Emerging Infectious Diseases

Review of State and Federal Disease Surveillance Efforts Gao ID: GAO-04-877 September 30, 2004

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.

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 This is the accessible text file for GAO report number GAO-04-877 entitled 'Emerging Infectious Diseases: Review of State and Federal Disease Surveillance Efforts' which was released on November 01, 2004. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. 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 (

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