The ASM supports the proposed FY 2012 budget of $11.3 billion for the Centers for Disease Control and Prevention (CDC), a 3.4 percent increase over the FY 2010 funding level. The budget recognizes the importance of maintaining a strong infrastructure to address infectious disease prevention and control. The CDC’s role, in partnership with state and local health departments and international partners, is to monitor for known and emerging infectious disease threats through surveillance and laboratory diagnosis, and to develop control and prevention strategies for these diseases. Examples include vaccine preventable diseases, foodborne diseases, pandemic influenza, vectorborne and zoonotic diseases, healthcare acquired infections (HAIs) and antimicrobial resistance. The proposed FY 2012 budget addresses these threats and provides targeted resources for them
The FY 2012 proposed budget includes an increase in funding for HIV/AIDS, sexually transmitted diseases (STD), tuberculosis (TB), and hepatitis, and gives the states added flexibility to shift funding among these programs based on local priorities. The ASM supports this approach. The ASM also supports the $68 million increase in funding for emerging and zoonotic diseases, including $40 million in funding from the Prevention and Public Health Fund to enhance epidemiology and laboratory capacity in state health departments.
However, caution must be taken regarding any reductions in effort for “low impact, disease specific programs” as proposed in the FY 2012 budget. Experience indicates that an emerging public health threat can occur with almost any pathogen, and capacity must be sustained with this possibility in mind. Examples of such complacency include the reemergence of drug resistant tuberculosis in the 1990s and West Nile virus in 1999. The proposed elimination of prion activities at CDC could have such an impact, as these diseases are related to human variant Creutzfeld Jakob Disease (vCJD) and to chronic wasting disease, which is an emerging animal health problem in several areas of the United States.
The ASM supports investments to address healthcare associated infections. CDC provided resources through the American Recovery and Reinvestment Act (ARRA) to develop programs for surveillance and prevention of HAIs, which have resulted in substantial HAI reductions in these infections with significant cost savings to the healthcare system. These investments must be sustained after ARRA funding ends, and the proposed $47 million for HAIs would accomplish this goal.
The ASM supports the $8.7 million increase in funding for food safety. The CDC recently released new estimates of foodborne diseases, concluding that 1 in 6 people in the United States get sick each year (about 48 million people). The delayed recognition of the widespread outbreaks of salmonellosis associated with eggs during 2010 demonstrates the need to sustain and enhance vigilance for foodborne outbreaks. In that outbreak, over 1,900 confirmed illnesses were reported (likely a small percentage of actual cases) and 500 million eggs were recalled. CDC’s surveillance systems will also play a pivotal role in assessing the success of programs developed as a result of the recently passed Food Safety Modernization Act.
The ASM is concerned about the following proposed reductions in the FY 2012 CDC budget:
- There is a substantial decline in preparedness funding, including a $72 million cut in funds for state and local preparedness grants. Such declines will have a significant impact on the ability of frontline public health workers to be able to respond to all hazard emergencies at a time of restrained budgets at the state and local level. The ASM recommends such grants be maintained at FY 2010 funding levels.
- The proposed elimination of funding for the CDC genomics program should be restored. Public health genomics is an area of growing importance, including the ability to identify risk factors for enhanced susceptibility or resistance to infectious diseases. Such genetic factors have important implications for disease prevention and treatment, and must be tied to epidemiologic investigations and disease surveillance efforts.
- The ASM does not endorse the elimination of targeted funding for CDC’s antimicrobial resistance (AR) activities and the transfer of these funds into the overall budget for emerging infections. While ASM appreciates the need for funding flexibility, antimicrobial resistance is a substantial public health problem that leads to significant morbidity and death and markedly increases healthcare costs. To address this threat, sustained dedicated funding is necessary.
CDC Infectious Disease Programs Protect Public Health
Infectious diseases cause about one fourth of all deaths globally, more than 11 million people, over half of them children. In the United States, influenza and pneumonia account for more than 56,000 deaths each year. Of the 1.1 million people living in the United States living with HIV/AIDS, about 21 percent do not know that they are HIV positive; there are more than 56,000 new HIV infections annually. Last year, the CDC responded to multiple disease outbreaks and incidents that included surveillance of cholera in post earthquake Haiti and activation of CDC’s Emergency Operations Center as part of the federal response to the Gulf oil spill.
