6
Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Volume 7, Number 1, 2009 © Mary Ann Liebert, Inc. DOI: 10.1089/bsp.2008.0021 EARLY WARNING INFECTIOUS DISEASE SURVEILLANCE Stephanie A. Dopson The Early Warning Infectious Disease Surveillance program (EWIDS) is part of the Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism administered by the Centers for Disease Control and Prevention (CDC). The purpose of EWIDS is to develop and implement a program to collaborate with states or provinces across in- ternational borders, to provide rapid and effective laboratory confirmation, and to expand surveillance capabilities. Prior to September 11, 2001, funds were not allocated to states for improving cross-border epidemiologic and laboratory sur- veillance activities that would increase cross-border preparedness. States were required through the Cooperative Agreement to self-report data twice a year in progress reports to the Division of State and Local Readiness Management Information System (MIS). An analysis of self-reported activities was conducted to determine the activities that states most frequently chose to implement based on existing public health infrastructure along the U.S. borders, since analysis of preparedness ac- tivities on the border has not previously been conducted. This article discusses how states chose to address expanding in- frastructure capacity with the EWIDS supplemental funding, the challenges that have prevented U.S. border states from addressing all suggested activities, and the importance of sustained funding for the investment of continued capacity build- ing and collaboration with international partners. 55 T HE EARLY WARNING INFECTIOUS DISEASE SURVEIL- LANCE program (EWIDS) was originally funded in 2003 as part of the Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism admin- istered by the Centers for Disease Control and Prevention (CDC). The purpose of the EWIDS funding and program is to develop and implement activities in collaboration with border states in the United States, the Mexican states, and the Canadian provinces to ensure the provision of rapid and effective laboratory confirmation of urgent infectious disease case reports. Funding is provided to give U.S. states financial assis- tance in coordinating with neighboring provinces and states in Canada and Mexico to improve surveillance capa- bilities at the state, local, and tribal levels to promptly launch an epidemiologic investigation, to share surveillance (including laboratory) data, and to provide for appropri- ately trained public health personnel for these activities. States could choose to meet the funding requirements, in- cluding assessing surveillance and laboratory capacity on each side of the international border, improving electronic sharing of laboratory information, maintaining a database of all sentinel/clinical labs, and working to develop and agree on a list of notifiable conditions. States chose to ad- dress activities based on existing infrastructure capacity and funding. As of August 2006, a total of 18 of 20 border states par- ticipated in EWIDS, although this number has fluctuated between fiscal years 2003 and 2006. Funding has ranged from $4 million to $5.4 million; this money is distributed to the border states on the basis of yearly inbound border land crossings (Table 1). Border land crossings are calcu- Stephanie A. Dopson, MSW, MPH, is a Public Health Advisor, Coordinating Office of Terrorism Preparedness and Emergency Re- sponse, Centers for Disease Control and Prevention, Atlanta, Georgia. The findings and conclusions in this report are those of the au- thor and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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Page 1: Early Warning Infectious Disease Surveillance

Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and ScienceVolume 7, Number 1, 2009 © Mary Ann Liebert, Inc.DOI: 10.1089/bsp.2008.0021

EARLY WARNING INFECTIOUS DISEASE SURVEILLANCE

Stephanie A. Dopson

The Early Warning Infectious Disease Surveillance program (EWIDS) is part of the Cooperative Agreement on Public

Health Preparedness and Response for Bioterrorism administered by the Centers for Disease Control and Prevention

(CDC). The purpose of EWIDS is to develop and implement a program to collaborate with states or provinces across in-

ternational borders, to provide rapid and effective laboratory confirmation, and to expand surveillance capabilities. Prior

to September 11, 2001, funds were not allocated to states for improving cross-border epidemiologic and laboratory sur-

veillance activities that would increase cross-border preparedness. States were required through the Cooperative Agreement

to self-report data twice a year in progress reports to the Division of State and Local Readiness Management Information

System (MIS). An analysis of self-reported activities was conducted to determine the activities that states most frequently

chose to implement based on existing public health infrastructure along the U.S. borders, since analysis of preparedness ac-

tivities on the border has not previously been conducted. This article discusses how states chose to address expanding in-

frastructure capacity with the EWIDS supplemental funding, the challenges that have prevented U.S. border states from

addressing all suggested activities, and the importance of sustained funding for the investment of continued capacity build-

ing and collaboration with international partners.

