Report to Congressional Requesters

United States General Accounting Office

GAO

August 2001 GLOBAL HEALTH

Challenges in

Improving Infectious

Disease Surveillance

Systems

GAO-01-722
Page i GAO-01-722 Global Health

Letter 1

Results in Brief 2

Background 4

Global Surveillance Varies by Disease 8

Global Framework’s Performance Constrained by Weaknesses in

Developing Countries 16

Impact of Improvement Initiatives Remains to Be Demonstrated 26

Concluding Observations 40

Agency Comments and Our Evaluation 41

Appendix I Objectives, Scope, and Methodology 44

Appendix II Disease Information 47

Appendix III Comments From the Department of Health and

Human Services 55

Appendix IV Comments From the World Health Organization 58

Appendix V Comments From the United States Agency for

International Development 60

GAO Comments 66

Appendix VI Comments From the National Aeronautics and Space

Administration 67

Appendix VII Comments From the World Bank 68

Appendix VIII Comments From the Department of Defense 69

Contents
Page ii GAO-01-722 Global Health

Appendix IX GAO Contact and Staff Acknowledgments 70

GAO Contact 70

Acknowledgments 70

Tables

Table 1: Health Expenditures by National Income Level 17

Figures

Figure 1: The Global Infectious Disease Surveillance Framework: A

Network of Networks 7

Figure 2: Distribution of WHO Collaborating Centers for Infectious

Disease Surveillance and Control 36

Abbreviations

CDC Centers for Disease Prevention and Control

HIV/AIDS Human Immunodeficiency Virus/Acquired

Immunodeficiency Syndrome

IDS Integrated Disease Surveillance and Response

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WHO World Health Organization
Page 1 GAO-01-722 Global Health

August 31, 2001

The Honorable Patrick Leahy

Chairman

The Honorable Mitch McConnell

Ranking Minority Member

Subcommittee on Foreign Operations

Committee on Appropriations

United States Senate

The Honorable Russell Feingold

Chairman

The Honorable Bill Frist

Ranking Minority Member

Subcommittee on African Affairs

Committee on Foreign Relations

United States Senate

According to the World Health Organization, infectious diseases account

for more than 13 million deaths every year, including nearly two-thirds of

all deaths among children under age 5. Although the great majority of

these deaths occur in developing countries, infectious diseases do not

recognize international boundaries. They present a substantial threat to

people in all parts of the world. In recent years, this threat has grown in

volume and complexity. New diseases have emerged, others once viewed

as declining in significance have resurged in importance, and many have

developed substantial resistance to known antimicrobial drugs. This

picture is complicated by the potential deployment of infectious disease

pathogens as weapons of war or instruments of terror.

Infectious disease surveillance provides national and international public

health authorities with information that they need to plan and manage

efforts to control these diseases. In the mid-1990s, public health experts in

the United States and abroad determined that global infectious disease

surveillance was inadequate, and both the World Health Assembly and the

United States General Accounting Office

Washington, DC 20548
Page 2 GAO-01-722 Global Health

President of the United States called for concerted action to develop an

effective global infectious disease surveillance and response system.1

In response to your concern about current arrangements for infectious

disease surveillance, we reported in July 20002

 that global surveillance is

carried out through a loose framework of formal, informal, and ad hoc

arrangements that World Health Organization (WHO) officials characterize

as a “network of networks.” In this second report, we (1) examine the

framework’s evolution and current operations, (2) identify factors that

constrain its performance, and (3) assess several initiatives designed to

improve global infectious disease surveillance and response.

In doing this work, we collected data from and consulted with experts in

the international public health community, including officials of WHO, the

Centers for Disease Control and Prevention (CDC), the U.S. Agency for

International Development (USAID), the World Bank, and prominent

nongovernmental organizations in the health sector. As you requested, we

emphasized surveillance operations in sub-Saharan Africa, visiting Malawi,

Tanzania, Uganda, and Zimbabwe to discuss relevant issues with public

health officials at every level. More detailed information about our scope

and methodology is in appendix I. Information on each of the diseases

mentioned in this report is in appendix II.

The strongest influence on the evolution of the current global infectious

disease surveillance framework has been the international community’s

focus on specific diseases or groups of diseases. The international

community has created diverse surveillance programs to support global

and/or regional efforts to control particular diseases. The longest standing

of these is the global influenza program, which was launched prior to the

WHO’s founding in 1948. The success of the intensified smallpox

 1

See World Health Assembly Resolution 48.13, Communicable Disease Prevention and

Control: New Emerging and Re-Emerging Infectious Diseases (Geneva, Switzerland: May

12, 1995); Emerging Infections: Microbial Threats to Health in the United States, Institute

of Medicine (Washington, D.C. 1992); Infectious Disease—A Global Health Threat, Report

of the National Science and Technology Council, Committee on International Science,

Engineering, and Technology, Working Group on Emerging and Re-emerging Infectious

Diseases (Washington, D.C.: Sept. 1995); and Presidential Decision Directive NSTC-7,

Emerging Infectious Diseases (Washington, D.C.: June 1996).

2

Global Health: Framework for Infectious Disease Surveillance (GAO/NSIAD-00-205R,

July 20, 2000).

Results in Brief
Page 3 GAO-01-722 Global Health

eradication effort, which began in 1966 and identified the last naturally

occurring case in 1977, spurred initiation of other eradication/elimination

efforts during the late 1980s and early 1990s, including the current

campaign to eradicate polio. International public health officials also

operate a number of programs directed at controlling noneradicable

diseases such as dengue. Under some circumstances, such as when a

disease can be eradicated with comparative ease or when it poses a high

risk of a global pandemic, disease-specific programs have attracted broad

support and substantial funding. In such situations public health officials

have been able to establish specific goals and create comparatively highperforming systems—including surveillance systems—to support

achievement of those goals. Surveillance for other diseases has received

less international support and is more limited.

Surveillance systems in all countries suffer from a number of common

constraints. However, these constraints have their greatest impact in the

poorest countries, where per capita expenditure on all aspects of health

care amounts to only about 3 percent of expenditure in high-income

countries. Surveillance in developing countries is often impaired by

shortages of human and material resources. Key positions in laboratories

and clinics often are filled by people who do not possess the necessary

qualifications. According to WHO, staff in over 90 percent of developing

country laboratories are not familiar with quality assurance principles, and

more than 60 percent of laboratory equipment is outdated or not

functioning. Sixteen of 19 WHO-sponsored assessments of sub-Saharan

African systems that we reviewed reported weaknesses in laboratory

capacity, ranging from a lack of trained technicians to deteriorating

buildings. In addition, poor roads and communications make it difficult for

health care workers to alert higher authorities about outbreaks or quickly

transport specimens to laboratories. Ten of the assessments found that

less than half of the local health facilities surveyed had operating

telecommunications equipment or vehicles for transport. In addition,

multiple surveillance systems are often poorly coordinated and not firmly

linked to response measures. The absence of a clear response discourages

lower level officials from investing effort in surveillance, and this leads to

many cases of disease going unrecorded and unreported. These

weaknesses limit the effectiveness of even the most widely supported

international disease control programs. They also impair routine

surveillance for other diseases and efforts to investigate and respond to

outbreaks, newly emerging diseases, and growth in antimicrobial

resistance.
Page 4 GAO-01-722 Global Health

The international community has recently launched a number of initiatives

that may improve global surveillance. First, the community has committed

itself to achieving specific reductions in the global burdens imposed by

three diseases—tuberculosis, human immunodeficiency virus/acquired

immunodeficiency syndrome (HIV/AIDS), and malaria—that present

complex challenges. Improving surveillance for these three diseases will

be an essential part of the global response to these new commitments.

Second, the community has launched more broadly targeted initiatives to

upgrade laboratories, strengthen epidemiological capacity, and otherwise

improve surveillance for infectious diseases as a group. The eventual

impact of both the disease-specific and the more broadly targeted

initiatives remains to be demonstrated. Public health experts observed

that major reductions in tuberculosis, HIV/AIDS, and malaria cannot be

achieved without substantial overall improvements in developing country

health systems, including surveillance operations of these systems. These

new disease-specific initiatives may therefore facilitate efforts to improve

surveillance for infectious diseases as a group. Nonetheless, efforts to

make broad improvements in developing country systems will be

proceeding in an environment wherein the priority will be to achieve

measurable results against HIV/AIDS, malaria, and tuberculosis, in

particular. The extent to which the global public health community’s

response to the new disease-specific commitments will improve

surveillance for all infectious diseases remains to be seen.

We received comments on a draft of this report from the Department of

Health and Human Services (which includes CDC), and the Departments

of Defense and State, as well as from WHO, USAID, the National

Aeronautics and Space Administration, and the World Bank. These

agencies generally concurred with our findings. The Department of Health

and Human Services and USAID elaborated upon the challenges to be

faced in developing programs to improve surveillance and response

capacity for specific diseases and for infectious diseases as a group, while

USAID and the Department of Defense commented that the report did not

adequately describe their contributions to improving global surveillance.

We modified this report to respond to these comments and to other

matters raised by the agencies.

Dramatic increases in the volume and speed of international travel and

trade in recent years have increased opportunities for diseases to spread

across international boundaries. The global reach of the ongoing HIV/AIDS

pandemic and the recent appearance in the United States of West Nile

virus—a pathogen never before identified in the Western Hemisphere—

Background
Page 5 GAO-01-722 Global Health

demonstrate this point. Diseases once regarded as declining in significance

have also reemerged in recent years to once again become major global

health threats. For example, according to WHO, global reports of yellow

fever have dramatically increased over the last 2 decades.

The emergence of previously unknown diseases and the development of

disease strains resistant to antimicrobial drugs further complicate

international disease control efforts. Over the past 3 decades, more than

30 previously unknown diseases have been identified. Many, including

Ebola hemorrhagic fever, Rift Valley fever, and Lyme disease, appear to

have become threats to human health because of increased human

movement into or alteration of the habitats of disease-carrying insects and

animals. Excessive, uncontrolled use of antimicrobial drugs has

contributed to the evolution of disease strains that are highly resistant to

available medications.

Infectious diseases can be a substantial obstacle to economic and social

advancement in developing countries, where the great majority of cases of

such diseases occur. For example, WHO has concluded that Africa’s gross

domestic product would be nearly one-third higher than it is today if

malaria alone had been eliminated 35 years ago. Development experts

believe that the HIV/AIDS pandemic will have a similar impact on African

economies.

Surveillance provides information for action against infectious disease

threats. Basic surveillance functions include detecting and reporting cases

of disease, analyzing and confirming this information to identify outbreaks

and clarify longer-term trends, and applying the information to inform

public health decisionmaking. When effective, surveillance can facilitate

(1) timely action to control outbreaks, (2) informed allocation of resources

to meet changing disease conditions, and (3) adjustment of disease control

programs to make them more effective. According to CDC, factors that

can be taken into account in evaluating surveillance systems include their

ease of operation; the extent to which health care providers and

laboratory personnel actually provide the system with information; and

the system’s ability to identify cases of disease, accurately diagnose them,

and generate timely and accurate information on disease events and

trends.

Basic responsibility for disease surveillance and response lies with

individual countries. The legal underpinnings for cooperation among

countries to control infectious diseases are limited in scope. The primary

function of the International Health Regulations—the most important and
Page 6 GAO-01-722 Global Health

only binding international agreement on disease control—is to delineate

measures that countries may take to protect themselves against epidemics

of three diseases: cholera, plague, and yellow fever.3

 To provide national

authorities with a basis for applying protective measures, the regulations

require countries that record cases of these three diseases to report to

WHO, which then makes that information available to other countries. The

Regulations do not provide an international framework for addressing

threatening epidemics at their source—within countries.

At the global level, surveillance functions are carried out through a loose

framework that links elements of national health care systems with

various entities, including media channels, nongovernmental organizations

active in health, and laboratories and other institutions participating in

networks focusing on particular diseases and/or regions. Figure 1 presents

one illustration of this global “network of networks.” The groupings

presented in this figure are not mutually exclusive. For example, national

public health authorities may operate WHO Collaborating Centers,

participate in epidemiology training networks, and maintain Internet

discussion sites.

 3

The origins of the International Health Regulations can be traced back to the 1892

adoption of the first International Sanitary Convention, which only addressed cholera. The

original convention has been revised and replaced on several occasions, with the term

“International Health Regulations” introduced in 1969. The Regulations were last revised in

1981 when smallpox reporting was eliminated due to the success of the global smallpox

eradication program. A total of 187 countries have agreed to comply with the Regulations

in full. Australia is the only WHO member country that has not accepted the Regulations.

Seven countries—Egypt, India, Iran, Libya, Madagascar, Pakistan, and Papua New

Guinea—have accepted them in part, or with reservations.
Page 7 GAO-01-722 Global Health

Figure 1: The Global Infectious Disease Surveillance Framework: A Network of

Networks

UNHCR

and UNICEF

country

offices

Formal

Informal

WHO

collaborating

centers/

laboratories

Epidemiology

training

networks

Military

laboratory

networks

Global Public

Health

Intelligence

Network

Internet

discussion

Media, sites

press

Nongovernmental

organizations

WHO

regional and

country

offices

National

public

health

authorities

Note 1: UNHCR represents the United Nations High Commissioner for Refugees.

Note 2: UNICEF represents the United Nations Children’s Fund.

Source: WHO.

