[House Report 109-436]
[From the U.S. Government Publishing Office]



From the House Reports Online via GPO Access
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109th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     109-436
_______________________________________________________________________

                                     

                                     

                                     

                                                 Union Calendar No. 243
 
                   STRENGTHENING DISEASE SURVEILLANCE

                               __________

                             EIGHTH REPORT

                                 by the

                     COMMITTEE ON GOVERNMENT REFORM


                                     


                                     

  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                               index.html
                      http://www.house.gov/reform

 April 25, 2006.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed



                    U.S. GOVERNMENT PRINTING OFFICE
26-929                      WASHINGTON : 2006
_____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
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                     COMMITTEE ON GOVERNMENT REFORM

                     TOM DAVIS, Virginia, Chairman
CHRISTOPHER SHAYS, Connecticut       HENRY A. WAXMAN, California
DAN BURTON, Indiana                  TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
GIL GUTKNECHT, Minnesota             CAROLYN B. MALONEY, New York
MARK E. SOUDER, Indiana              ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio           DENNIS J. KUCINICH, Ohio
TODD RUSSELL PLATTS, Pennsylvania    DANNY K. DAVIS, Illinois
CHRIS CANNON, Utah                   WM. LACY CLAY, Missouri
JOHN J. DUNCAN, Jr., Tennessee       DIANE E. WATSON, California
CANDICE S. MILLER, Michigan          STEPHEN F. LYNCH, Massachusetts
MICHAEL R. TURNER, Ohio              CHRIS VAN HOLLEN, Maryland
DARRELL E. ISSA, California          LINDA T. SANCHEZ, California
JON C. PORTER, Nevada                C.A. DUTCH RUPPERSBERGER, Maryland
KENNY MARCHANT, Texas                BRIAN HIGGINS, New York
LYNN A. WESTMORELAND, Georgia        ELEANOR HOLMES NORTON, District of 
PATRICK T. McHENRY, North Carolina       Columbia
CHARLES W. DENT, Pennsylvania                    ------
VIRGINIA FOXX, North Carolina        BERNARD SANDERS, Vermont 
JEAN SCHMIDT, Ohio                       (Independent)
------ ------

                      David Marin, Staff Director
                     Keith Ausbrook, Chief Counsel
                       Teresa Austin, Chief Clerk
          Phil Barnett, Minority Chief of Staff/Chief Counsel

Subcommittee on National Security, Emerging Threats, and International 
                               Relations

                CHRISTOPHER SHAYS, Connecticut, Chairman
KENNY MARCHANT, Texas                DENNIS J. KUCINICH, Ohio
DAN BURTON, Indiana                  TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         BERNARD SANDERS, Vermont
JOHN M. McHUGH, New York             CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio           CHRIS VAN HOLLEN, Maryland
TODD RUSSELL PLATTS, Pennsylvania    LINDA T. SANCHEZ, California
JOHN J. DUNCAN, Jr., Tennessee       C.A. DUTCH RUPPERSBERGER, Maryland
MICHAEL R. TURNER, Ohio              STEPHEN F. LYNCH, Massachusetts
JON C. PORTER, Nevada                BRIAN HIGGINS, New York
CHARLES W. DENT, Pennsylvania

                               Ex Officio

TOM DAVIS, Virginia                  HENRY A. WAXMAN, California
            Lawrence J. Halloran, Staff Director and Counsel
           Kristine K. Fiorentino, Professional Staff Member
                        Robert A. Briggs, Clerk
             Andrew Su, Minority Professional Staff Member
?

                         LETTER OF TRANSMITTAL

                              ----------                              

                                  House of Representatives,
                                    Washington, DC, April 25, 2006.
Hon. J. Dennis Hastert,
Speaker of the House of Representatives,
Washington, DC.
    Dear Mr. Speaker: By direction of the Committee on 
Government Reform, I submit herewith the committee's eighth 
report to the 109th Congress. The committee's report is based 
on a study conducted by its Subcommittee on National Security, 
Emerging Threats, and International Relations.
                                                 Tom Davis,
                                                          Chairman.

                                 (iii)

                                     
                            C O N T E N T S

                              ----------                              
                                                                   Page
Executive Summary................................................     1
  I. Background.......................................................2
      A. Centers for Disease Control and Prevention [CDC]........     4
      B. Department of Defense Global Emerging Infections 
          Surveillance and Response System [DOD-GEIS]............     9
      C. Government Accountability Office [GAO] Reports..........    11
 II. Discussion......................................................11
      A. Findings................................................    11
      B. Recommendation..........................................    14

                               APPENDIXES

Appendix I.......................................................    17
Appendix II......................................................    18
Appendix III.....................................................    23
  
                                                 Union Calendar No. 243
109th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     109-436

======================================================================


                   STRENGTHENING DISEASE SURVEILLANCE

                                _______
                                

 April 25, 2006.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

 Mr. Tom Davis, from the Committee on Government Reform submitted the 
                               following

                             EIGHTH REPORT

    On April 6, 2006, the Committee on Government Reform 
approved and adopted a report entitled, ``Strengthening Disease 
Surveillance.'' The chairman was directed to transmit a copy to 
the Speaker of the House.

