SURVEILLANCE AND DETECTION: A PUBLIC 

HEALTH RESPONSE TO BIOTERRORISM 

by 

Barbara F. Bullock 

The Counterproliferation Papers 

Future Warfare Series No. 12 

USAF Counterproliferation Center

Air University 

Maxwell Air Force Base, Alabama

Surveillance And Detection: 

A Public Health Response To Bioterrorism

Barbara F. Bullock 

February 2002 

The Counterproliferation Papers Series was established by the USAF 

Counterproliferation Center to provide information and analysis to assist 

the understanding of the U.S. national security policy-makers and USAF 

officers to help them better prepare to counter the threat from weapons of 

mass destruction. Copies of No. 12 and previous papers in this series are 

available from the USAF Counterproliferation Center, 325 Chennault 

Circle, Maxwell AFB AL 36112-6427. The fax number is (334) 953-

7530; phone (334) 953-7538. 

Counterproliferation Paper No. 12 

USAF Counterproliferation Center

Air University 

Maxwell Air Force Base, Alabama 36112-6427

The internet address for the USAF Counterproliferation Center is: 

http://www.au.af.mil/au/awc/awcgate/awc-cps.htm

Contents 

Page 

Disclaimer.....................................................................................................i

The Author.................................................................................................. ii

Acknowledgments ..................................................................................... iii

Tables..........................................................................................................iv

I. Introduction .............................................................................................1 

II. Local Disease Surveillance and Detection by Physicians......................5 

III. Local Laboratory Surveillance and Capacity .......................................9 

IV. Problems with Current Epidemiologic Investigation .........................11 

V. Efforts to Enhance Surveillance and Detection ...................................15 

VI. Recommendations ..............................................................................19 

VII. Conclusion.........................................................................................23 

Appendix A................................................................................................25 

Notes..........................................................................................................27 

i

Disclaimer 

The views expressed in this publication are those of the author and do 

not reflect the official policy or position of the U.S. Government, 

Department of Defense, or the USAF Counterproliferation Center. 
ii

The Author 

Barbara Franklin Bullock is an acquisition program manager at the 

Standard Systems Group, Maxwell AFB-Gunter Annex, Alabama. A 

June 2001 graduate of the Air Command and Staff College, she entered 

federal service in July 1974 as a computer programmer, after earning a 

Bachelor of Science degree in mathematics from Alabama A&M 

University. Her career encompasses over 27 years of experience 

facilitating the acquisition, development, testing, deployment and 

sustainment of Air Force base-level automated systems. She holds 

acquisition professional development program Level II ratings in program 

management and communications-computers. In her current assignment 

as the Deputy Program Manager for the Case Execution Management 

Information System (CEMIS), she works to develop a replacement 

management information system for the ordering and shipping of U.S. 

defense articles and services to foreign countries. 
iii

Acknowledgments 

I entered this elective course absent a wealth of knowledge about the 

subject matter. I end it appreciably more informed. For this, I thank 

Dr. Costanzo and other knowledgeable members of the seminar who 

contributed greatly to this evolution. Additionally, I thank the Air 

University Library staff for their assistance in locating needed material for 

my research and Ms. Pamela Hollabaugh for her assistance with the 

research template. 
iv

List of Tables 

Table 1. Epidemiologic Clues to a Possible Bioterrorist Attack ..............25 

Table 2. Diagnostic Samples, Assays, and Isolation Precautions for 

Biological Warfare Agents ........................................................................26 
Surveillance and Detection . . . 1 

Surveillance and Detection: 

A Public Health Response to Bioterrorism 

Barbara F. Bullock 

I. Introduction 

Perhaps the most frightening apparition of our times is the possibility 

that a biological agent (bacterium, virus, or toxin) will be used to attack 

our unprotected civilian population and inflict mass casualties. Until the 

Fall of 2001, anthrax attacks delivered through the mail to various U.S. 

senators, to the Governor of New York, and to various media offices, the 

previously expected use of a weapon of mass destruction against the 

United States has been a nuclear device that explodes or a chemical cloud 

that is set adrift. However, today, of all the weapons of mass destruction 

(nuclear, chemical, and biological), the biological weapons are the most 

feared by many defense experts but these are the ones that our country is 

least prepared to deal with.1

 Like the concept of a “nuclear winter,” the 

potential destructiveness of a biological attack can come in many forms and is 

presently very hard to detect and control, and its results could be catastrophic. 

The unleashing of biological agents against an unprotected civilian 

population also, in some cases, constitutes the ultimate medical disaster with 

the capability to completely overwhelm the present health care system. 

Patients might go to health facilities in unprecedented numbers and demands 

for intensive care could well exceed available medical resources. Discerning 

the threat of bioweapons and appropriate responses to them are critical if we 

are to prevent the devastating effects of bioterrorism. 

In the last century not a single American is known to have died as a 

result of bioterrorism.2

 Yet, even before the anthrax attacks of late 2001, 

in previous years, the threat of bioterrorism used against our civilian 

population had attracted the attention and the resources of U.S. leaders 

through congressional hearings, government warnings, funding, research 

studies, and commentaries.3

 For example, during the first “National 
2 . . . Surveillance and Detection

Symposium on Medical and Public Health Response to Bioterrorism” held 

in 1999, Donna Shalala, former Secretary of Health and Human Services, 

identified four challenges that our government cannot meet alone in 

combating this emerging threat: 1) awareness, 2) preparedness, 3) public 

health and medical communities taking the lead in this fight, and 4) 

cooperation between all levels of government and the medical community.4 

Awareness, our first challenge, centers on recognizing that an act of 

bioterrorism in the United States has already happened. In late 2001, 

someone mailed anthrax-laced envelopes to various U.S. Senators, the 

Governor of New York, media leaders, and others in the wake of the 

September 11th terrorist events sponsored by Osama bin Laden’s Al 

Qaeda organization. Because of America’s unrivaled military 

preparedness, potential enemies (rogue states, international terrorists, and 

national terrorists) are more likely to resort to asymmetrical biological 

attacks rather than conventional military confrontations. Jonathan B. 

