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  Box 2
  Infectious Diseases Do Not Recognize Borders

It is not possible to adequately protect the health of our nation without addressing infectious disease problems that are occurring elsewhere in the world. In an age of expanding air travel and international trade, infectious microbes are transported across borders every day, carried by infected people, animals, and insects (Box 2), and contained within commercial shipments of contaminated food (Box 3). “Old” diseases such as malaria, measles, and foodborne illnesses are endemic in many parts of the globe, and new diseases such as acquired immunodeficiency syndrome [AIDS; caused by the human immunodeficiency virus (HIV)]—as well as new forms of old diseases such as multidrug-resistant tuberculosis (TB)—can emerge in one region and spread throughout the world.

  Box 3
  Factors that Facilitate the International Spread of Foodborne Disease

Old diseases, as well as new ones, can travel. For example, between July 1999 and January 2000, 56 people in southern Texas fell ill with dengue fever, a mosquitoborne tropical disease endemic to South and Central America and parts of Asia. Seventeen of those people acquired their illness in the United States. In 1999, two Boy Scouts in New York State acquired malaria—eliminated as an endemic disease problem in the United States a half century earlier—from mosquitos at a summer camp in a rural area of Suffolk County. In August and September, 1999, six people in the northeastern United States and a Canadian visiting New York City died from West Nile encephalitis, a viral disease also transmitted by mosquitos. The West Nile virus, which is carried by migratory birds in Asia, Africa, and Europe, had never before been reported in the Western Hemisphere.

These outbreaks present new challenges for U.S. public health agencies at the local, state, and federal levels. They also remind us that millions of people live in tropical areas where mosquitoborne diseases like malaria and dengue are a fact of everyday life.

Because U.S. and international health are inextricably linked, fulfilling CDC’s domestic mission—to protect the health of the U.S. population—requires global awareness and strategic thinking. This document, Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy, describes how CDC and its international partners can collaborate to prevent the emergence and spread of infectious diseases.

  Box 4
  International Spread of Antimicrobial Resistance

The urgency of the situation is illustrated by the emergence of unforeseen disease problems in recent years. These include multidrug-resistant Streptococcus pneumoniae throughout the world and vancomycin-resistant Staphylococcus aureus in the United States and Japan (Box 4), avian influenza in Hong Kong (Box 5), a new disease called Nipah virus encephalitis identified in Malaysia, as well as the introduction of West Nile encephalitis into North America (Box 2).

  Box 5
  Avian Influenza in Hong Kong

Windows of opportunity for disease control may also close. For example, had smallpox not been eradicated before the global HIV/AIDS epidemic, one of the world’s crowning public health successes might have been impossible to achieve. There is now evidence that immune suppression such as that caused by HIV/AIDS may lead to a lack of response to smallpox vaccination or (in some cases) to disseminated vaccinia infection that may be life-threatening.

  Box 6
  Global Health Initiatives

Left unchecked, today’s emerging diseases can become the endemic diseases of tomorrow. This is what happened with HIV/AIDS, which emerged in a remote part of Africa during the 1970s, spread throughout the world during the 1980s, and is now entrenched on all continents, creating widespread devastation. During the 2000s, HIV/AIDS has become the target of a major international control effort (Box 6).

International Cooperation to Combat Infectious Diseases

The United States must participate more fully in combating infectious disease threats around the world. The urgency of expanding our contributions to infectious disease control was emphasized by an interagency working group of the National Science and Technology Council3Disclaimer.

There has also been an outpouring of interest in infectious disease issues in other nations, both in the developed and the developing world (Appendix B). In July 2000, at the summit meeting in Okinawa, the Group of Eight Industrialized NationsDisclaimer pledged to reduce deaths from infectious diseases in poor countries, agreeing to a set of time-limited objectives. The aim is to reduce the prevalence of HIV/AIDS among young people by 25%, and reduce the number of deaths due to TB and to malaria by 50% by 2010. These goals are based on global health initiatives endorsed by the World Health Organization (WHO) in its effort to address “diseases of poverty” in developing countries (Box 6). Another major initiative, spearheaded by the Global Alliance for Vaccines and ImmunizationDisclaimer (GAVI), aims to increase developing country access to new and underutilitzed vaccines against hepatitis B, Haemophilus influenzae type b, and yellow fever, and to improve delivery of traditional childhood vaccines against measles and other diseases.

  Box 7
  The World Health Organization Global Polio Laboratory Network

Our confidence that nations can come together to improve global health is reinforced by the success of the effort to eradicate smallpox, the interruption of measles transmission in the Americas, and the substantial progress made toward the worldwide eradication of polio (Box 7) and guinea worm disease.

