The Anthrax Epidemiologic Tool Kit: An Instrument for Public Health Preparedness

Dori B. Reissman, Ellen B. Steinberg, Julie M. Magri, Daniel B. Jernigan


Biosecur Bioterror. 2003;1(2) 

In This Article


The epidemiologic rapid response tool kit was used as a resource for bioterrorism preparedness and response during a national investigation of bioterrorism-related anthrax. Previous exercises demonstrated that investigation tools were difficult and time-consuming to create during an emergency response.[5] In the anthrax attack events of 2001, on-scene CDC investigation teams reported that they wanted access to documents created by other teams, but had to spend a lot of time calling other teams attempting to obtain materials. Teams were not always aware of activities or investigation tools implemented at other sites, and they spent time and resources in redeveloping needed materials.

The centralization of materials into a tool kit allowed field teams to contact one location to obtain investigation tools and learn which strategies and tools had proven useful in the field. This process may have improved the efficiency and effectiveness of subsequent on-site investigations. The tool kit allowed teams to customize existing instruments, created in similar situations, to fit newly emerging field situations. By centralizing not just forms, but also surveillance methods (i.e., case-finding strategies) and epidemiologic strategies, the tool kit may have facilitated more coordinated response efforts. Furthermore, it provided a continually updated repository of lessons learned from other field teams during the investigation process.

The tool kit's surveillance system inventory provided an overall perspective of case-finding strategies used in different on-site response locations. In addition, the inventory can be used as a starting point for future investigation teams who are considering what type of surveillance to institute as part of their response.

We faced a variety of challenges in creating the tool kit. To obtain the desired information, multiple contacts with each team were necessary as teams rotated staff. Prolonged and newly emerging investigations kept CDC field and EOC staff responding to demands for information to drive appropriate emergency public health interventions. There was little time to formally summarize the investigations until intervention pressures subsided. Some items may have been inadvertently omitted. Teams were busy and may not have been able to identify and send all types of documents that we requested. The existence of multiple drafts of investigation tools, often not dated or sequentially classified, made it difficult to determine which version represented the most useful product to include in the tool kit. Finally, tools were not always available in electronic form, which limited the ease with which tool kit items could be made accessible to others. Despite the challenges mentioned above, we believe that the tool kit contained most of the relevant materials from the investigation of the anthrax bioterrorist attacks in 2001.

We created the checklist in Table 3 to encourage operational preparedness for future emergency public health response efforts. These operational management issues can be easily forgotten while functioning in an emergency response framework, especially if multiple investigation teams are simultaneously deployed.[5,6] In developing the tool kit, we found that standardized data collection, well-defined data aggregation and reporting, and utilization of data sharing through a command and control structure were critical areas that could be improved for future response efforts.[6]

Although it is not the focus of this article, information technology plays a critical role in this process. Information technology solutions need to adhere to architectural standards for data elements, protect privacy for health records, provide unique health/laboratory identifiers, appropriately manage data, and provide decision support.[8] In addition, these new systems must address multiple challenges to maintain the integrity of the data between field and headquarters operations, including user access, connectivity, data exchangeability, security, and interoperability.


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