Effective information management is critical to track the spread of infectious disease, especially when saving time means saving lives. Quick response is the key to minimizing the impact of the next pandemic.
Paul Sockett remembers the construction of Canada’s "Sphinx." In its time, the Spatial Public Health Information Exchange (Sphinx) was an enormous, ambitious IT project aimed at public health surveillance. Its construction was as massive an undertaking as any of the ancient monuments in the Egyptian deserts.
The Sphinx was an attempt to give health care professionals a means to rapidly share public health data, as well as provide the tools to manage that information, explains Sockett, director of the Foodborne, Waterborne and Zoonotic Infections Division at Canada’s Centre for Infectious Disease Prevention and Control.
A decade later, the legacy of the Sphinx can be found coast to coast in a sophisticated network of common databases, analytical tools and surveillance software, many of which are global in scope and tightly integrated with advanced communications technologies.
Canada’s Public Health Agency (PHAC) has resuscitated the concepts behind its short-lived Sphinx project to develop the Canadian Network for Public Health Intelligence (CNPHI), which includes the Canadian Integrated Outbreak Surveillance Centre (CIOSC) and a response and resource management centre.
The Canadian government has also built a Web crawler and media monitoring application, dubbed the Global Public Health Intelligence Network (GPHIN), that’s fluent in eight languages and reports to both the Public Health Agency of Canada (PHAC), the World Health Organization, the Canadian Food Inspection Agency, the UN Food and Agriculture Organization and the Office of International Epizoonotics.
The WHO describes GPHIN as one of the most important ways of gathering informal information related to outbreaks. More than 60 per cent of the initial outbreak reports come from unofficial informal sources, it says, including sources other than the electronic media, which require verification.
“Right now, the whole basis of our pandemic response will undoubtedly rely on our capacity to exchange information rapidly and efficiently,” says Arlene King, director-general of PHAC’s Pandemic Preparedness Secretariat.
CNPHI and GPHIN are two cornerstones of Canada’s pandemic response, says King, designed to enhance the detection, collation, analysis and dissemination of information on infectious and contagious diseases.
“Our whole early-warning system is dependent on IT. Detection of events globally is dependent on our ability to get that information, put it into an electronic medium and then disseminate it.”
Global consciousness
When Margaret Chan of China took office as director-general of the WHO earlier this year, she set out six priorities. These included building the capacity of health systems and developing better information and knowledge.
She also warned that bird flu remains a global threat, after another outbreak of the disease hit Vietnam in December. In four years, avian influenza has claimed 163 lives: 62 in Indonesia, 42 in Vietnam, 17 in Thailand, 14 in China and 11 in Egypt.
The potential of a full-blown pandemic is real, although measured. Chan, who obtained her medical degree from the University of Western Ontario in London, admits there is no way to accurately predict when the next pandemic might strike.
“But the WHO has a responsibility to alert the international community when it appears the world is moving closer to a pandemic,” Chan says in an interview published on the WHO’s Web site.
“The preparations that we make for a pandemic are not disease-specific,” she adds. “They will increase our capacity to respond to all future outbreaks, including SARS (severe acute respiratory syndrome).”
SARS claimed 44 lives in Toronto and 251 worldwide, mainly in China and Hong Kong, in a matter of months during the spring of 2003.
The Naylor Commission’s investigation concluded among its findings that Canada was struggling to achieve the full potential of effective surveillance afforded by new technologies.
“The problems have been not only the cost of implementing these, but also the very slow progress in gaining consensus across jurisdictions on the architecture and standards,” reported the Commission headed by David Naylor, Dean of Medicine at the University of Toronto.
The Commission also urged greater capacity and closer interplay of provincial, territorial and federal responses to disease outbreaks, the interaction between outbreak management and broader emergency responses, as well as the design of information systems to cope with different sets of privacy legislation.
Since then, the federal government allocated $100 million in 2004 for Canada Health Infoway Inc. to invest in extending the pan-Canadian surveillance system to reach more regional and local health authorities, as well as another $15 million in 2005 to strengthen the public health systems in Southeast Asia and China.
Adding depth to pan-Canada
Canada’s provinces and territories need a better set of tools to manage and share information, says Tim Beasley, director of Infoway’s health surveillance program.
The new network is not only an outbreak management system, but is also used for the day-to-day case management of communicable diseases and immunization tracking.
CNPHI and GPHIN are good for Canada-wide alerting, says Beasley. One of the things the new system will give frontline health workers is their own alerting tools to issue local, regional or provincial alerts, and these can flow both up and down the communication pyramids, he explains.
