Small Premonitory Release or Contamination

The term premonitory release refers to intentional or accidental infection of one or a limited number of individuals with an unusual organism such as B. anthracis. The functional requirement here is one of sensitivity for single cases and small outbreaks, not extreme timeliness. To detect a single case, a biosurveillance system must have extremely high case detection sensitivity, specificity, and diagnostic precision (or the prior probability must be extremely high, e.g., owing to intelligence information). A biosurveillance system would have to rely either on case detection by the healthcare system or on computer-based case detection. Computer-based case detection would have to be capable of diagnostic precision at least at the level of finding individuals with Gram-positive rods in the blood or cerebrospinal fluid and pneumonia on chest radiograph (which would be highly suggestive of anthrax). Examples of potential computer-based components include clinical information systems with decision support at the point of care, systems to monitor laboratory reporting of microbiology cultures; and free-text processing algorithms that scrutinize autopsy reports, newspaper stories, and obituaries for unusual deaths of animals or humans. If there are multiple cases, the demographics of the victims or the discovery of a geographic clustering of victims could help to identify a common cause with case detection at lower levels of diagnostic precision. In the absence of astute clinical diagnosis, it is likely that a single case of disease caused by a weaponized organism will progress to fatality. The requirements, therefore, include biosurveillance components (manual or automatic) that analyze unexplained deaths.

The problem of detecting a single case is identical to the problem of accurate diagnosis in medicine, and there is great deal of literature on clinical decision support describing relevant techniques, which is summarized in Miller (1994).

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