The American Society for Microbiology (ASM) thanks you for the opportunity to provide a written statement for the record in support of the Fiscal Year 1998 (FY98) appropriation for the Centers for Disease Control and Prevention (CDC). The ASM is the largest single life science society in the world with a membership of over 42,000 individuals who are engaged in basic and applied research and diagnostics and work in clinical, public health, and industrial laboratories, as well as in academia and government. The ASM recognizes the difficult budget constraints the Committee on Appropriations faces in determining the fiscal priorities for the nation, and would like to thank you for your past support for the CDC, especially for infectious disease funding. The CDC has been recognized for its efforts to combat the continuing threats of new and reemerging infectious diseases, and the ASM recommends that Congress continue its support and adopt the Administration's request for new and reemerging infectious diseases.
The Administration's request for CDC's infectious disease program includes an increase of $15 million for new and reemerging infectious diseases and $10 million for its' role in foodborne disease prevention as outlined in the Presidential Food Safety Initiative. The ASM supports the Administration's request for an additional $25 million to combat new and reemerging infectious diseases, including foodborne diseases. This request represents the minimum level of resources needed by the CDC to improve the nation's public health capacity to combat infectious diseases. New and reemerging infectious diseases continue to proliferate and many chronic diseases and conditions have now been proven to have infectious origins (ulcers, cervical cancer, chronic liver disease. The ASM also recommends that Congress adopt the FY98 budget proposal developed by the CDC Coalition. The CDC Coalition members, over a 100 in number, are committed to improving the public's health through cost effective prevention and control strategies. For FY98, the CDC Coalition recommends Congress appropriate $3 billion for the CDC.
Our nation continues to be faced with new, reemerging and drug resistant infections. To what extent these infectious diseases are rising is still unknown due to the lack of a comprehensive needs assessment and evaluation of the nation's surveillance capabilities. Infectious diseases remain the world's leading cause of death, accounting for over half of the 50 million deaths annually. In the United States, the death rate from infectious diseases rose 58 percent between 1980 and 1992, claiming approximately 166,000 lives annually. At a cost of $120 billion each year, recognized infectious diseases account for one out of every six health care dollars and a quarter of all physician office visits. However, these are only estimates due to the lack of information and data on the actual national, state and local surveillance capabilities, the total infectious disease burden, and the economic and social costs of infectious diseases to the nation. There are a number of known and many still unknown reasons for increasing rates of infectious and multi-drug resistant diseases. Some examples and reasons for emergence include but are not limited to:
Social Factors-Child Care Facilities
Infectious diseases are the leading cause of pediatric visits. Children in child care facilities are 2-3 times more at risk of infectious diseases compared to children cared for at home. It is predicted that by the year 2000, 75 percent of mothers with children under 6 will work outside the home. Incidences of some child care associated infections (otitis media, giardia) have been rapidly increasing as well as related incidences of antimicrobial resistance. In spite of these trends, CDC does not have the resources to support routine surveillance of pediatric practices.
Ecological changes such as the development and deforestation of former woodlands, farms, and fields into housing developments and shopping centers have led to the emergence of new infectious diseases previously unknown to cause disease in humans. Humans, because of their recent accessability due to parts of rural America becoming suburban, have become the "new" hosts for many tick borne diseases. Although Lyme disease accounts for the majority of known tick borne diseases, the CDC has recently detected the emergence of a new tick borne disease, Ehrlichiosis, which can cause life threatening illness and sometimes death if not treated properly and quickly.
Chronic Diseases and Infectious Diseases
Many chronic diseases, and diseases once thought to be noninfectious, have been proven to be of infectious origin. The most well known example is peptic ulcer disease which was accepted for years by the medical community as a chronic condition which required constant medication. It has now been associated with helicobacter pylori, a bacterium found in the stomach and is treated much more effectively by a course of antibiotics.
