Emerging Infectious Diseases
Review of State and Federal Disease Surveillance Efforts Gao ID: GAO-04-877 September 30, 2004The threat posed by infectious diseases has grown. New diseases, unknown in the United States just a decade ago, such as West Nile virus and severe acute respiratory syndrome (SARS), have emerged. To detect cases of infectious diseases, especially before they develop into widespread outbreaks, local, state, and federal public health officials as well as international organizations conduct disease surveillance. Disease surveillance is the process of reporting, collecting, analyzing, and exchanging information related to cases of infectious diseases. In this report GAO was asked to examine disease surveillance efforts in the United States. Specifically, GAO described (1) how state and federal public health officials conduct surveillance for infectious diseases and (2) initiatives intended to enhance disease surveillance. GAO reviewed documents, such as policy manuals and reports related to disease surveillance, and interviewed officials from selected federal departments and agencies, including the Departments of Defense (DOD), Agriculture (USDA), and Homeland Security (DHS) as well as the Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC). GAO conducted structured interviews of state public health officials from 11 states.
Surveillance for infectious diseases in the United States comprises a variety of efforts at the state and federal levels. At the state level, state health departments collect and analyze data on cases of infectious diseases. These data are required to be reported by health care providers and others to the state. State public health departments verify reported cases of diseases, monitor disease incidence, identify possible outbreaks within their state, and report this information to CDC. At the federal level, agencies and departments collect and analyze disease surveillance data and maintain disease surveillance systems. For example, CDC uses the reports of diseases from the states to monitor national health trends, formulate and implement prevention strategies, and evaluate state and federal disease prevention efforts. FDA analyzes information on outbreaks of infectious diseases that originate from foods that the agency regulates. Some federal agencies and departments also fund and operate their own disease surveillance systems and laboratory networks and have several means of sharing surveillance information with local, state, and international public health partners. State and federal public health officials have implemented a number of initiatives intended to enhance disease surveillance, but challenges remain. For example, officials have implemented and expanded syndromic surveillance systems, which monitor the frequency and distribution of health-related symptoms among people within a specific geographic area. Although syndromic surveillance systems are used by federal agencies and departments and in all of the states whose officials GAO interviewed, concerns have been raised about this approach to surveillance. Specifically, syndromic surveillance systems are relatively costly to maintain compared to other types of surveillance and are still largely untested. Public health officials are also implementing initiatives designed to enhance public health communications and disease reporting. For example, CDC is working to increase the number of participants using its public health communication systems. In addition, state public health departments and CDC are implementing an initiative designed to make electronic disease reporting more timely, accurate, and complete. However, the implementation of this initiative is incomplete. Finally, federal public health officials have enhanced federal coordination on disease surveillance and expanded training programs for epidemiologists and other public health experts. In commenting on a draft of this report, the Department of Health and Human Services (HHS) said the report captures many important issues in surveillance. HHS also provided suggestions to clarify the discussion.
GAO-04-877, Emerging Infectious Diseases: Review of State and Federal Disease Surveillance Efforts
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Report to the Chairman, Permanent Subcommittee on Investigations,
Committee on Governmental Affairs, U.S. Senate:
United States Government Accountability Office:
GAO:
July 2004:
Emerging Infectious Diseases:
Review of State and Federal Disease Surveillance Efforts:
GAO-04-877:
GAO Highlights:
Highlights of GAO-04-877, a report to the Chairman, Permanent
Subcommittee on Investigations, Committee on Governmental Affairs, U.S.
Senate:
Why GAO Did This Study:
The threat posed by infectious diseases has grown. New diseases,
unknown in the United States just a decade ago, such as West Nile virus
and severe acute respiratory syndrome (SARS), have emerged. To detect
cases of infectious diseases, especially before they develop into
widespread outbreaks, local, state, and federal public health officials
as well as international organizations conduct disease surveillance.
Disease surveillance is the process of reporting, collecting,
analyzing, and exchanging information related to cases of infectious
diseases.
In this report GAO was asked to examine disease surveillance efforts in
the United States. Specifically, GAO described (1) how state and
federal public health officials conduct surveillance for infectious
diseases and (2) initiatives intended to enhance disease surveillance.