Tucker, noted expert at the Monterey Institute of International Studies, 

states that “a biological arsenal might serve as the basis of an ‘asymmetric 

strategy’ in which, instead of confronting a superior conventional military 

power head-on, the weaker state employs biological weapons to inflict 

high casualties, spread terror, and undermine the enemy’s will to fight.”5 

Biological weapons share seven characteristics that make them ideal 

weapons for rogue nations and terrorists: 1) ease and low cost of 

production; 2) ease of dissemination as aerosols; 3) efficient exposure of 

great numbers of people through inhalation; 4) delayed effect; 5) high 

potency; 6) high subsequent mortality and morbidity; and, 7) their ability 

to wreak psychological havoc.6

 

Biological attacks could create mass casualties if properly 

manufactured, if appropriate delivery systems are provided, and if 

meteorological conditions are right. For example, Secretary of Defense 

William Cohen has stated that a bioterrorism attack of 100 kilograms of 

anthrax, properly dispersed, would have the impact of two to six times the 

fatality consequence of a single megaton nuclear bomb.7

 Initially, 

discussions about the implications of bioterrorism were largely restricted 

to the Department of Defense, Department of State, Federal Bureau of 
Surveillance and Detection . . . 3 

Investigation (FBI), and the intelligence communities. Only recently have 

the civilian medical and public health communities begun to engage the 

practical challenges posed by this threat. Professional societies have 

begun to incorporate discussions of bioterrorism in national meetings and 

in 1998, the World Health Organization established an expert group to 

review and revise its 1970 landmark document, “Health Aspects of 

Chemical and Biological Weapons.”8

Once aware of the threat, preparing a credible national medical 

response to any such attack is the second challenge. In May 1998, 

President Clinton signed Presidential Decision Directive 62 to define the 

Administration’s policies on preparedness against weapons of mass 

destruction and other unconventional threats, and to designate the first 

National Coordinator to bring together various federal programs on 

unconventional threats.9

 The Department of Health and Human Services 

spent 158 million dollars and 230 million dollars in fiscal years 1999 and 

2000, respectively, to fund its ongoing “Anti-Bioterrorism Initiative,” 

devised to significantly raise our level of preparedness to include public 

health surveillance, epidemiological capacity, medical response, building a 

stockpile of pharmaceuticals, and research and development.10 Public 

health surveillance, the ongoing systematic collection, analysis, 

interpretation, and dissemination of health data, plays a major role in our 

preparedness by enabling epidemiologists to use the collected data to 

detect biological outbreaks and characterize disease transmission patterns 

by time, place, and person. 

With a bioterrorism attack, the public health and medical 

communities are our frontline response. They are the ones who must first 

detect that the incident has actually occurred, identify the biological agent, 

decontaminate the area (if needed), determine the likelihood of secondary 

transmission, identify the exposed population, and provide preventive 

measures and treatments.11 First responders are emergency department 

physicians and nurses, infectious disease physicians, infection control 

practitioners, epidemiologists, laboratory experts, public health officials, 

and hospital administrators. Rapid detection, accurate diagnosis, and 

speedy treatment by the first responders can save many lives. Hence, our 
4 . . . Surveillance and Detection

third challenge is to ensure that first responders are capable of performing 

this mission. 

Successfully combating biological warfare requires unprecedented 

cooperation between the federal government, state and local agencies, and 

the medical community, and is our fourth challenge. The federal 

government [Health and Human Services (HHS), the Federal Bureau of 

Investigation (FBI), Federal Emergency Management Agency (FEMA), 

and others] plays a key leadership role by supporting state and local 

planning efforts with funding, expertise, and training, and developing an 

infrastructure for detecting biological attacks and delivering mass medical 

care. Hence, medical response plans for managing the consequences of 

bioterrorism must be well integrated and coordinated with other 

emergency response systems. 

Of the four challenges cited by Secretary Shalala, ensuring that first 

responders are capable of performing this mission (the third challenge) is 

the most critical because the efficiency of the first responders determines 

the casualty count. Our medical response to a biological attack is vested 

in the local public health systems being able to detect that a biological 

attack has occurred, identify the biological agent, provide an accurate 

diagnosis, and effectively treat an uncommon disease. Because we do not 

have extensive experience with a biological attack, our public health 

systems would be challenged to undertake emergency management of 

bioterrorism. Special measures would be needed for patient care and 

hospitalization, obtaining laboratory confirmation regarding the identity of 

the biological agent, providing vaccine or antibiotics to a large population, 

and identifying and possibly quarantining patients. Rapid and accurate 

surveillance detection and epidemiologic investigation by the first 

responders would be a key factor in minimizing suffering and loss of life. 

The limitations of our public health departments in conducting disease 

detection and surveillance and epidemiologic investigations have caused 

many public health experts to raise concerns about the adequacy of the 

country’s infectious diseases surveillance network and its ability to 

function in the midst of a biological attack.12 
Surveillance and Detection . . . 5 

II. Local Disease Surveillance and Detection by Physicians 

The current system of medical response to a bioterrorism attack in the 

United States emphasizes the critical role of the first responders, the local 

emergency care systems, in the initial period of a biological attack. 

Knowing that a biological attack has occurred (detection) is the first 

challenge faced by first responders, since biological agents lend 

themselves to clandestine dissemination in the air, food or water supply.13 

The release would most likely be unannounced by the attacker and would 

most certainly be undetected. For example, an airborne or aerosol release 

would produce a cloud that would be invisible, odorless, and tasteless. 

Depending on the biological agent used, no one would know until days or 

weeks later that anyone had been infected. This knowledge would come 

long after a considerable amount of damage had been done. It is highly 

probable that most victims of an unannounced biological attack will delay 

seeking medical care because most of the biological agents used in such 

attacks will manifest flu-like symptoms in the early stages of infection.14 

Because of this delayed reaction, even the possibility of a bioterrorist 

attack causes trepidation in the medical community. It is not surprising 

that first responders from 22 cities who attended federal bioterrorism 

preparedness planning, training and equipment programs provided an 

average self-assessment rating of 4.1 out of a possible 10 points for their 

municipality’s medical bioterrorism response capability.15 These poor 

ratings are indicative of just how far emergency officials in these cities 

receiving federal aid to combat bioterrorism believe they have to go before 

they could truly handle a major infectious disease outbreak. 

Regardless of the trepidation of the first responders, eventually, 

patients would begin appearing in emergency rooms and physician offices 

with possibly flu-like symptoms and physicians would return most of them 

home without having ordered any diagnostic testing.16 A tide of patients 

would return to their care facilities and only then would physicians begin 

extracting cultures such as throat swabs, urine, stool, and blood samples. 

