PROTECTING THE NATION’S IN AN ERA OF CDC’s Global Infectious Strategy

Department of Health and Centers for Disease Control and Prevention DEPARTMENT OF HEALTH AND HUMAN SERVICES Tommy G. Thompson, Secretary

CENTERS FOR DISEASE CONTROL AND PREVENTION Jeffrey P. Koplan, M.D., M.P.H., Director David Fleming, M.D., Deputy Director for and Stephen B. Blount, M.D., M.P.H., Director, Office of

National Center for Infectious James M. Hughes, M.D., Director

National Center for HIV, STD, and TB Prevention Harold Jaffe, M.D., Acting Director

National Immunization Program Walter A. Orenstein, M.D., Director

Epidemiology Program Office Stephen B. Thacker, M.D., M.Sc., Director

Public Health Practice Program Office Edward L. Baker, M.D., M.P.H., Director

The following CDC staff members prepared this report. Scott F. Dowell, M.D., M.P.H., National Center for Infectious Diseases Alexandra M. Levitt, Ph.D., National Center for Infectious Diseases

With input from the Global Infectious Diseases Strategy Working Group Jay McAuliffe, M.D., Office of Global Health Kenneth Castro, M.D., National Center for HIV, STD, and TB Prevention Eugene McCray, M.D., National Center for HIV, STD, and TB Prevention Stephen Cochi, M.D., M.P.H., National Immunization Program Stephen Hadler, M.D., National Immunization Program Mark White, M.D., Program Office Michael Malison, M.D., M.P.A., Public Health Practice Program Office Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy

Atlanta, Georgia, 2002 For additional copies of this booklet, write to

Office of National Center for Infectious Diseases Centers for Disease Control and Prevention Mailstop C-14 1600 Clifton Road, NE Atlanta, GA 30333 Fax: 404-371-5490 or visit the website: www.cdc.gov/globalidplan.htm Preface 5 TABLE OF Executive Summary 6 CONTENTS INTRODUCTION 11 International Cooperation To Combat Infectious Diseases 15 U.S. Investment in Global Public Health 16 Protecting the health of U.S. citizens at home and abroad 18 Furthering U.S. humanitarian efforts 19 Providing economic and diplomatic benefits 19 Enhancing security 19 CDC’s Role in Promoting Global Public Health 20 An evolving mission 22

VISION FOR THE FUTURE 24

PARTNERSHIPS AND IMPLEMENTATION 26

PRIORITIES AND OBJECTIVES 28 1 International Outbreak Assistance 28 2 A Global Approach to 33 3 Applied on Diseases of Global Importance 38 4 Application of Proven Public Health Tools 44 5 Global Initiatives for Disease Control 48 6 Public Health Training and Capacity Building 53

List of Boxes 59 Acronyms 60 Appendix A: Global Health Websites 62 Appendix B: Diplomatic Forums That Address Emerging 64 Infectious Disease Issues Appendix C: Examples of International Outbreak Assistance 65 Appendix D: WHO Collaborating Centres Based at CDC 67 Appendix E: Regional and Disease-Specific Surveillance Networks 68 Acknowledgments 71 References 72

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 3

ince 1994, CDC has been engaged in a nationwide effort to revitalize PREFACE Snational capacity to protect the public from infectious disease. con- tinues to be made in the areas of disease surveillance and ; applied research; prevention and control; and infrastructure-building and train- ing. These efforts are intended to provide protection against diseases like and C, as as against whatever new or drug-resist- ant diseases arise.

Although safeguarding U.S. health is a domestic goal, its achievement requires international action and cooperation. This is because U.S. health and global health are inextricably linked. As the AIDS has illustrated, a disease that emerges or reemerges anywhere in the world can spread far and wide. With increased rates of and international trade, infectious microbes have many opportunities to spread across borders, whether carried by businessmen and tourists, by that “hitchhike” on airplanes, or by exotic imported as pets or livestock. Microbes have additional opportunities for spread on international shipments of fruits, , fish, or vegetables.

The international dimension of the effort to combat infectious diseases is reflect- ed in CDC’s growing international role. Whenever a new, highly dangerous, drug-resistant, or reemerging disease is detected anywhere on the globe, U.S. cit- izens, as well as foreign governments, have come to rely on CDC to provide assistance and public health . Established diseases such as HIV/AIDS, tuberculosis, and , as well as -preventable diseases such as , demand increasing attention and resources as well. This increased international engagement has stimulated CDC to rethink its infectious disease priorities, keeping in mind that it is far more effective to help other countries control or prevent dangerous diseases at their source than try to prevent their importation.

This document, Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy, represents an important advance in defining CDC’s evolving global mission and in considering how CDC and its international partners can work together to improve global capacity for disease surveillance and outbreak response. We look forward to working with our many partners throughout the nation and the world as we put this strategy into practice.

Jeffrey P. Koplan, M.D., M.P.H. Director Centers for Disease Control and Prevention

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 5 is not possible to adequately pro- eases of tomorrow. This is what hap- EXECUTIVE Ittect the health of our nation with- pened with HIV/AIDS, which spread out addressing infectious disease prob- from a remote part of to all SUMMARY lems that occur elsewhere in the other continents 20 years ago, and is world. In an age of expanding air trav- now entrenched all over the world, el and international trade, infectious necessitating a major international microbes are transported across bor- control effort. ders every day, carried by infected peo- Because U.S. and international ple, animals, and , and con- health are inextricably linked, the ful- tained within commercial shipments fillment of CDC’s domestic mission— of contaminated . “Old” diseases to protect the health of the U.S. popu- such as malaria, , and food- lation—requires global awareness and borne illnesses are endemic in many strategic thinking. This document, parts of the globe, and new diseases Protecting the Nation’s Health in an such as acquired Era of Globalization: CDC’s Global syndrome (AIDS; caused by the human Infectious Disease Strategy, describes immunodeficiency (HIV))—as how CDC and its international part- well as new forms of old diseases such ners can collaborate to prevent the as multidrug-resistant tuberculosis emergence and spread of infectious (TB)—can emerge in one region and diseases. spread throughout the world. Moreover, unforeseen disease prob- lems continue to appear. Recent exam- U.S. Investment in ples include vancomycin-resistant Global Public Health of Staphylococcus aureus in the United States and Japan, avian The United States must participate in Hong Kong, a new disease more fully in combating infectious dis- called Nipah virus encephalitis in ease threats around the world. These Malaysia, and outbreaks of dengue efforts will yield multiple benefits: in Texas and West Nile encepha- • Protecting the health of U.S. citi- litis in New York. Increased CDC zens at home and abroad. Control- engagement in efforts to improve glob- ling disease outbreaks as well as al disease surveillance and outbreak dangerous endemic diseases wher- response will help us detect new or un- ever they occur prevents those dis- usual diseases of any kind and respond eases from spreading international- to health emergencies of any kind— ly, saving lives and dollars. U.S. including both naturally occurring and citizens cannot be adequately pro- intentionally caused outbreaks. tected from diseases such as Left unchecked, today’s emerging measles, HIV/AIDS, and tuberculo- diseases can become the endemic dis- sis if our public health efforts are restricted to persons residing within our borders.

6 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy • Furthering U.S. humanitarian ef- er nations, damaging their econom- Health Organization (WHO) and min- forts. The potential for saving ic, social, political, military, and istries of health on projects that address human lives by preventing infec- educational infrastructures, and infectious disease problems related to tious diseases overseas is tremen- creating vast numbers of orphans. endemic diseases, wars, , or dous. Every year, an estimated three The recent intentional releases of other . Many of these projects million infant and child are biologic agents in the United States have been funded and coordinated by prevented by and other have also intensified international the U.S. Agency for International preventive health measures. Many concerns about . Due Development (USAID). CDC has also families and communities, includ- to the ease and frequency of modern supported research and public health ing and displaced people, travel, an intentionally-caused out- on diseases of regional or also benefit from international break that begins anywhere in the international importance, provided investigations that lead to prompt world can quickly become an inter- resources and leadership for the small- control of outbreaks. national problem. A contagious pox eradication effort, and established bioterrorist agent such as long-term collaborative research part- • Providing diplomatic and economic can spread rapidly from person to nerships with several developing benefits. Because health is an area of person and from country to coun- nations. While considerable effort has concern for all nations, international try. A noncontagious agent such as been devoted to these international projects that address infectious dis- can be spread by unexpect- activities, CDC’s primary focus has ease issues can open avenues of ed methods, including international remained on domestic health. communication and ease tensions mail. The United States must be In recent years, however, CDC’s between the United States and other prepared to work with other overseas role has expanded rapidly. nations. Improvements in global nations to prevent illness and deaths Global (http://www. health will also enhance the U.S. caused by acts of bioterrorism. cdc.gov/nip/global) and HIV/AIDS con- economy and contribute to global trol programs (http://www.cdc.gov/ prosperity. Reductions in disease Although the United States partici- nchstp/od/gap) have led to substantial burden will promote economic pates in health projects in many parts investments of CDC personnel and growth in nations that represent of the world, much more can be done, financial resources, as have a succes- growing markets for U.S. products. at relatively low cost, with political sion of complex international emer- Investments in global health will will, national leadership, and a clearly gencies. Between 1990 and 2000, also reduce U.S. healthcare costs by articulated global strategy. CDC provided outbreak assistance on decreasing the number of cases of an ad hoc basis to nations in Asia, imported diseases and by eradicat- Africa, Europe, and Latin America to ing diseases currently included in CDC’s Role in Promoting help investigate outbreaks of un- childhood vaccination programs. Global Public Health known, highly dangerous, and highly • Enhancing security. Slowed eco- infectious diseases, and provided diag- CDC, which is dedicated to the pre- nomic growth fueled by poor health nostic support for hundreds of local vention and control of disease and the and disease can impede democratic investigations around the globe. promotion of health, works by invita- development and political transi- Although there are no formal struc- tion in many different jurisdictions, tions in poor and former commu- tures and designated resources for including U.S. states and and nist nations, contributing to mili- international outbreak response, U.S. other nations. Throughout its history, tary conflicts and humanitarian citizens—as well as foreign govern- CDC has provided international lead- emergencies. The HIV/AIDS pan- ments—have come to rely on CDC to ership in public health, serving as a demic is already destabilizing poor- provide outbreak assistance and pub- technical consultant to the World

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 7 lic health information whenever a new 1. International 3. Applied Research on or reemerging disease threat is detect- Outbreak Assistance. Diseases of Global Importance. ed anywhere on the globe. Oubreak An underlying principle of the global A research program on diseases that assistance by CDC would also be strategy is the recognition that interna- are of global importance, including required if an intentionally caused out- tional outbreak assistance is an inte- some that are uncommon in the Unit- break occurred at home or abroad. gral function of CDC. Supporting this ed States, is a valuable resource, both CDC’s growing presence overseas function will require augmenting, for humanitarian reasons and because presents new opportunities and new updating, and strengthening CDC’s of the dangers represented by some challenges. This document—developed diagnostic facilities, as well as its imported diseases. CDC’s laboratori- in consultation with public and private capacity for epidemiologic investiga- ans, epidemiologists, and behavioral sector partners, at home and abroad— tion overseas. In the future, CDC must scientists will maintain an active represents an active effort to further also be prepared, as a matter of rou- research program to develop tools to define CDC’s evolving global mission. tine, to offer follow-up assistance after detect, diagnose, predict, and elimi- It considers how CDC and its interna- each emergency response. Such nate diseases of global or regional tional partners can work together over follow-up will assist -country min- importance. When a new disease the long term to improve the capacity istries of health to maintain control of threat is reported anywhere in the to detect, control, and prevent infec- new when an outbreak is world, CDC’s laboratorians and field tious diseases. CDC’s ongoing efforts over. investigators will be available to help to strengthen U.S. domestic public answer questions about disease trans- health infrastructure are critical to the 2. A Global Approach to mission, treatment, control, and pre- success of these international collabo- Disease Surveillance. vention. rations. In the years ahead, regional surveil- lance networks should expand, inter- 4. Application of Proven act, and evolve into a global “network Public Health Tools. Six Priority Areas of networks” that provides early There is often a long delay between the warning of emerging health threats development of a new public health Protecting the Nation’s Health in an and increased capacity to monitor the tool and its widespread use. CDC will Era of Globalization: CDC’s Global effectiveness of public health control intensify efforts to couple applied Infectious Disease Strategy defines measures. CDC will help stimulate this research with research on ways to pro- CDC’s global infectious disease priori- process by providing technical assis- mote the use of newly developed tools ties in six areas, selected in consulta- tance, evaluating regional progress, for disease control (“implementation tion with global public health part- and working with many partners to research”). CDC will help identify the ners. In looking towards the future, strengthen the networks’ telecommu- most effective tools and actively CDC envisions increased activity and nications capacities and encourage the encourage their international use, progress in each area: use of common software tools and applying expertise and resources in harmonized standards for disease laboratory research, public health pol- reporting. icy, program management, and health communications to overcome scientif- ic, financial, and cultural barriers.

8 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 5. Global Initiatives for Implementation of specific objectives National Institutes of Health [NIH], Disease Control. in these six areas will help realize the Food and Drug Administration CDC will make sustained contribu- CDC’s vision of a world in which U.S. [FDA], the Department of Defense tions to global initiatives to reduce the citizens and people throughout the [DoD], the Department of State, the of HIV/AIDS in young peo- world are better protected from infec- Department of Veterans Affairs ple by 25% and reduce deaths from tious diseases. [DVA], the U.S. Department of Agri- tuberculosis and malaria by 50% by [USDA], the National Oceanic 2010. CDC will also work with the and Atmospheric Administration Global Alliance for and Partnerships and [NOAA], and the National Aeronau- Immunization to reduce infant mortal- Implementation tics and Space Agency [NASA]), pro- ity through enhanced delivery and use fessional societies, research institu- of new and underutilitzed vaccines CDC’s global infectious disease strate- tions, and of public health, against respiratory illnesses and other gy was prepared by the National Cen- , , and veterinary sci- childhood diseases. CDC and its part- ter for Infectious Diseases, in collabo- ence. CDC will also participate in ners will also consult on future inter- ration with other CDC centers and international coalitions that support national priorities for disease control, offices, including the Office of Global disease eradication efforts and other elimination, and eradication efforts— Health, the National Center for HIV, regional and global health initiatives. as well on monitoring for antimicro- STD, and TB Prevention, the National These coalitions may include national bial resistance and planning for pan- Immunization Program, the Epidemi- and local nongovernmental organiza- demic influenza—and help evaluate ology Program Office, and the Public tions, community-based and faith- progress through the collection and Health Practice Program Office. Many based organizations, and communities analysis of disease surveillance data. global health organizations and agen- of color. Other implementation part- cies provided consultation and assis- ners will include pharmaceutical and 6. Public Health Training and tance during its development. companies, non-gov- Capacity Building. The strategy will be implemented ernmental organizations that address CDC will encourage and support the incrementally over the next five years, health problems, and development establishment of International Emerg- as funds become available, beginning agencies, development banks, founda- ing Infections Programs (IEIPs) in with the highest priorities for 2001- tions, and other organizations that developing countries—centers of 2002 (Box 1). As CDC carries out this aim to reduce by reducing the excellence that integrate disease sur- strategy, it will coordinate with foreign of endemic diseases. Website veillance, applied research, prevention, governments, international organiza- addresses for selected organizations and control activities. The IEIP sites tions (including WHO, the Joint Unit- and health publications and reports will partner with Field Epidemiology ed Nations Programme on AIDS referred to in this document are pro- Training Programs (FETPS) and other [UNAIDS], and the vided in Appendix A. institutions to strengthen national Children’s Fund [UNICEF]), other public health capacity and provide U.S. agencies (including USAID, the hands-on training in public health. Over time, they may help to strength- en capacity in neighboring countries as well as within the host country.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 9 Box 1

Implementation Priorities, 2001-2002 International Outbreak Assistance Help implement HIV/AIDS control programs on all Dedicate specific resources—epidemiologic, diagnostic, continents through CDC’s Global AIDS Program. and logistic—to international outbreak investigations. Work with the Roll Back Malaria partnership to help implement and monitor disease control and prevention A Global Approach to Disease Surveillance programs in areas with high rates of . Work with WHO and other partners to provide techni- cal assistance to regional networks in Africa, Asia, and Work with the Stop TB Initiative to improve global sur- Latin America that can fill gaps in global disease sur- veillance, prevention, and medical management of TB, veillance and become components of a global network including multidrug-resistant TB, in areas with high of networks. rates of transmission. Establish population-based surveillance centers to mon- Applied Research on Diseases of Global Importance itor the impact of vaccine use on diseases targeted by Establish two or more long-term, on-site research col- the Global Alliance for Vaccines and Immunization. laborations in developing countries to test new strate- These surveillance centers may become the nuclei of gies for disease control and prevention. future International Emerging Infections Program sites. Application of Proven Public Health Tools Public Health Training and Capacity Building Work with a developing-country partner to launch a Establish the first International Emerging Infections demonstration project that employs three or more Program as a partnership among a ministry of health, proven public health tools to prevent and control infec- CDC, a Field Epidemiology Training Program, and one tious diseases, depending on local priorities. or more local universities or medical research institutes. Global Initiatives for Disease Control An initial priority will be to establish training in field Work with foreign ministries of health and WHO to epidemiology, applied laboratory science, and public complete the eradication of polio and guinea worm dis- health management. ease.

10 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy is not possible to adequately pro- tember, 1999, six people in the north- INTRODUCTION Ittect the health of our nation with- eastern United States and a Canadian out addressing infectious disease prob- visiting New York died from West lems that are occurring elsewhere in Nile encephalitis, a viral disease also the world. In an age of expanding air transmitted by mosquitos. The West travel and international trade, infec- Nile virus, which is carried by migra- tious microbes are transported across tory birds in Asia, Africa, and Europe, borders every day, carried by infected had never before been reported in the people, animals, and insects (Box 2), Western Hemisphere. and contained within commercial ship- These outbreaks present new chal- ments of contaminated food (Box 3). lenges for U.S. public health agencies “Old” diseases such as malaria, at the local, state, and federal levels. measles, and foodborne illnesses are They also remind us that millions of endemic in many parts of the globe, people live in tropical areas where and new diseases such as acquired mosquitoborne diseases like malaria immunodeficiency syndrome (AIDS; and dengue are a fact of everyday life. caused by the human immunodeficien- Because U.S. and cy virus (HIV))—as well as new forms are inextricably linked, fulfilling of old diseases such as multidrug-resist- CDC’s domestic mission—to protect ant tuberculosis (TB)—can emerge in the health of the U.S. population— one region and spread throughout the requires global awareness and strate- world. gic thinking. This document, Protect- Old diseases, as well as new ones, ing the Nation’s Health in an Era of can travel. For example, between July Globalization: CDC’s Global Infec- 1999 and January 2000, 56 people in tious Disease Strategy, describes how southern Texas fell ill with dengue CDC and its international partners fever, a mosquitoborne can collaborate to prevent the emer- endemic to South and Central Ameri- gence and spread of infectious dis- ca and parts of Asia. Seventeen of eases. those people acquired their illness in the United States. In 1999, two Boy The urgency of the situation is illus- Scouts in New York State acquired trated by the emergence of unforeseen malaria—eliminated as an endemic disease problems in recent years. These disease problem in the United States a include multidrug-resistant Streptococ- half century earlier—from mosquitos cus pneumoniae throughout the world at a summer camp in a rural area of and vancomycin-resistant Staphylo- Suffolk County. In August and Sep- coccus aureus in the United States and

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 11 Box 2

Infectious Diseases Do Not Recognize Borders

From a public health point of view, domestic and inter- Because the had never before been national health are inextricably linked. Examples of dis- detected in the Americas—and because it had been ease spread from continent to continent include mentioned by an Iraqi defector as an of interest to the Iraqi bioweapons program—it was • HIV/AIDS—This disease apparently emerged in cen- speculated that a strain of West Nile virus isolated in 1 tral Africa in the 1950s or earlier and spread through New York City might have been deliberately engi- most of Africa, Asia, Europe, and the Americas dur- neered and disseminated to harm U.S. citizens. How- ing the 1970s and 1980s. ever, the scientific evidence suggests that the outbreak Because the AIDS virus weakens an individual’s was caused by a naturally occurring viral strain.2 immune defenses, an individual with HIV/AIDS may become coinfected with malaria, tuberculosis (TB), or • cholerae O1, El Tor biotype—A virulent strain pathogens that cause or . of has caused an ongoing that has lasted 40 years and affected more than 75 countries. •TB—During the 1980s, this age-old scourge, which had been nearly eliminated in the West by treatment, reemerged–sometimes in a multidrug- resistant form—in cities around the world, including in the United States. By 2000, approximately 46% of newly identified U.S. TB cases originated in other countries. The spread of TB has been hastened by lack of public health surveillance for this disease and by the concur- rent HIV/AIDS epidemic.

