Detailed Information on the
CDC: Infectious Diseases Assessment

The program will enhance budget and performance integration to identify changes in program outcomes associated with resource levels.

The program will track performance on the new long-term and annual performance measures

Over the next few years, the program will continue to identify areas to improve efficiency and cost effectiveness and document savings to demonstrate its improvement.

Make grantee performance data available to the public in a more transparent and meaningful way.

Measure: Meet targets for key foodborne pathogens, central line-associated bloodstream infections in ICU patients, invasive pneumococcal disease in children <5/adults >=65, and new cases of hepatitis A.

Explanation:The measure is a summary of multiple indicators of progress in reducing the burden of illness from infectious diseases. The target for foodborne pathogens is to reduce by 50% from a 1997 baseline, the target for bloodstream infections is to reduce by 10% from a 2003 baseline, the target for pneummococcal disease is 46 per 100,000 for children under age 5 and 46 per 100,000 for adults 65 and older from a 1997 baseline of 76 and 62, the target for hepatitis A is 2.25 per 100,000 from a 1997 baseline of 11.3. The program has made considerable progress in all four areas since 2000, with a few exceptions in certain years.

Measure: Achieve reductions in the burden of illnesses or death attributed to infectious diseases, as measured by meeting 3 of 4 targets for key foodborne pathogens, the rate of central line-associated bloodstream infections in medical/surgical ICU patients, the rate of invasive pneumococcal disease in children under 5 years of age and in adults aged 65 years and older and the number of new cases of hepatitis A.

Explanation:a) Reduce the incidence of infection with four key foodborne pathogens. Baseline (1997): Cases per 100,000. Campylobacter species, 24.6; Escherichia coli 0157:H7, 2.1; Listeria monocytogenes, 0.5; Salmonella species, 13.7. Annual Targets: Cases per 100,000 in 2005, 2006, 2007. Campylobacter species: 17.03, 16.10, 15.14; Escherichia coli 0157:H7: 1.42, 1.30, 1.25; Listeria monocytogenes: 0.35, 0.33, 0.31; Salmonella species: 9.45, 8.90, 8.39. b) Bloodstream infections. Baseline (2003): 3.7 infections per 1,000 days use. Annual Targets for 2005, 2006, 2007. 3.62, 3.58, 3.54. c) Pneumococcal disease in children under 5 years of age and in adults aged 65 years and older. Baseline (1997): Children under 5 years of age 76 per 100,000; Adults aged 65 years and older 62 per 100,000 Annual Targets for 2005, 2006, 2007. Children under 5 years of age: 50, 48, 46; Adults aged 65 years and older: 55, 47, 42. d) New cases of hepatitis A. Baseline (1997): 11.3 new cases of hepatitis A per 100,000 population. Annual Targets for 2005, 2006, 2007. 2.6, 2.6, 2.5.

Measure: The number of antibiotics prescribed for ear infections in children under 5 years of age per 100 children.

Explanation:A concerning increase in strains not covered by the currently licensed pneumococcal conjugate vaccine has been detected, and one strain shows high levels of antimicrobial resistance which will present new challenges. Antimicrobial resistance was previously represented by three performance measures but now is covered by this one measure of prescriptions for otitis media in young children. Although the measure was reworded the targets were not reset significantly. As the program sets forth goals for the next decade through the Healthy People 2020 process, the performance measure for reducing antibiotic resistance will be revisited to ensure that it is appropriately representative of the full scope of efforts to reduce antimicrobial resistance and targets are appropriately ambitious.

Measure: The percentage of Laboratory Response Network labs with cumulative proficiency testing scores of 90% or better

Explanation:The purpose of proficiency testing is to determine if LRN laboratories are continuously able to accurately identify the biological agents that may appear in naturally-occurring outbreaks or that may be used as agents of bioterrorism by using the instruments and protocols employed by the LRN. The cumulative score for a year is calculated by averaging the scores from each quarterly testing from each test site and then at the end of the year, calculating a national average from the total number of sites that participate in the program. Because of the difficulty in identifying certain of the select agents and because of logistic issues, the success rate in 2003 was about 75%.

