BIOWATCH AND PUBLIC HEALTH SURVEILLANCE

Evaluating Systems for the Early Detection of Biological Threats

Abbreviated Version

Committee on Effectiveness of National Biosurveillance Systems: BioWatch and the Public Health System

Board on Health Sciences Policy

Board on Chemical Sciences and Technology

Board on Life Sciences

INSTITUTE OF MEDICINE AND
NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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BIOWATCH AND PUBLIC HEALTH SURVEILLANCE Evaluating Systems for the Early Detection of Biological Threats Abbreviated Version Committee on Effectiveness of National Biosurveillance Systems: BioWatch and the Public Health System Board on Health Sciences Policy Board on Chemical Sciences and Technology Board on Life Sciences

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HSHQDC-08-C-00043 between the National Academy of Sciences and the Department of Homeland Security. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-13971-7 International Standard Book Number-10: 0-309-13971-6 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: IOM (Institute of Medicine) and NRC (National Research Council). 2011. BioWatch and public health surveillance: Evaluating systems for the early detection of biologi- cal threats. Abbreviated version. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON EFFECTIVENESS OF NATIONAL BIOSURVEILLANCE SYSTEMS: BIOWATCH AND THE PUBLIC HEALTH SYSTEM BERNARD D. GOLDSTEIN (Chair), Professor, Department of Environmental and Occupational Health, University of Pittsburgh Graduate School of Public Health, Pennsylvania JOSEPH M. DeSIMONE (Vice-Chair), Chancellor’s Eminent Professor of Chemistry, University of North Carolina at Chapel Hill, and William R. Kenan, Jr. Distinguished Professor of Chemical Engineering, North Carolina State University MICHAEL S. ASCHER, Senior Medical Advisor, California Emergency Management Agency, and Visiting Researcher, Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis JAMES W. BUEHLER, Research Professor, Department of Epidemiology, Center for Public Health Preparedness and Research, Rollins School of Public Health, Emory University, Atlanta, Georgia KAREN S. COOK, Ray Lyman Wilbur Professor of Sociology, Department of Sociology, Stanford University, California NORMAN A. CROUCH, Assistant Commissioner, Health Protection Bureau, Minnesota Department of Health, St. Paul (retired) FRANCIS J. DOYLE III, Professor, Duncan & Suzanne Mellichamp Endowed Chair in Process Control, Department of Chemical Engineering, University of California, Santa Barbara SETH FOLDY, State Health Officer and Administrator, Division of Public Health, State of Wisconsin ELIN A. GURSKY, Principal Deputy for Biodefense, ANSER/Analytic Services, Inc., Arlington, Virginia SANDRA HOFFMANN, Fellow, Resources for the Future, Washington, District of Columbia CALVIN B. JOHNSON, Vice President and Chief Medical Officer, Temple University Health System, Philadelphia, Pennsylvania PAUL KEIM, Regents Professor and Cowden Endowed Chair in Microbiology, Northern Arizona University, and Director of Pathogen Genomics, The Translational Genomics Research Institute ARTHUR L. KELLERMANN, Professor and Associate Dean for Health Policy, Emory University School of Medicine, Atlanta, Georgia KENNETH P. KLEINMAN, Associate Professor, Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts v

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MARCELLE LAYTON, Assistant Commissioner, Bureau of, Communicable Disease, New York City Department of Health and Mental Hygiene, New York EVA K. LEE, Associate Professor and Director, Center for Operations Research in Medicine and Health Care, School of Industrial & Systems Engineering, Georgia Institute of Technology, Atlanta SHANE D. MAYOR, Research Professor, Department of Geological and Environmental Sciences, California State University, Chico TIMOTHY F. MOSHIER, Senior Principal Scientist, Environmental Science Center, Syracuse Research Corporation, New York FREDERICK A. MURPHY, Department of Pathology, The University of Texas Medical Branch at Galveston ROYCE W. MURRAY, Kenan Professor, Department of Chemistry, University of North Carolina at Chapel Hill DOUGLAS K. OWENS, Senior Investigator, VA Palo Alto Healthcare System, and Professor of Medicine and of Health Research and Policy, Center for Primary Care and Outcomes Research and Center for Health Policy, Stanford University, California STEPHEN M. POLLOCK, Herrick Professor Emeritus of Manufacturing, Professor Emeritus of Industrial and Operations Engineering, University of Michigan I. GARY RESNICK, Bioscience Division Leader, Los Alamos National Laboratory, New Mexico R. PAUL SCHAUDIES, Chief Executive Officer, GenArraytion, Inc., Rockville, Maryland JEROME S. SCHULTZ, Distinguished Professor and Chair, Department of Bioengineering, University of California, Riverside Study Staff LOIS JOELLENBECK, Study Director, Board on Health Sciences Policy JANE DURCH, Senior Program Officer, Board on Health Sciences Policy MICHAEL McGEARY, Senior Program Officer, Board on Health Sciences Policy KATHRYN HUGHES, Program Officer, Board on Chemical Sciences and Technology ERICKA McGOWAN, Program Officer, Board on Chemical Sciences and Technology SUSAN McCUTCHEN, Senior Program Associate, Board on Health Sciences Policy JON Q. SANDERS, Program Associate, Board on Health Sciences Policy DONNA RANDALL, Financial Associate, Board on Health Sciences Policy vi