55

THE EARLY WARNING INFECTIOUS DISEASE SURVEIL-LANCE program (EWIDS) was originally funded in

2003 as part of the Cooperative Agreement on PublicHealth Preparedness and Response for Bioterrorism admin-istered by the Centers for Disease Control and Prevention(CDC). The purpose of the EWIDS funding and programis to develop and implement activities in collaboration withborder states in the United States, the Mexican states, andthe Canadian provinces to ensure the provision of rapidand effective laboratory confirmation of urgent infectiousdisease case reports.

Funding is provided to give U.S. states financial assis-tance in coordinating with neighboring provinces andstates in Canada and Mexico to improve surveillance capa-bilities at the state, local, and tribal levels to promptlylaunch an epidemiologic investigation, to share surveillance

(including laboratory) data, and to provide for appropri-ately trained public health personnel for these activities.States could choose to meet the funding requirements, in-cluding assessing surveillance and laboratory capacity oneach side of the international border, improving electronicsharing of laboratory information, maintaining a databaseof all sentinel/clinical labs, and working to develop andagree on a list of notifiable conditions. States chose to ad-dress activities based on existing infrastructure capacity andfunding.

As of August 2006, a total of 18 of 20 border states par-ticipated in EWIDS, although this number has fluctuatedbetween fiscal years 2003 and 2006. Funding has rangedfrom $4 million to $5.4 million; this money is distributedto the border states on the basis of yearly inbound borderland crossings (Table 1). Border land crossings are calcu-

Stephanie A. Dopson, MSW, MPH, is a Public Health Advisor, Coordinating Office of Terrorism Preparedness and Emergency Re-sponse, Centers for Disease Control and Prevention, Atlanta, Georgia. The findings and conclusions in this report are those of the au-thor and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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lated by adding the number of passengers crossing in trainsor buses that require U.S. Customs processing to the num-ber of passengers crossing in privately owned vehicles at aparticular port and pedestrian crossings on foot or by cer-tain conveyance.1

EWIDS funding awards are distributed each fiscal yearbeginning August 31 and have ranged from $10,000 to$1.5 million from 2003 to 2005 and from $18,000 to $1.5 million in 2006 (www.bt.cdc.gov/surveillance/ewids).Funding is distributed to states through CDC’s PublicHealth Emergency Preparedness Cooperative Agreement.

Current studies in public health, law, and infectious dis-ease have mainly focused on conceptualizing public healthpreparedness and legal issues surrounding public healthemergencies, working to establish a surveillance policy, col-laborating about preparedness planning, and working on is-sues across international borders.2-9 This article discussesand analyzes the activities states most commonly chose toimplement in order to improve cross-border preparedness.Before September 11, 2001, funding was not allocated toU.S. states to focus specifically on surveillance and labora-tory capability. This study was conducted to determinewhich activities states are implementing to improve cross-

border preparedness because our international neighborscould assist the U.S. in public health emergencies or in theevent of a terrorist attack.

