The Centers for Disease Control and Prevention (CDC) is at the frontline of public health with a mission to prevent disease, illness, and injury. CDC works to ensure the well-being of Americans by detecting disease, providing accurate and timely information used in health decisions, and cooperating with partner groups likewise involved in health promotion. The recent release of the Institute of Medicine Report, “Microbial Threats to Health: Emergence, Detection, and Response,” recognizes the “need for a new level of attention, dedication, and sustained resources to ensure the health and safety of this nation—and of the world.” The $6.5 billion proposed for the CDC in FY 2004 does not sufficiently address the complex health risks that confront the agency from within this country and throughout the world. Events just within the past month, such as possible bioterrorism against U.S. combat troops overseas and the emergence of yet another apparently new infectious threat SARS (severe acute respiratory syndrome), urgently underscore the need for increased funding for the CDC. The American Society for Microbiology (ASM) recommends that Congress appropriate $7.9 billion for CDC in FY 2004, which is the recommendation of the CDC Coalition.
Fighting Infectious Diseases
The ASM is concerned about the adequacy of the proposed FY 2004 funding of $332 million for CDC’s infectious disease control program, which is a decrease of $3 million from FY 2003. This level of funding is counter to the reality of infectious diseases, which continue to be the third leading cause of death in the United States and the cause of nearly one-third of deaths worldwide.
The CDC’s complex and costly mission is to prevent the ravages of infectious disease here and around the world, whether familiar threats such as influenza or newly discovered, emerging diseases like SARS. Here and abroad, CDC personnel conduct surveillance, investigate epidemics, support both intramural and extramural laboratory research, and provide training and public education programs to many millions.
During the past decade, more than 35 new infectious diseases were identified. SARS will add another emerging disease to this deadly list. In response to the initial overseas SARS cases, the CDC activated its Emergency Operations Center to manage what is a complicated, international and multijurisdictional disease outbreak. The CDC also conducts intensive studies of other emerging diseases such as hantavirus; for instance, last year it provided funding to four academic institutions to study hantavirus transmission.
The CDC is expected to be at the forefront of any new infectious disease outbreak, providing epidemiological expertise and state-of-the-art laboratory assistance. The CDC recently established International Emerging Infections Programs in Thailand and Kenya and developed seven domestic and global sentinel surveillance networks to link health care providers facing these newly emerging diseases. Much of the fieldwork depends on the CDC’s Epidemic Intelligence Service (EIS) Program. In FY 2002, EIS officers participated in Epi-Aids missions to more than 70 outbreaks worldwide, at the request of local, state, and foreign health officials.
Old enemies also endanger America’s public health, in spite of available prevention methods. In this country alone, an influenza pandemic would cause an estimated 89,000 to 207,000 deaths, 314,000 to 734,000 hospitalizations, and economic losses between $71 billion and $167 billion. Aware of this potential catastrophe, the CDC in the past year expanded U.S. sentinel surveillance sites for influenza. ASM recommends that an additional $10 million be allocated within the infectious diseases budget in FY 2004, to prepare for a pandemic flu outbreak.
There have been great successes throughout years of immunization programs, forcing vaccine-preventable diseases to or near historically low incidences in the United States. Measles, for example, is no longer endemic and the CDC estimates that measles immunization saves this country both thousands of lives and $7 billion each year. Only two cases of rubella were reported to CDC in 2001, compared to 1,401 cases a decade ago. However, weaknesses persist in our immunization barricade against preventable infectious diseases. Nearly one million two-year-old Americans have not received one or more of the available recommended childhood vaccines. Vaccine-preventable diseases in adults is an even greater challenge: as many as 50,000 adults die each year of hepatitis B, influenza, and pneumococcal infections. The annual cost of these diseases exceeds $10 billion.
The FY 2004 budget request includes more than $1.2 billion to continue CDC campaigns against HIV/AIDS, sexually transmitted diseases (STDs) and tuberculosis. This is more than $46 million above the President’s FY 2003 budget for these ongoing programs. Approximately 900,000 Americans are HIV-infected; unfortunately, the number of new HIV infections reported each year has been about 40,000 for the past decade, without showing any decline. STDs caused by chlamydia are the most commonly reported infectious disease in the United States (more than 700,000 cases in 2001). Non-HIV STDs cost the U.S. economy at least $10 billion in direct and indirect costs each year, due to an annual estimated 15 million new cases.