The severely ill would be admitted to intensive care units and medical 

wards. Due to the harried pace of the medical personnel, it is doubtful that 
6 . . . Surveillance and Detection

anyone would notice that the influx of patients currently being treated in 

multiple emergency facilities, came from the same geographic area.17 The 

patients would be treated by another set of physicians who are even less 

likely than their emergency department colleagues to recognize the 

symptoms that manifest from exposure to biological attacks, since few 

physicians have seen a case of anthrax, smallpox, or the plague.18 

A physician in Pennsylvania’s Allegheny County tested how alert his 

on-duty colleagues were to the signs of smallpox, a disease that has not 

been seen in the United States for decades.19 Of 17 physicians quizzed, 

only one of the two infectious disease specialists correctly connected the 

symptoms to smallpox. In another example, a Maryland emergency room 

physician who had completed the domestic preparedness training program, 

estimated that numerous people would have to be coughing up black 

blood, others on ventilators, and dozens dead before he and his colleagues 

would connect the symptoms to anthrax.20 A 1998 survey of 76 

physicians (53 percent reported that their emergency medicine residency 

programs included formal training in biological warfare agents) heightens 

the concern that most physicians would miss the clinical signs of a 

bioterrorist attack. Of those surveyed, over 70 percent rated their ability to 

detect the clinical signs of bioterrorism as very poor or less than 

adequate.21 Because bioterrorism is seen as a low probability event, active 

participation by critical private sector players may be minimal. This is 

evidenced by the “Train the Trainers” sessions on bioterrorism held in 

Baltimore in 1999 where only five emergency room physicians and no 

hospital representatives attended.22 If clinicians seeing a host of cases 

with similar symptoms considered factors such as the normal patterns of a 

disease, or a disease not endemic to a particular geography worthy of 

further investigation, they would get a head start on discerning a terrorist 

attack from a natural occurring disease; see Table 1.23 

Despite the emphasis on emergency room physicians as the early 

response team, the medical community may not identify the reason people 

are falling ill until days or even weeks later, after hospitalization and when 

laboratory results are available.24 By this time, many lives would have 

been lost. A 1972 outbreak of smallpox in Yugoslavia clearly illustrates 
Surveillance and Detection . . . 7

this point.25 The last smallpox outbreak in Yugoslavia had occurred in 

1927 but Yugoslavia continued population-wide vaccinations to protect 

against imported cases. A pilgrim returning home from Mecca became ill 

with an undiagnosed febrile disease and was hospitalized. He received 

visitors from a number of different localities; eleven of the visitors became 

ill within two weeks with high fever and rash. The patients were unaware 

of each other’s illness and their physicians, few of whom had ever seen a 

case of smallpox, failed to make a correct diagnosis. The first cases were 

correctly diagnosed two days after one of the visitors died and four weeks 

after the first patient became ill. By then, 150 persons were already 

infected. Nine weeks after the first patient became ill, 175 persons had 

contracted smallpox and 35 had died. The high casualty numbers were 

averted due to mass vaccination clinics held throughout the country. 
8 . . . Surveillance and Detection
Surveillance and Detection . . . 9 

III. Local Laboratory Surveillance and Capacity 

The next impediment to detection that hinders a rapid response by the 

first responders occurs in the laboratory. When a clinical specimen 

reaches the laboratory, diagnosis may be hindered for several reasons.26 

First, microbes that grow rapaciously in the lungs or intestines can be 

difficult to grow in a petri dish. Second, microbiologists have an even 

harder time growing cultures when samples are not taken with precision 

and properly prepared and stored. Prior to being received in the 

laboratory, cultures are handled by clinicians and delivery service 

personnel who may not be trained in the appropriate procedures for taking, 

preparing and storing cultures. It is not difficult to imagine this happening 

among harried medical personnel working with a large influx of patients. 

Before the late 2001 terrorist anthrax attacks against U.S Senators, the 

Governor of New York, and selected mass media leaders, it is likely that if 

microbiologists were to receive an unexpected result like anthrax, they 

previously might have been likely to consider it a fluke caused by 

mishandling and disregard the result. Hopefully, that is no longer the 

case. Third, microbiologists routinely run a series of time-consuming tests 

for ordinary diseases before they start testing for exotic ones. Fourth, if a 

disease is presented to them that they have only seen in textbooks, 

technicians are likely to restart the test, often requesting that a new culture 

be drawn from the patient. At some point, the cultures that are difficult to 

identify go into the stack of unknowns to be scrutinized by a pathologist, 

who may request additional diagnostic assays such as those shown in 

Table 2.27 Fifth, some microbiologists may be unfamiliar with how to 

plate and test for biological warfare agents; for example, a special medium 

has to be used to test for anthrax.28 Sixth, until September 11, 2001, and 

its aftermath, the vast majority of hospital, public health, and private 

laboratory technicians were not attuned to the possibility of a bioterrorist 

attack because they have not been targeted for awareness or other technical 

training.29 That may be changing but there is still a long way to go to train 

this group sufficiently to handle the level of threat we may face. A 

difficult, unknown culture still may be referred up the laboratory chain, 
10 . . . Surveillance and Detection

with the hospital or private laboratory sending the culture to the local 

public health laboratory, which could pass the culture on to its state 

counterpart, which may pass it on to the CDC or the U.S. Army Medical 

Research Institute of Infectious Diseases.30 With delays for re-tests, 

several weeks may pass before laboratories unravel the mystery. Delays 

in determining the scope and magnitude of a biological attack may result 

in illness and deaths that may have been avoided if a rapid response, based 

on accurate and timely surveillance data, were made.31 
Surveillance and Detection . . . 11 

IV. Problems with Current Epidemiologic Investigation 

A major mission of public health departments is prompt identification 

and suppression of infectious diseases. Our national concept of operations 

for an early bioterrorism response relies heavily on local, state, and federal 

health organizations being able to detect a biological attack through 

surveillance by first responders and their reporting of a possibly 

uncommon disease. Surveillance systems for collecting, analyzing, and 

interpreting reports of such cases and trained staffs to monitor for disease 

outbreak are the foundation of public health epidemiology.32 They are 

also the core of the problems with our current epidemiologic investigation 

capabilities. 

