United States General Accounting Office

GAO Testimony

Before the Committee on International Relations,

House of Representatives

Release on Delivery

Expected at

10:00 a.m., EDT

Wednesday,

May 20, 1998

INFECTIOUS DISEASES

Analysis of Eradication or

Elimination Estimates

Statement of Benjamin F. Nelson, Director, International

Relations and Trade Issues, National Security and

International Affairs Division

GAO/T-NSIAD-98-183

Mr. Chairman and Members of the Committee:

We are pleased to be here today to discuss the results of our review of the

World Health Organization’s (WHO) estimates for eradicating or eliminating

the following infectious diseases: dracunculiasis, polio, leprosy, measles,

onchocerciasis, Chagas’ disease, and lymphatic filariasis.1

 These diseases

exact an enormous cost on the developing world, killing almost 1.1 million

people and afflicting millions of others with serious disabilities and

deformities. Measles alone kills almost 1 million children each year, the

vast majority of them in the least developed countries.

In April 1997, WHO provided the House International Relations Committee

with estimated costs and target dates for eradicating or eliminating the

seven diseases. Subsequently, WHO revised some of the costs and time

frames based on more recent information. We reviewed the estimates

provided to us by WHO as of December 1997. WHO officials estimated that

about $7.5 billion would be needed to eradicate or eliminate the targeted

diseases.

Today, we will discuss (1) the soundness of WHO’s cost and time frame

estimates, (2) U.S. spending related to these diseases in fiscal year 1997

and any potential cost savings to the United States as a result of

eradication or elimination, (3) other diseases that international health

experts believe pose a risk to Americans and could be eventual candidates

for eradication, and (4) U.S. costs and savings from smallpox eradication

and whether experts view smallpox eradication as a model for other

diseases. We did not attempt to assess the cost-effectiveness of these

initiatives as compared to other options such as improving primary health

care delivery systems.

Background Eradication of infectious diseases involves reducing worldwide incidence

to zero, thereby obviating the need for further control measures.

Elimination of infectious diseases involves reducing morbidity to a level at

which they are no longer considered major public health problems.

Elimination still requires a basic level of control and surveillance.

Global disease eradication and elimination campaigns are initiated,

primarily by WHO, to concentrate and mobilize resources from both

affected and donor countries. WHO provides recommendations for disease

1

Infectious Diseases: Soundness of World Health Organization Estimates for Eradication or

Elimination (GAO/NSIAD-98-114, Apr. 23, 1998).

Page 1 GAO/T-NSIAD-98-183
eradication and elimination to its governing body, the World Health

Assembly, based on two general criteria—scientific feasibility and the

level of political support by endemic and donor countries. Formal

campaigns were initiated for dracunculiasis and leprosy in 1991, and for

polio and lymphatic filariasis in 1988 and 1997, respectively. Regional or

subregional campaigns are also underway against measles, onchocerciasis,

and Chagas’ disease. Disease eradication and elimination efforts are

normally implemented by national governments of the affected countries.

Developing countries typically receive assistance from bilateral and

multilateral donors, nongovernmental organizations, and the private

sector.

Developing costs and time frames for these efforts is difficult due to

challenges in gathering and verifying data from countries with minimal

health infrastructure. Unpredictable and unstable country conditions, such

as civil unrest, further complicate efforts to project how much these

efforts will cost and how much time is needed. The appendix at the end of

this statement provides a breakdown of costs and time frames for

eradicating or eliminating each disease.

Summary WHO and other experts we contacted generally agree on five factors

necessary to estimate the cost of eradicating or eliminating a disease:

(1) product costs; (2) information on disease incidence, prevalence, and

the size of the target populations; (3) administrative and delivery costs;

(4) disease monitoring and surveillance costs; and (5) primarily for

eradication, the costs of certifying that countries are free of the disease.

We focused our assessment on the accuracy and completeness of the

underlying data for these five factors. WHO’s estimates and our analysis did

not include an assessment of opportunity or indirect costs that may be

incurred as a result of eradication campaigns, such as the impact on

routine health care services in developing countries or the costs to

individuals of seeking vaccines or other treatment.

