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Infectious Disease and
National Security
Strategic Information Needs
Gary Cecchine, Melinda Moore
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Infectious disease and national security: strategic information needs / Gary Cecchine, Melinda Moore.
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Preface
The global community has suffered recently from newly emerged infectious diseases, includ-
ing HIV/AIDS and severe acute respiratory syndrome, and from reemerging diseases once
thought to be in decline. The world now faces the threat of a human influenza pandemic aris-
ing from the recently emerged avian influenza H5N1 virus. It has been increasingly recognized
that infectious disease can have significant effects on U.S. and world security. Collection and
analysis of information about the worldwide incidence of infectious disease is imperative for
the United States to understand and respond to subsequent related threats. This study, con-
ducted from July through October 2005, examines infectious diseases within the context of
national security and assesses the need for and adequacy of information that will enable U.S.
policymakers to prevent and respond to such threats.
This report should be of interest to those in U.S. federal and state agencies charged with
collecting information about infectious disease and protecting the United States from its threat,
the U.S. Congress, the world health community, and others who are interested in security and
the threat of infectious disease.
This research was sponsored by the Advanced Systems and Concepts Office of the
Defense Threat Reduction Agency and conducted within the Center for Military Health Policy
Research and the International Security and Defense Policy Center of the RAND National
Defense Research Institute, a federally funded research and development center sponsored by
the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the
Department of the Navy, the Marine Corps, the defense agencies, and the defense Intelligence
Community.
For more information on the RAND International Security and Defense Policy Center,
contact the Director, James Dobbins. He can be reached by email at James_Dobbins@rand.
org; by phone at 310-393-0411, extension 5134; or by mail at the RAND Corporation, 1200
South Hayes Street, Arlington, VA 22202-5050.
iii
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
CHAPTER ONE
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
About This Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Study Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Interviews with Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Survey of Online Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
How This Report Is Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
CHAPTER TWO
Background: Challenges of and Responses to Infectious Disease Threats . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Infectious Disease Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Toll of Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Infectious Diseases in a Modernizing World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Near-Term Infectious Disease Threat: Avian Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Responses to Threats from Infectious Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
U.S. Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Global Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Global Infectious Disease Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Recent Improvements in Global Disease Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Updated International Health Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
v
vi Infectious Disease and National Security: Strategic Information Needs
CHAPTER THREE
Addressing a New Paradigm: Infectious Disease and National Security . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Infectious Disease and Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Evolving Security Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Effects of Infectious Disease on Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Implications of a Biodefense Orientation for Natural Disease Outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Infectious Disease, Security, and Disease Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Infectious Disease and Recent U.S. National Security Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
BioWatch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
BioSense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
National Biosurveillance Integration System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
BioShield . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
National Biodefense Analysis and Countermeasures Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Department of Defense Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
CHAPTER FOUR
Defining Information Needs: Interviews with Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Stakeholders Do Perceive Global Infectious Disease as a Security Threat . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Information Supports Policy Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
There Were More Similarities Than Differences in Information Needs Across Government
Sectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Despite Similar Information Needs, Stakeholders Consult Different Information Sources . . . . . . . . 33
Classification of Information Is Important but Creates Some Obstacles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Stakeholders’ Information Needs Are Not Fully Met by Their Current Sources . . . . . . . . . . . . . . . . . . . . . 34
Preferences Vary for Information-Delivery Format and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Stakeholders Suggested Areas for Improvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
CHAPTER FIVE
Assessing the Adequacy of Current Information: A Survey of Online Sources . . . . . . . . . . . . . . . . . . . . 39
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Most Online Sources Have Unrestricted Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Online Sources Reflect a Broad Range of Organizational Sponsors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Over Half the 234 Sources Focus on Surveillance, Including Early Warning . . . . . . . . . . . . . . . . . . . . . . . 44
Sources Include Information on Diseases in Humans, Animals, and Plants . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Nearly One-Third of Our Sources Use Active Information Collection Methods . . . . . . . . . . . . . . . . . . . . 48
About One-Third of Sources Actively Disseminate Their Data Output. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Contents vii
CHAPTER SIX
Synthesis, Conclusions, and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Synthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
New Diseases with Global Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
New Populations of Interest: Diseases in Animals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
New Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
New Range of Stakeholders Interested in Global Infectious Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
New Active Information-Gathering Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
New Sources of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
New Disease Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
New Ways of Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
New Types of Analysis and Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
New Policy Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
How Has the Emerging Link Between Global Infectious Disease and U.S. National Security
Been Perceived and Acted Upon Across Government Sectors? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
What Types of Information About Global Infectious Disease Do U.S. Policymakers Need? . . . . . . . 57
How Sufficient Is the Available Information on Global Infectious Diseases? . . . . . . . . . . . . . . . . . . . . . . . . . 58
Implications and Remaining Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
APPENDIXES
A. Organizations Interviewed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
B. Interview Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
C. List of Online Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Figures
5.1. Accessibility of Online Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

5.2. Organizational Sponsors of Online Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.3. Primary Purpose of Online Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.4. Sources Addressing Human, Animal, and Plant Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.5. Information Collection Methods of Online Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
ix
Tables
2.1. Leading Causes of Mortality, United States, 1900 and 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

5.1. General Surveillance and Early Warning Surveillance Online Sources . . . . . . . . . . . . . . . . . . . . 46
5.2. Characteristics of Sources Using Active or Passive Information Collection . . . . . . . . . . . . . . . . 49
C.1. List of Online Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
xi
Summary
The global community has suffered recently from newly emerged infectious diseases, includ-
ing HIV/AIDS and severe acute respiratory syndrome (SARS), and from reemerging diseases
once thought to be in decline. Additionally, it is increasingly recognized that infectious disease
can pose a significant threat to U.S. and world security. To best understand and mitigate this
threat, U.S. policymakers require adequate and timely information about the occurrence of
infectious disease worldwide.
The Advanced Systems and Concepts Office of the Defense Threat Reduction Agency
asked the RAND Corporation to examine infectious diseases within the context of national
security and assess the need for and the adequacy of such information among U.S. policy-
makers. The primary objectives of this study were to assess the availability of information
concerning global infectious disease threats and to determine the suitability and use of
such information to support U.S. policymaking in preventing or otherwise responding to such
threats. During the study, we conducted literature and document reviews, surveyed the current
state of available information systems related to infectious disease, and interviewed 53 senior
policymakers and staff from agencies across the federal government and from selected outside
organizations. Our findings are summarized below.
Globalization Increases Both Risks and Opportunities
Approximately a quarter of all deaths in the world today are due to infectious diseases. In
decades and centuries past, an outbreak of infectious disease was often limited to the locale in
which it occurred. However, the pace of global travel, migration, and commerce has increased
dramatically in recent decades, and that increase poses an increased global risk of disease.
In the age of air travel, infectious disease agents can traverse the globe in less time than it
takes for an infectious agent to incubate and cause symptoms in an infected person. As was
seen with the rapid spread of SARS around the world, and into Canada in 2003, the risk
of a new or reemerging infectious disease being introduced in the United States is perhaps
higher now than ever. Certainly, the prospect of a pandemic caused by an avian influenza virus
(H5N1 or another strain yet to emerge) has occupied both the U.S. media and policymakers
in recent months; in fact, preparation for a pandemic influenza outbreak has recently become
one of the President’s top priorities. It is likely that such a pandemic would be enabled by
globalization—frequent and unencumbered travel and trade.
xiii
xiv Infectious Disease and National Security: Strategic Information Needs
The preparations for pandemic influenza being undertaken at the highest levels of the U.S.
government highlight the link between infectious disease and national security. Obviously, the
United States is concerned about infectious diseases crossing its borders, but the global toll of
infectious disease also raises security concerns. Infectious disease can have significant effects
that can lead to the destabilization of nations and regions through direct mortality and mor-
bidity as well as staggering economic and social loss. Indeed, the U.S. State Department con-
siders disease a potential war trigger.
While globalization has increased the risk and spread of infectious disease, there is no
doubt that it has also benefited the world economically and culturally. Similarly, the same
technologies that have enabled globalization also present opportunities to combat the threats
it may pose, particularly in controlling infectious disease. These technologies notably include
methods to collect and communicate information about infectious disease outbreaks more
effectively and quickly than ever before. Faster worldwide notification of outbreaks can result
in better and faster responses to contain them. Key questions, then, would address what types
of infectious disease information are needed, and what information is currently available to
U.S. policymakers.
The United States Has Responded to the Threat
The 1970s and 1980s saw complacency in the United States toward infectious diseases, in part
due to a general perception that they no longer posed a significant risk. Infectious disease mor-
tality declined in the United States during most of the 20th century. This trend was reversed
in the 1980s and 1990s, yet it remained unclear whether infectious diseases were seriously
considered in the national security strategy of the United States or other developed countries.
The terrorist and bioterrorist attacks of September and October 2001 changed that posture.
Since 2001, the United States has focused new attention on preparedness for detecting and
responding to acts of bioterrorism. Legislation and executive policy documents have triggered
a number of security-oriented initiatives directed at bioterrorism threats. It is clear that these
initiatives, and their underlying infrastructures, are also useful for detecting and responding to
naturally occurring outbreaks of infectious diseases. To policymakers involved in public health
and bioterrorism preparedness, the relationship between infectious disease and national secu-
rity is now clear, and it creates a need for timely and accurate information.
There Is Consensus About Information Needs
In recognizing that infectious disease and national security are linked, what kind of informa-
tion do policymakers need to counter the disease threat? Does the United States employ a sys-
tematic approach to the collection of information for the early warning of infectious disease
outbreaks originating outside its borders? Is adequate and timely information available?
We interviewed policymakers about their views on these questions and solicited their rec-
ommendations on how the assets of the U.S. government—across a broad range of sectors—
Summary xv
could best be harnessed to create a national information system, if warranted. While each
sector has its own focus and responsibilities, the information needs of policymakers across sec-
tors are characterized more by their similarities than by their differences. The policymakers
and other stakeholders we interviewed expressed a strong desire for a centralized system that
provides needed information to all stakeholders, and they described an ideal system as being
(1) robust, drawing information from a wide range of sources and collecting information that
is accurate and complete; (2) efficient, constituting a single, integrated source of timely infor-
mation available to all stakeholders; (3) tailored to meet individual stakeholder needs and pref-
erences; and (4) accessible, notwithstanding the need for protection of sensitive information.
Many Information Systems Currently Exist
To determine whether current systems might meet the expressed needs of policymakers, we
compiled a database of Internet-based sources of information relevant to the public health
aspects of infectious diseases, most notably disease surveillance. This database includes 234
sources from a wide range of organizational sponsors, including U.S. national and state gov-
ernments, foreign national governments, and multilateral organizations. While they vary in
their characteristics, these sources collectively provide abundant information. However, they
do not meet all the needs of policymakers as outlined above. Most notably, there exists no
single, integrated source of timely and accurate information.
The United States has recently funded an initiative that is intended to meet this need. The
National Biosurveillance Integration System (NBIS) is based in the Department of Homeland
Security (DHS) and is in the early stages of implementation; most policymakers we interviewed
were unaware of its existence. While many of the 234 sources we assessed were focused nar-
rowly in the way they collected information (e.g., reporting-based or Webcrawling) or in the
type of information (e.g., animal or human data), NBIS is intended to be relatively expansive.
NBIS is planned to combine data from multiple agencies—those with health, environmental,
agricultural, and intelligence data—to provide all stakeholders with broad situational aware-
ness that is expected to allow earlier detection of events and facilitate a coordinated response.
Once fully operational, NBIS will insert these data into a common platform and combine
them with environmental and intelligence data. DHS analysts are intended to work together
with analysts from other federal agencies to process this information and present their analysis
to the DHS Homeland Security Operations Center and an Interagency Incident Management
Group.
Emerging Information Systems Require Evaluation
More and better information must be collected, integrated, and shared across government
sectors that have, at best, a relatively short history of working together on shared priorities.
It was suggested by some policymakers during this study that the United States needs a new
centralized system for collecting, analyzing, and disseminating information about infectious
xvi Infectious Disease and National Security: Strategic Information Needs
diseases. Our main recommendation is for an integrated system that meets all the criteria
and requirements described above. We recommend early formative evaluation of NBIS or
any similar systems to ensure that they are designed to fulfill all critical requirements and
are implemented as designed. During early implementation, it will be important to ascertain
whether the systems are adequate or whether new or different strategies are needed to inform
the broad range of policymakers responsible for addressing infectious disease security threats
to the United States.
Acknowledgments
Many people gave generously of their time and expertise in support of this project. We thank
John Zambrano, Arindam Dutta, and Martha I. Nelson of RAND for assisting in the search
for online sources, and especially John for his work on the statistical analysis of the sources.
David Hamon and Clete DiGiovanni of the Defense Threat Reduction Agency provided
invaluable guidance from the inception of this project to its very end. We are indebted to
our RAND colleagues Terri Tanielian, Michael A. Wermuth, and C. Ross Anthony for their
careful and critical review of this work, and to Terri Tanielian and James Dobbins for their
supportive and helpful oversight. Jennifer Gelman conducted a useful literature search for
us, Monica Hertzman made thoughtful suggestions for the organization of the report, and
Roshon Gibson helped us prepare the final manuscript. We are grateful for the comprehensive
and thoughtful feedback on the final report from Ruth Berkelman of Emory University and
Michael A. Stoto of RAND. Finally, the people who shared their insights with us in interviews
are unfortunately too numerous to mention, but we thank them all.
xvii
Abbreviations
APEC Asia-Pacific Economic Cooperation

ASEAN Association of Southeast Asian Nations
BioSense RT BioSense Real-Time
BKC Biodefense Knowledge Center
CDC Centers for Disease Control and Prevention
CISET Committee on International Science, Engineering, and Technology
DHS U.S. Department of Homeland Security
DoD U.S. Department of Defense
EID emerging infectious diseases
EINet Emerging Infections Network
Epi-X Epidemic Information Exchange
ESSENCE Electronic Surveillance System for the Early Notification of
Community-Based Epidemics
FAO Food and Agriculture Organization of the United Nations
FBIS Foreign Broadcast Information Service
G8 Group of Eight
GAO U.S. Government Accountability Office, formerly U.S. General
Accounting Office
GEIS Global Emerging Infections System
GOARN Global Outbreak Alert and Response Network
GPHIN Global Public Health Intelligence Network
HHS U.S. Department of Health and Human Services
xix
xx Infectious Disease and National Security: Strategic Information Needs
HIV/AIDS human immunodeficiency virus/acquired immune deficiency syndrome

HSPD Homeland Security Presidential Directive
IHR International Health Regulations
IOM Institute of Medicine
LRN Laboratory Response Network
NBACC National Biodefense Analysis and Countermeasures Center
NBIS National Biosurveillance Integration System
NGO nongovernmental organization
NSPD National Security Presidential Directive
OIE Office International des Epizoöties
(World Animal Health Organization)
PAHO Pan American Health Organization
SARS severe acute respiratory syndrome
UN United Nations
USDA U.S. Department of Agriculture
WHO World Health Organization
CHAPTER ONE
Introduction
The emergence and spread of severe acute respiratory syndrome (SARS) in 2003 caused sig-
nificant effects on the health, trade, and economies of a number of countries, particularly in
Asia. Today, the world faces the potential threat of a human pandemic arising from avian
influenza. While SARS did not cause significant mortality and morbidity within the United
States, it served as yet another sobering lesson that emerging infectious diseases (EID) can have
a significant effect on U.S. national security, with potential health, social, military, economic,
and political effects. This lesson applies not only to newly emerging infectious diseases such
as SARS, avian influenza H5N1, West Nile virus, and HIV/AIDS, but also to known diseases
that have reemerged (such as tuberculosis and dengue fever), as well as emerging and reemerg-
ing animal (e.g., bovine spongiform encephalopathy [“mad cow disease”], foot-and-mouth
disease) and plant (e.g., citrus canker) diseases.
The U.S. National Security Strategy of 2002 recognizes infectious diseases as a potential
danger to the nation’s security. However, it is not clear whether the links between infectious
disease and national security are widely understood and how this new paradigm guides infor-
mation collection and programming across government sectors. Current worldwide health
information systems rely mostly on open and truthful reporting by governments. Such report-
ing does not always occur, either due to obfuscation (as appears to be partially the case with
the SARS outbreak in China; see Chapter Three and Huang, 2003) or in part to the lack of a
robust ability of some countries to detect and report human and animal disease within their
own borders (e.g., HIV/AIDS in some African countries or avian influenza in some countries
in southeast Asia).
Within the evolving new paradigm that links infectious disease to national security, what
kind of information do government leaders need? Does the United States have a systematic
approach to the collection of information for the early warning and tracking of infectious dis-
eases originating outside U.S. borders? Is information collected by or available to the United
States adequate for enabling a timely and effective response to protect national interests at
home and abroad? These questions apply to a range of information collection sources that
includes the more traditional health sector, the agriculture and foreign affairs sectors, and the
intelligence community. How can the assets and approaches of these various sectors feed into
coherent, integrated national information?
1
2 Infectious Disease and National Security: Strategic Information Needs
About This Study
Considering the need for good early warning information about infectious diseases that may
affect U.S. national security or interests, the Advanced Systems and Concepts Office of the
Defense Threat Reduction Agency asked the RAND Corporation to examine the evolving
recognition of infectious disease as a national security threat and study how the United States
collects, analyzes, and uses information about global infectious diseases. Data collection for
this study was undertaken from July through October 2005, and analyses were completed in
November 2005. The purpose of this study was to assess information priority needs concern-
ing global infectious disease threats, and to determine the suitability of current information to
support U.S. policy- and decisionmaking to prevent and respond to such threats. The research
questions require careful consideration to help ensure that government leaders’ information
needs in this area are identified and met in the most efficient and effective manner possible.
The following questions guided this study:
• How has the emerging link between global infectious disease and U.S. national security
been perceived and acted upon across government sectors?
• What types of information about global infectious diseases do U.S. policymakers need?
• How sufficient is the available information on global infectious diseases?
Study Methods
We employed several methods to address the central study questions. Those methods included
literature and document reviews, interviews with relevant stakeholders, and a survey of online
infectious disease information sources.
Literature Review
We undertook a literature review to provide background information on infectious disease
threats and impacts, responses to date, the evolution of connections between infectious
disease and national security, and key U.S. and global policies and initiatives. The literature
and document reviews covered peer-reviewed literature, government reports, congressional
testimony, and reports by nongovernmental organizations. Media reports were consulted for
timely information about specific events. In the climate of near-continuous changes in global
infectious disease information reporting and U.S. homeland security efforts of the past sev-
eral years, every effort was made to review the most recent documents, especially guidance
from the U.S. government and international organizations. We principally reviewed docu-
ments less than ten years old, and we did not include documents published after August 2005,
except where specifically noted. The results of our literature review are presented primarily in
Chapters Two and Three.
Introduction 3
Interviews with Stakeholders

To examine all three of our research questions, we conducted interviews with policymakers
and staff at various levels of government and with nongovernmental, academic, and interna-
tional experts. We sought input from a broad range of potential stakeholders, mostly within
the federal government. We targeted senior policymakers or their staff in all cabinet depart-
ments with a potential interest in global infectious diseases, as well as their relevant agencies.
We also sought the views of relevant stakeholders outside the federal government, including
representatives from a state health department, the association for U.S. state health officers,
and the World Health Organization. We developed a discussion guide for our semi-structured
interviews. Our discussions were more focused in a few instances when more specific informa-
tion was required: for example, details about specific infectious disease information systems
or new government initiatives. We conducted our interviews between July and October 2005.
The results of the interviews are presented at the end of Chapter Three and in Chapter Four.
Survey of Online Sources

To supplement the findings from our interviews and in assessing the adequacy of currently
available information related to global infectious disease, we conducted a systematic search for
and analysis of Internet-based information sources. Our early literature review suggested no
evidence for a comprehensive, consolidated source of information on global infectious diseases,
and our pilot interviews with selected government officials suggested that this would be useful
to them. Therefore, we compiled and assessed online sources that contained information rel-
evant primarily to the public health aspects of infectious diseases, most notably disease surveil-
lance information. Our findings are presented in Chapter Five.
How This Report Is Organized
Chapter Two provides background information to frame the challenges of infectious diseases
and highlight recent U.S. and global responses. Chapter Three addresses our first research
question related to perceptions about infectious disease and national security. It provides spe-
cific historical background on how infectious disease is related to concepts of security, high-
lights key U.S. security-oriented responses, and presents findings from our interviews con-
cerning current stakeholder perceptions about the connection between infectious disease and
national security. Chapter Four addresses our second research question related to informa-
tion needs, summarizing findings from stakeholder interviews, and Chapter Five addresses the
third research question related to the adequacy of current information, focusing on the survey
of online infectious disease information sources worldwide. Chapter Six presents our synthesis,
conclusions, and recommendations.
CHAPTER TWO
Background:
Challenges of and Responses to Infectious Disease Threats
Response to infectious disease threats is a long-standing priority of health agencies in the

United States and around the world. The link between infectious disease and national security
is a relatively new concept. Understanding the challenges of infectious disease threats from
this perspective provides a background from which to address our research questions about
information needs and the adequacy of currently available information. The first section in this
chapter highlights the toll and challenges of infectious diseases; the second section describes
U.S. and global responses in recent years.
Infectious Disease Threats

The Toll of Infectious Diseases
Approximately a quarter of all deaths in the world today are due to infectious diseases. HIV/
AIDS, tuberculosis, malaria, pneumonia, and diarrheal diseases are the leading infectious dis-
ease causes of death and take a particularly large toll in developing countries (World Health
Organization, 2004). In the United States, mortality due to infectious diseases decreased
over the first eight decades of the 20th century and then increased between 1981 and 1995
(Armstrong, Conn, and Pinner, 1999). The average decline in infectious disease mortality
rates accelerated from 2.8 percent per year from 1900 to 1937 to 8.2 percent per year between
1938 and 1952, then receded to an annual decline of 2.3 percent until 1980. Most experts
attribute the declining mortality trends to improved water and sanitation and the introduction
and widespread use of vaccines and antibiotics. From 1980 to 1992, the rate of deaths with
an underlying infectious disease cause increased 58 percent (Pinner et al., 1996). Mortality
increases in the more recent years were due to HIV/AIDS and, in the oldest age group, pneu-
monia and influenza.
The toll of infectious diseases over the past century can also be appreciated by compar-
ing the leading causes of death at the beginning and end of the century (see Table 2.1). In
1900, four of the ten leading causes of death in this country were infectious diseases and col-
lectively accounted for 31.9 percent of all deaths, including the top three (tuberculosis—11.3
percent of all deaths, pneumonia—10.2 percent, and diarrhea—8.1 percent) and the tenth
(diphtheria—2.3 percent) (Cohen, 2000). In 2000, only pneumonia and influenza, which
5
Table 2.1
Leading Causes of Mortality, United States, 1900 and 2000
Rank 1900 2000
1 Tuberculosis Heart disease
2 Pneumonia Cancer
3 Diarrhea Stroke
4 Heart disease Chronic lower respiratory disease
5 Liver disease Unintentional injuries
6 Injuries Diabetes
7 Stroke Pneumonia/influenza
8 Cancer Alzheimer’s disease
9 Bronchitis Nephritis
10 Diphtheria Septicemia
NOTE: Infectious diseases are listed in bold.
ranked seventh, 2.7 percent of all U.S. deaths, and a new infectious disease condition, septice-
mia (ranked tenth, 1.3 percent), were among the ten leading causes of death (National Center
for Health Statistics, 2000).1
Infectious Diseases in a Modernizing World