                           Executive Summary

    The spread of the H5N1 virus and the threat of pandemic 
influenza is the most recent reminder of the need for 
sensitive, vigilant disease surveillance. In 2002, the world 
conducted an involuntary, live-fire exercise of public health 
capacity against bioterrorism. Severe Acute Respiratory 
Syndrome [SARS] emerged from the microbial hothouse of the Far 
East through the same vulnerabilities and vectors terrorists 
would exploit to spread weaponized, genetically altered 
disease. The global response to SARS underscores the vital 
significance of sensitive disease surveillance in protecting 
public health from natural, and unnatural, outbreaks. It also 
discloses serious gaps and persistent weaknesses in 
international and U.S. health monitoring.
    The lessons of the West Nile virus and mail-borne anthrax 
have not gone unheeded. Substantial enhancements have been made 
to the accuracy, speed and breadth of health surveillance 
systems at home and abroad. The limited impact of SARS here can 
be attributed, in part, to increased preparedness to detect, 
control and treat outbreaks of known and unknown diseases.
    But the surveillance system standing guard over America's 
public health today is still a gaudy patchwork of 
jurisdictionally narrow, wildly variant, technologically 
backward data collection and communications capabilities. 
Records critical to early identification of anomalous symptom 
clusters and disease diagnoses are not routinely collected. 
Formats for recording and reporting the same data differ widely 
between cities, counties and states. Many key records are still 
generated on paper, faxed to state or Federal health 
authorities and entered manually one or more times into 
potentially incompatible databases.
    In a world made smaller by the speed of international 
travel and the rapid mutation of organisms in our crowded 
midst, the incubation period between local outbreak and global 
pandemic is shrinking. Virulent, drug-resistant organisms 
easily traverse the geographic and political boundaries that 
still define, and inhibit, public health systems. Efforts to 
build a more modern ``system of systems'' envision routine 
collection and rapid dissemination of real-time data from 
public and private health systems and laboratories. Early 
warning capabilities would be enhanced through the fusion of 
innovative syndromic surveillance--automated screening of 
emergency room traffic, pharmacy sales, news wires and other 
public data streams for potentially significant early signs of 
an outbreak.
    Pieces of this planned health monitoring system can be 
assembled at different times and places, but no fully national 
system yet integrates the observations and communications 
needed to protect public health from rapidly emerging 
biological hazards. Successfully operating the elaborate, 
elegantly sensitive surveillance network of the future will 
require unprecedented levels of human skill, fiscal resources, 
medical information and intergovernmental cooperation.
    At this moment, sophisticated radars scan the skies and the 
seas to detect the approach of forces hostile to the peace and 
sovereignty of this Nation. A similarly unified, sensitive 
system of disease sensors is needed to detect the advance of 
biological threats to our health and prosperity.

Finding

    1. Disease surveillance systems are fragmented and have 
been slow to adapt to new technologies which could improve the 
timeliness of outbreak reporting.

Recommendation

    1. The Centers for Disease Control and Prevention should 
clearly define the technical parameters and set a specific 
timeframe for establishing a unified national disease 
surveillance system to replace the current patchwork of 
reporting and monitoring programs.

                             I. Background

    According to the Centers for Disease Control and 
Prevention:

        Public Health Surveillance is the ongoing systematic 
        collection, analysis and interpretation of health data 
        essential to the planning, implementation, and 
        evaluation of public health practice, closely 
        integrated with the timely dissemination of these data 
        to those who need to know. The final link in the 
        surveillance chain is the application of these data to 
        prevention and control. A surveillance system includes 
        a functional capacity for data collection, analysis, 
        and dissemination linked to public health programs.\1\
---------------------------------------------------------------------------
    \1\ Rebecca A. Meriwether, ``Blueprint for a National Public Health 
Surveillance System for the 21st Century,'' Online at: [http://
www.cste.org/pdffiles/Blueprint.pdf] (accessed Mar. 23, 2006).

    Concerns about bioterrorism, and improvements in 
technology, have led to an increased emphasis on the 
development of early warning systems to detect the presence of 
disease. The sooner public health authorities are made aware of 
contagious disease outbreaks, the sooner protective measures 
can be put in place to contain and control its spread. An 
effective public health response will depend on the timeliness 
and quality of communication among local, state and Federal 
levels.
    There are several types of surveillance systems:

  Passive surveillance systems rely on laboratory and 
hospital staff and providers to take the initiative to provide 
data on diagnosed illnesses to health departments. The health 
department will analyze and interpret the information.

  An active surveillance system is one in which public 
health officials contact laboratories, hospitals and providers 
to acquire information on conditions or diseases in order to 
identify cases.\2\
---------------------------------------------------------------------------
    \2\ U.S. General Accounting Office, Pub. No. GAO-03-373, 
Bioterrorism: Preparedness Varied Across State and Local Jurisdictions, 
18-20 (April 2003).

  A syndromic surveillance system monitors various non-
diagnostic data elements that may indicate emergence of disease 
---------------------------------------------------------------------------
in a population.

  A diagnosis based surveillance system monitors only 
physician or laboratory confirmation of a disease.\3\
---------------------------------------------------------------------------
    \3\ Joe Lombardo and LTC Julie Pavlin MD MPH, ``Bio Surveillance: 
Utilizing ESSENCE II in Emergency Response,'' presented at the 2003 
NDMS Conference, Mar. 9, 2003, p. 3.

    Traditional disease reporting and surveillance methods were 
paper-based and relied on astute clinicians. In the past, 
accuracy was valued over speed when it came to disease 
surveillance. Traditional surveillance systems required a 
disease to be diagnosed before it was reported. Physicians and 
public health officers would gather data and send paper copies 
by mail. Federal, state and private laboratories would 
determine the cause of disease and confirm diagnoses. However, 
this process could take several days to weeks.\4\
---------------------------------------------------------------------------
    \4\ The New York Times, ``Threats and Responses: The Bioterror 
Threat,'' Jan. 27, 2003, p. 3.
---------------------------------------------------------------------------
    Recent advances in technology have led to the development 
of automated systems that can track symptoms along with 
demographic information in order to provide earlier 
notification of potential outbreaks. Syndromic surveillance 
involves monitoring the population for clusters of symptoms 
that may provide an early warning of the presence of diseases. 
It is the, ``collection and analysis of pre-diagnosis 
information that lead to an estimation of the health status of 
the community.'' \5\
---------------------------------------------------------------------------
    \5\ Joe Lombardo and LTC Julie Pavlin MD MPH, ``Bio Surveillance: 
Utilizing ESSENCE II in Emergency Response,'' presented at the 2003 
NDMS Conference, Mar. 9, 2003, p. 7.
---------------------------------------------------------------------------
    Syndromic surveillance uses health care indicators such as 
emergency room primary complaint, international classification 
of disease billing codes, requests for specific laboratory 
tests, and over-the-counter medication sales. These indicators 
are then grouped into specific syndromic categories such as 
respiratory, gastrointestinal, neurological, dermatological, 
febrile, etc.\6\ Other data sources for disease indicators 
include school absenteeism, pharmaceutical sales, nursing home 
information and animal and agriculture health. Syndromic 
surveillance looks for the change in the distribution or 
frequency of health indicators or syndromic groupings of 
indicators compared to anticipated occurrences.\7\ This can 
lead to a more timely notification process since the 
information is based on symptom reporting and not diagnosis. 
However syndromic surveillance systems can generate false 
positives (detecting an event that isn't there). A system that 
is sensitive and timelier will have a higher rate of false 
positives. Thus a balance must be created between the 
timeliness of detection and the ability to respond to and pay 
for the cost of false positives.
---------------------------------------------------------------------------
    \6\ Joe Lombardo and LTC Julie Pavlin MD MPH, ``Bio Surveillance: 
Utilizing ESSENCE II in Emergency Response,'' presented at the 2003 
NDMS Conference, Mar. 9, 2003, p. 7.
    \7\ Joe Lombardo and LTC Julie Pavlin MD MPH, ``Bio Surveillance: 
Utilizing ESSENCE II in Emergency Response,'' presented at the 2003 
NDMS Conference, Mar. 9, 2003, pps. 7-8.
---------------------------------------------------------------------------