We found that the soundness of WHO’s cost and time frames varied by

disease. Generally, the estimates were most sound for those diseases

closest to meeting eradication or elimination goals, including

dracunculiasis, polio, and leprosy. Estimates for these three diseases were

based on firm data about target populations and intervention costs from

ongoing initiatives. For the other diseases, WHO’s estimates are more

speculative because underlying data are incomplete or unavailable. WHO

Page 2 GAO/T-NSIAD-98-183
officials acknowledged this fact and said that estimates are continuously

revised as better data become available. They also noted the difficulty in

gathering and verifying data for countries with minimal health

infrastructure.

The United States spent about $391 million in 1997 to combat these

diseases. The United States spent $300 million on polio and measles

prevention and on leprosy treatment in this country. About another

$91 million went for overseas programs, primarily the polio eradication

campaign. Savings to the United States from eradicating or eliminating

these diseases would result primarily from not having to vaccinate U.S.

children against polio and measles.

Experts we contacted identified four other diseases that pose health

threats to the United States and could be possible candidates for

eradication: rubella, mumps, hepatitis B, and Hemophilus influenzae type

b, or Hib. WHO told us that, while it may be technically possible to eradicate

these diseases with existing vaccines, the international community cannot

support too many eradication initiatives at one time. Therefore, it is

unlikely that other diseases will be considered for eradication before

success is achieved with some of the diseases currently targeted.

The United States has saved almost $17 billion as a result of the

eradication of smallpox in 1977, due mostly to the cessation of

vaccinations. Experts generally agreed that the primary lesson from

smallpox is that a disease can actually be eradicated. The smallpox

eradication effort also provided a valuable lesson in how to mobilize

community, national, and international efforts. However, smallpox had

unique characteristics that made it particularly vulnerable to eradication

and therefore has limitations as a model for current efforts. Smallpox was

less infectious than polio or measles, easily diagnosed, and multiple mass

campaigns were unnecessary because the vaccine was effective with one

dose.

Soundness of

Estimates Varies by

Disease

WHO’s cost and time frame estimates, with the exception of measles,

addressed all five of the relevant factors. However, the completeness of

the data underlying the estimates varies by disease. Generally, estimates

for those diseases with long-standing eradication or elimination campaigns

are more complete, as the underlying data are based on actual experience

in endemic countries. For the other diseases, WHO is still gathering data

and refining its assumptions. Estimates for diseases with target dates of 

Page 3 GAO/T-NSIAD-98-183
5 years or longer are more speculative due to incomplete data and the

difficulty in predicting sustained commitment and stable country

conditions. We will briefly discuss the estimates for each disease and the

barriers to be overcome.

Dracunculiasis (Guinea

Worm Disease)

WHO’s cost estimate of $40 million for eradicating dracunculiasis included

data on each of the five key factors and appears to be sound.

Community-based programs to control this disease have been underway

since 1980. Continuing civil unrest in some endemic areas of Africa

precluded meeting the original 1995 target date for eradication. WHO now

expects that all countries except Nigeria and Sudan will be free of

dracunculiasis by 2005 at the latest, assuming safe access and appropriate

funding. WHO’s cost estimate includes certification costs that will continue

until 2011. The Centers for Disease Control and Prevention (CDC) and

officials from the Carter Center believe that some country-level

eradication goals may be met even sooner than WHO estimated. The main

barrier to eradication is ongoing civil strife in the endemic region. Experts

also point to the need for continued national and donor support.

Polio WHO’s cost estimate of $1.6 billion for eradicating polio is generally sound.

It includes well-developed data on all five factors based on experience in

controlling the disease. Many countries began polio vaccinations in the

1970s and 1980s. Most experts agreed that global interruption of the wild

polio virus will occur by 2002 or shortly thereafter. Global certification is

to take place about 3 years after the last case is reported—probably

around 2005. However, some experts have raised concerns about the

ability of less developed countries to maintain the required level of polio

vaccinations and surveillance until eradication is achieved. In addition,

WHO is concerned about the ability of some countries to detect and report

acute flaccid paralysis, a key component of polio surveillance. According

to WHO, unless sufficient resources are mobilized to improve detection

capability, eradication cannot be certified.