In the United States, the economic and societal costs of infectious diseases are significant, exacerbated by previously unknown microbial pathogens, rising drug resistance among pathogens and increasing travel and commerce between geographic areas. The CDC Office of Infectious Diseases leads US efforts to stop or minimize the onslaught of infectious diseases, with highly qualified personnel at three national centers that specialize in (1) Emerging and Zoonotic Infectious Diseases; (2) HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; or (3) Immunization and Respiratory Diseases.
The ASM endorses the proposed FY 2012 budget for key programs at CDC, including the following:
Emerging Infectious Diseases/Antimicrobial Resistance. CDC is a world leader in detecting and preventing emerging and reemerging infectious diseases, a role which depends on strong science capabilities and readiness to confront the unexpected. CDC’s infrastructure and partnerships have dealt quickly with the more than three dozen new human pathogens of medical significance identified in the past 30 years. Recent CDC advances include developing one of the first candidate vaccines against all four species of dengue virus, now in human trials, and a plan to screen US blood donations for West Nile virus. FY 2012 funding will support planned EID activities like the development and deployment of improved diagnostic tests for plague, dengue and chikungunya. About 75 percent of recently emerging human infectious diseases originated in animals, making zoonotic diseases another high priority at CDC, along with vectorborne diseases spread by mosquitoes, ticks, fleas and other vectors. Two reports last year illustrate the critical nature of CDC’s EID activities: In Florida, an estimated 5 percent of Key West’s population showed recent exposure to the dengue fever virus; and the new antimicrobial resistance gene called New Delhi metallo β lactamase (NDM-1), first detected in 2008, is spreading to additional countries.
Increased FY 2012 funding will support CDC efforts against the alarming (and rising) number of pathogens now resistant to antimicrobial drugs. As part of the US Interagency Task Force on Antimicrobial Resistance, CDC distributes both intramural and extramural AR funding for surveillance, prevention, and research activities. Agency surveillance networks routinely collect data on cases of resistant pathogens. CDC provides epidemiology and laboratory support for outbreaks of AR organisms, and distributes educational materials to promote appropriate use of antimicrobials. Investments in AR programs are cost effective; one study estimated that the additional medical cost per US patient infected with an AR pathogen ranges from about $19,000 to nearly $30,000. Another estimate concluded that preventing a single case of multi drug resistant (MDR) tuberculosis can save up to $700,000. In FY 2010, CDC diagnosed and treated about 1,000 cases of tuberculosis (including 40 MDR) among overseas immigrant applicants and US bound refugees, saving states an estimated $45 million.
HIV/AIDS. Scientific advances announced last year have added new tools to CDC’s numerous HIV prevention activities; using a vaginal microbicide or daily doses of an oral antiretroviral drug (PrEP) both lowered risk of infection in clinical trials. In July 2010, the Administration released its National HIV/AIDS Strategy for the United States (NHAS). Proposed FY 2012 budget increases would invest substantially in the NHAS five year goals to reduce new infections: (1) lower the annual number of new infections by 25 percent, from 56,300 to 42,225; (2) reduce the HIV transmission rate by 30 percent, from 5 persons infected per 100 people with HIV to 3.5 persons infected; and (3) increase from 79 to 90 the percentage of people living with HIV who know their serostatus.
Viral Hepatitis. Proposed FY 2012 increases for viral hepatitis prevention would boost CDC surveillance in ten high burden state and local health departments. Prevention of viral hepatitis has been successful in recent years, in large part due to vaccines against hepatitis A and B viruses. HAV incidence has decreased approximately 92 percent nationwide since 1995; rates of HBV have been reduced far below the original Healthy People 2010 goal of 4.5 cases per 100,000. In the first half of FY 2010, CDC funded health departments administered over 130,000 doses of HBV vaccine to at risk adults and ensured that 87 percent of infants born to HBsAg+ women were vaccinated. Incidence of hepatitis C infections has dropped from more than 45,000 cases annually to an estimated 20,000, primarily as a result of screening the US blood supply and falling case numbers among intravenous drug users. However, 2.7–3.9 million Americans have HCV, most unaware of their infection. The FY 2012 budget would address last year’s Institute of Medicine report, which concluded that public health programs have insufficient hepatitis related resources and that efforts to prevent and control viral hepatitis are not adequate.
