In North America, agencies at the state, local and federal levels use a wide variety of systems of differing degrees of sophistication to track influenza and share basic data among public health officials. Some of these are homegrown; others are "syndromic surveillance" applications -- dedicated systems created by third parties that track epidemics and help trigger a response from relevant agencies. Even with the information that's collected currently, the systems are unable to automatically do the requisite analysis and make the necessary recommendations to mount the most effective and aggressive response to stop a pandemic, say health officials.
There are virtually endless ways to improve the existing surveillance systems, according to Lynette Brammer, epidemiologist for influenza at the Centers for Disease Control in Atlanta, which uses seven different applications to track flu outbreaks. "The majority of our systems have been running for years and years, and some of the technology is definitely not state of the art," she says. The applications primarily feature Microsoft SQL Server database technology on the back end and an Access database management system on the front. The CDC also employs a SAS Institute Inc. database with custom-written scripts to track flu appearances across 122 cities in the U.S.
The databases handle various activities, says Brammer. For instance, one checks to see if a given city is experiencing a spike in mortality rates. If so, staffers can determine whether there are corresponding jumps in outpatient visits or reports of virus outbreaks. The data could also be checked against another system, which would analyze it to determine whether a given vaccine was effective and why. The agency would be able to see where the outbreak occurred and send alerts to doctors so they could recognize patients who are at risk.
The process of gathering data, which is received by fax or via the Web, tends to be slow and labor-intensive, says Brammer. For instance, one of the ways the CDC gleans its information is from the U.S. Influenza Sentinel Provider Surveillance System. This Web-accessible tool takes feeds from 2,200 volunteer doctors who have collected information from patients exhibiting flulike symptoms. The CDC would like to streamline the collection process, Brammer says. Efforts to establish a way to access hospital data as well are ongoing. The agency also taps into the World Health Organization's FluNet system, a Web-accessible database that lets users query on influenza-related activity by country or region.
Tying together the various systems for rapid analysis could be difficult, because every flu outbreak has a different pattern, Brammer says. Symptoms may be consistent between outbreaks, but geographic patterns aren't, and the peak season is long and variable, running from December through March, she notes. Interpreting the data probably will require some sort of manual intervention.
At regional or municipal levels, there is a hodgepodge of new IT systems arrayed against the flu. New York City may have the most advanced syndromic surveillance system established to date. It was launched in its present form as a response to the 9/11 terrorist attacks, says Dr. Farzad Mostashari, assistant commissioner at the New York City Department of Health and Mental Hygiene. The unit that operates the system oversees a mix of off-the-shelf and custom-written applications that track a variety of statistics through the city, including the daily pharmacy sales, the number and type of ambulance dispatches, and emergency-room visits. The software includes a SQL Server database, a SAS data warehouse and other tools that enable the analysis and visualization of information.
Mostashari notes that these systems are still "in their infancy," best practices have yet to be determined, and there is no standardization around the software or data formatting. His system receives information mostly via secure FTP with ebXML tags and so far has worked very well. Mostashari believes that overall, the next step for public health IT is to get "closer to the bedside" by accessing electronic medical records right from a doctor's office.
Communications and other high-tech capabilities must also extend to first responders -- that is, the health care workers and emergency personnel who would be the first professionals to encounter avian flu face to face, he says.
International efforts
The U.S. isn't alone in tracking the flu virus: The Public Health Agency of Canada has established the Global Public Health Intelligence Network (GPHIN), which functions as a secure, Internet-based early-warning system, according to an agency spokeswoman. The Java-based software has a search engine that works around the clock to pick up news reports of any significance to public health. The data is automatically filtered for relevance, analyzed by GPHIN officials and made available via reports and other means to interested parties -- including WHO personnel.
But despite efforts like these, the most vulnerable countries of Asia have few if any reliable monitoring systems in place. These blind spots could hamper activities such as making sure enough vaccine is available where it's needed the most.
Given the sophistication of the tools available today, finding ways to comprehensively track a pandemic in North America would be fairly simple, says Michael Stoto, an analyst at the Rand Corp., a research group in Arlington, Va. However, the best way to use the data is another matter. Tracking an outbreak doesn't necessarily demonstrate how the virus is spreading, or over what geographic area. A fully enabled system would help assess and cross-reference each patient, track the length of time spent in the hospital or in quarantine, and give an end-to-end picture of the operations of the pandemic over wide regions.
"There are a whole host of things we could be doing to make our public systems more powerful and more efficient using health-care-based IT," says Mostashari.