• Malaria—Although malaria was eliminated in the United States as an endemic disease by the 1960s (through swamp-draining and control pro- grams), approximately 1,500 cases of malaria are reported in the United States each year. One-half occur in U.S. travelers to malaria-endemic countries and the other half occur among foreign nationals who enter the United States already infected. Over the past 15 years, more than 80 people in the United States were infected by local transmission within our borders. In other countries, the spread of malaria has been augmented by the spread of anti-

malarial drug resistance, and many parasite strains Geographic extent of the Latin American cholera epidem- are increasingly resistant to preventive antimalarial ic over time, since its beginning in January 1991. Lines drugs taken by travelers. represent the advancing front of the epidemic at different times. Since 1995, most Latin American countries have • West Nile encephalitis—This mosquitoborne viral dis- reported diminishing numbers of cases. Cholera has not yet reached the Caribbean. ease carried by migratory birds in Asia, Africa, and Adapted from: Tauxe RV, Mintz ED, Quick RE. Epidemic cholera in the New Europe, caused 79 cases of encephalitis and 7 deaths World: translating field epidemiology into new prevention strategies. Emerg- in the northeastern United States in 1999. ing Infectious Diseases 1:141-6, 1995.

12 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 2

Beginning in 1961, O1, El Tor bio- with fever, and cough. Fungal disease was not type spread from through most of Asia into initially suspected. eastern Europe and Africa. From North Africa it spread to the Iberian Peninsula and into Italy in 1973. • Influenza spread on cruise ships—A 1997 outbreak of In the late 1970s, small outbreaks occurred in Japan the A/Sydney strain of influenza occurred among peo- and in the South Pacific. ple on a cruise that made stops in Canada and New England. In January, 1991, epidemic cholera appeared in Peru and spread rapidly through most of Latin America, The A/Sydney strain had been isolated in Australia causing over 1,000,000 cases by 1994. This was the too late in the year to be included in the vaccine for- first time in 100 years that a cholera pandemic had mulated for the fall/winter flu in the Northern reached the New World. Hemisphere. Therefore, the cruise ship passengers had not been immunized against it. • —A multistate outbreak carried by con- taminated mangoes grown in caused 79 cases • Measles—Fifty-six of the 87 cases of measles identi- of Newport infections in 13 states in fied in the United States in 2000 were traced to 1999. importations of the virus from outside our borders. The outbreak was detected and investigated using Twenty-six were direct importations, 18 were second- PulseNet, the U.S. early warning system for food- ary cases, and 8 involved whose DNA borne diseases (page 36). PulseNet linked 78 cases in sequences suggested a foreign origin. 22 states by comparing the molecular fingerprints of Comprehensive surveillance and genetic sequencing the isolates. Once mangoes were implicated as the of all identified strains of the virus allow for tracing common exposure for these cases, FDA traced the of the outbreak strains to the country of origin. The source of the mangoes back to a single farm in Brazil. finding that indigenous measles transmission can be The mangoes had been dipped in warm in a interrupted in the United States is an important impe- new process designed to kill fruit- larvae before tus for supporting a global measles elimination cam- exportation. Unfortunately, the processing water may paign. have been contaminated with Salmonella. • Polio—Eliminated from the Western Hemisphere • Coccidioidomycosis—Outbreaks caused by Coccid- since 1991, paralytic polio was again identified in ioides immitis, a soil-dwelling common in arid and the Dominican Republic in 2000, and and semiarid parts of the Western Hemisphere, were attributed to waning immunization coverage rates in reported in 1996 in Washington State and in 2000 in those countries. Pennsylvania. Unless immunization coverage can be strengthened in The outbreaks occurred among church mission other neighboring countries, diseases thought no groups who visited endemic regions of northern Mex- longer to be a risk for U.S. children may be imported ico to undertake construction projects. Infected indi- by travelers. viduals experienced a severe influenzalike disease

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 13 Box 3

Factors That Facilitate the International Spread of Foodborne Disease

• Globalization of the food supply, particularly of per- can be quickly disseminated to food animals around ishable , like fresh produce the world. Or, if ground beef is contaminated with E. U.S. citizens can now eat fresh fruits and vegetables all coli O157:H7 at a factory, hamburgers sold at fast- year round, produced in both Northern and Southern food restaurants in many locations (as well as pack- Hemispheres. However, some fresh foods may be con- ages of frozen sold at grocery stores) may trans- taminated during picking, packaging, , or mit . delivery. CDC and FDA are working together to reduce the risk to U.S. consumers. • Expanded U.S. market for “ethnic” foods There is increased familiarity with—and preferences • The development of new food production industries for—foods from different countries, due to interna- in developing nations to meet the needs of the export tional travel by U.S. citizens, the growing ethnic market diversity of our population, and our many immigrant This includes growing nonindigenous fruits and veg- communities. A recent outbreak of was etables that may be susceptible to contamination by associated with imported frozen mamey fruit pulp, indigenous microbes. For example, raspberries were popular among Central Americans living in Florida. recently introduced into with U.S. support Outbreaks of caused by antibiotic- as a potentially valuable commercial crop. Some of the resistant Salmonella have occurred in people who ate exported raspberries were found to be contaminated traditionally-prepared Mexican cheese made from with Cyclospora, a waterborne protozoan parasite not raw milk and sold informally. previously associated with foodborne disease. Cyclospora outbreaks associated with these raspber- • Increased international travel ries were reported in the United States and Canada. International tourists and business travelers often develop “traveler’s diarrhea,” caused by foodborne • Centralized processing of human and foods, that generally do not affect local adults, followed by widespread distribution most of whom have acquired from repeat- If an ingredient used in an animal feed, for example, is ed childhood exposures. contaminated with a strain of Salmonella, that strain

Japan (Box 4), in health successes might have been pened with HIV/AIDS, which emerged Hong Kong (Box 5), a new disease impossible to achieve. There is now in a remote part of Africa during the called Nipah virus encephalitis identi- evidence that immune suppression 1970s, spread throughout the world fied in Malaysia, as well as the intro- such as that caused by HIV/AIDS may during the 1980s, and is now en- duction of West Nile encephalitis into lead to a lack of response to smallpox trenched on all continents, creating North America (Box 2). vaccination or (in some cases) to dis- widespread devastation. During the Windows of opportunity for dis- seminated vaccinal infection that may 2000s, HIV/AIDS has become the tar- ease control may also close. For exam- be life-threatening. get of a major international control ple, had smallpox not been eradicated Left unchecked, today’s emerging effort (Box 6). before the global HIV/AIDS epidemic, diseases can become the endemic dis- one of the world’s crowning public eases of tomorrow. This is what hap-

14 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 4 International Cooperation To International Spread of Combat Infectious Diseases Resistance The United States must participate Drug-resistant pathogens are a growing menace to all more fully in combating infectious dis- people, regardless of age, sex, or socioeconomic back- ease threats around the world. The ground. They endanger people in affluent, industrial urgency of expanding our contribu- societies like the United States, as well as those in less tions to infectious disease control was developed nations. Many pathogens of international emphasized by an interagency work- importance are becoming resistant to standard thera- ing group of the National Science and pies, including bacteria that cause pneumonia, ear Council3 (http://www. infections, and (e.g., Streptococcus pneu- ostp.gov/CISET/html/toc.html). moniae); food and waterborne infections (e.g., Sal- There has also been an outpouring monella and ); sexually transmitted diseases of interest in infectious disease issues (e.g., Neisseria gonorrhoeae); the human immunode- in other nations, both in the developed ficiency virus that causes AIDS; and the parasites and the developing world (Appendix that cause malaria ( spp.). Other exam- B). In July 2000, at the summit meet- ples of clinically important microbes that are rapidly ing in Okinawa the Group of Eight developing drug-resistance include Mycobacterium Industrialized Nations pledged to tuberculosis; bacteria that cause skin, bone, lung, and reduce deaths from infectious diseases bloodstream infections (e.g., Staphylococcus aureus) in poor countries, agreeing to a and urinary tract infections (e.g., ); of time-limited objectives (http:// and pathogens transmitted in health care settings usinfo.state.gov/topical/econ/group8/s (e.g., enterococci and Klebsiella). ummit00). The aim is to reduce the CDC is working with many partners to help prevalence of HIV/AIDS among young improve global capacity to detect and control drug- people by 25%, and reduce the resistant infections. These efforts include working number of deaths due to TB and to with WHO to provide quality control and proficien- malaria by 50% by 2010. These goals cy testing for clinical laboratories in support of sur- are based on global health initia- veillance for emerging resistance problems. CDC is tives endorsed by the World Health also working with FDA, NIH, USAID, DoD, USDA, Organization (WHO) in its effort to and other U.S. agencies to develop Part II of the address “” in devel- U.S. Public Health Action Plan to Combat Antimi- oping countries (Box 6). Another crobial Resistance (http://www.cdc.gov/drugresis- major initiative, spearheaded by the tance/actionplan), which will serve as a blueprint for Global Alliance for Vaccines and U.S. government activities to address international Immunization (GAVI; http://www. issues. U.S. agencies and vaccinealliance.org/), aims to increase their partners will implement this blueprint in the access to new and context of WHO’s Global Strategy for the Contain- underutilitzed vaccines against hepati- ment of Antimicrobial Resistance (http://www.who. tis B, type b, int/emc/globalstrategy/strategy.html). and , and to improve deliv- ery of traditional childhood vaccines against measles and other diseases.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 15 Box 5 Our confidence that nations can Avian Influenza in Hong Kong come together to improve global health is reinforced by the success of Influenza viruses are constantly mutating and evolving, the effort to eradicate smallpox, the and new strains keep emerging. Because few people have interruption of measles transmission in immunity to a new strain—and because influenza spreads the Americas, and the substantial easily from person to person—new strains can travel progress made toward the worldwide quickly around the world. If a strain is particularly viru- eradication of polio (Box 7) and lent, it may cause a pandemic, like the 1918-19 “Spanish guinea worm disease. flu,” which killed 20 million people, including 500,000 Americans. The WHO International Influenza Surveillance Net- U.S. Investment in work, which includes 110 laboratories throughout the Global Public Health world (including a CDC-based WHO Collaborating Cen- tre), gathers influenza isolates on all continents and collects Promoting international cooperation data on new strains that have the potential for pandemic to address emerging infectious diseases spread. In 1997, the government of Hong Kong made use is a natural role for the United States, of this network to identify a dangerous strain of avian whose scientists and business leaders influenza transmitted from chickens to humans that infect- are important members of the biomed- ed 18 persons and killed 6. The authorities feared that the ical research and telecommunications strain (H5N1) might recombine with a human strain and communities that provide the technical become capable of human-to-human transmission and and scientific underpinning for infec- invited a CDC team to assist with control of the outbreak. tious disease surveillance and control. Transmission stopped after the government of Hong Kong The United States can continue to lead ordered the destruction of all chickens in Hong Kong that from its strengths in medical science might be carrying the virus (see also Box 15). and technology to help protect Ameri- This episode suggests that it may be possible to prevent can and global health. influenza before they begin, or to mitigate the Moreover, our nation now has a global impact of an through early window of opportunity to make pub- identification of a virulent strain and formulation of a lic health investments that will pay strain-specific vaccine. What is required is continued inter- increasingly valuable dividends in the national vigilance and cooperation (i.e., a global network) years to come. As noted in the 1997 and—at the national level—the political will and resources Institute of Medicine report, America’s to act on epidemiological and diagnostic evidence. Had the Vital Interest in Global Health4 WHO network not been in place, or had the Hong Kong (http://www.nap.edu/books/03090583 government been unable or unwilling to act, a virulent 41/html), investments in international hybrid chicken/human strain of influenza for which virtu- efforts to detect, control, and prevent ally all people lack immunity—and for which there is no infectious diseases can yield multiple vaccine and few drug treatments—might have caused a benefits: massive global pandemic.

16 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 6

Global Health Initiatives

Four major global health initiatives were launched and strengthening national capacities to collect dis- between 1998 and 2000: ease surveillance data and manage national • Roll Back Malaria, a global strategy to reduce deaths HIV/AIDS programs. The Global AIDS Program from malaria by increasing access to prompt and is the CDC component of the LIFE Initiative (see effective treatment (including protective intermittent Box 21). for pregnant women) and prevention tools • Global Alliance for Vaccines and Immunization (including -treated bednets); by facilitating (GAVI), a global effort to strengthen childhood rapid response to malaria outbreaks; and by develop- immunization programs and bring a new generation ing new products for the prevention and treatment of of recently licensed vaccines into use in developing malaria. countries. These include vaccines against , • Stop TB, a global strategy to stop the spread of TB childhood meningitis, yellow fever, and respiratory around the world. One of its objectives is to promote infections, which are the leading cause of in implementation of the directly observed therapy children under age five. Substantial resources for this short-course strategy (DOTS). The effective imple- purpose have been pledged by the Bill and Melinda mentation of DOT in NYC, in response to the epi- Gates Foundation and the governments of Norway, demic in the late 1980s and early 1990s, has served Netherlands and the United States. as a model in this country and around the world. Targets for Disease Reduction • International Partnership Against AIDS in Africa, a These targets for disease reduction were endorsed at the UNAIDS-led effort to mitigate the effects of the Group of Eight Industrialized Nations Summit in Oki- growing HIV/AIDS epidemic. In 1999, as part of this nawa in July 2000: effort, the U.S. government launched the Leadership HIV/AIDS: 25% reduction in prevalence in young and Investment for Fighting an Epidemic (LIFE) Ini- people by 2010 tiative, which provides support to the hardest-hit TB: 50% reduction in deaths by 2010 countries for reducing HIV transmission, improving Malaria: 50% reduction in deaths by 2010 treatment of HIV/AIDS and opportunistic infections,

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 17 Box 7

The World Health Organization Global Polio Laboratory Network

Specialized Reference Laboratory Regional Reference Laboratory National/Sub-national Laboratory Proposed National Laboratory

Ascertaining whether a disease is still present in a given area (and, therefore, that further prevention efforts are needed) is a crit- ical part of any disease eradication effort. The WHO Global Polio Laboratory Network uses molecular techniques to determine whether wild-type polio is circulating in areas undergoing eradication efforts. Since the worldwide campaign began, cases of polio have declined by 99% (from 350,000 cases to less than 3,000), and the number of countries in which polio is endemic has decreased from 125 to 20. CDC began training Network virologists in 1986, soon after the Pan American Health Organization declared its goal of elimi- nating polio from the Americas. CDC will continue to train Network virologists for several more years, as new diagnostic meth- ods are developed to meet the stringent surveillance criteria necessary to obtain certification of global polio eradication.