Sexually Transmitted Diseases. FY 2012 increases would strengthen CDC’s STD infrastructure, which supports 65 state and local prevention programs, and sustain the CDC’s surveillance of drug resistant STD pathogens like that causing gonorrhea. Reducing STD infections is highly cost effective; for example, CDC estimates that reductions in gonorrhea and syphilis from 1990 to 2003 saved the US economy $5 billion. Cost savings with chlamydia screening in sexually active young women are an estimated $2,500–$37,000 per year. Aggressive public health efforts to prevent STDs have had positive results; for instance, from 1999 to 2009, rates of primary and secondary syphilis among females declined by 30 percent, while congenital syphilis dropped 32 percent. Yet, in general, STDs in the United States persist at unacceptable levels: CDC estimates that there are approximately 19 million new STD infections each year, which cost the U.S. healthcare system $16.4 billion annually (2009 figures).
CDC Campaigns Prevent Disease in the United States, Worldwide
Healthcare Associated Infections. In the United States, 1 in 20 hospital patients get an infection during medical treatment. Of the nearly 2 million infections acquired in some type of healthcare setting annually, almost 100,000 are fatal. A 2009 CDC report estimates that each year US hospitals spend between $28 billion and $35.7 billion to treat often preventable HAIs. Depending on the effectiveness of infection control interventions used, the CDC expects that prevention measures could save from $5.7 billion–$31.5 billion of these costs. To illustrate, intensive care units have reduced bloodstream infections in patients with central lines by 58 percent since 2001, using CDC recommended infection control procedures and saving up to 27,000 lives and $1.8 billion. The proposed FY12 budget would significantly increase support for the CDC’s HAI activities and its National Health Care Safety Network (NHSN) that had provided monitoring capacity to more than 3,900 health facilities by the end of 2010. With the increased funding, routine NHSN participation will expand from 2,500 to 6,500 healthcare settings (5,500 hospitals; the rest include hemodialysis and long term care facilities). In March this year, the CDC awarded $10 million for HAI research at five academic medical centers, as part of its Prevention Epicenter program.
Immunization. The Administration’s FY 2012 CDC budget invests substantial resources into vaccine preventable diseases, continuing national immunization campaigns against diseases like seasonal and pandemic influenza. The number of lives saved and medical costs reduced can be considerable. According to the CDC, “for every birth cohort who receives seven [routine childhood] vaccines…society saves $9.9 billion in direct medical costs; over 33,500 lives are saved; and 14 million cases of disease are prevented.” Other examples of returns on CDC investment include vaccination against Haemophilus influenzae type b (Hib), responsible for a 99 percent decline in this leading cause of bacterial meningitis in children under age 5, for an estimated medical cost savings of $950 million per year plus another $1.14 billion of retained earnings by unpaid caregivers. In the past year, CDC reported that three years of rotavirus vaccinations had reduced severe rotavirus disease by 85 percent, and helped develop the guidelines for deploying the new pneumococcal vaccine expected to greatly reduce pneumonia and ear infections among children. In December, CDC launched its Vaccine Tracking System to follow vaccine orders from manufacturer to distributor to health providers.
Global Health. Lower respiratory tract infections, diarrheal diseases, HIV/AIDS, TB and malaria together account for nearly one fifth of deaths globally. CDC is a lead partner in the Administration’s Global Health Initiative, underscoring the importance of infectious diseases no matter where outbreaks occur. The FY 2012 budget includes increase of funds for global polio eradication, an international campaign begun in 1988 that is nearing victory with only four countries still harboring endemic disease. Last year, there were about 900 cases reported, declining from more than 350,000 in 1988. FY 2012 funds will purchase 254 million doses of oral polio vaccine for use in mass immunization campaigns in Southeast Asia, Africa and Europe, to achieve CDC’s target of zero polio endemic countries by the end of 2012. Funding will support the CDC vaccination campaign toward a 90 percent reduction in global measles related mortality; by 2008, CDC and its partners had helped reduce measles deaths by 78 percent, from an estimated 733,000 in 2000 to about 164,000.
Quarantine and migration related activities also are part of the agency’s multi level strategies in global health; CDC operates 20 US quarantine stations and responds to outbreaks in refugee camps overseas. Travel and trade allow pathogens to move quickly. The 2009 “swine flu” spread to 30 countries within six weeks. About 1.8 million airline passengers cross international borders daily, and about half of international travelers worldwide have some kind of health problem while traveling. An estimated 50,000 - 70,000 refugees and 1.2 million immigrants resettle in the United States each year, while more than two million people travel to or through this country by air, sea, or land daily.