Infectious disease surveillance: a crumbling foundation.

O u r ability to detect and monitor infectious disease threats to health is in jeopardy. False perceptions that such threats had dwindled or disappeared led to complacency and decreased vigilance regarding infectious diseases, resulting in a weakening of surveillance--the foundation for control of infectious diseases (1). However, such infectious diseases as acquired immunodeficiency syndrome (AIDS), influenza, and pneumonia are leading causes of death i,n the United States and the world. As microorganisms adapt to dramatic changes in our society and environment, we remain vulnerable to a wide array of new threats in the form of emerging, resurgent, and drug-resistant infections (Table 1) (2, 3). Surveillance has served as the basis for important public health responses to new threats: identifying contaminated food or other products, determining the influenza virus strains to include in each year's vaccine, and monitoring the safety of our blood supply. Improved surveillance, including strengthened laboratories, is needed to assess the extent of illness and death associated with infectious diseases so that priorities can be assigned to control efforts. Surveillance is also critical in assessing the effectiveness of regulatory and advisory veillance has encompassed not only the reporting and investigation of cases but also the submission of clinical specimens, when needed, for testing at local, state, or federal public health laboratories. This network has constituted the foundation for guiding communicable disease prevention and control activities. The system breaks down if any one step, such as appropriate diagnostic testing, reporting by physicians to public health agencies, or follow-up investigation, is not accomplished. During the past decade, state and local support for infectious disease surveillance has diminished as a result of budget restrictions. In 12 states, for example, no personnel are dedicated to foodborne disease surveillance despite dramatic evidence that the spectrum of disease caused by microbiaOlOgically contaminated food is expanding nd that foodborne disease outbreaks in this country may be increasing (5, 6). Moreover, there has been nO Federal financial support to states for the notifiable disease surveillance system and many state health laboratories receive no federal support (7). Targeted federal programs for prevention and control of AIDS, tuberculosis (TB), sexually transmitted diseases, and childhood vaccine-preventable diseases measures designed to safeguard public have been unable to rely on data from this health, such as drinking water standards and guidelines for the prevention of infectious diseases in child care facilities. Infectious disease surveillance in the UnitedStates relies heavily upon a national notifiable disease system. The legal authority for disease reporting rests with the states, which determine diseases or conditions to be reported by all physicians, laboratories, or others to local or state public health authorities (4). In turn, the states voluntarily report cases of more than 40 infectious diseases to the Centers for Disease Control and Prevention (CDC). Sur-