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Report to the Chairman, Permanent Subcommittee on Investigations, 
Committee on Governmental Affairs, U.S. Senate:

United States Government Accountability Office:

GAO:

July 2004:

Emerging Infectious Diseases:

Review of State and Federal Disease Surveillance Efforts:

GAO-04-877:

GAO Highlights:

Highlights of GAO-04-877, a report to the Chairman, Permanent 
Subcommittee on Investigations, Committee on Governmental Affairs, U.S. 
Senate: 

Why GAO Did This Study:

The threat posed by infectious diseases has grown. New diseases, 
unknown in the United States just a decade ago, such as West Nile virus 
and severe acute respiratory syndrome (SARS), have emerged. To detect 
cases of infectious diseases, especially before they develop into 
widespread outbreaks, local, state, and federal public health officials 
as well as international organizations conduct disease surveillance. 
Disease surveillance is the process of reporting, collecting, 
analyzing, and exchanging information related to cases of infectious 
diseases. 

In this report GAO was asked to examine disease surveillance efforts in 
the United States. Specifically, GAO described (1) how state and 
federal public health officials conduct surveillance for infectious 
diseases and (2) initiatives intended to enhance disease surveillance.

GAO reviewed documents, such as policy manuals and reports related to 
disease surveillance, and interviewed officials from selected federal 
departments and agencies, including the Departments of Defense (DOD), 
Agriculture (USDA), and Homeland Security (DHS) as well as the Food and 
Drug Administration (FDA), and the Centers for Disease Control and 
Prevention (CDC). GAO conducted structured interviews of state public 
health officials from 11 states. 

What GAO Found:

Surveillance for infectious diseases in the United States comprises a 
variety of efforts at the state and federal levels. At the state level, 
state health departments collect and analyze data on cases of 
infectious diseases. These data are required to be reported by health 
care providers and others to the state. State public health departments 
verify reported cases of diseases, monitor disease incidence, identify 
possible outbreaks within their state, and report this information to 
CDC. At the federal level, agencies and departments collect and analyze 
disease surveillance data and maintain disease surveillance systems. 
For example, CDC uses the reports of diseases from the states to 
monitor national health trends, formulate and implement prevention 
strategies, and evaluate state and federal disease prevention efforts. 
FDA analyzes information on outbreaks of infectious diseases that 
originate from foods that the agency regulates. Some federal agencies 
and departments also fund and operate their own disease surveillance 
systems and laboratory networks and have several means of sharing 
surveillance information with local, state, and international public 
health partners. 

State and federal public health officials have implemented a number of 
initiatives intended to enhance disease surveillance, but challenges 
remain. For example, officials have implemented and expanded syndromic 
surveillance systems, which monitor the frequency and distribution of 
health-related symptoms among people within a specific geographic area. 
Although syndromic surveillance systems are used by federal agencies 
and departments and in all of the states whose officials GAO 
interviewed, concerns have been raised about this approach to 
surveillance. Specifically, syndromic surveillance systems are 
relatively costly to maintain compared to other types of surveillance 
and are still largely untested. Public health officials are also 
implementing initiatives designed to enhance public health 
communications and disease reporting. For example, CDC is working to 
increase the number of participants using its public health 
communication systems. In addition, state public health departments and 
CDC are implementing an initiative designed to make electronic disease 
reporting more timely, accurate, and complete. However, the 
implementation of this initiative is incomplete. Finally, federal 
public health officials have enhanced federal coordination on disease 
surveillance and expanded training programs for epidemiologists and 
other public health experts. 

In commenting on a draft of this report, the Department of Health and 
Human Services (HHS) said the report captures many important issues in 
surveillance. HHS also provided suggestions to clarify the discussion.

www.gao.gov/cgi-bin/getrpt?GAO-04-877.

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Majorie Kanof at (202) 
512-7119.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

Disease Surveillance Comprises a Variety of Efforts at the State and 
Federal Levels:

Public Health Officials Have Implemented Initiatives Intended to 
Enhance Disease Surveillance, but Challenges Remain:

Concluding Observations:

Agency Comments and Our Evaluation:

Appendix I: Scope and Methodology:

Appendix II: Information on Nationally Notifiable Infectious Diseases 
and Selected Worldwide Emerging Infectious Diseases:

Description of U.S. List of Nationally Notifiable Infectious Diseases, 
2004:

Selected Worldwide Emerging Infectious Diseases:

Appendix III: Selected List of Systems and Networks Engaged in Disease 
Surveillance:

BioSense:

Electronic Laboratory Exchange Network (eLEXNET):

Electronic Surveillance System for the Early Notification of Community- 
based Epidemics (ESSENCE):

Epidemic Information Exchange (Epi-X):

Foodborne Disease Active Surveillance Network (FoodNet):

Global Outbreak Alert and Response Network (GOARN):

Global Public Health Intelligence Network (GPHIN):

Health Alert Network (HAN):

Infectious Diseases Society of America Emerging Infections Network 
(IDSA-EIN):

Laboratory Response Network (LRN):

National Animal Health Reporting System (NAHRS):

National Electronic Disease Surveillance System (NEDSS):

National Electronic Telecommunications System for Surveillance (NETSS):

National Retail Data Monitor (NRDM):

National Veterinary Services Laboratories (NVSL):

PulseNet:

Real-time Outbreak and Disease Surveillance (RODS):

Sexually Transmitted Disease Management Information System (STD*MIS):

Systematic Tracking of Elevated Lead Levels & Remediation (STELLAR):

Appendix IV: Comments from the Department of Health and Human Services:

Appendix V: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

Acknowledgments:

Related GAO Products:

Table:

Table 1: U.S. List of Nationally Notifiable Infectious Diseases, 2004:

Figure:

Figure 1: Selected Emerging Infectious Diseases, 1996-2004:

Abbreviations:

AIDS: acquired immunodeficiency syndrome: 
BSE: bovine spongiform encephalopathy: 
CDC: Centers for Disease Control and Prevention: 
CSTE: Council of State and Territorial Epidemiologists: 
DHS: Department of Homeland Security: 
DOD: Department of Defense: 
EIP: Emerging Infections Program: 
EIS: Epidemic Intelligence Service: 
ELC: Epidemiology and Laboratory Capacity: 
eLEXNET: Electronic Laboratory Exchange Network: 
Epi-X: Epidemic Information Exchange: 
ESSENCE: Electronic Surveillance System for the Early Notification of 
Community-based Epidemics: 
FDA: Food and Drug Administration: 
FELTP: Field Epidemiology and Laboratory Training Program: 
FETP: Field Epidemiology Training Program: 
FoodNet: Foodborne Disease Active Surveillance Network: 
GAS: group A streptococcus: 
GOARN: Global Outbreak Alert and Response Network: 
GPHIN: Global Public Health Intelligence Network: 
HAN: Health Alert Network: 
HIV: human immunodeficiency virus: 
HHS: Department of Health and Human Services: 
IDSA-EIN: Infectious Diseases Society of America Emerging Infections 
Network: 
IEIP: International Emerging Infections Program: 
IOM: Institute of Medicine: 
LRN: Laboratory Response Network: 
NAHRS: National Animal Health Reporting System: 
NBS: NEDSS-Base system: 
NEDSS: National Electronic Disease Surveillance System: 
NETSS: National Electronic Telecommunications System for Surveillance: 
NRDM: National Retail Data Monitor: 
NVSL: National Veterinary Services Laboratories: 
PHIN: Public Health Information Network: 
RODS: Real-time Outbreak and Disease Surveillance: 
SARS: severe acute respiratory syndrome: 
STD: sexually transmitted disease: 
STD*MIS: Sexually Transmitted Disease Management Information System: 
STELLAR: Systematic Tracking of Elevated Lead Levels & Remediation: 
STSS: streptococcal toxic shock syndrome: 
USAMRIID: U.S. Army Medical Research Institute of Infectious Diseases: 
USDA: U.S. Department of Agriculture: 
vCJD: variant Creutzfeldt-Jakob disease: 
WHO: World Health Organization:

United States Government Accountability Office:

Washington, DC 20548:

September 30, 2004:

The Honorable Norm Coleman: 
Chairman: 
Permanent Subcommittee on Investigations: 
Committee on Governmental Affairs: 
United States Senate:

Dear Mr. Chairman:

Infectious diseases account for millions of deaths every year. Although 
the great majority of these deaths occur in developing countries, 
infectious diseases are not confined by international borders and 
therefore present a substantial threat to populations in all parts of 
the world, including the United States. In recent years, the threat 
posed by infectious diseases has grown. New diseases, unknown in the 
United States just a decade ago, such as West Nile virus and severe 
acute respiratory syndrome (SARS), have emerged, and known infectious 
diseases once considered in decline have reappeared with increased 
frequency. Furthermore, there is always the potential for an infectious 
disease to develop into a widespread outbreak--which could have 
significant consequences. The Centers for Disease Control and 
Prevention (CDC) estimates that if an influenza pandemic[Footnote 1] 
were to occur in the United States, it could cause an estimated 314,000 
to 734,000 hospitalizations and 89,000 to 207,000 deaths, with 
associated costs ranging from $71 to $167 billion.[Footnote 2] In 
addition to naturally occurring infectious disease outbreaks, there is 
also the threat posed by the deployment of infectious disease 
pathogens[Footnote 3] as weapons of war or instruments of terror.

To detect cases of infectious diseases, especially before they develop 
into widespread outbreaks, local, state, and federal public health 
officials as well as international organizations conduct disease 
surveillance. Disease surveillance is the process of reporting, 
collecting, analyzing, and exchanging information related to cases of 
infectious diseases. Disease surveillance provides national and 
international public health authorities with information for planning 
and managing efforts to control these diseases. In the mid-1990s, 
public health experts in the United States and abroad determined that 
infectious disease surveillance was inadequate worldwide, and both the 
World Health Assembly and the President of the United States called for 
concerted action to develop effective disease surveillance and response 
capabilities.[Footnote 4] In 2003, the Institute of Medicine (IOM) of 
the National Academies published a report that acknowledged that the 
United States has taken some important steps over the past decade to 
improve its disease surveillance and response capabilities, but also 
emphasized the need for continued action.[Footnote 5]

You asked us to examine disease surveillance efforts in the United 
States. Specifically, we describe (1) how state and federal public 
health officials conduct surveillance for infectious diseases and (2) 
initiatives intended to enhance disease surveillance.

To describe how state and federal public health officials conduct 
disease surveillance, we reviewed reports, state policy manuals, 
journal articles, and various documents related to disease 
surveillance. We conducted structured interviews of state public health 
officials from 11 states; interviewed representatives from professional 
associations representing state and local public health officials, such 
as the Association of State and Territorial Health Officials; and 
interviewed officials from selected federal agencies and departments-- 
CDC, the Department of Defense (DOD), the Food and Drug Administration 
(FDA), the U.S. Department of Agriculture (USDA), and the Department of 
Homeland Security (DHS). To identify initiatives intended to enhance 
disease surveillance, we reviewed and analyzed documents, such as 
journal articles on states' innovative approaches to enhancing disease 
surveillance. We also interviewed state public health officials from 
the 11 states about their assessment of enhancements and continuing 
weaknesses in disease surveillance efforts. We also reviewed and 
analyzed related federal documents, such as policy directives and 
annual reports, and we interviewed relevant federal health officials. 
We focused our review of initiatives intended to enhance surveillance 
on those currently under way or implemented since 2001. Appendix I 
contains more details about our scope and methodology. We conducted our 
work from October 2003 through July 2004 in accordance with generally 
accepted government auditing standards.

Results in Brief:

Surveillance for infectious diseases in the United States comprises a 
variety of efforts at the state and federal levels. At the state level, 
state health departments collect and analyze data on cases of 
infectious diseases. These data are required to be reported by health 
care providers and others to the state. The diseases that must be 
reported vary by state. State public health departments verify reported 
cases of diseases, monitor disease incidence, identify possible 
outbreaks within their state, and report this information to CDC. At 
the federal level, agencies and departments collect and analyze disease 
surveillance data and maintain disease surveillance systems. For 
example, CDC uses the reports of diseases from the states to monitor 
national health trends, formulate and implement prevention strategies, 
and evaluate state and federal disease prevention efforts. FDA analyzes 
information on outbreaks of infectious diseases that originate from 
foods that the agency regulates. Some federal agencies and departments 
also conduct disease surveillance using disease surveillance systems 
that they operate or fund. For example, DOD has a syndromic 
surveillance system called the Electronic Surveillance System for the 
Early Notification of Community-based Epidemics (ESSENCE). ESSENCE and 
other syndromic surveillance systems gather data on patient symptoms 
looking for anomalous increases in the frequency of these symptoms that 
may indicate the presence of an infectious disease outbreak. CDC, FDA, 
USDA, and DOD also support networks of laboratories that test specimens 
and develop diagnostic tests for identifying infectious diseases and 
biological or chemical agents. As part of their role in national 
disease surveillance efforts, some federal agencies and departments 
also share information with local, state, and international partners 
through different means such as from public Web sites or secure Web- 
based communication systems. Finally, some federal agencies and 
departments provide training, technical assistance, and funding to 
support state and international disease surveillance efforts.

State and federal public health officials have implemented a number of 
initiatives intended to enhance disease surveillance, but challenges 
remain. For example, officials have implemented and expanded syndromic 
surveillance systems, such as the Real-time Outbreak and Disease 
Surveillance (RODS) system. RODS is used by officials from four of the 
state health departments we interviewed and automatically gathers data 
on patient symptoms from hospital emergency room visits. Although 
syndromic surveillance systems are used by federal agencies and 
departments and by all of the states we interviewed, concerns have been 
raised about this approach to surveillance. Specifically, syndromic 
surveillance systems are relatively costly to maintain compared to 
other types of disease surveillance and are still largely untested. 
Public health officials have also implemented initiatives designed to 
enhance public health communications and disease reporting. For 
example, CDC is working to increase the number of participants using 
its public health communication systems. In addition, state public 
health departments and CDC have taken steps intended to enhance the 
information technology used for disease reporting. CDC introduced the 
National Electronic Disease Surveillance System (NEDSS), which is 
designed to make electronic disease reporting more timely, accurate, 
and complete, in part, by consolidating the 60-100 different systems 
used by state health departments to report disease data to CDC. 
However, initiatives designed to enhance public health communications 
and disease reporting are incomplete. Finally, federal public health 
officials have enhanced federal coordination on disease surveillance 
and expanded training programs for epidemiologists and other public 
health experts.

In commenting on a draft of this report, the Department of Health and 
Human Services (HHS) said the report captures many important issues in 
surveillance. HHS also provided suggestions to clarify the discussion 
or incorporate additional information. HHS's comments are reprinted in 
appendix IV. In providing oral comments on a draft of this report, DOD 
said it concurred and did not have any substantive comments. USDA said 
it had no comments on the draft report. HHS and USDA provided technical 
comments that we incorporated where appropriate.

Background:

IOM defines an emerging infectious disease as either a newly 
recognized, clinically distinct infectious disease or a known 
infectious disease whose reported incidence is increasing in a given 
place or among a specific population. More than 36 newly emerging 
infectious diseases were identified between 1973 and 2003, and new 
emerging infectious diseases continue to be identified. Figure 1 
provides information on selected emerging infectious diseases compiled 
by the World Health Organization (WHO) and CDC.

Figure 1: Selected Emerging Infectious Diseases, 1996-2004:

[See PDF for image]

[A] SARS refers to severe acute respiratory syndrome.

[B] BSE refers to bovine spongiform encephalopathy, also called mad cow 
disease.

[C] vCJD refers to variant Creutzfeldt-Jakob disease.

[D] Influenza A (H5N1) is also called avian influenza.

