According to the July 2012 National Strategy for Biosurveillance, biosurveillance is the ongoing process of gathering, integrating, interpreting, and communicating essential information related to all- hazards threats or disease activity affecting human, animal, or plant health, for the purpose of (1) achieving early detection and warning, (2) contributing to overall situational awareness of the health aspects of the incident, and (3) enabling better decision making at all levels. As defined in the NBIC Strategic Plan, biosurveillance integration is combining biosurveillance information from different sources and domains (e.g., human, animal, and plant health; food and environmental safety and security; and homeland security) to provide partners and stakeholders with a synthesized view of the information, and what it could mean. The goal is to create new meaning—that is, to provide insights that cannot be gleaned in isolation, leading to earlier warning of emerging events and shared situational awareness. Example of a biological event monitored by the National Biosurveillance Integration Center: Middle East respiratory syndrome coronavirus (MERS-CoV) Since first recognized in September 2012 in Saudi Arabia, MERS-CoV has been detected in nearly 30 countries, including the United States. As of July 2015, there have been more than 1,300 confirmed cases and over 500 deaths, the vast majority of which have been in Saudi Arabia. Two cases have been detected in the United States from patients who had recently travelled to Saudi Arabia. MERS-CoV is characterized as a potentially severe respiratory illness and symptoms may include fever, cough, shortness of breath, congestion of the nose and throat, and diarrhea. Camels are considered the likely source for human infections. As of June 2015, human-to-human transmission has been limited and the risk of infection to travelers visiting the Arabian Peninsula is considered to be low. made in a shared risk environment that considers all domains. According to the NBIC Strategic Plan, shared situational awareness across the biosurveillance community is achieved cooperatively by entities that integrate mission essential, overlapping portions of their individual situational awareness for a unified purpose, leading to a common picture or understanding of potential and ongoing biological events. Further, the plan notes that shared situational awareness of the broader biological domain may provide insights that cannot be gleaned in isolation, and thus enhance the likelihood of identifying an event earlier and with more certainty. The importance of biosurveillance integration has also been described by key national planning documents. In July 2012, the White House issued the National Strategy for Biosurveillance, which describes the U.S. government’s approach to strengthening biosurveillance. Although the strategy does not specifically identify roles for NBIC, it does emphasize the need for integration across disparate information sources, including data derived from intelligence, law enforcement, environmental, plant, animal, and other relevant areas. In June 2013, the White House’s Office of Science and Technology Policy issued the S&T Roadmap. Building upon the National Strategy for Biosurveillance, the Roadmap identifies biosurveillance capability needs and key research and development priorities, including those related to integration. For example, the roadmap proposes the development of a national, interagency biosurveillance data- sharing framework that integrates data and information from disparate sources, as well as the development of tools that enhance the efficient manipulation of large data sets, including social media. As shown in table 2, the 9/11 Commission Act outlines certain requirements for NBIC. Drawing upon these requirements as well as the July 2012 NBIC Strategic Plan, we identified three main roles that NBIC, as a federal-level biosurveillance integrator, must carry out to achieve the duties and outcomes described by NBIC’s authorizing legislation. Senior NBIC officials agreed that these three roles are consistent with the center’s responsibilities. These roles are not mutually exclusive and can reinforce one other. For example, NBIC’s efforts as an Innovator might result in the in the development of data that could enhance its role as an Analyzer by providing the center with another dataset to review. Example of a biological event monitored by the National Biosurveillance Integration Center: Ebola virus disease (EVD) Since late 2013, the World Health Organization (WHO) has reported a cumulative over 27,000 suspected, probable, and confirmed cases of EVD and over 11,000 related deaths as of June 2015.The vast majority of cases have been in West Africa, but there have also been cases in the United States. Eleven cases of EVD have been treated in the U.S., of which 9 recovered and 2 patients died. Of the 11 cases, 9 were presumed to have been contracted in West Africa and 2 were presumed to have been contracted at a Texas hospital by nurses treating an infected patient. EVD symptoms typically develop 2 to 21 days after exposure to Ebola virus. Symptoms include fever, headache, joint and muscle aches, impaired liver and kidney function, stomach pain, and death. Although the WHO has classified the West African EVD epidemic as a Public Health Emergency of International Concern, the outbreak is considered to be unlikely to significantly affect U.S. public health. Example of a biological event monitored by the National Biosurveillance Integration Center: Measles in the United States From December 2014 through February 2015, state and local health departments reported 171 measles cases across 20 states and the District of Columbia. Most of these cases had been associated with an ongoing outbreak associated with Disneyland theme parks in California. Measles is a highly contagious viral illness that can spread rapidly in communities without proper vaccination. Symptoms include high fever, cough, runny nose, watery eyes, rash, and death. Measles was officially declared eliminated in the U.S. in 2000 and cases in the U.S. have primarily the result of international travel to countries experiencing outbreaks. Outbreaks in the U.S. have persisted mainly due to the increase in unvaccinated people. DHS to assist in achieving NBIC goals. The board is to meet at least twice a year and is to be chaired by DHS’s Chief Medical Officer, with a cochair that is to be rotated annually among the federal partners by a majority vote. The NBIC Advisory Board members are to provide formal recommendations to the Advisory Board Chair and Cochair on: (1) identifying, prioritizing, and addressing NBIC and other appropriate operational and programmatic needs; (2) reviewing draft guidance and other supporting documents related to national biosurveillance strategy and policy, as appropriate; and (3) improving communications and collaboration among local, state, tribal, territorial, and federal interagency partners. The NBIC Interagency Working Group is to provide support and respond to taskings from the Advisory Board to assist in addressing NBIC operational, programmatic, and scientific issues. The working group is to consist of senior-level federal officials from NBIS member departments and agencies and the Executive Office of the President who are authorized to make recommendations on behalf of their organizations. Each agency is to have at least one working group member, but can have more based on the relevance to their missions of the topics to be covered by the working group or subworking groups. The working group is to meet as needed, but generally more frequently than the Advisory Board, according to NBIC officials. The NBIS is a consortium of federal partners that was established to rapidly identify and monitor biological events of national concern and to collect; analyze; and share human, animal, plant, food, and environmental biosurveillance information with NBIC. The NBIS community predated the enactment of the 9/11 Commission Act. Beginning in 2004, DHS coordinated the NBIS community and developed an information technology (IT) system to integrate other agencies’ biosurveillance information, an effort that was moved among several DHS directorates, including DHS’s Science and Technology Directorate. In 2007, DHS created the Office of Health Affairs, headed by the DHS Chief Medical Officer, to lead DHS’s biodefense activities and provide timely incident- specific guidance for the medical consequences of disasters. At that time, DHS placed the responsibility for coordinating the NBIS in the Office of Health Affairs. Shortly after that, the 9/11 Commission Act created NBIC and gave it responsibility for coordinating the NBIS. NBIC has remained in the Office of Health Affairs since that time. Example of a biological event monitored by the National Biosurveillance Integration Center: Porcine epidemic diarrhea virus (PEDv) Since Spring 2013, there have been 11,364 confirmed samples of PEDv from 35 states as of April 2015. As a result, 5 countries and the European Union issued trade restrictions against U.S. swine imports, some of which have since lifted those restrictions. Hog and pig farming is a multi-billion dollar industry. However, despite earlier predictions, the economic decline due to PEDv has not been as drastic as predicted. PEDv is a highly infectious virus specific to swine and does not affect humans or other species. Symptoms in pigs include diarrhea, vomiting, and anorexia, and is particularly deadly to young pigs. In June 2014, the U.S. Department of Agriculture issued a Federal Order requiring mandatory reporting of all