Thank you for the opportunity to review the GAO draft report, "West Nile Virus Outbreak: Lessons for Public Health Preparedness" (GAO/HEHS-00-180). The Centers for Disease Control and Prevention (CDC) concurs with the conclusion that the West Nile outbreak holds important lessons for response to public health emergencies involving uncertain causes whethe intentional or unintentional. The finding that bioterrorism preparedness rests in large part on public health preparedness, and that surveillance, epidemiologic, laboratory, and communications capacity at local, state, and federal levels must be enhanced to ensure this preparedness is particularly noteworthy. In 1994, CDC issued a strategic plan, Addressing Emerging Infectious Disease Threats: a Prevention Strategy for the United States, which launched a major effort to rebuild the component of the U.S. public health system that protects U.S. citizens against infectious diseases. In 1998, CDC issued the second phase of this plan, Preventing Emerging Infectious Diseases: A Strategy for the 21st Century, which builds upon the first report to combat today's emerging diseases and prevent those of tomorrow. Both plans focus on four goals, each of whi has direct relevance to preparedness for bioterrorism: disease surveillance and outbreak response; applied research to develop diagnostic tests, drugs, vaccines, and surveillance tools; public health infrastructure and training; and disease prevention and control. The 1998 plan emphasizes the need to be prepared for the unexpected-whether it be a naturally occurring outbreak of West Nile virus or the deliberate release of anthrax by a terrorist. Likewise, in April 2000, CDC issued the executive summary of Biological and Chemical Terrorism: Strategic Plan of Preparedness and Response - Recommendations of the CDC Strategic Planning Workgroup in the Morbidity and Mortality Weekly Report (MMWR). This report outlines steps for strengthening public health and health-care capacity to protect the nati against these threats, and it reinforces the work CDC has been contributing to this effort and la a framework from which to enhance public health infrastructure. Five key focus areas have be identified which provide the foundation for local, state, and federal planning efforts: Preparedness and Prevention, Detection and Surveillance, Diagnosis and Characterization of Biological and Chemical Agents, Response, and Communication. These areas capture the goa of CDC's Bioterrorism Preparedness and Response Program. Append Comments From the Centers for Disease Сопция Depart - Janet Heinrich lieve that both the emerging infections documents and the bioterrorism strategic plan be acknowledged in the GAO report, since they have direct relevance to the findings and draft report mentions, several aspects of the 1999 WNV investigation went quite well; r of factors, at least some of which are CDC's support in both the emerging infections and peatedly stated in the draft report that the correct agent and cause of the illness were only aft report rightly emphasizes the lack of coordination between the human health and health communities, a valid observation that needs to be overcome. However, the report I also address the general lack of coordination within the animal health community, where does not appear to be any unified surveillance effort in place. Feels that this report is a thorough presentation of the challenges faced during the 1999 igation, but that addressing these additional issues could strengthen the final product. In on to these concerns, specific technical comments and suggestions follow this letter. We appreciated the opportunity to review the draft report entitled West Nile Virus Outbreak: Lessons for Public Health Preparedness. Overall, this is an extremely thorough account of the events of last year and provides an overview of the major lessons learned with respect to emerging infectious disease and bioterrorism preparedness. We strongly support yo conclusions that the most important preparations for responding to a bioterrorist event require enhancing the existing public health surveillance and laboratory infrastructure for infectious diseases. These efforts will have the benefit of enhancing the nation's ability to respond to an infectious disease threat, whether natural or intentional. We had the following general comments on the current draft report: 1 - Importance of effective disease surveillance at the local level: Effective infectious disease surveillance at the local level has two primary components mandated by local and state public health regulations: (a) reporting of specific diseases (e.g, tuberculosis, malaria) by healthcare providers and laboratories, and (b) reporting of any unusu disease manifestations or clusters of illness. The first component allows the tracking of individual diseases to monitor for changing trends in disease incidence, and for implementing and evaluating control measures, as needed. However, it is the latter component that is essenti to the recognition of outbreaks or new infectious disease threats, whether natural or intentional For public health surveillance to promptly recognize a bioterrorist attack, the following need to be in place: (a) the clinical community needs to be aware of the clinical aspects of the likely bioterrorist agents, and know who to call if they suspect an unusual disease or cluster of illness, and (b) as importantly, there needs to be an effective public health infrastructure, with 1 ologic, infectious disease and laboratory expertise to promptly respond to these reports. York City (NYC), the Department of Health has recognized the importance of physician g and continues to work on improving outreach to the healthcare community to ensure y know what, when and how to report unusual disease occurrences. This is an ongoing nd works best when communication is bidirectional, with constant feedback to the community on surveillance findings. The initial recognition of West Nile encephalitis among humans in New York City was ue to the report of a single physician who rapidly communicated her concerns to the epartment of Health. We recognize that many local and state