The American Society for Microbiology (ASM) is pleased to submit the following testimony on the Fiscal Year (FY) 2010 appropriation for the Centers for Disease Control and Prevention (CDC). The ASM supports the FY 2010 funding level of $8.6 billion for CDC recommended by the CDC Coalition and the Campaign for Public Health. Funding levels in recent years have not adequately supported the CDC mission to protect public health through health promotion and disease prevention. The ASM appreciates that the Administration and Congress have included science and public health programs in the American Recovery and Reinvestment Act of 2009. It is essential, however, to also provide increased funding through the FY 2010 appropriation and future fiscal years, at levels that sustain CDC programs to protect public health.
There are persistent challenges for the nation’s public health agencies at the federal, state, and local levels. Among these are the nationwide outbreaks of swine influenza, salmonella food poisoning, and upsurges in vaccine preventable diseases such as measles and meningitis.
CDC is instrumental in preventing death and illness caused by infectious diseases, contamination of food or water, or release of bioterror agents. The recent public health concern surrounding human cases of swine influenza A (H1N1) virus infection illustrates the importance of CDC’s role in the investigation and response to outbreaks of infectious diseases. CDC is working closely with officials in states where human cases of swine influenza A (H1N1) have been identified, as well as with health officials in other countries experiencing outbreaks of H1N1. CDC staff are deployed in the United States and internationally to provide guidance and technical support in response to this emerging health threat. During a rapidly evolving situation, CDC is working to reduce transmission and severity of the disease and to provide information to health care providers, public health officials, and the public.
CDC Combats Infectious Diseases
CDC mission specific components cover a wide spectrum of disease control and prevention activities. One of these, the Coordinating Center for Infectious Diseases (CCID), oversees national centers focused on immunization and respiratory diseases; zoonotic, vector-borne and enteric diseases; HIV/AIDS, viral hepatitis, sexually transmitted diseases and tuberculosis prevention; and healthcare associated infections, migration, and quarantine. CCID centers use the latest technological tools and scientific information to respond to emergent public health challenges as rapidly and effectively as possible.
Emerging infectious diseases. Newly recognized infectious diseases attract considerable attention from the public and the research community, evidenced by swine influenza A (H1N1) virus infection, H5N1 avian influenza, severe acute respiratory syndrome (SARS), HIV/AIDS, so-called “mad cow” disease, West Nile Virus, and methicillin-resistant Staphylococcus aureus (MRSA) among others. The CDC must respond to these and other emerging diseases with scientific proficiency and round-the-clock readiness. The National Center for Preparedness, Detection, and Control of Infectious Disease’s Division of Emerging Infections and Surveillance Services recruits partnerships across the CDC and with both national and international organizations, to track outbreaks and train laboratory scientists from around the world in preventing and responding to such threats. The CDC has repeatedly taken part in identifying previously unrecognized pathogens like the SARS virus. It also participates in relevant field research around the world.
Influenza preparedness. The CDC effort against influenza includes programs that focus on both seasonal and potential pandemic forms of the disease, such as human cases of swine influenza A virus infection. Every year, between 5 and 20 percent of the US population gets the flu, more than 200,000 are hospitalized, and about 36,000 die. The CDC works with US partners in health departments, clinical laboratories, vital statistics offices and healthcare providers to assess the annual burden of flu. Comprehensive CDC incidence reports use data from nine different sources, like the Nationally Notifiable Disease Surveillance System and the Emerging Infections Program’s Influenza Project. In October 2008, the CDC contracted with the American Type Culture Collection to implement the CDC Influenza Reagent Resource, which will serve as a source of diagnostic material for laboratories in the event of an emerging pandemic. The agency also awarded $24 million for 55 projects at 29 state and local health departments to develop better pandemic preparedness models. Last fall, the Food and Drug Administration approved a lab test co-developed by CDC that can reliably detect flu viruses with results within four hours.
CDC extensively monitors the avian influenza virus H5N1 that has spread throughout Asia, the Middle East, and parts of Europe. Recognition that the relatively new virus could cause a human pandemic has mobilized public health institutions worldwide. There have been only 413 confirmed human cases in 15 countries (by March 30), but the sustained 60-plus percent mortality is unprecedented for an influenza virus. The CDC developed a measurement tool to help at-risk countries assess their ability to respond to an avian influenza pandemic. Moreover, it continues its laboratory and field research on H5N1 and other flu viruses. CDC scientists reported last year that some avian influenza A H7 virus strains have acquired new features that might boost their potential to cause human disease.
HIV/AIDS. In August 2008, the CDC released its first estimates of HIV infections in the United States based on a new CDC developed laboratory assay called serologic testing algorithm for recent HIV seroconversion (STARHS). The results, unfortunately, indicate that approximately 56,300 new US HIV infections occurred in 2006, about 40 percent higher than CDC’s former estimate. The STARHS technology is the basis for the first national surveillance system relying on direct measurement of new HIV infections and provides more precise estimates of HIV incidence. CDC continually tracks the nation’s progress against this recalcitrant disease. For example, the CDC and other health agencies updated guidelines in March for the prevention and treatment of opportunistic infections in HIV-infected people.
Global infectious diseases. Infectious diseases are responsible for 15 million (26 percent) of the 57 million annual deaths worldwide and the CDC is a valuable contributor to public health campaigns against these diseases. Examples include its vigorous distribution in developing countries of Haemophilus influenzae type b (Hib) vaccine. One of the leading causes of severe childhood pneumonia and meningitis, Hib disease annually causes an estimated three million illnesses and 400,000 deaths worldwide in children five years and younger. Hib vaccines have been widely used in industrialized countries for nearly 20 years, but underused in the poorest countries. The CDC estimates that this year use of Hib vaccine in these countries will exceed 80 percent, compared to less than 20 percent in 2004.
