Medical Intelligence

Acknowledgment

The author wishes to acknowledge guidance provided by Mark Keim, MD, MBA. Dr. Keim’s assistance proved invaluable for the author’s development of this chapter.

Background

Medical intelligence can be defined as follows:

[. . .]that category of intelligence resulting from collection, evaluation, analysis, and interpretation of foreign medical, bio-scientific, and environmental information which is of interest to strategic planning and to military medical planning and operations for the conservation of the fighting strength of friendly forces and the formation of assessments of foreign medical capabilities in both military and civilian sectors. Also called MEDINT.

Medical intelligence related specifically to the threat of public health emergencies, including terrorism, has obvious applicability to civilian sectors as well. It involves information applied to the identification, characterization, and management of a risk, as applied to both medical and nonmedical countermeasures.

The collection of medical intelligence may include both classified and open sources. Evaluation may involve preexisting publications or ongoing public health surveillance and may also include analysis and/or interpretation of well-established or newly gained data. Characterizations may include situational awareness of current events, as well as descriptions of both foreign and domestic medical and public health capabilities and capacity.

Historical perspective

The Importance of Medical Intelligence

The greatest threat to military forces is often not enemy weapons, but rather the type of casualty referred to as a “disease and nonbattle injury.” The statistics regarding the impact of disease on military operations are remarkable. During the Civil War, there were an estimated 414,152 deaths due to disease, outranking battle deaths by a ratio of over 2:1.

The following statistics reveal that the threat of disease during military operations had not ceased by the twentieth century.

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Influenza killed 43,000 U.S. military personnel in World War I. In the U.S. Army, influenza accounted for 80% of all casualties during the war.
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Of the U.S. marines deployed to Lebanon in 1958, 50% were incapacitated with severe diarrhea.
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Of the U.S. sailors deployed to the Suez in 1975, 80% were stricken with dysentery.
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Of the U.S. soldiers deployed to the Sinai in 1982, 30% became dehydration casualties.

Llewellyn Legters and Craig Llewellyn of the Uniformed Services University of the Health Sciences (USUHS) highlighted the four main objectives of a successful preventive medicine program :

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To determine the nature and magnitude of the disease and injury threats in the planned area of operations before deployment.
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To identify the principal countermeasures that must be emphasized to reduce the threats to acceptable levels.
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To train individuals in the use of these countermeasures.
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To enforce rigorously these countermeasures in the operational area.
These measures correspond nicely with processes of analytical risk management: including risk assessment, countermeasure determination, risk communication, and countermeasure implementation.

Current practice

Civilian Medical Intelligence

The cause of a disease or even the occurrence of something unusual may be very difficult to determine, especially if the initial cases are few. However, surveillance needs to be more than routine because even relatively small and well-documented outbreaks of disease have the potential to go unrecognized as a bioterrorist attack. This initial investigation does not always have to be time consuming or involve law enforcement. Investigating the facts surrounding the outbreak to determine if anything seems unusual or indicative of bioterrorism will suffice in most cases. Infectious disease criteria for differentiation of bioterrorism from natural outbreaks have been well defined in the literature. The most important factors affecting early detection of a bioterrorist event are likely to be the rate of accrual of new cases at the outset of the epidemic, geographic clustering, the selection of syndromic surveillance methods, and the likelihood of making a diagnosis quickly in clinical practice.

National, regional, and local public health departments must be linked in a network of real-time communication with the medical response community, public safety, regional poison control centers, and regional laboratory capacities for integration of information management, passive and active surveillance systems, and epidemiological investigation. In 1998, Keim, Kauffman, and Rodgers were the first to propose the development of such a comprehensive system as part of the U.S. Public Health Service. Over the past decade, a “fusion center” process has been widely implemented in the United States as a method of managing the flow of information and intelligence across levels and sectors of government for integration of intelligence and knowledge management. Moreover, there has been a growing trend toward integration of medical intelligence into multisectoral systems for knowledge management.

Sources of Medical Intelligence

The primary source of civilian medical intelligence in the United States is the Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and Disease Registry (ATSDR). Table 91-1 represents a comprehensive listing of traditional sources of civilian medical intelligence available in the United States.

