The American Society for Microbiology (ASM), the largest single life science society with 43,000 members, is pleased to submit testimony on the FY 2005 budget for the Centers for Disease Control and Prevention (CDC). The CDC is the nation’s lead agency for protecting the health and safety of the public, both nationally and globally. Threats to public health and security have steadily increased in number and complexity over time, despite medical successes and technical innovation. The work of the CDC is of unprecedented importance in safeguarding public health.
The ASM is concerned that funding for CDC is not keeping pace with its growing responsibilities to address new health threats. The $6.9 billion FY 2005 request for the CDC is a 2.8 percent reduction below last year’s $7.1 billion. The ASM endorses the CDC Coalition’s recommendation of $8.1 billion in FY 2005 for CDC, followed by annual increases to achieve $15 billion for the agency by FY 2008. Increased support is crucial to the CDC’s primary goals for protecting public health: surveillance and response, basic and applied research, training and education, and prevention and control.
The CDC’s ability to mobilize rapidly to prevent or contain disease is an urgently needed line of defense against the economic and social havoc that can result from public health threats. In 2003, the CDC was essential in identifying the cause of the Severe Acute Respiratory Syndrome (SARS) epidemic in Asia and the first case of human monkeypox in the United States. Agency personnel also trained approximately 8,800 U.S. clinical laboratory staff in terrorism preparedness and response, while others investigated numerous outbreaks of infectious and food-borne diseases, as well as chronic disease diagnoses among diverse populations. Proposed cuts to a number of CDC programs could jeopardize the agency’s activities to address health threats.
The ASM is concerned that the proposed FY 2005 budget represents no or only slight increases in CDC programs such as emerging and re-emerging infectious diseases, antimicrobial resistance and domestic HIV/AIDS programs. The ASM also recommends that new bioterrorism preparedness initiatives be funded without redirecting resources from needed on-going state and local programs, as proposed in the FY 2005 budget. By adequately enlarging the CDC appropriation, Congress would strengthen significantly our defenses against naturally and intentionally caused disease in the United States and elsewhere.
Infectious Diseases and Public Health
The National Center for Infectious Diseases (NCID) supports programs to prevent and control endemic, new and reemerging infectious diseases in the United States and abroad. The proposed FY 2005 budget for the CDC includes $400.8 million for infectious diseases, an increase of $31.3 million over FY 2004 funding. Most of the increase benefits two CDC programs: $27.5 million to expand the CDC’s Global Disease Detection Initiative to $51 million, and $2 million to increase West Nile virus (WNV) research as well as state and local health department WNV surveillance and response capabilities. Because of increased world trade and travel, nations can no longer ignore any type of infectious disease and global strategies have become fundamental to CDC’s public health activities. The ASM supports the budgetary increases proposed for these two programs, but is concerned that critical components of the CDC infectious diseases mission also need additional resources in the FY 2005 budget.
In 2003 the Institute of Medicine (IOM) released a strongly worded, cautionary report on Microbial Threats to Health. The IOM report points out that infectious disease public health needs have been and will continue to increase. Between 1973 and 2003, more than three dozen newly emerging diseases were identified. Most recently, hantavirus, West Nile virus, SARS, bovine spongiform encephalopathy (BSE), and monkeypox became known enemies to public health in the United States. In the 1990s, the CDC revitalized its infectious disease programs to better reflect the emergence of new infectious diseases. By investing in partnerships with local and state health departments, academic research and teaching institutions, private industries, other federal agencies, world health organizations, and health agencies and researchers in other nations, the CDC expanded its ability to detect and contain infectious disease, as it intensified its own research and training programs. The vital need for CDC programs was emphasized dramatically last year with the SARS epidemic and hundreds of human WNV infections. The need remains as urgent today with concern about BSE and avian flu now in the United States.
Experts predict a major pandemic during this century and the most likely source remains influenza. A hallmark of pandemics and many small scale emerging infectious diseases is that they are zoonoses. Zoonotic diseases, infections which are naturally transmitted between animals and man, represent one of the leading causes of illness and death from infectious diseases and nearly all emergent episodes of the past 10 years have involved zoonotic infectious agents. In the United States alone, an influenza pandemic could cause an estimated 89,000 to 207,000 deaths and cost the nation from $71-167 billion in health care costs and lost productivity. Additional budgetary resources are needed to address issues such as zoonoses and influenza, which were highlighted in the IOM report. CDC infectious diseases should be increased by an additional $50 million. We recognize that significant investment will be required to enhance efforts to address the threat of pandemic influenza in order to develop a newer generation influenza vaccine that can be quickly produced and deployed, to strengthen the public health infrastructure at the state and local levels, and to ensure needed vaccines and antiviral medicines are readily available. We recommend that the Department of Health and Human Services (DHHS) assess the needs for resources to address pandemic flu within the NIH, CDC and FDA and coordinate the planning activities.
