A
Global Incident Analysis and Alerting System - the GIAAS
It is a given that accurate and timely
chemical, biological, radiological, terrorism and
outbreak information will save lives and avoid possible
escalation to armed conflict. But to ensure we have this
capability, we must continually use all sources in all
areas in all countries and on all continents.
The systems we rely on at this time are so fragmented and
disfunctional that they will cost many more lives than
they will save and in a worst case scenario, we could be
talking about millions of lives. And, unfortunately, this
point can not be disputed. How do we use and how do we
bring all sources together?
This subject was addressed in a Paper given by Richard
Price at the Third SISPAT in Singapore on 6 December. We
were surprised by the immediate response from many of our
fellow professionals in the SISPAT audience. Examples
include Prof. NÈstor Lagos of Santiago, Chile, who had
several excellent suggestions and who also said that he
would immediately take action on the paper's proposal as
soon as he returned to Chile; and he has now done so. Mr.
David Trudil, V.P. New Horizons Diagnostics, offered
several excellent ideas on launching the proposal with
members of Congress and other organizations. We will be
working closely with David. The Paper begins on page 3.
"Recent events have underlined the absolute
necessity for not only the earliest possible warning of a
putative bioterrorism (BT) attack, but also for rapid
communication and collaboration between those responsible
for mounting a response." John Woodall at CBMTS IV,
April 2002.
"The immediate investigation of outbreak sources
with precise identification of an infectious agent and
its individual genetic features requires modern,
well-equipped laboratories and highly qualified
personnel, which are not yet available in all
regions." Sergey Netesov, at CBMTS IV,
CBMTS-Industry I and II.
"In a heightened tension arena, consider the
multitude of questions that must be answered almost
immediately to help preclude miscalculations and avoid
possible escalation to armed conflict." Richard
Price opening comments CBMTS-Industry II "First
World Congress on Chemical and Biological Terrorism"
INTRODUCTION
Today our available systems for chemical, biological,
radiological (CBR) crisis management are convoluted and
fragmented. There is no single system to provide all
information needed to rapidly assess each situation and
help bring a CBR crisis under control. Where would one go
to determine needed actions to minimize effects of an
outbreak and to avoid miscalculations and an escalation
to armed conflict; to find and understand the region's
geopolitical situation; the suspected movement and
capabilities of known terrorist organizations and
individuals within the region; the intelligence and
interpol type organizations within the area; for
identification of best laboratories for specific reported
outbreak; whether or not the reported disease is endemic
to the area and for having a thorough knowledge of the
disease within a region; for available information on
designated quick reaction medical and operational teams
and agricultural specialists specific to each type of
crisis; for available pharmaceutical stockpiles across a
region and constraints to use of those stockpiles; for
airlift and air traffic control specialists; etc.? Today
- there is no single organization or geographical
location to answer all stated questions.
The outbreak of Rift Valley Fever (RVF) in Yemen and
Saudi Arabia is an example of a crisis management
situation caused by a natural medical disaster that could
have had serious international consequences. The WHO
provided a press release on 29 September 2000 saying they
and others were working the outbreak. This was 3.5 weeks
after ProMED Mail had reported the first information on
the outbreak. What the press release did not address were
the multitude of questions that, in a more heightened
tension arena, must be answered, immediately, to help
preclude miscalculations and avoid possible conflict.
These questions which were addressed by ASA to the CBMTS
family of professionals on 5 October 2000 included, in
part:
- Was RVF considered endemic to the area or have
there been outbreaks in the past? The answer: No.
This was first outbreak of RVF outside of Africa.
- Are morbidity and mortality characteristics
consistent with previous outbreaks? Typical
mortality rate for RVF is 1%, according to CDC.
Reports from Saudi Arabia and Yemen indicate
mortality rate of from 10% to 20% for this
outbreak. This would be a red flag for the Threat
Analysis / Assessment and Intelligence Analysis
groups - if they were available.
- Has RVF been considered a BW agent? Yes, it is on
the proposed BTWC lists.
- Have there been problems between the countries?
Yes, border and economic issues.
- Would either country have the internal capability
to develop, manufacture or acquire a sufficient
amount of RFV agent for dissemination across
border? Yes.
- Did either country acquire RFV cultures from
known BW agent culture dissemination sources,
such as American Type Culture Collection?
Unknown.
- Within the region, which countries may have
acquired RFV for experimental work and who may
have supplied RFV cultures to them? Suppliers -
many.