Protecting the health of U.S. citizens port for outbreak investigations pro- countries also endanger U.S. travelers at home and abroad. Seeking to con- vides U.S. scientists with opportunities abroad. trol disease outbreaks as well as dan- to focus on new or drug-resistant In terms of U.S. health, it is far gerous endemic diseases wherever they pathogens and consider how best to more effective to help other countries occur prevents those diseases from control, prevent, and treat them control or prevent dangerous diseases spreading internationally, saving lives before they arrive on our shores. Out- than try to prevent their importation, and dollars. In addition, CDC’s sup- breaks and endemic diseases in other because it is neither efficient nor feasi-

18 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy ble to examine each person who enters in many parts of the world, much more and the World Trade or returns to the United States for evi- can be done, at relatively low cost, with Organization (www.worldbank.org dence of infection, or to examine all political will, national leadership, and a and www.who.int.inf-pr-2000/en/note imported goods for evidence of con- clearly articulated global strategy. 2000-wha02.html), have concluded tamination. Some infections are Investing in global health is an area that disease reduction efforts are a nec- asymptomatic, and some infected indi- in which global humanitarian needs essary part of global development viduals may enter the country during and U.S. national interests coincide. strategies (Box 8). Infectious diseases the of a disease (the For example, U.S. efforts to help the can sap the strength of a nation’s work- time between infection and the states of the former Soviet Union force and deplete its medical resources, appearance of symptoms). Thus, dis- rebuild their collapsing public health making it more difficult to participate eases such as measles and TB continue infrastructures5 will also help prevent in the global economy. Promoting to be imported. the resurgence of dangerous diseases political stability and sustainable devel- (e.g., polio, diphtheria, and drug- opment in developing nations is a Furthering U.S. humanitarian efforts. resistant TB) that can spread to the major goal of U.S. foreign policy. Disease prevention is an investment in Americas. Similarly, U.S. efforts to Because health is an area of concern the young people of the world and in help China improve surveillance for for all nations, international projects our future. Every year, mil- new strains of influenza may be crucial that address infectious disease issues lions of infant and child deaths are in preventing or controlling the next can open avenues of communication prevented by vaccination and other influenza pandemic (see Box 5). and ease tensions between the United preventive health measures. Many States and other nations (Box 9). families and communities also benefit Providing economic and diplomatic Investments in global health can also from international investigations that benefits. Improvements in global help advance specific U.S. foreign pol- lead to prompt control of outbreaks. health can also enhance the U.S. econ- icy objectives, such as improving bilat- These include communities of re- omy in direct and indirect ways. eral relationships with Vietnam, fugees and displaced persons, who Domestic health care costs can be China, and the Palestinian Territories, may be especially vulnerable to infec- reduced by decreasing the number of and converting biological weapons tious diseases (see Box 13). CDC is cases of imported diseases and by plants in the Russian Federation and also a major contributor to global eradicating diseases currently included the newly independent states of the efforts to eradicate polio (http://www. in childhood vaccination programs. former Soviet Union to peaceful uses. cdc.gov/nip/global) and dracunculia- For example, the U.S. saved $3 billion sis (guinea worm disease; http://www. after investing $32 million in smallpox Enhancing security. Security experts, cdc.gov/ncidod/dpd/parasites/guinea- eradication, and promises to gain even including members of the U.S. Nation- worm and http://www.cartercenter. greater cost savings if the global polio al Intelligence Council6 (http://www. org/guineaworm.html). eradication effort is successful. More- cia.gov/cia/publications/nie/report/nie The potential for saving human over, a reduction in the infectious dis- 99-17d.html) are concerned that large lives by preventing infectious diseases ease burden in other countries helps outbreaks like the HIV/AIDS pandem- overseas is tremendous. For example, improve the economic well-being of ic may destabilize poorer nations. an additional three million deaths developing nations, which represent Slowed economic growth fueled by could be prevented annually by wider the fastest growing markets for U.S. poor health and disease in developing worldwide use of childhood vaccines. products. and former communist countries may Although the United States partici- Organizations concerned with eco- challenge democratic development and pates in international health projects nomic development, including the political transitions and contribute to

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 19 Box 8 humanitarian emergencies and mili- Infectious Diseases and tary conflicts. Economic Development The recent intentional releases of biologic agents in the United States Infectious diseases like malaria and HIV/AIDS act as have also intensified international con- a massive societal brake, slowing both economic and cerns about bioterrorism. Due to the human development. ease and frequency of modern travel, Each year, malaria slows economic growth in sev- an intentionally-caused outbreak that eral sub-Saharan African countries by as much as begins anywhere in the world can 1.3% per person per year.7 Besides interfering with quickly become an international prob- individuals’ abilities to earn a living or attend , lem. A contagious bioterrorist agent malaria affects national economies by impeding such as smallpox can spread rapidly trade, foreign investment, and commerce. It also from person to person and from coun- interferes with children’s mental and physical devel- try to country. A noncontagious agent opment and may encourage when such as anthrax can be spread by parents decide to have bigger families, knowing that unexpected methods, including inter- some of their children may die young. According to national mail. The United States must one estimate,8 if malaria had been eliminated 35 years be prepared to work with other ago, Africa’s current annual gross domestic product nations to prevent illness and deaths would be $400 billion, rather than $300 billion—a caused by acts of bioterrorism. loss that is nearly five times greater than all develop- ment provided to Africa last year. According to a World Bank report,9 HIV/AIDS CDC’s Role in Promoting may subtract an additional 1% a year from GDP Global Public Health growth in some sub-Saharan African countries, due to the continuing loss of skilled and unskilled work- As its name implies, CDC is dedicated ers in the prime of life. In South Africa, for example, to the control and prevention of dis- HIV/AIDS may depress GDP by as much as 17% over ease. The agency grew out of efforts to the next decade, which is a dangerous burden for a control malaria in the southern United young democracy. The HIV/AIDS pandemic is desta- States and today retains a critical role bilizing several other hard-hit nations, damaging their in addressing domestic infectious dis- economic, social, political, military, and educational ease threats. CDC is known in the infrastructures, and creating vast numbers of United States for orphans. • Working with state and local public health agencies to conduct disease surveillance • Providing national leadership in times of public health crisis

20 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 9 • Diagnosing rare, highly dangerous, and previously unknown diseases International Disease Control Efforts Can Create New Alliances • Responding rapidly to requests for outbreak assistance Mutual interest in addressing an outbreak or an ongoing infectious disease problem may provide the • Researching public health issues impetus for collaborations with countries who have and translating the findings into not historically cooperated with the United States on practical tools for disease control public health projects, or with countries whose rela- and prevention tionship to the United States is uncertain. One exam- • Using surveillance data to drive ple is Hong Kong during the transfer of sovereignty public health action and inform from the United Kingdom to China (see Box 5). strategic planning At times, concern about disease outbreaks may be sufficiently strong to allow national antagonisms to • Integrating epidemiologic and labo- be set aside in the interests of disease control. During ratory expertise to address infec- the outbreak of Marburg hemorrhagic fever in 1998, tious disease problems for example, an international investigative team was • Implementing programs for disease permitted to enter a contested part of the Democrat- prevention and control ic Republic of the Congo. Similarly, an international guinea worm eradication team sponsored by the • Training public health workers Carter Center received safe passage in southern CDC works by invitation in many dif- Sudan in 1995, due to a specially negotiated cease-fire ferent jurisdictions, including U.S. between the government of Sudan and rebel forces. states and cities and other nations. Moreover, a polio eradication team was allowed to Throughout its history, CDC has also operate in civil war–torn Sri Lanka during 2 “Days of provided international leadership in Peace for National Immunization” that were separat- public health, serving as a technical ed by 30 days of warfare. Three decades earlier, dur- consultant to WHO and ministries of ing the height of the Cold War, the United States and health on projects that address infec- the Soviet Union agreed on the need to provide coor- tious disease problems related to dinated financial and technical support to the small- endemic diseases, wars, famines, or pox eradication effort. other disasters. Many of these projects were funded and coordinated by the U.S. Agency for International Devel- opment (USAID). Through the Field Epidemiology Training Programs (see Box 24), the Epidemic Intelligence Ser- vice (http://www.cdc.gov/epo/dapht/ eis), and other programs, CDC has

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 21 also supported research and public investigate outbreaks of unknown, Disease Strategy, represents an active on diseases of highly dangerous, and highly infec- effort to further define CDC’s evolving regional or international importance. tious diseases (Appendix C), and pro- global mission. It was developed in CDC helped lead the smallpox eradi- vided diagnostic support for hundreds consultation with public and private cation effort in the 1960s, and estab- of local investigations around the sector partners at home and abroad. It lished collaborative research stations globe. Some of these investigations considers how CDC and its interna- (see Box 10) in Côte D’Ivoire, involved epidemic diseases and others tional partners can work together over Guatemala, and Kenya in the 1980s involved diseases that afflict refugees the long-term to improve capacity to and in Guinea, Botswana, Thailand, and other displaced persons. In many detect, control, and prevent infectious and Uganda in the 1990s. Although cases, CDC epidemiologists served as diseases. This document builds on two considerable effort has been devoted members of WHO-coordinated inves- ongoing efforts. First, it augments and to these international activities, CDC’s tigative teams supported by CDC- amplifies the international component primary focus has remained on based WHO Collaborating Centre of the 1998 CDC plan Preventing domestic health. laboratories (Appendix D). In addition Emerging Infectious Diseases: A Strat- to helping with outbreak control, egy for the 21st Century10 (http:// An evolving mission. In recent years, CDC provides on-going public health www.cdc.gov/ncidod/emergplan). CDC’s overseas role has expanded consultation by placing resident advi- CDC’s ongoing efforts to strengthen rapidly. Global polio eradication and sors and assignees with key partner U.S. domestic public health infrastruc- HIV/AIDS control programs have led agencies and by working with coali- ture are critical to the success of our to substantial investments of CDC tions of national groups on emerging international collaborations. Second, personnel and financial resources, as infectious disease issues. it fits within the larger framework of have a succession of complex interna- CDC’s growing presence overseas CDC’s efforts to improve international tional emergencies. Between 1990 and presents new opportunities and new health, as described in Working with 2000, CDC provided rapid response challenges. This document, Protecting Partners To Improve Global Health: teams to nations in Asia, Africa, the Nation’s Health in an Era of Glob- A Strategy for CDC and ATSDR11 Europe, and Latin America to help alization: CDC’s Global Infectious (http://www.cdc.gov/ogh/pub/strategy. htm).

22 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 10

Examples of CDC’s Long-term Research Collaborations Overseas

CDC manages research collaborations (sometimes The field station in Guatemala–the Medical Ento- referred to as “field stations”) in Côte D’Ivoire, mology Research and Training Unit/Guatemala, or Guatemala, Uganda, Guinea, Kenya, Botswana, and MERTU/G, is integrated into the Universidad del Valle Thailand, and is establishing long-term collaborative and works closely with the Guatemalan Ministry of projects that may form the basis for a permanent center Health. MERTU/G has helped evaluate national pre- in Vietnam. In general, CDC provides core funding for vention and control efforts related to malaria and the field stations, and USAID and other donors provide onchocerchiasis. Research on has led to additional support for both core activities and special improved clinical treatment regimens, and research on projects. foodborne and such as cholera has The field station in Kenya is a collaborative effort led to improved prevention methods. To reduce deaths between CDC and the Kenya Medical Research Institute due to —a significant health problem in (KEMRI). Most of the research takes place in western Guatemala—the Guatemalan Ministry of Health and Kenya, in an area of intense, year-round malaria trans- MERTU/G are conducting nationwide surveys to deter- mission and high incidence of HIV/AIDS. Major studies mine prevalence and risk factors; supporting field and have molecular studies of the triatomine that carries the disease; and evaluating bank practices that • Demonstrated that presumptive malaria treatment of may contribute to transmission through blood transfu- pregnant women decreases the number of low birth- sions. weight babies born. Future Directions: Capacity Building • Demonstrated that use of insecticide-impregnated The field stations have provided valuable opportunities bednets reduces mortality among children less than 2 for CDC scientists to participate in long-term, on-site years of age in areas of high transmission. research on selected diseases of importance in develop- • Provided critical information about the immune ing countries. Expansion of the field stations and response to malaria that is being used to design vac- strengthened ties with local ministries of health would cines. facilitate additional opportunities to investigate endem- ic diseases, respond to new or emerging diseases, and The field station is also studying the impact of coinfec- provide a stable training center for epidemiologists and tion with HIV and malaria, particularly in pregnancy. laboratory scientists from CDC and the local region. As Other ongoing activities concern the development of part of CDC’s global strategy, one of the existing field immunity to vaccines among HIV-positive children, stations may also provide the nucleus of the first Inter- defining local spectrum of diarrheal diseases and antimi- national Emerging Infections Program (page 53). crobial resistance among diarrheal pathogens, and addressing the consequences of coinfection with HIV and .

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 23 his document defines CDC’s glob- 3 Applied Research on Dis- VISION FOR Tal infectious disease priorities in eases of Global Importance. six areas, keeping in mind the intimate CDC’s laboratorians, epidemiologists, THE FUTURE relationship between international and and behavioral scientists will maintain U.S. health, selected in consultation an active research program to develop with global public health partners. In tools to detect, diagnose, predict, and looking towards the future, CDC envi- eliminate infectious diseases of global sions increased activity and progress in or regional importance. When a new each area: disease threat is reported anywhere in the world, CDC’s laboratorians and International Outbreak field investigators will be available to 1 Assistance. help answer questions about disease CDC will maintain the capacity to transmission, treatment, control, and identify and investigate a broad spec- prevention. trum of human diseases and serve as an internationally recognized resource Application of Proven that helps maintain global awareness 4 Public Health Tools. of new and emerging threats. The worldwide burden of infectious diseases will be significantly reduced A Global Approach to as currently available tools with docu- 2 Disease Surveillance. mented efficacy are rapidly dissemi- Regional and disease-specific surveil- nated to the most severely affected lance and response networks will populations. Research discoveries will increase in number and geographical be translated into practical treatments, area until they cover all parts of the vaccines, diagnostic tests, and disease world and monitor all infectious prevention strategies that are ready for diseases of regional or global impor- use by ministries of health and public tance. The networks will link up with health agencies. CDC’s resources will each other and evolve into a global be effectively marshaled to assist its “network of networks” that provides partners in applying these tools in early warning of new health threats— many countries, saving millions of including drug-resistant diseases—and lives. increased capacity to monitor the effectiveness of public health control 5 Global Initiatives for measures. Disease Control. Sustained global efforts will reduce the prevalence of HIV/AIDS in young peo- ple by 25% and reduce deaths from TB and malaria by 50% by 2010. will be reduced in the

24 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy poorest countries through enhanced and outbreak investigation. The IEIP delivery and use of vaccines against sites will partner with Field Epidemi- respiratory illnesses and other child- ology Training Programs (FETPS) and hood diseases. Polio and dracunculia- other institutions to perform popula- sis will be eradicated worldwide, tion-based research on transmission of paving the way for future efforts to endemic and emerging diseases and eliminate such diseases as measles, conduct emergency surveillance when- , onchocerchiasis, ever a new threat appears. The long- Chagas disease, , rubella, term goal of the IEIPs will be to devel- and hepatitis B. op sustainable, in-country human capacity to participate in national and Public Health Training and regional efforts for disease surveillance 6 Capacity Building. and outbreak response. An interconnected group of Interna- tional Emerging Infectious Disease Implementation of specific objectives Programs (IEIPs) will integrate disease in these six areas will help realize surveillance, laboratory studies, and CDC’s vision of a world in which U.S. prevention activities, and provide citizens and all people everywhere are hands-on public health training in dis- better protected from infectious dis- ease detection, program management, eases.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 25 his plan was prepared by CDC’s ed Nations Programme on AIDS PARTNERSHIPS TNational Center for Infectious [UNAIDS], and the United Nations Diseases, in collaboration with other Children’s Fund [UNICEF]), other AND major CDC centers and programs U.S. agencies (including USAID, the involved in addressing emerging infec- National Institutes of Health [NIH], IMPLEMENTATION tious diseases. These include the Office the Food and Drug Administration of Global Health, the National Center [FDA], the Department of Defense for HIV, STD, and TB Prevention, the [DoD], the Department of Veterans National Immunization Program, the Affairs [DVA], the U.S. Department of Epidemiology Program Office, and the Agriculture [USDA], the National Public Health Practice Program Office. Oceanic and Atmospheric Administra- CDC has also worked with global tion [NOAA], and the National Aero- organizations and agencies to develop nautics and Space Agency [NASA]), this strategy. Website addresses provid- professional societies, research institu- ing additional information about part- tions, and schools of public health, ner organizations and health publica- medicine, nursing, and veterinary sci- tions and reports referred to in this ence. document are provided in Box 2 and CDC will also participate in inter- throughout the text of the document. national coalitions that support dis- The strategy will be implemented ease eradication efforts and other incrementally over the next five years, regional and global health initiatives. as funds become available, beginning These coalitions may include national with the highest priorities for 2001- and local nongovernmental organiza- 2002 (Box 1). As CDC carries out this tion (NGOs; e.g., Rotary Internation- strategy, it will coordinate with foreign al and CARE), community-based and governments, international organiza- faith-based organizations, and com- tions (including WHO, the Joint Unit- munities of color. In addition, CDC will work closely with groups that conduct or promote regional disease surveillance, such as the Caribbean Epidemiology Center (CAREC), the Asia-Pacific Economic Cooperation (APEC; see also Appendix E), and the Training in Epidemiology and Pub- lic Health Interventions Network (TEPHINET).

26 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Other implementation partners • The primary modality for action include will be through partnerships with other institutions. • Pharmaceutical and biotechnology companies that develop vaccines, • CDC will work in technical areas in drugs, and rapid diagnostic tests which it has established expertise and capability. • NGOs that address related health problems (e.g., maternal and child • CDC will pursue long-term bilater- health, , occu- al relationships, because of their pational health, and chronic illness- enhanced productivity. es) • CDC will ensure that it has the • Development agencies, develop- workforce and administrative ment banks, foundations, and other mechanisms required for full imple- organizations that aim to reduce mentation of the infectious disease poverty by reducing the incidence strategy. of endemic diseases

As emphasized in CDC’s Work- ing with Partners To Improve Glo- bal Health: A Strategy for CDC and ATSDR11 (http://www.cdc.gov/ogh/ pub/strategy.htm), CDC’s collabora- tive work overseas will be based on five approaches: • CDC’s activities will be rooted in sound science, bioethical principles, and local needs.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 27 PRIORITIES AND Priority Area 1: International Outbreak Assistance

OBJECTIVES hen a new, highly dangerous, or States, including zoonotic diseases like Wreemerging disease is detected and . However, anywhere on the globe—whether in a CDC’s repeated experience with out- developing or industrialized country, breaks of diseases once thought to be in a close ally or a “nation of con- archaic or obscure—including a 1994 cern”—U.S. citizens, as well as foreign outbreak of plague in India, a 1995 governments, often rely on CDC to outbreak of a virulent pulmonary provide outbreak assistance and pub- form of leptospirosis in Nicaragua, lic health information. CDC is unusu- and a 2000 outbreak of leptospirosis al among public health institutions in in Malaysian Borneo among athletes its comprehensive capacity to identify at an international competition (Box a wide range of infectious bacteria, 11)—has underscored the value of viruses, fungi, parasites, and rickettsia. having a comprehensive, integrated In past years, however, maintaining ability to identify and investigate most this capacity has not always been a human diseases and to recognize new priority. Attempts have been made to threats. However, gaps remain in cut costs by reducing support for lab- CDC’s repertoire of diagnostic tools in oratory expertise on diseases that are such areas as diseases caused by prions currently uncommon in the United (e.g., new variant Creutzfeldt-Jakob

Outbreak of hemorrhagic fever, Uganda, 2000. The ward of Gulu Municipal Hospital, Gulu, Uganda, during an outbreak of Ebola hemorrhagic fever in October 2000. There is no known drug treatment or vaccine for this disease, which is transmitted person-to-person through contact with infected bodily fluids and has a case-fatality ratio of 50–90%. At the invitation of the Ugandan Min- istry of Health, CDC sent several teams of scientists to Gulu to participate in a multi- national WHO-coordinated response team. The response team helped bring the epi- demic under control by providing assis- tance and consultation to help rapidly iden- tify cases, provide safe care, and interrupt the spread of the virus.