The goal of the CDC’s new Global Disease Detection Initiative within its epidemic services and infectious disease control programs is to work faster and better in recognizing and controlling any infectious disease threatening public health. The CDC operates in a global arena, establishing myriad programs and collaborations beyond the nation’s borders and sending quick-response assessment teams around the world. It recently funded five university schools of public health and three non-government organizations to assist malaria-endemic African countries, where the disease kills and disables millions. CDC personnel provide consistent epidemiological expertise and lab support to nations under siege, most recently the Congo (Marburg virus disease), Uganda and Gabon (Ebola hemorrhagic fever), Saudi Arabia and Yemen (Rift Valley fever), and more. CDC programs will be expanded in five countries including Brazil and China and new sites will be created in six others, most of them in Africa. The CDC also will continue to be a major implementing agency for the U.S. Department of State’s Mother to Child HIV Prevention Initiative inaugurated last year. The new Global Disease Detection initiative includes improvement of the existing international surveillance network for influenza, to bolster the early warning system for identifying more uncommon viruses.
The multi-faceted network of disease surveillance in the United States expands and changes annually. The CDC last year enhanced its surveillance of prion diseases and responded to the first confirmed U.S. case of BSE in cattle. Food-borne illness surveillance has grown into one of the most extensively used networks: 76 million Americans suffer from contaminated foods each year at an estimated cost of over $1 billion. The CDC’s PulseNet is credited with revolutionizing food-borne surveillance in this country and overseas; recently it was expanded to incorporate a total of 21 participating countries. In 2003, it was critical in identifying U.S. outbreaks of salmonellosis from tomatoes and eggs, E. coli O157 infection from beef, and listeriosis from raw milk cheese. The CDC coordinates U.S. influenza surveillance and recently expanded its sentinel surveillance sites through one of many data-collecting networks. The 891 influenza sites will not only alert officials to impending flu epidemics, but also to other respiratory diseases.
Effective as surveillance networks are in preventing further spread of disease, protecting the public must stress prevention through effective education and science-based efforts. For instance, the CDC supplies funding to most states to promote appropriate use of antibiotics and thus limit the rising medical costs associated with antibiotic resistance. The agency has implemented a National Hepatitis C Prevention Strategy by establishing coordinators in all 50 state health departments. It developed guidelines for the prevention of perinatal group B streptococcal disease that have resulted in a 70 percent reduction since 1993. An initiative begun last year expects to increase HIV testing in this country and enhance prevention, in recognition that the rate of new infections (about 40,000 each year) has remained stable despite education efforts over the past two decades. The “Advancing HIV Prevention” approach shifts strategies to reduce even further the barriers to early HIV diagnosis and quality medical care.
In response to the 2001 Public Health Action Plan to Combat Antimicrobial Resistance (AR), the CDC announced a new extramural applied research grant program in 2003, to fund research in the areas of mechanisms of dissemination of AR genes, resistance in specific human pathogens of public health concern and the characterization of strains of community-associated methicillin-resistant Staphylococcus aureus (MRSA). The goal of the applied research program is to prevent and control the emergence and spread of antimicrobial resistance in the United States. Approximately $25 million is being requested for antimicrobial resistance research, surveillance, prevention and control activities. Considering the magnitude of the problem of antimicrobial resistance, additional new funding should be provided in the CDC budget to address the alarming issue of antimicrobial resistance.
Each year about 48,000 Americans die from vaccine-preventable diseases; worldwide, these diseases cause an estimated 2.4 million childhood deaths. The FY 2005 CDC budget request includes $1.9 billion for a number of significant vaccination programs. Some, like a stockpile of all routinely recommended childhood vaccines, already are in progress. Others are new, like an inventory of childhood influenza vaccine. The immunization budget will continue to provide global immunization activities ($151 million), including the goal of global polio eradication by 2005.
