text:
Kelly J. Henning, M.D.
Department of Medicine,
University of Pennsylvania School of Medicine
Infectious disease threats, both naturally occurring and intentional, continue to challenge the medical and public health communities. Even before the tragic events of September 11, 2001, public health officials had begun a search for new and innovative methods to enhance the detection of emerging infections and illness due to bioterrorist agents. In response to a series of Institute of Medicine reports citing deficiencies in the ability of U.S. public health systems to deal with emerging infectious diseases (Institute of Medicine, 1987, 1988, 1992) the Centers for Disease Control and Prevention (CDC) prepared a plan entitled Preventing Emerging Infectious Diseases (CDC, 1998). Strengthening surveillance is one of the primary objectives of this plan. Similarly, developing programs that allow for the "early detection and investigation of outbreaks"(CDC, 1998) is cited in Goal One of the 1998 CDC guideline Preventing Emerging Infectious Diseases: A Strategy for the 21st Century. And CDC's strategic plan for biological and chemical preparedness calls for early detection by integrating bioterrorism into existing systems and developing "new mechanisms for detecting, evaluating, and reporting suspicious events" (CDC, 2000).
At the local level, public health officials evaluated lessons learned during the 1999 introduction of West Nile virus into New York City, and emphasized the importance of preparing surveillance tools that would allow tracking of emerging infections and simultaneously be available for bioterrorism events (Fine and Layton, 1999). Likewise, a major obstacle identified in Operation Topoff, a simulated plague attack on metropolitan
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Appendix B
Syndromic Surveillance
Kelly J. Henning, M.D.
Department of Medicine,
University of Pennsylvania School of Medicine
Infectious disease threats, both naturally occurring and intentional, continue to challenge the medical and public health communities. Even before the tragic events of September 11, 2001, public health officials had begun a search for new and innovative methods to enhance the detection of emerging infections and illness due to bioterrorist agents. In response to a series of Institute of Medicine reports citing deficiencies in the ability of U.S. public health systems to deal with emerging infectious diseases (Institute of Medicine, 1987, 1988, 1992) the Centers for Disease Control and Prevention (CDC) prepared a plan entitled Preventing Emerging Infectious Diseases (CDC, 1998). Strengthening surveillance is one of the primary objectives of this plan. Similarly, developing programs that allow for the "early detection and investigation of outbreaks"(CDC, 1998) is cited in Goal One of the 1998 CDC guideline Preventing Emerging Infectious Diseases: A Strategy for the 21st Century. And CDC's strategic plan for biological and chemical preparedness calls for early detection by integrating bioterrorism into existing systems and developing "new mechanisms for detecting, evaluating, and reporting suspicious events" (CDC, 2000).
At the local level, public health officials evaluated lessons learned during the 1999 introduction of West Nile virus into New York City, and emphasized the importance of preparing surveillance tools that would allow tracking of emerging infections and simultaneously be available for bioterrorism events (Fine and Layton, 1999). Likewise, a major obstacle identified in Operation Topoff, a simulated plague attack on metropolitan
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Denver, was the lack of a surveillance system that could be sustained and available to continuously communicate information to the central command system (Hoffman and Norton, 2000).
Several epidemics of the recent past have illustrated the need for enhanced, more timely reporting of infectious diseases. The 1976 Legionnaires' Disease outbreak in Pennsylvania is an example of a point-source outbreak of an unknown agent with rapid transmission and high mortality associated with the dispersal of exposed persons (Fraser et al., 1977)—an outbreak that today would certainly require evaluation as a potential bioterrorist attack. Yet surveillance and outbreak data related to this investigation were so unwieldy that they had to be evaluated using mainframe computers (Martin and Bean, 1995). The 1993 hantavirus outbreak in the southwestern United States (CDC, 1993) and the West Nile virus encephalitis outbreak in New York City (CDC, 1999) illustrate the importance of prompt reporting by clinicians in triggered public health investigations. The availability of timely, flexible surveillance systems could have aided in characterizing and determining the scope of the outbreaks after their initial reporting.
CDC notes several recent successes in strengthening surveillance efforts and in implementing new surveillance strategies, and has initiated the Epidemiology and Laboratory Capacity program to provide health departments with laboratory and technical capacity in dealing with emerging infections (CDC, 1998). Seven states have initiated emerging infections programs (EIPs) to conduct population-based surveillance and special research on emerging and re-emerging diseases. Creation of the Foodborne Diseases Active Surveillance Network (FoodNet) within EIPs has provided a model program for outbreak detection within EIPs. Provider-based networks have been established to collect information from nontraditional public health venues (CDC, 1998; Binder et al., 1999). Examples include infectious diseases surveillance in 11 academic emergency rooms (EMERGEncy ID NET) (Talan et al., 1998) a network of enhanced communication among 500 infectious disease practitioners via the Internet (the Infectious Diseases Society of America Emergency Infections Network [IDSA EIN]), and a group of 22 linked travel medicine clinics in the United States and abroad to monitor disease among returning travelers (GeoSentinel) (CDC, 1998). With the exception of the unexplained death and severe illness project within selected EIP sites (discussed below), all of these enhanced or innovative systems rely on the reporting of specific clinically and/or laboratory-confirmed diagnosed cases. None of these systems are based on the reporting of clinical syndromes or groups of clinical signs and symptoms.
Although the need for innovative surveillance techniques had been identified prior to September 11, the U.S. outbreak of anthrax following the intentional delivery of B. anthracis spores through the mail in fall 2001,
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(CDC, 2001) greatly accelerated the development and initiation of enhanced surveillance systems around the country.
The covert aerosol release of a bioterrorist agent, such as anthrax, plague, or botulinum toxin, would require increased surveillance for illness by the public health and medical communities and rapid institution of illness prevention measures (Rotz et al., 2000). With these agents, as well as with numerous naturally occurring emerging infections, people would likely present initially with nonspecific mild illness. Exposed individuals might stay home from work or school, go to the pharmacy to buy over-the-counter remedies, and, as illness progressed, might call their physician's offices to report symptoms.
As their illness worsened, patients might seek appointments with primary care offices or go to emergency rooms for treatment. Even after presenting to a health care provider, many patients might be sent home with prescriptions for various antibiotics, while others would be ill enough to require hospital admission, some to intensive-care units. The rate with which new cases would occur might depend on infectious dose, location at time of agent release or exposure, environmental factors, and host factors. The geographic pattern of cases could be large-scale, widely dispersed, or focal. Surveillance for the above events, before definitive diagnosis, would require innovative, flexible, disease syndrome-based surveillance systems that do not currently exist in the United States.
No published definition of syndromic surveillance has been identified by this author. For the purpose of this discussion, syndromic surveillance is defined as the surveillance of disease syndromes (groups of signs and symptoms), rather than specific, clinical, or laboratory-defined diseases.
Syndromic surveillance is a relatively new concept in public health surveillance. Several different terms have been used to denote syndromic systems. Box B-1 lists selected examples. There is considerable overlap in structure and function among these systems, although the source of data collected by each may differ. The lack of an accepted definition for syndromic surveillance and the inconsistent nomenclature in the published literature add to confusion regarding the structure, usefulness, and applicability of this approach.
Public health surveillance can be described as the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and
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BOX B-1 Syndromic Surveillance Systems: Nomenclature
The various terms used to denote syndromic systems include the following:
Syndromic surveillance
Early warning systems
Prodromic surveillance
Outbreak detection systems
Information system-based sentinel surveillance
SOURCES: Adapted from the following: Brinsfield et al., 2001; Duchin et al., 2001; Harcourt et al., 2001; Lazarus et al., 2001; Lober et al., 2002; Mostashari and Karpati, 2002; Stern and Lightfoot, 1999; Wagner et al., 2001b; Treadwell, CDC, Personal Communication, 2002.
mortality and to improve health (CDC, 2001). CDC has identified a list of surveillance system attributes that are useful for evaluation, including usefulness, simplicity, flexibility, data quality, acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability.
Routinely evaluated surveillance system attributes are relevant to syndromic surveillance systems; however, timeliness and sensitivity may take on added importance (Bravata, 2001). CDC has identified early detection as an essential component for ensuring a prompt response to an intentional biological or chemical attack or the emergence of an unusual or unknown disease (CDC, 2000). Some authors have suggested that, given the level of importance associated with early detection of bioterrorist agents in initiating response, "extreme timeliness of detection" may become a new requirement of at least some public health surveillance systems (Wagner et al., 2001a). For syndromic surveillance, simplicity and acceptability of the system will likely require electronic data transfer that is transparent to providers. Syndromic systems will necessarily be flexible so they can capture a broad range of signs and symptoms that may emerge. Evaluation of the sensitivity of syndromic systems to detect new or emerging health diseases is an evolving science. Most investigators have used naturally occurring, cyclical influenza outbreaks to evaluate existing systems (Tsui et al., 2001; Espino and Wagner, 2001; Canas et al., 2000; CDC, 2002). Because bioterrorism-related events and emerging or reemerging diseases may be spread over very large geographic areas, the representativeness of any one syndromic surveillance system will likely depend on its ability to interact/ communicate with other systems in a given locale and with systems in neighboring states or regions.