novel swine enteric coronavirus diseases, including PEDv. Commission Act outlines a number of responsibilities for member agencies. For example, the member agencies are to use their best efforts to integrate biosurveillance information into NBIC and connect their biosurveillance data systems to the NBIC data system under mutually agreed protocols. Further, per the act, member agencies are to provide personnel to NBIC under an interagency personnel agreement and consider the qualifications of such personnel necessary to provide human, animal, and environmental data analysis and interpretation support to NBIC. We surveyed and interviewed officials from 19 federal departments and their component agencies across 13 of the 14 departments and agencies that compose the NBIS. On the basis of their roles and responsibilities related to biosurveillance, we categorized the NBIS partners agencies into three groups: Primary biosurveillance agencies: Primary biosurveillance agencies have major biosurveillance mission responsibilities that include collecting or analyzing biosurveillance information for the purposes of detecting, monitoring, or responding to biological events. These agencies generate information and develop subject matter expertise in pursuit of their missions that is directly relevant to disease detection and monitoring. In addition, they consume information from multiple sources—including nonfederal sources—to help achieve their missions. Examples of primary biosurveillance agencies include HHS’s Centers for Disease Control and Prevention (CDC) and USDA’s Animal and Plant Health Inspection Service (APHIS). Eleven of the 19 NBIS partners we interviewed and surveyed are primary biosurveillance agencies. Support biosurveillance agencies: Support biosurveillance agencies do not have missions that directly involve disease detection and monitoring; however, they collect data and information or have subject matter expertise that may be useful to efforts to detect, monitor, or respond to biological events. For example, the Department of Commerce’s National Oceanic and Atmospheric Agency collects meteorological data that may be used by NBIC to help inform the officials about progression of an outbreak based on weather patterns. Five of the 19 NBIS partners we interviewed and surveyed are support biosurveillance agencies. Biosurveillance information consumers: Biosurveillance information consumers generally do not have missions that directly involve disease detection and monitoring and generally do not produce information that is useful for biosurveillance. However, they consume such information because biological events can affect their main mission and they may have a particular role to play in responding to an event. For example, officials from DOT stated that their department consumes biosurveillance information because biological events can affect the national transportation system and transporting people and items through a contaminated area can further exacerbate a biological event. Three of the 19 NBIS partners we interviewed and surveyed are biosurveillance information consumers. Figure 1 and appendix I describe the missions and biosurveillance responsibilities of the 19 NBIS partners we interviewed and surveyed. Click on highlighted departments or agencies for more information. Click  to close. For a printer-friendly version, see app. I. Primary biosurveillance agencies: Have major biosurveillance mission responsibilities that include collecting or analyzing biosurveillance information for the purposes of detecting, monitoring, or responding to biological events. Support biosurveillance agencies: Do not have missions that directly involve disease detection and monitoring; however, they collect data and information or have subject matter expertise that may be useful to efforts to detect, monitor, or respond to biological events. Biosurveillance information consumers: Generally do not produce information that is useful for biosurveillance, but consume such information because biological events can affect their main mission and they may have a particular role to play in responding to an event. To fulfill its Analyzer role, NBIC develops a variety of products to enable early warning and enhance situational awareness of biological events, but the center faces challenges related to its ability to develop products that contribute meaningful information and has difficulty obtaining biosurveillance data. NBIC’s efforts to fulfill its Analyzer role include a variety of products and activities designed to enable early warning and shared situational awareness. As part of its daily analytic process, NBIC analysts review two main types of information: (1) open source, such as media reports, foreign, national, state, and local government agency websites, and industry and professional association reports and websites, and (2) partner-provided. First, to identify relevant open-source information, NBIC uses both automated and manual methods. For example, in addition to conducting manual searches of media, NBIC analysts also access commercial open source data feeds such as HealthMap and DOD’s National Center for Medical Intelligence’s (NCMI) Arkham data feeds, which provide open-source information in more than 80 languages that are translated automatically into English. Second, NBIC also relies on finished analytical products from NBIS partners, which may be obtained directly from partners or are available publically on agency websites. These products are usually received or obtained as written reports that represent the agency’s analysis and interpretation of the raw data that it collects on a routine basis or for a specific event. NBIC analysts may also make requests for information to NBIS partners for additional information. 24 hours a day: Department of Homeland Security’s Office of Health Affairs Watch Desk evaluates open- source biosurveillance information using a variety of tools and sources, which will inform the development of future products. NBIC analysts review watch desk information and reports from federal partners to identify items of potential significance. Late morning: Analysts conduct a daily internal NBIC discussion to determine items of significance and decide additional actions that are required. Afternoon: The Daily Biosurveillance Review is distributed to internal recipients including agency liaisons, and serves as a tool that generates a record of what was known, at what time, and from what source. Late afternoon: Monitoring List is distributed via e-mail to federal partners and other domestic and international stakeholders to update them on items being monitored, as well as other reports published by NBIC. NBIC produces a variety of regular products to enable early warning and enhance situational awareness, including its daily Monitoring List, Biosurveillance Event Reports, and Special Event Reports, as well as by responding to requests for information from its partners. NBIC’s Monitoring List is a daily e-mail that contains brief summaries on acute, ongoing biological events of concern or interest to the NBIS partners. Biosurveillance Event Reports provide additional detail on specific events. For example, throughout 2015, NBIC produced such reports on the Middle East respiratory syndrome coronavirus, highly pathogenic avian influenza, Ebola virus disease, measles, and porcine epidemic diarrhea virus, among others. NBIC has also produced Special Event Reports at the request of state and local authorities in advance of mass gathering events, such as the Super Bowl and the Little League World Series. NBIC also responds to requests for information from the NBIS partners and other stakeholders. According to agency officials we spoke with and strategic documents we reviewed, NBIC faces challenges in implementing its Analyzer role, including its limited ability to develop products that contribute meaningful information to its partners and difficulty obtaining biosurveillance data. Products That Provide New Meaningful Information Primary biosurveillance agencies generally reported that NBIC’s products do not provide them with meaningful information because those products contain information that they either already generate themselves or could obtain directly from other NBIS partners more quickly. As illustrated in figure 2, during our structured interviews, 8 of 11 primary biosurveillance agencies reported that NBIC products and activities help their agency identify potential or ongoing biological events (i.e., perception) to little or no extent. For example, officials from 2 of these agencies stated that much of the information in NBIC’s products related to their respective domains do not inform their biosurveillance activities because this information generally originates from reports that their agencies release publically. partners reported that NBIC’s products contain much information of which they are already aware or could access regardless of their participation with NBIC. For example, as illustrated by figure 3, EPA officials reported that their agency obtains information that enhances all three elements of situational awareness from seven agencies, including APHIS, CDC, and NBIC, among others. Further, EPA officials reported that they obtain information that enhances their comprehension and projection of biological events from DOI’s Office of Emergency Management and NCMI. NBIC Monitoring List: a daily e-mail to inform partners of new and ongoing events that NBIC is currently monitoring. These emails are sent to (1) federal; (2) state, local, tribal, and territorial; and (3) Biosurveillance Event Report: a more detailed report focused on a