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Testimony on Global Health: the United States Reponse to Infectious Diseases by David Satcher, M.D., Ph.D.
U.S. Surgeon General
Assistant Secretary for Health
U.S. Department of Health and Human Services

Before the Senate Committee on Labor and Human Resources, Subcommittee on Public Health and Safety
March 3, 1998


Good morning. I am Dr. David Satcher, Assistant Secretary for Health and U.S. Surgeon General at the U.S. Department of Health and Human Services. I am pleased to be here this morning to discuss an important issue -- "Global Health: U.S. Response to Infectious Diseases." I want to thank you, Mr. Chairman, for calling this hearing today.

Emerging infectious diseases are a continuing threat to the health of U.S. citizens and of people around the world. They cause suffering and death, and impose an enormous financial burden on society. The recent outbreak of a new and virulent strain of influenza in Hong Kong raised the specter of a pandemic and illustrated the potential danger posed by these diseases to all countries. This incident also illustrated, yet again, the need for the United States to work closely with other countries and the World Health Organization to assure that there is adequate global capacity to detect and address such outbreaks.

Background

Over the past century, tremendous strides have been made in medicine and science to combat infectious diseases. The development and widespread use of antibiotics and vaccines, coupled with earlier improvements in urban sanitation and water quality, have dramatically lowered death and disability from infectious diseases and have led to a near doubling of life expectancy in this country. Progress had been so great that three decades ago some experts predicted we would soon see the end of infectious diseases.

However, our optimism, though understandable, was premature. Today, we see a global resurgence of infectious diseases, including the identification of new infectious agents, the re emergence of old infectious agents, such as tuberculosis (TB) and the rapid spread of antimicrobial resistance. Between 1980 and 1992, the death rate in the United States from infectious diseases, excluding HIV/AIDS, rose by 22 percent. Worldwide, infectious and parasitic diseases remain the leading cause of death. These deaths disproportionately affect the developing countries of the world, with the most vulnerable segment of the population being children under the age of five years. Moreover, the factors that contribute to the resurgence of these diseases -- including increasing global travel, the globalization of the food supply, population growth and urbanization, ecological and climatic changes, and the evolution of drug- resistant microbes -- show no sign of abatement.

The CISET Emerging Infectious Disease (EID) Report

In 1995, I had the honor of chairing a workgroup on emerging diseases for a committee of the National Science and Technology Council (NSTC), which was charged with conducting a government-wide review of our ability to protect our citizens from emerging infectious diseases. The NSTC Committee -- the Committee on International Science, Engineering and Technology (CISET) -- was staffed by the Department of State. The issue of emerging infectious diseases was regarded as urgent by many U.S. agencies, 17 of which sent representatives to the first CISET EID meeting, with 23 agencies ultimately participating.

In September, 1995, the Committee issued a report that concluded existing mechanisms for surveillance, response to, and prevention of outbreaks of new and reemerging infectious diseases were inadequate, both at home and abroad. The report made specific recommendations that became the basis of a 1996 Presidential Decision Directive (PDD) that established a new national policy. The Directive called for a coordinated U.S. government response to address the growing health and national security threats posed by infectious diseases The new policy acknowledged that domestic and international health are intimately linked, that microbes do not respect borders, and that the United States cannot protect the health of its citizens without playing a leadership role in international health. Copies of the CISET EID report and the President's policy have been provided to the Subcommittee.

The Task Force

The PDD calls for the establishment of an Emerging Infectious Disease Task Force, which I co- chair with Dr. Kerri-Ann Jones, Associate Director for National Security and International Affairs of the White House Office of Science and Technology Policy. The President charged the EID Task Force with implementing the PDD. The lead agencies on the Task Force include three agencies from the U.S. Department of Health and Human Services: the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA) and the National Institutes of Health (NIH); as well as the U.S. Agency for International Development (USAID) and the Department of Defense (DOD). The U.S. Department of Agriculture (USDA) has played an increasingly important role. The National Oceanic and Atmospheric Administration (NOAA) of the Department of Commerce, the National Aeronautics and Space Administration (NASA), and the Department of Veterans Affairs are also active participants. The Office of Science and Technology Policy and the Department of State have provided guidance on international policy, particularly our efforts to strengthen relationships with other countries, including India, Japan, Mexico, Pakistan, South Africa, Vietnam, and the European Union, to name just a few.

