January 13, 2006 - PSAB Submits Comments on CDC Draft Health Protection Research Guide

Jamila R. Rashid, Ph.D., M.P.H.
Senior Health Scientist
Centers for Disease Control and Prevention
Office of Public Health Research
1600 Clifton Road, NE
Mail Stop D-72
Atlanta, GA 30333

Dear Dr. Rashid:

The American Society for Microbiology (ASM) appreciates the opportunity to comment on the Centers for Disease Control and Prevention’s (CDC) draft Health Protection Research Guide, which was announced in the Federal Register on November 18, 2005. Members of ASM’s Public and Scientific Affairs Board (PSAB) reviewed the Research Guide and the following is a summary of our comments and recommendations on the CDC Research Agenda:

Prevent and Control Infectious Diseases
Emerging and Re-Emerging Infectious Diseases (page 29)

  • Research on infectious disease prevention and control would benefit from a targeted focus on how and when diagnostics are currently used, strategies to increase effective use of diagnostics in clinical practice, and how the use of diagnostics affects the quality and completeness of notifiable disease surveillance. Similarly, research on the use of pathologic examination to determine how to improve the contribution of pathology to surveillance and clinical practice should be included.

The Research Agenda discusses the emergence and re-emergence of infectious diseases (i.e. including HIV, West Nile Virus, Mad Cow disease, SARS, and community-associated MRSA), but does not go into detail about research gaps and opportunities related to these diseases. There should be a focus on the growth of the HIV epidemic in certain areas of the United States, and the need for prevention in the United States. Social and economic issues related to HIV acquisition in the United States should be addressed. Globally, how does the provision of HIV treatment affect the rates of other communicable diseases (e.g., tuberculosis) and community well-being? What is the effect of HIV treatment on birth rates in HIV-infected women? What are the factors that result in increased or decreased transmission in different areas of the world following treatment? Is counseling and testing of persons an effective use of resources; should HIV diagnostics be incorporated into routine health care both in the United States and globally?

A large number of individuals are in the local and federal justice systems, both inside and outside prisons and jails. We need research on how the justice system affects the spread of infectious diseases (e.g. HIV, hepatitis C, MRSA).

Other infectious diseases are mentioned on pages 85-97 in Section VII, Work Together to Build a Health World (i.e. STDs, TB), which may give the appearance to some that these diseases are not problematic in the United States. The Research Agenda should focus on infectious diseases as they affect populations both nationally and globally.

Bioterrorism-related Environmental Microbiology (pages 30-31)

  • Research in bioterrorism-related environmental microbiology is a major undertaking that overlaps with responsibilities given to the Environmental Protection Agency and the Department of Homeland Security (DHS) under Homeland Security Presidential Directive 10. EPA, for example, has the lead for environmental decontamination and DHS is responsible for BioWatch. The plan should ensure coordination and avoidance of unnecessary duplication.
  • Research should be extended to other environmental microbiological issues that are critical to public health (e.g., mold, Legionnaire’s disease, and norovirus).

Emerging Infections (pages 31-32)

  • The Emerging Infections section attempts to cover all areas in a generic fashion, but more specificity could be useful, even if they are mentioned in more detail elsewhere in the agenda. For example, studies of the reservoirs and ecology of etiological agents, and the epidemiology and natural history of disease are not specifically mentioned. These areas seem relevant, given the SARS and Nipah/Hendra episodes of recent years. No mention is made of research on virulence determinants of pathogens and genetic exchange among microorganisms, which could be instrumental in disease emergence.
  • Research on new drugs or treatments is conspicuously absent from this section (except for vaccines) and could be a valuable addition. Although microbial DNA microarrays are instrumental for rapid detection of new etiological agents, research should be done with other techniques that could also be effective.
  • Research in bioterrorism and emerging infections should be considered together instead of separately as outlined in CDC’s Research Guide, which will lead to better and more comprehensive understanding of naturally occurring infectious diseases, such as West Nile Virus, dengue, influenza and multi-drug resistant infections.