specific event. These reports provide basic event details (e.g., pathogen, location, affected populations, and event progression) and describe interagency actions, among other things. These reports are distributed via e-mail as well as the Homeland Security Information Network, among others. Special Event Report: a report requested by government partners, such as state and local governments, to provide a public health assessment for a selected event. Requests for Information: biosurveillance information collection and gathering technique through analyst-to- analyst communications that can be submitted through the Department of Homeland Security’s National Operations Center, e-mail, phone calls, or a biosurveillance information-sharing portal known as Wildfire. Move mouse over agency names to show the sources from which that agency obtains biosurveillance information. The size of the circle for an NBIS partner reflects the number of times other primary and support biosurveillance agencies identified that agency as an information source that enhances situational awareness of a biological event. For a printer-friendly version, see app. II. However, agencies with more limited roles in biosurveillance, such as the biosurveillance support agencies and information consumers, had more favorable views on NBIC’s products and activities. For example, as also illustrated by figure 2, 5 of the 8 biosurveillance support agencies and information consumers stated that NBIC’s products and activities help their agencies identify potential or ongoing biological events (i.e., perception) to a moderate extent. Officials from some of these agencies reported that they leveraged NBIC products because their own agencies lacked time, capacity, or the infrastructure to regularly review disparate sets of information across multiple agencies and domains. For example, officials from a support biosurveillance agency reported that because the agency did not have the capacity to review all of the relevant biosurveillance information that it collected, NBIC’s products filled a critical information gap in its intelligence. Some NBIS partners suggested that NBIC’s reports might be useful for state and local entities that might not have access to the same breadth of information or the capacity to integrate biosurveillance information themselves. Further, as illustrated by figure 4, 5 of the 8 biosurveillance support agencies and information consumers stated that NBIC’s products and activities help their agencies understand the nature and scope of emerging biological events (i.e., comprehension) to a great or moderate extent. Officials from these agencies generally stated that NBIC’s products were easy to understand and provided useful context for events outside their scope of expertise. For example, officials from a support biosurveillance agency praised one of NBIC’s Biosurveillance Event Reports on the recent outbreak of highly pathogenic avian influenza, which included information from CDC, APHIS, and USDA’s Food Safety and Inspection Service (FSIS) on how the disease will affect the food chain, if it could cross to the human population, and what information is known locally. Regardless of their role in biosurveillance, partners noted that NBIC’s products and activities do not generally contribute new meaning or analysis—that is, insights that cannot be gleaned in isolation. For example, as shown in figure 5, 10 NBIS partners stated that NBIC’s products and activities enhance their agencies’ ability to carry out their biosurveillance roles and responsibilities to little or no extent, 4 responded to a moderate extent, and 5 responded that they did not have a basis to judge. Generally, partners that responded to little or no extent noted that NBIC products and activities do not, for example, identify trends and patterns or describe potential impacts of a biological event. For example, officials from a primary biosurveillance agency stated that NBIC’s products and activities do not “connect the dots” between dissimilar information, provide novel synthesis of information, or recommend possible courses of action. Further, as shown in figure 6, 11 of the 19 NBIS partners stated that NBIC’s products and activities help their agencies understand how emerging and ongoing biological events are likely to progress into the near future (i.e., projection) to little or no extent. Officials noted that forecasting and projection are inherently difficult, but suggested that NBIC could develop other kinds of analysis that would be useful for the projection element of situational awareness. For example, officials from a primary biosurveillance agency suggested that NBIC could integrate more data and information from other DHS components into its reports, which would help to provide a homeland security perspective on biological events. Officials from another agency stated that NBIC could combine information across multiple domains on a local disease outbreak with known travel and weather patterns to predict how a disease might spread. NBIC officials stated that the center is working to improve its products and its ability to contextualize the information it collects from open sources, and has sought partner input to do so. For example, beginning in late June 2015, partly on the basis of feedback the center received from its November 2014 Federal Stakeholder Survey, NBIC modified its daily Monitoring List to include an up-front summary that identifies the status of ongoing biological events as worsening, improving, unchanged, or undetermined. During our interviews with the NBIS partners, several agency officials suggested that the center make a similar change to this product because it would help them to more quickly scan the report to determine which events might be worth further examination. Although we are not able to analyze the effect this change had on partner views because the change took place after our interviews, it appears to be a positive step in response to one issue that partners raised. Further, NBIC officials noted that the center is also working to better integrate forecasts and projections into its products and activities. Specifically, NBIC is participating in a working group led by the Office of Science and Technology Policy to support the priorities articulated in the S&T Roadmap by developing a common interagency vision for specific federal capabilities and practical next steps leading to the application of reliable infectious disease forecasting models in decision-making processes. Data that NBIC could use to identify and characterize a biological event of national concern using statistical and analytical tools, as called for in the 9/11 Commission Act, are limited. Apart from searches of global news reports and other publically available reports generated by NBIS partners, NBIC has been unable to secure streams of raw data from multiple domains across the biosurveillance enterprise that would lend themselves to near-time quantitative analysis that could reveal unusual patterns and trends. NBIC acknowledged in its strategic plan that the data required to carry out its mission as envisioned in the 9/11 Commission Act either do not exist or are subject to a variety of information sharing challenges that make a large information technology-centered solution less feasible than originally imagined. NBIC and NBIS partners noted that there were several kinds of data that could be useful for this kind of biosurveillance integration, but these data may not exist or may not be in a usable form. For example, EPA officials stated that under the existing statutory framework, the federal government does not collect real-time data on water quality and contamination from drinking water utilities. Instead, water systems report violations of drinking water standards to EPA on a quarterly basis. In addition, officials from CBP and DOI’s U.S. Geological Survey (USGS) reported that there is a significant gap in the availability of animal health data, particularly data on wildlife disease, which makes it difficult to fully understand the dynamics of zoonotic diseases. NBIC officials also noted that other kinds of data are maintained in formats that make them difficult to analyze, such as paper health records. Further, the S&T Roadmap noted that many livestock health records are held by private industry and are not broadly accessible or standardized in a manner that would make such data usable. In our survey, few—5 of 19—NBIS partners reported that they shared raw data with NBIC, and during structured interviews NBIS partners discussed a variety of challenges they faced in sharing certain data with NBIC. Some agencies are reluctant to share their data with NBIC because they are unsure how the information will be used. For example, officials from a primary biosurveillance agency stated that the agency does not share some data with NBIC because sharing such information too broadly might have substantial implications on agricultural trade or public perception of safety. Further, officials from another primary biosurveillance agency noted that there is sometimes reticence to share information and data with components of DHS because, given the department’s roles in law enforcement and national security, the information might be shared outside of the health security community in a way that lacks appropriate context and perspective. Other agencies stated that they are unable to share data for regulatory or legal reasons, or because appropriately protecting the data would take too long. For example, officials from HHS’s Food and Drug Administration (FDA) stated that their agency is unable to share some of its data on food