          A. CENTERS FOR DISEASE CONTROL AND PREVENTION [CDC]

    The Centers for Disease Control and Prevention have taken 
steps toward strengthening U.S. disease surveillance and 
testing a national surveillance system to provide early warning 
of public health threats.
    The National Electronic Disease Surveillance System [NEDSS] 
is a CDC initiative that, ``promotes the use of data and 
information system standards to advance the development of 
efficient, integrated, and interoperable surveillance systems 
at Federal, state and local levels.'' \8\ The initiative is 
designed to, ``1) facilitate the electronic transfer of 
appropriate information from clinical information systems in 
the health care industry to public health departments, 2) 
reduce provider burden in the provision of information, 3) 
enhance both the timeliness and quality of information 
provided.'' \9\
---------------------------------------------------------------------------
    \8\ CDC Web site article on the National Electronic Disease 
Surveillance System [NEDSS], p. 1. Online at: [http://www.cdc.gov/
nedss/index.htm] (assessed Mar. 23, 2006).
    \9\ CDC Web site article on the National Electronic Disease 
Surveillance System [NEDSS], p. 1. Online at: [http://www.cdc.gov/
nedss/index.htm] (assessed Mar. 23, 2006).
---------------------------------------------------------------------------
    The vision of NEDSS is, ``to have integrated surveillance 
systems that can transfer appropriate public health, 
laboratory, and clinical data efficiently and securely over the 
Internet. This will help improve the Nation's ability to 
identify and track emerging infectious diseases and potential 
bioterrorism attacks as well as to investigate outbreaks and 
monitor disease trends.'' \10\ NEDSS is designed to make 
electronic disease reporting timely, accurate and complete, by 
consolidating and standardizing the many different systems used 
by state health departments to report disease data to CDC.\11\
---------------------------------------------------------------------------
    \10\ CDC Web site article on the National Electronic Disease 
Surveillance System [NEDSS], p. 1. Online at: [http://www.cdc.gov/
nedss/index.htm] (assessed Mar. 23, 2006).
    \11\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004) p. 4.
---------------------------------------------------------------------------
    NEDSS brings together different surveillance systems by 
establishing standards for data, information architecture, 
security and information technology. These standards will 
enable patient data to be entered once at the point of care, 
instead of being re-entered by local and state health 
officials. By standardizing this information, NEDSS will help 
health officials to recognize patterns of potentially related 
cases nationwide. Data can be shared easily.\12\
---------------------------------------------------------------------------
    \12\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 11.
---------------------------------------------------------------------------
    The CDC created NEDSS in order to move disease reporting 
from a paper based system to an electronic, real-time reporting 
system.\13\ NEDSS would link the health care system 
electronically and enable public health officials to be 
notified as soon as clinical laboratory receives a specimen, or 
makes diagnoses. According to Dr. David Fleming, Deputy 
Director for Public Health Science, CDC,
---------------------------------------------------------------------------
    \13\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 6.

        In the future, NEDSS coupled with a electronic real-
        time reporting of births and deaths (vital statistics) 
        and computerized medical records, not only in hospitals 
        but also in ambulatory care offices, could facilitate 
        immediate awareness of unusual illnesses such as 
        anthrax or smallpox, as well as our ability to detect 
        more subtle problems that may be dispersed across the 
        country.\14\
---------------------------------------------------------------------------
    \14\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, pps. 10-
11.

    Dr. Fleming stated, ``The fundamental principle that NEDSS 
is operating on is to say that, independent of whether systems 
are homegrown or developed outside, that they have to conform 
to an agreed-upon set of strict standards that assures 
interoperability.'' \15\ He further explained,
---------------------------------------------------------------------------
    \15\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, pps. 36-
37.

        At the end of the day, these systems will be 
        indistinguishable and transparent from each other as 
        far as enabling the needed transfer of information. But 
        the reality is--is that in different jurisdictions 
        there are different needs and issues such that it does 
        make sense for a particular jurisdiction adhering to a 
        set of standards to say, we want to be able to 
        customize this to meet not only the national needs but 
        our local needs as well.\16\
---------------------------------------------------------------------------
    \16\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, pps. 36-
37.

