Detailed Information on the
CDC: Division of Global Migration and Quarantine Assessment

Measure: Prevent the importation and spread of infectious diseases to the U.S. in mobile populations and non-human-primates, as measured by meeting 4 of 4 targets for the following measures: a. Increase the proportion of applicants for U.S. immigration screened for tuberculosis by implementing revised tuberculosis technical instruction. b. Increase the likelihood of travelers seeking pre-travel medical advice for travel to Africa and Asia c. Increase of the percentage of immigrants and refugees with a "Class A or B medical notification for tuberculosis" who undergo medical follow-up after arrival in U.S d. Maintain low mortality in nonhuman primates imported to the U.S. for science and research.

Explanation:The public health burden for each of the 4 annual measures is described in greater detail for each measure. As a composite long-term measure, it measures the overall trend towards preventing the importation and spread of infectious diseases to the U.S. through 4 different approaches for a key disease (i.e., tuberculosis), in key populations (i.e., in immigrants, refugees, and travelers), and in key regulated animals (non-human primates). Measurements are described for each annual measure of which this composite long-term measure is comprised. In order achieve the long-term measure each annual measure has to have reached its final target. Hence, while each annual measure shows a positive trend for past performance, only one of the annual measures has reached its target and is being measured by maintaining the target.

Measure: Increase the proportion of applicants for U.S. immigration screened for tuberculosis under the 2007 tuberculosis technical instruction (TB TI).

Explanation:The outcome being measured is the proportion of overseas applicants for U.S. immigration screened according to modernized tuberculosis screening protocols. The majority (57%) of tuberculosis cases diagnosed in the United States are diagnosed in persons born outside the United States. Medical screening for tuberculosis is legally required of refugees and applicants of U.S. immigration in order to receive a visa and enter the United States. Improving tuberculosis screening of this population is an opportunity to appropriately diagnose and treat persons with tuberculosis disease before they arrive in the United States and identify persons at risk for having tuberculosis disease for prompt stateside follow-up. Improving the tuberculosis screening should contribute to decreasing the burden of tuberculosis in the United States among foreign-born populations overall.

Measure: Increase the relative likelihood of travelers seeking pre-travel medical advice for travel to Africa and Asia compared to Eastern Europe. The measure can be read as, "In (year), compared to travelers to Eastern Europe, travelers to Asia or Africa were X times more likely to seek pre-travel advice." The likelihood is the ratio of the likelihoods of seeking pre-travel advice by different regions (Eastern Europe versus Asia/Africa).

Explanation:With globalization of the world's economy the risk of translocation of infectious disease via travel and transportation is increasing. In 2006, there were 35 million individual travelers departing the U.S. to go overseas; these travelers took >63 million trips of at least one night abroad. Our ability to protect the U.S. from the introduction of infectious diseases depends at least in part on DGMQ's ability to educate U.S. travelers and healthcare providers about immunizations, medications, and other precautions to ensure safe and healthy travel while abroad and upon returning to the U.S. Because the highest disease risk is for travel to Africa and Asia, DGMQ currently focuses its outreach and educational activities on travelers to those two continents. The Relative Likelihood is based on the number of U.S. residents who seek pre-travel advice as captured in GeoSentinel out of the total number of U.S. travelers who visit Africa and Asia.

Measure: Increase of the percentage of immigrants and refugees with a Class A or B medical notification for tuberculosis who undergo medical follow-up after arrival in U.S.

Explanation:The majority (57 percent) of tuberculosis cases diagnosed in the United States are diagnosed in persons born outside the United States. Tuberculosis represents the largest burden of infectious disease in immigrant and refugee populations. The overseas medical examination identifies persons with tuberculosis and those without tuberculosis disease but at risk of having tuberculosis and need of prompt follow-up after arrival in the U.S. Improving tuberculosis follow-up evaluation of this population is an opportunity to appropriately diagnose and treat persons with tuberculosis disease soon after they arrive in the United States and minimize secondary transmission to others. Improving the tuberculosis follow-up evaluation should contribute to decreasing the burden of tuberculosis in the United States among foreign-born populations.

Measure: Maintain low mortality in nonhuman primates (NHP) imported to the U.S. for science, exhibition and education.

Explanation:Maintaining low mortality in imported nonhuman primates (NHPs) means they are healthier when they arrive in the US, thus decreasing the likelihood that people will be exposed to/become infected with zoonotic pathogens carried by NHPs. Generally, NHPs are imported for scientific research, education or exhibition. Outbreaks of serious illness can result in the euthanasia of the entire shipment, resulting in an economic loss to the importer and a potential shortage of available animals for research. For example, a shipment of 100 nonhuman primates could be lost to research if mortality were not kept low, and represent a huge economic loss to the importer at e.g., $6,000 per NHP. Another example of the potential for substantial research efforts lost with huge loss human benefit of that research and economic implications would be if a researcher purchases 20 animals to add to his 80 that are already on a long term study and the animals became ill with an infectious disease, he would lose all 100 animals.

Measure: Protect the U.S. population by increasing the number of US international airports and land borders covered by a communicable disease preparedness plan to a total of 25.

Explanation:The first opportunity to detect and control imported infectious diseases is at international ports of entry. The 25 top US international airports and land borders account for about 85% of international arrivals in this country. A comprehensive communicable disease preparedness plan at such ports increases the likelihood that control will be successful. Such plans integrate the responses of all relevant agencies.

Measure: Increase the number of hospitals with Memorandum of Agreements (MOAs) in priority 1 cities.

Explanation:"Priority 1" cities have the largest number of passenger volume via commercial aircraft or border crossings and are therefore at increased risk for introduction and spread of infectious diseases. Having an MOA in place allows rapid selection of a referral hospital if and when a passenger with a potentially communicable disease arrives. The MOA process ensures that the hospital has adequate facilities to care for such passengers without endangering the health of other patients or the wider community.

Measure: Increase the number of illnesses in persons arriving in the United States that are reported to CDC DGMQ by conveyance operators, CBP, and others.

Explanation:Each year about 600 million persons cross into the United States temporarily or permanently. Each of these entries poses some risk of introduction of communicable disease. Although CDC/DGMQ operates quarantine stations at 20 of the most important ports of entry, DGMQ staff is not present at hundreds of ports and cannot visualize each and every person for signs of illness. DGMQ relies on conveyance operators or medical staff, the U.S. Coast Guard, and especially U.S. Customs and Border Protection (CBP) to be DGMQ's "eyes and ears" at all U.S. entry points. The number of reports received by DGMQ are an indication of DGMQ's success at forming public health partnerships with these other entities. CBP, for example, conducts passive public health surveillance on every person entering the U.S. based on DGMQ guidance and training, and plays an important role in reporting ill travelers to CDC for public health response.

Measure: Decrease the cost of notifying state health departments of disease conditions in incoming refugees and immigrants by implementing the electronic disease notification system.

Explanation:An overseas medical examination, performed by more than 650 panel physicians worldwide, is required for immigrant visa and refugee status applicants, before migrating to the United States. New immigrants and refugees arrive in the United States each year with this medical examination documentation. For immigrants and refugees arriving with a Class A/B medical condition, such as tuberculosis (TB), DGMQ notifies the local/state health department of their arrival to ensure medical follow up and electronically submit their medical information. This information is stored in the Electronic Disease Notification (EDN) system. The EDN system is replacing an untimely hard-copy mailing system prone to loss of information that used the U.S. postal service. Complete information from the thorough medical screening is entered for all refugees arriving in the U.S. each year (approximately 70,000), and for immigrants only those records indicating Class A/B conditions are being entered (approximately 20,000 per year).

Is the program purpose clear?

