Current Limitations And Future Directions

Although the current body of published literature addresses some critical issues and raises important questions, it is still limited in both the range of problems that have been studied and in the technical approaches used in the studies. A lack of funding and interest may partly explain the current state of the art. However, as interest in biosurveillance grows, so will the sophistication and use of economic studies of biosurveillance. Future methods and studies will have to address some of the following technical limitations:

6.1. Current Measures May Not Be Adequate

It remains to be seen whether the traditional cost and reward measures (such as dollars, life years, and QALYs) in their present forms are appropriate or if researchers need to modify current measures or develop new ones to match the unique aspects of bioterrorist attacks and epidemics. After all, many of these current measures originally arose in the context of more well circumscribed medical events, such as individual acute and chronic diseases. Such measures may not capture the complex scientific, economic, and social interactions that occur when the ambient environment is threatened and changed. For example, how does surrounding panic or loss of faith in daily business operations affect quality of life? Will existing measures adequately represent psychological distress? What is the cost of losing or damaging the life of a person, such as a healthcare worker, who is essential to mounting an adequate response to the outbreak? Do potential future earnings fully represent costs from a death? Because different measures may lead to different results and

1 This diagnostic strategy is an example of excluding SARS as a diagnosis by ruling-in another cause for a patient's illness.

different optimal choices, it will be important to use and develop measures germane to decision makers.

6.2. Studies Are Not Capturing All of the Effects

Most existing studies likely underestimate the impact of an outbreak or attack and do not account for all of the short-term and long-term effects. Outbreaks can shake the foundation of businesses, governments, and other organizations. Depending on who becomes ill, an attack can impede or disrupt vital services, such as transportation, health care, law enforcement, and food distribution, further compounding problems. For example, a sudden massive influx of victims into the healthcare system would divert resources and attention from other patients with more "traditional" but still urgent medical conditions, such as heart disease and stroke. Losing healthcare workers to death or quarantine would decrease an already limited response capacity. Setting up areas to place or quarantine victims would disrupt hospital workflow and reduce overall available space.

Existing studies also frequently overlook the psychological consequences of an outbreak, such as fear, hysteria, loss of confidence, and depression, which in sum could be substantial. Studies have shown that stress (Manning et al., 1996;Bejean and Sultan-Taieb, 2005), post-traumatic stress disorder (Frayne et al., 2004), and depression (Greenberg et al., 2003) are extremely costly ailments with insidious long-term consequences. Fear and hysteria can result in injury and bodily harm, as well as hinder response.A decline in consumer confidence could be very detrimental to businesses and the overall economy.

6.3. Studies Should Look at Other Scenarios

Many studies include only a limited number of scenarios, when, in fact, there is tremendous variability in where an outbreak can arise, how an agent may spread, and how a public health response may proceed. Although a number of studies have focused on very large cities such as New York City, attacks and outbreaks can occur almost anywhere. Conclusions from a New York City scenario may not be applicable to other cities and locations. A plethora of factors, including weather and climate conditions, geography, social structure and interactions, and transportation systems, can influence the pattern of spread, detection, and the ensuing response. Many other human and economic factors can alter the response. In addition, the response may not be efficient, especially if the event occurs during the weekends, holidays, or other concomitant crises.

6.4. Studies Should Take Other Perspectives

Most studies take the societal perspective, which is not necessarily the ideal perspective for all decision makers. The societal perspective may seem too abstract and inapplicable to many organizations and businesses that are busy addressing competing concerns that affect their daily operations. As a result, they may not make the time or effort to draw the link between the impact on society and the impact on their own situations.

Therefore, taking other perspectives to show specifically how outbreak and bioterrorist attacks will harm their own interests may be helpful for planning, lobbying, and funding purposes.

6.5. Costs and Rewards Are Not Necessarily Linear

Many of the studies assume that costs and rewards change linearly, which is not always the case in real life. For example, in many analyses, doubling the number of people killed by an attack will double the productivity losses. However, in reality, the cost of losing two million people presumably will not be exactly twice the cost of losing one million people. Similarly, doubling the death toll from seven to 14 is not the same as doubling it from 700,000 to 1.4 million. The relationship between costs and deaths is probably much more complicated and shifts at different thresholds.

6.6. There Is a Need for More Data

Because the current poverty of data forces researchers to make many assumptions, future studies should further assess the validity of these assumptions and acquire more data to improve existing and future economic studies. Multidimensional sensitivity analyses, i.e., sensitivity analyses that vary more than one variable at a time, can test these assumptions. Complex simulation studies can measure how these assumptions may behave in a variety of conditions. Researchers can see how these assumptions fare when applied to other better-characterized diseases and problems. At the same time, organizational and policy changes can help data collection. Collecting and generating necessary data requires adequate accounting systems, cooperation from correspondent authorities, alleviation of administrative barriers, appropriately trained personnel, and, in some cases, innovative research methods.

6.7. Current Analytic Methods, Benchmarks, and Resources May Not Be Enough

Because the nature, scale, and impact of bioterrorist attacks and outbreaks are so different from many other medical and health problems, established health economic analytic methods, benchmarks (such as $50,000 QALY) and resources (such as the HUI) may not be applicable or enough to tackle important biosurveillance questions. For instance, is it appropriate to label a biosurveillance measure as not cost-effective if its cost-utility exceeds $50,000 QALY? Is it reasonable to rely on quality-of-life data derived from people who were not in the midst of an epidemic or attack? Can researchers use other more advanced economic methods from other industries? These are just some of the questions researchers and decision makers will struggle with in the near future.

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