    However, as of January 3, 2006, only 11 states were using 
the CDC NEDSS Base System [NBS] to send reportable public 
health case data to CDC. Four additional states were in the 
final testing phase of the NBS with plans to send data to CDC 
in the next 2 to 4 months. Several states were still in early 
discussions with CDC regarding the potential for using NBS in 
the future.\17\
---------------------------------------------------------------------------
    \17\ E-mail correspondence from Zeno W. St. Cyr, Senior Legislative 
Analyst, Department of Health and Human Services to Subcommittee on 
National Security, Emerging Threats, and International Relations, 
Kristine K. Fiorentino, professional staff member (Jan. 11, 2006) (7:16 
p.m.). See committee files.
---------------------------------------------------------------------------
    The CDC is also collaborating with the American Association 
of Health Plans, Harvard Medical School, five health plans or 
physician groups (Harvard Pilgrim Health Care/Harvard Vanguard 
Medical Associates (Massachusetts), Health Partners 
(Minnesota), Kaiser Permanente (Colorado), Scott and White 
Healthcare System (Texas), the Austin Regional Clinic (Texas)), 
and Optum, a nationwide consumer health information company; to 
implement a syndromic surveillance system covering more than 20 
million individuals with pre-paid healthcare in all 50 states. 
This system uses data from routine and urgent office visits and 
from nurse telephone triage and health information systems. 
Information is received daily, and syndromes are grouped into 
specified geographic regions.\18\
---------------------------------------------------------------------------
    \18\ Journal of Urban Health, ``Syndromic Surveillance Using 
Minimum Transfer of Identifiable Data: The Example of the National 
Bioterrorism Syndromic Surveillance Demonstration Program,'' Jan. 24, 
2003, p. 1.
---------------------------------------------------------------------------
    The system will be based on an earlier project between CDC 
and Harvard Pilgrim Health Care entitled, ``National 
Bioterrorism Syndromic Surveillance Demonstration Program,'' 
which gathered symptom data from nurse call-in lines, and 
physician visits using patient zip codes to look for patterns 
of symptoms. Conducting surveillance through health plans is 
thought to be quicker than tracking emergency room visits since 
patients may call nurse help lines when symptoms first appear, 
before seeking emergency care.\19\
---------------------------------------------------------------------------
    \19\ National Journal, ``Health Plans Search For Bioterror 
Symptoms,'' Apr. 19, 2003, p. 1.
---------------------------------------------------------------------------
    Another effort, BioWatch, is a mutli-agency program with 
the Department of Energy [DOE], the Environmental Protection 
Agency [EPA], and the Department of Health and Human Services. 
The program includes air filter sampling to look for bio-agents 
in certain cities. The filters are tested for six agents. The 
program is an extension of EPA air quality testing. Since 2003, 
30 cities have been included in the program. There are 27 
Laboratory Response Network [LRN] BioWatch labs that test 
filters for bio-agents.\20\ In late September 2005, the Bio 
Watch filters detected Francisella tularensis (tularemia) in 
the Capitol region. Health officials were not notified until 6 
days after tularemia was detected. Thankfully, the incubation 
period for tularemia passed without any incident of human or 
animal illness. Besides concerns regarding a lag time in 
notification, detection systems are futher impeded by the lack 
of validation and standardization of detection thresholds. The 
subcommittee held a hearing in April 2005 looking into the 
agancies' activities to detect anthrax contamination in the 
U.S. Postal Service facilities after the 2001 anthrax incident 
and found the process had not been validated. Without 
validation, one cannot guarantee the results are accurate.\21\
---------------------------------------------------------------------------
    \20\ CDC BioWatch information sheet received as an attachment in an 
E-mail from Zeno W. St. Cyr, Senior Legislative Analyst, Department of 
Health and Human Services to Subcommittee on National Security, 
Emerging Threats, and International Relations, Kristine K. Fiorentino, 
professional staff member (Jan. 11, 2006) (7:16 p.m.). See committee 
Files.
    \21\ Chairman Tom Davis, Committee on Government Reform 
correspondence with Dr. Julie L. Gerberding, Director of the Centers 
for Disease Control and Prevention, and Michael Chertoff, Secretary of 
the Department of Homeland Security, October 3, 2005. See also 
Assessing Anthrax Detection Methods, hearing before the Subcommittee on 
National Security, Emerging Threats, and International Relations of the 
Committee on Government Reform, House of Representatives, 109th Cong., 
1st sess., Apr. 5, 2005, Serial No. 109-57, U.S. Government Printing 
Office, Washington: 2005.
---------------------------------------------------------------------------
    Data from yet another CDC program, called BioSense, can be 
used to match data from BioWatch to compare indicators.\22\ 
BioSense is a syndromic surveillance system that takes data 
from the Department of Defense Military Treatment Facilities, 
the Department of Veterans Affairs treatment facilities and 
Laboratory Corporation of America (LabCorp) test orders. Data 
includes the International Classification of Diseases, Ninth 
Revision, Clinical Modification [ICD-9-CM] diagnosis codes 
along with patient age, sex, zip code of residents, and 
facility identifier.\23\
---------------------------------------------------------------------------
    \22\ CDC Information Council Meeting Minutes, Feb. 27, 2003, Online 
at: [http://www.cdc.gov/cic/minutes/CIC%20minutes%202-27-03.pdf] 
(accessed Mar. 23, 2006).
    \23\ CDC MMWR ``BioSense: Implementation of a National Early Event 
Detection and Situational Awareness System,'' Aug. 26, 2005. Online at: 
[http://www.cdc.gov/mmwr/preview/mmwrhtml/su5401a4.htm] (assessed Mar. 
23, 2006).
---------------------------------------------------------------------------
    The Enhanced Surveillance Project [ESP] is another CDC 
program that can be used during special events to monitor 
sentinel hospital emergency department visit data to establish 
syndrome baseline and threshold data. ESP has been used at the 
World Trade Organization Ministerial in Seattle and the 
Republican and Democratic National Conventions.\24\
---------------------------------------------------------------------------
