health

32. Director’s Critical Information Requirements BioPHusion must provide situation awareness of: Current and emerging public health threats in the U.S. Events that may become a public health threat to the U.S. Any threat to CDC staff, facilities, or resources worldwide. Any public health-related event of media interest.

33. BioPHusion Conceptual Model

34. Collaborative Partnerships Operational Model: Relationships with other analytical groups Information- and Event-specific consultations Sensitive information processing Electronic information exchange between programs

35. BioPHusion Operational Model International CDC, HHS, DHS CDC EOC BioPhusion SA Team Urgent Response Reports Field Sites Report General Public Health and Federal Partners BioPHusion Daily Reports BioPHusion Analysis Processes Individual Information Reports Unclassified Event Summary Record Consult Consult Data Record Data Record OSEP Medical Intel Zoonosis Specific Zoonotic Program Classified GDDOC Report Report Discuss Discuss ZIP Info Sources

36. Basic Information Processing(BioPHusion Operations) General Public Health and Federal Partners BioPHusion Daily Reports BioPHusion Analysis Processes Individual Information Reports • Wide Variety of Information Sources • CDC Programs • Urgent notifications (Epi-X, HAN) • Pro Med, media services • State/local public health • Other Federal agencies • Non-government organizations

37. BioPHusion-Staffed Collaborations(BioPHusion Operations) CDC, HHS, DHS CDC EOC BioPhusion SA Team Urgent Response Reports General Public Health and Federal Partners BioPHusion Daily Reports BioPHusion Analysis Processes Individual Information Reports Report Discuss • Similar collaborations • National Biosurveillance Integration Community • Department of State medical consultant liaison

38. Partners with Field Sites(BioPHusion Operations) International Field Sites Report General Public Health and Federal Partners BioPHusion Daily Reports BioPHusion Analysis Processes Individual Information Reports Consult GDDOC • Similar collaborations • DGMQ Quarantine Stations • State/Local Public Health • - Career Epidemiology Field Officer Program • - Senior Management Officials

39. ”Sensitive” Collaboration Partners(BioPHusion Operations) General Public Health and Federal Partners BioPHusion Daily Reports BioPHusion Analysis Processes Individual Information Reports Unclassified OSEP Medical Intel Classified Report Discuss • Awareness of Sensitive Information • Biological Indicator, Analysis, and • Warning Community -Wildfire • Director of National Intelligence - Intelink

40. Integrated Operations(BioPHusion Operations) General Public Health and Federal Partners BioPHusion Daily Reports BioPHusion Analysis Processes Individual Information Reports Event Summary Record Consult Data Record Data Record Zoonosis Specific Zoonotic Program • Other Potential • Partners • BioSense • CDC EOC ZIP Info Sources

41. BioPHusion Operational Model International CDC, HHS, DHS CDC EOC BioPhusion SA Team Urgent Response Reports Field Sites Report General Public Health and Federal Partners BioPHusion Daily Reports BioPHusion Analysis Processes Individual Information Reports Unclassified Event Summary Record Consult Consult Data Record Data Record OSEP Medical Intel Zoonosis Specific Zoonotic Program Classified GDDOC Report Report Discuss Discuss Daily SA Report State/Local Report Watchboard Report Special Event Reports Welded Report (future) ZIP reports (future) ZIP Info Sources

42. Information Source Details BioPHusion is not a data generator! Information is derived from: Public Health SMEs Other federal agencies General “open” sources

43. Partial list of OCIIX Information Sources American Red Cross Daily Shelter Reports Avian Influenza Weekly CDC Report Avian/Pandemic Flu News Hits NCHM Avian-H5N1 Avian Influenza Weekly Maps BIC - BioSense Weekly Summary BIC Situational Awareness Digest BioSense Reports CDC Media Relations CDC Today's News OD/OEC DEOC Daily Report DEOC Situation Reports DGMQ Daily Quarantine Reports DHS NBIS Daily Report DHS NBIS Situation Reports Enteric Diseases Epidemiology Branch Reports EPA notices and news releases Epi-X Afternoon Media Report Epi-X GPHIN Media Report Epi-X Morning Media Report Epi-X notices FDA MedWatch and consumer announcements Foodborne Outbreak List Serve Fusion Center News GDACS Daily Newsletter and Alerts GDD - Outbreak Health Alert Network messages HHS Daily Report HHS Fusion HHS NIH Healthfinder.gov HHS Secretary Forecast Intelink Unlcassified Avian Influenza Daily Digest NCEH/ATSDR News clips NHTA Recalls OSEP Alert OSEP Cables Office OSEP Weekly Intelligence Summaries OSEP Weekly International Disease Summary Other Federal Agency Reports Preparedness Workforce Management System Pro-Med Select Blogs on Vaccines and Autism USAID ReliefWeb USDA notifications Vaccine and Immunization News Stories

44. Information SourcesExamples of “Pushed” Sources CDC Operational Reports Public Health Notifications Other Federal Agency Reports Media-Related Sources Non-Government Organizations

45. Information SourcesExamples of “Pulled” Sources SLTT Public Health Department web sites Health-related Information Monitoring sites General Media Sources Social Network Sources

46. Information SourcesExamples of “Consultation” Sources CDC SME contacts DHS / National Biosurveillance Integration Community (NBIC) Biological Indication and Warning Analytic Community (BIWAC)

47. Analysis Processes and Report Production Daily report production began July 2008 Report development and production “BioPHusion_Input” information receipt “Tier I, Tier II” analysis process Daily Situation Awareness Report/Dashboard production Established analysis contract to augment staff

48. Analytic Operations “Pushed” Input BioPHusion Database BioPHusion Input E-Mail BioPHusion Database BioPHusion Database “Consultation” Input Doc 1 Info Item 1 Event 1 Summary Output Report Tier 2 Analysis Meeting Tier 1 Analyst Review Tier 1 Doc 2 Info Item 2 Event 2 Summary Doc 3 Info Item 3 Portal Display Tier 2 Table “Pulled” Input WHO SLTT Web Sites Media Tier 1 Table

49. Output Report Production Current: Daily Situation Awareness Report (DSAR) CDC and Federal Partner audience State/Local public health audience Watchboard Report – analysis peers Special Event Reports – H1N1 Daily Report Portal Displays

50. Output Report Production Future – In collaboration with other programs, BioPHusion insfrastructure will support: “Welded” Report for Top 12 CDC Leaders Presents high priority items from GDDOC, CDC EOC, and BioPHusion EOC Daily Report Facilitate Situation Awareness and Common Operating Picture information sharing Zoonotic Information Program (ZIP) Daily Report