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 diseasesurveillance and response?
The U.S. Government has many existing resources that may becoordinated with those of foreign countries, WHO, and otherinternational agencies to build a global international system forinfectious disease surveillance and response. To make the bestpossible use of U.S. expertise and resources, the efforts of U.S.Government agencies should be well-coordinated. In thoseinstances in which a disease outbreak occurs in the midst of amajor disaster, USAID's OFDA has a clear mandate to facilitate acoordinated U.S. response. However, when an outbreak occurs inthe absence of a disaster, no U.S. Government agency has theauthority to take the lead in coordinating U.S. efforts, and nogovernment structure exists to oversee the development of asurveillance network, to mobilize a concerted response when adisease outbreak occurs, or to coordinate preventive measuresaimed at anticipated health threats. It is strongly recommendedthat some lead agency or agencies be given the authority andresources to fulfill these functions.
Establishment of an Interagency Task Force
Further strategic planning is required to help build aninternational network for infectious disease surveillance andresponse. To carry on this work, it is recommended that anInteragency Task Force be established that meets on a regularbasis to
Participation in the Task Force should include, but not belimited to, CDC, FDA, NIH, State, DoD, and USAID. These sixagencies should form a core group for facilitating U.S.Government responses to infectious disease outbreaks in othercountries.
Activities of individual U.S. Government agencies with regard todisease surveillance and control
As a matter of U.S. Government policy, all U.S. laboratories,field stations, and offices abroad should be encouraged toparticipate in infectious diseases surveillance, as far as it iswithin their resources and mandate to do so. Listed below arecurrent activities performed by U.S. Government agencies whichcontribute to infectious disease surveillance and responsethroughout the world. In some cases, recommendations are made onhow to overcome the gaps in authority and structure described inthis report.
Department of State
The Department of State coordinates interagency policy oninternational issues and should take a lead role in theInteragency Task Force's strategic planning efforts.
Department of Health and Human Services: Public Health Service
Centers for Disease Control and Prevention
CDC is the lead U.S. agency in matters of domestic diseasesurveillance, control, and prevention. However, CDC does not havedirect authority to support the development of internationalhealth programs. Because it lacks direct authority in this area,CDC cannot receive appropriations in support of internationalinfectious disease surveillance, except for AIDS surveillance.
Food and Drug Administration
The FDA has a broad mandate to ensure the safety of foods and thesafety and efficacy of a variety of other products it regulatesincluding drugs, biologics, blood and blood components,diagnostics and medical devices.
National Institutes of Health
The mandate of NIH includes the support of research and trainingrelated 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 insupporting research and training that will provide informationrelevant to the development of vaccines, therapeutics, anddiagnostics. These research and training activities shouldsupport the global disease surveillance network and responseefforts.
National Institute of Allergy and Infectious Diseases
The NIAID funds multiple research grants and contracts withclinical research and epidemiologic component. These include 11International Collaborations in Infectious Disease Research(ICIDR) and three Tropical Medicine Research Centers (TMRC), inseveral countries. The purpose of these centers is clinicalresearch, including population-based studies and epidemiologicresearch. In addition, NIAID supports nine HIVNET projectsoverseas and eight in the United States, which monitor theincidence of AIDS in populations likely to participate in futurevaccine trials and help create an infrastructure for futurevaccine efficacy trials by training technicians and supportingthe development of laboratories.
Fogarty International Center
The Fogarty International Center should support research andtraining efforts and bilateral and multilateral scientificcollaborations that enhance the capabilities of developingcountries to address emerging and re-emerging disease, includingepidemiology and surveillance and the conduct of research. Thecurrent FIC AIDS International Training and Research Program(AITRP) has linked 11 U.S. universities with institutions in 65countries. This network will provide a model for expansion intoother emerging diseases.
Office of International Health
The Office of International Health of the Department of Healthand Human Services should work with the Interagency Task Force tocoordinate U.S. global surveillance initiatives with those ofWHO.
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 healthcare delivery in over 40 developing countries. This support isprovided to national governments, non-governmental organizations,universities, research institutes, and private sector entities.USAID has resident technical staff managing bilateral andregional health programs in most of these countries. Inaccordance with its mandate and its current role in strengtheningthe capacity of developing countries to identify and solve healthproblems, USAID will:
Although USAID has the legislative mandate to implementinternational health programs, current and anticipated budgetconstraints will limit USAID activities that address emerging andre-emerging health threats. On-going health programs have alreadybeen cutback substantially due to lack of resources. Currentactivities in child survival, AIDS, and environmental healthaddress many issues related to the prevention and control of newand re-emerging diseases. Additional health funds would have tobe appropriated to enable the USAID to initiate new or expandedactivities in this area.