WHO plays a central role in the surveillance framework by working to

strengthen national and international surveillance capacity and

coordinating international efforts to monitor disease trends, detect and

respond to outbreaks, and carry out disease control programs. Foreign

assistance agencies such as the World Bank and USAID, as well as private

foundations, are important sources of support for strengthening

surveillance operations, particularly those taking place in developing
Page 8 GAO-01-722 Global Health

countries. For example, in commenting on a draft of this report, the World

Bank noted that it is actively working with a number of developing

country governments to strengthen their national surveillance systems,

within the context of the Bank’s overall emphasis on health. While many

technical agencies contribute to framework operations, CDC is the single

largest source of expertise and resources available to the international

surveillance and response system. The Department of Defense also

contributes to global surveillance through its Global Emerging Infections

Surveillance and Response System.4

 In commenting on a draft of this

report, for example, the department cited its contributions to global

surveillance for drug-resistant malaria and influenza.

The global surveillance framework’s capacity for serving the public

interest varies according to the level of commitment that the international

community has made to controlling individual diseases or groups of

diseases. The most significant influence on the framework’s development

has been the international public health community’s focus on controlling

specific diseases. In some circumstances—when a disease can be

eradicated with comparative ease or when it poses a high risk of a global

pandemic—these programs have attracted broad support and substantial

funding. In such situations, public health officials have been able to

establish specific goals and create comparatively high-performing

systems—including surveillance systems—to support achievement of

those goals. Surveillance for other diseases is more limited.

The strongest influence on the evolution of the existing surveillance

framework has been the collaboration among medical professionals,

national governments, and foreign assistance agencies to develop control

programs and associated surveillance efforts that focus on specific

diseases or groups of diseases. The longest standing of these diseasespecific efforts is the global influenza program, which was launched prior

to WHO’s founding in 1948. Later, the success of the global effort to

eradicate smallpox (1966 through 1977) spurred the creation of other

programs designed to eradicate or eliminate global disease threats, such as

polio and leprosy, and diseases found in specific regions, such as guinea

 4

For more information on this system, see http://www.geis.ha.osd.mil/.

Global Surveillance

Varies by Disease

Multiple Surveillance

Systems Created to

Support Disease-Specific

Control Programs
Page 9 GAO-01-722 Global Health

worm and river blindness, which are both found primarily in Africa.5

Global consensus in favor of these eradication/elimination campaigns was

achieved during the late 1980s and early 1990s, after reduction programs

had achieved substantial progress. WHO also collaborates with numerous

institutions around the world to maintain programs to control

noneradicable infectious diseases such as HIV/AIDS, cholera, tuberculosis,

malaria, and dengue. National disease-control programs reflect this focus

on specific diseases. They are generally managed through separate

programs aimed at specific diseases, such as polio and tuberculosis, or

groups of diseases, such as those covered by the Expanded Program on

Immunization.6

Variation in the quality of global surveillance systems can be attributed in

large measure to disease characteristics. Under certain circumstances—

for example, if a disease can be eradicated or if it poses a high risk of a

global pandemic—disease-specific control programs have attracted broad

support and have employed this support to create comparatively effective

surveillance systems. Surveillance for other diseases, including emerging

infections, has received less international support and is more limited.

The best surveillance systems have been established to support

international campaigns aimed at eradicating or eliminating certain

diseases, including polio and guinea worm, and at protecting the global

community against influenza—a disease that has the potential to inflict

global pandemics.7

 5

Disease control initiatives can be designed to reduce the number of cases below current

levels, or they may be directed at eliminating or eradicating a disease. Elimination

initiatives seek to reduce the number of cases in a particular area to zero and/or to reduce

morbidity to a level that does not constitute a major public health problem. Eradication

initiatives seek to reduce worldwide incidence of a disease to zero, obviating the need for

further control measures.

6

In addition to serving as the vehicle for the polio initiative, the Expanded Program on

Immunization generally provides vaccinations against tuberculosis, measles, tetanus,

diphtheria, and pertussis (whooping cough), and can provide vaccines against other

diseases such as haemophilus influenzae type B (HIB), rubella, hepatitis B, and yellow

fever.

7

For more information on influenza preparedness, see Influenza Pandemic: Plan Needed

for Federal and State Response (GAO-01-4, Oct. 27, 2000).

Disease Characteristics,

International Commitment

Affect Surveillance Quality

High-Quality Surveillance for

Some Diseases
Page 10 GAO-01-722 Global Health

The international community has been supportive of

eradication/elimination campaigns because they promise dramatic

results—the removal of targeted diseases as public health threats—after

relatively short periods of concentrated effort. However, only diseases

with certain characteristics can be eradicated or eliminated. In addition to

imposing substantial disease burdens—a trait common to many illnesses—

diseases that the global community has targeted for eradication or

elimination tend to share other characteristics that have encouraged

consensus in favor of concerted action. Although the international

community has targeted other diseases for eradication or elimination,

polio and guinea worm are discussed below to illustrate the

characteristics of eradicable diseases and the comparatively high quality

of surveillance systems that are created to support international

eradication/elimination campaigns.8

The polio virus and the guinea worm parasite both require human hosts to

complete their reproductive life cycles. Both can be controlled by

interrupting their transmission from infected to uninfected individuals.

Also, available diagnostic tools and approaches make these diseases

relatively easy to identify and differentiate from other illnesses. For

example, a small but predictable number of polio victims (less than 1

percent) develop acute flaccid paralysis—a condition in which those

infected suddenly lose control of the muscles in their limbs. This makes it

possible to readily identify communities where intervention may be

required. Guinea worm is easily detected when mature worms emerge

from infected people’s bodies. Moreover, these diseases generally can be

controlled through application of effective, comparatively inexpensive,

and easily applied interventions. Polio, for example, can be prevented

through immunization with vaccines that are available to developing

countries at very low prices. Guinea worm transmission can be

dramatically reduced through education and relatively cheap and simple

water filtration systems.

These characteristics have allowed disease experts to develop clearly

stated, technically feasible, time-limited goals and indicators for measuring

progress. Advocates for campaigns against these diseases have been able

 8

Global commitments to eradicating these two diseases are of longest standing. Campaigns

to eliminate river blindness, leprosy, and Chagas disease have also been under way for a

decade or more. An initiative against lymphatic filiariasis was launched in 1997, and the

international community is considering other global initiatives, including measles

eradication.
Page 11 GAO-01-722 Global Health

to obtain political commitment and financial support from countries with

these diseases and from public and private sources of foreign assistance.

For example, the global polio eradication effort has received financial

and/or technical support from the governments of the United States,

Japan, Norway, Australia, Canada, Denmark, the United Kingdom, and

other industrialized countries; Rotary International and other private

organizations; and developing country governments.

With major financial resources9

 and support from all concerned

governments, these campaigns have developed comparatively highperforming surveillance systems. For example, donors and developing

country governments have combined their efforts to create a system of

active surveillance10 for acute flaccid paralysis that can promptly identify

potential polio cases. This surveillance system has helped reduce the

global incidence of polio by 99 percent since 1988. The surveillance effort

is ambitious—most countries employ multiple surveillance officers to

conduct active surveillance for cases of acute flaccid paralysis. According

to CDC officials, most countries in Africa dedicate at least one motor

vehicle and significant financial resources to polio surveillance. The ability

to confirm the presence of the disease has been helped by creation of a

global network of 148 laboratories at the national, regional, and global

levels to ensure accurate diagnosis and differentiation among strains.11

These laboratories participate in an annual accreditation program to

ensure the accuracy of their analyses.

Surveillance efforts to eradicate guinea worm have been similarly

ambitious. This eradication program began with comprehensive village-byvillage surveys in endemic countries to identify every afflicted locality. To

use these data effectively, WHO and the U.N. Children’s Fund (UNICEF)

 9

In September 2000, for example, WHO reported that donor nations and agencies had

indicated that they would provide approximately $550 million dollars in support for the

polio eradication campaign through 2005. According to the World Bank and the Carter

Center, the guinea worm eradication campaign received more than $87 million in donor

support from 1987 through 1998.

10Passive surveillance systems rely on local health care providers to submit periodic

reports on infectious disease incidence. Active surveillance is often employed to help

compensate for the reporting shortfalls that are commonly encountered in passive systems.

In active surveillance systems, health workers from district or national levels “make the

rounds” to seek out possible cases.

11Differentiation among strains is valuable in determining the origins of specific cases so

that response measures can be directed where needed.
Page 12 GAO-01-722 Global Health

created a Joint Program on Health Mapping. The “HealthMapper” project

generated national and international maps of guinea worm incidence that

were used to target interventions and plot progress in interrupting

transmission. Endemic countries created networks of community workers

in every village to report guinea worm cases so that response measures

could be delivered in a timely fashion. This surveillance effort facilitated

reduction of the global incidence of this disease from an estimated 10

million to 15 million cases a year in the early 1980s to about 75,000 cases in

2000 (more than two-thirds of them occurring in war-torn Sudan).

Although influenza cannot be eradicated due to its presence in a variety of

animal hosts and its constantly evolving character, the international

community has created an extensive surveillance system for this disease.

Factors leading to the considerable level of investment in this system

include the disease burdens imposed by influenza and the character of

available interventions. Although often perceived as a comparatively lowlevel threat, the viruses that cause influenza are continually evolving and

occasionally appear in highly virulent forms. For example, the 1918 to 1919

influenza pandemic killed more than 20 million people in locations as

diverse as China, Spain, the United States, and Samoa. Although not as

severe, influenza pandemics in 1957 and 1968 killed a total of 1.5 million

people and caused an estimated $32 billion in economic losses worldwide,

according to WHO. While influenza’s adverse impacts can be reduced via

immunization, vaccines have to be re-engineered each year to target the

strains considered likely to be most prevalent in the upcoming “flu

season.”12 Worldwide surveillance is necessary to permit continuous

updating of the information that manufacturers use to reformulate these

vaccines.

Since the late 1940s, WHO has created a global network of 111 national

influenza centers in 83 countries, supported by 4 international reference

laboratories.13 These centers collaborate in collecting and analyzing

influenza strains to identify those that appear most likely to spread around

the globe and present major risks to public health. According to CDC, the

system produced vaccines that precisely or substantially targeted 12 of 13

virus strains that circulated widely between 1988 and 1997. WHO has also

 12In temperate countries, influenza cases are concentrated in the winter months.

13The international reference laboratories are operated by CDC and institutions in the

United Kingdom, Japan, and Australia.
Page 13 GAO-01-722 Global Health

created “FluNet,” an Internet site devoted to monitoring global influenza

activity.

Although diseases such as yellow fever, cholera, and dengue also present

substantial public health threats, surveillance for these diseases tends to

be more limited. These diseases have characteristics that work against

international commitment in favor of ambitious, goal-directed control

campaigns. Cholera, dengue, and yellow fever do not appear to be good

candidates for eradication because the pathogens that cause them can live

and reproduce without human hosts. Advocates for addressing these

diseases cannot therefore hold out the prospect of eradication or

elimination as an incentive for investing in control efforts.14 Without

laboratory confirmation, all three can be confused with other diseases

causing similar symptoms. They are therefore comparatively difficult to

identify, especially in developing country conditions. Although effective

yellow fever vaccines are available, many developing country governments

do not administer them routinely.15 Cholera vaccines are infrequently

employed,16 and there is currently no vaccine for dengue. No specific

treatment exists for any of the three diseases; all are treated primarily by

ensuring that patients are hydrated. Therefore, although all three cause

periodic outbreaks that require an organized response, health care

providers may simply address patient needs without seeking laboratory

confirmation of possible cases or reporting cases to higher level

authorities. This reduces the likelihood that surveillance reports will

accurately reflect disease incidence or trends and makes it difficult for

disease campaign advocates to set specific objectives for reductions in

these diseases. Finally, although all three diseases are quite serious and

can spread across international borders, they do not threaten to cause

rapidly spreading global pandemics like those that can be caused by

influenza.

 14The bacteria that cause cholera thrive in fresh or brackish estuarine waters and do not

rely on human hosts. Yellow fever is passed among monkeys, mosquitoes, and humans.

According to WHO, studies have shown that in some parts of the world monkeys may also

become infected with dengue, and may serve as a source of virus for uninfected

mosquitoes.

15Many countries, especially in Africa, prefer to administer the vaccine on an emergency

basis when yellow fever outbreaks are identified.

16Cholera vaccines are infrequently employed because they are less than 100 percent

effective and provide protection only for limited periods of time.

More Limited Surveillance

for Other Diseases
Page 14 GAO-01-722 Global Health

Global surveillance for yellow fever is quite limited. Efforts by WHO,

UNICEF, and others to encourage greater investment in controlling this

disease, including more widespread employment of yellow fever vaccines,

have met with limited success. Ongoing laboratory training organized by

WHO for the polio laboratory network in Africa has been expanded to

include yellow fever but the global community has not established any

specific targets for yellow fever reduction. According to WHO, countries

that report information on yellow fever immunization coverage typically

reach 50 percent or less of eligible children. Despite the fact that the

International Health Regulations require reporting on yellow fever, WHO

officials estimate that actual caseloads are up to 500 times greater than

reported.

Surveillance for cholera is also problematic. While WHO and multiple

partner organizations established a Global Task Force on Cholera Control

in 1991, the task force was not given specific targets. Seven years later, a

U.N. review found that the global community’s approach focused on

outbreak response and that, while this approach can reduce cholera death

rates, it failed to prevent cholera from occurring.17 Developing countries

have had little incentive to improve surveillance beyond the detection of

outbreaks. Although the International Health Regulations require reporting

on cholera, a WHO official estimated that the numbers of cholera cases

and deaths occurring in the world are 10 times higher than official reports

indicate. In 1999, WHO was officially notified of approximately 9,200

cholera deaths, but disease experts believe that the annual number of

deaths from cholera is closer to 120,000.

