From the window of his office’s 19th-floor conference room in downtown Honolulu, Dr. Paul Effler, epidemiologist for Hawaii, can see what he considers a logical entry point for pandemic flu into the United States: the runways at Honolulu International Airport, touchdown point for the planes carrying the majority of the state’s 2 million Asian visitors a year.

That huge pool of visitors outnumbers the state’s population of 1.2 million and puts Hawaii at ground zero of any coming pandemic, Effler said. Hawaii Gov. Linda Lingle shares that concern. She announced plans late last year to ask the state legislature to add $15 million to the Department of Health’s budget so the state can prepare to battle a pandemic flu outbreak.

“We’re a small swimming pool with a huge flush rate,” Effler said, referring to the state’s large number of visitors from Asia, where the H5N1 variant of avian flu has jumped from birds to humans in a limited but growing number of cases.

Effler wants to use $1 million of the extra funding to develop a statewide system to correlate a range of information, starting with increased flu surveillance that could yield insights into the onset of a pandemic.

But managing a flu outbreak requires more than disease surveillance, public health officials say. To assess the effectiveness of various treatments, they need input from clinics to track vaccination doses by lot numbers, patients’ ages, general health and pre-existing conditions. Antiviral medications must be tracked in similar ways. And public health officials must correlate that data with new surveillance information from schools, hospitals, pharmacies and community centers.

Effler believes that such data correlation is the key to managing a pandemic. To that end, Hawaii is partnering with the U.S. Pacific Command and other military installations on the islands to develop the state’s pandemic database. Because military personnel and their family members make up about 11 percent of the state’s population, health officials have deemed the collaboration essential to protecting the fleet as well as the state.

“Without data, we cannot track who has been sick and who has been exposed, who needs a vaccine and how do you allocate such a scarce resource,” said Col. Mike Bromage, chief preventive medical officer at Tripler Army Medical Center and public health emergency officer for the Joint Task Force for Homeland Defense for Hawaii and U.S. territories and protectorates in the Pacific.

States of play
Like Hawaii, state and local governments nationwide are wrestling with the best way to integrate disease surveillance and treatment-tracking systems to fight a potential pandemic. Their approaches reflect local conditions and resources.

Mike Williams, director of communicable disease control and emergency preparedness at the St. Louis County, Mo., Department of Health, believes in the value of real-time data but collects his information the old-fashioned way. Since 2001 his department has been calling the emergency department of every hospital in the county every day to find out how many patients they saw and the nature of their symptoms.

The Department of Health is also building a disease surveillance system for schools to gather information on student absences and their causes as an early warning system for flu and other diseases, Williams said.

Indiana has a massive project under way to connect all of the state’s 114 hospitals to a disease surveillance system, said Dr. Shaun Grannis, a research scientist at the Regenstrief Institute in Indianapolis. The system already includes more than 40 hospitals, Grannis said.

New York City has an automated syndrome surveillance system that gathers prediagnostic data daily from 48 emergency rooms in the city, while North Carolina started an automated, statewide disease surveillance system last September.

And in Lubbock, Texas, health officials are working on information technology systems that could help ward off a potential influx of flu strains carried by from Texas Tech University students who beat a path to Asia and back each year.

The heat is on
Despite those efforts, public health officials say more work remains to develop state and local systems that track diseases and the distribution of vaccines and antiviral medications. The federal government in particular must forge better working relationships with state and local health planning officials, they say. In the past three months, the federal government’s role in pandemic planning has been the subject of fierce criticism.

C. Mack Sewell, epidemiologist for New Mexico and president of the Council of State and Territorial Epidemiologists, said that since the 2001 anthrax attacks in Washington, D.C., and Florida, the federal government has focused too much on bioterrorism at the expense of routine disease surveillance. The effects of a pandemic flu outbreak in the United States “would dwarf any bioterrorist attack in scope,” Sewell said. Now, however, the federal government is inundating states with unfunded data-collection requests on the distribution and use of vaccines and antiviral medications.

The Trust for America’s Health, a Washington, D.C.-based organization, said that as of December 2005, only 27 states had a disease-tracking system in place to collect and monitor data electronically. In its 2005 “Ready or Not?” report on protecting public health, the trust gave the federal government a score of C-minus on the development of biosurveillance systems.

Meanwhile, in a December 2005 report, the Congressional Budget Office said that although billions of dollars have been spent preparing for health crises that could result from terrorist attacks, those programs would have limited benefits in the event of a flu pandemic.

