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Testimony on Infectious Diseases by James M. Hughes, M.D.
Director, National Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Before the Senate Committee on Appropriations, Subcommittee on Foreign Operations
April 23, 1998

Good morning. I am Dr. James Hughes, Director, National Center for Infectious Diseases, Centers for Disease Control and Prevention. I am pleased to be here with my colleagues from the U.S. Agency for International Development (USAID), the World Health Organization (WHO), and Eli Lilly and Company to discuss an important issue: the need to strengthen U.S. support for global infectious disease surveillance and response capacity. I will review the current situation and consider how CDC can use its unique capabilities in epidemiology, outbreak investigations, and diagnostics to assist USAID in making the best possible use of foreign assistance funds appropriated for this purpose.

The Global Implications of Emerging Infectious Diseases For fiscal year 1998, USAID has received 50 million dollars to strengthen global surveillance and control of infectious diseases. This appropriation reflects a recognition on the part of Congress and the public of the urgency and global implications of the emerging infectious disease issue.

The urgency of the situation is illustrated by the long list of unforeseen infectious disease problems that have emerged in recent years. To give a few examples: in 1997, an avian strain of influenza that had never before attacked humans began to kill previously healthy people in Hong Kong. This crisis raised the specter of an influenza pandemic similar to the one that killed more than 20 million people worldwide in 1918-1919. In 1997, we learned that vancomycin an antibiotic of last resort -- has begun to lose its power to cure infections caused by Staphylococcus aureus, a common bacterium that can cause life-threatening illness. This is a frightening example of how the emergence of drug resistance is reversing the miracles of the last fifty years. In addition, there is increasing concern that an infectious agent may be released deliberately in a U.S. city by a terrorist group or as a weapon of war.

There can also be disastrous consequences when two infectious disease epidemics afflict the same population. For example, the resurgence of tuberculosis in U.S. cities during the late 1980s and early 90s was exacerbated by the presence of a large population of people whose immune systems had been impaired by infection with HIV/AIDS. Another example concerns influenza patients, who are especially vulnerable to bacterial pneumonia, a disease that in the past has been treatable by certain antibiotics. By the time the next flu pandemic hits, those antibiotics may no longer be effective, and pneumonia may again become a serious health complication.

The global dimensions of infectious disease problems are evident. Infectious microbes can quickly travel from country to country within hours, and new diseases like HIV/AIDS and new forms of old diseases -- like multi-drug-resistant tuberculosis -- can emerge in one region and spread throughout the world. Today, when an outbreak of plague occurs in India, or an outbreak of Ebola hemorrhagic fever is reported in central Africa, the whole world takes notice. An outbreak is no longer viewed as a local tragedy that cannot affect us here in the United States, because the world has truly become a global village.

The challenge to the United States, and specifically to CDC as the nation's prevention agency, is to contain these outbreaks before they become international crises. When HIV/AIDS first emerged, there was no international disease surveillance and response system to detect it. Similarly, when a cluster of cases of Ebola hemorrhagic fever occurred in the city of Kikwit, in the Democratic Republic of the Congo (then Zaire) in 1995, it was months before the disease was identified and control measures were put in place. By that time, the already fragile health care infrastructure in Kikwit had deteriorated even further, numerous health care workers had died, and hospitals had become places of contagion.

Foreign Assistance to Address Emerging Infectious Diseases

It is imperative that emerging infectious disease issues be considered when making decisions about providing foreign aid to underdeveloped countries. It is in the best interest of the United States to help developing countries participate in national and international surveillance and response efforts. While the primary gains will be in health, secondary benefits will include improved economic productivity and increased political stability. A recent report from the Institute of Medicine, America's Vital Interests in Public Health: Protecting Our People, Enhancing our Economy, and Advancing our International Interests, stated that "the direct interests of the American people are best served when the U.S. acts decisively to promote health around the world." In the area of emerging infectious diseases, the United States can lead from its strengths in science and technology to protect American and global health while projecting U.S. influence internationally.

Collaboration and Partnerships

The challenge ahead outstrips the means available to any one agency, organization, or country. U.S. agencies like CDC and USAID are making every effort to maximize their resources by pooling their ideas and talents and by linking and strengthening existing programs and institutions. The principles of interagency coordination and collaboration are being applied both at home, where U.S. agencies are addressing emerging infectious diseases at state and local levels, and overseas, where U.S. agencies are working with the 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. An excellent example of a successful global partnership is the collaboration among CDC, USAID, Rotary International, WHO, UNICEF, and other international groups to eradicate polio worldwide.