From the beginning, the basic principles of the EID Task Force and the working group on emerging diseases have been collaboration and coordination. We know that the challenge ahead outstrips the means available to any one agency, organization, or country. However, if we pool our talents and resources, a great deal may be accomplished. This is well illustrated by the great success of smallpox eradication and the ongoing polio and guinea worm eradication programs. Globally, polio cases have decreased by more than 90% since 1988; and, $230 million will be saved by the United States annually, when the goal of polio eradication is achieved. An estimated $1.5 billion will be saved globally.

These principles of collaboration and coordination are being applied both at home -- where U.S. agencies have coordinated the effort to address emerging infectious diseases among themselves as well as at the state and local level -- and overseas, where U.S. agencies are working with the World Health Organization (WHO) and other international partners to improve global health communications, set standards for global surveillance of antimicrobial resistance, and share experience and training on disease prevention and control on a regional basis.

Progress/Implementation

I am pleased to say that much progress has been made. A detailed account of what has been achieved can be found in the first annual report of the EID Task Force, copies of which have been provided to the Subcommittee. I will mention a few highlights in four key areas emphasized by the PDD to give you a sense of what has been accomplished. They are:

  • Strengthening the global surveillance and response system to keep local outbreaks from growing into pandemics
  • Supporting research and training to detect, treat, prevent, and control disease outbreaks.
  • Working with the private sector to ensure that drugs, vaccines, and diagnostic tests are available during infectious disease emergencies.
  • Making the issue of emerging infectious diseases a priority with our international partners.
Surveillance and Response

In the area of disease surveillance and response, the President's policy calls for action both at the domestic and international levels. CDC has led the effort to revitalize the component of the U.S. public health infrastructure that protects the public from infectious disease, working closely with state and local health departments, community-based organizations, universities, professional organizations, and other U.S. agencies. CDC will discuss its ongoing efforts to improve the detection and containment of emerging diseases entering the United States. As evidenced by several recent multi-state outbreaks of diseases transmitted through contaminated food (including strawberries, raspberries, lettuce, apple juice, alfalfa sprouts, and ground beef), food-borne diseases are a special domestic concern. Three agencies -- CDC, FDA, and USDA-- established the Active Foodborne Disease Surveillance Network (FoodNet) through CDC's Emerging Infections Program sites in 1996.

The goals of FoodNet are to:

  • Describe the epidemiology of new and emerging bacterial, parasitic, and viral food-borne pathogens.
  • Estimate the frequency and severity of food-borne diseases that occur in the United States each year.
  • Determine how much food-borne illness results from eating specific foods, such as meat, poultry, and eggs.

The public health challenges of food-borne diseases are changing rapidly. Changes in food production have led to new safety concerns. Many foods, previously thought to be safe, such as eggs and fruit juice, have both transmitted Salmonella in recent outbreaks. Other food-borne diseases included infections caused by Shigella, Campylobacter, Escherichia coli O157, Listeria, Yersinia, and Vibrio bacteria.

Internationally, U.S. government agencies have intensified their efforts to respond to outbreaks of highly contagious, highly lethal, or drug-resistant diseases, especially when they occur in countries that lack the resources and infrastructure to contain them. USAID, CDC, and other agencies are also supporting the efforts of the WHO to improve communications networks and build regional centers for surveillance of and response to infectious diseases. The WHO is sponsoring the development of sub-regional teams, or "hubs," for disease surveillance and outbreak control -- an idea that is in full accord with the goals of the EID Task Force.

The DOD has contributed to the international surveillance and response effort by expanding the mandate of its overseas laboratories to include epidemiological training and laboratory capacity related to diagnosis of infectious disease outbreaks. These DOD facilities work closely with experts in the countries where they are located, thereby helping to build local capacity.

Research and Training

A major Task Force goal is to promote research on tropical diseases by combining the scientific and clinical experience of doctors and scientists in less-developed countries with the scientific resources of industrialized countries. The NIH is the lead agency in this area.

Over the past year, the National Institute of Allergy and Infectious Diseases (NIAID) at NIH has substantially expanded its research efforts on emerging diseases and the Fogarty International Center (FIC) at NIH, in close cooperation with NIAID, has launched a $1.9 million program to provide infectious disease training for scientists in developing countries. NIH has also launched a Multilateral Initiative on Malaria that includes participation by other agencies of HHS, French and English research institutes (the Pasteur; INSERM, France's counterpart to NIH; ORSTOM, part of France's overseas development effort; and the British Medical Research Council), the Wellcome Trust, and the European Commission. As part of this initiative, the NIH has committed more than $1 million for a WHO program to strengthen malaria research in Africa.

