Global Health: U.S. Agencies Support Programs to Build Overseas Capacity for Infectious Disease Surveillance
Published: 2007-10-04T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The rapid spread of severe acute respiratory syndrome (SARS) in 2003 showed that disease outbreaks pose a threat beyond the borders of the country where they originate. The United States has initiated a broad effort to ensure that countries can detect outbreaks that may constitute a public health emergency of international concern. Three U.S. agencies--the Centers for Disease Control and Prevention (CDC), the U.S. Agency for International Development (USAID), and the Department of Defense (DOD)--support programs aimed at building this broader capacity to detect a variety of infectious diseases. This testimony describes (1) the obligations, goals, and activities of these programs and (2) the U.S. agencies' monitoring of the programs' progress. To address these objectives, GAO reviewed budgets and other funding documents, examined strategic plans and program monitoring and progress reports, and interviewed U.S. agency officials. GAO did not review capacity-building efforts in programs that focus on specific diseases, namely polio, tuberculosis, malaria, avian influenza, or HIV/AIDS. This testimony is based on a report (GAO-07-1186), which is being released with this testimoy. GAO did not make recommendations. The agencies whose programs we describe reviewed our report and generally concurred with our findings. We incorporated their technical comments as appropriate.
section_title: What GAO Found
paragraphs: The U.S. government operates or supports four key programs aimed at building overseas surveillance capacity for infectious diseases. In fiscal years 2004-2006, U.S. agencies obligated approximately $84 million for these programs, which operate in developing countries around the world. Global Disease Detection is CDC's main effort to help build capacity for infectious disease surveillance in developing countries. The Field Epidemiology Training Programs, which CDC and USAID support, are another tool used to help build infectious disease surveillance capacity worldwide. Additionally, USAID supports CDC and the World Health Organization's Regional Office for Africa in designing and implementing Integrated Disease Surveillance and Response in 46 countries in Africa, with additional technical assistance to 8 African countries. DOD's Global Emerging Infections Surveillance and Response System also contributes to capacity building through projects undertaken at DOD overseas research laboratories. USAID supports additional capacity-building projects in various developing countries. For each of the four key surveillance capacity-building programs, the U.S. agencies monitor activities such as the number of epidemiologists trained, the number of outbreak investigations conducted, and types of laboratory training completed. In addition, CDC and USAID recently began systematic efforts to evaluate the impact of their programs; however, because no evaluations had been completed as of July 2007, it is too early to assess whether these evaluation efforts will demonstrate progress in building surveillance capacity.

section_title: Letter
paragraphs: Thank you for this opportunity to discuss GAO’s recent work on U.S.  efforts to strengthen international surveillance of infectious diseases.
Infectious diseases are a leading cause of deaths worldwide and represent  the third most common cause of death in the United States. As the recent  outbreaks and rapid spread of severe acute respiratory syndrome (SARS)  and avian influenza have shown, disease outbreaks pose a threat beyond  the borders of the country where they originate. The United States thus  has a clear interest in building capacity abroad to identify and respond to  outbreaks of infectious disease. Effective disease surveillance systems in  other countries contribute to lower morbidity and mortality rates and  improved public health outcomes, both in those countries and elsewhere  in the world.
Earlier efforts to improve surveillance worldwide focused on individual  diseases, beginning with global influenza surveillance in the 1940s and  followed by surveillance systems for smallpox and polio, among others. In  the mid-1990s, recognizing the threat posed by previously unknown  infectious diseases, the United States and other countries initiated a  broader effort to ensure that countries can detect any disease outbreak  that may constitute a public health emergency of international concern.  Three U.S. agencies—the Department of Health and Human Services’  Centers for Disease Control and Prevention (CDC), the U.S. Agency for  International Development (USAID), and the Department of Defense  (DOD)—have programs aimed at building this broader capacity to detect a  variety of infectious diseases.