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Syndromic surveillance systems can be categorized in several ways. Syndromic systems can operate for short-term surveillance projects or they can be designed for ongoing, sustained activities. Some syndromic systems have been designed to "drop in" to a locality, usually to bolster local public health surveillance efforts in response to a defined event. Such drop-in systems have been used to enhance surveillance efforts surrounding large-scale events that are national in scope. Drop-in syndromic surveillance, supported by local health departments and CDC, was implemented in Seattle for the 1999 World Trade Organization Meetings (Duchin, Public Health—Seattle and King County, Personal Communication, 2002), in the Washington metropolitan area for the 2001 presidential inauguration (Blythe, Maryland Department of Health and Mental Hygiene, Personal Communication, 2002; Sockwell, Virginia Department of Health (Northern Region), Personal Communication, 2002), in Philadelphia for the July 31–August 4, 2000, Republican National Convention (Chernak, Philadelphia Department of Health, Personal Communication, 2001), and in Los Angeles County for the August 14–17, 2000, Democratic National Convention (Bancroft, County of Los Angeles, Department of Health Services, Personal Communication, 2002; Peterson, County of Los Angeles, Department of Health Services, Personal Communication, 2002). Drop-in syndromic systems used to date have literally "dropped in" to a local health department, operated during the event and for a few days after (an incubation period), and then "dropped out" of the locality. Drop-in syndromic surveillance systems can be used to lay groundwork for sustained syndromic surveillance by building relationships with hospitals, infection control practitioners, information specialists, and others in the health care environment.
Since early recognition of new or emerging diseases or a bioterrorist release is expected to be an ongoing goal of innovative surveillance systems, sustained syndromic surveillance systems, ideally operating seven days a week throughout the year, are being actively investigated. Most of these systems are in the pilot or development phase. Syndromic systems differ primarily in the way that they capture data. Table B-1 lists several of the broad categories of syndromic systems that are being explored.
Manual systems rely heavily on hospital personnel. A simple, manual system is currently operating in Santa Clara County, California, where a "tally sheet" is used by the emergency department triage nurses in 12 acute care hospitals (Bravata, 2001; Cody, Santa Clara County Department of Health, Personal Communication, 2002). The nurse ticks a mark on the sheet for every patient who has a chief complaint compatible with one of six syndromes: flu-like symptoms, fever with mental status changes, fever with skin rash, diarrhea with dehydration, visual or swallowing difficulties/
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TABLE B-1 Syndromic Surveillance: Characteristics, Advantages, and Disadvantages
Selected Characteristics
Event-based surveillance
Defined time period Active Emergency departments (ED) Large clinics
Develop relationships with ED staff, ICPs; transportable to various sites
Labor intensive; not sustainable; not scalable
Sustained surveillance
Active/passive FAX-based reporting Usually ED triage logs/tally sheets
Develop relationships with hospital staff; easy to initiate; detailed information obtainable
Labor intensive; difficult to maintain 24/7; not sustainable
Passive Auromated transfer of hospital (usually ED triage or diagnosis) or outpatient data; use of data collected for other purposes; data mining for large collections from multiple sources
Can be scalable; minimum or no provider input programming required; data available continuously; data standardized
Need expertise and health dept. informatics expertise; confidentiality
Novel modes of collection
Active Hand-held or touch screen devices
Easy to use; rapid provider feedback; can post alerts/info
Requires providers input; not sustainable
Novel sources of data
Active/passive Medical examiner data; unexplained death or severe illness data
Clearly defined "syndrome"; may be supplemented with laboratory data
Not an early warning; scalable
SOURCES: This table was adapted from the following: Wagner et al., 2001a; Duchin et al., 2001; Pavlin, 2001; Lazarus et al., 2001; Moser et al., 1999; Zelicoff et al., 2001; Stanford report, 2001; Kluger et al., 2001; Rainbow et al., 2000.
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slurred speech or dry mouth, and acute respiratory distress syndrome. If the patient's condition does not fit any syndrome, the nurse puts a hash mark in the column "none of the above." The tally marks for each syndrome are totaled at the end of each nursing shift, and the sheet is faxed to the Santa Clara Health Department. No personal identifiers are transmitted. The information is entered into a computer program at the health department, and the totals are reviewed every 24 hours. As noted in Table B-1 and confirmed by the group in Santa Clara, this method is labor-intensive. Participation by hospitals has declined dramatically since the cessation of additional anthrax cases after December 2001, and Santa Clara County is now actively pursuing alternative systems for implementation. Despite the lack of baseline data for comparison and uncertainties regarding when and how to investigate "clusters" of particular syndromes, many local health departments across the country initiated similar efforts immediately following the terrorist attacks of September 11, 2001 (Blythe, Maryland Department of Health and Mental Hygiene, Personal Communication, 2002; Sockwell, Virginia Department of Health (Northern Region), Personal Communication, 2002; Chernak, Philadelphia Department of Health, Personal Communication, 2001; Paladini, Bergen County Department of Health Services, Personal Communication, 2002).
In contrast, several investigators and collaborating health departments have been exploring electronic transfer of data from health facilities to public health departments (Wagner et al., 2001b; Duchin et al., 2001; Pavlin, ESSENCE, Personal Communication, 2001; Mostashari, New York City Department of Health, Personal Communication, 2001; Lazarus et al., 2001; Moser et al., 1999). The key feature of electronic syndromic surveillance is the ability to collect data in an ongoing way without the direct input of health care personnel, so that their operation is transparent to providers. Systems that do not place additional burdens on health care providers are essential for large-scale, sustained syndromic surveillance. Electronic systems have been implemented by the U.S. military (Pavlin, ESSENCE, Personal Communication 2001), regionally within states (Lazarus et al., 2001; RODS; Piposzar, Alleghany County Health Department, Personal Communication, 2002), and at the local level (Mostashari, New York City Department of Health, Personal Communication, 2001). All of these systems are in the pilot or early development stages.
The network developed within the Department of Defense—Global Emerging Infections System (DoD-GEIS)—has initiated surveillance for early detection of infectious disease outbreaks by monitoring seven syndromes (respiratory, fever/malaise/sepsis, gastrointestinal, neurological, dermatological-infectious, dermatological-hemorrhagic, and coma/sudden death) in 313 military treatment facilities worldwide (Pavlin, ESSENCE, Personal Communication, 2001). This system, the Electronic Surveillance
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System for the Early Notification of Community-Based Epidemics (ESSENCE), captures data daily from the standardized ambulatory data record and categorizes syndromes based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnoses assigned by providers. The data are routed to a central server in Denver and forwarded to a secure server at Walter Reed Army Institute of Research for analysis and generation of reports. The time delay from visit to data capture and analysis is 2–4 days. Obtaining the syndromic information places no additional requirements on providers or clinic administrators. Regional and local syndromic surveillance systems, such the Real-Time Outbreak and Disease Surveillance (RODS) system in western Pennsylvania (RODS; Wagner et al., 2001b) and the emergency department chief complaint-based system in New York City (Mostashari, New York City Department of Health, Personal Communication, 2001), collect data principally from emergency department visits.
Novel modes of collecting electronic data include several devices that have been developed for direct data entry via touch screens, keypads, or web-based programs (Zelicoff et al., 2001; Stanford Report, 2001; Weiss, Stanford University, Personal Communication, 2001; Coiera, 2001; Zelicoff, Sandia National Laboratories, Personal Communication 2001). These systems simplify the collection of data, but generally require input from health care providers. Although the data transfer can be streamlined by downloading to health authorities via phone lines (Weiss, Stanford University, Personal Communication, 2001) or web-based interfaces (Zelicoff et al., 2001; Coiera, 2001), the systems are not transparent. The Rapid Syndrome Validation Program (RSVP), developed by Sandia National Laboratories, uses a touch-screen-based system to enable health care providers in the emergency department to enter clinical and demographic data on patients with a variety of infectious disease syndromes. The system has network-based reporting that is fast and relatively easy to use. The pilot phase has collected information on six syndromes (flu-like illness, fever with skin findings, fever with altered mental status, acute bloody diarrhea, hepatitis, and adult respiratory distress syndrome) as defined by "physician judgment." The system gives the physician immediate feedback after a syndrome has been entered. These reports include a geographic plot of the syndrome that has been entered, a temporal graph of similar reports over the past several weeks, and alert screens with outbreak information, if indicated. The New Mexico Department of Health can be notified (via beeper, cell phone, or e-mail) of each syndrome report. This system is in the pilot phase, and reports have not yet been received or utilized by the New Mexico Department of Health (Baumbach, New Mexico Department of Health, Personal Communication, 2002).