Explanation: The Division of Global Migration and Quarantine (DGMQ) is one of six divisions located in the National Center for Preparedness, Detection, and Control of Infectious Diseases (NCPDCID), Centers for Disease Control and Prevention (CDC). Its activities are authorized under the Public Health Service Act and the Immigration and Nationality Act. The mission of DGMQ is to reduce morbidity and mortality among immigrants, refugees, travelers, expatriates, and other globally mobile populations, and to prevent the introduction, transmission, and spread of communicable diseases through regulation, science, research, preparedness, and response. The Secretary of the Department of Health and Human Services (DHHS) has statutory responsibility for preventing the introduction, transmission, and spread of communicable diseases into the United States (42 U.S. Code § 264). The authority for carrying out these functions has been delegated to CDC's Division of Global Migration and Quarantine (DGMQ). DGMQ works to fulfill this responsibility through a variety of activities, including the administration of interstate and foreign quarantine regulations (42 CFR Parts 70 & 71), which govern the interstate and international movement of persons, animals, and cargo and the establishment of standards for medical examination of persons destined for the U. S. (42 CFR Part 34). The legal foundation for these activities is found in Titles 8 and 42 of the U.S. Code and relevant supporting regulations. To execute its mission, DGMQ has statutory authority to undertake major activities to prevent the introduction and spread of communicable diseases into the United States. These activities include the following actions: DGMQ administers regulations pertaining to travelers and imported animals and products, develops and coordinates disease-screening programs for immigrants and refugees, responds to outbreaks in refugee populations overseas, oversees CDC quarantine stations, disseminates health information for international travelers, develops measures to prevent the introduction of zoonotic diseases into the United States, and identifies diseases in mobile populations. DGMQ serves as the strategic leader at ports of entry by providing the training, education, and coordination to all partners essential to detecting and responding to diseases of public health significance at U.S. ports of entry. DGMQ's mission and purpose also shape its organizational structure. DGMQ is comprised of three branches: the Quarantine and Border Health Services Branch, the Geographic Medicine and Health Promotion Branch, and the Immigrant, Refugee, and Migrant Health Branch. Each branch has its own mission that aligns with DGMQ's overarching mission. The Quarantine and Border Health Services Branch's mission is to protect the health of the public from communicable diseases through science, partnerships and response at U.S. ports of entry. The mission of the Geographic Medicine and Health Promotion Branch is to characterize the health risks associated with international travel and develop ways to reduce the associated morbidity and mortality. The mission of the Immigrant, Refugee, and Migrant Health Branch mission is to promote and improve the health of immigrants, refugees, and migrants, and prevent the importation of infectious diseases and other conditions of public health significance into the United States by these groups.

Evidence: Evidence 1.1.1: Public Health Service Act 301, 307, 310, 311, 317, 318, 319, 322, 325, 327, 352, 361-369, 1102. http://www.os.dhhs.gov/about/opdivs/phs.html; Evidence 1.1.2: National Center for Preparedness, Detection, and Control of Infectious Diseases, Division of Global Migration and Quarantine Program Review May 14, 2007; Evidence 1.1.3: DGMQ Mission Statement http://www.cdc.gov/ncidod/dq/index.htm; Evidence 1.1.4: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006); Evidence 1.1.5: DGMQ's Regulatory Authorities: 42 U.S. Code § 264; 42 CFR Parts 70 & 71; and 42 CFR Part 34; Evidence 1.1.6: Immigration and Nationality Act.

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

Explanation: DGMQ reduces the morbidity and mortality among immigrants, refugees, travelers, expatriates, and other globally mobile populations and prevents the introduction, transmission, and spread of communicable disease into the United States by mobile populations. It accomplishes its mission through regulation, science, research, preparedness and response. The problem is supported by existing data provided in DGMQ's 2007 Program Review book on the increase in global travel and migration, as well as the increase in emerging health threats both natural and manmade (bioterrorism). This problem is still relevant to current conditions due to: 1. Globalization in the 21st century, facilitated by the unprecedented volume and speed of international travel and commerce; 2. Emergence and re-emergence of infectious diseases which pose a constant threat; and, 3. The risk of importation of disease by mobile populations. The combination of these realities poses a unique challenge to DGMQ to provide strategic public health leadership to a network of domestic and international partners. This growing concern has prompted CDC to invest in building a Quarantine and Migration Health System that meets the needs of the 21st century. DGMQ coordinates the nationwide response to global infectious disease threats that may cross U.S. borders. DGMQ's Quarantine System provides the critical infrastructure necessary to support the all-hazards (any public health threat) preparedness activities going on across the United States and throughout the world. DGMQ is expanding its activities to protect the U.S. public from pandemic influenza through research, science, partnership and collaboration, and increased presence and capacity at U.S. ports of entry. DGMQ responds to growing needs through its mission and the activities of its three branches. Specifically, as outlined in DGMQ's 2007 Program Review book, the three branches are involved in specific activities that cohesively address these growing needs. DGMQ supports an enhanced quarantine system with capabilities beyond responding to and evaluating travelers with suspect or probable illness. The quarantine system now plays an active, anticipatory role in nationwide biosurveillance. Quarantine stations are transitioning from the previous focus on federal inspection services at airports to become a full partner in public health response to a wide range of infectious disease threats, whether intentional??as in the case of bioterrorism??or related to emerging pathogens. DGMQ brings expertise to bridge gaps in public health and clinical practice, emergency services, and response management. DGMQ is working toward improved communications networks that will enable passengers to be notified promptly of potential exposures to infectious diseases. These expanded services are integrated into bioterrorism and emergency preparation and response plans and grounded in strengthened collaboration with state and local health departments, the travel industry, and the health-care community, as well as other federal agencies. DGMQ also works towards the quarantine system providing a stronger continuum of health support for refugees, whom the division helps prepare for migration to the United States, and immigrants.

Evidence: Evidence 1.2.1: National Center for Preparedness, Detection, and Control of Infectious Diseases, Division of Global Migration and Quarantine Program Review book, March 14, 2007; Evidence 1.2.2: National Center for Preparedness, Detection, and Control of Infectious Disease, Division of Global Migration and Quarantine Program Review May 14, 2007; Evidence 1.2.3: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006).

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

Explanation: DGMQ has a specific and unique function at the Federal level to prevent the transmission and spread of communicable diseases from foreign countries into the United States through people, animals, and cargo. The overarching responsibility of preventing the introduction of communicable diseases into the United States distinguishes the work of DGMQ at the Federal level from regulations at the State and local levels, which are implemented at their respective levels of responsibility. DGMQ carries out this responsibility by providing national direction and coordinating the efforts of public and private sector partners, both domestically and internationally. The Quarantine and Migration Health System is an integrated and comprehensive partnership of local, national, and global health authorities to prevent, detect, and contain infectious diseases in countries of origin and at U.S. ports of entry, and to plan responses to public health threats. DGMQ has the responsibility, the authority, and the resources for orchestrating the activities of the Quarantine System to protect the U.S. population from microbial threats of public health significance that originate abroad. DGMQ, in concert with its three organizational branches, has the unique ability to orchestrate a full-scale response to disease importation posed by mobile populations. The quarantine stations are the only members of the partnership whose primary purpose is the mitigation of imported microbial threats at U.S. ports of entry. However, the quarantine stations rely heavily on port-based inspectors from other federal agencies to identify and report travelers, crew, animals, and cargo that may pose a public health threat at the more than 400 ports that lack quarantine stations and at hours when the quarantine stations are closed. These activities are an official sidebar to the main duties of the port-based officers of the Department of Homeland Security's U.S. Customs and Border Protection (CBP). There are several broad areas of cooperation between quarantine field staff and CBP officers, including data sharing, enforcing federal quarantine, providing travelers' health information, and performing illness surveillance at ports of entry. With only 80 quarantine field staff (compared to 20,000 CBP staff) many times CBP will have initial contact with travelers and will contact quarantine field staff to respond as public health incidents occur. CDC works closely with CBP to train the CBP officers to incorporate these responsibilities into their daily activities. The quarantine stations rely not only on CBP but also on airline crews and ship masters to identify ill passengers. Officers of CBP and the U.S. Coast Guard (USCG) have statutory responsibility "to aid in the enforcement of quarantine rules and regulations." The CDC Quarantine Stations are technically responsible for inspecting all imports of animals under their authority to ensure that the animals do not display signs of communicable disease. In practice, however, this responsibility usually is carried out by CBP veterinary and animal health inspectors on behalf of the Quarantine Core. Legal and illegal imports of animal products, etiologic agents, hosts, and vectors that may pose a public health threat also lie within CDC jurisdiction. The Department of the Interior's U.S. Fish and Wildlife Service (USFWS) is yet another agency involved in the regulation and inspection of animal imports. USFWS enforces U.S. and international laws regarding the trade and transport of wildlife (Division of Law Enforcement, 2002). When cases of jurisdictional overlap arise, the agencies involved decide how to apportion operational responsibilities or cooperate to perform complementary responsibilities. In addition, the Division also strives to improve preparedness at ports of entry by collaborating with partners to create preparedness plans.

Evidence: Evidence 1.3.1: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006); Evidence 1.3.2: 42 USC § 268 (b); Evidence 1.3.3: 42 CFR § 71.54.