Most recently, the CDC has identified a fungus that thrives in waterlogged basements and may account for a percentage of infant deaths that had been previously attributed to sudden infant death syndrome (SIDS). CDC scientists have shown a link between exposure to this fungus, Stachybotrus atra, and to the death of six infants in the Cleveland area, and the hospitalization of twenty four other infants. This fungus had been previously known to cause severe gastrointestinal bleeding in livestock in Europe but had not been suggested as affecting human beings in this country. SIDS is listed as the cause of 6,000 infant deaths a year and is the leading cause of death in babies 1 month and older. CDC is now conducting a retrospective investigation of 172 infants who were considered SIDS babies to determine the prevalence of this fungus.
Hepatitis C is now considered the leading cause of chronic liver disease and the leading indicator for liver transplant. There are an estimated 8,000-10,000 number of persons who die as a result of chronic liver disease, and approximately 35,000 new infections occur each year. There are now an estimated 3.9 million chronically infected Americans. The consequences of Hepatitis C infection often occur years after infection. The medical, economic and social impacts of 3.9 million individuals infected with Hepatitis C are only s lowly being realized. The numbers of Americans who will eventually get chronic liver disease and require treatment, including liver transplants, may overwhelm the health care system in the next century.
Another example of the increasing numbers of chronic diseases which are now, in many cases, considered infectious in origin, is infertility and certain cancers which occur years after the initial onset of infection. The leading cause of infertility in this country is chlamydia infection. This is just one of the twenty-five or more infectious organisms (STD's) that are transmitted through sexual activity. In many women, chlamydia causes pelvic inflammatory disease which is one of the major causes of infertility in this country.
Sexually transmitted pathogens also cause certain types of cancer. For example, the human papilloma virus (HPV) has been shown to cause nearly 80 percent of invasive cervical cancer cases. Women with HPV infection of the cervix are 10 times more likely to develop invasive cervical cancer than are women without such an infection. In addition, it has been demonstrated that the Hepatitis B virus causes many cases of liver cancer.
New, resistant strains of bacteria continue to threaten the effectiveness of antibiotics. Antibiotics are the second most commonly prescribed category of drugs in the U.S. Children under the age of 15 are being prescribed antibiotics 3 times more than adults. Although, antibiotic resistance is not yet measured on a national scale due to a lack of resources and the absence of a national surveillance system, select studies strongly indicate a rapidly growing problem with resistant strains of bacteria. Treatment costs are escalating, and run into the billions, due to ineffective therapeutic treatments, and longer hospital stays which are required to fight resistant organisms.
As the CDC continues to expand its surveillance, investigational and research activities, it will gain knowledge of the growing toll of infectious diseases. However, once this knowledge is gained, the CDC will utilize this information to design effective prevention and control strategies to help prevent and eliminate the spread of infectious diseases.
CDC Infectious Diseases Program:
Surveillance is the primary public health tool used to combat the outbreak of infectious diseases. Without adequate surveillance, disease outbreaks flourish without abatement, causing unnecessary illness and death and contributing to the spiraling health care costs in this country. Surveillance involves people monitoring the incidences of disease, figuring out how to stop the spread of infectious diseases, and replicating proven strategies throughout the nation's communities. Prevention of infectious diseases is a national responsibility due to transmission of microorganisms across local, state, and international borders. The CDC conducts infectious disease surveillance working in cooperation with state and local health departments and private health care providers.
The Administration's request for an additional $15 million to continue implementation of the CDC plan to address new and reemerging infectious diseases is essential. The CDC emerging infectious disease plan is focused on four goals: strengthening the surveillance of and response to emerging infectious diseases; implementing an applied research extramural program to address important research questions related to emerging diseases (including research to develop new or improved diagnostic tests); developing and implementing prevention and health communication activities and strengthening the infrastructure of CDC and state/local health departments, including laboratories, to address new and reemerging diseases.
