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Public Health Surveillance for Smallpox --- United States, 2003--2005

In June 1987, nearly 10 years after the World Health Organization (WHO) declared smallpox eradicated, the Council of State and Territorial Epidemiologists (CSTE) recommended removal of smallpox, a highly contagious viral disease, from the National Notifiable Diseases Surveillance System (NNDSS) (1).* However, the attacks of September 11, 2001, raised concern that smallpox (variola) virus, might exist in laboratories other than two WHO-designated repositories and could be used as an agent of biologic terrorism (2). In response to this concern, CSTE and CDC recommended in June 2003 that smallpox again be made reportable through NNDSS and that all states, territories, and cities add smallpox to their lists of reportable diseases (3). In 2005, CSTE conducted a cross-sectional survey in the United States and its territories to assess key components for surveillance of suspected smallpox disease, including legal reporting requirements, laboratory testing, and training and education (e.g., oral presentations and guides). This report summarizes the results of that survey, which indicated that 100% had the capacity to receive and investigate reports, 94% of states had legal requirements to report suspected smallpox disease, 70% had mandatory laboratory reporting of results indicative of smallpox disease, and 68% were providing ongoing training and education of health-care providers and public health staff.

During August--October 2005, CSTE sent an e-mail to all state epidemiologists asking them to participate in the survey, which was available online to all 50 states, the District of Columbia (DC), eight U.S. territories, and health departments of nine large cities. A total of 46 states and DC (92%), one territory (13%), and seven large cities (78%) responded to the survey, for an overall response rate of 81%. The survey respondents were senior-level epidemiologists.

Forty-three of the 46 responding states and DC (94%) and all seven cities indicated having reporting requirements and other components of a surveillance system to detect suspected smallpox disease. In addition, 25 states and DC (55%) and four cities (57%) required reporting of varicella (chickenpox), a potentially severe vesicular or pustular rash illness with certain signs and symptoms similar to smallpox. Participants also reported that other surveillance systems were in place to detect suspected smallpox disease, including 1) syndromic surveillance in 33 states and DC (72%) and six cities (86%) and 2) rash illness surveillance in 29 states and DC (64%) and four cities (57%).

All 55 respondents reported having the capacity to receive and investigate reports of suspected smallpox disease 24 hours a day and 7 days a week. Forty-one states and DC (89%) had the capacity to receive disease reports primarily by telephone and 33 (70%) primarily by fax. Fifteen (32%) respondents indicated the capacity to receive reports by e-mail and 13 (28%) via the Internet. Of the 46 responding states and DC, 42 (89%) had the ability to investigate reports by telephone, 38 (81%) by e-mail, 33 (70%) by other methods, and 31 (66%) by fax. Field or home visits were reported as the methods least likely to be used for investigation of persons with suspected smallpox (12 [26%] of 46 respondents). For the seven large cities, the patterns for receiving and investigating reports were similar.

For tests related to orthopoxviruses, including smallpox virus, 31 states and DC (68%) reported they would use the CDC laboratory; 30 (64%) would use a state health laboratory, 10 (21%) a neighboring state laboratory, four (9%) another laboratory, and three (6%) an academic facility. Twenty-six states and DC (57%) reported their state public health laboratory could rapidly provide testing by orthopoxvirus nonvariola polymerase chain reaction (PCR) assay and viral culture; 22 (47%) could provide testing by orthopoxvirus PCR assay, 10 (21%) by a variola PCR assay, and seven (15%) by electron microscopy.

During 2004, an estimated 69,000 health-care and public health practitioners were trained in smallpox clinical presentation, diagnosis, and surveillance during pre-event and post-event periods by state, territorial, and large-city public health agencies. The primary means for training included presentations (58%) or using CDC materials (56%). An average of 7.8 training sessions (median: two; range: 0--133) were offered by a state public health agency, and 10.4 sessions (median: three; range: 0-- 116) were offered by local and county public health agencies. Professionals targeted for training were primarily public health personnel (64%), hospital emergency department staff members (44%), and other hospital staff members (45%).

Reported by: J Abellera, MPH, J Lemmings, MPH; CSTE Smallpox Working Group, Council of State and Territorial Epidemiologists. GS Birkhead, MD, New York State Dept of Health. SS Hutchins, MD, DrPH, National Center for Immunization and Respiratory Diseases (proposed), CDC.