In comparison with the world before the end of the Cold War, borders are generally more
open, and the pace of global travel, migration, and commerce has increased in recent decades.
The effect of “globalization” on public health has been widely considered (for example, see
Bettcher and Lee, 2002; Flanagan, Frost, and Kugler, 2001; Navarro, 1998; Roemer, 1998; and
Yach and Bettcher, 1998a, 1998b). With globalization comes the benefits of increased com-
merce and closer international relationships, but globalization also presents new challenges and
risks. One such challenge is that infectious diseases have followed a trend of increased global
travel and spread. Just as infectious diseases are not confined to their nations of origin and
have themselves become global in nature, appropriate responses to contain and control them
have become a challenge to nations and require a global approach. This challenge has been
addressed by the concept of global health, best described as “health threats and responses that,
while inclusive of national governments, go beyond the action of nation-states” (Store, Welch,
and Chen, 2003). While modern means of travel and migration have increased the threat of
global disease spread by facilitating disease transmission among people and nations, modern
times have also seen advances in the ability to recognize and treat infectious diseases.
Prior to the modern technologies that made rapid global travel possible, the geographic
spread of infectious diseases was constrained by slower transportation: first, walking, then
1 It should also be noted that, while the number of deaths caused directly by infectious diseases is significant, infectious
diseases also contribute to other causes of death, such as cancer.
Background: Challenges of and Responses to Infectious Disease Threats 7
travel by animal, then ships and trains. The historic role of travelers (particularly armies,
explorers, and merchants) and animals (e.g., rats carrying plague) in the introduction and
spread of disease is well documented (for examples, see Berlinguer, 1992, and Wilson, 1995b,
2003b). However, slower transportation and communications during those times also reduced
the potential for early warning and response to outbreaks. As ever-faster means of travel have
facilitated the spread of infectious disease, modern communications technologies have also
presented the opportunity for faster worldwide notification of disease outbreaks. Faster notifi-
cation, in turn, presents the opportunity for quicker response to control outbreaks. A critical
challenge is to harness the opportunities of modern communications to address the modern
challenges of infectious diseases.
Today, people can traverse the globe in less time than it takes for many infectious agents
to incubate and produce symptoms. For example, SARS emerged in rural China, spreading to
Hong Kong and, from there, to 30 countries on six continents within several months—and this
was a disease whose transmission rate pales in comparison with that of influenza (Osterholm,
2005). (SARS is discussed further in Chapter Three.) Compounding the problem is the fact
that many pathogens can be transmitted by asymptomatic or mildly symptomatic persons,
including travelers, who may be unaware that they are carriers (Wilder-Smith et al., 2002).
Also disturbing are reports that pathogens carrying resistance genes can be transmitted from
person to person, and among asymptomatic carriers (O’Brien, 2002), increasing the spread
and prevalence of antimicrobial resistance. Mary Wilson summarizes the problem this way:
“Current attributes of the world’s population—including size, density, mobility, vulnerability,
and location—have increased the risks for many infectious diseases, despite the availability of
an unprecedented array of tools to prevent, diagnose, treat, and track them” (Wilson, 2003a).
New infectious diseases are emerging at an average rate of one per year (Woolhouse and
Dye, 2001), and at least 30 new or newly recognized diseases have emerged in the last three
decades (CISET, 1995; World Health Organization, 1996). Modern-day infectious disease
risks are not limited to human-to-human contact. Approximately three-fourths of infectious
diseases that have emerged and reemerged in recent decades are zoonoses, i.e., diseases trans-
mitted to humans from animals (U.S. General Accounting Office, 2000b). Examples include
HIV, West Nile virus, SARS, monkeypox, and several of the hemorrhagic fever viruses. Such
exposures are characteristic of human encroachment into new habitats. Zoonotic diseases also
can be introduced into a human population via agricultural trade,2 which is a critical element
in many national economies worldwide.3
A crowded, interconnected, and mobile world has presented new opportunities for
pathogens to exploit their inherent abilities to rapidly multiply, mutate, evolve drug resistance
and increased virulence, and find new (human) hosts (Heymann, 2003; Rodier, Ryan, and
2 The transmission of plant and animal diseases within and among countries poses significant risks to an affected coun-
try’s economy and trade. Such agricultural diseases are beyond the scope of this report, which focuses more specifically on
the threat of diseases directly relevant to humans, including zoonotic diseases.
3 Significantly for the United States, due to its high volume of international trade, zoonoses may also be introduced by
the inadvertent introduction of animals. For example, as of this writing, the United States imports approximately 9 million
sea shipping containers per year (U.S. Customs and Border Protection, undated). These containers may include animals
or other biologics, either intentionally via trade or unintentionally as “stowaways.” The 2003 cases of monkeypox arising
Heymann, 2000). Rapid and unplanned urbanization, particularly in developing countries,

poses yet another set of risks for infectious disease transmission. Specific risk factors include
poor sanitation, crowding, and sharing resources such as food and water (Moore, Gould, and
Keary, 2003). As Heymann (2003) points out with numerous examples, the modernization
of global trade and travel has resulted in the unprecedented emergence of new diseases, the
reemergence of known diseases, and growing antimicrobial resistance.
Near-Term Infectious Disease Threat: Avian Influenza

As of this writing, the H5N1 strain of influenza (avian influenza) has raced through bird
populations in Asia and into eastern Europe, and has been documented to have jumped to
humans in some instances, with 204 officially reported cases (most of whom had direct contact
with infected birds) and 113 deaths in nine countries since 2003. It is widely feared that this
virus will adapt sufficiently to permit efficient human-to-human transmission, either through
mutations or through reassortment with a human influenza virus, resulting in a novel strain
that spreads easily among people. This could trigger a human influenza pandemic that could
potentially kill millions of people worldwide (estimates range from 2–7.4 million to 71 mil-
lion), proportionally rivaling the Spanish influenza pandemic of 1918–1919 (McKibben and
Sidorenko, 2006).4 Estimates vary on the worldwide death toll of the 1918–1919 pandemic,
but most estimates range from 20 to 50 million (Lederberg, 1997; Mills, Robins, and Lipsitch,
2004; Trampuz et al., 2004) or 50 to 100 million (Johnson and Mueller, 2002; Oxford et al.,
2005) deaths. While various experts offer a wide range of projections, the Centers for Disease
Control and Prevention (CDC) predicted that a “medium-level epidemic” could kill up to
207,000 Americans and sicken about a third of the U.S. population (Crosse, 2005), and a
larger epidemic of avian influenza could be even more devastating, perhaps resulting in 16
million U.S. deaths (Garrett, 2005). The HHS Pandemic Influenza Plan, released in November
2005, includes planning assumptions that 30 percent of the U.S. population will become sick
and 209,000 to 1.9 million will die in moderate and severe pandemic scenarios, respectively
(U.S. Department of Health and Human Services, 2005; see also White House, 2005).
In September 2005, President George W. Bush established an “International Partnership
on Avian and Pandemic Influenza” to coordinate global response strategies. Senate Majority
Leader Bill Frist (who is a physician) opined that the United States is “dangerously unprepared
to defend” against avian influenza, calling for an “all-out effort to defend against the threat of
human-made and naturally occurring infectious diseases” (Frist, 2005). Interviews conducted
during this study indicated that pandemic influenza response was among the President’s top
five national priorities as early as summer 2005. However, multiple interviewees in this study
from the importation of wild rodent pets from Ghana into the United States is an example of the former, and the historical
spread of bubonic plague by way of rats is an example of the latter. This annual volume reflects an increase of more than
3 million containers since 2001 (Fields, 2002). Of particular concern because of their small size and ubiquity are rats and
arthropod vectors of diseases that are transported inadvertently (Lounibos, 2002) and may successfully establish popula-
tions in new locations (Moore and Mitchell, 1997), sometimes without natural predators or other environmental controls.
4 See also World Health Organization (2005b).
also informed us that there is some evidence that nations are reluctant to report outbreaks of
avian influenza among birds or humans, fearing significant economic costs related to preven-
tive culling of bird flocks and reduced travel and trade.
While globalization has changed the world in ways that can foster the spread of infec-
tious disease, it has also changed traditional concepts of security. The remainder of this chapter
provides background information about U.S. and global responses to the threat of infectious
diseases.
Responses to Threats from Infectious Disease
Interest in infectious disease surveillance and response increased in the United States and, sub-
sequently, in the broader world community during the 1990s, probably due to a combination of
factors. First, at least in the United States, the emergence and resurgence of infectious diseases
since 1980 erased the attitude that the war against infectious disease had been won; second,
policymakers appreciated more fully the effect of globalization on the spread of infectious dis-
ease; and third, they recognized the increasing and profound global effect of HIV/AIDS.
U.S. Response
The 1970s and 1980s saw complacency in the United States toward infectious diseases, in part
due to a general perception that infectious diseases no longer posed a significant risk. Smallpox
was eradicated (the last naturally occurring case was in 1977), and other infectious diseases,
such as tuberculosis, seemed to be controlled. Indeed, U.S. public health literature is rife with
descriptions of such complacency. William Stewart, U.S. Surgeon General from 1965 to 1969,
is widely quoted as having “closed the book on infectious diseases” in 1969 and redirecting
public health priorities toward noncommunicable chronic diseases (Stewart, 1967; Lederberg,
Shope, and Oaks, 1992). (Of note, the U.S. Public Health Service historian was unable to
confirm that Dr. Stewart ever made such a statement in the congressional record, as it is
often cited.) State and federal spending on infectious disease surveillance and control declined
throughout the 1980s. However, during this same period—the 1970s and 1980s—new infec-
tious diseases began to appear: Legionnaire’s disease, Ebola, E. coli H7:0157, HIV/AIDS, and
others, and the prevalence of older diseases, including tuberculosis, malaria, and dengue fever,
increased.
By the early 1990s, infectious diseases began once again to attract attention on the public
policy agenda:
• In 1992, the Institute of Medicine (IOM) issued its landmark report, Emerging Infections:
Microbial Threats to Health in the United States, triggering heightened awareness of the
resurgence of infectious diseases and the need for adequate public health and medical
infrastructures to control them (Lederberg, Shope, and Oaks, 1992).
• In 1994, the CDC issued its first comprehensive national strategy on emerging infectious
diseases (CDC, 1994).
• In 1995, a U.S. National Science and Technology Council working group issued a compa-
rable strategy with a global reach, based on the evolving view that infectious diseases pose
challenges to foreign policy and could constitute a threat to national security (CISET,
1995).
• In 1996, President Clinton issued a Presidential Decision Directive (White House,
1996a) to implement elements of that strategy. The directive included a policy goal of
“establish[ing] a global infectious disease surveillance and response system, based on
regional hubs and linked by modern communications.” On the same day, Vice President
Gore declared that “emerging infectious diseases present one of the most significant health
and security challenges facing the global community” (White House, 1996b).
• In 1997, the IOM published another landmark report, America’s Vital Interest in Global
Health (Institute of Medicine, 1997), to “sell” the importance of global health and infec-
tious diseases to the American public.
• In 1998, the CDC updated its national EID strategy (CDC, 1998).
As more policy attention began to be paid to the potential security threat of global infec-
tious disease, the U.S. National Intelligence Council prepared a report on the future threat of
infectious diseases in response to “a growing concern by senior U.S. leaders” (U.S. National
Intelligence Council, 2000). The report examined alternative future scenarios that looked for-
ward 20 years. It concluded that the most likely scenario is one in which the infectious disease
threat worsens during the first half of that time frame but “decreases fitfully” thereafter due
to improved prevention, control, drugs and vaccines, and socioeconomic improvements. This
estimate, prepared before the emergence of SARS and the more recent spread of avian influ-
enza, concluded this scenario to be the most likely, barring the appearance of a deadly and
highly infectious new disease. The report stated that
• “New and reemerging infectious diseases will . . . complicate U.S. and global security
over the next 20 years. These diseases will endanger U.S. citizens at home and abroad,
threaten armed forces deployed overseas, and exacerbate social and political instability in
key countries and regions in which the United States has significant interests” (p. 5).
• “The relationship between disease and political instability is indirect but real” (p. 10).
• “The severe social and economic impact of infectious diseases is likely to intensify the
struggle for political power to control state resources” (p. 10).
• The spread of HIV/AIDS in Africa, together with other factors of instability, could jeop-
ardize U.S. national security and national interests (p. 54).
Global Response
Complacency at the global level during the 1970s mirrored that in the United States. The
landmark 1978 WHO “Health for All 2000” strategy, which predicted that even poor nations
would see improvements in health before the millennium, epitomized the optimism that global
infectious diseases could be managed and would not present a significant future threat (see
World Health Organization, 1978). However, by the 1990s, multilateral organizations also
began to recognize and respond to the growing global threat of infectious diseases:
• In May 1995, the World Health Organization (WHO) passed a resolution urging member
states to strengthen surveillance and reporting of emerging infectious diseases (World
Health Assembly, 1995).
• In January 2000, by U.S. example, the United Nations Security Council considered a
health issue for the first time, concluding that HIV/AIDS presented a threat to eco-
nomic development, global security, and the viability of states (United Nations Security
Council, 2000).
• Also in 2000, the Group of Eight (G8), at its meeting in Okinawa, Japan, acknowledged
the need for an international mechanism to fund the surveillance and control of infec-
tious diseases.
• In May 2001, U.S. President Bush and the UN Secretary-General called for the estab-
lishment of an international relief fund directed at three killer diseases. The Global Fund
to Fight AIDS, Tuberculosis and Malaria is a federation registered under Swiss law and
represents a partnership among governments, the private sector, and worldwide com-
munities. The fund awarded its first round of grants to 36 countries later in that same
year.5 The establishment of this fund, and the inclusion of the control of HIV/AIDS and
other diseases as one of eight measurable UN Millennium Development Goals in 2000
(United Nations, 2000), underscore the perceived importance of infectious diseases to
global development prospects.
• In 2003, leaders from the 21 members of the Asia-Pacific Economic Cooperation (APEC)
forum, including the U.S. President, endorsed a new health security initiative that included
a provision for infectious disease surveillance and response (see APEC, 2003).
Despite the renewed attention to global infectious disease since the 1990s, efforts to sig-
nificantly improve global surveillance have been only partly successful: In the late 1990s, the
IOM asserted, “The necessary information and communications technology are available, yet
no formal infectious-disease surveillance system exists on a global scale” (Howson, Fineberg,
and Bloom, 1998, p. 588). In a follow-up report in 2003, the IOM noted the ongoing nature of
the problem: “Health ministries may generate health reports, but the data are generally unreli-
able. Such numbers have been used as the basis for broad policy recommendations; if the num-
bers are incorrect, however, the resulting policies can be damaging” (Smolinski, Hamburg, and
Lederberg, 2003, p. 154).
Global Infectious Disease Surveillance

Global disease surveillance is conducted through a loose framework of formal, informal, and
ad hoc arrangements that the U.S. General Accounting Office, now the U.S. Government
Accountability Office (GAO), has characterized as a “network of networks” (U.S. General
5 For information about the Global Fund to Fight AIDS, Tuberculosis and Malaria, visit its Web site, http://www.
theglobalfund.org/ (online as of June 12, 2006).
Accounting Office, 2000a). Historically, surveillance systems have been developed mainly to
address specific diseases. Those that are targeted for eradication or elimination, such as polio,
tend to receive sustained financial and technical support, while surveillance for other diseases,
including emerging diseases, has received limited support (U.S. General Accounting Office,
2001). The lack of adequate sustained support for surveillance adds to the challenge of control-
ling emerging diseases.
Surveillance systems in all countries suffer from a number of common constraints, but
these constraints are more prevalent in the poorest countries, where annual per capita expendi-
ture on all aspects of health care is less than 30 U.S. dollars, representing 2–3 percent of these
nations’ gross domestic product (United Nations Development Programme, 2005). The most
common constraints are shortages of human and material resources: Trained personnel and
laboratory equipment are lacking in many cases (U.S. General Accounting Office, 2001). Poor
coordination of surveillance activities also constrains global disease surveillance. This poor
coordination is caused by multiple reporting systems, unclear lines of authority, and incom-
plete participation by affected countries (U.S. General Accounting Office, 2001), resulting in
knowledge gaps about putative outbreaks. Therefore, shortcomings in surveillance reporting
of infectious disease seem to exist for two main reasons: Some nations are either unable or
unwilling to report.
Recent Improvements in Global Disease Surveillance

In 2000, the WHO formalized the Global Outbreak Alert and Response Network (GOARN),
which links over 100 laboratory and reporting networks. Development of GOARN began in
1997. GOARN relies on a Canadian-developed system known as the Global Public Health
Intelligence Network (GPHIN), which includes software that actively gathers disease infor-
mation from Web sites, news wires, newspapers, public health email services, and electronic
discussion groups; processes the information centrally in Canada; and then sends alerts to the
WHO for verification. GPHIN has identified more than 40 percent of the outbreaks subse-
quently verified by the WHO (Heymann, 2003). GPHIN is beneficial because it can identify
possible outbreaks more quickly than can traditional systems, in which case reports must
be passed up from the local level to subnational and national governments, and ultimately
reported to the WHO. However, GPHIN can only identify rumors of outbreaks where they
might be reported in the media or on discussion Web sites, and some diseases occur in areas so
remote that they are not detected by the sources that GPHIN searches, or in countries using
foreign languages not currently compatible with GPHIN.
Updated International Health Regulations

The World Health Organization has recently revised its International Health Regulations
(IHR), which govern the responsibilities of member states and the WHO in response to
selected infectious disease threats of international concern. This was the result of a long process
and an even longer history of global governance related to infectious diseases. In this section,
we highlight the history and recent developments with respect to these IHR.
In 1896, the International Sanitary Conference agreed that there was a need for inter-
national health surveillance (Zacher, 1999). That year marked the beginning of cooperative
surveillance for global infectious disease. The Organisation Internationale d’Hygiène Publique
was established in Paris in 1907 to gather and share information on disease outbreaks among
participating countries (Cash and Narasimhan, 2000). Eventually requiring the reporting of
plague, cholera, yellow fever, smallpox, relapsing fever, and typhus, the impetus for this agree-
ment was that Europe feared that these diseases would enter from poorer countries where they
were most prevalent (Fidler, 1997).
The Organisation Internationale d’Hygiène Publique was replaced by the WHO, which
was created in 1948 and issued its International Sanitary Regulations in 1951. These regulations
were renamed the International Health Regulations in 1969 and were later revised in 1981. The
1981 regulations required member nations to notify the WHO within 24 hours of an outbreak
of plague, cholera, or yellow fever. However, the IHR applied only to nations that were mem-
bers of the WHO and only to those three diseases. The WHO, lacking strong enforcement
powers, has relied mostly on international persuasion to ensure compliance. Nations have not
always complied (Heymann and Rodier, 1998), fearing the economic consequences of preven-
tive actions and reduced travel and trade, even though the reporting of outbreaks often triggers
international assistance.
Although the revision process began before the 2003 SARS outbreak in China, the SARS
experience was undoubtedly on the minds of the 192 member nations of the World Health
Assembly when they ratified the revised IHR in May 2005 (see World Health Organization,
2005).6 The revision process began when the World Health Assembly, dissatisfied with the lim-
itations of the current IHR, endorsed a resolution in 1995 to revise them. These efforts failed,
but the Assembly renewed its resolve to revise the IHR through a new resolution in 2003,7 cul-
minating in a substantially revised agreement, a legally binding treaty that it endorsed in 2005
(see World Health Organization, 2005). The revised regulations include an expanded list of
diseases that member nations are required to report to the WHO. The IHR also include a deci-
sion matrix for nations to determine whether an outbreak—due to a disease on the expanded
list or a newly emerged disease—is significant enough to require reporting (i.e., a “public
health emergency of international concern”) with new attention paid to the propensity of dis-
ease to be spread via modern travel methods. Importantly, given the SARS and avian influenza
experiences, the IHR require nations to respond to requests for verification from the WHO,
whether the WHO learns of a putative outbreak from the affected nation or via other means,
such as GPHIN (World Health Organization, 2005). Cash and Narasimhan (2000), writing
while the IHR revisions were being discussed, suggested that the expansion of the number of
reportable diseases in the revised IHR could increase the use of trade and travel restrictions in
an attempt to prevent the spread of infectious agents across borders. In that paper, they pro-
vide examples of how “overreaction” to reported outbreaks has had significant consequences
for affected nations (e.g., see the discussion about plague in India in Chapter Three), and they
suggest that the IHR can be used to prevent such overreactions, in part by preventing the rapid
spread of inaccurate reports.
6 This revision is also timely, given the increasing threat of a human influenza pandemic arising from avian influenza that
is currently circulating in Asia and elsewhere.
7 For the text of the resolution to revise the IHR, Resolution 56.28, see World Health Assembly (2003).
Because the revised IHR emphasize timely disclosure of outbreaks by affected countries,
an important component is the assurance that technical assistance will be provided by the
WHO and its member states to help both strengthen surveillance and respond to outbreaks
of emerging disease threats of international concern. The revised regulations are aimed to
improve global disease detection and control through public health capacity and compliance.
Summary
Globalization and the modern-day threats of infectious diseases have kept these diseases on
the public policy agenda into the 21st century. Recent policy and programming responses by
both the United States and the broader global community provide the context from which we
examine the three research questions addressed in this study.
CHAPTER THREE
Addressing a New Paradigm:

Infectious Disease and National Security
Our first research question asks how the emerging link between global infectious disease and
U.S. national security has been perceived and acted upon across government sectors. This
chapter begins with a section describing the evolution of this new paradigm, the effects of
infectious disease on security, the implications of a biosecurity policy orientation to natural
disease outbreaks, and the implications for global disease reporting. This chapter then summa-
rizes a number of recent U.S. security initiatives addressing infectious diseases. The final sec-
tion presents the views of stakeholders we interviewed regarding their perceptions of the link
between infectious disease and national security.
Infectious Disease and Security

Evolving Security Concepts
Traditional views of the association between infectious disease and security have often focused
on the effect of health on military success (for example, see Szreter, 2003). In fact, many health
discoveries that were made in the course of efforts to protect armies ultimately benefited other
populations as well. For example, discoveries made near the turn of the 20th century, includ-
ing the tracing of the natural history of diseases such as yellow fever and malaria, were studied
initially in an effort to protect military forces (Berlinguer, 2003), and World War II provided
the impetus to mass-produce penicillin.
Similarly, the U.S. State Department has speculated that disease will emerge as a “con-
flict starter,” and possibly even a “war outcome determinant” (see, for example, Center for
Strategic International Studies, 2000, and U.S. Department of State, 1995). The relationship
between disease and warfare is as old as war itself. Indeed, disease among armies has long been
a contributing factor to military outcomes, and warfare has contributed to the spread of dis-
ease.1 Following World War II, and based upon the institutions established at the end of that
war, worldwide perceptions of national security were largely restricted to the military defense
of territorial borders and interests; these perceptions were not much different from concepts of
security prior to that war (Rothschild, 1995). The association of disease with warfare parallels
traditional views of national security, i.e., armed protection of a nation’s borders and inter-
1 A complete discussion of this subject is beyond the scope of this study; more information can be found in Gabriel and
Metz (1992) and Smallman-Raynor and Cliff (2004).
15
ests. Similarly, traditional views of the relationship between disease and security have focused
on the threat of disease spreading across borders. However, increasing worldwide attention
has recently been paid to a broader issue: the effect of infectious disease on other concepts of
security.
These newer concepts include the recognition of the inherent benefit of health: “[H]ealth
itself is a power, a fundamental capacity for the development or maintenance of all other
capacities” (Berlinguer, 2003, p. 57). This view has been extended from the individual to the
state: when nations recognize that investment in health can improve the health of a nation’s
population, advance its economy, and “promote humane values and moral leadership in a
world of opportunities and profound health needs” (Howson, Fineberg, and Bloom, 1998,
p. 590). This view illustrates the newly evolving concept of “human security.” In 1994, the
UN Development Programme wrote of a transition “from nuclear security to human secu-
rity,” meaning safety from “hunger, disease and repression” (United Nations Development
Programme, 1994, p. 23). Shortly thereafter, the UN Secretary-General gave formal voice to a
development that had been more than a decade in the making, calling for a “conceptual break-
through,” going “beyond armed territorial security” and protecting the “security of people in
their homes, jobs, and communities” (Rothschild, 1995, quoting then–UN Secretary-General
Boutros Boutros-Ghali).
The UN established an independent international commission on human security in
2001, mandated to clarify the concept of human security for global policy and action (Chen
and Narasimhan, 2003). Chen and Narasimhan (2003) assert that “a new people-centered
paradigm, with its policy and operational implications, can complement and strengthen state
security to protect people in an unstable and interconnected world,” and “control of global
infections is not possible without surveillance, control and response linked to international
trade, migration, and movements” (p. 11). The UN commission produced a working definition
of human security: “The objective of human security is to safeguard the vital core of human
lives from critical pervasive threats while promoting long-term human flourishing” (Chen and
Narasimhan, 2003, p. 4). In its final report, the commission asserted that “[g]lobal health
is both essential and instrumental to achieving human security,” and “illness, disability and
avoidable death are ‘critical pervasive threats’ to human security” (Commission on Human
Security, 2003, p. 96).
Effects of Infectious Disease on Security

The discussion of human security versus older, traditional ideas of security is useful in under-
standing the moral values with which the global community appears to approach the impor-
tance of health today. However, it remains somewhat intangible, leaving firm associations
between health (including infectious disease) and security incompletely defined. As Chen and
Narasimhan (2003) point out, “health and human security are fundamentally valued in all
societies, but their connections and interdependencies are not well understood.” Nonetheless,
some authors assert a solid association between health and security, at least for the United
States: “National security and public health experts agree that infectious diseases pose a sub-
stantial direct and indirect threat to U.S. interests” (U.S. Government Accounting Office,
2000a, p. 2). Such assertions are based on a growing body of evidence that associates infec-
Addressing a New Paradigm: Infectious Disease and National Security 17
tious disease with effects that may ultimately threaten both human and national concepts of
security. As Brower and Chalk (2003) conclude, there is a definite link between infectious
disease and security: Disease can affect individuals and also weaken public confidence in a
government’s ability to respond; they have an adverse economic impact, undermine a state’s
social order, catalyze regional instability, and pose a strategic threat through bioterrorism or
biowarfare.
Compelling arguments have been made linking infectious disease to conditions that logi-
cally can affect security. These conditions include those mentioned by Brower and Chalk (2003),
and others that have been argued by numerous other authors. The following is a summary of
research that has associated specific effects of infectious disease with threats to security.
Direct Mortality and Morbidity. The most obvious effect of disease that may result in
the instability of a nation or region is the toll of some diseases that have high mortality rates.
Such diseases, especially if highly prevalent, can pose a direct risk to a nation’s security by
threatening to sicken and kill a significant portion of a country’s population (Heymann, 2003;
Price-Smith, 2002), and a disease that targets sectors of a population that are relied upon
for production and military protection can be particularly ominous (see also Chyba, 1998;
Enemark, 2004; Frist, 2005; and White House, 2004). HIV/AIDS is a disease often cited in
this regard.
Economic Loss. As detailed in examples later in this chapter, an outbreak of disease—or
even the perceived threat of an outbreak—can have significant repercussions on trade and
travel for the affected nation. The economic effects of infectious diseases—whether endemic,
e.g., malaria, or epidemic, e.g., cholera—can be devastating. As just one example, it has been
estimated that Africa’s gross domestic product would be nearly one-third higher if malaria
alone had been eliminated several decades ago (U.S. General Accounting Office, 2001). Many
of these effects are indirect (e.g., loss of productivity and commerce), but there are also direct
economic costs (e.g., culling of animal herds and medical costs of treating humans) that may
affect security and relationships between nations in need and those able to provide assistance to
control outbreaks. (For examples of both direct and indirect costs, see Brower and Chalk, 2003;
Cash and Narasimhan, 2000; Enemark, 2004; Frist, 2005; Heymann, 2003; United Nations
Security Council, 2000; U.S. General Accounting Office, 2001; U.S. National Intelligence
Council, 2000; White House, 2004; and Wilson, 2003a.) In addition, the UN estimated in
2002 that $20 billion would be needed by 2007 to provide adequate prevention and care for
populations affected by HIV/AIDS in low- and middle-income countries (UNAIDS, 2002;
see also World Health Organization, 2002).
Social and Governmental Disruption. It has been documented that infectious diseases
cause significant social disruption through fear and anxiety about a disease (based on accurate
or inaccurate information), the loss of people in key social positions due to illness or death,
discrimination against groups affected by a disease, and the loss of the majority of (or entire)
specific demographic groups. (For examples of social disruption, see Chyba, 1998; Elbe, 2002;
Enemark, 2004; Heymann, 2003; Ostergard, 2002; Shisana, Zungu-Dirwayi, and Shisana,
2003; Store, Welch, and Chen, 2003; UNAIDS, 2004; U.S. National Intelligence Council,
2000; White House, 2004; and Wilson, 2003a.) Consider HIV/AIDS: In 2003, there were
3 million new infections in sub-Saharan Africa (UNAIDS, 2002, 2004). Since it was first
diagnosed in 1981, HIV/AIDS has accounted for approximately 20 million deaths worldwide.
Between 34.6 and 42.3 million people were living with HIV/AIDS in 2003, and the dis-
ease had orphaned approximately 12 million children in sub-Saharan Africa alone (UNAIDS,
2004). Half of new infections occur among 15- to 24-year-olds (UNAIDS, 2004), a tradition-
ally productive segment of society. The reduction of this demographic group can lead to eco-
nomic loss due to reduced productivity, but it also represents the loss of a core group of parents,
social leaders, and key members of society, such as teachers and soldiers. Ministries of defense
in some sub-Saharan African countries report HIV prevalence averages of 20–40 percent in
their armed services, potentially affecting their military capabilities (UNAIDS, 2002).
Not surprisingly, HIV/AIDS in sub-Saharan Africa has been associated with the destabi-
lization of infrastructures needed for governance (Heymann, 2003), as well as with the disrup-
tion of cohesion and stability of families, communities, and nation-states (Heymann, 2003;
Shisana, Zungu-Dirwayi, and Shisana, 2003; Store, Welch, and Chen, 2003). As a society is
degraded by infectious disease, its populace may lose confidence in a government that seems
unable to control the disease. Such a loss in confidence, it has been asserted, results in a deg-
radation of a government’s legitimacy and may lead to increased migration or increased vul-
nerability to economic or military competition from other nations. (For examples of govern-
ment disruption and instability, see Brower and Chalk, 2003; Enemark, 2004; Heymann,
2003; Huang, 2003; Ostergard, 2002; United Nations Security Council, 2000; U.S. National
Intelligence Council, 2000; and Wilson, 2003a.)
Implications of a Biodefense Orientation for Natural Disease Outbreaks

