V. What mandates and authority should be granted to U.S.Government agencies to enable them to strengthen global diseasesurveillance and response?

The U.S. Government has many existing resources that may becoordinated with those of foreign countries, WHO, and otherinternational agencies to build a global international system forinfectious disease surveillance and response. To make the bestpossible use of U.S. expertise and resources, the efforts of U.S.Government agencies should be well-coordinated. In thoseinstances in which a disease outbreak occurs in the midst of amajor disaster, USAID's OFDA has a clear mandate to facilitate acoordinated U.S. response. However, when an outbreak occurs inthe absence of a disaster, no U.S. Government agency has theauthority to take the lead in coordinating U.S. efforts, and nogovernment structure exists to oversee the development of asurveillance network, to mobilize a concerted response when adisease outbreak occurs, or to coordinate preventive measuresaimed at anticipated health threats. It is strongly recommendedthat some lead agency or agencies be given the authority andresources to fulfill these functions.

Establishment of an Interagency Task Force

Further strategic planning is required to help build aninternational network for infectious disease surveillance andresponse. To carry on this work, it is recommended that anInteragency Task Force be established that meets on a regularbasis to

• Oversee the coordination, strengthening, and geographicalwidening of existing global communications networks for use inthe surveillance and control of infectious diseases.
• Determine how gaps in U.S. capacity to respond to infectiousdisease outbreaks abroad may be filled by improved interagency orpublic/private sector coordination

Participation in the Task Force should include, but not belimited to, CDC, FDA, NIH, State, DoD, and USAID. These sixagencies should form a core group for facilitating U.S.Government responses to infectious disease outbreaks in othercountries.

Activities of individual U.S. Government agencies with regard todisease surveillance and control

As a matter of U.S. Government policy, all U.S. laboratories,field stations, and offices abroad should be encouraged toparticipate in infectious diseases surveillance, as far as it iswithin their resources and mandate to do so. Listed below arecurrent activities performed by U.S. Government agencies whichcontribute to infectious disease surveillance and responsethroughout the world. In some cases, recommendations are made onhow to overcome the gaps in authority and structure described inthis report.

Department of State

The Department of State coordinates interagency policy oninternational issues and should take a lead role in theInteragency Task Force's strategic planning efforts.

• As with other natural disasters, like earthquakes orhurricanes, U.S. ambassadors should be granted the authority tomake the determination that an outbreak of infectious diseaserequires U.S. attention and/or assistance.
• When a U.S. Ambassador makes such a determination, Stateshould facilitate a rapid U.S. Government response by
  • Contacting the Interagency Task Force, and
  • Coordinating U.S. action with that of other nations and WHO.
• U.S. ambassadors should be encouraged to support the effortsof other agencies, including the DoD, USAID, NIH, and CDC, instrengthening the global disease surveillance and responsenetwork. The DoD's infectious disease laboratories abroad arealigned with and dependent on close interaction with theembassies. U.S. ambassadors should ensure that personnel ceilingsin the DoD laboratories are adequate to allow global diseasesurveillance to proceed.
• The Department of State and USAID should take a lead role inencouraging and assisting other countries to make infectiousdisease detection and control a national priority.
• Diplomatic resources should be made available as needed toencourage foreign governments to cooperate with internationalefforts to contain epidemics that occur within their borders.
• The Department of State's Office of Medical Services employs24,000 doctors and nurse practitioners in 260 locations, some ofwhich are located in remote areas. Medical information gatheredfrom these locations should be supplied to the global diseasesurveillance network.

Department of Health and Human Services: Public Health Service

Centers for Disease Control and Prevention

CDC is the lead U.S. agency in matters of domestic diseasesurveillance, control, and prevention. However, CDC does not havedirect authority to support the development of internationalhealth programs. Because it lacks direct authority in this area,CDC cannot receive appropriations in support of internationalinfectious disease surveillance, except for AIDS surveillance.

• In view of the international nature of emerging infectiousdiseases, and of the increasing mobility of infectious microbes,CDC's mandate to protect the health of U.S. citizens should beextended by legislation to include outbreak investigations andresponses to epidemics overseas in coordination with appropriateU.S. agencies, including state and local health departments,USAID, DoD, etc, when they occur outside the context of disasterassistance.
• CDC should assist in formulating and implementing the USGovernment international surveillance, response, and preventionstrategies. They should provide epidemiology and laboratorypersonnel and direction for epidemic response. They should alsoprovide assistance with diagnostic referrals.
• CDC should serve as the primary link with the global networkof Field Epidemiology Training Programs (FETPs), providing forimproved communications and sharing of epidemiologic andlaboratory information among the FETP network (including CDC),and identifying epidemiologic and laboratory expertise in theglobal FETP network that could assist in emerging disease anddisaster assistance in partnership with the U.S. Government.
• Along with the USAID and the Office of International Healthof the Department of Health and Human Services, CDC shouldcoordinate the disease surveillance initiatives of the U.S.Interagency Task Force with those of WHO.