[End of figure]

According to CDC, nearly 70 percent of emerging infectious disease 
episodes during the past 10 years have been zoonotic diseases, which 
are diseases transmitted from animals to humans. The West Nile virus, 
which was first diagnosed in the United States in 1999, is an example 
of a zoonotic disease. The West Nile virus can cause encephalitis, or 
inflammation of the brain. Mosquitoes become infected with West Nile 
virus when they feed on infected birds, and infected mosquitoes 
transmit the virus to humans and animals by biting them. Other zoonotic 
diseases include SARS, avian influenza, human monkeypox, and variant 
Creutzfeldt-Jakob disease (vCJD), which scientists believe is linked to 
eating beef from cattle infected with bovine spongiform encephalopathy 
(BSE) and is also called mad cow disease. Surveillance for zoonotic 
diseases requires collaboration between animal and human disease 
specialists.[Footnote 6]

Disease surveillance provides information for action against infectious 
disease threats. Basic infectious disease surveillance activities 
include detecting and reporting cases of disease, analyzing and 
confirming this information to identify possible outbreaks or longer- 
term trends, and applying the information to inform public health 
decision-making. When effective, surveillance can facilitate (1) timely 
action to control outbreaks, (2) informed allocation of resources to 
meet changing disease conditions and other public health threats, and 
(3) adjustment of disease control programs to make them more effective.

Responsibilities for Disease Surveillance:

In the United States, responsibility for disease surveillance is 
shared--involving health care providers;[Footnote 7] more than 3,000 
local health departments including county, city, and tribal health 
departments; 59 state and territorial health departments; more than 
180,000 public and private laboratories; and public health officials 
from four federal departments. Although state health departments have 
primary responsibility for disease surveillance in the United States, 
health care providers, local health departments, and certain federal 
departments and agencies share this responsibility. In addition, the 
United States is a member of WHO, which is responsible for coordinating 
international disease surveillance and response efforts.

Health Care Providers:

Health care providers are responsible for the medical diagnosis and 
treatment of their individual patients, and they also have a 
responsibility to protect public health--a responsibility that includes 
helping to identify and prevent the spread of infectious diseases. 
Because health care providers are typically the first health officials 
to encounter cases of infectious diseases--and have the opportunity to 
diagnose them--these professionals play an important role in disease 
surveillance. Generally, state laws or regulations require health care 
providers to report confirmed or suspected cases of notifiable diseases 
to their local and/or state health department. A notifiable disease is 
an infectious disease for which regular, frequent, and timely 
information on individual cases is considered necessary for the 
prevention and control of the disease. States publish a list of the 
diseases they consider notifiable and therefore subject to reporting 
requirements. According to IOM, most states also require health care 
providers to report any unusual illnesses or deaths--especially those 
for which a cause cannot be readily established.[Footnote 8]

State and Local Health Departments:

States, through the use of their state and local health departments, 
have principal responsibility for protecting the public's health and 
therefore take the lead in conducting disease surveillance and 
supporting response efforts. Generally, local health departments are 
responsible for conducting initial investigations into reports of 
infectious diseases. They employ epidemiologists,[Footnote 9] 
physicians, nurses, and other professionals. Local health departments 
are also responsible for sharing information they obtain from providers 
or other sources with their state department of health. State health 
departments are responsible for collecting surveillance information 
from across their state, coordinating investigations and response 
efforts, and voluntarily sharing surveillance data with CDC and others.

Federal Agencies and Departments:

Several federal agencies and departments are involved in disease 
surveillance. For example,

* CDC, an agency in HHS, is charged with protecting the nation's public 
health by directing efforts to prevent and control diseases and 
responding to public health emergencies. It has primary responsibility 
for conducting national disease surveillance and developing 
epidemiological and laboratory tools to enhance disease surveillance. 
CDC also provides an array of technical and financial support for state 
infectious disease surveillance efforts.

* FDA, which is also a part of HHS, is responsible for protecting the 
public health by ensuring that domestic and imported food products 
(except meat, poultry, and certain processed egg products) are safe and 
properly labeled. It is also responsible for ensuring that all drugs 
and feeds used in animals are safe, effective, and properly labeled and 
produce no health hazards when used in animals that produce foods for 
humans. FDA enforces food safety laws by inspecting food production 
establishments and warehouses and collecting and analyzing food samples 
for microbial contamination that could lead to foodborne illnesses.

* USDA is responsible for protecting and improving the health and 
marketability of animals and animal products in the United States by 
preventing, controlling, and eliminating animal diseases. USDA is also 
responsible for regulating veterinary vaccines and other similar 
products. USDA undertakes disease surveillance and response activities 
to protect U.S. livestock, ensure the safety of international trade, 
and contribute to the national zoonotic disease surveillance effort. In 
addition, USDA is responsible for ensuring that meat, poultry, eggs, 
and certain processed egg products are safe and properly labeled and 
packaged. USDA establishes quality standards and conducts inspections 
of processing facilities in order to safeguard certain animal food 
products against infectious diseases that pose a risk to humans.

* DOD, while primarily responsible for the health and protection of its 
service members, contributes to global disease surveillance, training, 
research, and response to emerging infectious disease threats.

* DHS's mission involves, among other things, protecting the United 
States against terrorist attacks. One activity undertaken by DHS is to 
coordinate the surveillance activities of federal agencies and 
departments related to national security.[Footnote 10]

World Health Organization:

While national governments have primary responsibility for disease 
surveillance and response within their country, WHO plays a central 
role in coordinating international surveillance and response efforts. 
An agency of the United Nations, WHO administers the International 
Health Regulations, which outline WHO's role and the responsibility of 
member states in preventing the global spread of infectious diseases. 
Adopted in 1951 and last modified in 1981, the International Health 
Regulations require, among other things, that WHO member states report 
the incidence of three diseases within their borders--cholera, plague, 
and yellow fever. There are currently proposed revisions to these 
regulations that will expand the scope of reporting beyond the current 
three diseases to include all events potentially constituting a public 
health emergency of international concern.[Footnote 11] WHO is the 
agency that serves as the focal point for international information on 
these diseases as well as others, and the agency also helps marshal 
resources from member states to control outbreaks within individual 
countries or regions. In addition, WHO works with national governments 
to improve their surveillance capacities through--for example-- 
assessing and redesigning national surveillance strategies, offering 
training in epidemiologic and laboratory techniques, and emphasizing 
more efficient communication systems.

Disease Surveillance Comprises a Variety of Efforts at the State and 
Federal Levels:

Disease surveillance comprises a variety of efforts at the state and 
federal levels. At the state level, state health departments collect 
and analyze data on notifiable diseases submitted by health care 
providers and others, although the diseases considered notifiable and 
the requirements for reporting them vary by state. State-run 
laboratories conduct testing of samples for clinical diagnosis and 
participate in special clinical or epidemiologic studies. State public 
health departments verify cases of notifiable diseases, monitor disease 
incidence, and identify possible outbreaks within their state. At the 
federal level, agencies and departments collect and analyze 
surveillance data gathered from the states and from international 
sources. Some federal agencies and departments also support their own 
national surveillance systems and laboratory networks and have several 
means of sharing surveillance information with local, state, and 
international public health partners. Finally, some federal agencies 
and departments support state and international surveillance efforts by 
providing training and technical expertise.

States Collect and Report Data on Notifiable Diseases, Although the 
Diseases Considered Notifiable and the Reporting Requirements Vary by 
State:

To conduct disease surveillance at the state level, state public health 
officials collect reports on cases of notifiable diseases from health 
care providers and others. Both the diseases considered notifiable and 
the requirements for reporting them vary by state. Most states have 
their list of notifiable diseases approximate a national list of 
notifiable diseases maintained and revised by the Council of State and 
Territorial Epidemiologists (CSTE) in collaboration with CDC.[Footnote 
12] (See table 1 for the 2004 national list of notifiable diseases 
maintained by CSTE.) This national list is reviewed annually and 
revised periodically.[Footnote 13] State lists of notifiable diseases 
generally include cholera, plague, and yellow fever--consistent with 
WHO's International Health Regulations. On the other hand, according to 
state and federal health officials, states modify their list of 
notifiable diseases to reflect the public health needs of their region. 
States may include diseases on their state list that impact their state 
but do not appear on the national list. For example, one border state 
includes the gastrointestinal disease amebiasis--a disease most often 
found in the United States among immigrants from developing countries-
-in its state list of notifiable diseases. However, amebiasis is not 
included on the current national list of notifiable diseases. 
Conversely, states may exclude diseases that are on the national list 
but have little relevance for their state. For example, although Rocky 
Mountain spotted fever is listed on the national list of notifiable 
diseases, it was excluded from one state's list we reviewed because 
relatively few cases of this disease are reported in that area. 
Appendix II provides a description of diseases on the national 
notifiable disease list and other selected emerging infectious diseases.

Table 1: U.S. List of Nationally Notifiable Infectious Diseases, 2004:

Acquired immunodeficiency syndrome (AIDS); 
Anthrax; 
Botulism; 
* Botulism, foodborne; 
* Botulism, infant; 
* Botulism, other (wound unspecified); 
Brucellosis; 
Chancroid; 
Chlamydia trachomatis, genital infections; 
Cholera; 
Coccidioidomycosis; 
Cryptosporidiosis; 
Cyclosporiasis; 
Diphtheria; 
Ehrlichiosis;
* Ehrlichiosis, human granulocytic; 
* Ehrlichiosis, human monocytic; 
* Ehrlichiosis, human, other, or unspecified agent; 
Encephalitis/meningitis, Arboviral; 
* Encephalitis/meningitis, California serogroup viral; 
* Encephalitis/meningitis, eastern equine; 
* Encephalitis/meningitis, Powassan; 
* Encephalitis/meningitis, St Louis; 
* Encephalitis/meningitis, West Nile; 
* Encephalitis/meningitis, western equine; Enterohemorrhagic 
Escherichia coli; 
* Enterohemorrhagic Escherichia coli, O157:H7; 
* Enterohemorrhagic Escherichia coli, shiga toxin + (not serogrouped); 
* Enterohemorrhagic Escherichia coli, shiga toxin positive, serogroup 
non-O157;
Giardiasis; 
Gonorrhea; 
Haemophilus influenzae, invasive disease; 
Hansen disease (leprosy); 
Hantavirus pulmonary syndrome; 
Hemolytic uremic syndrome, post-diarrheal; 
Hepatitis, viral, acute; 
* Hepatitis A, acute; 
* Hepatitis B virus, perinatal infection; 
* Hepatitis B, acute; 
* Hepatitis C, acute; 
Hepatitis, viral, chronic;
* Chronic Hepatitis B;
* Hepatitis C virus infection (past or present); 
HIV infection; 
* HIV infection, adult (>=13 years); 
* HIV infection, pediatric (<13 years); Legionellosis; 
Listeriosis; 
Lyme disease; 
Malaria;
Measles;
Meningococcal disease;
Mumps;
Pertussis;
Plague;
Poliomyelitis, paralytic;
Psittacosis;
Q Fever;
Rabies;
* Rabies, animal;
* Rabies, human;
Rocky Mountain spotted fever;
Rubella, congenital syndrome;
Rubella;
Salmonellosis;
Severe acute respiratory syndrome-associated coronavirus (SARS-CoV) 
disease;
Shigellosis;
Smallpox;
Streptococcal disease, invasive, Group A; 
Streptococcal toxic-shock syndrome;
Streptococcus pneumoniae, drug resistant, invasive disease; 
Streptococcus pneumoniae, invasive in children <5 years; 
Syphilis;
* Syphilis, early latent;
* Syphilis, late latent;
* Syphilis, late, non-neurological;
* Syphilis, latent unknown duration;
* Syphilis, latent;
* Syphilis, primary;
* Neurosyphilis;
* Syphilis, secondary;
Syphilis, congenital;
* Syphilitic Stillbirth;
Tetanus;
Toxic-shock syndrome;
Trichinosis;
Tuberculosis;
Tularemia;
Typhoid fever;
Vancomycin--intermediate Staphylococcus aureus (VISA); 
Vancomycin--resistant Staphylococcus aureus (VRSA); 
Varicella (deaths only);
Varicella (morbidity);
Yellow fever;

Source: Council of State and Territorial Epidemiologists and Centers 
for Disease Control and Prevention.

[End of table]

States also vary in their requirements for who should report notifiable 
diseases, and the deadlines for reporting these diseases after they 
have been diagnosed vary by disease. Officials from the 11 states we 
interviewed told us that, in addition to health care providers, they 
require clinical laboratories to report notifiable diseases. On the 
other hand, some--but not all--of the11 states have expanded the 
responsibility for reporting suspected notifiable diseases. Depending 
on the state, those required to report suspected notifiable diseases 
can include veterinarians, day care centers, hotels, and food service 
establishments. Penalties for not reporting a notifiable disease vary 
by state. For example, failing to report a notifiable disease in one 
state is a misdemeanor, and upon conviction, violators may be fined 
from $50 to $1,000 and/or may be imprisoned for up to 90 days. In 
another state, the penalty ranges from $25 to $300. Depending on the 
contagiousness or virulence of the disease, some diseases have to be 
reported more quickly than others. For example, in one state, botulism 
must be reported immediately after a case or suspected case is 
identified, while chronic hepatitis B must be reported within one month 
of its identification.[Footnote 14] Similarly, in another state, Q 
fever must be reported within one working day, while gonorrhea must be 
reported within one week.[Footnote 15]

Health care providers rely on a variety of public and private 
laboratories to help them diagnose cases of notifiable diseases. In 
some cases only laboratory results can definitively identify pathogens. 
Every state has at least one state public health laboratory to support 
its infectious diseases surveillance activities and other public health 
programs. State laboratories conduct testing for routine surveillance 
or as part of clinical or epidemiologic studies. For rare or unusual 
pathogens, these laboratories provide diagnostic tests that are not 
always available in commercial laboratories. For more common pathogens, 
these laboratories provide testing using new technologies that still 
need controlled evaluation. State public health laboratories also 
provide specialized testing for low-incidence, high-risk diseases, such 
as tuberculosis and botulism. Results from state public health 
laboratories are used by epidemiologists to document trends and 
identify events that may indicate an emerging problem.

Upon diagnosing a case involving a notifiable disease, local health 
providers and others who report notifiable diseases are required to 
send the reports to state health departments[Footnote 16] through a 
variety of state and local disease reporting systems, which range from 
paper-based reporting to secure, Internet-based systems. Our interviews 
of public health officials in 11 states found that about half of these 
states have systems that allow public health care providers to submit 
reports of notifiable diseases to their state health department over 
the Internet. For example, state officials in one state we interviewed 
said their public health department has supported a state-wide Internet-
based electronic communicable disease reporting and outbreak alert 
system since 1995. Officials in another state told us that since 2002, 
the state has had a secure statewide Web-based hospital, laboratory, 
and physician disease-reporting system.

State health officials conduct their own analysis of disease data to 
verify cases, monitor the incidence of diseases, and identify possible 
outbreaks. States voluntarily report their notifiable disease data to 
CDC, using multiple and sometimes duplicative systems. For example, 
state officials currently report information on gonorrhea to CDC 
through two CDC systems: the Sexually Transmitted Disease Management 
Information System (STD*MIS) and the National Electronic 
Telecommunications System for Surveillance (NETSS). STD*MIS is a 
national electronic surveillance system that tracks sexually 
transmitted diseases, including gonorrhea throughout the United States. 
NETSS is a computerized public health information system used for 
tracking notifiable diseases. Although states are not legally required 
to report information on notifiable diseases to CDC, CDC officials 
explained the agency makes such reporting from the states a 
prerequisite for receiving certain types of CDC funding. Appendix III 
provides additional information on NETSS and other types of systems 
used for disease surveillance.

Federal Agencies and Departments Conduct and Support Disease 
Surveillance in a Variety of Ways:

In partnership with states, the federal government also has a key role 
in disease surveillance. Federal agencies and departments collect and 
analyze national disease surveillance data and maintain disease 
surveillance systems. Federal agencies and departments become involved 
in investigating the causes of infectious diseases and maintain their 
own laboratory facilities. Federal agencies and departments also share 
disease surveillance information. In addition, federal agencies and 
departments provide funding and technical expertise to support disease 
surveillance efforts at the state, local, and international levels.