Table 91-1

Sources of Medical Intelligence

Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) Resources
Public Health Information Network (PHIN)	The PHIN is a national initiative to increase the capacity of public health agencies to exchange data and information electronically across organizations and jurisdictions (e.g., clinical care to public health, public health to public health, and public health to other federal agencies). It is intended to harmonize the National Notifiable Diseases Surveillance System (NNDSS), and the Public Health Emergency Preparedness (PHEP) Cooperative Agreement for case notifications, as well as the CDC Health Alert Network (HAN).
NNDSS	The NNDSS is a public health surveillance system for infectious conditions operated in all 50 states, New York City, the District of Columbia, and five U.S. territories by the CDC in collaboration with the Council of State and Territorial Epidemiologists (CSTE). It serves as a core, routine surveillance activity that utilizes PHIN standards for electronic transmission of case notification data from reporting jurisdictions to the CDC.
PHEP cooperative agreement	The PHEP provides funding to build and upgrade the preparedness infrastructure of public health departments to improve their ability to respond to the public health emergencies and it supports core surveillance capabilities.
CDC Epidemic Information Exchange (EPI-X)	Epi-X is a secure web-based communications network for public health professionals: CDC officials, state and local health departments, poison control centers, and other public health professionals can access and share preliminary health surveillance information quickly and securely, 24 h, 7 days/wk (24 × 7). Users can also be actively notified of breaking health events as they occur. Key features of Epi-X include unparalleled scientific and editorial support, controlled user access, digital credentials and authentication, rapid outbreak reporting, and peer-to-peer consultation.
CDC PulseNet	The CDC PulseNet is a U.S. national laboratory network made up of 87 laboratories—at least one in each state. It connects food-borne illness cases together to detect and define outbreaks. PulseNet tracks what is being reported to the CDC on any given day and compares it to what was reported in the past to look for changes through use of its cumulative database representing nearly half a million isolates of bacteria from food, the environment, and human food-borne illness. PulseNet International now spans more than 80 countries, to establish similar networks in Canada, Europe, Latin America, the Caribbean, Asia Pacific, the Middle East, and Africa. These networks collaborate with one another and with PulseNet USA.
BioWatch	BioWatch is a Department of Homeland Security program intended to perform 24 × 7 environmental surveillance using existing Environmental Protection Agency and Department of Energy (DOE) air quality monitoring systems. Air samples will be tested in cities for the presence of biological pathogens to generate early warnings of possible attacks. The CDC Laboratory Response Network (LRN) labs test filters from these samplers.
CDC Laboratory Response Network (LRN)	The LRN is a consortium of more than 150 laboratories comprised primarily of state, local, and federal public health laboratories, each with different capabilities and levels of expertise. As a network, they provide immediate and sustained laboratory testing and communication in the event of public health emergencies, particularly in response to acts of terrorism. Members belong to different agencies and jurisdictions but are unified by a common system of operations.
CDC Health Alert Network (HAN)	The HAN is a public health alerting system that serves as the primary way of getting validated information to federal, state, territorial, and local public health practitioners; clinicians; public information officers; and public health laboratories about urgent public health incidents that are occurring or have occurred. PHIN Communication and Alerting (PCA) describes the capabilities needed by the CDC and state and local health departments to issue alerts and emergency communications to their own staffs, to other organizations, to people within their jurisdictions that are critical to emergency response, and to other affected public health jurisdictions.
ATSDR National Toxic Substance Incidents Program (NTSIP)	The NTSIP is system for collecting and combining information from many resources to protect people from harm caused by spills and leaks of toxic substances. The NTSIP has three components: National Database, State Partners, and Incident Investigation.
CDC Emergency Communications System (ECS)	The ECS ensures rapid, effective, and consistent CDC/ATSDR communication response to the news media, the public, and key stakeholders in the event of a national public health emergency.
CDC Morbidity and Mortality Weekly Report (MMWR)	The MMWR is a weekly publication containing data on specific diseases as reported by state and territorial health departments and reports on infectious and chronic diseases, environmental hazards, natural or human-generated disasters, occupational diseases and injuries, and intentional and unintentional injuries.
Other Resources
American Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS)	The AAPCC and NPDS form a national near-real-time surveillance system that improves situational awareness for chemical and poison exposures, according to data from U.S. poison centers.
WHO Weekly Epidemiological Record (WER)	The WER is an instrument for the rapid and accurate dissemination of epidemiological information on cases and outbreaks of diseases under the International Health Regulations and on other communicable diseases of public health importance, including newly emerging or reemerging infections.

The Origin of Modern Civilian Medical Intelligence in the United States

The role of the U.S. public health system has evolved significantly since 9/11 and the anthrax attacks of fall 2001. The public health threat associated with the release of chemical, biological, and radiological and nuclear agents has drawn the CDC and the entire public health system into a national security role. The safety and health of people across the United States and around the globe demand the best science, immediate public health service, and a sound strategy to prepare and respond to terrorist threats.

In 2000, with the realization that the threat of bioterrorism was increasing, the CDC developed its first strategic plan for preparedness and response to terrorism. The CDC centers, institutes, and offices contribute their expertise toward this effort by improving :

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Detection and investigation
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Prevention programs
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Worker safety
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Laboratory sciences research
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Communication
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Workforce development
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Long-term consequence management

Terrorism-preparedness activities described in the CDC’s 2000 strategic plan included the development of a public health communication infrastructure, a multilevel network of diagnostic laboratories, and an integrated disease surveillance system, all consistent with the 1998 recommendations of Keim, Kauffmann, and Rodgers. Surveillance systems now collect and monitor data for disease trends and/or outbreaks so that public health personnel can protect the nation’s health. Multiple agencies now maintain effective surveillance tools and systems that can be used to gain medical intelligence for the detection and characterization of outbreaks.