Photographer: Daniel Bausch, Division of Viral and Rick- ettsial Diseases, National Center for Infectious Diseases, CDC

28 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 11

An Outbreak of Leptopirosis Affecting Athletes from 26 Countries Reported by the GeoSentinel Disease Surveillance System

In September 2000, several athletes returning home from all communicated their findings to CDC. Further eval- the EcoChallenge- 2000 multisport expedition uation indicated that all cases were clinically compati- race in Malaysian Borneo fell ill with leptospirosis, ble with leptospirosis. apparently contracted while swimming in a contaminat- Leptospirosis is contracted by coming into contact ed river. Leptospirosis causes severe fever, , with or swallowing water contaminated with animal chills, muscle pain, and . Left untreated, it can urine. During the 12-day Eco-Challenge race, approxi- lead to and failure, meningitis, and death. mately 300 athletes from 26 countries sailed on open Three clinics that participate in GeoSentinel, the glob- ocean and then bicycled and hiked through torrential al surveillance network of the International Society of jungle and mud. After that, the racers swam and (Appendix E), reported a cluster of canoed in a storm-swollen river and waded through acute febrile illness among Eco-Challenge racers and caves filled with bat guano. Analysis by CDC suggested helped identity its cause. A clinic in London, England, that participating in the river swim was significantly reported four instances of suspected leptospirosis and associated with illness. At least 44% of the 155 U.S. queried other GeoSentinel sites for similar cases. Clinics participants were affected. Additional cases of lep- in New York City and Toronto responded with reports tospirosis were identified in athletes from several other of five more cases among the same group of athletes, and countries as well.

disease, the human consequence of tional outbreak assistance is an inte- prevention team to revisit the out- infection with bovine spongiform gral function of CDC. Supporting this break site and suggest additional encephalopathy, or “mad cow dis- function will require augmenting, strategies to improve disease surveil- ease”), and some areas require updating, and strengthening CDC’s lance and outbreak response. The upgrading to remain effective (e.g., diagnostic facilities, including labora- team will share clinical and epidemio- leptospirosis, yellow fever, diphtheria, tories that participate in the WHO logic outbreak data with health anthrax, and helminthic diseases). Collaborating Centre network, as well authorities and work to strengthen as capacity for epidemiologic investi- local laboratories. The team may also CDC frequently collaborates on inter- gation overseas, including field logis- sponsor local workshops or confer- national outbreak investigations con- tics and data management. ences to consider lessons learned from ducted in partnership with host the outbreak, review local hospital nations. CDC participation occurs on Outbreak follow-up. In the future, as resources, and discuss long-term sur- an ad hoc basis, in response to part of the global strategy, CDC will veillance efforts. These follow-up requests for assistance from foreign routinely offer to assist host-country efforts will help maintain mutually governments or WHO. There is no ministries of health and WHO in beneficial relationships and research formal structure for this activity, nor assessing the public health situation in partnerships between CDC, WHO, are there designated resources. An the aftermath of a major outbreak. If and local health authorities (Box 12 underlying principle of the global requested, CDC will send a dedicated and Priority Area 2). strategy is the recognition that interna-

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 29 Box 12

Follow-up Activities in the Aftermath of the 1994 Plague Outbreak in India

In September, 1994, rumored outbreaks of bubonic and and new and advanced molecular methods for identify- pneumonic plague in western India caused widespread ing and characterizing Y. pestis strains. panic and extensive disruptions in international travel The relationships that developed among U.S. and and trade. The Indian Ministry of Health authorized an Indian scientists during the 1994 outbreak and subse- investigation by a WHO international team that includ- quent collaborations had lasting scientific and diplo- ed scientists from CDC, the Russian Federation, and by matic effects. During the Cold War, India had main- the WHO South East Asia Regional Office. The work of tained few contacts with the U.S. public health this team was severely compromised by the inability of community, preferring to collaborate with Russian Indian laboratories to confirm plague cases by using health officials, who (up until 1989) had sent regular standard diagnostic methods. shipments of plague diagnostic reagents to NICD. The lack of diagnostic capabilities arose because the After 1994, however, India was more open to public Indian Ministry of Health, a former world leader in health collaboration with the United States. For exam- plague vaccines and diagnosis, believing that plague no ple, the Indian Ministry of Health worked closely with longer existed in the country, had allowed its laboratory CDC when it renovated and modernized its national diagnostic infrastructure to deteriorate. At the sugges- plague laboratory during the late 1990s, and also when tion of WHO, the government of India invited CDC it reorganized and computerized its national communi- team members to return to conduct field training exer- cable disease surveillance system. The Indian Ministry cises with Indian epidemiologists and hold workshops in of Health also played an active role in two regional and plague at India’s National Institute for two global workshops on plague organized by WHO Communicable Diseases (NICD). Later that year, micro- and CDC between 1996 and 2000. biologists from NICD, the All-India Institute of Medical International contacts made during the 1994 plague Science, and the Haffkine Institute in Bombay came to outbreak also led to working relationships with the CDC’s laboratory in Fort Collins, Colorado, as visiting Kazakh Institute for Research on Plague Control in scientists to learn techniques for confirming infection Almaty, Kazakhstan, the Chinese Academy of Preven- with Yersinia pestis (the causative agent of plague), pro- tive Medicine in Beijing, and the Institute of Endemic cedures for preparing standardized diagnostic reagents, Diseases Control and Research in Yunnan, China.

Objectives for Priority Area 1 - Identifying and purchasing diseases of regional or global equipment and reagents and importance Dedicate Resources to Interna- increasing capacity for logistical - Maintaining a registry of disease tional Outbreak Assistance support specialists outside of CDC who • Facilitate CDC participation in - Establishing standard proce- have expertise in diseases of international outbreak investiga- dures for distributing and track- regional or global importance tions by ing specimens for efficient testing (“Active Reserves”) at more than one CDC laborato- - Developing standard operating - Developing research protocols ry when the cause of an outbreak procedures for responding to that might be used during out- is unknown. governments’ requests for out- break investigations for con- break assistance, in coordination - Maintaining an inventory of trolled trials of drug treatments with WHO CDC personnel with expertise in or other public health interven- tions (see Priority Area 3)

30 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 13

Outbreaks Among Refugees in Kosovo and the Sudan

Tularemia in Kosovo rodent excrement and carcasses containing the bacteria In April and May, 2000, an epidemiologist and ecologist Francisella tularensis. The epidemic was halted by insti- from CDC joined a WHO-led investigation of an out- tuting simple measures. break of among displaced persons returning to damaged homes and farms in rural Kosovo. The ill- Louseborne Relapsing Fever in the Sudan ness, which affected 500 to 1,000 people, was charac- In April, 1999, epidemiologists from CDC assisted terized by fever, severe sore throat, enlarged lymph WHO in investigating an apparent outbreak of hemor- nodes in the neck, and abscess formation. rhagic fever in southern Sudan among seminomadic The people who fled from Kosovo in March 1999 tribes displaced by , civil war, and intertribal had left behind unharvested crops and homes with strife. The causative agent proved to be the spirochete unprotected stocks of food. Over the following months, Borrelia recurrentis, which is transmitted by body lice. the local populations of field mice and domestic rats The outbreak affected about 20,000 people and caused increased exponentially. Returning refugees became ill about 2,000 deaths before the diagnosis was established after ingesting food and water contaminated with and disease control measures were implemented.

- Strengthening the capacity of ence reagents, laboratory manuals, http://www.who.int/emc- developing countries to identify and training opportunities for labo- documents/surveillance/docs/ outbreaks and to request WHO, ratory scientists. whocdscsr2002.pdf). CDC, or other outside assis- - European Programme for Inter- tance as needed Strengthen Investigative vention Epidemiology Training Capacity at CDC (EPIET; Strengthen Diagnostic • Rebuild CDC’s capacity to respond http://www.epiet.org/epiet). Capacity to international outbreaks. - U.S.-Mexico Border Infectious • Strengthen CDC laboratories (in- • Maintain and expand epidemiolog- Disease Surveillance system cluding CDC-based WHO Collabo- ic expertise in a wide range of path- (BIDS; rating Centres) that can identify ogens, helping to create a new gen- http://www.r10.tdh.state.tx.us/ diseases that are rare or unknown, eration of experts in infectious dis- obh/bids.htm). drug-resistant, or highly dangerous. ease prevention and control. - Training Programs in Epidemiol- This effort will include strength- ogy and Public Health Interven- ening CDC’s capacity to identify • Strengthen international collabora- tions Network (TEPHINET animal diseases that can affect tion during investigations, working http://asclepius.ic.gc.ca/tephinet/. humans, working in conjunction with many partners, including with USDA and other partners. - WHO Global Alert and Re- • Improve coordination among the sponse Network (Box 14; Department of State, CDC, state • Strengthen national public health http://www.who.int/emc- and local agencies during investiga- laboratories in developing coun- documents/surveillance/docs/ tions of infectious disease threats at tries by providing diagnostic refer- whocdscsr2003.pdf and U. S. ports of entry.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 31 Box 14

WHO and CDC: Collaboration on International Outbreak Assistance WHO and CDC work in close partnership to help con- WHO does not maintain laboratory resources of its trol outbreaks that involve diseases of unknown cause, own, it relies upon an international network of Col- diseases with high fatality rates, and diseases that are laborating Centres that includes more than 30 diag- likely to spread across borders: nostic laboratories located at CDC (Appendix D) • As an international entity, WHO is a critical partner At the present time, WHO is strengthening its in opening doors to U.S. scientists, facilitating U.S. ability to facilitate international outbreak response participation in international efforts to identify new efforts, as well as to support global health initiatives threats and contain potential pandemics. WHO also that address infectious diseases (see Box 6). As part plays a special role in international press manage- of this effort, WHO is establishing a Global Alert ment, encouraging nations to share outbreak infor- and Response Network to promote prompt report- mation while helping to minimize false rumors that ing of disease outbreaks and help coordinate offers cause damage to the trade and tourism industries of of outbreak assistance—e.g., supplies, consultation, affected countries. or on-site support—from public and private sector partners. • CDC provides WHO with technical guidance, includ- ing diagnostic and epidemiologic support. Because

• Ensure that the United States is • Support efforts to provide supplies - Sharing data to guide ongoing prepared to assist in investigations during outbreak emergencies by control programs of international bioterrorist inci- partners such as FDA, WHO, - Improving infection control dents. NGOs, pharmaceutical companies, practices multinational corporations, and • Continue to work with WHO and - Building laboratory capacity other members of the private sector. other partners to investigate epi- - Establishing ongoing surveil- demics that occur among refugees Offer Follow-Up lance for the outbreak and displaced persons (Box 13). • Offer to conduct follow-up activi- - Implementing long-term preven- Strengthen Control Efforts ties at the site of an outbreak, in tion strategies through the appli- collaboration with ministries of cation of proven health tools (see • Strengthen CDC’s capacity to pro- health, WHO, International also Priority Area 4) vide prompt and effective epidemic Emerging Infections Programs control, by assigning epidemiolo- (IEIPs; page 53), and existing gists to help monitor disease spread national or donor-supported dis- overseas, laboratory scientists to ease control programs. Activities provide rapid diagnostic testing, may include and social and behavioral scientists to design and implement communi- ty education and mobilization efforts.

32 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Priority Area 2: A Global Approach to Disease Surveillance

timulated in part by the AIDS fledgling networks (Appendix E) rep- nized standards for disease reporting. Spandemic, national and interna- resent pioneering attempts to work CDC can also help revise the Interna- tional groups, including the National across borders to enhance detection tional Health Regulations, which Science and Technology Council in and control of outbreaks of known describe internationally-reportable di- 1995 and the Group of Eight in 1997, diseases while maintaining the flexibil- seases and syndromes. In addition, have called for the establishment of a ity to recognize new disease problems. CDC will encourage linkages between global system for disease surveillance The networks are testing many differ- regional networks and veterinary sur- and outbreak response. U.S. agencies ent approaches (e.g., syndromic sur- veillance systems that monitor illness- are working with international part- veillance, laboratory-confirmed dis- es and among agricultural ners to help achieve this goal. ease-specific surveillance, hospital- and feral animals. Several major out- Despite advances in public health based surveillance, and district-level breaks of zoonotic diseases (diseases telecommunications, however, the surveillance), depending on local of animals that also affect humans) global implementation of this goal has needs, cultural preferences, and human involving agricultural animals have not been straightforward. Notable and technological resources. occurred in recent years (Box 15). progress has been made at the regional CDC will also support disease surveil- level, with the establishment of such In the years ahead, regional disease lance efforts in tropical or heavily international programs as the Carib- surveillance networks will grow in forested areas that are likely sources of bean Epidemiology Center’s disease number and geographical scope. In the human infection with unknown surveillance network, the Amazon and long run, regional and disease-specific zoonotic or vectorborne diseases. Southern Cone networks in South networks should expand, interact, and CDC’s priorities in global surveil- America, the Integrated Disease Sur- evolve into a global “network of net- lance will be balanced with the priori- veillance and Epidemic Preparedness works” that helps ensure early warn- ties of collaborating countries, and and Response Project in Africa, the ing of new and reemerging threats and CDC’s programs will be coordinated Mekong Basin Disease Surveillance increased capacity to monitor the with the ongoing efforts of develop- system in Southeast Asia, and the effectiveness of public health control ment agencies and NGOs that build International Circumpolar Surveil- measures disease surveillance capacity at the lance system in Alaska, Canada, national level. CDC can best support Greenland, and the circumpolar CDC can stimulate this process by both national and regional efforts regions of Europe. These and other providing technical assistance, evalu- by providing state-of-the-art diagnos- ating regional progress, and working tic and epidemiologic tools; by devel- with WHO, other U.S. agencies, and oping surveillance standards and other interested groups to strengthen guidelines, and by creating new meth- the networks’ telecommunications ods for predicting disease risk. capacities and encourage the use of CDC can also increase training oppor- common software tools and harmo- tunities by helping establish new or expanded Field Epidemiology Training Programs (FETPs), Public

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 33 Health Schools Without Walls (PHSWOW; http://www.tulane.edu/ ~phswow/), and Sustainable Manage- ment Development Programs (Priority Area 6, Boxes 16 and 24). The surveillance data gathered by the regional networks will be used not only to detect outbreaks but also to evaluate global health initiatives (Pri- ority Area 5) and to drive national public health programs and decision- making. Disease surveillance data are crucial, for example, in assessing the effectiveness of vaccination programs and the risk factors for underimmu- nization in a given area.

Objectives for Priority Area 2

Facilitate Regional Disease Disease surveillance personnel at the • Compile weekly reports of notifiable Surveillance Caribbean Surveillance System diseases (CARISURV) of the Carribean Epidemi- • Maintain a database of deaths • Work with WHO and other part- ology Center (CAREC). CARISURV is an caused by infectious agents ners to identify gaps in global dis- electronic disease surveillance system • Help provide distance-learning that serves 21 nations: Anguilla, courses for public health and ease surveillance by conducting a Antigua & Barbuda, Aruba, Bahamas, medical personnel health situation analysis. Barbados, Belize, Bermuda, British A new module that facilitates hotel- Virgin Islands, Cayman Islands, based disease surveillance is under • Provide technical and material Dominica, Grenada, Guyana, Jamaica, development. assistance to regional networks that Montserrat, Netherlands Antilles, St. Kitts & Nevis, St. Lucia, St. Vincent & can fill global gaps in disease sur- CDC and the Walter Reed Army Institute Grenadines, Suriname, Trinidad & of Research have worked with CAREC to veillance. Tobago (host country), Turks & provide CARISURV members with bioin- Caicos Islands. formatics training, technical support, • Host meetings that bring the lead- CARISURV employs computer- computer equipment, and ers of regional surveillance net- based modules to: public health software, including the works together on a periodic basis • Track cases of measles as part of Information to exchange experiences and meth- PAHO’s campaign to eliminate System (PHLIS) for reporting laboratory- measles in the Americas confirmed cases of infectious disease. ods and facilitate collaboration. • Track cases of HIV/AIDS PHLIS was originally developed at CDC • Track cases of unusual or unex- for use by U.S. state health depart- • Develop surveillance modules that plained diseases reported by ments. can facilitate standardization of CAREC's Physician-Based Sentinel Information Services Unit, CAREC. disease reporting among regional Surveillance system disease surveillance networks.

34 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 15

Agricultural Costs of Controlling Zoonotic Diseases Carried by Food Animals

When a dangerous animal-borne disease spills over into ernment officials have come under fire, and consumers the human population, a government may be forced to across Europe have changed their habits due to slaughter large numbers of food animals as a control concern over the spread of BSE. Control measures, measure, despite considerable economic costs. including the slaughter of affected cows, have thus far This happened in 1999 when Malaysian health cost the U.K. government an estimated 3.5 billion authorities were faced with an outbreak of encephalitis pounds (about 5 billion U.S. dollars). among farm workers that had a nearly 50% mortality The rapidly spreading outbreak of foot-and-mouth rate. The cause of the outbreak turned out to be a pre- disease in Great Britain and continental Europe in 2001 viously unknown paramyxovirus called the Nipah virus, threatens to dwarf the economic costs of the BSE epi- which is carried by swine. To control the outbreak, mil- demic and devastate the centuries-old British livestock lions of pigs were slaughtered within a few weeks, severe- industry. Foot-and-mouth disease does not infect ly harming the Malaysian meat industry. Two years humans but can be spread by travelers who have con- before, a similar precautionary measure was taken by the taminated soil on their shoes or or who carry government of Hong Kong, which arranged the culling of contaminated food products. The St. Patrick’s Day all 1.6 million chickens on Hong Kong Island and the parade in Ireland was cancelled due to concerns about New Territories to prevent chicken-to-human transmis- spreading the virus, and the British army has been draft- sion of a virulent avian form of influenza (Box 5). ed to help bury the carcasses of animals slaughtered The costs of measures to control the outbreak of because of potential exposure to the disease. Officials bovine spongiform encephalopathy (BSE, or “mad cow credit high-quality animal health surveillance and disease”) in the United Kingdom and continental importation restrictions for the absence of foot-and- Europe, and the related outbreak of an invariably fatal mouth disease in the United States, but remain con- human neurodegenerative disease (new variant cerned because similar measures have failed to contain Creutzfeldt-Jakob disease [nvCJD]) have also been high. the spread of the disease in continental Europe. Ingestion of beef containing the causative agent of BSE These examples demonstrate the potential impact an (a prion) can result in the development of nvCJD many infectious can have on commerce as years later. The export of live cattle and cattle products well as on human and animal health. If the United (other than milk) from the UK has been temporarily States were forced to destroy a significant number of banned by the European Commission, and trade in cattle, sheep, pigs, or chickens to control an epidemic, these products has been affected on a global basis. Gov- the costs might easily rise into the billions.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 35 Modules may cover sentinel disease • Work with many partners to pro- Strengthen WHO’s Disease- surveillance, disease-specific sur- vide regional networks with field- Specific Global Surveillance veillance, and syndromic disease friendly diagnostic tests (e.g., dip- Networks surveillance. sticks). • Provide technical assistance to • Help WHO strengthen WHO coun- • Work with WHO and other part- WHO-sponsored networks that try and regional offices by provid- ners to develop laboratory stan- monitor specific diseases of global ing CDC scientists, as needed, to dards for diagnostic testing and importance, such as polio, measles, assist with national and regional data standards for disease and syn- influenza, and TB (Appendix E). disease surveillance efforts. drome reporting. • Work with WHO to help establish • Assign epidemiologists and labora- a global network for surveillance Promote New for tory scientists from CDC to DoD and control of plague, using the Global Disease Surveillance laboratories in Indonesia, Kenya, WHO Influenza Surveillance Net- and Thailand, in addition to those • Establish mechanisms for regular work as a model. already in Egypt and Peru, to sup- information exchange between vet- • Work with WHO and other part- port DoD efforts to help strengthen erinary and agricultural organiza- ners to help draft a new set of Inter- regional disease surveillance (Ap- tions and public health agencies on national Health Regulations (IHR) pendix E). new and re-emerging animal dis- that includes a set of international- eases that might affect humans. • Engage nontraditional partners, ly-reportable diseases or disease such as medical missionary organi- • Work with NOAA, NASA, DoD, syndromes. zations and multinational corpora- NIH, the National Science Founda- tions, in regional disease surveil- tion, and many other partners to Facilitate Surveillance for lance activities, particularly in create models that predict the risk Foodborne and Waterborne regions that lack adequate public of zoonotic and vectorborne disease Diseases health infrastructures. by integrating climatic, environ- • Improve global surveillance for mental, veterinary, entomologic, foodborne and waterborne diseases Use State-of-the-Art Tools and epidemiologic data. CDC can by play a major role in providing epi- • Work with DoD, USAID, develop- demiologic data. - Establishing sentinel surveillance ment banks, foundations, and other sites for foodborne and water- partners to provide public health • Encourage the use of molecular borne disease at International agencies in developing countries methods for microbial subtyping Emerging Infections Programs with hardware (e.g., hand-held and outbreak detection, such as (IEIPs; page 53). computers for field use), specialized PulseNet methods for the detection - Working with PAHO and FDA software (e.g., 2000, of foodborne disease outbreaks (see to expand PulseNet—the U.S. PHLIS, and LITS+), and reliable Surveillance for Foodborne and early warning system for food- Internet access to facilitate partici- Waterborne Diseases). borne diseases—into a regional pation in regional infectious disease system for detecting outbreaks of networks and training activities. foodborne disease throughout

36 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy the Americas. PulseNet com- rating Center for Salmonella Sur- addressing global resistance prob- pares the molecular fingerprints veillance that provides support to lems, such as the spread of mul- of bacterial isolates from many WHO’s Global Salmonella Surveil- tidrug-resistant TB. different sources. It can trace the lance system (Global Salm-Surv). • Increase the number of regional source of an outbreak to ship- laboratories that conduct state-of- ments of contaminated food Facilitate Surveillance for the-art testing for drug resistance, bought and consumed at differ- Antimicrobial Resistance working through the WHO Exter- ent geographic locations. (See • Provide technical assistance to help nal Quality Assurance System and Box 2.) implement WHO’s Global Strategy the WHO Collaborating Centre for - Establishing a mechanism for the for the Containment of Antimicro- Antimicrobial Resistance and using regular exchange of surveillance bial Resistance (http://www.who. the new WHO/CDC laboratory information on foodborne dis- int/emc/globalstrategy/strategy. manual for standardized suscepti- eases (e.g., salmonellosis, shigel- html). bility testing. losis, and E. coli O157:H7 infec- tion), including PulseNet finger- • Work with other U.S. agencies to • In collaboration with WHO, the printing data, with European draft and implement Part II of the European Union, and other part- Union partners. U.S. Public Health Action Plan To ners, explore the possibility of Combat Antimicrobial Resistance establishing an expert working • Seek WHO approval for establish- (Box 4), which will consider the group that sets international stan- ing a CDC-based WHO Collabo- role of the U.S. Government in dards for detecting and reporting drug-resistant threats.

