Extensive means that the skill is a primary objective of the professional training for this individual typically involving many courses and apprenticeship experience.

*Diagnosis means that the individual is trained to establish a diagnosis from symptom, sign, and laboratory data, fInformation technology refers to training in programming, system architecture, and algorithms.

Wanes Epidemiologists and medical informaticians often have dual degrees, including MD or DVM (Doctor of Veterinary Medicine) so the ability related to diagnosis may vary widely.

§Physicians refers to physicians that are practicing medicine. There are thousands of MDs who have expertise in other areas such as environmental testing (e.g., physicians who supervise environmental testing by industrial hygienists, Association of Occupational and Environmental Medicine [ACOEM]). HHospital ICP: hospital infection control practitioner.

and may have difficulty communicating with each other unless their training includes exposure to the roles, methods, and concepts used by other individuals.

Many of these individuals have different "day jobs.'' Most physicians, for example, work in medical care, not biosurveillance. They, nevertheless, must be competent in the skills related to biosurveillance, such as diagnosing rare diseases and reporting the existence of a person with a communicable disease to the appropriate authorities. The professional and continuing education of physicians, veterinarians, and medical technologists must ensure that they have the necessary training in the diseases and procedures related to their biosurveillance roles—skills that will allow them to operate as components in a larger system whose goal is disease and outbreak detection and characterization. Conversely, a biosurveillance system must ensure that these individuals have the information that they need when they need it.

4.2. Multiorganizational

Biosurveillance of just a single city requires the cooperation of many organizations, including hospitals, infection control units within hospitals, laboratories within hospitals, medical practices, commercial laboratories, water suppliers, and health departments (Table 1.2).

In a region the size of the United States, there are more than 7,500 hospitals (U.S. Census Bureau, 2005), 40,000 long-term care facilities (National Center for Health Statistics, 1986), 160,000 water departments, and 185,000 clinical laboratories (CLMA, 2005). There are 3,000 local public health agencies and 60 state tribal, or territorial health departments (Hearne et al., 2004). In addition, 1.3 million farms carry livestock (Kellog, 2002), and there exist large numbers of manufacturers and distributors of food and drugs.

These organizations work collaboratively in the service of biosurveillance by communicating, exchanging data, and acting in concert during outbreaks. As we will see in Chapter 2, disease does not respect national boundaries. Outbreaks of diseases, such as severe acute respiratory syndrome (SARS) and influenza, spread quickly around the world. The set of organizations that may have to communicate and exchange information about an international outbreak may be 100-fold larger than the set that would have to collaborate for a nationwide outbreak, and the difficulty of coordination among these organizations is exacerbated by differences in languages, customs, and laws.

An engineer or a computer scientist reading the previous paragraphs would immediately characterize biosurveillance as a highly distributed process. The engineer would realize that each person and organization must perform specific functions for such an arrangement to work, and that were she to attempt to improve the process, significant attention would need to be paid to communication and coordination among the components.

TABLE 1.2 Responsibilities of Organizations for Monitoring of Environment, Detection of Cases, Detection of Outbreaks, and Outbreak Characterization


Monitoring Water, Food, Drug, Air

Case Detection

Outbreak Detection

Outbreak Characterization


Primary in hospital


Primary in hospital,

Primary in hospital,

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