The American Society for Microbiology (ASM), the largest single life science society in the world with over 42,000 members, appreciates the opportunity to provide recommendations for the FY 2008 budget for the Centers for Disease Control and Prevention (CDC). The ASM remains concerned by the persistence of infectious diseases worldwide, and the real possibility of even greater problems in the future. We can expect that previously unknown infectious diseases, as well as old infectious diseases with new virulence, will imperil human health. Worldwide, more than 15 million deaths are due to infectious diseases. Infectious diseases respect no borders and make no distinctions among people, especially in a time of unprecedented global travel and commerce. Newly emerging and reemerging infectious diseases are appearing at the same time that microbial resistance to standard therapeutics is on the increase. This lethal combination of events presents enormous challenges for public health and science agencies, whose resources are already strained.
Being prepared and building the capacity to prevent and respond to infectious diseases is critical for the United States and for its lead public health agency, the CDC. The magnitude of the problem of infectious diseases mandates that additional resources be provided for CDC, which plays a pivotal position in the battle to protect public health and safety. Even during this time of competing budget priorities and fiscal constraints, we strongly recommend that the CDC budget be increased to a level that is more commensurate with its responsibilities to address pressing public health issues that threaten world populations and US national security.
Despite the burden of disease responsibilities confronting the CDC, the proposed FY 2008 budget for CDC is a decrease of 5 percent below the FY 2007 enacted level of funding. We urge Congress to support a budget of $10.7 billion for the CDC in FY 2008. This level of funding will provide needed resources for the CDC to be in a stronger position to address pressing infectious disease problems and other critical health issues facing the nation.
The ASM has reviewed the FY 2008 budget proposed for the CDC and would like to comment on the following issues and programs of concern to the Society:
Newly Emerging and Reemerging Infectious Diseases, Special Pathogens, Extreme Drug Resistant TB, and Zoonotic and Vector-Borne Diseases
Over the past 25 years, CDC has confronted legions of infectious diseases, such as HIV/AIDS, Ebola hemorrhagic fever, Lyme disease, toxic shock syndrome, legionnaires disease, hantavirus pulmonary syndrome, West Nile fever, SARS, and others. Funding for infectious diseases is critical to public health and safety; yet funding has not kept pace with the demands these diseases place on the nation.
Special Pathogens Laboratory Capacity: The increase of $5.2 million for Special Pathogens laboratory capacity only serves to partially correct years of neglect in investment for this critical national resource. A comparison of the special pathogens budget to those of other high containment laboratories now under construction clearly demonstrates that this important CDC program is severely underfunded.
Extreme Drug Resistant TB: Recognized pathogens are also taking on new forms, raising new concerns and challenges. Of particular concern are the “extensively drug-resistant” strains of Mycobacterium tuberculosis (XDR-TB). Previously recognized multidrug-resistant tuberculosis (MDR-TB) was already of great concern worldwide, identified in growing proportions of the 9 million active TB cases and 2 million deaths reported each year. Now XDR-TB, which is resistant to at least two first line TB drugs and to three or more of the six classes of second line drugs, has been identified by the CDC as the cause of “virtually untreatable” tuberculosis cases in the United States and abroad.
Last March, the CDC warned health officials of an impending crisis predicted by its survey of TB diagnostic laboratories worldwide, which found 20 percent of TB isolates were multidrug-resistant (MDR-TB) and 2 percent were XDR-TB. Over the 2000-2004 survey period, XDR-TB isolates increased from 5 percent of total drug-resistant TB isolates to 6.5 percent. In industrialized nations (including the US), XDR-TB had climbed to 11 percent of resistant strains by 2004. A follow up survey just published by CDC scientists and their collaborators found the proportion of XDR-TB still rising, confirming the worldwide emergence of a deadly new version of an ancient disease.
The Administration has proposed no funding increases for TB programs in FY 2008 and funding for TB has been flat funded since FY 2006. The ASM urges Congress to pay attention to this emerging health threat and provide necessary funding increases in this critical area.
