PERSPECTIVE Table 3. Epidemic Intelligence Service investigations in which bioterrorism or intentional contamination was considered a cause 84-093 97-008 Outbreak Salmonellosis, Oregon, Shigella dysenteriae type 2, Texas, 1996 A total of 751 persons became ili with salmonella gastroenteritis. Rehgious group deliberately containinated salad bars. Salmonella enterica Typhimurium strain found in laboratory at commune was indistinguishable from outbreak strain (5). Diarrheal illness in hospital laboratory workers who ate pastries, anonymously placed in break room. Identical strains of S. dysenteriae type 2 were isolated from stool cultures of case patients, from recovered muffin, and from laboratory stock culture, part of which was missing. Seven laboratory workers at local hospital became ill with gastroenteritis. Most cases caused by strain A 38 year old woman was admitted to a hospital with fever, myalgia, and weakness; severe illness low because the reports that were recorded as originating from local or state health departments may actually have been brought to the attention of health departments by frontline practioners. Because of the importance of this frontline in detection and reporting, preparedness efforts must include education and support of these healthcare professionals. The clinical laboratory should have the capacity and legal latitude to use all appropriate testing. This capacity should include Gram stain of tissue smears for agents such as B. anthracis. Trip reports (Epi-2) are summaries, not finalized data and are written for the state and local health departments and CDC and the U.S. Department of Health and Human Services. They are primarily internal documents and are not independently peer reviewed or standardized; however, each investigation may use standardized techniques. In general, problems we encountered were not inaccuracies (when a subset of trip reports were compared to the articles that followed them) but rather incompleteness of data we were interested in reviewing. We suggest that trip reports include standardized data collection on certain variables important in evaluating the effectiveness of detecting and reporting outbreaks (e.g., source of outbreak detection, date of the first case diagnosis, and date the outbreak was recognized). Because we cannot rely on astute healthcare practitioners alone, existing national health surveillance systems should be modified or strengthened to increase their effectiveness in identifying bioterrorism (10). Systems already in existence for laboratory-based reporting should be enhanced for use in bioterrorism surveillance. Improved surveillance for unexplained critical illness and death may also be an important component in improved health surveillance for bioterrorism (5). In addition to healthcare providers and public health departments, other persons and organizations may identify and report outbreaks. For example, veterinarians may be the first to see evidence of bioterrorism because pets and livestock may be more susceptible than humans to agents released in the environment or because a large susceptible Table 4. Number of days from beginning to notification for outbreaks in which bioterrorism or intentional contamination was considered Beginning of No. of days from first case to outbreak problem identification Report no 84-93 Investigation No. of days from problem identification to initial CDC contact 97-603 10/29/96 PERSPECTIVE animal population may be present in the affected area (11). Detection of discase in lower animals may be essential to detecting a bioterrorism event because most of the bioterrorism threat agents are zoonotic disease agents, causing disease in both humans and lower animals The West Nile virus outbreak, while naturally occurring, is a good example of the importance of animal disease surveillance because detection of illness and death in birds was important to identification of the outbreak. Other potential resources include persons not in the bealthcare field. Employers may notice a high rate of illness in their employees, or schools may report a larger than usual absentee rate. Enhancing surveillance systems, providing a mechanism of instant reporting to the proper officials, educating healthcare professionals and others in the community, and strengthening knowledge and skills for thorough outbreak investigations will improve collective preparedness for bioterrorism. In the future, shortening the time from detecting to reporting an outbreak to public health authorities, including CDC, will be essential to an effective response. National health surveillance systems are ar. important adjunct that, with further development, may allow for early detection of bioterrorism. Finally, education about bioterrorism should go beyond a mere description of the threat agents and strive to enhance the epidemiologic and investigative skills of healthcare professionals, including laboratory personnel, especially those in primary care settings, who are likely to be the first contact for people and communities affected by acts of bioter rorism. Dr. Ashford is an epidemiologist in the Meningitis and Special Pathogens Branch, Centers for Disease Control and Prevention, where he serves as a subject matter expert for several zoonotic diseases. His research interests include the epidemiology and control of zoonotic diseases and bioterrorism preparedress. References 1. Jernigan JA, Stephers DS. Ashford DA, Omenaca C, Topiel MS, Galbraith M, et al. