5

Future Opportunities for State and Local Collaboration

The objective of the workshop’s third and final panel session, moderated again by Terry Mullins, was to explore opportunities to expand BioWatch collaboration efforts, strengthen collaborations with existing partners, and develop new collaborations to meet interagency objectives. The panelists were Mark Buttner, Kathy Forzley, Julia Gunn, Roger Pollok, Al Romanosky, Wendy Smith, and Sandy Wedgeworth.

In Georgia, said Wendy Smith, the state health department has deemed preparedness and homeland security as a high-priority issue, which means her agency is always open to partnering with other agencies on special projects. For example, over the past 5 years or so, the department of public health has worked collaboratively with the state’s civil support team on different complex laboratory exercises, including one that started with a simulated BioWatch Actionable Result (BAR). “I personally would love to see the federal agencies that are responsible for leading these kinds of initiatives collaborate a little more,” said Smith. In particular, she would like to see biosurveillance data shared at an aggregate level for situational awareness in the case of a BAR. As an example, she explained that BioSense, the Centers for Disease Control and Prevention’s (CDC’s) National Syndromic

Surveillance Program, could provide a bigger picture of what is happening in neighboring states and across the rest of the country.

Al Romanosky said there is a great disparity in how the 250-plus agencies within the National Capital Region are prepared to collaborate with state and local public health departments. He hopes that the Department of Homeland Security (DHS) can help bring a broader set of partners into the region’s response paradigm. In particular, he would like to know which other agencies have biological monitoring capabilities so that he could incorporate their data with his to create a better overall picture of the entire region. He suspects, for example, that the Secret Service and the U.S. Navy have their own monitoring capabilities, and he knows the Pentagon does because he already collaborates with the Pentagon’s program. Romanosky noted that when the region was preparing for one of President Obama’s inaugurations, the Secret Service approached Romanosky and demanded that if there was a BAR during the inauguration that he wait 1 hour before notifying anyone else at the state and local levels. What Romanosky would like is to meet with someone from the Secret Service and start building a relationship so that each party understands the paradigm by which his program will manage notifications.

Lisa Gordon-Hagerty added that Romanosky is not alone in encountering hurdles working with the Secret Service, as they have field offices around the country. She said she would advocate for everyone to reach out to the local Secret Service office and local postal facilities. She recounted how during the 2001 anthrax attacks, the head of the Central Intelligence Agency was sitting next to the Postmaster General at one meeting, something she never thought she would ever see given the perceived gap between their respective work. She argued that some federal organization, perhaps the DHS Office of Health Affairs (OHA), should have the responsibility to facilitate and coordinate these relationships among federal agencies and state and local authorities.

Romanosky also said that when there was a potential incident at the U.S. Senate mail-handling facilities, he had to be invited into that federal enclave to see how that facility handles an alert. He also pointed out that the contractor that runs the DHS mail facility has been a good partner, and lessons learned have been exchanged between the contractor and his program. He considers that facility’s response plan to be the gold standard and he does not see that consistency for indoor deployments at other mail-handling facilities in the national capital region. He would like to see DHS develop a response template for mail-handling facilities so that he can know from a state perspective what to expect at these different departmental mail-handling facilities.

Mark Buttner said he would add collaborations with other weapons of mass destruction countermeasure groups to Romanosky’s list because he

believes those collaborations would strengthen BioWatch. He also noted that because BioWatch is an operational unit and not one that conducts research, he would like to see some collaborations with academia to answer questions that require further research. Terry Mullins then asked Buttner how, as a local BioWatch coordinator, he would respond to a request for data from a legitimate academic researcher. While Buttner said he had never considered that question, his knee-jerk response would be to contact the national program office and the local jurisdictional coordinator.

Pollok said he would stop short of providing any data and might even reply to such a request by saying, “What is BioWatch?” In San Antonio, BioWatch’s existence is a closely held secret among the members of the BioWatch advisory committee, city council members, county commissioners, and county judges. “Outside of that, nobody knows so we would not even risk putting that information out,” said Pollok. Romanosky had an infectious disease expert at an academic institution ask him for data during a BAR for Francisella tularensis. Given what was known and unknown at the time, he declined that request and the researcher accepted that decision. In Julia Gunn’s opinion, DHS will need to develop a mechanism to release different kinds of information if the program is going to evolve and grow. Dave Fluty said it is common practice in law enforcement circles to treat any data from a collector as sensitive information, but that after-action reports could be valuable and released to the academic community. Daren Brabham suggested that it might be useful to reach out to the social science research community to monitor the communication process and understand how programs maintain their knowledge base, among other issues. “You might not have to release sensitive information at all,” he said.