And in a report released last November, the Congressional Research Service said the Centers for Disease Control and Prevention had only limited disease surveillance and detection capabilities. CDC faced “key challenges in the detection of novel flu viruses,” such as “the vagueness of flu symptoms, which can be seen with many other diseases, and the difficulty in distinguishing specific strains of interest from the background of other flu strains commonly in circulation,” the report states.

Leavitt: Hours, not weeks
The government might be slow in developing a pandemic plan, but few debate the size of the federal task in coordinating a national pandemic defense. As a year filled with natural disasters ended, the crisis rose to the top of the Bush administration’s health policy agenda.

Last November, Department of Health and Human Services Secretary Mike Leavitt made pandemic disease surveillance his top priority at the first meeting of the American Health Information Community, a federal advisory board convened to help spearhead development of electronic health records. Leavitt called biosurveillance one of the group’s first breakthrough projects and urged the building of systems with “the capacity to accelerate dramatically the reporting of public health incidents related to bioterrorism, pandemic flu or other public health threats.”

He added that threats should be identified not in a matter of weeks or days, but between two to three hours.

CDC is working to meet this challenge with a set of programs and projects that together form the Public Health Information Network (PHIN). CDC’s BioSense disease surveillance system will act as a starting point to meet Leavitt’s goal for identifying pandemic threats, said Laura Conn, acting director of the agency’s newly established Public Health Informatics branch.

BioSense pulls real-time disease diagnosis data from emergency rooms into a central CDC repository using secure Internet connections. By the end of this year, CDC officials hope to link emergency rooms in 30 cities to the system, said Dr. Blake Caldwell, co-director of CDC’s Coordinating Center for Health Information and Services. The data will include information on medical complaints, such as fevers or respiratory infections, that could indicate an avian flu outbreak.

The system will send the information to a CDC data center where detection algorithms will pinpoint disease clusters or outbreaks. The information will also be correlated with data from automatic biosurveillance detectors operated by the Homeland Security Department through its BioWatch program. That information in turn will be added to data that BioSense already collects from hospitals run by the Department of Veterans Affairs and the Pentagon. CDC will share the final information with state and local health departments, Conn said.

Glass half full
The National Electronic Disease Surveillance System (NEDSS) is a major PHIN component designed to help states collect, process and transmit surveillance data to CDC. Currently, 11 states have installed the NEDSS base system, Conn said, and a total of eight more should be using NEDSS by March. Sewell said New Mexico is in the process of installing NEDSS, adding that the system should give the state a framework for disease surveillance complemented by an electronic lab reporting system New Mexico plans to use.

Another new PHIN program, the Countermeasure and Response Administration (CRA), will track vaccine distribution and people quarantined during a pandemic.

Marty Cicchinelli, acting director of the Division of Alliance Management and Consultation at CDC’s Public Health Informatics, said quarantine and vaccine-tracking information will be separate modules of CRA, a secure system based on Extensible Markup Language that she described as relatively easy to use. Cicchinelli said CDC will activate the data-collection module for pandemic influenza by the end of March.

In a pandemic, CRA’s vaccine-tracking module could be required to handle a potentially large amount of data resulting from the need for mass inoculations — as many as 180 million records, Cicchinelli said. But to better manage this data flow, CDC is considering collecting aggregate records by the age groups of vaccine recipients.

For quarantine information, CDC plans to use CRA to collect information on the type of restriction, the event that triggered the quarantine or isolation, and ongoing patient-monitoring efforts.

CRA will assign a unique identifier to each isolated or quarantined person. Required data includes the patient’s name, date and time of monitoring, name of the health professional doing the monitoring, type of patient encounter (in person or by telephone), and whether or not the patient is complying with the order.

CDC will run CRA on midtier servers and will evaluate the need for additional server capacity once CRA starts to take in large amounts of data.

CDC also wants to use nationwide immunization registries to help gather data on vaccine use and distribution. However, the usefulness of such databases might be limited because some registries track only immunizations for children, not adults. Consequently, CDC is surveying all of the registries to determine what kind of information they can supply CRA.

Conn said PHIN and its various programs are a visionary framework for transforming public health information. CDC would like to see BioSense used in hundreds of major cities, she said, “but we’re not there yet.” Some people might look at the status of PHIN “as a glass half empty. We look at it as a glass half full.”