With increased resources , the CDC will be able to expand its Emerging Infections Programs (EIP) from seven states to eight in FY98. The EIP states are conducting "early warning" surveillance activities and investigations to monitor more accurately and respond to infectious disease outbreaks, illnesses and death. These surveillance sites are the backbone of the national surveillance system for new and reemerging pathogens. At these sites, applied epidemiological and laboratory research are conducted to help identify known microbial agents responsible for infectious diseases and also discover new pathogens which have emerged to create a new niche for microbial proliferation in humans.
The proposed new funds for new and reemerging infectious diseases will also allow CDC to expand its Epidemiology and Laboratory Capacity (ELC) program which provides states with financial and technical support towards modernizing the public health laboratory's facilities and abilities to combat new and reemerging pathogens. To prevent the public health infrastructure and laboratories from further deterioration, these additional resources will provide specific states with upgraded information systems, enhanced laboratory technology, and trained staff to strengthen the capacity for public health surveillance and disease outbreak response. A portion of these resources will also be devoted to implementing health communication strategies for the general public to prevent the spread of new and reemerging infectious diseases and developing and implementing educational programs to improve antimicrobial drug use practices among health care providers and consumers.
There are more than 250 foodborne diseases which have been diagnosed and recognized. Many different bacteria (such as Campylobacter, Salmonella and Escherichia coli O157:H7) viruses, and parasites (such as Giardia) cause foodborne disease and microbiological contamination. Estimates for incidences of foodborne disease vary widely from 6 million to more than 33 million cases per year due to incomplete data and sporadic surveillance. Impacts of foodborne illnesses range from mild to severe cramps and diarrhea which can cause a range of mild to severe illness, paralysis and sometimes death.
As part of the Presidential Food Safety Initiative, CDC is a partner with the United States Department of Agriculture and the Food and Drug Administration to combat infectious foodborne hazards. Collaboratively, these agencies have established FoodNet, the foodborne disease component of the CDC Emerging Infections Program. FoodNet provides a network for responding to new and emerging foodborne disease of national importance, monitoring the burden of foodborne diseases, and defining the source of specific foodborne diseases so that proper action and prevention measures can be taken. The major components of FoodNet are active laboratory based surveillance, surveying clinical laboratories and physicians for cases of foodborne illnesses, surveying the population and conducting case-control studies using patient samples including antibiotic resistance testing. FoodNet was established in 1995 at five sites in Minnesota, Oregon, Georgia, California and Maryland. 14.7 million people or 6% of the U.S. population are 'covered' by this foodborne disease surveillance system. The ASM supports the additional $10 million the Administration has requested to expand the FoodNet program to 8 states which will lead to a more effective early warning system which will detect outbreaks earlier and should lead to the prevention of illness and death from foodborne pathogens.
The CDC is the primary federal agency responsible for guarding the public's health, including, among other activities, safeguarding the food and water supply and investigating outbreaks of potentially life threatening infectious diseases. The CDC has developed a strategic plan to address emerging infectious diseases and was able to begin implementation of this plan three years ago. The strategic plan, "Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States," emphasizes surveillance and targeted research and prevention activities to maintain a strong defense against infectious diseases that threaten the public's health. The ASM supports the Administration's FY 98 CDC budget request which includes a total of $112 million for infectious diseases. The additional $25 million proposed for FY 1998 ($15 million for infectious disease, $10 million for foodborne diseases) would allow the CDC to continue implementation of the emerging disease plan by expanding the five networked domestic surveillance sites to seven sites. These sites are linked electronically and allow for a more rapid dissemination of information and increased ability to detect pathogens and antimicrobial resistance. These funds would also increase the number of states receiving additional critical and technical resources to investigate infectious disease outbreaks.
The ASM would like to thank you for your continued support for CDC funding and recognition of its unique role in combating infectious diseases. There have been a proliferation and increase in the numbers and types of infectious diseases being identified and diagnosed both here in the United States and abroad. Infectious diseases remain the single most prevalent cause of death worldwide, and are the third ranked cause of mortality of Americans of all ages. The extraordinary resilience of infectious microbes which have a remarkable ability to evolve, adapt, and develop resistance to drugs requires the nation's attention and resources to prevent unnecessary human suffering.