Global Microbial Threats in the 1990s

V. What mandates and authority should be granted to U.S. Government agencies to enable them to strengthen global disease surveillance and response?

The U.S. Government has many existing resources that may be coordinated with those of foreign countries, WHO, and other international agencies to build a global international system for infectious disease surveillance and response. To make the best possible use of U.S. expertise and resources, the efforts of U.S. Government agencies should be well-coordinated. In those instances in which a disease outbreak occurs in the midst of a major disaster, USAID's OFDA has a clear mandate to facilitate a coordinated U.S. response. However, when an outbreak occurs in the absence of a disaster, no U.S. Government agency has the authority to take the lead in coordinating U.S. efforts, and no government structure exists to oversee the development of a surveillance network, to mobilize a concerted response when a disease outbreak occurs, or to coordinate preventive measures aimed at anticipated health threats. It is strongly recommended that some lead agency or agencies be given the authority and resources to fulfill these functions.

Establishment of an Interagency Task Force

Further strategic planning is required to help build an international network for infectious disease surveillance and response. To carry on this work, it is recommended that an Interagency Task Force be established that meets on a regular basis to

• Oversee the coordination, strengthening, and geographical widening of existing global communications networks for use in the surveillance and control of infectious diseases.
• Determine how gaps in U.S. capacity to respond to infectious disease outbreaks abroad may be filled by improved interagency or public/private sector coordination

Activities of individual U.S. Government agencies with regard to disease surveillance and control

As a matter of U.S. Government policy, all U.S. laboratories, field stations, and offices abroad should be encouraged to participate in infectious diseases surveillance, as far as it is within their resources and mandate to do so. Listed below are current activities performed by U.S. Government agencies which contribute to infectious disease surveillance and response throughout the world. In some cases, recommendations are made on how to overcome the gaps in authority and structure described in this report.

Department of State

The Department of State coordinates interagency policy on international issues and should take a lead role in the Interagency Task Force's strategic planning efforts.

• As with other natural disasters, like earthquakes or hurricanes, U.S. ambassadors should be granted the authority to make the determination that an outbreak of infectious disease requires U.S. attention and/or assistance.
• When a U.S. Ambassador makes such a determination, State should facilitate a rapid U.S. Government response by
  • Contacting the Interagency Task Force, and
  • Coordinating U.S. action with that of other nations and WHO.
• U.S. ambassadors should be encouraged to support the efforts of other agencies, including the DoD, USAID, NIH, and CDC, in strengthening the global disease surveillance and response network. The DoD's infectious disease laboratories abroad are aligned with and dependent on close interaction with the embassies. U.S. ambassadors should ensure that personnel ceilings in the DoD laboratories are adequate to allow global disease surveillance to proceed.
• The Department of State and USAID should take a lead role in encouraging and assisting other countries to make infectious disease detection and control a national priority.
• Diplomatic resources should be made available as needed to encourage foreign governments to cooperate with international efforts to contain epidemics that occur within their borders.
• The Department of State's Office of Medical Services employs 24,000 doctors and nurse practitioners in 260 locations, some of which are located in remote areas. Medical information gathered from these locations should be supplied to the global disease surveillance network.

Centers for Disease Control and Prevention

CDC is the lead U.S. agency in matters of domestic disease surveillance, control, and prevention. However, CDC does not have direct authority to support the development of international health programs. Because it lacks direct authority in this area, CDC cannot receive appropriations in support of international infectious disease surveillance, except for AIDS surveillance.

• In view of the international nature of emerging infectious diseases, and of the increasing mobility of infectious microbes, CDC's mandate to protect the health of U.S. citizens should be extended by legislation to include outbreak investigations and responses to epidemics overseas in coordination with appropriate U.S. agencies, including state and local health departments, USAID, DoD, etc, when they occur outside the context of disaster assistance.
• CDC should assist in formulating and implementing the US Government international surveillance, response, and prevention strategies. They should provide epidemiology and laboratory personnel and direction for epidemic response. They should also provide assistance with diagnostic referrals.
• CDC should serve as the primary link with the global network of Field Epidemiology Training Programs (FETPs), providing for improved communications and sharing of epidemiologic and laboratory information among the FETP network (including CDC), and identifying epidemiologic and laboratory expertise in the global FETP network that could assist in emerging disease and disaster assistance in partnership with the U.S. Government.
• Along with the USAID and the Office of International Health of the Department of Health and Human Services, CDC should coordinate the disease surveillance initiatives of the U.S. Interagency Task Force with those of WHO.