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In 1994, CDC provided funds through state EIPs to Connecticut, California, Minnesota, and Oregon for the conduct of population-based surveillance on unexplained life-threatening illnesses and deaths due to possibly infectious causes among previously healthy persons aged 1 to 49 years (Kluger et al., 2001; Rainbow et al., 2000; Hajjeh et al., 2002). This network was designed to detect emerging infections, and has an extensive laboratory component that includes advanced serological and polymerase chain reaction (PCR) testing to identify novel disease associations or new agents. Reported cases of severe illness or death are assigned clinical syndromes based on the predominant system involved (neurological, cardiac, respiratory, hepatic, or other) (Hajjeh et al., 2002). From 1995 to 1998, 137 cases were identified at the four sites (population 7.7 million), for an overall incidence rate of 0.5 per 100,000 per year. The projects are beginning to report new presentations of known infectious agents. The northern California project has identified a new virus–disease syndrome association, adenovirus Type 3 as an agent of adult toxic shock syndrome (Price et al., 2001), and a novel presentation of Sin Nombre virus (Passaro et al., 2001). The network is not designed for the timely reporting of death or severe illness. Clusters or outbreaks of unexplained death or severe illness have not yet been reported by the network (Hajjeh et al., 2002).
There is no published literature on the cost-effectiveness of syndromic surveillance. However, models for estimating the economic impact of a bioterrorist attack due to anthrax, brucellosis, or tularemia have clearly demonstrated that rapid implementation of a post-attack prophylaxis program is the most important means of reducing cost (Kaufmann, 1997). Similarly, modeling of potential responses to the use of smallpox as a biological weapon has emphasized that delay in intervention would be very costly (Meltzer et al., 2001). For a smallpox scenario with 100 initially infected persons, holding the number infected per infectious person, the percent of the population removed by quarantine, and the percent vaccinated constant, a delay in initiation of control measures of 15 days would result in 15,705 excess cases at 1 year (Meltzer et al., 2001). Because outbreak detection must necessarily precede post-attack prophylaxis or other control measures, rapid outbreak detection (by whatever means available) is key. Some authors have used modeled data (Kaufmann et al., 1997) on anthrax to estimate the financial benefit of even 1 hour of earlier detection for an aerosol release of B. anthracis affecting 100,000 persons (Dato et al., 2001). Most of the achievable benefit occurs by day 4, and the monetary savings from even 1 hour of earlier detection during days 2 and 3 (the steepest part of the cumulative cost curve) could be as high as $200
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million. These estimates assume that postexposure treatment is 90 percent effective, and that treatment is available and administered instantaneously.
Several elements of evaluating a public health surveillance system apply to syndromic surveillance (Centers for Disease Control and Prevention, 2001). A number of features of syndromic surveillance, such as defining specific disease syndromes and ensuring timeliness of reporting, are unique. Most of these components have not been systematically evaluated to date. Box B-2 lists selected practical issues faced by investigators and public health officials as syndromic systems are being developed or contemplated.
Public Health Authority
Most local and state health departments interviewed for this report cited local public health laws that allow the collection of syndromic data (Blythe, Maryland Department of Health and Mental Hygiene, Personal Communication, 2002; Sockwell, Virginia Department of Health (Northern Region), Personal Communication, 2002; Chernak, Philadelphia Department of Health, Personal Communication, 2001; Cody, Santa Clara County Department of Health Services, Personal Communication, 2002;
BOX B-2 Issues in Developing Syndromic Surveillance Systems
The following issues must be addresses during the development of syndromic surveillance systems:
Is there legal authority to support the system?
What are the correct syndromes to monitor?
How are these syndromes defined?
What population should be under surveillance?
Which sources of data are most sensitive, specific, and useful?
How is timeliness ensured?
Are security and confidentiality requirements met?
What is the best method for detecting syndrome aberrations?
How are aberrations (disease clusters) prioritized and investigated?
Are there adequate personnel and laboratory resources available for investigations?
How will surveillance results be disseminated to those who need to know?
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Paladini, Bergen County Department of Health Services, Personal Communication, 2002; Mostashari, New York City Department of Health, Personal Communication, 2001; Baumbach, New Mexico Department of Health, Personal Communication, 2002; Barry, Boston Department of Health, Personal Communication, 2002; Klundt, Massachusetts Department of Health, Personal Communication, 2001). The specific areas of public health law viewed by epidemiologists as allowing such jurisdiction varied. Some states cited mandatory reporting of anthrax as sufficient to allow the collection of syndromic data; other localities referred to public health laws designed to allow data collection for clusters of unusual illness. Recent articles have highlighted the special challenges to public health law that would result from a widespread bioterrorist attack (Barbera et al., 2001; Fidler, 2001). However, the degree to which current public health law addresses any of the unique aspects of syndromic surveillance, such as the acquisition of large data sets to search systematically for particular disease syndromes, requires further evaluation and discussion.
Definition of Syndromes
Categorization of clinical symptoms into disease syndromes is the cornerstone of syndromic surveillance. Almost all syndrome categories currently in use are based on expected prodromal symptoms associated with the most likely biological weapon agents. Nevertheless, it is not clear which syndromes are most sensitive for identifying emerging infections or agents of bioterrorism.
Many systems operating since September 11, 2001, have adopted the seven ICD-9-CM code-based syndromes used in the ESSENCE system (Pavlin, ESSENCE, Personal Communication, 2001). As noted earlier, ESSENCE includes seven syndromes: respiratory (common cold, sinus infection), fever/malaise/sepsis, gastrointestinal (vomiting, diarrhea, abdominal pain), neurological (headache, meningitis), dermatological-infectious (vesicular rash), dermatological-hemorrhagic (bruising, petechiae), and coma/ sudden death. The drop-in surveillance systems implemented for the 2000 Republican and Democratic National Conventions used somewhat different categories: respiratory infection with fever, diarrhea/gastroenteritis, rash with fever, sepsis or nontraumatic shock, meningitis/encephalitis, botulism-like syndrome, and unexplained death with history of fever (Chernak, Philadelphia Department of Health, Personal Communication, 2001; Bancroft, County of Los Angeles, Department of Health Services, Personal Communication, 2002). Systems that rely on novel collection devices, such as touch-screen or hand-held devices, often query the provider in an algorithm style (e.g., fever present; if yes, rash present; if yes, hemorrhagic, etc.) (Weiss, Stanford University, Personal Communication, 2001). The RSVP touch-
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TABLE B-2 Selected Syndromic Surveillance Systems: Domestic
Date Initiated
Population Studied
Data Source(s)
Special Feature(s)
Future Plans
Philadelphia Republican National Convention: CDC Drop-In
Philadelphia, adjoining PA, NJ, DE counties— census data 5 Phila. ED
First-aid stations, ED syndrome diagnoses, hospital census
Multifaceted approach, engaged surrounding counties
Provider fatigue, not sustainable, lots of coding and data, entry errors
Planning regional approach, enhanced communication with all providers
Los Angeles Democratic National Convention: CDC Drop-In
11 LA County emergency departments 1 airport clinic
ED/clinic syndrome diagnoses
Manually grouped previous ED data into syndromes for baseline (36,000 visits)
Required training of hosptials, lots of data (IT) problems, not sustainable
Development of ongoing electronic data collection from ED
Maryland Department of Health
2 counties adjacent to Wash., DC— 9 hospital ED
ED triage logs— manually code and enter syndromes
Close collaboration with VA and DC health depts.
Very labor-intensive, inefficient
Developing Web-based reporting and electronic data transfer
Virginia Health Dept.-Northern Region (5 health districts)
7 hospital ED, counties adjacent to Wash., DC
ED triage logs— manually code and enter syndromes, share daily with Maryland/D.C.
Close collaboration with other states and between health districts
Very labor-intensive, data have been used for other purposes
Would like to collaborate with Maryland in web-based reporting
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Santa Clara County Health Dept.