GAO reviewed documents, such as policy manuals and reports related to
disease surveillance, and interviewed officials from selected federal
departments and agencies, including the Departments of Defense (DOD),
Agriculture (USDA), and Homeland Security (DHS) as well as the Food and
Drug Administration (FDA), and the Centers for Disease Control and
Prevention (CDC). GAO conducted structured interviews of state public
health officials from 11 states.
What GAO Found:
Surveillance for infectious diseases in the United States comprises a
variety of efforts at the state and federal levels. At the state level,
state health departments collect and analyze data on cases of
infectious diseases. These data are required to be reported by health
care providers and others to the state. State public health departments
verify reported cases of diseases, monitor disease incidence, identify
possible outbreaks within their state, and report this information to
CDC. At the federal level, agencies and departments collect and analyze
disease surveillance data and maintain disease surveillance systems.
For example, CDC uses the reports of diseases from the states to
monitor national health trends, formulate and implement prevention
strategies, and evaluate state and federal disease prevention efforts.
FDA analyzes information on outbreaks of infectious diseases that
originate from foods that the agency regulates. Some federal agencies
and departments also fund and operate their own disease surveillance
systems and laboratory networks and have several means of sharing
surveillance information with local, state, and international public
health partners.
State and federal public health officials have implemented a number of
initiatives intended to enhance disease surveillance, but challenges
remain. For example, officials have implemented and expanded syndromic
surveillance systems, which monitor the frequency and distribution of
health-related symptoms among people within a specific geographic area.
Although syndromic surveillance systems are used by federal agencies
and departments and in all of the states whose officials GAO
interviewed, concerns have been raised about this approach to
surveillance. Specifically, syndromic surveillance systems are
relatively costly to maintain compared to other types of surveillance
and are still largely untested. Public health officials are also
implementing initiatives designed to enhance public health
communications and disease reporting. For example, CDC is working to
increase the number of participants using its public health
communication systems. In addition, state public health departments and
CDC are implementing an initiative designed to make electronic disease
reporting more timely, accurate, and complete. However, the
implementation of this initiative is incomplete. Finally, federal
public health officials have enhanced federal coordination on disease
surveillance and expanded training programs for epidemiologists and
other public health experts.
In commenting on a draft of this report, the Department of Health and
Human Services (HHS) said the report captures many important issues in
surveillance. HHS also provided suggestions to clarify the discussion.
www.gao.gov/cgi-bin/getrpt?GAO-04-877.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Majorie Kanof at (202)
512-7119.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Disease Surveillance Comprises a Variety of Efforts at the State and
Federal Levels:
Public Health Officials Have Implemented Initiatives Intended to
Enhance Disease Surveillance, but Challenges Remain:
Concluding Observations:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Information on Nationally Notifiable Infectious Diseases
and Selected Worldwide Emerging Infectious Diseases:
Description of U.S. List of Nationally Notifiable Infectious Diseases,
2004:
Selected Worldwide Emerging Infectious Diseases:
Appendix III: Selected List of Systems and Networks Engaged in Disease
Surveillance:
BioSense:
Electronic Laboratory Exchange Network (eLEXNET):
Electronic Surveillance System for the Early Notification of Community-
based Epidemics (ESSENCE):
Epidemic Information Exchange (Epi-X):
Foodborne Disease Active Surveillance Network (FoodNet):
Global Outbreak Alert and Response Network (GOARN):
Global Public Health Intelligence Network (GPHIN):
Health Alert Network (HAN):