Box 16

A Growing Community of International Public Health Leaders

By fostering contacts between CDC staff and scientists In addition to these informal exchanges, CDC offers from other countries (during outbreak investigations, formal training programs in epidemiology (e.g., through scientific conferences, training courses, and disease pre- Field Epidemiology Training Programs, the Public vention projects), CDC is helping build an international Health Schools Without Walls, and the Epidemic Intel- community of epidemiologists and laboratory scientists ligence Service), laboratory diagnostics (e.g., through who are prepared to respond to emerging infectious dis- fellowships and disease-specific training workshops), ease threats, whenever and wherever they arise. Often and public health management (e.g., through the Sus- linked by e-mail, as well as by phone and fax, these indi- tainable Management Development Program) that sup- viduals are part of an informal network that shares out- port the development of public health leaders around break alerts and research data and provides assistance the world. and consultation during infectious disease emergencies.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 37 Priority Area 3: Applied Research on Diseases of Global Importance

DC’s researchers have a dual role. in the United States, because han- break team in Four Corners was CThey not only identify the tavirus-associated disease had never armed with sophisticated serologic microbes, risk factors, and epidemio- before been recognized in the Western and molecular tools that allowed them logic conditions that lead to outbreaks, Hemisphere. However, a few laborato- to diagnose HPS in a short time. but also conduct applied research on ries supported by DoD had continued Because it was known that the HFRS ways to detect, prevent, and control to collect information on a hantaviral hantavirus is transmitted by rodents, them. Maintaining a comprehensive disease called Korean hemorrhagic the team rapidly honed in on the ani- diagnostic and investigative capacity fever or hemorrhagic fever with renal mal of the HPS virus and goes hand-in-hand with maintaining a syndrome (HFRS) that killed a signifi- provided disease prevention guidelines broad-based research program on cant number of United Nations troops to the people in the area. endemic and epidemic diseases that during the Korean Conflict. Because of Several fundamental precepts includes studies in applied epidemiolo- these HFRS studies, the CDC out- inform CDC’s infectious disease gy, microbiology, and behavioral and social science.

A research program on diseases that are uncommon in the United States is a valuable resource, both for humani- tarian reasons and because of the dan- gers represented by some imported dis- eases. Had scientists begun to study “slim disease”—now known as AIDS—when the syndrome was de- scribed in central Africa in the late 1970s,12 the world health community might have learned much earlier how HIV is acquired and what can be done to prevent its spread.

An in-depth knowledge of a wide range of infectious pathogens can also facilitate the identification and charac- terization of new microbes that emerge Life cycle of West Nile virus. West Nile encephalitis—which is carried by birds in in the United States. One example con- Asia, Africa, and Europe and spread to humans by bite—has been rec- ognized as a U.S. health threat since 1999. CDC is working with colleagues in Aus- cerns hantavirus pulmonary syndrome tralia, the Czech Republic, France, Israel, Romania, and Russia to study the epi- (HPS), an often-fatal disease first iden- demiology, ecology, and pathogenesis of the West Nile virus and find ways to tified in 1993 in the Four Corners prevent and control its transmission. region of the United States. In 1993 From the CDC website: http://www.cdc.gov/ncidod/dvbid/westnile/birds&mammals.htm hantavirus research was a low priority

38 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy research collaborations with other Objectives for Priority Area 3 Conduct Research on Vector- countries. First, the overriding purpose borne and Zoonotic Diseases of CDC’s research work overseas is to Strengthen Overseas Research • Support the development of field- lead the way in demonstrating how Collaborations by Establishing friendly diagnostic tests for the individuals and governments can best IEIPs detection of zoonotic and vector- prevent and control disease. Second, it • Establish an inventory of existing borne disease, as well as new meth- is important for CDC to help strength- and potential sites for long-term, ods for animal and . en international research capacity by on-site research collaborations to supporting extramural research at • Support research on the epidemiol- address infectious disease problems home and abroad, through collabora- ogy, ecology, and pathogenesis of of regional importance. The inven- tions, cooperative agreements, and vectorborne and zoonotic diseases tory should evaluate: peer-reviewed grants. Third, CDC’s of current international concern, research activities must be rooted in - How the site might fill geo- including malaria, , bioethical principles, respecting the graphical and disease-specific , Nipah virus ence- needs and rights of human research research gaps phalitis, , Q fever, - subjects. Fourth, CDC must strive to - The site’s potential as a center sis, , plague, and Chagas dis- engage new research partners, in addi- for research training ease. tion to its traditional partners at uni- - Opportunities to engage multi- • Search for the animal or insect versities and schools of public health. ple partners, including in- of Ebola and Marburg Research collaborators may include country partners (e.g., public hemorrhagic , working scientists from private companies, health agencies and universities) through the CDC-based WHO Col- NGOs, and other U.S. agencies (e.g., and U.S. agency partners laborating Centre for Viral Hemor- NIH, FDA, DoD, NASA, NOAA, and (e.g., NIH and DoD) rhagic Fevers and collaborating USDA). - Opportunities to leverage with the South African National resources and ensure Institute of Virology and other part- Long-term, on-site research collabora- sustainability ners. tions are especially important, because it is often very difficult to study new • Create International Emerging • Investigate the relationship between and hazardous pathogens while an Infections Programs (IEIPs), using environmental conditions and the outbreak is in progress. Long-term the information from the inventory emergence of zoonotic and vector- partnerships with in-country research described above. (See also Priority borne diseases. institutions may be mutually benefi- Area 6.) cial, facilitating collaborative field research and clinical studies, providing opportunities for technology transfer and training, and building internation- al friendships and trust within the sci- entific and public health communities.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 39 Conduct Vaccine Research Box 17 • Encourage and support the devel- CDC’s Role in the Development of Vaccines opment and evaluation of vaccines Against Diseases of Global Importance against diseases of global health importance (Boxes 17 and 18). CDC supports the vaccine development goals of the Global Alliance for Vaccines and Immunization (GAVI), the International AIDS Vaccine Ini- • Support research on ways to tiative, the DHHS Blueprint for TB Vaccine Development, and the Malar- decrease the cost of expensive vac- ia Vaccine Initiative. Over the next 5 years, CDC will work with NIH, cines like conjugate Haemophilus FDA, USAID, DoD, and many other public and private partners to help influenzae type b and pneumococ- develop: cal vaccines in developing countries • A multistage vaccine against malaria, as part of the Malaria Vaccine (e.g., administering them less fre- Initiative, funded by the Bill and Melinda Gates Children's Vaccine quently or in lower doses). Program • Help define the epidemiology and • A DNA-based vaccine against HIV/AIDS, in collaboration with the public health burden (illness, mor- Emory Vaccine Center in Atlanta, Georgia tality, and cost) of vaccine-prevent- • Strain-specific vaccines against dengue and dengue hemorrhagic fever, able diseases in developing coun- in collaboration with Mahidol University in Salaya, Nakhonpathom, tries, and monitor the declining Thailand burden of disease associated with widespread vaccination. (See also • Conjugate vaccines against meningococcal meningitis group A, in col- the next section.) laboration with WHO and the Bill and Melinda Gates Children's Vac- cine Program Conduct Research in Support • An Ebola vaccine, in collaboration with NIH of Global Initiatives for • Third generation vaccines against using Disease Control proteins common to all pneumococcal serotypes. (Second generation • Encourage and support basic conjugate vaccines are currently under evaluation [see Box 18].) research to improve our under- standing of the genetics, physiology, and pathogenesis of parasites, bac- teria, and viruses that cause illness- es targeted by global initiatives for disease control.

CDC vaccine researcher working in a biosafety level 4 (BSL-4) containment facility. BSL-4 laboratories are used for work on infectious agents for which there are no cur- rent vaccines or treatments (e.g., Ebola virus).

40 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 18 • Help develop and evaluate CDC’s Role in the Evaluation of Vaccines Against - Tools and strategies to prevent Diseases of Global Importance transmission of TB, malaria, and HIV/AIDS Over the next 5 years, CDC will work with many different partners to help implement: - Treatments for drug-resistant cases of TB, malaria, and • Phase III trials in Thailand of an HIV vaccine based on the glycopro- HIV/AIDS tein-20 antigen developed by the VaxGen company - Improved methods for the detec- • Studies to evaluate the effectiveness of 7-valent pneumoccocal conju- tion of TB, HIV/AIDS-related gate vaccines on opportunistic infections, and - among Native American communities that have early-stage HIV infections high rates of invasive disease. This is a phase III, cluster-randomized • Assess the impact of coinfection trial of conjugate pneumococcal vaccine conducted in collaboration with HIV and malaria and with with Johns Hopkins School of Public Health. HIV and TB on disease control - Nasopharyngeal carriage of pneumococci in Alaska efforts. - Invasive pneumococcal disease throughout the United States, using Conduct Research on Food- the Active Bacterial Core Surveillance (ABCs) system. borne and Waterborne • Phase III trial in the Gambia of a 9-valent conjugate pneumococcal Diseases vaccine against all-cause mortality and acute-respiratory-infection- • Evaluate diagnostic strategies for specific mortality, conducted in collaboration with the Medical foodborne and waterborne infec- Research Council-Gambia, USAID, NIH, the Bill and Melinda Gates tions that are common in develop- Children’s Vaccine Program, and WHO’s Vaccine Development, Vac- ing countries, but for which current cines and Biologicals program. diagnostic procedures are slow, • USAID-supported Phase I trials of two vaccines against Schistosomia- expensive, or difficult. sis mansoni, conducted by the Schistosome Vaccine Development • Conduct targeted research studies Project, a partnership involving the Government of Egypt, CDC, in sentinel IEIP sites (page 53) to NIH/NIAID, NAMRU-3, academic centers, and private industry. determine the sources of, and risk • A multisite in Southeast Asian countries using an factors for, specific foodborne and attenuated human rotavirus vaccine produced in India. waterborne infections so that appropriate prevention measures can be developed. • In collaboration with WHO and others, assess the efficacy, , and utility of vaccination to prevent selected foodborne and waterborne infections (e.g., typhoid fever) in combination with other prevention strategies. (See also Conduct Vac- cine Research.)

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 41 Conduct Research on Diseases Conduct Research on - Determine whether of Pregnant Women and Antimicrobial Resistance purchased over the counter in Newborns developing countries (and often • Encourage and support the devel- used in subtherapeutic doses) are • Develop point-of-care diagnostic opment of drug susceptibility tests hastening the emergence of drug methods suitable for use in prenatal and surveillance systems to detect resistance. and obstetric healthcare settings in emerging resistance problems. developing countries and provide FDA supports these efforts. • Evaluate the impact of new vac- quality assurance programs for cines (such as the conjugate pneu- their use. Conduct Research on mococcal vaccines) on the control Healthcare-Acquired • Field test new treatments and pre- of antimicrobial resistance and (Nosocomial) Infections vention measures, such as infection. (See also Conduct Vac- • Develop methods for identifying - Drug combinations for the treat- cine Research.) nosocomial infections and reducing ment or prophylaxis of malaria • Determine how disease prevention their transmission in hospitals with in infants and in pregnant programs that include mass chemo- limited resources for infection con- women, for use in areas in which therapeutic treatments can be opti- trol. chloroquine-resistance is com- mized to minimize potential for the mon. emergence of drug resistance. • Provide technical assistance to hos- - Simple and inexpensive regimens Examples include the use of prazi- pital staff in assessing risk factors for the treatment and prevention quantel to prevent schistosomiasis, for acquiring of HIV/AIDs that can be admin- albendazole to prevent lymphatic - Mycobacterium tuberculosis istered to mothers and babies filariasis, ivermectin to prevent (e.g., transmitted from patients during labor and the first week onchocerchiasis, azithromycin to to health care workers or to of life. prevent trachoma, trimethoprim- other patients). sulfamethoxazole to prevent AIDS- - Nosocomial respiratory and • Explore ways to extend the benefits associated opportunistic infections, enteric infections (e.g., inade- of intrapartum or neonatal prophy- and nevirapine or zidovudine to quate barrier nursing practices) laxis (e.g., for prevention of prevent mother-to-child transmis- HIV/AIDS and hepatitis C infec- sion of HIV/AIDS. - Nosocomial bloodborne infec- tion) to pregnant women with little tions (e.g., re-use of medical or no prenatal care. • Encourage efforts by WHO and devices or surgical equipment) other partners to • Explore the effectiveness of perina- tal application of topical antimicro- - Evaluate the quality of commer- bial agents in preventing neonatal cially available antibiotic stocks sepsis and tetanus. and determine whether low- potency stocks are hastening the • Assess the relationship between emergence of drug-resistant particular maternal infections and strains of pneumococci, Myco- low birthweight or preterm babies. bacterium tuberculosis, Plas- modium spp., Neisseria gonor- rhoeae, or other pathogens.

42 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Conduct Research on Conduct Research on Sexually Infectious Causes of Transmitted Diseases Chronic Diseases • Study the contribution of herpes • Conduct research on infectious simplex virus type 2 infection and agents of international importance other genital diseases on HIV that cause or may cause chronic dis- transmission, and devise appropri- eases (e.g., hepatitis B and C virus- ate intervention strategies. es and hepatocellular carcinoma, • Develop more standardized diag- Helicobacter pylori and peptic ulcer nostic reagents and assays for disease or gastric carcinoma, to enhance the capacity to pneumoniae and car- control neonatal syphilis world- diovascular disease, and human wide. papillomaviruses and cervical can- cer) • Monitor the development of antimi- crobial resistance among strains of Chlamydia trachomatis and devise appropriate alternative treatments.

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 43 Priority Area 4: Application of Proven Public Health Tools

nother major priority for CDC is vector control, chemotherapy, Ato translate research innovations and insecticide-treated bed- into practical public health tools and nets) are ready for national or ensure that they are disseminated regional implementation, widely and rapidly for the benefit of pending the availability of people all over the world. Examples resources and political com- of public health tools that have had a mitment (see Priority Area 5). major impact on global infectious dis- CDC can also help develop- ease control are antibiotics, childhood ment agencies, NGOs, and vaccines, , other partners address prob- Bednets protect children from malaria. Nightly use of 13 and supplements. lems related to public health insecticide-impregnated bednets reduces childhood mortality by 20–30%, and use in one village protects There is often a long delay between training and to drug or vac- children in neighboring villages by reducing the the development of a new public cine delivery (see also Priority number of infectious mosquitos. Nevertheless, bed- health tool and its widespread imple- Area 6). nets are used by fewer than 10% of persons at risk, due to lack of knowledge, unavailability of bednets, mentation. A country may lack the As part of the global strategy, and other logistical constraints. means to buy a new medical product CDC will intensify efforts to or it may lack a public health delivery couple applied research with system and trained workers to admin- research on ways to promote the use ister it. There may be low demand, Objectives for Priority Area 4 of newly developed tools for disease because the public is not informed control (“implementation research”). about a new drug or vaccine, or low Promote Effective Drug Use CDC will help identify the most effec- political interest, because the national tive tools and actively encourage their • Conduct implementation research government is not convinced that the international use, applying expertise and demonstration projects to pro- drug or vaccine will be cost-effective. and resources in laboratory research, mote the use of therapeutic drugs CDC can use its experience in dis- public , program manage- such as ease surveillance to demonstrate the ment, and health communications to value of public health tools to min- - Ivermectin to eliminate oncho- overcome scientific, financial, and cul- istries of health and finance and to the cerchiasis in West Africa and tural barriers. public, using pilot studies, demonstra- tion projects, and health education Examples of new tools with the - Diethylcarbamazine and alben- campaigns (Box 19). For example, potential for significant worldwide dazole or mebendazole therapy CDC will continue to work with impact include point-of-use disinfec- to eliminate lymphatic filariasis USAID, WHO, and other partners to tion and safe water storage to prevent in the Americas demonstrate that mechanisms for the waterborne diseases; auto-disable - Single-dose azithromycin to prevention or control of malaria (via (one-use) syringes to prevent blood- eliminate blinding trachoma in borne transmission of hepatitis B and endemic regions in Africa, Mid- C viruses and HIV; and diethylcarba- dle East, Asia, and Central mazine and albendazole therapy to America eliminate lymphatic filariasis.