Editorial Note:

As with any notifiable disease, legal requirements for mandatory reporting of smallpox are necessary for complete and timely reporting of suspected or confirmed cases (4,5). These legal requirements are the foundation for state-based surveillance in the event of a terrorist attack, specifically for smallpox and other agents of biologic terrorism (i.e., Category A, B, and C agents as defined by CDC) (6). Most states also have general authority to collect data on matters of public health importance, disease outbreaks, or unusual or unforeseen occurrences (7,8). State reporting requirements, including laboratory reporting requirements, constitute a core set of components for smallpox-specific surveillance that can detect disease quickly and lead to rapid case investigation (9). These components are coupled with increased ability of terrorism-preparedness programs in states to receive and investigate reports, conduct key syndromic or other surveillance to detect smallpox, and conduct ongoing education and training sessions on smallpox recognition and disease surveillance.

Several factors have contributed to the ability of state health departments to conduct surveillance and respond to suspected smallpox cases. States can mandate reporting by hospitals, laboratories, physicians, and other health entities for a disease within their jurisdiction. In October 2005, CSTE updated its annual NNDSS Queriable Database and noted that smallpox was reportable by law in 46 states and DC (7). Since then, two of the four states in the database that had not indicated smallpox was a reportable condition now have listed it as one of the state's notifiable diseases. The other two states report outbreaks of any kind or an unusual number of cases of any infectious disease, including smallpox.

Increases in federal funds also have affected state preparedness programs. During 2002--2005, state and local health departments received nearly $3.5 billion in federal funds to bolster state public health preparedness programs. The funds were used in part to strengthen surveillance capacity related to agents of biologic terrorism. Increased funding in terrorism preparedness and emergency response also has increased the number of epidemiologists and increased the capacity for state-level preparedness (9). Furthermore, a greater percentage of states reported substantial to full capacity to monitor health status and to identify and investigate health problems and health hazards in communities (9).

Current reporting requirements and surveillance systems, access to laboratory facilities and modes of communication to receive information, and training of public health professionals and health-care practitioners have enhanced the public health system's capacity for responding to suspected cases of smallpox disease. The findings from the CSTE survey indicate that, in the event of suspected smallpox, the public health infrastructure has components in place to detect, receive reports of, investigate, and confirm or rule out the disease. Given that states have addressed the legal and infrastructure requirements necessary to report smallpox, continued measures should focus on the advancement of 1) reported data from physicians, laboratories, and hospitals to a public health agency, and 2) early-event--detection systems to detect suspected smallpox disease. Finally, because clinicians typically are the first to identify and diagnose disease (10), measures should focus on dissemination of educational and training materials to health-care providers, emergency medical services personnel, and public health practitioners.


  1. Council of State and Territorial Epidemiologists. Removal of smallpox, relapsing fever and fleaborne typhus fever from the list of nationally notifiable diseases. Position statement 1987-5. Available at
  2. CDC. National vaccination strategy for smallpox outbreak containment. Available at
  3. Council of State and Territorial Epidemiologists. Smallpox surveillance. Available at
  4. Roush S, Birkhead G, Koo D, Cobb A, Fleming D. Mandatory reporting of diseases and conditions by health care professionals and laboratories. JAMA 1999;282:164--70.
  5. Horton HH, Misrahi JJ, Mathews GW, Kocher PL. Critical biological agents: disease reporting as a tool for determining bioterrorism preparedness. Available at:
  6. CDC. Bioterrorism agents/disease. Available at:
  7. Council of State and Territorial Epidemiologists. 2001 NNDSS queriable database. Available at
  8. Council of State and Territorial Epidemiologists. 2005 NNDSS queriable database. Available at
  9. Council of State and Territorial Epidemiologists. 2004 epidemiology capacity assessment: findings and recommendations. Available at
  10. Woods R, McCarthy T, Barry MA, Mahon B. Diagnosing smallpox: would you know it if you saw it? Biosecur Bioterror 2004;2:157--63.

* Decisions to include or exclude a disease from NNDSS are based on the extent of its associated morbidity and mortality and on its amenability to intervention and control.

Certain states indicated that their state public health laboratory could perform a viral culture; however, viral culture for variola virus is not recommended for patients with suspicious rash illness, and such a procedure should be conducted only in a designated Biosafety Level 4 laboratory because of the increased risk to unvaccinated laboratory personnel. CDC/Association of Public Health Laboratories guidelines for suspected smallpox and specimen handling are available at and

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Date last reviewed: 12/13/2006


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