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

Explanation: The program is well designed and free of major flaws that would limit effectiveness and efficiency. The program has expanded following specific design recommendations of the Institute of Medicine (IOM), published in September 2005, that CDC increase the number of quarantine stations from eight to twenty-five. By the end of FY 2007, CDC had opened 20 domestic quarantine stations, focusing on improving the scope and quality of services provided at these domestic stations. These 20 domestic stations serve the over 120 million airline passengers who fly internationally each year and were strategically placed based upon factors of efficiency and effectiveness. Each quarantine station is responsible for all international ports of entry (air, land, and sea) within its area of jurisdiction. These jurisdictions may include territories, additional States, and international pre-clearance ports. In the FY 2009 President's Budget, CDC requests additional resources to fully staff the existing 20 domestic stations and open an additional five international stations. Establishing the additional five stations at key international air travel hubs leverages CDC's ability to protect the U.S. public in all 50 states and supports design efficiency and effectiveness. This is best demonstrated by the experience with SARS. In an effort to control the entry into the United States at over 23 airports of potentially infected persons, CDC placed persons in Toronto, Canada, to identify these travelers prior to arrival into the United States, increasing CDC's ability to respond and prevent introduction of disease. Similarly, with refugee resettlement there are international hubs that high-risk mobile populations transit through before entering the 50 states. Strategically placing the next five quarantine stations internationally at ports of departure rather than U.S. arrival cities will improve the ability to reduce the risk of importation of disease and response time to execute appropriate layered containment/border strategies in the event of a pandemic or other crisis. The expansion of the Quarantine System to include an international presence is consistent with the principle of defending U.S. borders through a series of layered, concentric defensive measures. In addition, DGMQ's mission and purpose also drive its programmatic design. DGMQ is comprised of three branches: the Quarantine and Border Health Services Branch; the Geographic Medicine and Health Promotion Branch; and the Immigrant, Refugee, and Migrant Health Branch. Each branch has its own mission that aligns with DGMQ's overarching mission. The Quarantine and Border Health Services Branch's mission is "To protect the health of the public from communicable diseases through science, partnerships and response at U.S. ports of entry." The Geographic Medicine and Health Promotion Branch's mission is "to characterize the health risks associated with international travel and develop ways to reduce the associated morbidity and mortality." The Immigrant, Refugee, and Migrant Health Branch's mission is "to promote and improve the health of immigrants, refugees and migrants and prevent the importation of infectious diseases and other conditions of public health significance into the United States by these groups."

Evidence: Evidence 1.4.1: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006); Evidence 1.4.2: National Strategy for Pandemic Influenza: Implementation Plan; Evidence 1.4.3: DGMQ Mission Statement, http://www.cdc.gov/ncidod/dq/index.htm; Evidence 1.4.4: National Center for Preparedness, Detection, and Control of Infectious Disease, DIVISION OF GLOBAL MIGRATION AND QUARANTINE Program Review May 14, 2007; Evidence 1.4.5: Learning from SARS: Preparing for the Next Disease Outbreak -- Workshop Summary (2004), http://books.nap.edu/openbook.php?record_id=10915&page=R1.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: DGMQ's program has an integrated and comprehensive partnership of local, national, and global health authorities to prevent, detect, and contain infectious diseases in countries of origin and at U.S. ports of entry, and to plan responses to public health threats. DGMQ has the specific and unique responsibility, the authority, and the resources for orchestrating the activities of the Quarantine System to protect the U.S. population from microbial threats of public health significance that originate abroad and to orchestrate a full-scale response to disease importation posed by mobile populations. DGMQ uses detection, response and prevention strategies to target mobile populations at greatest risk of disease. DGMQ's program targets the following beneficiaries: 1) the U.S. population; 2) international travelers inbound to the United States; 3) immigrants and refugees coming to the United States; 4) States and localities that receive refugees; 5) host countries of refugees being resettled to the United States; 6) animal importers/researchers (receipt of healthy monkeys); 7) health-care providers, including U.S. physicians, civil surgeons, and overseas panel physicians; 8) Federal Inspection Services; 9) U.S. Department of Homeland Security; and 10) commercial importers. In order to reach these beneficiaries, DGMQ opened 20 quarantine stations by 2007, expanding the number of stations from eight in 2004. DGMQ has increased staffing to a little over 50 percent at these 20 stations, and as resources are available, DGMQ will work to staff all 20 stations at 100 percent levels and open an additional five international stations. In addition, DGMQ reaches refugee and immigrant populations through partnerships with panel physicians and oversight of the medical screening required for entrance into the United States. DGMQ also conducts surveillance and outbreak response overseas to assure refugees coming to the United States are healthy. Field staff placed in Kenya and Thailand offer direct technical assistance in surveillance, outbreak response, and resettlement activities for mobile populations. DGMQ's program design assures resources are being used directly and effectively to meet the program purpose of preventing introduction of disease by mobile populations. This is assured by placing quarantine stations at 20 strategic ports of entry. The locations of the current 20 stations were chosen in order to cover 85 percent of inbound international travelers. The following criteria were utilized in the planning: 1. The volume of international human travelers (airports with more than 500,000 arriving international air travelers per year; seaports in major cities with more than 150,000 arriving international maritime travelers per year; and land crossings in major cities with more than 10 million arriving international travelers); 2. Total volume of human travelers at airports (airports with more than 25 million arriving international and domestic air travelers per year); 3. Volume of imported wildlife (major cities that serve as designated or nondesignated ports of entry by the U.S. Fish and Wildlife Service to receive international shipments of wildlife); and 4. National security considerations (the selected cities are among the 83 so-called Tier One (1) U.S. cities, which are believed to be strategic destinations from a national security standpoint).

Evidence: Evidence 1.5.1: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006); Evidence 1.5.2: Division of Global Migration and Quarantine Strategic Plan CDC/Booz Allen Hamilton, February 2006; Evidence 1.5.3: Disease-specific incidence in mobile populations: a) Tuberculosis Surveillance Data of Incidence in Foreign Born; b) Tuberculosis Diagnosis in Immigrants; c) Institute of Medicine (IOM) Report, "Ending Neglect"; d) MMWR 2005. Multidrug-Resistant Tuberculosis in Hmong Refugees Resettling from Thailand into the United States, 2004-2005; and e) Maloney SA, et al. Assessing the performance of overseas tuberculosis screening programs: a study among US-bound immigrants in Vietnam. Arch Intern Med. 2006 Jan 23;166(2):234-40.

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: DGMQ has one long-term performance goal that focuses on outcome and reflects the purpose of the program. This goal covers the entire DGMQ budget line. Overarching goal: Protect the U.S. population from the importation of infectious diseases. Under the overarching goal, DGMQ has two specific long-term performance measures that focus on outcomes and reflect the purpose of the program. Long-term measure #1: Prevent the importation of infectious diseases to the U.S. in mobile populations and non-human primates, as measured by meeting 4 of 4 targets for the following measures: 1. Increase the proportion of applicants for U.S. immigration screened for tuberculosis by implementing the revised tuberculosis technical instructions 2. Increase the likelihood of travelers seeking pre-travel medical advice for travel to Africa and Asia 3. Increase the percentage of immigrants and refugees with a "Class A or B medical notification for tuberculosis who undergo medical follow-up after arrival in the U.S." 4. Maintain low mortality in nonhuman primates (NHP) imported to the U.S. for science and research. Long-term measure #2: Protect the U.S. population by increasing the number of U.S. international airports and land borders covered by a communicable disease preparedness plan to a total of 25.

Evidence: Evidence 2.1.1: FY 2009 CDC Justification of Estimates for Appropriations Committees; Evidence 2.1.2: CDC's budget tracking tool, HealthImpact.net; Evidence 2.1.3: DGMQ Mission Statement http://www.cdc.gov/ncidod/dq/index.htm; Evidence 2.1.4: National Center for Preparedness, Detection, and Control of Infectious Diseases, Division of Global Migration and Quarantine Program Review book, March 14, 2007; Evidence 2.1.5: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006).

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

Explanation: DGMQ has two long-term performance measures that focus on outcome. These measures are specific and realistic yet ambitious, given past performance. Long-term measure #1 is a composite measure of four ambitious annual measures, aiming to achieve all of the annual measures included in it by 2015. Since each of the annual measures is ambitious, the long-term performance measure is equally ambitious in aiming to achieve all four annual measures. The targets for long-term measure #2 are ambitious because of the large number of stakeholders who need to provide input and agree to the components of the communicable disease preparedness plans. The targets of this performance measure are regularly reviewed by an outside contractor.

Evidence: Evidence 2.2.1: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006); Evidence 2.2.2: Communicable Disease Emergency Response Plan Template; Evidence 2.2.3: Port Preparedness Exercise Plan; Evidence 2.2.4: Port Preparedness After-Action Report;

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: DGMQ has four annual performance measures for Long-term measure #1 and two annual performance measures for Long-term measure #2. Long-term measure #1: Prevent the importation of infectious diseases to the U.S. in mobile populations and non-human primates, as measured by meeting four of four targets for the following measures: 1. Increase the proportion of applicants for U.S. immigration screened for tuberculosis by implementing the revised tuberculosis technical instructions; 2. Increase the likelihood of travelers seeking pre-travel medical advice for travel to Africa and Asia; 3. Increase the percentage of immigrants and refugees with a "Class A or B medical notification for tuberculosis who undergo medical follow-up after arrival in the U.S.; and 4. Maintain low mortality in nonhuman primates (NHP) imported to the U.S. for science and research. Long-term measure #2: Protect the U.S. population by increasing the number of U.S. international airports and land borders covered by a communicable disease preparedness plan to a total of 25. Annual measures: 1. Increase the number of hospitals with Memoranda of Agreements (MOAs) in priority 1 cities; and 2. Increase the number of reports of illnesses in persons arriving in the U.S. to CDC/DGMQ by conveyance operators, Customs and Border Protection (CBP) personnel, and others. Addendum: Nonhuman primates are of considerable research importance in the U.S. Thus, it is critical to have a program that will ensure the health of the animals and of the people who handle them. The diseases carried by nonhuman primates are of significance because of high consequences should humans be infected (tuberculosis, herpes, hemorrhagic fever viruses). CDC regulates other animals including dogs, cats, turtles, rodents and civets. Other than rabies, which is rare in imported dogs, no single species in this list has the potential to transmit as broad a combination of significant zoonotic diseases as nonhuman primates. Usage data for the new edition of the online Yellow Book. There have been 20,319,317 page views for the current edition. The top 5 pages selected from the Yellow Book were: 1) Hepatitis A (252,373); 2) Yellow Fever (217,424); 3) Dengue Fever (153,527); 4) Hepatitis B (149,141); and 5) Typhoid Fever (146,685).