Prevention of disease is the CDC’s primary mission. Therefore, the ASM urges Congress to provide an additional $93 million in FY 2004 to enable CDC to complete its strategic plan for the 21st century, “Preventing Emerging Infectious Diseases.”
Global Infectious Disease
Disease outbreaks anywhere in the world put U.S. citizens at risk; American health has become intertwined with global health. In 2002, the CDC announced its Global Infectious Disease Strategy, to create effective collaborations with international partners against the emergence and spread of infectious diseases. International efforts can make impressive progress: the number of polio-endemic countries dropped from 125 in 1988 to only eight today. But if ignored, infectious disease anywhere could spread into disaster, as have periodic influenza outbreaks and HIV infection. The current SARS outbreak of just a few reported cases in China in November has increased to more than 5,600 worldwide, today. The suspected number of cases in the United States has grown to 250, across 22 states. CDC recognizes that protecting the well-being of Americans is now impossible without supporting global strategies. The Administration recognized this as well, in its recently announced International Mother and Child HIV Prevention Initiative, to be administered in part by the CDC and meant to reduce HIV transmission from infected mother to child by 40 percent. At the end of 2001, 2.7 million children younger than 15 were living with HIV/AIDS worldwide, nearly all of them infected by their mothers. The ASM recommends that Congress allocate $9 million over the appropriated FY 2003 level, for global infectious disease activities.
Antimicrobial resistance among pathogenic microorganisms is a frightening trend found in a widening range of disease agents. The pathogenic agents of tuberculosis, malaria and gonorrhea are among those that have developed mechanisms to disarm their standard drug treatments. A recent study at Harvard concluded that by the summer of 2004, as many as 40 percent of the strains of Streptococcus pneumoniae could be resistant to both penicillin and erythromycin. This streptococcus causes thousands of cases of ear infections, pneumonia, meningitis, and sinusitis every year. The CDC estimates that as many as 100,000 are hospitalized each year with methicillin-resistant Staphylococcus aureus infections, bacteria capable of causing many different illnesses including bloodstream and skin infections. In addition, antimicrobial-resistant tuberculosis bacteria, which have evolved new strains immune to drugs typically used to treat the disease, has also emerged. Government agencies joined the CDC in 2001 to address this trend under the Public Health Action Plan to Combat Antimicrobial Resistance. This past year, the CDC initiated a research grant program focused on antimicrobials in the environment and in rural areas and on ways in which resistant genes spread among pathogens. In recent weeks the agency launched a topic-specific education campaign for physicians, on using antimicrobials wisely and preventing the spread of resistant pathogens. The ASM recommends that an increase of $13 million be appropriated for antimicrobial resistance programs and activities implemented by the CDC.
Ensuring National Security and Public Health
As events in late 2001 sadly demonstrated, this nation and its citizens abroad are at high risk from possible terrorist attacks, including the intentional release of pathogenic microorganisms. The CDC responded immediately and aggressively to those events with personnel, information, and financial support. CDC requires adequate resources to optimally prepared to meet such tragedy, to join with state, local, and international agencies in a well-coordinated defense.
The proposed FY 2004 budget for CDC includes $1.1 billion for the agency’s multi-faceted Bioterrorism Preparedness and Response Program, equal to the FY 2003 bioterrorism-related request. Within this sum are $940 million to improve state and local preparedness, $158 million to improve CDC’s internal preparedness, and $18 million to continue anthrax research. This steady-state sum total reflects the creation of the new Department of Homeland Security and subsequent transfer of CDC’s smallpox vaccine program and the Strategic National Stockpile (SNS) to the new department. The SNS is designed to warehouse counterterrorism vaccines and pharmaceuticals. Despite these two recent program shifts, the CDC responsibility for homeland security remains immense. The ASM supports the Administration’s request of $940 million for state and local capacity. We also support and strongly encourage CDC efforts to quickly assess the cost of the smallpox immunization program, including an evaluation of the impact of the program on human resources and the redirection of resources from other state and local public health activities and broader bioterrorism preparedness, as recommended in a March 27 report by the Institute of Medicine’s Committee on Smallpox Vaccination Program Implementation. The IOM recommendation was based on state and local health department concerns that resources are being diverted from other public health services to respond to smallpox preparedness and that cost issues constitute a difficulty in program implementation. The assessment should also focus on the human resources needed, training issues and the allocation of resources to state and local health departments. Understanding and responding to the cost implications is critical for the safe and effective implementation of the program and for funding of ongoing public health services and broader bioterrorism preparedness.