Infectious Diseases Society of America Emerging Infections Network
(IDSA-EIN):
Laboratory Response Network (LRN):
National Animal Health Reporting System (NAHRS):
National Electronic Disease Surveillance System (NEDSS):
National Electronic Telecommunications System for Surveillance (NETSS):
National Retail Data Monitor (NRDM):
National Veterinary Services Laboratories (NVSL):
PulseNet:
Real-time Outbreak and Disease Surveillance (RODS):
Sexually Transmitted Disease Management Information System (STD*MIS):
Systematic Tracking of Elevated Lead Levels & Remediation (STELLAR):
Appendix IV: Comments from the Department of Health and Human Services:
Appendix V: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Acknowledgments:
Related GAO Products:
Table:
Table 1: U.S. List of Nationally Notifiable Infectious Diseases, 2004:
Figure:
Figure 1: Selected Emerging Infectious Diseases, 1996-2004:
Abbreviations:
AIDS: acquired immunodeficiency syndrome:
BSE: bovine spongiform encephalopathy:
CDC: Centers for Disease Control and Prevention:
CSTE: Council of State and Territorial Epidemiologists:
DHS: Department of Homeland Security:
DOD: Department of Defense:
EIP: Emerging Infections Program:
EIS: Epidemic Intelligence Service:
ELC: Epidemiology and Laboratory Capacity:
eLEXNET: Electronic Laboratory Exchange Network:
Epi-X: Epidemic Information Exchange:
ESSENCE: Electronic Surveillance System for the Early Notification of
Community-based Epidemics:
FDA: Food and Drug Administration:
FELTP: Field Epidemiology and Laboratory Training Program:
FETP: Field Epidemiology Training Program:
FoodNet: Foodborne Disease Active Surveillance Network:
GAS: group A streptococcus:
GOARN: Global Outbreak Alert and Response Network:
GPHIN: Global Public Health Intelligence Network:
HAN: Health Alert Network:
HIV: human immunodeficiency virus:
HHS: Department of Health and Human Services:
IDSA-EIN: Infectious Diseases Society of America Emerging Infections
Network:
IEIP: International Emerging Infections Program:
IOM: Institute of Medicine:
LRN: Laboratory Response Network:
NAHRS: National Animal Health Reporting System:
NBS: NEDSS-Base system:
NEDSS: National Electronic Disease Surveillance System:
NETSS: National Electronic Telecommunications System for Surveillance:
NRDM: National Retail Data Monitor:
NVSL: National Veterinary Services Laboratories:
PHIN: Public Health Information Network:
RODS: Real-time Outbreak and Disease Surveillance:
SARS: severe acute respiratory syndrome:
STD: sexually transmitted disease:
STD*MIS: Sexually Transmitted Disease Management Information System:
STELLAR: Systematic Tracking of Elevated Lead Levels & Remediation:
STSS: streptococcal toxic shock syndrome:
USAMRIID: U.S. Army Medical Research Institute of Infectious Diseases:
USDA: U.S. Department of Agriculture:
vCJD: variant Creutzfeldt-Jakob disease:
WHO: World Health Organization:
United States Government Accountability Office:
Washington, DC 20548:
September 30, 2004:
The Honorable Norm Coleman:
Chairman:
Permanent Subcommittee on Investigations:
Committee on Governmental Affairs:
United States Senate:
Dear Mr. Chairman:
Infectious diseases account for millions of deaths every year. Although
the great majority of these deaths occur in developing countries,
infectious diseases are not confined by international borders and
therefore present a substantial threat to populations in all parts of
the world, including the United States. In recent years, the threat
posed by infectious diseases has grown. New diseases, unknown in the
United States just a decade ago, such as West Nile virus and severe
acute respiratory syndrome (SARS), have emerged, and known infectious
diseases once considered in decline have reappeared with increased
frequency. Furthermore, there is always the potential for an infectious
disease to develop into a widespread outbreak--which could have
significant consequences. The Centers for Disease Control and
Prevention (CDC) estimates that if an influenza pandemic[Footnote 1]
were to occur in the United States, it could cause an estimated 314,000
to 734,000 hospitalizations and 89,000 to 207,000 deaths, with
associated costs ranging from $71 to $167 billion.[Footnote 2] In
addition to naturally occurring infectious disease outbreaks, there is
also the threat posed by the deployment of infectious disease
pathogens[Footnote 3] as weapons of war or instruments of terror.