Evidence: Evidence 2.3.1 (Annual Measure 1.1): a) Institute of Medicine, "Ending Neglect: The Elimination of Tuberculosis in the U.S." The National Academies Press, Washington D.C. (2000); b) MMWR, 2005. Multi-drug resistant Tuberculosis in Hmong Refugees Resettling from Thailand into the United States, 2004-2005; c) Publications of Overseas TB Screening; d) Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2005); e) CDC Immigration Requirements: Technical Instructions for Tuberculosis Screening and Treatment, 2007; f) Reported Tuberculosis in the United States, 2006; and g) Legal Requirements: Medical Examination of Aliens (42 CFR 34); Medical Examination of Aliens (42 USC 252); Aliens with Diseases of Public Health Significance (8 USC 1182); Detention of aliens for physical and mental examination (8 USC 1222). Evidence 2.3.2 (Annual Measure 1.2): a) GeoSentinel (website and selected publications); b) CDC Yellow Book: Health Information for International Travel; c) Travelers' Health Research Centers - Evaluation of Measures to Protect the Health of International Travelers; and d) Travel Medicine Education Tools for Medical Students and Health Care Professionals: Module Announcement. Evidence 2.3.3 (Annual Measure 1.3): a) Institute of Medicine Report, Ending Neglect: The Elimination of Tuberculosis in the United States (2000); b) Federal Tuberculosis Task Force Plan in Response to the IOM Report, Ending Neglect: The Elimination of Tuberculosis in the United States (2003); c) Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2005); d) Revised Technical Instructions for Tuberculosis Screening and Treatment; e) Reported Tuberculosis in the United States, 2006; f) Cain KP, et al. Tuberculosis among Foreign-born Persons in the United States. Achieving Tuberculosis Elimination. Am J Respir Crit Care Med 2007 (Vol 175):75-79; and g) Wells, CD, et al. Tuberculosis Prevention Among Foreign-born Persons in Seattle-King County, Washington. Am J Respir Crit Care Med 1997;156:573-7. Evidence 2.3.4: (Annual Measure 1.4): a) Non-human Primate Importation Data; b) Selected publications illustrating disease risk in imported non-human primates; c) Selected CDC/DGMQ Guidance for the Prevention of Infectious Disease from Non-human Primates to Humans or other Non-human Primates; d) BT Bennett, et al. Nonhuman Primates in Biomedical Research: Biology and Management. Academic Press (1995); e) Centers for Disease Control, Center for Prevention Services; Division of Quarantine, Nonhuman Primate Isolation and Quarantine Facility Inspection; and f) 42 CFR 71. Evidence 2.3.5 (Annual Measure 2.1): a) Memorandum of Agreement Tier Criteria; b) Priority 1 Cities from 2002; c) Travel patterns for arriving or departing travelers; d) Hospital Criteria for Becoming an MOA Hospital; and e) Memorandum of Agreement Tracking System (MOATS). Evidence 2.3.6 (Annual Measure 2.2): a) Legal Requirements: Interstate Quarantine (42 CFR 70); Foreign Quarantine (42 CFR 71); Control of Communicable Diseases (42 USC 264-272); b) Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2005); c) Quarantine Activity Reporting System (QARS); d) Training of Customs and Border Protection staff - Training Module and Abstract; and e) Notification to Public Health Authorities of Ill Passengers and Crew on Flights Destined for the United States; and Dear Colleague Letter to Conveyance Operators.

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

Explanation: Each annual measure has baselines and quantifiable, ambitious targets. The targets for the annual measures, which all aim at decreasing the importation and spread of infectious diseases to the U.S include having increased numbers of formal agreements with stakeholders (i.e., port preparedness plans, and MOAs with hospitals), increasing illness detection, reporting and follow up (i.e., improved TB screening and follow up of immigrants and refugees, and illness reporting of travelers), increasing the number of travelers seeking pre-travel advice, and maintaining low mortality in imported non-human primates. The efficiency measure target aims to decrease the costs of reporting and follow up of classified medical conditions to state health departments while increasing the timeliness and completeness of reporting.

Evidence: Evidence 2.4.1: DGMQ measures document

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: Per the IOM Report, DGMQ personnel at headquarters and at the 20 U.S. ports of entry serve as the strategic national public health leadership for Quarantine System activities. Partnerships with other agencies are critical to the success of the annual and long-term goals and the mission of preventing importation of disease. DGMQ is involved in training, surveillance, and response activities on a day-to-day basis with over 30 domestic and international partners. The following are specific examples of how DGMQ partners report performance as it relates to achieving program goals. DGMQ works with U.S. Customs and Border Protection (CBP) to increase the number of reports of illnesses in travelers on conveyances traveling to the United States. A Memorandum of Understanding with DHS/CBP (see Evidence 2.5.2), outlines the responsibilities of each agency to ensure reporting of ill passengers and efficient data exchange necessary for contact tracing. Reports of ill passengers and other items of public health significance are entered daily by the CDC Quarantine Stations into the Quarantine Activity Reporting System (QARS), a robust surveillance system, thereby reducing the risk of importation of disease. The daily reports generated assist DGMQ in monitoring progress toward program goals. DGMQ also works with local and State public health departments to assure that immigrants and refugees being resettled to the United States arriving with "Class A or B medical classification for tuberculosis" undergo medical follow-up after arrival into the United States. Utilizing the Electronic Disease Notification (EDN) System, DGMQ assures that select states and local health departments receiving immigrants and refugees are aware of conditions. Sites not yet on-line with EDN receive notification via conventional mail. State and local health departments provide data to DGMQ confirming case follow-up, allowing DGMQ to monitor progress toward program goals. DGMQ works with the GeoSentinel network of travel and tropical medicine providers to track geographic and temporal trends in infectious diseases among international travelers, immigrants and refugees. DGMQ funds the network to examine temporal trends and surveillance for events of concern. This information allows the Travelers' Health team to post outbreak notices and travel advisories and to disseminate relevant information to travelers. These efforts work toward the goal of monitoring disease trends and providing pre-travel medical advice to reduce illness in travelers. Quarterly reports provided by GeoSentinel providers provide DGMQ the ability to monitor pre-travel advice to travelers. Additionally, DGMQ provides technical guidance to overseas panel physicians who are appointed by the Department of State to perform the medical screening examination at 670 sites. To assure overseas panel physicians conduct quality exams and are working toward annual and long-term program goals, DGMQ developed the Quality Assessment Program (QAP) and monitors the quality of overseas examination. As part of QAP, DGMQ teams with medical and laboratory expertise perform on-site visits using standardized evaluation tools. The tools that are used to perform quality assessments and the panel physician licensing agreement are found in the evidence section. Lastly, DGMQ oversees the permitting process for all registered nonhuman primate (NHP) NHP importers. DGMQ monitors all incoming shipments of NHPs and requires importers to complete a mandatory 31-day minimum quarantine period for all imported NHPs. DGMQ inspects all registered facilities that import NHPs to ensure compliance with federal guidelines and works with importers to maintain low mortality in NHPs. Data available in QARS allow DGMQ to track progress toward program goals related to the health of animals in transit.

Evidence: Evidence 2.5.1: U.S. Quarantine Station Fact Sheet, http://www.cdc.gov/ncidod/dq/resources/Quarantine_Stations_Fact_Sheet.pdf; Evidence 2.5.2: Memorandum of Understanding with the Department of Homeland Security; Evidence 2.5.3: EDN User Agreement and EDN Rules of Behavior; Evidence 2.5.4: GeoSentinel RFA; Evidence 2.5.5: Quality Assessment Program Tools for panel physicians; Evidence 2.5.6: Non-human Primate Importer Packet; Evidence 2.5.7: 2007 DGMQ Program Review book [Alien Processing Team (collaboration with IRMH Branch), Aviation Team, Community Preparedness Team, Land Border Team, Maritime Team, Policy Team, Port Preparedness Team, Quarantine Activity Reporting System (QARS) Team, and Quarantine Training and Education Team (QTET); and Evidence 2.5.8: CDC Health Information for International Travel 2008 (Yellow Book).

