CONTEXT: Traditional biothreat surveillance systems are vulnerable to incomplete and delayed reporting of public health threats. OBJECTIVE: To review current and emerging approaches to detection and monitoring of biothreats enabled by laboratory methods of diagnosis and to identify trends in the biosurveillance research. DATA SOURCES: PubMed (1995 to December 2007) was searched with the combined search terms "surveillance" and "infectious diseases." Additional articles were identified by hand searching the bibliographies of selected papers. Additional search terms were "public health," "disease monitoring," "cluster," "outbreak," "laboratory notification," "molecular," "detection," "evaluation," "genomics," "communicable diseases," "geographic information systems," "bioterrorism," "genotyping," and "informatics." Publication language was restricted to English. The bibliographies of key references were later hand searched to identify articles missing in the database search. Three approaches to infectious disease surveillance that involve clinical laboratories are contrasted: (1) laboratory-initiated infectious disease notifications, (2) syndromic surveillance based on health indicators, and (3) genotyping based surveillance of biothreats. Advances in molecular diagnostics enable rapid genotyping of biothreats and investigations of genes that were not previously identifiable by traditional methods. There is a need for coordination between syndromic and laboratory-based surveillance. Insufficient and delayed decision support and inadequate integration of surveillance signals into action plans remain the 2 main barriers to efficient public health monitoring and response. Decision support for public health users of biosurveillance alerts is often lacking. CONCLUSIONS: The merger of the 3 scientific fields of surveillance, genomics, and informatics offers an opportunity for the development of effective and rapid biosurveillance methods and tools.
Laboratory-Guided Detection of Disease Outbreaks Three Generations of Surveillance Systems Vitali Sintchenko, MD, PhD; Blanca Gallego, PhD ● Context.—Traditional biothreat surveillance systems are Three approaches to infectious disease surveillance that in- vulnerable to incomplete and delayed reporting of public volve clinical laboratories are contrasted: (1) laboratory- health threats. initiated infectious disease notiﬁcations, (2) syndromic sur- Objective.—To review current and emerging approaches veillance based on health indicators, and (3) genotyping to detection and monitoring of biothreats enabled by lab- based surveillance of biothreats. Advances in molecular di- oratory methods of diagnosis and to identify trends in the agnostics enable rapid genotyping of biothreats and inves- biosurveillance research. tigations of genes that were not previously identiﬁable by Data Sources.—PubMed (1995 to December 2007) was traditional methods. There is a need for coordination be- searched with the combined search terms ‘‘surveillance’’ tween syndromic and laboratory-based surveillance. Insuf- and ‘‘infectious diseases.’’ Additional articles were identi- ﬁcient and delayed decision support and inadequate inte- ﬁed by hand searching the bibliographies of selected gration of surveillance signals into action plans remain the papers. Additional search terms were ‘‘public health,’’ ‘‘dis- 2 main barriers to efﬁcient public health monitoring and ease monitoring,’’ ‘‘cluster,’’ ‘‘outbreak,’’ ‘‘laboratory no- response. Decision support for public health users of bio- tiﬁcation,’’ ‘‘molecular,’’ ‘‘detection,’’ ‘‘evaluation,’’ ‘‘gen- surveillance alerts is often lacking. omics,’’ ‘‘communicable diseases,’’ ‘‘geographic informa- Conclusions.—The merger of the 3 scientiﬁc ﬁelds of tion systems,’’ ‘‘bioterrorism,’’ ‘‘genotyping,’’ and ‘‘infor- surveillance, genomics, and informatics offers an oppor- matics.’’ Publication language was restricted to English. tunity for the development of effective and rapid biosur- The bibliographies of key references were later hand veillance methods and tools. searched to identify articles missing in the database search. (Arch Pathol Lab Med. 2009;133:916–925) B iosurveillance has been made a health care priority be- cause of rising concerns over emerging infectious dis- eases and possible bioterrorism.1,2 The number of micro- demiology presents new challenges to countries, both in terms of the understanding and monitoring of determi- nants of infections and in terms of service provision and bial threats—in the form of newly identiﬁed pathogens, the implementation of appropriate prevention measures. infections crossing the species barrier to people, diseases Traditional biothreat surveillance systems are vulnera- and vectors adapting to new environments, and microbial ble to the incomplete and delayed reporting of public agents appearing in more virulent forms—has multiplied health threats.4 Recent outbreaks of reemerging and new to an unprecedented degree.2,3 New and newly recognized communicable diseases have highlighted inefﬁciencies in infectious diseases are now being reported at the rate of public health monitoring and control systems. Speciﬁcally, about 1 per year. At least 33 completely new pathogens, many outbreaks have been characterized by delayed rec- including HIV and severe acute respiratory syndrome, have ognition and/or public health response.5,6 For example, emerged during the past 3 decades.3 In addition, the ep- analysis of 51 outbreaks reported in the United States be- idemiology of well-known infectious diseases has been tween 1999 and 2000 demonstrated that only 42% were changing because of the globalization of trade and in re- detected within 1 week of the ﬁrst case, and 29% were sponse to immunization campaigns. This changing epi- identiﬁed after a month or more.7 Such delays diminish the window of opportunity to mount effective response measures and are likely to be costly to society.8 It was Accepted for publication January 6, 2009. estimated that in Canada, a 1-week delay in the imple- From the Centre for Infectious Diseases and Microbiology, Western mentation of control measures for severe acute respiratory Clinical School, The University of Sydney, Westmead Hospital (Dr syndrome resulted in a 2.6-fold increase in the mean ep- Sintchenko), and the Centre for Health Informatics, University of New idemic size and a 4-week extension of the mean epidemic South Wales (Drs Sintchenko and Gallego), Sydney, Australia. duration.9 Deaths from anthrax would be expected to dou- Based on a presentation delivered at the First World Congress On
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