To detect cases of infectious diseases, especially before they develop
into widespread outbreaks, local, state, and federal public health
officials as well as international organizations conduct disease
surveillance. Disease surveillance is the process of reporting,
collecting, analyzing, and exchanging information related to cases of
infectious diseases. Disease surveillance provides national and
international public health authorities with information for planning
and managing efforts to control these diseases. In the mid-1990s,
public health experts in the United States and abroad determined that
infectious disease surveillance was inadequate worldwide, and both the
World Health Assembly and the President of the United States called for
concerted action to develop effective disease surveillance and response
capabilities.[Footnote 4] In 2003, the Institute of Medicine (IOM) of
the National Academies published a report that acknowledged that the
United States has taken some important steps over the past decade to
improve its disease surveillance and response capabilities, but also
emphasized the need for continued action.[Footnote 5]
You asked us to examine disease surveillance efforts in the United
States. Specifically, we describe (1) how state and federal public
health officials conduct surveillance for infectious diseases and (2)
initiatives intended to enhance disease surveillance.
To describe how state and federal public health officials conduct
disease surveillance, we reviewed reports, state policy manuals,
journal articles, and various documents related to disease
surveillance. We conducted structured interviews of state public health
officials from 11 states; interviewed representatives from professional
associations representing state and local public health officials, such
as the Association of State and Territorial Health Officials; and
interviewed officials from selected federal agencies and departments--
CDC, the Department of Defense (DOD), the Food and Drug Administration
(FDA), the U.S. Department of Agriculture (USDA), and the Department of
Homeland Security (DHS). To identify initiatives intended to enhance
disease surveillance, we reviewed and analyzed documents, such as
journal articles on states' innovative approaches to enhancing disease
surveillance. We also interviewed state public health officials from
the 11 states about their assessment of enhancements and continuing
weaknesses in disease surveillance efforts. We also reviewed and
analyzed related federal documents, such as policy directives and
annual reports, and we interviewed relevant federal health officials.
We focused our review of initiatives intended to enhance surveillance
on those currently under way or implemented since 2001. Appendix I
contains more details about our scope and methodology. We conducted our
work from October 2003 through July 2004 in accordance with generally
accepted government auditing standards.
Results in Brief:
Surveillance for infectious diseases in the United States comprises a
variety of efforts at the state and federal levels. At the state level,
state health departments collect and analyze data on cases of
infectious diseases. These data are required to be reported by health
care providers and others to the state. The diseases that must be
reported vary by state. State public health departments verify reported
cases of diseases, monitor disease incidence, identify possible
outbreaks within their state, and report this information to CDC. At
the federal level, agencies and departments collect and analyze disease
surveillance data and maintain disease surveillance systems. For
example, CDC uses the reports of diseases from the states to monitor
national health trends, formulate and implement prevention strategies,
and evaluate state and federal disease prevention efforts. FDA analyzes
information on outbreaks of infectious diseases that originate from
foods that the agency regulates. Some federal agencies and departments
also conduct disease surveillance using disease surveillance systems
that they operate or fund. For example, DOD has a syndromic
surveillance system called the Electronic Surveillance System for the
Early Notification of Community-based Epidemics (ESSENCE). ESSENCE and
other syndromic surveillance systems gather data on patient symptoms
looking for anomalous increases in the frequency of these symptoms that
may indicate the presence of an infectious disease outbreak. CDC, FDA,
USDA, and DOD also support networks of laboratories that test specimens
and develop diagnostic tests for identifying infectious diseases and
biological or chemical agents. As part of their role in national
disease surveillance efforts, some federal agencies and departments
also share information with local, state, and international partners
through different means such as from public Web sites or secure Web-
based communication systems. Finally, some federal agencies and
departments provide training, technical assistance, and funding to
support state and international disease surveillance efforts.
State and federal public health officials have implemented a number of
initiatives intended to enhance disease surveillance, but challenges
remain. For example, officials have implemented and expanded syndromic
surveillance systems, such as the Real-time Outbreak and Disease
Surveillance (RODS) system. RODS is used by officials from four of the
state health departments we interviewed and automatically gathers data
on patient symptoms from hospital emergency room visits. Although
syndromic surveillance systems are used by federal agencies and
departments and by all of the states we interviewed, concerns have been
raised about this approach to surveillance. Specifically, syndromic
surveillance systems are relatively costly to maintain compared to
other types of disease surveillance and are still largely untested.