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JESSICA PULLEN, Administrative Assistant, Board on Chemical Sciences and Technology ANDREW POPE, Director, Board on Health Sciences Policy FRANCES SHARPLES, Director, Board on Life Sciences DOROTHY ZOLANDZ, Director, Board on Chemical Sciences and Technology Consultants JENNIFER BAXTER, Industrial Economics, Incorporated, Cambridge, Massachusetts DAVID BUCKERIDGE, Assistant Professor, McGill University, Montreal, Canada HENRY ROMAN, Industrial Economics, Incorporated, Cambridge, Massachusetts vii

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Damon T. Arnold, Illinois Department of Public Health Cynthia J. Bruckner-Lea, Pacific Northwest National Laboratory J. Wiley Davidson, Los Alamos National Laboratory Richard C. Flagan, California Institute of Technology Mary J. Gilchrist, Massachusetts Department of Public Health Thomas V. Inglesby, University of Pittsburgh Medical Center Peter R. Jutro, U.S. Environmental Protection Agency Edward H. Kaplan, Yale School of Management Lisa G. Kaplowitz, Alexandria (Virginia) Health Department Frances S. Ligler, Naval Research Laboratory Joseph S. Lombardo, Johns Hopkins University Donald Prosnitz, RAND Corporation ix

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x REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Georges C. Benjamin, American Public Health Association, and Chris G. Whipple, ENVIRON. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface B iological warfare is not a new phenomenon. In North America, the first historically documented use was by Lord Jeffery Amherst, the British commander in North America during the French and Indian War, who proposed spreading smallpox among vulnerable American Indians. Population vulnerability to infectious agents wielded by enemies who wish to destroy and terrorize is of increasing concern to our nation. We also have come to recognize the threats to our health and to our social well-being caused by the natural emergence of infectious diseases, such as HIV and SARS, that can be rapidly spread in our interconnected globe. In response to these concerns, the United States of America, as well as many other countries, has been actively seeking means to improve capabilities to detect and respond to biological threats. Our nation has done so through a mixture of enhancing existing time-honored public health approaches to disease and by developing new approaches to prevention, early detection, and treatment. These new approaches need to be integrated into the overall prevention and response system, and their cost-effectiveness needs to be evaluated in comparison to other investments that could be made to attain the same goals. As described in the body of this report, the Committee on Effective- ness of National Biosurveillance Systems: BioWatch and the Public Health System has prepared a review and assessment of the effectiveness and costs of surveillance for and detection of disease threats through the Department of Homeland Security’s (DHS’s) BioWatch program and through the public health and health care systems. The report presents the committee’s findings and conclusions concerning the comparative merits of these approaches, xi