Federal Agencies and Departments Collect and Analyze Surveillance Data 
Gathered by States:

One way federal agencies and departments support disease surveillance 
is by collecting and analyzing surveillance data gathered by the 
states. CDC, for example, analyzes the reports it receives from state 
health departments on cases of notifiable diseases in humans. CDC uses 
the reports from the states to monitor national health trends, 
formulate and implement prevention strategies, and evaluate state and 
federal disease prevention efforts. The agency publishes current data 
on notifiable diseases in its Morbidity and Mortality Weekly 
Report.[Footnote 17] Like CDC, USDA also collects surveillance data 
from the states. Specifically, USDA collects information from 
participating state veterinarians on the presence of specific confirmed 
clinical diseases in specific livestock, poultry, and aquaculture 
species in the United States. State animal health officials obtain this 
information from multiple sources--including veterinary laboratories, 
public health laboratories, and veterinarians--and report this 
information to the National Animal Health Reporting System 
(NAHRS).[Footnote 18] Similarly, FDA, often in cooperation with CDC, 
receives and interprets state data. For example, FDA officials told us 
they analyze state information from CDC on outbreaks of infectious 
diseases that originate from foods that FDA regulates. FDA then uses 
this information to trace the regulated food back to its origin and 
investigate possible sources of contamination. In addition, FDA and CDC 
interpret data on emerging infectious diseases to establish safeguards 
to minimize the risk of infectious disease transmission from regulated 
biological products, such as blood and vaccines.

Federal agencies and departments also collect and analyze information 
from international sources. For example, CDC and DOD obtain information 
on potential outbreaks from WHO. According to CDC, in many cases the 
initial alert of potential outbreaks is reported to WHO through the 
Global Public Health Intelligence Network (GPHIN), a system developed 
by Canadian health officials and used by WHO since 1997.[Footnote 19] 
GPHIN is an Internet-based application that searches more than 950 news 
feeds and discussion groups around the world in the media and on the 
Internet. WHO then verifies the reported outbreak and, if necessary, 
notifies the global health community. About 40 percent of the 
approximately 200 outbreaks investigated and reported to WHO each year 
come from the GPHIN.[Footnote 20]

In addition to these formal mechanisms for collecting and analyzing 
data, federal public health officials stressed the importance of 
obtaining information through their contacts at state and local health 
departments, other federal agencies and departments, foreign ministries 
of health, or other international organizations. For example, according 
to state public health officials, CDC learned of last year's monkeypox 
outbreak in one state through a phone call from the state public health 
department officials. After this initial contact, the state health 
department officials, in collaboration with officials from CDC, 
arranged a conference call that included federal officials from CDC and 
USDA, state and local health department officials, health care 
providers, and hospital epidemiologists to further share information on 
the outbreak.

Federal Agencies and Departments Operate and Fund Disease Surveillance 
Systems:

Some federal agencies and departments conduct disease surveillance 
using disease surveillance systems they operate or fund. These systems 
gather data from various locations throughout the country to monitor 
the incidence of infectious diseases. These systems supplement the data 
on notifiable diseases collected by states and monitor surveillance 
information states do not collect. In general, these surveillance 
systems are distinguished from one another by the types of infectious 
diseases or syndromes they monitor and the sources from which they 
collect data. Some surveillance systems, known as sentinel surveillance 
systems, rely on groups of selected health care providers who have 
agreed to routinely supply information from clinical settings on 
targeted diseases. Other systems, known as syndromic surveillance 
systems, monitor the frequency and distribution of health-related 
symptoms--otherwise known as syndromes--among people within a specific 
geographic area.[Footnote 21] Syndromic surveillance systems are 
designed to detect anomalous increases[Footnote 22] in certain 
syndromes, such as skin rashes, that may indicate the beginning of an 
infectious disease outbreak.[Footnote 23] Because these systems monitor 
symptoms and other signs of disease outbreaks instead of waiting for 
clinically confirmed reports or diagnoses of a disease, some experts 
believe that syndromic surveillance systems help public health 
officials increase the speed with which they may identify outbreaks.

There are a number of disease surveillance systems operating in the 
United States that are operated or funded by federal agencies and 
departments. Some of these include the following:

* IDSA-EIN--A Sentinel Disease Surveillance System:

The Infectious Diseases Society of America Emerging Infections Network 
(IDSA-EIN) consists of about 900 physicians who specialize in 
infectious diseases.[Footnote 24] The network conducts surveillance by 
contacting the physicians every six to eight weeks to request 
information about any unusual clinical cases they have 
encountered.[Footnote 25] IDSA-EIN members, CDC, and state and 
territorial epidemiologists all receive summaries of the information 
obtained by the IDSA-EIN.

* EIP Site Surveillance--Participants Conduct Population-Based 
Surveillance:

Participants in CDC's Emerging Infections Programs (EIPs) conduct 
population-based[Footnote 26] surveillance of specific diseases in 
certain locations throughout the United States. As of May 2004, there 
were 11 EIP sites nationwide that involved partnerships among CDC, 
state and local public health departments, and academic centers. The 11 
EIP sites are California, Colorado, Connecticut, Georgia, Maryland, 
Minnesota, New Mexico, New York, Oregon, Tennessee, and Texas. The type 
of surveillance conducted by EIP sites depends on local priorities and 
expertise. For example, the Connecticut EIP conducts active 
surveillance for emerging tick-borne diseases in the state.

* FoodNet--A National Surveillance System for Monitoring Foodborne 
Diseases:

One of the principal systems used for surveillance of foodborne 
diseases is the Foodborne Disease Active Surveillance Network 
(FoodNet). FoodNet--a collaborative effort among CDC, USDA, FDA, and 
nine EIP sites[Footnote 27]--is a system that collects information 
about the occurrence and causes of certain types of foodborne 
outbreaks. FoodNet is used to detect cases or outbreaks of foodborne 
disease, identify their source, recognize trends, and respond to 
outbreaks. Public health departments that participate in FoodNet 
receive funds from CDC, USDA, and FDA to systematically contact 
laboratories in their geographical areas and solicit incidence data. 
According to CDC, as a result of this active solicitation, FoodNet 
provides more accurate estimates of the occurrence of foodborne 
diseases than are otherwise available.

* ESSENCE--A DOD Syndromic Surveillance System:

Similar to CDC, DOD maintains its own surveillance system. DOD's 
ESSENCE is a syndromic surveillance system designed to increase the 
rapid detection of disease outbreaks. DOD's system collects data on 
patient symptoms from military treatment facilities and selected 
civilian populations. ESSENCE then classifies these symptoms into 
syndrome groups based on presented signs, symptoms, and diagnoses. 
These syndrome groups include respiratory, fever/malaise/sepsis, 
gastrointestinal, neurologic, dermatologic, and coma or sudden death. 
The frequency of these syndromes can be monitored by DOD and 
participating state public health officials on a daily basis, and 
unusual increases can be detected through data analysis.

Federal Agencies and Departments Maintain Laboratories and Support 
Networks of Laboratories:

Federal agencies and departments also support networks of laboratories 
that test specimens and develop diagnostic tests for identifying 
infectious diseases and biological or chemical agents. In some cases, 
these laboratories provide highly specialized tests--such as tests for 
anthrax--that are not always available in state public health or 
commercial laboratories, and they assist states with testing during 
outbreaks. These laboratories help diagnose life-threatening or unusual 
infectious diseases for which satisfactory tests are not widely or 
commercially available, and they confirm public or private laboratory 
test results.[Footnote 28]

For example, to strengthen the nation's capacity to rapidly detect 
biological and chemical agents that could be used as a terrorist 
weapon, CDC, in partnership with the Federal Bureau of Investigation 
and the Association of Public Health Laboratories, created the 
Laboratory Response Network (LRN). According to CDC, the LRN, which was 
created in 1999, leverages the resources of 126 laboratories to 
maintain an integrated national and international network of 
laboratories that are fully equipped to respond quickly to acts of 
chemical or biological terrorism, emerging infectious diseases, and 
other public health threats and emergencies. The network includes the 
following types of laboratories--federal, state and local public 
health, military, and international laboratories, as well as 
laboratories that specialize in food, environmental, and veterinary 
testing. LRN laboratories have been used in several public health 
emergencies. For example, in 2001, a Florida LRN laboratory discovered 
the presence of Bacillus anthracis, the pathogen that causes anthrax, 
in a clinical specimen it tested.

CDC has also developed and operates PulseNet. PulseNet is a national 
network of public health laboratories that perform DNA "fingerprinting" 
on bacteria that may be foodborne.[Footnote 29] The network identifies 
and labels each "fingerprint" pattern and permits rapid comparison of 
these patterns through an electronic database at CDC. This network is 
intended to provide an early warning system for outbreaks of foodborne 
disease.

FDA's system, the Electronic Laboratory Exchange Network (eLEXNET), is 
a Web-based system for real-time sharing of food safety laboratory data 
among federal, state, and local agencies. It is a secure system that 
allows public health officials at multiple government agencies engaged 
in food safety activities to compare and coordinate laboratory analysis 
findings. According to FDA officials, it enables public health 
officials to assess risks and analyze trends, and it provides the 
necessary infrastructure for an early warning system that identifies 
potentially hazardous foods. As of July 2004, FDA officials said there 
were 113 laboratories representing 50 states that are part of the 
eLEXNET system.

DOD also maintains laboratories that perform and develop diagnostic 
tests for infectious diseases. For example, the U.S. Army Medical 
Research Institute of Infectious Diseases (USAMRIID)[Footnote 30] has 
the capability to diagnose infectious diseases that require relatively 
more advanced testing techniques. During the SARS outbreak, CDC 
requested assistance from USAMRIID to conduct laboratory testing 
related to the SARS investigation. USAMRIID is also a member of the 
LRN. In addition, DOD maintains a network of five overseas medical 
research laboratories that support worldwide efforts to detect and 
respond to infectious diseases.[Footnote 31] These five overseas 
laboratories primarily focus on surveillance for drug-resistant 
pathogens, unexplained fevers, and influenza. In addition, two of these 
overseas laboratories are WHO Collaborating Centers.[Footnote 32]

Like DOD and CDC, the USDA has laboratories that test for infectious 
diseases. USDA's National Veterinary Services Laboratories is the only 
federal program in the United States dedicated to testing for domestic 
and foreign animal diseases. In doing so, it supports surveillance for 
zoonotic diseases. The National Veterinary Services Laboratories have 
the ability to test for more than 100 diseases in animals, and some of 
these--such as rabies, anthrax, and BSE (also known as mad cow 
disease)--can be transmitted to humans. In addition, the National 
Animal Health Laboratory Network is a pilot program of diagnostic 
laboratories that provide animal disease surveillance testing and 
develop standardized and rapid diagnostic techniques.[Footnote 33] 
According to a USDA official, this network has improved zoonotic 
disease detection due to the use of better technology, improved 
coordination among the network laboratories, and improved disease 
reporting.

Federal Agencies and Departments Share Disease Surveillance Information:

As part of their role in national disease surveillance efforts, 
officials from federal agencies and departments share the surveillance 
information they collect and analyze with local, state, and 
international partners. One mechanism federal agencies and departments 
use to share information is their respective Internet sites. For 
example, in its annual "Summary of Notifiable Diseases," CDC posts on 
its Internet site the data it collects from state health departments. 
The agency also posts information on foodborne diseases on its FoodNet 
Internet page. During the SARS outbreak, CDC, USDA, FDA, DOD, and DHS 
posted information about the disease on their respective Web sites. Web 
site postings included information on clinical evaluation and 
diagnosis, travel advisories, and assessments of the impact of the 
outbreak on food consumption in various regions.

CDC also operates an early warning and response system, the Health 
Alert Network (HAN), that is designed to ensure that state and local 
health departments as well as other federal agencies and departments 
have timely access to emerging health information. Through HAN, CDC 
issues health alerts and other public health bulletins to an estimated 
1 million public health officials, including physicians, nurses, 
laboratory staff, and others. During the SARS outbreak, for instance, 
CDC used HAN to disseminate what the agency knew about the emerging 
infectious disease. Also, state officials we interviewed reported 
receiving updates through HAN on the avian influenza outbreak in Asia. 
According to CDC, as of March 2003, 89 percent of local health 
departments have high-speed continuous Internet access and the ability 
to receive broadcast health alerts.

CDC also shares information on infectious diseases through a restricted 
communication system, the Epidemic Information Exchange (Epi- 
X).[Footnote 34] Developed by CDC, this system is a secure, Web-based 
communication system operating in all 50 states. CDC uses this system 
primarily to share information relevant to disease outbreaks with state 
and local public health officials and with other federal officials. CDC 
uses Epi-X to issue emergency alerts, but unlike HAN, Epi-X also serves 
as a forum for routine professional discussions and non-emergency 
inquiries.[Footnote 35] Authorized Epi-X users can post questions and 
reports, query CDC, and receive feedback on ongoing infectious disease 
control efforts. According to CDC, as of 2004, over 1,200 public health 
officials at the federal, state, and local levels had used the system 
to communicate with colleagues and experts, track information for 
outbreak investigations and response efforts, conduct online 
discussions, and request assistance. In addition, according to CDC, it 
has agreements with Canada and Mexico that allow international public 
health officials to become authorized Epi-X users. These international 
users include officials from both the Canadian and Mexican Ministries 
of Health and health officials in Mexican states that border the United 
States. In addition, CDC staff assigned to WHO and health care 
providers working internationally for the U.S. Department of State are 
authorized Epi-X users.

Federal Agencies and Departments Provide Training, Technical 
Assistance, and Funding:

Federal agencies and departments also provide training, technical 
assistance, and funding to state and international public health 
officials. For example, to enhance the U.S. public health 
infrastructure for disease surveillance and response to infectious 
diseases, CDC operates several programs, including the Epidemiology and 
Laboratory Capacity (ELC) program, the Epidemic Intelligence Service 
(EIS) program, and EIP. The ELC program provides training, technical 
assistance, and funding to 58 state and local health departments. The 
program assists state and local health departments in maintaining 
surveillance for infectious diseases, providing technical support 
through laboratory services, and investigating outbreaks. Additionally, 
the EIS is a 2-year postgraduate program intended to increase the 
number of federally trained epidemiologists working in public health. 
While the majority of EIS officers train at CDC headquarters, others 
are trained at state and large local health departments. Graduates of 
the program are employed in federal government, state health 
departments and other health care settings. Further, the EIP--which is 
a collaboration among CDC, state health departments, and other public 
health partners--is a network of sites that acts as a national resource 
for the surveillance, prevention, and control of emerging infectious 
diseases. These sites conduct population-based surveillance for 
selected diseases or syndromes and research that go beyond the routine 
functions of local health departments to address issues in infectious 
diseases and public health. CDC provided nearly $20 million in funding 
to EIPs in fiscal year 2003 in order to support their surveillance and 
research activities.

In selected foreign locations, CDC operates international training 
programs, such as the Field Epidemiology Training Program (FETP). For 
more than 20 years, CDC has collaborated with foreign ministries of 
health around the world to help establish and conduct field 
epidemiology training programs in those countries. CDC officials said 
that through FETP, CDC trains approximately 50 to 60 physicians and 
social scientists each year from these countries. This training in 
applied public health integrates disease surveillance, applied 
research, prevention, and control activities. Graduates of the FETP 
program serve in their native country and provide links between CDC and 
their respective ministries of health. CDC officials said that trainees 
from its international programs have frequently provided important 
information on disease outbreaks. Another international program 
sponsored by CDC is the International Emerging Infections Program 
(IEIP). IEIP sites are modeled on the EIP sites in the United States 
that integrate disease surveillance, applied research, training, and 
prevention and control activities. According to CDC, the IEIP in 
Thailand that was established in 2001 played a key role in the global 
response to the SARS and avian influenza outbreaks. DOD has also taken 
steps to increase the international disease surveillance expertise by 
providing various types of laboratory and epidemiology training through 
its overseas laboratories.