Measure: The number of foodborne isolates identified, fingerprinted, and electronically submitted to CDC's computerized national database networks, with annual level funding.

Explanation:This measure helps capture how well the program is progressing to enhance detection and control of foodborne outbreaks.

Measure: Increase the percentage of Pandemic Influenza Collborative Agreement grantees (SLTTs) that meet the standard for surveillance and laboratory capability criteria (as defined by in Appendix B1 of the annual SLTT Review Plan Assessment).

Explanation:The measure demonstrates integrated State and local improvements in preparedness and response planning for an influenza pandemic by identifying the extent to which pandemic influenza collaborative agreement grantees meet high priority standards in surveillance and laboratory capability. Influenza pandemics pose a sustained threat of serious illness and death that can spread rapidly and simultaneously throughout the United States. CDC is responsible for monitoring and assessing public health components of grantee operation plans that help protect communities and minimize the impact of infection as much as possible. The performance measure will directly assess states and local communities in regard to ongoing improvement of their surveillance and laboratory capability. The Pandemic Influenza Collaborative Agreement has 62 grantees, composed of state, territories, tribal nations, and a few major metropolitan areas. Grantees must submit a report annually on their progress in preparedness and response readiness for influenza pandemics. The reports are the basis for an annual assessment by the U.S. Government. CDC is designated as the HHS OpDiv to a) coordinate the collaborative agreements, and b) coordinate assessment of public health components of the annual assessments that grantees submit. The SLTT Review Plan Assessment provides detail about the process: http://www.pandemicflu.gov/news/guidance031108.pdf. A list of categories covered by the comprehensive assessment is on p. 9 of this document.

Is the program purpose clear?

Explanation: The program purpose of Infectious Diseases at the Centers for Disease Control and Prevention within the Department of Health and Human Services is clear. The purpose of the Infectious Diseases program is to prevent illness, disability and death caused by infectious diseases. The program is active in the United States and also works internationally to protect the US population from infectious diseases initiating in other countries and to provide assistance to other countries. The program's mission and planning documents are consistent with this program purpose.

Evidence: Infectious Diseases activities are primarily the responsibility of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention. The program's activities, including infectious disease control, quarantine and immigration activities, international activities, research and other efforts are authorized in the Public Health Service Act and the Immigration and Nationality Act. Relevant provisions of the PHS Act include sections 301, 307, 310, 311, 317-319, 322, 325, 327, 352, 361-369. Relevant provisions of the Immigration and Nationality Act include sections 212 and 232. The agency's reports, Preventing Emerging Infectious Diseases: A Strategy for the 21st Century, 1998, and Protecting the Nation's Health in an Era of Globalization: CDC's Global Infectious Disease Strategy, 2002, outline the program's purpose and role.

Does the program address a specific and existing problem, interest or need?

Explanation: The program addresses a specific and existing problem of infectious diseases domestically and to some extent globally. Infectious diseases remain a significant problem, and emerging infectious and multiresistant strains pose new challenges. Most emerging infectious disease episodes in recent years have been zoonotic diseases transmitted from animals to humans. For example, West Nile virus was documented in the US in 1999. SARS was first recognized in 2003.

Evidence: The program reports more than 36 newly emerging infectious diseases were identified between 1973 and 2003. Each year over 20 million US travelers use malaria prevention medicines. Globally, malaria causes more than one million deaths and 500 million infections each year. According to the WHO World Health Report, 2003, infectious and parasitic diseases accounted for 19.5% of deaths and respiratory infections accounted for an additional 6.7%. Non-communicable conditions account for 58.6%. A report by the Institute of Medicine, Microbial Threats to Health, 2003, documents other renewed concerns.

