The ASM strongly believes that the Centers for Disease Control and Prevention (CDC) must receive sustained and sufficient funding to support its mission as the nation’s principal public health agency. The Administration’s proposed FY 2009 budget for CDC falls 7.5 percent below the FY 2008 level and clearly is inadequate to support CDC’s science based programs which are so critical to preserving public health.
The recently released World Health Organization’s (WHO) report of higher than expected incidences of extensively drug-resistant tuberculosis (XDR-TB), illustrates the consequences of underestimating the global threat from infectious diseases. In the United States, recent recalls of contaminated ground beef, peanut butter and produce, along with other events like the spread of drug-resistant staph infections in medical facilities and communities, also warn us against under funding of CDC programs in infectious disease surveillance and prevention.
The ASM believes that the Administration’s FY 2009 proposed budget for CDC would undermine essential CDC capabilities. We recommend instead that Congress appropriate $7.4 billion for the FY 2009 CDC budget. With annual US healthcare costs projected by federal economists to exceed $4 trillion by 2017, it seems prudent to invest now in preventing diseases, present and future. We need to make increased investments in the CDC to slow or stop disease outbreaks through education, prevention, preparedness and research.
CDC Infectious Disease Programs Safeguard US and Global Public Health
The Administration’s proposed funding cuts for the FY 2009 CDC budget will weaken the Agency’s key infectious disease programs. The $1.87 billion allocated for infectious diseases is a decrease of $30 million, or 5.1 percent below the FY 2008 level. CDC’s diverse programs include research and surveillance activities that must be sustained, long term, not suddenly created in response to some unexpected disease outbreak. CDC initiatives that focus on preparing against emerging infectious diseases or slowing the spread of antimicrobial resistant (AR) pathogens are wisely investing federal resources in cost effective prevention. All these programs rely on adequate Congressional appropriations that recognize infectious disease control as central to the CDC’s overall mission of protecting the public. Unfortunately, the proposed individual program levels for FY 2009 would constrict these CDC activities, which is shortsighted given the ever changing nature of pathogens and patient populations.
Antimicrobial Resistance: Across the CDC, any program related to infectious disease must now consider potential pathogens that have evolved sufficiently to resist traditional drug therapies. Last year’s media reports of highly virulent staph infections among sports teams and international travelers infected with XDR-TB were snapshots of the reality that AR infections are steadily increasing in incidence and severity. A CDC study released in October determined that in the United States during 2005, methicillin-resistant Staphylococcus aureus (MRSA) caused more than 94,000 life threatening infections and nearly 19,000 deaths, the first national baseline of MRSA’s impact on public health. Earlier CDC studies had determined that more than 70 percent of bacterial hospital-acquired infections are resistant to at least one of the antimicrobial drugs most commonly used to treat them. In 2007, the CDC made new treatment recommendations for gonorrhea after finding that rising numbers of cases are resistant to commonly used and previously highly effective antimicrobials. Surveillance data had shown that between 2001 and 2006, fluoroquinolone-resistant cases rose from less than 1 percent of reported infections to over 13 percent. Gonorrhea, the nation’s second most commonly reported infectious disease, causes an estimated 700,000 new infections annually. Additionally, oseltamivir-resistant H1N1 was recognized in Europe and the US this year. Continued emergence of this strain could be a potential threat in the context of pandemic flu preparedness and the stockpiling of Tamiflu.
Another year of shrinking support for the CDC will undercut the nationwide strategy begun in 1999 with creation of the interagency Antimicrobial Resistance Task Force, co-chaired by the CDC. In 2001, the Task Force launched its Public Health Action Plan to Combat Antimicrobial Resistance, outlining an ambitious agenda to improve surveillance, prevention and control, and research and product development. Last fall, ASM commented on the Strategies to Address Antimicrobial Resistance Act (STAAR Act; HR 3697, S. 2313), which encourages greater federal efforts against AR infections, and recommended that the CDC be appointed the lead agency for the Task Force and the Action Plan. The Agency’s infectious disease programs integrate proven CDC expertise that ranges from case reporting networks to research on faster diagnostic tests for field use. Monitoring outbreaks like those caused by MRSA, pathogenic E. coli, or XDR-TB, is optimized through CDC surveillance systems that include the National Healthcare Safety Network. However, as more and more hospitals are required via state mandates to report nosocomial infections including MRSA, they will have to register with the National Healthcare Safety Network database, causing a strain on this network. Additional resources will be necessary to for the database to support this growth.
ASM recommends that Congress appropriate additional resources for CDC antimicrobial resistance programs of $65 million in FY 2009. The Administration’s FY 2009 CDC budget would instead cut allocations for AR activities to $16.5 million, 2.5 percent below last year. This is an unfortunate backward approach to a public health problem that is growing nationally and internationally.
Emerging Infectious Diseases: Funding for emerging infectious diseases (EID) would be cut under the proposed FY 2009 budget which decreases funding to “All Other Infectious Diseases” by $26.6 million, or 20 percent under last year’s appropriation. ASM recommends that at a minimum, funding for this group of diseases should be restored to the FY 2007 or FY 2008 level of $130-132 million, with an adjustment for inflation. Failure to do so could impinge on the CDC’s capacity to quickly respond to EID outbreaks in the United States and abroad. Rapid responses rely upon a well funded infrastructure of special pathogens expertise and laboratories, training programs for state and local laboratory personnel, and domestic or global case reporting computer networks. Weak fiscal support of EID-related programs could slow what has been to date, very rapid CDC reaction, typified by the SARS, West Nile virus and foodborne outbreaks that mobilized CDC resources in recent years.