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xii PREFACE examines costs, and describes promising enhancements to strengthen the nation’s capacity to conduct surveillance for major natural and man-made disease threats. As a result of its review, the committee identified various op- portunities to further these enhancements, and it recommends actions that DHS, the Department of Health and Human Services, and others should undertake to help realize them. The members of the committee have welcomed being participants in the ongoing recalibration of the nation’s response to the threat of major natural and man-made disease outbreaks. Review and recalibration is a continu- ous process. Changes in technology related both to the threat and to the response will necessitate repeated revisiting of the many issues related to how best to protect the public. We hope that our specific recommendations about technical aspects of detection of disease threats will soon be out of date—replaced by newer methodologies that provide enhanced security to our nation. We also hope that our recommendations related to process will persist, particularly those that call for improved coordination among the disparate governmental bodies: local, state, and national. The fragmentation of powers related to protecting the health of the public, which is built into our Constitution and in many ways has served us so well, inherently necessitates coordination among governmental orga- nizations to effectively address national issues that require local or regional responses. This is particularly true for the BioWatch program for which the organizations involved in assessing the threat and in determining the technology, configuration, and reporting pathways of this key surveillance approach extend well beyond those traditionally involved in disease surveil- lance and response. In view of its formation at a time of recognized need for rapid response, and the decision to place the BioWatch program within DHS where it can most effectively coordinate with others involved in the national response to terrorism, as well as the inherent fragmentation of our public health system, it is not surprising that the committee has found that coordination of BioWatch with the public health community is still a work in progress. Fortunately, it is clear that the BioWatch program has recognized this need and is moving toward meeting it. The breadth of the topic, and the involvement of so many different governmental programs at the federal, state, and local levels which con- tribute to the overall mission of protecting the public against biothreats, inevitably has limited our ability to probe as deeply as we would like in all of the relevant areas. Not surprisingly, it has been challenging to compare BioWatch, a reasonably well-defined system with a specific budget and hosted in a single federal agency that began just a few years ago, with a diverse public health system that has roots dating back to the middle ages, diverse responsibilities, and a structure that does not readily lend itself to comparative cost accounting of essential cross-cutting activities, such as

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xiii PREFACE surveillance for infectious diseases. Meeting this challenge has been helped by the committee’s recognition that BioWatch should best be considered as part of the nation’s overall surveillance activities. We also recognize that in response to concern about the nation’s public health infrastructure, the National Academy of Sciences (NAS) and other major national organiza- tions in recent years have reviewed and made recommendations about the U.S. public health system that are pertinent to our charge. This recognition has led us to focus on the BioWatch system and how it could be integrated into an enhanced public health surveillance system. It is also clear that the nation’s public health system is a funnel that collects and sees all types of health situations, natural and otherwise, and in many ways is the ideal place to detect all biological outbreaks, regard- less of the disease or the exposure mechanism (air, food, water). It is also a place where small improvements may pay significant dividends to improve its effectiveness. We have also faced the challenges of needing a relatively large commit- tee (25 members) so as to adequately address the broad range of scientific and technical issues, and of having a relatively short time period (6 months between the first and last of our five meetings) to do so. As leaders of the committee, we want to particularly acknowledge the hard work and col- legiality of the committee members. Without their willingness to listen and to learn, and the deep respect they have shown to each other and to the committee staff, this report could not have been completed. We deeply appreciate the cooperation received from the leadership and staff of the BioWatch program, especially Robert Hooks, Diane Berry, Malcolm Johns, Constantin Langa, and Brian Smith. Also providing es- pecially notable assistance to the committee are Daniel Sosin and many unnamed colleagues at the Centers for Disease Control and Prevention and three consultants to the committee: Jennifer Baxter and Henry Roman of Industrial Economics, Incorporated, and David Buckeridge at McGill Uni- versity. The committee is also very grateful to numerous other contributors to the committee’s information gathering during meetings held in Washing- ton, DC. These contributors are listed in Appendix A. We also note that the staffing for this committee cut across three different NAS organizational components: the Board on Health Sciences Policy in the Institute of Medicine (IOM) and the Board on Chemical Sci- ences and Technology and the Board on Life Sciences in the Division on Earth and Life Studies (DELS). The challenge of coordinating all of these components was ably met by all of the contributing staff: Lois Joellenbeck, IOM (study director); Jane Durch, IOM; Kathryn Hughes, DELS; Susan McCutchen, IOM; Michael McGeary, IOM; Ericka McGowan, DELS; Andrew Pope, IOM; Jessica Pullen, DELS; Donna Randall, IOM; Jon Sanders, IOM; Frances Sharples, DELS; and Dorothy Zolandz, DELS. We

