Recent infectious disease outbreaks, including the 2001 anthrax attacks and the emergence of SARS in 2003, have made it clear that no single community can fully prepare for or respond to a large-scale bioterrorism attack. Still, there is little consensus about what level of regionalization or localization is ideal for the many services and resources that need to be mobilized for a response to bioterrorism.

A report by the Stanford-UCSF Evidence-based Practice Center, titled "Regionalization of Bioterrorism Preparedness and Response," provides practical guidance on this timely issue. Researchers evaluated the effectiveness of various strategies for coordinating resources across local and state lines during a bioterrorism response. They found that regionalization was beneficial in several areas, such as maintaining inventories of bioterrorism-response antibiotics and vaccines. The report noted, however, that much more research is needed which specifically evaluates the regionalization of systems relevant to bioterrorism preparedness.

The researchers, led by CHP/PCOR research associate Dena Bravata, examined literature from a wide variety of fields relevant to the regionalization of bioterrorism responses, including supply chain management and disaster logistics, regionalization of trauma care, bioterrorism surveillance, and responses to natural disasters and disease outbreaks such as SARS. They initially reviewed more than 8,000 citations, and based their final report on 406 articles, 74 government reports and 83 Web sites. The report was commissioned by the federal Agency for Healthcare Research and Quality (AHRQ) and was publicly released by the agency on May 7, 2004.

The researchers' analyses found that regionalization of bioterrorism responses was potentially beneficial in three key areas:

*Regionalization can expand healthcare systems' ability to provide critical services in a bioterrorism event (known as surge capacity), such as providing medical care and dispensing prophylactic antibiotics and vaccines.

*By sharing in tasks such as training response personnel and maintaining inventories of needed supplies, regionalization can help state and local governments get the most out of scarce resources.

*Strategies used for disaster preparedness and response -- such as regional mutual aid agreements, and written plans that specify response roles, payment and chain of command -- would be beneficial in coordinating the numerous organizations likely involved in responding to a bioterrorist attack

These findings confirm the importance of working together under extreme circumstances," said Carolyn Clancy, director of the AHRQ.

The report is being distributed to a host of federal and state decision-makers, including members of Congress and officials in public health, emergency medicine, disaster response and homeland security.

"Our hope is that this report will be used to inform the ongoing preparations for bioterrorism," said Bravata, who served as project director for the bioterrorism report. "There are front-line policy makers who are actively trying to figure out the best way to get pills into the mouths of people in case of a bioterrorist attack."

In addition to the three general conclusions listed above, the report identifies more than 20 specific lessons learned, which can guide decisions about particular bioterrorism-related tasks. These lessons, which are summarized in a user-friendly format, include the following:

*Redesigning medical supplies to be assembled from fewer parts can save money and reduce inventories.

*Information technology systems can provide accurate, up-to-date information on the availability of medical supplies and personnel needed for a bioterrorism response.

*Strategies to protect responders -- such as providing vaccinations and protective gear -- are crucial to maintaining adequate numbers of response personnel.

*Predesignating certain hospitals for trauma care has increased efficiency and improved patient outcomes, as the designated hospitals have valuable experience in treating severely injured patients. Bioterrorism preparedness efforts may benefit from a similar system.

*Formalized protocols for pre-hospital care -- such as first responders knowing where and how to rapidly transport exposed patients -- could contribute to improved patient outcomes.

For two of their areas of inquiry -- bioterrorism surveillance and the stockpiling of medical supplies -- the investigators found no relevant evidence on the effectiveness of regionalization, so they constructed simulation models.

The surveillance simulation found that while large disease outbreaks can be relatively easy to detect using either localized or regionalized data analysis, small outbreaks can be difficult to detect through either approach. The stockpiling simulation found that maintaining local stockpiles of medical supplies is cost-effective only when the annual probability of a bioterrorist attack is very high.

While the researchers found no shortage of articles describing responses to disasters and disease outbreaks, Bravata said, they were surprised to find very little discussion of lessons learned from these events. "The reports we reviewed provide a lot of detail about the event, the number of responders, the number of dead, but there's no summary of, 'Here's what we did well, here's what we didn't do well,'" Bravata explained. "Without that kind of self-reflection, valuable knowledge is being lost. Self-evaluation must become a routine part of any disaster drill or response."