12 hospital ED in the county
Tick mark by ED triage nurse for 6 syndromes
Data entry, analysis labor-intensive; provider fatigue
Evaluating several systems, incl. Health Buddy
Baltimore City Health Department
All Baltimore ED, selected community clinics, 911 calls, dog/cat deaths, school absenteeism
ED diagnosis-based syndromes, no. dog/cat deaths, total school absentees
Comprehensive collaboration with academic centers, strong political will by the city
Not yet real-time or entirely electronic, staff needed to follow-up flags from multiple sources
Planning real-time, electronic ED syndromic system
Alleghany County, western Pennsylvania
60–70% Alleghany County
ED chief complaint, electronic
Incorporating several health systems, fully automated
HD only receives aggregate data
Expanding to 13 counties, 54 hospitals
Minnesota Department of Health
September 2000–present
St. Paul/ Minneapolis metro area
ED closures/bed capacity (web-based); electronic ICD-9 Health Partner discharge dx
Already available data source (Health Partners), flexible —can easily change codes to new syndrome
Unclear how useful, sensitive; denominator and historical data pending
Planning to add EMS data, couple Health Partners data with laboratory component
New Mexico Department of Health—U of NM, statewide medical examiner System
Autopsy if antecedent syndromes, specific pathological syndromes reported to NMHD
Uniform criteria for performing autopsies and reporting cases to HD; captures reportable conditions, not only BT
Broad range of timeliness, required training of field staff
Expect to export the system to other medical examiner systems
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Date Initiated
Population Studied
Data Source(s)
Special Feature(s)
Future Plans
Boston City Department of Health
11 ED-total volume data— electronic, Poison Control call volume, death certificate and EMS data
Jan. 2002 increase ED volume due to falls on black ice, Oct—review of volume flag noted cases seeking swabs and Cipro
83 days in 2000 exceeded threshold— real-time follow-up may be labor-intensive and frequent
Add additional sites, including adjacent county; collect additional data from some sites
Seattle-King County Health Department
Selected sites in Seattle
3 ED and 1 large primary care clinic—electronic data transfer
Have detected influenza seasonal patterns; collaborate with academic partner
HIPAA issues with obtaining identifiers
Expand to population-based system, increase number of data sources, collect identifiers, add GIS capacity
Hawaii Department of Health
Infectious disease subset of all claims from largest insurer (60–65% coverage)
ICD-9 based, electronic, insurer with excellent data processing capability
Long lagtime (18% claims available ≤ 7 days), poor coding accuracy
Continue to work toward improved timeliness, add GIS component
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Massachusetts Department of Health/Harvard Vanguard Medical Associates
About 10% of greater Boston area (250,000 pop.)
HMO electronic medical record, electronic calls to nurse and doctors
Uses 4–5 years of historical data, good denominator data, real-time; academic partners
Special population (insured)
Developing outbreak reporting algorithms, plan to integrate with other systems
Children's Hospital Boston
not available
Children's Hospital Boston and Beth Israel Hospital
ED chief complaint, ED ICD-9 discharge diagnosis, web-based MD reporting
Reviewed 500 ED charts, chief complaint "respiratory syndrome" detected ~60%
Operating on a small pilot basis presently, no data to health dept. yet, no clusters investigated
Refine detection algorithms, add 9 hospitals for web-based reporting
SOURCES: Blythe, Maryland Department of Health and Mental Hygiene, Personal Communication, 2002; Sockwell, Virginia Department of Health (Northern Region), Personal Communication, 2002; Chernak, Philadelphia Department of Health, Personal Communication, 2001; Bancroft, County of Los Angeles, Department of Health Services, Personal Communication, 2002; Peterson, County of Los Angeles, Department of Health Services, Personal Communication, 2002; Cody, Santa Clara County Department of Health, Personal Communication, 2002; RODS; Piposzar, Alleghany County Health Department, Personal Communication, 2002; Hirshon, University of Maryland and Baltimore City Department of Health, Personal Communication, 2002; ; Kassenborg, Minnesota Department of Health, Personal Communication, 2002; Barry, Boston Department of Health, Personal Communication, 2002; Nolte, University of New Mexico, Personal Communication, 2002; Kleinman, Harvard Pilgrim Health Care and Harvard Vanguard Medical Associates, Personal Communication, 2001; Lazarus, Channing Laboratory, Brigham and Women's Hospital, Harvard medical School, Personal Communication, 2001; Chang, Hawaii Department of Health, Personal Communication, 2002; Mandl, Children's Hospital Boston, Personal Communication, 2002; Klundt, Massachusetts Department of Health, Personal Communication, 2001.
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FIGURE B-2 Gastroenteritis syndrome count, ESSENCE, San Diego, 2002. Reproduced with permission. J. Pavlin, ESSENCE program, Department of Defense.
access now allow for much more rapid awareness of local disease outbreaks at distant points around the globe. Although there are few published reports of syndromic surveillance systems operating outside of the United States, efforts to enhance outbreak detection and link disease surveillance information have increased.
The World Health Organization (WHO) established a new approach to global disease surveillance in 1997 termed "outbreak verification." This system collects data from a broad range of sources, including national institutes of health, nongovernmental organizations, media, the World Wide Web, and electronic mail-based discussion groups. Follow-up is performed by outbreak verification teams in WHO regional offices. Information on outbreaks with potential international public health importance is circulated to subscribers on the Outbreak Verification List. This system is not strictly designed to detect clusters of disease syndromes, but the early nature of reports often includes disease syndromes prior to laboratory diagnosis. Between 1997 and 1999, 246 outbreaks were reported, the most common being cholera (78), acute hemorrhagic fever (24), and acute diarrheal disease (22).
Internet outbreak reporting, although not specifically designed for syndrome detection, is timely and increasingly available. As more and more countries and international organizations post information on outbreaks or syndrome clusters on publicly accessible e-mail services, such as ProMED-mail (Woodall, 1997, 2001), the use of this modality for international syndromic surveillance may increase.
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A network of 22 travel/tropical medicine clinics (14 in the United States and 8 in other countries), GeoSentinel, was initiated in 1996 to collect disease- or syndrome-specific diagnoses on returning travelers, immigrants, and foreign visitors (Freedman et al., 1999). GeoSentinel was designed as a sentinel system and does not have the elements of timeliness or representativeness demonstrated by most syndromic surveillance systems, although it may serve as an early warning system.
ESSENCE collects data from DoD medical treatment facilities worldwide and is therefore international in scope. The U.S. Naval Medical Research Unit No. 2 participates in an Early Warning Outbreak Recognition System (EWORS) that collects real-time electronic syndromic data from selected hospital pediatric and internal medicine clinics and emergency departments in Indonesia (Corwin, 2000). A V. cholerae 0139 outbreak was identified in the 1999 pilot phase of the project.
The Israeli Ministry of Health has reported on a system of enhanced infectious disease surveillance in Israel during the six-week Gulf War, specifically looking for evidence of biological warfare (Slater and Costin, 1992). Details of the enhanced system are not available, but it apparently included analysis of daily mortality data (rather than the standard weekly procedure) and measures of pneumonia or other severe respiratory symptoms suggestive of pulmonary anthrax.
Other international reports stress early detection of outbreaks (Toubiana and Flahault, 1998; Reintjes et al., 2001; Hashimoto et al., 2000) and the importance of networks and collaborations for outbreak detection (Osaka et al., 1999; Pebody et al., 1999). However, the systems described do not collect data.
Syndromic surveillance is a method of obtaining information about cases exhibiting one or more disease symptoms before a definitive clinical or laboratory diagnosis is available. Outbreaks of disease due to a biological warfare agent may be difficult to diagnose. Delays in diagnosis would likely result in larger numbers of casualties and a more prolonged outbreak. Early detection, by monitoring increases in prodromal symptoms such as fever and cough, forms the basis for most current syndromic surveillance systems. More complex systems that include an advanced laboratory component, such as the CDC unexplained death and critical illness project, are being explored for the detection of emerging infections.
The implementation of syndromic surveillance is under way. Many public health officials perceive the need to provide enhanced surveillance following the attacks of September 11, and syndromic surveillance is meeting that need in some localities. Similarly, academic and industry partners
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are quickly embracing this surveillance technique. There is no nationally coordinated plan to guide the development of syndromic surveillance. More research is needed to guide future planning before specific recommendations can be made.
There are a number of potential benefits from syndromic surveillance:
New opportunities for collaboration among health departments, emergency medical service providers, hospitals, information system managers, and commercial vendors
An opportunity to reinforce the importance of identifying standards-based vocabularies, messages, and case definitions to facilitate the use and transfer of data from clinical information systems to public health surveillance
Improved training for public health personnel in the area of information systems and disease-detection techniques
The potential to enhance notifiable disease and noninfectious disease reporting systems.
