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1.  Animals as Sentinels of Bioterrorism Agents 
Emerging Infectious Diseases  2006;12(4):647-652.
Pets, wildlife, or livestock could provide early warning.
We conducted a systematic review of the scientific literature from 1966 to 2005 to determine whether animals could provide early warning of a bioterrorism attack, serve as markers for ongoing exposure risk, and amplify or propagate a bioterrorism outbreak. We found evidence that, for certain bioterrorism agents, pets, wildlife, or livestock could provide early warning and that for other agents, humans would likely manifest symptoms before illness could be detected in animals. After an acute attack, active surveillance of wild or domestic animal populations could help identify many ongoing exposure risks. If certain bioterrorism agents found their way into animal populations, they could spread widely through animal-to-animal transmission and prove difficult to control. The public health infrastructure must look beyond passive surveillance of acute animal disease events to build capacity for active surveillance and intervention efforts to detect and control ongoing outbreaks of disease in domestic and wild animal populations.
doi:10.3201/eid1204.051120
PMCID: PMC3294700  PMID: 16704814
bioterrorism; animals; sentinel surveillance; evidence based medicine; Zoonoses; biological warfare
2.  Detection of Disease Outbreaks by the Use of Oral Manifestations 
Journal of Dental Research  2009;88(1):89-94.
Oral manifestations of diseases caused by bioterrorist agents could be a potential data source for biosurveillance. This study had the objectives of determining the oral manifestations of diseases caused by bioterrorist agents, measuring the prevalence of these manifestations in emergency department reports, and constructing and evaluating a detection algorithm based on them. We developed a software application to detect oral manifestations in free text and identified positive reports over three years of data. The normal frequency in reports for oral manifestations related to anthrax (including buc-cal ulcers-sore throat) was 7.46%. The frequency for tularemia was 6.91%. For botulism and smallpox, the frequencies were 0.55% and 0.23%. We simulated outbreaks for these bioterrorism diseases and evaluated the performance of our system. The detection algorithm performed better for smallpox and botulism than for anthrax and tularemia. We found that oral manifestations can be a valuable tool for biosur-veillance.
doi:10.1177/0022034508327546
PMCID: PMC3144048  PMID: 19131324
bioterrorism; dental informatics; dental public health; early detection; oral manifestations
3.  Syndromic surveillance using automated collection of computerized discharge diagnoses 
The Syndromic Surveillance Information Collection (SSIC) system aims to facilitate early detection of bioterrorism attacks (with such agents as anthrax, brucellosis, plague, Q fever, tularemia, smallpox, viral encephalitides, hemorrhagic fever, botulism toxins, staphylococcal enterotoxin B, etc.) and early detection of naturally occurring disease outbreaks, including large foodborne disease outbreaks, emerging infections, and pandemic influenza. This is accomplished using automated data collection of visit-level discharge diagnoses from heterogeneous clinical information systems, integrating those data into a common XML (Extensible Markup Language) form, and monitoring the results to detect unusual patterns of illness in the population. The system, operational since January 2001, collects, integrates, and displays data from three emergency department and urgent care (ED/UC) departments and nine primary care clinics by automatically mining data from the information systems of those facilities. With continued development, this system will constitute the foundation of a population-based surveillance system that will facilitate targeted investigation of clinical syndromes under surveillance and allow early detection of unusual clusters of illness compatible with bioterrorism or disease outbreaks.
doi:10.1007/PL00022320
PMCID: PMC3456541  PMID: 12791784
Biological warfare; Bioterrorism; Data collection; Database; Informatics; Information systems; Sentinel surveillance
4.  Automated Syndromic Surveillance for the 2002 Winter Olympics 
The 2002 Olympic Winter Games were held in Utah from February 8 to March 16, 2002. Following the terrorist attacks on September 11, 2001, and the anthrax release in October 2001, the need for bioterrorism surveillance during the Games was paramount. A team of informaticists and public health specialists from Utah and Pittsburgh implemented the Real-time Outbreak and Disease Surveillance (RODS) system in Utah for the Games in just seven weeks. The strategies and challenges of implementing such a system in such a short time are discussed. The motivation and cooperation inspired by the 2002 Olympic Winter Games were a powerful driver in overcoming the organizational issues. Over 114,000 acute care encounters were monitored between February 8 and March 31, 2002. No outbreaks of public health significance were detected. The system was implemented successfully and operational for the 2002 Olympic Winter Games and remains operational today.