44 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy - Single-dose nevirapine to pre- Box 19 vent perinatal HIV transmission. (See also Priority Area 5.) Narrowing the Interval Between the Invention and Use of an Effective Public Health Tool - Praziquantel to treat schistoso- miasis In the past, the time between the development of a new public health tool and its widespread use was often extremely long. For example, the tetanus • Promote the widespread use of the toxoid vaccine, developed in 1926 and used to protect soldiers during directly observed therapy short- II, was not widely administered to children in industrialized course strategy (DOTS) to treat TB. countries until the 1940s and 1950s, and did not reach high levels of cov- (See also Priority Area 5.) erage in developing countries until the mid-1980s, a 60-year interval. Improve Immunization Today, this gap is narrowing. After the hepatitis B vaccine was licensed in 1981, universal infant hepatitis B vaccination projects were initiated in • Use CDC resources to strengthen many countries, including five U.S.-affiliated Pacific islands where HBV routine immunization services and infection is highly endemic and HBV-induced chronic is a to encourage the introduction of leading cause of death. After a decade of successful demonstration proj- new and underutilized vaccines, ects, routine childhood hepatitis B vaccination was recommended by the including vaccines against hepatitis World Health Assembly for all countries. During the 1990s, more than B, yellow fever, Haemophilus in- 100 countries (including the United States) implemented hepatitis B fluenzae type b, and other child- immunization programs, although lack of financing hindered vaccine use hood diseases. (See also Priority in the poorest countries. In 2000, financial assistance for the purchase of Area 5.) hepatitis B vaccine became available through The Vaccine Fund, and the Global Alliance for Vaccines and Immunization (GAVI) targeted hepatitis Promote the Use of Proven B vaccine for universal introduction into developing countries by 2007. Disease Prevention Strategies The history of the hepatitis B vaccine provides a good example of how the gap in time between introduction and widespread use of a new pub- • Work with ministries of health and lic health tool can be shortened through strategic planning, a rapid PAHO to encourage the adoption sequence of efficacy studies and demonstration projects, active of vector control measures to elim- and funding. As future vaccines and other public health innovations are inate Chagas disease from Central developed, it should be possible to narrow the gap further. CDC can play America and reduce morbidity and an important role in this area. mortality from dengue and dengue hemorrhagic fever (http://www. cdc.gov/ncidod/dpd/parasites/ A man being immunized against hep- chagasdisease and http://www.cdc. atitis B virus. Expanded use of the hepatitis B vaccine will decrease mor- gov/ncidod/dvbid/dengue). tality from cirrhosis, liver failure, and • Work with private and public sec- hepatocellular carcinoma, which is the 4th leading cause of death tor partners to promote widespread worldwide.

implementation of CDC’s Safe Adapted from: Centers for Disease Control and Water System, which uses point-of- Prevention. Preventing emerging infectious dis- eases: Addressing the issue of vaccine develop- use disinfection and safe water stor- ment and use. Atlanta, GA: U.S. Department of age to prevent cholera, , Health and Human Services, 2001. and other waterborne diseases (Box 20; http://www.cdc.gov/safewater).

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 45 Box 20

CDC’s

In the poorest, least industrialized nations, diarrheal In the future, the elements of the Safe Water System diseases caused by contaminated food and water remain may also be used to promote: a leading cause of death in childhood. Many of these • Safe preparation of foods and beverages by street deaths could be prevented by simple sanitation meas- vendors ures. With assistance from ministries of health, funding • Safe preparation of medications, such as oral rehy- from USAID and Rotary International, and special dration solutions to treat cholera expertise from nongovernmental organizations and the • Safe preparation of formula for use by HIV-infected private sector, CDC has developed a sustainable way to women who choose not to breast-feed their infants improve the safety of . The • Handwashing and improvements in components of CDC's sate water system, as implement- ed in pilot projects in Zambia, include • The addition of nutritional supplements to drinking water • Water disinfection. Population Services International (PSI) has marketed a locally produced solution for (CLORIN) to commu- nities in the southern, eastern, and western regions of Zambia. A CDC case-control study documented a 65% reduction of risk of cholera in Zambian house- holds that use CLORIN. • Safe storage of water. CDC, the Procter and Gamble Company, and Rotary International have con- tributed to the design of a narrow-mouthed vessel for safe storage of water. The mold for the new vessel was shipped to South Africa in January 2000, where vessels have been produced for use in Zambia, Madagascar, Kenya, Côte d’Ivoire, and . A safe water storage vessel employed by participants in an • Social marketing. PSI has trained public health work- ongoing Safe Water System implementation project in Homa ers in Lusaka, Kitwe, and Ndola, Zambia, on how to Bay, Kenya, initiated in October 2000 in collaboration with CARE Kenya. The vessel was designed to eliminate a major involve their communities in the safe-water effort. source of diarrheal disease contamination that results when hands, cups, ladles, or other objects are dipped into open USAID has increased funding for the safe water project buckets to remove water for drinking. Because the local popu- lation in Homa Bay preferred to use vessels made of clay in Zambia to permit nationwide coverage within the rather than plastic, CDC and CARE Kenya incorporated a nar- next few years, and the CARE/CDC Health Initiative is row mouth, lid, and spigot into traditional clay pots to ensure funding similar projects in western Kenya and in safe water storage. The use of plastic vessels with similar char- Antananarivo, Madagascar. Each CARE/CDC Health acteristics, in combination with water , has reduced diarrheal diseases by 30–50% in communities in Zam- Initiative project will target a population of 200,000 bia, Pakistan, and Bolivia.14

people and combine the methods of the Zambian proj- Photographer: Bobbie Person, Office of Health Communication, National Center ect with the community organizing techniques of CARE. for Infectious Diseases, CDC

46 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy • Work with WHO and ministries of Disseminate Diagnostic Tests Use Surveillance Data To health in central African countries Direct Public Health Policy • Work through the WHO Collabo- to provide training in hospital bar- rating Centre laboratory network • Work with ministries of health and rier nursing practices that prevent to provide proven diagnostic ministries of finance, WHO, and nosocomial spread of viral hemor- reagents for the detection of endem- NGOs to rhagic fevers like Ebola and Mar- ic diseases to national public health burg. - Conduct disease surveillance to laboratories and regional surveil- assess national public health • Continue to support the Safe injec- lance networks. (See Priority Area needs and recommend specific tion Global Network (SIGN) and 1.) public health tools to address work with development agencies • Work with WHO and donor agen- them. and other partners to promote safe cies to provide national public - Demonstrate the use of specific injection practices to prevent the health laboratories with state-of- surveillance methods for detect- spread of hepatitis B and C, the-art laboratory tests that measure ing outbreaks, for evaluating HIV/AIDS, and other bloodborne antimicrobial resistance in Myco- public health programs, and for diseases. bacterium tuberculosis and other driving public health decision- • Work with the Roll Back Malaria common bacterial pathogens, as making. partnership to promote the use of well as in malaria parasites and • Work with global partners to evalu- insecticide-impregnated bednets for in the AIDS virus. (See Priority ate the progress of global initiatives the prevention of malaria and other Area 5.) to combat malaria, TB, AIDS, and mosquitoborne diseases. (See Prior- • Work with ministries of health to vaccine-preventable diseases. (See ity Area 5.) transfer technology for molecular Priority Area 5.) • Work with ministries of health and subtyping of common bacterial WHO to provide public health edu- pathogens (e.g., PulseNet tech- cation and mobilize communities to niques; page 36) to national public use proven public health tools. health laboratories for use in detect- ing outbreaks of foodborne dis- eases).

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 47 Priority Area 5: Global Initiatives for Disease Control

r. Gro Bruntland, Director- their implementation are still under (Box 6). CDC and its partners will also DGeneral of WHO, has said that discussion. Previous efforts to eradi- consult on future international priori- “solutions, like problems, have to be cate malaria by using a narrow ties for disease control, elimination, global in scope.” In accord with this approach to vector control ended in and eradication efforts—as well as for idea, WHO is helping to coordinate failure. Because no proven vaccines antimicrobial resistance monitoring major global initiatives to reduce are yet available against malaria, TB, and pandemic influenza preparedness deaths from malaria, TB, and or AIDS, “one-shot” solutions are not planning—and help evaluate progress HIV/AIDS—diseases that contribute feasible, and it will be necessary to through the collection and analysis of to poverty and economic stagnation. employ multiple control strategies, disease surveillance data. This approach was endorsed by the including behavioral interventions Group of Eight Industrialized Nations that require a high degree of coopera- Increased participation in global at the Okinawa summit in July 2000. tion and trust in affected communities. health initiatives will require long- WHO is also helping to coordinate The incidence of TB, HIV/AIDS, and term partnerships with host countries, global initiatives to increase develop- acute respiratory infections is high in as well as improved coordination with ing-country access to vaccines against poor, war-torn, or post-Communist public health partners throughout the acute respiratory diseases, yellow countries in which public health infra- world. CDC will build on its strengths fever, hepatitis B, and other diseases, structures have deteriorated. More- in disease surveillance, laboratory sci- through the Global Alliance for Vac- over, emerging drug resistance compli- ence, and program evaluation to assist cines and Immunization (GAVI; cates the treatment and control of development agencies, international http://www.vaccinealliance.org). each of these diseases. organizations, NGOs, and develop- Although these global initiatives ment banks that support international have clearly stated goals and are sup- A new priority for CDC will be to ele- programs to strengthen healthcare sys- ported by multiple private and public vate the level of its participation tems and control disease. As a partner sector partners (Box 6), the details of in these and other global initiatives in the Global AIDS alliance (Boxes 6

Children from villages hard-hit by AIDS. Thirteen million children in sub- Saharan Africa have lost one or both parents to AIDS, and the number is expected to reach 40 million by 2010.15 The number of AIDS orphans is also growing in Asia and Latin America. Global efforts are underway to help these children and prevent further devastation from HIV/AIDS and other infectious diseases. These global ini- tiatives involve complex alliances among public and private groups, health and trade experts, and national and international donor organizations.

Photographer: Bobbie Person, Office of Health Communication, National Center for Infectious Diseases, CDC

48 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 21 and 21), for example, CDC has a special opportunity to work with The Global AIDS Program UNAIDS and USAID to implement HIV/AIDS control programs on all Thirty-six million people worldwide have been infected with HIV, the continents (http://www.unaids.org/ virus that causes AIDS, and more than 21.8 million have died. Eighty- africapartnership/files/mrpretoria.doc). five percent of all AIDS deaths have occurred in the countries of sub- As a partner in Roll Back Malaria Saharan Africa. In at least five of these countries, more than 20% of (http://www.rbm.who.int), Stop TB adults are HIV-positive. Infection rates are also climbing in parts of Asia, (http://www.stoptb.org), and GAVI, Latin America, the Caribbean, and the former Soviet Union countries CDC can contribute to the Shared and Eastern Europe. Only a concerted global effort coordinated by Agenda for Health in the Americas WHO and led by the United States and other industrialized countries can (http://wbln0018.worldbank.org/exte stop this pandemic. rnal/lac/lac.nsf)16 developed by PAHO, Through the Global AIDS Program (GAP), CDC is working with the Inter-American Development USAID and other DHHS agencies to assist ministries of health. In 2001, Bank, and the World Bank. the program targeted 17 of the hardest-hit African countries (Angola, Increased participation in global Botswana, Côte d’Ivoire, the Democratic Republic of the Congo, health initiatives also will require Ethiopia, Kenya, Malawi, Mozambique, Namibia, Nigeria, Rwanda, additional staff to work on projects Senegal, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), as overseas, as well as to provide diag- well as India, Brazil, Cambodia, Guyana, Haiti, Thailand, and Vietnam. nostic support from CDC laboratories GAP’s mission is to implement the U.S. Leadership and Investment for in the United States. Full participation Fighting an Epidemic (LIFE) Initiative, which is the U.S. contribution to in GAVI, for example, will require the International Partnership Against AIDS in Africa and to AIDS efforts increased programmatic support and on other continents. technical expertise in acute respiratory The goals of the Global AIDS program are to diseases, yellow fever, hepatitis B, and • Reduce HIV transmission through primary prevention of sexual, meningococcal meningitis. There mother-to-child, and bloodborne transmission remains a shortage of U.S. and world • Improve community and home-based care and treatment of expertise in many infectious disease HIV/AIDS, sexually transmitted infections, and opportunistic areas. (See also Priority Area 6.) infections CDC staff will also continue to work with ministries of health, WHO, • Strengthen national capacities to collect and use surveillance data PAHO, USAID, and other partners and manage national HIV/AIDS programs on disease elimination or eradication Additional information on the Global AIDS Program is available at campaigns. In addition, CDC staff http://www.cdc.gov/nchstp/od/gap will help further efforts to reduce ill- ness and death from acute respiratory diseases and diarrheal diseases,

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 49 which—in addition to HIV/AIDS, TB, some countries this will include imported) cases of measles in the and malaria—are the leading infec- integrating specialized HIV, TB, and Americas, and work with WHO, tious causes of death, worldwide. STD surveillance programs into UNICEF, the UN Foundation, CDC will also continue to conduct national surveillance and laboratory USAID, the American Red Cross, applied research to improve our service systems for infectious dis- the International Federation of Red understanding of the genetics, physiol- eases. Cross and Red Crescent Societies ogy, and pathogenesis of microbes (IFRC), and other partners to • Improve coordination among CDC that cause illnesses targeted by global reduce by 50% by 2005 the nearly personnel who work overseas in the initiatives for disease control. (See Pri- 900,000 annual measles deaths same country or region. ority Area 3.) worldwide.17 Enhance Support for Disease Participate in the Roll Back Control, Elimination, and Erad- Objectives for Priority Area 5 Malaria Initiative ication Programs • Contribute to Roll Back Malaria Establish a Solid Foundation • Help complete the eradication of (RBM; http://www.rbm.who.int) for Global Initiatives polio by 2005. The global effort to through full endorsement and eradicate polio is led by WHO, in • Expand the cohort of public health active promotion of RBM strategics partnership with an international professionals at CDC who have in malaria-endemic countries in coalition that includes CDC, Rotary international expertise and can pro- sub-Saharan Africa, Southeast Asia, International, UNICEF, and the vide support for global initiatives to and the Americas. Although RBM governments of many countries combat infectious diseases. (See strategies vary by region and by (http://www.cdc.gov/nip/global). also Priority Area 6) local malaria transmission dynam- The WHO Global Polio Labora- ics, 90% of the world’s malaria is in • Help suggest international priori- tory Network (Box 7), which uses sub-Saharan Africa, where the ties for current and future global molecular techniques to determine strategies for malaria prevention initiatives for disease control. whether wild-type polio is circulat- and control include Future initiatives might include ing in areas undergoing eradication antimicrobial resistance monitor- efforts, should be expanded to - Prompt effective case manage- ing, pandemic influenza prepared- include monitoring for other vac- ment of malaria illness ness planning, and campaigns to cine-preventable diseases, such as - Prevention of malaria and its control or eliminate measles, lym- measles and rubella. consequences in pregnancy, phatic filariasis, onchocerchiasis, • Help complete the eradication of through prophylaxis or preven- trachoma, rubella, neonatal teta- tive intermittent treatment regi- nus, or hepatitis B. , working in partner- ship with the Carter Center’s Glob- mens with an effective anti- • Provide technical assistance to al 2000 Program, UNICEF, WHO, malarial drug national health authorities in public and other groups (http://www. - Widespread use of insecticide- health management of diseases tar- cdc.gov/ncidod/dpd/parasites/ treated bednets, particularly by geted by global health initiatives, guineaworm and http://www.carter- young children and pregnant working through the Sustainable center.org/guineaworm.html). women Management Development Pro- - Prompt recognition and manage- gram and other mechanisms. In • Work with PAHO to complete the elimination of indigenous (i.e., non- ment of malaria epidemics

50 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy • Conduct operations research on ed to the Democratic Republic of - Providing technical assistance - Antimalarial drug efficacy and the Congo, Nigeria, Senegal, and and laboratory support to imple- the management and prevention Uganda. ment global antituberculosis drug resistance surveys of antimalarial drug resistance • Assist ministries of health in malar- - Malaria prevention in pregnancy ia control efforts and in the moni- • Consult with ministries of health in toring and evaluation of antimalar- Russia, Vietnam, and other coun- - Transmission reduction through ial drug efficacy. CDC is currently tries on training issues related to TB the use of insecticide-treated bed- working on national malaria con- diagnosis and treatment. nets and other strategies trol programs in Kenya, Tanzania, • Conduct operations research on - Malaria assessment in complex Peru, and Nepal. emergencies, such as outbreaks - TB surveillance, program man- that occur among refugees or Strengthen the Stop TB agement, and program evalua- outbreaks that occur after hurri- Program tion strategies canes or other natural disasters - Multidrug-resistant TB treat- • Contribute to Stop TB (http://www. - Malaria diagnostics ment approaches and evaluation stoptb.org) by - Social attitudes and practices strategies - Assigning an epidemiologist to that facilitate or hinder the effec- - Treatment strategies for latent WHO’s Stop TB secretariat tiveness of malaria control pro- TB among persons with HIV grams - Providing technical assistance to infection facilitate the use of the directly - Malaria surveillance, monitor- - Factors that improve adherence observed therapy short-course ing, and evaluation strategies to antituberculosis therapy strategy (DOTS) for TB. (See • Provide technical assistance to the also Priority Area 4) - New diagnostic methods, drugs, and vaccine for TB African Integrated Malaria Initia- - Strengthening TB treatment pro- tive (http://www.usaid.gov/regions/ grams in LIFE Initiative/Global Expand the LIFE Initiative and afr/abic/sddev/sddspr96/sddspr96. AIDS Program countries (see Other International Efforts To htm; see also Appendix A), a below) USAID-sponsored initiative that Address HIV/AIDS - Supporting demonstration proj- enhances integrated malaria treat- ects on the medical management CDC will work with foreign ministries ment and prevention in Kenya, of drug-resistant TB of health and public and private sector Malawi, Zambia, and Benin by pro- partners in countries targeted by the - Providing technical assistance to moting the use of interventions in LIFE Initiative/Global AIDS Program improve hospital TB control and the home (e.g., insecticide-impreg- (Boxes 6 and 21; http://www.cdc.gov/ detect hospital and community nated bednets), in healthcare facili- nchstp/od/gap) to ties (e.g., ), and outbreaks in communities with among pregnant women (e.g., pro- high HIV prevalence • Prevent primary transmission of tective intermittent chloroquine - Assigning a medical officer to the HIV by therapy, as recommended by the International Union Against TB - Expanding voluntary counseling USAID Safe Motherhood Initiative). and Lung Diseases (IUATLD) to and testing programs for youth During 2001, the African Integrat- train a cadre of international TB and other vulnerable popula- ed Malaria Initiative will be extend- experts, as a joint effort with tions USAID and WHO

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 51 - Building large-scale programs to • Build public health and medical Support Global Vaccine reduce mother-to-child transmis- infrastructure by Initiatives sion - Expanding and strengthening • Help GAVI partners (http://www. - Strengthening programs to surveillance for HIV, STIs, and vaccinealliance.org/) develop and reduce bloodborne HIV trans- TB implement strategies to strengthen mission - Providing laboratory support for routine immunization services and - Strengthening medical manage- diagnosis and surveillance of monitor their effectiveness. ment of sexually transmitted HIV, STIs, TB, and opportunis- •Provide assistance to GAVI in infections (STIs) tic infections, as well as for HIV assessing the burden of hepatitis B, screening of blood supplies - Supporting and strengthening yellow fever, Haemophilus influen- national education and mobi- - Expanding and strengthening zae type b, pneumococcus, rota- lization efforts for disease pre- public health information sys- virus, meningococcus A, measles, vention tems and congenital rubella syndrome in • Improve community and home- - Providing training in managing developing countries and use this based care and treatment by and implementing HIV treat- information to design, implement, - Expanding and strengthening ment and prevention programs and evaluate immunization pro- TB prevention and care (see also page 55). grams against these infections. - Enhancing care and treatment of - Enhancing evaluation of HIV/ • Support efforts by GAVI partners— HIV/AIDS and AIDS-related AIDS prevention and care pro- including pharmaceutical compa- opportunistic infections grams. nies, foundations and development - Exploring the innovative use of banks—to develop and evaluate antiretroviral therapy new vaccines that are needed in developing countries, and to pro- mote their availability. (See also Pri- ority 3.)