Leprosy WHO’s cost estimate of $225 million for eliminating leprosy includes

well-developed data on all key elements and appears to be sound. The

current elimination strategy is based on the multidrug therapy begun in

1981. Endemic countries have made great progress toward eliminating

leprosy since that time, but some challenges remain. WHO noted that it is

possible that some countries with concentrated pockets of leprosy might

Page 4 GAO/T-NSIAD-98-183
need to continue campaigns beyond the target year 2000 to reach the

global leprosy elimination target of less than 1 case per 10,000 people. In

addition, ongoing civil strife in endemic areas and difficult country

conditions may preclude meeting all targets. Also, since leprosy patients

are often ostracized and hidden, case identification is difficult. However,

experts generally agreed that WHO’s cost and time frame estimates

appeared reasonable.

Measles WHO’s estimate of $4.9 billion for global measles eradication by 2010 is

speculative. While vaccine costs are well known, we found several areas in

which the current estimates may be low or based on incomplete data.

Essentially, data are incomplete regarding the number of children to be

vaccinated, administrative costs, the number of mass campaigns that may

be needed, and the costs of surveillance in less developed countries.

Finally, the estimate does not include certification costs. WHO officials

noted that they used information from their previous experience with

polio eradication in developing the measles estimate. The vaccine

administration and surveillance costs for polio are adjusted upward to

account for difficulties in administering an injectable rather than an oral

vaccine.

Many international health experts believe that measles is the next

candidate for a formal global eradication effort,2

 pointing to some

successes in controlling measles in the Americas as well as support from

developing countries where measles is a major cause of mortality among

children. However, experts also point out that there are some challenges

to eradicating measles by 2010. Measles is highly contagious, requiring

higher routine vaccination rates than smallpox and polio. In addition,

outbreaks can occur even in areas of high routine vaccination coverage.

Furthermore, costly mass campaigns are necessary to catch those still

susceptible after routine vaccination because the vaccine is not

100-percent effective. Finally, some industrialized countries do not

perceive measles to be a major public health problem and have not

initiated measles elimination efforts. More than half of the estimated cost

of measles eradication is expected to be incurred by developed countries.

WHO and CDC estimate the cost of eradicating measles in less developed

countries at up to $1.8 billion.

2

The World Health Assembly has not yet voted on a resolution to eradicate measles.

Page 5 GAO/T-NSIAD-98-183
Onchocerciasis (River

Blindness)

WHO’s estimate of $143 million for eliminating onchocerciasis is

speculative. It incorporates data on all key cost elements, but data on the

size of the target population are incomplete. The control programs for

West Africa and Latin America have been ongoing for a period of time and

are likely to reach their elimination targets within or near the costs and

target dates estimated by WHO. However, WHO is still mapping disease

prevalence for the 19 African countries in the most recent control

program. WHO’s earlier estimates may have underestimated the population

eligible for treatment upon which the cost and time frame estimates were

based. For example, the latest estimate for those to be treated in this area

is 42 million, compared to the original estimate of 35 million. Also, WHO

does not yet have a reliable estimate on the number to be treated in the

Democratic Republic of the Congo (formerly Zaire).

Chagas’ Disease Although WHO included data on all cost factors, the $391 million estimated

for eliminating Chagas’ disease is speculative for two reasons—not all

countries have submitted estimates, and countries that are targeted for

elimination of Chagas’ disease by 2010 only submitted estimates through

2005. The first regional program began in the southern portion of South

America in 1991. Data from this region are more complete, and the

program appears to be on track for completion by 2005. However, the

efforts in the Central American and Andean countries only began last year

and are targeted for completion by 2010. Costs and time frames in these

countries are less certain because three countries have not submitted cost

estimates or prevalence and incidence data, and all countries submitted

cost data only through 2005.

Lymphatic Filariasis The $228 million estimated for eliminating lymphatic filariasis is very

speculative. While all cost factors were addressed in the estimates, the

data are very preliminary. WHO has limited historical data on costs because

formal campaigns have only recently begun in some of the 73 countries in

which lymphatic filariasis is known to be endemic. Also, WHO has not yet

completed its assessments to establish the number of people to be treated

in endemic countries and to determine whether there are other endemic

countries.

