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Monitoring disease activity has been one of the primary responsibilities of government-supported public health units since they first came into being during the formative years of our nation. For much of our nation’s history, surveillance has focused on the most important infectious disease threats, such as cholera, tuberculosis, or more recently HIV/AIDS. Today, developing accurate and reasonable specific surveillance systems capable of identifying bioterrorism accurately and swiftly is one of the most active areas of development and research relating to bioterrorism. Early detection of exposures could allow for containment and treatment that could greatly reduce morbidity and mortality of countless numbers. Unfortunately, implementation of such surveillance systems is no simple task. There are several general approaches to surveillance: clinical or case-based surveillance, environmental surveillance, or laboratory-based surveillance. This chapter summarizes general principles of surveillance systems, as well as various models for conducting surveillance as it relates to bioterrorism. The concept of sentinel health events is also introduced, and its potential as a useful tool for practitioners in diagnosing bioterrorism is considered. Last, the chapter ends with a discussion of the utility of syndromic surveillance and how this might be applied in order to distinguish naturally occurring sentinel health events (e.g., a case of plague) from a deliberate bioterrorist attack.

Developing and testing surveillance systems to detect at the earliest possible stage potential bioterrorist incidents ranks high as a national public health priority. In 2002 alone, the CDC distributed over $1 billion in funds to accelerate research and development of surveillance systems with two specific objectives. First, to create state-based surveillance systems capable of receiving and evaluating diagnoses, disease case reports, or illness syndromes that could signal a bioterrorist attack. Second, to establish communication networks capable of sharing quickly critical public health information to emergency departments, local and state public health units, and local and state law enforcement officials. Although progress is being made, the degree to which these goals have been met varies considerably from state to state.

The overall objectives of an effective surveillance system are defined readily enough. According to the CDC, ideal surveillance systems are capable of recognizing a BCN terrorist event quickly, with reasonable sensitivity and specificity, and capable of quickly disseminating these data to critical nodal points in the public health decision-making structure. Further, surveillance systems should monitor diseases or illness syndromes with manifest public health importance. The operational requirements of surveillance systems should be known as well, including direct costs, and personnel and information technology requirements. The accuracy, flexibility, and acceptability of the system should be known, preferably through actual field testing or computer-simulated modeling. A surveillance system that cannot be modified as existing threats evolve, or as new ones emerge, has limited long-term utility and the costs associated with implementing such a system will be difficult to justify. If a surveillance system has limited acceptability to those who are being asked to assume the real costs of the system, for example, onerous, unduly complex, ...

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