    \24\ CDC Web site article on Enhanced Surveillance Project [ESP] 
Online at: [http://www.bt.cdc.gov/episurv/esp.asp] (assessed Mar. 23, 
2006).
---------------------------------------------------------------------------
    The Health Alert Network [HAN] is a nationwide program to 
establish communication, information and distance learning. The 
HAN will link local health departments to one another and to 
laboratories, CDC, and community first responders. Early 
warning systems such as broadcast faxes can be used to alert 
local, state, and Federal authorities.\25\
---------------------------------------------------------------------------
    \25\ CDC Health Alert Network, Online at: [http://www.bt.cdc.gov/
documentsapp/han/han.asp] (accessed Mar. 23, 2006).
---------------------------------------------------------------------------
    The National Electronic Telecommunications System for 
Surveillance [NETSS] is a computerized public health 
surveillance information system that provides the CDC with 
weekly data regarding cases of nationally notifiable disease. 
The list of mandatory notifiable diseases changes overtime and 
varies by state. The Council of State and Territorial 
Epidemiologists [CSTE] determines the list of infectious 
diseases, conditions, and toxic exposure under nationwide 
surveillance in consultation with CDC.\26\
---------------------------------------------------------------------------
    \26\ CDC Web site article on National Electronic Telecommunications 
System for Surveillance [NETSS]. Online at: [http://www.cdc.gov/epo/
dphsi/netss.htm] (accessed Mar. 23, 2006).
---------------------------------------------------------------------------
    The CDC has also provided funding for bioterrorism 
surveillance and epidemiology coordination to all state health 
departments, and some major metropolitan cities and 
territories. Several cities and states have implemented their 
own syndromic surveillance systems including California, New 
Mexico, Texas, Boston, New York City, and Pittsburgh.\27\ 
Pittsburg uses a syndromic surveillance system entitled Real-
time Outbreak and Disease Surveillance [RODS]. RODS collects 
data from hospitals including patients' chief complaints, and 
classifies them according to syndrome in order to look for 
potential disease outbreaks.\28\
---------------------------------------------------------------------------
    \27\ The New York Times, ``Threats and Responses: The Bioterror 
Threat,'' Jan. 27, 2003, p. 3.
    \28\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 58.
---------------------------------------------------------------------------
    The National Retail Data Monitor [NDMR] is a syndromic 
surveillance system developed by the University of Pittsburgh 
in collaboration with the CDC. NDMR is used by state public 
health officials to monitor sales data of over the counter 
medications from 19,000 stores and pharmacies that might 
indicate the onset of a disease outbreak.\29\
---------------------------------------------------------------------------
    \29\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 57. See also Emerging 
Infectious Diseases, ``Medication Sales and Syndromic Surveillance, 
France,'' March 2006, p. 416.
---------------------------------------------------------------------------
    The Infectious Diseases Society of America Emerging 
Infections Network [IDSA-EIN] is a network of more than 900 
infectious disease practitioners who provide assistance to CDC 
and state health departments during outbreak 
investigations.\30\
---------------------------------------------------------------------------
    \30\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 56.
---------------------------------------------------------------------------
    Several surveillance systems have been established to 
monitor the safety of the food supply. The Epidemic Information 
Exchange [Epi-X] is a web-based communication system used by 
CDC to share information about food health concerns with local 
and state and Federal health officials.\31\ The Electronic 
Laboratory Exchange Network [eLEXNET] is a web based program 
for sharing food safety laboratory data among local, state and 
Federal agencies.\32\ The Foodborne Disease Active Surveillance 
Network (FoodNet) is a surveillance system used to detect 
diseases and outbreaks in food.\33\ PulseNet is a nationwide 
system of public health laboratories that provide DNA 
``fingerprinting'' on bacteria that may be foodborne in order 
to provide an early warning system for outbreaks of foodborne 
disease. DNA patterns are compared through a database at 
CDC.\34\
---------------------------------------------------------------------------
    \31\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 55.
    \32\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 54. See also Emerging 
Infectious Diseases, ``Web-based Surveillance and Global Salmonella 
Distribution, 2000-2002,'' March 2006, p. 381.
    \33\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 55.
    \34\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 58.
---------------------------------------------------------------------------
    The National Animal Health Reporting System [NAHRS] 
collects data from state veterinarians regarding confirmed 
clinical disease in livestock, poultry and marine life. This 
program is a joint venture between the United States Department 
of Agriculture [USDA] the U.S. Animal Health Association, the 
American Association of Veterinary Laboratory Diagnostics and 
several states.\35\ The National Veterinary Services 
Laboratories [NVSL] are veterinary laboratories run by the USDA 
that provide diagnostics for domestic and foreign animal 
diseases.\36\
---------------------------------------------------------------------------
    \35\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 56.
    \36\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 58.
---------------------------------------------------------------------------
    There are several international disease surveillance 
systems. The Global Outbreak Alert and Response Network [GOARN] 
issues real-time outbreak alerts worldwide from various sources 
including media reports, laboratories, and World Health 
Organization offices. The Global Public Health Intelligence 
Network [GPHIN] is an internet based system developed in Canada 
and used by the World Health Organization. GPHIN searches 
through media sources for information on disease outbreaks.\37\
---------------------------------------------------------------------------
    \37\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004), p. 55.
---------------------------------------------------------------------------