The importance of partnerships cannot be over-emphasized. This idea was stressed in CDC's 1994 plan, Addressing Emerging Infectious Disease Threats: a Prevention Strategy for the United States, which launched a major domestic effort to rebuild the component of the U.S. public health infrastructure that protects U.S. citizens against infectious diseases. Copies of the plan have been provided to the Subcommittee. CDC is preparing an updated version which has been reviewed by many partners, including colleagues from USAID, WHO, and the U.S. pharmaceutical industry. We anticipate that the plan will be finalized in a few months and will include a strong global emphasis.

The theme of partnerships was also stressed at last month's International Conference on Emerging Diseases in Atlanta, which was sponsored by CDC. Approximately 2650 representatives from various scientific and public health disciplines -- from government, academia, non-profit agencies, and the private sector and from all 50 states and 96 countries -- participated in sessions that covered such topics as antimicrobial resistance; tuberculosis; international cooperation; perinatal transmission of HIV/AIDS; the detection of novel disease agents; traveler's health; bioterrorism; and the formal release of USAID's strategy on infectious diseases.

CDC and USAID are longstanding partners in the effort to combat emerging diseases overseas. CDC is the lead domestic agency for disease surveillance and prevention and has a strong scientific focus in areas that have useful applications overseas as well as at home. In many cases, CDC serves as a technical consultant to USAID, WHO, and ministries of health on overseas projects that involve epidemiological or diagnostic research or the investigation and control of infectious disease problems related to wars, famines, or other disasters.

Twenty years ago, CDC and USAID collaborated with WHO and other partners to eradicate smallpox. They are now working together to achieve the goals of polio and Guinea worm eradication. In recent years, CDC has extended U.S. assistance overseas by pursuing U.S. interests in countries that do not host USAID missions, such as China, where CDC supports twelve influenza surveillance sites; Hong Kong, where CDC assisted the Ministry of Health and WHO to contain the recent outbreak of avian influenza; the Sudan, where CDC has helped document epidemic levels of African trypanosomiasis (African sleeping sickness) and design control programs, as well as eliminate Guinea worm disease; and Vietnam, where CDC is initiating a variety of joint programs.

USAID and CDC have worked as partners to develop U.S. policy on emerging infectious diseases. In 1995, the two agencies participated in a government-wide review of our nation's ability to protect our citizens from emerging infectious diseases. The review concluded that existing mechanisms for surveillance, response, and prevention of outbreaks of emerging infectious diseases were inadequate, both at home and abroad. Copies of the report (Infectious Disease A Global Health Threat, Working Group on Emerging and Re-emerging Infectious Diseases, Committee on International Science, Engineering, and Technology (CISET), National Science and Technology Council (NSTC)) have been provided to the Subcommittee.

The recommendations derived from this report became the basis of a 1996 Presidential Decision Directive that established a new national policy to address the growing health and national security threat posed by infectious diseases, including the potential threat posed by bioterrorism. This directive calls for action in four key areas: strengthening the global surveillance and response system; supporting research and training as the key to the prevention and control of outbreaks; creating partnerships with the private sector to ensure the availability of drugs, vaccines, and emergency medical supplies; and encouraging other nations to make infectious disease control a national priority. NSTC has created an interagency task force to implement this policy. CDC and USAID are among the lead agency members.

CDC's Role in International Infectious Disease Issues CDC's role in international health has become more prominent in recent years, as CDC has received an increasing number of requests for assistance from foreign governments and WHO. CDC is often asked for help when local health authorities respond to outbreaks that have high fatality rates or the potential to spread internationally. CDC's assistance may also be requested when the cause of an outbreak is unknown, or when it involves a highly dangerous microbe that must be handled under the most stringent laboratory biocontainment conditions. In 1997, CDC sent personnel to 145 countries for scientific exchange and technical assistance and provided diagnostic support for hundreds of local investigations around the globe.

Over the past few years, CDC has responded to several extraordinarily serious situations that required large numbers of personnel over extended periods of time. These included the 1995 outbreak of Ebola hemorrhagic fever in the Democratic Republic of the Congo; the 1997 outbreak of avian influenza in Hong Kong; and the 1998 outbreak of Rift Valley Fever in Kenya.

After an outbreak has been contained, part of CDC's overseas job is to provide the affected population with tools to prevent or control recurrences of the disease. For example, since the 1995 Ebola fever outbreak, CDC staff have helped the local community maintain improvements in hospital infrastructure and hospital nursing practices. In coordination with WHO, CDC has also remained involved in on-going efforts to develop long-term surveillance of hemorrhagic fever outbreaks in the region.

CDC's increasing presence in overseas investigations and research and training activities is due in part to the re-emergence of infectious diseases as a major health threat in developed as well as developing countries. It is also partly due to changing expectations at home and abroad.