BACKGROUND

Although many of the proposed activities in the EWIDSsection of the Preparedness and Response CooperativeAgreement focus on epidemiology and surveillance, U.S.border states participating in EWIDS decided to developan all-hazards approach to cross-border preparedness andsurveillance. The all-hazards approach is not a requirementfor receiving EWIDS funding, but enhancing laboratorycapacity by being able to transport samples or communi-cate laboratory results electronically across the border anddeveloping cross-border surveillance also entails trainingpersonnel and expanding electronic information technol-ogy systems, and states determined that the all-hazards ap-proach would be the most logical in working to build re-sponse capacity across the border. Border states that choseto accept funding were given a list of activities outlined inthe EWIDS section of the Cooperative Agreement thatthey could address. Programmatic options include:

• hiring a full-time, trained epidemiologist with a master’sor doctorate degree who is devoted to border infectiousdisease surveillance;

• expanding existing infectious disease surveillance to in-clude cross-border surveillance;

EARLY WARNING INFECTIOUS DISEASE SURVEILLANCE

56 Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science

Table 1. Allocation of U.S. Border States EWIDS Funds, FY2003-FY2007

FY 2003 FY 2004 FY 2005 FY 2006State Allocation (US$) Allocation (US$) Allocation (US$) Allocation (US$)

Alaska 10,000 15,000 15,000 18,000Idaho 10,000 15,000 15,000 18,000Maine 74,220 100,121 105,825 117,309Michigan 234,139 315,848 301,285 296,641Minnesota 32,033 43,211 47,429 50,928Montana 28,279 38,148 23,414 23,837New York 341,493 460,667 401,281 427,665North Dakota 20,105 27,121 27,535 28,198Vermont 36,915 49,797 48,659 47,557Washington 125,752 169,636 170,252 182,822Illinois 10,000 15,000 15,000 N/AIndiana 10,000 15,000 15,000 N/ANew Hampshire 10,000 15,000 15,000 18,000Ohio 10,000 15,000 15,000 N/APennsylvania 10,000 15,000 15,000 18,000Wisconsin 10,000 15,000 15,000 18,000Arizona 439,378 592,711 573,948 587,973California 1,059,378 1,429,078 1,537,683 1,463,654New Mexico 23,442 63,630 46,114 46,838Texas 1,504,867 2,030,032 2,036,574 2,046,577

NOTE: Laboratory exchange method includes procedures/labora-tory database/notification /reporting protocols and laboratory as-sessment. Surveillance assessment includes sentinel sites, surveil-lance assessment tools, establishing active surveillance, exchangingdata, and joint investigations.

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• developing a 24-hour, 7 days-a-week binational borderinfectious disease surveillance coverage plan;

• planning and participating in a binational terrorism pre-paredness tabletop exercise; and

• conducting binational surveillance,10 epidemiology, andlaboratory training workshops.

States also were encouraged to develop a Health AlertNetwork (HAN) and cross-border secure internet informa-tion exchange. Laboratory surge capacity is essential, sostates were encouraged to assess laboratory capacity, im-prove electronic sharing of laboratory information, main-tain a database of all sentinel/clinical laboratories, and de-velop a list of notifiable conditions that are the same onboth sides of the border.

Since the inception of EWIDS, U.S. border states thatparticipate in EWIDS have chosen to create geographic re-gions to minimize duplication and to work with theirCanadian and Mexican counterparts in a more effectivemanner. The U.S. border states also wanted to maximizefunding distributed through the Cooperative Agreement tocomplete activities they have chosen to address either as astate or together as a region. Collaborations include part-nerships with U.S. Health and Human Services, the PublicHealth Agency of Canada, the British Columbia Centre forDisease Control, provincial ministries of health, the U.S.Department of Agriculture, the U.S. Department ofHomeland Security, U.S. Customs and Border Protection,the United States-Mexico Border Health Commission, andthe General Directorate of Epidemiology, Ministry ofHealth, Mexico.

Eighteen U.S. border states divided themselves into logi-cal geographic regional groups across the northern andsouthern borders of the United States (Indiana and Illinoischose not to accept funding and participate in the EWIDSprogram because of the limited funding they received). TheEastern Border Health Initiative is composed of Maine,New Hampshire, Vermont, and New York (NewBrunswick, Nova Scotia, Quebec). The Great Lakes BorderGroup is composed of Michigan, Ohio, Wisconsin, Min-nesota, and Pennsylvania (Ontario). The Pacific NorthwestBorder Group includes Alaska, Washington, Idaho, Mon-tana, and North Dakota (British Columbia, Alberta, YukonTerritory). The Southern Border Group is composed ofTexas, New Mexico, Arizona, and California (they workwith Mexican states across their borders including Baja Cal-ifornia, Sonora, Chihuahua, Coahuila, Nuevo Leon, andTamaulipas).