Some federal agencies and departments also provide direct technical 
assistance to foreign countries both directly and through WHO. For 
example, CDC officials told us they provide support in the form of 
technical assistance and training that supports the development of 
major international networks that are critical to enhancing global 
surveillance, such as the WHO Global Influenza Surveillance Network. 
Additionally, throughout the SARS outbreak, CDC was the foremost 
participant in WHO's multilateral efforts to identify and respond to 
SARS in Asia, with CDC officials constituting about two-thirds of the 
115 public health experts deployed to the region. CDC also contributed 
its expertise and resources by conducting epidemiological studies, 
laboratory testing, and clinical research on the disease. Specifically, 
CDC assigned epidemiologists, laboratory scientists, hospital infection 
control specialists, and environmental engineers to provide technical 
assistance in Asia. CDC also assigned senior epidemiologists to work 
locally with a WHO team to investigate the outbreak in China.[Footnote 
36] DOD has also provided technical assistance during investigations of 
potential outbreaks. For example, DOD established a field laboratory 
during the Rift Valley fever epidemic in Yemen in 2000 to assist with 
surveillance during the outbreak.

Public Health Officials Have Implemented Initiatives Intended to 
Enhance Disease Surveillance, but Challenges Remain:

Public health officials at the state and federal level have undertaken 
several initiatives that are intended to enhance disease surveillance 
capabilities. Public health officials have implemented and expanded 
syndromic surveillance systems in order to detect outbreaks more 
quickly, but there are concerns that these systems are costly to run 
and still largely untested. Public health officials have also 
implemented initiatives designed to improve public health 
communications and disease reporting. However, some of these 
initiatives have not been fully implemented. Federal public health 
officials have also undertaken initiatives intended to improve the 
coordination of zoonotic surveillance efforts. Finally, federal 
officials have also expanded training programs for epidemiologists and 
other public health experts.

Public Health Officials Have Implemented and Expanded Syndromic 
Surveillance Systems, but There Are Some Concerns about the Value of 
This Type of Surveillance:

In an effort to enhance the ability to detect infectious disease 
outbreaks, particularly in their early stages, states have implemented 
numerous syndromic surveillance systems.[Footnote 37] Officials from 
each of the state public health departments we interviewed reported 
that at least one syndromic surveillance system was used in their 
state. These systems collect information on syndromes from a variety of 
sources. For example, the Real-time Outbreak and Disease Surveillance 
(RODS) system, used in four of the states in our study, automatically 
gathers patient data from hospital emergency room visits. This system 
identifies patients' chief medical complaints, classifies the 
complaints according to syndrome, and aggregates that data in order to 
look for anomalous increases in certain syndromes that may reveal an 
infectious disease outbreak.

Another syndromic surveillance system used by some state public health 
officials that we interviewed, the National Retail Data Monitor (NRDM), 
collects data from retail sources instead of hospitals. As of February 
2004, NRDM collected sales data from about 19,000 stores, including 
pharmacies, in order to monitor sales patterns in such items as over- 
the counter influenza medications for signs of a developing infectious 
disease outbreak. The system looks for unusual sales patterns--such as 
a spike in the number of over-the-counter medications purchased in a 
particular city or county--that might indicate the onset of an 
infectious disease outbreak. The system monitors the data automatically 
on a daily basis and generates summaries of sales patterns using 
timelines and maps.

At the federal level, CDC has recently introduced a new syndromic 
surveillance system called BioSense. BioSense aggregates data from 
numerous electronic sources to enhance early detection of possible 
disease outbreaks, bioterrorist threats, or other urgent public health 
threats. The data are collected and analyzed by CDC and also made 
available to state and local public health departments. In the first 
quarter of 2004, BioSense became available for use, gathering data from 
DOD and the Department of Veterans Affairs medical treatment facilities 
in the United States and more than 10,000 over-the-counter retail drug 
stores nationwide. According to CDC, the agency plans to add other data 
sources, such as data from laboratories, poison control centers, health 
plan medical records, nursing call centers, emergency medical service 
dispatches, health care provider billing claims, and pharmacy 
prescriptions.

Since the end of 2001, DOD has made enhancements designed to improve 
its syndromic surveillance system, ESSENCE. Specifically, DOD expanded 
ESSENCE to include data from all military treatment facilities 
worldwide and data from various civilian sources, such as civilian 
intensive care units, over-the-counter pharmacies, school attendance 
records and laboratory test results. In addition, DOD officials told us 
they are in the process of improving ESSENCE's mapping capabilities and 
developing more advanced statistical algorithms for identifying 
anomalous increases in syndromes. DOD officials also told us that they 
are exploring additional data sources for ESSENCE, such as large health 
maintenance organizations, and working on improving the speed at which 
the system's data can be accessed.

Although syndromic surveillance systems are used by federal agencies 
and departments and in all 11 of the states whose officials we 
interviewed, concerns about this approach to surveillance have been 
raised. Relative to traditional methods of surveillance, syndromic 
surveillance systems are costly to maintain and still largely untested. 
According to a recent IOM report, the resource requirements for 
automatic reporting of syndromic data from hospitals, clinics, and 
emergency departments are currently high, but these costs may lessen 
over time with standardization of software.[Footnote 38] Syndromic 
surveillance systems require relatively more resources to operate than 
other types of surveillance systems, in part, because their sensitivity 
makes them more likely to issue false alarms, which in turn have the 
potential to overtax public health systems. Furthermore, some state 
officials as well as public health experts noted that it has not been 
demonstrated in a rigorous way that these systems can detect emerging 
infectious diseases or bioterrorist events more rapidly than they would 
otherwise be detected through traditional surveillance. According to 
public health experts, evaluation tools, performance measures and 
evidence-based standards for syndromic surveillance are needed. CDC 
recently published a "Framework for Evaluating Public Health 
Surveillance Systems for Early Detection of Outbreaks."[Footnote 39] 
This framework creates a standardized evaluation methodology intended 
to help public health officials improve decision-making regarding the 
implementation of syndromic and other surveillance systems for outbreak 
detection.

Public Health Officials Are Implementing Initiatives Designed to 
Enhance Public Health Communications and Disease Reporting, but Some 
Initiatives Are Incomplete:

CDC is taking steps to enhance its two public health communications 
systems, HAN and Epi-X, which are used in disease surveillance and 
response efforts. For example, CDC is working to increase the number of 
HAN participants who receive assistance with their communication 
capacities. According to CDC, the agency will continue to increase the 
number of local jurisdictions that have high-speed Internet capability 
from 90 percent to 100 percent. Similarly, CDC has expanded Epi-X by 
giving officials at other federal agencies and departments, such as 
DOD, the ability to use the system. In addition, CDC is also adding 
users to Epi-X from local health departments, giving access to CDC 
staff in other countries, and making the system available to FETPs 
located in 21 countries. Finally, CDC is facilitating Epi-X's interface 
with other data sources by allowing users to access GPHIN, the system 
that searches Web-based media for information on infectious disease 
outbreaks worldwide.

In addition to the efforts to enhance communication systems, public 
health officials are taking steps to enhance the reporting of 
notifiable disease data and other surveillance information. Some of the 
state public health officials we interviewed told us that they have 
implemented efforts to increase health care providers' reporting of 
notifiable diseases to their state health department. For example, an 
official from one state we interviewed said that the state health 
department now uses liaisons that regularly visit health care providers 
to establish regular communication between the providers and local 
public health authorities. The liaisons remind the providers of their 
responsibility for reporting cases of notifiable diseases to the state. 
Similarly, the Commissioner of Health from another state sent letters 
to health care providers in the state, reminding the providers of their 
important role in recognizing an infectious disease outbreak or 
bioterrorist event. The letter contained information on changes to the 
state's notifiable disease list, a listing of references and Internet 
sites for clinical information on specific pathogens, and information 
on the Internet-based communication system the state department of 
health used to disseminate and gather sensitive information regarding 
disease surveillance.

Despite some states' efforts to increase disease reporting by health 
care providers, some public health experts believe that underreporting 
by providers is still a problem. According to the IOM, many health care 
providers do not fully understand their role in infectious disease 
surveillance, including the importance of prompt reporting of clinical 
information to relevant public health authorities. According to the 
study, few medical or other health science schools' curricula emphasize 
the importance of and the requirements for reporting diseases of public 
health significance; residency programs seldom address the need for 
health care provider participation in public health surveillance; and 
little, if any, continuing medical education exists on the topic, nor 
is it widely integrated into board certification exams. Furthermore, 
despite the existence of state notifiable disease lists and related 
laws, some providers may be unaware of basic reporting requirements. 
One study noted that health care providers failed to report disease 
information because they often lacked information about what, when, and 
how to report such information.[Footnote 40]

Other efforts by public health officials to enhance notifiable disease 
reporting target the information technology used in such reporting. For 
example, public health officials in several states told us that they 
are enhancing their electronic systems to permit providers in their 
states to report notifiable diseases to the states' health department. 
For example, public health officials in one state told us that they are 
enhancing their reporting system to permit 20,000 to 30,000 physicians 
to report 61 notifiable diseases using an integrated, secure, Web-based 
system. Similarly, some states have also implemented electronic 
reporting systems that obtain information on notifiable diseases 
directly from clinical laboratories. When the laboratories conduct 
tests for health care providers on cases that may involve notifiable 
diseases, in some states the results of those tests--if positive--are 
automatically reported to the state health department. Several state 
public health officials we interviewed told us that they receive 
electronic laboratory reports from clinical laboratories in their 
state. Other state officials told us that they were developing or 
piloting this capability. According to state public health officials 
and IOM, automated laboratory reporting of notifiable infectious 
diseases has been shown to improve the timeliness of reporting on these 
diseases.

At the federal level, CDC is deploying a technological initiative known 
as NEDSS. According to CDC, this initiative is designed to make the 
electronic reporting from both clinical laboratories and practitioners 
to state and local health departments and from state and local health 
departments to CDC more timely, accurate, and complete. CDC officials 
said that NEDSS will facilitate reporting by supporting a unified and 
standardized way of transmitting information to CDC, and result in the 
integration of 60 to 100 different systems used by state health 
departments to report disease data to CDC. As part of the NEDSS 
initiative, CDC is developing an architecture that consists of a set of 
standards that can be used for creating interoperable[Footnote 41] 
systems. These standards comprise (1) data standards,[Footnote 42] (2) 
parameters for an Internet-based communications infrastructure and (3) 
policy-level agreements on data access and sharing as well as on 
protections for confidentiality. CDC has also developed ready-to-use 
software--the NEDSS-Base system (NBS)--that operates within these 
standards. State and local health departments that are updating their 
reporting systems have the option of either using the NBS software or 
developing their own systems based on the common NEDSS architecture.

According to CDC, when fully implemented, the use of NEDSS- 
architecture-compliant-software or NBS software by local and state 
public health departments and CDC will allow public health partners to 
exchange data, merge data from different laboratories, and obtain 
information on cross-jurisdictional outbreaks. Whereas states currently 
use multiple and sometimes duplicative systems to report different 
notifiable diseases to CDC, NEDSS will replace many of these systems 
with a single system. For example, the National Electronic 
Telecommunications System for Surveillance (NETSS), STD*MIS (sexually 
transmitted diseases), TIMMS (tuberculosis), STELLAR (lead poisoning in 
children) and EHARS (HIV) will be consolidated through NEDSS.

Despite the advantages that may be gained from creating interoperable 
systems, the NEDSS initiative has not been implemented in many states. 
The NEDSS initiative first began in fiscal year 2000,[Footnote 43] and 
by May 2004, only 4 states that use the NBS software are able to 
transfer data to CDC. According to CDC, 10 states are actively 
deploying NEDSS-architecture-compliant-software or NBS software and 16 
states are in the preliminary process of developing their technical and 
security infrastructure to accommodate NEDSS standards. Some state 
officials told us that even though they have developed electronic 
systems that comply with the NEDSS standards, they have not been able 
to transfer data to CDC using their systems because the systems are 
still not compatible. CDC officials said that the national industry 
standards on design, development, and data transport have continued to 
evolve and they are working with the states to receive data from those 
who opted to use the NEDDS architecture to develop their own compliant 
software.[Footnote 44]

Federal Public Health Officials Have Enhanced Federal Coordination on 
Zoonotic Disease Surveillance and Expanded Training Programs, but 
Surveillance Efforts Still Face Challenges:

CDC, USDA, and FDA have made recent efforts to enhance their 
coordination of zoonotic disease surveillance. For example, CDC and 
UDSA are working with two national laboratory associations to enhance 
coordination of zoonotic disease surveillance by adding veterinary 
diagnostic laboratories to the LRN. As of May 2004, 10 veterinary 
laboratories have been added to the LRN, and CDC officials told us that 
they have plans to add more veterinary laboratories in the future. In 
addition, CDC officials told us it has appointed a staff person whose 
responsibility, in part, is to assist in finding ways to enhance 
zoonotic disease coordination efforts among federal agencies and 
departments and with other organizations. This person is helping CDC 
reconstruct a working group of officials from CDC, USDA, and FDA to 
coordinate on zoonotic disease surveillance.[Footnote 45] According to 
CDC officials, the goal of this working group is to explore ways to 
link existing surveillance systems to better coordinate and integrate 
surveillance for wildlife, domestic animal, and human diseases. CDC 
officials also said that the feasibility of a pilot project to 
demonstrate this proposed integrated zoonotic disease surveillance 
system is being explored. Finally, USDA officials told us that they 
hired 23 wildlife biologists in the fall of 2003 to coordinate disease 
surveillance, monitoring, and management activities among USDA, CDC, 
states and other agencies. While each of these initiatives is intended 
to enhance the surveillance of zoonotic diseases, each is still in the 
planning stage or the very early stages of implementation.

Another way CDC has worked to enhance disease surveillance is through 
its support for epidemiological training programs. In general, these 
programs are aimed at developing an experienced workforce for state and 
local public health departments and disease surveillance 
systems.[Footnote 46] For example, in recent years, CDC has expanded 
its EIS program. CDC has increased the number of participants in this 
program from 148 in 2001 to 167 in 2003. During this time period, CDC 
has also increased the number of EIS participants assigned to state and 
local health departments from 25-35 per year to about 50 per year. CDC 
has also enhanced the type of training the participants receive. All 
participants now receive training in terrorism preparedness and 
emergency response.

CDC has also expanded its training programs intended to increase the 
expertise involved in international disease surveillance efforts. For 
example, CDC is helping to implement a comprehensive system of 
surveillance and containment of global infectious diseases through the 
expansion of its IEIP and the creation of the Field Epidemiology and 
Laboratory Training Program (FELTP). CDC is enhancing a comprehensive 
global surveillance and response network for infectious diseases by 
adding two new IEIP sites in China and Kenya and by expanding 
activities in the existing site in Thailand. CDC officials said that 
the program in Kenya began in June 2004 and they may be able to begin 
recruitment for the program in China by the end of 2004. CDC is 
expanding its FETP program by creating a laboratory training component, 
known as the FELTP. According to CDC officials, FELTPs are designed to 
increase laboratory capacity in overseas locations. Currently, there is 
one FELTP located in Kenya whose students recently began their training 
program.

The efforts to build disease surveillance capacities abroad, which were 
discussed above, may also help domestic disease surveillance efforts. 
According to a recent IOM report, surveillance of and response to 
emerging infectious diseases in other parts of the world can directly 
benefit the United States as well as the country in which the disease 
is detected.[Footnote 47] According to the IOM, some disease outbreaks 
that have been detected internationally allowed the United States to 
develop diagnostic tests, prepare for influenza outbreaks, or recognize 
zoonotic threats like avian influenza. Similarly, the IOM points out 
that coordination between U.S. and European sentinel surveillance 
systems have allowed several countries, including the United States, to 
remove products from the market that were contaminated with pathogens.