Heymann (2003) points out that the response of industrialized countries has not been com-
mensurate with the views of various organizations, such as the UN and the U.S. National
Intelligence Council, that infectious diseases pose a threat to international security. During
the 1990s, it remained unclear whether or not infectious diseases were seriously considered in
the national security strategies of developed countries. That changed after the attacks on the
United States in September and October 2001, and the newly perceived risk of bioterrorism,
“immediately raised the infectious disease threat to the level of a high priority security impera-
tive worthy of attention in defense and intelligence circles” (Heymann, 2003, p. 105).
While there is growing recognition in recent U.S. policy that improved preparation for
bioattacks (i.e., bioterrorism) on the U.S. homeland can also result in improved surveillance for
and response to naturally occurring disease outbreaks and vice versa, it is obvious that many
of the initiatives since 2001 (described later in this chapter) have been focused on the former.
There has been some debate about whether preparation for both events is complementary or
whether a focus on bioattacks distracts from surveillance of naturally occurring disease, or vice
versa. Brower and Chalk (2003) suggested that the United States expends considerable policy
attention and resources to defend against “relatively unlikely” scenarios, such as a large-scale
bioterrorist attack, concluding that “[r]esponses to more commonly occurring and currently
more taxing natural outbreaks remain relatively overlooked and underfunded” (p. xix).
In recent years, the public health and homeland security communities seem to have come
to a realization that the public health infrastructure for infectious diseases in fact also under-
pins the public health aspects of bioterrorism detection and early response. It seems to many
that the only rational way to defend the world against a bioterrorist attack is to have a central
principle of global public health security and to strengthen the capacity to detect and con-
tain naturally occurring outbreaks (Heymann, 2003). Some authors have argued compellingly
that public health surveillance for emerging diseases and preparedness for and detection of
biological terrorism are strongly related (see, for example, Chyba, 1998). Presentations by the
United States and other countries at the July 19–24, 2004, Meeting of Experts, held during
the Biological and Toxins Weapon Convention, addressed surveillance and mitigation within
this very framework, i.e., bioterrorism detection and early response relying in large part on the
underlying public health infrastructure.2
The themes of the 2002 U.S. National Security Strategy include defeating terrorism and
tyranny, as well as fostering the spread of freedom worldwide. U.S. experts recognized that
infectious diseases pose a substantial obstacle to U.S. efforts to encourage economic growth
and betterment in the lives of the poor in the developing world (U.S. General Accounting
Office, 2000a). For example, the National Security Strategy recognizes that the United States’
strategic priority of combating global terror is threatened by disease (as well as war and des-
perate poverty) in Africa. While a significant focus of the strategy is defense against terror-
ist attacks in the United States, it also acknowledges that investments to defend against such
attacks also present related opportunities: “Our medical system will be strengthened to manage
not just bioterror, but all infectious diseases and mass-casualty dangers” (White House, 2002,
pp. 6–7).
Infectious Disease, Security, and Disease Reporting

Given the potential consequences of infectious disease on a country’s international trade and
economy (and, by extension, security), it is not surprising that some countries choose not to
report disease outbreaks, or at least to delay their reporting. Such decisions can have global
effects.
With the major exception of HIV/AIDS, newly identified infectious diseases have not
had a large effect on global infectious disease mortality, but new diseases are of concern due to
their large numbers of casualties and high profile (Wilson, 2003a). While this observation is
not necessarily predictive of the mortality caused by future emerging and reemerging diseases,
the visibility of some diseases has caused anxiety that is sometimes out of proportion with
the actual risk. Examples include plague in India (Wilson, 1995a) and Ebola in sub-Saharan
Africa, which has emerged periodically since 1976, even though no scientific evidence suggests
a serious risk of global spread of Ebola (other than through bioterrorism) (Wilson, 2003a). It
should be noted that the level of anxiety caused by some diseases is, in fact, commensurate
with the scale of their actual medical and societal effects. HIV/AIDS is one such example. In
other cases, an increased level of anxiety can make permissible intensive and large-scale public
health measures that may not have been possible previously, as was seen in the global response
to SARS and the public acceptance of containment measures.
2 Melinda Moore, an author of this report, was a U.S. delegate to this meeting. The meeting report is available at
http:// www.opbw.org/new_process/mx2004/bwc_msp.2004_mx_3_E.pdf, and a related press release is available at http://
www2.unog.ch/news2/documents/newsen/dc04029e.htm (both as of October 31, 2005).
Nonetheless, anxiety associated with such diseases, as well as subsequent legitimate public
health intervention measures, has sometimes resulted in significant economic effects, including
lost trade and tourism and the required culling of animal herds. Such economic effects or other
unfavorable treatment by the world community have been a disincentive for countries to report
outbreaks (see Cash and Narasimhan, 2000, and Fidler, 1997), yet they can have an important
net benefit on public health and the global economy.3 As such, a disinclination of countries to
report and respond appropriately to disease outbreaks poses a dangerous prospect in the face of
a potential worldwide disease outbreak, such as pandemic influenza.
International knowledge about infectious disease outbreaks, whether reported by the
affected country or otherwise discovered, can have significant negative economic consequences
through decreased trade and travel. Cash and Narasimhan (2000), in a study on the impedi-
ments of global infectious disease surveillance, found that “current guidelines and regulations
on emerging and re-emerging infectious diseases do not sufficiently take into account the fact
that when developing countries report outbreaks they often derive few benefits and suffer dis-
proportionately heavy social and economic consequences” (p. 1358). Their article presented
two cases to support this conclusion: plague in India and cholera in South America. The illus-
trative case of plague in India is summarized below.
Plague in India. In September 1994, a hospital in Surat, India, admitted seven patients
with pneumonia-like symptoms. Rather than waiting a week for laboratory confirmation
of plague-like bacilli from patient samples, Indian officials declared an outbreak of plague.
This decision may have also reflected a conservative public health approach, prompted by the
fact that India’s public health laboratory infrastructure had eroded in the previous decade.
Unfortunately, like many other places in the world, India lacked a robust diagnostic capability
to confirm or rule out plague infections rapidly and confidently.4 Within three days, as many
as 500,000 people fled Surat and the surrounding area, reacting to media reports of a plague
outbreak. A low-threshold case definition of plague was adopted, and any persons showing
respiratory symptoms were quarantined. Schools were closed, cargo was fumigated against
rodents, flea controls were implemented, and antibiotics were administered to individuals who
were presumed to be exposed. A WHO investigative team concluded that these measures were
excessive. After implementing control measures, India declared the epidemic controlled in
early October 1994, and the WHO concurred at the end of October of that year. In the end,
either no (Cash and Narasimhan, 2000) or few cases of plague were confirmed on the basis of
WHO bacterial standards.5
Even without a scientific confirmation of a plague outbreak, press reports were estimat-
ing the magnitude of the outbreak, and some nations responded by stopping air travel to and
from India. Although the WHO requested that no travel or trade restrictions be imposed,
Bangladesh, Oman, Qatar, and the United Arab Emirates stopped importing all Indian food;
3 Economic benefits of local intervention measures may be realized outside the affected country by preventing the inter-
national spread of disease, thus avoiding increased costs of additional, widespread animal culling and reduced trade and
travel among other countries, for example.
4 Ruth Berkelman, Emory University, personal communication, March 14, 2006.
5 Ruth Berkelman, Emory University, personal communication, March 14, 2006.
Bangladesh halted all goods and people from crossing its border with India. Canada, France,
Germany, Italy, the United Kingdom, and the United States issued travel warnings. Italy
placed an embargo on all Indian goods, and Sweden canceled all textile shipments (Cash and
Narasimhan, 2000, citing media reports).
The world reaction to the suspected—but unconfirmed—plague outbreak had a signifi-
cant impact on India’s economy. In 1994, India’s trade deficit doubled in comparison to the
year before (Fidler et al., 1997). Overall, losses associated with the reported outbreak have
been estimated at $2 billion (Levy and Gage, 1999), though long-term loss projections may
be higher (Cash and Narasimhan, 2000). Cash and Narasimhan (2000) comment that other
countries, observing the price that India paid, will probably be more reluctant to report similar
outbreaks in the future. These authors observe that “[p]aradoxically, when a country reports
an outbreak, the international community may benefit relatively little, whereas the reporting
country itself may suffer great losses” (Cash and Narasimhan, 2000, p. 1364). They conclude
that, if the interests of reporting countries are not protected, they are “likely to continue trying
to conceal epidemics, and the goals of global surveillance are unlikely to be fully achieved”
(p. 1365).
In addition to economic consequences, countries may also be unwilling to report out-
breaks or may overstate their preparedness for reasons of international prestige. For example,
nearly every country initially denied or minimized the prevalence of HIV/AIDS within its
borders (U.S. National Intelligence Council, 2000), partly because of the social and sexual
stigma surrounding the disease. There is some evidence that a desire to protect its international
image was a factor in China’s reluctance to report an outbreak of SARS in 2003, although the
economic consequences of that outbreak were also significant, as discussed below.
SARS in China and Beyond. The world experience of the 2003 SARS outbreak that began
in China underscored the consequences of a nation failing to report an outbreak in a timely
and accurate manner. The earliest human case of SARS is thought to have occurred in the
Guangdong province, China, in November 2002. It apparently spread to humans through the
slaughter of infected animals in unsanitary and crowded markets (Osterholm, 2005). The out-
break came to the attention of Chinese health officials as early as a month later (Huang, 2003).
Because Chinese law regarding the handling of public health–related information mandated
that information about such outbreaks be classified as a state secret before being announced
by the Ministry of Health, any physician or journalist who reported on the disease would risk
accusation of leaking state secrets. Therefore, although the Chinese Ministry of Health was
informed of the outbreak in January 2003, a news blackout persisted until February of that
year (Huang, 2003), and the provincial government did not show evidence of taking the public
health threat seriously and responding in a timely and appropriate manner. A contagious dis-
ease coupled with government inaction took a significant toll on the frontline responders—
health care providers (Huang, 2003). By the end of February 2003, nearly half the 900 cases
in the Guangdong province city of Guangzhou were among health care workers (Pomfret,
2003). With a blackout on reporting about the disease within China, let alone the rest of the
world, carriers of the disease traveled to other cities, provinces, and countries, perhaps oblivi-
ous to the risk that they could spread the disease. The SARS outbreak was eventually noticed
by the WHO. Finally, WHO experts were invited to China, where they were given access to
Guangdong only after waiting eight days in Beijing. They were not allowed to inspect military
hospitals in Beijing for another week, and by that time the disease had already spread interna-
tionally (Huang, 2003).
In addition to the delay in reporting to the WHO, the information provided by Chinese
officials was suspect, perhaps because they tried to avoid damage to China’s international image,
as well as economic consequences that may have resulted from international reactions. When
the WHO issued the first travel advisory in its 55-year history, recommending that people not
visit Hong Kong or Guangdong, the Chinese health minister promised that China was safe
and that the outbreak was under control. Earlier, the minister announced that only 12 cases
of SARS had been identified in Beijing when in fact in the city’s No. 309 People’s Liberation
Army Hospital alone there were 60 SARS patients (Huang, 2003).
By the end of 2003, SARS had killed 774 people and infected over 8,000 people in 29
countries (World Health Organization, 2003). The initial lack of cooperation from officials in
China may have contributed to this spread, but the extent to which it did so is unclear and may
never be known (U.S. Government Accountability Office, 2004). It is also unclear the extent
to which this initial lack of cooperation affected the overall economic consequence of the out-
break, estimated at $11 billion to $18 billion (U.S. Government Accountability Office, 2004).
What is clearer is that SARS highlighted the importance of prompt and accurate reporting of
disease outbreaks.
As summarized above and illustrated by the examples of plague in India and SARS in
China and beyond, numerous authors have suggested that infectious disease can have signifi-
cant effects on security, for individuals, nations, and the world. Because some of these effects
are manifest in international relationships (e.g., travel and commerce), nations are caught in a
difficult position when they experience an infectious disease outbreak. Reporting an outbreak
can initiate a response internally and from outside the nation, which may result in timely and
effective disease-control actions that mitigate social disruption, government destabilization,
and loss of productivity within the affected country. On the other hand, a nation reporting
a disease outbreak may experience disruption of trade and travel and suffer economic losses
related to intervention measures (e.g., culling of bird flocks in the case of avian influenza). The
resulting economic effects may be disproportionately large in the affected nation, in compari-
son with the effects on its multiple trading partners. Faced with this possibility, an affected
country may be reluctant to report an outbreak, given the current lack of protection against
(what may be unnecessary) international reactions. Policymakers hope that improved global
disease surveillance and the recently revised International Health Regulations, both described
in Chapter Two, may help mitigate this problem.
Infectious Disease and Recent U.S. National Security Initiatives
While global infectious disease began to receive increased policy attention in the United States
beginning in the 1990s, the attacks of September 11, 2001, and the anthrax attacks of the fol-
lowing month, focused new attention on preparedness for detecting and responding to bio-
terrorism attacks. The U.S. Department of Homeland Security (DHS), which was formed in
response to the 2001 attacks, is the integrator of numerous new initiatives. The remainder of
this chapter summarizes efforts to operationalize the new paradigm linking infectious diseases
to national security, specifically the policy decisions following the attacks of 2001 and the
resulting organizations and initiatives. These organizations and initiatives either build upon or
supplement already-established systems for infectious disease surveillance.
On June 12, 2002, Congress passed the Public Health Security and Bioterrorism
Preparedness and Response Act (Public Law 107-188), requiring specific actions related to
bioterrorism preparedness and response (U.S. Government Accountability Office, 2005). The
law required the establishment of an integrated communications and surveillance network
among federal, state, and local public health officials, as well as public and private health-
related laboratories and hospitals. The act pertained to bioterrorism on the U.S. homeland, but
the intended improvements are also useful for detecting and responding to natural infectious
disease outbreaks.
Concerned primarily about the potential risk to the United States from the deliberate use
of biological agents, the President instructed federal departments and agencies to review their
efforts and find ways to improve security against bioattacks in the United States. The result
of this review was a joint strategy, embodied in Homeland Security Presidential Directive
(HSPD) 10 and National Security Presidential Directive (NSPD) 33, Biodefense for the 21st
Century, collectively (White House, 2004). HPSD-10/NSPD-33 gives DHS the authority to
coordinate a sustained effort against biological weapons threats, and it is based on four essen-
tial pillars (White House, 2004; Vitko, 2005):
1. Threat awareness, including biological weapons–related intelligence, risk assessments,

and anticipation of future threats
2. Prevention and protection, including proactive prevention and infrastructure protection
3. Surveillance and detection, including attack warning and attribution
4. Response and recovery.
HSPD-10/NSPD-33 addresses the threat of deliberate use of a biological agent. While

recognizing that “disease outbreaks, whether natural or deliberate, respect no geographic or
political borders” (White House 2004), in only one instance does the document note that
preparation for an intentional outbreak can also benefit the broader risk of natural infectious
disease: “Private, local, and state capabilities are being augmented by and coordinated with
Federal assets, to provide layered defenses against biological weapons attacks. These improve-
ments will complement and enhance our defense against emerging or reemerging natural infec-
tious diseases” (White House, 2004).
HSPD-10/NSPD-33 spurred the development of a number of specific, related initia-
tives. For example, the Office of Science and Technology Policy considers the Biosurveillance
Initiative to be composed of three key initiatives: BioWatch, BioSense, and the National
Biosurveillance Integration System (NBIS) (Office of Science and Technology Policy, 2005).
Also stemming from HSPD-10/NSPD-33 are two initiatives related to research on and pro-
curement of medical countermeasures directed mostly against terrorism threats: BioShield and
the National Biodefense Analysis and Countermeasures Center (NBACC). The following sec-
tions summarize initiatives created by the U.S. government since 2001.
BioWatch
BioWatch is an early warning environmental monitoring system that collects air samples from
multiple locations in approximately 30 U.S. cities deemed to be at high risk of an intentional
attack with biological agents (Office of Science and Technology Policy, 2005). BioWatch labo-
ratories, all of which are part of the CDC’s Laboratory Response Network (LRN), test the
samples for selected agents and use a reporting system to send data to the CDC in order
to support response to a potential outbreak (U.S. Government Accountability Office, 2005).
BioWatch is a cooperative effort of DHS, the CDC’s LRN, and the Environmental Protection
Agency (Office of Science and Technology Policy, 2005).
BioSense
Project BioSense was initiated by the CDC in fiscal year 2003 to improve the United States’
ability to monitor human health events.6 This nationwide system monitors the health status of
American populations by analyzing diagnoses from ambulatory care sites, laboratory testing
orders, and over-the-counter drug sales, in addition to other data sources. Monitored human
disease trends can be integrated with environmental sampling data from Project BioWatch to
present coordinated information to support response efforts (Office of Science and Technology
Policy, 2005). However, the GAO has reported that BioSense is not widely used by state
and local public health officials, primarily because of limitations in the data it collects (U.S.
Government Accountability Office, 2005).
National Biosurveillance Integration System

A nascent government-wide system managed and coordinated by DHS, NBIS is intended
to combine multiple data streams from sector-specific agencies—those with health, environ-
mental, agricultural, and intelligence data—to provide all stakeholders with broad situational
awareness that is expected to allow for earlier detection of events and to facilitate coordinated
response (U.S. Government Accountability Office, 2005). The main goal of NBIS is to collect,
assemble, and analyze a wide range of relevant information and make such information avail-
able to government stakeholders in a timely and reliable fashion. Once fully operational, NBIS
will collect data from DHS sources and other U.S. government agencies within a common
platform and combine those data with environmental and intelligence data. Analysts from
DHS will work together with analysts on DHS and NBIS detail from other federal agen-
cies to process this information and present “situational awareness” to the DHS Homeland
6 Since the completion of data collection for this study, BioSense was revised and is now referred to as BioSense Real-Time
(BioSense RT). This system is intended to receive a broad set of data directly from health care organizations in real time,
with a special emphasis on information from emergency rooms, where people are most likely to go during an outbreak. It is
also intended to provide simultaneous access to these data by all jurisdictional levels of public health (hospital, city, county,
state, national). The emphasis of Biosense RT is less on the early detection of an event and more on how the health care
system is able to respond by allocating available resources (see Caldwell, 2006).
Security Operations Center (Morr, 2005) and an Interagency Incident Management Group, as
described in the National Response Plan (U.S. Department of Homeland Security, 2004).
NBIS is intended to help meet the HSPD-10/NSPD-33 call for “creating a national bio-
awareness system that will permit the recognition of a biological attack at the earliest possible
moment” (White House, 2004). Like other new DHS initiatives, NBIS was originally intended
to focus only on intentional disease outbreaks (i.e., bioattacks) (Vitko, 2005). In fact, all of the
DHS initiatives are intended to fit within the department’s “niche” by focusing exclusively on
a homeland-directed attack (Morr, 2005), but officials at NBIS acknowledged that, because
it is often difficult to determine initially whether or not an outbreak is deliberately caused,
NBIS will also be useful in providing early warning of naturally occurring outbreaks. Further,
unlike most other DHS initiatives, NBIS is more international in scope, though its intent is
ultimately domestic protection. (NBACC also considers international information, including
intelligence, to identify material threats.)
A key component of NBIS is software that actively probes the Internet for reports or
rumors of disease events; the software systematically searches over 1 million sites each day.
There is some evidence that this software has identified recent outbreaks significantly earlier
than other systems have.
The DHS Science and Technology Directorate developed the NBIS system requirements
and then transferred the initiative to the Directorate for Information Analysis and Infrastructure
Protection in December 2004 for implementation. The genesis of NBIS appears to be a com-
prehensive 2003 study of the ability of the United States to rapidly detect bioattacks. A series
of interagency meetings culminated in a report in December 2004 that marked the end of
the requirements-determination process and the start of the implementation process. (The
December 2004 report was not made available to RAND.) As of this writing, NBIS is under
development, and its staff of analysts and information systems are being established in phases.
NBIS officials intend for NBIS to serve as the “eyes and ears” of the nation for indicators and
warnings that prompt early detection of a disease outbreak, whether natural or deliberate in
origin; it is not designed to replace existing agencies’ responsibilities for response, risk assess-
ment, or forensic attribution.
BioShield
Signed into law by President Bush in July 2004, Project BioShield is an initiative to speed the
development and procurement of new medical countermeasures against chemical, biological,
radiological, and nuclear terrorist threats. The President committed $5.6 billion over ten years
to accelerate development and stockpile vaccines, drugs, and diagnostic aids to fight anthrax,
smallpox, and other potential threat agents (Office of Science and Technology Policy, 2005).
The procurement of these products is supported by work at the NBACC.
National Biodefense Analysis and Countermeasures Center

In accordance with HSPD-10/NSPD-33, DHS requested and received appropriated funding,
beginning in fiscal year 2003, for the construction of NBACC, a biodefense facility dedicated
to homeland security activities. As of this writing, NBACC research programs are operating
while the facility itself is being constructed within the National Interagency Biodefense Campus
at Fort Detrick, Maryland. Other agencies on this campus will include the Department of
Health and Human Services’ National Institutes of Health (specifically, its National Institute
of Allergy and Infectious Diseases) and Centers for Disease Control and Prevention, the
Department of Agriculture’s Agricultural Research Service and Foreign Disease–Weed Science
Research Institute, and the Department of Defense’s (DoD’s) U.S. Army Medical Research
Institute of Infectious Diseases (U.S. Department of Homeland Security, 2005). Coordination
of NBACC is performed by various interagency committees at different levels of seniority.
NBACC principally comprises two component parts: the National Bioforensic Analysis
Center and the Biological Threat Characterization Center (McQueary, 2005). A third com-
ponent, the Biodefense Knowledge Center (BKC), was dedicated in September 2004 and is
located at the Department of Energy’s Los Alamos National Laboratory (Shea, 2005). Programs
undertaken by NBACC are currently conducted through partnerships and agreements with
federal and private institutions (Martinez-Lopez, 2004); for example, the BKC draws upon
the Lawrence Livermore National Laboratory and three DHS Centers of Excellence, at the
University of Minnesota, the University of Southern California, and Texas A&M University
(U.S. Department of Energy, 2004). The mission of the NBACC is to understand current
and future biological threats, assess vulnerabilities and determine potential consequences, and
provide a national capability for conducting forensic analysis of evidence from biocrimes and
terrorism (Albright, 2005). This mission will support the procurement of countermeasures
under Project BioShield by assessing potential bioterrorism agents as “material threats.” Project
BioShield requires that the Secretary of Homeland Security determine whether such a “mate-
rial threat” exists before countermeasures can be taken (Gottron, 2003). NBACC provides a
formal threat assessment every two years; the first is due in 2006 (Vitko, 2005). The scope of
this first assessment has been agreed upon by the interagency Biodefense Policy Coordinating
Committee, which is cochaired by the Homeland Security Council and the National Security
Council. It will address 29 biological agents, evaluate the vulnerability of the United States
to threats posed by these agents, and consider the potential consequences of any such attacks
(Vitko, 2005).
Department of Defense Initiatives