 B. DEPARTMENT OF DEFENSE GLOBAL EMERGING INFECTIONS SURVEILLANCE AND 
                       RESPONSE SYSTEM [DOD-GEIS]

    The Department of Defense Global Emerging Infections 
Surveillance and Response System [GEIS] was established in 
response to Presidential Decision Directive NSTC-7, June 1996. 
According to President Bill Clinton, ``the mission of the DOD 
would be expanded to include support of global surveillance, 
training, research, and response to emerging infectious disease 
threats.'' DOD-GEIS is designed to, ``strengthen the prevention 
of, surveillance of and response to infectious diseases that 
are a threat to military personnel and families, reduce medical 
readiness or present a risk to U.S. national security.'' \38\
---------------------------------------------------------------------------
    \38\ DOD GEIS Web site article ``About DOD-GEIS.'' Online at: 
[http://www.geis.fhp.osd.mil/aboutGEIS.asp] (assessed Mar. 24, 2006).
---------------------------------------------------------------------------
    DOD-GEIS is managed by a Central Hub office located at the 
Walter Reed Army Institute of Research. DOD-GEIS operates 
within five Army and Navy overseas medical research 
laboratories, and within the infrastructure of the military 
health system [MHS]. DOD-GEIS works to strengthen laboratory-
based surveillance, and monitors for global emerging 
infections.\39\
---------------------------------------------------------------------------
    \39\ DOD GEIS Web site article ``About DOD-GEIS.'' Online at: 
[http://www.geis.fhp.osd.mil/aboutGEIS.asp] (assessed Mar. 24, 2006).
---------------------------------------------------------------------------
    In response to concerns about bioterrorism, and calls to 
create an early warning system, DOD-GEIS created the Electronic 
Surveillance System for the Early Notification of Community-
based Epidemics called ESSENCE. ESSENCE started receiving 
Ambulatory Data System [ADS] information from military 
treatment facilities [MTF] in December 1999 for the National 
Capital Area [NCA]. Seven syndrome groups were created based on 
the International Classification of Diseases, Ninth Revision, 
Clinical Modification [ICD-9-CM] codes. ICD-9-CM is the 
official system of assigning codes to diagnoses and procedures 
associated with hospital utilization in the United States.\40\ 
These groups include respiratory, gastrointestinal, neurologic, 
dermatologic-hemorrhagic, dermatologic-vesicular (smallpox-
like), fever/malaise/sepsis, and coma/sudden death.\41\ In 
September 2001, ESSENCE began receiving information from all 
MTFs that submit data to the ADA. ESSENCE collects information 
that is available via secure DOD website.\42\
---------------------------------------------------------------------------
    \40\ International Classification of Diseases, Ninth Revision, 
Clinical Modification, Sixth Edition, Online at: [http://www.cdc.gov/
nchs/about/otheract/icd9/abticd9.htm] (accessed Mar. 23, 2006).
    \41\ Joe Lombardo and LTC Julie Pavlin MD MPH, ``Bio Surveillance: 
Utilizing ESSENCE II in Emergency Response,'' presented at the 2003 
NDMS Conference, Mar. 9, 2003, p. 10-11.
    \42\ DOD GEIS Web site articles on ESSENCE: Electronic Surveillance 
System for the Early Notification of Community-based Epidemics. Online 
at: [http://www.geis.fhp.osd.mil/GEIS/SurveillanceActivities/ESSENCE/
ESSENCE.asp] p. 3. (assessed Mar. 24, 2006).
---------------------------------------------------------------------------
    Every 8 hours data is downloaded and graphs of syndrome 
counts are automatically generated. Based on historical data, a 
baseline of normal ranges is created. If syndrome counts exceed 
baseline ranges, further investigation will be needed to 
determine the cause. Syndromic cases can be sorted by patient 
home zip code. There are plans to sort active duty personnel 
records by work zip code since geographic identification is 
useful in determining the source of an outbreak.\43\ ESSENCE 
has already detected outbreaks domestic and worldwide. Most of 
the detected outbreaks were in the gastrointestinal or 
respiratory category.\44\
---------------------------------------------------------------------------
    \43\ DOD GEIS Web site articles on ESSENCE: Electronic Surveillance 
System for the Early Notification of Community-based Epidemics. Online 
at: [http://www.geis.fhp.osd.mil/GEIS/SurveillanceActivities/ESSENCE/
ESSENCE.asp] p. 2. (accessed Mar. 24, 2006).
    \44\ Joe Lombardo and LTC Julie Pavlin MD MPH, ``Bio Surveillance: 
Utilizing ESSENCE II in Emergency Response,'' presented at the 2003 
NDMS Conference, Mar. 9, 2003, p. 19.
---------------------------------------------------------------------------
    In fiscal year 2001, Walter Reed Army Institute of Research 
[WRAIR] DOD-GEIS entered into a Cooperative Research and 
Development Agreement with the John Hopkins University Applied 
Physics Laboratory for development of nontraditional sources of 
data for disease outbreak detection and management. This 
agreement led to ESSENCE II, a project that was awarded a 
Defense Advanced Research Projects Agency [DARPA] grant for $12 
million over a 4 year period.\45\
---------------------------------------------------------------------------
    \45\ DOD GEIS Web site articles on ESSENCE: Electronic Surveillance 
System for the Early Notification of Community-based Epidemics. Online 
at: [http://www.geis.fhp.osd.mil/GEIS/SurveillanceActivities/ESSENCE/
ESSENCE.asp] p. 3. (accessed Mar. 24, 2006).
---------------------------------------------------------------------------
    Essence II is a syndromic surveillance system that collects 
non-traditional data sources from military and civilian 
outpatient visits, over the counter drug sales, school 
absenteeism, and animal health data in Washington DC, Maryland 
and Virginia. ESSENCE II also collects data on emergency room 
activity, requests for lab tests, confirmed lab results, 911 
calls, and ems services. The ESSENCE II system is only 
accessible by secure web site to health departments 
participating in the program. Maryland, the District of 
Columbia Health Department, and the Virginia Health Department 
are members of ESSENCE.\46\
---------------------------------------------------------------------------
    \46\ DOD GEIS Web site articles on ESSENCE: Electronic Surveillance 
System for the Early Notification of Community-based Epidemics. Online 
at: [http://www.geis.fhp.osd.mil/GEIS/SurveillanceActivities/ESSENCE/
ESSENCE.asp] p. 3. (accessed Mar. 24, 2006).
---------------------------------------------------------------------------
    Syndromic based systems such as ESSENCE have several 
limitations. There is a lag time in data acquisition. 
Currently, data is received within 1 to 3 days of a patient 
visit. However some believe this is not timely enough should an 
outbreak occur.\47\ An astute clinician may call attention to 
an illness of concern faster than a syndromic surveillance 
system. In the case of the anthrax incidents in 2001, it was a 
Florida clinician who determined it to be anthrax.\48\ However, 
others argue while a syndromic surveillance system may not be 
useful to catch a small number cases, it will be helpful in 
recognizing larger incidents of bioterrorism.
---------------------------------------------------------------------------
    \47\ DOD GEIS Web site articles on ESSENCE: Electronic Surveillance 
System for the Early Notification of Community-based Epidemics. Online 
at: [http://www.geis.fhp.osd.mil/GEIS/SurveillanceActivities/ESSENCE/
ESSENCE.asp] p. 2. (accessed Mar. 24, 2006).
    \48\ The Washington Post, ``Unprepared For a Plague'' (Apr. 18, 
2003), p. 1.
---------------------------------------------------------------------------
    There is also debate within the public health community as 
to whether syndromic surveillance systems are worth the 
financial and manpower costs. Surveillance systems may place an 
increased burden on public health personnel since they will be 
responsible for checking out and responding to alerts from 
surveillance systems. Thus, it is necessary to ensure 
sufficient staff will be available to monitor and provide 
consequence management for surveillance systems.\49\ Syndromic 
surveillance systems are still relatively new and concerns 
about false positives may limit their sensitivity and 
timeliness for detecting events. An astute clinician may call 
attention to an illness of concern faster than a syndromic 
surveillance system. In the case of the anthrax incidents in 
2001, it was a Florida clinician who determined it to be 
anthrax.
---------------------------------------------------------------------------
    \49\ National Association of County & City Health Officials 
[NACCHO] statement entitled, ``Strengthening Local Public Health 
Readiness.'' See committee Files.
---------------------------------------------------------------------------

           C. GOVERNMENT ACCOUNTABILITY OFFICE [GAO] REPORTS

    There are various challenges to improving health data 
collection and reporting. The threat of bioterrorism has placed 
additional burden on public health departments to develop 
surveillance capacity and to have staff available to provide 
timely analysis and response.
    A GAO report entitled, Bioterrorism: Preparedness Varied 
across State and Local Jurisdictions found shortages in 
personnel in state and local public health departments, 
laboratories and hospitals. Some states and cities were 
concerned they did not have enough epidemiologists to do the 
appropriate investigations in an emergency.\50\
---------------------------------------------------------------------------
    \50\ U.S. General Accounting Office, Pub. No. GAO-03-373, 
Bioterrorism: Preparedness Varied Across State and Local Jurisdictions 
(April 2003), p. 17.
---------------------------------------------------------------------------
    GAO found local officials felt their surveillance systems 
were inadequate to detect a bioterrorist event. Some of the 
cities used a passive surveillance system. A passive 
surveillance system is not timely, and is therefore inadequate 
for identifying diseases early. There is also chronic 
underreporting and a time lag between diagnosing a condition 
and the health department's receipt of the report. Many local 
health departments were lacking the resources needed to sustain 
an active surveillance system. According to GAO, ``To improve 
disease surveillance, six of the states and two of the cities 
we visited were developing electronic surveillance systems.'' 
\51\
---------------------------------------------------------------------------
    \51\ U.S. General Accounting Office, Pub. No. GAO-03-373, 
Bioterrorism: Preparedness Varied Across State and Local Jurisdictions 
(April 7, 2003), p. 18.
---------------------------------------------------------------------------
    Another GAO report entitled, Emerging Infectious Diseases: 
Review of State and Federal Disease Surveillance Efforts found 
``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.'' \52\
---------------------------------------------------------------------------
    \52\ U.S. Government Accountability Office, Pub. No. GAO-04-877, 
Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts (September 2004) p. 1.
---------------------------------------------------------------------------