Page 6 GAO/T-NSIAD-98-183
U.S. Spending on

These Diseases and

Potential U.S. Savings

Associated With Their

Eradication or

Elimination

The United States currently spends about $391 million a year on these

diseases. This includes about $300 million on polio and measles prevention

programs and leprosy treatment in the United States and about another

$91 million abroad for all the diseases under discussion except leprosy.

Most of this amount would be saved if eradication and elimination goals

were met and efforts to combat the diseases were ceased or reduced.

The overall savings to the United States if polio were eradicated are

estimated to be at least $304 million a year. This includes about

$230 million in public and private expenditures—including

administration—for controlling polio within U.S. borders and about

$74 million for the global eradication efforts. CDC estimates that an

additional $20 million will be spent in the United States each year due to a

1996 CDC recommendation to administer two doses of the more expensive

injectable vaccine before the two doses of oral vaccine.

The overall savings to the United States as a result of eradicating measles

are estimated at about $61.7 million a year, including about $50 million for

domestic vaccine costs and about $11.7 million for global measles efforts.

The $50 million only includes the cost of the vaccine and not

administration expenses. Immunization against measles is included in the

vaccine for mumps and rubella, and the United States would continue

administering the mumps and rubella vaccine even if measles were

eradicated. Additional savings would be realized from preventing periodic

measles epidemics in the United States. CDC estimates that the last measles

epidemic of 1989-1991 cost $150 million.

The United States spends about $25 million a year for the other five

diseases. The U.S. Department of Health and Human Services spends

about $20 million a year to treat a small number of leprosy patients in the

United States. The U.S. Agency for International Development (USAID)

funds the dracunculiasis effort at $500,000 a year and the onchocerciasis

control programs at $3.5 million a year. CDC spends more than $1 million

for overseas efforts against dracunculiasis, Chagas’ disease, and lymphatic

filariasis. The United States does not currently track domestic costs

related to Chagas’ disease. However, U.S. blood banks may begin

screening donated blood for the disease due to a significant number of

infected Latin American immigrants in certain areas. An American Red

Cross official estimated that this would cost about $25 million a year.

Page 7 GAO/T-NSIAD-98-183
Other Diseases as

Possible Eradication

Candidates

International public health experts identified several diseases that pose

health threats to the United States and that are technically possible to

eradicate with existing vaccines: rubella, mumps, hepatitis B, and Hib. CDC

suggested rubella and mumps could be considered as part of the measles

eradication effort, since vaccinations against all three are often

administered in one trivalent shot. CDC estimated that the United States

spends about $255.5 million a year in administering this vaccination.

Rubella is considered a significant health burden in the form of birth

defects and is being discussed as an eradication initiative for the Americas.

However, health experts generally believe that the costs to eradicate

mumps would be difficult to justify because the global burden is

considered low. The primary challenges in eradicating rubella and mumps

are diagnostic difficulties and the additional costs that would be incurred.

Hepatitis B is considered a possible candidate because the vaccine is

effective and relatively inexpensive, and a good diagnostic tool is

available. Hepatitis B is viewed as a major public health threat, causing

almost 1.2 million deaths per year, usually from liver cancer or chronic

liver disease. CDC estimates that the U.S. public and private sectors spend

from $308 million to $383 million a year for hepatitis B vaccines alone. The

major barrier to an eradication initiative is that some people are chronic

carriers and would have to die before the disease could be considered

eradicated.

Hib is a bacterial infection that is the most common cause of childhood

meningitis. About 400,000 to 700,000 children in developing countries die

each year from the disease. U.S. public and private sectors spend about

$162 million a year on Hib vaccines. According to CDC, Hib has potential

for eradication, but more needs to be known about the vaccine before this

disease could be an eradication candidate.

WHO told us that rubella, hepatitis B, and Hib could be eventual candidates

for eradication due to their associated public health burdens and the

success in controlling these diseases in some parts of the world. However,

they noted that, due to the high costs associated with eradication efforts, it

is important to limit the number of ongoing efforts, and they do not

support adding campaigns at this time.