doi:10.1197/jamia.M1352
PMCID: PMC264432  PMID: 12925547
5.  Syndromic surveillance: A local perspective 
Conclusions
The promise of syndromic surveillance extends beyond early warning for bioterrorist attacks. Even if bioterrorism is first detected by an astute clinician, syndromic surveillance can help delineate the size, location, and tempo of the epidemic or provide reassurance that a large outbreak is not occurring when a single case or a small, localized cluster of an unusual illness is detected. More broadly, however, as public health and medicine proceed in our information age, the use of existing electronic data for public health surveillance will not appear to be an untested experiment for long. The challenge is to allow these systems to flower without burdening them with unrealistic expectations, centralized control, and unbalanced funding. To help syndromic surveillance systems reach their full potential, we need data standards, guidance to the developers of clinical information systems that will ensure data flow and interoperability, evaluations of best practices, links to improved laboratory diagnostics, regulations that protect privacy and data security, and reliable sustained funding for public health infrastructure to ensure the capacity to respond when the alarm sounds.
doi:10.1093/jurban/jtg042
PMCID: PMC3456537  PMID: 12892064
6.  Measuring the effect of commuting on the performance of the Bayesian Aerosol Release Detector 
Background
Early detection of outdoor aerosol releases of anthrax is an important problem. The Bayesian Aerosol Release Detector (BARD) is a system for detecting releases of aerosolized anthrax and characterizing them in terms of location, time and quantity. Modelling a population's exposure to aerosolized anthrax poses a number of challenges. A major difficulty is to accurately estimate the exposure level--the number of inhaled anthrax spores--of each individual in the exposed region. Partly, this difficulty stems from the lack of fine-grained data about the population under surveillance. To cope with this challenge, nearly all anthrax biosurveillance systems, including BARD, ignore the mobility of the population and assume that exposure to anthrax would occur at one's home administrative unit--an assumption that limits the fidelity of the model.
Methods
We employed commuting data provided by the U.S. Census Bureau to parameterize a commuting model. Then, we developed methods for integrating commuting into BARD's simulation and detection algorithms and conducted two studies to measure the effect. The first study (simulation study) was designed to assess how BARD's detection and characterization performance are impacted by incorporation of commuting in BARD's outbreak-simulation algorithm. The second study (detection study) was designed to measure the effect of incorporating commuting in BARD's outbreak-detection algorithm.
Results
We found that failing to account for commuting in detection (when commuting is present in simulation) leads to a deterioration in BARD's detection and characterization performance that is both statistically and practically significant. We found that a simplified approach to accounting for commuting in detection--simplified to maintain tractability of inference--nearly fully restored both detection and characterization performance of BARD detector.
Conclusion
We conclude that it is important to account for commuting (and mobility in general) in BARD's simulation algorithm. Further, the proposed method for incorporating commuting in BARD's detection algorithm can successfully perform the necessary correction in the detection algorithm, while preserving BARD's practicality. In our future work, we intend to further study the problem of the trade-off between running time and accuracy of the computation in BARD's version that includes commuting and ultimately find the best such trade-off.
doi:10.1186/1472-6947-9-S1-S7
PMCID: PMC2773922  PMID: 19891801
7.  Rapid deployment of an electronic disease surveillance system in the state of Utah for the 2002 Olympic Winter Games. 
The key to minimizing the effects of an intentionally caused disease outbreak is early detection of the attack and rapid identification of the affected individuals. The Bush administration's leadership in advocating for biosurveillance systems capable of monitoring for bioterrorism attacks suggests that we should move quickly to establish a nationwide early warning biosurveillance system as a defense against this threat. The spirit of collaboration and unity inspired by the events of 9-11 and the 2002 Olympic Winter Games in Salt Lake City provided the opportunity to demonstrate how a prototypic biosurveillance system could be rapidly deployed. In seven weeks we were able to implement an automated, real-time disease outbreak detection system in the State of Utah and monitored 80,684 acute care visits occurring during a 28-day period spanning the Olympics. No trends of immediate public health concern were identified.