Food and Drug Administration

The FDA has a broad mandate to ensure the safety of foods and the safety and efficacy of a variety of other products it regulates including drugs, biologics, blood and blood components, diagnostics and medical devices.

• As a member of the Interagency Task Force, the FDA should make its expertise available to the Task Force to the extent resources allow, to ensure adequate supplies and to assist others in the emergency development and production of vaccines, drugs and diagnostics. The FDA should serve as the focal point for coordination between the Interagency Task Force and U.S. or multinational private companies, trade associations or other suppliers that may be called upon to assist in the emergency manufacture or development of medical supplies.
• The FDA should collaborate with CDC and USDA in establishing an active surveillance system for foodborne diseases.
• The FDA should continue its emergency response efforts in cooperation with CDC and USDA to investigate sources of food-borne pathogens and to respond to outbreaks by taking appropriate measures.

The mandate of NIH includes the support of research and training related to infectious disease. In accordance with this mandate, the National Institute of Allergy and Infectious Diseases (NIAID) and the Fogarty International Center should take the lead in supporting research and training that will provide information relevant to the development of vaccines, therapeutics, and diagnostics. These research and training activities should support the global disease surveillance network and response efforts.

National Institute of Allergy and Infectious Diseases

The NIAID funds multiple research grants and contracts with clinical research and epidemiologic component. These include 11 International Collaborations in Infectious Disease Research (ICIDR) and three Tropical Medicine Research Centers (TMRC), in several countries. The purpose of these centers is clinical research, including population-based studies and epidemiologic research. In addition, NIAID supports nine HIVNET projects overseas and eight in the United States, which monitor the incidence of AIDS in populations likely to participate in future vaccine trials and help create an infrastructure for future vaccine efficacy trials by training technicians and supporting the development of laboratories.

• Workers at NIAID-supported units should be encouraged to report any infectious disease outbreaks that come to their attention. Overseas centers may also be able to facilitate communication with their local ministries of health.
• Many of NIAID's projects involved in research on parasitic, enteric and respiratory diseases are linked in a network of international centers for tropical disease research, which includes academic institutions in over 15 countries and meets regularly with federal agencies and international organizations involved in international research. This network could form an effective base for expanded international collaboration on emerging disease issues, and should be encouraged to take a leadership role in this area.
• In accordance with their mandates, the NIAID, Fogarty, and other NIH-supported facilities should participate in research and training in support of the global disease surveillance network.

The Fogarty International Center should support research and training efforts and bilateral and multilateral scientific collaborations that enhance the capabilities of developing countries to address emerging and re-emerging disease, including epidemiology and surveillance and the conduct of research. The current FIC AIDS International Training and Research Program (AITRP) has linked 11 U.S. universities with institutions in 65 countries. This network will provide a model for expansion into other emerging diseases.

Office of International Health

The Office of International Health of the Department of Health and Human Services should work with the Interagency Task Force to coordinate U.S. global surveillance initiatives with those of WHO.

U.S. Agency for International Development

USAID is the lead U.S. agency in support of international health. As such, USAID provides assistance in health research and health care delivery in over 40 developing countries. This support is provided to national governments, non-governmental organizations, universities, research institutes, and private sector entities. USAID has resident technical staff managing bilateral and regional health programs in most of these countries. In accordance with its mandate and its current role in strengthening the capacity of developing countries to identify and solve health problems, USAID will:

• Help to strengthen developing country capacity to address emerging health threats such as AIDS and drug resistant malaria;
• Develop and improve methods for detecting and responding to antimicrobial resistance to drugs used for the treatment of pneumonia, malaria, diarrhea, and TB;
• Assist, together with other donors in efforts to strengthen health information systems;
• Support and expand existing programs to strengthen developing countries' capacities in epidemiology and laboratory and clinical diagnosis;
• Continue to play a leadership role with WHO and international donors in addressing emerging health issues of major importance to developing countries.

Although USAID has the legislative mandate to implement international health programs, current and anticipated budget constraints will limit USAID activities that address emerging and re-emerging health threats. On-going health programs have already been cutback substantially due to lack of resources. Current activities in child survival, AIDS, and environmental health address many issues related to the prevention and control of new and re-emerging diseases. Additional health funds would have to be appropriated to enable the USAID to initiate new or expanded activities in this area.

Department of Defense

The DoD operates research laboratories in the United States for studying infectious diseases that threaten military personnel. The emphasis is on insect-borne parasitic and viral diseases and diarrheal diseases of travelers. Work focuses on improved diagnosis and development of better preventive measures. DoD operates a U.S. research laboratory and treatment unit with the highest level of biocontainment. DoD has the capability of transporting patients infected with hazardous agents from anywhere in the world for care.