- Terrorism: what individuals, non-government
organizations, and state sponsored organizations,
known to have expertise in chemical and
biological terrorism (CBT), are known to have an
interest in or actually have operatives in the
region? Unfortunately, intelligence information
is not shared.
To help overcome these and other deficiencies, we propose
developing an independent system, the Global Incident
Analysis and Alerting System (GIAAS), to provide
immediate information and analysis as well as alerting
functions to those responsible for readiness and response
to major CBR incidents, whether these incidents are
natural or man-made.
PROPOSED GIAAS SYSTEM
We would use 12+ Incident Analysis and Alerting Centers
(IAACs), each responsible for a specific geographical
area and receiving/analyzing their area data from
Regional Alert and Information Centers (RAICs), located
within a specific region within a geographical area.
RAICs would receive data from the local Area Information
Centers (AICs), the focal points for individual reports
within a portion of a region. IAAC shift or duty teams
would be international and would include specialists
across the medical spectrum, pharmaceutical stockpile
programs, airlift/air traffic control, intelligence,
information, Interpol, plus others as identified.
Parallel to, but reporting through the IAACs are the
International Centers for Disease Research, Analysis and
Reporting (ICDRAR), an interconnected series of
internationally recognized Laboratories established to
provide a prime laboratory focal point for each specific
region. Each ICDRAR will also have a dual responsibility
for a specific portion of emerging and re-emerging
disease spectrum. Each ICDRAR accepts information flow of
significance to their laboratories' designated expertise
and/or area of responsibility. The ICDRARs rapidly digest
data and provide initial analysis to the GIAAS via their
IAAC. The initial analyses by the AICs, RAICs and IAAC
are enhanced with additional data requested by the
concerned ICDRAR. The network is shown in Figure 1.
Figure 1. The GIAAS and the reporting scheme.
The area IAAC is expected to know the available, required
pharmaceutical stockpile items plus other rapid response
supplies and equipments and designated response teams. An
example of a decision mechanism and communications at the
IAAC/ICDRAR levels would be that raw reports coming in
through the RAICs/AICs would be automatically filtered
against an A List of agents of concern, along with all
outbreaks of unidentified etiology. Duplicate reports
would be identified based on the identity of numbers of
cases/deaths and location, and removed. The resulting
product would then be sent to non-government infectious
disease or toxin specialists for evaluation. Thus, for
example, a report coming in containing the keyword
"anthrax" would immediately be routed to the
designated anthrax specialist on duty (of course, some
specialists could cover more than one disease agent or
toxin). In the case of a zoonosis, it would be necessary
to have the report seen by a public health veterinarian.
The on-duty team (shift) members would add their
preliminary evaluation to each report, at the same time
consulting by the fastest possible means with any other
specialist they consider might have useful advice. They
would also give a preliminary hazard rating, using a
system such as the RED-YELLOW-GREEN or the 1-3 or 1-5
star system, of the danger of the outbreak spreading.
This would be updated in the light of further incoming
reports. The actual evaluation of whether the outbreak is
likely due to bio- or agro-terrorism would be done by
another group who scans the evaluated reports, composed
of Interpol and intelligence community specialists.
An Example of an IAAC candidate: Singapore's DSO with its
excellent facilities, professional staff, and
communications hub, could function as the IAAC for South
East Pacific area with RAICs in Australia, Indonesia,
Malaysia and Thailand. ICDRARs could be located in China,
Australia and Japan. VECTOR in Novosibirsk might have an
ICDRAR and IAAC co-located. CDC in Atlanta might also
serve double functions. There are many possibilities.
An Example of an ICDRAR Laboratory candidate: VECTOR, the
State Research Center of Virology and Biotechnology,
Koltsovo, Novosibirsk Region, Russia which was
established in 1974 to conduct basic and applied research
on extremely pathogenic viral agents such as Marburg,
Ebola, Lassa and other viruses related to potential BW
agents and to evaluate the potential threat posed by
these agents. VECTOR is near the geographical center of
Russia and 900 km from Mongolia and China. VECTOR is well
suited for effective collection of viral/bacterial
strains and establishing, using specific diagnostic
procedures for study/analysis of specimens from Asian
Russia, Central Asia FSU republics, Mongolia, neighboring
countries.
