Introduction

This chapter explores types of biosurveillance data not already discussed in Part IV and elsewhere in this book. We discuss data for which research shows significant potential, as well as data for which value is suggested by early research or conjectured, but awaits confirmation by definitive studies. We also mention data that have been studied and have not panned out. We conclude the chapter with a discussion of monitoring in permissive environments. Permissive environments are situations in which more 'privacy-invasive' biosurveillance may be possible through consent of those being monitored.

We group the data into clinical, preclinical, and presympto-matic categories. Preclinical data are data that are the result of illness behavior that precedes seeking of clinical care. Presymptomatic data are data that might be obtained about a person during the incubation period of a disease.

We use the clinical-preclinical-presymptomatic distinction to group data in this chapter because it indicates the inherent earliness of data for detection of outbreaks. Although the inherent earliness of data is not the only factor that determines when an outbreak will be detected, it does define a theoretical limit to the earliness that can be achieved.

Clinical data, for example, become available about a patient relatively late after the onset of illness, but this delay is potentially offset by better diagnostic precision of the data. Moreover, clinical data typically are associated with a patient identifier, allowing a biosurveillance system to link the data with other observations about a sick individual to improve the accuracy and precision with which the patient is classified into a syndrome or disease category.

Preclinical data are inherently earlier than clinical data, but often cannot be linked at the patient level. Preclinical data are especially helpful for outbreaks in which people do not seek medical advice or care, or do not do so early in the illness.

Presymptomatic data such as antibody or antigen levels detected in blood samples are theoretically the earliest data— dramatically earlier than preclinical or clinical data for diseases with very long incubation periods such as HIV—but, presymp-tomatic data are rarely collected at present.

For convenient reference,Table 28.1 summarizes the surveillance data already discussed in this book and provides chapter numbers. Table 28.2 lists data discussed in this chapter.

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