sponders to public health emergencies in their jurisdictions. This allocation of responsibility reflects the fact that protection of public health was not established as a federal function in the Constitution and is therefore reserved to the states. However, the federal government has acquired public health responsibilities over the years, including acting in support of state and local public health agencies. A bioterrorism event, or other significant health emergency, will likely be met with a multiagency and multilevel response that includes participation by law enforcement and emergency management in addition to public health agencies. Federal roles and responsibilities in working with states and localities in the event of a major disaster or public health emergency are outlined annexes to the National Response Framework (FEMA, 2008a,b).

To ensure the broadest surveillance capabilities, health departments depend on receiving information from health care, occupational settings, environmental monitoring, and other sources, with the health care sector being the most critical source. Accordingly, a major determinant of the effectiveness of disease surveillance is the capacity of health care providers in various settings—hospitals, outpatient practices, and laboratories—to collect and report relevant information to public health authorities. Equally important is the capacity of public health agencies to receive and compile the data, conduct analyses, interpret the results, report the findings to constituents, and mount a timely and appropriate response when the data indicate a need for further investigation or public health intervention. Figure 4-1 illustrates in a generic fashion the basic flow of information for surveillance for significant infectious disease threats.

Especially in the event of an outbreak associated with a highly pathogenic organism or a bioterrorist attack, the capacity to act promptly in response to surveillance alerts is crucial to mitigate morbidity and mortality. But surveillance systems aimed at detecting outbreaks quickly must be calibrated in a way that effectively balances the inherently competing demands for timely recognition of outbreaks that merit public health intervention and for avoidance of excessive false alarms that may consume public health and health care resources for investigations, or even lead to an inappropriate and potentially dangerous response.


Surveillance refers to an ongoing process of systematic collection, analysis, interpretation, and dissemination of health data that can be used to plan, implement, and evaluate appropriate medical and public health interventions (Thacker and Berkelman, 1988). Surveillance for the health effects of bioterrorism is generally integrated with other public health surveillance systems aimed at detecting the full range of infectious disease threats.

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