Stephen B. Blount MD, MPH
Office for Global Health
US Centers for Disease Control and Prevention (CDC)
Committee on Appropriations
Subcommittee on Labor, Health and Human Services, Education and Related Agencies
United States Senate
Wednesday May 2, 2007
Good afternoon Mr. Chairman, Senator Specter, and members of the Subcommittee. My name is Stephen Blount. I serve as the Director of the Centers for Disease Control and Prevention’s (CDC) Coordinating Office for Global Health. I am honored to be here today to talk with you about the important contributions that CDC is making to improve the world’s health.
The scope and nature of the agency’s global health efforts have expanded over the years, but the constant is that CDC is on the frontlines of international disease eradication and health promotion. The most recent addition to our global mandate is the ambitious goal of protecting the U.S and world population from emerging global threats.
CDC’s Commitment to Global Health
In FY 2007, CDC has devoted approximately $334 million to global health efforts, in addition to the approximately $815 million it has received thus far in transfers from the Department of State, Office of the Global AIDS Coordinator, as part of the President’s Emergency Plan for AIDS Relief (PEPFAR). We strongly believe that program and scientific staff should be embedded in the countries they serve. As of May 2007, the CDC has 166 staff working on assignments in 46 countries around the world. Besides these assigned staff, the agency employs approximately 1,200 local staff in host countries to support these programs and has approximately 40 staff detailed to work with our international partners. It is this commitment of funding, staff, and resources that has produced effective, efficient, and high quality global health results at CDC. Today, I will share with you some of our greatest accomplishments.
CDC’s Strategy to Address Global Health Concerns
CDC is committed to working with partners, both domestic and international, to achieve our goal of Healthy People in a Healthy World. Through the leadership of the Coordinating Office for Global Health (COGH), CDC is developing the first-ever agency-wide strategy to improve global health. This strategy includes health promotion, health protection, and health diplomacy.
Our health promotion activities help prevent the major causes of global illness and death through the implementation of proven interventions. Our commitment to health protection focuses on our collaborations within a transnational network of countries and other organizations that are dedicated to protecting the health of Americans and the global community from emerging threats. Finally, our health diplomacy efforts reflect our commitment to provide humanitarian leadership by sharing tools that enable other countries to identify and act on their own health priorities.
CDC also understands that our global health work cannot be accomplished without strong global partnerships. Today, approximately 30 of CDC’s programs serve as World Health Organization (WHO) Collaborating Centers. In this role, CDC efforts help to protect the world’s health by strengthening laboratory and epidemiological capacity and improving control and prevention strategies for selected diseases. CDC also works with a variety of sectors including government, private, and non-profits organizations. We partner with Ministries of Health, the Pan American Health Organization, USAID, CARE, the Carter Center, and UNICEF, just to name a few.
CDC Global Health Success: Health Promotion
A key CDC strength is our work in global health promotion activities. I will highlight a few outstanding examples.
Global HIV/AIDS, tuberculosis, and hepatitis
CDC’s Global AIDS Program (GAP) is a proud partner in the President’s Emergency Plan for AIDS Relief (PEPFAR). Secretary Leavitt has already shared with you some of its major program components and achievements. Through PEPFAR CDC is also engaged in developing next-generation solutions to the HIV/AIDS problem.
CDC is working to deploy known strategies to address Global HIV/AIDS in support of PEPFAR through new biomedical interventions. For example, we are conducting clinical trials on the safety and effectiveness of carageenan, a vaginal gel microbicide in Thailand, and on the safety and effectiveness of daily use of the antiretroviral agent tenofovir in the United States, Thailand, and Botswana. As part of the Partnership for AIDS Vaccine Evaluation, CDC is developing new animal models for the evaluation of vaccine candidates. CDC’s current research priorities include microbicides, pre-exposure prophylaxis (PrEP), HIV vaccine development, and emerging retroviruses.
Tuberculosis (TB) remains a major cause of illness and deaths globally, and is closely tied to our HIV/AIDS program activities because of high rates of co-infection. Nearly 9 million people develop TB each year, and 2 million die from the disease. CDC is actively engaged in addressing the emerging global concern arising out of reports of extensively drug-resistant tuberculosis (XDR TB). XDR TB has been reported in all regions of the world that have looked for drug resistance to second-line medications. The keys to preventing the development and spread of XDR TB are to ensure that patients are treated until cured with medications that are effective and by implementing appropriate infection control practices in medical care settings. CDC is working closely with the other parts of HHS, the Department of State, USAID, WHO and other international partners to address XDR TB.