Food and Drug Administration

The FDA has a broad mandate to ensure the safety of foods and thesafety and efficacy of a variety of other products it regulatesincluding drugs, biologics, blood and blood components,diagnostics and medical devices.

• As a member of the Interagency Task Force, the FDA shouldmake its expertise available to the Task Force to the extentresources allow, to ensure adequate supplies and to assist othersin the emergency development and production of vaccines, drugsand diagnostics. The FDA should serve as the focal point forcoordination between the Interagency Task Force and U.S. ormultinational private companies, trade associations or othersuppliers that may be called upon to assist in the emergencymanufacture or development of medical supplies.
• The FDA should collaborate with CDC and USDA in establishingan active surveillance system for foodborne diseases.
• The FDA should continue its emergency response efforts incooperation with CDC and USDA to investigate sources offood-borne pathogens and to respond to outbreaks by takingappropriate measures.

National Institutes of Health

The mandate of NIH includes the support of research and trainingrelated to infectious disease. In accordance with this mandate,the National Institute of Allergy and Infectious Diseases (NIAID)and the Fogarty International Center should take the lead insupporting research and training that will provide informationrelevant to the development of vaccines, therapeutics, anddiagnostics. These research and training activities shouldsupport the global disease surveillance network and responseefforts.

National Institute of Allergy and Infectious Diseases

The NIAID funds multiple research grants and contracts withclinical research and epidemiologic component. These include 11International Collaborations in Infectious Disease Research(ICIDR) and three Tropical Medicine Research Centers (TMRC), inseveral countries. The purpose of these centers is clinicalresearch, including population-based studies and epidemiologicresearch. In addition, NIAID supports nine HIVNET projectsoverseas and eight in the United States, which monitor theincidence of AIDS in populations likely to participate in futurevaccine trials and help create an infrastructure for futurevaccine efficacy trials by training technicians and supportingthe development of laboratories.

• Workers at NIAID-supported units should be encouraged toreport any infectious disease outbreaks that come to theirattention. Overseas centers may also be able to facilitatecommunication with their local ministries of health.
• Many of NIAID's projects involved in research on parasitic,enteric and respiratory diseases are linked in a network ofinternational centers for tropical disease research, whichincludes academic institutions in over 15 countries and meetsregularly with federal agencies and international organizationsinvolved in international research. This network could form aneffective base for expanded international collaboration onemerging disease issues, and should be encouraged to take aleadership role in this area.
• In accordance with their mandates, the NIAID, Fogarty, andother NIH-supported facilities should participate in research andtraining in support of the global disease surveillance network.

Fogarty International Center

The Fogarty International Center should support research andtraining efforts and bilateral and multilateral scientificcollaborations that enhance the capabilities of developingcountries to address emerging and re-emerging disease, includingepidemiology and surveillance and the conduct of research. Thecurrent FIC AIDS International Training and Research Program(AITRP) has linked 11 U.S. universities with institutions in 65countries. This network will provide a model for expansion intoother emerging diseases.

Office of International Health

The Office of International Health of the Department of Healthand Human Services should work with the Interagency Task Force tocoordinate U.S. global surveillance initiatives with those ofWHO.

U.S. Agency for International Development

USAID is the lead U.S. agency in support of international health.As such, USAID provides assistance in health research and healthcare delivery in over 40 developing countries. This support isprovided to national governments, non-governmental organizations,universities, research institutes, and private sector entities.USAID has resident technical staff managing bilateral andregional health programs in most of these countries. Inaccordance with its mandate and its current role in strengtheningthe capacity of developing countries to identify and solve healthproblems, USAID will:

• Help to strengthen developing country capacity to addressemerging health threats such as AIDS and drug resistant malaria;
• Develop and improve methods for detecting and responding toantimicrobial resistance to drugs used for the treatment ofpneumonia, malaria, diarrhea, and TB;
• Assist, together with other donors in efforts to strengthenhealth information systems;
• Support and expand existing programs to strengthendeveloping countries' capacities in epidemiology and laboratoryand clinical diagnosis;
• Continue to play a leadership role with WHO andinternational donors in addressing emerging health issues ofmajor importance to developing countries.

Although USAID has the legislative mandate to implementinternational health programs, current and anticipated budgetconstraints will limit USAID activities that address emerging andre-emerging health threats. On-going health programs have alreadybeen cutback substantially due to lack of resources. Currentactivities in child survival, AIDS, and environmental healthaddress many issues related to the prevention and control of newand re-emerging diseases. Additional health funds would have tobe appropriated to enable the USAID to initiate new or expandedactivities in this area.

Department of Defense

The DoD operates research laboratories in the United States forstudying infectious diseases that threaten military personnel.The emphasis is on insect-borne parasitic and viral diseases anddiarrheal diseases of travelers. Work focuses on improveddiagnosis and development of better preventive measures. DoDoperates a U.S. research laboratory and treatment unit with thehighest level of biocontainment. DoD has the capability oftransporting patients infected with hazardous agents fromanywhere in the world for care.