and drug contamination because this information is confidential commercial information that FDA is restricted from sharing outside the agency. According to CDC officials, their agency receives electronic data from state, territorial, local, and tribal sources for a variety of programs and purposes that are covered by data use agreements that do not allow CDC to share the data outside the terms of those agreements and as allowed or required by applicable federal laws, such as the Privacy Act of 1974 and the Freedom of Information Act. Pursuant to federal law and the terms of these agreements, CDC may share aggregated information as long as it protects an individual’s privacy. However, according to CDC officials, some of these data cannot be shared without extensive, time- consuming work to appropriately redact the data to ensure that individuals may not be identified and that privacy is protected, which results in the release of the data being postponed to the point that the data are no longer actionable. Further, officials from VA noted that the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations also restrict their ability to share some data because it requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. Concerns over data are a long-standing issue with NBIC and the federal biosurveillance integration mission. We have previously reported that scant availability of data throughout the federal government, a lack of trust, and partners’ concerns over sharing sensitive information with NBIC were major barriers in NBIC’s ability to obtain the data and other information that it needed to support data integration. NBIC officials recognize that these barriers inhibit the ability of their partners to share some data with the center, but noted that they are trying to work with some of their partners to address these issues. For example, NBIC is currently developing a project with VA to determine how the center can use VA’s data for biosurveillance purposes while ensuring that sensitive data are properly managed. To fulfill its Coordinator role, NBIC has established procedures that occur daily, weekly, and as emerging or significant biological event occur, but the center faces challenges related to participation of NBIS partners in the center’s activities, the provision of partner personnel to NBIC, and competing structures for convening NBIS partners. in. Biweekly Calls: Until recently NBIC hosted a Weekly Reporting Call to present and discuss the most significant biosurveillance events from the previous week. In response to feedback the center received from its November 2014 Federal Stakeholder Survey, NBIC changed the format of the weekly call in January 2015 to a biweekly call with a rotating responsibility among the NBIS partners to provide a featured speaker on a relevant issue, as well as an opportunity to pose questions to NBIC and the other partners on ongoing or potential biological events. National Biosurveillance Integration System (NBIS) Protocol: a mechanism that brings federal partners together on a short-notice teleconference to provide information sharing on an emerging or significant biological event. Daily Analysts’ Call: a daily teleconference in which NBIC analysts and other participants discuss newly identified potential and active hazards. Bi-weekly Reporting Call: NBIC hosts the Interagency Biosurveillance Presentation Series bi-weekly via teleconference with NBIS Partners presenting and discussing biosurveillance project findings of interest. interagency information-sharing portal— housed within the National Center for Medical Intelligence—through which participating entities can request information among a trusted subset of interagency subject matter experts within the federal biosurveillance community. Jointly Developed Products: NBIC brings together its multidisciplinary partners to develop joint products that enhance understanding of new or potential biological events. multidisciplinary partners to develop joint products that enhance understanding of new or potential biological events. For example, NBIC coordinated with APHIS to facilitate a study by DHS’s Homeland Infrastructure Threat and Analysis Center that modeled the potential biological and economic impacts of the Kudzu bug, a pest that presents a potential risk to the U.S. soybean crop if pesticide applications failed. NBIC has also developed joint classified intelligence products developed by DHS’s Office of Intelligence and Analysis by, for example, describing the scope and context of a biological agent in these products. According to agency officials we spoke with and strategic documents we reviewed, NBIC faces challenges that affect its ability to implement its Coordinator role, including the limited participation of NBIS partners in NBIC activities, limited provision of partner personnel to NBIC, and competing structures for convening NBIS partners. Although NBIC has implemented its Coordinator role through a variety of interactions and procedures, partner participation in key NBIC activities has generally been limited. For example, as shown in figure 7, about half of the NBIS partners reported in our survey that they regularly participated in NBIC’s Weekly Reporting Calls (9 of 19) during the time period between August 2012 and December 2014, and even fewer reported regularly participating in the Daily Analyst Calls (2 of 19). Some of the agencies that reported not regularly participating in the daily and weekly calls are primary biosurveillance agencies that are generally considered to be among the lead generators of biosurveillance information in their respective domains. Officials from one of these agencies noted that much of the information presented during the daily and weekly calls was already provided in the daily Monitoring List e-mail, and therefore provided relatively little new information. The National Strategy for Biosurveillance notes that in a reduced resources environment, it is important to pursue activities that add value for all participants, and officials across the NBIS noted that the modification to the weekly call was a positive step. For example, officials from a primary biosurveillance agency stated that the change provided them with an opportunity to advertise the services their agency provides. Officials from another primary biosurveillance agency noted that the new presentation-focused format is more likely to benefit all partners across the NBIS. NBIC officials stated that they plan to request feedback from the partners in the future on the new format of these calls to determine what, if any, additional changes are needed. Limited Provision of Partner Personnel Another challenge faced by NBIC concerns its ability to obtain personnel from its partners as originally envisioned in the 9/11 Commission Act. NBIC officials told us that effective biosurveillance depends on subject matter experts to interpret events and place them in context. Although all of the NBIS partners provide key points of contact for NBIC, few (3 of 19) partners currently provide a dedicated liaison as of July 2015. Officials across the NBIS partners provided various reasons for why their agencies did not provide a liaison. For example, officials from one primary biosurveillance agency stated that for their agency, and likely other agencies as well, it is difficult to provide personnel to NBIC on a full- or part-time basis because of their own resource constraints. Further, officials from a support biosurveillance agency noted that the lack of clarity about NBIC’s value to its partners is a barrier to providing the center with detailees. In order to obtain more personnel from its partners, NBIC has agreed to partially fund some of the liaisons. For example, according to NBIC officials, the center already funds liaisons from VA, DOI, and USDA’s APHIS and is working to establish a liaison with CDC. .According to NBIC, liaisons have provided great benefit to the center such as by providing special knowledge of their agency’s roles and areas of responsibility and providing NBIC with the critical ability to reach-back into their respective agency or department. According to the officials, NBIC would like to more fully leverage the capabilities of its partners and obtain a liaison from each NBIS partner; however, budget constraints currently prohibit NBIC from obtaining fully funded liaisons from each partner. Competing Structures for Convening Partners Federal partners noted that they were unclear about the differences between two of the major structures used for convening federal stakeholders to discuss emerging biological events. The NBIS Protocol, as previously identified, is managed by NBIC, while the other, the Biological Assessment Threat Response (BATR) Protocol, is managed by the White House’s National Security Council Staff. According to the NBIC Strategic Plan, the BATR Protocol is a national-level interagency consultation process with mid-to-high level decision makers that is designed to achieve coordinated action and desired outcomes to prevent, protect from, and respond to high-consequence bioterrorism and biosecurity threats. According to NBIC, each of the protocols is designed to serve a different purpose for a different set of participants according to their respective roles in the recognition of, and response to, a biological event. The NBIS Protocol is a mechanism to bring together federal analysts and operators for information sharing early in a biological event’s discovery and development phase; whereas the BATR Protocol is designed to enable the most senior level of federal leadership to achieve situational awareness to effectively coordinate available