PMCID: PMC2244330  PMID: 12463832
8.  Advancing a Framework to Enable Characterization and Evaluation of Data Streams Useful for Biosurveillance 
PLoS ONE  2014;9(1):e83730.
In recent years, biosurveillance has become the buzzword under which a diverse set of ideas and activities regarding detecting and mitigating biological threats are incorporated depending on context and perspective. Increasingly, biosurveillance practice has become global and interdisciplinary, requiring information and resources across public health, One Health, and biothreat domains. Even within the scope of infectious disease surveillance, multiple systems, data sources, and tools are used with varying and often unknown effectiveness. Evaluating the impact and utility of state-of-the-art biosurveillance is, in part, confounded by the complexity of the systems and the information derived from them. We present a novel approach conceptualizing biosurveillance from the perspective of the fundamental data streams that have been or could be used for biosurveillance and to systematically structure a framework that can be universally applicable for use in evaluating and understanding a wide range of biosurveillance activities. Moreover, the Biosurveillance Data Stream Framework and associated definitions are proposed as a starting point to facilitate the development of a standardized lexicon for biosurveillance and characterization of currently used and newly emerging data streams. Criteria for building the data stream framework were developed from an examination of the literature, analysis of information on operational infectious disease biosurveillance systems, and consultation with experts in the area of biosurveillance. To demonstrate utility, the framework and definitions were used as the basis for a schema of a relational database for biosurveillance resources and in the development and use of a decision support tool for data stream evaluation.
doi:10.1371/journal.pone.0083730
PMCID: PMC3879288  PMID: 24392093
9.  Simulated Anthrax Attacks and Syndromic Surveillance 
Emerging Infectious Diseases  2005;11(9):1394-1398.
Bioterrorism surveillance systems can be assessed using modeling to simulate real-world attacks.
We measured sensitivity and timeliness of a syndromic surveillance system to detect bioterrorism events. A hypothetical anthrax release was modeled by using zip code population data, mall customer surveys, and membership information from HealthPartners Medical Group, which covers 9% of a metropolitan area population in Minnesota. For each infection level, 1,000 releases were simulated. Timing of increases in use of medical care was based on data from the Sverdlovsk, Russia, anthrax release. Cases from the simulated outbreak were added to actual respiratory visits recorded for those dates in HealthPartners Medical Group data. Analysis was done by using the space-time scan statistic. We evaluated the proportion of attacks detected at different attack rates and timeliness to detection. Timeliness and completeness of detection of events varied by rate of infection. First detection of events ranged from days 3 to 6. Similar modeling may be possible with other surveillance systems and should be a part of their evaluation.
doi:10.3201/eid1109.050223
PMCID: PMC3310627  PMID: 16229768
Anthrax; bioterrorism; managed care programs; Minnesota; statistical models; population surveillance; research
10.  Antibodies for biodefense 
mAbs  2011;3(6):517-527.
Potential bioweapons are biological agents (bacteria, viruses and toxins) at risk of intentional dissemination. Biodefense, defined as development of therapeutics and vaccines against these agents, has seen an increase, particularly in the US, following the 2001 anthrax attack. This review focuses on recombinant antibodies and polyclonal antibodies for biodefense that have been accepted for clinical use. These antibodies aim to protect against primary potential bioweapons or category A agents as defined by the Centers for Disease Control and Prevention (Bacillus anthracis, Yersinia pestis, Francisella tularensis, botulinum neurotoxins, smallpox virus and certain others causing viral hemorrhagic fevers) and certain category B agents. Potential for prophylactic use is presented, as well as frequent use of oligoclonal antibodies or synergistic effect with other molecules. Capacities and limitations of antibodies for use in biodefense are discussed, and are generally applicable to the field of infectious diseases.
