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.
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
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.
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.
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.
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.
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.
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:
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.
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.
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.
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).