“When we invest in a project with the Ministère de la Santé [et des Services sociaux, in Quebec], as an example, the implementation of the system means rolling it out to 18 different public health regions,” Beasley says.
“The implementation is largely a process of installing the software once, but it also entails a change management process; it means getting the system’s users trained and the data converted.”
The Internet makes this physically easier to do. “You don’t have to invest in private networks,” he says. “The architecture is such that typically there’ll be just one copy of the software that sits on a server in the provincial capital, but the people using it are all over the place.”
The British Columbia Ministry of Health is acting as the lead jurisdiction, working with IBM to build and integrate the various system components. Separately, Infoway is working with other provinces and territories on allocating funds, planning and implementation of the project.
All the systems are on track to be available by mid-2007, but the various jurisdictions are in different stages of planning, says Beasley, with Quebec most recently having been approved to go ahead with implementation.
From Sphinx to Phoenix
After funding dried up for the IBM Sphinx project, Canada’s health surveillance program in 2001 took the form of CEOSC, the Canadian Enteric Outbreak Surveillance Centre.
Provinces and territories used this Web-based application to report directly to Health Canada on outbreaks of food and water-borne disease, says Sockett. “It had nothing else around it.”
Today, the revised CIOSC continues to provide front-end public health workers the ability to provide rapid alerts on outbreaks in their jurisdictions, but PHAC has added alerting functions for respiratory and zoonotic diseases to cover things like avian flu, he adds.
Two-way communication means PHAC can both send and receive alerts to and from the provinces and regional jurisdictions and there's a built-in capacity to identify the level of urgency. Alerts can be sent from within the application not only by e-mail but also by telephone and pagers.
To enhance the Canadian Early Warning System (CEWS), PHAC hopes to collect data on over-the-counter sales of anti-diarrhoea drugs or cold relief drugs.
This information can be linked within CNPHI to analytical tools that create maps right down to the local level, says Sockett. A health unit can see by the colour on a map whether or not the pharmacies in their jurisdiction are reporting higher than normal dispensing of anti-flu drugs, for example.
“And by linking this information to things like emergency room visits and telephone calls to nurses — by putting two or three of these databases together into the same system, putting them on maps with graphs — we can give people a very rapid, eyeball indication that there’s a public health issue that needs to be addressed.”
In the case of a real threat, health workers can use the CNPHI management site to set up collaboration centres for sharing information and to schedule meetings.
“If there’s a salmonella outbreak, for example, we can do something called pulsed field gel electrophoresis — it’s like a DNA fingerprint of the bug — and we have a component that links into CNPHI and to colleagues in the United States.
“This allows us to post the DNA fingerprint and ask whether anyone is seeing this specific bug and if there are any clues on where it came from. We’re also able to link other information into the equation, like diagnostic technologies.”
Sockett says PHAC uses the system literally on a day-to-day basis, sending alerts that range from food poisoning to outbreaks of flu-like illnesses and zoonotic diseases like West Nile.
A more general alert system accommodates other disease entities, like sexually transmitted diseases, or even very specific non-disease categories. Sockett points to the case of a Toronto New Year’s Eve party that turned sour when family and friends drank punch from a container that had previously contained windscreen washer fluid.
Planning to test the plan
King says PHAC has yet to carry out a fully comprehensive pandemic exercise — one that would test every aspect of the national pandemic preparedness plan right from the local health authorities through to the national authority.
Such a large-scale undertaking would be costly and could paralyze the public health system for the duration of the exercise, notes King. She adds that with proper planning and time, disruption could be held to a minimum.
Some aspects of the plan are being tested as large table-top exercises. A national forum is co-hosted annually by the Centre for Emergency Preparedness and Response, and Public Safety and Emergency Preparedness Canada.
The idea is to evaluate Canada’s group response to an influenza pandemic, explains Frank Welsh, a director at PHAC’s Centre for Emergency Preparedness and Response.
The centre uses emergency management software called E Team to record and exchange information, from a company called NC4 Public Sector LLC (National Center for Crisis and Continuity Coordination) in Laguna Niguel, Calif.
PHAC is also developing and implementing a geospatial information system to map an event, track how it’s expanding from a geographical standpoint and perhaps better predict where to apply resources, says Welsh.
Some key questions to emerge in the exercise were how best to share information, how to effectively manage the flow of information, and were there new technologies out there, beyond the traditional teleconferences and e-mails, to share information more cleanly and quickly?
The Sphinx may have died a quick death, but the principle concepts were more than ideas blowing in the wind, as Socket says. Managing and sharing information in the most effective, rapid ways can help to prevent the next pandemic. At worst, it will leave us better prepared to deal with it.