On the other hand, efforts to enhance international disease 
surveillance still face challenges. Foremost among these are 
limitations in the amount of surveillance information that many 
countries can collect and therefore share with international partners. 
Many developing countries lack health care infrastructures and the 
ability to administer simple diagnostic tests for diseases such as 
tuberculosis. We have previously reported that few developing countries 
have public heath laboratories.[Footnote 48] Also, many developing 
countries lack the ability to compile basic health indices, such as 
death rates, causes of death, or general disease burden. Furthermore, 
even countries with public health infrastructures may lack developed 
surveillance systems for reporting crucial disease information to 
authorities. For example, officials in China noted that during the 
first SARS outbreak, a large number of cases in Beijing were not 
reported because there was no system to collect this information from 
hospitals in the city.

Concluding Observations:

The threat posed by infectious diseases has continued to grow as new 
diseases have emerged and as known diseases have reappeared with 
increased frequency. In addition, there are concerns about the threat 
posed by the deployment of infectious disease pathogens as instruments 
of terror or weapons of war. The U.S. surveillance system is built 
largely on cooperation among many different individuals and entities at 
the local level. State and federal initiatives to enhance their ongoing 
disease surveillance efforts are important to ensure that disease 
surveillance in the United States can meet the threat posed by 
infectious diseases. Some of these initiatives, such as improvements to 
information technology, offer the possibility of increasing the 
accuracy and timeliness of disease surveillance. As state and federal 
public health officials develop these initiatives, their ongoing 
evaluation efforts may help decision-makers address technical issues 
and allocate resources to the most effective disease surveillance 
systems.

Agency Comments and Our Evaluation:

HHS, USDA, and DOD reviewed a draft of this report. HHS provided 
written comments.

In its written comments, HHS stated that the draft captures many 
important issues in surveillance. However, HHS stated that the draft 
includes a discussion of programs that do not directly pertain to 
surveillance for emerging infectious diseases. In this report, we 
defined surveillance activities to include detecting and reporting 
cases of disease, analyzing and confirming this information to identify 
possible outbreaks or longer-term trends, and applying the information 
to inform public health decision-making; and the programs and 
surveillance systems discussed in this report fit within that 
definition.

HHS's written comments also stated that the report should characterize 
the essential purpose of the NEDSS initiative as an initiative designed 
to transform surveillance at the local and/or state health department 
level. It said that the current gap NEDSS seeks to address is primarily 
between the clinical sector and local and state public health 
departments. We have added information to indicate that NEDSS is 
designed to enhance the electronic reporting of information from both 
clinical laboratories and practitioners to state and local health 
departments and from state and local health departments to CDC.

HHS's written comments also pointed out that FDA does not collect 
surveillance reports on foodborne outbreaks as a part of a national 
surveillance system, but that CDC shares its findings with FDA. We have 
clarified the report to say that FDA analyzes state information it 
receives from CDC. HHS's written comments also suggested that 
information be added to the draft report. Specifically, it said that 
the draft report should have described the PulseNet network and should 
have included information on CDC's technical advice and training that 
supports major international networks, such as the WHO Global Influenza 
Surveillance Network. Although this report only provides examples of 
selected surveillance systems and we could not describe all systems, we 
have added some information on these networks.

Finally, HHS said that we should clarify that CDC is the lead agency 
for human disease surveillance and that it fulfills this responsibility 
in close collaboration with states, other federal agencies, WHO, and 
other partners. As we noted in the draft report, CDC is charged with 
protecting the nation's public health by directing efforts to prevent 
and control diseases and CDC has primary responsibility for conducting 
national disease surveillance.

HHS's comments are reprinted in appendix IV. In providing oral comments 
on a draft of this report, DOD said it concurred and did not have any 
substantive comments. USDA said it had no comments on the draft report. 
HHS and USDA provided technical comments that we incorporated where 
appropriate.

As agreed with your office, we plan no further distribution of this 
report until 30 days from its date of issue, unless you publicly 
announce its contents. At that time, we will send copies of this report 
to the Secretaries of Health and Human Services, Agriculture, and 
Defense; appropriate congressional committees; and other interested 
parties. We will also make copies available to others upon request. In 
addition, the report will be available at no charge on GAO's Web site 
at http://www.gao.gov.

If you or your staff have any questions about this report, please 
contact me at (202) 512-7119. Other contacts and staff acknowledgments 
are listed in appendix V.

Sincerely yours,

Signed by: 

Marjorie Kanof: 
Managing Director--Health Care Issues:

[End of section]

Appendix I: Scope and Methodology:

To describe how state and federal public health officials conduct 
disease surveillance, we reviewed state documents--such as state policy 
manuals, reports, cooperative agreements with the Centers for Disease 
Control and Prevention (CDC), and various other documents--from 11 
states. These states--California, Colorado, Indiana, Louisiana, 
Minnesota, New York, Pennsylvania, Tennessee, Texas, Washington, and 
Wisconsin--were selected based on their participation in CDC's Emerging 
Infections Program, each state's most recent infectious disease 
outbreak, and their geographic location. Of these 11 states, 
California, Colorado, Minnesota, New York, Tennessee, and Texas 
participate in CDC's Emerging Infections Program. We also conducted 
structured interviews of state public health officials from these 
states. In addition to our structured questions, we asked public health 
officials from Colorado, Louisiana, and New York questions about their 
most recent West Nile outbreak. We asked public health officials from 
Indiana and Wisconsin questions about their monkeypox outbreak, and 
public health officials from Pennsylvania and Tennessee about their 
hepatitis A outbreak. We asked public health officials from the 
remaining states--California, Minnesota, Texas, and Washington--to 
describe their respective experiences with their most recent infectious 
disease outbreak, which included outbreaks of wound botulism and severe 
acute respiratory syndrome (SARS). We also reviewed documents and 
interviewed officials from the Departments of Agriculture, Defense, and 
Homeland Security; CDC, and the Food and Drug Administration. In 
addition, we interviewed representatives from professional associations 
representing state and local public health officials. These 
associations included the Association of Public Health Laboratories, 
the Association of State and Territorial Health Officials, Council of 
State and Territorial Epidemiologists, and the National Association of 
County and City Health Officials. We reviewed related publications by 
these professional organizations, including studies and position papers 
written by these associations.

To identify initiatives intended to enhance disease surveillance, we 
reviewed information on states' initiatives designed to enhance 
infectious disease surveillance, including the use of syndromic 
surveillance systems, information technology systems, and journal 
articles assessing the value of syndromic surveillance systems. We also 
interviewed public health officials from the 11 states and 
representatives from professional associations about their assessments 
of enhancements and continuing concern in infectious disease 
surveillance efforts. To identify federal initiatives to enhance 
disease surveillance, we reviewed related federal documents, including 
federal policy directives, agency and departmental strategies, and 
annual reports. In addition, we interviewed federal health officials 
involved in disease surveillance, asking them about efforts to enhance 
existing surveillance programs and activities. We also reviewed reports 
and recommendations published by the Institute of Medicine related to 
emerging infectious diseases. We focused our review of initiatives 
intended to enhance surveillance on those currently underway or 
implemented since 2001. We conducted our work from October 2003 through 
July 2004 in accordance with generally accepted government auditing 
standards.

[End of section]

Appendix II: Information on Nationally Notifiable Infectious Diseases 
and Selected Worldwide Emerging Infectious Diseases:

This appendix provides descriptions of the diseases contained on the 
U.S. List of Nationally Notifiable Infectious Diseases for 2004 as well 
as other selected worldwide emerging infectious diseases.

Description of U.S. List of Nationally Notifiable Infectious Diseases, 
2004:

Acquired immunodeficiency syndrome (AIDS) is caused by the human 
immunodeficiency virus (HIV), which progressively destroys the body's 
immune system. AIDS patients may contract opportunistic infections that 
usually do not make healthy people sick. Symptoms of opportunistic 
infections common in people with AIDS include coughing and shortness of 
breath, seizures, difficult or painful swallowing, fever, vision loss, 
nausea, weight loss and extreme fatigue, severe headaches, and coma. 
The term AIDS applies to the most advanced stages of HIV infection.

Anthrax is an acute infectious disease caused by a bacterium commonly 
found in the soil. Although anthrax can infect humans, it occurs most 
commonly in plant-eating animals. Human anthrax infections have usually 
resulted from occupational exposure to infected animals or contaminated 
animal products. Anthrax infection can take one of three forms: 
cutaneous, usually through a cut or an abrasion; gastrointestinal, 
usually by ingesting undercooked contaminated meat; or inhalation, by 
breathing airborne anthrax spores into the lungs. The symptoms are 
different for each form and usually occur within 7 days of exposure. 
Anthrax can be treated with antibiotics and a vaccine is available.

Botulism is a muscle-paralyzing disease caused by a bacterial toxin. 
Symptoms of botulism include double vision, blurred vision, drooping 
eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle 
weakness that always descends through the body. Paralysis of breathing 
muscles can cause a person to stop breathing and die, unless mechanical 
assistance is provided. An antitoxin exists that is effective in 
reducing the severity of symptoms if administered early in the course 
of the disease.

Brucellosis, a disease of animals, is transmitted to humans through 
contact with infected animals or contaminated milk. Infection produces 
a wide range of symptoms, including fever, generalized aches and pains, 
and fatigue, which may last from a few weeks to several months. 
Brucellosis can be treated with antibiotics.

Chancroid is a highly contagious sexually transmitted disease (STD) 
caused by a bacterial infection. Transmission results through either 
skin-to-skin contact with open sore(s) or when contact is made with the 
pus-like fluid from the ulcer. Chancroid causes ulcers, usually of the 
genitals and if left untreated, may facilitate the transmission of HIV. 
Chancroid can successfully be treated with antibiotics.

Chlamydial infection is a STD resulting from a bacterial infection. One 
of the most widespread bacterial STDs in the United States, genital 
chlamydial infection can occur during oral, vaginal, or anal sexual 
contact with an infected partner. Because chlamydial infection does not 
make most people sick, infected persons may not know they have it and 
symptoms that do develop may be mild. Chlamydial infection is treated 
with antibiotics. However, if left untreated, it can lead to serious 
illnesses.

Cholera is a bacterial illness that is contracted by ingesting 
contaminated water or food. Infection results in acute watery diarrhea, 
leading to extreme dehydration and death if left unaddressed. Known 
vaccines and antibiotics have only limited impact on the disease-- 
treatment focuses on rehydration. In the United States, cholera has 
been virtually eliminated by modern sewage and water treatment systems. 
However, travelers have brought contaminated seafood back to the United 
States resulting in foodborne outbreaks.

Coccidioidomycosis is a disease caused by a fungus that grows as a mold 
in the soil. It is transmitted through inhalation after a disturbance 
of contaminated soil by humans or natural disasters, such as 
earthquakes and usually presents as a flu-like illness with symptoms 
such as fever, cough, headaches, and rash. Although most infections are 
undetectable, it can cause serious and life-threatening infections, 
especially among the immunosuppressed. The disease causing fungus is 
endemic in soil in semiarid areas, including the Southwestern United 
States. Various drugs are now available to treat this disease.

Cryptosporidiosis is caused by a microscopic parasite and can be spread 
through contaminated water, uncooked contaminated foods, including 
fruits and vegetables, and any surface that has been in contact with 
the parasite. Symptoms include diarrhea, stomach cramps or upset 
stomach, and a slight fever. People with weak immune systems may have 
more serious reactions. There is currently no consistently effective 
treatment for this disease.

Cyclosporiasis is a foodborne illness caused by a microscopic parasite 
that infects the small intestine. Humans contract the illness by 
ingesting contaminated water or food. Cyclosporiasis usually results in 
watery diarrhea. Other symptoms can include loss of appetite, 
substantial weight loss, bloating, stomach cramps, nausea, muscle 
aches, and fatigue. This disease is often treated with a combination of 
two antibiotics.

Diphtheria is a respiratory disease occurring worldwide that is spread 
through coughing and sneezing. Symptoms range from mild to severe and 
can be complicated by damage to the heart muscle or peripheral nerves. 
Treatment for diphtheria consists of immediate administration of 
diphtheria antitoxin and antibiotics.

Ehrlichiosis is the general name used to describe several bacterial 
diseases that affect humans and animals. In the United States, the 
disease is transmitted through the bite of an infected tick. Early 
clinical presentations of ehrlichiosis may resemble nonspecific signs 
and symptoms of various other infectious and non-infectious diseases, 
such as fever, headache, and muscle ache. In some cases, patients 
develop a very mild form of the disease and may not seek medical 
attention or present any symptoms. In other cases, Ehrlichiosis may be 
treated with an antibiotic. The disease occurs primarily in the 
southeastern and south central regions of the United States.

Encephalitis, Arboviral is an inflammation of the brain that may be 
caused by arthropod-borne viruses, also called arboviruses. Six types 
of arboviral encephalitides are present in the United States--eastern 
equine encephalitis, western equine encephalitis, St. Louis 
encephalitis, La Crosse encephalitis, and West Nile encephalitis, all 
of which are transmitted by mosquitoes, and Powassan encephalitis, 
which is transmitted by ticks. The majority of human infections are 
asymptomatic or may result in a nonspecific flu-like syndrome. However, 
in a small proportion of cases, infections may lead to death or 
permanent neurologic damage. No effective antiviral drugs have been 
discovered and there are no commercially available human vaccines for 
these diseases.

Enterohemorrhagic Escherichia coli (E. coli) is a bacterium that 
includes multiple serotypes, such as E. coli O157:H7, that can cause 
gastroenteritis in humans. E. coli is normally found in the intestines 
and serves a useful function in the body. However, a minority of E. 
coli strains are capable of causing human illness. Transmission occurs 
by ingesting contaminated food or water. Infections vary in severity 
and may be characterized by diarrhea (often bloody) and abdominal 
cramps. The illness is usually self-limited and lasts for an average of 
8 days.

Giardiasis is a diarrheal illness caused by a one-celled, microscopic 
parasite in the intestines of humans and animals. It has become 
recognized as one of the most common causes of waterborne disease in 
humans in the United States. Humans may contract the disease by 
accidentally swallowing the parasite, such as through swallowing 
contaminated water or eating uncooked, contaminated food. Symptoms of 
giardiasis include diarrhea, loose or watery stool, stomach cramps, and 
upset stomach. Several drugs are available to treat this disease.

Gonorrhea is a bacterial STD that infects the genital tract, the mouth, 
and the rectum. Gonorrhea is transmitted during sexual intercourse and 
affects both women and men. Symptoms in women include bleeding 
associated with vaginal intercourse and painful or burning sensations 
when urinating. Symptoms in men include pus from the penis and pain and 
burning sensations during urination. Gonorrhea is usually treated with 
antibiotics.

Haemophilus influenzae is a bacterium found in the nose and throat that 
is transmitted through direct contact with respiratory droplets from a 
carrier or patient. It causes a variety of illnesses including 
meningitis (inflammation of the coverings of the spinal column and 
brain), bacteremia (infection of the blood), pneumonia (infection of 
the lungs), and septic arthritis (infection of the joints). Serious 
infections are treated with specific antibiotics.

Hansen's disease (leprosy) is a chronic bacterial infection for which 
the exact mode of transmission is not fully understood. However, most 
investigators think that the bacterium is usually spread from human-to- 
human through respiratory droplets. Primarily affecting the skin, 
nerves, and mucous membranes, leprosy causes deformities of the face 
and extremities after many years but those receiving antibiotic 
treatment are considered free of active infection.

Hantavirus pulmonary syndrome is caused by several strains of a virus 
that is transmitted by exposure to infected rodents. Symptoms include 
fever, fatigue, muscle aches, coughing, and shortness of breath; the 
onset of respiratory distress often leads to death. There is no 
specific treatment for the disease, other than appropriate management 
of respiratory problems. The virus was first identified in the 
Southwestern United States in 1993.