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The program shares some responsibilities with other entities at CDC, such as the Epidemiology Program Office, but is unique and not redundant of other Federal, state, local or private efforts. The program's bio-safety level 3 and BSL 4 laboratories serve a unique purpose that is largely distinct from the work of NIH and FDA. The program receives support for specific research projects from multiple federal partners. The program also worked with NIH to avoid overlap with biodefense and emerging infectious disease research. The program fulfills a leadership role in infectious disease outbreaks such as SARS. The program provides technical assistance and cooperative agreement funds to states. The program's Board of Scientific Counselors helps identify potential areas of overlap. The General Accounting Office has documented fragmentation and overlap in food safety activities at the Federal level, but noted it may make sense to keep CDC's foodborne illness surveillance separate from a consolidation (04-832R).

Evidence: The program's BSC includes 21 individuals from academia, industry, private practice, associations and public health agencies, as well as two non-voting members from Canada and Mexico. GAO has noted that the program's testing and services are not available at the state level.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: There is no direct evidence that a different mechanism, such as regulatory action, would be more effective in meeting the program purpose. The program fulfills the purpose through cooperative agreements and grants to states and other partners, contracts, interagency agreements and intramural research and surveillance efforts. The program's staff focus on surveillance, epidemiology and laboratory research, outbreak response and other areas. The program relies on a combination of civil service scientists and members of the commissioned corps.

Evidence: Of the program's 812 scientific staff, 107 are commissioned corps officers, primarily medical officers, and 657 are civil service, primarily microbiologists, biologists, health scientists, epidemiologists and medical officers.

Is the program effectively targeted, so that resources will reach intended beneficiaries and/or otherwise address the program's purpose directly?

Explanation: The program targets state, local and tribal health departments, other federal agencies, professional associations, academia, clinical settings, and international organizations. There is no evidence of unintended subsidies or poor distribution of cooperative agreement and other funds. The program provides guidelines for infectious disease control to help public health entities better target resources.

Evidence: Examples of guidelines include for hand hygiene in health care settings, for control of the West Nile virus and for prevention of streptococcal disease in infants.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The program has adopted a new long-term outcome measure that captures the program's progress in reducing illness from infectious diseases in four major program areas. The program has also developed a second long-term measure of global influenza surveillance and detection that will track the establishment of in-country influenza networks that are actively producing usable samples with broad geographic and population coverage as an indicator of our preparedness for a pandemic influenza outbreak.

Evidence: The first new measure is that by 2010 to achieve reductions in the burden of illnesses or death attributed to infectious diseases, as measured by meeting 3 of 4 targets for key foodborne pathogens, the rate of central line-associated bloodstream infections in medical/surgical ICU patients, the rate of invasive pneumococcal disease in children under 5 years of age and in adults aged 65 years and older and the number of new cases of hepatitis A. The second measure tracks preparedness for pandemic influenza as measured by the number of in-country influenza networks that are actively producing usable samples for testing and meeting percentage targets for geographic coverage and for population coverage.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program has adopted a new long-term outcome measure that captures the program's progress in reducing illness from infectious diseases in four major program areas and has set discrete targets for each sub-area.

Evidence: The target for foodborne pathogens is to reduce by 50% from a 1997 baseline, the target for bloodstream infections is to reduce by 10% from a 2003 baseline, the target for pneummococcal disease is 46 per 100,000 for children under age 5 and 46 per 100,000 for adults 65 and older from a 1997 baseline of 76 and 62, the target for hepatitis A is 2.25 per 100,000 from a 1997 baseline of 11.3. The target for the second measure is 10 in-country networks by 2010 that have at least 75% of geographic coverage and 75% of population coverage by 2010.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The program has adopted new annual performance measures that are a combination of outcomes and outputs. Taken together, the measures capture much of the program's activities and will be useful to indicate progress toward meeting the long-term measures. Some areas excluded from the measures include West Nile disease, Lyme disease, hantavirus, Chronic Fatigue Syndrome, and capacity grants. The program's efficiency measure relates to the productivity of the program's computerized national database networks for foodborne illness at a constant level of funding.