Public health officials have also implemented initiatives designed to
enhance public health communications and disease reporting. For
example, CDC is working to increase the number of participants using
its public health communication systems. In addition, state public
health departments and CDC have taken steps intended to enhance the
information technology used for disease reporting. CDC introduced the
National Electronic Disease Surveillance System (NEDSS), which is
designed to make electronic disease reporting more timely, accurate,
and complete, in part, by consolidating the 60-100 different systems
used by state health departments to report disease data to CDC.
However, initiatives designed to enhance public health communications
and disease reporting are incomplete. Finally, federal public health
officials have enhanced federal coordination on disease surveillance
and expanded training programs for epidemiologists and other public
health experts.
In commenting on a draft of this report, the Department of Health and
Human Services (HHS) said the report captures many important issues in
surveillance. HHS also provided suggestions to clarify the discussion
or incorporate additional information. HHS's comments are reprinted in
appendix IV. In providing oral comments on a draft of this report, DOD
said it concurred and did not have any substantive comments. USDA said
it had no comments on the draft report. HHS and USDA provided technical
comments that we incorporated where appropriate.
Background:
IOM defines an emerging infectious disease as either a newly
recognized, clinically distinct infectious disease or a known
infectious disease whose reported incidence is increasing in a given
place or among a specific population. More than 36 newly emerging
infectious diseases were identified between 1973 and 2003, and new
emerging infectious diseases continue to be identified. Figure 1
provides information on selected emerging infectious diseases compiled
by the World Health Organization (WHO) and CDC.
Figure 1: Selected Emerging Infectious Diseases, 1996-2004:
[See PDF for image]
[A] SARS refers to severe acute respiratory syndrome.
[B] BSE refers to bovine spongiform encephalopathy, also called mad cow
disease.
[C] vCJD refers to variant Creutzfeldt-Jakob disease.
[D] Influenza A (H5N1) is also called avian influenza.
[End of figure]
According to CDC, nearly 70 percent of emerging infectious disease
episodes during the past 10 years have been zoonotic diseases, which
are diseases transmitted from animals to humans. The West Nile virus,
which was first diagnosed in the United States in 1999, is an example
of a zoonotic disease. The West Nile virus can cause encephalitis, or
inflammation of the brain. Mosquitoes become infected with West Nile
virus when they feed on infected birds, and infected mosquitoes
transmit the virus to humans and animals by biting them. Other zoonotic
diseases include SARS, avian influenza, human monkeypox, and variant
Creutzfeldt-Jakob disease (vCJD), which scientists believe is linked to
eating beef from cattle infected with bovine spongiform encephalopathy
(BSE) and is also called mad cow disease. Surveillance for zoonotic
diseases requires collaboration between animal and human disease
specialists.[Footnote 6]
Disease surveillance provides information for action against infectious
disease threats. Basic infectious disease surveillance activities
include detecting and reporting cases of disease, analyzing and
confirming this information to identify possible outbreaks or longer-
term trends, and applying the information to inform public health
decision-making. When effective, surveillance can facilitate (1) timely
action to control outbreaks, (2) informed allocation of resources to
meet changing disease conditions and other public health threats, and
(3) adjustment of disease control programs to make them more effective.
Responsibilities for Disease Surveillance:
In the United States, responsibility for disease surveillance is
shared--involving health care providers;[Footnote 7] more than 3,000
local health departments including county, city, and tribal health
departments; 59 state and territorial health departments; more than
180,000 public and private laboratories; and public health officials
from four federal departments. Although state health departments have
primary responsibility for disease surveillance in the United States,
health care providers, local health departments, and certain federal
departments and agencies share this responsibility. In addition, the
United States is a member of WHO, which is responsible for coordinating
international disease surveillance and response efforts.
Health Care Providers:
Health care providers are responsible for the medical diagnosis and
treatment of their individual patients, and they also have a
responsibility to protect public health--a responsibility that includes
helping to identify and prevent the spread of infectious diseases.