Surveillance for dengue is similarly limited. WHO developed a Global

Strategy for Prevention and Control of Dengue Fever and Dengue

Hemorrhagic Fever in 1995 and has, with USAID support, held two

international meetings to focus attention on this disease. In collaboration

with the French National Institute for Medical Research and Health and

other partners, WHO has also created “DengueNet,” an Internet site

dedicated to gathering and sharing dengue-related information. However,

without the incentive that would be provided by a clear, goal-directed

international commitment to responding to the threat posed by this

disease, surveillance for dengue remains limited. For example, although

 17See Preventive Action and Intensification of the Struggle Against Malaria and

Diarrheal Diseases, in Particular Cholera, Report by the Secretary General to the

Economic and Social Council, E/1998/20.
Page 15 GAO-01-722 Global Health

WHO officials pointed out that progress has been made in the Americas,

no organized surveillance for dengue exists in Africa, even though disease

experts are certain that the illness is present there. Countries use different

definitions of what constitutes a reportable case of dengue and different

procedures for deciding when to report cases (that is, with or without

laboratory confirmation) and for reporting on dengue versus dengue

hemorrhagic fever. WHO officials highlighted the general inadequacy of

laboratory support for dengue surveillance and observed that

epidemiological data on dengue is “frequently incomplete, delayed, and

not used for decisionmaking purposes.”18 While national authorities are

officially reporting just over 1 million cases per year, WHO estimates the

actual number of cases at more than 50 million per year.

In addition, public health experts observe that global surveillance for

identifying and investigating emerging infections is weak. Sizable,

apparently sudden outbreaks of unknown diseases, such as the 1976 Ebola

outbreak in Zaire, often occur after the disease has been infecting local

populations for weeks or months. Health authorities are frequently

unaware of the problem until sick people begin showing up at hospitals,

where concentration of infected individuals and reuse of unsterile

equipment can dramatically increase the spread of the disease. Isolated

cases or small clusters of cases of such diseases can be easily missed, and

diseases that closely resemble others may spread before they are detected

and identified. Disease experts believe, for example, that HIV/AIDS began

to appear in humans decades before WHO called for its worldwide

surveillance in 1981. However, these early cases were isolated and those

contracting the disease tended to die from other infections, which

forestalled identification and investigation of the disease. Similarly,

isolated Ebola cases may have been occurring for many years, only to be

diagnosed as shigella or other diseases.

 18See Strengthening Implementation of the Global Strategy for Dengue Fever/Dengue

Hemorrhagic Fever Prevention and Control, Report of the Informal Consultation, Oct. 18-

20, 1999 (WHO/CDS/(DEN)/IC/2000.1).
Page 16 GAO-01-722 Global Health

Developing country systems are a weak link in the global surveillance

framework. Surveillance systems in industrialized and developing

countries suffer from a number of common constraints, including a lack of

human and material resources, weak infrastructure, poor coordination,

and uncertain linkages between surveillance and response.19 However,

these constraints are more pronounced in developing countries, which

bear the greatest burden of disease and are where new pathogens are

more likely to emerge, old ones to reemerge, and drug-resistant strains to

propagate. Weaknesses in these countries thus substantially impair global

capacity to understand, detect, and respond to infectious disease threats.

Several disease experts we met with observed that health care systems

typically emphasize the care and treatment of sick people and that support

systems such as surveillance are generally assigned a lower priority and

receive comparatively few human and material resources. A 2000 report by

the National Intelligence Council20 concluded that, with some exceptions,

such as Thailand and South Africa, developing country governments

throughout Africa and Asia assigned health care a comparatively or

extremely low priority. The report observed that, as a result, these

countries have rudimentary or no domestic systems for disease

surveillance, response, or prevention. As shown in table 1, both overall

health care spending and government health expenditures tend to decline

along with national income levels. For example, total health care spending

per capita in low income countries amounts to about 3 percent of per

capita spending in high income countries. With the fewest resources to

call upon and intense pressure to provide care and treatment services,

public health authorities in the poorest countries are likely to spend the

least amount of resources on surveillance.

 19For perspectives on difficulties in the United States, see Emerging Infectious Diseases:

Consensus on Needed Laboratory Capacity Could Strengthen Surveillance

(GAO/HEHS-99-62, Feb. 5, 1999); and Emerging Infectious Diseases: National

Surveillance System Could be Strengthened (GAO/T-HEHS-99-62, Feb. 25, 1999). For

perspectives on surveillance in Canada, see Report of the Auditor General of Canada—

September 1999, “Chapter 14: National Health Surveillance: Diseases and Injuries.”

20The Global Infectious Disease Threat and Its Implications for the United States, No.

NIE-99-17 of the National Intelligence Estimates, National Intelligence Council

(Washington, D.C.: Jan. 2000).

Global Framework’s

Performance

Constrained by

Weaknesses in

Developing Countries

Surveillance Systems Lack

Qualified People and

Equipment
Page 17 GAO-01-722 Global Health

Table 1: Health Expenditures by National Income Level

Country

category

Government

expenditures on

health as

percentage of gross

domestic producta

Total expenditures on

health as percentage

of gross domestic

producta

Total annual health

expenditures per

capitaa

 in

international dollarsb

High income 6.0 9.7 2,587

Upper-middle

income

3.4 6.2 549

Lower-middle

income

2.3 4.7 190

Low income 1.2 4.5 74

Source: Data from 2001 World Development Indicators (The World Bank, Washington, D.C., 2001).

a

These numbers represent the most recent annual figures available from the period 1990

through1998.

b

The term “international dollars” means that data on expenditures at the official dollar-exchange rate

have been adjusted to reflect real differences in relative prices, using price surveys conducted by the

United Nations’ International Comparison Program.

The human resources necessary to perform surveillance activities are at a

premium in developing countries. In the United States, surveillance

officials at the state level report that inadequate staffing and training

hinder their ability to operate. In developing countries, human resources

are an even more pressing concern. Many African officials with whom we

spoke said that poor salaries and working conditions drive many qualified

public health workers abroad in search of work. One CDC official

observed that, in Zimbabwe, only two people are devoted to surveillance

at the national level.

Key positions in developing countries, including laboratory technicians

and health care workers, are often filled by people who do not possess the

necessary qualifications. In Uganda, for example, officials charged with

assessing the national surveillance system found that a shortage of trained

health care workers at peripheral health units contributed to inadequate

analysis and application of data for decisionmaking, incomplete and

untimely reports sent to higher levels, and a lack of laboratory

confirmation or accurately validated diagnoses. WHO officials stated that

laboratory personnel in developing countries often cannot competently

test blood samples for malaria because they are not properly trained. WHO

also observed that, although quality assurance programs are an important

means of ensuring laboratory competence, staff in more than 90 percent of

developing country laboratories are not familiar with quality control or

quality assurance principles. Few surveillance workers in developing

countries possess the epidemiological skills that make CDC so effective at
Page 18 GAO-01-722 Global Health

clarifying and resolving infectious disease challenges. For example, one

WHO official commented that many of those assigned responsibility for

analyzing disease information in developing countries are able to produce

accurate tables and graphs but cannot probe the data to identify

discrepancies that bear investigation.

Equipment shortages also constrain surveillance. In the United States,

public health departments often lack computers and fax machines or

integrated data systems that allow surveillance data to be immediately

shared with public and private partners. Developing country health

departments have little access to such equipment. The ability of

developing country health officials to provide accurate disease

information is further compromised by their frequent lack of clear and

accurate diagnostic tests that they can perform themselves or ready access

to functioning laboratories. As a result, they have difficulty making

appropriate decisions about disease control measures and may waste

valuable resources, such as antibiotics and vaccines. Inexpensive, rapid

diagnostic tests are available for some diseases, including hepatitis B and

HIV, but many other diseases, including cholera and yellow fever, can only

be confirmed by a laboratory. CDC and WHO officials observed that public

health laboratories in Africa are generally poorly funded, understaffed, and

underequipped. According to WHO, more than 60 percent of laboratory

equipment in developing countries is outdated or not functioning. Sixteen

of the 19 WHO-sponsored assessments of African national surveillance

systems that we reviewed reported weaknesses in laboratory capacity,

ranging from a lack of trained technicians to deteriorating buildings, and 9

specifically cited a lack of laboratory equipment or poorly maintained

equipment as reasons for difficulty in confirming cases. During fieldwork

in Malawi, for example, we were told that all clinics should have a

microscope to scan blood for malaria parasites, but at the clinic we visited,

the only microscope was broken.

Weaknesses in transportation and communications infrastructure in

developing countries substantially impair surveillance in these countries.

Many people in developing countries live in remote areas that are not

served by organized health care facilities. Several national surveillance

system assessments we reviewed specifically cited this as a problem or

identified large portions of their populations as not having access to health

care. In Uganda, for example, less than half the population lives within a 3-

mile walk of a health facility.

Weak Infrastructure

Exacerbates Surveillance

Difficulties in Developing

Countries
Page 19 GAO-01-722 Global Health

Many cases of disease thus go unrecorded. As an epidemiologist with the

Armed Forces Medical Intelligence Center commented, because the

effective reach of the formal health care systems in most developing

countries extends to so little of the population, patients seen at clinics

represent merely the “the tip of the iceberg” in terms of disease trends and

events. For example, research conducted by the Tanzanian health ministry

found that, from 1992 through 1995, 46 percent of all deaths in one district

occurred without prior contact with a health facility and 90 percent of all

children under age 5 with high fever and seizures—a key symptom of

malaria—died at home. Because local health authorities had not

previously had a full understanding of disease burdens in their district,

they had not chosen to focus on malaria as a top priority. However,

according to national officials, the local authorities made malaria a high

priority and quintupled the share of resources dedicated to controlling this

disease after they learned of the data generated by this research project.

Poor roads and communications in many developing countries make it

difficult for health care workers to alert higher authorities about

outbreaks or quickly transport specimens to laboratories. At least 10 of the

19 assessments of African national surveillance systems that we reviewed

found that less than 50 percent of the local health facilities surveyed had

either telephones (or other means of communication) or vehicles for

transport.21 Even in facilities that had these resources, performance was

hampered by breakdowns and insufficient funds for fuel. One clinic

official in Tanzania, who did not have access to a vehicle or

telecommunications equipment, informed us that in the event of an

emergency, such as the need to report a suspected case of polio or

cholera, he hitches a ride on one of the trucks that occasionally pass

through his village. He observed that this was a workable alternative for

him because his clinic was only about an hour’s drive from the district

health office but that his colleagues operated clinics much further away

from district headquarters. These obstacles also affect the ability of

higher-level officials to give feedback to the health care workers they

supervise on the quality of the data being collected. Such feedback,

according to public health experts, is critical to motivating health workers

to continue investing time and energy in surveillance activities.

 21This is a conservative figure because the assessments do not indicate if some or all of the

sites with telephones also had radio call boxes, or if some or all of the sites with cars also

had motorbikes, bicycles, etc.
Page 20 GAO-01-722 Global Health

Global disease surveillance is also constrained by poor coordination of

surveillance activities. Multiple reporting systems, unclear lines of

authority in the event of an outbreak, poor integration of laboratories into

public health systems, and nonparticipation among private health care

providers have combined to further hamper surveillance efforts. While

these problems exist in industrialized countries, they are particularly

severe in the developing world.

The disease-specific focus of control efforts has resulted in the creation of

multiple surveillance systems at the national and global levels. The WHOsponsored assessments of surveillance systems in sub-Saharan Africa

found that many countries maintained at least five separate surveillance

systems and that two countries had as many as nine systems. For example,

in addition to maintaining separate routine surveillance systems for

multiple diseases within the country and at the border, Madagascar

maintains surveillance systems to support independent programs to

control malaria; tuberculosis and leprosy; HIV/AIDS and other sexually

transmitted diseases; plague, schistosomiasis, and cysticercosis; and

diseases targeted by the Expanded Program on Immunization. While

industrialized countries have more resources and expertise to cope with

the resulting duplication of effort, multiple reporting systems tax

developing countries’ weak public health systems. As we observed during

our fieldwork in Africa and our review of the 19 WHO-sponsored

assessments, overburdened individuals at the lowest levels of the health

system are frequently required to do everything from caring for patients to

filling out reporting forms for several disease surveillance programs. These

individuals may often have to choose between their responsibilities for

patient care and filling out reporting forms. The accuracy, timeliness, and

completeness of the disease surveillance data collected and reported may

therefore be compromised. The disease-specific nature of these programs

also impairs the ability of national governments to analyze overall disease

trends. In Madagascar, for example, the WHO-sponsored assessment of the

national surveillance system found that there was no central point for

analyzing (or responding to) disease information; each of the country’s

multiple surveillance programs maintained its own reporting chain.

Unclear lines of authority make it difficult to know whom to contact and

who is responsible for which tasks in the event of an outbreak. Such

problems exist in both industrialized and developing countries. For

example, a Canadian government report critiquing the national response

to a 1998 salmonella outbreak in that country noted that a key local official

did not know who to contact at the national level and that national

officials were not sure who at their agency was responsible for handling

Surveillance Activities Are

Poorly Coordinated
Page 21 GAO-01-722 Global Health

the issue. As a result, vital information about the scope of the outbreak

was delayed.22 Uncertainty about what to report, when, and to whom was

also evident in the 1999 West Nile virus outbreak in New York City.23 Many

of the assessments of African surveillance systems that we reviewed cited

weakness in this area as an important problem, as did World Bank and

WHO officials.