DoD operates overseas infectious disease laboratories in Brazil,Egypt, Indonesia, Kenya, Peru, and Thailand. These laboratoriesconduct research on diseases of mutual interest to the hostcountry and the United States. Each laboratory has a capabilityfor evaluating new problems through epidemiologic investigation,for diagnosing diseases, and for recommending control measures.

DoD has a limited capability to produce prototype vaccines forhuman testing. Vaccines produced are for diseases uncommon in theUnited States. Large-scale vaccine manufacture depends oncontracts with commercial facilities. Emergency scale-up ofvaccine production by contractors is available for a select groupof highly hazardous agents.

• DoD should strengthen communication among its laboratoriesto create a communication network for global surveillance.
• DoD should work with USAID, CDC, and host nations to providediagnostic, logistical, and communication assistance forresponding to epidemics.

U.S. Department of Agriculture

USDA cooperates with the Centers for Disease Control andPrevention, the Food and Drug Administration, and the Departmentof Defense on international disease issues, as well as withinternational organizations such as the World Health Organizationand Food and Agriculture Organization. A permit and healthcertificates must be obtained from APHIS by people intending toimport animals into the United States. APHIS then arranges thesupervision of testing and examinations of animals by licensedand accredited veterinarians in that country.

• Rapid detection and diagnostic capabilities need to bedeveloped and made available for many zoonotic diseases.
• Innovative risk management approaches are needed, especiallywith increasing travel and trade.

The Peace Corps

The Peace Corps' Epidemiologic Surveillance System receivesreports on the medical status of volunteers in 92 developingcountries, and thus, can serve as a valuable component in theglobal surveillance network. Possibly this surveillance systemcould be expanded to include wider reporting of illnesses in thevillages where the volunteers work.

Department of Veterans Affairs

One of the Department of Veterans Affairs' (DVA) four missions isemergency preparedness. DVA's experience in tracking theillnesses of soldiers who return from abroad, as well as ininvestigating disease transmission, should help the InteragencyTask Force detect and respond to infectious diseases.

U.S. Department of Commerce

National Oceanic and Atmospheric Administration

The NOAA ability to forecast El Nino currents has yielded usefulpredictions of climate variability up to one year in advance incertain parts of the world, particularly in the tropics. Thisactivity offers the opportunity to provide a predictive dimensionto the global disease surveillance system.

Climate variability affects the distribution and number of insectand rodent disease vectors, as well as of other animals thatserve as reservoirs for human diseases. Climate variability alsoaffects the distribution and quality of fresh water and thereforeaffects the incidence of waterborne diseases. Climate monitoringand forecasting should be integrated with global diseasesurveillance to enhance U.S. predictive and preventivecapacities.

National Institute of Standards and Technology

The National Institute of Standards and Technology (NIST)laboratories are responsible for the standardization of manyproducts used in measurement and testing, including somediagnostic reagents. NIST's Advanced Technologies Program (ATP)currently supports research and development on diagnostic testsfor infectious diseases based on DNA probes. NIST should beencouraged to continue work on the standardization of productsfor the diagnosis of infectious diseases.

Environmental Protection Agency

The Environmental Protection Agency (EPA) is studying the effectsof long-term climate change on vector-borne diseases, which canbe especially sensitive to subtle changes in temperature,precipitation, and weather variability. Ecological perturbationsresulting from either climate change or human land use patternsmay alter the environment in such a way as to promote diseaseemergence.

EPA should have the capacity to provide to the Interagency TaskForce results from the monitoring of environmental changes whichmay relate to shifting disease distribution or emergence. Asenvironmental factors involved in disease systems become betterunderstood, the EPA could be encouraged to improve monitoring,surveillance, and reporting of such potential indicators toprovide the opportunity for earlier pubic health intervention.

EPA personnel working in the environmental health offices of WHOcould further serve to help link relevant environmental data tothe international disease surveillance efforts of WHO.

Cooperation with the World Health Organization

The WHO is often in the best position for early recognition ofinfectious disease outbreaks through its interactions with thevarious networks of WHO Collaborating Centres, and is also oftenbest suited to coordinate response activities. The InteragencyTask Force should therefore maintain close communications withthe WHO.

During the 1995 World Health Assembly, a resolution was passedthat deals specifically with emerging and re-emerging infectiousdiseases. The resolution defines a global leadership role for WHOin addressing emerging infectious diseases, and its endorsementby member states will facilitate implementation activities. TheU.S. Government strongly supported both the acceptance andimplementation of the resolution.

As the WHO has no laboratory resources of its own, it relies uponan international network of Collaborating Centres for technicalguidance. Many of these WHO Collaborating Centres are located inthe United States, but most of them do not receive funds from WHOto offset the costs they incur in providing this criticalservice. The Interagency Task Force should identify WHOCollaborating Centres within the United States that are essentialto address emerging and re-emerging infectious diseases andshould ensure their core funding through a combination of U.S.Government (CDC, NIH, USAID, and others) and internationalresources (WHO and others).

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