Despite these potential benefits, however, caution is appropriate. Syndromic surveillance is a new area of public health surveillance. Studies have not yet been completed to demonstrate the value of this surveillance tool. There is scant information available regarding the best syndromes to monitor for bioterrorism or emerging infections, and among those syndromes being used, there are no generally accepted case definitions. Rather, syndrome definitions differ from site to site, and comparisons across jurisdictions may be difficult. Moreover, the best source of syndromic data is unknown. A combination of different sources may be needed to best capture an increase in early or new disease in a community. And syndromic surveillance systems, by definition, are not laboratory-based, yet supplementing syndromic data with laboratory results may greatly enhance the power and specificity of current systems.
Minimally, syndromic surveillance systems should be electronic, should not rely on provider input (be transparent), should be monitored continuously, and should have a mechanism that allows for follow-up if critical increases are detected. Methods for the detection of clusters amid background syndrome "noise" require additional evaluation to identify optimal alarm thresholds. Public health epidemiologists should be involved in the planning of detection methods and response protocols. Sustainability, personnel training needs, and cost are other major considerations. Syndromic surveillance systems should also be viewed as but one of several methods for detection of bioterrorism and emerging infections; resources should not be diverted from proven, core public health functions to syndromic surveillance programs.
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Studies are needed to evaluate the incremental contribution of syndromic surveillance to other surveillance and outbreak detection programs that are in place or planned. Syndromic surveillance appears to be useful for early outbreak detection and potentially for the identification of emerging infections, but numerous questions remain.
Barbera J, Macintyrre A, Gostin L, Inglesby T, O'Toole T, DeAtley C, Tonat K, Layton M. Large-scale quarantine following biological terrorism in the United States: scientific examination, logistic and legal limits, and possible consequences. JAMA 2001;286:2711– 2717.
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CDC. Outbreak of West Nile-like viral encephalitis—New York, 1999. MMWR 1999;48: 845–849.
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Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR 2001;50(No. RR-13):1–35.
Coiera E. Use of web-based systems for clinician reporting of suspected bioterrorism events. 20 pages. A report prepared for AHRQ. June 2, 2001.
Corwin A. Developing regional outbreak response capabilities early warning outbreak recognition system (EWORS). Navy Med 2000;Sept/Oct:1–5.
Dato VM, Wagner MM, Allswede MP, Aryel R, Fapohunda A. The Nation's Current Capacity for the Early Detection of Public Health Threats Including Bioterrorism. 78 pages. Report commissioned by AHRQ. June 8, 2001.
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Duchin JS, Karras BT, Trigg LJ, Bliss D, Vo D, Ciliberti J, Stewart L, Rietberg K, Lober WB. Syndromic surveillance for bioterrorism using computerized discharge diagnosis databases. Proc AMIA Symp 2001;897.
Espino J, Wagner M. The accuracy of ICD-9 coded chief complaints for detection of acute respiratory illness. Proc AMIA Symp 2001:164–168 (in press).
Fidler DP. The malevolent use of microbes and the rule of law: legal challenges presented by bioterrorism. Clin Infect Dis 2001;33:686–689.
Fine A, Layton M. Lessons from the West Nile viral encephalitis outbreak in New York City, 1999: implications for bioterrorism preparedness. Clin Infect Dis 2001;32:277–282.
Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG, Harris J, Mallison GF, Martin SM, McDade JE, Shepard CC, Brachman PS. Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med 1977;297:1189–1197.
Freedman DO, Kozarsky PE, Weld LH, Cetron MS. GeoSentinel: the global emerging infections sentinel network of the International Society of Travel Medicine. J Travel Med 1999;6:94–98.
Goldenberg A, Shmueli G, Caruana RA, Fienberg SE. Early statistical detection of anthrax outbreaks by tracking over-the-counter medication sales. Proc Nat Acad Sci 2002 (under consideration for publication).
Grein TW, Kamara K-BO, Rodier G, Plant AJ, Bovier P, Ryan MJ, Ohyama T, Heymann DL. Rumors of disease in the global village: outbreak verification. Emerg Infect Dis 2000:97– 102.
Hajjeh RA, Relman D, Cieslak PR, Sofair AN, Passaro D, Flood J, Johnson J, Hacker JK, Shieh W-J, Hendry RM, Nikkari S, Ladd-Wilson S, Hadler J, Rainbow J, Tappero JW, Woods CW, Conn L, Reagan S, Zaki S, Perkins BA. Surveillance for unexplained deaths and critical illnesses due to possibly infectious causes, United States, 1995–1998. Emerg Infect Dis 2002;8:145–152.
Harcourt SE, Smith GE, Hollyoak V, Joseph CA, Chaloner R, Rehman Y, Warburton F, Ejidokun OO, Watson JM, Griffiths RK. Can calls to NHS Direct be used for syndromic surveillance? Commun Dis Pub Health 2001;4:178–182.
Hashimoto S, Murakami Y, Taniguchi K, Nagai M. Detection of epidemics in their early stage through infectious disease surveillance. Int J Epidemiol 2000;29:905–910.
Hoffman RE, Norton JE. Lessons learned from a full-scale bioterrorism exercise. Emerg Infect Dis 2000;6:652–653.
http://epi.health.state.nm/rsvpdesc/default.asp. Accessed December 12, 2001.
http://www.army-technology.com/contractors/nbc/idaho/. Accessed February 6, 2002.
http://www.ehealthinitiative.org/. eHealth Initiative 2001:Year in Review. Accessed February 8, 2002.
Hutwagner LC, Maloney EK, Bean NH, Slutsker L, Martin SM. Using laboratory-based surveillance data for prevention: an algorithm for detecting Salmonella outbreaks. Emerg Infect Dis 1997;3:395–400.
Institute of Medicine. 1987. The U.S. Capacity to Address Tropical Infectious Disease Problems. National Academy Press. Washington, D.C.
Institute of Medicine. 1988. The Future of Public Health, National Academy Press. Washington, D.C.
Institute of Medicine. 1992. Emerging Infections: Microbial Threats to Health in the United States. National Academy Press, Washington, D.C.
Jormanainen V, Jousimaa J, Kunnamo I, Ruutu P. Physician database searches as a tool for early detection of epidemics. Emerg Infect Dis 2001;7:474–476.
Jousimaa J, Kunnamo I, Makela M. Physicians' patterns of using a computerized collection of guidelines for primary health care. Int J Technol Assess Health Care 1998;14:484–493.
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Kaufmann A, Meltzer M, Schmid G. The economic impact of a bioterrorist attack: are prevention and post attack intervention programs justifiable? Emerg Infect Dis 1997;3:83– 94.
Kluger MD, Sofair AN, Heye CJ, Meek JI, Sodhi RK, Hadler JL. Retrospective validation of a surveillance system for unexplained illness and death: New Haven County, Connecticut. Am J Pub Health 2001;91:1214–1219.
Kortepeter MG, Pavlin JA, Gaydos JC, Rowe JR, Kelley PW, Ludwig G, McKee KT, Eitzen EM. Surveillance at US military installations for bioterrorist and emerging infectious disease threats. Mil Med 2000;165:ii–iii.
Kulldorff M. Prospective time periodic geographical disease surveillance using a scan statistic. JR Stat. Soc 2001;164, Part 1:61–72.
Lazarus R, Kleinman KP, Dashevsky I, DeMaria A, Platt R. Using automated medical records for rapid identification of illness syndromes (syndromic surveillance): the example of lower respiratory infection. BMC Public Health. 2001;1:9. Accessed at http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11722798 on December 3, 2001.
Lober WB, Karras BT, Wagner MM, Overhage JM, Fraser H, Mandl KD, Espino JU, Tsui FC. Roundtable on bioterrorism detection: information systems-based surveillance. JAMIA. 2002 (in press).
Martin SM, Bean NH. Data management issues for emerging diseases and new tools for managing surveillance and laboratory data. Emerging Infect Dis 1995;1:124–128.
Meltzer MI, Damon I, LeDuc JW, Millar JD. Modeling potential responses to smallpox as a bioterrorist weapon. Emerg Infect Dis 2001;7:959–969.
Moser SA, Jones WT, Brossette SE. Application of data mining to intensive care unit microbiologic data. Emerg Infect Dis 1999;5:454–457.
Mostashari F, Karpati A. Towards a theoretical (and practical) framework for prodromic surveillance. Abstract. International Conference on Emerging Infectious Diseases, Atlanta. March 24–27, 2002 (accepted).