Hemolytic uremic syndrome is one of the most common causes of sudden, 
short-term kidney failure in children. Most cases occur after an 
infection of the digestive system by a specific E. coli bacterium. It 
develops when the bacteria lodged in the digestive system make toxins 
that enter the bloodstream and start to destroy red blood cells. 
Symptoms may not become apparent until a week after the digestive 
problems and include, paleness, tiredness, and irritability, as well as 
small, unexplained bruises or bleeding from the nose or mouth. 
Treatments usually consist of maintaining normal salt and water levels 
in the body, but may include blood transfusions.

Hepatitis A is an acute viral infection of the liver. Human-to-human 
transmission of hepatitis A often occurs by placing something 
contaminated in the mouth. Symptoms include jaundice, fatigue, 
abdominal pain, loss of appetite, nausea, diarrhea, and fever. A 
vaccine is available for protection against hepatitis A and once a 
person has had the disease, it cannot be contracted again.

Hepatitis B is a viral infection of the liver that is transmitted by 
contact with the body fluids of an infected person. The virus may cause 
an acute illness, as well as a life-long infection that carries a high 
risk of serious illness or eventual death from liver cancer or 
cirrhosis. Symptoms include jaundice, fatigue, abdominal pain, loss of 
appetite, nausea, vomiting, and joint pain. An effective vaccine that 
has been available for this disease since 1982 is the best protection 
against hepatitis B. Treatment is also available for chronic hepatitis 
B.

Hepatitis C is a viral infection of the liver that may be either acute 
or chronic and is transmitted by contact with the body fluids of an 
infected person. Symptoms of this disease include jaundice, fatigue, 
dark urine, abdominal pain, loss of appetite, and nausea. There is 
currently no vaccine available for hepatitis C; however two drugs are 
available for treatment.

Human immunodeficiency virus (HIV) causes AIDS and is transmitted 
through contact with the body fluids of an infected person or from 
mother to baby. Infected adults may be asymptomatic for 10 years or 
more. Because the immune system is weakened there is eventually greater 
susceptibility to opportunistic diseases such as pneumonia and 
tuberculosis. Drugs are available that can prevent transmission from 
pregnant mothers to their unborn children and can help slow the onset 
of AIDS.

Legionellosis is a bacterial infection that has two distinct forms-- 
Legionnaires' disease, the more severe form of infection, which 
includes pneumonia, and Pontiac fever, a milder illness. Legionellosis 
outbreaks have often occurred after persons have breathed mists that 
come from a contaminated water source. Symptoms for Legionnaires' 
disease usually include fever, chills, and a cough. Chest X-rays often 
show pneumonia; however additional tests are needed to confirm 
diagnosis. Those with Pontiac fever experience fever and muscle aches 
and do not have pneumonia. Legionnaires' disease is treated with 
antibiotics, while those with Pontiac fever generally recover without 
treatment.

Listeriosis is a bacterial foodborne illness. The disease affects 
primarily pregnant women, newborns, and adults with weakened immune 
systems and is spread through the consumption of contaminated food. 
Symptoms of listeriosis include fever, muscle aches, and, at times, 
gastrointestinal symptoms, such as nausea or diarrhea. Listeriosis is 
treated with antibiotics.

Lyme disease is a bacterial illness transmitted by ticks. The area 
around the tick bite sometimes develops a "bull's eye" rash, typically 
accompanied by fever, headache, and musculoskeletal aches and pains. 
There is an effective vaccine for adults at high risk. If untreated by 
antibiotics, arthritis, neurologic abnormalities, and--rarely--cardiac 
problems may follow. The disease is rarely, if ever, fatal and is 
endemic in North America and Europe. The pathogen for Lyme disease was 
first detected in the United States in 1982.

Malaria is a parasitic disease transmitted by infected mosquitoes. 
Symptoms include fever, shivering, joint pain, headache, repeated 
vomiting, severe anemia, convulsions, coma, and, in severe cases, 
death. Malaria is becoming increasingly resistant to known antimalarial 
treatments and is now reemerging in countries where it was once under 
control.

Measles is a highly contagious viral disease, transmitted through human-
to-human contact, such as by coughing or sneezing. It often strikes 
children and causes fever, conjunctivitis, congestion, and cough, 
followed by a rash. Secondary infections often cause further 
complications. A measles vaccine is available.

Meningococcal disease, caused by a particular type of bacteria, is 
transmitted by human-to-human contact and is characterized by sudden 
onset of fever, headache, neck stiffness, and altered consciousness. 
There is a vaccine for this disease, but it loses its effectiveness 
over time and must be repeated.

Mumps is a viral disease of the lymph nodes, transmitted though human- 
to-human contact, such as by coughing or sneezing. Symptoms include 
fever, headache, muscle ache, and swelling of the lymph nodes close to 
the jaw. A vaccine is available to prevent mumps.

Pertussis (whooping cough) is a highly contagious bacterial disease 
transmitted though human-to-human contact, such as by coughing or 
sneezing. Symptoms include runny nose and sneezing, a mild fever, and a 
cough that gradually becomes more severe, turning into coughing spasms 
that end in vomiting and exhaustion. Pertussis is treatable with 
antibiotics, and a pertussis vaccine is available.

Plague, a severe bacterial infection, is usually transmitted to humans 
by infected rodent fleas (bubonic plague) and uncommonly by human-to- 
human respiratory exposure (pneumonic plague). Symptoms of bubonic 
plague include swollen, painful lymph glands, fever, chills, headache, 
and exhaustion. People with pneumonic plague develop cough, bloody 
sputum, and breathing difficulty. Plague is treatable with antibiotics 
if diagnosed early.

Poliomyelitis, paralytic (polio) is a virus transmitted through human- 
to-human contact. In most cases, there are no symptoms or only mild, 
flu-like symptoms. However, it may lead to debility of the lower 
extremities. Although there is no cure, an effective vaccine is 
available.

Psittacosis (parrot fever) is a bacterial infection that is spread from 
birds to humans. Humans become infected by inhaling aerosolized dried 
bird droppings and by handling infected birds. Symptoms of psittacosis 
include fever, headache, rash, chills, and sometimes pneumonia. The 
disease is treatable with antibiotics.

Q Fever is a bacterial disease that is spread from livestock or 
domesticated pets to humans. Infection of humans usually occurs by 
inhalation of barnyard dust contaminated with animal fluids. Symptoms 
for Q fever are not specific to this disease, making it difficult to 
make an accurate diagnosis without appropriate laboratory testing. 
However, most acute cases begin with a sudden onset of symptoms such as 
high fevers, severe headache, confusion, sore throat, nausea, vomiting, 
abdominal pain, and chest pain. Q fever is treated with antibiotics.

Rabies is a viral disease transmitted through contact with saliva of 
infected animals. Symptoms progress from respiratory, gastrointestinal, 
or central nervous system affliction to hyperactivity to complete 
paralysis, coma, and death. Once symptoms start to appear, the disease 
is not treatable. Multiple-dose courses of vaccine and immunoglobulin 
can be used to prevent onset of the disease if administered immediately 
after contact with a suspected carrier.

Rocky Mountain spotted fever is a bacterial disease spread to humans by 
ticks. It can be difficult to diagnose in the early stages. Initial 
signs and symptoms of the disease include sudden onset of fever, 
headache, and muscle pain, followed by the development of a rash. 
Without prompt and appropriate treatment of antibiotics, it can be 
fatal.

Rubella is a viral disease that is transmitted through human-to-human 
contact, such as by coughing and sneezing. Symptoms of this disease 
include a rash, conjunctivitis, low fever, and nausea. Natural rubella 
infection normally confers lifelong immunity. A number of vaccines for 
rubella are also available.

Congenital rubella syndrome is a form of rubella that is characterized 
by multiple defects, particularly to the brain, heart, eyes, and ears. 
This syndrome is an important cause of hearing and visual impairment 
and mental retardation in areas where the mild form of rubella has not 
been controlled or eliminated. The primary purpose of the rubella 
vaccine is to prevent the occurrence of this disease.

Salmonellosis (salmonella infection) is a bacterial infection 
transmitted to humans by eating contaminated foods. Most persons 
infected with salmonella develop diarrhea, fever, and abdominal cramps. 
Infections often do not require treatment unless the patient becomes 
severely dehydrated or the infection spreads from the intestines. In 
this latter instance, antibiotics are used to treat salmonellosis.

Severe acute respiratory syndrome (SARS) is an emerging, viral 
respiratory illness that seems to be transmitted primarily through 
close human-to-human contact, such as through coughing and sneezing. In 
general, SARS begins with a high fever. Other symptoms may include 
headache, an overall feeling of discomfort, and body aches. Some people 
also have mild respiratory symptoms at the onset and may develop a dry 
cough and most patients develop pneumonia. Currently, there is no 
definitive test to identify SARS during the early phase of the illness, 
which complicates diagnosis. Furthermore, there is no specific 
treatment for SARS. SARS was first reported in Asia in February 2003.

Shigellosis is a highly contagious, diarrheal disease caused by four 
strains of bacteria and is transmitted by human-to-human contact and 
contaminated food and water. One of these strains, an unusually 
virulent pathogen, causes large-scale, regional outbreaks of dysentery 
(bloody diarrhea). In addition to diarrhea, patients experience fever, 
abdominal cramps, and rectal pain. The disease is treatable by 
rehydration and antibiotics.

Smallpox is an acute, contagious, and sometimes fatal viral disease 
transmitted through human-to-human contact. Symptoms usually begin with 
high fever, head and body aches, and sometimes vomiting. A rash follows 
that spreads and progresses to raised bumps and pus-filled blisters 
that eventually fall off, leaving pitted scars. There is no treatment 
for smallpox. However, it can be prevented through use of the smallpox 
vaccine.

Streptococcal disease (invasive Group A) is a bacterial disease 
transmitted through direct contact with an infected person's mucus or 
through contact with wounds or sores on the skin. Invasive group A 
streptococcus (GAS) infections occur when bacteria get into parts of 
the body where they are not usually found, such as the blood, muscle, 
or lung. GAS infections can be treated with many different antibiotics.

Streptococcal toxic shock syndrome (STSS) is one of the most severe, 
but least common forms of invasive GAS diseases. STSS, which is not 
spread from human-to-human, causes blood pressure to rapidly drop and 
organs to fail. Symptoms include fever, dizziness, confusion and a flat 
red rash over large areas of the body. Early treatment of GAS 
infections with antibiotics may reduce the risk of death from invasive 
GAS disease.

Streptococcus pneumoniae is a bacterium that includes more than 90 
strains and is transmitted through human-to-human contact. It is the 
cause of multiple diseases, including pneumonia, bacteremia, 
meningitis, and sinusitis. Some strains of this bacterium are becoming 
resistant to one or more antibiotics. CDC and several states are 
currently conducting additional surveillance for the resistant forms of 
this bacterium.

Syphilis is a bacterial STD with signs and symptoms that are 
indistinguishable from those of other diseases. Syphilis is passed from 
person-to-person through direct contact with a syphilis sore and 
progresses through three stages. The primary stage is usually marked by 
the appearance of a single sore. The second stage is involves a skin 
rash and mucous membrane lesions. Finally, the late stage begins when 
secondary symptoms disappear. Many people infected with syphilis do not 
have any symptoms for years yet remain at risk for late complications 
if they are not treated. Syphilis is easy to treat in its early stages, 
usually with antibiotics.

Tetanus (lockjaw) is caused by a bacterium found in the intestines of 
many animals and in the soil. It is transmitted to humans through open 
wounds. Symptoms include generalized rigidity and convulsive spasms of 
the skeletal muscles. Tetanus can be treated with an antitoxin, and 
there is an effective vaccine.

Toxic shock syndrome is a bacterial disease that develops when the 
disease-causing bacterium colonizes skin and mucous membranes in 
humans. This disease has been associated with the use of tampons and 
intravaginal contraceptive devices in women and occurs as a 
complication of skin abscesses or surgery. Characterized by sudden 
onset of fever, chills, vomiting, diarrhea, muscle aches, and rash, 
toxic shock syndrome can rapidly progress to severe and intractable 
hypotension and multisystem dysfunction. Treatment usually includes the 
use of antibiotics and supportive treatment to prevent dehydration and 
organ failure.

Trichinosis (trichinellosis) is food-borne illness caused by eating raw 
or undercooked pork and wild game products infected with a species of 
worm larvae. It cannot be spread from human-to-human, but only through 
consumption of contaminated food. Symptoms include nausea, diarrhea, 
vomiting, fatigue, fever, and abdominal discomfort, followed by 
additional symptoms, such as headaches, fevers, chills, aching joints, 
and muscle pains. Several drugs are available to treat trichinosis.

Tuberculosis is a bacterial disease that is usually transmitted by 
contact with an infected person. People with healthy immune systems can 
become infected but not ill. Symptoms of tuberculosis can include a bad 
cough, coughing up blood, pain in the chest, fatigue, weight loss, 
fever, and chills. Several drugs can be used to treat tuberculosis, but 
the disease is becoming increasingly drug resistant.

Tularemia is caused by a bacterium often found in animals. Humans can 
contract tularemia in different ways, including being bitten by an 
infected tick or other insect, handling infected animal carcasses, by 
ingesting contaminated food or water, or by inhaling the bacterium. 
Symptoms of this disease can include sudden fever, chills, headaches, 
muscle aches, joint pain, dry cough, and progressive weakness. 
Tularemia is often treated with antibiotics.

Typhoid fever is a bacterial illness transmitted through contaminated 
food and water. Symptoms include high fever, stomach pains, and in some 
cases a rash. It is treatable by antibiotics and there is also a 
vaccine available, although it is not always effective.

Vancomycin-Intermediate/Resistant Staphylococcus aureus are specific 
bacteria resistant to the antimicrobial agent vancomycin. Persons that 
develop these infections have certain characteristics such as having 
several underlying health conditions (such as diabetes and kidney 
disease), recent hospitalizations, and recent exposure to vancomycin 
and other antimicrobial agents. Despite their resistance to vancomycin, 
these infections can be treated with several drugs.

Varicella (chickenpox) is highly infectious, viral disease that spreads 
from human-to-human contact, such as through coughing or sneezing. It 
results in a blister-like rash that appears first on the trunk and 
face, but can spread over the entire body. Other symptoms include 
itching, tiredness, and fever. Multiple drug treatments and a vaccine 
for varicella are available.

Yellow fever is a mosquito-borne viral disease that occurs in tropical 
and subtropical areas. The yellow fever virus is transmitted to humans 
through a specific mosquito. Symptoms include fever, muscle pain, 
headache, loss of appetite, and nausea. There is no treatment for 
yellow fever beyond supportive therapies. A vaccine for yellow fever is 
available.

Selected Worldwide Emerging Infectious Diseases:

Variant Creutzfeldt-Jakob disease (vCJD) is a rare, degenerative, fatal 
brain disorder in humans. It is believed that vCJD is contracted 
through the consumption of cattle products contaminated with the agent 
of bovine spongiform encephalopathy (BSE) or "mad cow disease"--a 
slowly progressive, degenerative, fatal disease affecting the central 
nervous system of adult cattle. There is no known treatment of vCJD.

Dengue fever is a mosquito-borne infection that results in a severe, 
flu-like illness with specific symptoms that vary based on the age of 
the victim. Dengue hemorrhagic fever is a potentially lethal 
complication that may include convulsions. There is no vaccine for 
dengue fever, nor is there any treatment beyond supportive therapy.

Ebola hemorrhagic fever, a viral disease, is transmitted by direct 
contact with the body fluids of infected individuals, causing acute 
fever, diarrhea that can be bloody, vomiting, internal and external 
bleeding, and other symptoms. There is no known cure, although some 
measures, including rehydration, can improve the odds of survival. 
Ebola kills more than half of those it infects. Identified for the 
first time in 1976, the Ebola virus is still considered rare, but there 
have been a number of outbreaks in central Africa.