Today I will describe U.S. efforts to build developing countries’ broader  capacity for infectious disease surveillance, specifically: (1) the  obligations, goals, and activities of key U.S. programs to develop  epidemiology and laboratory capacity and (2) U.S. agencies’ monitoring of  the progress achieved by these programs. My statement—based on our  report released today—does not address U.S. efforts to build international  capacity for surveillance of specific diseases, namely polio, tuberculosis,  malaria, HIV/AIDS, or avian influenza. However, we recently issued  reports on domestic preparedness for avian influenza outbreaks and on  international efforts to prevent pandemic influenza. In addition, we are  beginning to examine, at the subcommittee’s request, U.S. capacity to  protect against naturally or intentionally introduced outbreaks of zoonotic  diseases as well as lessons that can be learned from previous outbreaks in  other countries.
For our September 2007 report, we reviewed annual budgets, grants, and  project funding for four infectious disease surveillance programs—Global  Disease Detection (GDD), Field Epidemiology Training Programs (FETP),  Integrated Disease Surveillance and Response (IDSR), and Global  Emerging Infections Surveillance and Response System (GEIS)—and  examined U.S. agencies’ budget, planning, and reporting documents. In  addition, we interviewed U.S. and World Health Organization (WHO)  officials responsible for implementing capacity-building activities. We  determined that the budget and performance data that we obtained had  some limitations but were sufficiently reliable for our purposes. We did  not make recommendations in our report. We conducted our work from  October 2006 through July 2007 in accordance with generally accepted  government auditing standards.
DOD, HHS, and USAID provided written comments on a draft of our  September 2007 report, generally concurring with our findings. DOD  provided information to clarify the extent of GEIS’s global involvement,  goals, and priorities. HHS provided additional information regarding GDD  operations, noting that the GDD centers bring together CDC’s existing  international expertise in public health surveillance, training, and  laboratory methods. Additionally, HHS indicated that disease-specific  programs contribute to building surveillance capacity. USAID’s comments  also focused mainly on the support it provides to disease-specific and  other activities that contribute to building surveillance capacity.
subsections: section_title: Background
paragraphs: Dramatic growth in the volume and speed of international travel and trade  in recent years have increased opportunities for diseases to spread across  international boundaries with the potential for significant health and  economic implications. International disease control efforts are further  complicated by, for instance, the emergence of previously unknown  zoonotic diseases, such as Ebola hemorrhagic fever and avian influenza.
Surveillance provides essential information for action against infectious  disease threats. Basic surveillance involves four functions: (1) detection,  (2) interpretation, (3) response, and (4) prevention. (See fig. 1.)
Global efforts to improve disease surveillance have historically focused on  specific diseases or groups of diseases. For example, as we reported in  2001, the international community has set up surveillance systems for  smallpox, polio, influenza, HIV/AIDS, tuberculosis, and malaria, among  others, with the goal of eradicating (in the case of smallpox and polio) or  controlling these diseases. In 2006, the United States adopted a national  strategy to prepare for pandemic influenza outbreaks both domestically  and internationally, which included planned funding by U.S. agencies to  support influenza surveillance and detection. Such disease-specific  efforts can build capacity for surveillance of additional diseases as well.
The United States acknowledged the need to improve global surveillance  and response for emerging infectious diseases in 1996, when the President  determined that the national and international system of infectious disease  surveillance, prevention, and response was inadequate to protect the  health of U.S. citizens. Addressing these shortcomings, the 1996  Presidential Decision Directive NSTC-7 enumerated the roles of U.S.  agencies—including CDC, USAID, and DOD—in contributing to global  infectious disease surveillance, prevention, and response.
