le many officials and experts we contacted believe aspects of the break investigation went quickly and well, nearly all of them also eve there were lessons to be learned. These lessons may be especially vant for acts of bioterrorism, where the outbreak of cases may be much e rapid and law enforcement agencies may need to be involved to vent terrorists from releasing additional biological agents. The time lable for decision-making and response may be compressed from days weeks to a matter of hours. The lessons we identified related primarily ddressing possible needs in five areas: ocal surveillance and response capabilities, communication among public health agencies, coordination between public health and animal health efforts, apabilities of laboratories, and efforts to distinguish between natural and unnatural events. West Nile outbreak provided a number of lessons about surveillance. learned that many aspects of the surveillance network worked well, eding the response to the outbreak. These positive lessons can serve as lels for other communities that may have less substantial surveillance vorks. However, while several of the lessons are positive, the outbreak exposed some weaknesses. human outbreak of West Nile began with a few unusual cases. The ntial that one or two persons' medical conditions could be an cation of some larger concern, such as an emerging infectious disease, not be readily apparent to the health professionals involved. In many s, such events might not be noticed until a number of physicians have rted the cases and the local health department identifies a cluster, or a ber of victims seek care for similar conditions at the same location. t responses by the doctors and nurses who first see such victims are cularly crucial in alerting the public health community to the ibility of a wider problem. e West Nile outbreak, several actions were particularly important in iding this early alert, as well as in providing valuable evidence for the stigation. Among these actions are the following: ne physician who encountered the first human cases at the local 8 GAO/HEHS-00-180 West Nile Virus Outbreak public health officials. Such occurrences could easily go unrep for example, the physician does not consider the circumstance unusual enough to report or does not recognize a rare disease. • Epidemiologists and staff at the New York City Department of took a number of actions that were essential to containing the They quickly investigated and recognized the potential signific the initial case reports. Their interviews with patients and fam identified common features in how the patients were exposed doors, suggesting that a mosquito-borne disease might be invol canvassed all New York City area hospitals to identify potentia and throughout their investigation, they remained in daily touc many local, state, and federal officials who had quickly becom involved. These staff members said previous planning for biot response in place at the city health department was key to the of the Department's response.' 11 • Autopsies were performed on the victims. The New York City Department of Health and Office of Chief Medical Examiner w together to ensure that autopsies were performed on any fatal encephalitis. Autopsies were performed on over 25 fatal cases initially suspected as having viral encephalitis, including all 4 f of West Nile encephalitis that occurred among city residents. A to one assessment of the response, information obtained from autopsies pointed to a flavivirus as the cause and helped guide subsequent laboratory testing.12 Autopsy rates nationally have decreasing, at a time when public health officials believe they increase to help detect infectious diseases. The decline has be influenced by such factors as costs and jurisdictional and auth uncertainties. 12 "Officials indicated that most critical was the collaborative relationship in plac the health department and the Office of Emergency Management due to the bio planning efforts. This collaboration helped facilitate the rapid mobilization of e control measures, establishment of the public hotline, and rapid mobilization of the holiday weekend to assist in canvassing local neighborhoods with education 12Wun-Ju Shieh, Jeannette Guarner, Marci Layton, Annie Fine, James Miller, Der Grant L. Campbell, John T. Roehrig, Duane J. Gubler, and Sherif R. Zaki, "The R Pathology in an Investigation of an Outbreak of West Nile Encephalitis in New! Emerging Infectious Diseases, Vol. 6, No. 4 (May-June 2000). ile the West Nile outbreak was identified more quickly than otherwise ese problems have been noted in other instances besides the West Nile 999 assessment by the Institute found that disease surveillance systems Some Inadequac for Surveillance Better Commun Needed Among Health Agencies titute of Medicine, Public Health Systems and Emerging Infections: Assessing the bilities of the Public and Private Sectors, Workshop Summary (Washington D.C.: ɔnal Academy Press, November 2000), p. 5. itute of Medicine and National Research Council, Chemical and Biological Terrorism: cies in Resources e Were Exposed that education about the threat posed by bioterrorism and abou diagnosis and treatment of various agents deserves priority. Although this outbreak was relatively small in terms of the num human cases, it taxed the resources of one of the nation's larges health departments. The strain on resources is particularly note because local health departments in the United States have initia all the investigations that led to the recognition of infectious dis outbreaks. At the time of the West Nile outbreak, the New York Department of Health had a unit of about eight people responsib surveillance and case investigations related to over 50 reportable diseases. Officials told us that having even this small number of staff available was critical to the quick response to the initial ou Once the outbreak was identified, these and other staff assigned from other agencies and departments worked long hours, seven week. We reported in 1999 that surveillance for important emerging inf diseases is not comprehensive in all states, leaving gaps in the na surveillance network.15 Many state epidemiologists reported ina staffing for generating and using laboratory data—often conside reliable for case investigation purposes than physician-reported performing infectious disease surveillance. The Institute of Medi workshop reported that, in general, epidemiological investigatio surveillance efforts are challenged by a variety of factors. These changes in the health care system and the continuing use of pap disease-reporting systems in many locations, where surveillance consequently sporadic and inadequate. 16 unication Is ng Public cies Experts consider rapid and reliable communication among publi agencies to be essential to bioterrorism preparedness and coord Timely dissemination of information allows public health official decisions with the most current information available. During the outbreak, however, officials indicated that the lack of leadership initial stages of the outbreak and the lack of sufficient and secure 15 Emerging Infectious Diseases: Consensus on Needed Laboratory Capacity Co Strengthen Surveillance (GAO/HEHS-99-26, Feb. 1999), p. 2. 16 Public Health Systems and Emerging Infections, p. 4. communication among the large number of agencies involved vented them from sharing information efficiently. y officials interviewed pointed to the lack of clear reporting guidelines ne source of confusion. Knowing who was in charge or could act as an ncy spokesperson, and which agency was responsible for what, would e allowed each agency to operate more effectively. Some officials gested that each agency should have one "point person" overseeing rations and the flow of information. ing the outbreak, local, state, and federal officials held daily conference 17 le a secure electronic communication network was in place at the time Links Between wvolved official indicated that these problems were improved with the implementation andard format and agenda for each call. 12 GAO/HEHS-00-180 West Nile Virus Outbreak |