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Public Health Preparedness: Getting ‘Left of Boom’

Image of Public Health Preparedness: Getting ‘Left of Boom’. One of the critical areas of focus for Defense Public Health as it transitions some of the military component public health functions to the Defense Health Agency is public health preparedness and response. (Defense Health Agency Public Health graphic illustration by Joyce Kopatch)

Public health preparedness and response is a critical area of focus as Defense Public Health transitions some of the military component public health functions to the Defense Health Agency. This includes all-hazard biosurveillance and public health emergency management, or PHEM.

All-Hazard Biosurveillance

According to the Defense Health Agency, biosurveillance is the process of gathering, integrating, interpreting, and communicating essential information related to all-hazards threats or disease activity affecting human, animal, or plant health to achieve early detection and warning, contribute to overall situational awareness of the health aspects of an incident, and enable better decision making at all levels.

In his remarks at the 2023 Defense Health Information Technology Symposium, U.S. Public Health Service Rear Adm. Brandon Taylor, DHA Public Health Director, explained that the purpose of all-hazard biosurveillance is to integrate and enhance the biosurveillance community, including medical, intelligence, tactical, and public health responders.

“We play a significant role in the world of biosurveillance,” said Taylor. “All-hazards biosurveillance is a critical pillar of both public health and battlefield intelligence.”

One of the benefits of an all-hazards biosurveillance effort is improved force health protection, said Taylor. each geographic combatant command has an FHP mission, which informs decision makers on protection efforts to the joint force. DHA Public Health, across its four Defense Centers for Public Health supply crucial and timely biosurveillance information to the GCCs, the military departments, and to fourth estate agencies which include defense agencies and Department of Defense field activities.

All-hazard biosurveillance identifies and examines multiple sources of threats using a one-health model, a collaborative, multisectoral, and transdisciplinary approach that examines health outcomes because of interactions between humans, animals, flora, and fauna, and the environment, said Juan Ubiera, chief of the Armed Forces Health Surveillance Division Integrated Biosurveillance Branch.

DHA Public Health uses several DOD and non-DOD data sources to monitor potential indicators of biothreats to identify unusual patterns, trends, and other anomalies that may indicate the presence of a health threat, said Ubiera. The all-hazards biosurveillance approach seeks to address natural and artificial vulnerabilities to predict, detect, report, and develop an understanding of global human health threats.

“DHA Public Health provides early warning and situational awareness of potential bio-threats to the force,” said Ubiera. “For example, our biosurveillance efforts identify the circulating respiratory viruses, from the emergence of any novel virus to an increased circulation of an endemic respiratory viruses like COVID-19, respiratory syncytial virus, and influenza. Data forecasting and trend analyses provide information and projections about the geography and magnitude of the threat’s impact. All this biosurveillance information can be used for effective planning, resource allocation, decision making, and other aspects of operations at the local level.”

Taylor says DHA is making investments in this process to give warning and decision space to operational leaders. This action will enable risk mitigation and avoidance from health threats.

“The goal is to provide timely, actionable information for decision makers at every level of the enterprise, from installation public health officer to combatant commander,” said Taylor.

Taylor explained the field of biosurveillance was originally developed to fill surveillance gaps for the intelligence community. This is done by providing early warning of potential emerging and infectious diseases as well as nation-state and terrorist attacks.

Biosurveillance has evolved to include a holistic understanding about the potential threats to service members, their families, DOD civilians, contractors, military working animals and all environments.

“Now the threats that face our warfighters and decision makers are much more complex,” said Taylor. “Threats that will decimate units come from all directions: engineered threats, occupational threats, and environmental threats. Whether a troop gets poisoning because of intentionally tainted food or because the galley cook didn’t wash their hands properly, the result is the same: a detriment to mission readiness.”

In common military parlance, getting “left of boom” is the timeline of events before an explosion or incident–a period when the command or unit still has a chance to prepare for and avert a crisis. This is the goal of integrated biosurveillance.

“DHA is the ideal defense agency to serve as the biosurveillance hub/portal since we have the ability to surveil across all of these warfighter threats,” said Taylor.