METHODS

States are required through the Cooperative Agreement toself-report data, programmatic activities, and progress twice

a year in mid- and end-of-year progress reports, which arethen submitted through the Division of State and LocalReadiness Management Information System (MIS). MIS isan electronic reporting system used by states to enter theirproposed activities for the upcoming fiscal year and mid-year and end-of-year progress reports. The information en-tered is then submitted electronically to CDC.

Some states report progress on their EWIDS activities asa region for consistent qualitative data collection purposes.After the end-of-year progress reports for the 2004 and2005 fiscal years were submitted through the MIS system,the information was extracted and descriptive statisticsanalysis was conducted for the 11 most frequently ad-dressed programmatic activities. A programmatic activitywas counted as completed if the state reported substantialprogress in implementing the activity or if the activity wasconcluded with documented results, after-action reports, orother reports. The states most frequently addressed the fol-lowing programmatic activities for cumulative fiscal years2004 and 2005 (Table 2):

• laboratory exchange/assessment,• web-based needs assessment,• training assessment,• surveillance assessment,• cross-border memoranda of understanding (MOUs),• capability of sending HAN messages across the border,• cross-border conferences with Canadian provinces or

Mexican states,• compilation of common reportable diseases,• binational training,• binational exercises, and• cross-border laboratory training.

RESULTS

There are 6 activities U.S. border states consistently ad-dressed as part of their EWIDS program. All 18 states con-ducted cross-border conferences, and 16 states (88%) de-termined which diseases were notifiable if identified by theU.S. state, Mexican state, or Canadian province. A list wascompiled of those notifiable diseases that require reportingon both sides of the border.

Laboratory exchange of information was addressed in 14(77%) of the 18 states, and 13 (72%) states conducted sur-veillance assessments. Eleven (61%) states chose to conductcross-border exercises and binational training, and 10 (55%)states are working to develop and sign MOUs or declara-tions of cooperation. Eight (44%) states are working to ex-pand the messaging capability of HAN messages across theborder. Four (33%) states conducted training assessmentsand a web-based needs assessment, and only 1 state had alaboratory exchange of personnel.

DOPSON

Volume 7, Number 1, 2009 57

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Regional groups varied in how they addressed the 11 ac-tivities. Annual regional conferences, which occurred inBritish Columbia, Bellingham (WA), New York, Michi-gan, and El Paso (TX), allowed border states to gain con-currence or conduct in-depth discussions with their Cana-dian and Mexican counterparts on pertinent issues thatwould need to be addressed during a response. These issuesincluded epidemiologic investigations, isolation and quar-antine, and moving personnel across the border to assist ina response.

The 3 regional groups with states along the Canadian bor-der have hosted annual cross-border meetings, and thesouthern border states hosted a US-Mexico Border Healthand Infectious Disease Conference.11 These regional confer-ences enabled the appropriate personnel working in cross-border preparedness efforts on both sides of the border tocollaborate over a 2- to 3-day meeting to discuss issues, meetwith working groups, and determine the next steps for mak-ing progress on identified activities. The northern borderstates produced updates on the regional workgroups and de-veloped work plans for the next fiscal year. EWIDS leadersand coordinators from all U.S. border states were usually in-vited to each of the regional meetings to foster collaborationand exchange ideas on implementation of activities.

