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.