Unpredictable emerging and re-emerging infectious diseases are a constant in public health and must not be ignored. The viruses causing HIV infection and Ebola fever were once unknown pathogens eventually linked by scientists to newly emergent diseases. Long familiar diseases like dengue fever and cholera are today spreading to new geographic regions or reappearing in areas once thought freed of the diseases. CDC assisted studies reported in 2007 included discovery of a new, potentially deadly bacterial species isolated from a US traveler to Peru and related to trench fever. Researchers using a new molecular typing test developed by CDC reported that a viral strain typically tied to common colds and stomach flu, adenovirus 21, is becoming more virulent and more common in the United States, with half of the patients requiring hospitalization. The agency prepares for the unexpected through its time tested blend of ongoing surveillance, education and training programs, prevention protocols, and basic research on best methods. CDC uses these science based tools in an impressive range of activities that could be curtailed by the Administration’s inopportune budget cuts for FY 2009.
If Congress does not reverse the downturn in CDC funding, another specific budget category to be reduced is the National Center for Zoonotic, Vector-Borne and Enteric Diseases (NCZVED), which addresses a broad range of relatively rare emerging pathogens and diseases like SARS, hantavirus, Ebola, and “mad cow” disease. The program also includes activities on far more prevalent disease like Lyme disease and foodborne diseases such as salmonellosis and E. coli 0157, as well as the growing threat of drug-resistant malaria, the reemergence of yellow fever in South America, and the increasing threat of dengue and dengue hemorrhagic fever throughout much of Asia and the Americas. The CDC 2009 request includes $60.6 million for NCZVED, a decrease of $7.2 million below FY 2008, despite the continual call for CDC expertise in special pathogens and food safety. For example, CDC recently confirmed test results from the national lab in Uganda that identified a new virus subtype causing an outbreak of Ebola fever. CDC also responded last year to outbreaks of Marburg hemorrhagic fever in Uganda and Rift Valley fever in Kenya, where it led efforts to establish a Rift Valley fever veterinary diagnostic laboratory. The agency also updated traveler advisories based on rising reports of mosquito-borne dengue fever in Latin America and the Caribbean. Disease patterns in this category can be altered by diverse elements like farming practices, human or vector migration, and climate patterns. Public health responses undoubtedly benefit from CDC’s skillful collaboration among scientific disciplines and across national borders.
Additionally, Federal investment in the WNV program over the years has created a strong infrastructure assisting states in the prevention, detection and response to WNV and other vector-borne diseases. Since FY 2007, however, program funding has dwindled causing concern that the infrastructure will not be able to support the core capacity of activities, including lab capacity and national, state and local expertise in all vector-borne diseases. Appropriate support for this program in FY 2009 and beyond is critical as WNV becomes more endemic in this country.
Finally, as foodborne disease outbreaks continue to rise, CDC needs additional resources to support databases such as PulseNet and FoodNet. Last year’s investigation of over 700 cases of Salmonella infection in 48 states which were linked to contaminated peanut butter, is an example of CDC’s real time surveillance and control efforts. Large multiple state investigations, however, are a strain on CDC’s limited databases. Additional resources will help to improve and enhance these data collection networks.
HIV/AIDS, Viral Hepatitis, STDs and TB Prevention: The CDC budget category covering HIV/AIDS, hepatitis, sexually transmitted diseases (STDs), and tuberculosis characterizes the breadth of CDC responsibilities in protecting public health. Unfortunately, funding on these programs would stagnate under the FY 2009 budget, losing $2 million, or 0.2 percent of its FY 2008 level. The recent report of hepatitis C infections traced by public health officials to outpatient procedures at a Las Vegas clinic is a timely reminder that the various types of viral hepatitis, which kill more than 5,000 Americans annually, are not a minor health problem. New infections with sexually transmitted pathogens are rising in the United States. In 2006, more than 1 million cases of chlamydia broke the unenviable US record for annual reports of a sexually transmitted disease, but officials believe that actual case numbers are closer to 2.8 million. CDC surveillance networks also reveal that cases of syphilis and gonorrhea are increasing, complicated by drug resistant forms.
At the end of 2007, there were about 33.2 million persons worldwide living with HIV infection, including over 1 million in the United States. Co-infection with TB is becoming more prevalent (an estimated one third of persons living with HIV), and TB is the cause of death in up to half of AIDS cases. The concurrent spread of drug resistant forms of tuberculosis, especially in areas hard hit by HIV/AIDS, deeply worries public health experts. CDC should work towards assuring necessary laboratory support for tuberculosis diagnosis and sensitivity testing in areas where antiretroviral therapy and anti-tuberculosis therapy are being distributed in HIV endemic areas that are co-endemic with TB. Without such laboratory support, we are at risk of contributing to the MDR and XDR-TB epidemic through the use of ineffective drugs. Any advances made in diagnosis and controlling tuberculosis and HIV/AIDS must be preserved with sufficient federal funding. The Administration’s proposed CDC FY 2009 budget does correctly recognize the opportunity offered by estimates that up to 25 percent of US cases are unaware of their infection, providing increased funds to expand domestic HIV testing and early diagnosis in high risk US locations and populations.
ASM Asks Congress to Reverse Erosion of CDC Funding
ASM recommends that Congress approve $7.4 billion for CDC funding in FY 2009. This request to significantly increase the CDC budget acknowledges the major contributions made by the agency to disease prevention in the United States and elsewhere. Whether focusing on influenza, bioterrorism, quarantine stations, or other priorities, ongoing CDC programs bring together agency and other scientists, along with health care officials and governments, to find science based solutions to complex situations. The CDC surveillance networks and field research teams can detect and help contain disease outbreaks anywhere in the world. The strength of CDC’s many infectious disease programs lies in steady sources of talented personnel and sufficient funding. Eroding federal support with flat or declining appropriations is not the best advised approach to preserving the nation’s public health.