Perinatal transmission of hepatitis B also remains an international concern. The good news, however, is that through support for WHO and work with the Global AIDS Vaccine Initiative (GAVI) Alliance and other partners, CDC has contributed to the substantial progress in control of global hepatitis B. To date, 158 of 192 WHO member states have introduced hepatitis B vaccine into routine infant immunization programs.
Malaria and other Neglected Tropical Diseases
Malaria is responsible for 300 to 500 million clinical episodes and 1 million deaths each year, mostly in young children in sub-Saharan Africa. Recently malaria control efforts have been expanded by the President’s Malaria Initiative (PMI). CDC is an active technical partner in PMI, and science conducted by CDC and our partners underpins the proven strategies being used in PMI: indoor residual spraying, insecticide- treated bednets, anti-malarial drugs and prevention in pregnancy. CDC’s contributions to the fight against malaria generally—and to PMI specifically—capitalize on the agency’s strengths in translation of data into policy and program, monitoring and evaluation, and applied research and the advancement of science that can quickly be translated into effective prevention and control strategies. CDC also supports ongoing activities to address the malaria burden in Asia and the Americas.
Beyond the burden of malaria, as much as one sixth of the world’s population is affected by one or more of a group of maladies collectively known as neglected tropical diseases. These diseases are responsible for tremendous illness and death worldwide and pose direct threats to the health of the American public. Yet efforts to reduce or eliminate these diseases have historically received little attention and few resources. CDC is actively working with a broad range of partners, including the pharmaceutical industry, to bring much-needed treatments and preventive interventions to those in greatest need.
Global immunizations is another major global health program at CDC, and Secretary Leavitt provided significant details about achievements to date in polio eradication. The Urgent Stakeholder Consultation on Polio Eradication at the World Health Organization in Geneva in February 2007 reconfirmed that polio eradication remains both technically and operationally feasible. New, targeted strategies in each of the four remaining endemic countries, together with monovalent oral polio vaccine—which has proven to be up to 3 times as effective as the traditional vaccine—provide powerful tools to help achieve polio eradication. As a key member of the Global Polio Eradication Initiative, CDC is actively involved in providing technical support and advocacy to reach this worthwhile goal.
Another major effort in immunization where we are seeing dramatic strides is measles control and elimination. Although entirely preventable with a vaccine that costs less than $1 per child in the developing world, measles ranks among the top 10 killers of young children around the world—taking the lives of 345,000 in 2005. Reflecting one of the greatest successes in global public health in recent years, in January2007, Measles Initiative partners announced that measles deaths had fallen by 60% between 1999 and 2005, from 873,000 to 345,000, surpassing a United Nations goal of cutting measles deaths by half during that period. CDC is a founding member of the Measles Initiative, which has provided funding and technical assistance to developing countries to fight this scourge. This achievement has led to the setting of a bold new global goal: to cut measles deaths by 90% by 2010. Protecting children against measles globally also protects American children from measles because of the risk of importation of the disease.
In other immunization-related activities, CDC is expanding surveillance for rotovirus and pneumococcus and is helping to introduce vaccines for those diseases in countries where they are needed most. These new vaccines will help prevent diarrhea and pneumonia, two of the biggest killers of children in developing countries.
As I mentioned earlier, chronic diseases contribute substantially to global illness and deaths, and CDC is increasing its involvement in this area by addressing major risk factors such as inadequate or poor nutrition, tobacco use, and physical inactivity. CDC has several programs involved in chronic disease prevention and treatment work. One program is the International Micronutrient Malnutrition Prevention and Control Program (IMMPaCt). This program assesses the state of micronutrient malnutrition in a community and works to eliminate it through evaluation and expansion of effective interventions, assistance and guidance in communication and advocacy, and strengthening of global micronutrient laboratory capacity.
CDC has worked with WHO to develop and implement the Global Youth Tobacco Survey (GYTS) to track tobacco use among youth throughout the world using a common methodology and core questionnaire. This survey has been vitally important in providing evidence to demonstrate the effectiveness of youth tobacco prevention activities worldwide. Late last year the CDC Foundation received a grant from the Bloomberg Foundation to establish systematic surveys to monitor global tobacco use among adults. The grant is part of a $125 million initiative by Bloomberg to create a partnership devoted to reducing dependence on tobacco around the world.