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xiv PREFACE also want to thank other NAS staff members who aided our core staff in important ways: Clyde Behney, Detra Bodrick-Shorter, Greta Gorman, Kevin Hale, Bronwyn Schrecker Jamrok, Abbey Meltzer, Paul Michaels, Machelle Reynolds, Janice Sabuda, Gregory Symmes, Jackie Turner, and Jordan Wyndelts. Before its public release, and as required under the terms of the con- tract for this study, the full report was sent to DHS for security classifica- tion review. DHS has determined that the full report contains information exempt from public disclosure pursuant to the Freedom of Information Act (FOIA), 5 USC Sections 552(b)(2), 552(b)(7)(E), and 552(b)(7)(F). Therefore, dissemination of the full report is limited to those federal, state, and local governments and their officials, employees, and contractors, as well as non-governmental entities, who have a need to know the informa- tion exempt from public disclosure pursuant to the cited FOIA exemptions. Requests for the full report may be directed to the NAS Program Security Office. Requests for the full report may also be directed to DHS. Requests for the full report will be considered on a case-by-case basis. The NAS reached agreement with DHS that this abbreviated version of the report could be released without restriction. Although certain op- erational details have been omitted in the public version of the report, the committee’s recommendations remain unchanged from the full report provided to DHS. Bernard D. Goldstein Chair Joseph M. DeSimone Vice Chair Committee on Effectiveness of National Biosurveillance Systems: BioWatch and the Public Health System

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Contents ACRONYMS AND ABBREVIATIONS xix SUMMARY 1 1 INTRODUCTION AND BACKGROUND 22 2 THE BIOWATCH SYSTEM 47 3 EVALUATION OF THE BIOWATCH SYSTEM 61 4 DETECTING BIOLOGICAL THREATS THROUGH THE PUBLIC HEALTH AND HEALTH CARE SYSTEMS: CURRENT STATUS 96 5 ENHANCING SURVEILLANCE TO DETECT AND CHARACTERIZE INFECTIOUS DISEASE THREATS 119 6 BIOWATCH AND ENHANCED NATIONAL BIOSURVEILLANCE RESOURCES 155 APPENDIXES A Study Activities 189 B Glossary 193 xv

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xvi CONTENTS C Summary of Research into the Costs of Enhanced Public Health Surveillance Systems 199 D Biographical Sketches of Committee Members 217

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Tables, Figures, and Boxes TABLES S-1 Capabilities and Costs of the BioWatch System and Surveillance Through the Public Health and Health Care Systems, 16 1-1 Federal Funding for Selected Civilian Activities to Defend Against Bioterrorism and Other Significant Biological Threats, Fiscal Years 2007–2010, 29 2-1 Features of BioWatch Generations 1, 2, and 3, 52 2-2 Forecasted Cost of Implementing Alternative BioWatch Scenarios (10-year forecast), 59 3-1 Key Features of the BioWatch Generation 2 System and the Proposed Generation 3 System, 78 6-1 Steps Necessary for BioWatch to Help Reduce Illness and Loss of Life, 157 6-2 Implied Number of Additional Lives That BioWatch Would Have to Save in the Event of an Attack to “Break Even” on Program Costs, 172 6-3 Capabilities and Costs of the BioWatch System and Surveillance Through the Public Health and Health Care Systems, 176 xvii

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xviii TABlES, FIguRES, ANd BOxES FIGURES 1-1 Schematic illustration of the temporal relation among potential mech- anisms for detecting an aerosolized biological threat, 34 2-1 Event-to-detection time line for BioWatch Generations 1 and 2, 54 4-1 Simplified depiction of information flow in outbreak detection and reporting through the public health and health care systems, 98 4-2 A schematic depiction of the relationships between functional compo- nents of biosurveillance and the associated flows of information, 110 6-1 A schematic illustration of the relation between the BioWatch pro- gram and other sources of information needed for infectious disease surveillance in the public health and health care systems, 174 BOXES S-1 Statement of Task, 4 1-1 Statement of Task, 26 1-2 CDC Categories of Potential Bioterrorism Agents and Their Related Diseases, 30 2-1 Definitions of Key Terms Related to the Performance of BioWatch, 51 3-1 Potential Approaches for Improving Incident Characterization, 71 3-2 Possible Elements of an After-Action Report Following a BAR, 75 4-1 National Biosurveillance System: Laboratory Response Network, 106 5-1 Biosurveillance: A Critical Component of Public Health and Medical Preparedness, 135 5-2 The 10 Essential Public Health Services, 139 5-3 Pandemic Influenza A (H1N1): Implications for Enhanced Surveil- lance, 142 6-1 Potential Enhancements to Surveillance Through Public Health and Health Care, 163