Surveillance systems that rely on voluntary disease reporting from 

health care providers are called passive surveillance systems and are 

notorious for their poor sensitivity, lack of timeliness, and minimal 

coverage.33 Because the passive system is inexpensive to implement, it 

comprises the majority of surveillance systems in place at local, state, and 

federal levels. Generally, the quality of information in passive 

surveillance systems is greatly limited, making them not well suited to the 

needs of bioterrorism surveillance. The CDC oversees a large number of 

passive disease surveillance systems. They are based on collaboration 

with state and local health departments, which in turn depend on 

physician-initiated reports of specific diseases or information from state 

health laboratories; the National Notifiable Disease Surveillance System is 

probably the best known. CDC and state epidemiologists compile and 

periodically review a national list of fifty diseases; this list currently 

includes anthrax, smallpox, plague, hemorrhagic fevers, and botulism. By 

state laws, clinicians, hospitals, and laboratories are required to report 

cases involving any of these fifty diseases.34 Although many states have 

legal penalties against a health provider that does not report, the penalties 

are seldom imposed. Hence, the reliability of passive surveillance systems 

is often low because physicians or hospitals often fail to make the initial 

report or do not do so in a timely manner. Because little if any federal 
12 . . . Surveillance and Detection

funding is provided to support surveillance, local and state health 

departments have no incentives to actively support it. 

Active surveillance, which requires a staff to actively search for and 

identify new cases, provides more timely and accurate information than 

the passive systems but must have sufficient numbers of adequately 

trained epidemiologists to collect, compile, analyze, and interpret the data 

to determine the source of the biological agent; an example of an active 

system is the Sentinel Surveillance Networks.35 Detecting and 

characterizing an outbreak caused by a covert release of a biological agent 

can be difficult, but it may also be startlingly obvious. A reported case of 

anthrax in an area of the country where anthrax is never reported or in an 

individual with no obvious risk factors for the disease would raise the 

suspicions of the public health epidemiologist. Although intentional 

infection would not necessarily be the first explanation investigated, a 

process of elimination or additional case reports would eventually lead to 

a serious consideration of this possibility. The time it takes to reach this 

point can determine if we have a small casualty count or mass casualties. 

In the case of a biological attack, lost time may quickly translate into lost 

lives. Therefore, it is a critical infrastructure resource and expertise 

problem of national importance that we have a sufficient number of 

adequately trained epidemiologists at both the local and state levels. The 

CDC trains a cadre of Epidemic Intelligence Service (EIS) officers, who 

are available to assist state and local epidemiological response. 

Surprisingly, the EIS was created during the Korean war in response to 

fears about biological weapons and the perception that state and local 

public health resources were inadequate to deal with disease outbreaks.36 

Now, nearly fifty years later, facing a threat from these same biological 

weapons, our country finds itself understaffed and underprepared. 

Former Minnesota State epidemiologist Dr. Michael Osterholm 

surveyed the policies and scientific capabilities of all fifty state health 

departments. He discovered that the tremendous variations in disease 

reporting reflected enormous discrepancies in the policies and capabilities 

of the health departments.37 In the United States, all disease surveillance 

begins at the local level, and then is transmitted to the state level and 
Surveillance and Detection . . . 13 

finally to the CDC. Because the United States has a very mobile 

population, a weak link in the local to federal chain severely compromises 

the entire system, and could lead to unnecessary deaths when dealing with 

a biological attack. 

In a General Accounting Office (GAO) report on state surveillance 

systems, which also found that disease surveillance is not comprehensive 

in all states, many state laboratory directors and epidemiologists blamed 

inadequate staffing, information-sharing problems, and the CDC as 

culprits in hindering their ability to generate and use laboratory data to 

conduct infectious diseases surveillance.38 First, the state laboratory 

directors and epidemiologists asserted that the number of laboratory staff 

to perform tests and the number of epidemiology staff who can analyze 

data, translate surveillance information into disease prevention and control 

activities are insufficient. The number of epidemiologists who are 

prepared for fieldwork is limited because the public health sector 

competes poorly with academia and industry for new epidemiology 

graduates.39 Second, they reported that participants in the surveillance 

network (especially at the local level) often lack basic computer systems 

needed to allow them to rapidly share information. Third, they cited a 

requirement for training to ensure that their staffs have the skills to take 

advantage of the technological advances in laboratory methods and 

information-sharing systems. These three assertions reinforced a prior 

Dr. Osterholm study which discovered that nearly two decades of 

government belt tightening, coupled with decreased local and state 

revenues, had limited the ability of public health departments to hire the 

quantity of trained personnel needed, and to purchase new equipment and 

training.40 Advances in information technology, in large part, have not 

reached local and some state health agencies. The capacity of state and 

local health departments to communicate electronically with each other is 

limited, with fewer than fifty percent of local health departments having 

any capacity for Internet connectivity. Fourth, they expressed concerns 

about CDC’s many separate data reporting systems rather than an 

integration of its many systems. This results in duplication of effort and 

further drains limited resources. Fifth, they wanted CDC to help the states 
14 . . . Surveillance and Detection

build systems that link them with local and private surveillance partners. 

Large medical practices and managed care facilities often have patient 

medical records in electronic form that may identify a case of a potential 

biological terrorism-related illness. Sixth, the states wanted CDC to 

provide more hands-on training experience. They placed high value on 

CDC’s testing and consulting services, but they also stated that CDC 

needed to improve its on-site expertise. Last, state officials pointed out 

that obtaining assistance with problems that cut across programmatic 

boundaries could be improved if CDC’s departments communicated better 

with one another. The many separate departments often failed to share 

information within CDC. 
Surveillance and Detection . . . 15 

V. Efforts to Enhance Surveillance and Detection 

Detection and identification of biological agents, either in the 

environment or in victims’ bodies, is currently a piecemeal operation that, 

in the absence of other information, is as much art as science.41 Local 

health officials and emergency planners, state public health officials, and 

the CDC are striving to find more expedient ways to detect and respond to 

a biological attack. 

At the local level, several syndrome surveillance concepts are being 

implemented to achieve early detection of suspicious disease outbreaks by 

auditing fluctuations in the number of patients admitted to hospitals; the 

numbers are derived from the activity levels of the emergency 

management systems (EMS).42 In some cities like Boston, Cleveland, and 

Denver, doctor supervision of the EMS personnel provides valuable 

information about community health problems, enabling the doctors to 

identify a disease outbreak early. Some cities are operating websites to 

monitor the number of incoming patients, the diversion status of hospitals, 

and the number of incoming patients with similar symptoms. Additionally, 

they are requiring the EMS crews and hospital emergency departments to 

inform the attending emergency doctor or charge nurse when they see a 

rapid or developing rise in patients with similar symptoms. 