Kathy Forzley suggested that one place for improvement in her region would be to take advantage of local laboratory capabilities rather than having to drive every sample to the state laboratory, which in her case adds at least 90 minutes of driving time to the process of determining if a release has occurred. Gordon-Hagerty suggested that Forzley ask OHA to reach out to the state to explain why the BioWatch laboratory should be closer to the state program offices. Forzley also suggested that DHS should consider that local public health agencies have tremendous capacity beyond traditional disease surveillance and could provide intelligence in real time that could overcome some of the data lags associated with normal surveillance. She, too, noted the lack of collaboration and cooperation her program receives from the postal service. “We never hear from the postal service until it is time that they are required to do an exercise,” said Forzley. Even then, she added, the postal service is not interested in any input she might have. Roger Pollok said he has had the same type of experiences as Forzley has had with the post office.

Other than the post office, Forzley believes she has all of the major

federal agencies at the table when planning an exercise, and she even offers training every 2 years on how to dispense medical countermeasures to their patients. She suggested that a conference with federal partners and local BioWatch officials could be fruitful for laying out the responsibilities that each partner would have in the event of a BAR.

Julia Gunn said she was unclear how federal health information privacy rules apply to BioWatch communications. “What are the standards?” she asked, using as an example a case where someone in the field wants to send her a picture of a lesion on someone’s body. “How should that be sent?” Gunn asked. Mullins responded that the assistant secretary for preparedness and response recently issued guidance to clarify how to communicate public health information among various providers involved in a patient care event.

Yes, said Romanosky, and he pointed to a link that now exists between the federal emergency planning grant program and the hospital preparedness grant program as a valuable example. Sandy Wedgeworth said her program benefits from a 3 percent public health–related carve-out from Long Beach’s Urban Area Security Initiative grant because prior to establishing that carve-out, the police and fire departments would outvote public health, and her program would be lucky to get any funds from that grant. She pointed out, though, that this carve-out is not universal and suggested that a top-level mandate to set aside funds from grant programs such as this for public health would benefit BioWatch nationwide. Roger Pollok said that San Antonio has been cut off from Urban Area Security Initiative funds even though it is the seventh most populous city in the United States.

Romanosky said getting the veterinary community involved is important, particularly for companion animal surveillance, but doing so is challenging because it is a diffuse industry, unlike the networked and integrated system of human hospitals, clinics, and health care systems. Getting the veterinary community involved would require a labor-intensive outreach effort or perhaps a central reporting dashboard where a veterinarian could enter data on the incidence of specific illnesses. What would still be missing, he noted, are response curves for each agent and each animal species.

“We may not have enough information that would allow us to interpret animal surveillance data given the varying sensitivities to different biological agents,” said Romanosky.

Smith said her office partnered with the U.S. Department of Agriculture (USDA) and the Georgia Veterinary Medical Association to reach out to veterinarians. This project, she said, provided valuable lessons on how to reach out to veterinarians, what to tell them, and what information to request from them. The main challenge she identified is that, in Georgia, veterinarians do not conduct routine laboratory testing for the agents that concern BioWatch. “So that’s a real gap in our ability to discern what’s happening in the animal population in my opinion,” said Smith. She wondered if there might be federal funding available to do that kind of testing and noted that there would need to be a protocol in place for where to send a dead rat, for example, found near one of the collectors. Also needed, she said, would be a mechanism to collect and analyze data from the veterinary community. In Georgia, for example, veterinarians report syndromes to the state veterinarian’s office, which has two employees. “During a post-BAR situation, we would need to have some enhanced capability to do the analysis,” said Smith. She suggested that a surge team might provide that kind of capability. Another issue she raised was how to share information securely with this community.

