The Agency for Healthcare Research

and Quality (AHRQ) is the lead agency

charged with supporting research

designed to improve the quality of

health care, reduce its cost, address

patient safety and medical errors, and

broaden access to essential services.

AHRQ sponsors and conducts research

that provides evidence-based

information on health care outcomes;

quality; and cost, use, and access. 

The information helps health care

decisionmakers—patients and 

clinicians, health system leaders, and

policymakers—make more informed

decisions and improve the quality of

health care services.

Bioterrorism

and Health System Preparedness

Issue Brief

Bioterrorism and Other Public 

Health Emergencies: Linkages 

with Community Providers

No. 6

Introduction

At the core of any public health

emergency response plan is an

indispensable group of professionals:

community providers. These providers—

whether local clinicians, emergency

responders, or the staff of public health

clinics—play a critical role in planning

for, detecting, and responding to acts of

bioterrorism and other public health

emergencies. In the event of an

emergency, these providers must be able

to send and receive critical information to

and from the public health system in a

timely, efficient, and effective manner.

A Web-assisted audioconference sponsored

by the Agency for Healthcare Research and

Quality (AHRQ) in December 2003

examined the role of community providers

in detecting and responding to a potential

bioterrorist event or other public health

emergency. The conference highlighted

resources available to community providers

from AHRQ, the Centers for Disease

Control and Prevention (CDC), and the

American Academy of Pediatrics. The

conference also examined the efforts of a

pediatric practice-based research network

to enable community-based providers to

share information on emerging public

health threats. 

Presentations were made by the following

researchers and practitioners:

▲ Helen Burstin, M.D., M.P.H. 

Director, Center for Primary Care,

Prevention, and Clinical Partnerships

Agency for Healthcare Research and

Quality

Rockville, Maryland

▲ Dan Baden, M.D., Clinician

Communication Team Lead

Emergency Communication System

Centers for Disease Control and

Prevention

Atlanta, Georgia

▲ Molly Hicks, M.P.A., Associate

Director, Department of Federal

Affairs

American Academy of Pediatrics

Washington, D.C.

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality
▲ Jeralyn Bernier, M.D., M.P.H.

Research Director

Cincinnati Pediatric Research

Group

Cincinnati Children’s Hospital

Medical Center

Cincinnati, Ohio

A question and answer session

followed the presentations.

The Role of

Community Providers

in Bioterrorism

Preparedness

Local providers are not only essential

to detecting the first signs of

bioterrorist activity, they are key

resources for responding to a potential

bioterrorist event. These providers

need better links to the public health

infrastructure, including local health

departments, State laboratories, and

emergency departments. Strengthening

these links is especially important now

because of the increased threat of a

bioterrorist incident. A survey in the

Journal of Family Practice found that,

before the anthrax attacks, two-thirds

of family physicians said they felt

unprepared to respond to a bioterrorist

event.1

1 Chen FM, Hickner J, Fink KS, Galliher JM,

Burstin H. On the front lines: family physicians’

preparedness for bioterrorism. Journal of Family

Practice. 2002 Sept; 51(9):745-750.

Community providers serve as critical

sentinels in detecting the first signs of

a public health threat, whether a

bioterrorist attack or other disaster.

These providers face challenges,

however, in identifying symptoms

associated with bioterrorist activity.

Patients often come to their providers

with vague symptoms that may be

confused with flu. Training and pointof-care information could better

prepare community providers to

diagnose and manage patients

appropriately. 

Providers need to interact with public

health departments or emergency

responders to develop ongoing

relationships with the public health

infrastructure (such as health

departments and emergency medical

services), develop community-based

data sharing systems for ongoing

surveillance for bioterrorism and other

public health emergencies (such as the

flu), and develop a role for community

and volunteer providers to respond to

public health emergencies.

AHRQ has several initiatives to help

community providers prepare to detect

and respond to potential bioterrorist

activity. Under a contract from AHRQ,

Vanderbilt University and the

University of Alabama at Birmingham

are developing training and

information tools to meet the needs of

clinicians in the community in the

event of a bioterrorist attack. AHRQ

also supports several practice-based

research networks of communitybased providers in their efforts to

address important questions related to

bioterrorism preparedness. According

to Dr. Helen Burstin, AHRQ is

enhancing and reinforcing linkages

and information technology

connectivity between the health 

care system and the public health

infrastructure. Further information 

on these and other AHRQ 

bioterrorism planning and response

initiatives can be found at 

www.ahrq.gov/browse/bioterbr.htm.

CDC Resources for

Community Providers

With the emergence of multiple public

health threats ranging from the threat

of chemical weapons to flu outbreaks,

it is more important than ever for

community providers to receive up-todate public health information. To

meet this need, Dr. Dan Baden

explained that the CDC leads several

outreach efforts designed to

communicate with clinicians across

the country. 

▲ Clinician Outreach and

Communication Activity

(COCA). The CDC offers regular

conference calls on emerging

topics—such as updated

information on Severe Acute

Respiratory Syndrome (SARS)—

to a network of more than 84

clinician and professional

organizations, including the

American Medical Association,

American Nurses Association, and

the American Academy of

Pediatrics. 

▲ Clinician Registry. The CDC’s

free registry provides clinicians

with real-time information to help

prepare for and respond to

bioterrorism and other emergency

events. More than 40,000 members

have received more than 800,000

e-mail updates on terrorism,

emerging diseases, and relevant

2

Community providers serve

as critical sentinels in

detecting the first signs of a

public health threat.
3

training opportunities. Clinicians

may sign up at www.cdc.gov,

selecting “emergency preparedness

and response” and click on the

clinician registry featured link.