DoD’s Walter Reed Army Institute of Research oversees the identification of possible biologi-
cal threats to populations worldwide through the joint Global Emerging Infections System
(GEIS), which draws upon overseas military medical research facilities to help monitor dis-
ease, and the Electronic Surveillance System for the Early Notification of Community-Based
Epidemics (ESSENCE), which uses data-mining techniques to identify unusually high rates
of specified clinical syndromes. Additionally, DoD is deploying an improved Joint Biological
Agent Identification and Diagnosis System to rapidly identify biological threat agents (Office
of Science and Technology Policy, 2005).
Summary
A new paradigm has evolved that links infectious disease to security, recognizing the broad
effects of disease on societies. One implication of this paradigm is that nations may take actions
against one another to prevent infectious disease from reaching their borders. In some cases,
these actions may be of some global benefit (i.e., in preventing disease spread), but their effects
may result in disproportionate costs to a nation experiencing an outbreak. This situation can
present disincentives to disease reporting by nations, even if the nation possesses the capability
to do so. In recognition of this emerging paradigm, the United States has recently undertaken a
number of initiatives to address infectious disease, including a DHS initiative, NBIS, intended
to detect outbreaks worldwide and to provide information to all relevant federal stakeholders.
Many stakeholders we interviewed acknowledged a link between infectious disease and
national security. Their views are detailed in the next chapter.
CHAPTER FOUR
Defining Information Needs: Interviews with Stakeholders
Our second study objective called for assessment of the information needs of U.S. policymak-
ers related to infectious diseases in the context of U.S. national security, and our third objective
called for assessment of the adequacy of available information. Therefore, we sought input from
a broad range of potential stakeholders, mostly within the federal government. This chapter
describes our methods and our findings regarding stakeholder information needs, as well as the
stakeholders’ suggestions for enhanced information systems.
Methods
We identified each federal department with a potential interest in global infectious diseases,
and within each, specific agencies or offices with specific interests in this issue. We sought to
interview relatively senior policymakers or advisors in each of these organizational units, or
members of their staff. We also sought the views of stakeholders outside the federal govern-
ment, including representatives from the U.S. domestic public health community and the
WHO. We conducted the interviews between July and October 2005.
We interviewed 53 individuals across a broad range of federal agencies and from relevant
stakeholder organizations. Interviewees included 43 current and four former federal officials
and six individuals from outside the federal government. Current federal staff represented the
U.S. Departments of Homeland Security, Health and Human Services (HHS), Defense, State,
and Agriculture (USDA); the Peace Corps; and agencies within the intelligence community.
To the extent possible, we interviewed senior officials in policymaking positions or staff in
their offices. As a result, nearly all the federal interviewees were within three reporting steps
of a cabinet-level official or the equivalent. Nonfederal interviewees represented a state health
department, the Homeland Security Institute, the U.S. Association of State and Territorial
Health Officers, and the World Health Organization.1
1 A list of all organizations included in our interviews is in Appendix A.
29
We asked these individuals about2
• the relationship between infectious diseases and national security and the role of their
organizations in addressing infectious diseases
• how they use infectious disease information and the impact of their information
products
• their infectious disease information needs
• their current sources of such information
• their views about open-source versus protected information
• gaps in infectious disease information
• their preferred information-delivery format
• their suggestions to improve global infectious disease information systems.
In this chapter, we summarize the views of interviewees on these questions, describing

both areas of convergence and individual views that offered important insights or innovative
ideas.
Results
Stakeholders Do Perceive Global Infectious Disease as a Security Threat
As described in Chapter Three, a new paradigm linking infectious disease to national security
was already evolving during the 1990s, and it became more of a priority after the terror events
of September and October 2001. Recent U.S. policy initiatives clearly recognize the rela-
tionship between infectious disease—both deliberate and naturally occurring threats—and
national security, and seek to operationalize responses to these new threats. What is less clear
is how this new paradigm is perceived across U.S. government sectors and how it has shaped
the information needs of senior policymakers.
Virtually all persons we interviewed said that they believe that the global spread of infec-
tious diseases represents a threat to U.S. national security. Some described this in narrow terms
closely related to the mission of their own organization; however, the majority—including
both health officials and non–health officials—described the broader-ranging impact of infec-
tious diseases on trade, economic development, political stability, and international relations.
Several elaborated on this in describing the indirect impact on jobs, productivity, and military
force protection. One noted that healthy people underpin healthy economies, hence the broad
benefits of investing in global health. Two individuals noted that health is a societal indica-
tor of the public’s perception of government success. Hence, less-than-successful handling of
infectious disease outbreaks can undermine a population’s confidence in, and ultimately the
stability of, its government. Nearly all felt that both deliberate and naturally occurring diseases
threaten national security. Examples of the former include smallpox, anthrax, and genetically
manipulated pathogens. Examples of the latter include, among others, the broad and long-
2 A list of specific interview questions is included in Appendix B.

Defining Information Needs: Interviews with Stakeholders 31
standing impact of the HIV/AIDS pandemic; the SARS outbreak of 2002–2003; the current
avian influenza H5N1 circulating in Asia, Europe, and Africa, including its potential to trigger
a worldwide human influenza pandemic; and antimicrobial resistance. A number of officials
across federal agencies noted that avian influenza H5N1 is their organization’s current top pri-
ority. Perhaps related to this, several interviewees expressed particular concern over zoonotic
diseases, i.e., human infectious diseases arising from animals. Interviewees from the USDA
and one from the State Department expressed concern over plant diseases; one interviewee
noted particular concern about genetically engineered pathogens, and another expressed con-
cern about protecting the U.S. food supply.
The roles related to addressing global infectious disease spanned the breadth of the
organizations represented in our interviews. The military focuses primarily on force protec-
tion; diplomats focus on humanitarian concerns, international relations, foreign policy, and
the safety of Americans abroad; agriculture officials focus on protecting the domestic agri-
culture industry and maintaining U.S. exports; intelligence agencies are interested in the
far-reaching impact of infectious diseases on political stability and U.S. national security;
homeland security officials focus on protecting the United States against all security threats,
including biologic threats; and health officials are responsible for protecting the public’s health,
both in the United States and internationally. Two individuals noted that HSPD places
global infectious diseases prominently on the U.S. national security agenda. Several inter-
viewees noted that strengthening public health infrastructures internationally is a national
security priority, enabling detection and protection against both deliberate and naturally occur-
ring infectious disease threats. These comments also encompassed veterinary health infra-
structures. Several respondents also described how their own organizations and others have
increasingly recognized the threats posed by global infectious diseases and hence the need to
reorganize or rechannel efforts to address them.
In short, officials across government sectors perceive infectious diseases as a threat to
national security and recognize both their own agency’s role in addressing such threats and the
larger context in which their own efforts are undertaken.
Information Supports Policy Decisions

Virtually all the federal respondents said that they need and use infectious disease information
to prepare memoranda, reports, briefing papers, talking points, and strategy papers for senior-
level government officials, including the President and his Cabinet secretaries. By design, most
of these respondents are in policy-oriented offices and either are themselves, report directly
to, or are not far removed from such senior government officials. Information on infectious
disease threats has helped drive the new perception among those outside the health com-
munity of the connection between infectious disease and national security. Other respon-
dents noted that such information is essential to relevant foreign policy decisions of the State
Department, decisions by the USDA regarding the exclusion of animal and other products for
import into the United States, and strategic decisions about international staffing by HHS.
The State Department Bureau of Consular Affairs has used such information to prepare public
announcements and travel warnings for American citizens. The State Department and Peace
Corps use such information to help protect their own overseas staff, for example, the evacua-
tion of Peace Corps staff from China during the SARS outbreak. Certain information has reg-
ulatory implications, e.g., the emergence of significant drug resistance that may prompt public
health announcements from the Food and Drug Administration. All respondents commented
that their information products have influenced policy, including policy at the highest national
and international levels. Several mentioned regular briefings to the President, Vice President,
and National Security Council. Illustrative examples of infectious disease information prod-
ucts feeding into U.S. foreign policy include recent initiatives of the G8 and the APEC forum,
international trade negotiations, and policies and actions of the most senior government offi-
cials with respect to national and foreign counterparts.
There Were More Similarities Than Differences in Information Needs Across Government
Sectors
While most respondents converged around the need for timely, accurate, complete (i.e., suf-
ficiently detailed), understandable, and actionable information related to infectious disease
threats, not surprisingly, their information needs naturally focused in particular on areas
directly related to the mission of their offices or agencies, or their own specific responsibili-
ties. For example, regional focus was particularly important to individuals and offices with
specific regional responsibilities; detailed health information was needed by those with specific
health-related responsibilities; and non-health contextual information was most needed by the
diplomatic and intelligence communities. Most respondents described needs for information
about disease outbreaks that are occurring. Virtually all interviewees described needs in terms
of human disease, most added the need for animal disease information, and a few mentioned
an additional need for information on plant diseases. Ideally, these stakeholders would like
information that reflects disease and outbreaks down to the community, rather than strictly
national, level. Some recognized the shortcomings of sentinel surveillance, i.e., noncompre-
hensive disease surveillance from selected health service sites, emphasizing that such systems
may miss important disease occurrence. Some respondents also noted the need for informa-
tion on medical and health infrastructure in countries where outbreaks occur, including medi-
cal practices and government responses to the outbreaks. Several respondents described the
need for information on relevant policies and decisionmaking in such countries, as well as the
broader social, economic, political, and military context of disease outbreaks. They recognized
that such information was unlikely to come from traditional public health sources.
Interestingly, a substantial number of health officials (both in HHS and other agencies)
included broad political and economic impact among their priority information needs, and
virtually all non–health officials cited traditional medical and public health information needs,
e.g., clinical presentation, disease transmission patterns, disease prevention, and treatment
availability and effectiveness, in helping define their own priority disease information needs.
The more contextual social, economic, and political information does not lend itself to routine
reporting. Also, with respect to national policies and outbreak response, several respondents
noted that some countries are not timely or transparent in disease reporting and that sources
other than official government reporting are important for purposes of early warning and alert.
Only a few respondents described the need for anticipatory information, and did so mostly
in response to direct questioning. The notable exceptions were among the intelligence com-
munity, whose information-gathering and -processing are by nature anticipatory, and within
DHS, which has both anticipatory and response mandates.
Despite Similar Information Needs, Stakeholders Consult Different Information Sources

The stakeholders we interviewed described a wide range of information sources, including
open-source and limited-access Web sites, official cable traffic, personal contacts with federal
agency experts and federal staff overseas, and nonspecific intelligence-gathering. Most respon-
dents use both active (“push”) and passive (“pull”) data-access or -delivery modes. Several
subscribe to specific “push” email lists, e.g., ProMED (Program for Monitoring Emerging
Diseases); U.S. Pacific Command daily alerts; or open-source tailored information alerts, such
as Google Alerts™ email update service. Respondents were generally familiar with a larger
number of Web sites than they actually used. Among the most frequently consulted open
Web sites, consulted largely on a “pull” basis, are those of the CDC and the WHO. Well-
regarded password-protected or subscription-based Web sites are the CDC’s Epi-X (Epidemic
Information Exchange), the Foreign Broadcast Information Service, and GPHIN. Respondents
also reported consulting directly with experts within their own departments, federal staff in
other departments, and experts outside the U.S. government. Some interviewees (e.g., those
in different parts of the State Department) rely on colleagues to send them information when
and as appropriate. Respondents who drew upon personal contacts for key information valued
this type of information source greatly, since direct discussion yields the timely and tailored
information they need.
Classification of Information Is Important but Creates Some Obstacles

Respondents across all government agencies recognize the importance of both open-source and
protected information, including information related to infectious diseases. However, some
agencies (e.g., the Peace Corps and HHS) noted their sensitivity to international perceptions
that their staff may have links to the intelligence community, and they felt that such percep-
tions jeopardize their good standing with key national counterparts and, hence, limit their
ability to operate effectively. Information is classified to protect sources and methods. Sensitive
content relates to potential U.S. vulnerabilities, including bioterrorism, military movements,
new medical countermeasures under development (e.g., intellectual property protection),
information needed for diplomatic leverage, and information that is politically sensitive to the
United States. Several respondents commented that some unclassified information arrives via
classified channels, e.g., reporting cables with both classified and unclassified sections, and as
a result may be unnecessarily inaccessible to a broader range of government officials who do
not have the necessary clearances. A number of respondents cited inadequate security clear-
ances as an impediment to optimal information-sharing. For example, some respondents from
the intelligence community said that HHS staff do not necessarily have the full range of secu-
rity clearances they probably need. Also, the domestic public health establishment typically
and systematically lacks security clearances that would facilitate their emergency preparedness
planning.
Stakeholders’ Information Needs Are Not Fully Met by Their Current Sources
Respondents noted many gaps related to global infectious disease information. Many respon-
dents noted the current ad hoc nature of information, i.e., a lack of systematic inputs and out-
puts. Many commented on the glut of available information and the resulting need for infor-
mation management processes to enhance delivery, presentation, and efficient data use. One
respondent commented, “There is never enough information when you need it, but otherwise
there is too much information.” According to another respondent, the need is not necessar-
ily for more information, but for the right information that is accessible in a timely fashion
through a convenient delivery mechanism. Several respondents commented on the gap in
relevant international agriculture-sector disease data. One noted that some information, e.g.,
detailed animal disease surveillance data, is not collected in some countries and hence is simply
not available. This particular gap can be due to poor infrastructure and/or lack of appropriate
incentives to report animal disease.
The majority of respondents noted that agencies across the federal government need the
same basic information, and that several agencies have important information, but that infor-
mation is not widely shared. For example, one office reported that its secretary, a major stake-
holder, had to contact the director of national intelligence to ask for information after learning
that the President was being briefed on a strategic global infectious disease issue without direct
input from his department. Other shortcomings in currently available information include
inadequate timeliness, accuracy, completeness, and larger contextual analysis. Gaps relate to
both “signals intelligence” (e.g., communications about local disease outbreaks or animal die-
offs) and “human intelligence” (e.g., information based on direct observation or personal con-
tacts). Several respondents commented that what is lacking is a resource to coordinate and
consolidate public health and other information and share useful, common analytic products
with stakeholders across government.
Questions about specific disease scenarios (i.e., SARS, avian influenza, the next—as yet
unknown—emerging disease, or any other infectious disease threat of particular concern)
yielded additional insights. For example, respondents from several government agencies noted
that overseas-based U.S. federal staff, including their own staff, are the “eyes and ears on the
ground” to help identify and sort out early information about emerging outbreaks. Several
respondents commented that infectious disease problems require new sources and types of
“public health intelligence” and that more non-U.S. sources are needed. One official in a regu-
latory agency would like information on domestic surge capacity needs, particularly as related
to the medical supplies and equipment his agency regulates.
Preferences Vary for Information-Delivery Format and Methods

Nearly all respondents commented on the overwhelming amount of information and the need
for efficiency in obtaining desired information. Many respondents draw upon both “push”
and “pull” sources of information. Preferences for the former include selected or customiz-
able email alerts, i.e., providing information limited to their specific topical, regional, or other
defined interests. Virtually no respondent expressed a desire for broad, frequent, nonselec-
tive “push” information. A notable exception was one official who reported directly to a cab-
inet secretary and commented that he prefers “push” approaches and would like to know
more rather than less because information that is too filtered is useless, and one risks missing
early clues to a subsequent significant threat. Currently, “push” information is based largely
on unofficial reporting, including the media, rather than official—and more traditional—
government reporting. Preferred “pull” information is mostly from Web sites, notably those of
the CDC and WHO, and direct consultation with technical experts or overseas staff.
Not surprisingly, the preferred format and presentation of information varied by both
agency and the level of the individual within her or his agency. For example, those higher
in the federal structure tended to prefer filtered or processed information presented as con-
cise analysis products, including daily or weekly summaries of a single disease or a handful
of key diseases. Those responsible for preparing briefings and papers for senior officials need
more detailed information, including basic disease information and reports on the status of an
ongoing outbreak, preferably based on validated case reports. Respondents outside the health
sector commented on the need for information to be presented in a way that they as non–
health policymakers can readily understand and use, including contextual political and eco-
nomic information and implications.
Stakeholders Suggested Areas for Improvement

Virtually all respondents offered suggestions and insights for improving global infectious dis-
ease information. They generally framed their suggestions to address both bioterrorism and
naturally occurring disease threats, easing what some viewed as disproportionate attention to
deliberate threats at the expense of more likely threat scenarios. A common suggestion was
for improved detection capacity and timeliness and transparency of disease reporting by for-
eign governments. However, these are not necessarily within the direct purview of the United
States. At least two respondents called upon the United States to invest more in the disease
surveillance activities of foreign governments. This would serve the dual purpose of helping to
strengthen foreign public health infrastructures for the collective good and providing oppor-
tunities for more U.S. “eyes and ears on the ground” working in mutually trusting relation-
ships with their national counterparts, making them potentially privy to early disease outbreak
information. One State Department official also described his plans for taking fuller advantage
of embassy staff and the U.S. business community in foreign countries through better briefings
to sensitize them about possible disease threats and encourage them to report back. In contrast,
two individuals from the intelligence community commented that the current era of global
communications limits the need for additional U.S. personnel in the field. Several respondents
commented on the need for different government agencies to understand and interact more
fruitfully with one another. One interviewee noted that there might not be sufficient focus on
health at the highest levels in the U.S. government security apparatus, which would be affir-
matively demonstrated by the appointment of a dedicated health and medical expert to the
National Security Council.
Most current federal employees we interviewed offered one or more specific sugges-
tions for a centralized, time-sensitive (i.e., reliably current), integrated, coordinated U.S.
government–wide system. Only one office, interviewed after a full month of completed inter-
views (approximately 25 percent of the total number of interviews), explicitly mentioned the
new National Biosurveillance Integration System, coordinated by the Department of Homeland
Security (see Chapter Three for further details on NBIS). Even when those interviewed subse-
quently were directly queried, very few were aware of NBIS. Their suggestions were therefore
largely independent of, but highly consistent with, the intended features of NBIS. The sug-
gestions of different respondents included a system with the following attributes to collect
and disseminate information on the occurrence of and risks for infectious disease threats:
(1) top-down creation of a better environment for information-sharing, which in turn would
help optimize agency budgets and break down agency “silos” to collect and share informa-
tion most efficiently; (2) a single integrated system with “robust capabilities” that would pro-
vide “science-based actionable information” to the full range of stakeholders, in the format
most appropriate for each; (3) 24/7 access to experts, as needed, to anticipate or respond
to specific threats; (4) a central data repository for “pull” access, as needed, including links to
more detailed information for those interested; (5) use of data-mining and other methods for
active information collection; (6) an expanded collection that encompasses a broader range
of pathogen hosts (i.e., animal and plant diseases) and a broader range of foreign language
sources; (7) systematic data filtering to help distinguish signal from noise; (8) reconciliation of
conflicting information from different sources, e.g., those about a specific disease or outbreak;
(9) information system interoperability; and (10) avoidance of duplication of efforts. Several
respondents commented that they would welcome a multilateral or philanthropic initiative to
collect, integrate, coordinate, and actively disseminate open-source information on infectious
disease threats worldwide. One respondent further suggested a strong “marketing” initiative
to educate federal stakeholders regarding sources of available infectious disease information,
including intervention measures.
Summary
There is now an impressively broad range of government stakeholders interested in informa-

tion on worldwide infectious disease threats. As noted in Chapter Three, health professionals
increasingly recognize the broader social, economic, and political impact of these diseases, and
officials in other sectors and agencies increasingly appreciate the transition of infectious dis-
eases and public health into the realm of high politics.3 As presented in this chapter, stakehold-
ers across government sectors described their need for information that is both directly related
to their own agency’s responsibilities and also beyond their direct areas of action, e.g., beyond
more technical disease information for security and diplomatic officials and broader economic
and political information for health officials.
In beginning to address our third research question about the adequacy of current infor-
mation, the majority of federal officials we interviewed called for better efficiency and coordi-
nation of information collection, processing, and dissemination across the federal government
3 A more detailed discussion of the ascendance of health from “low politics” to “high politics” can be found in Lee, Buse,
and Fustukian (2002), which also references a definition of “high politics”: “First, in foreign policy analysis, it is used as a
collective expression for certain issue areas of crucial importance” (citing Evans and Newnham, 1992).
and to other stakeholders as possible, including U.S. state and local and foreign governments,
and multilateral organizations engaged in global infectious disease prevention and control. In
the next chapter, we further address this question.
CHAPTER FIVE
Assessing the Adequacy of Current Information:

A Survey of Online Sources
Our third research question asks about the adequacy of currently available information related
to global infectious disease. The preceding chapter summarized the views of stakeholders
regarding current information sources and ideas for improvements. In this chapter, we describe
a more systematic assessment of currently available information.
We compiled and assessed Internet-based (“online”) sources of information relevant to
infectious diseases globally (see Appendix C for the complete list and brief descriptions of the
sources we assessed). Online information sources are added or changed frequently. Therefore,
while not purporting to have captured all such sources, we encompassed a number and range
of online sources that is sufficient to both assess the nature of current online information and
serve as a potentially useful resource for U.S. policymakers. A comprehensive analysis of the
content or quality of these sources was beyond the scope of this project. This chapter describes
our methods and the detailed descriptive analyses of the key characteristics of these sources,
based on our survey.
Methods
We identified potential online sources through four mechanisms: (1) online searches using
terms such as “disease surveillance,” “infectious disease network,” “infectious disease alert,”
“disease surveillance bulletin,” and “ministry of health”; (2) a review of pertinent published
literature; (3) a review of a limited list of compiled online sources from a separate, unpublished
RAND project that sought approximately similar online sources; and (4) suggestions from
our interviewees. The sources we compiled focused predominately on human diseases but also
included animal and plant diseases relevant to human health. We reviewed all potential online
sources to ascertain accessibility and content directly relevant to the public health aspects of
infectious diseases or useful in support of disease control. We retained sources that were both
accessible (or could be described based on publicly available information online or in the lit-
erature, if the sources were accessible only via authorization or subscription) and that we con-
sidered sufficiently relevant, as described below. We extracted key information on each source
and created a standardized database describing their features to enable analysis and to facilitate
searches based on selected features. We captured the following information, when available,
for each source:
39
• general information
– name
– sponsor: name of organization
– sponsor category: multilateral (global, regional), national (U.S. national, state, for-
eign), nongovernmental organization (NGO), professional/academic, commercial
– Web address
– brief description
– geographic reach (global, regional—with named region, national—with named coun-
try, subnational—with name of local district (e.g., U.S. state)
– primary purpose: surveillance (general), surveillance (early warning), surveillance bul-
letin, terrorism, reference or research resources, others
– data content
– specific disease, if any (otherwise, “various”)
• data input
– host species (human, animal, and/or plant)
– data source(s)
– active or passive data collection
– voluntary or mandatory data reporting
– standardized or non-standardized data reporting
– cases or outbreaks
– disease-specific or symptom or syndrome-based
– frequency of reporting
– data analysis process
– limitations in access to the source (e.g., password-protected, subscription-only)
– limitations in data quality (e.g., outdated, missing information; low specificity; foreign
language)
– sdditional notes, if any
• data output
– active or passive dissemination
– audience
– frequency or timeliness of dissemination
– standardized or nonstandardized data format
– reporting based on individual cases or outbreaks
– type of information outputs
– value or veracity, i.e., if and how data are verified before dissemination.
Following completion of the database, we distributed it on a test basis to interviewees who

had expressed an interest in such a tool. We also tabulated the number of sources according to
the various characteristics described above.
Assessing the Adequacy of Current Information: A Survey of Online Sources 41
Results
The remainder of this chapter summarizes key characteristics of these online sources. It is
organized into the following sections: accessibility of information; organizational sponsorship;
primary purpose, with further discussion of general and early warning surveillance sources;
human and nonhuman disease sources; active and passive information collection; and infor-
mation dissemination.
Most Online Sources Have Unrestricted Access

As shown in Figure 5.1, nearly two-thirds of all sources (62 percent, 144 sources) are acces-
sible without limitation, 29 percent (68 sources) require authorization,1 and 9 percent (22
sources) require either paid or solicited subscription.2 Of the 144 unrestricted-access sources,
slightly over half (79 sources, or 55 percent) function primarily for surveillance purposes, and
one-quarter are reference sources (36 sources, 25 percent). The remaining open-access sources
have research (10 sources, 7 percent) or other primary functions (19 sources, 13 percent).
The sponsors of open-access sources cover a broad range, including U.S. agencies at both the
national and state levels (42 sources, 29 percent), multilateral organizations at both global (20
sources, 14 percent) and regional (11 sources, 8 percent) levels, foreign countries (39 sources,
27 percent), professional/academic organizations (20 sources, 14 percent), and commercial (six
sources, 4 percent) and nongovernmental organizations (six sources, 4 percent). Open-access
sites include global (45 sources, 32 percent), regional (15 sources, 10 percent), or national infor-
mation, including U.S. (36 sources, 25 percent) or foreign (48 sources, 33 percent) national.
Most of them provide information on a passive, or “pull” basis rather than pushing informa-
tion out to users.
Three-fourths of the 68 sources requiring authorized access, i.e., not fully open sources,
focus on surveillance: general surveillance (30 sources, 45 percent), early warning surveillance
(11 sources, 16 percent), or surveillance bulletins (10 sources, 15 percent). The remaining 24
percent of these sources is evenly distributed across other primary functions (between two and
four sources in each category). Nearly two-thirds of the sources that require authorized access
are from U.S national or state sponsors (43 sources, 63 percent); just over 10 percent (seven
sources) are sponsored by professional or academic organizations; and the remaining sources
are sponsored by multilateral organizations (eight sources, 12 percent), foreign countries (six
sources, 9 percent), commercial entities (three sources, 4 percent), or NGOs (one source,
2 percent).
1 Authorization is defined here as access obtained through permission granted by the source host, such as ministries of
health surveillance systems that participate in WHO global surveillance programs.
2 Paid subscription refers to access through a purchased membership to a Web-based service, whereas solicited refers to
access granted upon request or registration to a notification list.
Figure 5.1
Accessibility of Online Sources
Subscription
9%
Authorization
29%
Unrestricted
62%
RAND TR405-5.1
The U.S. federal government sponsors 39 of the sources that require authorization for
access (the remaining four U.S. government sources are from U.S. state agencies):
• Department of Defense (18 sources)