State public health departments are also becoming more diligent about 

active surveillance. A few states have instituted a statewide system to 

recognize an elevation in hospital admissions by requiring a designated 

area hospital to notify the state public health department if two or 

more of the hospitals in the network are experiencing an increase in 

same-symptom cases.43 State health officials then determine if something 

out of the ordinary is taking place and, if so, send a high priority facsimile 

to hospitals and EMS services throughout the state. 

Some states are also employing the syndrome surveillance approach 

in a rather unique manner: rather than waiting for laboratory identification 

of a culture, data about disease types and rates are collated from various 

sources, allowing the geographic and temporal evolution of a disease in a 

given area to be mapped.44 This information can assist public health 
16 . . . Surveillance and Detection

officials in differentiating between disease patterns, in determining if the 

disease is contagious, and in deducing whether the disease outbreak was 

natural. This surveillance approach uses sources such as over-the-counter 

medication sales, private practice physicians, and primary care clinics to 

detect a covert bioterrorist attack. In New Mexico, the state health 

department and some hospitals are testing a syndrome-based surveillance 

system designed to differentiate normal cycles of disease from a possible 

bioterrorist attack by documenting patient admissions for five different 

causes (flu-like illness, mental status change with fever, fever and skin 

rash, hepatitis/acute jaundice, and diarrhea with fever). The data is 

transmitted in real-time and tabulated in a central database, which is used 

to provide the doctor information on whether the patient being treated is 

an isolated case or part of a more widespread pattern of illness. 

Additionally, this system will help the state health care authorities to 

manage a budding health care crisis by increasing shipment of medicines 

and controlling access into and out of an affected area. 

In 1994, the CDC identified three complementary programs to help 

rebuild the U.S. public health infrastructure for surveillance and response 

to infectious diseases that will prove useful in a bioterrorism incident: the 

Epidemiology and Laboratory Capacity (ELC) program, the Emerging 

Infections Programs (EIP), and provider-based sentinel networks.45 The 

goal of the ELC program is to help large health departments develop the 

core capacity to meet the infectious disease threats of the future by 

providing technical tools, training, and financial resources. ELC activities 

include developing innovative systems for early detection and 

investigation of disease outbreaks, and ensuring electronic reporting of 

surveillance data. Between September 1995 and September 1998, CDC 

entered into ELC agreements with 30 states and localities and plans to 

involve all 50 states by 2002. The goal of the EIP is to conduct 

population-based surveillance and research to address new problems in 

infectious diseases and public health, and to enhance laboratory and 

epidemiologic capacity. The EIP also evaluates certain disease syndromes 

of unknown origin. The CDC 1994 plan established provider-based 

sentinel networks to study conditions that are not covered by health 
Surveillance and Detection . . . 17

department surveillance and that are likely to be seen by specific kinds of 

health providers. Since 1997, three networks have been established. The 

first is the Emergency Department Sentinel Network for Emerging 

Infections (EMERGEncy ID NET). This is a network of academically 

affiliated emergency medicine centers that operate emergency departments 

at 11 hospitals in large cities and monitors syndromes such as bloody 

diarrhea, illnesses that follow exposure to animals, illness in immigrants 

and travelers, and first-time seizures not associated with head trauma. The 

second is the Infectious Diseases Society of America Emerging Infections 

Network (IDSA EIN) which is a network of over 500 infectious disease 

practitioners whose purpose is to enhance communications and health 

education among its members, to collaborate on research projects, and to 

provide assistance in casefinding during outbreak investigations. The 

third is the Sentinel Network of Travel Medicine Clinics (GeoSentinel) 

which is composed of 22 travel medicine clinics located in the United 

States and other countries that monitor temporal and geographic trends of 

infectious diseases among travelers, immigrants, and refugees. 

With the cooperation of health care personnel in Atlanta, Seattle, 

Philadelphia, and Los Angeles, the CDC has also begun to test its own 

variation of an active syndrome surveillance system. During the 

Centennial Olympic Games held in Atlanta in the summer of 1996, the 

CDC worked with 40 federal, state, and local agencies to develop an 

operational concept for response to a chemical or biological terrorism 

incident.46 Subsequent tests occurred in Seattle during the World Trade 

Center Convention in December 1999, in Philadelphia during the 

Republican National Convention in July 2000, and in Los Angeles during 

the Democratic National Convention in August 2000.47 In Philadelphia, 

the template included surveillance at first aid stations, hospital census data 

(number of admissions in the emergency department, ICU, regular 

admissions, and the number of deaths), and sentinel emergency 

department surveillance data.48 These data were used to track patients 

with the following disease syndromes: 1) respiratory tract infection with 

fever; 2) diarrhea/gastroenteritis; 3) rash and fever; 4) sepsis and/or acute 

shock; 5) meningitis/encephalitis; 6) botulism-like syndrome; and 7) 
18 . . . Surveillance and Detection

unexplained death with history of fever. Syndrome surveillance promises 

to be a powerful disease detection tool. 

An important laboratory development is the ability to sequence 

different parts of microbial genomes.49 By identifying distinct features of 

different genes, it is possible to identify not only microbes of interest but 

specific strains, and thus more precisely track infectious disease outbreaks. 

This fingerprinting technique is useful as a sentinel indicator that a new 

strain has entered a community, and in distinguishing natural occurrences 

from intentional releases by identifying microbial or viral strains that are 

foreign to the normal community or by matching new outbreak pathogens 

with pathogen strains from suspected terrorist groups. An example of a 

sentinel system utilizing fingerprinting technology is the PulseNet system, 

a national network of state health laboratories initiated in 1998. These 

systems allow seemingly disparate infectious disease outbreaks, a likely 

objective in a bioterrorist attack, to be potentially linked. Through their 

computerized databases, these systems can possibly mitigate attacks of 

bioterrorism and minimize their aftermaths by allowing outbreaks to be 

more rapidly recognized and investigated and information more rapidly 

shared50. 
Surveillance and Detection . . . 19 

VI. Recommendations 

Efforts to improve disease surveillance and continue research and 

development of better diagnostic capabilities, therapeutic agents, and 

effective response plans capable of mitigating the effects of a biological 

attack remain paramount.51 Although authorities are to be commended for 

the improvements already initiated by them, much work is still needed. 

Hence, the following recommendations for improvements in local, state, 

and CDC surveillance and epidemiology infrastructure are provided. 