Because health care providers are typically the first health officials
to encounter cases of infectious diseases--and have the opportunity to
diagnose them--these professionals play an important role in disease
surveillance. Generally, state laws or regulations require health care
providers to report confirmed or suspected cases of notifiable diseases
to their local and/or state health department. A notifiable disease is
an infectious disease for which regular, frequent, and timely
information on individual cases is considered necessary for the
prevention and control of the disease. States publish a list of the
diseases they consider notifiable and therefore subject to reporting
requirements. According to IOM, most states also require health care
providers to report any unusual illnesses or deaths--especially those
for which a cause cannot be readily established.[Footnote 8]
State and Local Health Departments:
States, through the use of their state and local health departments,
have principal responsibility for protecting the public's health and
therefore take the lead in conducting disease surveillance and
supporting response efforts. Generally, local health departments are
responsible for conducting initial investigations into reports of
infectious diseases. They employ epidemiologists,[Footnote 9]
physicians, nurses, and other professionals. Local health departments
are also responsible for sharing information they obtain from providers
or other sources with their state department of health. State health
departments are responsible for collecting surveillance information
from across their state, coordinating investigations and response
efforts, and voluntarily sharing surveillance data with CDC and others.
Federal Agencies and Departments:
Several federal agencies and departments are involved in disease
surveillance. For example,
* CDC, an agency in HHS, is charged with protecting the nation's public
health by directing efforts to prevent and control diseases and
responding to public health emergencies. It has primary responsibility
for conducting national disease surveillance and developing
epidemiological and laboratory tools to enhance disease surveillance.
CDC also provides an array of technical and financial support for state
infectious disease surveillance efforts.
* FDA, which is also a part of HHS, is responsible for protecting the
public health by ensuring that domestic and imported food products
(except meat, poultry, and certain processed egg products) are safe and
properly labeled. It is also responsible for ensuring that all drugs
and feeds used in animals are safe, effective, and properly labeled and
produce no health hazards when used in animals that produce foods for
humans. FDA enforces food safety laws by inspecting food production
establishments and warehouses and collecting and analyzing food samples
for microbial contamination that could lead to foodborne illnesses.
* USDA is responsible for protecting and improving the health and
marketability of animals and animal products in the United States by
preventing, controlling, and eliminating animal diseases. USDA is also
responsible for regulating veterinary vaccines and other similar
products. USDA undertakes disease surveillance and response activities
to protect U.S. livestock, ensure the safety of international trade,
and contribute to the national zoonotic disease surveillance effort. In
addition, USDA is responsible for ensuring that meat, poultry, eggs,
and certain processed egg products are safe and properly labeled and
packaged. USDA establishes quality standards and conducts inspections
of processing facilities in order to safeguard certain animal food
products against infectious diseases that pose a risk to humans.
* DOD, while primarily responsible for the health and protection of its
service members, contributes to global disease surveillance, training,
research, and response to emerging infectious disease threats.
* DHS's mission involves, among other things, protecting the United
States against terrorist attacks. One activity undertaken by DHS is to
coordinate the surveillance activities of federal agencies and
departments related to national security.[Footnote 10]
World Health Organization:
While national governments have primary responsibility for disease
surveillance and response within their country, WHO plays a central
role in coordinating international surveillance and response efforts.
An agency of the United Nations, WHO administers the International
Health Regulations, which outline WHO's role and the responsibility of
member states in preventing the global spread of infectious diseases.
Adopted in 1951 and last modified in 1981, the International Health
Regulations require, among other things, that WHO member states report
the incidence of three diseases within their borders--cholera, plague,
and yellow fever. There are currently proposed revisions to these
regulations that will expand the scope of reporting beyond the current
three diseases to include all events potentially constituting a public
health emergency of international concern.[Footnote 11] WHO is the
agency that serves as the focal point for international information on
these diseases as well as others, and the agency also helps marshal
resources from member states to control outbreaks within individual
countries or regions. In addition, WHO works with national governments
to improve their surveillance capacities through--for example--
assessing and redesigning national surveillance strategies, offering
training in epidemiologic and laboratory techniques, and emphasizing
more efficient communication systems.