U.S. Investment in Global Public Health

Promoting international cooperation to address emerging infectious diseases is a natural role for the United States, whose scientists and business leaders are important members of the biomedical research and telecommunications communities that provide the technical and scientific underpinning for infectious disease surveillance and control. The United States can continue to lead from its strengths in medical science and technology to help protect American and global health.

Moreover, our nation now has a window of opportunity to make public health investments that will pay increasingly valuable dividends in the years to come. As noted in the 1997 Institute of Medicine report, America’s Vital Interest in Global HealthDisclaimer4, investments in international efforts to detect, control, and prevent infectious diseases can yield multiple benefits:

Protecting the health of U.S. citizens at home and abroad. Seeking to control disease outbreaks as well as dangerous endemic diseases wherever they occur prevents those diseases from spreading internationally, saving lives and dollars. In addition, CDC’s support for outbreak investigations provides U.S. scientists with opportunities to focus on new or drug-resistant pathogens and consider how best to control, prevent, and treat them before they arrive on our shores. Outbreaks and endemic diseases in other countries also endanger U.S. travelers abroad.

In terms of U.S. health, it is far more effective to help other countries control or prevent dangerous diseases than try to prevent their importation, because it is neither efficient nor feasible to examine each person who enters or returns to the United States for evidence of infection, or to examine all imported goods for evidence of contamination. Some infections are asymptomatic, and some infected individuals may enter the country during the incubation period of a disease (the time between infection and the appearance of symptoms). Thus, diseases such as measles and TB continue to be imported.

  Box 13
  Outbreaks Among Refugees in Kosovo and the Sudan

Furthering U.S. humanitarian efforts. Disease prevention is an investment in the young people of the world and in our collective future. Every year, millions of infant and child deaths are prevented by vaccination and other preventive health measures. Many families and communities also benefit from international investigations that lead to prompt control of outbreaks. These include communities of refugees and displaced persons, who may be especially vulnerable to infectious diseases (Box 13). CDC is also a major contributor to global efforts to eradicate polio ( and dracunculiasis (guinea worm disease; and

The potential for saving human lives by preventing infectious diseases overseas is tremendous. For example, an additional three million deaths could be prevented annually by wider worldwide use of childhood vaccines. Although the United States participates in international health projects in many parts of the world, much more can be done, at relatively low cost, with political will, national leadership, and a clearly articulated global strategy.

Investing in global health is an area in which global humanitarian needs and U.S. national interests coincide. For example, U.S. efforts to help the states of the former Soviet Union rebuild their collapsing public health infrastructures5 will also help prevent the resurgence of dangerous diseases (e.g., polio, diphtheria, and drug-resistant TB) that can spread to the Americas. Similarly, U.S. efforts to help China improve surveillance for new strains of influenza may be crucial in preventing or controlling the next influenza pandemic (see Box 5).

Providing economic and diplomatic benefits. Improvements in global health can also enhance the U.S. economy in direct and indirect ways. Domestic healthcare costs can be reduced by decreasing the number of cases of imported diseases and by eradicating diseases currently included in childhood vaccination programs. For example, the U.S. saved $3 billion after investing $32 million in smallpox eradication, and promises to gain even greater cost savings if the global polio eradication effort is successful. Moreover, a reduction in the infectious disease burden in other countries helps improve the economic well-being of developing nations, which represent the fastest growing markets for U.S. products.

  Box 8
  Infectious Diseases and Economic Development

Organizations concerned with economic development, including the World BankDisclaimer and the World Trade Organization ( 2000-wha02.htmlDisclaimer), have concluded that disease reduction efforts are a necessary part of global development strategies (Box 8). Infectious diseases can sap the strength of a nation’s workforce and deplete its medical resources, making it more difficult to participate in the global economy. Promoting political stability and sustainable development in developing nations is a major goal of U.S. foreign policy.

  Box 9
  International Disease Control Efforts Can Create New Alliances

Because health is an area of concern for all nations, international projects that address infectious disease issues can open avenues of communication and ease tensions between the United States and other nations (Box 9). Investments in global health can also help advance specific U.S. foreign policy objectives, such as improving bilateral relationships with Vietnam, China, and the Palestinian Territories, and converting biological weapons plants in the Russian Federation and the newly independent states of the former Soviet Union to peaceful uses.

Enhancing security. Security experts, including members of the U.S. National Intelligence Council6 ( are concerned that large outbreaks like the HIV/AIDS pandemic may destabilize poorer nations. Slowed economic growth fueled by poor health and disease in developing and former communist countries may challenge democratic development and political transitions and contribute to humanitarian emergencies and military conflicts.

