Strengthening Surveillance for Health Security Threats: The Time Is Now

Now, more than ever, it is critical for the health security community to examine its surveillance capabilities. Back-to-back epidemics of Zika and Ebola have demonstrated the severe health, social, and economic consequences generated by infectious disease outbreaks. Because initial detection of both outbreaks was slow, the viruses spread quickly—in some cases, across multiple countries—before affected communities could launch effective public health responses. Key questions about the underlying epidemiology of these viruses have further complicated decision making around response efforts. That the public health community was caught off guard by the emergence and spread of these viruses should encourage a closer analysis of the surveillance systems we rely on to detect and respond to health security threats and should spur action toward much-needed, sustainable improvements.

It is against this backdrop that we publish this special issue of Health Security, titled “Surveillance and Health Security: Building the New Systems We Need to Detect and Manage Health Threats.” Surveillance systems are the cornerstone of effective public health and healthcare responses to existing, emerging, and evolving health threats. Such systems inform efforts to secure the world from infectious disease outbreaks, as well as a wide spectrum of other naturally occurring and man-made threats: cases of endemic disease, disease outbreaks, industrial accidents, environmental catastrophes, acts of terrorism, and other mass-casualty events. While there have been important advances in surveillance over the past 15 years, recent crises remind us that important gaps in our current capabilities nevertheless remain.

This issue features wide-ranging analyses of current and future surveillance practices and their associated impacts. First, we present 2 articles on the role of diagnostics in improving detection and characterization of infectious disease threats. Deshpande et al. describe advances in multiplexed molecular diagnostics that could expedite detection of various organisms with epidemic potential, including Ebola, malaria, and dengue. Rapid, point-of-care diagnostics may enable practitioners to capture diagnostic information as well as surveillance-relevant data. However, despite such advances in molecular diagnosis, a consensus-review by Doggett et al. concludes that the current state of molecular testing does not yet replace the need for culture-based diagnostics. Rather, key surveillance information, such as epidemic linkages made through PFGE testing and characterization of antibiotic sensitivity, may be lost through increasing clinical reliance on rapid molecular tests. Taken together, these articles underscore a need for a balanced approach to development and acquisition of diagnostics that considers the specific impact of such tools on existing surveillance systems.

Next, we learn in this issue that traditional, indicator-based surveillance systems continue to play important roles in describing the burden of routine infections and collecting data that shed new light on the epidemiology of such infections. Li et al., for example, describe how surveillance for shigellosis can elucidate patterns and risk factors associated with antimicrobial-resistant infections. This article demonstrates the value of traditional indicator-based surveillance systems in improving understanding of emerging disease threats, and it underscores the importance of strengthening research efforts around those threats.

We also consider the role of new surveillance systems in enhancing situational awareness during public health crises. Rhee et al. describe the use of syndromic surveillance during a joint US-Korea military collaboration and present lessons learned from that effort. Ricardo et al. offer insights into preparing for mass gatherings, recounting Italian health authorities' efforts to establish an event-based surveillance system for an international exposition in Milan that drew more than 21 million visitors from across the world. Additionally, Ayala et al. describe local public health surveillance strategies employed during Super Bowl XLIX in 2015, as well as associated health outcomes, challenges, and lessons learned.

Two articles describe future visions for health security surveillance and efforts to improve global capacities for detecting and responding to health security events. Velsko and Bates describe a new conceptual framework that synthesizes existing literature on biosurveillance, addresses digital applications and “big data” analytics for surveillance systems, proposes governance structures for future surveillance systems, and offers suggestions for improving surveillance system integration into state and local public health capabilities. Finally, Wolicki et al. argue that as nations work domestically and with international partners to strengthen national and collective health security under the Global Health Security Agenda, improving surveillance capacities at the local, national, and international levels should remain a top priority of these efforts.