Disease surveillance systems in developing countries do not take full

advantage of nor do they coordinate the contributions that laboratories

can make to surveillance. Few developing countries have public health

laboratories, which means that testing to confirm outbreaks must compete

with testing to support individual patient-care decisions. Laboratories and

epidemiologists often report to separate sections of a nation’s health

ministry, resulting in poor communication between those who test disease

specimens to confirm diagnoses and those who analyze disease outbreaks

and trends.

Finally, private health care providers, who play an increasingly important

role in many developing countries, often do not participate in surveillance

programs. One health official in an urban area in Tanzania noted, for

example, that her efforts to monitor local disease trends were

substantially handicapped by the fact that more than 80 percent of the

population in the area now seek care through private clinics. Her efforts to

obtain surveillance information from these clinics had met with limited

success. Another Tanzanian official working in a rural area noted that he

had exerted considerable effort in building relationships with traditional

healers to improve his awareness of local trends and events and had had

some success, but that not all public health officials could be expected to

do the same.

Surveillance is further constrained by uncertain linkages between data

collection, analysis, and response. In the United States, physicians are

often unaware of the need to gather information necessary for surveillance

efforts and may not have had any education regarding the criteria used to

launch a public health investigation. One WHO official observed that

 22Report of the Auditor General of Canada—September 1999, “Chapter 15: Management of

a Food-Borne Disease Outbreak.”

23For more information, see West Nile Virus Outbreak: Lessons for Public Health

Preparedness (GAO/HEHS-00-180, Sept. 11, 2000).

Uncertain Linkages

Between Surveillance and

Response
Page 22 GAO-01-722 Global Health

overburdened health care workers in developing countries are frequently

not motivated to collect disease data because they do not see any evidence

that the information is being applied or because no one has explained to

them why it is valuable. A Malawi health official said that some health

workers had simply thrown away the registers in which they were

supposed to record data on their patients. In Zimbabwe, according to a

national health official, clinic data on surges in malaria incidence often do

not reach the appropriate authorities until many people have become sick

or died because the clerks responsible for transmitting this information

are unaware of its urgency.

The information generated by many developing country systems often

does not produce a response because it is not timely or reliable enough to

be useful. For example, during the 1990s, several sub-Saharan African

countries introduced broadly targeted health management information

systems to consolidate data collection and analysis on disease incidence

and a variety of other health issues such as vaccination rates. World Bank

and WHO officials commented that, while useful for other purposes, these

information systems had often proven too broad in scope, cumbersome in

detail, and slow to be used as effective surveillance tools. In fact, many

national surveillance assessments we reviewed indicated that, despite

attempts to use these systems as a means of simplifying disease reporting,

they had become yet another parallel disease reporting system. Several

officials with whom we spoke said that routine reporting systems often do

not provide data that can be used to make long-term disease control

management decisions, even though they were designed with this purpose

in mind. For example, an official at the Tanzanian health ministry said that

data from the country’s health management information system are not

reliable enough to be used for this purpose. Tanzanian government

officials also observed that limitations in the routine reporting system have

led them to create a separate system for gathering information on disease

outbreaks through weekly telephone calls to regional-level officials within

the country.

In addition, the surveillance systems that developing countries rely upon

most heavily (routine reporting by health care providers) cannot, by

themselves, fully inform health care decision-makers about disease trends

and events. Experts at WHO, CDC, and USAID commented that

supplementary efforts, such as long-term demographic surveys and

analyses of vital statistics (births and deaths), can make major
Page 23 GAO-01-722 Global Health

contributions to understanding disease trends.24 CDC officials stated that

the recordation and use of vital statistics should be a priority for every

country and that such activities should be linked to disease surveillance.

However, developing countries seldom invest funds in supplementary

studies25 and often do not record vital statistics. Effective outbreak

investigations also can make substantial contributions to understanding

disease trends. For example, mapping the location of infected households

and tracing the contacts of sick people help identify modes of

transmission and risk factors. Health authorities can use this information

to formulate an appropriate response to the current outbreak and forestall

future outbreaks of the same illness. However, developing countries often

lack the capacity to conduct thorough outbreak investigations.

Weaknesses in developing country systems reduce the ability of public

health authorities at every level to understand and control infectious

disease threats. These shortcomings limit the success of ambitious

international programs such as the polio eradication effort, and impair the

routine surveillance of other diseases and the identification and control of

outbreaks, newly emerging diseases, and antimicrobial resistance.

The surveillance achievements recorded by programs such as the polio

eradication effort have been possible only because intensive international

assistance has been given to developing countries so that they can

participate in these programs. In spite of this assistance, poor surveillance

in developing countries has continued to limit the ability of these

programs to achieve their goals. For example, according to CDC, four

countries in southern Africa were unable to meet international

expectations in 1999 for detecting cases of acute flaccid paralysis, a key

indicator of polio surveillance quality.26 Seven countries in the region fell

 24Other types of surveillance information that developing country systems do not typically

generate can be used in disease control efforts. These include data on the use of drugs or

other remedies that can indicate the prevalence of a disease in a given area, and on weather

and drought patterns affecting populations of disease-bearing insects or animals.

25The Tanzania research that resulted in increased resources for controlling malaria was

funded primarily by the United Kingdom’s Department for International Development and

the Canadian International Development Agency.

26Acute flaccid paralysis can be brought on by a number of causes. Even when polio is

believed to have been eliminated from a country, polio officials continue to monitor

surveillance systems to ensure that they report at least 1 case of acute paralysis for every

100,000 children, thus preserving the system’s ability to detect cases of paralysis caused by

polio.

Weaknesses in Developing

Country Systems Impair All

Facets of Global Surveillance
Page 24 GAO-01-722 Global Health

short of the targeted 80-percent rate for collecting stool samples from

suspected cases. The African region as a whole performed more poorly

than any other, detecting less than the target number of potential polio

cases and attaining less than the 90-percent goal for completeness of

reporting. According to CDC, completing the global eradication effort is

complicated by systemic weaknesses in the remaining endemic areas,

which are located primarily in sub-Saharan Africa and South Asia.27

Ineffective routine surveillance seriously compromises the international

community’s ability to understand global disease burdens and trends. As

already indicated with regard to yellow fever, cholera, and dengue, the

global incidence of many diseases is unknown. One WHO official noted

that health authorities in Equatorial Guinea, which lies within the yellow

fever endemic zone of Africa, had informed him that their country has

never experienced an outbreak of yellow fever. This statement cannot be

disproved because no surveillance for yellow fever exists in Equatorial

Guinea. Even when adequate data exist to identify gross trends, the data

generally are not adequate for in-depth analyses or informed decisions

about targeting resources to achieve specific control objectives.

Developing countries often cannot investigate or address outbreaks on

their own. CDC’s investigative expertise, including laboratory support, is

comparatively rare in the rest of the world. Many of the African

surveillance assessments we reviewed indicated that outbreaks there are

often not thoroughly investigated, if they are investigated at all. Health

officials in countries we visited and at WHO headquarters in Geneva noted

that serious outbreaks strain developing countries’ relatively weak public

health systems, requiring them to request international assistance to cope.

For example, India experienced an outbreak of plague in 1994 that

resulted in hundreds of cases across the country, 56 deaths,28 and over a

billion dollars in economic damage from the travel restrictions and trade

embargoes imposed by other countries. The outbreak was severe in part

because India had largely discontinued surveillance for plague. Health

authorities did not respond to initial complaints of flea infestation and did

not take appropriate measures to contain the outbreak. The disease spread

 27CDC also noted that armed conflict in several of these areas presents a major obstacle to

completing the eradication program.

28This is the number reported in Morbidity and Mortality Weekly Report (Oct. 21, 1994),

the official weekly publication of the CDC. Unofficial estimates put the death toll at several

hundred.
Page 25 GAO-01-722 Global Health

to crowded urban slums where it progressed unchecked to its highly

contagious, pneumonic form and became a serious national problem.

Shortcomings in developing country systems also limit the global

community’s ability to identify and effectively control newly emerging and

reemerging diseases. Several factors combine to make the emergence of

new pathogens more likely in developing countries. These include

accelerating urbanization and overcrowding without benefit of adequate

water supply and sewage systems, population displacement due to civil

wars and other disasters, and increased human incursion into ecosystems

where contact with pathogens that previously affected only animals or

insects is more likely to occur. Developing countries are poorly equipped

to conduct surveillance for such pathogens. For example, during the 1980s

a bacteria long recognized as a cause of routine eye infections evolved into

a pathogen capable of causing an extremely serious disease—Brazilian

Purpuric Fever.29 Since its first appearance, cases of this disease have been

documented in Brazil and Australia. Experts observe that other cases may

have occurred, only to be misdiagnosed as meningococcal disease.

According to experts at the State University of New York at Buffalo and

CDC, outbreaks of Brazilian Purpuric Fever appear to have waned.

However, no organized surveillance exists for this disease, and its actual

global distribution is unknown. In Uganda, local health professionals at

the scene of the fall 2000 Ebola outbreak did not at first suspect the

disease, despite the fact that Ebola outbreaks had previously occurred in

two neighboring countries.

Although antimicrobial resistance problems have emerged in

industrialized countries, such problems are more likely to escape

immediate attention and become severe in developing countries.

Impoverished developing countries are particularly ripe breeding grounds

for the unchecked spread of drug-resistant strains due to their citizens’

poor access to medical facilities; high rates of self-medication; economic,

educational, and logistical difficulties in completing full courses of drug

treatment; and limited drug oversight by governments. While disease

experts generally regard global surveillance for antimicrobial resistance as

 29All 10 children known to have contracted this disease in the first known outbreak died.
Page 26 GAO-01-722 Global Health

inadequate, developing countries conduct the least ambitious programs in

this area. These countries’ weak laboratories are a key constraint.30

The international community has recently launched a number of initiatives

that may improve global surveillance. First, the international community

has made unprecedented commitments to achieving specific reductions in

the burdens imposed by HIV/AIDS, malaria, and tuberculosis. These

diseases present complex challenges, and substantial effort will be

required to create surveillance systems for these diseases that will permit

these initiatives to move forward as their sponsors intend. Second, WHO

and other members of the global public health community have launched a

number of broader initiatives intended to strengthen global capacity for

surveillance of infectious diseases as a group. The impact of both sets of

initiatives remains to be seen.

Malaria, tuberculosis, and HIV/AIDS have continued to grow as public

health threats, especially in developing countries, despite years of

organized international control efforts. All three diseases have their most

severe impacts in sub-Saharan Africa. Disease experts estimate that about

90 percent of malaria cases and 70 percent of HIV cases occur in subSaharan Africa. They believe that if current trends continue, Africa will

also have more cases of tuberculosis than any other region by 2005.

These diseases share several characteristics that make surveillance and

response comparatively difficult. First, they are relatively difficult to

identify; laboratory confirmation is required for certainty in diagnosing all

three. Malaria, in particular, is easily confused with other febrile illnesses

in the absence of laboratory analysis. HIV-positive people often become

sick—and die—from “opportunistic” infections. The underlying cause of

the patient’s illness may never be recognized. Further, humans can carry

the pathogens that cause these diseases for extended periods without

exhibiting overt symptoms. This is particularly problematic for HIV-

 30For more information on the complex challenges that must be faced in conducting

surveillance for antimicrobial resistance, see Antimicrobial Resistance: Data to Assess

Public Health Threat From Resistant Bacteria Are Limited

(GAO/HEHS/NSIAD/RCED-99-132, Apr. 28, 1999); Containing Antimicrobial Resistance,

WHO/CDC/CSR/DRS/99.2, WHO, Geneva; and A Public Health Action Plan to Combat

Antimicrobial Resistance, U.S. Interagency Task Force on Antimicrobial Resistance, June

2001.

Impact of

Improvement

Initiatives Remains to

Be Demonstrated

Recent International

Commitments to Control

HIV/AIDS, Malaria, and

Tuberculosis Will Require

Improved Surveillance
Page 27 GAO-01-722 Global Health

positive persons, who can infect others despite their apparent lack of

disease.

Second, none of these three diseases elicits a clear and effective response

from the human immune system. These immunological complexities have

hampered the development of easily applied, effective, and comparatively

inexpensive diagnostic tools, preventive measures, or treatments that

would simplify surveillance and encourage commitment to control

efforts.31 Vaccines that could effectively prevent these diseases have not

yet been developed.32 Extended multidrug medication regimens are

required to cure active tuberculosis, and retard the development of AIDS

symptoms in HIV-positive patients. In the case of tuberculosis these

regimens take months to complete while, in the case of HIV patients, they

must be followed for the life of the patient. In the case of malaria, the

limited ability of the human body to develop effective immunity means

that persons living in endemic areas may become sick with this disease on

repeated occasions throughout their lives and must therefore be treated

repeatedly.33

Notwithstanding these difficulties, the international community has, over

the last few years, moved to adopt specific objectives for controlling these

three diseases. In 1998, several organizations, including WHO, other U.N.

organizations, and the World Bank, inaugurated campaigns to “Roll Back

Malaria” and “Stop TB.” Since that time, effective advocacy by many

parties has increased support for these initiatives and for international

 31The diseases occur in different forms within the body, presenting multiple challenges to

the immune system. For example, the HIV virus evolves at such a high rate that HIVpositive patients often carry multiple strains. The malaria parasite passes through several

life stages within the human body, each of which elicits a different reaction from the body’s

immune system.