doi:10.4161/mabs.3.6.17621
PMCID: PMC3242838  PMID: 22123065
antibody; anthrax; plague; smallpox; botulism; tularemia; brucellosis; hemorrhagic; ricin; SEB
11.  Review of syndromic surveillance: implications for waterborne disease detection 
Syndromic surveillance is the gathering of data for public health purposes before laboratory or clinically confirmed information is available. Interest in syndromic surveillance has increased because of concerns about bioterrorism. In addition to bioterrorism detection, syndromic surveillance may be suited to detecting waterborne disease outbreaks. Theoretical benefits of syndromic surveillance include potential timeliness, increased response capacity, ability to establish baseline disease burdens, and ability to delineate the geographical reach of an outbreak. This review summarises the evidence gathered from retrospective, prospective, and simulation studies to assess the efficacy of syndromic surveillance for waterborne disease detection. There is little evidence that syndromic surveillance mitigates the effects of disease outbreaks through earlier detection and response. Syndromic surveillance should not be implemented at the expense of traditional disease surveillance, and should not be relied upon as a principal outbreak detection tool. The utility of syndromic surveillance is dependent on alarm thresholds that can be evaluated in practice. Syndromic data sources such as over the counter drug sales for detection of waterborne outbreaks should be further evaluated.
doi:10.1136/jech.2005.038539
PMCID: PMC2563943  PMID: 16698988
syndromic surveillance; waterborne disease; surveillance
12.  Enhanced Influenza Surveillance using Telephone Triage Data in the VA ESSENCE Biosurveillance System 
Objective
To evaluate the utility and timeliness of telephone triage (TT) for influenza surveillance in the Department of Veterans Affairs (VA).
Introduction
Telephone triage is a relatively new data source available to biosurveillance systems.1–2 Because early detection and warning is a high priority, many biosurveillance systems have begun to collect and analyze data from non-traditional sources [absenteeism records, over-the-counter drug sales, electronic laboratory reporting, internet searches (e.g. Google Flu Trends) and TT]. These sources may provide disease activity alerts earlier than conventional sources. Little is known about whether VA telephone program influenza data correlates with established influenza biosurveillance.
Methods
Veterans phoning VA’s TT system, and those admitted or seen at a VA facility with influenza or influenza-like-illness (ILI) diagnosis were included in this analysis. Influenza-specific ICD-9-CM coded emergency department (ED) and urgent care (UC) visits, hospitalizations, TT calls, and ILI outpatient visits were analyzed covering 2010–2011 and 2011–2012 influenza seasons (July 11, 2010–April 14, 2012). Data came from 80 VA Medical Centers and over 500 outpatient clinics with complete reporting data for the time period of interest. We calculated Spearman rank-order coefficients, 95% confidence intervals and p-values using Fisher’s z transformation to describe correlation between TT data and other influenza healthcare measures. For comparison of time trends, we plotted data for hospitalizations, ED/UC visits and outpatient ILI syndrome visits against TT encounters. We applied ESSENCE detection algorithms to identify high-level alerts for influenza activity. ESSENCE aberration detection was restricted to the 2011–2012 season because limited historical TT and outpatient data from 2009–2010 was available to accurately predict aberrancy in the 2010–2011 season. We then calculated the peak measure of healthcare utilization during both influenza seasons (2010–2011 and 2011–2012) for each data source and compared timing of peaks and alerts between TT and other healthcare encounters to assess maximum healthcare system usage and timeliness of surveillance.
Results
There were 7,044 influenza-coded calls, 564 hospitalizations, 1,849 emergency/urgent visits, and 416,613 ILI-coded outpatient visits. Spearman rank correlation coefficients were calculated for influenza-coded calls with hospitalizations (0.77); ED/UC visits (0.85); and ILI-outpatient visits (0.88), respectively (P< 0.0001 for all correlations). Peak influenza activity occurred on the same week or within 1 week across all settings for both seasons. For the 2011–2012 season, TT alerted with increased influenza activity before all other settings.
Conclusions
Data from VA telephone care correlates well with other VA data sources for influenza activity. TT may serve to augment these existing clinical data sources and provide earlier alerts of influenza activity. As a national health care system with a large patient population, VA could provide a robust early-warning system for influenza if ongoing biosurveillance activities are combined with TT data. Additional analyses are needed to understand and correlate TT with healthcare utilization and severity of illness.