resources for incident response. However, although we did not ask a specific question about the two protocols in our structured interviews, about a quarter of the NBIS partners (5 of 19) we interviewed were unclear about the differences between the two protocols. For example, in structured interviews, officials from two of the agencies noted that the protocols appeared to serve the same purpose or were attended by the same officials. To fulfill its Innovator role, NBIC has funded several pilot projects, sought new data sources, and made efforts to enhance its IT system, but faces challenges related to its limited resources and the varying needs of its partners. rapid characterization and mitigation of disease outbreaks. The resulting product, which was completed in October 2014, provides biosurveillance analysts with procedures for selecting and applying uncertainty methods as well as a standardized format for reporting information. National Collaborative for Bio- Preparedness (NCB-Prepared): a pilot project sponsored by NBIC and the University of North Carolina at Chapel Hill, among others. According to NBIC, a September 2014 prototype was capable of real-time analysis of health data in a geographic format, enabling users to search data, for example, on clinical symptoms and text within health records, using data from Emergency Medical Services, 911 phone calls, and Poison Control Centers. According to NBIC, this pilot program is intended to be offered to state and local governments and the private sector. Social Media pilot projects: NBIC has conducted several pilot projects to examine the extent that social media can augment existing biosurveillance detection and analysis. The pilot projects assessed the feasibility of using commercial and government off-the-shelf systems to aggregate social media information for biosurveillance. The most recent pilot, initiated in fiscal year 2012, funds the Department of Defense’s Naval Surface Warfare Center to develop analytical techniques to improve the use of social media data for biosurveillance. NBIC plans to conclude the project at the end of fiscal year 2015, and transition the project’s algorithms for operational use. The 2012 NBIC Strategic Plan also identified a number of pilot projects designed to assess the extent to which such projects could be adopted full-scale. According to the plan, each pilot project is intended to improve collaboration or information sharing. According to NBIC, these pilots are routinely assessed and evaluated to determine what is most helpful and effective, and those that prove successful will be integrated into normal operations, while those that are not will be discontinued. For example, NBIC has jointly funded the National Collaborative for Bio-Preparedness pilot project to develop a comprehensive, state-level system to analyze public health trends and detect emerging biological incidents by using data analytics and anomaly algorithms. Further, NBIC has also funded three pilot projects examining the feasibility of using open-source data from various social media applications in order to identify possible health trends. NBIC has completed two of these pilots and one is ongoing. NBIC has been seeking new sources of data and information in order to fulfill its mission for early warning and shared situational awareness of acute biological events, including data and information from other DHS components and NBIS partners, as well as classified information. First, in September 2013, NBIC analyzed the usefulness of department-wide absenteeism data from DHS’s Office of the Chief Human Capital Officer, which could be an indicator of an emerging epidemic. Based on an analysis of 20 months of DHS workforce data from 2012 and 2013, the study concluded that absenteeism data could be a useful component in biosurveillance, as understanding differences between normal leave behavior and expected rises in leave behavior during peak flu seasons would help in establishing baseline values for comparison. In August 2014, NBIC, working with DHS’s Science and Technology Directorate and Lawrence Livermore National Laboratory, evaluated the usefulness of DHS components’ data systems as potential biosurveillance data sources. The assessment identified two Customs and Border Protection (CBP) databases as the most useful to NBIC’s mission, and in June 2014, NBIC funded a part-time liaison to CBP’s Office of Intelligence to determine the extent to which NBIC can use CBP databases for biosurveillance purposes. Second, NBIC has also sought to obtain new sources of data from NBIS partners and other stakeholders. For example, as of July 2011, VA has provided NBIC a liaison to, among other responsibilities, identify ways NBIC can use VA’s patient healthcare information to support its early detection and situational awareness mission. Finally, according to NBIC officials, the center has enhanced its process for analyzing intelligence information and reviews various intelligence sources to supplement, corroborate, or provide additional context to the biosurveillance items identified through other sources. For example, an NBIC intelligence analyst reviews all source intelligence information to identify potential topics of interest, such as indications of novel infectious disease or terrorism, and if necessary, reaches back to partners in the intelligence community for further information. NBIC officials noted that the center’s recent focus is on building its internal IT infrastructure, rather than pilot projects. For example, through its current Biofeeds project with the Pacific Northwest National Laboratory, NBIC is seeking to build a visual and text analytics capability that to enable the center to more effectively and efficiently identify relevant information in open source data. Officials also noted that NBIC is partnering with the Defense Threat Reduction Agency on the Biosurveillance Ecosystem project to build a collaborative analytic workbench for the center. Further, officials stated that NBIC has obtained an IT program manager as a detailee from the Transportation Security Administration to help build the center’s internal IT program. According to agency officials we spoke with and strategic documents we reviewed, NBIC faces challenges that affect its ability to implement its Innovator role, including its limited resources and the varying needs of partners. Although we did not ask a specific question about resource limitations, officials from 9 of the 19 NBIS partners identified it as a challenge NBIC faces in developing new biosurveillance tools and technology. From fiscal year 2012 through 2015, NBIC’s budget ranged from $10 million to $13 million annually. Officials from 2 primary biosurveillance agencies noted that NBIC’s budget limits its ability to enhance its existing technology systems to invest in innovations such as disease event modeling. Further, officials from 3 primary biosurveillance agencies more generally expressed concerns regarding the imbalance between the size and nature of NBIC’s mission, including its role as an innovator, and the resources that it had available to achieve it. NBIC officials stated they have never requested a budget increase, because their larger DHS office, the Office of Health Affairs, has experienced budget reductions, and an increase for NBIC would require a decrease for another program. However, NBIC officials noted that they would likely use any increase in its budget to help develop more analytical tools for itself and its partners. Related to its limited resources, NBIC also faces challenges prioritizing its innovation efforts because its partners have diverse, and sometimes conflicting, needs. The S&T Roadmap noted that active collaboration for biosurveillance presents challenges because stakeholders have varying missions and roles. As previously noted, NBIC asked its partners to identify existing capability gaps. The 13 submissions covered a wide variety of biosurveillance issues and domains, such as wildlife disease surveillance, integration of pharmacy data, and analysis of Medicare claims data. However, although NBIC asked partners to prioritize the 13 submissions identified as existing capability gaps, the proposal that was selected had been ranked third by the partners, and officials from a primary biosurveillance agency stated that it was unclear why the higher ranking proposals were not selected. Further, officials from a primary biosurveillance agency suggested that NBIC conduct its own needs analysis to determine what tools and technology NBIC could invest in. NBIC officials noted that the third ranked proposal was selected because it was the highest ranked proposal that was “shovel ready”, thereby allowing funding to be applied when funding was available, whereas the top two proposals were not. According to NBIC officials, future investments will be informed by the S&T Roadmap. Although 13 of the 19 NBIS partners stated in our structured interviews that the concept of having a federal entity whose mission is to serve as the integrator of national biosurveillance information across agencies and disease domains is very or moderately important, some also expressed doubts about the feasibility and practicality of this mission. Specifically, although we did not specifically ask a question about the practicality of NBIC’s mission, about a third of the NBIS partners (7 of 19) expressed skepticism and doubts about the feasibility of NBIC’s mission, including whether federal integration of biosurveillance information could actually achieve early warning and situational awareness of biological events. Among the specific reasons officials cited for the skepticism