Good morning. I am Dr. David Satcher, Assistant Secretary for Health and
U.S. Surgeon General at the U.S. Department of Health and Human Services. I am
pleased to be here this morning to discuss an important issue -- "Global
Health: U.S. Response to Infectious Diseases." I want to thank you, Mr.
Chairman, for calling this hearing today.
Emerging infectious diseases are a continuing threat to the health of U.S.
citizens and of people around the world. They cause suffering and death,
and impose an enormous financial burden on society. The recent outbreak of
a new and virulent strain of influenza in Hong Kong raised the specter of a
pandemic and illustrated the potential danger posed by these diseases to
all countries. This incident also illustrated, yet again, the need for the
United States to work closely with other countries and the World Health
Organization to assure that there is adequate global capacity to detect and
address such outbreaks.
Background
Over the past century, tremendous strides have been made in medicine and
science to combat infectious diseases. The development and widespread use
of antibiotics and vaccines, coupled with earlier improvements in urban
sanitation and water quality, have dramatically lowered death and
disability from infectious diseases and have led to a near doubling of life
expectancy in this country. Progress had been so great that three decades
ago some experts predicted we would soon see the end of infectious
diseases.
However, our optimism, though understandable, was premature. Today, we see
a global resurgence of infectious diseases, including the identification of
new infectious agents, the re emergence of old infectious agents, such as
tuberculosis (TB) and the rapid spread of antimicrobial resistance. Between
1980 and 1992, the death rate in the United States from infectious
diseases, excluding HIV/AIDS, rose by 22 percent. Worldwide, infectious and
parasitic diseases remain the leading cause of death. These deaths
disproportionately affect the developing countries of the world, with the
most vulnerable segment of the population being children under the age of
five years. Moreover, the factors that contribute to the resurgence of
these diseases -- including increasing global travel, the globalization of
the food supply, population growth and urbanization, ecological and
climatic changes, and the evolution of drug- resistant microbes -- show no
sign of abatement.
The CISET Emerging Infectious Disease (EID) Report
In 1995, I had the honor of chairing a workgroup on emerging diseases for a
committee of the National Science and Technology Council (NSTC), which was
charged with conducting a government-wide review of our ability to protect
our citizens from emerging infectious diseases. The NSTC Committee -- the
Committee on International Science, Engineering and Technology (CISET) --
was staffed by the Department of State. The issue of emerging infectious
diseases was regarded as urgent by many U.S. agencies, 17 of which sent
representatives to the first CISET EID meeting, with 23 agencies ultimately
participating.
In September, 1995, the Committee issued a report that concluded existing
mechanisms for surveillance, response to, and prevention of outbreaks of
new and reemerging infectious diseases were inadequate, both at home and
abroad. The report made specific recommendations that became the basis of a
1996 Presidential Decision Directive (PDD) that established a new national
policy. The Directive called for a coordinated U.S. government response to
address the growing health and national security threats posed by
infectious diseases The new policy acknowledged that domestic and
international health are intimately linked, that microbes do not respect
borders, and that the United States cannot protect the health of its
citizens without playing a leadership role in international health. Copies
of the CISET EID report and the President's policy have been provided to
the Subcommittee.
The Task Force
The PDD calls for the establishment of an Emerging Infectious Disease Task
Force, which I co- chair with Dr. Kerri-Ann Jones, Associate Director for
National Security and International Affairs of the White House Office of
Science and Technology Policy. The President charged the EID Task Force
with implementing the PDD. The lead agencies on the Task Force include
three agencies from the U.S. Department of Health and Human Services: the
Centers for Disease Control and Prevention (CDC), the Food and Drug
Administration (FDA) and the National Institutes of Health (NIH); as well
as the U.S. Agency for International Development (USAID) and the Department
of Defense (DOD). The U.S. Department of Agriculture (USDA) has played an
increasingly important role. The National Oceanic and Atmospheric
Administration (NOAA) of the Department of Commerce, the National
Aeronautics and Space Administration (NASA), and the Department of Veterans
Affairs are also active participants. The Office of Science and Technology
Policy and the Department of State have provided guidance on international
policy, particularly our efforts to strengthen relationships with other
countries, including India, Japan, Mexico, Pakistan, South Africa, Vietnam,
and the European Union, to name just a few.
From the beginning, the basic principles of the EID Task Force and the
working group on emerging diseases have been collaboration and
coordination. We know that the challenge ahead outstrips the means
available to any one agency, organization, or country. However, if we pool
our talents and resources, a great deal may be accomplished. This is well
illustrated by the great success of smallpox eradication and the ongoing
polio and guinea worm eradication programs. Globally, polio cases have
decreased by more than 90% since 1988; and, $230 million will be saved by
the United States annually, when the goal of polio eradication is achieved.