Evidence: The program has adopted new annual performance measures that capture the program's progress on the new long-term outcome measure on an annual basis, measure the progress of the Laboratory Response Network, measure foodborne isolates identified, fingerprinted, and electronically submitted to CDC's computerized national database networks, and measure progress in reducing antibiotic use for ear infections among children.

Does the program have baselines and ambitious targets for its annual measures?

Explanation: The program has adopted new annual performance measures that are a combination of outcomes and outputs and has set discrete targets for each measure.

Evidence: The targets for the outcome measure of illness are multiple and are cited in the measures tab. The target for the LRN is 90% proficiency, the target for isolates is 24,866 in 2006, the target for antibiotics is 60 per 100 children in 2006.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: Program managers take steps to ensure cooperative agreement partners support the overall goals of the program and report on their performance. Partners are required to develop measurable outcomes that align with the program's overall goal to protect Americans from infectious diseases and in one case the goal of reducing the spread of antimicrobial resistance. The program's memoranda of understanding and inter-agency agreements are used to ensure the commitment of partners to the program's objectives. The program's awards include language specifying grant activities will align with the program's performance goals.

Evidence: For example, the announcement for FY 2003 and FY 2004 for the Epidemiology and Laboratory Capacity for Infectious Diseases cooperative agreement outlines the program and partner activities and requires measures of effectiveness that are objective and quantitative and focused on outcomes. The announcement for the applied research on antimicrobial resistance grants requires grantees to adopt measurable outcome measures that align with the program's overall goal to reduce the spread of antimicrobial resistance.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: The program has had regular evaluations or targeted evaluations as needed to fill gaps in performance information, including by multiple reports by GAO. The program has also supported some external evaluations on select issues and has published numerous research findings related to the effectiveness of specific interventions. The program's Board of Scientific Counselors reviews the center's activities and provides guidance and feedback. The program supports external peer reviews by program area to review grants and receive general feedback on program priorities and accomplishments. The program has also contracted with the National Academy of Sciences for a study on microbial threats and has used HHS evaluation funds for targeted reviews, such as of the program's guidelines for prevention of surgical site infections. The program is also contracting with the National Council of State and Territorial Epidemiologists to evaluate the program's Epidemiology and Laboratory Capacity program for West Nile virus surveillance, prevention and control.

Evidence: GAO evaluations include on the agency's response to anthrax (GAO-04-152), data on antimicrobial resistance (GAO-99-132), the program's oversight of select agency programs (GAO-03-315R), bioterrorism preparedness (GAO-01-822/915), the Strategic National Stockpile (GAO-01-463), chronic fatigue syndrome research (GAO-00-98), emerging infectious diseases (GAO-99-26), food safety (GAO-01-973), global health surveillance (GAO-01-722,00-205R), lyme disease (GAO-01-755), SARS (GAO-03-1058T) and West Nile virus (GAO-00-180).

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: While the program has made some progress in this area, it has not yet met the criteria specified for this question to show resource allocation decisions are made in order to accomplish specific targeted performance levels and the effects of funding on results.

Evidence: Evidence includes the GPRA plans and reports and annual Congressional Justifications and budget documents provided to OMB. Additional evidence includes program documents used to establish annual spending plans.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The question that remains a No in this section is on budget and performance integration. The program has not taken meaningful steps to explicitly tie accomplishment of performance goals to the budget and present them in a clear manner that would indicate changes in outcome associated with changes in funding level.

Evidence: Evidence includes agency planning documents, draft performance measures and back-up materials provided for the assessment.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: The program collects performance information from its divisions and program partners and uses the information to change program direction and guidelines. The program's internal programs are peer-reviewed by external experts. Review panels examine program direction, resource allocation and contributions. They make recommendations to the program on changing program direction and making improvements. The program now requires cooperative agreement recipients to report on measures of effectiveness that are to be objective and quantitative and related to the goals of the program. Performance information fro program partners can be used to recommended program changes and in some cases set conditions for approval, but are generally not used to make resource allocation decisions.

