Currently, public health officials, legislators and primary care providers are in hot debate concerning the U.S. readiness and ability to contend with a biological terrorist attack.

In recent testimony to the U.S. Senate Appropriations Subcommittee on Health concerning Bioterrorism, Jonathan Tucker, Ph.D., Director of Biologic Weapons Studies at the Monterey Institute of International Studies, revealed a serious gap between primary care providers and public health departments. Another testifier, Dr. Patricia Quinlisk, Medical Director/Epidemiologist of the Iowa Public Health Department, stated the national Biological and Chemical Terrorism Strategic Plan for Preparedness and Response identified five areas of focus-one was Detection and Surveillance. Dr. Jeffery Koplan, Director of the Centers for Disease Control and Prevention, in an address to Public Health Officials following the Sept. 11 tragedy, related seven priority areas of focus for state and local level departments-echoing that surveillance is critical to rapidly detect health threats. Most experts agree that the single biggest problem is the ability to rapidly identify whether or not an attack by some agent has indeed occurred.

The cornerstone of a strong bio-defense program includes a surveillance system that is effectively linked to our public health organizations. This system has to be one that can identify unexplained variation in disease patterns through surveillance and provide early warning of an outbreak.

Influenza is the recommended model because it is a real public health issue and one that has both rapid detection capabilities and a historical database. The first symptoms of an illness from many of the most probable agents that will be used by terrorists mimic those of influenza. The first indication of a biological agent release, therefore, will likely be a large number of people seeking medical attention for symptoms suggestive of influenza.

Surveillance that quickly detects variations of normal patterns of this symptomology is necessary to minimize the delay between agent release and the realization that a release has occurred. Each day that passes magnifies the effect of the agent upon an exposed population. Rapid diagnostic testing coupled with a real-time reporting system has the potential to:

• Alert physicians in offices, emergency rooms and clinics that "something else" is going on beyond the routine causes of the presenting symptoms. Ruling out influenza as a causative agent enhances the discovery of the true source of the symptoms, which could be a bioterrorist agent.
• Alert public health authorities of variations in normal influenza symptom patterns concomitant with a high number of negative tests for the influenza virus itself. This event would then trigger protocols for further diagnostic studies to quickly identify the causative agent.

One recommendation for a bioterrorism application of this established influenza reporting network would be to fully integrate it with the public health entities electronically and develop software to monitor incoming data that would identify variations in previously determined patterns of disease spread and incidence.

Currently, viral surveillance is conducted by the public health sector and its national presence, the Centers for Disease Control and Prevention (CDC), and involves a process of sentinel physician sites across the country that report "influenza-like illnesses" (ILI) to local and state public health agencies and the CDC. In addition, viral cultures are obtained, which grow for 3-21 days and are typed and sent to the CDC. This culture confirmation of influenza type and strain is used as the means of influenza viral specific surveillance. The objective is to track type and strain, prepare the coming years vaccine and monitor flu virus change for pandemic preparedness.

Around the nation programs are being proposed for future development of systems, testing and disease surveillance methods that may take many months or years to develop.

However, a nationwide real-time surveillance and notification system is currently in place that is linked to healthcare providers. It is not yet linked to alert public health and government officials nationwide. This disease surveillance network is the National Flu Surveillance Network™ (NFSN). Re-creation of a similar government network will be expensive and time-consuming but would not be necessary if the existing NFSN were used and the least expensive part of a system-the link to the government agencies-was developed.

The NFSN originated influenza disease surveillance and recruited physicians across the country in 1998. The NFSN currently has more than 1,000 sites and 6,300 physicians testing for influenza. These sites are located in physician offices, emergency rooms, urgent care centers, public clinics and nursing homes. New technology produced the tool that makes this surveillance possible, a 99-percent specific, rapid throat swab test, called ZstatFlu®. The sites report the flu test results daily, and these electronic results are posted on www.FluWatch.com. The website received over 11,000,000 page views during the last flu season. The NFSN does surveillance 12 months of the year. (This summer, 37 states reported influenza.)

Weekly educational information is communicated to each site. Each member has received an alert that the National Flu Surveillance Network could assist in countering a biological agent attack as well as information for review of possible biological agents and their symptoms. This information is also posted on the NFSN website, www.FluWatch.com.

Now is the time to investigate a public/private venture to quickly facilitate a coordinated and operational surveillance system to fulfill the surveillance component of the national counter-bioterrorism plan.