On Sunday, March 8, the American Society for Microbiology (ASM), CDC, and NIH are convening a workshop, "Training in Emerging and Re-Emerging Infectious Diseases." This and other workshops related to emerging infectious diseases globally will be convened prior to and after the International Conference on Emerging Infectious Diseases to be held March 8-11, 1998, in Atlanta. This international conference is being organized by CDC, the Council of State and Territorial Epidemiologists, ASM, and the CDC Foundation, and has more than sixty cosponsors. There will be participation by many of our partner countries as well as WHO, PAHO, the World Bank, and USAID.

I would like to mention two other relatively new areas of infectious disease research that may be of interest to this Committee. One is the use of remote sensing technologies and global positioning systems to examine links between weather changes (such as those due to El Nino) and the incidence of infectious diseases carried by insects and animals. The hope is that this avenue of research will lead to the development of methods for predicting outbreaks of such diseases as malaria and dengue fever. CDC, NIH, NOAA, and NASA are collaborators in these efforts. The other area is research on infectious agents that may cause or exacerbate chronic conditions like ulcers, heart disease, or some types of cancer.

Engaging the Private Sector

FDA has taken the lead in creating partnerships with the private sector. In collaboration with WHO and private sector partners, the EID Task Force is preparing an international procedures manual for obtaining medical products during emergencies. FDA and its partners are also consulting with representatives of the U.S. pharmaceutical industry on how to promote the development of new drugs, vaccines, and diagnostic tests. In addition, FDA has engaged the regulatory bodies and pharmaceutical industries of Japan and the European Union (EU) in an effort to promote international harmonization of standards for medical products.

Private sector partnerships have been crucial in responding to particular outbreaks and emergencies over the past year. For example, CDC and FDA collaborated with drug manufacturers to address the shortage of vaccines for use in controlling a meningitis outbreak in Sub-Saharan Africa during the 1996-97 winter season. During the avian flu crisis in Hong Kong last fall, CDC, FDA, and NIH worked with the pharmaceutical industry to begin the development of novel vaccines that could be used to prevent disease due to this strain.

In addition, Rotary International is a private sector partnership that has been instrumental in achieving the outstanding progress in the global polio eradication effort. By the year 2005, Rotary International will have contributed more than $400 million to polio eradication. But Rotary International does more than just contribute money. In December 1996, I personally witnessed in India how active the Rotary can be in obtaining legislative support and mobilizing participation of over 150,000 Rotarians. Over 120 million children in India were immunized during their national 1996 polio immunization day.

Making Emerging Infections a Priority with Other Nations

Addressing the threat of emerging infectious diseases depends on international cooperation. Our confidence that nations can come together to improve global health has been reinforced by the success of smallpox eradication program as well as current efforts to eradicate polio and guinea worm. These were and are truly global efforts. The U.S. agencies are working with partners on every continent to develop a shared sense of responsibility and mutual confidence in the global effort to combat infectious diseases.

Some of these efforts are conducted through our development assistance program. Over the past year, USAID has continued its effort to strengthen basic public health infrastructures in developing countries and to develop in-country capacity to combat infectious diseases. For Fiscal Year 1998, Congress has allocated an additional 50 million dollars in developmental assistance to further this aim. USAID plans to focus on four new areas, which will be integrated into its on- going health programs. They are: antimicrobial resistance, tuberculosis, malaria, and the improvement of global disease surveillance and response.

U.S. agencies are also engaging other nations in the effort to combat infectious diseases. Many governments view emerging infections as an economic issue as well as a public health issue, because healthy people are more productive and more able to contribute to their country's economy. Moreover, outbreaks can impede economic development by interfering with tourism and trade. Since 1995, emerging infectious diseases has become an agenda item at several bilateral and multilateral meetings.

For example, in 1997, at the Denver Summit, the Group of Eight industrialized nations, including the United States, pledged to help develop a global disease surveillance network, coordinate international response to outbreaks of infectious disease, and help build capacity to prevent, detect, and control emerging infectious diseases. In addition, some members of the Asian-Pacific Economic Cooperation (including Thailand, Indonesia, Philippines) have developed an emerging infectious disease communications network that tracks cases of multi-drug resistant tuberculosis. Bilateral talks that cover emerging infectious diseases have also been held with India, Japan, South Africa, the Russian Confederation, and the European Union.