PMCID: PMC3692747
Surveillance; Influenza; Telephone triage; Veterans
13.  Developing open source, self-contained disease surveillance software applications for use in resource-limited settings 
Background
Emerging public health threats often originate in resource-limited countries. In recognition of this fact, the World Health Organization issued revised International Health Regulations in 2005, which call for significantly increased reporting and response capabilities for all signatory nations. Electronic biosurveillance systems can improve the timeliness of public health data collection, aid in the early detection of and response to disease outbreaks, and enhance situational awareness.
Methods
As components of its Suite for Automated Global bioSurveillance (SAGES) program, The Johns Hopkins University Applied Physics Laboratory developed two open-source, electronic biosurveillance systems for use in resource-limited settings. OpenESSENCE provides web-based data entry, analysis, and reporting. ESSENCE Desktop Edition provides similar capabilities for settings without internet access. Both systems may be configured to collect data using locally available cell phone technologies.
Results
ESSENCE Desktop Edition has been deployed for two years in the Republic of the Philippines. Local health clinics have rapidly adopted the new technology to provide daily reporting, thus eliminating the two-to-three week data lag of the previous paper-based system.
Conclusions
OpenESSENCE and ESSENCE Desktop Edition are two open-source software products with the capability of significantly improving disease surveillance in a wide range of resource-limited settings. These products, and other emerging surveillance technologies, can assist resource-limited countries compliance with the revised International Health Regulations.
doi:10.1186/1472-6947-12-99
PMCID: PMC3458896  PMID: 22950686
Electronic biosurveillance; Software development; Public health; Disease outbreak; Resource-limited settings
14.  Syndromic Surveillance and Bioterrorism-related Epidemics 
Emerging Infectious Diseases  2003;9(10):1197-1204.
To facilitate rapid detection of a future bioterrorist attack, an increasing number of public health departments are investing in new surveillance systems that target the early manifestations of bioterrorism-related disease. Whether this approach is likely to detect an epidemic sooner than reporting by alert clinicians remains unknown. The detection of a bioterrorism-related epidemic will depend on population characteristics, availability and use of health services, the nature of an attack, epidemiologic features of individual diseases, surveillance methods, and the capacity of health departments to respond to alerts. Predicting how these factors will combine in a bioterrorism attack may be impossible. Nevertheless, understanding their likely effect on epidemic detection should help define the usefulness of syndromic surveillance and identify approaches to increasing the likelihood that clinicians recognize and report an epidemic.
doi:10.3201/eid0910.030231
PMCID: PMC3033092  PMID: 14609452
15.  Integrated Disease Investigations and Surveillance planning: a systems approach to strengthening national surveillance and detection of events of public health importance in support of the International Health Regulations 
BMC Public Health  2010;10(Suppl 1):S6.
The international community continues to define common strategic themes of actions to improve global partnership and international collaborations in order to protect our populations. The International Health Regulations (IHR[2005]) offer one of these strategic themes whereby World Health Organization (WHO) Member States and global partners engaged in biosecurity, biosurveillance and public health can define commonalities and leverage their respective missions and resources to optimize interventions. The U.S. Defense Threat Reduction Agency’s Cooperative Biologica Engagement Program (CBEP) works with partner countries across clinical, veterinary, epidemiological, and laboratory communities to enhance national disease surveillance, detection, diagnostic, and reporting capabilities. CBEP, like many other capacity building programs, has wrestled with ways to improve partner country buy-in and ownership and to develop sustainable solutions that impact integrated disease surveillance outcomes. Designing successful implementation strategies represents a complex and challenging exercise and requires robust and transparent collaboration at the country level. To address this challenge, the Laboratory Systems Development Branch of the U.S. Centers for Disease Control and Prevention (CDC) and CBEP have partnered to create a set of tools that brings together key leadership of the surveillance system into a deliberate system design process. This process takes into account strengths and limitations of the existing system, how the components inter-connect and relate to one another, and how they can be systematically refined within the local context. The planning tools encourage cross-disciplinary thinking, critical evaluation and analysis of existing capabilities, and discussions across organizational and departmental lines toward a shared course of action and purpose. The underlying concepts and methodology of these tools are presented here.
doi:10.1186/1471-2458-10-S1-S6
PMCID: PMC3005578  PMID: 21143828
16.  The Biosurveillance Resource Directory - A One-Stop Shop for Systems, Sources, and Tools 
Objective
The goal of this project is to identify systems and data streams relevant for infectious disease biosurveillance. This effort is part of a larger project evaluating existing and potential data streams for use in local, national, and international infectious disease surveillance systems with the intent of developing tools to provide decision-makers with timely information to predict, prepare for, and mitigate the spread of disease.