Public Health Emergency Management and Force Health Protection

Despite the powerful health surveillance tools DHA has at its disposal and because of the agency’s links to installation public health departments, DHA Public Health continues to mature towards full operational capability. A significant hurdle for next-generation biosurveillance is the creation of a synergistic communication capability across health and intelligence domains. This action, directed by Congress, is outlined in DOD Biosurveillance Directive 6420.02.

“We’re operationalizing the requirements of DoDI 6200.03, which is the DOD instruction for public health emergency management and operationalizing the public health aspects of the DHA administrative instruction for emergency management,” said Steve Starbuck, who is helping plan DHA’s public health emergency response efforts as the deputy Public Health Emergency Management Officer. “If there's a public health emergency of DOD-wide significance, DHA PHEM will help coordinate and synchronize the response across the services. We also will provide guidance and standards that will be used at across military hospitals and clinics. This ensures the public health emergency enterprise is resourced and standardized.”

Ubiera says this biosurveillance coordination provides valuable information on the emergence of a biothreat, its pattern of spread, and informs medical countermeasures.

“All government agencies, including DHA, should have an emergency preparedness plan in place, especially when it is recognized that the potential for any number of different emergencies, like Ebola virus, could occur at any time,” said Ubiera. “The public health emergency plans must outline, temporally, the specific resources and protocols to be followed in the event of an emergency in order to minimize the risk of transmission among service members and Military Health System beneficiaries.”

Ubiera says using an all-hazard biosurveillance approach requires an integrated operational planning for a broader list of emergencies, it is in many cases not necessary to plan for all public health emergencies. An example of this would be allocating DOD resources for natural disasters or new disease outbreaks in countries with limited U.S. military presence.

“In the early stages of a health threat, we advise on non-pharmaceutical interventions,” said Starbuck. “Depending on the type of disease, different mitigation practices are used. For example, using masks, or in the alternative, social distancing for respiratory disease. As part of the national response, there is a pandemic stockpile for personal protective equipment, antibiotics, and antivirals. In the preparedness stage we would work to make sure that the supplies are sufficient as we work with medical logistics and infectious disease specialists.”

Ubiera said another critical component of all-hazard biosurveillance is the biosurveillance hub and portal, which consists of two components. First, the analyst hub is the network of analysts compiling and exchanging all-hazards information to provide a composite characterization of the biothreat. The second component is the biosurveillance portal, which is the information technology tool that rapidly facilitates the data exchange from the Hub to the processing and reporting of the threat to the DOD enterprise. More information about integrated biosurveillance as well as additional tools and reports can be found at on the AFHSD pages at health.mil.

“This works on the same principle as a situational report, or SITREP, during a deployment mission,” said Ubiera. “Medical and public health professionals gather, analyze, and report on potential show-stoppers. They can use BSHP to crosstalk and exchange information with our interagency partners. Service leaders can then use this subject matter expert-generated information for their situational awareness, and decision matrix.”

Ubiera also says this all supports our national biodefense strategy and implementation plan for countering biological threats, enhancing pandemic preparedness, and achieving global heath security, which requires a whole-of-government effort.

“DHA Public Health and its interagency partners are committed to early detection, near real-time reporting, analytical assessment, and early warning of potential biothreats,” said Ubiera. “Expanding the analyst hub to capture information from different and multiple mission sets will help characterize a biothreat. Interconnectedness of information technology systems will broaden and facilitate how we all monitor for biothreats. The larger network and use of artificial intelligence technology and applications will expand our investigation, analysis, and reporting mechanisms, which will in turn provide more useful and comprehensive biosurveillance information.”

Taylor said the goal of this effort is a place where open-source and unclassified data can be shared across multiple agencies such as the Federal Emergency Management Agency, the Department of Homeland Security, and the Department of Health and Human Services, including the Indian Health Service, National Institutes of Health, and the Centers for Disease Control and Prevention.

“We foresee an even larger interagency biosurveillance network, where we share knowledge rapidly and synergistically across a multitude of government agencies,” said Taylor. “Investments in detection, integration, communication, and prevention will carry us into the next generation of biosurveillance capability, enabling every level of the enterprise to respond in, or before, ‘real time.’”

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