March 9, 1998 - Global Infectious Diseases

Senator William H. Frist
Subcommittee on Public Health and Safety
Senate Labor and Human Resources Committee
Senate Dirksen Office Building
Room 422
Washington, DC 20510

Dear Chairman Frist:

The American Society for Microbiology (ASM) would like to commend you and the members of the Subcommittee for your leadership in addressing issues related to new, emerging and drug resistant infectious diseases and their impact on global health. The ASM would like to submit the following statement for the hearing record on global infectious diseases. The ASM is the largest single life science society in the world with a membership of over 42,000 individuals working in research, public, clinical and industrial laboratories. The ASM would like to emphasize the critical role the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) play in the fight against infectious diseases in the United States and in the world.

The United States continues to be faced with new, reemerging and drug resistant infections. The world's leading cause of death are infectious diseases, which account for over seventeen million deaths annually. Approximately 9 million of these deaths are among children. In the United States, the death rate from infectious diseases, excluding AIDS, rose 22 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 25 percent of all physician office visits.

Few public health concerns today carry as great a sense of urgency and importance as infectious diseases. Each day headlines in the national news describe new diseases that are rapidly arising worldwide and "old" diseases that are reemerging as infectious agents evolve or spread and as changes occur in ecology, socioeconomic conditions and population patterns. Humans through rapid world travel and unprecedented trade have become a major vector of infectious diseases, transporting disease from one country to another, often in less than 24 hours. Infectious diseases can be spread from human and animal sources but also from "bioterrorism," the intentional release of pathogens to harm human health or the animal and plants on which humans depend. The threats posed by infectious diseases to the security and well being of the world community are now apparent, and the United States is no exception.

It has become clear in recent years that many chronic diseases and cancers have infectious origins, including: ulcers (Helicobacter pylori), cervical cancer (human papilloma virus (HPV), and liver cancer, (the hepatitis C and hepatitis B viruses). According to the World Health Report up to 84 percent of some cancers worldwide are attributable to viruses, parasites or bacteria. Peptic ulcer disease 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. 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 to 10,000 individuals 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 slowly 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. 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. More research into the links between chronic and infectious diseases is an opportunity to potentially reduce health care costs by treatment with antibiotics and other drugs and perhaps by prevention through immunization.

The ASM is concerned with the growing world-wide problem of antimicrobial resistance. Serious infections are becoming increasingly resistant to antibiotics and treatment of patients is often difficult and sometimes impossible. Antibiotics that we took for granted are now failing to control common diseases such as bacterial pneumonia. Recent reports indicate that in some parts of the country as many as 40 percent of the strains of pneumococci are resistant to penicillin and other antibiotics. In addition, 90 percent of the strains of Staphylococcus aureus, one of the most common disease producing organisms in humans, are resistant to penicillin and other related antibiotics. The incidence of vancomycin resistant strains of Enterococcus, one of the most common causes of infections in hospital patients, has increased 20 fold since 1989. Strains of Staphylococcus aureus resistant to vancomycin, the most powerful drug in our antimicrobial arsenal, have already been identified and isolated in patients. New, resistant strains of bacteria will continue to threaten the effectiveness of antibiotics. Antimicrobials 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. The ASM is also concerned that antimicrobial resistance is not measured on a national scale due to a lack of resources. Costs to treat infectious diseases are escalating, and run into the billions, due to ineffective therapeutic treatments, and longer hospital stays which are required to fight resistant organisms.

The ASM would like to emphasize the global problem of food and water safety. 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 water-borne parasites (such as Giardia) cause food and water borne 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, NIH, CDC, the United States Department of Agriculture and the Food and Drug Administration are working collaboratively to combat infectious foodborne hazards. These agencies have established FoodNet, 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. 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 resources that have been requested to expand the FoodNet program 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. Increasingly, the U.S. relies on imported food for domestic consumption. Increased attention must be paid to international food production and distribution.