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: DGMQ has undergone a number of independent evaluations and peer reviews of its programs. Lessons learned from the SARS incident in 2003 were provided in an independent reviews by GAO on DGMQ's role in preparedness and response. In 2005, the Institute of Medicine convened an expert committee that assessed all of DGMQ's programs and specifically assessed the present CDC Quarantine Stations and recommended how they should evolve to meet the challenges posed by microbial threats at the nation's gateways. This recommendation resulted in the current state of DGMQ's organizational structure and function. In addition, DGMQ recently began external peer reviews of core programs every three years. Participants on each review are selected on the basis of the particular expertise needed to evaluate the program under review. The Travel Health external peer review occurred in May 2007. DGMQ's next review, for the the Immigrant, Refugee, and Migrant Health Branch, is scheduled for November 2008. Beginning in 2002, NCID, now NCPDCID, instituted a formal process whereby every program in the Center has to undergo a highly detailed external peer review at least once every five years by the members of the Agency's Board of Scientific Counselors (BSC). The BSC is an independent group of scientists appointed by the Secretary for Health and Human Services. By November 2008, all programs in DGMQ will have undergone BSC peer review. These reviews document the central roles of the program, describe program contributions and challenges, and provide recommendations on how programs can improve. The Traveler's Health external peer review occurred in May 2007. The review was performed through a four day meeting of the 35 independent experts with the intent of reviewing the current CDC Traveler's Health program and developing recommendations to help guide the program's strategic planning for the next five years. Prior to the meeting, each of the experts provided responses to 10 questions and responses were used to form the basis of the meeting agenda with substantial input by a member of the Institute of Medicine, who was one of the 35 experts. The meeting was facilitated by an external moderator. The experts performed a Strengths, Weaknesses, Opportunities, and Threats analysis of the CDC Traveler's Health program and developed several recommendations for the CDC Traveler's Health program. CDC has incorporated several of these recommendations into its short term plan and is working to incorporate many of the recommendations into its long term strategic plan. In addition, GeoSentinel, the cornerstone of Traveler's Health surveillance, was reviewed by the CCID Board of Scientific Counselors (BSC) in May 2008. CDC received positive feedback on the GeoSentinel program and recommendations for improvement. CDC will work towards incorporating recommendations into program activities. A list of conducted and planned peer reviews is attached as evidence.

Evidence: Evidence 2.6.1: GAO report: Emerging Infectious Diseases: Asian SARS Outbreak Challenged International and National Responses. GAO-04-564, April 28, 2005. http://www.gao.gov/cgi-bin/getrpt?GAO-04-564; Evidence 2.6.2: Institute of Medicine "Quarantine Stations at Ports of Entry: Protecting the Public's Health," The National Academies Press, Washington D.C. (2006); Evidence 2.6.3: 2007 Travelers' Health Peer Review; Evidence: 2.6.4: 2002 Evaluation of the Role of Quarantine Stations in the U.S.; and Evidence 2.6.5: Spreadsheet of Peer Review activities for NCPDCID.

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: CDC utilizes the Congressional Justification of the budget to outline budget performance integration. As provided in the CDC FY 2009 Congressional Justification, DGMQ outlines what performance could be achieved with additional investments. For example, fully staffing the existing U.S.-based stations and standing up an additional five international migration quarantine stations will increase by at least 100 percent the number of reported illnesses the quarantine system is able to respond to in real time. Additional staffing in current domestic stations will allow stations to adjust hours of operation from the current average of 60 to approximately 112 hours per week with all stations operating seven days per week (currently only four of the stations operate on weekends). Full staffing of stations will allow for more robust partnership activities with federal agencies operating at the ports of entry as well as state and local agencies and industry in the port community. These activities will lead to increased surveillance and prevention of introduction, transmission, and spread of infectious disease into the United States from foreign countries. In addition, HealthImpact.net, a CDC budget and performance integration tool, is an important step towards a web-enabled agency-wide planning, execution, and searchable knowledge tool that contains budget, strategy, and extramural information. HealthImpact.net is designed to transparently provide CDC leaders at all levels with the basic information they need to manage complex portfolios of public health activities to achieve CDC's Health Protection Goals and implement CDC's Strategic Imperatives. A significant amount of funding is allocated to DGMQ through the Coordinating Office for Terrorism Preparedness & Emergency Response (COTPER) utilizing HealthImpact.net. This web-based planning tool allows COTPER to thoroughly and efficiently analyze each submitted proposal, allowing for informed funding decisions and augmented strategic planning. DGMQ's project data within HealthImpact.net are a rich source of information that can be used to describe the capacities, capabilities, and successes of DGMQ's programs. HealthImpact.net can also be analyzed to identify gaps and opportunities for new investments and projects. Data are currently being used by DGMQ in various ways. Project leads use HealthImpact.net to track and make comparisons between projects. Branch Chiefs use HealthImpact.net to encourage successful, on time milestone completion, which is increasing effectiveness and accountability. For the past two years, through the HealthImpact.net planning and budget integration process, DGMQ has been working toward and reporting on two success factors: 1. Readiness and Response at US Ports of Entry - increase readiness and response capability at US international ports of entry to prevent and contain the introduction of biological threats to human health occurring from either natural or manmade (i.e., bioterrorism) origins; and 2. Disease Surveillance Among Mobile Populations - increase surveillance capability to detect and identify biological threats to human health occurring from either natural or manmade (i.e., bioterrorism) origins among globally mobile and migrating populations. Each success factor has 12 annual measures that are reported quarterly. The HealthImpact.net project for DGMQ includes strategic alignment of DGMQ investments to goals, objectives, focus areas, and population characteristics; and allocation of these investments across basic areas of work, including intervention/technical assistance, research, surveillance, education/training/exercise, and information technology. For extramural programs and procurement of other services, HealthImpact.net includes information on the sectors and organizations being engaged, and what agreements are planned or in place to work with these partners.

Evidence: Evidence 2.7.1: FY 2009 CDC Justification of Estimates for Appropriation Committees, http://www.cdc.gov/fmo/PDFs/FY09_CDC_CJ_Final.pdf; Evidence 2.7.2: HealthImpact.net - Terrorism Preparedness at U.S. Ports (Quarantine Expansion); and Evidence 2.7.3: CDC Health Protection Goals, http://www.cdc.gov/osi/goals/goals.html.

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

Explanation: Since the release of the IOM Report in 2005, DGMQ has moved forward with implementing the concepts around each of the seven IOM recommendations to assure effectiveness and efficiency toward expanding our strategic public health leadership role. At current levels of resources, the robust design has not yet been fully implemented to include 100 percent staffing of 25 stations. However, what DGMQ has accomplished in the past four years is significant. The seven IOM recommendations address: 1) Strategic Leadership; 2) Harmonization of Authorities and Functions; 3) Infrastructure; 4) Location of Stations; 5) Surge Capacity; 6) Research; and 7) Measuring Performance. CDC developed six (6) Strategic imperatives, and twenty-four (24) Health Protection Goals under four (4) themes (Healthy People in Every Stage of Life; Healthy People in Healthy Places; Healthy People in a Healthy World; and People Prepared for Emerging Health Threats). Programs are working with CDC's Office of Strategy and Innovation and the Financial Management Office to align program activities and budget resources to these newly developed goals. Current and future budget requests will be linked to further program activities needed to support these goals. Of the 24 Health Protection Goals, nine (9) are Preparedness Goals. The goals are ordered according to Pre-Event, Event, and Post-Event activities. The goals are further ordered by Prevention (1 goal); Detection and reporting (3 goals); Investigation (1 goal); Control (1 goal) and Recover (2 goals); and Improve (1 goal). The goals address scenarios that include both natural and intentional threats. The first round of the scenarios will include influenza, anthrax, plague, emerging infections threats, toxic chemical exposure, and radiation exposure. As a step toward more tightly integrating financial and performance information, CDC's Office of Strategy and Innovation (OSI), FMO, Procurement and Grants Office (PGO), Management Information Systems Office, and the Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER) developed HealthImpact.net (HI.net) to facilitate the alignment of budget with Agency goals down to the lowest organizational level. Data regarding funding distribution and goals alignment were entered into the application beginning in August of 2005 (for FY 06).