VECTOR consists of six scientific research institutes
with 1200 of its professional staff either directly
involved in or in support of scientific research. This
staff includes specialists in genetic engineering,
molecular biology, epidemiology, immunology, virology,
theoretical virology, ecology with experience in highly
dangerous viruses research and production of
diagnostic/prophylactic preparations for public
health/veterinary requirements.
VECTOR's Collection of Cultures of Microorganisms
comprises over 10,000 deposit entries including various
viral strains (such as the national collection of variola
virus strains and strains of viral BSL-4 pathogens). This
Collection is affiliated with the European Culture
Collection Organization (ECCO). VECTOR is a WHO
Collaboration Center for orthopox- viruses diagnosis and
is a repository for variola virus strains and DNA. VECTOR
also has maximum biological containment laboratory
facilities available.
VECTOR's Disease Spectrum Responsibilities could include
but not be limited to: Arboviruses such as West Nile
virus and tick-borne encephalitis virus which is endemic
in Russia; the Crimean-Congo hemorrhagic fever virus; and
Omsk hemorrhagic fever virus which are endemic in Siberia
and/or in European Russia. Also Marburg and Ebola
filoviruses and Orthopoxviruses:smallpox virus,
monkeypox, cowpox and other poxviruses and bacteria and
parasites, as specified. GIAAS
COMMUNICATIONS: REPORTING AND ANALYSIS SYSTEMS
Basic to our premise of a fast, reliable, responsive
system is that no communication from any GIAAS level is
ignored and all communications flow uninterrupted. The
uninterrupted flow is considered 'raw data' until picked
up by an IAAC. Each reporting level within the GIAAS is
responsible for the rapid and best analysis possible with
the assumption that the local area has the best knowledge
of who the players are in the area; whether or not the
outbreak appears to be endemic to area; whether the
incident appears to be natural or man made, deliberate or
an accident.
We expect the GIAAS will need access to the following
restricted networks:
- the WHO Outbreak Verification List (OVL), which
collects reports from GPHIN (see below) and its
offices covering 192 countries worldwide.
Currently restricted to ministries of health, WHO
offices & Collaborating Centers;
- the Global Public Health Intelligence Network
(GPHIN), operated by Health Canada, which scans
current media outbreak reports on the Internet
several times a day. Restricted to Health Canada
and WHO/HQ, Geneva;
- the Global Emerging Infections System (GEIS),
operated by the US military;
- the Epi-X, operated by CDC. Restricted to state
and local public health epidemiologists and
laboratories in the USA. The GIAAS will also
subscribe to these public networks:
- ProMED-mail, the independent, free, network with
more than 27,000 subscribers in over 155
countries worldwide
- MITRE Text and Audio Processing (MiTAP, a
prototype system available for monitoring
infectious disease outbreaks and other global
events. MiTAP focuses on providing timely,
multi-lingual, global information access to
medical experts and individuals involved in
humanitarian assistance and relief work. MiTAP
currently [October 2002] stores over one million
articles and processes an additional 2,000 to
10,000 daily. This is a free internet-based
service to the public health community.
The GIAAS would also share databases with any future
BTWC, as well as the in-place OPCW group, and the WHO,
CDC and other organizations with similar missions.
An Example: ProMED as a Communications model has been
selected to be the model for the GIAAS' requirement for a
fast, reliable, responsive system. ProMED often reports
outbreak data well ahead of reports of outbreak by
official sources, WHO or CDC. Examples include plague in
India on 15 February 2002 followed by WHO on 1 March;
yellow fever in Bolivia on 23 March 2002 which had not
yet been officially notified to WHO by 31 June, and the
RVF outbreak in Saudi Arabia and Yemen which was reported
on by ProMED as early as 4 September 2000, well ahead of
others. ASA detailed this outbreak because of
bioterrorism implications and this outbreak specifically
provided the impetus to pursue this paper.
Other examples: October 2001, WHO published in its weekly
Epidemiological Record (WER) and its Outbreak News page
on the Internet, a report of the case on anthrax in a
Florida USA magazine photographer. This was first report
by WHO of anthrax in 2001. Yet at least 13 outbreaks of
anthrax in humans in 11 countries, including the USA,
were reported in the news media in the preceding 12
months. In the 12 month period ending 31 March 2002,
human cases of botulism (South Africa, UK, USA), cowpox
(Ukraine), monkeypox (Congo), plague (Brazil, Congo,
India, Kazakhstan, Mongolia, Uganda, USA) and tularemia
(Kosovo and USA) were reported in the media. Only the
outbreak of plague in India was reported by the WHO.