An estimated $1.5 billion will be saved globally.
These principles of collaboration and coordination are being applied both
at home -- where U.S. agencies have coordinated the effort to address
emerging infectious diseases among themselves as well as at the state and
local level -- and overseas, where U.S. agencies are working with the World
Health Organization (WHO) and other international partners to improve
global health communications, set standards for global surveillance of
antimicrobial resistance, and share experience and training on disease
prevention and control on a regional basis.
Progress/Implementation
I am pleased to say that much progress has been made. A detailed account of
what has been achieved can be found in the first annual report of the EID
Task Force, copies of which have been provided to the Subcommittee. I will
mention a few highlights in four key areas emphasized by the PDD to give
you a sense of what has been accomplished. They are:
- Strengthening the global surveillance and response system to keep
local outbreaks from growing into pandemics
- Supporting research and training to detect, treat, prevent, and
control disease outbreaks.
- Working with the private sector to ensure that drugs, vaccines, and
diagnostic tests are available during infectious disease emergencies.
- Making the issue of emerging infectious diseases a priority with our
international partners.
Surveillance and Response
In the area of disease surveillance and response, the President's policy
calls for action both at the domestic and international levels. CDC has led
the effort to revitalize the component of the U.S. public health
infrastructure that protects the public from infectious disease, working
closely with state and local health departments, community-based
organizations, universities, professional organizations, and other U.S.
agencies. CDC will discuss its ongoing efforts to improve the detection and
containment of emerging diseases entering the United States. As evidenced
by several recent multi-state outbreaks of diseases transmitted through
contaminated food (including strawberries, raspberries, lettuce, apple
juice, alfalfa sprouts, and ground beef), food-borne diseases are a special
domestic concern. Three agencies -- CDC, FDA, and USDA-- established the
Active Foodborne Disease Surveillance Network (FoodNet) through CDC's
Emerging Infections Program sites in 1996.
The goals of FoodNet are to:
- Describe the epidemiology of new and emerging bacterial, parasitic,
and viral food-borne pathogens.
- Estimate the frequency and severity of food-borne diseases that occur
in the United States each year.
- Determine how much food-borne illness results from eating specific
foods, such as meat, poultry, and eggs.
The public health challenges of food-borne diseases are changing rapidly.
Changes in food production have led to new safety concerns. Many foods,
previously thought to be safe, such as eggs and fruit juice, have both
transmitted Salmonella in recent outbreaks. Other food-borne diseases
included infections caused by Shigella, Campylobacter, Escherichia coli
O157, Listeria, Yersinia, and Vibrio bacteria.
Internationally, U.S. government agencies have intensified their efforts to
respond to outbreaks of highly contagious, highly lethal, or drug-resistant
diseases, especially when they occur in countries that lack the resources
and infrastructure to contain them. USAID, CDC, and other agencies are also
supporting the efforts of the WHO to improve communications networks and
build regional centers for surveillance of and response to infectious
diseases. The WHO is sponsoring the development of sub-regional teams, or
"hubs," for disease surveillance and outbreak control -- an idea that is in
full accord with the goals of the EID Task Force.
The DOD has contributed to the international surveillance and response
effort by expanding the mandate of its overseas laboratories to include
epidemiological training and laboratory capacity related to diagnosis of
infectious disease outbreaks. These DOD facilities work closely with
experts in the countries where they are located, thereby helping to build
local capacity.
Research and Training
A major Task Force goal is to promote research on tropical diseases by
combining the scientific and clinical experience of doctors and scientists
in less-developed countries with the scientific resources of industrialized
countries. The NIH is the lead agency in this area.
Over the past year, the National Institute of Allergy and Infectious
Diseases (NIAID) at NIH has substantially expanded its research efforts on
emerging diseases and the Fogarty International Center (FIC) at NIH, in
close cooperation with NIAID, has launched a $1.9 million program to
provide infectious disease training for scientists in developing countries.
NIH has also launched a Multilateral Initiative on Malaria that includes
participation by other agencies of HHS, French and English research
institutes (the Pasteur; INSERM, France's counterpart to NIH; ORSTOM, part
of France's overseas development effort; and the British Medical Research
Council), the Wellcome Trust, and the European Commission. As part of this
initiative, the NIH has committed more than $1 million for a WHO program to
strengthen malaria research in Africa.