Evidence: Evidence 2.8.1: 42 USC § 268 (b); Evidence 2.8.2: CDC Immigration Requirements: Technical Instructions for Tuberculosis Screening and Treatment (2007); Evidence 2.8.3: Port Preparedness Plans; Evidence 2.8.4: 42 CFR 71; Evidence 2.8.5: CDC Yellow Book: Health Information for International Travel; Evidence 2.8.6: International Health Regulations; Evidence 2.8.7: Community Strategy for Pandemic Influenza Mitigation; Evidence 2.8.8: Memorandum of Understanding with Department of Homeland Security; Evidence 2.8.9: FY 2009 CDC Justification of Estimates for Appropriation Committees; Evidence 2.8.10: DGMQ Research Cooperative agreements; Evidence 2.8.11: CDC reorganization: http://www.cdc.gov/futures/; Evidence 2.8.12: GAO report on the use of COO Concept to address governance challenges: http://www.gao.gov/new.items/d03192sp.pdf; and Evidence 2.8.13: CDC Fact Sheet on 6 Strategic Imperatives and 24 Health Protection Goals: http://www.cdc.gov/about/goals/default.htm.

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 Division of Global Migration and Quarantine (DGMQ) uses a variety of methods (including QARS, the EDN system, GeoSentinel) to capture and track performance information which is used for program management and performance improvement. The Quarantine Activity Reporting System (QARS) captures the detailed day-to-day activities of the quarantine stations, includingtrends in morbidity and mortality in travelers at U.S. ports of entry and disseminate surveillance results to the DGMQ and its partners. It is also used to track individual employee activities and performance. The Electronic Disease Notification (EDN) system is a comprehensive system to communicate with domestic and international partners about disease occurrence and outbreaks among mobile populations entering the United States which will ultimately encompass all 50 states. It addresses significant time lags and accuracy in notification of states when immigrants and refugees arrive with a communicable disease such as tuberculosis. In partnership with the International Society of Travel Medicine (ISTM), the GeoSentinel system tracks geographic trends in infectious diseases among international travelers and contributes to global surveillance for emerging infections. Additional systems, such as eManifest, Electronic Contact List, and MOA Tracking System (MOATS), are also used to manage and improve performance.

Evidence: Evidence 3.1.1: Practical Use of QARS in Presentations and Papers; Evidence 3.1.2: Performance-based Reports in QARS; Evidence 3.1.3: EDN System Improvements http://www.cdc.gov/ncidod/dq/pdf/Comparison_Chart_NEW.pdf; Evidence 3.1.4: GeoSentinel Programmatic Activities and Data Evaluation http://www.istm.org/geosentinel/documents/GeoS_Fever_Wilson_CID_07Jun15.pdf; and Evidence 3.1.5: Published Research Using eManifest data http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5514a6.htm.

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: Both the Division of Global Migration and Quarantine's managers and program partners are held accountable for program performance and achieving results. Within the Division, senior managers' performance plan components are part of a cascade that aligns with Agency goals. Project Officers are charged with monitoring partners' performance. In addition, Grants Administrators must adhere to the Procurement and Grants Office (PGO) guidance on post-award monitoring and ensure that grantees are in compliance with their specific grant agreements and applicable laws and regulations. The program may take and has taken various measures to correct poor performance, including revising work plans or reducing funding.

Evidence: Evidence 3.2.1: Department of Health and Human Services Performance Management Appraisal Program (PMAP) and Senior Executive Service (SES) and Organizational Performance Management System; Evidence 3.2.2: Performance Plans for select CDC and DGMQ managers; Evidence 3.2.3: Description of Financial Status Reports (FSRs); and Evidence 3.2.4: Description of Request for Applications (RFAs).

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

Explanation: CDC's Financial Management Office (FMO) ensures that appropriated funds are properly obligated in a timely manner and that mechanisms are in place to ensure that funds are spent for the purpose for which they are intended. This is demonstrated by efforts in the areas of budget execution consolidation, spending plan execution, cancelled year appropriations, and erroneous payments.

Evidence: Evidence 3.3.1: Budget Execution Branch (BEB) Service Level Agreement; Evidence 3.3.2: Budget Execution Standard Operating Procedure (SOP); Evidence 3.3.3: FY 2007 Spending Plan Guidance; Evidence 3.3.4: DGMQ Example Spending Plan; Evidence 3.3.5: DGMQ Status of Funds Report; Evidence 3.3.6: Appropriations Law http://www.gao.gov/legal/index.html; and Evidence 3.3.7: CDC FY 2006 Improper Payments Information Act Risk Assessment.

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: DGMQ proposes the following efficiency measure for this review: Decrease the cost of notifying state health departments of disease conditions in incoming refugees and immigrants by implementing the electronic disease notification (EDN) system. An overseas medical examination, performed by more than 650 panel physicians worldwide, is required for immigrant visa and refugee status applicants, before migrating to the US. New immigrants and refugees arrive in the US each year with this medical examination documentation. For immigrants and refugees arriving with a Class A/B medical condition, such as tuberculosis (TB), DGMQ notifies the local/state health department of their arrival to ensure medical follow up and electronically submit their medical information. This information is stored in the EDN system. The EDN system is replacing an untimely hard-copy mailing system prone to loss of information that used the U.S. postal service. Complete information from the thorough medical screening is entered for all refugees arriving in the U.S. each year (approximately 70,000), and for immigrants only those records indicating Class A/B conditions are being entered (approximately 20,000 per year). CDC benefits from this measure by fulfilling its regulatory role of notifying the state of local health department of newly arriving migrants with a notifiable condition, and by preventing the importation and spread of infectious diseases and other conditions of public health significance into the US by these groups. US taxpayers benefit because the money saved through EDN can be applied to programmatic efforts, rather than administration/infrastructure. As an agency, CDC continues to examine operations to identify areas where efficiencies may be realized. These actions have occurred both at an agency level and at the program level. Major efforts include competitive sourcing studies to meet the requirements of the President's Management Agenda and review and reorganization of organizational and reporting structures across the agency. Within the Coordinating Center for Infectious Disease (CCID), which the Division is part, efficiencies have been realized though the creation of the Strategic Business Unit (SBU), the Strategic Science and Program Unit (SSPU), and the Performance Management Team (PMT).

Evidence: Evidence 3.4.1: CDC Connects Article: A-76 Competitions: Rigorous, Innovative; Evidence 3.4.2: FY 2009 CDC Justification for Estimates for Appropriation Committees http://www.cdc.gov/fmo/PDFs/FY09_CDC_CJ_Final.pdf; Evidence 3.4.3: Memo with OMB approving Public Health Integrated Business Services (PHIBS) and Budget Execution Service/Financial Management Office (BES/FMO) as HPOs; and Evidence 3.4.4: Federal Register Notice of CCID Reorganization http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/pdf/07-1905.pdf.

Does the program collaborate and coordinate effectively with related programs?

Explanation: In order to fulfill its mission to reduce morbidity and mortality among globally mobile populations and prevent the introduction, transmission, and spread of communicable diseases, the Division collaborates and coordinates effectively with related programs and partners. The programs and partners come from broad setting: within the Agency, throughout the Federal government, from Nongovernmental Organizations (NGOs), from the private sector, and in academia. The Division is involved in training, surveillance, and response activities on a day-to-day basis with numerous partners, such as Customs and Border Protection, Fish and Wildlife Service; Department of Agriculture: Animal Plant and Health Inspection Services; U.S. Coast Guard; Food and Drug Administration; Department of State; Department of Homeland Security; Department of Transportation; Federal Aviation Administration; Transportation Security Administration; Federal Bureau of Investigation; Port officials; Airlines; Cruise lines; Customs brokers and forwarders; Emergency Medical Services; Local and state public health departments; State public health laboratories; State and territorial epidemiologists; Hospitals; Health-care providers; Canadian/Mexican border authorities; World Health Organization; Public Health Agency of Canada; Overseas panel physicians; International Organization for Migration; Foreign governments; Courts; and news media. These collaborations lead to improvement in management and resource allocation.

Evidence: Evidence 3.5.1: Community Strategy for Pandemic Influenza Mitigation http://www.pandemicflu.gov/plan/community/commitigation.html; Evidence 3.5.2: Research of Community Mitigation and NPIs (Requests for Application); Evidence 3.5.3: CDC Travel Notices http://wwwn.cdc.gov/travel/notices.aspx#TravelNoticeDefinitions; Evidence 3.5.4: Port Preparedness Plan for Anchorage, AK http://www.pandemicflu.alaska.gov/PDFs/AnchorageAirport.pdf; Evidence 3.5.5: Infectious Diseases among U.S.-bound Refugees Projects (Requests for Application); Evidence 3.5.6: Public Health Screening at Ports of Entry Guidance; Description: The Division provides their CBP Officers with this guidance to aid in the detection of disease in travelers. It is available online at: http://www.cdc.gov/ncidod/dq/pdf/hguide.pdf; Evidence 3.5.7: Overseas Medical Examination Program Details: Description: Statutory authority and program overview available at: http://www.cdc.gov/ncidod/dq/health.htm; Background information on tuberculosis technical instructions can be accessed from: http://www.cdc.gov/ncidod/dq/titb_background_2007.htm; Most recent technical instructions for tuberculosis screening and treatment by panel physicians can be found at: http://www.cdc.gov/ncidod/dq/panel_2007.htm; Evidence 3.5.8: Response to Tuberculosis in Hmong Refugees: http://www.cdc.gov/ncidod/dq/refugee/hmong/index.htm, http://www.cdc.gov/ncidod/dq/pdf/hmong_colleague.pdf, http://www.cdc.gov/tb/pubs/HmongQA/Default.htm, http://www.cdc.gov/ncidod/dq/refugee/hmong/hmong_refugees.htm, http://www.cdc.gov/ncidod/dq/pdf/TB_Follow_up_Comparison_Chart.pdf; Evidence 3.5.9: Questions about Domestic Refugee Health for the public and partners: http://www.cdc.gov/ncidod/dq/refugee/faq/faq.htm#11; and Evidence 3.5.10: Early Warning Infectious Disease Surveillance (EWIDS) Collaboration http://emergency.cdc.gov/surveillance/ewids/.