National Electronic Disease Surveillance System Working Group: National Electronic Disease Surveillance System (NEDSS): A standards based approach to connect public health and clinical medicine. J Pub Health Manage Prac 2001;7:43–50.
Osaka K, Inouye S, Okabe N, Taniguchi K, Izumiya H, Watanabe H, Matsumoto Y, Yokota T, Hashimoto S, Sagara H. Electronic network for monitoring travellers' diarrheoea and detection of an outbreak caused by Salmonella enteritidis among overseas travellers. Epidemiol Infect 1999;123:431–436.
Passaro DJ, Shieh W-J, Hacker JK, Fritz CL, Hogan SR, Fischer M, Hendry RM, Vugia DJ. Predominant kidney involvement in a fatal case of hantavirus pulmonary syndrome caused by Sin Nombre virus. 2001;33:263–264.
Pavlin J. Electronic surveillance system for the early notification of community-based epidemics (ESSENCE). Information Paper. Personal communication. December 17, 2001.
Pebody (RG, Furtado C, Rojas A, McCarthy N, Nylen G, Ruutu P, et al. An international outbreak of Vero cytotoxin-producing Escherichia coli 0157 infection amongst tourists: a challenge for the European infectious disease surveillance network. Epidemiol Infect 1999;123:217–223.
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Spring Prop Check: Are You Propped Right? - 03/09/2011
In spring, a young man's fancy turns to thoughts of ... propellers? With apologies to Tennyson, more of BoatTEST.com's readers think of their propellers than they do of love – at least, we think so. And what better time to order a new prop, or at least confirm that your present one is just right, than now, when your boat's out of the water and you can get to her running gear without holding your breath?
Submit a propeller worksheet here... When it comes to performance, your propeller is the most important thing on your boat. Spinning the wrong one can waste power, reduce top speed, increase fuel burn and/or produce excessive noise and vibration. If your boat shows any of these symptoms, spend a bit of quality time now with a propeller expert, and maybe a bit more money (OK, quite a bit more) on a new prop – the fuel you save over a couple of seasons could well pay for it, and your boat will feel like she's new again. But before calling in an expert we recommend the folks at PowerTech! Propellers (www.ptprop.com) in Shreveport, LA. (If anybody knows more about props than those guys, we haven't found them yet.) You'll need to gather some facts and figures. The more accurate the info you give them, the better they'll be able to analyze your situation. PowerTech! has a prop worksheet on their website that you can fill out and send to them for technical assistance; this is what they ask for: Boat InformationMake and model of your boat, hull length, material – those are easy. What's difficult is estimating her weight. It's almost certainly more than on the spec sheet, since you've added all kinds of things – tools, gear, utensils, safety equipment, and so forth; even dirt in the bilge and antifouling paint on the bottom add weight. And don't forget to add the weight of your typical crew (Uncle Joe has been putting on weight recently) and average levels of fuel and water; figure 7 lbs/gal for fuel, 8 lbs/gal for water. Horsepower-to-weight ratio is one of the most important factors in predicting speed, so do your best working out your boat's real weight. Motor ID PlateYou'll want your boat's top speed and maximum rpm, and typical cruising speed and RPM. If your fuel consumption increased markedly last year vs. the season before, make a note of that, too – it can point to other performance-robbing factors, like engine problems or excess weight on board. (See above.)
Motor Information Now it's time to head for your boat. Take a tape measure, flashlight, magnifying glass, notebook and camera with you. Along with the year, make, model and horsepower of your engine(s), you'll need the serial number and, for inboards, the reduction ratio off the plate on the transmission. For stern drives, note if the exhaust is through the hub, underwater, through the transom or via a Captain's Choice or another selectable method. Prop Information For inboard engines, the propeller's diameter and pitch are stamped on the hub – "12x12" for example. Make a note of the rotation, either "right hand" (spins clockwise when viewed from astern to go forward) or "left hand" (counterclockwise). Sometimes "RH" or "LH" are also stamped on the hub. Note the material, although most inboard props are bronze or some alloy, the number of blades and, if possible, the manufacturer. Record any serial numbers, too.
For outboards or stern drives, get the manufacturer, model number and serial number off the prop -- record any numbers you see. Note the material – stainless or aluminum – and the number of blades. Basically, the more information you have, the better. While you're at it, check your prop for damage – nicks or dings, tip erosion, even a twisted blade. Inspect both sides of the blades for pitting, especially near the tips, which can indicate chronic cavitation due to overloading. Crunch the Numbers Armed with as much data as you can collect, contact PowerTech! and let them crunch the numbers. They'll ask you about hole shot, acceleration, minimum planing speed, performance issues (porpoising, blow-out, etc.) and so forth. Based on the information you provide, they'll tell you if you already have the correct prop, or if you'd be better off with one that's a little different. If you need a new prop, now's the time to order one. |

subset: commoncrawl


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View the embedded image gallery online at:
Image Gallery
'In my life, I've noticed that I have the ability of constant analyzation. Even in my most emotional times, I am still evaluating my body's and mind's reaction to the stimulus of my emotional state. This data usually finds itself bound to a more metaphysical visualization--comparing the emotional sensation to a worldly constant.' James Linkous


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Help us record NSW memorials and those veterans commemorated at each memorial.
Lismore and District Memorial - Great War
Two Marble Wall mounted memorials listing the names of the fallen from Lismore & District. Located in the main entrance to the Lismore Memorial Baths.
Notes on Veteran Names:
No records could be found for deceased veterans from this area with the following names:
E I Baker, D S Conway, T W Hollingsworth, P J Kelly, T J Lee, A McAllister, P B Mailey, A R Pavey, F X Walsh, E Wyatt. Their status codes have been given as KIA, as that is what is indicated by the memorial.
A McAllister may be Adam McAllister who DOW, P B Mailey may be Percy Benjamin Mailey of Petersham who DOW, A R Pavey may be Arthur Richard Pavey who was KIA, and F X Walsh may be Francis Xavier Walsh who DOW.
The cause of death for H E Grant could not be ascertained - he died in the service of the British forces - therefore his status code is also given as KIA.
All other status codes are taken from information contained in the Australian War Memorial Roll of Honour, the Commonwealth War Graves Commission database, and the National Archives of Australia.
On the memorial, E R Snowdon is given as E R Snowden (Snowdon is the name given on the National Archives scanned documents for this veteran, including those filled out by the veteran), and N L B Somerville is given as N L B Sommerville.
Lismore & District Memorial,Great War,1914 – 1919
Let not their sacrifice be in vain
This stone was laid by
Lt. Gen. Sir Harry Chauvel
1st October 1927
Erected to perpetuate the memoryof the men of Lismore and District
who gave their lives
in the Great War 1914-1919
Greater love hath no man than this
that a man lay down his life for his friends
Recorded By:
Location / Surrounding Area:
Address Data:
Community contribution
Veterans Listed
FirstName | LastName | Conflict | Status | Link |
R J | Ainsworth | World War 1 | Acc Kd | view |
J | Akers | World War 1 | KIA | view |
G D | Alexander | World War 1 | DOW | view |
G G | Anschau | World War 1 | KIA | view |
C R | Anstey | World War 1 | DOW | view |
C C G | Anstis | World War 1 | KIA | view |
J H | Armstrong | World War 1 | KIA | view |
C | Arthur | World War 1 | DOW | view |
M W H | Aspery | World War 1 | KIA | view |
H McL | Avery | World War 1 | KIA | view |


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Sign Up NOW for Online Newsletters for Boomers and 2nd HALF
Posted: April 13th, 2015
Click here – to sign-up for the online version of the Boomer Ministry and the 2nd HALF Ministry newsletters. By signing up online you will receive these weekly newsletters in your email inbox. Stay informed – signup today!


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Mars Attacks Monologue
Mars Attacks by Jonathan Gems | |
Character: | President (Jack Nicholson) |
Gender: | Male |
Age (range): | 18 - 55 |
Style: | Comedy |
Length: | 1 minutes |
Like Our Site? Then please be sure to "Like" us. You can also "+1" us! Thanks for your support! |
President (Jack Nicholson): Why...are you doing this? Why? Isn't the universe big enough for both of us? What is wrong with you people? We could work together. Why be enemies? Becausewe're different? Is that why? Think of the things that we could do. Thank how strong we would be. Earth...and Mars...together. There is nothing that we could not accomplish. Think about it. Think about it. Why destroy when you can create? We can have it all. Or we can smash it all. Why can't we...work out our differences? Why can't we...work things out? Little people...why can't we all just...get along?