Zoonotic and Vector-Borne Diseases: According to the CDC, 75 percent of emerging and reemerging infectious diseases, including SARS, hantavirus pulmonary syndrome, Nipah virus encephalitis, influenza, and West Nile fever, are zoonotic, i.e., they are transmitted between animals and humans. Because of the nature of these diseases, it is difficult to predict when and where they will occur. Vector-borne diseases such as Lyme disease and malaria are difficult to control because of their unique vectors of transmission, e.g., ticks and mosquitoes. Basic and applied research combined with interaction among professionals representing multiple disciplines, is key to understanding, preventing and controlling both zoonotic and vector-borne diseases. For example, West Nile Virus training programs provided to academic centers have had a substantial impact on building human resources in medical entomology and allied public health expertise. Opportunities for training in medical entomology are severely limited in the United States and it is essential to maintain the training opportunities that have emerged through the support of this program. ASM is concerned that zoonotic and vector-borne diseases are flat funded in CDC’s FY 2008 budget. Furthermore, ASM is concerned that funding for West Nile virus has been decreased by $17 million. Other countries routinely call upon CDC for its expertise in zoonotic and vector-borne diseases. Additional resources dedicated to these emerging and reemerging disease areas are critically needed.
Up to 30 percent of Streptococcus pneumoniae isolates in some areas of the United States are no longer susceptible to penicillin, and multidrug-resistant strains responsible for recalcitrant respiratory and ear infections are increasingly common. A growing problem for hospitals and nursing homes is also emerging. In 1972, only 2 percent of Staphylococcus aureus isolates were drug resistant, but by 2004, 63 percent were resistant to the drugs commonly used to treat staph infections. In October 2006, the CDC issued new guidelines and strategies to prevent or slow the further spread of drug resistant pathogens in healthcare facilities. In FY 2008, CDC plans to further expand surveillance and education systems, which not only track novel or drug-resistant pathogens, but also detect common health problems like the recently reported disease outbreaks caused by bacteria contaminated foods.
The proposed FY 2008 budget identifies antimicrobial resistance as a priority need. However, the budget requests only $17.5 million for antimicrobial resistance activities, only a slight increase over FY 2006. The ASM strongly recommends that funds for antimicrobial resistance be increased to $25 million.
Seasonal and Pandemic Influenza
The Administration’s FY 2008 budget appropriately prioritizes pandemic influenza with an increase of $158 million to further enhance response readiness in the United States and limit outbreaks worldwide. In the United States, seasonal influenza causes about 36,000 deaths and 200,000 hospitalizations annually, clearly a significant public health issue. But it is the potential of pandemic influenza to rapidly kill millions of human victims that pushes much of CDC’s current laboratory research, surveillance, and prevention strategies related to influenza. The agency is focusing on the avian influenza H5N1 virus that has killed millions of birds worldwide, infected a small number of humans, and, most importantly, has potential to genetically acquire human-to-human-transfer capabilities.
In 2006, the CDC refined and expanded its domestic and global avian influenza strategies, while deploying investigative teams to many countries with H5N1 outbreaks and sharing scientific advances and financial resources with a growing number of international partners. CDC scientists have been studying changes in viral composition that affect H5N1 transmissibility or its susceptibility to antiviral treatments. In 2006, CDC developed a new method to reshuffle viral genes, to study lab-designed hybrid H5N1 viruses and their spread among lab animals. Other CDC research, just released in February, shows that a modest genetic change lab-engineered in the infamous 1918 influenza virus can stop the virus’s facile transmission among lab animals, though does not eliminate its ability to cause disease. Last December, the CDC awarded $11.4 million in new contracts to four private companies to develop rapid-diagnostic tests for H5N1 and other emerging influenza viruses, aiming toward point-of-care differential diagnosis within 30 minutes, a notable advance over existing tests.
Increases in funding to address the threat of pandemic influenza is well justified; however, there is relatively little emphasis on increasing capacity at the state and local level, which is the first link to effective national surveillance. ASM supports planned CDC activities related to pandemic influenza. We also recommend additional funding to states and academic centers that could be used to pilot enhanced influenza surveillance and collection and characterization of strains in circulation at the state level, coupled with expanded local response to outbreaks of seasonal influenza. As pandemic influenza planning continues to evolve, the states and academic centers should be encouraged to explore the practical aspects of how pharmaceutical and non-pharmaceutical interventions will be implemented. It will be important to sustain a robust CDC institutional capacity, but the investments must also extend beyond the walls of CDC if they are to truly influence national preparedness.
Once a newly emerging disease, HIV/AIDS is now endemic in many nations, including the United States where more than one million people are living with HIV infection. One in four of those infected is unaware of his or her infection, delaying needed medical treatments, risking transmission, and exacerbating overall healthcare issues. About $63 million of the proposed $93 million increase in CDC’s HIV/AIDS funding will support intensified HIV testing in the ten US jurisdictions with greatest rates for new infections, as well as among incarcerated persons and drug users. The CDC estimates that more than two million Americans will be tested and over 31,000 new infections will be diagnosed, therefore decreasing events of transmission to uninfected persons and saving an estimated $1.5 billion in annualized medical care and low productivity costs. The CDC also continues its international HIV/AIDS contributions through its Global AIDS Program (GAP). Through its role as principal partner in the President’s Emergency Plan for AIDS Relief (PEPFAR), CDC/GAP has supplied highly trained health professionals to provide technical assistance, expertise and support for programs in 29 countries. For example, laboratory scientists are assisting with laboratory capacity building, and epidemiologists and public health advisors are helping with surveillance, monitoring and evaluation. Furthermore, GAP is well positioned to work with other CDC global health programs focused on the prevention, detection and control of other infectious diseases such as malaria and tuberculosis.