Echinococcosis (Alveolar Hydatid disease) is caused by a parasitic 
tapeworm found mostly in the Northern Hemisphere. The disease is 
transmitted to humans when they swallow the tapeworm eggs, either on 
contaminated food, or after contact with an animal carrier. Symptoms 
are slow to appear, usually involving the liver--and may mimic liver 
cancer or cirrhosis--and can include abdominal pain, weakness, and 
weight loss. Surgery is the most common form of treatment, although 
follow-up medication is often needed.

Hendra virus infection occurs in both humans and many species of 
animals. In humans, it causes a respiratory disease that is often 
fatal. It was discovered in 1994, and has not been found outside of 
Australia.

Human monkeypox is a rare viral disease caused by a virus related to 
smallpox. It is transmitted to humans through contact with infected 
animals as well as through human-to-human contact. In humans, symptoms 
of monkeypox are similar to smallpox, but usually they are milder. 
Monkeypox symptoms include fever, muscle ache, swelling of the lymph 
nodes, and a fluid-filled rash. The first case of monkeypox in the 
United States occurred in June 2003. There is no specific treatment for 
monkeypox but the smallpox vaccine may offer protection against the 
disease.

Influenza A, H5N1 (avian influenza) is a type of influenza that infects 
birds and may be transmitted to humans. Symptoms of avian influenza in 
humans range from typical influenza-like symptoms to eye infections, 
pneumonia, acute respiratory distress, and other severe and life- 
threatening complications.

Lassa fever is a viral disease, transmitted through contact with 
infected rats. Symptoms include deafness, fever, nausea, vomiting, 
diarrhea, and, in more severe cases, seizures and hemorrhage. This 
disease is difficult to distinguish from several other diseases. No 
vaccine is currently available, although ribavirin has been used as a 
preventive measure as well as to treat the disease.

Marburg hemorrhagic fever is a rare and severe viral disease that 
affects both humans and animals. The mode of transmission from animals 
to humans is unknown. However, humans who become ill may spread the 
virus to other people. The onset of the disease is sudden and includes 
fever, chills, and headache. Symptoms progress to include a rash, 
nausea, vomiting, and chest pain as well as jaundice, inflammation of 
the pancreas, shock, massive hemorrhaging, and multi-organ dysfunction. 
Because many of the signs and symptoms of Marburg fever are similar to 
other infectious diseases, it may be difficult to diagnose. A specific 
treatment for this disease is unknown.

Nipah virus is an emerging disease causing encephalitis. It is believed 
to be transmitted through contact with infected pigs. Symptoms include 
headache, fever, muscle spasms, coma, and brain damage. There is no 
treatment beyond alleviation of symptoms.

O'nyong-nyong fever is a viral illness spread by mosquitoes. It causes 
symptoms such as joint pain, rash, high fever, and eye pain. Fatalities 
are rare.

Rift Valley fever is a viral disease that primarily affects animals-- 
including domesticated livestock--but can be transmitted to people by 
mosquitoes or contact with the body fluids of infected animals. Rift 
Valley fever usually causes a flu-like illness lasting 4 to 7 days, but 
can develop into a more severe hemorrhagic fever that can result in 
death. There is no established course of treatment for infected 
patients. The disease has occurred in many parts of Africa and, in 
September 2000, was for the first time reported outside of Africa, in 
Saudi Arabia and Yemen.

Venezuelan equine encephalitis is a mosquito-borne viral disease that 
can be transmitted to humans from equine hosts. Symptoms in humans 
include flu-like symptoms of fever and headache. Severe illness and 
death can occur in the young and the elderly and those with weakened 
immune systems. The only treatment available is supportive therapy.

West Nile virus is a mosquito-borne viral disease that is transmitted 
to humans through infected mosquitoes. Many people infected with the 
virus do not become ill or show symptoms. Symptoms that do appear may 
be limited to headache, sore throat, backache, or fatigue. There is no 
vaccine for the West Nile virus, and no specific treatment besides 
supportive therapies. The disease occurs in Africa, Eastern Europe, 
West Asia, and the Middle East. This disease appeared for the first 
time in the United States in 1999.

[End of section]

Appendix III: Selected List of Systems and Networks Engaged in Disease 
Surveillance:

Below we describe selected electronic systems and networks to support 
disease surveillance that are discussed in this report. This list 
encompasses electronic communications and surveillance systems as well 
as networks of laboratories and public health officials engaged in 
disease surveillance.

BioSense:

BioSense is a syndromic surveillance system operated by CDC. BioSense 
aggregates syndromic data from a variety of electronic sources to 
improve early detection of possible disease outbreaks, bioterrorism 
threats, or other urgent public health threats. The data are collected 
and analyzed by CDC and also made available to state and local public 
health agencies. Data sources include patient encounters from the 
Department of Defense's medical treatment facilities in the United 
States, the Department of Veterans Affairs' medical facilities, 
national clinical laboratory test orders, and more than 10,000 over- 
the-counter retailers nationwide.

Electronic Laboratory Exchange Network (eLEXNET):

eLEXNET is a Web-based system for real-time sharing of food safety 
laboratory data among federal, state, and local agencies. It is a 
secure system that allows public health officials at multiple 
government agencies engaged in food safety activities to compare and 
coordinate laboratory analysis findings. According to FDA officials, it 
enables public health officials to assess risks, and analyze trends, 
and it provides the necessary infrastructure for an early warning 
system that identifies potentially hazardous foods. As of July 2004, 
FDA officials said there were 113 laboratories representing 50 states 
that are part of the eLEXNET system.

Electronic Surveillance System for the Early Notification of Community- 
based Epidemics (ESSENCE):

ESSENCE is a syndromic surveillance system operated by DOD. ESSENCE is 
used in the early detection of infectious disease outbreaks and it 
provides epidemiological tools for improved investigation. The system 
collects data from hospitals and clinics on a daily basis. 
Epidemiologists can track, in near real-time, the syndromes being 
reported in a region through a daily feed of reported data. ESSENCE 
uses the daily data downloads, along with traditional epidemiological 
analyses using historical data for baseline comparisons and analytic 
methods such as a geographic information system. A geographic 
information system, among other things, can be used to identify spatial 
clustering of abnormal health events as the data are collected. This 
can assist public health officials in identifying affected areas. DOD 
is in the process of improving ESSENCE's mapping capabilities and 
developing more advanced statistical algorithms for identifying 
anomalous increases in syndromes.

Epidemic Information Exchange (Epi-X):

Epi-X is a secure, Web-based communication system operating in all 50 
states. CDC uses this system primarily to share information relevant to 
disease outbreaks with state and local public health officials and with 
other federal officials. Epi-X also serves as a forum for routine 
professional discussions and non-emergency inquiries. Authorized Epi-X 
users can post questions and reports, query CDC, and receive feedback 
on ongoing infectious disease control efforts. According to CDC, as of 
2004, over 1,200 public health officials at the federal, state, and 
local levels had used the system to communicate with colleagues and 
experts, track information for outbreak investigations and response 
efforts, conduct online discussions, and request assistance.

Foodborne Disease Active Surveillance Network (FoodNet):

FoodNet is a surveillance system that is a collaborative effort among 
CDC, USDA, and FDA. FoodNet operates in nine states that participate in 
CDC's Emerging Infections Program. FoodNet provides a network for 
responding to new and emerging foodborne diseases of national 
importance, monitoring foodborne diseases, and identifying the sources 
of specific foodborne diseases. FoodNet is used to detect cases or 
outbreaks of foodborne disease, identify their source, recognize 
trends, and respond to outbreaks. State public health departments that 
participate in FoodNet receive funds from CDC to systematically contact 
laboratories in their geographical areas to solicit incidence data. As 
a result of this active solicitation, FoodNet is intended to provide 
more accurate estimates of the occurrence of foodborne diseases than 
are otherwise available.

Global Outbreak Alert and Response Network (GOARN):

GOARN electronically links WHO member countries, disease experts, 
agencies, and laboratories in order to keep them informed of disease 
outbreaks, either rumored or confirmed. GOARN is the primary mechanism 
by which WHO mobilizes technical resources for the investigation of, 
and response to, disease outbreaks of international importance. GOARN 
issues real-time outbreak alerts and gathers global disease information 
from a number of sources, including media reports, ministries of 
health, laboratories, academic institutes, and WHO offices in various 
countries.

Global Public Health Intelligence Network (GPHIN):

GPHIN is an electronic system developed by Canadian health officials 
and used by WHO. GPHIN is an Internet-based application that searches 
in French and English more than 950 news feeds and discussion groups 
around the world in the media and on the Internet for information on 
possible outbreaks of infectious diseases. CDC officials said that 
translation capabilities will be expanded in 2004 from French and 
English to also include Arabic, Chinese, Russian, and Spanish.

Health Alert Network (HAN):

CDC operates an early warning and response system, the Health Alert 
Network (HAN), that is designed to ensure that state and local health 
departments as well as other federal agencies and departments have 
timely access to emerging health information. Through HAN, CDC issues 
health alerts and other public health bulletins to an estimated 1 
million public health officials, including physicians, nurses, 
laboratory staff, and others.

Infectious Diseases Society of America Emerging Infections Network 
(IDSA-EIN):

IDSA-EIN is a network of over 900 infectious disease practitioners. The 
network surveys its members regularly on topical issues in clinical 
infectious diseases. It also enhances communications and health 
education among its members, collaborates in research projects, and 
provides assistance during outbreak investigations. Its membership 
represents a source of infectious disease expertise for CDC and state 
health departments to draw on during outbreaks or when unusual 
illnesses occur.

Laboratory Response Network (LRN):

LRN is an integrated network of public health and clinical laboratories 
run by CDC to test specimens and develop diagnostic tests for 
identifying infectious diseases and biological or chemical agents. The 
network includes the following types of laboratories--federal, state 
and local public health, military, and international laboratories, as 
well as laboratories that specialize in food, environmental, and 
veterinary testing. Some LRN laboratories provide highly specialized 
tests not always available in state public health or commercial 
laboratories.

National Animal Health Reporting System (NAHRS):

NAHRS is collaborative program with USDA, the U.S. Animal Health 
Association, the American Association of Veterinary Laboratory 
Diagnosticians, and participating states. NAHRS collects data from 
state veterinarians in participating states on the presence of 
confirmed clinical diseases of major international significance in 
livestock, poultry and aquaculture species in the United States. 
Individual state reports are submitted monthly to the central 
collection point at the USDA where they are verified, summarized and 
compiled into a report.

National Electronic Disease Surveillance System (NEDSS):

CDC's NEDSS is an initiative that is designed to make the electronic 
reporting of disease surveillance data to CDC by state and local health 
departments more timely, accurate, and complete. Specifically, NEDSS is 
intended to replace or enhance the interoperability of CDC's numerous 
existing surveillance systems. Interoperability is the ability of two 
or more systems or components to exchange information and to use the 
information that has been exchanged. As part of the NEDSS initiative, 
CDC is developing an architecture that consists of a set of standards 
that can be used for creating interoperability among systems. These 
standards comprise (1) data standards, (2) parameters for an Internet- 
based communications infrastructure, and (3) policy-level agreements on 
data access and sharing as well as on protections for confidentiality. 
CDC has also developed ready-to-use software--the NEDSS-Base system 
(NBS)--that operates within these standards.

National Electronic Telecommunications System for Surveillance (NETSS):

NETSS is a computerized public health surveillance system that provides 
CDC with weekly data regarding cases of nationally notifiable diseases. 
Core surveillance data--date, county, age, sex, and race/ethnicity--and 
some disease-specific epidemiologic information for nationally 
notifiable diseases and for some nonnotifiable diseases are transmitted 
electronically by the state public health departments to CDC through 
NETSS each week. Data from NETSS is published in CDC's Morbidity and 
Mortality Weekly Report. NETSS will be phased out as NEDSS is deployed 
and implemented.

National Retail Data Monitor (NRDM):

NRDM is a syndromic surveillance system developed by the University of 
Pittsburgh in collaboration with CDC and others, and it is used by 
state public health officials. NRDM collects data from retail sources. 
NRDM collects sales data from 19,000 stores, including pharmacies, to 
monitor sales patterns in such items as over-the counter medications 
for signs of a developing infectious disease outbreak. The system looks 
for unusual sales patterns--such as -a spike in the number of over-the- 
counter medications purchased in a particular city or county--that 
might indicate the onset of an infectious disease outbreak. The system 
monitors the data automatically on a daily basis and generates 
summaries of sales patterns using timelines and maps.

National Veterinary Services Laboratories (NVSL):

NVSL are veterinary laboratories run by USDA. These laboratories are 
the only U.S. federal veterinary reference laboratories to provide 
diagnostics for domestic and foreign animal diseases. NVSL also 
provides diagnostic support for disease control and eradication 
programs, testing imported and exported animals, training, and 
laboratory certification for selected diseases.

PulseNet:

PulseNet is a national network of public health laboratories that 
perform DNA "fingerprinting" on bacteria that may be foodborne. The 
network idenifies and labels each "fingerprint" pattern and permits 
rapid comparison of these patterns through an electronic database at 
CDC. This network is intended to provide an early warning system for 
outbreaks of foodborne disease.

Real-time Outbreak and Disease Surveillance (RODS):

RODS is a syndromic surveillance system developed by the University of 
Pittsburgh and used by state public health officials. RODS 
automatically gathers data from hospital clinical encounters in order 
to identify patients' chief medical complaints, classify them according 
to syndrome, and aggregate that data in order to look for anomalous 
increases in certain syndromes that may reveal an infectious disease 
outbreak.

Sexually Transmitted Disease Management Information System (STD*MIS):

STD*MIS is an electronic system used by state and local health 
departments to report sexually transmitted diseases to CDC.

Systematic Tracking of Elevated Lead Levels & Remediation (STELLAR):

STELLAR is an electronic system used by state and local health 
departments to report lead poisoning cases to CDC.

[End of section]

Appendix IV: Comments from the Department of Health and Human Services: 

DEPARTMENT OF HEALTH & HUMAN SERVICES: 

Office of Inspector General:

JUL 22 2004:

Ms. Marjorie Kanof:
Managing Director, Health Care:
United States Government Accountability Office: Washington, D.C. 20548:

Dear Ms. Kanof:

Enclosed are the Department's comments on your draft report entitled, 
"Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts" (GAO-04-877). The comments represent the 
tentative position of the Department and are subject to reevaluation 
when the final version of this report is received.

The Department provided several technical comments directly to your 
staff.

The Department appreciates the opportunity to comment on this draft 
report before its publication. 

Sincerely,

Signed by: 

Dara Corrigan:

Acting Principal Deputy Inspector General:

Enclosure:

The Office of Inspector General (OIG) is transmitting the Department's 
response to this draft report in our capacity as the Department's 
designated focal point and coordinator for Government Accountability 
Office reports. OIG has not conducted an independent assessment of 
these comments and therefore expresses no opinion on them.

Comments of the Department of Health and Human Services on the U.S. 
Government Accountability Office's Draft Report, "Emerging Infectious 
Diseases: Review of State and Federal Disease Surveillance Efforts" 
(GAO-04-877):

General Comments:

The draft report covers a broad mix of surveillance, communications, 
and training programs, including existing or new programs and some that 
are still in planning stages, and programs that do not directly pertain 
to surveillance for emerging infectious diseases. While overall the 
draft report satisfactorily captures many important issues in 
surveillance, several key systems and issues deserve clarification. 
First, at the Federal level, the Centers for Disease Control and 
Prevention (CDC) is the lead agency for human disease surveillance. It 
fulfills this responsibility in close collaboration with States, other 
Federal agencies, the World Health Organization (WHO), and other 
partners. In addition, some specific systems and topics should be 
addressed including:

The PulseNet network for subtyping bacterial pathogens, developed at 
and hosted by CDC, which links State public health laboratories, CDC, 
United States Department of Agriculture (USDA) and Food and Drug 
Administration (FDA) laboratories for molecular fingerprinting of 
bacterial food borne pathogens. (See: http://www.edc.gov/pulsenet/)

* The support CDC provides in the form of technical advice and training 
to the development of major international networks that are critical to 
enhancing global surveillance, such as the WHO Global Influenza 
Surveillance Network 
(http://www.who.int/csr/disease/influenza/influenzanetwork/en/) and 
Global Salm Surv (http://www.who.int/salmsurv/en/).

