Twenty years ago, in the fall of 2001, the United States was attacked — twice. On September 11, hijacked jet airliners brought down the Twin Towers and set the Pentagon ablaze, ushering in a new era of global terror. Weeks later, in early to mid-October, anthrax laden envelopes were opened in media offices in Florida, New York, and Washington, D.C. adding the specter of biological terrorism to the new list of threats facing the U.S.

I was part of the urban search and rescue response (USAR) to the Pentagon, one of the medical team managers for Virginia Task Force 1, the elite USAR team that has deployed across the globe to many of the most significant disasters of the past quarter century. I was in the building on the third night of operations when two of my medics correctly identified the American Airlines Flight 77 black boxes. Looking for survivors from the crash and building collapse, this could only be considered a "consolation prize", at best. Because we were there to save lives. What was most troubling to us was that our trauma center at Inova Fairfax Hospital remained empty, waiting for days for victims of that horrific attack that never came.

Weeks later in mid-October, as the inhalation anthrax cases began to surface along the East Coast, I was back in the emergency department, with another chance to make a critically important discovery. This time around, Inova Fairfax Hospital's emergency department was being inundated with patients, many fearing exposure to the anthrax powder that had killed a journalist from Florida and sickened office staff at NBC News in New York City. Amongst the thousand or so patients who came seeking answers as to whether or not they were exposed to the deadly powder were two postal workers who spent time at the Brentwood mail handling facility and delivered mail to the U.S. Senate. Brentwood is the large center that sorted the letters that ended up in the offices of Senators Tom Daschle and Patrick Leahy. We didn't know much about anthrax at that time, but were anticipating cases, and made the successful diagnosis of these two US Postal Service workers based on the recognition of a combination of abnormal vital signs, worrisome symptoms, and the application of judicious medical acumen. Those two gentlemen (we also contributed to the successful diagnosis of a third postal worker who presented for care at another Virginia hospital) were lucky — because we were lucky. Or perhaps good. But two other postal workers from Brentwood did not fare as well, succumbing to their exposures.

It became abundantly clear to me right then and there that we needed to do a whole lot more to protect Americans from the consequences of intentional attack, whether that was due to conventional or catastrophic terrorism, infectious disease outbreak (purposefully introduced or arising from nature), or other means of harm.

It was obvious that there is no "national security" without "health security".

From the anthrax diagnosis experience, it became clear that the U.S. healthcare system would quickly be overwhelmed with patients seeking reassurance that they were not exposed, that they were not sick, especially in the context of an outbreak event. Our team at Inova Fairfax challenged the CDC anthrax screening protocols (which heavily relied on geographic proximity to the exposure event, and time of exposure, not taking into account the dynamic elements that comprise an aerosolized exposure). CDC noted a date, time, and location as the risks for anthrax exposure in October 2001 — not taking into account the upstream risks of envelope leakage, which is how the five postal workers in the D.C. Brentwood facility ended up being affected. We wrote a screening protocol — the Fairfax Protocol — that highlighted the importance of fever and tachycardia in addition to a number of presenting symptoms. We stated the obvious — vital signs are vital. In the paper that described these findings, we were able to demonstrate that the Inova Fairfax algorithm successfully diagnosed 9 of the 11 inhalation anthrax cases that occurred in the fall of 2001. The existing CDC guidelines only identified one of the 11 cases. We were onto something. Although it took the CDC another 15 years to validate this work I, along with colleagues from CDC, published a checklist for initial triage after an anthrax mass exposure event in April 2019 that will now serve as the initial screening tool for widespread inhalation anthrax exposure, should it ever be needed. Rapid heart rate, rapid breathing — along with confusion and headache — helped identify more than half of all known historical cases of inhalation anthrax. No doubt about it, vital signs were noted to be abnormal early in the course of disease progression.

With this paper making it to publication, I got to thinking how digital health tools, especially wearables and other sensors, might make a difference in the next large-scale outbreak. How could we protect our hospitals from being over-run by patients seeking assurance that they were not ill? How could we streamline access to care for those whose vital signs and risk profile suggested more urgent evaluation is needed? 

How close are we to being able to "forecast" where people are sick, when they are sick, and what implications that may have for the healthcare system?

In December 2019, mere weeks before the World Health Organization's (WHO) declaration of a public health emergency of international concern with the recognition that a new coronavirus was circulating in Hubei Province, China — the practice at IQT convened a Roundtable meeting to explore the role that digital health technologies could play in an epidemic disease outbreak scenario. We noted that the use of AI and ML-based triage tools could help guide patients to important information (K Health). We began to see how fever monitoring (Kinsa Health) could provide important insights regarding potential disease spread. Real-time monitoring of vital signs, displayed in the context of geographic heat mapping, began to provide insights regarding COVID spread. And numerous off-the-shelf wearable products like the Apple Watch, Fitbit, and Garmin and startup efforts like Whoop and Empatica have begun to explore the role their devices can play in the early detection of COVID-19 signs and symptoms.

Combining a wide array of digital health tools that can provide multiple data inputs with data analytic capabilities are the next steps needed in creating a better information supply chain required for disaster response. Ingesting clinical data from wearables and sensors and other inputs and making sense of them at the regional, state, or national level are all key elements that must be woven into our nation's preparedness and response efforts going forward. In addition to wearables and sensors, telehealth and telemedicine offerings, point-of-care diagnostics, and data analytics and predictive modeling should all be prioritized in the re-imagination of public health preparedness post COVID-19. With the surge conditions seen in any disaster event — whether it is the on-going pandemic, or the next hurricane, earthquake or terrorist attack-- key efforts informed by better technologies will be critical to ensuring a successful response.

Although by no means exhaustive, the following list of requirements in the digital health arena comes to the fore in the immediate context of what we have all experienced with the COVID-19 disaster. We must be able to do a better job of patient "load balancing" which is another way of saying that we have to ensure we are getting the right patient to the right place at the right time for the right care. This is very important if we are to avoid overloading any given healthcare facility. This will be facilitated by having access to real time data feeds for situational awareness. Such information can also be purposed to help support the augmentation of staffing needs, especially in being able to provide virtual and remote-based care. Once the data streams are established, having the means to analyze that data in real-time and apply forecasting and other predictive algorithms will be of tremendous benefit. This becomes particularly important in helping to identify the intersection between demand for patient care services and the available supply of resources needed to provide such care. Moreover, applied to the clinical arena, it may be able to help us better predict who is likely to benefit from any given therapy or intervention, which is likely to be in short supply. Finally, as we consider the dual challenges of providing care under crisis conditions while trying to keep abreast of the rapidly expanding medical literature, particularly in the setting of a novel or rare occurrence, we need to figure out a better way to learn from these experiences. With the tsunami of pre-print literature that was posted in the midst of the COVID-19 response, it would be extremely beneficial to use natural language processing and machine learning data ingestion tools to better identify those studies and experiences that might be relevant to patient care delivery. Who really remembers what anthrax does to your lungs, unless you've been there, done that, or are in the infinitesimally small cadre of experts who study these rare illnesses?

Just as 9/11 was a wake-up call to the nation to get better prepared, so too must we look at our COVID-19 experience to help move our health security efforts into the 21^st century.

Hear more from Dan and the team on the IQT Podcast episode that further explores digital health!