Enhancing capacity for detecting and responding to emerging infectious  disease outbreaks is also a key focus of the revised International Health  Regulations (IHR). For many years, the IHR required reporting of three  diseases—cholera, plague, and yellow fever—and delineated measures  that countries could take to protect themselves against outbreaks of these  diseases. In May 2005, the members of WHO revised the IHR, committing  themselves to developing core capacities for detecting, investigating, and  responding to other diseases of international importance, including  outbreaks that have the potential to spread. The regulations entered into  force in June 2007; member states are required to assess their national  capacities by 2009 and comply with the revised IHR by 2012.
section_title: Four U.S.–funded Programs Help Build Capacity for Overseas Infectious Disease Surveillance
paragraphs: U.S. agencies operate or support four key programs aimed at building  overseas surveillance capacity for infectious diseases: Global Disease  Detection (GDD), operated by CDC; Field Epidemiology Training  Programs (FETP), supported by CDC and USAID; Integrated Disease  Surveillance and Response (IDSR), supported by CDC and USAID; and  Global Emerging Infections Surveillance and Response System (GEIS),  operated by DOD. USAID also supports additional capacity-building  projects.
In 2004-2006, the U.S. government obligated about $84 million for these  four programs (see table 1). Funding for these programs is obligated to  support the ability of laboratories to confirm diagnosis of disease as well  as the training of public health professionals who will work in their  countries to improve capacity to detect, confirm, and respond to the  outbreak of infectious diseases.
Collectively, these four programs operate in 26 developing countries. (See  fig. 2.) To limit duplication and leverage resources in countries where  some or all of the capacity-building programs operate, CDC, DOD, and  USAID coordinate their efforts by colocating activities, detailing staff to  each other’s programs, participating in working groups, and  communicating by phone.
subsections: section_title: Global Disease Detection
paragraphs: GDD is CDC’s primary effort to build public health capacity to detect and  respond to existing and emerging infectious diseases in developing  countries, according to CDC officials. In 2004-2006, CDC obligated about  $31 million to support GDD capacity-building efforts. GDD’s goals are to    enhance surveillance,    conduct research,  respond to outbreaks,  facilitate networking, and  train epidemiologists and laboratorians.
Established in 2004, GDD aims to set up a total of 18 international centers  that would collaborate with partner countries, surrounding regions, and  WHO to support epidemiology training programs and national laboratories  and conduct research and outbreak response around the world. Two GDD  centers were established in Kenya and Thailand in 2004, and three centers  are currently under development in Egypt, China, and Guatemala. In  addition, CDC established a GDD Operations Center in Atlanta to  coordinate information related to potential outbreaks.
According to CDC officials, GDD capacity-building activities consist of  strengthening laboratories, providing epidemiology training, and  conducting surveillance activities. CDC aims to establish laboratories with  advanced diagnostic capacity—for example, in Kenya, CDC established  several laboratories with biosafety levels 2 and 3. GDD centers conduct  formal, 2-year training programs in analyzing epidemiological data,  responding to outbreaks, and working on research projects. The centers  also conduct short-term training—for example, in 2006, GDD centers  trained more than 230 participants from 32 countries to respond to  pandemics. In addition, the centers provide opportunities for public health  personnel in host countries to work with CDC to evaluate existing  surveillance systems, develop new systems, write and revise peer- reviewed publications, and use surveillance data to inform policy  decisions.
section_title: Field Epidemiology Training Programs
paragraphs: Assisted by USAID and WHO, and at the request of national governments,  CDC has helped countries establish their own FETPs to strengthen their  public health systems by training epidemiologists and laboratorians in  infectious disease surveillance. CDC and USAID obligated approximately  $19 million to support these programs in 2004-2006. Each FETP is  customized in collaboration with country health officials to meet the  country’s specific needs, emphasizing    applied epidemiology and evidence-based decision making for public    effective communication with the public, public health professionals,  and the community; and    health program design, management, and evaluation.