Does the program use strong financial management practices?

Explanation: CDC uses effective financial management practices in administering program funds. This is demonstrated by efforts in the following areas: 1. Unified Financial Management System; 2. Performance and Accountability Report; 3. Improper Payments and Recovery Audits; 4. Restructure/Transformation of the Financial Management Office; 5. Budget Execution Consolidation; 6. Skills-based Training and Development; 7. Service Level Agreements; 8. Certification Authority and Responsibility; 9. Budget Notes and Money Matters; 10. FMO Service Desk; 11. Standard Operating Procedures; and 12. A-123 Response.

Evidence: Evidence 3.6.1: HHS Performance and Accountability Reports http://www.hhs.gov/of/reports/account/; Evidence 3.6.2: Attachment detailing BEB services: This document outlines the responsibilities of FMO's Budget Execution Services branch and the responsibilities of CDC programs concerning budget execution activities; Evidence 3.6.3: IDP Implementation Plan Announcement; Evidence 3.6.4: JFMIP Core Competencies/FY 2005 Training Comparison Table; Evidence 3.6.5: CDC Individual Development Plan (IDP) Form and Instructions for Completion; Evidence 3.6.6: Request for Nominations to the AMA Management Certificate Program; Evidence 3.6.7: Spend Plan Development Standard Operating Procedure (SOP); and Evidence 3.6.8: Monitoring Analysis of Spending Plan Standard Operating Procedure (SOP).

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

Explanation: The Division of Global Migration and Quarantine (DGMQ) has taken significant and effective steps to address management issues within the program. Through the recommendations found in the Institute of Medicine's report "Quarantine Stations at Ports of Entry, Protecting the Public's Health," the program has taken steps to improve its strategy and practice to ultimately better achieve its mission. The program has also addressed areas from a Booz Allen Hamilton evaluation and a GAO report regarding the SARS response. In addition, the Division systematically strives to improve management competency and accountability.

Evidence: Evidence 3.7.1: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006); Evidence 3.7.2: Division of Global Migration and Quarantine Strategic Plan CDC/Booz Allen Hamilton, February 2006; and Evidence 3.7.3: DGMQ response to SARS and the findings of the GAO report: Emerging Infectious Diseases: Asian SARS Outbreak Challenged International and National Responses. GAO-04-564, April 28. http://www.gao.gov/cgi-bin/getrpt?GAO-04-564, http://www.cdc.gov/ncidod/dq/roleofdq.htm,

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

Explanation: DGMQ has achieved overall progress towards both long-term measures. The first long-term measure, "Prevent the importation and spread of infectious diseases to the United States in mobile populations and nonhuman primates" is a composite measure that assesses the overall trend towards preventing the importation and spread of infectious diseases to the United States through four different aspects: a key disease (tuberculosis), in key populations (immigrants and refugees and travelers), and in key regulated animals (nonhuman primates). Although long-term measure #1 meets only one of its four targets at present, of the other three annual measures, two show a positive trend and a third has established a solid baseline (see Section 4.2). DGMQ plans to meet its target of all four annual targets by FY 2015. This long-term measure is in direct alignment with DGMQ's mission of preventing the importation and spread of infectious diseases in the United States and covers the range of legal requirements towards achieving DGMQ's mission through appropriate public health interventions, guidance, and communications. The second long-term measure, "Protect the U.S. population by increasing the number of U.S. international airports and land borders covered by a communicable disease preparedness plan to a total of 25," also shows good progress towards achieving its final target, with all quarantine stations having one or more plans in progress or completed and exercised. The first opportunity to detect and control imported infectious disease is at international ports of entry. The 25 top U.S. international airports and land borders account for approximately 85 percent of international arrivals in this country. A comprehensive communicable disease preparedness plan increases the likelihood that control will be successful. These plans integrate the responses of all relevant agencies. The preparedness plans are measures according to completeness of recommended elements met; a plan is considered to have met its target when it includes at least 95 percent of recommended elements. What is being measured is the extent to which CDC and other relevant agencies have considered the practical issues involved in responding to an infectious disease event at an international port, and how that port would address each issue. The issues include command and control, who will respond, assignment of responsibilities, aircraft and ship movement, care for ill passengers (where, how, by whom, how to prevent exposure and infection of others), quarantine of exposed passengers, personal protection of responders, prophylaxis, security, media relations, legal issues, and aircraft/vessel decontamination. DGMQ is making progress in this measure. Of 20 DGMQ airports and land borders, 19 have plans at present. Six of the 18 plans have been revised extensively since creation of the plan template and contain more than 95 percent of the recommended elements. In FY 2004, none of the airports and land borders was covered by a communicable disease preparedness plan. In FY 2007, 9 of the airports and land borders have a plan. DGMQ has targeted FY 2015 for all airports and land borders to have a plan. The achievement of both long-term measures requires extensive partnership building and leadership, which is a key role of DGMQ.

Evidence: Evidence 4.1.1: DGMQ Measures document providing an in-depth explanation of each long-term and annual performance measure; Evidence 4.1.2: DGMQ Communicable Disease Response Plan Assessment Summary Table, January 25, 2008; Evidence 4.1.3: CDC HealthImpact.net - Terrorism Preparedness at U.S. Ports (Quarantine Expansion) 2006, 2007, and 2008.

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

Explanation: For the majority of its annual measures, DGMQ is showing consistent progress towards achieving the targets. The measures reflect the range of activities towards the common goal of preventing the importation and spread of infectious diseases to the United States. Annual Measure 1.1, "Increase the proportion of applications for U.S. immigration screened for tuberculosis under the 2007 tuberculosis Technical Instructions (TI)," reflects the regulatory requirement for medical screening of all applicants of U.S. immigration in order to receive a visa and enter the United States. The TI were phased in beginning in 2007 to four countries, 22% of applicants for U.S. immigration were screened for tuberculosis using the new TI. Annual Measure 1.2, "Increase the likelihood of travelers seeking pre-travel medical advice for travel to Africa and Asia," reflects the increased risk of bringing infectious disease into the United States via travel and transportation. CDC's ability to protect the United States from the introduction of infectious diseases depends in part on DGMQ's ability to educate U.S. travelers and health-care providers about immunizations, medications, and other precautions to ensure safe and healthy travel while abroad and upon returning to the United States. Since the baseline year of 2003, the trend data shows significant progress in the likelihood that travelers to target countries in Asia and Africa will seek pre-travel advice. Annual Measure 1.3, "Increase the percentage of immigrants and refugees with a Class A or B medical notification for tuberculosis who undergo medical follow-up after arrival in the United States," reflects the importance of follow-up evaluation of this population. Improving follow-up is an opportunity to diagnose and treat persons with a class A or B TB condition soon after they arrive in the United States and minimize secondary transmission. Improving follow-up will also contribute to decreasing the burden of tuberculosis in the United States among foreign-born populations. Immigrants arrive in the United States with their medical screening package, which is reviewed upon arrival by Customs and Border Protection (CBP) officers. DGMQ has established a baseline of 60% based on FY 2002-2008 activities. Annual Measure 1.4, "Maintain low mortality in nonhuman primates imported to the United States for science, exhibition, and education," is a long-standing success story for DGMQ. Maintaining low mortality in these primates means that the animals are healthier when they arrive in the United States, thus decreasing the likelihood that people will be exposed to or become infected with zoonotic pathogens carried by the nonhuman primates. Mortality has been decreased dramatically from the baseline of greater than 20% in 1989 to less than 1% in 1999, and this level has been successfully maintained in all subsequent years. Annual Measure 2.1, "Increase the number of hospitals with MOAs in priority 1 cities," ensures rapid selection of a referral hospital if and when a passenger with a potentially communicable disease arrives in the United States. Priority 1 cities have the largest number of passenger volume via commercial aircraft or border crossings and are therefore at increased risk for introduction and spread of infectious diseases. DGMQ has worked to increase the number of hospitals from a baseline of zero in 2003 to 163 in 2007. Annual Measure 2.2, "Increase the number of illnesses in persons arriving in the United States that are reported to DGMQ by conveyance operators, CBP, and others," is an indication of DGMQ's success at forming public health partnerships. This is a direct measurement of the number of illness reported to DGMQ. Some of the reporting is required by regulation and some reflects formal agreements between CDC and CBP and U.S. Coast Guard. Significant progress has been made, from a 2005 baseline of 620 reports of illnesses to 1543 in 2007.

