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. 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. 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. 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. 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. 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. 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. 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. 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. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. 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Summary: 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. 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.