health departments may not e staff resources in place to improve communications with their local medical nities and to effectively triage and investigate these initial reports of unusual disease when they occur. We urge you to emphasize that there is a need to continue to enhance astructure at the state and local levels to ensure that there are sufficient and appropriatelystaff with an understanding of clinical infectious disease, surveillance, epidemiology and ■ry diagnostics to respond to potential outbreaks. d for better communication between public health agencies We recognize that communication became more difficult as the number of agencies d increased over the course of the West Nile virus outbreak investigation. Although some, telephone conference calls are often the most effective way to ensure that everyone d is updated regularly, to coordinate the investigation and to allow discussion of the issues and concerns. During the 1996 multi-state investigation of the foodborne outbreak ospora cayetensis, the daily conference calls chaired by the CDC were well-organized e an effective means of coordinating the public health response. This outbreak involved different state, provincial and local health departments and several federal agencies. Part roblem during the West Nile calls last year was the initial lack of leadership to ensure that ussion remained focused. However, this did improve significantly with the entation of a standard format and agenda for each call. Although electronic discussion forums can be valuable, the West Nile virus forums have ʼn regularly utilized on either the CDC or NY State Department of Health's Website this d the telephone conference calls have remained the most effective way for sharing tion. Decision-making during a multi-jurisdictional outbreak can be difficult to address and the port does not acknowledge that the authority to make the final decisions with respect to entation of mosquito control measures was at the local, and not the federal, level. The nd the state health departments involved provided guidance and recommendations, but cal health department had the final responsibility to decide and implement their public esponse. Toving linkages with animal health agencies: We also recognize that this is one of the most important lessons learned from the West us outbreak last year. However, it is essential to note, that the monitoring of veterinary health issues is multidisciplinary with several different agencies responsible for different 2 Department of Health types of animals: (a) domestic animals, such as dogs and cats, are usually the responsibility of state and local health departments, (b) livestock, such as cattle and swine, are usually the responsibility of state agricultural agencies, and (c) wildlife, such as birds, are under the state environmental or wildlife agencies. This division also occurs at the federal level, and hinders effective communication and coordination during investigations that involve multiple animal species. The early investigation of the avian outbreak was slow and the common pathologic finding of encephalitis among the affected birds was not reported until almost two months after the first reports of a bird die-off in the NYC area. In early to mid-August 1999, there were numerous articles on the avian outbreak in the local community papers that reported that no common pathology or etiology was identified despite multiple submission of dead birds for pathologic examination. It was not until the media announcements reporting the human outbreak of St. Louis encephalitis, that the veterinary pathologists began to more intensively investigate the cause of the bird deaths. Although there was reportedly concern among these veterinarians and wildlife specialists that the avian outbreak was related to the human outbreak, there was never an attempt to communicate this directly to the NYC Department of Health, which was the lead agency investigating the human outbreak - especially regarding the key finding that most of these birds also had evidence of viral encephalitis. As documented in the report, local health officials at the NYC Department of Health had been accurately informed by arboviral experts at CDC and elsewhere that the avian die-offs were likely unrelated to the human outbreak as flaviviruses do not normally kill their avian host reservoirs, and simultaneous avian and human arboviral encephalitis outbreaks have never been reported previously for SLE, or other flaviviruses such as West Nile virus. Bird die-offs due to various causes are not unexpected during the fall migration, but the finding that the majority of these birds, especially crows, had autopsy evidence suggesting viral encephalitis was an important clue that these outbreaks were indeed related, and this information could have been more rapidly and effectively shared with the epidemiologists investigating the human outbreak. 4- Recognition of unusual clusters of human illness - Among the five patients that were admitted to the community hospital in Queens during August, at least three of them did not initially present with "unusual symptoms". Three of the four earliest cases did not develop symptoms of encephalitis with muscle weakness until almost a week into their hospital stay. Also, as commonly occurs in any hospital, these patients were initially seen by different physicians, and it was not until there was a single infectious disease consultant reviewing their cases that the opportunity to recognize that these patients were part of a cluster or outbreak presented itself. Therefore, the ability to recognize these patients as an unusual cluster was not possible until the third week in August. There is a need for hospitals to ensure the capacity to detect clusters of unusual illnesses among their patient populations, so that the local and state health departments can be notified of any suspect outbreaks, even before a diagnosis is made. Infection control practitioners, infectious disease consultants or chief medical and pediatric residents may be in the best position to recognize unusual patterns of illness in their institutions and local and state health departments 3 |