Training 

Availability of Training 

Training is cheaper if it is available locally; therefore, federal grants 

should be sent directly to the cities to avoid siphoning funds by state 

governments.52 Additionally, CDC and other such national organizations 

should develop or sponsor internet-based training, videos, and other 

information exchange technology aimed at the education of local and state 

health departments. Because training would be conducted locally, scarce 

funding previously allocated to training could be used in other areas. 

Institutionalization 

If preparedness, our ability to survey, detect, and identify biological 

agents, is to take hold nationally on the frontlines and be sustained, then it 

belongs in the local and state training academies and in the nursing and 

medical schools.53 Responsibility for institutionalizing training belongs 

to the federal government, with the CDC as the agency responsible for its 

implementation. The CDC should be tasked to develop a standardized 

syllabus to be used in all local and state training and medical facilities. 
20 . . . Surveillance and Detection

Certification/Re-certification 

First responders should be tested at least annually on their knowledge 

of biological agents and their surveillance and detection skills, and should 

receive annual refresher training in epidemiologic improvements.54

Standards 

Standards are the backbone of accountability and should be 

established nationally for surveillance and detection of biological agents 

so they do not differ from state to state.55 

Public Awareness 

Because a bioterrorism attack would likely be directed towards the 

civilian population, public awareness of the threat must occur. If nothing 

else positive flows from the anthrax attacks in CONUS that occurred after 

the Al Qaeda attacks of September 11th, at least the public, media, and 

Congress are all aware of the potential for future bioterrorist attacks and, 

perhaps, how they could have been much more serious. In much the same 

way as the public prepared for a nuclear holocaust during the Cold War 

era, today’s citizens must be better educated on this biological threat. 

Public service announcements using television and radio are good 

beginnings. All levels of government and large corporations should 

institute an annual training awareness program on how to react and deal 

with this threat. The time devoted to this could pay huge dividends in the 

event of an actual attack by avoiding unnecessary panic and casualties. 

Epidemiology and Laboratory Capacity 

Regional Laboratory Network 

The establishment of a network of regional laboratories capable of 

rapid diagnostic testing is essential to mitigate the number of fatalities 

caused by inadequate laboratory capabilities. Because biological warfare 

is a low-occurring event, many of our laboratories may not be capable of 
Surveillance and Detection . . . 21 

performing the required assays, and even the “experts” (to include some at 

the CDC) may miss the identification.56 This forwarding of cultures will 

more than likely be of limited benefit to the initial victims but will 

facilitate rapid diagnosis of delayed or secondarily infected patients. 

Symptom-based Diagnostic Aids 

An interactive diagnostic decision-making system to assist clinicians 

in considering a biological exposure (and possibly provide an early 

warning) would be of great value.57 This type of system would necessitate 

a complex, multiple search mechanism that includes early signs and 

symptoms of atypical disorders caused by biological agents. An 

integrated system that utilizes natural disease rates, clinical probabilities 

based upon signs and symptoms, and laboratory findings could further 

enhance an early warning system. 

Communication 

Electronic Communication 

Advances in information technology must be used to enhance the 

capacity of local and state health departments to communicate 

electronically with one another. Few public health epidemiologists have 

sophisticated knowledge about biological warfare, but through information 

technology, many could have access to some of the best minds in this 

field. The Federation of American Scientists established the system, 

Program for Monitoring Emerging Diseases (ProMED) (approximately 

100,000 scientists participate in it), to provide communication among 

sentinel stations around the world capable of reporting unusual disease 

outbreaks, including those resulting from a biological attack.58 ProMED 

could serve to improve the response capabilities of public health 

departments by electronically bringing together experienced scientists to 

discuss the situation.59 
22 . . . Surveillance and Detection

Laboratory Reporting System 

A national electronic laboratory reporting system would assist 

immensely in getting important laboratory information quickly to the 

epidemiologists, enabling the country to improve its public health 

response to a biological attack.60 A national reporting system could 

provide epidemiologists with nearly real-time notification of a suspected 

biological agent. The linchpin in our ability to respond is early detection. 

Funding 

Political Coalitions 

Government programs for responding to bioterrorism should be 

designed to be multi-purpose rather than highly specialized, so that they 

are considered worthwhile regardless of how the threat is assessed.61 The 

measures needed to impede the threat of bioterrorism are similar to those 

needed to control and prevent emerging infections. Improving 

capabilities and capacities to respond to one issue will almost certainly 

benefit the other. For example, developing rapid diagnostic techniques 

that would make it possible to quickly detect bioterrorist attacks involving 

anthrax or the plague would have considerable usefulness in the routine 

clinical diagnosis of pneumonia.62 Policies that provide social benefit as 

well as reduce the country’s vulnerability to bioterrorism make it easier to 

build political coalitions that support funding responses to bioterrorism. 
Surveillance and Detection . . . 23 

VII. Conclusion 

Biological terrorism, aimed at our unprotected civilian population, is 

more likely than ever before and far more threatening than nuclear or 

chemical attacks. Our population is vulnerable and the terrorists are 

motivated and capable. Because of the accessibility to knowledge about 

the manufacturing of biological agents and the inexpensive cost of doing 

so, preventing bioterrorism is nearly impossible. Since biological agents 

lend themselves to clandestine dissemination, detecting their release will 

almost always be delayed with the first evidence of such use being in our 

medical emergency departments, clinics, and physician offices. Thus, the 

medical community will constitute our frontline of defense. The rapidity 

with which the medical community reaches a proper diagnosis will 

determine the speed with which preventive and therapeutic measures can 

be applied. It will be the difference between a small casualty count and 

mass casualties. However, few of our physicians have ever seen a case of, 

or would recall the characteristics of, anthrax, smallpox, plague, 

hemorrhagic fever, or botulism, the most likely candidates to be used in a 

biological attack. Few diagnostic laboratories are prepared to promptly 

confirm promptly such diagnoses. 

Our medical community must be prepared to detect, to diagnose, and 

to characterize epidemiologically outbreaks of disease resulting from the 

intentional release of a biological weapon. We need at all levels of 

government (local, state and national) a greater capacity for surveillance 

and detection, an improved network of laboratories, better diagnostic 

instruments, and a more adequate cadre of trained epidemiologists, 

clinicians, and researchers. The federal government, specifically the 

CDC, would be prudent to refine syndrome surveillance and evaluate its 

effectiveness for recognizing unusual disease patterns in order to direct 

more intensive laboratory analysis, epidemiological investigation, and 

medical intervention as early as possible in a disease outbreak. 