32Research is proceeding to develop vaccines against malaria and HIV/AIDS and to provide

an improved antituberculosis vaccine. The available vaccine against tuberculosis has been

effective in preventing the disease in young children in many parts of the world. However,

according to the National Institutes of Health, the vaccine has shown highly variable

efficacy in preventing tuberculosis in adults and has not been effective in controlling the

disease in most countries of the Southern Hemisphere.

33 In areas where there is continuous transmission of malaria (e.g., no break during a dry

season), most people who survive initial infection during childhood continue to have

asymptomatic reinfections throughout their lives.
Page 28 GAO-01-722 Global Health

collaboration to combat HIV/AIDS. In July 2000, at the G834 summit in

Okinawa, leaders of the major industrialized countries pledged to work

toward achieving the following goals by 2010:

• Under “Roll Back Malaria,” to reduce global burdens of malaria by 50

percent;

• Under “Stop TB,” to reduce tuberculosis deaths and prevalence by 50

percent;

• As proposed by the U.N. Secretary General, to reduce the number of

HIV/AIDS-infected young people (15 to 24 years old) by 25 percent.35

In commenting on a draft of this report, the Department of Health and

Human Services and the Department of State pointed out that at the July,

2001 G8 summit in Italy, the industrialized countries pledged to provide at

least $1.3 billion to support a new Global AIDS and Health Fund that

would provide support for achieving these objectives.

Public health experts observed that substantial improvements are needed

to create the surveillance support necessary to achieve these and other

targets.36 Since baseline estimates of the incidence of these diseases are

subject to wide margins of error, the initiatives do not have a firm starting

point from which to measure progress. For example, WHO estimates of

the global incidence of tuberculosis are based on the work of a panel of

disease experts that the organization called upon to analyze available data

from 1997. The panel observed that the number of new cases occurring

could have been as much as 21 percent lower or 40 percent higher than

estimated.37 Malaria experts observe that, because of the large margin of

error in estimates of malaria incidence—which range from 300 million to

 34The Group of Eight consists of the heads of state of Canada, France, Germany, Italy,

Japan, Russia, the United Kingdom, and the United States. The President of the European

Commission also participates in G8 deliberations.

35The U.N. General Assembly had previously expressed support for this goal (see “Report of

the Ad Hoc Committee of the Whole of the Twenty-First Special Session of the General

Assembly,” A/S-21/5/Add.1, July 1999), and reaffirmed its support in a “Declaration of

Commitment on HIV-AIDS” on June 27, 2001. The World Health Assembly has also

supported an intensified effort against HIV/AIDS. See “Scaling up the Response to

HIV/AIDS,” World Health Assembly Resolution 54.10, May 2001.

36Other targets include a plan developed by WHO, UNICEF, and CDC to reduce measles

deaths by 50 percent by 2005.

37See “Global Burden of Tuberculosis,” The Journal of the American Medical Association,

Vol. 282 (Aug. 18, 1999).
Page 29 GAO-01-722 Global Health

500 million cases—and the fact that many malaria cases and deaths are

never diagnosed or reported, the Roll Back Malaria campaign also does

not have a reliable baseline. HIV/AIDS data are similarly limited. For

example, because AIDS typically appears in HIV-positive individuals years

after they have been infected, HIV/AIDS surveillance systems commonly

rely not only on surveillance for AIDS but on the administration of blood

tests to specific populations, such as pregnant women, to provide

information on HIV infection rates. However, according to the Joint United

Nations Programme on HIV/AIDS and WHO, more than 40 percent of these

national “sero-surveillance” systems, especially those in Africa, are of poor

quality or completely nonfunctional.

Surveillance shortcomings also make it difficult to implement control

programs. For example, developing country surveillance systems often

cannot identify people who need treatment for these diseases. WHO

estimates that, in 1999, the 23 countries with the highest burden of

tuberculosis successfully detected only about 44 percent of the active

cases in their countries. WHO experts also commented that laboratories in

developing countries frequently cannot be relied upon to provide accurate

diagnostic tests for malaria. The WHO-sponsored assessment of Uganda’s

surveillance system found that almost half of local health facilities could

not accurately diagnose this disease. All three diseases tend to be unevenly

distributed by region and population group, thus requiring improved

surveillance to effectively target control efforts. HIV/AIDS experts, in

particular, commented that more surveillance will be required to

understand the character of HIV infection patterns and how they vary

among disparate populations, including high-risk groups such as sex

workers and their clients. HIV experts also observed that more

surveillance information is needed on behaviors such as condom use so

that effective strategies for limiting HIV transmission can be prepared.38

Because all three diseases have demonstrated a capacity for developing

resistance to drugs, surveillance for antimicrobial resistance is also

critically important. In fact, the international effort to eradicate malaria

was abandoned in the late 1960s when it became apparent that both the

malaria parasites and the mosquitoes that carry them were becoming

resistant to the chemicals used for their control. WHO and the

International Union Against Tuberculosis and Lung Disease, with support

 38See Second Generation Surveillance for HIV: The Next Decade,

WHO/CDS/CSR/EDC/2000.5-UNAIDS/00.03E.
Page 30 GAO-01-722 Global Health

from other organizations, launched a Global Project to monitor AntiTuberculosis Drug Resistance in 1994. Under this project, a global

laboratory network was created, with internationally recognized

laboratories providing support (including quality assurance testing) for

lower-capacity facilities. This project has produced information on the

magnitude of the threat posed by resistant strains of tuberculosis.

However, the most recent report on the project’s results includes data

from geographic areas that include only about 28 percent of the reported

tuberculosis cases in the world and two-thirds of the 23 high-burden

countries targeted by the Stop TB campaign.39 A WHO tuberculosis expert

commented that he would like to see the project’s geographic reach

extended. Surveillance for antimicrobial resistance in malaria and AIDS

patients is less organized. One malaria expert observed that data on

resistance to malaria drugs are scarce, often outdated, and collected in

ways that make data comparison and analysis difficult.

WHO and CDC officials observed that developing country public health

systems need substantial strengthening in multiple areas to permit them to

participate effectively in ambitious campaigns such as Roll Back Malaria

and Stop TB. These officials observed that programs that are developed to

support the new disease-specific commitments should therefore be

broadly targeted. Such broadly targeted efforts could facilitate across-theboard improvements in surveillance for all infectious diseases.

The international community has introduced a number of initiatives to

strengthen overall global capacity for surveillance of infectious diseases as

a group. These include efforts to (1) strengthen global outbreak

management, (2) strengthen surveillance capacity within developing

countries, and (3) improve surveillance coordination and cooperation at

national and regional levels. While available evidence suggests that these

initiatives have merit, they are still in their early stages.

Prior to the mid-1990s, the international public health community’s

approach to identifying and responding to major disease outbreaks was ad

hoc in nature, resulting in poor responses to several significant outbreaks,

including the 1994 plague epidemic in India and the 1995 Ebola outbreak

in Zaire. WHO has since established a system for verifying outbreak

 39Anti-Tuberculosis Drug Resistance in the World, Report No. 2: Prevalence and Trends

(Geneva, Switzerland: WHO, 2000).

Broader Initiatives Aimed

at Strengthening Global

Surveillance

Strengthening Global Outbreak

Management
Page 31 GAO-01-722 Global Health

reports, inaugurated a network to organize and coordinate outbreak

responses, and is coordinating a process to revise the International Health

Regulations to provide a firmer foundation for international collaboration

in identifying and responding to threatening outbreaks.

WHO launched an outbreak verification process in 1997 to help identify

significant disease outbreaks around the world. This process involves

collecting and verifying outbreak reports with national health authorities

and others, assessing their significance, and disseminating information. To

further this effort, WHO worked with the Canadian government to develop

the Global Public Health Intelligence Network, an electronic surveillance

system that scans the Internet for reports of infectious disease in news

sources, Internet discussion groups, biomedical journals, and elsewhere.

WHO officials stated that they do not receive prompt information about

every important outbreak because some countries control that

information, and the Network only searches the Internet in a few

languages.40 Given that outbreak reports vary in quality, WHO tries to

verify reports to ensure that they present issues of potential international

importance before calling attention to them. WHO generally focuses on

outbreak reports from developing countries, where public health systems

are weaker and more likely to require outside assistance. During the

verification process, WHO may offer technical assistance, supplies,

transport of specimens, or training on control measures, or help organize

vaccination programs. Between November 1999 and October 2000, WHO

investigated 228 outbreak reports, eventually confirming 169 significant

outbreaks. The vast majority of these outbreaks occurred in developing

countries; more than 40 percent occurred in sub-Saharan Africa.

In April 2000, WHO inaugurated the Global Outbreak Alert and Response

Network to help organize and coordinate international outbreak

response.41 Various organizations have volunteered to participate,

including national public health institutions such as CDC, as well as U.N.

 40As of November 2000, searches were done in English and French and plans to use Spanish

were under way.

41The World Health Assembly officially endorsed this effort in its Resolution 54.14, adopted

May 2001, entitled “Global Health Security: Epidemic Alert and Response.” In commenting

on a draft of this report, WHO stated that its effort to develop a coordinated outbreak

response system, as well as affiliated efforts to improve laboratory and epidemiological

capacity in developing countries and obtain agreement on revisions to the International

Health Regulations, are now being managed as an overall “Global Health Security”

initiative.
Page 32 GAO-01-722 Global Health

and nongovernmental organizations. While Network procedures for

rapidly mobilizing technical and financial support and for governing

response teams are still being finalized, WHO officials believe that their

efforts have improved international outbreak coordination and response.

There is now a central source of verified information on outbreaks, and

rapid response teams have been deployed to countries that need

assistance in investigating and controlling outbreaks. For example, WHO

reported that its request for assistance in an investigation of an apparent

acute hemorrhagic fever outbreak in Afghanistan in June 2000 produced

offers from five institutions within 12 hours and the placement of a team

in-country within a week of the outbreak being verified. A major test of

Network operations occurred during the Ebola hemorrhagic fever

outbreak in Uganda in the fall of 2000. At the request of the Ugandan

government, WHO coordinated the international response, which included

more than 20 Network partners. While this system can provide effective

assistance when requested by countries experiencing outbreaks, the

Network partners cannot require countries experiencing outbreaks to

request assistance or to take recommended measures.

In 1995, WHO initiated an effort to revise the International Health

Regulations to create a firmer legal footing and a stronger institutional

commitment to outbreak surveillance and response. WHO plans to have a

draft revision ready for international review in late 2002, to be followed by

World Health Assembly approval and acceptance by individual countries.

Full implementation is projected for 2005. In launching this initiative,

WHO officials noted that, for several reasons, the existing regulations’

disease reporting requirements (for cholera, plague, and yellow fever)

have been widely ignored. Among other things, the regulations provide

little incentive for reporting. Although WHO often organizes international

assistance to help countries investigate or control significant outbreaks,

the regulations do not commit WHO or the international community to

provide such assistance. In addition, the regulations do not protect

reporting countries against trade and travel restrictions that national

governments may impose against countries affected by serious disease

outbreaks. While such restrictions may be justified in some cases, disease

experts have found that the restrictions are sometimes excessive. For

example, in 1998, the European Commission banned imports of fresh fish

from four countries in East Africa during a cholera epidemic despite WHO

and U.N. Food and Agriculture Organization statements that the fish posed

no health risk if cooked, dried, or canned properly. Although the two

organizations advised the Commission that trade restrictions were not

necessary or effective in protecting consumers, the ban continued for 6

months.
Page 33 GAO-01-722 Global Health

Key changes to the International Health Regulations would include the

following:

• Redefining reporting requirements to replace the focus on identifying all

occurrences of a few specific diseases (no matter how minor) with a new

focus on identifying all “events of urgent international health importance”

(i.e. outbreaks of any disease that may impose adverse consequences on

other countries).

• Authorizing WHO to define a range of acceptable protective measures that

may be employed by countries in response to outbreaks. This provision is

directed at providing reporting governments with some assurance that

they will not be harmed by unreasonable trade sanctions.42 For example,

WHO would provide guidance as to whether goods entering a country

from an area experiencing an outbreak should be inspected, treated,

destroyed, or refused entry.

• Obligating WHO—and by extension, the international community—to

respond to outbreak reports by helping reporting countries assess and

control outbreaks that may have adverse impacts beyond their borders.

• Defining a set of core requirements for countries in carrying out

surveillance, notification, and response.

In commenting on a draft of this report, the Department of Health and

Human Services stated that the proposed revisions offer an important

channel for pursuing improvements in global surveillance; but the

department added that many countries will need assistance to achieve

basic surveillance, notification, and response capabilities. WHO added that

the revision exercise has recently gained impetus through endorsement

from the World Health Assembly in its spring 2001 session43 and that the

number of countries actively involved in the negotiations has increased.

WHO, CDC, USAID, other foreign assistance agencies, and developing

country governments are collaborating in a number of efforts to improve

developing country surveillance and response capacity. These include

 42Binding measures would have more of an impact in limiting trade sanctions. However,

WHO and World Trade Organization experts agreed that national governments would be

reluctant to accept in advance such restrictions on their ability to protect themselves under

emergency conditions.