The Pacific Northwest Alliance has alternated meetingsbetween Washington State and British Columbia for thepast 4 years, and a summary report of proceedings has beenproduced from each regional meeting.12 As a component ofthe conferences, binational tabletop exercises have beenconducted on topics including pandemic influenza and

Escherichia coli. The exercises are designed to clearly definethe international roles and responsibilities of agencies dur-ing a cross-border public health emergency and identify ar-eas that need further jurisdictional clarification. The after-action report from the 2006 Great Lakes Border HealthConference tabletop exercise identified economics as a con-sideration when making a definitive diagnosis of disease,and there are differences between jurisdictions regardingwhen notification should occur across the border. The exer-cise did provide an opportunity to learn about barriers andrestrictions to health in states and along international bor-ders and to discuss what would occur between the jurisdic-tions as the response progressed.13

Those states with regional groups created work groupsthat were tasked with specific goals and objectives. Thework groups have varied among regions. The PacificNorthwest Alliance formed epidemiology, laboratory, surgecapacity, emergency medical services, communications, ex-ercise planning, and public health law work groups. TheGreat Lakes Border Health Initiative created emergency re-sponse, food defense, laboratory, legal, and public healthcommunications subcommittees, and the Eastern BorderHealth Initiative work groups focused on epidemiology andsurveillance, laboratory, legal, and public information. Thetopic areas of the work groups are similar between the re-gions, and they further demonstrate the comprehensive ef-fort to address preparedness, since epidemiology, labora-tory, and communication will align in a public healthemergency. The legal work groups have focused on how tomove personnel and equipment across the border to assist

EARLY WARNING INFECTIOUS DISEASE SURVEILLANCE

58 Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science

Table 2. Border States’ Self-reported Programmatic Activitiesa

Activity No. of States Participating (%)

Cross-border conferencesb 18 (100)Compiling a list of common reportable diseasesc 16 (88)Laboratory exchange of informationd 14 (77)Surveillance assessmentse 13 (72)Cross-border exercises and binational training 11 (61)MOUsf or Declarations of Cooperation 10 (55)Expanding the messaging capability of HAN messages across the borderg 8 (44)Training assessments and a web-based needs assessment 4 (33)Laboratory exchange of personnel 1 (05)

aSubmitted through the Division of State and Local Readiness Management Information System. These categories were themost frequently chosen.

bCross-border conferences with Canadian provinces or Mexican states.cCompiling a list of common reportable diseases that must be reported to both sides of the border.dLaboratory exchange includes procedures/lab database/notification/reporting protocols and lab assessment, lab reporting,

sentinel lab database, and surge capacity.eSurveillance assessment includes sentinel sites, surveillance assessment tool, establishing active surveillance, exchanging

data, and joint investigations.fMemoranda of Understanding.gCapability of sending HAN (Health Alert Network) messages across the border.

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during an emergency and on developing formal agreementsbetween the countries.

Regions have drafted and signed MOUs or declarationsof cooperation for sharing data, personnel, and equipmentacross the border during a public health emergency. The le-gal subcommittee developed a formal agreement that wassigned by the states in the Great Lakes Border Health Ini-tiative and the Ontario Ministry of Health and Long-TermCare on October 18, 2007. The agreement identifies re-sources that would be shared between states and theprovince of Ontario. The Eastern Border Health Initiativeis currently drafting a public health data sharing agreementwith Nova Scotia, and the state of Washington Departmentof Health signed a Memorandum of Understanding forPublic Health Emergencies with the British ColumbiaMinistry of Health on June 20, 2006, for preparing and re-sponding to public health emergencies and assistance dur-ing recovery. They are also in the final stages of formalizinga Pacific Northwest Border Health Alliance that will in-clude Washington, Oregon, Idaho, Alaska, British Colum-bia, and the Yukon Territory. Creating these agreementsand determining the legal parameters of assistance before anemergency will enable the ease of movement of needed per-sonnel and goods between the 2 countries when respondingto an event.