                             II. Discussion


                               A. FINDING

1. Disease surveillance systems are fragmented and have been slow to 
        adapt to new technologies which could improve the timeliness of 
        outbreak reporting

    At a subcommittee hearing, Dr. Seth Foldy, Commissioner of 
Health, Milwaukee, WI testified:

        The Nation's traditional approach to disease 
        surveillance has been slow and cumbersome. States 
        establish lists of reportable diseases. Physicians and 
        laboratories confirm the diagnosis of a reportable 
        disease and record the information manually on paper. 
        The paper is sent to the local or state health 
        department, which processes it and determines whether 
        it needs to be sent elsewhere and whether action needs 
        to be taken. Often the paper forms are missing crucial 
        pieces of information, such as the address or phone 
        number of the patient`` It can take a long time before 
        these pieces of paper add up to the identification of a 
        disease outbreak. Valuable time for preventing the 
        spread of the disease is lost.\53\
---------------------------------------------------------------------------
    \53\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, pps. 79-
80.

---------------------------------------------------------------------------
    Dr. Foldy further stated:

        Traditionally legally mandated disease reporting that 
        is based on the definitive diagnosis of illness and 
        relies on clinicians making the effort to notify public 
        health authorities may be too slow and unreliable for 
        some of today's challenges. It has been estimated that 
        each hour delay in the recognition of an airborne 
        anthrax might cost hundreds of millions of dollars due 
        to missed opportunities to limit exposures and offer 
        prophylactic treatment. Moreover, the traditional model 
        will not detect emerging communicable diseases that too 
        new for mandated reporting regulations.\54\
---------------------------------------------------------------------------
    \54\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 80.

    The Institute of Medicine [IOM] report entitled, Microbial 
---------------------------------------------------------------------------
Threats To Health: Emergence, Detection, and Response observed:

        The ability to gather and analyze information quickly 
        and accurately would improve the Nation's ability to 
        recognize natural disease outbreaks, track emerging 
        infections, identify intentional biological attacks, 
        and monitor disease trends. Surveillance systems within 
        the United States, however, remain fragmented and have 
        not evolved at the same rate as the electronic 
        technological advances that could significantly improve 
        the timelines and integration of data collection.\55\
---------------------------------------------------------------------------
    \55\ Institute of Medicine, Microbial Threats To Health: Emergence, 
Detection, and Response, 2003, p. 10.

    The IOM recommended, ``Research on innovative systems of 
surveillance that capitalize on advances in information 
technology should be supported.'' \56\ However IOM stated, 
``Before widespread implementation, these systems should be 
carefully evaluated for their usefulness in detection of 
infectious disease epidemics, including their potential for 
detection of the major biothreat agents, their ability to 
monitor the spread of epidemics and their cost effectiveness.'' 
\57\
---------------------------------------------------------------------------
    \56\ Institute of Medicine, Microbial Threats To Health: Emergence, 
Detection, and Response, 2003, p. 11.
    \57\ Institute of Medicine, Microbial Threats To Health: Emergence, 
Detection, and Response, 2003, p. 11.
---------------------------------------------------------------------------
    The IOM report further stated, ``CDC should take the 
necessary actions to enhance infectious disease reporting by 
medical health care and veterinary health care providers.'' 
\58\
---------------------------------------------------------------------------
    \58\ Institute of Medicine, Microbial Threats To Health: Emergence, 
Detection, and Response, 2003, p. 10.
---------------------------------------------------------------------------
    The difficulties posed by the wide variance in capabilities 
and the lack of computerized systems in the health community 
were noted in Dr. Fleming's statement, ``There are two things. 
One is the capacity on the clinical side, the clinical 
laboratory side, to computerize and send their information. So 
even if a public health department is equipped to receive 
information, that information can't be received if it can't be 
sent on the clinical side.'' \59\ When asked by Congressman 
Janklow, ``What's holding that up?'' Dr. Fleming replied, 
``There's a wide range of systems that are out there, and in 
fact some aspects of the health care system still aren't 
computerized.'' \60\
---------------------------------------------------------------------------
    \59\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 53.
    \60\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 54.
---------------------------------------------------------------------------
    Dr. Foldy also noted this lack of computer access in his 
statement, ``I hasten to remind the committee that, prior to 
Congress creating specific health alert network funding that 
was earmarked to local health departments, the majority of 
health departments had no Internet connections in this 
country.'' \61\
---------------------------------------------------------------------------
    \61\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 128.
---------------------------------------------------------------------------
    Marcy C. Selecky, president of the Association of State and 
Territorial Health Officials also noted local health department 
weaknesses in her statement, ``In many parts of the country, 
only the state Health Department has the sophisticated 
laboratory and highly trained laboratorians, epidemiologists 
and other public health professionals needed to tackle the most 
serious public health challenges.'' \62\
---------------------------------------------------------------------------
    \62\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 68.
---------------------------------------------------------------------------
    When discussing the current status of disease surveillance 
Dr. Fleming stated, ``The system is working. We can make it 
better. It's not broken, but it can be improved.'' However when 
Congressman Janklow asked Dr. Fleming, ``In terms of the world 
that we live in where terrorism is directed toward us, are we 
where we need to be?'' Dr. Fleming replied, ``No.'' \63\
---------------------------------------------------------------------------
    \63\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 55.
---------------------------------------------------------------------------
    Even with the various types of disease surveillance systems 
currently in place, diseases can still slip through the system.