Evidence: External review panels are made up of infectious disease experts from state and federal public health entities, academia and private entities. The program has conducted peer reviews on multiple activity areas since 1994. Scheduled peer reviews include special pathogens and infectious diseases pathology. An example of a cooperative agreement is the Epidemiology and Laboratory Capacity for Infectious Diseases, Federal Register, May 5, 2003. Detailed site visit reports provide evidence of the program's use of site visits to determine progress and detect and resolve problems with cooperative agreements.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: Accountability for cost, schedule and specific outputs is established through performance appraisals for program managers, but there is not currently a consistent method of accountability for program results. Senior managers have some elements of accountability built into performance evaluation systems, including for the Commissioned Corps, and employees now incorporate one or more general performance measures from the agency or department level into their workplans. These measures may not be specific or traceable to the employee's position. Cooperative agreement recipients are required to report on program progress.

Evidence: Program partners report on progress toward meeting objectives. Evidence includes site visit reports, state ELC progress reports and financial status reports. The program uses the Integrated Resource Information System to track costs and resources for subordinate offices.

Are funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: The program obligates funds in a timely manner and has spent them on their intended purpose. The HHS Office of Inspector General documented problems the program had in spending funds for chronic fatigue syndrome on the intended purpose. The agency is near repayment of these funds and has instituted multiple changes to help ensure funds are spent for the intended purpose in the future. There were two delinquent A-133 audits for the program in FY 2001, but no disallowed costs.

Evidence: A May 1999 report by the HHS Office of Inspector General found from FY 1995-FY1998 an estimated $8.8 million (39%) of funding charged to chronic fatigue syndrome activities by the program was incurred for non-CFS-related activities and an additional $4.1 million (18%) could not be determined due to insufficient documentation. Since that time, the program has sought and obtained numerous audits of CFC activities. These audits have consistently confirmed the program has spent funds for CFS on their intended purpose.

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The agency has numerous procedures in place to improve the efficiency of program execution. At the program level, the program has abolished nearly 50 administrative sections to streamline the center. The program announced A-76 competitions on commercial activity functions in animal husbandry services and laboratory glassware and associated laundry services in January 2004. The program has also consolidated IT services and reassigned 17 program FTE to an IT office at the agency level. The program recently initiated an internet based system for the Emerging Infectious Diseases journal and doubled submissions, spead publication, and reduced printing costs per copy. The program contracted with McKing consulting in 2003 to review a division's administrative systems and processes and received recommendations to change support procedures in response to workload challenges. The program also supports internet-based training and has converted the travelers' health activities to the internet.

Evidence: The agency consolidated information technology services and is consolidating budget execution, travel processing, training and graphics and has delayed to no more than four management levels. The agency now has a supervisory ratio of one to ten, up from one to seven at the end of FY 2002. The agency is conducting competitive sourcing studies on or has converted over 460 FTEs. The agency has used FedBizOpps to post all contracts electronically. The agency is reviewing migration to two enterprise grant management systems.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The program collaborates with related programs in a meaningful way through research investments and other state, federal and international partnerships. The program collaborates with NIH on research and has reviewed research proposals through an NIH grant notice. The program includes representatives from other federal agencies on the BSC and the program's director sits on the council for the National Institute of Allergy and Infectious Diseases. The program's PulseNet works with other federal, state and local public health laboratories to quickly identify foodborne bacteria to more quickly identify and characterize outbreaks of foodborne disease. The program collaborates with FDA on blood safety activities, such as for West Nile virus transmission. The program collaborates with the CDC Foundation to expand program activities, such as in safe water systems. The program's International Emerging Infection Program is a partnership between the program and international ministries of health. The program also collaborates with the US Department of State on international activities.