The medical community plays an integral role in detecting biological 

warfare because they participate in the network of disease surveillance and 

reporting that may be the first indication of a biological attack. From a 
24 . . . Surveillance and Detection

public health perspective, timely surveillance, clinician awareness of 

syndromes potentially from bioterrorism, epidemiologic investigation 

capacity, laboratory diagnostic capacity, continued research and 

development of improved diagnostic capabilities, and the ability to rapidly 

communicate critical information remain paramount. Recognition of the 

need for preparedness at all levels of government provides an opportunity 

to strengthen the public health system and its linkages with current and 

new partners.63 As former President Bill Clinton said in his address at the 

National Academy of Sciences in January 1998, “These cutting edge 

efforts will address not only the threat of weapons of mass destruction, but 

also the equally serious danger of emerging infectious diseases. So we 

will benefit even if we are successful in avoiding these attacks.”64 
Surveillance and Detection . . . 25 

Table 1 

Epidemiologic Clues To A Possible Bioterrorist Attack 

• Distribution of cases that is inconsistent with normal disease patterns 

(geographically and/or temporally), with greater than anticipated numbers of 

patients, especially in a distinct population. 

• More severe illness than is typical for a given pathogen, as well as unusual routes 

of exposure (e.g., inhalation anthrax as opposed to cutaneous or gastrointestinal 

cases). 

• Disease that is not endemic to a given geographic area, unusual for the time of 

year, or impossible to transmit naturally, since the disease carrier (e.g., mosquito, 

rodent) is not present in the area. 

• Simultaneous upswings of different diseases. 

• Disease outbreak affecting both animal and human populations. 

• Unusual strain of a disease or atypical antibiotic resistance patterns. 

• Higher rates of disease among those who were located in certain areas at a certain 

point in time (e.g., inside a building where agent was released, outside if the attack 

was outdoors). 

• Intelligence data that a country or terrorist group possessed a certain biological 

warfare agent or agents. 

• Claims by a terrorist group to have released a biological agent. 

• Direct evidence (e.g., environment samples, delivery system) that an agent was 

released. 

Source: Julie A. Pavlin, “Epidemiology of Bioterrorism,” in Emerging Infectious 

Diseases 5, no. 4 (July/August 1999); 529. 
26 . . . Surveillance and Detection

Table 2 

Diagnostic Samples, Assays, And Isolation Precautions For Biological 

Warfare Agents 

Agent Diagnostic Sample Diagnostic Assay Patient Isolation 

Precautions 

Anthrax • Blood (Level 2) • Gram stain 

• Antigen – ELISA* 

Serology: ELISA 

• Standard 

precautions 

Smallpox • Pharyngeal 

swab 

• Scab material 

(Level 4) 

• ELISA 

• Polymerase chain reaction 

• Virus isolation 

• Airborne 

precautions 

Plague • Blood 

• Sputum 

• Lymph node 

• Aspirate (Level 

2/3) 

• Gram or Wright-Giemsa 

Stain 

• Antigen – ELISA 

• Culture Serology 

• ELISA 

Immunofluorescence assay 

• Pneumonic: 

droplet 

• Precautions until 

patient treated for 

3 days 

Viral 

Hemorrhagic 

Fevers 

• Serum 

• Blood (Level 3 

for Rift Valley, 

Yellow and 

Korean 

hemorrhagic 

fevers; Level 4 

for others) 

• Virus isolation 

• Antigen – ELISA 

• Reverse transcriptase 

polymerase chain reaction 

• Serology: antibody ELISA 

• Contact 

precautions 

• Consider 

additional 

precautions if 

massive 

hemorrhage 

Botulinum • Nasal swab 

(Level 2) 

• Antigen – ELISA 

• Mouse neutral 

• Standard 

precautions 

*ELISA: enzyme-linked immunosorbent assay 

Source: David R. Franz et al., “Clinical Recognition and Management of Patients 

Exposed to Biological Warfare Agent,” Journal of the American Medical Association 

278, no. 5 (6 Aug 1997): 400-1. 
Surveillance and Detection . . . 27

Notes 

1. Donald A. Henderson, “The Looming Threat of Bioterrorism,” Science 283 (26 

February 1999): 1279-82. 

2. Jonathan B. Tucker and Amy Sands, “An Unlikely Threat,” Bulletin of the 

Atomic Scientists 55, no. 4 (July/August 1999): 46-8. 

3. Jeffrey D. Simon, Ph.D., “Biological Terrorism – Preparing to Meet the Threat,” 

Journal of American Medication Association 278, no.5 (6 August 1997): 428-30. 

4. Donna E. Shalala, Secretary of Health and Human Services, “How Prepared Are 

We?” Emerging Infectious Diseases 5, no. 4 (July/August 1999): 492-3. 

5. Jonathan B. Tucker, “The Biological Weapons Threat,” Current History (April 

1997): 170. 

6. Ibid., 171-2. 

7. William S. Cohen, “Defending Against Biological Warfare,” Public 

Broadcasting System: Frontline 1998, n.p.; on-line, Internet, 9 February 2001, available 

from http://www.pbs.com/frontline.htm. 

8. Henderson, “The Looming Threat of Bioterrorism.” 

9. “Response to Terrorism,” United States Information Agency, 15 March 1999, n.p.; 

on-line, Internet, 9 February 2001, available from http//usinfo.state.gov/topical/pol/ 

terror/99031501.htm. 

10. “White House Fact Sheet: President Clinton Unveils New Efforts to Combat 

Terrorism in an Address to the International Association of Firefighters,” United States 

Information Agency, 15 March 1999, n.p.; on-line, Internet, 9 February 2001, available 

from http://usinfo.state.gov/topical/pol/terror/99031501.htm. 

11. Shalala, “Bioterrorism: How Prepared Are We?” 

12. Henderson, “The Looming Threat of Bioterrorism.” 

13. David W. Siegrist, “The Threat of Biological Attack: Why Concern Now?”, 

Emerging Infectious Diseases 5, no. 4 (July/August 1999), n.p.; on-line, Internet, 9 

February 2001, available from http://www.cdc.gov/ncidod/EID/vol5no4/siegrist.htm. 

14. Melissa Hendricks, “Rx Against Terror,” Johns Hopkins Magazine (February 1999), 

n.p.; on-line, Internet, 9 February 2001, available from http://www.johnshopkins.com. 