National Security and Biodefense
Intentional release of biological weapons troubled the CDC well before events of 2001, but the enormity of those attacks brought home the grave potential of bioterrorism. The attacks also forced the CDC to shift much of its mission focus to bioterrorism preparedness, in collaborations with other federal, state, and local health organizations. The agency quickly formed emergency response teams, established extensive state-of-the-art communication systems, and concentrated on basic and applied research related to possible bioweapons. The FY 2005 request of $1.1 billion would continue CDC efforts related to terrorism preparedness and emergency response at a funding level identical to that implemented so effectively in FY 2004. The ASM recognizes the dire consequences of bioterrorism and supports extensive funding of CDC preparedness programs. However, the programmatic impact of removing $105 million from state/local programs and $25 million from internal CDC activities to subsidize CDC’s component in a new cross-agency Biosurveillance initiative deserves evaluation.
The new Biosurveillance Initiative was designed by a coalition of federal agencies after the Homeland Security Council identified early bioattack warning and surveillance as top priority areas in need of improvement. The CDC’s contribution, funded at $130 million in the proposed FY 2005 budget, includes three new program activities, the BioSense surveillance system ($100 million), real-time laboratory reporting ($20 million), and expanded border health inspection and quarantine capability ($10 million). The BioSense program represents a new and largely untested generation of infectious disease surveillance that does not rely upon mandatory or voluntary case reporting from healthcare providers. Instead, sets of anonymous health data will be automatically and electronically gathered from pre-determined sources like over-the-counter retail sales of home health remedies and visits to emergency rooms. This system is intended to provide public health officials with “a near real-time sense” of the community’s health status and to reduce the time needed to detect threats from days or weeks to hours.
The ASM strongly supports two programs of the new initiative which build on the importance of trained personnel who respond locally but work together within the national goal of preventing bioterrorist attacks. One program will expand the CDC’s existing Laboratory Response Network (LRN) by adding animal diagnostics and food safety capabilities to public health, clinical, and private commercial laboratories. The other program recognizes that every day more than 2 million people travel to or through this country by air, sea or land, and that each year, more than 350,000 new immigrants arrive. It adds new, strategically placed quarantine stations and creates multidisciplinary teams able to respond to infectious disease emergencies at U.S. seaports, border crossings, and airports.
By the end of FY 2004, over $3 billion will have been allocated by the CDC to upgrade state and local health departments since the 2001 terrorist attacks. Supporting this nationwide community of anti-terrorism capability extends the CDC’s own efforts and provides a greater return on funding investments. CDC support also comes from the many wide-ranging communication networks used by the CDC to disseminate new scientific information, health risk alerts, and population- or disease-specific updates. An example is the Epidemic Information Exchange, Epi-X, which provides swift exchange of information among more than 2,000 key public health officials nationwide. The Public Health Information Network sends health alerts and advisory messages to one million recipients, including 90 percent of all county public health departments. The Laboratory Response Network, to be expanded under the new Biosurveillance Initiative, already includes 113 members in the United States and elsewhere; an increasing number of these labs could confirm the presence of anthrax, tularemia, and smallpox, and more than half are qualified to handle some of the most dangerous pathogens.
The complex CDC infrastructure used to prevent bioterrorism also incorporates the training of specialized personnel, the stockpiling of crucial supplies needed in mass emergencies, and the careful monitoring of pathogens and other toxic agents used in research. Management of the Strategic National Stockpile has been returned to the HHS from the Department of Homeland Security, as a source of smallpox vaccine and other medical supplies shippable to any scene of mass trauma in the United States. The Epidemic Intelligence Service grew from 148 officers in 2001, to 167 in 2003; 49 of these first-line responders are assigned to local or state health departments. With the U.S. Department of Agriculture, this year the CDC will inspect 300 laboratories using potential bioagents in research, through the Select Agent Program that controls the possession and transfer of infectious agents. The SAP program should have adequate resources.
Buildings and Facilities
A total of $81.5 million is proposed in the FY 2005 budget for CDC buildings and facilities. CDC is undertaking and has made substantial progress in a ten-year effort to rebuild its physical infrastructure and replace and upgrade decrepit out-dated buildings and facilities. State of the art, safe and secure laboratories and facilities, as well as modern equipment, are essential to an effective CDC response to the broad range of public health threats facing the country and the world. The ASM recommends that Congress appropriate $250 million for CDC’s critical infrastructure needs.