Public health infrastructure desperately needs modernization

When Hurricane Sally hit the coasts of northern Florida and Alabama in September 2020, emergency preparedness and public health officials were concerned about food and water safety. And sure enough, the hurricane created issues for both. Shortly after the hurricane, cases of Giardia (a waterborne disease) and hepatitis A (a foodborne disease) spiked in northern Florida. But the increases went largely unnoticed. Why?

Experts can gauge food and water safety by monitoring reportable diseases and conducting water quality testing. Yet it’s rare for those data sources to be triangulated for use in allocating emergency resources. Current public health infrastructure does not support such connections or real-time data exchanges.

To rapidly prepare for and respond to outcomes of natural disasters like hurricanes – or events like a pandemic – our public health infrastructure needs to be redesigned to help us quickly:

• Obtain relevant health data, integrate and structure it to optimize analysis.
• Examine the data to identify situations of interest and make data-driven decisions.
• Communicate and share data in accessible, easy-to-understand ways – with the public, government leaders, politicians and the media.
• Make evidence-based health evaluations using informative and robust statistical metrics.
  

The urgency grows

As the global climate shifts and individuals become increasingly mobile, the urgency to detect the impact on human health grows. Whether it’s a natural disaster, new interactions between animals carrying novel diseases or the emergence of an old disease in a new location, our public health infrastructure must be able to handle the challenges of the future. There are obvious detriments to population health if public health infrastructure is not modernized.

As citizens, we notice the obvious signs of decaying physical infrastructure – bridges crumbling, potholes in roads or heavy traffic on overutilized highways. Yet public health works best when it is not seen. The effects of neglected public health infrastructure become apparent when an outbreak is not contained, a novel disease goes undetected for months, or progress in eliminating racial and ethnic disparities is never realized.

Despite the emergence of three completely new-to-human strains of coronaviruses in the last 18 years, US public health organizations experienced a 10% reduction in federal and state funding and the same decrease in its workforce. The time to build an infrastructure for future generations is now.

Understanding the infrastructure behind public health

The foundation of public health infrastructure – whether local public health departments, the Department of Health and Human Services (DHHS) in Washington, DC, or other public health agencies – is technical infrastructure. Like health care, decisions about protecting and promoting public health are informed by data. Health care systems are built to capture, integrate, transmit and receive copious amounts of data on an individual. Those systems started to move toward national interconnectivity long ago – an effort that continues today.

Public health continues to be plagued by immunization registries with redundant entries, disease systems that cannot be scaled, antiquated servers, arduous and inefficient access to data and outdated statistical tools. While connections between providers of health information and public health exist, widespread connectivity is elusive. In health care, the Centers for Medicare and Medicaid Services drove uniform change requiring electronic health record exchanges through meaningful use. Public health lacks a similar carrot to incentivize.

While data coordination is foundational, public health plays a larger role in promoting the health of communities. Public health agencies manage a myriad of complex issues, including:

• Community health needs assessments and health improvement planning.
• Mental health care provision and coordination.
• Maternal and child health programs, such as those for women, infants and children (WIC).
• Child fatality prevention.
• Health equity and disparity elimination programming.
• Chronic disease management.

Public health agencies must be adept at flexing to longitudinal health crises as well as acute emergencies. Adequate public health infrastructure is essential to their success.

Surveillance and advanced analytics

The surveillance landscape is complex and often disjointed. There are more than 120 nationally notifiable infectious diseases in the US alone. Following an investigation with local agencies, each state reports a subset of those diseases by submitting data to the Centers for Disease Control and Prevention (CDC).

In terms of how public health events are identified, investigated and communicated, health experts often perform key tasks using a small collection of technologies. Data from public health events and surveillance data is rarely integrated with health information exchanges (HIEs) or electronic health records (EHRs). Most states that manage the National Notifiable Diseases Surveillance System (NNDSS) simply accept reports, push them out to locals, then send them back to the CDC.

On top of the sheer volume – that is, having to routinely report on more than 120 notifiable diseases – there are other infrastructure challenges associated with surveillance systems:

• Difficulty accessing the data.
• Manual processes and a lack of automated reporting.
• Problems with intra-agency reporting.
• Siloed systems that can’t scale.
• Challenges performing analyses within surveillance systems.
• Hurdles in managing user roles and access (permissions).
  