• Department of Health and Human Services, Centers for Disease Control and Prevention
(16 sources)
• Department of Energy (two sources)
• U.S. Department of Agriculture (one source)
• Department of Veterans Affairs (one source)
• Central Intelligence Agency (one source).
The 22 sources (9 percent) requiring a subscription serve various purposes, including

reference (seven sources, 32 percent), antiterrorism (seven sources, 32 percent), surveillance
(five sources, 23 percent), or other purposes (three sources, 14 percent). Slightly more than
three-fourths of subscription-based sources (17 sources, 77 percent) are sponsored by com-
mercial organizations, with professional and academic organizations sponsoring three (14 per-
cent) and foreign governments sponsoring two (9 percent) sources. Subscription-based sources
focus primarily on U.S. national (13 sources, 59 percent) or global (eight sources, 36 percent)
information.
Online Sources Reflect a Broad Range of Organizational Sponsors

Partly because of the focus of our search and the type of information we sought, the 234 online
sources come largely from government sponsors (see Figure 5.2). These included 36 percent (85
sources) from U.S. government agencies at the federal and state levels, e.g., from HHS (several
from CDC), DoD, USDA, DHS, and others. Twenty percent of sources (47) are from foreign
governments, and a combined 16 percent are from global (24 sources, 10 percent) and regional
(15 sources, 6 percent) multilateral organizations, such as the WHO, the Pan American
Health Organization (PAHO), the Office International des Epizoöties (World Animal Health
Organization) (OIE), and the Food and Agriculture Organization of the United Nations
(FAO). The remaining sources are sponsored by professional or academic, commercial, or non-
governmental organizations.
Nearly one-third of all sources (76 sources, 32 percent) are global in coverage; 21 sources
(9 percent) focus on regional coverage; and the remainder focus on national coverage, includ-
ing U.S. national or subnational (81 sources, 35 percent) and foreign national (56 sources,
24 percent).3 The foreign national and regional sources collectively span the globe, includ-
ing Europe (33 sources), Asia and the Pacific (24 sources), the Americas (11 sources), Africa
(5 sources), and the Middle East (4 sources).
Figure 5.2
Organizational Sponsors of Online Sources
Commercial NGO
11% 3%
Multilateral—
global
10%
Professional or
academic
13%
Multilateral—
regional
6%
National—
foreign
20%
National—U.S.
37%
RAND TR405-5.2
3 Foreign national, as used in this and subsequent sections, refers to non-U.S. countries.
Over Half the 234 Sources Focus on Surveillance, Including Early Warning
Our study focused in particular on information related to infectious disease surveillance and
public health. Over half our online sources related to disease surveillance, including 98 general
surveillance (42 percent), 23 surveillance bulletins (10 percent), and 14 surveillance early warn-
ing (6 percent). (See Figure 5.3.)
Surveillance systems collect and monitor information to identify disease trends or out-
breaks. Early warning surveillance plays a more active role in acquiring and disseminating
timely (especially daily or near–real-time) information on specific diseases or less specific
indicators and warnings, often reflecting early rumors rather than confirmed diagnoses, but
intending to serve the purpose of timely alert to a potential problem.4 Surveillance bulletins
function as official information dissemination routes and information archives for surveil-
lance data and tend to be sites closely linked to actual surveillance systems. Examples of these
Figure 5.3
Primary Purpose of Online Sources
All other
12%
Terrorism
5%
Research
resource
5%
Surveillance—
general
42%
Reference
20%
Surveillance— Surveillance—
early warning bulletin
6% 10%
RAND TR405-5.3
4 While early warning surveillance systems, especially syndromic surveillance (reports of disease diagnosed clinically
without laboratory confirmation), can be highly sensitive in detecting disease events, but they often suffer from low speci-
ficity. This trade-off can increase the proportion of false positives compared with other surveillance systems. Moreover,
attribution of an epidemic to the incorrect disease can trigger inappropriate interventions. Verification through investiga-
tion and definitive diagnosis (e.g., as the WHO does through its GOARN program) can offset this problem and has proven
extraordinarily useful. Additionally, most early warning systems in the United States have provided early detection of mild
to moderately severe outbreaks but not outbreaks of severe disease.
sources include the CDC Morbidity and Mortality Weekly Report, the WHO Weekly
Epidemiological Report, and Eurosurveillance bulletins (weekly, monthly, and quarterly surveil-
lance summaries on diseases in the European region).
Table 5.1 compares the characteristics of sources serving general surveillance and early
warning surveillance functions. Most (87 of 98 sources, 89 percent) of the general surveil-
lance sources in our database focus on human disease information, including 73 sources
(74 percent) that focus exclusively on human diseases and 14 sources (14 percent) that also
include animal and/or plant disease; the remaining general surveillance sources (11 sources,
11 percent) address animal diseases only.
We were particularly interested in the 14 sources (6 percent) that provide early warn-
ing information. Most of them (nine) are U.S. government sources addressing various dis-
eases. All 14 address human disease, including one that also addresses animal and plant
diseases. Half (seven) of the sources have largely U.S. national reach, five have global reach,
and one each is specific to a country (Pakistan) or a region (Southeast Asia). Not surprisingly,
most of these early warning sources employ active data collection (eight of 14 sources) and
active dissemination (seven of 14), with two-thirds (nine of 14) disseminating information
daily or on a near–real-time basis. In contrast, data collection and dissemination from general
surveillance sources are more likely through passive methods, and dissemination frequency is
more variable, from daily or near–real-time (11 percent) to frequencies ranging from weekly to
annual (42 percent), or ad hoc dissemination (28 percent).
Beyond the largest group of online sources focusing on surveillance, 47 primarily serve
reference purposes (20 percent). Reference sources contain a wide range of information, such as
a virologic database, a directory of surveillance systems, a searchable database of documented
global disease outbreaks, and a virtual information center that posts disease announcements.
Twelve sources (5 percent) are categorized as research resources and serve as data centers
or online archives of reports, or contain analytic tools intended for open use by researchers.
Among the remaining sources, 11 (5 percent) primarily serve antiterrorism purposes, and a small
handful each serve laboratory, networking, communications, or other primary purposes.
The majority of sources focus exclusively on specific diseases (141 sources, 60 percent),
rather than on syndromes (13 sources, 6 percent).5 Some (27 sources, 12 percent) include infor-
mation on both diseases and syndromes; this information is unknown or not applicable for the
remaining sources (53 sources, 23 percent). Most sources (146, 62 percent) include informa-
tion on a broad range of infectious diseases. Several sources address a defined set of diseases or
pathogens, and others are dedicated sources, focusing on a single pathogen, disease, or issue
(e.g., influenza, tuberculosis, gonorrhea, measles, antimicrobial resistance, biothreat agents).
5 A syndrome is the concurrence of several symptoms that collectively indicate a type of illness but not a specific disease
diagnosis.
Table 5.1
General Surveillance and Early Warning Surveillance Online Sources
General Surveillance Sources Early Warning Surveillance Sources
Characteristic N % N %
Total 98 100 14 100
Sponsor category
Multilateral—global 11 11 0 0
Multilateral—regional 8 8 0 0
National—U.S. 36 37 9 64
National—U.S. state 3 3 0 0
National—non-U.S. 25 26 2 14
Academic/professional 8 8 3 22
Commercial 5 5 0 0
NGO 2 2 0 0
Geographic coverage
Global 18 18 5 36
Regional 12 12 1 7
Disease host
Human 74 75 13 93
Animal and human 13 13 0 0
Animal 11 11 0 0
Animal, human, and plant 1 1 1 7
Frequency of information dissemination
Ad hoc 28 28 4 29
Annual 16 16 0 0
Weekly to biannually 26 26 1 7
Daily or near real-time 11 11 9 64
Unknown 18 18 0 0
NOTE: The data in this table reflect only the 112 general and early warning surveillance sources; the remaining 122
sources do not address these areas.
Sources Include Information on Diseases in Humans, Animals, and Plants

Because of the nature of our search and the focus of this study, most of the online sources
we compiled address human diseases. However, the evolving nature of emerging diseases
(described in Chapter Two) and the threat of terrorism are reflected in the substantial number
of online sources that include information on animal or plant diseases. As shown in Figure 5.4,
a total of 87 percent of sources (205 sources) address human diseases, 24 percent (57 sources)
address animal diseases, and 4–5 percent (11 sources) address plant diseases. However, many
sources include combinations of the three.
Nearly all the 57 sources with information on animal diseases have unrestricted access
(50 sources, 88 percent). The 57 sources are sponsored mostly by U.S. government agencies
at the national or state level (16 sources, 28 percent), multilateral organizations (13 sources,
23 percent), foreign governments (12 sources, 21 percent), and professional or academic orga-
nizations (11 sources, 19 percent). These sources predominantly serve surveillance (34 sources,
60 percent) or reference (16 sources, 28 percent) purposes. Similarly, most of the 11 sources
with information on plant diseases have unrestricted access (eight sources, 73 percent), but
they are more evenly distributed across types of sponsoring organizations and serve a wider
range of purposes, particularly reference or research (each, 3 sources, 27 percent).
Figure 5.4
Sources Addressing Human, Animal, and Plant Diseases
Human and animal

10%
Animal only
10%
Human, animal, plant

3%
Human only
74% Animal and plant
1%
Human and plant
<1%
Not applicable
2%
RAND TR405-5.4
Nearly One-Third of Our Sources Use Active Information Collection Methods

A key element used to characterize online sources of disease information is the way in which
the information presented by sources is collected. The method of information collection is an
important consideration in the interpretation, application, and ultimate use of information
by policymakers. Passive data collection, which is typically used in traditional disease sur-
veillance, denotes an approach in which disease information reaches sponsors—usually gov-
ernment authorities and health departments—through a voluntary or mandatory reporting
system that includes primary data sources, such as clinical facilities and laboratories. In con-
trast, active data collection denotes a system in which sponsors seek out disease information,
e.g., through site visits, medical records reviews, or surveys. Active data collection processes are
particularly important in the context of surveillance—especially early warning surveillance—
and emerging infections as a way to closely monitor, detect, and respond to disease occurrence
in a timely fashion. The approach to the collection of health information depends largely on
the objectives and capabilities of sponsor organizations.
We examined our online sources to determine their approach to data collection. Overall,
26 percent of sources (61 sources) use active methods only, 63 percent (146 sources) use passive
methods only, and 5 percent (12 sources) use both active and passive methods; this informa-
tion is unknown or not applicable for 6 percent of sources (15 sources) (see Figure 5.5).6 Thus,
Figure 5.5
Information Collection Methods of Online Sources
Not applicable or
unknown
6%
Active only
26%
Passive only Active and

63% passive
5%
RAND TR405-5.5
6 Some sources do not collect information but instead serve other purposes, such as reference or research support.
31 percent of sources use active data collection and 69 percent use passive data collection, with
12 sources using a combination of methods included in both categories.
While most online sources reflect passive information collection, we were particularly
interested in those that obtain data through active methods (73 sources, 31 percent overall;
61 sources, 26 percent using active methods only). As shown in Table 5.2, active data collec-
tion methods are more common than passive methods among sources that serve antiterrorism,
networking, communication, and early warning surveillance purposes. Multilateral regional
Table 5.2
Characteristics of Sources Using Active or Passive Information Collection
Active Sources Passive Sources
Total 73 100 158 100
Primary purpose
General surveillance 25 25 79 80
Surveillance bulletin 6 26 17 74
Early warning surveillance 8 57 7 50
Reference 11 23 32 68
Research resource site 4 33 7 58
Terrorism 7 64 1 9
Networking 4 67 2 33
Communication 3 100 0 0
Laboratory 0 0 2 100
Other early warning acts 2 67 0 0
Other 3 20 12 80
Sponsor category
Multilateral—global 6 25 19 79
Multilateral—regional 7 47 9 60
National—U.S. state 2 29 5 71
Academic/professional 8 28 20 69
Commercial 11 42 12 46
NGO 2 29 5 71
Table 5.2—Continued
Active Sources Passive Sources
Geographic coverage
Global 19 25 54 71
Regional 7 33 15 71
Disease host
Animal 6 26 17 74
Human 50 29 118 68
Animal and human 9 38 17 71
Animal and plant 0 0 3 100
Animal, human, and plant 6 86 2 29
Not applicable 2 67 1 33
Standardization
Standardized 21 32 45 69
Semi-standardized 27 33 56 68
Not standardized 19 28 46 68
Mixed 3 100 2 67
Unknown 3 30 4 40
Not applicable 0 0 6 86
NOTE: The data columns reflect any active or passive collection. Twelve sources use both methods and are counted
in both categories.
organizations and commercial sponsors were more likely than others to use active data collec-
tion methods. Finally, sources with comprehensive information on human, animal, and plant
diseases were more likely to use active information collection than were sources with informa-
tion limited to human or animal diseases only.
About One-Third of Sources Actively Disseminate Their Data Output

Nearly one-third of online sources (76 sources, 32 percent) use active or “push” data dissemina-
tion; the remainder use passive or “pull” dissemination. Active dissemination takes the form of
government notification to health providers regarding disease updates, email alerts and other
communications to relevant authorities, and public announcements by health departments.
Passive or “pull” dissemination in the context of these online sources means that information
is available for users to consult, but users are not actively notified of such information. Sources
with information collected through active means are more likely to disseminate their output
actively (48 percent), compared with active dissemination from sources using passive data col-
lection methods (23 percent, chi-square = 15.348, df = 1, p = 0.00009). Sources that actively
“push” their data output also disseminate information more frequently than do sources that
rely mostly on passive “pull” dissemination: Forty percent of the former, but only 7 percent of
the latter, update or disseminate their data on a daily or near–real-time basis.
Summary
In this chapter, we described an array of online infectious disease information sources that
could be used by a range of technical experts and policy staff to inform policy decisions. These
sources vary according to their accessibility, organizational sponsors, primary purposes, dis-
ease hosts, information collection methods, timeliness of data collection and output, and other
characteristics. We undertook this compilation of sources because our literature review indi-
cated that there were potentially many information sources available but few, if any, sources
that compile, analyze, and distribute the large amount of available information in a com-
prehensive and useful manner. Early interviews during this study indicated that identifying
useful and relevant sources of information among the many sources available is a significant
challenge, further prompting the analysis in this chapter. The database we compiled was not
intended to result in an authoritative compendium of online sources; it cannot be exhaus-
tive, since the population of online sources changes continuously. The database was intended
primarily to allow for the above descriptive analysis, to inform response to our third research
question regarding the adequacy of current information. However, several U.S. government
stakeholders we interviewed expressed considerable interest in the database, and we have given
it to them for their use. In addition, the online sources from our database could be relevant to
DHS as it further develops NBIS, i.e., by adding our sources to the large number of sources
from which NBIS currently draws its information. Our sources likewise span a wide range of
infectious disease information, from comprehensive to disease-specific, from human to animal
and plant diseases, from domestic to foreign, and from surveillance to widely ranging support
information related to infectious diseases.
CHAPTER SIX
Synthesis, Conclusions, and Recommendations
Synthesis
As described throughout this report, a key theme regarding infectious diseases over the past
century, and likely into the future, is change. Some changes present challenges, while others
present opportunities. The world is being challenged by a resurgence of infectious disease mor-
tality; the emergence and rapid spread of new diseases, including zoonotic diseases and diseases
resistant to antimicrobial drugs; and the broad impact of infectious diseases on trade, security,
and economic development. Opportunities arise from new perspectives, new stakeholders, new
technologies, and new approaches to disease detection and control. The following discussion
synthesizes challenges, opportunities, and new initiatives related to global infectious diseases,
focusing on transformations in disease evolution, the way U.S. policymakers can think about
and respond to infectious disease challenges around the world, and implications for the future.
The chapter then concludes with our responses to the three original questions addressed in this
study and our recommendations for further action.
New Diseases with Global Distribution

Emerging and reemerging infectious diseases have posed numerous challenges over recent
decades. Factors associated with the emergence and spread of these diseases include ecological
changes, human demographics and behavior, international travel and trade, changes in land
use, inadequacy and deterioration of public health infrastructures worldwide, microbial adap-
tation and change, misuse of antimicrobial drugs, and others. The CDC and the Committee
on International Science, Engineering, and Technology (CISET) reported 30 examples of
pathogens that emerged or reemerged between 1973 and 1995 (CDC, 1998; CISET, 1995).
More recent examples include SARS and avian influenza H5N1. These have captured attention
because of their spread across countries, illustrating yet again that diseases know no borders in
this age of globalization, and an infectious disease threat anywhere in the world can become a
threat everywhere.
New Populations of Interest: Diseases in Animals

Zoonotic diseases represent approximately three-fourths of newly emerged and reemerged
infectious diseases in recent decades. As the current avian influenza H5N1 outbreaks illustrate,
this means that disease surveillance and control must extend beyond the human population
into the animal population. This requires veterinary health infrastructures as well as those for
53
human public health. While human public health infrastructures may range in strength across
different countries, animal health infrastructures are often lacking altogether.
New Perspectives
Recent high-profile diseases such as SARS and avian influenza have served to underscore the
relatively new view of some infectious diseases as a threat to national security. They have
captured attention through their broad impact not only on health but also on international
trade, security, and national economies. During the 1990s, economists and political scientists
increasingly considered HIV/AIDS a broad threat to economic development, national stabil-
ity, and national security. For example, the real or perceived decimation of foreign militaries
by HIV and the loss of productive workers across all economic sectors undermine economic
and social development and threaten political stability. The more recent outbreak of SARS and
the almost-certain prospect of a human influenza pandemic, whether or not it arises from the
currently circulating H5N1 avian influenza strain, have raised heightened concern because of
their potential for even more rapid and extensive spread. Further, the current avian influenza
outbreaks in Asia and eastern Europe are a constant reminder of the links between the public
health sector and the agriculture, trade, tourism, economic, and political sectors, and thus not
only the collective impact of such diseases but also the opportunity for collective, i.e., stronger,
actions to combat them.
New Range of Stakeholders Interested in Global Infectious Diseases

These new perspectives on infectious diseases in the age of globalization have given rise to a
broader range of stakeholders, i.e., leaders not just from the health sector but also from the
agriculture, trade, tourism, economic, foreign affairs, security, and political sectors. This is
our reason for interviewing a broad range of stakeholders with the objective of soliciting views
regarding current information needs of U.S. policymakers (see Chapter Four). As a result of
the broader range of stakeholders now concerned with infectious disease, leadership on these
“health” issues has extended into new domains, resulting in initiatives from such groups as the
UN General Assembly, the G8, the APEC forum, the Association of Southeast Asian Nations
(ASEAN), and others. Shared leadership presents both the significant opportunities and the
broad challenges of working effectively across different sectors that may have different cultures,
incentives, and methods and that typically do not interact directly with one another.
New Active Information-Gathering Approaches

Traditionally, infectious disease surveillance information has come from passive reporting of
clinical or laboratory data to government officials, often with significant delay. Active data
collection approaches can range from labor-intensive human outreach to obtain clinical or
laboratory data to automated active data collection methods. GPHIN is just one example of
automated data collection that serves an important surveillance and early warning function.
It employs data-mining techniques to actively search worldwide media sources in various lan-
guages; data are quickly analyzed in Canada and then sent to the WHO for verification with
affected countries. The U.S. government’s new biosurveillance system, NBIS, is intended to
employ active and extensive data-mining approaches to provide early warning signals relevant
Synthesis, Conclusions, and Recommendations 55
to infectious diseases worldwide. These are both promising early warning systems to improve
sensitivity and timeliness of disease alerts.
New Sources of Information

Our study, including the literature review, interviews with a broad range of government offi-
cials, and the compilation of online data sources, has supported the hypothesis that govern-
ments are no longer the sole, or perhaps even the most reliable, sources of information on infec-
tious diseases. NGOs (e.g., the Global Disaster Information Network), the media (e.g., sources
actively accessed via GPHIN), and Internet discussion groups (e.g., ProMED) are increas-
ingly providing critical early warning of outbreaks. As noted in Chapter Two, the WHO has
acknowledged that a significant proportion of confirmed outbreaks are first reported by such
sources, rather than by affected governments. Approximately one-fourth of the 234 online
sources we compiled were sponsored by NGOs, professional or academic institutions, or com-
mercial sources; moreover, even some government-sponsored sources (e.g., GPHIN, NBIS)
draw information from media sources rather than from official government reports.
New Disease Indicators

Traditional disease reporting has been based on government notification of clinical diagnoses,
especially hospital inpatients or clinic outpatients, or laboratory testing. However, less tradi-
tional indicators of disease cases and outbreaks offer promise as well and are being implemented
through new initiatives. For example, retail sales of over-the-counter medicines, the tracking
of which is part of the U.S. BioSense initiative, can indicate localized surges in demand for
treatments for respiratory and diarrheal diseases and, hence, serve as a community indicator
of disease occurrence. School absenteeism has been used in the past as a potential early warn-
ing proxy for community spread of disease, such as influenza-like illness or other respiratory
disease; however, this approach has been discontinued. These are just two examples of indica-
tors that complement the more traditional disease indicators and hence may offer added value
in terms of comprehensiveness (because they do not rely strictly on persons seeking clinical
care) and potentially timeliness (such reports may come earlier than government notification
through official surveillance reporting). It will be important to consider comparably innovative
indicators for animal and plant infections that have the potential for spread to humans.
New Ways of Reporting

Local, national, and international media increasingly report on infectious disease occurrences.
SARS and avian influenza H5N1 are recent examples. The media serve to provide timely infor-
mation to a broader audience (i.e., the general public) than the more traditional information
that is channeled almost exclusively through government sources. GPHIN and NBIS capital-
ize upon active data-mining techniques to capture such information. Additionally, the Internet
has facilitated a revolution in real-time information dissemination. Infectious disease informa-
tion is reported through a number of active and passive mechanisms. Distribution lists, such as
ProMED, APEC Emerging Infections Network (EINet), and others, push general information
to users; Google Alerts and other sources actively provide more tailored information based on
user requests. The stakeholders we interviewed expressed strong wishes for tailored information
that meets their needs without being overwhelming.
New Types of Analysis and Presentation

With the growing breadth of infections across host species and the accompanying growing
interest in government sectors, it has become increasingly important to consider ways to inte-
grate information from individual sources and make it useful and usable by all relevant stake-
holders. This was a clear message from the stakeholders we interviewed. Thus, public health
and veterinary health data must be integrated with more contextual and analytic information
from the security, foreign affairs, and intelligence sectors. Further, information must be pre-
sented in a way that is understandable, and preferably actionable, even to non–health experts
and non-policymakers. Disease information presentation can be in the form of numbers, tables,
or maps, and it may be more fully analyzed in terms of context and broader implications. The
USDA’s Center for Emerging Issues worksheets provide a good example of more complete
analysis and reporting of infectious disease issues—in this case, those that are relevant to the
agriculture sector.
New Policy Initiatives

Finally, the United States has established a number of recent high-level policy initiatives to
operationalize responses to infectious disease threats within the context of national security.
All of these either represent or depend upon information related to infectious diseases. These
initiatives are unprecedented in two regards: They make clear the connection between infec-
tious disease and security, and they involve U.S. presidential leadership on what might other-
wise be considered simply health issues. A number are domestically oriented initiatives address-
ing bioterrorism threats, stemming mostly from the 2004 HSPD-10/NSPD-33. However,
the majority are internationally oriented bilateral and multilateral initiatives. These include
a 1996 Presidential Decision Directive to operationalize the U.S. global EID strategy (see
White House 1996b); U.S. leadership to bring the first health issue (HIV/AIDS) to the UN
Security Council (2000); U.S. leadership in the 2001 establishment of the Global Fund to
Fight AIDS, Tuberculosis and Malaria; the President’s 2002 Emergency Plan for AIDS Relief;
the APEC Health Security Initiative (2003); and the 2005 International Partnership on Avian
and Pandemic Influenza. In addition, planning for a nationwide U.S. response to pandemic
influenza is under way at the highest levels of government, as demonstrated by President Bush’s
release of the National Strategy for Pandemic Influenza and the HHS Pandemic Influenza Plan.1
The number and high political profile of these recent initiatives clearly signals the escalation of
infectious disease threats into the realm of high politics and makes it all the more important
for stakeholders across government sectors to have the information they need to implement
these initiatives.
1 White House (2005) and U.S. Department of Health and Human Services (2005), respectively. Both documents are
also available through http://www.pandemicflu.gov/ (online as of June 12, 2006).
Conclusions
This section summarizes our findings and conclusions in response to the three central research
questions. It then discusses the implications of these conclusions for the future and provides
recommendations.
How Has the Emerging Link Between Global Infectious Disease and U.S. National Security
Been Perceived and Acted Upon Across Government Sectors?
Recent history of HIV/AIDS, SARS, and avian influenza H5N1, among other infectious dis-
eases, has demonstrated once again the broad effects that “health” problems, specifically infec-
tious diseases, can have on trade, economies, and social and political stability and, hence,
on the national and global security of the United States and countries around the world.
The threats posed by infectious disease have traditionally been considered strictly through a
public health and medical lens. Similarly, the intelligence community has addressed a wide
range of threats that heretofore has not fundamentally included health and infectious diseases.
However, events evolving over the past ten years and accelerated by the terror attacks of 2001
and the imminent threat of a human influenza pandemic have highlighted the potential for
infectious diseases to threaten U.S. national security. This heightened awareness is indicative
of the link between the globalization of the world’s economies and the spread of infectious
diseases. As detailed in Chapter Three, these relationships have been confirmed by our review
of the literature, and virtually all the stakeholders we interviewed clearly understood the new
paradigm linking infectious disease to national security. With regard to collecting and using
disease-related information, “business as usual” is no longer possible. The health sector is now
obliged to address global infectious diseases from a broader context that includes national
security, and the health sector will likely look increasingly to the intelligence community in
order to collect needed and relevant information.
The U.S. government has begun to operationalize this new paradigm through security-
oriented initiatives, such as those described in Chapters Two and Three and synthesized in the
preceding section above. A now-broader community of stakeholders must find ways to com-
bine their various expertise, methods, and perspectives to facilitate coherent and responsible
action across government sectors to address the broad range of consequences associated with
global infectious disease.
What Types of Information About Global Infectious Disease Do U.S. Policymakers Need?
Stakeholders from across a wide range of disciplines and sectors, including health, agriculture,
foreign affairs, homeland security, and intelligence, have expressed the need for timely, accu-
rate, complete, and understandable information that is delivered in a way that meets a wide
range of requirements and does not overwhelm. These requirements range from technical dis-
ease and surveillance data to information about the social and political contexts related to out-
breaks and subsequent responses. They range from raw data to synthesized analysis products,
and from “push” to “pull” mechanisms of delivery.
While each sector has its own focus and responsibilities, the information needs of policy-
makers across sectors were characterized more by their similarities than by their differences.
The stakeholders we interviewed expressed a strong desire for a centralized system that provides
needed information to all stakeholders. An ideal system to collect, analyze, and disseminate
infectious disease information would be (1) robust, drawing information from a wide range of
sources and collecting information that is accurate and complete; (2) efficient, constituting a
single, integrated source of timely information available to all stakeholders; (3) tailored to meet
individual stakeholder needs and preferences; and (4) accessible, notwithstanding the need for
protection of sensitive data.
How Sufficient Is the Available Information on Global Infectious Diseases?