Evidence: Evidence 4.2.1: DGMQ measures document providing an in-depth explanation of each long-term and annual performance measure; Evidence 4.2.2a: Posey, D. L. "Technical Instructions for Overseas Screening and Treatment of Tuberculosis - Update," Presentation to the Advisory Council for the Elimination of Tuberculosis, December 5, 2006; Evidence 4.2.2b: Posey, D. L. "Implementation of 2007 TB Technical Instructions," Presentation to the Advisory Council for the Elimination of Tuberculosis, November 27, 2007; Evidence 4.2.2c: Posey, D. L. "Immigrant, Refugee, and Migrant Health Branch Tuberculosis Activities Update," Presentation to the Advisory Council for the Elimination of Tuberculosis, March 26, 2008; Evidence 4.2.3: CDC HealthImpact.net - Terrorism Preparedness at U.S. Ports (Quarantine Expansion) 2007 and 2008; Evidence 4.2.4: Letter from Julie L. Gerberding to the Honorable Jerry Moran on the 2007 TB TI efforts, April 30, 2008; Evidence 4.2.5a: Omniture SiteCatalyst Report "Most Popular Site Sections for CDC," March 2008; Evidence 4.2.5b: Omniture SiteCatalyst Report "Correlation Report," March 2008.

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

Explanation: DGMQ has been involved in a number of activities to achieve increased efficiency and reduce operating costs. As part of CDC, DGMQ has also been involved in a process to consolidate and restructure all of its support services. The Division has achieved improved efficiencies around IOM's recommendation concerning infrastructure (enhancements in competences, number of people, training, physical space, and utilization of technology). The focus has been on planning and implementation of preparedness strategies, DGMQ headquarters staff and quarantine station personnel formed nine functional teams based on the Strategic Plan (see Evidence 1.4.6). This team structure allows for increased communication, standardization of port response activities, and less duplication of efforts, which improves the efficiency of field operations. The Division has also embarked upon a long-term, multi-year initiative to develop a centralized, comprehensive electronic system to communicate with both national and international partners about diseases and disease outbreaks occurring among mobile populations entering the U.S. These efforts are reflected in the efficiency measure, "Decrease the cost of notifying state health departments of disease conditions in incoming refugees and immigrants by implementing the Electronic Disease Notification system (EDN)." Efficiencies are being achieved by switching from a paper-based to an electronic database system, saving substantial staff time in the field and improving the timeliness of notification to the State health departments, which in turn gives health departments an opportunity to successfully contact newly arrived immigrants and refugees at their first arrival destination in the U.S. It also allows health departments to inform other health departments of secondary migration of immigrants and refugees with TB conditions within the U.S, and provides them with an electronic system to record and evaluate the outcome of domestic follow-up examinations. The centralized data entry function at the CDC headquarters is expected to significantly reduce the personnel costs compared to a decentralized model and facilitate the monitoring of the system from a management and technical support perspective. By monitoring the system performance, DGMQ staff can detect, identify, and include needed improvements into EDN before extending its use to additional states. Because data entry and processing for EDN are being centralized, performance consistency, quality and timeliness have significantly improved. DGMQ has also focused on improving efficiencies through performance management by developing milestones to measure progress. Examples include "Develop and launch a quarantine-specific learning management system to provide access to training on core competencies for quarantine-station staff, with 100 percent of staff registered in the system," and drafting and integrating Public Health Emergency Response plans with local quarantine system partners at 20 ports of entry. CDC has made major achievements in achieving agency-wide efficiencies though the President's Management Agenda (PMA). Earlier PMA activities resulted in 14 completed competitive sourcing studies from 2003 through present covering 610 CDC positions, resulting in five-year savings of $70 million. More recently, CDC has consolidated or restructured almost 40 human capital or business service areas. In 2002, CDC's supervisory ratio was 1:5.5, currently it is 1:12.45. The agency has also consolidated over 13 IT infrastructure functions, services, staff, and fiscal resources into one centralized office, with reduced operating costs of almost 40% and a 29% reduction in staff. Though the end of FY 2007, CDC has had three existing high performing organizations (HPOs) that included over 1,130 positions. The HPO projected savings are $350-375 million over a five year period.

Evidence: Evidence 4.3.1: DGMQ measures document providing an in-depth explanation of each long-term and annual performance measure as well as the proposed efficiency measure. Evidence 4.3.2: CDC HealthImpact.net - Terrorism Preparedness at U.S. Ports (Quarantine Expansion) 2006, 2007, and 2008; Evidence 4.3.3: CDC Proposal for Centralizing EDN Data Entry, Version 1.0, October 3, 2006; Evidence 4.3.4: 2009 CDC Congressional Justification- PMA Section, http://www.cdc.gov/fmo/PDFs/FY09_CDC_CJ_Final.pdf; Evidence 4.3.5: CDC Connects "CoCHP Creates High Performing Organization, Finds Cost Savings for Agency," May 6, 2008; Evidence 4.3.6: CDC Report " CDC Public Health Integrated Business Services (PHIBS) High Performing Organization (Phase 1) Key Performance Indicators & Performance Measures."

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

Explanation: No other agencies exist that have a similar purpose or goals as DGMQ. Three key pieces of legislation make DGMQ's purpose clear. The Secretary of the Department of Health and Human Services has statutory responsibility for preventing the introduction, transmission, and spread of communicable diseases in the United States (42 U.S. Code § 264). The authority for carrying out these functions has been delegated to CDC's Division of Global Migration and Quarantine. DGMQ works to fulfill this responsibility through a variety of activities, including the administration of interstate and foreign quarantine regulations (42 CFR Parts 70 & 71), which govern the interstate and international movement of persons, animals, and cargo and the establishment of standards for medical examination of persons destined for the United States (42 CFR Part 34). The legal foundation for these activities is found in Titles 8 and 42 of the US Code and relevant supporting regulations.

Evidence: None necessary.

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

Explanation: DGMQ has undergone a number of independent evaluations and peer reviews of its programs. These evaluations cover the entire scope of the program and indicated that the program is effective. These reviews document the central roles of the program, describe program contributions and challenges, and provide recommendations on how programs can improve. The following evaluations have been completed since 2005, and recommendations for improvement have been implemented. DGMQ's preparedness planning has its foundation in lessons learned from the DGMQ response to SARS and the findings of the GAO report, "Emerging Infectious Diseases: Asian SARS Outbreak Challenged International and National Responses." In 2005, the Institute of Medicine convened an expert committee that assessed all of DGMQ's programs and specifically assessed the CDC Quarantine Stations and recommended how they should evolve to meet the challenges posed by microbial threats at the nation's gateways. This report resulted in the current state of DGMQ's organizational structure and function. Since the release of the IOM Report, DGMQ has made significant progress in achieving success in the committee's strategic planning recommendations. DGMQ has moved forward with implementing the concepts around each of the seven IOM recommendations to assure effectiveness and efficiency toward expanding our strategic public health leadership role. DGMQ recently began external peer reviews of core programs every three years. Participants on each review are selected on the basis of the particular expertise needed to evaluate the program under review. The Travelers' Health external peer review occurred in May 2007. The review was performed through a four day meeting of the 35 experts who performed a Strengths, Weaknesses, Opportunities, and Threats analysis and developed several recommendations for the CDC Traveler's Health program. CDC has incorporated several of these recommendations into its short term plan and is working to incorporate many of the recommendations into its long term strategic plan. In addition, GeoSentinel the cornerstone of Traveler's Health surveillance was reviewed by the CCID Board of Scientific Counselors (BSC) in May 2008. CDC received positive feedback and recommendations for improvement in areas including targeting expansion efforts and improving linkage to state and local public health. CDC will work towards incorporating recommendations into program activities. NCID, now NCPDCID, instituted a formal process whereby every program in the Center has to undergo a highly detailed external peer review at least once every five years by the members of the Agency's Board of Scientific Counselors (BSC). The BSC is an independent group of scientists appointed by the Secretary of Health and Human Services. All programs in DGMQ have undergone BSC peer review.

Evidence: Evidence 4.5.1: Institute of Medicine, Quarantine Stations at Ports of Entry: Protecting the Public's Health, The National Academies Press, Washington D.C. (2006); Evidence 4.5.2: 2007 Travel Health Peer Review; Evidence 4.5.3: 2008 National Center for Preparedness, Detection, and Control of Infectious Diseases Peer Review; and Evidence 4.5.4: 2002 Evaluation of the Role of Quarantine Stations in the U.S.