Introduction
Local, national, and global infectious disease surveillance systems have been implemented to meet the demands of monitoring, detecting, and reporting disease outbreaks and prevalence. Varying surveillance goals and geographic reach have led to multiple and disparate systems, each using unique combinations of data streams to meet surveillance criteria. In order to assess the utility and effectiveness of different data streams for global disease surveillance, a comprehensive survey of current human, animal, plant, and marine surveillance systems and data streams was undertaken. Information regarding surveillance systems and data streams has been (and continues to be) systematically culled from websites, peer-reviewed literature, government documents, and subject-matter expert consultations.
Methods
A relational database has been developed and refined to allow for detailed analyses of data streams and surveillance systems. To maximize the utility of the database and facilitate one-stop-shopping for biosurveillance system information, we have expanded our scope to include not only biosurveillance systems, but also data sources, tools, and biosurveillance collectives. Captured in the information collected about the resource (if available) is the name and acronym of the resource, the date the resource became available, the accessibility of the resource (is it open to all, or are there limitations to access), the primary sponsors, if the resource is associated with GIS functionality, and if the focus is health. Also collected is contact information, information regarding the scope and domain of the resource, the pertinent diseases or disease categories, and the geographic and population coverage of the resource. Websites associated with the resource are directly accessible from the database. Data stream information is also captured based on our developed data stream framework. If the resource uses other specified systems/sources/tools for data gathering or analysis, then that is also captured and directly linked within the database.
Results
The Biosurveillance Resource Directory (BRD) is in the process of being tested by multiple potential end users in the public health, biosecurity, and biosurveillance communities. Feedback from these testers is being used to refine the database to maximize functionality and utility. Additionally, methods for dynamically updating and maintaining the database are being evaluated. Automated and semi-automated queriable reports have been developed and are integral to demonstrating specific use-case scenarios in which the BRD would be beneficial for end-users.
Conclusions
A need for a biosurveillance one-stop shop has been increasingly called for to help in evaluating what data streams and systems are available and relevant for many different biosurveillance needs and goals. The prototype Biosurveillance Resource Directory is a search-able, dynamic database for biosurveillance systems, sources, and tools information.
PMCID: PMC3692785
infectious disease; biosurveillance; database
17.  Bioterrorism – Health emergency preparedness and response 
Paediatrics & Child Health  2003;8(2):93-96.
Health emergency planning for preparedness and response against acts of terrorism, including the malfeasant threat or actual release of biological agents designed to harm others, has assumed a higher level of concern for most western nations, including Canada, following the explosive attacks in the United States on September 11, 2001. These terrorist attacks were followed by an outbreak of anthrax infections. The Bacillus anthracis spores in these attacks were dispersed by using regular postal services in the United States. In addition to the unsettling sense of social vulnerability that resulted from these attacks, a greater appreciation that the integration of public health, emergency health and social services with security activities was required to fully address the need to protect the health and other interests of the citizens. Collaborative work among regional, provincial, territorial, federal and international authorities within these domains is emerging as an effective response to the risk management of bioterrorism. The following is a brief description of the health framework for preparedness and response, and the biological agents of major concern in terrorism.
PMCID: PMC2791430  PMID: 20019925
Bioterrorism; Health emergency
18.  SAGES: A Suite of Freely-Available Software Tools for Electronic Disease Surveillance in Resource-Limited Settings 
PLoS ONE  2011;6(5):e19750.
Public health surveillance is undergoing a revolution driven by advances in the field of information technology. Many countries have experienced vast improvements in the collection, ingestion, analysis, visualization, and dissemination of public health data. Resource-limited countries have lagged behind due to challenges in information technology infrastructure, public health resources, and the costs of proprietary software. The Suite for Automated Global Electronic bioSurveillance (SAGES) is a collection of modular, flexible, freely-available software tools for electronic disease surveillance in resource-limited settings. One or more SAGES tools may be used in concert with existing surveillance applications or the SAGES tools may be used en masse for an end-to-end biosurveillance capability. This flexibility allows for the development of an inexpensive, customized, and sustainable disease surveillance system. The ability to rapidly assess anomalous disease activity may lead to more efficient use of limited resources and better compliance with World Health Organization International Health Regulations.
doi:10.1371/journal.pone.0019750
PMCID: PMC3091876  PMID: 21572957
19.  Syndromic Surveillance for Influenzalike Illness in Ambulatory Care Setting 
Emerging Infectious Diseases  2004;10(10):1806-1811.