DoD operates overseas infectious disease laboratories in Brazil, Egypt, Indonesia, Kenya, Peru, and Thailand. These laboratories conduct research on diseases of mutual interest to the host country and the United States. Each laboratory has a capability for evaluating new problems through epidemiologic investigation, for diagnosing diseases, and for recommending control measures.

DoD has a limited capability to produce prototype vaccines for human testing. Vaccines produced are for diseases uncommon in the United States. Large-scale vaccine manufacture depends on contracts with commercial facilities. Emergency scale-up of vaccine production by contractors is available for a select group of highly hazardous agents.

• DoD should strengthen communication among its laboratories to create a communication network for global surveillance.
• DoD should work with USAID, CDC, and host nations to provide diagnostic, logistical, and communication assistance for responding to epidemics.

U.S. Department of Agriculture

USDA cooperates with the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Department of Defense on international disease issues, as well as with international organizations such as the World Health Organization and Food and Agriculture Organization. A permit and health certificates must be obtained from APHIS by people intending to import animals into the United States. APHIS then arranges the supervision of testing and examinations of animals by licensed and accredited veterinarians in that country.

• Rapid detection and diagnostic capabilities need to be developed and made available for many zoonotic diseases.
• Innovative risk management approaches are needed, especially with increasing travel and trade.

The Peace Corps

Department of Veterans Affairs

One of the Department of Veterans Affairs' (DVA) four missions is emergency preparedness. DVA's experience in tracking the illnesses of soldiers who return from abroad, as well as in investigating disease transmission, should help the Interagency Task Force detect and respond to infectious diseases.

U.S. Department of Commerce

National Oceanic and Atmospheric Administration

The NOAA ability to forecast El Nino currents has yielded useful predictions of climate variability up to one year in advance in certain parts of the world, particularly in the tropics. This activity offers the opportunity to provide a predictive dimension to the global disease surveillance system.

Climate variability affects the distribution and number of insect and rodent disease vectors, as well as of other animals that serve as reservoirs for human diseases. Climate variability also affects the distribution and quality of fresh water and therefore affects the incidence of waterborne diseases. Climate monitoring and forecasting should be integrated with global disease surveillance to enhance U.S. predictive and preventive capacities.

National Institute of Standards and Technology

The National Institute of Standards and Technology (NIST) laboratories are responsible for the standardization of many products used in measurement and testing, including some diagnostic reagents. NIST's Advanced Technologies Program (ATP) currently supports research and development on diagnostic tests for infectious diseases based on DNA probes. NIST should be encouraged to continue work on the standardization of products for the diagnosis of infectious diseases.

Environmental Protection Agency

The Environmental Protection Agency (EPA) is studying the effects of long-term climate change on vector-borne diseases, which can be especially sensitive to subtle changes in temperature, precipitation, and weather variability. Ecological perturbations resulting from either climate change or human land use patterns may alter the environment in such a way as to promote disease emergence.

EPA should have the capacity to provide to the Interagency Task Force results from the monitoring of environmental changes which may relate to shifting disease distribution or emergence. As environmental factors involved in disease systems become better understood, the EPA could be encouraged to improve monitoring, surveillance, and reporting of such potential indicators to provide the opportunity for earlier pubic health intervention.

EPA personnel working in the environmental health offices of WHO could further serve to help link relevant environmental data to the international disease surveillance efforts of WHO.

Cooperation with the World Health Organization

The WHO is often in the best position for early recognition of infectious disease outbreaks through its interactions with the various networks of WHO Collaborating Centres, and is also often best suited to coordinate response activities. The Interagency Task Force should therefore maintain close communications with the WHO.

During the 1995 World Health Assembly, a resolution was passed that deals specifically with emerging and re-emerging infectious diseases. The resolution defines a global leadership role for WHO in addressing emerging infectious diseases, and its endorsement by member states will facilitate implementation activities. The U.S. Government strongly supported both the acceptance and implementation of the resolution.

As the WHO has no laboratory resources of its own, it relies upon an international network of Collaborating Centres for technical guidance. Many of these WHO Collaborating Centres are located in the United States, but most of them do not receive funds from WHO to offset the costs they incur in providing this critical service. The Interagency Task Force should identify WHO Collaborating Centres within the United States that are essential to address emerging and re-emerging infectious diseases and should ensure their core funding through a combination of U.S. Government (CDC, NIH, USAID, and others) and international resources (WHO and others).

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