ing of physicians and other health care providers, in terms of both disease awareness and their responsibilities to public health. In addition, the important systems linking hospitals around the country with CDC, known as sentinel surveillance systems, need to be enhanced; they can establish whether a common cause of disease is being seen simultaneously in multiple regions. Research should be conducted on the strategies likely to be most useful in enhancing the notifiable human disease reporting system for the broad range of potential threat agents (strategies such as education, animal sentinels, changes to the surveillance systems, and the use of infection control specialists). Mathematical models of disease transmission and distribution using simulations of a covert release of various agents could be helpful in assessing the potential and relative value of different surveillance systems. An integrated national system that can report diseases electronically in real time is needed to support these networks. Information technology advances should be explored both to automate required reporting (e.g., laboratory reporting of pathogens) and to develop new surveillance tools (e.g., the automated scanning of electronic media, such as that utilized by the Global Public Health Information Network).

Systems of syndrome surveillance—that is, screening for changes in the frequency of cases of flulike illness seen in hospital emergency rooms across a city or town—should be developed to identify outbreak patterns. Relevant computer programs are being developed, but there are known fluctuations in emergency room admissions from season to season and day to day, and it will be important to determine their potential predictive value, specificity, and usefulness. Syndrome surveillance has allowed early recognition of some respiratory and diarrheal disease outbreaks, but it is not clear whether it will be useful for early detection of key threat agents such as smallpox, anthrax, and tularemia.

Because infectious diseases do not respect national borders, international cooperation is vital in the sharing of epidemiological and clinical data, both on emerging infectious diseases and on outbreaks caused by potential bioterror agents. A global network for surveillance of infectious diseases in humans and animals would be strengthened by augmenting the numbers and capabilities of U.S. overseas laboratories and by providing enhanced support for current initiatives on international surveillance (e.g., DOD’s Global Emerging Infectious Diseases program and corresponding Department of Health and Human Services (HHS) initiatives).

Increased support for the development and expansion of public health and agricultural laboratories in other countries, particularly in their capacity to diagnose threat agents, would yield dividends for recipient and donor alike. This means that CDC and other agencies must reach out to educate, train, and collaborate with scientists from many countries on aspects of surveillance and identification of threats. The World Health Organization could play a critical role in building and strengthening international capabilities.

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