Detection algorithm using proxy data for a bioterrorism agent release and historical data for influenza was effective.
Conventional disease surveillance mechanisms that rely on passive reporting may be too slow and insensitive to rapidly detect a large-scale infectious disease outbreak; the reporting time from a patient's initial symptoms to specific disease diagnosis takes days to weeks. To meet this need, new surveillance methods are being developed. Referred to as nontraditional or syndromic surveillance, these new systems typically rely on prediagnostic data to rapidly detect infectious disease outbreaks, such as those caused by bioterrorism. Using data from a large health maintenance organization, we discuss the development, implementation, and evaluation of a time-series syndromic surveillance detection algorithm for influenzalike illness in Minnesota.
doi:10.3201/eid1010.030789
PMCID: PMC3323280  PMID: 15504267
Bioterrorism; Surveillance; ICD-9; Syndrome; Research
20.  Enhanced health event detection and influenza surveillance using a joint Veterans Affairs and Department of Defense biosurveillance application 
Background
The establishment of robust biosurveillance capabilities is an important component of the U.S. strategy for identifying disease outbreaks, environmental exposures and bioterrorism events. Currently, U.S. Departments of Defense (DoD) and Veterans Affairs (VA) perform biosurveillance independently. This article describes a joint VA/DoD biosurveillance project at North Chicago-VA Medical Center (NC-VAMC). The Naval Health Clinics-Great Lakes facility physically merged with NC-VAMC beginning in 2006 with the full merger completed in October 2010 at which time all DoD care and medical personnel had relocated to the expanded and remodeled NC-VAMC campus and the combined facility was renamed the Lovell Federal Health Care Center (FHCC). The goal of this study was to evaluate disease surveillance using a biosurveillance application which combined data from both populations.
Methods
A retrospective analysis of NC-VAMC/Lovell FHCC and other Chicago-area VAMC data was performed using the ESSENCE biosurveillance system, including one infectious disease outbreak (Salmonella/Taste of Chicago-July 2007) and one weather event (Heat Wave-July 2006). Influenza-like-illness (ILI) data from these same facilities was compared with CDC/Illinois Sentinel Provider and Cook County ESSENCE data for 2007-2008.
Results
Following consolidation of VA and DoD facilities in North Chicago, median number of visits more than doubled, median patient age dropped and proportion of females rose significantly in comparison with the pre-merger NC-VAMC facility. A high-level gastrointestinal alert was detected in July 2007, but only low-level alerts at other Chicago-area VAMCs. Heat-injury alerts were triggered for the merged facility in June 2006, but not at the other facilities. There was also limited evidence in these events that surveillance of the combined population provided utility above and beyond the VA-only and DoD-only components. Recorded ILI activity for NC-VAMC/Lovell FHCC was more pronounced in the DoD component, likely due to pediatric data in this population. NC-VAMC/Lovell FHCC had two weeks of ILI activity exceeding both the Illinois State and East North Central Regional baselines, whereas Hines VAMC had one and Jesse Brown VAMC had zero.
Conclusions
Biosurveillance in a joint VA/DoD facility showed potential utility as a tool to improve surveillance and situational awareness in an area with Veteran, active duty and beneficiary populations. Based in part on the results of this pilot demonstration, both agencies have agreed to support the creation of a combined VA/DoD ESSENCE biosurveillance system which is now under development.
doi:10.1186/1472-6947-11-56
PMCID: PMC3188469  PMID: 21929813
21.  Knowledge-based bioterrorism surveillance. 
An epidemic resulting from an act of bioterrorism could be catastrophic. However, if an epidemic can be detected and characterized early on, prompt public health intervention may mitigate its impact. Current surveillance approaches do not perform well in terms of rapid epidemic detection or epidemic monitoring. One reason for this shortcoming is their failure to bring existing knowledge and data to bear on the problem in a coherent manner. Knowledge-based methods can integrate surveillance data and knowledge, and allow for careful evaluation of problem-solving methods. This paper presents an argument for knowledge-based surveillance, describes a prototype of BioSTORM, a system for real-time epidemic surveillance, and shows an initial evaluation of this system applied to a simulated epidemic from a bioterrorism attack.