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Timothy D. Stickney
Fifth season: Friar Francis in Much Ado About Nothing and Duke of Exeter in Henry V. Stratford: Sebastian (The Tempest, with Christopher Plummer), Banquo (Macbeth), Corporal Nym (The Merry Wives of Windsor), Pothinus (Caesar and Cleopatra, with Christopher Plummer); years after his debut with the National Shakespeare Company, reprised Tybalt in Stratford. Elsewhere: 2011: Stickney was Macbeth (Repertory Theatre of St. Louis). Previous: Hamlet (AUDELCO-nominated, Take Wing and Soar); Oswald, King Lear (with Kevin Kline), The Taming of the Shrew (Public Theater); Escalus, Romeo and Juliet (Central Park's Delacorte); Achilles, Troilus and Cressida (Shakespeare Theatre); Orsino, Twelfth Night (Seattle Rep.); Lorenzo, The Merchant of Venice (Hartford Stage). Timothy's led award-nominated productions of Othello (Africa Arts) and Richard III (TWAS). Directed AUDELCO-winning The Pecong and King Lear, with Trezana Beverly, for TWAS (associate artistic director). TV: Best known as One Life to Live's R.J. Gannon. Training: American Academy of Dramatic Arts/Company.Meet Timothy D. Stickney at Festival Friday Chats on August 17 and August 24.


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Guest list
Not sure what to get? Click here for the perfect gift! NauticalTropical.com gift certificates!!!! email@example.com
Nautical decor, nautical gifts page 10 Decorate with an Island or Beach Decor, and bring a bit of Paradise Home. We have a HUGE collection of nautical decor for the home and office as well as great nautical gifts... many unique to our store only!
This adorable wooden stool is a perfect accessory for your home to put in your kitchen, your bathroom, or anywhere! Measures 15 inches x 15 inches x 17.25 inches. **NEW Product for 2013!
This very unique piece of furniture for your home is painted in a white wash coating with blue handles. Assembly Required. Measures 26 inches x 24.5 inches x 33 inches. **NEW Product for 2013!
This boat table is painted white with blue detailing and stands atop two crisscrossing oars. Measures 25 inches x 14 inches x 27 inches
**NEW Product for 2013!
This nautical table sits atop two wooden, painted life rings with anchor decals and blue detailing.. Measures 45 inches x 24 inches x 26 inches
Perfect as a side table next to a couch or in the restroom, this lifering table comes painted in white with blue detail and stands atop two matching, crisscrossing oars. Measures 20.5 inches x 25 inches
19 inch Wooden Bathtub Mirror- $74.95 This mirror is perfectly sized to mount on a bath or washroom wall. Adorable miniature bathtub figurine with nautical detailing frame a flawless mirror. Measures 19 inches x 15 inches x 3.3 inches - **NEW Product for 2013!
Fun and unique table design! This "dock" table is your own piece of the boardwalk. Comes with natural wood coloring and rope detailing. Measures 47 inches x 23.5 inches x 34 inches
Select size!
6 Cork Floats on Rope with floats - $19.95 Floats measure 5" x 3.5" and Rope measures 40" long. Quantity:
Select type here!
Decorative Wood/Rope Replica Harpoons Set of 3 - $19.95 Measures 47" in length. Regularly $9.95 Each - NOW Get all three for $19.95!! Comes with Fork Tipped, Spear Tipped and Scraper Tipped Harpoons! Quantity:
10 Foot Rope Piece - $5.95
This is a real 10 foot long length of rope cut from an actual fishing net. Lots of potential to use it to embellish other items with a rustic fishing theme with no two pieces exactly alike.
Wooden Paddles! Available in 2 Sizes: 48" Wooden Paddle - $39.95 30" Wooden Paddle - $22.95 Quantity. Select item! 48inch Wooden Paddle 30inch Wooden Paddle
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Lab Members
Current graduate students
Welcome new students!
Cory Chew, Univeristy of Michigan, Ann Arbor
Melissa Maczuga, University of Michigan, Dearborn
Graduates of Sengelabs
Heather Eisthen, Ph.D.1992
Anatomy of peripheral olfactory and vomeronasal systems
Assoc. Prof., Michigan State University
Alice Mills, Postdoctoral Fellow 1992-1995
Development and steroid regulation of sexually dimorphic
neuron number in lumbosacral dorsal root ganglia
Linda Goldstein, Ph.D. 1993
Ontogenetic cues involved in the regulation of motoneuron
morphology in a sexually dimorphic neuromuscular system
Senior Medical Writer, Complete Healthcare Communications
Cara Wellman, Ph.D. 1993
Changes in spatial learning and neocortical morphology in
adult and aged basal forebrain lesioned rats
Professor, Indiana University
Marie Clark-Phelps, Ph.D. 1997
Aging in an androgen-sensitive neuromuscular system
Ceylan Isgor, Ph.D. 1997
Effects of perinatal gonadal steroids on adult spatial navigation
and hippocampal morphology
Assoc. Prof., Florida Atlantic University
Kristy Hamilton, Ph.D. 2000
The role of lMAN in perceptual selectivity for individual songs in
female brown-headed cowbirds
Mark Harty, Ph.D. 2000
Androgen effects on the morphology and electrophysiology of
sexually dimorphic and non-dimorphic rat spinal motoneurons
Research Associate, Rhode Island Hospital
Allison Foster, Ph.D. 2004
Ontogenetic function in a sexually dimorphic rat neuromuscular
Medical Writer, Clinical Research, Advanced Bionics
Keith Fargo, Ph.D. 2006
Prevention of dendritic atrophy after induced motoneuron loss
Director of scientific programs and membership initiatives,
Alzheimer's Association
Kathryn Lenz, Ph.D. 2009
Maternal influences on dendritic development of motoneurons in a
sexually dimorphic neuromuscular system
Asst. Prof., Ohio State University
Tom Verhovshek, Ph.D. 2010
Target-mediated androgenic regulation of neurotrophic effects in spinal motoneurons
Research Director, Objective Medical
Lauren Rudolph, Ph.D. 2014
Developmentally restricted effects of estrogens
Postdoctoral Fellow, UCLA


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AH.7, 1/35 Accurate Armour As
the 1/35 scale kit of the Lynx was available from Accurate Armour I had to get
one for my showcase, even if it was the most expensive single kit I ever
ordered. Before
doing so I had to decide, which version I wanted to build, because the Lynx is
available in two versions, with normal or IRCM-exhaust. I
wanted to build a helo from the 2003 – now period in Iraq from the British
Army, so I had to buy the Gulf War variant (offered as a 1991 Gulf War helo). Click on images below to see larger images The
kit has great overall details and was fun to build, but it should not be the
first resin kit to start with. As
I wanted to build the newer Lynx AH.7 I had to change some details of the Lynx. The
easiest part was to leave the TOW-launchers off, some more time was spent to add
the "Disco Light", Flare-Launchers, Machine Gun and the newer BERP rotor
blades. The
parts where made from plastic sheet, some made as master with resin copies,
where I needed more than one.
was with Gunze acryl colors, weathering with washings, pastel chalks and
pigments, the helo should look worn. All
in all it was a special project for me and due to the great kit it was fun and
didn`t take as long as I feared. Hope
you like it, Click on images below to see larger images
Photos and text © by Thomas Neuss


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5 ways to speed up your Wi-Fi (that work!)
Constantly resetting your router? Here's what to do to make your Wi-Fi faster and more reliable.
You've heard that the iPhone 4S offers a better camera than the iPhone 4's. In a series of photos, CNET shows you just how much better it is.