While there may never be enough good information to meet all legitimate policy needs, there
is considerable information already available via open sources, complemented by protected
information. Chapter Five describes the characteristics of the 234 online sources we compiled
for this study. Our database alone can be useful to some policymakers, but it may never be
sufficient, since online sources are added frequently and even 234 sources can be somewhat
overwhelming. The organization and delivery of information thus poses a major challenge: It
must be sufficiently complete while not overwhelming. The variety of information-gathering
techniques, which now includes active Web crawling in addition to more standard disease
reporting techniques, and the addition of intelligence collection methods, adds to the timeli-
ness, breadth, and value of the overall body of information available to policymakers. There
are new efforts to address information requirements centrally in order to serve needs more
broadly across the federal government. One such effort is NBIS. Such efforts must focus on
both data content and data coordination, i.e., they must be well integrated across agencies to
support national goals. They must also be versatile enough to meet the wide range of policy-
makers’ needs. The need for versatility suggests that a carefully managed system involving
human analysts and experts is preferable to a solution based purely on information technology.
Again, NBIS is intended to have such versatility. However, because NBIS is only in its early
stages of implementation, it is too early to reach conclusions regarding the sufficiency of avail-
able information that NBIS may collect, process, and disseminate. There does not appear to
be any other source that satisfies the full range of desired criteria expressed by the stakeholders
we interviewed.
Implications and Remaining Challenges

Globalization of the world’s economy has given rise to the globalization of infectious dis-
eases and the need for a global approach to control them. Countries around the world require
timely, accurate, and complete information on infectious diseases, presented in a way that is
both understandable and actionable. Ideally, disease emergence and spread would be prevented
altogether; if not, as is more likely, early warning indicators need to be followed and disease
occurrences detected promptly so that appropriate actions can be taken to control their spread.
Realizing this goal will require an understanding of diseases and information collection and
analysis methods by a broad range of stakeholders.
Remaining challenges include not only efforts to collect more and better infectious dis-
ease information but also the efficient and effective integration and sharing of information
across government sectors that have, at best, a relatively short history of working together on
shared priorities. Thus, challenges include not only the type and amount of information that is
needed but also the processes to share and make most effective use of such information across
government sectors.
It was suggested by some stakeholders during this study that the United States needs
a novel system for collecting, analyzing, and disseminating infectious disease information.
Indeed, this need was an original hypothesis of this study. Like many of the stakeholders we
interviewed, we were unaware of NBIS at the start of this study. Based on information we col-
lected during the study, it seems that NBIS is intended to address many of the issues identified
by policymakers. First, NBIS seeks to create an information technology platform to integrate
data input from disparate sources, including extant U.S. information systems. Second, it seeks
to integrate data analysis across sources and sectors, including anticipatory analyses. Third,
it seeks to provide expert analysis of the integrated data by a team of interagency analysts.
The extent to which NBIS fulfills these criteria and meets government-wide infectious disease
information requirements and the expectations set by Congress will determine whether it ulti-
mately provides sufficient information to policymakers.
Recommendations
Based on this study, our primary recommendation is for the implementation of a U.S.
governmentwide system that provides timely, accurate, complete (i.e., integrated and suffi-
ciently comprehensive), and understandable information on infectious disease threats and
occurrences, presented and delivered in ways that are most convenient and usable to a wide
range of policymakers. At this time, a recommendation of an entirely new infectious disease
information system would be imprudent; a new system, NBIS, has already been funded but
has not yet been fully implemented and evaluated. Rather, at this time, we recommend a sys-
tematic formative evaluation of NBIS to help ensure that NBIS is designed to fulfill all critical
requirements and is implemented as designed. A subsequent summative evaluation can ascer-
tain whether NBIS is adequate or whether new or different strategies are needed to collect, ana-
lyze, and deliver infectious disease information to the broad range of policymakers responsible
for addressing infectious disease security threats to the United States. The following illustrative
questions highlight issues we consider relevant to a near-term evaluation of NBIS. (The final
question pertains to the proposed summative evaluation.)
• Are there remaining technological issues that need to be resolved to fully implement
NBIS; i.e., is further research needed?
• How is NBIS integrated with other information and analysis systems?
• What authorities are required and exercised, and by whom, for collection-tasking?
• Is an appropriate leadership mechanism in place to coordinate efforts across sectors?
• Are other agencies
– aware of NBIS authority?
– appropriately resourced?
– ready to integrate their own systems into NBIS?
• What are the long-term requirements for

– interagency support and processes?
– updating types of needed information and products?
• How can accessibility (classification) issues be resolved?
• Are there valuable lessons from other interagency initiatives, particularly in the area of
effective cooperation and coordination across government sectors?
• Will NBIS meet the information needs articulated by stakeholders and described in this
report?
APPENDIX A
Organizations Interviewed
This appendix lists the organizations with which our 53 stakeholder interviewees were affili-
ated. Our semistructured interview guide is presented in Appendix B.
U.S. Federal Organizations

Department of Agriculture
Animal and Plant Health Inspection Service
Foreign Agricultural Service
Department of Defense
Defense Threat Reduction Agency
Deputy Assistant Secretary of Defense for Chemical and Biological Defense
Office of the Assistant Secretary of Defense, Health Affairs
Uniformed Services University of the Health Sciences
U.S. Central Command
U.S. Pacific Command
Department of Health and Human Services

Centers for Disease Control and Prevention
Food and Drug Administration
Office of the Secretary
Office of Global Health Affairs
Office of Public Health Emergency Preparedness
Department of Homeland Security

Directorate of Science and Technology
National Biodefense Analysis and Countermeasures Center
National Biosurveillance Integration System
61
Department of State
Bureau of Arms Control
Bureau of Consular Affairs
Bureau of East Asian and Pacific Affairs/Bureau of Economic Policy/Asia-Pacific Economic
Cooperation
Office of International Health Affairs
Office of the Medical Director
Intelligence Community
Central Intelligence Agency
National Intelligence Council
Peace Corps
White House
Homeland Security Council
Office of Science and Technology Policy
Other Organizations
Association of State and Territorial Health Officials

Georgia Department of Human Resources, Division of Public Health
Homeland Security Institute
RAND Corporation (former officials of the U.S. Departments of State, Defense, Health and
Human Services, and the Agency for International Development)
World Health Organization
APPENDIX B
Interview Guide
We developed the following discussion guide for our semi-structured interviews. We used it
as a general reference, selecting and tailoring the questions based on the organizational affilia-
tion and level of each interviewee. We pilot tested the interviews with nine individuals (repre-
sentatives of selected government offices, former federal officials now at RAND, and others),
and then finalized the discussion guide based on these pilot interviews. Our results reflect
the views of all persons interviewed, i.e., including those during the pilot phase. The research
conducted during this study complied with RAND Human Subjects Committee policies and
procedures.
1. In what ways, if any, are infectious diseases related to U.S. national security?
1.1. What (kinds of) infectious diseases pose a threat to the United States?
1.2. Are there specific characteristics of these diseases that make them a threat?
1.3. What is the interest of your organization in addressing these disease threats, and
why?
1.4. Does your organization have a specific mandate to address these disease threats?
2. What kind of information related to global infectious diseases does your organization
need?
2.1. What information do you collect or receive?
2.2. What gaps, if any, exist between information you need and what you already have or
can collect?
2.3. What is the primary purpose for collecting or receiving this information?
2.4. How is the information analyzed?
2.5. What product is produced from this information, and to whom is it presented?
2.6. Has this product influenced policy decisions? If not, why? Would different/
additional information or analysis have had a different influence?
2.7. Address these same questions specifically for these cases: SARS, avian influenza, and
the next as yet unknown emerging or reemerging disease.
3. Are there specific disease or infectious disease problems that worry you in terms of their
emergence or reemergence?
3.1. What actions are you taking to track these diseases or problems?
3.2. How are you using the information you obtain?
63
4. What criteria would you consider most important for setting your organization’s stra-
tegic infectious disease information needs? Please rate the following on a scale of zero
to 10:
– Geographic location/distribution of disease threat
– (Low) likelihood of timely reporting by country of origin
– Number of cases (i.e., few versus many)
– Endemic (expected) versus epidemic (unexpected)
– Source of pathogen/disease (air, food, water, zoonosis, etc.)
– Possibility of malicious intent (bioterrorism)
– Severity of disease/problem (morbidity, mortality)
– (Poor) local public health/medical capacity to control spread
– Potential for spread to other countries
– Potential for spread to the United States
– Ability to detect and control the disease in the United States
– Availability and cost of effective treatment in the United States
– Potential for disruption to foreign trade and economies
– Potential for disruption to U.S. trade and economy
– U.S. political concern
– National security concern (if not captured above)
– Other
5. Is sufficient information already available about global infectious diseases?

5.1. What information sources does your organization currently use to collect or receive
information on infectious diseases?
5.2. Are you able to control the information coming into your organization?
5.3. Are you able to task intelligence collection?
6. What kind of global infectious disease information is not publicly available, and under
what circumstances?
6.1. Is the current system of “honest reporting” of global infectious disease information
sufficient for U.S. national security interests?
7. What delivery format and system for infectious disease information is most useful to
your organization for strategic and tactical purposes?
8. Do you have specific suggestions regarding how to obtain additional needed informa-
tion or make better use of existing information?
9. Do you believe that the United States should change the way it collects, analyzes, and
considers information about global infectious diseases?
9.1. How would you label such a system?
9.2. If a change is warranted, please explain and describe the key features of recom-
mended changes.
APPENDIX C
List of Online Sources
This appendix lists 234 online sources related to the detection, surveillance, and dissemination
of information on infectious diseases and infectious disease outbreaks. The list is not intended
to be exhaustive but serves to demonstrate the variety of open- and restricted-access sources
available for these purposes. All data in the table are current as of the period in which data were
collected for this study, July through October 2005.
65
66
Table C.1
Infectious Disease and National Security: Strategic Information Needs

Name Sponsor Location Brief Description Access
Multilateral Organizations—Global
1 Food and Agriculture FAO http://www.fao.org/DOCREP/ Manual on livestock disease surveillance and Open
Organization of the 004/X3331E/X3331E00.HTM information systems
United Nations (FAO)
Livestock Disease
Surveillance Manual
2 Regional Animal Disease FAO http://www.fao.org/ag/aga/ A joint FAO/International Fund for Agricultural Open
Surveillance and Control agah/id/radiscon/Database. Development (IFAD) endeavor (since June 1996)
Network (RADISCON) htm targeting 29 nations located in North Africa, the
Sahel, the Horn of Africa, the Middle East, and
the Arab Gulf, RADISCON aims to promote animal
disease surveillance within and among countries.
Standardized data input includes RADISCON
Disease Outbreak Report (RADDOR), RADISCON
Monthly Report (RADM); integrated national,
regional and international veterinary information
system compatible and complementary to the FAO
Emergency Prevention System (EMPRES) and the
Office International des Epizoöties global systems
3 Filariasis Surveillance Global Alliance to http://www.filariasis.org/ Provides data and supporting documents for the Open
Eliminate Lymphatic index.pl?iid=2377 Program to Eliminate Lymphatic Filariasis (PELF)
Filariasis
4 Office International des OIE http://www.oie.int/eng/en_ Required international reporting of animal diseases; Open
Epizoöties (OIE) index.htm collects and disseminates the information gathered
by national surveillance programs on epizootic
diseases; includes alerts, weekly and monthly
reports, inter alia
5 OIE Animal Disease OIE http://www.oie.int/hs2/report. Database organized chronologically and by country, Open
Data—Handistatus II asp?lang=en containing information on “List A” and “List B”
Database animal diseases that have serious consequences for
international trade or public health
6 OIE Standards on OIE http://www.oie.int/eng/ Ordering and abstract page for the OIE standards Open
Antimicrobial Resistance publicat/Ouvrages/a_119.htm book for antimicrobial resistance research
Table C.1—Continued
7 Arab Ministries of United Nations http://www.unesco.org/ List of links to Arab ministries of health (or similar- Open
Health Database Educational, webworld/portal_bib/ level institutions)
Scientific, and Libraries/Health/Arab_States/
Cultural Organisation index.shtml
(UNESCO)
8 United Nations United Nations High http://www.unhcr.ch/cgi-bin/ Data, trends, and statistical reports on refugees, Open
statistical database on Commissioner for texis/vtx/statistics asylum-seekers, returned refugees, and internally
refugees Refugees displaced and stateless persons in more than 150
(UNHCR) countries
9 World Health WHO http://www.who.int/entity/csr/ Serves as a global alert mechanism for the Registration
Organization (WHO) disease/influenza/surveillance/ emergence of influenza viruses with pandemic
Global Influenza en/index.html potential.
Surveillance/FluNet
10 WHO drug resistance WHO http://www.who.int/drug Gateway page for the WHO program to assist Open
information resistance/surveillance/en/ countries in instituting antimicrobial resistance
surveillance
11 WHO Disease Outbreak WHO http://www.who.int/csr/don/ Posts alerts on confirmed worldwide disease Open
News en/ outbreaks; input: diseases versus syndromes (mostly
diseases)
12 WHO outbreak WHO http://www.who.int/csr/ Unofficial WHO distribution list to inform 800 Authorization
verification list alertresponse/verification/en/ selected subscribers about infectious disease
index.html outbreak threats
13 WHO Global Outbreak WHO http://www.who.int/csr/ A technical collaboration of existing institutions and Authorization
Alert and Response outbreaknetwork/en/ networks that pool human and technical resources
Network (GOARN) for the rapid identification, confirmation, and

response to outbreaks of international importance
14 WHO Weekly WHO http://www.who.int/wer/en/ Provides rapid and accurate dissemination of Open
Epidemiological Report epidemiological information on cases and outbreaks
of diseases
15 WHO Antimicrobial WHO http://oms2.b3e.jussieu.fr/ Interactive resource that is open to all to access Open
Resistance Information arinfobank/ and contribute to the global understanding of
Bank antimicrobial resistance as a public health problem
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68

16 WHO disease outbreak WHO http://www.who.int/csr/don/ Site cataloging of worldwide disease outbreaks by Open
archives by country archive/country/en/ country
17 WHO Disease outbreak WHO http://www.who.int/csr/don/ Site cataloging worldwide disease outbreaks by year Open
archives by year archive/year/en/
18 WHO Communicable WHO http://www.who.int/csr/en/ Tracks and responds to the evolving infectious Registration
Disease Surveillance disease situation
and Response
19 WHO Global Atlas of WHO http://globalatlas.who.int In a single electronic platform, brings together for Open
Infectious Disease analysis and comparison standardized data and
statistics for infectious diseases at country, regional,
and global levels
20 WHO Supranational WHO http://www.who.int/ National Reference Laboratories conducting quality- Open
Reference Laboratory drugresistance/tb/labs/en/ assured drug susceptibility testing in conjunction
Network for Drug- with national or area anti-TB drug resistance
Resistant Tuberculosis (antimicrobial resistance) surveillance
21 WHO Global Network WHO; United http://www.polioeradication. Describes the Global Polio Eradication Initiative Open
for Eradication of Polio/ Nations Children’s org/ (GPEI), spearheaded by national governments, the
Measles Fund (UNICEF); U.S. WHO, Rotary International, the CDC, and UNICEF
Department of Health
and Human Services
(HHS)/Centers for
Disease Control and
Prevention (CDC)
22 Guinea Worm WHO, HHS/CDC, http://www.who.int/ctd/ General information on Guinea Worm–related Open
Surveillance UNICEF dracun/strategies.htm disease, surveillance information, and network
23 Global Environment WHO http://www.who.int/ Compiles food contamination monitoring data in Open
Monitoring System/ foodsafety/chem/gems/en/ Europe
Food Contamination index5.html
Monitoring and
Assessment Programme
(GEMS/Food)
24 Global Salm-Surv (GSS) WHO; Danish http://www.who.int/salmsurv/ Facilitates communication and data exchange Open
Institute for Food and en/ between labs that isolate, identify, and test
Veterinary Research specimens for salmonella in order to improve the
(DFVF); HHS/CDC; quality and capacity of testing
Institut Pasteur;
Public Health Agency,
Canada; Animal
Sciences Health
Group, Wageningen
University and
Research Centre
Multilateral Organizations—Regional
25 Southeast Asian Nations Association of http://www.asean- Infectious Disease Surveillance network for ASEAN Registration
Infectious Diseases Southeast Asian disease-surveillance. and three member organizations
Outbreak Surveillance Nations (ASEAN) net/ASNSurveillance.
Network Secretariat; Ministry asp?Country=sg
of Health, Republic of
Indonesia
26 Emerging Infections Asia-Pacific Economic http://depts.washington.edu/ A forum for reporting, discussion, and dissemination Open
Network (EINet) Cooperation (APEC) einet/?a=home of information regarding unusual infectious disease
cases/outbreaks in the Asia-Pacific region, and
emerging infectious disease–related papers and
meetings
27 Enter-Net, formerly European Commission http://www.hpa.org.uk/hpa/ International surveillance network for human Open
known as Salm-Net inter/enter-net_menu.htm gastrointestinal infections
28 EuroTB European Commission http://www.eurotb.org/ Coordinates the surveillance of TB and TB Authorization

antimicrobial resistance in the 52 countries of the
WHO European region since 1996; its overall aim
is to improve the contribution of epidemiological
surveillance to TB control in Europe.
29 Directory of European European Commission, http://europa.eu.int/comm/ Directory of links to surveillance systems in the Open
Disease Surveillance Public Health Section health/ph_threats/com/comm_ European region for communicable diseases
Systems diseases_networks_en.htm
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30 European Influenza European Commission http://www.eiss.org/ EISS collects and exchanges timely information on Authorization
Surveillance Scheme influenza activity in Europe; most clinical influenza
(EISS) surveillance is based on reports from sentinel
general practitioners and sentinel pediatricians
and physicians with other specializations. (Sentinel
physicians usually represent 1–5% of physicians
working in the country or region.) During the
influenza season, clinical and virological data are
collected on a weekly basis by each participating
network. The data are processed, analyzed, and
assessed before being entered into the EISS online
database, available for query and analysis to
authorized members.
31 Eurosurveillance European Centre for http://www.eurosurveillance. Peer-reviewed information on communicable disease Open
Disease Prevention org/releases/index-02.asp surveillance and control across Europe
and Control (ECDC)
32 European Union public European Union http://europa.eu.int/pol/ Gateway site to European Union activities related to Open
health Web site health/index_en.htm public health
33 WHO, Regional Office WHO/AFRO http://www.afro.who.int/csr Provides reporting on Africa-centric health issues, Open
for Africa (WHO-AFRO) bulletins, and other programmatic content
34 Integrated Disease WHO/AFRO http://www.afro.who.int/csr/ Contributes to the improvement of epidemic Open

Surveillance (IDS) and ids/ preparedness and response and to the control of
Epidemic Preparedness communicable diseases in the Africa region
and Response Project
35 WHO, Regional Office WHO/EURO http://data.euro.who.int/cisid Centralized information system for infectious Authorization
for Europe, Centralized diseases; uses advanced technology to collect,
Information System analyze, and present data on infectious diseases in
for Infectious Diseases the WHO European region
(CSID)
36 WHO Surveillance WHO/EURO http://www.euro.who.int/ Monitors and registers foodborne diseases and Open
Program for the Control eprise/main/WHO/Progs/FOS/ contamination
of Foodborne Infections Surveillance/20020903_3
and Intoxicants in
Europe
37 Caribbean Epidemiology WHO/Pan American http://www.carec.org/ Research, training, and advocacy organization Open
Center (CAREC) disease Health Organization publications/reg-pub. based in Trinidad and Tobago that concentrates on
surveillance system (PAHO) html#surveil statistical and laboratory research, analysis, and
reporting, as well as training for citizens of regional
members in the practicum of public health
38 PAHO Antimicrobial WHO/PAHO http://www.paho.org/english/ PAHO homepage for antimicrobial resistance; Open
Resistance hcp/hct/eer/antimicrob.htm includes surveillance, prevention and control,
activities, and materials
39 Eurosurveillance ECDC http://www.eurosurveillance. Directory of links to surveillance summaries for Open

European national org/links/links-05.asp# communicable diseases in the European region
bulletins bulletinsEU
National—U.S.
40 California Electronic California Department URL not available Laboratory-based surveillance of reportable diseases Authorization
Laboratory Disease Alert of Health Services in California
and Reporting (CELDAR) (DHS)
system
41 California Influenza California DHS, http://www.dhs.ca.gov/ps/ Reflects statewide influenza surveillance year- Open
Surveillance Project Division of dcdc/VRDL/html/FLU/Fluintro. round; weekly updates of the Web site occur during
(CISP) Communicable Disease htm influenza season
Control; HHS/CDC;
Kaiser Permanente
42 Foreign Broadcast Central Intelligence https://www.fbis.gov/ Provides translated foreign media reporting and Authorization
Information Service Agency (CIA) analysis to policymakers, government institutions,
(FBIS) (now Open Source and strategic partners
Center)

43 U.S. Census Bureau U.S. Census Bureau http://www.census.gov/ipc/ Statistical tables of demographic and socioeconomic Open
International Data Base www/idbnew.html data for 227 countries and areas of the world
44 Data Web U.S. Census Bureau; http://www.thedataweb.org/ Network of data libraries focused on demographic, Open
HHS/CDC economic, environmental, health, and other data
already collected by a variety of U.S. organizations
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45 Lower Echelon U.S. Department of http://www.tricare.osd.mil/ LERSM provides a query capability to the local Authorization
Reporting and Defense (DoD) peo/tmip/programs.htm medical treatment facility (MTF) commander based
Surveillance Module on information collected at that location; when this
(LERSM) information is analyzed, the local MTF commander
will be able to take preventive actions to further
protect individual soldiers
46 Defense Medical Office of the Secretary http://www.tricare.osd.mil/ Provides automation support of reengineered Authorization
Logistics Standard of Defense (Health dmlss/more_info.cfm medical logistics business practices and delivers a
Support (DMLSS) Affairs); Joint Medical comprehensive range of materiel, equipment, and
Logistics Functional facilities management information systems; DMLSS is
Development Center an Acquisition Category 1A acquisition program
47 Disease Occurrence DoD/Armed Forces http://mic.afmic.detrick.army. DOW is a monthly summary of disease occurrences of Authorization
Worldwide (DOW) Medical Intelligence mil/ military importance.
Center (AFMIC)
48 DOD-GEIS (Global DoD-GEIS http://www.geis.fhp.osd. Asia-Pacific Disease Outbreak/Surveillance Reports Open