Working through the Trans-Atlantic Agenda with the European Union, U.S. agencies and EU member countries have begun to share surveillance data on Salmonella infections, a major cause of food poisoning. This is an especially important project, in view of the globalization of the food supply, the increasing recognition of multinational disease outbreaks, and the disturbing occurrence of Salmonella infections that are resistant to many drugs. The long-term aim of the US-EU project is to expand the Salmonella network to cover other food-borne diseases and include other developed countries, outside Europe and North America.

Under the US-South Africa Binational Commission, U.S. agencies are working with the South African Department of Health to train personnel in surveillance and applied epidemiology. The Mandela government is committed to extending the South African public health infrastructure to include the entire country.

Through the US-Japan Common Agenda and the U.S.-Japan Cooperative Medical Science Program, United States and Japanese scientists have held three international conferences on infectious disease research and science policy. As the first follow-up action to the July 1996 meeting in Tokyo of the Common Agenda ERIDS Working Group, a team from CDC and FDA was invited to Tokyo to participate in an investigation of outbreak of E. coli O157:H7. Japan has sent one of its scientists to CDC for long-term training in epidemiologic investigations. The level of engagement between the U.S. and Japan on infectious diseases and related issues is substantial and growing. In addition, under the auspices of the U.S.-Japan Common Agenda ERIDS Working Group, NIAID is working with Japan to develop an action plan to address the public health problem posed by E. coli O157:H7. A meeting of NIH, CDC and Japanese scientists was held in Baltimore in 1997 to discuss research advances and opportunities to learn more about this shiga-like toxin that causes the lethal hemolytic-uremic syndrome seen in outbreaks of food- borne diseases.

USAID, CDC, and FDA are also providing assistance to the Russian Federation and the Newly Independent States. In some of these States, there has been a significant breakdown in public health services since the fall of the Soviet Union. Resurgences of vaccine-preventable diseases (such as diphtheria, polio, and whooping cough) have been reported. For example, while I was visiting with the Russian Minister of Health in 1995, he received a report of 33 new cases of polio in Chechnya, during the height of the political instability. The EID Task Force is working under the umbrella of the US-Russia Commission on Economic and Technological Cooperation to strengthen epidemiological capacity in Russia, improve vaccine quality control and to help prevent the further spread of tuberculosis, STDs, and HIV/AIDS, which are now at epidemic levels. The US-Russia will hold its next meeting in Washington, D.C. next week--March 10 and 11. At that time, we expect to agree on next steps on at number of fronts.

A Demonstration Project

I'd like to leave you with a special illustration that demonstrates what can be accomplished when international partners pool their resources and expertise.

In the Sub-Saharan countries of Burkina Faso, Cameroon, Chad, Mali, Niger, and Nigeria, seasonal outbreaks of meningitis occur every 2 to 4 years, causing high morbidity and mortality in older children and young adults. In 1996, there were about 154,000 cases of meningitis and 20,000 deaths in the largest meningitis epidemic yet recorded. To prevent a predicted recurrence in 1997, the EID Task Force encouraged WHO and other partners to help prepare local public health workers for the next meningitis season. The CDC-based WHO Collaborating Center for Control of Epidemic Meningitis provided the technical lead.

The project involved five U.S. government agencies (CDC, FDA, NIH, USAID, DOD); several non-governmental organizations (Medecins Sans Frontieres, CARE, Epicentre, and the Fondation Merieux); three WHO offices; and three vaccine manufacturers. In addition, two other WHO Collaborating Laboratories -- in Oslo and Marseilles supplied diagnostic reagents and provided training in laboratory diagnostics in the affected countries. Major funds were provided to WHO by the British Overseas Development Agency and the Government of Japan.

The meningitis project was initiated in summer 1996. The number of cases in the "meningitis belt" countries was reduced from approximately 154,000 since the winter of 1995-96 to 60,000 in the winter of 1996-97. We must interpret this result with some caution, as some of the dramatic decline may be attributable to natural variation in disease patterns, as well as to improved detection and control. Nevertheless, the project strengthened human and technical resources in the affected countries, and forged on-going links among many international partners.

Conclusions

I am proud of the interagency work that has moved this policy and accomplished so much in such a short time. I believe that the U.S. position of leadership should be fostered, for the sake of our people and for the sake of the global community. Promoting the international effort to combat emerging diseases is a natural role for the United States, and one that benefits people everywhere. The EID Task Force has proved to be an excellent vehicle for getting this effort underway.

We must not stop now. The challenges ahead demand our continued attention. Our goal is to ensure that we are able to protect ourselves and the global community from emerging pathogens, whenever and wherever they may arise.

Thank you for the opportunity to testify before the Subcommittee. I will be happy to answer any questions you may have.


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