Department of Defense
The DoD operates research laboratories in the United States forstudying infectious diseases that threaten military personnel.The emphasis is on insect-borne parasitic and viral diseases anddiarrheal diseases of travelers. Work focuses on improveddiagnosis and development of better preventive measures. DoDoperates a U.S. research laboratory and treatment unit with thehighest level of biocontainment. DoD has the capability oftransporting patients infected with hazardous agents fromanywhere in the world for care.
DoD operates overseas infectious disease laboratories in Brazil,Egypt, Indonesia, Kenya, Peru, and Thailand. These laboratoriesconduct research on diseases of mutual interest to the hostcountry and the United States. Each laboratory has a capabilityfor evaluating new problems through epidemiologic investigation,for diagnosing diseases, and for recommending control measures.
DoD has a limited capability to produce prototype vaccines forhuman testing. Vaccines produced are for diseases uncommon in theUnited States. Large-scale vaccine manufacture depends oncontracts with commercial facilities. Emergency scale-up ofvaccine production by contractors is available for a select groupof highly hazardous agents.
U.S. Department of Agriculture
USDA cooperates with the Centers for Disease Control andPrevention, the Food and Drug Administration, and the Departmentof Defense on international disease issues, as well as withinternational organizations such as the World Health Organizationand Food and Agriculture Organization. A permit and healthcertificates must be obtained from APHIS by people intending toimport animals into the United States. APHIS then arranges thesupervision of testing and examinations of animals by licensedand accredited veterinarians in that country.
The Peace Corps
The Peace Corps' Epidemiologic Surveillance System receivesreports on the medical status of volunteers in 92 developingcountries, and thus, can serve as a valuable component in theglobal surveillance network. Possibly this surveillance systemcould be expanded to include wider reporting of illnesses in thevillages where the volunteers work.
Department of Veterans Affairs
One of the Department of Veterans Affairs' (DVA) four missions isemergency preparedness. DVA's experience in tracking theillnesses of soldiers who return from abroad, as well as ininvestigating disease transmission, should help the InteragencyTask 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 usefulpredictions of climate variability up to one year in advance incertain parts of the world, particularly in the tropics. Thisactivity offers the opportunity to provide a predictive dimensionto the global disease surveillance system.
Climate variability affects the distribution and number of insectand rodent disease vectors, as well as of other animals thatserve as reservoirs for human diseases. Climate variability alsoaffects the distribution and quality of fresh water and thereforeaffects the incidence of waterborne diseases. Climate monitoringand forecasting should be integrated with global diseasesurveillance to enhance U.S. predictive and preventivecapacities.
National Institute of Standards and Technology
The National Institute of Standards and Technology (NIST)laboratories are responsible for the standardization of manyproducts used in measurement and testing, including somediagnostic reagents. NIST's Advanced Technologies Program (ATP)currently supports research and development on diagnostic testsfor infectious diseases based on DNA probes. NIST should beencouraged to continue work on the standardization of productsfor the diagnosis of infectious diseases.
Environmental Protection Agency
The Environmental Protection Agency (EPA) is studying the effectsof long-term climate change on vector-borne diseases, which canbe especially sensitive to subtle changes in temperature,precipitation, and weather variability. Ecological perturbationsresulting from either climate change or human land use patternsmay alter the environment in such a way as to promote diseaseemergence.
EPA should have the capacity to provide to the Interagency TaskForce results from the monitoring of environmental changes whichmay relate to shifting disease distribution or emergence. Asenvironmental factors involved in disease systems become betterunderstood, the EPA could be encouraged to improve monitoring,surveillance, and reporting of such potential indicators toprovide the opportunity for earlier pubic health intervention.
EPA personnel working in the environmental health offices of WHOcould further serve to help link relevant environmental data tothe international disease surveillance efforts of WHO.
Cooperation with the World Health Organization
The WHO is often in the best position for early recognition ofinfectious disease outbreaks through its interactions with thevarious networks of WHO Collaborating Centres, and is also oftenbest suited to coordinate response activities. The InteragencyTask Force should therefore maintain close communications withthe WHO.
During the 1995 World Health Assembly, a resolution was passedthat deals specifically with emerging and re-emerging infectiousdiseases. The resolution defines a global leadership role for WHOin addressing emerging infectious diseases, and its endorsementby member states will facilitate implementation activities. TheU.S. Government strongly supported both the acceptance andimplementation of the resolution.
As the WHO has no laboratory resources of its own, it relies uponan international network of Collaborating Centres for technicalguidance. Many of these WHO Collaborating Centres are located inthe United States, but most of them do not receive funds from WHOto offset the costs they incur in providing this criticalservice. The Interagency Task Force should identify WHOCollaborating Centres within the United States that are essentialto address emerging and re-emerging infectious diseases andshould ensure their core funding through a combination of U.S.Government (CDC, NIH, USAID, and others) and internationalresources (WHO and others).
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