Emergency Infections mil/GEIS/SurveillanceActivities/
System), Asia-Pacific apdosr/apdosrmenu.asp
Disease Outbreak/
Surveillance Reports
49 DoD-GEIS Antimicrobial DoD-GEIS http://www.geis.fhp.osd. Program for the development of a DoD-wide Open
Resistance mil/GEIS/SurveillanceActivities/ surveillance mechanism for identifying antimicrobial
AntiMicrobialResistance/AR- resistance occurrences and trends within the U.S.
surveillance.asp military force using The Surveillance Network®
(TSN®); U.S. military locations
50 DoD Influenza DoD-GEIS http://www.geis.fhp.osd. Goals are to detect local respiratory outbreaks, Authorization
Surveillance Program mil/GEIS/SurveillanceActivities/ provide isolates to the WHO, and detect emerging
(formerly known as Influenza/influenza.asp strains
Project Gargle)
51 Military Public Health DoD-GEIS; Armed http://www.geis.fhp.osd. Provides information on these laboratories as part of Authorization
Laboratories Forces Institute of mil/GEIS/SurveillanceActivities/ the development of regional surveillance networks
Pathology (APHIP) AFIP/directory.asp
52 Theater Medical Office of the Secretary http://www.tricare.osd.mil/ Integrates DoD’s “peacetime” medical software Authorization
Information Program of Defense (Health peo/tmip/default.htm and tailors it to run on a combination of handheld
(TMIP) Affairs) devices, stand-alone laptop
53 Joint Biological Agent DoD/Joint Program http://www.jpeocbd.osd.mil/ An integrated system for the rapid identification and Authorization
Identification and Executive Office MS_JBAIDS.htm diagnostic confirmation of biological agent exposure
Diagnostic System for Chemical and or infection
(JBAIDS) Biological Defense
54 Electronic Surveillance DoD/U.S. Army URL not available ESSENCE provides population-based monitoring and Authorization
System for the Early an early warning capability of a potential chemical or
Notification of biological attack on or near a military installation.
Community-based
Epidemics (ESSENCE)
55 Army Medical DoD/U.S. Army, Center http://amsa.army.mil/AMSA/ Performs comprehensive medical surveillance and Authorization
Surveillance Activity for Health Promotion amsa_home.htm routinely publishes background rates of diseases and
(AMSA) and Preventive injuries for the Army population
Medicine (USACHPPM)
56 Early Warning Outbreak DoD/U.S. Navy http://www.apha.confex.com/ A hospital-based network of computerized linkages Authorization
Recognition System that provides surveillance for early detection of
(EWORS) infectious disease outbreaks by establishing trend
information that distinguishes epidemic from
endemic diseases
57 Medical Surveillance DoD/USACHPPM http://amsa.army.mil/AMSA/ The U.S. Army Medical Surveillance Activity’s Open
Monthly Report (MSMR) AMSA_MSMROverview.htm (AMSA) principal vehicle for disseminating medical
surveillance information of broad interest
58 Defense Occupational DoD/USACHPPM http://chppm-www.apgea. Records contain a history of individual worker pre- Authorization
and Environmental army.mil/IndustrialHygiene/ deployment, deployment, and post-deployment
Health Readiness System DOEHRS.aspx exposures; the data can then be analyzed and
(DOEHPS) utilized by practitioners to prioritize preventive
medicine actions

59 Medical Situational DoD/U.S. Army https://fhp.osd.mil/msat/index. Uses current and emerging technologies and applies Authorization
Awareness–Advanced Medical Research and jsp artificial intelligence and computerized decision-
Concept Technology Materiel Command support systems to transform collected, scattered
Demonstrator (MSAT- (USAMRMC) data into timely, actionable information for
ACTD) combatant commanders
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60 Battlefield Medical DoD/USAMRMC, https://www.mc4.army.mil/ An application used on a point-of-care handheld Authorization

Information System Telemedicine and HTML/BMIST-J.asp assistant, enabling medics and front-line providers
(BMIST) Advanced Technology to record, store, retrieve, and transmit the essential
(TATRC), U.S. Special elements of patient encounters in an operational
Operations Command setting
(USSOCOM)
61 Joint Medical DoD/U.S. Central http://acq.osd.mil/actd/articles/ Enables commanders and medical personnel to note Authorization
Workstation (JMeWS) Command JMEWS.doc trends and collect data on the health of service
(USCENTCOM), members, and provides information on medical
Defense Information treatment facilities, such as stock of blood available
Systems Agency (DISA)
62 Epidemic Outbreak DoD/U.S. Joint Forces http://www.jfcom.mil/ A proposed advanced concept technology Authorization
Surveillance (EOS) Command (USJFCOM), newslink/storyarchive/2004/ demonstrator (ACTD) sponsored by the USJFCOM
system U.S. Air Force Surgeon pa040504.htm command surgeon with the USAF/SG; detects viruses
General (USAF/SG) days earlier than conventional methods
63 Shipboard Non-Tactical DoD/U.S. Navy http://www.mhs-helpdesk. A versatile, automated medical support application Authorization
Automated Medical com/Pages/SAMS.asp developed to improve naval health care by reducing
System (SAMS) the administrative burden on health care providers
(ship-based)
64 Medical Data DoD/U.S. Navy, U.S. http://www.stormingmedia. Designed and developed as a Web-enabled system Authorization
Surveillance System Marine Corps (USMC) us/57/5753/A575334.html for data analysis and reporting for the medical
(MDSS) surveillance of Navy and Marine Corps deployed
forces; the primary objective of the system is to
rapidly detect medical threats from the analysis of
routine patient data
65 LandScan U.S. Department http://www.ornl.gov/sci/gist/ Provides detailed worldwide population information Subscription
of Energy (DOE)/ landscan/ for estimating ambient populations at risk during
Oakridge National hazardous releases (e.g., chemical, biological,
Laboratory radiological)
66 Bio-Detection Systems HHS/Agency for http://www.ahrq.gov/ List of biodetection systems for four categories of Open
Healthcare Research downloads/pub/evidence/pdf/ detection systems: collection systems, particulate
and Quality (AHRQ) bioit/evtbls.pdf counters and biomass indicators, identification
systems, and integrated collection and identification
systems
67 Rapid Syndrome DOE/Sandia and Los http://www.ca.sandia.gov/ Provides medical (syndromic) surveillance and rapid Authorization
Validation Project (RSVP) Alamos National chembio/implementation_ communication by clinicians in a variety of clinical
Laboratories; proj/rsvp/ areas
University of New
Mexico; New
Mexico Office of
Epidemiology
68 National Guideline HHS/AHRQ; American http://www.guideline.gov/ A public resource for evidence-based clinical Open
ClearinghouseTM (NGC) Medical Association; practice guidelines; it is a clearinghouse of clinical
American Association practice guidelines on wide-ranging topics in clinical
of Health Plans medicine
69 CDC Gonococcal Isolate HHS/CDC http://www.cdc.gov/ncidod/ Monitors antimicrobial resistance in Neisseria Open
Surveillance Project dastlr/gcdir/Resist/gisp.html gonorrhoeae in the United States
70 Global Laboratory HHS/CDC http://www.cdc.gov/ncidod/ Facilitates communication among laboratories that Open
Network for Measles dvrd/revb/measles/index.htm conduct measles diagnosis and virus characterization,
Surveillance as well as those involved in the surveillance of
measles
71 National Malaria HHS/CDC http://www.cdc.gov/malaria/ Collects epidemiological and clinical information on Open
Surveillance System cdcactivities/nmss.htm malaria cases diagnosed in the United States (vector)
(notifiable disease)
72 National Tuberculosis HHS/CDC http://www.cdc.gov/ncidod/ Studies epidemiology of tuberculosis outbreaks via Open
Genotyping and dastlr/TB/TB_TGSN.htm laboratory strain-typing
Surveillance Network
73 CDC Bacterial HHS/CDC http://www.cdc.gov/ncidod/ Study of adverse transfusion reactions suspected to Open
Contamination of Blood hip/bacon/index.htm be due to bacterial contamination of blood or blood

Study products
74 CDC Active Bacterial HHS/CDC http://www.cdc.gov/ncidod/ An active laboratory- and population-based Open
Core Surveillance dbmd/abcs/default.htm surveillance system for invasive bacterial pathogens
of public health importance
75 Public Health HHS/CDC http://www.cdc.gov/phin/ A national initiative to implement a multi- Authorization

Information Network index.html organizational business and technical architecture
(PHIN) for public health information systems
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76 Unexplained Deaths HHS/CDC http://www.cdc.gov/ncidod/ Improves the CDC’s capacity to rapidly identify the Open
and Critical Illnesses eid/vol8no2/01-0165.htm causes of unexplained deaths or critical illnesses and
Surveillance System to improve understanding of the causes of specific
infectious disease syndromes for which an etiologic
agent is frequently not identified
77 Environmental Public HHS/CDC http://www.cdc.gov/nceh/ Ongoing collection, integration, analysis, Authorization

Health Tracking (EPHT) tracking/network.htm interpretation, and dissemination of data from
Network environmental hazard monitoring and from human
exposure and health-effects surveillance
78 Health Alert Network HHS/CDC http://www.phppo.cdc.gov/ A secure Web-based information and communication Authorization
(HAN) han/ system designed by the CDC to link local and state
public health agencies with each other and with
other organizations responsible for responding to a
bioterrorism attack
79 Epidemic Information HHS/CDC http://www.cdc.gov/mmwr/ Provides secure Web-based communication and Authorization
Exchange (Epi-X) epix/epix.html information functions for use in both routine and
emergency public health situations
80 International Network HHS/CDC http://www.cdc.gov/ncidod/ Main purposes in the hospital/health care facility are Authorization
for the Study and hip/surveill/inspear.HTM to (1) serve as an early warning system for emerging
Prevention of Emerging antimicrobial resistance, (2) rapidly distribute
Antimicrobial Resistance information about this resistance, and (3) serve as a
(INSPEAR) model for the development and implementation of
infection-control interventions
81 National Electronic HHS/CDC http://www.cdc.gov/epo/dphsi/ System for reporting notifiable disease and injury Authorization
Telecommunications netss.htm reports from participating health agencies (and U.S.
System for Surveillance territories) to state health departments and the CDC
(NETSS)
82 CDC Morbidity and HHS/CDC http://www.cdc.gov/mmwr Comprehensive source of information-reporting Open

Mortality Weekly Report at different time intervals and on diverse disease-
(MMWR) related issues in the United States and abroad
83 Electronic Foodborne HHS/CDC http://www.cdc.gov/ Investigates outbreaks and establishes both short- Open
Outbreak Reporting foodborneoutbreaks/index. term control measures and long-term improvements
System (EFORS) htm to prevent similar outbreaks in the future
84 National West Nile Virus HHS/CDC http://www.cdc.gov/ncidod/ Monitors the geographic and temporal spread of Open
Surveillance System dvbid/westnile/surv&control. West Nile virus in humans and animals in the United
(ArboNET) htm States (i.e., birds and mosquitoes) (West Nile virus is
not nationally notifiable)
85 121 cities’ mortality HHS/CDC http://www.cdc.gov/epo/ Weekly mortality reports from 122 cities in the Open
reporting system (122 dphsi/121hist.htm United States within 2–3 weeks from the date
cities participating) of death; total number of deaths occurring in
these cities/areas each week, and number due to
pneumonia and influenza
86 National Nosocomial HHS/CDC http://www.cdc.gov/ncidod/ Collects nosocomial infection surveillance data that Authorization
Infections Surveillance hip/SURVEILL/NNIS.HTM can be aggregated into a national database for
(NNIS) System monitoring of trends in infections and risk factors
87 National Respiratory and HHS/CDC http://www.cdc.gov/ncidod/ Monitors temporal and geographic patterns Open
Enteric Virus Surveillance dvrd/revb/nrevss/ associated with the detection of respiratory and
System (NREVSS) enteric viruses
88 National Healthcare HHS/CDC http://www.cdc.gov/nchs/nhcs. Encompasses a family of health care provider surveys, Open
Survey (NHCS) htm obtaining information about the facilities that
supply health care, the services rendered, and the
characteristics of the patients served
89 National Molecular HHS/CDC http://www.cdc.gov/ncidod/ Creates a national molecular subtyping network for Authorization
Subtyping Network eid/vol7no3/swaminathan.htm foodborne bacterial disease surveillance
for Foodborne Disease
Surveillance (PulseNet)
90 CDC Surveillance Systems HHS/CDC http://www.cdc.gov/ncidod/ Page of links to disease surveillance programs Open
Monitoring Infectious osr/site/sentinel/surv-sys.htm nationwide

Diseases
91 United States Influenza HHS/CDC http://www.cdc.gov/flu/ Weekly report of U.S. influenza cases Open
Sentinel Physicians weekly/
Surveillance Network
92 Dialysis Surveillance HHS/CDC http://www.cdc.gov/ncidod/ Monitors bloodstream and vascular infections at Open
Network (DSN) hip/DIALYSIS/dsn.htm dialysis centers nationwide
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93 National Surveillance HHS/CDC http://www.cdc.gov/ncidod/ Allows the CDC to monitor trends, detect emerging Authorization
System for Healthcare hip/SURVEILL/nash.htm occupational hazards, and evaluate prevention
Workers (NaSH) policies for infectious disease exposure of health care
workers
94 Laboratory Information HHS/CDC http://www.cdc.gov/ncidod/ Data management and laboratory specimen-tracking Authorization
Tracking System (LITS) dbmd/litsplus/default.htm system; this page describes the system
95 Waterborne-Disease HHS/CDC http://www.cdc.gov/ncidod/ Collaborative surveillance system of the occurrences Open

Outbreak Surveillance osr/site/sentinel/surv-sys.htm and causes of waterborne disease outbreaks.
System
96 Laboratory Response HHS/CDC http://www.bt.cdc.gov/lrn/ Standardized nationwide public health laboratory Open
Network network to improve response capabilities for a
bioterrorism attack
97 Foodborne Diseases HHS/CDC, Food and http://www.cdc.gov/foodnet/ Monitors foodborne diseases Open
Active Surveillance Drug Administration
Network (FoodNet) (FDA); U.S.
Department of
Agriculture (USDA)
98 National Antimicrobial HHS/CDC, FDA; http://www.cdc.gov/narms/ Monitors antimicrobial resistance in human enteric Open
Resistance Monitoring USDA/Food Safety pathogens
System (NARMS) and Inspection Service
(FSIS), Agricultural
Research Service (ARS)
99 National Prion Disease HHS/CDC, National http://www.cjdsurveillance. Established as a surveillance center to monitor Open
Surveillance Institutes of Health com (Case Western Reserve the occurrence of prion diseases, or spongiform
(NIH); American University) encephalopathies, in response to the epidemic of
Association of bovine spongiform encephalopathy (BSE)
Neuropathologists
100 Salmonella Outbreak HHS/CDC, National http://www.cdc.gov/ncidod/ Tracks, via serotyping and a statistical algorithm, Open
Detection Algorithm Center for Infectious dbmd/phlisdata/default.htm outbreaks and clinical isolates of salmonella
(SODA) Diseases (NCID)
101 EMERGEncy ID NET HHS/CD, National http://www.cdc.gov/Ncidod/ An interdisciplinary, multicenter, emergency Authorization
Center for Infectious osr/site/surv_resources/surv_ department–based network for research on
Diseases sys.htm emerging infectious diseases
102 Global Emerging HHS/CDC; http://www.istm.org/ A worldwide communication and data collection Authorization
Infections Sentinel International Society geosentinel/main.html network for the surveillance of travel-related
Network (GeoSentinel) of Travel Medicine morbidity
(ISTM)
103 Lightweight HHS/CDC; Oracle, http://www.scenpro.com/sec_ Integrates a data collection, analysis, and Authorization
Epidemiology Advanced Idaho Technology Inc.; prod_leaders.html management system for syndromal and other
Detection and Defense Advanced event-based surveillance for early detection of a
Emergency Response Research Projects bioterrorism event; can also track casualties, bed
System (LEADERS) Agency (DARPA) occupancy, and emergency department diversion
status
104 Surveillance for HHS/CDC, Division of http://www.cdc.gov/ncidod/ Monitors vancomycin-resistant S. aureus and provide Authorization
Emerging Antimicrobial Healthcare Quality dhqp/dprc_search.html confirmatory MIC testing when local testing is not
Resistance Connected to Promotion (DHOP) feasible (antimicrobial resistance)
Healthcare (SEARCH)
105 National Electronic HHS/CDC, PHIN http://www.cdc.gov/nedss/ The surveillance/monitoring component of the Public Authorization
Disease Surveillance Health Information Network; detects outbreaks
System (NEDSS) rapidly and facilitates electronic data transfer
from clinical information systems to public health
departments
106 BioSense Early Event HHS/CDC, PHIN http://www.cdc.gov/phin/ An initiative to improve U.S. capabilities for near– Authorization
Detection System component-initiatives/ real-time disease detection by using data (without
biosense/index.html patient names or medical numbers) from existing
health-related databases
107 Composite Health Care DoD http://www.mhs-helpdesk. Modified from CHCS II to provide clinical encounter Authorization
System II—Theater com/Pages/chcsii-t.asp functionality on a stand-alone laptop computer in a
(CHCS II-T) deployed theater environment

108 Indianapolis Network for HHS/NIH National http://www.inpc.org/ and five The INPC is being created as a shared database Authorization
Patient Care (INPC) Library of Medicine participating Indianapolis storing emergency room encounter records, hospital
(through Regenstrief hospitals abstracts, clinical laboratory data, and other data as
Institute for available for use by emergency departments.
Healthcare)
109 HEALTHCOM New York State http://www.health.state.ny.us/ Web-based communication system connecting Authorization
Department of Health county health departments of New York state
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110 New York State New York State http://www.health.state.ny.us/ Homepage for NY Department of Health; multiple Open
Department of Health, Department of Health topics, including disease statistics, emergency
Bureau of Community preparedness and response, food preparation
Sanitation and Food practices, etc.
Protection (BCSFP)
111 Syndromal Surveillance Santa Clara http://www.scvmed.org/scc/ Reflects data from Santa Clara County, California Authorization
Tally Sheet County, California, assets/docs/932939Keyboard
Department of Public Transmittal-0048376.PDF
Health
112 Texas Department of Texas Department of http://www.tdh.state.tx.us/ Program assists local or regional public health Open
State Health Services State Health Services ideas/about/overview/ officials in investigating and reporting outbreaks of
Infectious Disease acute infectious or rare diseases; conducts routine
Control Unit and special morbidity surveillance of diseases (Epi/
Surveillance homepage)
113 USACHPPM Health DoD/USACHPPM http://chppm-www.apgea. Weekly news update on preventive medicine, Open
Information Operations army.mil/Hioupdate/ environmental and occupational health, health
Weekly Update promotion and wellness, epidemiology and disease
surveillance, toxicology, and related laboratory
sciences related to global medical and veterinary
issues of interest
114 U.S. Geological Survey U.S. Geological Survey http://wildlifedisease.nbii.gov/ Shows the available disease data in wild animal Open
Disease Surveillance Mapping/maps.html populations overlaid on a map of the United States
Mapping
115 USDA Foreign USDA http://www.fas.usda.gov/icd/ Intended to help improve foreign market access for Open
Agricultural Service protecting.asp U.S. products and protecting the food supply
(FAS)
116 Cornell University USDA; American Meat http://cbsusrv01.tc.cornell.edu/ This internet database currently allows access to Authorization
Pathogen Tracker 2.0 Institute Foundation users/PathogenTracker/pt2/ genetic, phenotypic, and source information of a
login/login.aspx collection of foodborne and zoonotic pathogens and
food-spoilage organisms.
117 National Bovine USDA/Animal and http://www.aphis.usda.gov/ Involves the use of a rapid screening test, followed Open
Spongiform Plant Inspection lpa/issues/bse_testing/test_ by confirmatory testing for any samples that come
Encephalopathy Testing Service (APHIS) results.html back “inconclusive”
Program
118 Center for Emerging USDA/APHIS http://www.aphis.usda.gov/vs/ Assessment of disease occurrences in the United Open
Issues (CEI) Impact ceah/cei/worksheets.htm States and in foreign countries and threats to U.S.
Worksheets livestock
119 APHIS Hot Issues Archive USDA/APHIS http://www.aphis.usda.gov/ Issues considered to be of immediate interest by the Open
lpa/issues/issues.html USDA-APHIS, such as disease outbreaks and new
discoveries
120 National Animal Health USDA/APHIS http://www.aphis.usda.gov/vs/ Collects data on animal disease incidence and Open
Monitoring System ceah/ncahs/nahms/index.htm prevalence, mortality, management practices, and
(NAHMS) disease costs
121 Vesicular Stomatitis Virus USDA/APHIS http://www.aphis.usda.gov/vs/ Surveillance reports on vesicular stomatitis in U.S. Open
Surveillance ceah/ncahs/nsu/surveillance/ states
vsv/vsv.htm
122 Food and Animal USDA/FSIS http://www.farad.org/ A computerized databank of data necessary to Open
Residue Avoidance solve a drug or chemical residue problem in food-
Databank (FARAD) producing animals
123 Emerging Pathogens Department of http://www.nibs.org/FMOC/ For surveillance of emerging pathogens in 172 Authorization
Initiative (EPI) Veterans Affairs (VA) VA.pdf VA health care facilities worldwide; pathogens:
Program for Infectious vancomycin-resistant enterococcus, penicillin-
Diseases resistant pneumococcus, E. coli, candida bloodstream
infections, Clostridium difficile, cryptosporidium,
dengue, antibody-positive hepatitis C, legionella,
leishmaniasis, malaria, and others.
124 USAID Infectious Disease United States Agency http://www.usaid.gov/our_ Description and links to various USAID infectious Open
Programming for International work/global_health/id/ disease programs and reports, including specific
Development (USAID) topics: malaria, TB, surveillance, antimicrobial

resistance
National—Foreign
125 Hong Kong Government Government of the http://www.info.gov.hk/dh/ For communicable diseases, the surveillance and Open
Disease Surveillance People’s Republic of diseases epidemiology branch conducts surveillance on 30
China, Hong Kong statutorily notifiable diseases and other infections of
Special Administrative public health significance.
Region
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126 Australia National Govternment of http://www.nrl.gov.au/ Maintains quality in serological testing, particularly Open
Serology Reference Australia for retroviral and other bloodborne diseases and
Laboratory (NRL) sets standards to provide accurate and cost-effective
serological testing in screening
127 Australian National Government of http://www. Monitors animals’ health status and aids in Open
Animal Health Australia/Animal animalhealthaustralia.com. decisionmaking
Information System Health au/status/nahis.cfm
(NAHIS)
128 Transmissible Government of http://www. TSE Freedom Assurance Program homepage with TSE Open
Spongiform Australia/Animal animalhealthaustralia.com. surveillance information
Encephalopathy (TSE) Health au/programs/adsp/tsefap/
Freedom Assurance tsefap_home.cfm
Program Australia
129 Salmonella Potential Government of http://www.health.gov.au/ For early detection of potential salmonella outbreaks Open
Outbreak Targeting Australia/Department internet/wcms/publishing.nsf/
System (SPOT)/National of Health and Ageing Content/cda-surveil-surv_sys.
Enteric Pathogens htm#nepss
Surveillance Scheme
(NEPSS)
130 Australia Zoonotic Government of http://www.health.gov.au/ Pilot surveillance program for antimicrobial Open
Disease Australia/Departments internet/wcms/publishing. resistance in bacteria of animal origin; summary
of Health and Ageing nsf/Content/health- information and links to details
and Agriculture, pubhlth-strateg-jetacar-pdf-
Fisheries, and Forestry amrstrategy_affa.htm
131 Communicable Diseases Government of http://www.health.gov.au/ Current surveillance intelligence on communicable Open
Intelligence Australia/Department internet/wcms/Publishing. diseases in Australia accompanied by interpretation
of Health and Ageing nsf/Content/cda-pubs-cdipubs. and expert commentary
(Surveillance Section), htm
Communicable
Diseases and
Biosecurity Branch
132 Ministry of Health, Government of http://www.moh.gov.bh/ Ministry of health Web site containing information Open
Bahrain Bahrain for the general public and preparedness information
for health professionals
133 Ministry of Health, Government of http://www.moh.gov.bw/ Ministry of health Web site containing information Open
Botswana Botswana for the general public and preparedness information
134 Animal Disease Government of http://www.inspection.gc.ca/ A nationwide network known as CAHNet (Canadian Open
Surveillance Unit Canada/Food english/anima/surv/surve.shtml Animal Health Network) unites the disease-detection
Inspection Agency capabilities of practicing veterinarians, provincial and
university diagnostic laboratories, and the federal
government.
135 Global Public Health Government of http://www.phac-aspc.gc.ca/ GPHIN’s powerful search engines actively crawl Subscription
Intelligence Network Canada/Health the World Wide Web for reports on communicable
(GPHIN) Canada; WHO diseases and syndromes.
136 Canadian Disease Government of http://www.hc-sc.gc.ca/dc-ma/ Enhances infection-prevention and -control Open
Surveillance Directory Canada/Health surveill/index_e.html programs in health care facilities and other
Canada community settings by collecting, analyzing,
interpreting, and disseminating information related
to diseases and conditions
137 Canada Communicable Government of http://www.phac-aspc.gc.ca/ Presents current information on infectious and other Subscription
Disease Report (CCDR) Canada/Health publicat/ccdr-rmtc/05vol31/ diseases for surveillance purposes
Canada index.html
138 Notifiable Diseases Government of http://dsol-smed.phac-aspc. Database for cases of notifiable diseases in Canada Open
On-Line Canada/PHAC gc.ca/dsol-smed/ndis/c_ind_ by province, age, and sex
e.html#top_list
139 Canadian Integrated Government of http://www.phac-aspc.gc.ca/ Information is being collected on resistance in Open
Program for Canada/Public Health cipars-picra/ enteric pathogens and commensal organisms from
Antimicrobial Resistance Agency of Canada the agri-food sector, in enteric pathogens isolated