PMCID: PMC2244298  PMID: 12463790
22.  First Case of Bioterrorism-Related Inhalational Anthrax, Florida, 2001: North Carolina Investigation 
Emerging Infectious Diseases  2002;8(10):1035-1038.
The index case of inhalational anthrax in October 2001 was in a man who lived and worked in Florida. However, during the 3 days before illness onset, the patient had traveled through North Carolina, raising the possibility that exposure to Bacillus anthracis spores could have occurred there. The rapid response in North Carolina included surveillance among hospital intensive-care units, microbiology laboratories, medical examiners, and veterinarians, and site investigations at locations visited by the index patient to identify the naturally occurring or bioterrorism-related source of his exposure.
doi:10.3201/eid0810.020389
PMCID: PMC2730300  PMID: 12396911
Bacillus anthracis; anthrax; bioterrorism; epidemiology and surveillance
23.  Roundtable on Bioterrorism Detection 
During the 2001 AMIA Annual Symposium, the Anesthesia, Critical Care, and Emergency Medicine Working Group hosted the Roundtable on Bioterrorism Detection. Sixty-four people attended the roundtable discussion, during which several researchers discussed public health surveillance systems designed to enhance early detection of bioterrorism events. These systems make secondary use of existing clinical, laboratory, paramedical, and pharmacy data or facilitate electronic case reporting by clinicians. This paper combines case reports of six existing systems with discussion of some common techniques and approaches. The purpose of the roundtable discussion was to foster communication among researchers and promote progress by 1) sharing information about systems, including origins, current capabilities, stages of deployment, and architectures; 2) sharing lessons learned during the development and implementation of systems; and 3) exploring cooperation projects, including the sharing of software and data. A mailing list server for these ongoing efforts may be found at http://bt.cirg.washington.edu.
doi:10.1197/jamia.M1052
PMCID: PMC344564  PMID: 11861622
24.  Precautions against biological and chemical terrorism directed at food and water supplies. 
Public Health Reports  2001;116(1):3-14.
Deliberate food and water contamination remains the easiest way to distribute biological or chemical agents for the purpose of terrorism, despite the national focus on dissemination of these agents as small-particle aerosols or volatile liquids. Moreover, biological terrorism as a result of sabotage of our food supply has already occurred in the United States. A review of naturally occurring food- and waterborne outbreaks exposes this vulnerability and reaffirms that, depending on the site of contamination, a significant number of people could be infected or injured over a wide geographic area. Major knowledge gaps exist with regard to the feasibility of current disinfection and inspection methods to protect our food and water against contamination by a number of biological and chemical agents. However, a global increase in food and water safety initiatives combined with enhanced disease surveillance and response activities are our best hope to prevent and respond quickly to food- and waterborne bioterrorism.
PMCID: PMC1497290  PMID: 11571403
25.  An Evaluation of Three Policies for Updating Product Categories in the National Retail Data Monitor 
A problem in biosurveillance is how frequently to update controlled vocabularies that identify various data elements such as laboratory tests and over-the-counter healthcare products. More frequent updates improve completeness of data captured over time, but introduction of new codes into a surveillance system may cause false alarms when codes are aggregated into analytic categories. We studied the effect of three policies for updating UPCs, the controlled vocabulary for over-the-counter healthcare products used by the National Retail Data Monitor.
To compare different policies for updating, we analyzed historical data from two cities for the 18 product categories of the National Retail Data Monitor under annual, quarterly, or monthly UPC update policies. We measured the effect on data completeness and false alarm rate.
We found that the monthly update policy had the highest data completeness and led to the fewest number of additional false alarms.
Overall, monthly updating of UPCs was the superior policy.
PMCID: PMC1560721  PMID: 16779055

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