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States Fmerg Infect Dis 2001,7.933-44. 2 Centers for Disease Control and Prevention. Biological and chemical terrorism. strategic plan for preparedness and response. MMWR Recomm Rep 2000 49(RR-4):1-14. 3. Thacker SB. Dannenberg AL Hamilton DH. Epidemic Intelligence Service of the Centers for Disease Control and Prevention. 50 years of training and service in applied epidemiology Am J Epidemiol 2001 154-985-92. 4 Goodman RA, Bauman CF, Gregg MB. Videto JF. Stroup DF, Chalmers NP. Epidemiologic field investigations by the Centers for Disease Control and Epidemic Intelligence Service, 1946-87. Puble Health Rep 1990;105.604-10. 5. Centers for Disease Control and Prevention Suspected Lorellosis case prompts investigation of possible bioterrorism-related activity-New Hampshire and Massachusetts. 1999, MMWR Morb Mortal Wkly Rep 2000,49:509-12. 6. Centers for Disease Contre! and Prevention. Outbreak of West Nilelike virs! encephalitis-New York, 1999. MMWR Morb Mortal Wky Rep 1999 48-845-9. 7. Centers for Disease Control and Prevention. Bioterrorism alleging use of anthrax and interm guidelines for management — United States, 1998. MMWR Morɔ Mortal Wkly Rep 1999;48:69-74. 8. Torok 71, Tauxe RV, Wise RP, Livengood JR, Sokolow R, Mauvais 3, et al. A large community outbreak of salmonellosis caused by intertional contamination of restaurant salad bars JAMA 1997:278-389-95. 9. Kolavic SA. Kimura A, Simons SL, Slutsker L, Barth S, Haley CE An outbreak of Shigella dysenteriae type 2 among laboratory workers due to intentional food contamination. JAMA 1997,278.396-8 10. Centers for Disease Control and Prevention National Electronic Disease Surveillance System (NEDSS) Programs in Brief 2001 Available from: URL: http://www.cdc.gov/programs 11. Ashford DA. Gomez TM, Noah DL, Scott DP, Franz DR. Biological terrorism and veterinary medicine in the United States. J Am Vet Med Assoc 2000,217:664-7. Address for correspondence. David A Ashford, Centers for Disea e Control and Prevention, 1600 Clifton Rd., Mailstop C09, Atlanta, GA 30333, USA; fax: 404-317-5220; email: doa4@cdc.gov www.cdc.gov/eid To receive tables of contents of new issues send an e-mail to listserve@cdc.gov with subscribe eid-toc is the body of your message. Mr. SHAYS. You both have been wonderful witnesses, and we realize we're also wrestling with this. I think that what I am wrestling with is that I see this as the whole package. So when you talk about your not being able to talk about the technology to present this, you know, rather than its—you know, some of these are paper transactions. For me, I don't really-I don't like the feeling that I'm getting that we're not-I guess what I'm beginning to think is who's in charge? I don't mean that in a disparaging way, but who is taking ownership of this? Ultimately who takes ownership of making sure that this reporting happens quickly, that it's not paper transactions, that we're asking for the right things? Who ultimately, in your judgment, has that responsibility? Dr. FLEMING. Well, the short answer is that CDC can and is taking a leadership role in this, and if I haven't conveyed that clearly, I sincerely apologize. I want you to know that our organization is committed to making this happen. Mr. SHAYS. I get a feeling that you're content that a lot of progress is being made. And maybe what I'm hearing as well is that from a scientific standpoint, you know, we just-we study it, we check it, and we just-and so it'll happen when it happens. That's kind of the feeling, that we're making progress, but that's the kind of feeling I'm getting. From a politician and public policy standpoint, I'm thinking should we be tasking you to just make sure in a year or two it's done. And then you're probably saying, hello. You know, what do you mean it's done? So the process begins, you know, continues here. Any last comment that you'd like to make before-OK. You both have been excellent witnesses, and I thank you. Excuse me. Let me just say this. Is there anything, Dr. Tornberg or Dr. Fleming, that you want to put on the public record before we adjourn? A question maybe you had prepared for that you think we should have asked, and we just didn't have the common sense to ask it? Dr. TORNBERG. No, sir. I think both my oral and written statement cover the areas that we would like to address for the committee's attention. Mr. SHAYS. Dr. Fleming. Dr. FLEMING. No. We will get back to you on the record on the issues that we talked about. Mr. SHAYS. OK. And on this article. Dr. FLEMING. Yes. Mr. SHAYS. OK. Thank you both very much. Let me just announce the second panel. I'm going to ask three people to come up to be sworn in: Ms. Mary Selecky, Dr. Seth L. Foldy, and Ms. Karen Ignagni. And then afterwards I'll invite Dr. Julie Hall to sit down at the desk as well. We're swearing in three of our four witnesses. [Witnesses sworn.] Mr. SHAYS. And at this time we'll also invite Dr. Julie Hall, medical officer of the World Health Organization, to join us. Evidently we didn't make it clear to the World Health Organization we swear our witnesses in, and they have a policy as an international agency And Ms. Selecky is Secretary, Washington State Department of Health, president of the Association of State and Territorial Health