43 World Health Assembly Resolution 54.14 included an expression of support for the

ongoing revision effort and called on member countries to designate focal points for the

negotiations.

Initiatives to Strengthen

Surveillance Capacity in

Developing Countries
Page 34 GAO-01-722 Global Health

efforts to improve laboratory and epidemiological capacity and to increase

disease-mapping capability.

Upgrading Laboratory Capacity

While the global health community has focused on creating laboratory

systems that can provide reliable support for high-priority efforts such as

polio eradication and influenza control, comparatively less effort has been

devoted to broader laboratory improvements. Well-functioning laboratory

systems need trained personnel, adequate facilities and equipment, quality

assurance programs to ensure accurate test results, and participation from

laboratories with greater levels of expertise to answer complex or unusual

questions.

WHO coordinates several broadly targeted training and quality assurance

programs designed to strengthen national public health laboratories, make

cost-effective laboratory technology available, and develop and refine

laboratory standards and reference materials. For example, WHO has

organized voluntary quality assessment programs to monitor and improve

the quality of laboratory performance in areas such as hematology and

bacteriology. These programs, administered by various prominent disease

laboratories around the world, periodically send out samples for

participating national laboratories to examine and identify. The testing

results are scored and feedback is provided to participating laboratories.

While the programs involve about 450 laboratories around the world, they

do not reach all countries or all laboratories. Further, they are not fully

funded by WHO, and the various laboratories charged with operating them

have had to cover most of the costs of operating these programs. Some of

WHO’s regional offices have also begun investing in programs to

strengthen national laboratories in their regions.

In 2001, WHO, with support from the city of Lyon, the Government of

France, and the Merieux Foundation, established a new program to

strengthen laboratory and epidemiological capacities for handling disease

outbreaks in developing countries. Intended to serve 45 developing

countries over the next 5 years, the program’s first phase began in April

2001, with 15 senior staff from national public health laboratories in 7

French-speaking African countries. During their 2-year course of study,

participants will be expected to develop detailed plans for addressing the

needs of their laboratories. Plans are for later trainees to come from the

Middle East and North Africa, the Baltics and Central Asia, and possibly

South Asia and additional African countries. In commenting on a draft of

this report, USAID pointed out that it is working with the new program in
Page 35 GAO-01-722 Global Health

Lyon to develop a Quality Control/Quality Assurance Program for national

laboratories in Africa.

International networking is an effective way to provide developing

countries with access to more highly specialized laboratory services as

well as assistance in improving the quality of their own laboratory

services. Such international networks are a prominent feature of some

disease-specific initiatives, including polio eradication and influenza

control. WHO has created a system of Collaborating Centers, in part to

ensure that developing countries can access support services when

needed. WHO currently maintains a worldwide system of more than 270

Centers that focus on infectious diseases. However, as shown in figure 2,

Collaborating Centers tend to be concentrated in industrialized countries.

Relatively few are located in Africa, despite the high burden of infectious

diseases on that continent. With 38 Collaborating Centers, CDC is the

single largest contributor of expertise and resources to this system.
Page 36 GAO-01-722 Global Health

Figure 2: Distribution of WHO Collaborating Centers for Infectious Disease Surveillance and Control

Source: Prepared by GAO using list of Collaborating Centers provided by WHO.

In 1999, WHO issued a report that identified a number of shortcomings in

the Collaborating Centers system, including a lack of consistency in the

criteria for selecting centers and the absence of a systematic means for

evaluating their activities. WHO found that some Collaborating Centers

contribute little to international disease control efforts. WHO is amending

its procedures for working with the Centers to address these shortcomings

through a more rigorous and consistent designation process, joint

preparation of Center work plans, closer monitoring and evaluation, and

the development of a global database to meet the needs of national and

international health authorities. WHO also continues to work with

Collaborating Centers and other institutions to encourage the growth of
Page 37 GAO-01-722 Global Health

existing networks for sharing information on particular diseases and

initiatives to establish additional networks.

Improving Epidemiological Capacity

International public health officials have long recognized the need to

develop strong epidemiological skills in countries and institutions around

the world. CDC is widely acknowledged as having the strongest

institutional capabilities for investigating and resolving complex disease

management challenges. Since its founding in 1951, CDC’s Epidemic

Intelligence Service has provided approximately 2,300 health professionals

from the United States and elsewhere with the skills to investigate disease

events and trends and improve surveillance systems. At the request of

national governments, CDC, WHO, USAID, the Rockefeller Foundation,

and the European Union have helped establish 27 additional training

programs in applied epidemiology worldwide, which are modeled after

CDC’s Epidemic Intelligence Service. According to CDC, non-U.S.

programs, about half of which are located in lower-income countries, had

trained over 900 people as of January 2001.44

The common goals of these programs include (1) developing a cadre of

national public health professionals, (2) providing essential

epidemiological and public health services to the country during and after

training, and (3) building regional and international linkages between

countries to support public health response and training. According to

public health experts, an underlying goal is to develop an informationbased culture for public health decisionmaking in every country.

A CDC-sponsored evaluation of five of these programs in 1998 found that

epidemiologists trained by the programs have had a positive impact on the

quality of their national public health programs. For example, graduates

have helped (1) improve surveillance system procedures and outbreak

investigations, (2) develop local surveillance capacity, and (3) design

research programs that influenced national health policy decisions.

According to CDC and WHO staff, graduates of these programs made

important contributions to addressing recent outbreaks of Ebola in

Uganda and Rift Valley fever in Yemen and Saudi Arabia.

 44Programs in lower income countries include those located in Colombia, Cote d’Ivoire,

Egypt, Ghana, Indonesia, Jordan, Peru, the Philippines, Thailand, Uganda, Vietnam, and

Zimbabwe, as well as a regional program in Central America.
Page 38 GAO-01-722 Global Health

Many of the disease experts we spoke with cited continued expansion of

these programs as a key element in global efforts to improve surveillance

capacity and performance.

However, a low mentor-student ratio is one key factor in the success of

applied epidemiology training programs, and this places a limit on the

speed at which such programs can be expanded. Twenty of the programs

currently in existence were inaugurated within the last decade. For

example, programs in Brazil and the Indian state of Tamil Nadu have just

begun, while a program in China is still in the planning stages. These

programs will take many years to have a significant impact.

Increasing capacity for mapping disease information

CDC, the WHO Regional Office for the Americas, and WHO headquarters

(in collaboration with UNICEF) have all developed computer software to

generate maps of disease conditions in specific geographic areas that can

help inform decisionmaking. Over the past decade, these disease-mapping

systems have had a positive effect on surveillance in developing countries,

especially in supporting disease-specific initiatives. For example, the

WHO/UNICEF HealthMapper application was used to support the guinea

worm eradication and river blindness elimination efforts and is beginning

to be used in global efforts against malaria and HIV/AIDS. Experts believe

that there is great potential for employing such systems to predict disease

outbreaks and trends in relation to climate and weather patterns.

However, they note that such systems are constrained by the quality of

available data on diseases and underlying features such as population

distribution and the locations of health facilities and water supplies, as

well as limited access to satellite-generated information.

The international community has initiated efforts to expand coordination

of surveillance at the national level, especially in developing countries, and

within regions. These efforts can help reduce reporting burdens and make

better use of limited resources.

With assistance from CDC, WHO’s Regional Office for Africa launched the

Integrated Disease Surveillance and Response (IDS) initiative in 1998 to

improve linkages between surveillance and response by generating more

accurate, timely, relevant, and complete data. In commenting on a draft of

this report, USAID added that it has also assisted in launching this

initiative, making several grants to WHO’s Regional Office for Africa to

support relevant activities. Although the World Health Assembly has not

Coordinating Surveillance

Operations
Page 39 GAO-01-722 Global Health

officially endorsed IDS, a number of countries and regions of the world are

also seeking greater integration of their surveillance operations.

IDS is not intended to replace disease-specific programs. Rather, it seeks

opportunities for pooling funds and personnel to improve surveillance for

multiple diseases. While the long-term goal is to improve coordination

among all surveillance programs, the initiative is presently directed

primarily at encouraging greater cooperation in surveillance for epidemicprone diseases such as cholera and vaccine-preventable diseases, such as

measles.

Evidence suggests that the initiative may have a favorable impact. For

example, according to WHO, IDS planning has enhanced coordination and

support for surveillance within public health ministries in at least three

African countries. CDC found that 26 African countries had already begun

to employ polio eradication resources to perform surveillance for other

diseases, without impairing the quality of polio surveillance. However,

implementing IDS presents significant challenges and will require

substantial time and effort. For example, baseline assessments of African

surveillance systems began in late 1998. As of April 9, 2001, only 10 of 46

countries in WHO’s Africa region had both completed assessments and

developed plans for addressing weaknesses. CDC and WHO took several

years to develop generic surveillance guidelines that can be used to put

these plans into action. The guidelines were sent to WHO’s Africa Regional

Office in the summer of 2001. CDC officials observed that this slow pace

reflects the inherent difficulties in creating manageable systems that

satisfy multiple stakeholders. For example, IDS requires agreement on

issues such as how to reduce reporting burdens by requiring routine

reporting of only “essential information.” However, disease-specific

program managers typically have a very broad definition of the term

“essential information” when it comes to diseases for which they are

responsible. CDC officials also noted that the IDS negotiations have

required national officials to agree on issues that they have never before

addressed, such as defining threshold levels to determine what constitutes

an outbreak and creating procedures for outbreak response.

Public health authorities and others are also working on creating regional

surveillance networks. For example:
Page 40 GAO-01-722 Global Health

• The Pacific Public Health Surveillance Network was established in 1996 to

improve surveillance and response among the Pacific Community’s 22

member states and territories.45 Network activities include (1) an Internet

system for sharing information on disease trends and events, and (2)

diagnostic and other types of assistance to isolated health care facilities.

The network has begun to function as an outbreak response coordinator

and is working to assemble a regional laboratory system to support timely

and appropriate outbreak response.

• Countries in the Amazon basin and the “Southern Cone” of South

America46 have been working since 1998 to create laboratory networks to

improve surveillance of new, emerging, and reemerging infectious

diseases. Because of these efforts, participating laboratories have

identified an increasing number of Hantavirus pulmonary syndrome cases,

including in areas where the disease had not previously been recognized.

Participating countries are emphasizing integration of epidemiologists and

laboratory personnel to advance network goals.

• With CDC and Department of Defense support, several countries in

Southeast Asia are working to establish a regional network to improve

outbreak detection and response.

The global disease surveillance framework is dominated by networks

directed at providing information on specific disease threats. The

framework supplies comparatively good information when demanded by

well-supported, goal-oriented disease control initiatives. Surveillance

capacity for other diseases is comparatively weak, and these weaknesses

are most acute in developing countries. The continued weakness of

developing country surveillance systems not only impairs global

surveillance operations, but necessitates the application of substantial

resources to create effective global systems each time the international

community identifies an additional priority disease target. It also requires

institutions such as CDC to devote resources to respond to outbreaks in

developing countries that exceed local authorities’ capacity. To date, while

facilitating the relatively rapid achievement of disease-specific results, the

 45The members of the Community are the Cook Islands, the Federated States of Micronesia,

Fiji, Guam, Kiribati, the Northern Marianas, the Marshall Islands, Nauru, Niue, New

Caledonia, Palau, Papua New Guinea, Pitcairn Island, French Polynesia, the Solomon

Islands, Samoa, American Samoa, Tokelau, Tonga, Tuvalu, Vanuatu, and Wallis and Futuna.

46Countries participating in the Amazon regional effort are Bolivia, Brazil, Colombia, Peru,

and Venezuela. Countries participating in the Southern Cone regional effort are Argentina,

Bolivia, Brazil, Chile, Paraguay, and Uruguay.

Concluding

Observations
Page 41 GAO-01-722 Global Health

creation of additional surveillance systems to serve new initiatives has left

developing countries’ underlying surveillance problems unresolved.

International public health officials concerned about the overall threat of

infectious disease are seeking to take advantage of the global community’s

apparent willingness to commit itself to achieving measurable progress

against three major disease threats—HIV/AIDS, tuberculosis, and

malaria—to support broader systemic improvements in developing

country surveillance and response capacity. These broad improvements

may eventually reduce the need for disease-specific campaigns. However,

given the need to demonstrate progress against these three diseases in

particular, the extent to which the global public health community can

manage the new disease-specific initiatives in a manner that significantly

improves surveillance for all infectious disease threats, remains to be

demonstrated.

USAID’s and the Department of Health and Human Services’ comments on

a draft of this report offer additional perspectives on the challenges to be

faced in developing strategies for responding to specific disease threats

while also addressing overall weaknesses in surveillance capacity. USAID

noted the failure of past disease-specific initiatives (like smallpox

eradication) to leave a lasting positive impact on surveillance capacity in

developing countries. The agency is attempting to insure that its ongoing

polio-eradication activities advance the eradication program while also

upgrading developing countries’ capacity for monitoring and responding to

other diseases. USAID also observed that many of the weaknesses in

developing country systems documented in this report require donor

attention outside the range of disease specific programs. The Department

of Health and Human Services observed that while expanded efforts to

improve surveillance and response capacity for HIV/AIDS, malaria, and

tuberculosis are clearly warranted, other significant infectious disease

threats also need attention. The department concluded that both diseasespecific and cross-cutting programs are needed, and that these programs

can and should be carried forward in ways that are mutually supportive.