CDC and USAID collaborate with host-country ministries of health in  Brazil, Central America, Central Asia, China, Egypt, Ghana, India,  Jordan, Kenya, Pakistan, South Africa, Sudan, Thailand, Uganda, and  Zimbabwe to build surveillance capacity through the FETPs. In addition to  receiving formal classroom training in university settings, FETP students  and graduates participate in surveillance and outbreak response activities,  such as analyzing surveillance data and performing economic analysis, and  publish articles in peer-reviewed bulletins and scientific journals. At the  end of the 2-year program, participants receive a postgraduate diploma or  certificate.
According to CDC, these programs graduated 351 epidemiologists and  laboratorians in 2004-2006. As of February 2007, according to CDC, six  programs established between 1999 and 2004 tracked their graduates and  found that approximately 92 percent continued to work in the public  health arena after the training. For example, in Jordan, 21 of 23 graduates  of its FETP are working as epidemiologists at the central and governorate  levels.
section_title: Integrated Disease Surveillance and Response
paragraphs: USAID has supported CDC in (1) designing and implementing IDSR, with  WHO/AFRO, in 46 African countries and (2) providing technical assistance  to 8 of these countries. In 2004-2006, USAID obligated approximately $12  million to support IDSR, transferring about one-quarter of this amount to  CDC through interagency agreements and participating agency service  agreements. IDSR’s goal is to use limited public health resources  effectively by integrating the multiple disease-specific surveillance and  response systems that exist in these countries and linking surveillance,  laboratory confirmation, and other data to public health actions.
CDC has collaborated with WHO/AFRO in developing tools and guidelines,  which are widely disseminated in the region to improve surveillance and  response systems. CDC’s assistance has included    developing an assessment tool to determine the status of surveillance    developing technical guidelines for implementing IDSR,    working to strengthen the national public health surveillance    conducting evaluations of the cost to implement IDSR in several  African countries.
In addition, CDC is providing technical assistance to eight countries in  Africa, which CDC and USAID selected as likely to become early  adopters of surveillance best practices and therefore to be models for  other countries in the region. With funding from USAID, CDC has  undertaken activities in these countries such as evaluating the quality of  national public health laboratories in conjunction with WHO, developing a  district-level training guide (published in English and French) for  analyzing surveillance data, and developing job aids for laboratories to  train personnel in specimen-collection methods.
section_title: Global Emerging Infections Surveillance and Response
paragraphs: DOD established GEIS in response to the 1996 Presidential Decision  Directive NSTC-7 on emerging infectious diseases, which called on DOD to  support global surveillance, training, research, and response to infectious  disease threats. In 2005-2006, DOD obligated approximately $8 million  through GEIS to build capacity for infectious disease surveillance. GEIS,  as part of its mission, provides funding to DOD research laboratories in  Egypt, Indonesia, Kenya, Peru, and Thailand as well as to other military  research units for surveillance projects located in 36 countries, according  to DOD officials,. GEIS conducts many projects jointly with host-country  nationals, providing opportunities to build capacity through their  participation in disease surveillance projects. GEIS officials noted that  they view its primary goal as providing surveillance to protect the health  of U.S. military forces and consider capacity building a secondary goal that  occurs as a result of surveillance efforts.
GEIS funded more than 60 capacity-building projects in 2005 and 2006,  supporting activities such as establishing laboratories in host countries,  training host-country staff in surveillance techniques, and providing  advanced diagnostic equipment. For example, in Nepal, GEIS funded  surveillance of febrile illnesses, such as dengue fever, and through this  project provided a field laboratory with training and equipment to conduct  advanced diagnostic techniques. GEIS has also funded more direct  training; for example, the laboratory in Peru conducted an outbreak- investigation training course for public health officials from Peru,  Argentina, Chile, and Suriname in 2006 with GEIS funding.
section_title: Additional Capacity- Building Activities
paragraphs: Funding provided by USAID’s Bureau for Global Health and USAID  missions has supported additional activities to build basic epidemiological  skills in developing country health personnel. In 2004-2006, USAID  obligated about $14 million for these activities. For example, USAID  funded a WHO effort to assist the government of India in improving  disease surveillance, including strengthening laboratories, developing  tools for monitoring and evaluating surveillance efforts, and creating  operational manuals for disease surveillance.
section_title: Agencies Monitor Surveillance Capacity- Building Activities and Have Begun to Evaluate Programs’ Impact
paragraphs: The U.S. agencies operating or supporting the disease surveillance  capacity building programs collect data to monitor the programs’  activities. CDC and USAID also recently began systematic efforts to  evaluate program impact, but it is too early to assess whether the  evaluations will demonstrate progress in building surveillance capacity.