Key Components of Civilian Medical Intelligence

Methods for conducting public health surveillance may often differ considerably by program and disease. Regardless of these differences, all surveillance activities share many common practices in the way data are collected, managed, transmitted, analyzed, accessed, and disseminated. For many nations, the long-term vision is that of complementary electronic information systems, which routinely gather health data from a variety of sources on a real-time basis and facilitate the monitoring of the health of communities, assist in the ongoing analysis of trends and detection of emerging public health problems, and provide information for setting public health policy.

There must be multiple systems in place to support communications for public health labs, the clinical community, and state and local health departments. Each information system has demonstrated the importance of being able to exchange health information. However, it is possible for many of these systems to operate in isolation, not capitalizing on the potential for a cross-fertilization of data exchange between the various systems. There should therefore also be numerous, ongoing efforts among public health agencies to provide an integrated and unifying framework to monitor these data streams better for early detection of public health issues and emergencies. Ensuring the security of this information is critical, as is the ability of the network to work reliably in times of national crisis.

A bioterrorist attack, like other public health threats, is likely to be detected first at the local level. Health departments throughout the nation must therefore be prepared to detect and respond to those threats. Communications, information sharing, distance-learning, and organizational infrastructure established among health organizations are necessary to provide for an adequate and timely public health emergency response, including the possibility of bioterrorism. Federal officials, state and local health departments, poison control centers, and other public health professionals should be capable of accessing and sharing preliminary health surveillance information quickly and securely. Users should also be actively notified of breaking health events as they occur. Veterinarians are also considered as a key part of the disease surveillance system.

In the United States, most bioterrorism agents can be diagnosed at standard hospital clinical laboratories. The CDC Laboratory Response Network (LRN) represents a consortium of laboratories comprised primarily of state, local, and federal public health laboratories, each with different capabilities and levels of expertise. National laboratories, including those operated by the CDC and the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), are responsible for specialized strain characterizations, bio-forensics, select agent activity, and handling highly infectious biological agents and toxic chemicals. Reference laboratories are responsible for investigation and/or referral of specimens. They are made up of more than 100 state and local public health, military, international, veterinary, agriculture, food, and water testing laboratories. In addition to laboratories located in the United States, facilities located in Australia and Canada also serve as reference laboratories abroad. Sentinel laboratories are hospital-based, clinical institutions, and commercial diagnostic laboratories. These sentinel laboratories now play a key role in the early detection of biological agents. Sentinel laboratories provide routine diagnostic services, as well as rule-out, and referral steps in the identification process.

To investigate unusual epidemics, information is often required about the ecological and biological characteristics of the pathogen, the natural routes of infection, the pathogenesis, the clinical picture and immunology of certain diseases, the epidemic foci, and the special characteristics of an artificial dissemination of the pathogen. It is also essential that there is an adequate and efficient field analysis of the epidemic, an examination of the clinical picture and the epidemiological situation, and a collection of representative samples and data for statistically sound epidemiological, epizootiological, medical, and laboratory analysis. This necessitates properly trained mobile investigation teams with appropriate technical equipment.

Integration of Medical Intelligence into National-Level Knowledge Management Systems

Fusion Centers

Because of the 2007 National Strategy for Information Sharing, many states and urban areas have established fusion centers. The fusion process is postulated as a method of managing the flow of information and intelligence across levels and sectors of government to integrate information for analysis. Most notably, this process directs the flow of information gathered from state, local, and tribal levels to U.S. federal agencies such as the U.S. Department of Justice, the Federal Bureau of Investigation, the U.S. military, and the Central Intelligence Agency (CIA). The intelligence component of a fusion center focuses on the intelligence process, where information is collected, integrated, evaluated, analyzed, and disseminated. The concept is based upon the assumption that nontraditional collectors of intelligence (such as public health) do in fact possess a form of intelligence that can be fused with law enforcement data to provide meaningful information and intelligence about threats and criminal activity.

The focus for sharing of this information is the fusion center, a facility-based center designed to promote information sharing at the federal, state, and local levels of government of the United States. According to the National Fusion Center Association, as of 2014, there are 74 fusions centers operating in the United States.

The role of the public health sector within the fusion center is to gather, analyze, and relay health-related information routinely, including health security risks associated with the detection of suspicious biological or chemical agents within a community, and share this information with other sectors of government. From a national perspective, this collective epidemiological network is intended to contribute to the execution of various national plans to defend against biological attacks.