We received written comments on a draft of this report from the

Department of Health and Human Services, the Department of Defense,

WHO, USAID, the National Aeronautics and Space Administration, and the

World Bank. The World Bank’s letter was transmitted through the

Department of the Treasury. These comments are reprinted in appendixes

III through VIII, along with our evaluations, where appropriate. The

Department of State provided oral comments. In addition, WHO’s

Agency Comments

and Our Evaluation
Page 42 GAO-01-722 Global Health

Department of Communicable Disease Surveillance and Response and

CDC provided technical comments, which we have incorporated where

appropriate.

In general, the agencies concurred with the report’s findings. The

Department of Health and Human Services commented that the report

presents an accurate and thorough evaluation of global infectious disease

surveillance. In their oral comments, officials from the State Department’s

Bureaus for International Organization Affairs and Oceans and

International Environmental and Scientific Affairs stated that the report

accurately portrayed the issues and obstacles that the international

community faces in dealing with infectious disease surveillance. The

Department of Health and Human Services and USAID elaborated upon

the reports’ concluding observations concerning the challenges to be faced

in pursuing both disease-specific and more-broadly focused improvements

in surveillance capacity. We expanded our concluding observations to

reflect these comments.

USAID, the Department of Defense and, to a lesser extent, the World Bank,

WHO, and the Department of Health and Human Services provided

additional information on their contributions to building global

surveillance capacity. USAID and the Department of Defense, in particular,

said that the draft report did not adequately describe their efforts to

improve global surveillance. USAID highlighted its efforts to assist

developing countries in developing surveillance capacity outside the

bounds of disease-specific initiatives. The Department of Defense cited

relevant activities being undertaken through the Department’s Global

Emerging Infections Surveillance and Response System. The World Bank

pointed out that as part of its emphasis on health, it is actively working

with a number of governments to strengthen national surveillance system.

The Department of Health and Human Services cited CDC’s global strategy

paper Working with Partners to Improve Global Health: A Strategy for

CDC and ATSDR47—a document which provides extensive information on

CDC activities that contribute to strengthening global surveillance

capacity. Where appropriate, we added information on these agencies’

efforts to the report. However, the report was not designed to provide a

comprehensive accounting of all worldwide efforts. We refer the reader to

the appendixes for additional information as provided by the agencies.

 47The Agency for Toxic Substances and Disease Registry.
Page 43 GAO-01-722 Global Health

We are sending this report to interested congressional committees, the

Secretary of the Treasury, the Secretary of State, the Secretary of Health

and Human Services, the Secretary of Defense, the Administrator of

USAID, the Administrator of the National Aeronautics and Space

Administration, and the Director General of the World Health

Organization. We will also make copies available to other interested

parties on request.

Please contact me on (202) 512-8979 if you or your staff have any

questions concerning this report. An additional GAO contact and staff

acknowledgements are listed in appendix IX.

Joseph A. Christoff, Director

International Affairs and Trade
Appendix I: Objectives, Scope, and

Methodology

Page 44 GAO-01-722 Global Health

At the request of the Chairmen and Ranking Members of the Senate

Subcommittee on Foreign Operations, Committee on Appropriations, and

the Senate Subcommittee on African Affairs, Committee on Foreign

Relations, we evaluated the global infectious disease surveillance

framework. Specifically, we (1) examined the surveillance framework’s

evolution and current operations, (2) identified factors that constrain its

performance, and (3) assessed several initiatives designed to improve

global infectious disease surveillance and response.

To determine the surveillance framework’s evolution and current

operations, we interviewed officials responsible for international

surveillance-related activities at World Health Organization (WHO) offices,

including WHO headquarters in Geneva, Switzerland; the Pan-American

Health Organization (the WHO Regional Office for the Americas) in

Washington, D.C.; and the Regional Office for Africa in Harare, Zimbabwe.

We interviewed officials at various U.S. agencies, including the Centers for

Disease Control and Prevention (CDC), the National Institutes of Health

(both of which are constituent elements of the Department of Health and

Human Services), the U.S. Agency for International Development (USAID),

the Armed Forces Medical Intelligence Center, the Walter Reed Army

Institute of Research, the National Aeronautics and Space Administration,

and the White House Office of Science and Technology Policy; and at

multilateral development institutions, including the World Bank. We

interviewed disease experts in academia and officials at nongovernmental

organizations such as the Association of Public Health Laboratories. We

reviewed the International Health Regulations, as well as documents and

studies from WHO and other sources pertaining to international efforts to

control specific diseases and guide surveillance. We also attended

conferences dealing with international infectious disease control and

surveillance issues.

To identify factors that constrain the performance of the global disease

surveillance framework, we interviewed the officials listed above and

conducted fieldwork in four African countries—Malawi, Tanzania,

Uganda, and Zimbabwe. We selected these countries from a larger group

of African countries that had recently conducted assessments of their

national disease surveillance systems. We limited our fieldwork to Africa

because of interest expressed in this region by the requesters of this work,

as well as Africa’s infectious disease burden, the weak condition of most

African health care systems, and the concerted efforts under way to

improve surveillance in this region. While in Africa, we interviewed

officials at national health ministries; multilateral agencies, including WHO

country and regional offices, the World Bank, and the African

Appendix I: Objectives, Scope, and

Methodology
Appendix I: Objectives, Scope, and

Methodology

Page 45 GAO-01-722 Global Health

Development Bank; foreign assistance and technical agencies from the

United States and other countries, including USAID and CDC; and

nongovernmental organizations active in the health sector. We reviewed

documentation on surveillance systems in each country and discussed

these countries’ experiences with recent disease outbreaks. We also

visited health facilities in each country, including central and district

hospitals and laboratories, research institutions, local clinics, and

designated surveillance sites for specific diseases such as malaria. At each

site, we observed conditions and discussed with knowledgeable officials

the ways in which surveillance is conducted, the extent to which

surveillance data are analyzed and used, and factors that constrain

surveillance activities. In addition, we systematically reviewed the 19

assessments of surveillance systems in African countries that WHO,

together with CDC and national health authorities, had completed as of

April 2001. We also reviewed studies of surveillance problems in

developing and industrialized countries, including the United States and

Canada.

To assess initiatives designed to improve global infectious disease

surveillance and response, we interviewed WHO, World Bank, CDC,

USAID, and other officials to identify and discuss key initiatives currently

under way to improve regional and global surveillance. When pertinent,

we also asked national officials we met during our fieldwork about their

involvement in these initiatives, particularly WHO’s Integrated Disease

Surveillance and Response effort in the Africa region. We reviewed

documents describing the purpose, status, and outcomes to date (where

appropriate) of these programs. For our review of WHO efforts to improve

international outbreak detection and response, we collected and analyzed

information from WHO on disease outbreaks that had been entered in its

Outbreak Verification List database from November 1999 through October

2000, including detailed case histories of the international response to a

small number of these outbreaks. We also collected and reviewed

information on outbreaks from other sources—including ProMED, an

Internet service of the International Society for Infectious Diseases.

We did not address specific surveillance problems that arise in countries

or regions affected by armed conflict or the complex humanitarian

emergencies that such conflicts often produce. As noted in our July 2000

report on surveillance, health care to populations affected by such

emergencies is typically provided by international and nongovernmental

organizations rather than by national governments, and these

organizations face obstacles and pressures that are not faced by public

health systems functioning in nonemergency conditions. Since this report
Appendix I: Objectives, Scope, and

Methodology

Page 46 GAO-01-722 Global Health

focused on the development and application of surveillance information,

we did not explore the feasibility of improvements in diagnostic,

preventive, or treatment technologies.

We conducted our work from July 2000 through June 2001 in accordance

with generally accepted government auditing standards.
Appendix II: Disease Information

Page 47 GAO-01-722 Global Health

This appendix provides descriptive information on the diseases mentioned

in the body of this report. The information is derived primarily from WHO

and CDC documents.

Brazilian purpuric fever, first observed in 1984, is caused by an evolved

form of a bacterium that causes a common eye infection, conjunctivitis. In

its evolved form, this pathogen can invade the bloodstream and cause a

lethal infection characterized by high fever, shock, and a severe bleeding

disorder. Outbreaks of the disease have appeared to wane. The factors

that caused the disease to suddenly appear and then seem to disappear

have yet to be determined. According to disease experts, northern Africa

and other parts of the world where the original form of the bacterium in

question is common are potentially at risk for epidemics of this disease.

Chagas disease is caused by a parasite transmitted by insects, by

transfusions of contaminated blood, or from mother to fetus. The acute

phase of the disease often has no symptoms or an inflammation at the site

of the infection and flu-like symptoms. If caught in its early stages, the

parasite can be seen in the blood and the disease can be cured with drugs.

After that, the parasite moves into body tissue, where it cannot be treated

and can cause severe, life-threatening conditions 10 to 30 years later,

including heart disease. Up to 18 million people in 18 countries in South

and Central America are infected. As many as 100,000 infected people,

mostly immigrants, are estimated to reside in the United States.

Cholera is caused by a water- and food-borne bacterium. Infection results

in acute watery diarrhea, leading to extreme dehydration and death if not

addressed. Known vaccines and antibiotics have only limited impact on

the disease; treatment focuses on rehydration. According to WHO, recent

cholera outbreaks have killed 3.6 percent of those who become ill

worldwide. Cholera is endemic in more than 80 countries. During the

1990s, global cholera reports varied from about 100,000 to about 600,000

cases per year.

Cysticercosis is a parasitic infection caused by the pork tapeworm,

whose eggs may be ingested in contaminated food and water. Inside the

human body, the larvae hatch and form cysts in the organs, particularly

the muscles, eyes, and brain. Although most cases are asymptomatic or

mild, patients may experience vision problems, headaches, seizures, and

brain swelling. The infection can be treated with drugs and sometimes

surgery. The disease occurs worldwide but is found most often in rural,

developing countries with poor sanitary conditions and where pigs are

allowed to roam freely.

Appendix II: Disease Information
Appendix II: Disease Information

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Dengue fever, a mosquito-borne infection caused by four distinct but

closely related viruses, is a severe, flu-like illness with specific symptoms

that vary based on the age of the victim. Dengue hemorrhagic fever is a

potentially lethal complication that may include convulsions. There is no

vaccine for dengue fever, nor is there any treatment beyond supportive

therapy. With treatment, fatality rates can be less than 1 percent; without

it, they can exceed 20 percent. Dengue is endemic in more than 100

countries.

Diphtheria is a respiratory disease caused by a virus-infected bacterium.

Occurring worldwide, the disease is spread through human-to-human

contact. Symptoms range from mild to severe. Diphtheria can be

complicated by damage to the heart muscle or peripheral nerves. An

effective vaccine is typically provided through national childhood

vaccination programs. The disease is fatal 5 to 10 percent of the time, even

when treated by administration of antibiotics and diphtheria antitoxin.

Untreated, the fatality rate can be much higher.

Ebola hemorrhagic fever, a viral disease, is transmitted by direct

contact with the body fluids of infected individuals, causing acute fever,

diarrhea that can be bloody, vomiting, internal and external bleeding, and

other symptoms. There is no known cure, although some measures,

including rehydration, can improve the odds of survival. Ebola kills more

than half of those it infects. Identified for the first time in 1976, the Ebola

virus is still considered rare, but there have been a number of outbreaks in

central Africa.

Guinea worm disease, formally known as dracunculiasis, is transmitted

by drinking water contaminated with parasite larvae. The mature parasite

travels through the body, usually emerging through the foot or leg.

Perforation of the skin is accompanied by fever, extreme pain, nausea, and

vomiting, and an infected person can stay ill for several months. Fatalities

are rare, but secondary infection and permanent deformity can occur.

There is no vaccine or drug to prevent infection or kill the worms;

however, transmission of the disease can be halted through education and

the provision of safe drinking water. The disease has been eradicated from

several countries, but remains present in 13 African nations, according to

CDC.

Hantavirus pulmonary syndrome is caused by several strains of a virus

that is transmitted by exposure to infected rodents. Symptoms include

fever, fatigue, muscle aches, coughing, and shortness of breath; the onset

of respiratory distress often leads to death. There is no specific treatment
Appendix II: Disease Information

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for the disease, other than appropriate management of respiratory

problems. The virus was first identified in the southwestern United States

in 1993, but several hundred cases have since been confirmed in other U.S.

locations, Canada, and several countries in South America.

Hepatitis B is a viral infection of the liver that is readily transmitted by

contact with the body fluids of an infected person. In many developing

countries, most children become infected. The virus may cause an acute

illness, as well as a life-long infection that carries a high risk of serious

illness or eventual death from liver cancer or cirrhosis. An effective

vaccine is available, and WHO has recommended that it be added to

routine childhood immunization programs in all countries. About 2 billion

people worldwide have been infected with the virus, and about 350 million

people remain chronically infected.

Human immunodeficiency virus (HIV) causes acquired

immunodeficiency syndrome (AIDS), a disease of the immune system. HIV

is transmitted through contact with the body fluids of an infected person

or from mother to baby. Infected adults may be asymptomatic for 10 years

or more. Because the immune system is weakened, there is eventually

greater susceptibility to opportunistic diseases such as pneumonia and

tuberculosis. Drugs are available that can prevent transmission from

pregnant mothers to their unborn children and can help slow the onset of

AIDS. As of December 2000, an estimated 36.1 million people worldwide

were living with HIV/AIDS and about 21.8 million had died.