was their uncertainty that the current model of biosurveillance integration was the most effective investment for strengthening the national biosurveillance capability. For example, officials from one agency noted that while the concept makes sense intuitively, there is no reliable evidence, such as a peer-reviewed study, that has confirmed the viability of the concept, nor has there been a large-scale biological threat that has been detected through integration; moreover, such a system—by virtue of its being federally-based—would lack timely detection and response capabilities because events occur at the local level. Officials from another agency questioned the feasibility of NBIC’s mission because the data and technology that are currently available do not provide for the accurate projection of biological events or facilitate the provision of early warning. Additionally, an NBIC official told us that the ability to achieve early detection of emerging events—especially unexpected or novel events—is dubious because most of the tools and techniques used in surveillance rely on contrasting current conditions with known baseline trends and patterns, but as an event emerges, surveillance practitioners are not necessarily going to be focused on those patterns and trends until something prompts their attention. Moreover, when a biological event is novel, its patterns and trends are not yet known. We have previously reported on skepticism on the part of some of the NBIS partners regarding the value of the federal biosurveillance mission as well as NBIC’s role in that mission. In our 2009 report, most of the NBIS partners we interviewed at that time expressed uncertainty about the value of participating in the NBIS or confusion about the purpose of NBIC’s mission. For example, officials from 1 of the partners stated that it was unsure whether NBIC contributed anything to the federal biosurveillance community that other agencies were not already accomplishing in the course of carrying out their biosurveillance-relevant missions. We, the NBIS partners, and other major stakeholders in the biosurveillance community acknowledge that no single problem limits NBIC’s mission to integrate biosurveillance data. Rather, over the years, several long-standing problems have combined to inhibit the achievement of this mission as envisioned in the 9/11 Commission Act. Most notably, to operationalize the federal biosurveillance integration concept requires the simultaneous sharing and consideration of information from vastly disparate domains, including health, law enforcement, intelligence, and international partners. However, as noted in the S&T Roadmap, the sharing of this information is limited and is often not possible. The challenges previously described illustrate that NBIC faces significant obstacles in implementing its roles as a biosurveillance integrator as originally described in the 9/11 Commission Act. Below, we discuss options for policy or structural changes that could help better fulfill the biosurveillance integration mission. We identified these options and their benefits and limitations, on the basis of the roles of a federal-level biosurveillance integrator we identified in the 9/11 Commission Act, NBIC’s strategic plan, and the perspectives of the NBIS partners obtained during our structured interviews. These options are not exhaustive, and some options could be implemented together or in part. In developing these options, we did not evaluate the financial implications of implementing each option, to the extent it is knowable, but we acknowledge they are likely to result in an increase, decrease, or shifting of funding based on the changes described. Developing meaningful information not otherwise available: This option would address some of the challenges NBIC faces in implementing its Analyzer role, such as access to data from the NBIS partners, and would better position the center to develop meaningful information that could not be gleaned in isolation, potentially leading to earlier warning of emerging events and shared situational awareness. Capitalize on new data sources and analysis techniques: Focusing on providing the resources, infrastructure, and frameworks for data sharing may provide the foundation to capitalize on future advancements in data analytics, including big data analysis and electronic health records, to mine data for emerging patterns. Uncertain need: The probability that a disease event with significant national consequences occurring in such a way that it would be detected more quickly by overlaying various data streams and applying statistical and analytical tools to them is not known. Uncertain data availability: There may not be a significant amount of meaningful data available that is not already being provided to facilitate advanced analytical techniques. For example, although partners identified other potential data sources that could contribute to a more robust integration tool, such as water contamination and wildlife disease data, it is unknown whether such data could be collected and managed to make a meaningful contribution, and if they could, at what cost. Unproven concept: Even with access to more data, it is unclear whether a federal biosurveillance integrator would be able to identify patterns or connections that would lead to earlier warning of emerging events or reduce the time it takes to discover, prevent, or respond to a potentially catastrophic event, or that it would merit the associated costs. Finding patterns and trends without knowing specifically what to look for is challenging, and about a third of the NBIS partners (7 of 19) expressed skepticism and doubts about the feasibility of NBIC’s mission, including whether federal integration of biosurveillance information could actually achieve early warning and situational awareness of biological events. Unknown impact of earlier detection: If NBIC were able to discern signals that gave warning of an emerging event, there is no guarantee that it would significantly decrease the amount of time it would take federal partners to confirm the warning and implement response actions. Increased costs: Creating the enterprise architecture both within NBIC and across the NBIS that would facilitate transfer and computer- aided analysis of data would likely require a significant investment in technology, as well as skilled personnel with data analytic, legal, and regulatory expertise. Although we have not specifically assessed the costs of these options, such costs, at least in the near term, would likely exceed NBIC’s current annual budget. Clear leadership: This option would create clear leadership across the interagency for developing and implementing biosurveillance policy in general and in response to specific biological events, which may also encourage partners to more fully participate in NBIC activities, such as regularly attending NBIC’s Daily Analysts’ and Bi- weekly Reporting calls. Better institutional connection: NBIC officials have stated that the current liaisons have provided great benefit to the center. Ongoing interaction among more dedicated liaisons from various agencies may strengthen biosurveillance subject matter expertise and could enhance communication across all the agencies. Routine, institutionalized channels to monitor for emerging trends and patterns: Clarifying the federal integrator’s role in routinely convening and drawing on the analytical capacity of the various pockets of federal expertise across the NBIS could enhance the ability of NBIC to go beyond daily surveillance and monitoring activities to recognize connections and generate meaningful insights that may not be gleaned in isolation. Enhanced accountability for implementing the National Strategy for Biosurveillance: Formally vesting a federal entity with responsibility for leadership of the national biosurveillance enterprise would fill a longstanding need to institutionalize and create accountability for common goals and deliberate, results-driven, risk- based investment across the enterprise. Because the mission responsibilities and resources needed to develop a national biosurveillance capability are dispersed across a number of federal agencies, efforts could benefit from a focal point to provide sustained leadership that helps direct interagency efforts to invest in and implement new and existing programs in a way that ensures generation of meaningful data with the potential to discover emerging biological events with potentially catastrophic consequences. Role conflict: Some of these responsibilities overlap with responsibilities that have historically been the purview of the National Security Council Staff, and legislative direction to assume these responsibilities could create more role conflict and confusion unless authority, roles, and responsibilities were very clearly designated. Authority and legitimacy: It may be difficult for an agency at NBIC’s level to successfully influence decision making across the interagency. For example, discussions we had with some NBIS partners demonstrated that both DHS and NBIC have encountered and may continue to encounter issues with perceived legitimacy in the health security arena. New tools and technology: NBIC could foster the development of tools and technology that benefit multiple federal partners and other members of the NBIS (e.g., state and local health agencies), thus enhancing the overall national biosurveillance capability. For example, the 2013 S&T Roadmap identified the need to strengthen detection by developing new modeling and ecological forecasting approaches that could enhance current ways of predicting disease