The World Animal Health Organization, OIE, reports
outbreaks in livestock. Reports on its List A diseases
are posted on its website when received. But anthrax is
an OIE B List disease, it is only reportable annually.
OIE does not cover cowpox, monkeypox, or plague.
There is no official world combined list of on-going
outbreaks of diseases in humans and animals caused by
agents and toxins which are also on the
bioterrorism/agroterrorism list. However, there is an
unofficial one, which also reports infectious diseases of
crop plants, thus covering all of the bases. ProMED
posted ALL of the disease outbreaks mentioned above in
its daily e-mailings to its over 27,000 subscribers.
Their cross-agency, interstate, international membership
is unique and not matched by any official system.
Very importantly, ProMED maintains over 20,000 archived
reports and comments which can be searched by keyword.
For example, anyone hearing of a case of anthrax in
Kazakhstan can immediately access the ProMED data base to
verify that anthrax has frequently been reported there,
is endemic, and occurs at predictable times of year.
ProMED also has a roster of moderators that include
infectious disease specialists, virologists,
bacteriologists, parasitologists, epidemiologists,
veterinarians and plant pathologists. All reports are
screened by the moderators before posting. When in doubt
the moderators try to obtain further information from the
source or country concerned. If this is not possible,
ProMED will post the current report while requesting
additional information.
THREE PHASE APPROACH FOR GIAAS
DEVELOPMENT/IMPLEMENTATION
All phases of development of GIAAS will be based on a
thorough knowledge of the existing experience of
different countries with their informational/analytical
networks for disease reporting.
Phase I GIAAS: Proof of Concept. For each
geographical area an IAAC will be identified. Initially,
if a specific identified geographical location can not be
established in a timely manner, an internet nodal point
will be constructed to serve as an interim IAAC for the
area. The IAAC for each area will assist the GIAAS in
identifying and securing agreements with a representative
number of RAICs and AICs within each region. We recognize
that the Centers will initially be part of worldwide
network on a voluntary basis to establish Proof of
Concept while providing a much needed capability;
however, these Centers must eventually be established via
intergovernmental agreement and funding (not later than
Phase III). For Proof of Concept the GIAAS in
coordination with all GIAAS entities, will develop and
test specific scenarios in command post type exercises
(CPXs). From these numerous tests of the system the GIAAS
will develop uniform reporting, requests, analysis, and
decision making procedures.
Phase II GIAAS: Interim Implementation and partial
funding. The GIAAS will Incorporate agreed upon
changes as a result of observations and recommendations
from the CPX's. During Phase II, the IAAC/RAIC/IAC layout
will be finalized and the system will be thoroughly
tested from the individual reporter to the AIC and
through the RAIC to the IAAC. Additional and current
communication and reporting systems, i.e., disease
reporting, crisis management, communications into and out
of the GIAAS will be incorporated. During this phase the
GIAAS will be continually updated based on knowledge
gained via CPXs and recommendations from the field. The
GIAAS system will be implement at least to the
communication nodal points in each area, and organized
per the ProMed model until funding is achieved. In
preparing for Phase III GIAAS full implementation the
GIAAS will document and package GIAAS requirements and
proof of concept along with system testing results.
During this phase, a cadre of professionals will be
identified to work in the system to gather, analyze and
disseminate information on a rapid basis. Initially this
may be done via internet only and from Labs and other
Centers who volunteer their resources until funding
sources are identified.
Phase III GIAAS: System Implementation and full
funding. The GIAAS will be prepared to present
documentation and proof of concept to the United Nations
with simultaneous transmissions to concerned government
entities such as public health authorities, organizations
such as CDC, and independent agencies such as Interpol,
ICAO, WHO, OIE, FAO, etc. A worldwide symposium will be
called to finalize details of the GIAAS system and to
request support both for funding and for professionals
who would assist with the GIAAS operations both
administratively and in the 7/24 operations of the
system. The GIAAS will continue to develop and train a
cadre of professionals (volunteers) who would work and
test the system continuously. At an agreed time, the
system becomes operational. Plans for the system will
include operations both with and without official support
and funding.
CONCLUSION
We have presented a three phase approach to building and
operating a global network to quickly and reliably
assess, outbreaks and epidemics. These assessments will
include political realities and evaluations of natural
and man-made outbreaks as well as other natural and
man-made disasters across the CBR spectrum.
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