Officials. Dr. Seth L. Foldy-am I saying it right? Dr. FOLDY. Foldy. Mr. SHAYS. Foldy-commissioner of health, city of Milwaukee; Chair, National Association of County and City Health Officials, Information Technology Committee. And Ms. Karen Ignagni is president and CEO of American Association of Health Plans. And Dr. Julie Hall, as I said, is medical officer of the World Health Organization. We'll go in the order that you're sitting. And again, 5 and then another 5. Your testimony is very important to us. And I think that I would say that if you want to ad lib a bit, and given that you sat through this first panel, that you may want to jump in and make some points, because I think some of the questions we've asked you you're well prepared to answer. So we'll start with you, Ms. Selecky. STATEMENTS OF MARY C. SELECKY, SECRETARY, WASHING- Ms. SELECKY. Thank you, Mr. Chairman, distinguished- MS. SELECKY. Thank you, Mr. Chairman and distinguished members of the subcommittee. My name is Mary Selecky. I'm the Secretary of Health in Washington State, and I'm honored to be testifying before you today as president of the Association of State and Territorial Health Officials. And also having been a local health department director for 20 years and having the experience of, on the ground, working local, State and working with our Federal colleagues, we certainly can address some of the issues that came up earlier. I certainly would like to thank the committee for your past support of work that goes on with public health, but most particularly your attention to the issue. It has not been in the recent past that we've had the opportunity to bring public health issues before you. This hearing focuses on one of our most important, although invisible and forgotten, public health tools, and that is public health surveillance. It's not something people think about every day. As early as 1878, Congress recognized that this is an important issue when it authorized the U.S. Marine Hospital Service to collect morbidity reports concerning cholera, smallpox, plague and yellow fever from U.S. Consuls overseas. Now the diseases may have changed, but the issues are very, and Puerto Rico were participating in national surveillance and reporting on 29 diseases. And in 1950, ASTHO, my organization, created its affiliate, the Council of State and Territorial Epidemiologists [CSTE], to determine and work together, States, local and Federal, to see which diseases should be reported to the U.S. Public Health Service. All States now voluntarily provide information to the Centers for Disease Control and Prevention [CDC] on nationally notifiable diseases. One of the core functions of State health departments is to collect, analyze, interpret and disseminate public health data. States do this to identify health problems, determine the programs or other responses needed to address the problems, specific health concerns, and evaluate the effectiveness of the responses. Health departments depend upon the receipt of quality public health data to identify and track emerging infectious diseases such as already mentioned, SARS and West Nile virus. Equally important, although often overlooked, is the collection of public health surveillance data that identifies the burden and causes of the Nation's leading causes of death. That's chronic diseases, heart disease, diabetes, injury and risk factors. We may have more attention paid at times to communicable disease, but we must do the same with the noncommunicable. State health departments have a unique role to play in public health surveillance. Public health threats do not respect political boundaries, be it the local level or the State level. Reporting of disease entities, therefore, needs to be uniform within any given State in order to work with Federal and local colleagues to assure an adequate immediate response to public health emergencies. In many parts of the country, only the state Health Department has the sophisticated laboratory and highly trained laboratorians, epidemiologists and other public health professionals needed to tackle the most serious public health challenges. I had that personal experience. I was in northeast rural Washington, Colville, Washington, up in Representative George Nethercutt and formerly Speaker Tom Foley's district. We didn't have the levels of sophistication that perhaps our colleagues in Seattle did, and, in fact, Seattle might be very busy with the work going on with their own communicable diseases. Work we did from our rural community was dependent on our State colleagues helping us and opening the door, if needed, to the Federal kinds of resources available. In this testimony I'd like to make four points. Since the 1988 Institute of Medicine's Future of Public Health Report recognized the inadequacy of our public health infrastructure in general, and public health surveillance in particular, we've made great strides, and you have heard some of those. Substantial congressional investments in preparedness funding have enabled States and local to expand our surveillance capacities. We must continue our efforts to integrate and coordinate public health surveillance systems. You've already heard that. While tremendous efforts are focused on developing high-tech surveillance systems, and technology is critically important, a computer without the right software and without a trained user is just |