The draft report currently presents the essential purpose of the 
National Electronic Disease Surveillance System (NEDSS) initiative as a 
mechanism to transmit surveillance data from States to CDC (which the 
National Electronic Telecommunications System for Surveillance (NEDSS) 
already does). However, the essential purpose of the NEDSS initiative 
would be better represented as an initiative designed to transform 
surveillance at the local and/or State health department level. 
Obviously, CDC will also benefit by getting the data at the national 
level, but the current gap NEDSS seeks to address is primarily between 
the clinical sector and local/State public health. NEDSS does this by 
providing:

* an automatic electronic tool for sending disease information from the 
clinical diagnostic laboratory to the local and/or State health 
department, thus improving timeliness, accuracy, and completeness of 
disease reporting:

* a web page instead of a paper form for submitting disease reports to 
the local and/or State health department:

The draft report mentions multiple times that FDA collects surveillance 
reports on food-borne outbreaks. However, we are not aware that FDA 
collects these as part of a formal national surveillance system. 
Rather, CDC shares its findings with FDA. CDC operates the national 
reporting systems for outbreaks of food-borne and waterborne diseases. 
(See http://www.cdc.gov/foodborneoutbreaks/report_pub.htm for more 
information about the electronic food-borne outbreak-reporting system 
(EFORS) at CDC). 

[End of section]

Appendix V: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

Kristi A. Peterson, (202) 512-7951; 
Gloria E. Taylor, (202) 512-7160:

Acknowledgments:

In addition to the persons named above, Louise M. Duhamel, Krister 
Friday, Gay Hee Lee, and Merrile Sing made key contributions to this 
report.

[End of section]

Related GAO Products:

Emerging Infectious Diseases: Asian SARS Outbreak Challenged 
International and National Responses. GAO-04-564. Washington, D.C.: 
April 28, 2004.

Public Health Preparedness: Response Capacity Improving, but Much 
Remains to Be Accomplished. GAO-04-458T. Washington, D.C.: February 12, 
2004.

Infectious Diseases: Gaps Remain in Surveillance Capabilities of State 
and Local Agencies. GAO-03-1176T. Washington, D.C.: September 24, 2003.

Severe Acute Respiratory Syndrome: Established Infectious Disease 
Control Measures Helped Contain Spread, But a Large-Scale Resurgence 
May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.

Bioterrorism: Information Technology Strategy Could Strengthen Federal 
Agencies' Abilities to Respond to Public Health Emergencies. GAO-03- 
139. Washington, D.C.: May 20, 2003.

SARS Outbreak: Improvements to Public Health Capacity Are Needed for 
Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03- 
769T. Washington, D.C.: May 7, 2003.

Bioterrorism: The Centers for Disease Control and Prevention's Role in 
Public Health Protection. GAO-02-235T. Washington, D.C.: November 15, 
2001.

Food Safety: CDC Is Working to Address Limitations in Several of Its 
Foodborne Disease Surveillance Systems. GAO-01-973. Washington, D.C.: 
September 7, 2001.

Global Health: Challenges in Improving Infectious Disease Surveillance 
Systems. GAO-01-722. Washington, D.C.: August 31, 2001.

West Nile Virus Outbreak: Lessons for Public Health Preparedness. GAO/ 
HEHS-00-180. Washington, D.C.: September 11, 2000.

Global Health: Framework for Infectious Disease Surveillance. GAO/ 
NSIAD-00-205R. Washington, D.C.: July 20, 2000.

West Nile Virus: Preliminary Information on Lessons Learned. GAO/HEHS- 
00-142R. Washington, D.C.: June 23, 2000.

Emerging Infectious Diseases: National Surveillance System Could Be 
Strengthened. GAO/T-HEHS-99-62. Washington, D.C.: February 25, 1999.

Emerging Infectious Diseases: Consensus on Needed Laboratory Capacity 
Could Strengthen Surveillance. GAO/HEHS-99-26. Washington, D.C.: 
February 5, 1999.

FOOTNOTES

[1] Pandemics are worldwide epidemics. Influenza pandemics can have 
successive "waves" of disease and last for up to 3 years. Three 
pandemics occurred in the 20th century: the "Spanish Flu" of 1918 which 
killed at least 20 million people worldwide; the "Asian flu" of 1957; 
and the "Hong Kong flu" of 1968.

[2] See Centers for Disease Control and Prevention, Fiscal Year 2005 
Justification of Estimates for Appropriations Committees, 172.

[3] Pathogens are bacteria, viruses, parasites, or fungi that have the 
capability to cause disease in humans.

[4] See World Health Assembly Resolution 48.13m, Communicable Disease 
Prevention and Control: New Emerging and Re-Emerging Infectious 
Diseases (Geneva, Switzerland: May 12, 1995); Emerging Infections: 
Microbial Threats to Health in the United States, Institute of Medicine 
(Washington, D.C.: 1992); Infectious Disease--A Global Health Threat, 
Report of the National Science and Technology Council, Committee on 
International Science, Engineering, and Technology, Working Group on 
Emerging and Re-emerging Infectious Diseases (Washington, D.C.: Sept. 
1995); and Presidential Decision Directive, Addressing the Threat of 
Emerging Infectious Diseases (PDD, NSTC-7: June 1996).

[5] Institute of Medicine, Microbial Threats to Health: Emergence, 
Detection and Response (Washington, D.C.: 2003).

[6] The initial outbreak of the West Nile virus in the United States in 
1999 demonstrated this need. An infectious disease specialist first 
reported two cases of an unusual neurological disease, which she 
initially suspected to be botulism, to the New York City Department of 
Health. Further investigation and tests suggested that her patients had 
a type of viral encephalitis that might have been transmitted by an 
insect. The Department of Health subsequently consulted with experts at 
CDC and an entomologist from the American Museum of Natural History in 
New York and initially misdiagnosed the disease as St. Louis 
encephalitis. More than a month after the initial outbreak, the disease 
was correctly diagnosed as West Nile virus when it was discovered that 
a biologist at the New York State Department of Environmental 
Conservation and a veterinary pathologist at the Bronx Zoo had found 
several dead birds that had died of viral encephalitis. 

[7] For this report, the term "health care providers" includes all 
health care professionals, such as physicians and nurses, as well as 
health care institutions, such as hospitals and clinics.

[8] The requirement to report the clinically anomalous is particularly 
important for the detection of emerging infectious diseases, many of 
which may be unfamiliar to health care providers.

[9] Epidemiologists are specialists who study how diseases are 
distributed and transmitted in populations and the factors that 
influence or determine this distribution and transmission. 
Epidemiologists at state health departments are often responsible for 
analyzing data collected through disease reporting systems, conducting 
outbreak investigations, and designing and evaluating disease 
prevention and control efforts.

[10] DHS officials told us it is only beginning these efforts and 
therefore its roles and responsibilities for the coordination of 
surveillance activities related to national security are still evolving.

[11] Efforts to revise the International Health Regulations began in 
1995, and the revised regulations are scheduled to be ready for 
submission to the World Health Assembly, the governing body of WHO, in 
May 2005. As part of the revision process, WHO is considering criteria 
to determine whether an outbreak is serious, unexpected, and likely to 
spread internationally. Furthermore, the draft regulations would 
broaden the definition of a reportable disease to include significant 
illness caused by biological, chemical, or radionuclear sources.

[12] CSTE is a professional organization of public health 
epidemiologists from every U.S. state and territory, as well as Canada 
and Great Britain.

[13] For example, a disease might be added to the list as a new 
pathogen emerges, or a disease might be deleted as its incidence 
declines. 

[14] Botulism is a bacterial disease that is spread through the 
ingestion of contaminated food. It is a muscle-paralyzing disease that 
can cause a person to stop breathing and may result in death. In 
contrast, chronic hepatitis B is a viral disease affecting the liver 
that is transmitted through contact with blood or body fluids.

[15] Q fever is a zoonotic disease that became a notifiable disease in 
1999. Infection of humans usually occurs through inhalation of the 
disease-causing bacteria. Q fever is difficult to diagnose and this 
highly infectious agent is resistant to heat and drying. This agent 
could be developed for use in biological warfare and is considered a 
potential terrorist threat. In contrast, gonorrhea is a sexually 
transmitted disease with symptoms that can usually be treated with a 
single dose of antibiotics.

[16] In some cases, depending on state law, providers and others report 
first to local health departments, which report the disease information 
to the state health department. Local health departments may also 
conduct their own follow-up investigations into reports of notifiable 
diseases.

[17] The Morbidity and Mortality Weekly Report may include weekly and 
annual tables on nationally notifiable diseases, periodic surveillance 
summaries on a wide variety of conditions, and articles on acute 
infectious disease outbreaks.

[18] NAHRS is a collaborative program with USDA, the U.S. Animal Health 
Association, the American Association of Veterinary Laboratory 
Diagnosticians, and participating states. State participation is 
voluntary and at the end of calendar year 2003, 40 states were active 
participants in the system, and 5 states were developing plans to begin 
reporting.

[19] GPHIN is a part of WHO's Global Outbreak Alert and Response 
Network (GOARN). GOARN is the primary mechanism by which WHO mobilizes 
technical resources for the investigation of, and response to, disease 
outbreaks of international importance.

[20] U.S. General Accounting Office, Emerging Infectious Diseases: 
Asian SARS Outbreak Challenged International and National Responses, 
GAO-04-564 (Washington, D.C.: Apr. 28, 2004).

[21] Some syndromic surveillance systems monitor data from hospital and 
emergency room admissions or data from over-the-counter drug sales. 
Other data sources may include poison control centers, health plan 
medical records, first aid stations, emergency medical service data, 
insurer claims, and discharge diagnosis information.

[22] Some increases in symptoms are not anomalous, such as those 
associated with influenza during influenza season.

[23] Anomalous increases in certain syndromes may also indicate an 
environmental exposure representing a public health threat that may not 
be infectious.

[24] The IDSA-EIN is supported by a cooperative agreement from the CDC 
and is overseen by an executive committee with membership from CDC, 
IDSA, and the Pediatric Infectious Diseases Society.

[25] Members may also submit reports at their own initiative.

[26] The population base for EIP activities is roughly 36 million 
people, representing an approximation of the U.S. population with 
respect to demographic characteristics such as age, gender, residence, 
and race and health indicators, such as population density and 
percentage of persons at or below the poverty level.

[27] CDC officials told us that FoodNet would soon be in use in all 11 
of its EIP sites.

[28] Laboratories are categorized as either Biosafety Level 1, 2, 3, or 
4, with Biosafety Level 4 laboratories providing the highest degree of 
protection to personnel, the environment, and the community. Biosafety 
levels represent combinations of laboratory practices and techniques, 
safety equipment, and laboratory facilities. Each combination is 
specifically appropriate for the operations performed, the documented 
or suspected routes of transmission of the infectious agents, and the 
laboratory function or activity. Both CDC and DOD have one Biosafety 
Level 4 Laboratory.

[29] The "fingerprinting" is called pulsed field gel electrophoresis, 
which can distinguish strains of an organism, such as Escherichia coli, 
Salmonella, Shigella, or Listeria at the DNA level.

[30] USAMRIID is DOD's lead laboratory for conducting research to 
develop vaccines, drugs, and diagnostics for laboratory analysis 
related to countering the medical effects of agents used in biological 
warfare.

[31] These five laboratories are located in Peru, Indonesia, Egypt, 
Thailand, and Kenya.

[32] A WHO Collaborating Center is a national institution designated by 
WHO to form part of an international collaborative network that 
contributes to implementing WHO's program priorities and to 
strengthening institutional capacity in countries and regions. 
Collaborating Center activities include collection and dissemination of 
information, education and training, and participation in collaborative 
research developed under WHO's leadership. According to CDC, it has 
more that 20 Collaborating Centers.

[33] The National Animal Health Laboratory Network was established as a 
collaboration among USDA, the National Veterinary Services 
Laboratories, the American Association of Veterinary Laboratory 
Diagnosticians, and state laboratory directors.

[34] Participation in Epi-X is limited to public health officials 
designated by individual health agencies, such as state health 
departments. These officials--experts engaged in identifying, 
investigating, and responding to health threats--must obtain pre- 
approval from the appropriate health agency. Access to Epi-X is limited 
to these designated officials to ensure the security necessary for the 
exchange of preliminary information.

[35] Both HAN and Epi-X are systems that operate as part of CDC's 
Public Health Information Network (PHIN), which coordinates information 
technology systems and related organizations that support various 
public health functions. PHIN is intended to enable real-time data 
flow, computer assisted analysis, professional collaboration, and rapid 
dissemination of information.

[36] For more information on CDC's role in fighting SARS in Asia, see 
U.S. General Accounting Office, Emerging Infectious Diseases: Asian 
SARS Outbreak Challenged International and National Responses, GAO-04- 
564 (Washington, D.C.: Apr. 28, 2004).

[37] Many syndromic surveillance systems currently in use in the United 
States were developed in response to the September 11, 2001 attacks on 
the World Trade Center and Pentagon and to the anthrax outbreaks that 
occurred shortly afterwards.

[38] See Institute of Medicine, Microbial Threats to Health: Emergence, 
Detection and Response (Washington, D.C.: 2003), 172.

[39] Department of Health and Human Services, Centers for Disease 
Control and Prevention, "Framework for Evaluating Public Health 
Surveillance Systems for Early Detection of Outbreaks," Morbidity and 
Mortality Weekly Report, vol. 53 (2004). According to CDC, this builds 
on the earlier Updated Guidelines for Evaluating Public Health 
Surveillance Systems published in 2001.

[40] Nkuchia M'ikanatha et al., "Use of the Web by State and 
Territorial Health Departments to Promote Reporting of Infectious 
Disease," Journal of the American Medical Association, vol. 291, no. 9, 
1069-1070, (2004).

[41] Interoperability is the ability of two or more systems or 
components to exchange information and to use the information that has 
been exchanged.

[42] Data standards will govern the way surveillance data are assembled 
and transmitted. These standards include common definitions and codes 
for medical terms as well as accepted sequences for transmitting 
complex segments of data.

[43] While the NEDSS initiative first began in fiscal year 2000, the 
1995 report Integrating Public Health Information and Surveillance 
Systems by The Steering Committee on Public Health Information and 
Surveillance Systems was the basis for the NEDSS initiative.

[44] According to CDC, a recent effort by a standards development group 
has lead to an agreement on a standard message for transmission of data 
from states to CDC.

[45] This working group was created in response to a congressional 
mandate that the Secretary of Health and Human Services, through FDA 
and CDC, and USDA, coordinate the surveillance of zoonotic diseases. 
Public Health Security and Bioterrorism Preparedness and Response Act 
of 2002, Pub. L. No. 107-188, 313, 116 Stat. 594, 674 (2002). 

[46] A recent IOM report notes that in 2001, it was estimated that U.S. 
public health departments needed at least 600 new epidemiologists 
merely to meet the requirements for bioterrorism preparedness.

[47] Institute of Medicine, Microbial Threats to Health: Emergence, 
Detection and Response (Washington, D.C.: 2003).

[48] U.S. General Accounting Office, Global Health: Challenges in 
Improving Infectious Disease Surveillance Systems, GAO-01-722 
(Washington, D.C.: Aug. 31, 2001).

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