outbreaks and determining likely impacts when a threat is detected. Specifically, this should be accomplished by developing methods that integrate traditional monitoring (i.e., pathogen, environmental, and health) with background data (i.e., meteorological and population dynamics). Coordinate research and development efforts: The S&T Roadmap notes that there are dozens, and possibly hundreds, of biosurveillance initiatives and pilot projects that have been implemented at local, state, regional, and national levels, NBIC would be well positioned to help coordinate and deconflict biosurveillance research and development across the interagency, which would help to avoid any unnecessary duplication, overlap, and fragmentation of effort. Further, the S&T Roadmap identifies 14 research priorities, many of which would benefit from coordination across the federal government, as well as with state, local, and private entities. For example, one of the research priorities is to develop multilateral communication mechanisms among the various levels of government and the private sector to enable timely decision making. Effectively addressing such a research priority would likely require the collaboration of multiple federal and nonfederal partners, including HHS, USDA, and DHS, as well as healthcare providers and international partners, among others. Increased costs: Although we have not specifically assessed the costs associated with the options, supporting the development of new tools and technology would likely exceed NBIC’s current annual budget. More research and development expertise: Although NBIC has engaged in some pilot projects that develop tools and technology, a national integrator that focuses on innovation would likely need to acquire more expertise in research and development. Significant restructuring: In comparison with its other roles, NBIC’s role as an Innovator is the least well defined in the 9/11 Commission Act, and NBIS partners noted that the center’s current budget limits its ability to fulfill this role. Focusing attention on this role may represent a significant mission shift from the status quo, and may require very different sets of resources and procedures. NBIC has made progress and may continue to do so: Although most (10 of 19) federal partners stated that NBIC has limited impact on their ability to carry out their biosurveillance roles and responsibilities, 12 of 19 NBIS partners interviewed noted that NBIC has made improvements in its products, outreach, coordination, and other activities. Further, in recent years, NBIC has been able to obtain or partially fund liaisons from other agencies. Establishing itself as a trusted and effective federal integrator with limited direct authority is a difficult task, and the center and its NBIS partners may merely need more time to evolve their roles and relationships to realize the full potential of the current NBIC as the federal biosurveillance integrator. Some agencies currently find value in NBIC’s products: Agencies with more limited roles in biosurveillance, such as biosurveillance support agencies and information consumers, generally stated that they like NBIC’s products because their own agencies do not have enough resources to review biosurveillance information across multiple agencies and domains. Further, NBIC officials noted that the center’s products benefit some of their nonfederal stakeholders that have limited resources for biosurveillance, such as state, local, tribal, and territorial agencies. For example, as of July 2015, NBIC’s daily Monitoring List e-mail is distributed to 338 individuals representing state, local, tribal, and territorial entities, including state departments of health and agriculture, fusion centers, and police departments. Data challenges: NBIC will likely continue to face challenges in obtaining all the biosurveillance data it needs to effectively apply statistical and analytical tools to identify and characterize biological events of national concern in as close to real time as practicable, per requirements in the 9/11 Commission Act. Partners remain skeptical of NBIC’s value: NBIC has implemented our recommendation to create a strategy, in partnership with the NBIS agencies, that better defines its mission and focus on other collaborative practices. Nevertheless, NBIS partners remain skeptical of NBIC’s value. As previously shown in figure 5, few of the NBIS partners (4 of 19) we interviewed stated that NBIC’s products and activities enhanced their agency’s ability to carry out their biosurveillance roles and responsibilities. Further, as illustrated in figure 8, 8 of 19 NBIS partners we interviewed stated that NBIC is achieving its mission to little or no extent. It is unclear whether additional time or what additional actions will improve partners’ experience with NBIC’s overall value to the national biosurveillance capability. Cost savings: Given that most federal partners stated that they integrate some biosurveillance information themselves and that NBIC has limited impact on their ability to carry out their biosurveillance roles and responsibilities, the cost of operating NBIC may not be worth its benefits. Officials report that a federal integrator is important: Although federal partners generally thought that NBIC’s products and activities did not provide meaningful new information, they largely thought that the concept of having a federal entity to integrate biosurveillance information across the federal government was important. Specifically, in our structured interviews, 13 of the 19 NBIS partners stated that the concept of having a federal entity whose mission is to serve as the integrator of national biosurveillance information across agencies and disease domains is very or moderately important. Potential loss of investment: As previously noted, 13 of 19 NBIS partners stated that NBIC has made improvements in its products, outreach, coordination, and other activities. Defunding NBIC could create a loss of investment, institutional learning, and progress made toward developing a federal biosurveillance integrator, which may need more time to evolve to become effective. Another integrator may experience similar challenges: Even if one of the other primary biosurveillance agencies were designated as the federal biosurveillance integrator, that entity may still find it difficult to overcome organizational boundaries and engender agency cooperation, given that multiple agencies have key biosurveillance responsibilities. We provided a draft of this report for review and comment to DHS and the 13 other departments and agencies that compose the NBIS—the Departments of Agriculture, Commerce, Defense, Energy, Health and Human Services, Interior, Justice, State, Transportation, and Veterans Affairs, as well as EPA, ODNI, and USPS. DHS provided written comments on September 16, 2015, which are summarized below and presented in their entirety in appendix III of this report. DHS, EPA, USPS, and the Departments of Agriculture, Interior, Health and Human Services, and Veteran’s Affairs provided technical comments, which we considered and incorporated, where appropriate. The ODNI and the Departments of Commerce, Defense, Energy, Justice, State, and Transportation did not comment. DHS expressed appreciation for our recognition of its progress fulfilling our prior recommendations, which were designed to enhance interagency collaboration. DHS also acknowledged the array of challenges detailed in this report, and noted some actions it is undertaking to try to address them. DHS noted that the report does not include nonfederal biosurveillance stakeholders in its scope, and posits that these stakeholders may find value in NBIC’s current products. Although we cannot comment on the extent to which these nonfederal stakeholders value NBIC’s current products, we have previously reported on the important role that nonfederal partners in the biosurveillance enterprise, particularly because most of the resources necessary to generate biosurveillance information are outside of the federal government. The federal departments and agencies with primary biosurveillance roles, as outlined in this report, have a variety of relationships and agreements with nonfederal partners to facilitate partnership and information sharing. We note that NBIC’s authorizing legislation calls for NBIC to work with state and local entities in coordination with, and through when possible, its federal partners and these existing relationships. We are sending copies of this report to the Departments of Agriculture, Commerce, Defense, Energy, Health and Human Services, Homeland Security, the Interior, Justice, State, Transportation, and Veterans Affairs; the Environmental Protection Agency; the United States Postal Service; and the Office of the Director of National Intelligence. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report please contact me at (404) 679-1875 or curriec@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this product are listed in appendix IV. We surveyed and interviewed officials from 19 federal departments and their component agencies across 13 of the 14 departments and agencies that compose the National Biosurveillance Integration System (NBIS). We refer to these 19 agencies as NBIS-partner agencies, and we categorized these into three groups: Primary biosurveillance agencies: Have major biosurveillance mission responsibilities that include collecting or analyzing biosurveillance information for the purposes of detecting, monitoring, or responding to biological events. Support biosurveillance agencies: Do not have missions that directly involve disease detection and monitoring; however, they collect data and information or have subject matter expertise that may be useful to efforts to detect, monitor, or respond to biological events. Biosurveillance information consumers: Generally do not produce information that is useful for biosurveillance, but consume such information because biological events can affect their main mission and they may have a particular role to play in responding to an event. We developed these categories based on each partner’s roles and responsibilities related to biosurveillance. Table 3 includes brief summaries of the NBIS partners, including agency type, mission, domains, and biosurveillance responsibilities. We conducted a Web-based survey of the 19 National Biosurveillance Integration System (NBIS) partners to identify the federal agencies from which they obtain information that contributes to their agency’s situational awareness of biological events. Because this was not a sample survey, it has no sampling errors. However, the practical difficulties of conducting any survey can introduce errors, commonly referred to as nonsampling errors. We took steps in developing the questionnaire, collecting the data, and analyzing them to minimize such nonsampling errors. We conducted pretests with 3 agencies to help ensure that the questions were clear and unbiased, and that the questionnaire did not place an undue burden on respondents. An independent reviewer within GAO also reviewed a draft of the questionnaire prior to its administration. We made appropriate revisions to the content and format of the survey questionnaire based on the pretests and independent review. The survey was administered on the Internet from March 25, 2013, to May 15, 2013. To increase the response rate, we followed up with emails and personal phone calls to the experts to encourage participation in our survey. We received responses from all 19 agencies in our population (100 percent response rate). Based on comments we received from two agencies, we also conducted two follow- up phone calls with officials at these agencies who responded to our survey to verify their answers to survey questions about the federal agencies from which their agency obtains information that contributes to their agency’s situational awareness of biological events. We made appropriate changes to the responses recorded on these officials’ questionnaires to reflect the clarifications made during these phone calls. When we analyzed the data, an independent analyst verified all programs. Because this was a Web-based survey, respondents entered their answers directly into the electronic questionnaire, eliminating the need to key data into a database, minimizing error. In the survey, we asked each agency whether it obtains information from each of the other agencies in our population, as well as which types of information it obtains from them (perception-, comprehension-, or projection-related information). For the purposes of this report, we use the definition of situational awareness that the NBIC Strategic Plan uses in the articulation of its mission. The definition has its basis in the work of Mica Endsley, who described situational awareness as having three elements: (1) perception that a situation has occurred, (2) comprehension of the situation’s meaning, and (3) projection of the event’s likely course in the near future. We performed a network analysis of these survey data, which is a quantitative and graphical technique for identifying the underlying patterns in a complex system of relationships among entities of interest. Figure 9 illustrates the agency sources from which the primary and support biosurveillance agencies in our survey obtain data that enhances their situational awareness of biological events. For example, officials from the Environmental Protection Agency (EPA) reported that their agency obtains information that enhances all three elements of situational awareness from seven agencies, including the Animal and Plant Health Inspection Service, Centers for Disease Control and Prevention, and National Biosurveillance Integration Center, among others. Further, EPA officials reported that they obtain information that enhances their comprehension and projection of biological events from the Department of the Interior’s Office of Emergency Management and the National Center for Medical Intelligence. In addition to the contact named above, Kathryn Godfrey (Assistant Director), Andrew Brown, David Dornisch, Lorraine Ettaro, Eric Hauswirth, R. Denton Herring, Tracey King, Erin O’Brien, Lerone Reid, John Vocino, Brian Wanlass, and Christopher Yun made key contributions to this report.

Summary: A biological event, such as a naturally occurring pandemic or a terrorist attack with a weapon of mass destruction, could have catastrophic consequences for the nation. This potential threat underscores the importance of a national biosurveillance capability—that is, the ability to detect biological events of national significance to provide early warning and information to guide public health and emergency response. The 9/11 Commission Act of 2007 addresses this capability, in part, by creating NBIC within the Department of Homeland Security (DHS); it was tasked with integrating information from human health, animal, plant, food, and environmental monitoring systems across the federal government, to improve the likelihood of identifying a biological event at an earlier stage. In recent years, NBIC's budget has ranged from $10 million to $13 million annually. GAO was asked to evaluate NBIC. This report discusses the (1) extent to which NBIC is implementing its roles as a biosurveillance integrator, and (2) options for improving such integration. To conduct this work, GAO reviewed NBIC products and activities; conducted interviews and surveyed 19 federal partners, 11 of which have key roles in biosurveillance; interviewed NBIC officials; and analyzed the 9/11 Commission Act, NBIC Strategic Plan , and National Strategy for Biosurveillance . The National Biosurveillance Integration Center (NBIC) has activities that support its integration mission, but faces challenges that limit its ability to enhance the national biosurveillance capability. In the Implementing Recommendations of the 9/11 Commission Act of 2007 (9/11 Commission Act) and NBIC Strategic Plan , GAO identified three roles that NBIC must fulfill to meet its biosurveillance integration mission. The following describes actions and challenges in each role: Analyzer: NBIC is to use technology and subject matter expertise, including using analytical tools, to meaningfully connect disparate datasets and information for earlier warning and better situational awareness of biological events. GAO found that NBIC produces reports on biological events using open-source data, but faces challenges obtaining data and creating meaningful new information. For example, most of the federal partners with key roles in biosurveillance (8 of 11) stated that NBIC's products help their agencies identify biological events to little or no extent, generally because they already obtain such information directly from other federal partners more quickly. In addition, data that could help to identify and characterize a biological event may not exist or are not in a usable form. Further, few federal partners (5 of 19) reported that they share the data they do have with NBIC, citing legal and regulatory restrictions, among other reasons.. Coordinator: NBIC is to bring together partners across the federal biosurveillance community to enhance understanding of biological events. NBIC has developed procedures and activities to coordinate with partners, such as daily and biweekly calls, but faces challenges related to the limited partner participation in the center's activities, lack of partner personnel detailed to NBIC, and competing structures for convening federal partners. For example, although NBIC would like to obtain liaisons from each of its federal partners, only 3 of 19 partners provided NBIC with dedicated liaisons. Innovator: NBIC is to facilitate the development of new tools to address gaps in biosurveillance integration. GAO found that NBIC has efforts underway to develop some tools, such as pilot projects examining the use of social media data to identify health trends, but faces challenges prioritizing developmental efforts. For example, partners noted limitations in NBIC's ability to address gaps, like limited resources and the difficulty in prioritizing the center's innovation efforts because its partners have diverse needs. GAO identified various options that could address these challenges, ranging from strengthening the center's ability to implement its current roles to repealing NBIC's statute. GAO also identified potential benefits and limitations with each option. For example, one option would be to provide NBIC with additional authorities to obtain data to better develop meaningful information; however this may also require additional investments. Another option is to not pursue national biosurveillance integration through NBIC and to consider designating one of the other federal partners with key roles in biosurveillance as the federal integrator. The options identified are not exhaustive, and some could be implemented together or in part. GAO did not evaluate the financial implications of each option, but acknowledges some options may require additional investment or shifting of resources or priorities to result in significant long lasting change. GAO is not making recommendations. GAO provided this draft to DHS and its federal partners who provided technical comments which were incorporated, as applicable.