Evidence: A May 2003 article in Science described the discoveries of CDC scientists working in collaboration with researchers from domestic universities, Germany and the Netherlands to sequence the genome of the SARS coronavirus. A May 2003 article in the New England J of Medicine summarizes studies of program scientists working in collaboration with researchers from multiple countries to identify the etiologic agent of the SARS outbreak. Additional evidence of NIH collaborations include an NIH-CDC collaborations update that describes specific activities. The West Nile virus transfusion work is described in the September 25, 2003 edition of the New England J. of Medicine. A GAO report on resistant bacteria (HEHS-99-132) cited collaboration between the program and USDA and FDA. A GAO report on chronic fatigue research at CDC and NIH (HEHS-00-98) found limited coordination between the two agencies and no joint research in this area.

Does the program use strong financial management practices?

Explanation: An independent auditor's report in Section IV of the FY 2003 HHS Performance and Accountability Report concludes the CDC/ATSDR central financial system lacks the ability to generate financial statements, trian balance and financial statements need to be created offline, which is manually intensive, inefficient and increases the risk of error. The FY 2002 report also noted reportable conditions relating to information systems; the internal controls over preparation, analysis and monitoring of financial information; reimbursable agreements; and grants accounting and oversight. None of the reportable conditions are considered material internal control weaknesses. GAO reported the agency's financial management capacity systems and procedures were insufficiently developed to address the agency's mission and budget growth. CDC has automated reimbursable billings, enhanced year end closing transactions and implemented a new indirect cost methodology and is addressing staffing needs, including core accounting competencies, professional staff recruitment, financial systems, training and customer service.

Evidence: A May 1999 report by the HHS Office of Inspector General found from FY 1995-FY1998 an estimated $8.8 million (39%) of funding charged to chronic fatigue syndrome activities by the program was incurred for non-CFS-related activities and an additional $4.1 million (18%) could not be determined due to insufficient documentation. The OIG attributed the problem to deficiencies in the agency's internal control system for direct and indirect costs. The agency has taken multiple steps to correct these deficiencies. A December 2003 report by the OIG noted the agency had not implemented a system to allocate indirect costs until FY 2003, but found the new system to be a significant improvement for equity and accuracy. The OIG recommends CDC periodically review indirect costing methods. Indirect costs cover core business processes and centrally managed services. CDC has received five consecutive unqualified opinions. CDC issued 64 duplicate or erroneous payments in FY 2002, or 0.042% of all payments and has a 97% compliance rate for prompt payments. Also GAO-01-40, November 2000.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: The program is taking steps to improve accountability at the Federal level and is taking additional steps at the agency level to improve financial oversight. CDC is also working at the agency level to develop a new policy on sharing information with the states that may expand information on performance that is available to the public in the future.The program has been following a repayment plan for chronic fatigue syndrome activities and plans to complete the payback in FY 2004. The program contracted with PriceWaterhouseCoopers to conduct a forensic accounting of reported chronic fatigue expenditures from FY 2000-FY 2002. The agency has also taken numerous steps to improve the financial management system and oversight of resources. The agency is extending the incorporation of performance measures into employee evaluations and work contracts. The agency is also putting considerable effort into setting priorities and reorganizing operations through the Future's Initiative, including to improve CDC's business practices. The program is developing a set of performance measures for grantees to report on in FY 2005.

Evidence: Management changes at the agency level were also documented in a January 2004 GAO report (04-219). The program contracted with Ernst & Young to develop an indirect cost methodology for costs incurred at the office of the director level similar to the agency's new system in 2001. The program uses salary costs per budget activity, which are tracked quarterly by branch through labor distribution surveys, and is using the system to determine full costs and match costs with outputs. Following the chronic fatigue disclosure, the program offered appropriations law training for budget officers and managers and revised administrative procedures. The program also established a firewall between intramural and extramural research programs to improve accountability and transparency of extramural funding. A framework for program evaluation in public health was published in MMWR in September, 1999. To better integrate animal and human health, the program brought on an acting associate director for veterinary medicine and public health. The FY 2003 PAR cites improvements in preparing financial statements. CDC will implement UFMS in October 2004. The agency submitted first quarter financial statements to the Department ahead of schedule.