On Sunday, March 8, the American Society for Microbiology (ASM), CDC, and
NIH are convening a workshop, "Training in Emerging and Re-Emerging
Infectious Diseases." This and other workshops related to emerging
infectious diseases globally will be convened prior to and after the
International Conference on Emerging Infectious Diseases to be held March
8-11, 1998, in Atlanta. This international conference is being organized by
CDC, the Council of State and Territorial Epidemiologists, ASM, and the CDC
Foundation, and has more than sixty cosponsors. There will be participation
by many of our partner countries as well as WHO, PAHO, the World Bank, and
USAID.
I would like to mention two other relatively new areas of infectious
disease research that may be of interest to this Committee. One is the use
of remote sensing technologies and global positioning systems to examine
links between weather changes (such as those due to El Nino) and the
incidence of infectious diseases carried by insects and animals. The hope
is that this avenue of research will lead to the development of methods for
predicting outbreaks of such diseases as malaria and dengue fever. CDC,
NIH, NOAA, and NASA are collaborators in these efforts. The other area is
research on infectious agents that may cause or exacerbate chronic
conditions like ulcers, heart disease, or some types of cancer.
Engaging the Private Sector
FDA has taken the lead in creating partnerships with the private sector. In
collaboration with WHO and private sector partners, the EID Task Force is
preparing an international procedures manual for obtaining medical products
during emergencies. FDA and its partners are also consulting with
representatives of the U.S. pharmaceutical industry on how to promote the
development of new drugs, vaccines, and diagnostic tests. In addition, FDA
has engaged the regulatory bodies and pharmaceutical industries of Japan
and the European Union (EU) in an effort to promote international
harmonization of standards for medical products.
Private sector partnerships have been crucial in responding to particular
outbreaks and emergencies over the past year. For example, CDC and FDA
collaborated with drug manufacturers to address the shortage of vaccines
for use in controlling a meningitis outbreak in Sub-Saharan Africa during
the 1996-97 winter season. During the avian flu crisis in Hong Kong last
fall, CDC, FDA, and NIH worked with the pharmaceutical industry to begin
the development of novel vaccines that could be used to prevent disease due
to this strain.
In addition, Rotary International is a private sector partnership that has
been instrumental in achieving the outstanding progress in the global polio
eradication effort. By the year 2005, Rotary International will have
contributed more than $400 million to polio eradication. But Rotary
International does more than just contribute money. In December 1996, I
personally witnessed in India how active the Rotary can be in obtaining
legislative support and mobilizing participation of over 150,000 Rotarians.
Over 120 million children in India were immunized during their national
1996 polio immunization day.
Making Emerging Infections a Priority with Other Nations
Addressing the threat of emerging infectious diseases depends on
international cooperation. Our confidence that nations can come together to
improve global health has been reinforced by the success of smallpox
eradication program as well as current efforts to eradicate polio and
guinea worm. These were and are truly global efforts. The U.S. agencies are
working with partners on every continent to develop a shared sense of
responsibility and mutual confidence in the global effort to combat
infectious diseases.
Some of these efforts are conducted through our development assistance
program. Over the past year, USAID has continued its effort to strengthen
basic public health infrastructures in developing countries and to develop
in-country capacity to combat infectious diseases. For Fiscal Year 1998,
Congress has allocated an additional 50 million dollars in developmental
assistance to further this aim. USAID plans to focus on four new areas,
which will be integrated into its on- going health programs. They are:
antimicrobial resistance, tuberculosis, malaria, and the improvement of
global disease surveillance and response.
U.S. agencies are also engaging other nations in the effort to combat
infectious diseases. Many governments view emerging infections as an
economic issue as well as a public health issue, because healthy people are
more productive and more able to contribute to their country's economy.
Moreover, outbreaks can impede economic development by interfering with
tourism and trade. Since 1995, emerging infectious diseases has become an
agenda item at several bilateral and multilateral meetings.
For example, in 1997, at the Denver Summit, the Group of Eight
industrialized nations, including the United States, pledged to help
develop a global disease surveillance network, coordinate international
response to outbreaks of infectious disease, and help build capacity to
prevent, detect, and control emerging infectious diseases. In addition,
some members of the Asian-Pacific Economic Cooperation (including Thailand,
Indonesia, Philippines) have developed an emerging infectious disease
communications network that tracks cases of multi-drug resistant
tuberculosis. Bilateral talks that cover emerging infectious diseases have
also been held with India, Japan, South Africa, the Russian Confederation,
and the European Union.
Working through the Trans-Atlantic Agenda with the European Union, U.S.
agencies and EU member countries have begun to share surveillance data on
Salmonella infections, a major cause of food poisoning. This is an
especially important project, in view of the globalization of the food
supply, the increasing recognition of multinational disease outbreaks, and
the disturbing occurrence of Salmonella infections that are resistant to
many drugs. The long-term aim of the US-EU project is to expand the
Salmonella network to cover other food-borne diseases and include other
developed countries, outside Europe and North America.