Factors that Favor the Emergence and Spread of Emerging Infectious Diseases Although we usually think of modern advances as helping to reduce the incidence of infectious illnesses, some modern demographic and environmental trends actually favor the emergence and spread of certain diseases. These factors include the ease and frequency of modern travel, the globalization of the food supply, and dramatic population growth causing sanitation problems and overcrowding in cities all over the world. Other concerns are population movements due to economic factors, and migrations caused by civil wars, famines, and other man-made or natural disasters. There has also been an increase in development projects involving irrigation, deforestation, and reforestation, which can alter the habitats of disease-carrying insects and animals. Finally, our increased use of antibiotics and other antimicrobial drugs has hastened the evolution of drug-resistant microbes.

New Expectations

At the same time, there are new expectations, both domestic and international, that favor increased CDC participation in international outbreak investigations. During the last few years, the issue of emerging infectious diseases has moved beyond the public health community to engage the community at large. The American public has become better informed on the dangers of microbial epidemics, and there is widespread understanding that a disease which originates in one continent can easily spread to another. The national and international press has educated the public by focusing on some of the more dramatic outbreaks. Furthermore, because of modern communications and international public health reporting, diseases that emerge in remote areas are less commonly overlooked.

Internationally, there has been an outpouring of interest in emerging infectious disease issues both in the developed and the developing world. In 1997, at the Denver Summit, the Group of Eight industrialized nations, including the United States, pledged to protect the health of the international community by developing a global disease surveillance network; coordinating international response to outbreaks of infectious disease; and helping to build worldwide capacity to prevent, detect, and control emerging infectious diseases. International projects to improve global surveillance and response to infectious diseases have been initiated through several major bilateral meetings, including the Common Agenda with Japan, the Transatlantic Agenda with the European Union, the U.S.-South Africa Binational Commission, and the U.S.-Russia Commission on Economic and Technological Cooperation. Emerging infections are also on the agenda of the Asian-Pacific Economic Cooperation (APEC), which includes eighteen developed and developing countries.

WHO has made a major effort to provide international leadership in this area, especially among developing countries. In association with its Division of Emergency and Humanitarian Action, WHO's new Division of Emerging and Other Communicable Diseases Surveillance and Control is focusing on the containment of epidemics all over the world. CDC is prepared to assist WHO in accomplishing this goal.

USAID's Strategic Plan

The increased interest in emerging infectious diseases among other nations presents us with an important opportunity for building a global network for disease surveillance and response and bodes well for the success of USAID's new initiative on emerging infectious diseases.

CDC applauds USAID's effort to develop a global strategy for strengthening national and regional capacities for addressing emerging diseases, and we concur with their key priority areas: antimicrobial resistance, tuberculosis, malaria, and surveillance and response. These are critical areas that developing countries must address in their efforts to monitor and contain emerging diseases. The spread of antimicrobial resistance presents a particularly difficult challenge. Tuberculosis is the leading cause of infectious disease deaths in the world and is the most common opportunistic infection among HIV-infected persons. Malaria kills more than one million African children every year, and there is still no vaccine to prevent it. Surveillance systems and response capabilities need to be strengthened throughout the world so that known diseases can be identified and treated and new diseases can be recognized and contained. Success in each of these areas over the next 5 to 10 years will be crucial to improving global health.Implementation In response to language in the fiscal year 1998 Senate Foreign Operations Subcommittee report, CDC has been pleased to consult with USAID on the development of the strategy and has outlined approaches for working with USAID and other partners to help ensure its implementation. CDC is eager to make contributions in each of the priority areas, particularly in the fourth - enhancing surveillance and response capacity - an area in which CDC has unique expertise.

CDC can help build surveillance and response capacity in two related areas: epidemiology and laboratory diagnostics, the two basic and interdependent components of an effective surveillance and response system. Epidemiologic capacity includes the ability to monitor the occurrence of infectious diseases and to conduct outbreak investigations, using modern analytic tools. Laboratory capacity involves the ability to diagnose diseases and track the source of epidemics, using a variety of approaches, including molecular "fingerprinting." Research on emerging pathogens is also critical for the invention of better tools to diagnose, monitor, and prevent emerging infectious diseases.

Building Regional Capacity in Epidemiology

First, I will use a successful domestic program as a model to illustrate the principles on which CDC might help USAID build regional centers for epidemiological research and outbreak investigations. I refer to CDC's Emerging Infections Programs, or EIPs, which provide a regional resource on infectious diseases within the United States.

The seven current EIP sites conduct population-based surveillance and research that go beyond the routine functions of state and local health departments to address important issues in infectious diseases and public health. They invest in cutting edge research, assist state and local health departments in emergency outbreak responses, and provide a flexible infrastructure for responding to new problems whenever they arise. (For example, the EIPs established population-based surveillance for new variant Creutzfeldt-Jakob Disease, an invariably fatal neurological disease, immediately after this disease was reported in the United Kingdom as a possible consequence of eating beef from animals afflicted with "mad-cow disease.") Moreover, the EIP sites are the backbone of the Active Surveillance Network for Foodborne Diseases, or FoodNet, which is a collaborative effort involving the Food and Drug Administration, the Department of Agriculture, and CDC.