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: The program relies on peer review from external infectious disease experts from the federal, state and local level. The program maintains competitive awards for the Emerging Infections Program, which currently funds 11 state health departments, and the Epidemiology and Laboratory Capacity for Infectious Diseases program, which funds 57 state, local and territorial health departments. The program uses special emphasis panels for certain awards, such as West Nile and antimicrobial resistance. Applications that are of the highest merit and given a priority score and receive a second level of peer review by CDC senior staff or the program's Board of Scientific Counselors.

Evidence: The program established an office of extramural research in August 2002 to run the peer review process and take a variety of steps to improve accountability and transparency of extramural awards. The program's peer review policy is provided on the internet through the office of extramural research. Applications are open typically to any member of broad categories of public and private nonprofit organizations, state, local and tribal governments, academic institutions, and other entities. The program has received a number of Congressional earmarks, funded through Public Health Improvement. The program's review criteria are availalbe in the May 5, 2003 edition of the Federal Register. As mentioned previously, the Board of Scientific Counselors reviews the program's activities in extramural research. The program announces awards in the Federal Register, on the agency website and in publications such as the CDC/ATSDR Federal Assistance Funding Book. The program also supports some outreach at conferences for cooperative agreement partners.

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: In addition to technical reviews for progress reports and annual and end of project reports from grantees, the program conducts site visits of projects. Cooperative agreement recipients submit interim progress reports, financial status reports and final financial and performance reports. The program conducts external peer review of intramural and extramural research.

Evidence: Progress reports from program partners include detailed information on program activities and progress on general goals and objectives. Site visit reports include detailed information on awardee activities and areas of needed improvement. Two people conduct site visits for 57 Epidemiology and Laboratory Capacity cooperative agreement core grants, additional staff review ELC program grants. Cooperative agreement awards are scored on the partner's measures of effectiveness and plans for monitoring proposed activities and implementation. An example of a cooperative agreement is the Epidemiology and Laboratory Capacity for Infectious Diseases, Federal Register, May 5, 2003. The program's Prevention Epicenters maintain active contact with program participants and share information on grantee activities.

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The program places aggregated performance information in the GPRA reports, but does not provide data disaggregated at the grantee level. The program does provide surveillance data from states in the Morbidity and Mortality Weekly Report. The program also publishes award announcements that describe planned activities of grantees and program highlights from partners and provides links to grantee internet sites, but does not provide systematic information on grantee performance. As is noted above, CDC is working at the agency level to develop a new policy on sharing information with the states that may expand information on performance that is available to the public in the future.

Evidence: Evidence includes the program's annual GPRA plan and report and internet materials. An example of a more detailed program summary is from the Get Smart antibiotic use program.

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: A large extent is given because the program has data showing progress on the two recently developed long-term outcome measures. Considerable progress is shown in key disease areas highlighted by the program. Some progress has been reached in improving influenza surveillance through in-country networks.

Evidence: For the disease outcome measure, campylobacter species declines from 15.42 per 100,000 population in 2000 to 12.60 in 2003, e-coli 0157:H7 declined from 2.15 to 1.1, listeria increased marketedly in 2003 to 3.3 from 0.27 in 2002, salmonella held steady from 14.13 in 2000 to 14.5 in 2003. Central line associated bloodstream infection rates per 1,000 days of use declined from 4.1 in 2000 to 3.7 in 2003. Invasive pneumococcal disease in children under 5 years of age declined from 71.8 per 100,000 population in 2000 to 23.2 in 2002 and in adults from 57.6 to 43.3. Hepatitis A declined from 11.21 per 100,000 population in 1997 to 2.6 (provisional data) in 2003. The program has established one in-country influenza network with 60% geographic coverage and 60% population coverage.