Surveillance (CIPARS) (PHAC) from humans, and on antimicrobial use in humans
and animals.
140 Danish National Hospital Government of http://www.sst.dk/Informatik_ Develops a discharge registry of all patients admitted Authorization
Discharge Registry Denmark/National og_sundhedsdata/Registre_ to Danish hospitals (except psychiatric); an algorithm
Board of Health og_sundhedsstatistik/ was developed to see if data source is useful for
Beskrivelse_af_registre/ surveillance
Landspatientregister.
aspx?lang=en
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141 Institute de Veille Government of France http://www.invs.sante.fr/beh INVS, a public establishment, under the Ministry for Open
Sanitaire (INVS) Health and the Family, has the role of supervising
the health of the whole of the population, and of
alerting the authorities in the event of threat to the
public health in France
142 SentiWeb Government of http://rhone.b3e.jussieu. Web-based reporting of weekly sentinel reports on Open
France/Department fr/senti/ communicable diseases in France
of Health, National
Institute of Health
and Medical Research
(INSERM)
143 Arbeitsgemeinschaft Government of http://www.influenza.rki. A system for monitoring influenza in Germany, led Open
Influenza (AGI) Sentinel Germany; Robert de/agi by the Robert Koch Institute, Berlin, with German
Surveillance System Koch Institute; Green Cross, Marburg, and the National Reference
pharmaceutical Center for Influenza, Berlin
companies
144 Germany GENARS Government of http://www.genars.de/ The project is concerned with the collection Open
(German Network for Germany/Federal and evaluation of antimicrobial resistance
Antimicrobial Resistance Ministry of Health epidemiological data from microbiological institutes
Surveillance) of German university clinics.
145 Robert Koch Institute Government of http://www.rki.de/cln_011/ The tasks of the Robert Koch Institute include the Open
Germany/Federal nn_231704/EN/Content/ monitoring of emerging diseases and risk factors in
Ministry of Health Prevention/prevention__ the general population, as well as the provision of
node__en.html__nnn=true scientific research.
146 Salmonella Data Bank Government of Frankfurt an der Oder, Creates a single salmonella reporting system that Authorization
(SDB) Germany/Frankfurt an Germany; URL not available combines case reports, laboratory data, veterinary
der Oder-Municipal data, agricultural data, and labor statistics
Medical Investigation
Office
147 Indian Council of Government of India http://www.icmr.nic.in/ Research priorities coincide with national health Open
Medical Research (ICMR) priorities, e.g., control and management of
communicable diseases, etc.; searchable email and
telephone directory; ICMR also has a list of medical
research centers in India
148 Ministry of Health, India Government of India http://www.mohfw.nic.in/ Ministry of health Web site containing information Open
depth.htm for the general public and preparedness information
149 Central Bureau of Health Government of India/ http://cbhidghs.nic.in/ Provides ready information on various health Open
Intelligence (CBHI) CBHI indicators for India that are of great significance to
the planners, policymakers, health administrators,
research workers, and others engaged in raising the
health and socioeconomic status of the country
150 EPIFAR Government of http://www.ncbi.nlm.nih. Tracks individual prescription histories in order to Open
Italy/National Health gov/books/bv.fcgi?rid=hstat1. provide estimates of disease prevalence
Service (NHS) table.79221
151 Ministry of Health Government of http://www.moh.gov.jm/ Ministry of health Web site containing information Open
Jamaica Jamaica for the general public and preparedness information
152 Ministry of Health, Government of Japan http://www.mhlw.go.jp/ Ministry of health Web site containing information Open
Japan english for the general public and preparedness information
153 Infectious Disease Government of Japan/ http://idsc.nih.go.jp/ The infectious Disease Surveillance Center was Open
Surveillance Center Ministry of Health, established in 1997, replacing the Division of
Labor and Welfare Infectious Disease Epidemiology.
154 National Veterinary Government of http://www.nval.go.jp/taisei/ Web page with information and contact details for Open
Assay Laboratory Japan/Ministry of etaisei/JVARM(text%20and% (JVARM)
(NVAL)–Japanese Agriculture, Forestry 20Fig)%20Final.htm
Veterinary Antimicrobial and Fisheries
Resistance Monitoring

(JVARM)
155 Ministry of Health, Government of http://www.public-health.gov. Ministry of health Web site containing information Open
Lebanon Lebanon lb/index.shtml for the general public and preparedness information
156 Ministry of Health Government of http://dph.gov.my/ddc/index. Ministry of health Web site containing information Open
Malaysia Malaysia html for the general public and preparedness information
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157 Border Infectious Government of http://www.azdhs.gov/phs/ Detects infectious disease along the U.S.-Mexico Authorization
Disease Surveillance Mexico/Secretariat of borderhealth/bids.htm border
(BIDS) Project Health; PAHO, HHS/
CDC; multiple U.S. and
Mexican state health
departments
158 Netherlands National Government of the http://www.epiet.org/ Catalogs and tracks resistance patterns of clinically Within network
Institute of Public Health Netherlands/ RIVM institutes/Bilthoven2004.htm isolated bacteria in the Netherlands
and the Environment
(RIVM) Surveillance
System
159 Ministry of Health, Government of New http://www.moh.govt.nz/moh. Ministry of health Web site containing information Open
New Zealand Zealand nsf for the general public and preparedness information
160 Disease Early Warning Government of http://www.gisdevelopment. Detects and predicts outbreaks and epidemics in Open
System (DEWS) Pakistan/National net/magazine/gisdev/2003/ Pakistan
Institute of Health may/dewsi.shtml
161 Ministry of Health, Government of Saudi http://www.moh.gov.sa/ Ministry of health Web site containing information Open
Saudi Arabia Arabia for the general public and preparedness information
162 Ministry of Health, Government of http://www.moh.gov.sg/corp/ Ministry of health Web site containing information Open
Singapore Singapore index.do for the general public and preparedness information
163 Thailand National Government of http://narst.dmsc.moph.go.th Provides trend information based on research at the Open
Antimicrobial Resistance Thailand/National facility on antimicrobial drug resistance in Thailand
Surveillance Center Institute of Health for a variety of infectious organisms
(NARST)
164 Uganda Disease Government of http:// www.health.go.ug/ Cholera, HIV/AIDS, malaria, fever, and other Open
Surveillance Uganda disease.htm transmittable diseases are continuously monitored to
ensure that the area of infection in confined
165 Communicable Disease Government of the http://www.hpa.org.uk/cdr/ National public health bulletin for England and Open
Report Weekly, Health UK/Health Protection default.htm Wales
Protection Agency UK Agency
166 Public Health Laboratory Government of the http://www.hpa.org.uk/ Provides control, surveillance, and expert advice on Open
Service (PHLS) UK/Health Protection infections/about/about.htm the control of infectious disease
Communicable Disease Agency
Surveillance Centre
(CDSC)
167 UK Zoonotic Disease Government of the http://www.noah.co.uk/ Strategy for the study of antimicrobial resistance Open
Surveillance UK/Environment, papers/defra_ab_resist_ trends among animals in England and Wales
Food, and Rural surveillance_strat_0504.pdf
Affairs
168 U.K. Food Micromodel Government of the http://www.food.gov. Allows the prediction of organism responses under a Authorization
(or Microbase) UK/Food Standards uk/science/research/ variety of conditions/stresses applied to food
Agency researchinfo/foodborneillness/
microriskresearch/
b12programme/B12projlist/
169 EpiMAN-FMD (foot- Massey University, http://www.farmpro.co.nz/ Assists disease-control authorities in the containment Authorization
and-mouth disease) and New Zealand; New devel-massey.asp and eradication of animal disease outbreaks
EpiMAN-SF (swine fever) Zealand Ministry of
Agriculture
170 Regional Influenza Northern France http://www.grog.org/ Surveillance on the arrival and circulation of Open
Surveillance Group Reference Centre influenza viruses in France
(GROG)
171 Scotland antimicrobial Health Protection http:// www.show.scot.nhs. Gateway site for antimicrobial resistance research Open
resistance information Scotland uk/scieh/infectious/hai/SSHAIP/ in Scotland, including the Scottish Antimicrobial
antimicrobial_resistance.htm Resistance Surveillance program
172 UK prion/Creutzfeldt- http://www.cjd.ed.ac.uk/ The incidence of CJD is monitored in the UK by the Open

Jakob disease PROTOCOL.htm National CJD surveillance unit based at the Western
surveillance General Hospital in Edinburgh, Scotland.
Nongovernmental Organizations
173 Biblio Directory for Geneva Foundation http://www.gfmer.ch/ A database of links to medical journals for Infectious Open
Infectious Disease for Medical Education Medical_journals/Infectious_ diseases, microbiology, tropical medicine
and Research, Geneva diseases_microbiology_
tropical_medicine.htm
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174 British Society BSAC http://www.bsacsurv.org/ The BSAC Resistance Surveillance Project monitors Open
for Antimicrobal antimicrobial resistance in England, Wales, Scotland,
Chemotherapy (BSAC) Northern Ireland, and Ireland.
Resistance Surveillance
Project
175 Global Disaster Global Disaster http:// www.gdin.org/wg/ An informational site on disasters (especially natural Open
Information Network Information Network disease.html and chemical), providing maps, reports, press
(GDIN) (GDIN) releases, and other information
176 Rapid Emergency Digital Hospital Association http:// www.reddinet.com/ A communication network linking hospitals, Authorization
Data Information of Southern California emergency medical services agencies, first
Network (ReddiNet) responders, and public health officials
177 Russia Antibiotics Interregional http://www.iacmac.ru/iacmac/ Russia’s national network for monitoring of Open
ROSNET Association for en/rosnet/ antibiotic resistance of both community-acquired
Clinical Microbiology and nosocomial infections
and Antimicrobial
Chemotherapy
(IACMAC), Russia
178 National Foundation NFID http://www.nfid.org/ A nonprofit organization founded in 1973 that Open
for Infectious Diseases educates the public and healthcare professionals
(NFID) about the causes, treatment, and prevention of
infectious diseases
179 Infectious Disease Various http://www.idrn.org/ Network for research-sharing and collaboration with Open
Research Network respect to infectious disease
Professional/Academic
180 Agriculture Network Academic alliance http://www.agnic.org/agnic/ Searchable archive of the emerging plant disease Open
Information Center pmp announcements posted to the ProMED-mail mailing
(AgNIC): Disease list
Announcements
181 American Veterinary AVMA http://www.avma.org/disaster/ AVMA disaster preparedness guides Open
Medical Association default.asp
(AVMA)
182 National Retail Data Center for Biomedical http://rods.health.pitt.edu/ Monitors sales of over-the-counter health care Authorization
Monitor (NRDM) Informatics, University NRDM.htm products to identify disease outbreaks as early as
of Pittsburgh possible; in operation since December 2002, there
are nearly 20,000 retail pharmacy, grocery, and mass-
merchandise stores that participate in the NRDM and
more than 500 public health officials across 46 states,
the District of Columbia, Puerto Rico, and the CDC
have user accounts
183 Centro de CIVIHET http://www.virus-venezuela. A center of reference for dengue and viral Open
Investigaciones de org/instituciones-centros.htm hemorrhagic disease control in Venezuela (site is in
Virosis Hemorrágicas Spanish)
y Enfermedades
Transmisibles (CIVIHET)
184 Biomedical Security Carnegie Mellon http://www.umc.pitt.edu/ The institute provides a preparedness detection Authorization
Institute (BMSI) University; University media/pcc001030/biomedical. and response capability network that can be
of Pittsburgh html used to rapidly and accurately respond to acts of
bioterrorism
185 Minnesota Microbiology Departments of Departments of Laboratory This system provides Web-based access to inpatient Authorization
Information System Laboratory Medicine Medicine and Pathology microbiology results to reduce errors in data
and Pathology and and Medicine University of retrieval.
Medicine, University Minnesota, Minneapolis; URL
of Minnesota, not available
Minneapolis
186 Stepwise and Interactive Dept. of Food http://www.google.com/ Decision-support tool, provides microbiologic Open
Evaluation of Food Technology and search?hl=en&q=Stepwise+ quantitative risk assessment for food products and
Safety by an Expert Nutritional Sciences, and+Interactive+Evaluation+ their production processes
System (SIEFE) Wageningen of+Food+safety+by+an+

Agricultural University, Expert+System+%28SIEFE
the Netherlands %29 (information search)
187 European Committee on European Society of http://www.eucast.org/ Gateway site to the EUCAST system for monitoring Open
Antimicrobial Sensitivity Clinical Microbiology antimicrobial resistance
Testing (EUCAST) and Infectious Disease
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188 FAS Terrorism Analysis FAS http:// www.fas.org/ahead/ Analysis of methods to use disease surveillance to Open
agroterror.htm prepare for bioterrorism aimed at US agricultural
systems. Also links to other FAS information,
projects.
189 Infectious Diseases IDSA http:// www.idsociety.org/ Professional association Web site, gateway for Subscription
Society of America detailed information on infectious disease topics
(IDSA)
190 ProMed Mail searchable IDSA http://www.promedmail.org/ Searchable database of global disease outbreaks Open
database pls/promed/f?p=2400:1200:164 dedicated to the rapid dissemination of information
5512851361371015 on infectious diseases and acute exposures to toxins
that affect human health, including those in animals
and in plants grown for food or animal feed
191 IDSA Emerging Infectious Disease http://www.idsociety.org/ Provider-based emerging infections sentinel Subscription
Infections Network (EIN) Society of America network providing a resource for case detection and
identification for health professionals
192 ProMed Mail Daily Infectious Disease http://www.promedmail.org/ Early warning system for emerging infectious Open
update Society of America pls/askus/f?p=2400:1000: diseases and toxins, including agroterrorism
424240
193 Microbiology Reference/ Mount Sinai Hospital; http://microbiology.mtsinai. Surveillance of antimicrobial resistance at the Mount Open
Resistance Surveillance Toronto; Pfizer, Inc. on.ca/research/cbsn/default. Sinai Hospital, Toronto, as part of the Canadian
asp Bacterial Surveillance Network
194 Virology Down Under, Queensland http://www.uq.edu.au/vdu/ A suite of pages providing information about a Open
List of Diseases University/Emerging InfectiousDiseaselinks.htm variety of human viruses, including RNA viruses and
Virus Group DNA viruses
195 Intensive Care Rollins School of http://www.sph.emory.edu/ Tracks antimicrobial resistance among pathogens Open
Antimicrobial Resistance Public Health, ICARE/index.php responsible for nosocomial infections in ICUs
Epidemiology ICARE Emory University;
Abbott; AstraZeneca;
bioMerieux; Elan;
Pfizer, Inc.
196 Haemsept Royal Victoria http://www.ncbi.nlm.nih. Detects bloodborne infections among hospitalized Authorization
Hospital, Belfast, gov/books/bv.fcgi?rid=hstat1. patients and provides guidance for antibiotic
Northern Ireland table.79218 prescribing on a hematology unit
197 UK-Scotland Animal Scottish Agricultural http://www.sac.ac.uk/ Animal health epidemiology site in Scotland, UK Open
Disease Surveillance College research/animalhealth/
researchteams/epidemiology/
198 Sociedad Venezolana de Sociedad Venezolana http://www.svinfectologia. This society deals with infectious diseases and Open
Infectología (Infectious de Infectología org/ antimicrobial resistance in Venezuela. Pathogens
Diseases Society of for antimicrobial resistance reporting Acinetobacter
Venenuela) spp, Enterobacter cloacae, Enterococcus spp, E. coli,
Haemophilus influenzae, Klebsiella spp, Neisseria
meningitidis
199 Bio-Spatio-Temporal Stanford Medical http://smi-web.stanford.edu/ A research program to develop and evaluate Open
Outbreak Reasoning Informatics, Stanford projects/biostorm/research. intelligent systems for epidemic detection and
Module (BioSTORM) University htm characterization
200 Computer-Assisted University Hospital of http://www.ncbi.nlm.nih. Integrates patient, lab, and epidemiologic Subscription
Infection (CAI) Tubingen, Germany gov/books/bv.fcgi?rid=hstat1. surveillance of antibiotic-resistance data in order to
Monitoring Program table.79218 manage nosocomial infections in ICU patients
203 Rodent Disease University of Indiana http://www.dar.uiuc.edu/ Various fact sheets prepared on rodent diseases and Open
Surveillance Program (Urbana-Champaign) disease.htm surveillance of such diseases
201 University of Alabama University of Alabama http://www.medmined.com/ Paper describing data-mining approaches for Open
Data Mining Surveillance images/pdf/MIMPaper.pdf nosocomial infection surveillance; automatically
System (DMSS) identifies new, unexpected, and interesting patterns
in surveillance data for infections that are not
constrained to outbreaks for user-defined outcomes
202 Knowledge-Based University of Giessen, http://www.ncbi.nlm.nih. Detects nosocomial infections, even when only Authorization
Information Network Germany gov/books/bv.fcgi?rid=hstat1. limited amounts of clinical data are available
Giessen (WING) table.79218

204 Realtime Outbreak and University of http://rods.health.pitt.edu/ Open-source public health surveillance software, Authorization
Disease Surveillance Pittsburgh; Carnegie RODS collects and analyzes disease surveillance data
(RODS) Mellon University in real time and has been in development since 1999
by the RODS laboratory
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205 The Disaster Database University of http://cygnet.richmond.edu/is/ Searchable database of disasters, including animal Open
Project Richmond Dept of esm/disaster/default.asp epidemics, epidemics, foodborne illness, mass
Emergency Services outbreak, waterborne illness, occupational, and
Mgmt. unknown afflictions
206 Asian Network for Various http://www.ansorp.org/ Large collaborative study group for the antimicrobial Open
Surveillance of Resistant (primary: Samsung resistance research in Asian countries
Pathogens (ANSORP) Medical Center,
Sungkyunkwan
University, Seoul,
Korea)
207 GermWatcher Washington http://www.computer. Nosocomial infection surveillance in Washington Authorization

University, St. Louis privateweb.at/judith/special_ University (St. Louis, Mo.) hospitals, based on
field3.htm#germwatcher laboratory reports; detects outbreaks of new
infections and rising endemic rates of preexisting
infections
208 World Veterinary WVA http://www.worldvet.org/ Gateway site to information of interest to Open
Association (WVA) professional veterinarians worldwide
Commercial
209 Pig Disease Surveillance 5M Enterprises, Ltd. http://www.thepigsite.com Gateway site to all information related to pig Open
farming and pork consumption
210 Meteorological ABS Consulting http://www.absconsulting. Models attacks involving weapons of mass Subscription
Information and com/midas/ destruction using real-time meteorological data
Dispersion Assessment
System Anti-Terrorism
(MIDAS-AT)
211 Animal Disease Blackwell Publishing http:// www.vetsite. Directory of publications on a wide range of Open
Surveillance Book net/~cgilib/vetbook. veterinary health issues, including abstract and
asp?File=10022256 information for the book Animal Disease Surveillance
and Survey Systems
212 Nuclear-Biological- Bruhn-Newtech, UK/ http://www.bnl-cbrn.co.uk/ Serves as a tool for risk management in emergency Subscription
Chemical Analysis Denmark and training incidents involving hazardous materials
213 DOR BioPharma, Inc. DOR BioPharma, Inc. http://www.dorbiopharma. Products in development are bioengineered vaccines Authorization
com/ designed to protect against the deadly effects
of ricin and botulinum toxins, both of which are
considered serious bioterrorism threats.
214 Automated Decision Aid Edgewood Chemical http://www.adashi.org/ Improves the response of military and civilian Subscription
System for Hazardous Biological Center personnel to a biological or chemical incident;
Incidents (ADASHI) includes hazardous agent identification, source
analysis, physical protection of responders,
decontamination, medical treatment, casualty care,
resources, and equipment
215 Emergent Biosolutions Emergent Biosolutions http://www.emergentbio A biologics company focused on the research, Authorization
solutions.com/home.asp development, and manufacture of vaccines and
related products for prophylactic and therapeutic
use against common diseases and biological
weapons of mass destruction
216 Epocrates Rx®/ Epocrates, Inc. http://www2.epocrates.com/ A drug information program for use on handheld Subscription
EpocratesID® products/rxpro/ devices by clinicians
217 Geographic Information ESRI (Environmental http://www.esri.com/ Product page for ESRI’s ArcGIS mapping software in Open
System (GIS) Disease Systems Research industries/health/index.html the health services field
Surveillance Institute, Inc.)
218 FirstWatch International First Watch http://www.firstwatchint.org/ Pay-for-use open-source intelligence service that uses Subscription
chemical, biological, International projects.html#nlr a “software agent” to collect information on CBRN
and nuclear (CBRN) data
collection
219 The Surveillance Focus Technologies http://www.focustechnologies. “World’s largest electronic laboratory surveillance Subscription

Network® (TSN®) USA com/bioinova/cms/cms. network and antimicrobial [resistance] profiling
asp?cms_XIKI33Z0G database”
220 Chemical/Biological General Dynamics http://www.veridian.com/ For the prediction of casualty and human Subscription
Operational Decision Aid Advanced Information offerings/suboffering.asp? performance-degradation analysis for military
(CODA) Systems offeringID=266&historyIDs= operations in the chemical, biological, and
0,70,266 radiological environment
93
94

221 Global Expeditionary Gerald Technologies, http://equalnox.com/eqnx/ Provides an integrated biohazard surveillance and Subscription
Medical System Inc. (contract DoD- gems.shtml detection system to keep a global watch over U.S.
USAF) military forces
222 Global Infectious Disease GIDEON Informatics, http://www.gideononline. Web-based diagnostic tool of global infectious Subscription
and Epidemiology Inc. com/ diseases and disease treatments
Online Network
(GIDEON)
223 GIS methods GIS Development Pvt. http://www.gisdevelopment. Portal to GIS methods for surveillance purposes Open
Ltd. net/application/health/links/
ma04026abs.htm
224 Biothreat Active Health Hero Network http://www.pdacortex.com/ A pilot program for use the “Health Buddy” notifier Authorization
Surveillance Integrated Inc. BASIICS.htm device to transmit patient syndromic data to a local
Information and health authority
Communication System
(BASIICS)
225 Medcast Healtheon Corp. and http://www.webmd.com/ A commercial information service for practicing Subscription
WebMD physicians; five nights a week, current medical news
stories are summarized and formatted for delivery
to the physician’s office [Service may now be part of
regular WebMD offerings]
226 EMSystemTM Infinity Healthcare, 300 hospitals in 18 EMSystem software is an Internet-based tool that Subscription
Milwaukee metropolitan regions in the can help manage hospital diversion status and
United States and Melbourne, collect real-time information for current and future
Australia; URL not available planning by EMS agencies.
227 Nuclear-biological- Litton Integrated URL not available Provides decision-support during nuclear, biological, Subscription
chemical command and Systems (now part of and chemical weapons events
control Northrop Grumman)
228 Antimicrobials, General Medscape® (WebMD) http://www.medscape.com/ Gateway site to information contained in the Subscription
Information infectiousdiseaseshome Medscape online archives
229 Motorola Emergency Motorola Corp. URL not available A wide-area radio communications network Subscription
Medical Communications designed to enhance the delivery of emergency
System medical assistance to the public
230 Systematic Approach for SAFER Corp. http://www.safersystem.com/ Models toxic releases using real-time weather Subscription
Emergency Response information
(SAFER) Real-Time
System
231 Travax® EnCompass Shoreland http://shoreland.com/ Travax functions as a reference tool for travelers Subscription
and traveling clinics. It provides country-specific
information on diseases, immunizations, travel
advisories, and WHO and CDC statements.
232 SENTRY (Jones Group/ SmithKline Glaxo http://www.fda.gov/ohrms/ A longitudinal surveillance program designed to Open
JMI Laboratories) dockets/ac/03/slides/3919S2_ track antimicrobial resistance patterns of nosocomial
03_Carnevale/sld030.htm and community-acquired infections
233 The Economist: The Economist http://www.eiu.com/ Risk assessments for over 200 separate countries that Subscription
Economist Intelligence include reporting of violent incidents
Unit
234 National Flu Surveillance ZymeTx, Inc. http://www.fluwatch.com/ Produces virtual real-time reports to keep the public Open
Network (NFSN) and public health officials alerted to the movement
of flu across the United States
NOTE: All information listed in the table is current as of the period during which data were collected for this study, July through October 2005. Some descriptions
in the table are included as self-reported by the individual sources.

95
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5.1. Accessibility of Online Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2.1. Leading Causes of Mortality, United States, 1900 and 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Globalization Increases Both Risks and Opportunities

The United States Has Responded to the Threat

There Is Consensus About Information Needs

Many Information Systems Currently Exist

Emerging Information Systems Require Evaluation

APEC Asia-Paciﬁc Economic Cooperation

HIV/AIDS human immunodeﬁciency virus/acquired immune deﬁciency syndrome

About This Study

Interviews with Stakeholders

Survey of Online Sources

How This Report Is Organized

Response to infectious disease threats is a long-standing priority of health agencies in the

Infectious Disease Threats

Rank 1900 2000

1 Tuberculosis Heart disease

4 Heart disease Chronic lower respiratory disease

5 Liver disease Unintentional injuries

8 Cancer Alzheimer’s disease

NOTE: Infectious diseases are listed in bold.

Infectious Diseases in a Modernizing World

Heymann, 2000). Rapid and unplanned urbanization, particularly in developing countries,

Near-Term Infectious Disease Threat: Avian Inﬂuenza

Responses to Threats from Infectious Disease

Global Infectious Disease Surveillance

Recent Improvements in Global Disease Surveillance

Updated International Health Regulations

Addressing a New Paradigm:

Infectious Disease and Security

Effects of Infectious Disease on Security

Implications of a Biodefense Orientation for Natural Disease Outbreaks

Infectious Disease, Security, and Disease Reporting

Infectious Disease and Recent U.S. National Security Initiatives

1. Threat awareness, including biological weapons–related intelligence, risk assessments,

HSPD-10/NSPD-33 addresses the threat of deliberate use of a biological agent. While

National Biosurveillance Integration System

National Biodefense Analysis and Countermeasures Center

Department of Defense Initiatives

Deﬁning Information Needs: Interviews with Stakeholders

1 A list of all organizations included in our interviews is in Appendix A.

We asked these individuals about2

In this chapter, we summarize the views of interviewees on these questions, describing

2 A list of speciﬁc interview questions is included in Appendix B.

Information Supports Policy Decisions

Despite Similar Information Needs, Stakeholders Consult Different Information Sources

Classiﬁcation of Information Is Important but Creates Some Obstacles

Preferences Vary for Information-Delivery Format and Methods

Stakeholders Suggested Areas for Improvement