15. Amy E. Smithson, “Ataxia: The Chemical and Biological Terrorism Threat and 

the US Response,” 319, on-line, Internet, 9 February 2001, available from 

http://www.stimson.org/cwc/ataxia.htm. 
28 . . . Surveillance and Detection

16. John G. Bartlett, “Applying Lessons Learned from Anthrax Case History to 

Other Scenarios,” Emerging Infectious Diseases 5, no. 4 (July/August 1999): 561-3. 

17. Ibid. 

18. Henderson, “Bioterrorism as a Public Health Threat,” Emerging Infectious 

Diseases 4, no. 3 (July/September 1998), n.p.; on-line, Internet, 9 February 2001, 

available from http://www.cdc.gov/ncidod/EID/vol5no4/hendrsn.htm. 

19. Jonathan D. Silver, “Local Doctors Fail Their Test on Diagnosing Germ 

Terrorism,” Pittsburgh Post-Gazette, 13 February 2000. 

20. Bartlett, “Applying Lessons Learned from Anthrax Case History to Other 

Scenarios.” 

21. Smithson, “Ataxia,” 252. 

22. Bartlett, “Applying Lessons Learned from Anthrax Case History to Other 

Scenarios.” 

23. Julie A. Pavlin, “Epidemiology of Bioterrorism,” Emerging Infectious Diseases

5, no. 4 (July/August 1999): 529. 

24. Bartlett, “Applying Lessons Learned from Anthrax Case History to Other 

Scenarios.” 

25. Henderson, “Bioterrorism as a Public Health Threat.” 

26. Laurie Garrett, The Coming Plague: Newly Emerging Diseases in a World Out 

of Balance (New York: Farrar, Straus and Giroux, 1994), 174-91. 

27. David R. Franz et al, “Clinical Recognition and Management of Patients 

Exposed to Biological Warfare Agent,” Journal of the American Medical Association

278, no. 5 (6 August 1997): 400-1. 

28. Bartlett, “Applying Lessons Learned from Anthrax Case History to Other 

Scenarios.” 

29. Henderson, “The Looming Threat of Bioterrorism.” 

30. Smithson, “Ataxia,” 251. 

31. Henderson, The Looming Threat of Bioterrorism.” 

32. “Chemical and Biological Terrorism: Research and Development to Improve 

Civilian Medical Response,” Committee on Research and Development Needs for 

Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents, 

National Research Council, n.p.; on-line, Internet, 9 February 2001, available from 

http://www.nap.edu/readingroom/books/terrorism.html. 
Surveillance and Detection . . . 29 

33. “Emerging Infectious Diseases: Concerns on Needed Laboratory Capacity 

Could Strengthen Surveillance,” General Accounting Office, GAO-HEHS-99-26, 5 

February 1999, n.p.; on-line, Internet, 9 February 2001, available from 

frevebgate.access.gpo.gov/cgi-bin/multidb.cgi. 

34. “Chemical and Biological Terrorism: Research and Development to Improve 

Civilian Medical Response,” National Research Council. 

35. Ibid. 

36. Ibid. 

37. Garrett, The Coming Plague, 605. 

38. “Emerging Infectious Diseases: Concerns on Needed Laboratory Capacity 

Could Strengthen Surveillance,” General Accounting Office, GAO-HEHS-99-26. 

39. Hendricks, “Rx Against Terror.” 

40. Garrett, The Coming Plague, 605-6. 

41. “Chemical and Biological Terrorism: Research and Development to Improve 

Civilian Medical Response,” National Research Council. 

42. Smithson, “Ataxia,” 254-8. 

43. Ibid. 

44.Ibid. 

45. “Preventing Emerging Infectious Diseases: A Strategy for the 21st Century,” 

Centers for Disease Control and Prevention, 28 September 1999, n.p.; on-line Internet, 9 

February 2001, available from http://www.cdc.gov/ncidod/emergplan/9obj11.htm. 

46. Jonathan B. Tucker, “National Health and Medical Services Response to 

Incidents of Chemical and Biological Terrorism,” Journal of the American Medical 

Association 278, no. 5 (6 August 1997): 362-8. 

47. Smithson, “Ataxia,” 254-8. 

48. Ibid. 

49. “Chemical and Biological Terrorism: Research and Development to Improve 

Civilian Medical Response,” National Research Council. 

50. Ibid. 

51. James M. Hughes, “The Emerging Threat of Bioterrorism,” Emerging Infectious 

Diseases 5, no.4 (July/August 1999), n.p., on-line, Internet, 9 February 2001, available 

from http://www.cdc.gov/ncidod/EID/vol5no4/hughes.htm. 
30 . . . Surveillance and Detection

52. Smithson, “Ataxia,” 300. 

53. Ibid. 

54. Ibid., 301. 

55. Ibid., 302. 

56. “Chemical and Biological Terrorism: Research and Development to Improve 

Civilian Medical Response,” National Research Council. 

57. Ibid. 

58. Garrett, The Coming Plague, 602. 

59. “Chemical and Biological Terrorism: Research and Development to Improve 

Civilian Medical Response,” National Research Council. 

60. Ibid. 

61. Tucker, “National Health and Medical Services Responses to Incidents of 

Chemical and Biological Terrorism.” 

62. Joseph E. McDade, “Addressing the Potential Threat of Bioterrorism--Value 

Added to an Improved Public Health Infrastructure,” Emerging Infectious Diseases 5, 

no.4 (July/August 1999), n.p., on-line, Internet, 9 February 2001, available from 

http://www.cdc.gov/ncidod/EID/vol5no4/mcdade.htm. 

63. Hughes, “The Emerging Threat of Bioterrorism.” 

64. William J. Clinton, “Keeping America Secure for the 21st Century,” National 

Academy of Sciences, Washington, D.C., 2 January 1998. 
Surveillance and Detection . . . 31 

USAF Counterproliferation Center 

 The USAF Counterproliferation Center was established in 1999 to provide 

education and research to the present and future leaders of the USAF, to assist them in 

their activities to counter the threats posed by adversaries equipped with weapons of mass 

destruction 

Barry R. Schneider, Director 

USAF Counterproliferation Center 

325 Chennault Circle 

Maxwell AFB AL 36112-6427 

Email: Barry.Schneider@maxwell.af.mil

Jo Ann Eddy, Associate Editor 

The Counterproliferation Papers 

Email: JoAnn.Eddy@maxwell.af.mil

(334) 953-7538 (DSN 493-7538) 
32 . . . Surveillance and Detection