CDC funding supports rigorous research on globally significant diseases like malaria and tuberculosis, and underwrites incidence data gathered from around the world. The CDC is developing a network of Global Disease Detection (GDD) Centers, along with the participating nations’ ministries of health, academic institutions, the World Health Organization, and US Departments of State and Defense. Centers currently operational are located in China, Egypt, Guatemala, Kenya, Thailand, and, added in 2008, Kazakhstan. They extend the reach of three established CDC programs in emerging infections, epidemiology training, and influenza. The Coordinating Office for Global Health oversees more than 200 CDC staff in over 50 countries, as first-responders to disease outbreaks. In 2008, CDC responded to more than 90 international disease outbreaks and public health events and found 22 new pathogens.
An estimated 1.8 million airline passengers cross international borders daily, opening multiple routes for disease transmission. The CDC maintains a specific branch to deal with global migration and quarantine issues, using its GeoSentinel Network Surveillance System to collect information from 41 sentinel sites and 200 medical clinics in 75 countries around the world. CDC personnel now staff US quarantine stations at 20 ports of entry and land border crossings. The CDC also provides US travelers with health threat alerts; educational efforts last year included recommendations to the US Olympic teams traveling to China.
Vaccination campaigns. CDC collects vaccine-related information to assist federal, state and local health officials. The CDC also invests considerable resources in educating the public on the importance of vaccination as a preventive tool. At times, vaccines can also alleviate disease rather than prevent initial infection. Last year, the CDC recommended that people age 60 and older be vaccinated against shingles to reduce the number of painful episodes, even in those with previous cases. The most recent CDC survey of childhood immunization in this country found that rates remain at or near record levels, with at least 90 percent coverage for all but one of the recommended series for young children. Still, more measles cases were reported in 2008 than any year since 1996 largely due to failure to vaccinate. Another CDC report concluded that marked reductions in rotavirus-caused gastroenteritis in US infants and young children may be due to a recently introduced rotavirus vaccine, recommended by CDC in 2006 for routine immunization of infants. Rotavirus is the leading cause of severe gastroenteritis in the young, typically causing 55,000-70,000 US hospitalizations and about 410,000 physician office visits annually. Every day, rotavirus kills about 1,600 children under age five worldwide.
CDC Confronts Healthcare-Associated Infections, Antimicrobial Resistance
Each year, healthcare-associated infections (HAI) account for an estimated 1.7 million infections and 99,000 associated deaths in the United States. With over one billion hospital and doctor visits made by Americans each year, there unfortunately is ample opportunity for HAI exposure. A CDC report released in March estimates that the annual direct hospital cost of treating HAI ranges from $28.4 billion to $45 billion, and that improving infection control could save roughly $6 billion to $32 billion, depending on the percentage of infections preventable in health care settings. With 2009 healthcare costs expected to reach $2.5 trillion, saving resources through CDC-facilitated prevention clearly offers a sensible public health strategy.
CDC works to optimize practices for HAI prevention. For example, CDC reports that 85 percent of all invasive infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are associated with healthcare settings. CDC guidelines help assure best practices in healthcare settings. Hospitals in a CDC-supported study reduced bloodstream and MRSA infections as much as 70 percent by implementing CDC prevention guidelines. Last September, CDC launched a public MRSA education campaign.
Antimicrobial resistance has emerged as a daunting global challenge, increasing the lethality of pathogens from extensively drug-resistant tuberculosis (XDR TB) to this year’s flu virus strain highly resistant to the most commonly used prescription drug. Last year, 16 CCID surveillance systems and programs gathered incidence data on antimicrobial resistance among bacterial, fungal, parasitic and viral agents. CDC scientists are developing laboratory protocols and diagnostics for a growing list of drug-resistant pathogens. One example is a new protocol for molecular typing of methicillin-resistant S. aureus. The CDC’s Antimicrobial Resistance Team also recently validated tests that will amend 2009 clinical and lab standards in testing microbial resistance to mupirocin (used for staph infections) and the carbapenem drugs used to treat enteric pathogens resistant to most other drugs.
CDC Strengthens National Defenses against Bioterrorism, Public Health Crises
The CDC’s Terrorism, Preparedness and Emergency Response (TPER) funds support the Coordinating Office for Terrorism Preparedness and Emergency Response objectives. CDC provides science-based strategies and tactical coordination during public health events and maintains emergency response operations like the Strategic National Stockpile (SNS) and the Emergency Operations Center (EOC). The SNS is an invaluable national repository of antibiotics, antitoxins and other medical supplies that can be mobilized rapidly to augment state and local resources during a large-scale health emergency. Opened in 2003, the DEOC is staffed with experts 24/7/365, an integral part of the country’s National Incident Management System.
The CDC’s inaugural annual report on its TPER-funded activities released in January enumerates its wide-ranging activities. Activities include assessing current administration routes and dosage for anthrax vaccine, inspecting 110 research entities registered to possess microbes on the federal select agents list, and mapping the DNA of the vaccinia virus (similar to smallpox virus) and tularemia bacteria for greater scientific insight into potential bioagents. TPER-funded capabilities help CDC respond more aggressively to public health crises of all kinds, far beyond the threat of bioterrorism. In FY 2008, the EOC was activated in response to 55 domestic and 16 international events, including the floods in the Midwest, multistate Salmonella and E.coli 0157 outbreaks, and outbreaks of cholera and hemorrhagic fever in Africa.
The ASM concurs with the recommended level of $8.6 billion, which will provide needed new funding for CDC’s programs that are so critical to protecting people in the United States and worldwide.