▲ Clinician-Specific Web Pages.

The CDC offers several Web pages

with information on the avian flu,

smallpox, SARS, West Nile virus,

and other potential public health

threats. Click on the “A-Z Index”

shown at the top of the CDC Web

site (www.cdc.gov). 

▲ Clinician Information Line

(CIL). The CDC’s information

line at (877)554-4625 responds to

questions from clinicians on

emerging health concerns ranging

from the flu to smallpox. Staffed

by clinicians, the CIL is accessible

24 hours a day, 7 days a week.

Resources for

Pediatric Terrorism

Preparedness 

When it comes to the threat of

terrorism, community providers need

extra resources to respond to the

special needs of children. Children

have unique health and mental health

needs that really distinguish them

from adults and make them more

vulnerable than adults to bioterrorism

and other catastrophic events,

according to Molly Hicks of the

American Academy of Pediatrics. For

example, children will not understand

the complexity of an evacuation plan

that is broadcast over radio or

television. In addition, a chemical

weapon may cause greater harm to

children because they breathe more

rapidly than adults and will absorb

more of any chemical agent that is

released.

While the pediatric workforce is

familiar with children’s special needs,

providers outside the pediatric

community would benefit from

continuing education to better respond

to children in the event of a possible

terrorist attack. The American

Academy of Pediatrics, a national

membership organization of 57,000

pediatricians and pediatric specialists,

provides several resources that can

help community providers prepare for

a possible terrorism threat. Foremost

among these is the Academy’s

“Children, Terrorism & Disasters”

Web site, which is located at

www.aap.org/terrorism. The site

provides information on biological

agents as well as extensive resources

and links for providers, community

planners, and families.

The Academy also provides a

“Children, Terrorism & Disasters”

toolkit, which offers important tips for

parents and caregivers. The toolkit can

be downloaded from the Academy’s

Web site free of charge

(www.aap.org/terrorism/topics/parents.

pdf).

Through funding from AHRQ, the

Academy is developing the Pediatric

Terrorism Preparedness Resource. 

The resource guide will serve as a

comprehensive clinical and policy

reference on the needs of children

following a terrorist attack or other

disaster. This resource will improve

the ability of all health care

professionals to undertake pediatric

preparation and planning, and will

provide activities for hospitals,

schools, emergency medical systems,

and communities. The resource guide

will have an accompanying Web site

where the Academy will post updates.

The Academy plans to publish a

comprehensive resource for providers

working with children on crisis-related

mental health problems. Until then,

the Academy has on its “Children,

Terrorism & Disasters” Web site a

section devoted to children’s mental

health needs during times of crisis

(entitled “Psychosocial Aspects”). In

this section, the Academy provides

guidance on the role of pediatricians

in responding to children’s emotional

needs and advice on talking to

children about disasters. 

Surveillance Tool

Launched by Pediatric

Practice-Based

Research Network

Another group working to address the

special needs of children in the event

of a public health emergency is the

Cincinnati Pediatric Research Group

(CPRG), a Midwestern regional

practice-based research network

spanning 8 counties in 3 States. The

CPRG comprises 45 community child

health care providers in 22 practices.

With support from AHRQ, this

regional network of pediatricians is

working on strategies that allow

community-based provider networks

to share critically important

information to help them identify and

respond to bioterrorist events and

other health threats. 

A chemical weapon may

cause greater harm to

children because they 

breathe more rapidly than

adults and will absorb more

of any chemical agent that 

is released.
AHRQ Pub. No. 05-0032

January 2005

The CPRG recently launched the

Symptom Surveillance Project, a Webbased surveillance system with a

pediatric focus, which facilitates

communication between community

providers and government agencies

charged with monitoring symptoms

associated with transmissible diseases

or bioterrorism. According to Dr.

Jeralyn Bernier of the CPRG, the

Symptom Surveillance Project involves

providers in the detection of

bioterrorism and outbreaks that are both

naturally occurring and intentional, and

establishes regular two-way

communication between providers and

health departments. 

CPRG members enter data about

prevalent symptoms and unusual cases

in their outpatient pediatric office

settings. Symptoms entered into the

password-protected database include

those associated with transmissible

diseases and bioterrorism-linked

illnesses. Interactive computer graphs

enable physicians to view customized

snapshots of symptoms prevalent in

their region. While the system does not

replace required reporting of diseases,

the local health department reviews the

data regularly, allowing for more timely

detection of disease outbreaks.

With many providers occupied with

busy practices, CPRG strives to keep

data collection simple. Weekly data

collection takes about 10 minutes for

participating physicians to review and

enter. The network is studying different

incentives to motivate providers to

participate, including offering modest

financial remuneration and

complimentary staff lunches for active

participants. 

In the future, the CPRG plans to

expand its activities by linking with

other provider networks. CPRG also

hopes to improve threat detection by

adding automated analyses of claims

data and telephone triage information.

Information on CPRG and updates on

the network’s research projects can be

found at http://cprg.cchmc.org.

For More Information

The audioconference on which this

Issue Brief is based, “Bioterrorism and

Other Public Health Emergencies:

Linkages with Community Providers,”

is available on the AHRQ Web site

(www.ahrq.gov/bioterbr.htm).

Information on the tools discussed in

this Issue Brief, and other tools and

publications related to health system

preparedness for bioterrorism, will be

posted on the AHRQ Web site as it

becomes available. Please check the

Web site frequently.

This issue brief was prepared for 

AHRQ by AcademyHealth under

contract number 290-98-0003.

AHRQ’s Bioterrorism Preparedness 

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