Case in point: Dengue

We’ve seen recent shifts in the range of Aedes aegypti mosquitoes that can transmit dengue: the most common and fastest-spreading mosquito-borne virus in the world. These disease-carrying mosquitoes normally reside in tropical climates. In recent years, the A. aegypti were found in Florida. This resulted in a significant outbreak of dengue, which is now considered an endemic disease. The warming of ocean waters and prolonged summer seasons gave these mosquitoes the chance to emerge in a new environment.

There is no treatment or vaccine for this disease. Combating dengue requires using vector control measures to protect populations in vulnerable areas. Surveillance data, whether monitoring sentinel animals or sampling mosquitoes, helps determine where to focus mitigation efforts and ramp up disease detection. The mosquito vector is likely to move north over time. As this happens, the public health system must be prepared to capture essential information about dengue cases, communicate the presence of disease to health care providers and tell the public to take precautions.

Dengue is not an isolated incident. The emergence of Hendra virus in Australia occurred when bats were forced into a new habitat. Zika virus became rampant with the explosion of its mosquito vector combined with prevalent international travel. H1N1 emerged as a triple-reassortant virus – carrying parts of swine, avian and human genes – and it was able to infect many species, including humans.

Such situations are no longer rare and unusual. While the science of pathogenic genomics has greatly advanced, we cannot yet predict how and when new threats to human health will emerge.

Opportunities for the future of public health

The recent pandemic renewed a deep interest in public health investment. In our recovery, we have an unparalleled opportunity. Redesigning our public health infrastructure is the first and most essential step to a long-term fortification.

Enterprise data infrastructure, whether managed at the state or agency level, must be designed for efficiency, scalability and interoperability. There are extensive options for hosting data, whether in the cloud or on premise. The private sector’s experience in using advanced data architecture is remarkable – public health now can explore the art of the possible.

Data capture systems, such as those for notifiable diseases, immunization or cancer registries, must be reengineered to scale and to house the information public health requires – as well as information the public desires. Instead of relying on small budgets and limited-term engagements, vendors and agencies should collaborate to build broader, more refined solutions, while ensuring knowledge transfer for sustainability.

The final element needed in public health infrastructure is the piece most visible to those outside of public health – visualization. In recent years, it has become standard practice to use multiple tools for publishing public health data. Few of these tools allow for data preparation, analysis or modeling – as well as visualization – in a single space.

Data visualizations: Icing on the data cake

With the right visualizations, epidemiologists can gain rapid insights into problem clusters, areas with increased case counts, surges in disease and potentially new pathogens. Visualizations, as we all experienced with COVID-19, also give the public much-needed insight into what, where and how a disease is progressing.

Sadly, disease reporting dashboards are largely outdated and housed in the depths of PDF files. Hindered by the difficulty of extracting data from case investigation systems, analysts spend most of their time cleaning the data instead of interpreting and sharing what it means.

The public and the media have never been more interested in public health data than now. At the start of the COVID-19 pandemic, many public health agencies struggled to produce real-time data displays urgently needed for situational awareness. As the pandemic moves into continued waves – and as public health adapts to longer-term visualization needs – many are trying to integrate statistical programs, even multiple programming languages and visualizations, into one space. This integrative approach is widely used in private sectors, from banking to retail. Public health now has the means to access these essential tools.

The necessity of connections

Public health is already moving in the direction of modernization. While infrastructure, systems and analytical tools are revamped, another set of relationships must be formed between health care and public health.

Health care has a front-row seat to what may be a new public health emergency, but its purview is limited to those seeking care within its system or to the data approved to share across systems. Aggregating public health data from care providers in real time is the only way to get ahead of a public health crisis. As public health revamps its infrastructure, it must be prepared to accept real-time messaging, exchange data with HIEs, receive electronic case reports and allow for the receipt of unknown cases of interest.

Connections within various levels of government are also important. The CDC, for example, embarked on a 20-year data modernization initiative where its 700-plus data systems would migrate into more efficient storage. This was intended to facilitate better exchange of information between federal agencies, state and local partners, and even across international boundaries.

A long-term vision for public health infrastructure

Whatever the goal – to prevent or treat infectious diseases, plan for and respond to emergencies, or simply promote healthy people – public health infrastructure is the backbone of success. With the right type of infrastructure in place, we can quickly gather and analyze data, share it, make smarter, faster decisions and respond effectively to an array of public health needs.

Many public health experts were disheartened by the response to the COVID-19 pandemic. It was not for lack of effort, skill or compassion. Our public health infrastructure simply was lacking – underfunded, outdated and not prepared for the task. We now know what happens when public health is broadly seen and heard. We need to propel into the future where public health silence is the norm.