Infectious Disease Surveillance and Response (page 35)

  • CDC and NIH have a history of very limited funding for extramural research in the surveillance and epidemiology of infectious diseases (with some notable exceptions such as HIV). This contrasts with other areas of research (e.g. cardiovascular, cancer). One possibility would be for CDC to work with NIH to address this gap through supplementation of the regional centers of excellence (RCEs) to make them more comprehensive as it relates to these issues.
  • We recommend adding the development of strategies for systematic investigation of ill-defined syndromes (e.g. Morgellon’s disease, Gulf War syndrome), to the scope of research.

Vaccines and Immunization
Vaccine Safety (pages 38-39)

  • The need to assess the safety of live veterinary vaccines as a zoonotic risk for human populations should be added to the scope of vaccine safety research.

Behavioral, Social, and Economic Research in Infectious Diseases
Economic Analyses of Infectious Diseases (page 41)

  • The economic analyses of infectious diseases should include an analysis of the social and economic costs due to the fear and chaos that may be produced by contagion. • In calculating burden of disease, the CDC should include the costs of social breakdown associated with infectious diseases.

Special Populations and infectious Diseases
Perinatal and Neonatal Infectious Diseases (page 45)

  • We commend CDC’s attention to the role of infectious diseases in birth defects and disability in children, and in particular, the attention to examining “…the relationship between particular maternal and infant infections…”

Create Safe Places to Live, Work, Learn, and Play
Occupational Safety and Health (pages 76-80)

  • Occupational acquisition of communicable diseases (e.g., influenza, SARS through a laboratory) is an important public health concern, even if a rare occurrence. We recommend that laboratory occupations be included in the scope of research in the chapter on research in occupational diseases on page 78.

Work Together To Build A Healthy World
Disease and Injury Prevention and Control in Global Settings (pages 89-91)

  • While the introduction to this section on page 89 discusses the major causes of morbidity and mortality (both infectious and non-communicable chronic diseases) and provides separate research priorities in these two areas (page 90), it does not mention the association between the two and the need for this to be a global research priority, as mentioned previously under the U.S. research priorities for Infectious Diseases and Chronic Disease Associations on page 43 (“Investigate, define and quantify chronic diseases attributable to infectious agents, particularly those with modifiable, confirmed and still unproven etiologies. Define the epidemiology of infections and chronic diseases in the presence and absence of infection and other cofactors.”).
  • We are pleased that one of the priority areas of research will address infectious diseases that pose the greatest threat to public health. We recommend that additional focus be placed on the global burden of infectious diseases, as similarly specified under research area #2, Global Burden of Non-Communicable Diseases. It is clear from such analyses as those in The Global Burden of Disease (Murray, Lopez) that we have poor data in many countries on infectious disease occurrence (e.g., malaria, bacterial infections). The research should include assurance of diagnostic testing and accuracy of testing for infectious conditions. Research on improvements in diagnosis of disease globally is needed, both to improve public health and clinical care.

Manage and Market Health Information
Public Health Data Statistical and Data Science (page 101)

  • The quality and usefulness of vital statistics and ICD codes for infectious diseases and their prevention and control deserves a research focus.

Cross Cutting Research
Physical Environment and Health (pages 112-113)

  • We recommend a separate section on the cross cutting research topic of veterinary and human health, e.g. the question of animal reservoirs and disease burden in animals as it relates to zoonoses and human heath.

Public Health Systems and Professionals
Workforce and Career Development (page 115)

  • CDC should assure a solid science base among public health professionals (e.g., a sound knowledge of biology, microbiology, and environmental health).

Social Determinants of Health and Health Disparities
Burden of Disease (page 128)

  • We recommend that CDC add the following to the scope of research in this area: ascertain and mitigate the unanticipated adverse effects of public health efforts (i.e. conduct public health impact assessments before recommendations are made e.g., increase in foodborne illness when promoting fruits and vegetable consumption).

Again, we appreciate the opportunity to comment and would be pleased to respond to any questions or requests for additional information.

Sincerely,

Ruth L. Berkelman, Ph.D.
Chair, Public and Scientific Affairs Board

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