Gunn said that she is less concerned with dogs and cats and more concerned with rats and mice, which would not be part of veterinary syndromic surveillance. An important relationship to build, then, would be with whatever department is responsible for rodent control. She also suggested that the BioWatch community might want to reach out to the USDA’s Animal and Plant Health Inspection Service (APHIS) Center for Epidemiology and Animal Health. The center, located in Colorado, involves veterinarian epidemiologists who are developing a surveillance system. Forzley pointed out that veterinarians are used to working with one animal at a time and that there is no public health–type perspective in that profession. “That is why I think the BioWatch veterinary group could help with this conversation,” said Forzley.

In Texas, said Pollok, every region in the state has a regional veterinarian, and in San Antonio the regional veterinarian is a member of the BioWatch advisory committee. That individual reaches out to the Texas Animal Health Commission and Texas Parks and Wildlife for information, and he has also identified several “sentinel veterinary clinics” that report to him. He noted that in San Antonio the relevant agency for companion animals is the Animal Care Department, which is alert to cases of rabies and could be a useful partner. Wedgeworth said the Long Beach Animal Care Services department works closely with BioWatch and provides regular updates on anything having to do with rodents and bats in the city. She said

that although that department does not have a member on the BioWatch advisory committee, she is going to reach out to that department to become involved given what she has heard at this workshop.

Wedgeworth said she wants to increase coverage in Long Beach from two collectors and to move one of the two current collectors to a new location. “Ideally, I would like DHS to have more funding to be able to provide more coverage for cities such as mine, and then also, a little bit of flexibility with us locally being able to determine where the best placement for the collectors should be,” said Wedgeworth.

Romanosky said he would like to have a public information guide that he could provide to his public information officers that would inform them about the program and give them advice on how to answer certain questions or who to approach to get answers to questions. He would also like DHS to provide some ideas on decision-making triggers for developing a scalable or flexible public health response to a BAR. “If anthrax is found tomorrow, we pull the trigger, but if it is non-viable, we are going to get criticized,” said Romanosky, adding, “but if we do not act, we are going to get criticized. I see that as a particular issue and I do not think that the subject matter expertise or academic research is out there to make that decision.” Pollok said the city of Austin’s BioWatch program has developed a decision-making tool based on an analysis of some 20 collector data points. Once this tool has been tested, he would share it with all of the BioWatch programs.

Another need Romanosky identified was how to put together a national response. For example, what would the national response be if anthrax was released in the Washington, DC, Metrorail system given that many of the people who ride the subway are not from the Washington, DC, metropolitan area? Because most people buy their tickets using a credit card, it should be possible to track down the tourists who may have been exposed, but the issue will be whether the Washington Metropolitan Area Transit Authority would provide BioWatch with the data. “How would we address that paradigm of a national response?” asked Romanosky. His final suggestion was to co-locate biological, chemical, and radiation collectors because if one collector detects something, the others should increase the airflow through the collection system.

Forzley suggested creating an inventory of all of the best practices that the local BioWatch programs have developed. “We have all worked hard responding to different issues in our communities and have learned a lot

along the way,” said Forzley, and she wondered if regular national calls for the advisory committee chairs might help those lessons spread through the BioWatch community. She said she is interested in understanding how different BioWatch advisory committees work and how they plan their training exercises. Both she and Romanosky suggested holding an annual national meeting where discussions could be held in person and benefit the community as a whole.

Gunn said that as BioWatch moves into indoor settings, it will need a different type of communication strategy. Her worry is that in today’s social media environment, something like the Government Accountability Office report and the negative message it conveyed about BioWatch not working could spread rapidly and make it difficult to reassure people that a situation was not dangerous. Romanosky added that BioWatch needs to do more to counter the negative impressions about the program that have been conveyed in the media. Jonathan Greene responded that DHS has “learned not to try to engage in fights with people who buy ink by the barrel. Choosing the venue and the avenue and choosing not to respond directly is usually the wisest course, but we always consider all of our options when confronted with situations like that.” Romanosky countered that “if you do not tell the story, somebody will make it up and I think that is largely what we have over the last several years.” He suggested focusing on telling the story of how and why BioWatch works, and of the terrific collaborative environment the program has created.

This page intentionally left blank.