Smallpox Eradication

Showed That Success

Was Possible

As the first and only disease to be eradicated through human intervention,

smallpox is used as evidence that disease eradication is technically

feasible. According to some experts, the smallpox effort yielded lessons

that have since been applied to other efforts, such as the role of

Page 8 GAO/T-NSIAD-98-183
surveillance and the ability to garner resources for massive campaigns. It

also showed that eradication can be cost-effective. Using 1967 estimated

smallpox costs as a baseline measure and adjusting for annual birth rates,

we estimated the cumulative present value global savings in 1997 dollars

for the period 1978-1997 at $168 billion. For the United States, cumulative

savings from smallpox eradication are estimated at almost $17 billion. The

United States spent about $610 million in 1997 dollars for domestic

smallpox control in 1968 and about $130 million in 1997 dollars during

1968-1977 on the overseas eradication effort. We estimated the annual real

rate of return for the United States at about 46 percent a year since

smallpox was eradicated.

Smallpox had characteristics that experts consider desirable for

eradication. The disease was easily diagnosed, and all infection resulted in

visible symptoms. The vaccine was effective in only one dose, stable in

heat, and inexpensive. Polio and measles share many of the desirable

eradication characteristics of smallpox. Both diseases are caused by viral

agents, are found only in humans, and have effective interventions

available that provide long-lasting immunity. However, certain differences

exist that may limit the usefulness of smallpox as a model for other

eradication efforts. Smallpox was less infectious than either polio or

measles and required less immunization coverage. Polio and measles

require mass campaigns in addition to routine coverage to interrupt virus

transmission. Polio and measles are also difficult to diagnose without

laboratory confirmation. The vast majority of polio infections show no

symptoms, and the typical paralytic manifestations of polio can be due to

other causes. Dracunculiasis differs from smallpox in that is a parasitic

disease and not vaccine preventable. However, like smallpox, it is

vulnerable to eradication because the interventions are inexpensive and

effective, and the infection is easily diagnosed.

Mr. Chairman, this concludes our prepared remarks. We would be happy

to answer any questions you or the Committee members may have.

Page 9 GAO/T-NSIAD-98-183
Appendix I 

World Health Organization Estimated Target

Dates and Costs for Eradicating or

Eliminating Selected Diseases as of

December 1997

1997 dollars in millions

Disease Goal Target date Estimated costa

Dracunculiasis Eradication 2011b $40

Polio Eradication 2000c $1,600

Leprosy Elimination 2000 $225

Measles Eradication 2010 $4,900

Onchocerciasis Elimination 2010 $143

Chagas’ disease Elimination 2010 $391

Lymphatic filariasis Elimination 2030 $228

aThese costs represent projected public expenditures by national governments and donor

countries for eradication or elimination campaigns.

bWHO expects that all but two countries will be free of dracunculiasis by 2005.

cCertification of polio eradication is expected by 2005.

(711348) Page 10 GAO/T-NSIAD-98-183
Ordering Information

The first copy of each GAO report and testimony is free.

Additional copies are $2 each. Orders should be sent to the

following address, accompanied by a check or money order

made out to the Superintendent of Documents, when

necessary. VISA and MasterCard credit cards are accepted, also.

Orders for 100 or more copies to be mailed to a single address

are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office

P.O. Box 37050

Washington, DC 20013

or visit:

Room 1100

700 4th St. NW (corner of 4th and G Sts. NW)

U.S. General Accounting Office

Washington, DC

Orders may also be placed by calling (202) 512-6000 

or by using fax number (202) 512-6061, or TDD (202) 512-2537.

Each day, GAO issues a list of newly available reports and

testimony. To receive facsimile copies of the daily list or any

list from the past 30 days, please call (202) 512-6000 using a

touchtone phone. A recorded menu will provide information on

how to obtain these lists.

For information on how to access GAO reports on the INTERNET,

send an e-mail message with "info" in the body to:

info@www.gao.gov

or visit GAO’s World Wide Web Home Page at:

http://www.gao.gov

PRINTED ON RECYCLED PAPER
United States

General Accounting Office

Washington, D.C. 20548-0001

Official Business

Penalty for Private Use $300

Address Correction Requested

Bulk Rate

Postage & Fees Paid

GAO

Permit No. G100