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Acronyms and Abbreviations AAR after-action report AHIC American Health Information Community AIDS acquired immune deficiency syndrome AOAC Association of Analytical Communities APDS Automated Pathogen Detection System APHL Association of Public Health Laboratories ASTHO Association of State and Territorial Health Officials BAC BioWatch Advisory Committee BAND Bioagent Autonomous Networked Detector BAR BioWatch Actionable Result BASIS Biological Aerosol Sentry and Information System BDS Biohazard Detection System BERT Bioagent Event Reconstruction Tool BRRAT Bioterrorism Rapid Response and Advanced Technology Laboratory BTAC BioWatch Technical Advisory Committee BTRA Bioterrorism Risk Assessment BWIC Biological Warning and Incident Characterization CBRN chemical, biological, radiological, and nuclear CDC Centers for Disease Control and Prevention CIDRAP Center for Infectious Disease Research and Policy CRS Congressional Research Service CSTE Council of State and Territorial Epidemiologists xix

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xx ACRONymS ANd ABBREVIATIONS DFU Dry Filter Unit DHS Department of Homeland Security DNA deoxyribonucleic acid DoD Department of Defense DOE Department of Energy DSBCC Detection Systems for Biological and Chemical Countermeasures DT&E developmental testing and evaluation ED emergency department EHR electronic health record ELR electronic laboratory reporting EMR electronic medical record EPA Environmental Protection Agency ESP Electronic Support for Public Health ESSENCE Electronic Surveillance System for the Early Notification of Community-based Epidemics FBI Federal Bureau of Investigation FEMA Federal Emergency Management Agency FOUO For Official Use Only FTE full-time equivalent positions FY fiscal year GAO Government Accountability Office GI gastrointestinal HAN Health Alert Network HEPA high-efficiency particulate air HHS Department of Health and Human Services HIE health information exchange HITSP Healthcare Information Technology Standards Panel HPP Hospital Preparedness Program HSARPA Homeland Security Advanced Research Projects Agency HSEEP Homeland Security Exercise and Evaluation Program HSPD Homeland Security Presidential Directive HVAC heating, ventilation, and air conditioning ICD-9 International Classification of Diseases, Ninth Revision ICD-10 International Classification of Diseases, Tenth Revision IEc Industrial Economics, Incorporated IMAAC Interagency Modeling and Atmospheric Assessment Center

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xxi ACRONymS ANd ABBREVIATIONS IOM Institute of Medicine IT information technology LACDPH Los Angeles County Department of Public Health LANL Los Alamos National Laboratory lidar light detection and ranging LIMS Laboratory Information Management System LLNL Lawrence Livermore National Laboratory LOINC Logical Observation Identifiers Names and Codes LRN Laboratory Response Network MDHSS Missouri Department of Health and Senior Services NACCHO National Association of County and City Health Officials NAS National Academy of Sciences NBAS National Biosurveillance Advisory Subcommittee NBIC National Biosurveillance Integration Center NBIS National Biosurveillance Integration System NEDSS National Electronic Disease Surveillance System NETSS National Electronic Telecommunications System for Surveillance NIAID National Institute of Allergy and Infectious Diseases NIH National Institutes of Health NNDSS National Notifiable Diseases Surveillance System NPHPSP National Public Health Performance Standards Program NRC National Research Council NSF National Science Foundation O&M operation and maintenance ODIN Outbreak Detection Information Network OHA Office of Health Affairs OMB Office of Management and Budget ORD operational requirements document OT&E operational testing and evaluation PA-OH Pennsylvania-Ohio PCR polymerase chain reaction PHEP Public Health Emergency Preparedness PHRED Public Health Reporting of Electronic Data PSU Portable Sampling Unit RHIO regional health information organization RODS Real-time Outbreak and Disease Surveillance

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xxii ACRONymS ANd ABBREVIATIONS RT-PCR real-time polymerase chain reaction S&T Science and Technology Directorate SARS severe acute respiratory syndrome SNOMED Systematized Nomenclature of Medicine–Clinical Terms SPADA Stakeholder Panel on Agents for Detection Assays STD sexually transmitted disease T&E testing and evaluation TCL Target Capabilities List TEMP Test and Evaluation Master Plan TFAH Trust for America’s Health TOPOFF Top Officials TRL technology readiness level USAMRIID U.S. Army Medical Research Institute of Infectious Diseases USPS U.S. Postal Service UTL Universal Task List VSL value of a statistical life WADOH Washington State Department of Health WHO World Health Organization WMD weapons of mass destruction