Following the attacks of September 11, 2001, and the intentional release of anthrax shortly thereafter, the CDC refocused its priorities to be ready against all types of terrorism, whether chemical, biological, radiological or conventional. In partnership with the Agency for Toxic Substances and Disease Registry (ATSDR), the CDC reinforced its capability to respond rapidly, having learned along with the nation that the public health system is central to any conflict with terrorism. The ongoing, integrated effort includes improving state and local laboratory capacity to detect possible biological and chemical agents, as well as upgrading surveillance and reporting systems nationwide.
Over the past year the CDC established a national Emergency Communication System, to quickly and accurately include all groups involved in defending public health. This system already has been utilized during the West Nile virus outbreak, the initial distribution of smallpox vaccine, and recently, to track the SARS outbreak. At the same time, the agency trained more than 1.5 million health professionals in terrorism-specific areas through its online Public Health Training Network. In 2002 the CDC released its National Public Health Performance Standards for state and local systems, part of its strategy to strengthen public health practice as called for by the 2002 Bioterrorism Act. This January, the CDC began distributing to state and local governments shipments of smallpox vaccine, which had been deposited by the agency at the centralized national vaccine stockpile. The CDC and ATSDR recently joined with the FBI in a renewed investigation of the 2001 anthrax contamination in Florida. CDC scientists have examined reputed anthrax-containing parcels/letters submitted by many state health departments.
What is learned about the epidemiology of infectious diseases in general also applies to potential weapons of bioterrorism, making all aspects of CDC infectious disease activities important to homeland security. Biological agents can be difficult to identify in advance of and even during an attack, and infectious disease can spread quickly through a population. The CDC is able to respond within minutes of receiving infectious outbreak reports, but strives to improve its own and others’ counterterrorism capabilities. To upgrade its own responses, the CDC is revamping the Rapid Response and Advanced Technology (RRAT) laboratory at the agency’s National Center for Infectious Diseases (NCID). NCID also is distributing millions of dollars to non-CDC investigators for basic research in biodefense and emerging infectious diseases, with emphasis on the A list of potential biological agents – those causing anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers, all easily disseminated and capable of high mortality rates. Through the government’s Select Agent Program, the CDC and the Department of Agriculture register facilities that use these and other agents for legitimate purposes.
Reinforcing CDC Infrastructure
The total funding for CDC buildings and facilities in the FY 2004 proposed budget is $114 million, which is $70 million less than the President’s FY 2003 request. CDC’s priority items are security upgrades and construction of a new building for agency headquarters and the Emergency Operations Center. The CDC utilized last year’s funding to open two new research laboratories, to investigate toxic chemicals in the environment and parasitic diseases, respectively. But the physical component of the CDC remains greatly inadequate, out-of-date and scattered. Some of CDC’s laboratories continue to have leaking roofs, rotted floors, and cramped conditions.
Newly emerging diseases and today’s greater risk of terrorism can overload an already strained communications system. The CDC tracks more than 60 notifiable infectious diseases in the United States, while watching worldwide for new and old diseases. Within the proposed FY 2004 budget, CDC priorities include building a Public Health Information Network that goes beyond the many existing CDC surveillance systems. It will guarantee secure and accurate information-sharing in emergency and non-emergency situations. Last year the agency improved public access to its Internet information, increasing the average monthly visits to 3.6 million. It educated on-line thousands of health care providers about emerging critical issues such as smallpox and anthrax vaccines. The ASM recommends that Congress appropriate $250 million for the critical infrastructure needs at CDC.