The problems of AIDS, tuberculosis, malaria and sexually transmitted diseases continue to be major public health concerns. Since AIDS was first recognized in the early 1980s, worldwide there have been over 29 million adult and child HIV infections, and approximately 1.5 million adult and child deaths in 1996, including 39,000 people in the United States. There are over 8 million new cases of active TB each year in the world and an annual death rate of approximately 2-3 million. Recent data indicate that over 10 percent of people with tuberculosis are infected with stains of Mycobacterium tuberculosis resistant to at least one of the four first-line anti-TB drugs. Malaria continues to be a global public health problem and has emerged in the United States from returning international travelers. The recent outbreak of "bird flu" in Hong Kong has focussed new attention on the threat of influenza which presents the most imminent viral threat to public health. Strengthening and maintaining a first-rate surveillance system is the first line of defense against these "old" and new diseases. Influenza reemerges worldwide each year in a new form and causes between 10,000 and 40,000 deaths yearly in the United States alone.

The ASM strongly supports continued and increased collaboration and coordination between the agencies of the public health service who have the primary responsibility of protecting the nation against infectious diseases. Congress should continue strong support for NIH sponsored research into the causes and treatments necessary to combat new and emerging infectious diseases. Strengthening the global surveillance capabilities of the CDC to keep local outbreaks from growing is also of critical importance and deserves Congressional attention and support.

As a direct result of the Congressional commitment to biomedical research, new technical advances are occurring in the biological sciences and the opportunities for translation of recent discoveries in molecular biology to the diagnosis and treatment of human diseases have never been greater. For example, new technologies have led to methods for sequencing the genomes of disease-causing microbes, revealing information that can be used to find targets for therapies, identifying antigens to incorporate into vaccines, detecting mutations that cause drug resistance and determining the factors that influence the antigenicity or virulence of a microbe. Emerging technological innovations, such as DNA chip technology and microarrays, promise further advances in science and medicine.

The ASM, however, concurs with many Congressional leaders that the United States is not spending enough on scientific research and prevention. It is essential that the United States pursue a plan and a strategy to achieve a higher level of national coordination in research and prevention activities to capitalize fully on scientific achievements and opportunities and to respond to a growing array of public health concerns. The future health, quality of life, economy and security of Americans and the world depends on a high level of national investment in research and prevention. Increased attention and investment in research and prevention will help lead to faster development of more effective surveillance, screening programs, vaccines, and better drugs and treatments to combat emerging and drug resistant infections.

The emergence of new or altered pathogens is unpredictable, occurring as the result of microbial evolution, changes in host-parasite interactions, human demographics and behavior and other mechanisms. Basic research and discovery are urgently needed and investments in a strong public health infrastructure must be made. Infectious disease research and prevention encourage new research opportunities, such as sequencing the genomes of medically important bacteria, determining the host factors and mechanisms involved in infections with the hepatitis B and C viruses, research on antimicrobial resistance and defining the potential role of infectious agents in chronic diseases, such as cancer. Continued implementation of the CDC emerging infectious disease plan is encouraged. 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 is essential. 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.

Investment in prevention and research reduces human suffering and has proven to be cost effective. For example, the vaccine for Haemophilus influenzae type b (Hib) introduced just a few years ago has virtually eliminated one form of childhood meningitis, the leading cause of acquired mental retardation and a major cause of deafness in children, and resulted in savings estimated at more than $400 million a year. Prior to the development of the vaccine, Hib infected one of every 250 infants; 5 percent of patients died and 30 percent suffered permanent central nervous system injury. Every dollar spent on the vaccine against measles, mumps and rubella saves $21 and every dollar spent on the vaccine against diphtheria, tetanus and pertussis saves $29.

As we approach the crossroads of the new century, it is essential that the nation invest wisely in research and prevention to maintain US scientific and technological leadership and to address the health, environmental and technological problems of the next century.

We appreciate the opportunity to submit written testimony for the record and would be pleased to submit additional information and to assist the Subcommittee as it addresses issues related to emerging infectious diseases.