Regional groups also developed cross-border surveillanceprotocols, which will ensure consistent methods of con-ducting an epidemiologic outbreak investigation. Surveil-lance capability is being expanded along the border, anddatabase directories of laboratories are being establishedwith each laboratory’s testing capabilities. Other statescompiled a comparison guide of category A agents, testmethods, and reporting units for Laboratory Response Net-work (LRN) and non-LRN laboratories. Surveillance capa-bility is of particular importance, since conducting epi-demiologic case investigations during an outbreak is easierwith an existing infrastructure capability. Before the sup-plemental EWIDS funding, many border states did nothave the funding to create or expand this capability.

Along the southern border, California has been workingwith laboratories in Mexico for several years, with a currentfocus on easier transport of laboratory samples across theborder. There have been several conferences hosted in ElPaso, Texas, for the southern border states including a US-Mexico Border Health and Infectious Disease Conferencein July 2005 and a Security and Prosperity Conference,which included Canada and Mexico, in March 2007. TheAssociation of State and Territorial Health Officials, aCDC partner organization, also hosted 2 border meetingsfor the northern and southern border states;11 the fundingwas provided by CDC through a Cooperative Agreementwith the Association of State and Territorial Health Offi-cials. These meetings provided another opportunity for the

U.S. border states to meet and discuss the issues and barri-ers they were experiencing in implementing their activitieswith Canada and Mexico.

States also have chosen to address expanding electronicmessaging and transmission of data across the border. Pilottesting is currently being conducted with Canada usingtheir Canadian Integrated Outbreak Surveillance Centresystem to transmit information. The expense of buildinginformation technology systems is a barrier in expandinginformation systems, and a current frustration for Mexico isthe challenge of interfacing with 4 different U.S. systemswhen Mexico has 1 comprehensive system. Conducting as-sessments and training across the border has been impor-tant, but these assessments and training sessions are time-consuming and costly for public health staff. However, theassessments enable U.S. states to determine where to focustheir programmatic efforts, given limited funding.

Barriers prevented implementation of certain activitiesthat were not addressed frequently, including messagingacross the border, conducting training assessments, andconducting a web-based needs assessment and laboratoryexchange of personnel, which are very time- and labor-in-tensive because they require preparatory work prior to im-plementation. Expanding the Health Alert Network formessaging is a long-term project, and more federal involve-ment is needed, along with funding, for building informa-tion technology systems. Another barrier is bureaucracy onboth sides of the border, including the difficulty of gettinga foreign country to agree to participate in certain activities,especially for those projects that will require long-term in-vestment and participation, such as conducting needs as-sessments. For laboratory exchange, some states have con-ducted 1-day site visits, but state restrictions on personneltraveling internationally have hampered multiple visits.There is also the issue of provincial laboratories agreeing toreceive someone from the U.S. for a visit to learn their lab-oratory protocols.

Limitations of this study include using subjective dataanalysis that is based on self-reporting, which is not alwaysconsistent between states. In addition, subjectivity plays apart in determining which states had sufficiently addressedan activity through specific tasks or deliverables to becounted as completed. The greatest limitation is not havinga concept or definition of “preparedness”; therefore, no de-fined set of activities exists by which to measure states as be-ing “prepared.” Had preparedness been defined through aset of specific activities, CDC could have required states toaddress these activities, thereby ensuring preparedness orthe capability of responding to a public health emergencyor terrorist attack. Another limitation is that only end-of-year reports were used for fiscal years 2004 and 2005, be-cause these were the only reports available at the time ofsubmission.

DOPSON

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CONCLUSION

Base funding for the Terrorism Preparedness CooperativeAgreement has continued to decrease since the attacks ofSeptember 11, 2001, from the initial budget appropriationof approximately $1 billion to $705 million for the 2008fiscal year. Although the EWIDS supplemental fundinghas remained steady, this funding is also expected to de-cline.

