slurred speech or dry mouth, and acute respiratory distress syndrome. If the patient’s condition does not fit any syndrome, the nurse puts a hash mark in the column “none of the above.” The tally marks for each syndrome are totaled at the end of each nursing shift, and the sheet is faxed to the Santa Clara Health Department. No personal identifiers are transmitted. The information is entered into a computer program at the health department, and the totals are reviewed every 24 hours. As noted in Table B-1 and confirmed by the group in Santa Clara, this method is labor-intensive. Participation by hospitals has declined dramatically since the cessation of additional anthrax cases after December 2001, and Santa Clara County is now actively pursuing alternative systems for implementation. Despite the lack of baseline data for comparison and uncertainties regarding when and how to investigate “clusters” of particular syndromes, many local health departments across the country initiated similar efforts immediately following the terrorist attacks of September 11, 2001 (Blythe, Maryland Department of Health and Mental Hygiene, Personal Communication, 2002; Sockwell, Virginia Department of Health (Northern Region), Personal Communication, 2002; Chernak, Philadelphia Department of Health, Personal Communication, 2001; Paladini, Bergen County Department of Health Services, Personal Communication, 2002).

In contrast, several investigators and collaborating health departments have been exploring electronic transfer of data from health facilities to public health departments (Wagner et al., 2001b; Duchin et al., 2001; Pavlin, ESSENCE, Personal Communication, 2001; Mostashari, New York City Department of Health, Personal Communication, 2001; Lazarus et al., 2001; Moser et al., 1999). The key feature of electronic syndromic surveillance is the ability to collect data in an ongoing way without the direct input of health care personnel, so that their operation is transparent to providers. Systems that do not place additional burdens on health care providers are essential for large-scale, sustained syndromic surveillance. Electronic systems have been implemented by the U.S. military (Pavlin, ESSENCE, Personal Communication 2001), regionally within states (Lazarus et al., 2001; RODS; Piposzar, Alleghany County Health Department, Personal Communication, 2002), and at the local level (Mostashari, New York City Department of Health, Personal Communication, 2001). All of these systems are in the pilot or early development stages.

The network developed within the Department of Defense—Global Emerging Infections System (DoD-GEIS)—has initiated surveillance for early detection of infectious disease outbreaks by monitoring seven syndromes (respiratory, fever/malaise/sepsis, gastrointestinal, neurological, dermatological-infectious, dermatological-hemorrhagic, and coma/sudden death) in 313 military treatment facilities worldwide (Pavlin, ESSENCE, Personal Communication, 2001). This system, the Electronic Surveillance

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