Since 2001, CDC bioterrorism efforts have built effective bioagent surveillance networks, expanded high level containment laboratory facilities, and strengthened state and local rapid response capabilities. Specific CDC programs marked for increased FY 2008 funding include the Strategic National Stockpile, which delivers medical supplies to any point in the United States within 12 hours. In FY 2008, CDC proposes to update the Stockpile with additional supplies as a result of an evaluation of Hurricane Katrina responses. CDC also expects to target FY 2008 dollars at raising the number of quarantine stations at US international ports of entry to 25, up from 20.
By the end of 2006, the CDC had increased the number of laboratories in its Laboratory Response Network (LRN) to 152, up from 91 in 2001. Now located in all 50 states and several locations abroad, the LRN labs can confirm the presence of pathogens that cause diseases like anthrax, plague, and SARS. To share CDC expertise beyond elite laboratories, the CDC also has trained to date more than 8,800 clinical laboratory personnel in detecting, diagnosing, and reporting public health emergencies. Past investments in CDC programs to counter potential bioterrorism have benefited our nation’s disease surveillance networks in general.
CDC needs to sustain strong state and local public health capabilities, including resources for epidemiology and surveillance. While it is important to evaluate past investments in bioterrorism preparedness, there needs to be a strong commitment to supporting state and local capacity, coupled with appropriate investments in the academic sector that contributes to these programs and is the source of novel approaches and techniques. ASM is extremely concerned about CDC’s proposed FY 2008 decreases state and local capacity at a time when state and local health departments are increasingly asked to take on more responsibility.
Furthermore, the BioSense program could benefit from a comprehensive external review and evaluation. The public health community and the general public need to be assured that this is the best investment to be made during this era of scarce resources.
Preventing disease saves human lives and economic resources. In 2006, US spending on health care reached $2.1 trillion, and it is expected to double ($4.1 trillion) over the next decade, to account for nearly $1 out of every $5 spent in the United States. For every dollar spent on the standard childhood series of seven vaccines, the nation saves an estimated $16.50 in direct and indirect costs. Public health promotion of childhood vaccines has resulted in annual savings in the United States of an estimated $43.3 billion. Vaccination campaigns have led to the elimination in 2005 of rubella in the United States and to the dramatic 60 percent decrease in measles worldwide since 1999 (between 2000 and 2005 more than 360 million children were vaccinated for measles). Global polio incidence declined from about 350,000 cases in 1988 to 1,791 reported cases in 2006. In 2006, CDC scientists helped develop new laboratory procedures to confirm polio infection in half the usual time required, ensuring more rapid outbreak response and vaccinations where needed.
In 2006, the agency’s Advisory Committee on Immunization Practices evaluated and recommended three new vaccines against three viruses: human papillomavirus (HPV) in girls 11-12 years old, herpes zoster in people age 60 or older, and rotavirus in infants. HPV is the most common sexually transmitted infection in the United States, with 6.2 million new infections each year. It also is the cause of most cases of cervical cancers, which annually kill 3,700 American women. Herpes zoster infection can lead to shingles, a painful condition that afflicts about 25 percent of Americans during their lifetime (about one million cases/year). The new vaccine reduces clinical episodes by about 50 percent and, if an episode does occur, minimizes the amount of pain post-episode. Rotavirus is the leading cause of severe gastroenteritis in infants and children worldwide, causing more than 500,000 deaths each year. In the United States, it is responsible for more than 400,000 doctor visits and costs our economy an estimated $1.2 billion annually in direct and indirect expenses. These three newly recommended vaccines alone are certain to return substantial economic dividends, clearly derived from earlier investments in research and public health.
In summary, the ASM asks the Congress to recognize CDC’s critical role in protecting people in this country and millions in other nations who benefit from CDC expertise and support. The President’s FY 2008 budget request for CDC falls below what is necessary to sustain a strong scientific base and the capacity to react to newly emerging and reemerging infectious diseases. The ASM concurs with the CDC Coalition that the CDC should be funded at $10.7 billion in FY 2008.