Injury, violence, and safety
Car crashes kill 1.2 billion people a year worldwide and currently rank as the 11th leading cause of death, accounting for 2% of all deaths globally. Another 20 to 50 million people per year are injured or disabled as a result of car crashes. CDC collaborates with WHO to develop the World Report on Road Traffic Injury Prevention and to provide technical assistance to develop and implement hospital-based injury surveillance systems in Central and South America. We also supported WHO in the publication of the WHO multi-country study on domestic violence against women, contributing to worldwide efforts to prevent intimate partner violence and sexual violence. In addition, CDC funded the creation of a curriculum to train first responders on the nature of blast injuries and proper triage criteria and collaborated with WHO on guidelines for essential trauma care.
Health and safety in the occupational setting is also a concern for CDC, particularly related to Americans who work overseas. CDC has been a WHO Collaborating Center in Occupational Health since 1976 and currently serves as Chair of the Global Network of 64 Centers. CDC contributes to the reduction of occupational diseases, injuries, and fatalities among workers employed globally by cultivating international partnerships and sharing pertinent information.
Maternal, infant and child health
While chronic diseases are a threat to both the developed and developing world, the vast majority of maternal, fetal, and neonatal deaths occur in the developing world. It is estimated that worldwide, more than half a million maternal deaths occur annually, and 4 million late fetal deaths and 4 million neonatal deaths occur each year.
With respect to HIV/AIDS, the prevention of mother-to-child transmission of HIV/AIDS (PMTCT) is a main focus and strong component of PEPFAR. In addition to the PMTCT activities that CDC undertakes as part of PEPFAR, we also conduct research that helps influence global policy change. For example, CDC research conducted in Thailand reduced rates of maternal to child transmission through effective treatment of mothers infected with HIV. This led to a policy change in Thailand that eventually became the world’s standard.
Another example of how CDC research activities have influenced policy decisions is our critical collaboration with global partners to advance research focused on the prevention of birth defects and developmental disabilities and the identification of strategies to improve the health and quality of life individuals affected by these conditions. CDC’s country-specific efforts also leverage unique research capacities and opportunities found globally. For example, China recently had the highest known rate of neural tube defects in the world—5 per 1,000 infants. Following a collaborative study conducted jointly by CDC and China, these birth defects were reduced by up to 85% in high risk areas of China and by 40% in areas with prevalence similar to the United States. Our research in China has provided important information about strategies to prevent such defects, and underpins the continuation of flour fortification in the United States by addressing safety concerns and providing evidence for other countries considering fortification.
CDC Global Health Success: Health Protection
Currently, the US and the rest of the world are facing a very real threat posed by the highly pathogenic H5N1 avian influenza virus. Our experience with SARS showed us how a highly infectious disease in a remote region of the world can spread in a matter of days and weeks. Thanks to the rapid and constant movement of people and commodities, pathogens can hitch rides on airplanes and boats and slip across national borders unnoticed. The key to interrupting these pathogenic journeys is early detection as close to the source as possible.
An estimated 60% of all known human infectious diseases and approximately 75% of all recently recognized emerging infectious diseases affecting humans are of animal origin. We witnessed sobering evidence of the health impact of the human-animal interface during our rapid multidisciplinary response to the large epidemic of potentially fatal Rift Valley fever virus earlier this year in east Africa. Additional disease surveillance tools, laboratory capacity, and CDC expertise deployed abroad can rapidly improve our ability to recognize and intervene to contain emerging threats—including a possible avian influenza pandemic—before they become significant problems within U.S. borders.
To prepare for a pandemic of influenza, key issues we need to address are appropriate training and exercising of rapid response teams to identify, investigate, and contain local outbreaks. We also need to be able to trust that we have the most accurate and reliable information about influenza viruses and novel human influenza cases—through strong and established surveillance systems, laboratory capacity, and communication channels so we can respond effectively.
One of the most significant USG contributions to our preparedness for an influenza pandemic is the CDC’s Global Disease Detection (GDD) Program. This program improves our ability to recognize infectious disease outbreaks faster and then better control and perhaps contain them. In collaboration with host countries and the World Health Organization, CDC is establishing GDD Centers across the globe that are already strengthening global capacity to detect and respond to infectious disease outbreaks. The GDD Centers build upon proven, effective interventions and approaches including the International Emerging Infections Program and the Field Epidemiology and Laboratory Training Program. Having CDC staff on the ground was invaluable in providing initial response support for the December 2004 Tsunami, particularly in Thailand, and is a mainstay of global response to the current avian influenza outbreaks. During the past year, CDC’s GDD staff helped countries respond—in less than 48 hours—to all 28 human cases of H5N1 influenza reported to WHO. The GDD Centers have collectively responded to more than 144 outbreaks of avian influenza, hemorrhagic fever, meningitis, cholera and unexplained sudden death. CDC also helped train more than 230 participants from 32 countries in influenza pandemic response, contributing to the development of more than 1,000 local Rapid Response Teams that are prepared act in the case of a pandemic.