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Overview : Although "The Haight" is best known for being the center of '60's hippy culture, there's more to the strip between Baker and Stanyan... more » streets than just smoke and nostalgia shops. One look beyond the tie-dye reveals a host of neighborhood gems that reflect the diverse character of the people who actually live there. The area is home to San Francisco's best music store, a number of excellent vintage shops, and bars ranging from dive to longwinded cocktail. It's an interesting mix of grime and grandiose, with painted ladies, gutter punks, and sauntering tourists battling speedy locals for sidewalk space. less «
This throwback ice cream shop and soda fountain offers both original Prohibition-era recipes and upgrades with old ingredients. "The World's Best Pistachio Milkshake" with raw Sicilian pistachio syrup, pistachio ice cream, milk, and egg is an essential order—and best enjoyed without a straw. Address: 815 Cole St. San Francisco, CA, 94117 United... More States Phone: (415) 742-4932Less
The heavily wooded, 36-acre hill makes for a quick quiet place just off the bustle of Haight Street. The interior paths of San Francisco's first city park curl around the 589-foot incline toward an idyllic outlook typically just enjoyed by locals. Address: Haight St. at Buena Vista Ave. San Francisco, CA, 94117 United States
The biggest and oldest (opened in 1978) of three linked Haight Street vintage shops, Held Over carries garments, hats, and shoes from the 40's through the 90's. The higher end boutique, La Rosa, which is just a few blocks west, covers turn of the century through the 40's, and Haight Ashbury Vintage, located on the famous corner, deals older... More clothes with local bent. Address: 1543 Haight St. San Francisco, CA, 94117 United States Phone: (415) 864-0818Less
Locals have been standing in line for Pork Store's delicious diner-style breakfasts since the 1970's. The hash browns (the second most popular item that starts with "hash" in the neighborhood) and scrambles (both veggie and meat varieties) are well worth the wait. Address: 1451 Haight St. San Francisco, CA United States Phone: (415) 864-6981
When new owners took over this beloved independent bookstore in 2007, they added over 100 new events annually, launched a Berkeley-based lecture series, and designed a brighter and more pleasant place for books. A comic book artist (responsible for the wonderful illustrations the circle the store) and a New York Times bestselling author (often... More manning the register) are among the store's many accomplished employees. Address: 1644 Haight St. San Francisco, CA, 94117 United States Phone: (415) 863.8688Less
Amoeba Music on Haight Street is a must for music lovers: 24,000 square feet packed with 2.5 million new and used CDs, DVDs, video games, and vinyls. This converted bowling alley houses every genre, from rock and jazz to hip-hop and Japanese pop to electronica and reggae, with an emphasis on the experimental. Collections include musicians such as ... MoreSun Ra, Zappa, Derek Bailey, and Merzbow. Amoeba also hosts artist's signings and live shows on the "psychedelic Victorian living room"—recent celebrity visitors have included Sonic Youth, Ozzy Osbourne, and Anthrax. Address: 1855 Haight St. San Francisco, CA, 94117 United States Phone: (415) 831-1200Less
The Alembic Bar is renowned for mixologist Daniel Hyatt's cocktail program, but executive chef Ted Fleury also delivers adventurous snacks like pickled quail eggs and jerk-spiced duck hearts. Main courses include hearty options like beef tongue sliders, lamb shoulder, and arctic char with vegetables. The marquee dessert is chocolate pudding made... More with Eagle Rare bourbon, topped with Graham cracker crumbs and almond mousse. The space stands out as especially polished in gritty Haight-Ashbury, with mustard-colored walls, wood accents, and a pressed tin ceiling. Insider Tip: Owner Dave McLean also owns Magnolia Pub & Brewery down the street, so don't disregard his English-style ales. Address: 1725 Haight St. San Francisco, CA, 94117 United States Phone: (415) 666-0822 (415) 666-0844Less
Beer lovers congregate at Magnolia Gastropub and Brewery in the Upper Haight neighborhood. Brewmaster-owner Dave McLean produces artisan ales in the seven-barrel brewery beneath the pub. His creations include Kalifornia Kölsch, and a variety of European beers are also available. This converted early 20th-century pharmacy has a dark wood... More interior and picture windows. Executive chef Matt Kerley prefers seasonal local, sustainable ingredients for his menu selections, which include beer bratwurst and the Magnolia pub burger. Address: 1398 Haight St. San Francisco, CA 94117 United States Phone: (415) 864-7468Less
For Joe Swinney and Cheryl Cohen, the owners of the trendsetting Wasteland in Haight-Ashbury, fashion begins with the kids in the street. Wasteland takes these signals and rebroadcasts them with its own vivacious interpretation in modern, vintage, and designer styles. The formula was a hit, gaing the shop recognition is fashion magazines like ... MoreVogue, Vanity Fair, and Glamour. Items that can be found on the shop's racks include 50's cocktail dresses, classic 70's rock t-shirts, 1930's and '40s rayon floral dresses. Address: 1660 Haight St. San Francisco, CA 94117 United States Phone: (415) 863-3150Less


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Subject: | Yes, but you don't have "C..A...R...L...Y." on the site. Maybe she thinks her name looks purttier spelt that way. :p n/t |
Author: | Nanaea (Authenticated as Nanaea) |
Date: | October 10, 2001 at 5:58:22 AM |
Reply to: | Actually, 'Carly' is already here by Mike C |
Because this message is archived you cannot respond to it. |
Messages in this thread: |


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Although fashion is constantly changing, we have committed to one goal for the last 32 years; to provide our customers with an opportunity to look sexy and glamorous. Our friendly and knowledgeable fashion consultants...
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Jackie Gleason |
Host (1950 - 1952) |
Trini Reyes |
Guest Star |
Cab Calloway |
Guest Star |
Sammy Spear |
Orchestra Leader |
Recurring Role |
Art Carney |
Series Regular (1950-1952) |
Recurring Role |
June Taylor Dancers |
Series Regulars (1950-1952) |
Recurring Role |
The kinescope of this Honeymooners sketch was featured in The Honeymooners: The Really Lost Debut Episodes, a special hosted by Paul Reiser airing on the Disney Channel 10/30/1993.
This storyline was rehashed for the sketch This Is Your Life airing on CBS' The Jackie Gleason Show 1/16/1954.
Joyce Randolph joins the Honeymooners cast in this episode, assuming her signature role as Trixie Norton.
In an interview for "The Archive of American Television," Randolph said she had done a live Clorets commercial on Cavalcade of Stars and its sister series Cavalcade of Bands. Joe Cates, who worked on both shows, called her back some weeks later to play in a brief dramatic sketch with Gleason. A few weeks passed and Jackie was looking for a new Trixie (Elaine Stritch was not brought back after her one appearance in the role.) He recalled liking Joyce from her previous appearance and told Cates to "get me that serious actress."
No one has discussed Cavalcade of Stars yet. Start a conversation!
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If you're flying from or into Akhiok airport or simply collecting someone from their flight to Akhiok, discover all the latest information you need from Akhiok airport. Find directions, airport information and local weather for Akhiok airport and details of airlines that fly to and from Akhiok. Make use of our handy maps or videos to ensure you'll easily find your way to Akhiok airport, whatever you need, Skyscanner's got it covered. If you haven't booked your flights yet, but want to fly from Akhiok airport, let Skyscanner find you the best deals. Skyscanner lets you search for the very best flight prices from Akhiok airport quickly and easily, you can search for flights from Akhiok airport by month, to find the cheapest days to fly, or even the whole year. If you're not sure where you want to fly to, why not let Skyscanner inspire you with our 'flights to everywhere' search tool. Skyscanner searches hundreds of airlines and compares flights on thousands of routes to bring you find the best holiday deals. Did you know that Skyscanner is not just for flights? Whether you need a hotel at Akhiok airport, Skyscanner compares all major hotel suppliers to find you the best prices of hotels in Akhiok. Need to get around? No problem; Skyscanner searches all major car hire companies to bring you the best deal on 4 wheels for your Akhiok stay.
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- See all airports in United States.


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Folica's Warranty
Folica stands behind every product we sell and we honor all manufacturers' warranties. For all electrical appliances we offer complete protection. If you experience any problem with an item purchased from us and it's still under the warranty period, all you have to do is fill out our Warranty Replacement form, send us the items plus a small shipping and handling fee and we will take care of the rest. We'll repair or replace your item with a new product or a Folica Certified Refurbished product. It's that simple.
Conair Stubble Trim 14-Piece Grooming System includes everything you need to trim, taper, and clean your neck, jawline, beard, mustache, nose and ears.
Powerful stainless steel blades and 5 stubble combs provides 15 precise, even stubble lengths for your beard and face. Two jawline combs create a clean jawline look while taper control gives you multiple settings while trimming. Nose and ear trimmer attachment allows you to safely remove nose and ear hair with the same tool you use to trim the rest of your beard and face. Conair Stubble Trim is an all-in-one tool for all of your face grooming needs!
- Cordless and rechargeable multi-use handle
- Taper control for multiple settings
- Powerful stainless steel blades
- Non-slip grip
- Facial trimming blade
- Five stubble combs
- Nose/ear trimmer attachment
- Two jawline blending combs
- Five position attachment combs
- Lubricating oil for continued maintenance
- Soft storage pouch
- Adapter
- 2-Year limited warranty
Joe Grooming Grooming Cream helps to thicken your hair without weighing it down. Great for control and manageability with a subtle sheen.
New Price: $16.50 -
The Amika Styler Cleaning Kit was designed specifically to care for Amika styler products.
New Price: $12.00