Does the program (including program partners) achieve its annual performance goals?

Explanation: A small extent is given because the program has data showing progress on two of the recently developed annual outcome, output and efficiency measures. Progress is shown for the disease outcome measure and for the antibiotics prescription measure. Proficiency data for the Laboratory Response Network was available for the first time in 2003. The program only has one year of baseline data available for the number of foodborne isolates identified, fingerprinted, and electronically submitted to CDC's computerized national database networks.

Evidence: For the disease measure, campylobacter species declines from 13.37 per 100,000 population in 2002 to 12.60 in 2003, e-coli 0157:H7 declined from 1.73 to 1.1, listeria increased marketedly in 2003 to 3.3 from 0.27 in 2002, salmonella decreased from 16.1 in 2002 to 14.5 in 2003. Central line associated bloodstream infection rates per 1,000 days of use declined from 3.8 in 2002 to 3.7 in 2003. Data on invasive pneumococcal disease are only available up to 2002. The rate declined in children under 5 years of age declined from 38.9 per 100,000 population in 2001 to 23.2 in 2002 and in adults from 50.7 to 43.3. Hepatitis A declined from 3.13 per 100,000 population in 2002 to 2.6 (provisional data) in 2003. The number of antibiotics prescribed for ear infectious in children under 5 years of age per 100 children declined from 69 courses per 100 children in 1997 to 63 courses in 2002.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: A small extent is given because the program has numerous processes in place to improve efficiencies, but only limited data to demonstrate improvement. Insufficient evidence of efficiencies or cost effectiveness in achieving program goals each year has been provided. The program reduced the number of staff hours required to respond to travelers health inquiries and increased processing of food isolates with level funding. The agency has reduced some costs at the Federal level.

Evidence: The agency is reducing IT costs by $16.5 million (15%) in FY 2004 and will redeploy 39 FTEs (16%) to program positions. The results from the program's two competitive sourcing studies willl be available in September 2004.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: There are no other federal programs that share the role of the program and the program's activities cannot be compared directly with other federal, state or private entities. The processes that the program undertakes, such as laboratory research and surveillance, and select activities may be comparable.

Evidence: While other federal, state, local and international entities conduct similar research and program activities, there is insufficient evidence to draw a full comparison between the activities carried out by the Infectious Disease program at CDC and other related programs.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: A large extent is given because GAO has released numerous reports related to the activities of the program and in general the reports highlight areas of needed improvement but indicate the program is having a positive impact. GAO recently noted (04-877) CDC has multiple initiatives to improve disease surveillance and reporting, but challenges remain. GAO noted (01-973) that the program's multiple food safety surveillance systems release data more quickly and the program is funding health departments to address limitations behind delays. GAO testimony on SARS (03-1058T) noted general success in infectious disease control measures and efforts to provide guidelines and checklists of preparedness activities. GAO (04-152) noted the program and CDC struggled to manage large amounts of information during the anthrax events, but supported local response efforts and is taking steps to improve leadership and response. A GAO report on Lyme disease (01-755) noted the agency's progress in laboratory research, surveillance and outreach and responsiveness to outside experts and Congress.

Evidence: Additional findings include a GAO report on surveillance of infectious diseases (HEHS-99-26/62) that noted states find CDC's separate reporting systems result in a duplication of effort and drain staff resources, but place high value on CDC's testing, training and technical assistance. A GAO report on resistant bacteria (HEHS-99-132) notes the program's role in collecting information and collaboration with other partners. A GAO report on the select agent program (03-315R) found internal management weaknesses that could compromise oversight. A GAO report on West Nile virus (00-180) noted the importance of surveillance and response and found better communication among public health agencies is needed. GAO reports on global disease surveillance (01-722, 00-205R) noted some strong successes in internation disease surveillance, of which the program plays a part, and substantial challenges.