Challenges and innovations in real-time infectious disease surveillance: A U.S. public health infrastructure perspective

The U.S. public health infrastructure includes real-time infectious disease surveillance as one of its pillars, but its effectiveness is conditioned by a complicated interaction between structural fragmentation, workforce shortages, data lapses, and technological advancement. This narrative review summarizes the existing literature on national surveillance systems, such as NSSP/ESSENCE, NNDSS, wastewater monitoring, genomic sequencing networks, and immunization registries, and how they can be used and in what ways they are limited in a decentralized context. Although the modernization efforts like the CDC data modernization Initiative and electronic expansion of case reporting have enhanced interoperability and timeliness, the fact that the systems of the states differ, some datasets are still missing, and reporting delays still occur, hinder prompt identification. Other constraints to the capacity of health departments to utilize advanced analytics are workforce shortages and low informatics capacity. Recent developments, such as the use of digital epidemiology, machine learning-based forecasts, and extended genomic and wastewater surveillance have high potential in detecting the outbreak earlier and providing better situational awareness. Nonetheless, biased coverage, artificial preferences, privacy issues, and governmental restrictions constrain the fair usage of these tools. The development of the future needs to be based on the integration of the models of analysis, long-term financing, enhanced human resources, and the coordinated system of sharing data. Combined, these results indicate the potential transformations and challenging issues that define real-time surveillance of infectious diseases in the United States.