GDD. Since 2006, CDC has monitored the number of outbreaks that  GDD has investigated, the numbers of participants in GDD long-term  and short-term training, and examples of collaboration among GDD  country programs. In addition, in 2006, CDC developed a framework  for evaluating progress toward GDD’s five goals and collected data for  8 of 14 indicators. (Fig. 3 shows the GDD evaluation framework.)  However, as of July 2007, the agency had not collected data on the two  surveillance indicators to evaluate the program’s contribution to  improved surveillance.
FETP. CDC has collected data such as the numbers of FETP trainees  and graduates, the numbers of FETP graduates hired by public health  ministries, the number of outbreak investigations conducted, and the  number of surveillance evaluations conducted. In 2006, CDC developed  a framework for monitoring and evaluating FETPs’ impact on  countries’ health systems, with 13 indicators related to FETP activities  (see fig. 4 for the FETP indicators). CDC hopes to implement the  framework fully by 2009, but because FETPs are collaborations  between CDC and the host countries, the framework’s implementation  depends on country cooperation.
IDSR. Since 2000, CDC has collected data on activities completed  under its IDSR assistance program, including the number of job aids  developed, the training materials adopted, and the number of training  courses completed, and it reports on these activities annually to  USAID. In 2003, WHO/AFRO adopted 11 indicators, developed with  input from CDC and USAID, to monitor and evaluate progress in  implementing IDSR in Africa (see fig. 5 for the IDSR indicators).  According to WHO/AFRO, 19 of 46 African countries reported data in  2006 for at least some of these indicators, showing some success in  IDSR implementation; however, U.S. agencies cannot require the  collection of data in the remaining countries that did not report on the  indicators, because IDSR is a country-owned program. Separately, in  2005, CDC completed an evaluation of IDSR implementation in 4 of the  8 countries where it assists with IDSR—Ghana, Tanzania, Uganda, and  Zimbabwe—and, using a set of 40 indicators based on WHO guidance,  found that these countries had implemented most of the elements of  IDSR.
GEIS. Since 2005, DOD has monitored GEIS capacity-building activities  through individual project reports that detail each activity completed,  such as training for staff involved in surveillance studies and  development of laboratory diagnostic capabilities. According to GEIS  officials, DOD does not plan to develop a framework to monitor and  evaluate the impact of GEIS on countries’ surveillance capacity,  because capacity building in host countries is not GEIS’s primary  purpose. Rather, GEIS’s goal is to establish effective infectious disease  surveillance and detection systems with the ultimate aim of ensuring  the health of U.S. forces abroad. However, GEIS has reviewed some of  its surveillance projects, and GEIS officials stated that the program’s  activities in the host nations have led to improved surveillance capacity  for infectious diseases.
Mr. Chairman, this concludes my statement. I would be happy to respond  to any questions you or other members of the subcommittee may have at  this time.
section_title: GAO Contact and Staff Acknowledgment
paragraphs: For further information about this testimony, please contact David  Gootnick at (202) 512-3149 or gootnickd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Audrey Solis, Julie Hirshen, Reid Lowe,  Diahanna Post, Elizabeth Singer, and Celia Thomas made key  contributions to this testimony and the report on which it was based.  David Dornisch, Etana Finkler, Grace Lui, Susan Ragland, and Eddie  Uyekawa provided technical assistance.
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