Disease Surveillance Comprises a Variety of Efforts at the State and
Federal Levels:
Disease surveillance comprises a variety of efforts at the state and
federal levels. At the state level, state health departments collect
and analyze data on notifiable diseases submitted by health care
providers and others, although the diseases considered notifiable and
the requirements for reporting them vary by state. State-run
laboratories conduct testing of samples for clinical diagnosis and
participate in special clinical or epidemiologic studies. State public
health departments verify cases of notifiable diseases, monitor disease
incidence, and identify possible outbreaks within their state. At the
federal level, agencies and departments collect and analyze
surveillance data gathered from the states and from international
sources. Some federal agencies and departments also support their own
national surveillance systems and laboratory networks and have several
means of sharing surveillance information with local, state, and
international public health partners. Finally, some federal agencies
and departments support state and international surveillance efforts by
providing training and technical expertise.
States Collect and Report Data on Notifiable Diseases, Although the
Diseases Considered Notifiable and the Reporting Requirements Vary by
State:
To conduct disease surveillance at the state level, state public health
officials collect reports on cases of notifiable diseases from health
care providers and others. Both the diseases considered notifiable and
the requirements for reporting them vary by state. Most states have
their list of notifiable diseases approximate a national list of
notifiable diseases maintained and revised by the Council of State and
Territorial Epidemiologists (CSTE) in collaboration with CDC.[Footnote
12] (See table 1 for the 2004 national list of notifiable diseases
maintained by CSTE.) This national list is reviewed annually and
revised periodically.[Footnote 13] State lists of notifiable diseases
generally include cholera, plague, and yellow fever--consistent with
WHO's International Health Regulations. On the other hand, according to
state and federal health officials, states modify their list of
notifiable diseases to reflect the public health needs of their region.
States may include diseases on their state list that impact their state
but do not appear on the national list. For example, one border state
includes the gastrointestinal disease amebiasis--a disease most often
found in the United States among immigrants from developing countries-
-in its state list of notifiable diseases. However, amebiasis is not
included on the current national list of notifiable diseases.
Conversely, states may exclude diseases that are on the national list
but have little relevance for their state. For example, although Rocky
Mountain spotted fever is listed on the national list of notifiable
diseases, it was excluded from one state's list we reviewed because
relatively few cases of this disease are reported in that area.
Appendix II provides a description of diseases on the national
notifiable disease list and other selected emerging infectious diseases.
Table 1: U.S. List of Nationally Notifiable Infectious Diseases, 2004:
Acquired immunodeficiency syndrome (AIDS);
Anthrax;
Botulism;
* Botulism, foodborne;
* Botulism, infant;
* Botulism, other (wound unspecified);
Brucellosis;
Chancroid;
Chlamydia trachomatis, genital infections;
Cholera;
Coccidioidomycosis;
Cryptosporidiosis;
Cyclosporiasis;
Diphtheria;
Ehrlichiosis;
* Ehrlichiosis, human granulocytic;
* Ehrlichiosis, human monocytic;
* Ehrlichiosis, human, other, or unspecified agent;
Encephalitis/meningitis, Arboviral;
* Encephalitis/meningitis, California serogroup viral;
* Encephalitis/meningitis, eastern equine;
* Encephalitis/meningitis, Powassan;
* Encephalitis/meningitis, St Louis;
* Encephalitis/meningitis, West Nile;
* Encephalitis/meningitis, western equine; Enterohemorrhagic
Escherichia coli;
* Enterohemorrhagic Escherichia coli, O157:H7;
* Enterohemorrhagic Escherichia coli, shiga toxin + (not serogrouped);
* Enterohemorrhagic Escherichia coli, shiga toxin positive, serogroup
non-O157;
Giardiasis;
Gonorrhea;
Haemophilus influenzae, invasive disease;
Hansen disease (leprosy);
Hantavirus pulmonary syndrome;
Hemolytic uremic syndrome, post-diarrheal;
Hepatitis, viral, acute;
* Hepatitis A, acute;
* Hepatitis B virus, perinatal infection;
* Hepatitis B, acute;
* Hepatitis C, acute;
Hepatitis, viral, chronic;
* Chronic Hepatitis B;
* Hepatitis C virus infection (past or present);
HIV infection;
* HIV infection, adult (>=13 years);
* HIV infection, pediatric (