Naturally emerging infections like influenza or hemorrhagic fever are not the only disease threats we face. Through its administration of and leadership in the World Health Organization’s Global Salm-Surv network, CDC is helping to greatly increase the laboratory surveillance and diagnostic capacity of more than 100 countries worldwide to monitor, detect and respond to foodborne and other infectious enteric diseases, as well as potential bioterrorist threat agents, such as anthrax.
CDC Global Health Success: Health Diplomacy
CDC recognizes the importance of the leveraged investments we make in sustainable health systems that can help develop the people, tools and systems needed to carry out essential public health functions above and beyond what CDC can do alone.
Sustainable health systems
A key component of such sustainable capacity is the development of a trained and skilled workforce. CDC has made significant contributions to the global health workforce through the Field Epidemiology Training Programs (FETPs), developed in response to country requests for programs like the U.S. Epidemic Intelligence Service (EIS). Trainees provide epidemiologic services, including surveillance system assessments and outbreak investigations, to the Ministry of Health during their training.
Since 1980, CDC has provided a resident advisor to 28 programs covering 36 countries. Of these, 19 no longer need support from a full-time resident advisor and 19 are still producing graduates. Of the more than 1,200 epidemiologists who have graduated from these programs, many are in influential decision-making positions in their respective countries’ Ministries of Health.
Safe water, sanitation and hygiene
A key area in which we have the potential to have a significant impact is through provision of safe water and sanitation systems. More than a billion people worldwide have no access to safe water and more than 2 billion lack access to adequate sanitation, resulting in an estimated 3 million deaths each year, mostly among children younger than 5 years. Unsafe water is the source not only of potentially deadly enteric diseases such as cholera, E. coli O157:H7, and shigella, but also greatly debilitating illnesses such as Guinea worm, schistosomiasis, and trachoma. Targeted improvements in water, sanitation, and hygiene in developing countries could save millions of lives each year, adding an expected 15 years to the average life expectancy, and providing powerful health and economic developmental benefits. To achieve reductions in this enormous disease burden in resource-poor nations, CDC is developing, evaluating and promoting the use of simple and sustainable approaches to providing safer, cleaner water. For example, with our international partners, we have developed a low-cost technology—
The Safe Water System—that has reduced diarrheal disease in some locations by 50%.
Next Steps for CDC’s Global Health Work
Today I have shared with you the framework and strategies supporting our global health portfolio, as well as substantial evidence of the scope and magnitude of CDC’s efforts. While we celebrate our successes in global health, we must also look forward to next steps and future challenges.
First, CDC needs to continue to engage our external partners in the development of our strategic vision for global health action. CDC is committed to sustaining and improving our collaborations with WHO and other multilateral partners, and to continuing to foster strong bilateral relationships with Ministries of Health in our host countries. As never before, we are also working more closely with other federal partners such as the Departments of State, Defense, and Agriculture, and the US Agency for International Development. CDC is also expanding existing collaborations and seeking out and working to engage with new partners.
Second, recent global experience with integrated campaigns focusing on immunization, malaria prevention and vitamin supplementation shows us that CDC needs to seek more ways to promote integration across global programs. Some examples of the kind of success we can have in this arena are the simple addition of bednet distribution to prevent malaria within HIV/AIDS prevention and treatment activities, or within polio/measles immunization campaigns, and the integration of information about simple techniques to ensure safe water into the PEPFAR basic care package. Research supporting other integrated interventions must be conducted, and when proven, implemented in the field.
Third, CDC and the entire global health community must begin to build a foundation for a collaborative response to the increasing burden of non-communicable diseases in the developing world. Left unchecked, chronic diseases like heart disease, diabetes, high blood pressure, and preventable cancers are poised to be an ever larger proportion of global disease burden.
I thank the Chair, the Committee, and Congress for this opportunity to discuss our global health work and for your support for global health. The world looks to the United States for public health leadership and guidance and it is imperative that we fulfill our responsibility as a world leader in this arena. Furthermore, our nation’s commitment to global health provides a unique opportunity for humanitarian leadership, which CDC is implementing through its priority on Global Health Diplomacy. With our resources, our partners, and our innovative spirit, I am confident that CDC can help America help the world.
Last revised: April 19, 2011