Under the US-South Africa Binational Commission, U.S. agencies are working
with the South African Department of Health to train personnel in
surveillance and applied epidemiology. The Mandela government is committed
to extending the South African public health infrastructure to include the
entire country.
Through the US-Japan Common Agenda and the U.S.-Japan Cooperative Medical
Science Program, United States and Japanese scientists have held three
international conferences on infectious disease research and science
policy. As the first follow-up action to the July 1996 meeting in Tokyo of
the Common Agenda ERIDS Working Group, a team from CDC and FDA was invited
to Tokyo to participate in an investigation of outbreak of E. coli O157:H7.
Japan has sent one of its scientists to CDC for long-term training in
epidemiologic investigations. The level of engagement between the U.S. and
Japan on infectious diseases and related issues is substantial and growing.
In addition, under the auspices of the U.S.-Japan Common Agenda ERIDS
Working Group, NIAID is working with Japan to develop an action plan to
address the public health problem posed by E. coli O157:H7. A meeting of
NIH, CDC and Japanese scientists was held in Baltimore in 1997 to discuss
research advances and opportunities to learn more about this shiga-like
toxin that causes the lethal hemolytic-uremic syndrome seen in outbreaks of
food- borne diseases.
USAID, CDC, and FDA are also providing assistance to the Russian Federation
and the Newly Independent States. In some of these States, there has been a
significant breakdown in public health services since the fall of the
Soviet Union. Resurgences of vaccine-preventable diseases (such as
diphtheria, polio, and whooping cough) have been reported. For example,
while I was visiting with the Russian Minister of Health in 1995, he
received a report of 33 new cases of polio in Chechnya, during the height
of the political instability. The EID Task Force is working under the
umbrella of the US-Russia Commission on Economic and Technological
Cooperation to strengthen epidemiological capacity in Russia, improve
vaccine quality control and to help prevent the further spread of
tuberculosis, STDs, and HIV/AIDS, which are now at epidemic levels. The
US-Russia will hold its next meeting in Washington, D.C. next week--March
10 and 11. At that time, we expect to agree on next steps on at number of
fronts.
A Demonstration Project
I'd like to leave you with a special illustration that demonstrates what
can be accomplished when international partners pool their resources and
expertise.
In the Sub-Saharan countries of Burkina Faso, Cameroon, Chad, Mali, Niger,
and Nigeria, seasonal outbreaks of meningitis occur every 2 to 4 years,
causing high morbidity and mortality in older children and young adults. In
1996, there were about 154,000 cases of meningitis and 20,000 deaths in the
largest meningitis epidemic yet recorded. To prevent a predicted recurrence
in 1997, the EID Task Force encouraged WHO and other partners to help
prepare local public health workers for the next meningitis season. The
CDC-based WHO Collaborating Center for Control of Epidemic Meningitis
provided the technical lead.
The project involved five U.S. government agencies (CDC, FDA, NIH, USAID,
DOD); several non-governmental organizations (Medecins Sans Frontieres,
CARE, Epicentre, and the Fondation Merieux); three WHO offices; and three
vaccine manufacturers. In addition, two other WHO Collaborating
Laboratories -- in Oslo and Marseilles � supplied diagnostic reagents and
provided training in laboratory diagnostics in the affected countries.
Major funds were provided to WHO by the British Overseas Development Agency
and the Government of Japan.
The meningitis project was initiated in summer 1996. The number of cases in
the "meningitis belt" countries was reduced from approximately 154,000
since the winter of 1995-96 to 60,000 in the winter of 1996-97. We must
interpret this result with some caution, as some of the dramatic decline
may be attributable to natural variation in disease patterns, as well as to
improved detection and control. Nevertheless, the project strengthened
human and technical resources in the affected countries, and forged
on-going links among many international partners.
Conclusions
I am proud of the interagency work that has moved this policy and
accomplished so much in such a short time. I believe that the U.S. position
of leadership should be fostered, for the sake of our people and for the
sake of the global community. Promoting the international effort to combat
emerging diseases is a natural role for the United States, and one that
benefits people everywhere. The EID Task Force has proved to be an
excellent vehicle for getting this effort underway.
We must not stop now. The challenges ahead demand our continued attention.
Our goal is to ensure that we are able to protect ourselves and the global
community from emerging pathogens, whenever and wherever they may arise.
Thank you for the opportunity to testify before the Subcommittee. I will be
happy to answer any questions you may have.