The EIPs, which are based in state health departments, demonstrate the importance of institutionalized, on-going epidemiological research that fills both regional and national needs. They also illustrate the benefits of maintaining a regional resource for providing technical and financial assistance during infectious disease emergencies. Finally, they demonstrate the importance of partnerships between public health authorities and other agencies. Each EIP involves collaborations among state and local health departments, academic medical centers, and other local organizations and institutions.

These general principles can be applied by CDC and USAID in building an international network of regional centers that integrate surveillance, applied research, and prevention activities. Like the domestic EIP Program, such a network could incorporate pre-existing sites (e.g., public health agencies, research institutions, private companies, and non-governmental organizations); use the sites in an integrated fashion; and establish an international steering committee to provide assistance for specific projects conducted at one or more sites. Some sites could partner with, or build upon, existing Field Epidemiology Training Programs, which CDC has helped established in 14 foreign countries. Areas in which these sites might play an especially important role are in surveillance for drug-resistant forms of malaria, tuberculosis, pneumonia, and dysentery. All of the sites would be linked by electronic communications to keep health experts around the world in close contact with one another.

Building Regional Capacity for Laboratory Diagnostics

CDC and USAID could also help develop a complementary network of regional diagnostic laboratories. This might be accomplished most readily by building on WHO's existing network of more than 200 Collaborating Centres and Reference Laboratories worldwide. The laboratories specialize in particular areas of diagnostics and laboratory research, including foodborne diseases, respiratory diseases, diarrheal diseases, drug-resistant diseases, and many others. They are an important source of high quality diagnostic reagents, and they can provide international training opportunities in their specialty areas. For example, after the 1994 plague outbreak in India, the CDC-based WHO Collaborating Centre for Reference and Research on Plague Control provided diagnostic reagents and educational materials to Indian health authorities.

Wherever there are gaps in global capacity to recognize certain diseases, CDC could help USAID improve the diagnostic capacity of appropriate WHO Collaborating Centres. In some cases, CDC would work with WHO to evaluate and strengthen local laboratories for eventual designation as new Collaborating Centres. This project would be in good accord with WHO's plan to expand the number of Collaborating Centres in developing countries, and it would further USAID's strategy for developing in-country expertise in specific disease areas.

A recent example illustrates the potential benefits of expanding the Collaborating Centre network to fill gaps in regional capacity. During the winter of 1996-97, WHO and CDC spearheaded a successful international effort to help prevent a seasonal recurrence of meningitis in sub-Saharan Africa. The winter before, the disease burden had been unusually high, with over 200,000 cases and 20,000 deaths. Three WHO Collaborating Centres -- one in Marseilles, one in Oslo, and one at CDC in Atlanta-- supplied diagnostic reagents, laboratory assessments, and diagnostic training in the affected countries. After the outbreak was over, the three Centres worked together to continue training activities in the affected countries and to strengthen regional facilities that might become permanent reference laboratories for meningitis. At the present time, laboratories in Ghana and in Mali have been recommended for possible designation as new WHO Collaborating Centre reference laboratories.

Training in Disease Surveillance, Outbreak Response, and Laboratory Diagnostics

The success of the regional networks I have described ultimately depends on the efforts and abilities of the people who operate them. A major component of the effort to implement USAID's strategy will be to train an international cadre of epidemiologists and laboratorians who are prepared to respond to emerging infectious disease threats, whenever and wherever they arise.

This year, CDC is expanding its Laboratory Fellowship Program in Emerging Infectious Diseases to include a track for foreign students. The Laboratory Fellowship Program trains medical microbiologists in public health approaches to diagnosis and molecular epidemiology. Its graduates are qualified to operate and lead public health laboratories. CDC also trains foreign students to become epidemiologists ("disease detectives") through its Epidemic Intelligence Service, which has served as the model for Field Epidemiology Training Programs in many countries throughout the world. It is interesting to remember that EIS was founded with global problems in mind; in fact, it was established during the cold war in response to the threat of biological warfare.


CDC is proud of its accomplishments in the area of global health. We are confident that the funds provided by Congress will be used effectively to strengthen global capacity to combat emerging diseases. We appreciate the efforts USAID has made to involve CDC scientists in discussions and decision-making related to developing its strategy for addressing emerging infections. CDC strongly supports USAID's expanded activities on emerging infectious diseases, and we look forward to working in full partnership on this important endeavor.

Thank you very much for your time and attention. I will be happy to answer any questions you may have.

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