52 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Priority Area 6: Public Health Training and Capacity Building

DC’s growing visibility as an Intelligence Service and the Emerging countries—centers of excellence that Cinternational outbreak consultant Infectious Disease Laboratory Fellow- will integrate disease surveillance, has also led to increased participation ship Program, which is a joint effort applied research, prevention, and con- in efforts to build global public health between CDC and the Association of trol activities. Each site will represent capacity. Although CDC is not a devel- Public Health Laboratories (APHL). a partnership between a ministry of opment agency, CDC has traditionally In recent years, in the aftermath of health and CDC, with additional part- assisted USAID with the public health outbreaks and other infectious disease nerships involving local Field Epidemi- and research components of develop- crises, CDC has responded to requests ology Training Programs (FETPs) and ment projects (Box 22) and has con- from more than 80 foreign govern- one or more local universities or med- sulted with private foundations and ments for epidemiologic, laboratory, ical research institutes. The IEIP sites development banks on efforts to or research assistance to ensure pre- will build on existing CDC overseas strengthen public health infrastruc- paredness for future emergencies. activities to strengthen national public tures (Box 23). Over the past decade, However, most of these efforts— health capacity and provide hands-on CDC has also helped strengthen which included training courses, training in public health. Over time, healthcare systems in developing research collaborations, program eval- they may have a regional as well as a countries, working with hospital uations, health education campaigns, national impact on health. administrators and physicians to and the provision of laboratory refer- The IEIPs will be broad-based pub- improve infection control practices ence support—were limited in scope lic health collaborations between the and ensure safe blood supplies. CDC and duration and were not integrated ministry of health of the host country has also managed overseas field sta- into a larger effort to build public and CDC, with both parties contribut- tions that facilitate on-site collabora- health capacity. ing resources and reaching agreement tive research on diseases of regional As part of the global strategy, CDC on the priorities of the program. Each and global importance (Box 10). In will propose the establishment of a site will be built on existing CDC field addition, several foreign scientists series of International Emerging Infec- capacity in that country. Some IEIPs enroll each year in CDC’s Epidemic tions Programs (IEIPs) in developing may be based at research institutions

Presentation of certificates: Workshop on HIV/AIDS Epidemi- ology, Surveillance, and Prevention, May 2000, Nha Trang City, Khanh Hoa Province, Vietnam. Since Vietnam and United States renewed diplomatic relations, Vietnamese and U.S. sci- entists and public health workers have collaborated on work- shops, training courses, and research projects that build national capacity to detect and prevent HIV/AIDS, TB, malaria, typhoid fever, influenza, hospital-acquired infections, plague, and dengue and dengue hemorrhagic fever.

Photographer: Nguyen Thi Thu Hong, HHS/CDC/Hanoi

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 53 Box 22 where CDC has long-standing collab- orations. Others may be based at CDC USAID and CDC: Collaboration on Capacity Building field stations or adjacent to other U.S. The U.S. Agency for International Development (USAID) and CDC are institutions abroad, such as NIH’s longstanding partners in the effort to combat emerging diseases overseas. Research Centers Twenty years ago, CDC and USAID collaborated with WHO and other or DoD’s overseas laboratories. Each partners to eradicate smallpox. Today, CDC and USAID are helping erad- site will maintain close ties with WHO icate polio; reduce deaths from malaria, HIV/AIDs, TB, and acute respi- country and regional offices, and, if ratory infections; and improve global surveillance for emerging threats. possible, will collaborate with one of In many countries, CDC partners with USAID on evaluations of infec- the Field Epidemiology Training Pro- tious disease problems related to wars, famines, or other disasters, as well grams (FETPs) that CDC has helped as on development projects that involve epidemiologic or diagnostic establish in more than 16 countries research. CDC also helps implement USAID-supported programs in the (Box 24). four key areas of USAID’s emerging infectious disease initiative: The IEIPs will be modeled in part on the U.S. Emerging Infections Pro- • Antimicrobial resistance: Developing and implementing strategies and gram (EIP; http://www.cdc.gov/ interventions for detecting, studying, and containing emerging resist- ncidod/osr/EIP.htm) whose nine sites ance problems. conduct population-based surveil- • TB: Working for a sustainable reduction in the incidence of TB among lance, provide emergency outbreak key populations in selected countries through by the introduction of assistance, invest in cutting-edge directly observed therapy short-course strategy (DOTS; see Box 6). research, and address new problems whenever they arise. Because the EIP • Malaria: Improving the diagnosis and treatment of malaria; promoting sites combine specialized epidemiolog- effective preventive strategies; addressing the challenges of malaria in ic and laboratory expertise, they are pregnancy; containing malaria outbreaks; responding to malaria dur- able to go beyond the routine func- ing complex emergencies; slowing the emergence and spread of drug- tions of local health departments to resistant malaria; and accelerating the development of tools for malar- address important issues in infectious ia control. diseases and public health. For exam- • Disease surveillance and response: Improving public health capacity to ple, when “mad cow disease” was obtain and use good quality data for disease surveillance and effective reported in the United Kingdom in response to infectious diseases. 1996, the EIP surveillance sites were able to reassure the U.S. public within As part of the global strategy, CDC will intensify its efforts to work a short time that the disease had not with USAID to develop mutually reinforcing ways of working together at spread to the United States. the country level to maximize the impact of U.S. investments in global Like the domestic EIPs, the Interna- health. tional EIP sites will perform multiple functions, including research on endemic diseases and emergency sur- veillance when a new threat appears.

54 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy They will also provide disease surveil- Objectives for Priority Area 6 - DPDx, an Internet-based system lance data to ministries of health and to help confirm diagnoses of par- finance to help assess the burden of Establish International asitic diseases specific diseases and evaluate the cost- Emerging Infections - International public health man- effectiveness of national public health Programs (IEIPs) agement programs. Also like the EIPs, the IEIPs • Help create International Emerging - Managing and implementing will incorporate preexisting sites (e.g., Infections Programs (IEIPs) that HIV treatment and prevention U.S. institutions, public health agen- programs in Global AIDS Pro- cies, research institutions, and non- - Train local scientists and CDC gram countries (see page 52) governmental organizations); use the personnel sites in an integrated fashion; and - Provide diagnostic and epidemi- • Work through TEPHINET and establish an international steering ologic resources when outbreaks other mechanisms to provide tech- committee to provide guidance for occur nical assistance to health authorities core projects conducted at all of the - Serve as platforms for regional in countries that are establishing or IEIP network sites. Areas in which infectious disease control activi- expanding national schools of pub- IEIP sites might play an especially ties lic health, new Field Epidemiology important role are in surveillance for Training Programs (FETPs), new drug-resistant forms of malaria, TB, - Conduct public health research Sustainable Management Develop- pneumonia, and dysentery. All of the of global importance ment Programs, or the Rocke- sites will be linked by electronic com- - Disseminate proven health tools feller Foundation-supported Public munications to keep health experts Health Schools Without Walls around the world in close contact with Expand Training in (PHSWOW). TEPHINET is a pub- one another. Epidemiology, Public Health lic health network network that The long-term goal of the IEIPs will Management, and Laboratory links FETP and PHSWOW staff. be to develop sustainable, in-country Diagnostics • Help increase the number of public capacity for disease surveillance, out- • Increase training opportunities for health workers in developing coun- break investigation, and research on foreign scientists in epidemiology, tries who are trained in vaccine diseases of regional or global impor- public health management, and work by tance by fostering the next generation state-of-the-art laboratory tech- of international public health leaders - Encouraging training efforts by niques. For example, CDC will pro- (Box 16). The implementation of this foreign governments, founda- vide training in goal will require extensive scientific, tions, and donor organizations human, and financial resources from - PulseNet’s methods for finger- (e.g., the WHO public health both private and public sources, as printing strains of foodborne training project in Lyon, France) well as sustained efforts over many bacteria (page 36) - Incorporating training compo- years. However, the costs will be low - Methods for identifying food- nents into such projects as the in relation to potential benefits, in borne viruses U.S.-India Vaccine Plan, the terms of both human health and - Drug susceptibility testing of Egyptian Schistosomiasis Vac- increased global prosperity. pathogens of public health cine Development Project, and importance the HIV vaccine trials in Kenya and Côte D’Ivoire (Box 18)

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 55 Box 23

The World Bank and CDC Sign a Memorandum of Understanding

Infectious diseases are not just a result of, but also a The memorandum will also facilitate previously cause of, poverty (see Box 8). In recognition of this fact, established collaborations between the World Bank the World Bank, a leading global development lender, and CDC, including an ongoing project to upgrade the signed a memorandum of understanding with CDC in surveillance infrastructure for infectious diseases in February 2001, to intensify joint efforts to prevent and Argentina and Brazil, from the local to the national control diseases that take a heavy toll in developing level. That effort includes countries. • Training public health workers in epidemiology, Under the agreement, CDC and the World Bank will management, and laboratory science collaborate on a broad range of global health activities, related to , maternal and child health, endemic • Establishing electronic reporting networks and sen- diseases such as HIV/AIDS, TB, and malaria, public tinel sites for disease surveillance health, health surveillance, health policy and statistics, • Enhancing laboratory capacity research, and healthcare technology. Over the next year, for example, CDC will transfer technical experts to the • Strengthening outbreak response World Bank to help design, implement, and evaluate • Instituting measures to prevent the spread of TB projects to control the spread of malaria in Africa and and other priority diseases promote worldwide use of vaccines against many child- hood diseases.

- Training national and regional - Creating an inventory of CDC number of graduate courses that health workers in vaccine pro- staff to identify gaps in interna- cover global infectious disease gram planning, monitoring, and tional expertise issues evaluation as part of GAVI’s - Developing an international • Expand opportunities for training effort to improve routine immu- infectious disease training pro- in-hospital infection control and nization services and to intro- gram or seminar series for CDC clinical surveillance by providing duce new and underutilized vac- staff, in collaboration with pub- cines into developing countries lic health and medical schools - Train-the-trainer courses in hos- pital epidemiology • Provide training opportunities that - Establishing an exchange pro- increase international expertise in gram that enables visiting scien- - Technical assistance to hospital the detection and treatment of pre- tists from other countries to staff in designing and implement- natal and perinatal infections. work at CDC and vice versa ing programs to reduce transmis- sion of nosocomial pathogens • Expand the cohort of public health - Working with the Association of professionals at CDC who have Schools of Public Health and the international infectious disease Association of Teachers of Pre- expertise, by ventive Medicine to increase the

56 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Box 24

Applied Field Epidemiology Training Programs

For more than 20 years, CDC has collaborated with As of 2000, in addition to EIS, there were 27 ministries of health around the world to establish Field Applied Epidemiology Training Programs, including 20 Epidemiology Training Programs (FETPs) for specialists FETPs, 4 PHSWOWs, and 3 other Applied Epidemiol- in epidemiology. These programs are modeled on the ogy Training Programs (the European Programme Epidemic Intelligence Service, CDC’s primary applied for Intervention Epidemiology Training [EPIET], the epidemiology training program, which was founded in WHO Global Health Leadership Officers Programme 1951. Canada established a field epidemiology training [GHLOP], and the WHO/AFRO Programme d’Epi- program in 1975, and Thailand launched one in 1980, demiologie Pratique [PEP]). Of 19 programs over 4 in collaboration with CDC and WHO. CDC partners years old, 18 (95%) continue to produce graduates. who have helped establish other FETPs include the Thus far, it is estimated that the 27 Applied Epidemiol- World Bank (Brazil), PAHO (a regional FETP in Central ogy Training Programs have trained more than 900 America), and USAID (Egypt, Jordan, Peru, Philippines, international public health leaders in epidemiology and and Central America). outbreak investigation. Approximately 420 more are CDC has also provided consultants to Public Health currently in training. Schools Without Walls (PHSWOW), which helps post- graduate-level public health per- sonnel attain the epidemiologic, managerial and leadership com- Number of Applied Epidemiology Training Programs 1950–2001. petencies required to run 30 increasingly decentralized health systems. The PHSWOWs are 25 funded by the Rockefeller Foun- dation with technical support from Tulane University. The 20 first PHSWOW was launched in Zimbabwe in 1993 at the Uni- versity of Zimbabwe; the sec- 15 ond in Uganda in 1994 at Mak- erere University; and the third in Number of Programs 10 Ghana in 1995 at the University of Ghana. In 1997, Vietnam started a PHSWOW in collabo- 5 ration with the Hanoi School of Public Health. 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 57 - Consultation to USAID and over-the-counter. Regional health - Management of exposures to other donor organizations on care guidelines can be used to bloodborne pathogens like HIV infectious disease projects that mount public health education and hepatitis B and C. build infrastructure to improve campaigns on antibiotic usage to • Disseminate new information on the provision of prenatal and help retard the development of infectious disease issues through perinatal care in developing drug resistance. the Morbidity and Mortality Week- countries. • Provide consultation to ministries ly Report (MMWR), the Emerging of health in developing national Infectious Diseases journal, and the Enhance Availability of Guide- guidelines for CDC website. lines and Other Publications - Hospital infection control, • In collaboration with WHO and including prevention of hospital- international experts, draft region- acquired pneumonia, TB, HIV/ al health care guidelines on the AIDS, and other nosocomial judicious use of antibiotics, includ- infections of local concern. ing antibiotics that are purchased

58 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy LIST OF BOXES Box 1: Implementation Priorities, 2001-2002 Box 2: Infectious Diseases Do Not Recognize Borders Box 3: Factors That Facilitate the International Spread of Foodborne Disease Box 4: International Spread of Antimicrobial Resistance Box 5: Avian Influenza in Hong Kong Box 6: Global Health Initiatives Box 7: The World Health Organization Global Polio Laboratory Network Box 8: Infectious Diseases and Economic Development Box 9: International Disease Control Efforts Can Create New Alliances Box 10: Examples of CDC’s Long-term Research Collaborations Overseas Box 11: An Outbreak of Leptopirosis Affecting Athletes from 26 Countries Reported by the GeoSentinel Disease Surveillance System Box 12: Follow-up Activities in the Aftermath of the 1994 Plague Outbreak in India Box 13: Outbreaks Among Refugees in Kosovo and the Sudan Box 14: WHO and CDC: Collaboration on International Outbreak Assistance Box 15: Agricultural Costs of Controlling Zoonotic Diseases Carried by Food Animals Box 16: A Growing Community of International Public Health Leaders Box 17: CDC’s Role in the Development of Vaccines Against Diseases of Global Importance Box 18: CDC’s Role in the Evaluation of Vaccines Against Diseases of Global Importance Box 19: Narrowing the Interval Between the Invention and Use of an Effective Public Health Tool Box 20: CDC’s Safe Water System Box 21: The Global AIDS Program Box 22: USAID and CDC: Collaboration on Capacity Building Box 23: The World Bank and CDC Sign a Memorandum of Understanding Box 24: Applied Field Epidemiology Training Programs

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 59 ACRONYMS AFRIMS Armed Forces Research Institute of Medical Science, Bangkok, Thailand AIDS acquired immunodeficiency syndrome AIMI African Integrated Malaria Initiative AMREF African Medical and Research Foundation APEC Asia-Pacific Economic Cooperation APHL Association of Public Health Laboratories ATSDR Agency for Toxic Substances and Disease Registry BIDS U.S.-Mexico Border Infectious Disease Surveillance system CAREC Caribbean Epidemiology Center DoD Department of Defense DOTS directly observed therapy short-course strategy DVA Department of Veterans Affairs ELISA enzyme-linked immunosorbent assay EPI Expanded Programme on Immunization EPIET European Programme for Intervention Epidemiology Training EIP Emerging Infections Program EWORS Early Warning Outbreak Recognition System FDA Food and Drug Administration FETP Field Epidemiology Training Program GAP Global AIDS Program GAVI Global Alliance for Vaccines and Immunization GHLOP WHO Global Health Leadership Officers Programme HIV human immunodeficiency virus HIV/AIDS human immunodeficiency virus infection/acquired immunodeficiency syndrome HFRS hemorrhagic fever with renal syndrome HPS hantavirus pulmonary syndrome IFRC International Federation of Red Cross and Red Crescent Societies IHR International Health Regulations IPAA International Partnership Against AIDS in Africa IUATLD International Union Against TB and Lung Diseases KEMRI Kenya Medical Research Institute LIFE Leadership and Investment for Fighting an Epidemic initiative LITS Laboratory Information Tracking System

60 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy MERTU/G Medical Entomology Research and Training Unit/Guatemala NAMRU-2 Naval Medical Research Unit No. 2, Jakarta, Indonesia NAMRU-3 Naval Medical Research Unit No. 3, , Egypt NASA National Aeronautics and Space Agency NGO nongovernmental organization NIH National Institutes of Health NMRCD Naval Medical Research Center Detachment, Lima, Peru NOAA National Oceanic and Atmospheric Administration PacNET Pacific Public Health Surveillance Network PAHO Pan American Health Organization PEP WHO/AFRO Programme d’Epidemiologie Pratique PHLIS Public Health Laboratory Information System PHSWOW Public Health Schools Without Walls RBM Roll Back Malaria initiative SIGN Safe Injection Global Network STD sexually transmitted diseases STI sexually transmitted infections TB tuberculosis TEPHINET Training in Epidemiology and Public Health Interventions Network UNAIDS Joint United Nations Programme on AIDS UNESCO United Nations Educational, Scientific, and Cultural Organization UNICEF United Nations Children’s Fund USAID United States Agency for International Development USAMRU-K United States Army Medical Research Unit, Nairobi, Kenya USDA United States Department of Agriculture WHO World Health Organization WHO/AFRO World Health Organization Regional Office for Africa WHO/EMRO World Health Organization Regional Office for the Eastern Mediterranean

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 61 APPENDIX A GLOBAL HEALTH WEBSITES