Influenza, or flu, is a highly contagious respiratory infection caused by

three types of virus, of which two (types A and B) can reach epidemic

proportions and are found worldwide. Symptoms include fever, cough,

sore throat, runny or stuffy nose, headache, muscle aches, and often

extreme fatigue that may last 1 to 2 weeks. Severe complications such as

pneumonia sometimes occur in children, the elderly, and other vulnerable

populations. There is an influenza vaccine, but the viruses change so

quickly that the vaccine must be updated every year. Several drugs exist to

prevent and treat influenza.

Leprosy is a chronic bacterial infection. The exact mode of transmission

is not fully understood. Primarily affecting the skin, nerves, and mucous

membranes, leprosy causes deformities of the face and extremities after

many years but can be cured with drugs. About 680,000 new cases were

reported in 1999. India, Myanmar, and Nepal account for about 70 percent

of all leprosy cases.
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Lyme borellosis, or Lyme disease, is a bacterial illness transmitted by

ticks. The pathogen was first detected in the United States in 1982 and

identified as the cause of the disease. The area around the tick bite

sometimes develops a “bull’s eye” rash, typically accompanied by fever,

headache, and musculoskeletal aches and pains. There is an effective

vaccine for adults at high risk. If untreated by antibiotics, arthritis,

neurologic abnormalities, and—rarely—cardiac problems follow. The

disease is rarely if ever fatal and is endemic in North America and Europe.

Lymphatic filariasis is a parasitic disease transmitted by mosquitoes.

The infection causes severe pathology of the lymph system resulting in

elephantiasis, or gross swelling, of the limbs and genitals and organ

damage. Diagnostic tools have improved, and more recently drug

treatment options have replaced mosquito control as a strategy for

eliminating the disease. At least 120 million people in 80 countries

worldwide are infected in both rural areas and densely populated urban

slums.

Malaria is a parasitic disease, transmitted by mosquitoes and endemic in

101 countries and territories. Symptoms include fever, shivering, joint

pain, headache, repeated vomiting, severe anemia, convulsions, coma, and

in severe cases death. Malaria is becoming increasingly resistant to known

primary drug treatments. About 40 percent of the world population is

considered at risk for malaria. Ninety percent of malaria cases are in subSaharan Africa, but the disease is now reemerging in countries where it

was once under control.

Measles, a highly contagious viral disease, often strikes children and

causes fever, conjunctivitis, congestion, and cough, followed by a rash.

This disease is transmitted by human-to-human contact, and secondary

infections often cause further complications. Sustained efforts to

immunize children have reduced the prevalence of this disease, but it still

occurs worldwide, with an estimated 30 million cases leading to

approximately 900,000 deaths every year.

Meningitis, a condition that may be caused by several disease agents, is

an infection and severe inflammation of the fluid membranes surrounding

the brain and spinal cord.

Meningococcal meningitis, caused by a particular type of bacteria, is

transmitted by human-to-human contact and is characterized by sudden

onset of fever, headache, neck stiffness, and altered consciousness. There

is a vaccine for this disease, but it loses its effectiveness over time and
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must be repeated. Untreated epidemics can incur fatality rates of over 50

percent but epidemic fatality rates in the last 30 years have generally been

in the 8 to 12 percent range. Epidemics of meningococcal meningitis are a

frequent occurrence in Africa’s “meningitis belt,” which stretches from

Senegal to Ethiopia. An estimated 500,000 cases and 50,000 deaths occur

each year due to meningococcal meningitis.

Pertussis, or whooping cough, is a highly contagious bacterial disease

spread through respiratory droplets from an infected person. Symptoms

include runny nose and sneezing, a mild fever, and a cough that gradually

becomes more severe, turning into paroxysms of coughing that end in

vomiting and exhaustion. Pertussis is treatable with antibiotics, and the

pertussis vaccine is commonly administered as part of routine childhood

immunization programs. Twenty million to 40 million cases with 200,000 to

300,000 deaths are reported worldwide every year. Most occur in

developing countries.

Plague, a severe bacterial infection, is usually transmitted to humans by

infected rodent fleas (bubonic plague) and uncommonly by person-toperson respiratory exposure (pneumonic plague). Symptoms of bubonic

plague include swollen, painful lymph glands (buboes), fever, chills,

headache, and exhaustion. People with pneumonic plague develop cough,

bloody sputum, and breathing difficulty. Plague is treatable with

antibiotics. However, unless diagnosed and treated early, it is highly fatal.

Approximately 1,000 to 4,000 cases of plague are reported each year, but

these figures represent only a portion of the actual number of cases.

Poliomyelitis, or polio, is a virus transmitted through human-to-human

contact. In most cases, there are no symptoms or only mild, flu-like

symptoms. Five to 10 percent of cases can lead to aseptic meningitis, while

only 1 percent of infections lead to the acute flaccid paralysis associated

with polio. Although there is no cure, an effective vaccine is included as

part of routine childhood immunizations. Fewer than 3,500 confirmed

cases were reported in 2000, with transmission still occurring in up to 20

countries.

Rift Valley fever is a viral disease that primarily affects animals—

including domesticated livestock—but can be transmitted to people by

mosquitoes or contact with the body fluids of infected animals. Rift Valley

fever usually causes a flu-like illness lasting 4 to 7 days, but about 1

percent of cases develops into a more severe hemorrhagic fever that has

an approximately 50-percent fatality rate. An antiviral drug has been

identified and is being tested, and vaccines are under development. The
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disease has occurred in many parts of Africa and, in September 2000, was

for the first time reported outside of Africa, in Saudi Arabia and Yemen.

River blindness, or onchocerciasis, is a parasitic disease. Blackflies

transmit the larvae of parasitic worms to humans, where they grow into

adult worms with a lifespan of 12 to 15 years. These worms spawn millions

of microscopic parasites that travel throughout the body causing

unbearable itching, skin disfigurement, and vision impairment or

blindness. Treatment with the drug ivermectin kills the infant parasites but

has very limited if any effect on adult worms. The disease is endemic in 37

countries, with nearly all cases in Africa.

Salmonella infection, or salmonellosis, is caused by a group of bacteria

that may be present in contaminated foods—often raw or undercooked

foods of animal origin. It causes acute diarrheal illness, for which

treatment is usually not required. In some cases, however, the infection

can spread in the bloodstream and cause death unless antibiotics are used.

Over 2,200 strains of Salmonella bacteria have been identified, including

some that have developed antibiotic resistance and are hence more

difficult to control. The disease is common in both developed and

developing countries.

Schistosomiasis, known in some regions as Bilharzia, is caused by five

species of parasitic flatworms, called schistosomes. The flatworms, which

are carried during part of their lifecycle by fresh water snails, penetrate

the skin when people swim or wade in contaminated water. The flatworms

grow inside the blood vessels and produce eggs that can damage the

intestines, bladder, and other organs and eventually cause bladder cancer,

kidney failure, or serious complications of the liver and spleen. Safe, costeffective drugs are available to treat the disease. Schistosomiasis is

endemic in more than 70 developing countries, infecting an estimated 200

million people, 20 million of whom have severe illness. Over 80 percent of

the cases are found in Africa.

Shigellosis is a highly contagious, diarrheal disease caused by four strains

of bacteria. One of these strains, an unusually virulent pathogen, causes

large-scale, regional outbreaks of dysentery (bloody diarrhea) with

mortality rates of 5 to 15 percent. Transmitted by human-to-human contact

and contaminated food and water, this disease is common in crowded

areas with poor sanitation and unsafe water supplies. In addition to

diarrhea, patients experience fever, abdominal cramps, and rectal pain.

The disease is treatable by rehydration and antibiotics, but antimicrobial
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resistance has become widespread. All types of shigellosis together cause

an estimated 600,000 deaths per year, mostly in developing countries.

Smallpox is a highly contagious viral disease transmitted from person to

person, with a high mortality rate and a history of epidemics throughout

the world. Patients experience fever, aching, and prostration, followed by

a painful rash that spreads over the entire body and eventually leaves

pitted scars and sometimes causes blindness. There is no effective

treatment for the disease; however, the development of a vaccine enabled

the worldwide eradication of smallpox by 1977. At the start of the

eradication campaign in 1966, an estimated 10 million to 15 million cases

occurred globally each year, resulting in more than 2 million deaths.

Tetanus, or lockjaw, is caused by a bacterium found in the intestines of

many animals and in the soil. It is transmitted to humans through open

wounds. Neonatal tetanus is a particular problem in newborn infants due

to unsanitary birthing practices. Symptoms include generalized rigidity

and convulsive spasms of the skeletal muscles. Tetanus can be treated

with an antitoxin, and there is an effective vaccine, commonly included in

childhood vaccination programs. It is fatal about 30 percent of the time

and occurs worldwide. Neonatal tetanus causes an estimated 270,000

deaths each year, mostly in developing countries.

Tuberculosis is a bacterial disease that is usually transmitted by contact

with an infected person. People with healthy immune systems can become

infected but not fall ill—more than one-third of the world’s population is

thought to be infected. Symptoms of tuberculosis can include a bad cough,

coughing up blood, pain in the chest, fatigue, weight loss, fever, and chills.

Several drugs can be used to treat tuberculosis, but the disease is

becoming increasingly drug resistant. The available vaccine, commonly

administered to children, has a limited effect. The disease is estimated to

kill 2 million people each year.

West Nile fever is a mosquito-borne viral disease. Symptoms include

fever, head and body aches, rash, and, in more serious cases, stupor,

coma, convulsions, and paralysis. Death occurs in 3 to 15 percent of cases.

There is no vaccine for the West Nile virus, and no specific treatment

besides supportive therapies. The disease occurs in Africa, Eastern

Europe, West Asia, the Middle East, and, since 1999, the United States.
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Yellow fever is a mosquito-borne viral disease whose symptoms include

fever, muscle pain, headache, loss of appetite, and nausea. Fifteen percent

of patients progress to a toxic phase, which can include jaundice,

abdominal pain, and bleeding from the mouth, nose, eyes, or stomach. The

kidneys deteriorate and may fail. Half of patients who enter this phase die.

There is no treatment for yellow fever beyond supportive therapies. A safe

and highly effective vaccine for yellow fever is available but is often not

included in national vaccination programs. Yellow fever is endemic in

more than 40 countries in Africa and Central and South America and

causes an estimated 200,000 cases of illness and 30,000 deaths each year.
Appendix III: Comments From the

Department of Health and Human Services

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Appendix III: Comments From the

Department of Health and Human Services
Appendix III: Comments From the

Department of Health and Human Services

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Appendix III: Comments From the

Department of Health and Human Services

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Appendix IV: Comments From the World

Health Organization

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Appendix IV: Comments From the World

Health Organization
Appendix IV: Comments From the World

Health Organization

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Appendix V: Comments From the United

States Agency for International Development

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Appendix V: Comments From the United

States Agency for International Development

Note: GAO comments

supplementing those in

the report text appear at

the end of this appendix.

See comment 2.

See comment 1.
Appendix V: Comments From the United

States Agency for International Development

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Appendix V: Comments From the United

States Agency for International Development

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Appendix V: Comments From the United

States Agency for International Development

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Appendix V: Comments From the United

States Agency for International Development

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Appendix V: Comments From the United

States Agency for International Development

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See comment 4.

Now on p. 39.

See comment 3.
Appendix V: Comments From the United

States Agency for International Development

Page 66 GAO-01-722 Global Hea

1. We reviewed the examples of relevant USAID activities provided on

pages 3-5 of the agency’s written comments and inserted into the

report references to those activities that could be included in the text.

For example, we added a reference to USAID support to our existing

discussion on “Coordinating Surveillance Operations.”

2. We revised the draft report’s concluding observations to reflect

USAID’s subsequent comments that past disease-specific initiatives

have failed to improve overall developing country surveillance

capacity, many of the weaknesses of developing country programs

identified in the report require donor attention outside the range of

disease specific programs, if the balance of resource flows between

disease-specific surveillance initiatives and routine surveillance

remains heavily in favor of the former, then the ability of the donor

community to support overall system strengthening will continue to be

severely inhibited.

3. We retained the original language after consulting with experts on

these diseases at CDC and the Case Western Reserve University

School of Medicine.

4. We retained the original wording, with the qualification that the

information cited was accurate as of April 9, 2001. As of this date, after

detailed communications with WHO’s Africa Regional Office, we had

received 19 completed assessments and 10 completed plans of action.

We were informed, in addition, that health officials had conducted

fieldwork in a 20th country, Kenya, but that their assessment report

was not yet available.

No change was made to reflect the comment that the goal of the

Integrated Disease Surveillance and Response initiative “involved only

23 countries that requested inclusion in the initiative.” No reference to

such requests was made to us during the course of our work with WHO

or the countries involved in the initiative.

GAO Comments
Appendix VI: Comments From the National Aeronautics and

Space Administration

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Appendix VI: Comments From the National

Aeronautics and Space Administration
Appendix VII: Comments From the World Bank

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Appendix VII: Comments From the World

Bank
Appendix VIII: Comments From the

Department of Defense

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Appendix VIII: Comments From the

Department of Defense
Appendix IX: GAO Contact and Staff

Acknowledgments

Page 70 GAO-01-722 Global Health

Michael McAtee (202) 512-8978

In addition to the person named above, key contributors to this report were

Ann Baker, Lynn Cothern, Kay Halpern, Lynne Holloway, John Hutton,

Bruce Kutnick, and Tom Zingale.

Appendix IX: GAO Contact and Staff

Acknowledgments

GAO Contact

Acknowledgments

(711544)
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