                           B. RECOMMENDATION

1. The Centers for Disease Control and Prevention should clearly define 
        the technical parameters and set a specific timeframe for 
        establishing a unified national disease surveillance system to 
        replace the current patchwork of reporting and monitoring 
        programs

    Given the fragmented state of U.S. disease surveillance, 
the subcommittee recommends the Centers for Disease Control and 
Prevention set a clear timeframe for modernizing, improving, 
and linking disease surveillance systems.
    The threat of bioterrorism as well as new emerging diseases 
such as SARS makes it imperative local and state public health 
departments are modernized and disease surveillance is 
strengthened. The CDC is responsible for providing ``national 
and international leadership in the public health and medical 
communities to detect, diagnose, respond to, and prevent 
illnesses including those that occur as a result of a 
deliberate release of biological agents,'' and is therefore 
responsible for setting this timeframe.\64\
---------------------------------------------------------------------------
    \64\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 8.
---------------------------------------------------------------------------
    Dr. Julie A. Pavlin, chief, Department of Field Studies, 
Walter Reed Army Institute of Research, has noted the basic 
requirements for a robust, timely surveillance system,

        Any surveillance system for bioterrorism must be dual 
        use and able to detect diseases of natural occurrence, 
        because in most cases it will not be readily apparent 
        if a disease outbreak is natural or manmade. The system 
        must assist public health officers, and not overly 
        burden them with false alarms and unreasonable costs. 
        Finally, the surveillance system must augment other 
        public health practices, and assist in educating 
        clinical colleagues on the importance of maintaining a 
        high index of suspicion and reporting unusual diseases 
        or disease clusters.\65\
---------------------------------------------------------------------------
    \65\ Dr. Julie A. Pavlin, ``Medical Surveillance for Biological 
Terrorism Agents,'' Human and Ecological Risk Assessment, June 2005, p. 
534.

    During a subcommittee hearing on Public Health 
Surveillance, Congressman Chris Bell noted his concern about 
the lack of a timeline for the establishment of a national 
---------------------------------------------------------------------------
disease surveillance system,

        I want to go back for just a minute to this idea that 
        was discussed with the previous panel of trying to 
        create one unified system for reporting . . . I'm 
        curious as to where you would rate the importance and 
        if you are as troubled as I am by the fact that we at 
        the present time don't know how much it would cost and 
        really don't have any time line for getting there, and 
        the amount of money being committed toward spending on 
        that type of surveillance system is decreasing rather 
        than increasing.\66\
---------------------------------------------------------------------------
    \66\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 127.

---------------------------------------------------------------------------
    Ms. Selecky responded

        . . . There are multiple plans, they're private and 
        public, and having a one system fits all doesn't cut it 
        in this country very often. That's why I think that you 
        hear us talking about common standards so that the 
        information that's collected can speak and give us the 
        information that we need to take quick and rapid 
        action.\67\
---------------------------------------------------------------------------
    \67\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 127.

    There is concern public health officials may be waiting for 
the perfect disease surveillance system, instead of using what 
is available now. Ms. Selecky noted this concern during the 
subcommittee hearing, ``When I hear you all talk about and when 
we talk about a common system, I get concerned that we are 
waiting for the perfect system when what we really need to have 
are the foundations to be able to use whatever system exists.'' 
\68\ Ms. Selecky stated, ``We can't wait for someone to say, 
here is the perfect system that is going to be used 
nationally.'' \69\
---------------------------------------------------------------------------
    \68\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 135.
    \69\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 132.
---------------------------------------------------------------------------
    The importance of early detection of a disease is apparent 
in Dr. Fleming's statement,

        One key successful defense against any threat to the 
        health of the public, whether naturally occurring or 
        deliberately caused, continues to be accurate, timely 
        recognition of a problem. Awareness and diagnosis of a 
        condition by a clinician or laboratory is a key element 
        of our current surveillance system. Clinicians and 
        laboratories report diseases to State and Local health 
        departments which share information with CDC.\70\
---------------------------------------------------------------------------
    \70\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 9.

A nationwide disease surveillance system would help ensure the 
timeliness of this recognition.
    While the establishment of a nationwide disease 
surveillance system is essential, the subcommittee also 
acknowledges a disease surveillance system is only as good as 
the public health response that comes after it to prevent and 
save lives. Effective disease surveillance will require a 
commitment of funds not just to Federal agencies, but also to 
the state public health departments, who will be on the 
frontlines of any disease outbreak, epidemic, or pandemic. Dr. 
Fleming expresses this clearly in his statement,

        the true measure of a system is how responsive it is 
        not in detecting the event, but in responding to the 
        event and putting the actions in place that need to be 
        put there to keep people healthy. And so my definition 
        of the perfect system, if you will, is a system that is 
        rapid enough such that the preventative action that 
        need to be put in place will happen before individuals 
        become sick or die.\71\
---------------------------------------------------------------------------
    \71\ Homeland Security: Improving Public Health Surveillance, 
hearing before the Subcommittee on National Security, Emerging Threats, 
and International Relations of the Committee on Government Reform, 
House of Representatives, 108th Cong., 1st sess., May 5, 2003, Serial 
No. 108-55, U.S. Government Printing Office, Washington: 2003, p. 51.

    Monitoring CDC publications and peer review articles since 
the testimony at the subcommittee hearing confirms a lack of 
adequate progess toward a unified surveillance system. It would 
be unwise to expect the individual pieces of disease 
surveillance to come together on their own and grow into a 
coherent whole.

                          A P P E N D I X E S

                                ------                                



                               APPENDIX I


                      Disease Surveillance Systems


BIOSENSE
eLEXNET                                     Electronic Laboratory
                                             Exchange Network
ESSENCE                                     Electronic Surveillance
                                             System for the Early
                                             Notification of Community-
                                             based Epidemics
Epi-X                                       Epidemic Information
                                             Exchange
ESP                                         Enhanced Surveillance
                                             Project
FoodNet                                     Foodborne Disease Active
                                             Surveillance Network
GEIS                                        Global Emerging Infections
                                             Surveillance and Response
                                             System
GOARN                                       Global Outbreak Alert and
                                             Response Network
GPHIN                                       Global Public Health
                                             Intelligence Network
HAN                                         Health Alert Network
IDSA-EIN                                    Infectious Diseases Society
                                             of America Emerging
                                             Infections Network
LRN                                         Laboratory Response Network
NAHRS                                       National Animal Health
                                             Reporting System
National Bioterrorism Syndromic
 Surveillance Demonstration Program
NEDSS                                       National Electronic Disease
                                             Surveillance System
NETSS                                       National Electronic
                                             Telecommunications System
                                             for Surveillance
NRDM                                        National Retail Data Monitor
NVSL                                        National Veterinary Services
                                             Laboratories
PulseNet
RODS                                        Real-time Outbreak and
                                             Disease Surveillance


                              APPENDIX II



                              APPENDIX III



                                 