Organization Publication Web Address Carter Center Guinea Worm Eradication Program http://www.cartercenter.org/guineaworm.html Center for Strategic and Contagion and Conflict: Health as a http://www.csis.org International Studies Global Security Challenge Centers for Disease Control and Prevention The HIV/AIDS Collaboration, http://www.hac.or.th/ CDC and The Ministry of Public Health Thailand Centers for Disease Control and Prevention Global Polio Eradication Initiative http://www.cdc.gov/nip/global Centers for Disease Control and Prevention Guinea Worm Disease Fact Sheet http://www.cdc.gov/ncidod/dpd/parasites/guineaworm Centers for Disease Control and Prevention Global AIDS Program http://www.cdc.gov/nchstp/od/gap Centers for Disease Control and Prevention Working with Partners to Improve Global http://www.cdc.gov/ogh/pub/strategy.htm Health: A Strategy for CDC and ATSDR Centers for Disease Control and Prevention International Health Data Reference http://www.cdc.gov/nchs/data/ihdrg99.pdf Guide, 1999 Centers for Disease Control and Prevention U.S.-Mexico Border Infectious http://www.r10.tdh.state.tx.us/obh/bids.htm Diseases Surveillance Centers for Disease Control and Prevention Preventing Emerging Infectious http://www.cdc.gov/ncidod/emergplan Diseases: A Strategy for the 21st Century Centers for Disease Control and Prevention Biological and ChemicalTerrorism: http://bt.cdc.gov/documents/btstratplan.pdf Strategic Plan for Preparedness and Response Centers for Disease Control and Prevention Protecting the Nation’s Health in an Era http://cdc.gov/globalidplan.htm of Globalization: CDC’s Global Infectious Disease Strategy Council on Foreign Relations and Why Health Is Important to http://www.cfr.org//public/pubs/Kassalow_Health_ Milbank Memorial Fund U.S. Foreign PolicyPaper.htm Department of Defense Global Emerging Infections System http://www.geis.ha.osd.mil Department of Health and Human Services DHHS Global Health Website http://www.globalhealth.gov Bill and Melinda Gates Foundation www.gatesfoundation.org Global Alliance for Vaccines and Immunization http://www.vaccinealliance.org/ Institute of Medicine Emerging Infections from the Global to http://www4.nationalacademies.org/iom/iomhome.nsf Local Perspective Institute of Medicine America’s Vital Interest in Global Health http://www.nap.edu/books/0309058341/html Joint United Nations Programme for AIDS (UNAIDS) http://www.unaids.org National Institute of Allergy and Global Research Plan for HIV/AIDS, http://www.niaid.nih.gov/publications/globalhealth / Infectious Diseases, National Institutes Malaria, and Tuberculosis global.pdf of Health National Intelligence Council The Global Infectious Disease Threat http://www.cia.gov/cia/publications/nie/report/ and Its Implications for the United States nie99-17d.html

62 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy Organization Publication Web Address National Science and Technology Infectious Disease—A Global Health http://www.ostp.gov/CISET/html/toc.html Council, Committee on International Science, Threat Engineering, and Technology, Working Group on Emerging and Reemerging Diseases Rockefeller Foundation Program on Health Equityhttp://www.rockfound.org/display.asp? context=3& SectionTypeID=18 Roll Back Malaria http://www.rbm.who.int Safe injection Global Network http://www.injectionsafety.org Stop TB Initiative http://www.stoptb.org United Nations Foundation http://www.unfoundation.org United States Agency for International Development Infectious Disease Strategy http://www.usaid.gov/pop.health/ID/index/html World Bank, Pan- American Health Organization, Shared Agenda for Health in the Americas http://wbln0018.worldbank.org/external/lac/lac.nsf and Inter- American Development Bank World Bank World Development Report 2000/2001 http://www.worldbank.org/poverty/wdrpoverty/report World Health Organization Removing Obstacles to Healthy Development http://www.who.int/infectious-disease- report/index-rpt99.html World Health Organization WHO Antimicrobial Resistance Infobank http://oms2.b3e.jussieu.fr/arinfobank World Health Organization WHO Report on Global Surveillance of http://www.who.int/emc- documents/surveillance/ Epidemic-prone Infectious Diseases docs/whocdscsrisr2001.ht ml/Tableofcontents/about.htm World Health Organization Overcoming Antimicrobial Resistance http://www.who.int/infectious-disease-report/2000/ index.html World Health Organization Global Strategy for the Containment http://www.who.int/emc/globalstrategy/ of Antimicrobial Resistance strategy.html World Health Organization The 2000 http://www.who.int/whr/2000/en/report.htm World Health Organization, Rotary International, Global Polio Eradication Initiative http://www.polioeradication.org Centers for Disease Control and Prevention, United Nations Children Fund (UNICEF) World Health Organization, UNICEF, UNAIDS, Health a Key to Prosperity http://www.who.int/inf-new/ World Bank, United Nations Educational, Scientific, and Cultural Organization (UNESCO), United Nations Population Fund

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 63 APPENDIX B Emerging infectious diseases are a topic of discussion at many high-level international meetings, including

DIPLOMATIC Group of Eight Industrialized Nations (G8)a FORUMS THAT http://usinfo.state.gov/topical/econ/group8 Asia-Pacific Economic Cooperation (APEC)b ADDRESS http://www.apecsec.org.sg Common Agenda with Japan EMERGING http://www.mofa.go.jp/region/n-america/us/agenda

INFECTIOUS Transatlantic Agenda with the European Union http://www.eurunion.org/partner/agenda.htm DISEASE ISSUES U.S.-Mexico Binational Commission http://www.r10.tdh.state.tx.us/obh/bids.htm

The Arctic Council http://www.arctic-council.org

a. The Group of Eight Industrialized Nations includes: Canada, France, Germany, Italy, Japan, the Russian Federation, the United States, and the United Kingdom. b. The economies of the Asia-Pacific Economic Cooperation include Australia, Brunei, Canada, Chile, China, Hong Kong China, Indonesia, Japan, Republic of Korea, Malaysia, Mexico, New Zealand, Papua New Guinea, Peru, the Philippines, Russia, Singapore. Chinese Taipei, Thailand, the United States, and Vietnam. c. The Arctic Council includes: Canada, , Greenland/Denmark, Iceland, Norway, Russia, Sweden, and the United States.

64 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy APPENDIX C uring the 1990s, CDC participated in numerous outbreak investigations in Dother countries, sometimes as part of an international WHO team and EXAMPLES OF sometimes in direct response to a request from an affected nation. These inves- tigations included

INTERNATIONAL 1990 Japanese encephalitis in Saipan OUTBREAK 1990 Epidemic dysentery in Burundi 1991 Hepatitis E in Kenya and Somalia ASSISTANCE 1991-92 Epidemic dysentery in Zambia 1991 Cholera in Bolivia, Ecuador, El Salvador, Guatemala, and Peru 1991 Cholera in Brazil 1991 Polio in Romania 1991 Polio in Bulgaria 1992 Polio in Jordan 1992-96 Diphtheria in Ukraine 1993-96 Diphtheria in Russia 1993 Polio in Namibia 1993 Polio in Uzbekistan 1994 Dengue in Nicaragua 1994 Plague in India 1994-95 Measles in Palau, Guam, and the Federated States of Micronesia 1995 Diphtheria in Georgia, Kyrgyzstan, Kazakhstan, Uzbekistan, and Turkmenistan 1995 Leptosporosis in Nicaragua 1995 Ebola fever in the Democratic Republic of the Congo (then Zaire) 1996 Epidemic dysentery in South Africa 1996 West Nile encephalitis in Romania 1996 Typhoid fever in Tadjikistan 1996 E. coli O157:H7 infection in Japan 1996 Polio in Albania 1997 Polio in Turkey 1997 in Argentina 1997 Cholera in Kenya 1997 Avian influenza in Hong Kong 1997 in Kenya 1997 O’nyong-nyong fever in Uganda

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 65 1997 Nosocomial HIV-associated multidrug-resistant TB in Argentina 1997 Multidrug-resistant TB in Colombia 1998 Measles in Romania 1998 Bolivian hemorrhagic fever in Bolivia 1999 Louseborne relapsing fever in southern Sudan 1998 Plague in Ecuador 1998 Dengue in Palau 1998 Dengue in Yap 1998 Amebiasis in the Republic of Georgia 1998-99 Influenza outbreaks on cruise ships (U.S.-Canada) 1999 Dengue fever on U.S.-Mexico border 1999 Epidemic poststreptococcal glomerulonephritis in Brazil 1999 Typhoid fever in Nauru 1999 Nipah virus encephalitis in Malaysia 1999 Marburg fever in the Democratic Republic of the Congo 1999 Polio in Angola 1999 Measles in Costa Rica 1999-2000 Hantavirus pulmonary syndrome in Panama 2000 Polio in the Democratic Republic of the Congo 2000 Tularemia in Kosovo 2000 Cholera in Pohnpei State, Federated States of Micronesia 2000 Rift Valley fever in Saudi Arabia and Yemen 2000 Ebola hemorrhagic fever in Uganda 2000 Measles in Haiti, Dominican Republic, Bolivia 2000 Polio in Haiti and the Dominican Republic 2000 Measles in Zambia 2000 Diphtheria in Latvia 2000 Dengue hemorrhagic fever in El Salvador

66 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy WHOCC for Antimicrobial Resistance APPENDIX D WHOCC for -Borne Viruses in the Western Hemisphere WHOCC for WHO WHOCC for Dengue and Dengue Hemorrhagic Fever WHOCC for Research, Training, and Eradication of Dracunculiasis COLLABORATING WHOCC for HIV/AIDs WHOCC for Reference and Reagents for Human Immunoglobulin Subclasses CENTRES (WHOCCS) WHOCC for Foodborne Disease Surveillance WHOCC for Surveillance, Epidemiology, and Control of Influenza BASED AT CDC WHOCC for Evaluating and Testing New WHOCC for Leptospirosis WHOCC for Control and Elimination of Lymphatic Filariasis WHOCC for Malaria Control in Africa WHOCC for Production and Distribution of Malaria Sporozoite ELISAs WHOCC for Mycoses in North America WHOCC for Reference and Research on Plague Control WHOCC for and Enterovirus Surveillance WHOCC for Reference and Research on Rabies WHOCC for Respiratory Viruses Other Than Influenza WHOCC for Rickettsial Diseases WHOCC for Shigella WHOCC for Smallpox and Other Poxvirus Infections WHOCC for Reference and Research in Syphilis Serology WHOCC for Viral Hemorrhagic Fevers WHOCC for Reference and Research on Viral Hepatitis

Tentative WHO Approval: WHOCC for Lyme Borreliosis WHO/PAHO Collaborating Center for Rotavirus and the Agents of Viral Gastroenteritus WHOCC for Public Health Systems and Practice

Proposed New Centers: WHOCC for Cysticercosis WHOCC for Molecular Identification and Typing of Insect Disease Vectors WHOCC for Measles Virus Diagnostics (also serves as the PAHO Regional Measles Reference Laboratory) WHOCC for Prevention and Control of Epidemic Meningitis WHOCC for Prevention and Control of Mycobacterium ulcerans () WHOCC for Insecticide Resistance WHOCC for Infectious Disease WHOCC for Salmonella Surveillance WHOCC for Streptococcus WHOCC for Vibrio cholerae O1 and O139

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 67 APPENDIX E A. Regional Networks for Disease Surveillance & Outbreak Response REGIONAL AND Africa • Integrated Disease Surveillance and Epidemic Preparedness and Response DISEASE-SPECIFIC Project, led by WHO/AFRO • International Disease Survey for diseases of epidemic potential (e.g., menin- SURVEILLANCE gitis, yellow fever, cholera, measles, and polio), supported by USAID NETWORKS Other disease surveillance activities in Africa: The disease surveillance component of UNAIDS’ International Partnership Against HIV/AIDS in Africa (IPAA) monitors progress in reducing infection rates and deaths from HIV/AIDS, TB, and opportunistic infections. As part of USAID’s African Integrated Malaria Initiative (AIMI), CDC helps ministries of , Kenya, Malawi, and Zambia monitor progress in reducing illness and deaths from malaria. During 2001, AIMI surveillance activ- ities will also be conducted in collaboration with the ministries of health of the Democratic Republic of the Congo, Nigeria, Senegal, and Uganda. The U.S. Army Medical Research Unit in Nairobi (USAMRU-Kenya) is coor- dinating an effort to enhance surveillance for HIV/AIDS, malaria, yellow fever, and enteric illnesses in east Africa. Partners include ministries of and Uganda. the Kenya Medical Research Institute (KEMRI), the African Med- ical and Research Foundation (AMREF), and CDC’s Kenya Field Station.

The Americas and the Caribbean • Amazon Basin Network Includes 7 laboratories from 5 nations • Southern Cone Network Includes 8 laboratories from 6 nations • Caribbean Epidemiology Center (CAREC) disease surveillance system Includes the 21 members of CAREC • Middle America Network • U.S.-Mexico Border Infectious Disease Surveillance System • U.S./Canada International Circumpolar Surveillance project to enhance sur- veillance for invasive bacterial infections among indigenous peoples in sub- arctic regions of northern Canada and Alaska. This project is conducted in association with the International Circumpolar Surveillance project in Europe (see: Europe).

Other disease surveillance activities in the Americas and the Carribean: The U.S. Naval Medical Research Center Detachment (NMRCD) in Lima is coordinating an effort to enhance surveillance for malaria, yellow fever, dengue, and other hemorrhagic fevers in . Planners include ministries of

68 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy health of Peru, Ecuador, and Bolivia, WHO/PAHO, and CDC. An epidemiolo- gist from CDC is currently stationed at NMRCD.

Asia • Mekong Delta Surveillance Network. Includes China (Yunan), Cambodia, Laos, Thailand, Myanmar, and Vietnam • Pacific Public Health Surveillance Network (PacNet) Includes 20 Pacific Islands • Early Warning Outbreak Recognition System (EWORS) A collaboration between the Indonesian Ministry of Health and U.S. Naval Medical Research Unit No. 2 (NAMRU-2). It currently involves hospitals throughout Indonesia and is expanding to include hospitals in Cambodia.

Other disease surveillance activities in Asia: Disease Surveillance and Electronic Networking are two of six “pillars” in a strategy to fight HIV/AIDS and infectious diseases endorsed at the 2001 summit meeting of the Asia Pacific Economic Cooperation (APEC). (The other pillars are: Outbreak Response, Capacity Building, Partnering Across Sectors, and Political and Economic Leadership.) As part of this effort, work has begun toward the creation of an Asia-Pacific network of networks that will knit togeth- er existing electronic infectious disease networks and facilitate timely transmis- sion of public health information across APEC economies. The cooperative sys- tem will build on existing APEC projects that enhance surveillance for influenza, E. coli O157 infection, dengue, and dengue hemorrhagic fever. The first International Emerging Infectious Program (IEIP) was established in Bangkok in September 2001, as a collaboration between CDC and the Ministry of Health of Thailand. This IEIP site will serve as a resource for infectious dis- ease surveillance networks in Asia. The United States participates in binational projects to improve disease sur- veillance with Vietnam, Thailand, and Cambodia. These collaborations are coordinated by CDC, the Armed Forces Research Institute of Medical Science (AFRIMS-Thailand) in Bangkok, and NAMRU-2 in Jakarta. For example, an epidemiologist from CDC stationed at NAMRU-2 and a laboratory in Phnom Pen is working with the Cambodian Ministry of Health to establish a school of public health. An epidemiologist from CDC has also been assigned to China to facilitate collaborative projects that address the prevention and control of viral hepatitis, which is a mjor public health concern in China.

Europe • E.U.’s EnterNet system for surveillance of international foodborne outbreaks • International Circumpolar Surveillance project to enhance monitoring of invasive bacterial infections in the circumpolar regions of Europe (Iceland,

Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy 69 Greenland [Denmark], Norway, Sweden, Finland and Russia). This project is conducted in association with the U.S./Canada International Circumpolar Surveillance project (see: The Americas and the Caribbean).

The • WHO Middle East Initiative to enhance disease surveillance in Israel and the Palestinian territories

Other disease surveillance activities in the Middle East: The U.S. Naval Medical Research Unit No. 3 (NAMRU-3) in Cairo is coordi- nating a collaborative effort to enhance surveillance for diseases of importance in the Middle East (e.g., meningitis, influenza, acute febrile illnesses, and antibi- otic-resistant enteric ). Partners include the Egyptian Ministry of Health and Population, health authorities in Yemen, Pakistan, and the Palestin- ian Territories, WHO/EMRO, and CDC. An epidemiologist from CDC is cur- rently stationed at NAMRU-3.

B. Selected Global Networks for Infectious Disease Surveillance & Outbreak Response

• WHO Influenza Surveillance Network • WHO Global Network for Polio Eradication/Measles Elimination • WHO Supranational Reference Laboratory Network for Antituberculosis Drug Resistance • WHO Global Salmonella Surveillance (Global Salm-Surv) • WHO Global Alert and Response Network (see Box 14) • Surveillance in support of the worldwide eradication of guinea worm disease • Surveillance for vaccine-preventable diseases under the Expanded Programme on Immunization (EPI) • GeoSentinel, the global surveillance network of the International Society of Travel Medicine Includes 26 travel and tropical medicine clinics, 15 in the United States, 2 in the United Kingdom, 2 in Australia, and 1 each in Canada, Germany, Israel, Italy, Nepal, New Zealand, and

As mentioned above, the first International Emerging Infectious Program (IEIP) was established in 2001 in Thailand. As new IEIP sites are founded (see page 53), they will provide technical assistance to local disease surveillance networks and become members of a global IEIP network.

70 Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy ACKNOWLEDGMENTS Fred Angulo, Felice Apter, Ray Arthur, Judith Bale, Daniel Bausch, David Bell, Sue Binder, Stephen Blount, Queta Bond, Joel Breman, Jennifer Brooks, Bruce Brown, Donald S. Burke, Jay Butler, Gail Cassell, Martin Cetron, Mitchell Cohen, Stephen Corber, Kenneth Castro, Patrick S. Chong, Gary G. Clark, Stephen Cochi, Daniel Colley, Carol Crawford, Nils Daulaire, Jonathan Davis, David T. Dennis, Frances L. de Peyster, Deborah Deppe, Lynn DiFato, Cedric Dumont, Laura Efros, Judith F. English, Charles Erics- son, David Fleming, Anna Flisser, Julie Gerberding, Jerry Gibson, Jesse Goodman, Thomas Gomez, Duane Gubler, Richard Guerrant, Stephen Hadler, Wendy Hall, Margaret Hamburg, Walter Hierholzer, David Hey- mann, Allen Hightower, Nguyen Thi Thu Hong, Don Hopkins, James Hospedales, Harold Jaffe, Stephanie James, William Jarvis, Warren Johnson, Gregory Jones, Marsha Jones, Bradford Kay, Robert Keegan, Richard Keenlyside, Patrick Kelley, Keith Klugman, Christopher E. Laxton, James W. LeDuc, Michael Levine, Arthur Liang, Scott Lillibridge, Lavinia M. Limon, Earl Long, Michael Malison, Eric Mast, Alison Mawle, Jay McAuliffe, Patrick J. McConnon, Eugene McCray, Joseph McDade, John McGowan, Martin Meltzer, Eric Mintz, Thomas Monath, Melinda Moore, Anthony Moulton, Stephen Ostroff, Mark Papania, Alan Parkinson, Anthony Perez, Robert Perry, Bradley Perkins, Bobbie Person, Francisco Pinheiro, Gabriel Ponce de Leon, Robert Quick, Rosemary Ramsey, Arthur Reingold, Joy Riggs-Perla, Nancy Rosenstein, Ronald St. John, Anne Schuchat, Ben Schwartz, Larry Slutsker, Carol Snarey, Richard Steketee, Mary Grace Stobierski, Charles Stokes, Susan Stout, Robert Tauxe, Ralph Timperi, Laura Trent, Juli Trtanj, Mark Walkup, J. Todd Weber, Mark White, Gillian Woollett, Michael Zeilinger.

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