The recent intentional releases of biologic agents in the United States have also intensified international concerns about bioterrorism. Due to the ease and frequency of modern travel, an intentionally-caused outbreak that begins anywhere in the world can quickly become an international problem. A contagious bioterrorist agent such as smallpox can spread rapidly from person to person and from country to country. A noncontagious agent such as anthrax can be spread by unexpected methods, including international mail. The United States must be prepared to work with other nations to prevent illness and deaths caused by acts of bioterrorism.

CDC’s Role in Promoting Global Public Health

As its name implies, CDC is dedicated to the control and prevention of disease. The agency grew out of efforts to control malaria in the southern United States and today retains a critical role in addressing domestic infectious disease threats. CDC is known in the United States for

  • Working with state and local public health agencies to conduct disease surveillance
  • Providing national leadership in times of public health crisis
  • Diagnosing rare, highly dangerous, and previously unknown diseases
  • Responding rapidly to requests for outbreak assistance
  • Researching public health issues and translating the findings into practical tools for disease control and prevention
  • Using surveillance data to drive public health action and inform strategic planning
  • Integrating epidemiologic and laboratory expertise to address infectious disease problems
  • Implementing programs for disease prevention and control
  • Training public health workers
  Box 24
  Applied Field Epidemiology Programs

CDC works by invitation in many different jurisdictions, including U.S. states and cities and other nations. Throughout its history, CDC has also provided international leadership in public health, serving as a technical consultant to WHO and ministries of health on projects that address infectious disease problems related to endemic diseases, wars, famines, or other disasters. Many of these projects were funded and coordinated by the U.S. Agency for International Development (USAID). Through the Field Epidemiology Training Programs (see Box 24), the Epidemic Intelligence Service, and other programs, CDC has also supported research and public health education on diseases of regional or international importance. CDC helped lead the smallpox eradication effort in the 1960s, and established collaborative research stations (see Box 10) in Côte d’Ivoire, Guatemala, and Kenya in the 1980s and in Guinea, Botswana, Thailand, and Uganda in the 1990s. Although considerable effort has been devoted to these international activities, CDC’s primary focus has remained on domestic health.

  Box 10
  Examples of CDC's Long-term Research Collaborations Overseas

An evolving mission. In recent years, CDC’s overseas role has expanded rapidly. Global polio eradication and HIV/AIDS control programs have led to substantial investments of CDC personnel and financial resources, as have a succession of complex international emergencies. Between 1990 and 2000, CDC provided rapid response teams to nations in Asia, Africa, Europe, and Latin America to help investigate outbreaks of unknown, highly dangerous, and highly infectious diseases (Appendix C), and provided diagnostic support for hundreds of local investigations around the globe. Some of these investigations involved epidemic diseases and others involved diseases that afflict refugees and other displaced persons. In many cases, CDC epidemiologists served as members of WHO-coordinated investigative teams supported by CDC-based WHO Collaborating Centre laboratories (Appendix D). In addition to helping with outbreak control, CDC provides ongoing public health consultation by placing resident advisors and assignees with key partner agencies and by working with coalitions of national groups on emerging infectious disease issues.

CDC’s growing presence overseas presents new opportunities and new challenges. This document, Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy, represents an active effort to further define CDC’s evolving global mission. It was developed in consultation with public and private sector partners, at home and abroad. It considers how CDC and its international partners can work together over the long term to improve the capacity to detect, control, and prevent infectious diseases.

This document builds on two ongoing efforts. First, it augments and amplifies the international component of the 1998 CDC plan Preventing Emerging Infectious Diseases: A Strategy for the 21st Century10. CDC’s ongoing efforts to strengthen U.S. domestic public health infrastructure are critical to the success of our international collaborations. Second, it fits within the larger framework of CDC’s efforts to improve international health, as described in Working with Partners To Improve Global Health: A Strategy for CDC and ATSDR11.

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Booklet Contents
item Contributors
item Table of Contents
item Preface
item Executive Summary
item Introduction
item International Cooperation To Combat Infectious Diseases
item U.S. Investment in Global Public Health
item Protecting the health of U.S. citizens at home and abroad
item Furthering U.S. humanitarian efforts
item Providing economic and diplomatic benefits
item Enhancing security
item CDC's Role in Promoting Global Public Health
item An evolving mission
item Vision for the Future
item Partnerships and Implementation
item Priorities and Objectives
1. International Outbreak Assistance
item Objectives
2. A Global Approach to Disease Surveillance
item Objectives
3. Applied Research on Diseases of Global Importance
item Objectives
4. Application of Proven Public Health Tools
item Objectives
5. Global Initiatives for Disease Control
item Objectives
6. Public Health Training and Capacity Building
item Objectives
item List of Boxes
item Acronyms
item Appendix A
item Appendix B
item Appendix C
item Appendix D
item Appendix E
item Acknowledgments
item References

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Date published: 2002

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