However, the issues surrounding cross-border prepared-ness efforts persist. Despite limited EWIDS funding forsurveillance, some activities have expanded, including elec-tronic messaging systems for notification across the borderand legal issues surrounding international agreements andMOUs, and much of this work would not have been con-ducted without the separate EWIDS funding. The workand activities that have not been addressed have been ham-pered by limited funding and the time needed to build andsustain a program. The U.S. border states, Mexico, andCanada want to continue working to expand CDC’s Labo-ratory Response Network into Canada and Mexico and lab-oratory surveillance through PulseNet and FoodNet. Ex-pansion of the LRN into Canada and Mexico will increasethe number of laboratories in the LRN network of labs thatcan respond to public health emergencies and terrorism.Many EWIDS states have not conducted training assess-ments and laboratory training because states were limited tochoosing activities to address on the basis of existing infra-structure capacity and funding.

Sustained funding for the investment of building capa-bilities and collaboration with international partners will al-low states to continue implementation of their activitiesand look at those activities they have not had the opportu-nity to address. Advances made in defining the parametersfor cross-border preparedness will advance the efforts to de-fine overall state preparedness and the activities that shouldoccur to ensure a state is prepared for a public health emer-gency.

ACKNOWLEDGMENTS

Funding for EWIDS is provided by the U.S. Departmentof Health and Human Services. I acknowledge John Erick-son, Wayne Turnburg, Kathy Allen-Bridson, RichardBuck, Chaz Lacy-Martinez, and Bob Benson for their per-sistence and dedication to cross-border preparedness effortsand Rich Anne Baetz, MSCRP, for her assistance with dataextraction and interpretation. Special thanks to Raul So-tomayer.

REFERENCES

1. U.S. Department of Transportation, Research and InnovativeTechnology Administration, Bureau of Transportation Sta-tistics, Border Crossing/Entry Data; based on data from U.S.Department of Homeland Security, Customs and BorderProtection, OMR database. www.transtats.bts.gov/omepage.asp. Accessed January 7, 2009.

2. Bashir Z, Lafronza V, Fraser MR, Brown CK, Cope JR. Localand state collaboration for effective preparedness planning. J Public Health Manag Pract 2003;9(5):344-351.

3. Colmers JM, Fox DM. The politics of emergency healthpowers and the isolation of public health. Am J Public Health2003;93:397-399.

4. Fidler DP. Legal issues surrounding public health emergen-cies. Public Health Rep 2001;116(Suppl 2):79-86.

5. Garfield R. State preparedness for bioterrorism and publichealth emergencies. Issue Brief (Common Fund) 2005;829:1-12.

6. Nelson C, Lurie N, Wasserman J, Zakowski S. Conceptualiz-ing and defining public health emergency preparedness. Am JPub Health 2007;97(Suppl 1):S9-S11.

7. Steir DD, Goodman RA. Mutual aid agreements: essential le-gal tools for public health preparedness and response. Gov-ernment, Politics and Law 2007;97(Suppl 1):S62-S68.

8. Vernick JS. Bioterrorism and public health law. JAMA2002;288:2685-2687.

9. Williams JR, Edwards JC, et al. Study of Disease SurveillancePolicy Issues across the International Borders of the UnitedStates. College Station: Rural and Community Health Insti-tute, Health Science Center, Texas A&M University System;2006.

10. Weinberg M, Waterman S. The U.S. Mexico Border Infec-tious Disease Surveillance Project: establishing binationalborder surveillance. Emerg Infect Dis 2003;9:97-102.

11. Association of State and Territorial Health Officials. Issue Re-port: Improving Public Health Preparedness in the U.S. MexicoBorder Region. Washington, DC: Association of State andTerritorial Health Officials; 2007. www.astho.org/pubs/US-MexicoCrossBorderReport.pdf. Accesses January 7, 2009.

12. Washington State Department of Health. Summary Reportfor Annual Pacific Northwest Cross Border Workshop; 2005.

13. Michigan Department of Community Health. Great LakesBorder Health Initiative Conference; 2006.

Manuscript received April 1, 2008;accepted for publication December 9, 2008.

Address reprint requests to:Stephanie A. Dopson, MSW, MPH

Centers for Disease Control and Prevention1600 Clifton Road

MS A-20Atlanta, GA 30333

E-mail: [email protected]

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60 Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science