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Section VII.

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Global Microbial Threats in the 1990s

VII. What research and training programs are required to supportthe nation's leadership role in global disease surveillance?

Laboratory and epidemiologic research are the essential foundation upon which a sound disease surveillance and responsesystem is based. This is especially true in regard to emergingand unknown infectious diseases. To combat new diseases for whichno treatments are known, it is essential to maintain an activecommunity of epidemiologists and experimental scientists readyand able to seek new solutions for new disease threats. Inaddition, continued emphasis on effective social and behavioralscience methods to enhance health promoting behavior should bemaintained. To meet the challenge of emerging and re-emerginginfectious diseases requires critical knowledge of thefundamental biology of infectious agents and the clinical diseaseprocesses they induce. Scientific studies of infectious agentsand the diseases they cause provide the fundamental knowledgebase used to develop diagnostic tests to identify diseases, drugsto treat them, and vaccines to prevent them. In addition, theability to intervene effectively in an outbreak or epidemic, orto implement a successful prevention strategy, requires athorough understanding of the epidemiology of the disease. Anespecially important research challenge that may require thecombined efforts of epidemiologists, microbiologists,pharmacologists, and others is to find new ways to combatantibiotic resistance, either by preventing its development or bydesigning vaccines or new classes of drugs effective againstbacteria, viruses, fungi, and parasites. Further, theestablishment of an infrastructure of researchers trained inepidemiology and laboratory research provides a sound basis for aglobal network for surveillance and response.

At the present time, major gaps exist in U.S. research andtraining programs concerned with infectious diseases. The levelof support for research on infectious diseases other than AIDSand TB is extremely limited. At NIH, funding for work related toinfectious diseases, excluding AIDS and TB represents only about5% of their total budgets. At CDC, although approximately 65% ofthe budget is dedicated to the prevention and control ofinfectious diseases, about 95% of these funds are earmarked forAIDS, TB, and sexually transmitted and vaccine preventablediseases. Furthermore, the number of individuals receivinginfectious disease training at NIH and CDC is extremely low, andthe number receiving field training overseas is even lower. Thetraining capacity of the DoD in this area has also been eroded.Few individuals in the United States, for example, had thenecessary expertise in the diagnosis and treatment of plague toprovide assistance during the recent plague outbreak in India.For these reasons, it is imperative that an active scientificcommunity focus on infectious diseases be maintained andsupported.

It is likely that many new infectious diseases will emerge inother parts of the world. The earliest possible detection of suchemerging problems is in our nations' best interest to anticipatethem and respond in an effective manner. To develop effectiveprevention and control strategies for new and emerging pathogens,research is required on the complex interaction between humansand microbes and the evolutionary and genetic factors that causeepidemics.

Currently, there exist a number of international research andtraining programs funded by USAID, NIH, NIAID, Fogarty and CDC,that offer a base for studies of infectious diseases and are alsowell-situated to detect arising infectious diseases. Theseinclude the NIAID's TMRC and ICIDR and Fogarty's AIDSInternational Training and Research Programs, and CDC's FETP.Optimal utilization of these research teams will strengthenrecognition and identification of emerging infectious pathogensat their sites of origin. These teams are positioned to developnew prevention strategies through the discovery of thoseepidemiologic and biological principles that determine theemergence of new and re-emerging microbial diseases.

Strategic objectives

  • Strengthen or expand support for laboratory research relatedto infectious diseases.
  • Increase support for epidemiologic research.
  • Encourage linkages between epidemiologic and laboratoryresearch training.
  • Sustain support for international research and training.

Recommendations for research

Support laboratory research in these areas:

  • Fundamental aspects of microbial physiology, genetics, andbiochemistry
  • Pathogenesis of infectious diseases
  • Human immune response to infectious diseases
  • Development and standardization of diagnostic tests
  • Development of drugs
  • Development of vaccines
  • Development of vector control interventions
  • Improvement of surveillance tools, including computer programsfor data management and reporting
  • Methods for monitoring drug resistance
  • Factors that accelerate the development of drug resistance andmethods for limiting those factors
  • Environmental and climatic factors that influence temperature,the quality and distribution of water, and the populationbiology of insect and rodent vectors

Support epidemiologic research in these areas:

  • The transmission patterns and risk factors of infectiousdiseases
  • The effectiveness of intervention strategies for limiting thespread of new diseases and preventing and controlling resurgentdiseases
  • New epidemiologic and statistical methods, including thedevelopment of predictive models for the occurrence and spreadof epidemics, and the use of geographical information systems
  • Environmental factors that influence the population biology ofinsect and rodent vectors
  • Human behavior and human demographics as they relate to theepidemiology of infectious diseases

Support social science research in these areas:

  • Human social behavior and demographics as they relate to thecauses and control of infectious diseases
  • Economic assessments of the cost-effectiveness of differentsurveillance and response strategies.

Ensure that resources are available for studies of new microbialthreats both here and abroad. Maintaining diversity in infectiousdisease research will also allow us to retain expertise on typesof bacteria, viruses, and parasites that may emerge and orre-emerge unexpectedly.

Encourage the development of tools to monitor, investigate, andintervene in public health problems involving emerging orantibiotic resistant microbes. Also, ensure that facilities aremade available to test these products under field conditions.

Recommendations for training

  • 1. Strengthen interdisciplinary and interagency scientificexchanges and training programs within the United States in thearea of infectious diseases.

These interactions need to be fostered both between agencies andbetween scientific and public health disciplines. For example,CDC and NIH need to expand and strengthen exchange programsbetween the epidemiologic and laboratory based science, at thedoctoral, post-doctoral, and mid-career levels. Maintaining acadre of trained investigators who can deal with new diseaseproblems is an essential part of U.S. preparedness. Theestablishment of an international training program on emerginginfectious diseases as outlined by Fogarty in its long-range planwould help to maintain this cadre.

  • 2. Coordinate U.S. agency efforts to enhance existinginternational research and training programs in infectiousdiseases.

  • NIAID and DoD could work with CDC to strengthen laboratorybased research at CDC's FETP units, whose primary focus isepidemiology.
  • CDC could work with NIAID to strengthen epidemiology researchtraining at ICIDR and TMRC, which emphasize clinical research.
  • CDC's FETP units could collaborate with the USAID-supportedINCLEN (see "International Clinical Epidemiology Units (INCLEN: The Essential Role of Training and Research in Surveillance and Prevention of Infectious Disease") to strengthen both programs. Ingeneral, enhanced communication among oversees infectious disease programs supported by CDC, DoD, Fogarty, NIAID, and USAIDcould have a synergistic effect on the global surveillance andresponse network.
  • USAID, CDC and FDA could work with DoD to strengthen thein-country training components of DoD's overseas researchlaboratories.
  • Capacity building at home and abroad could be enhanced by DoDand CDC collaborations with developing country researchinstitutions supported by USAID, such as the ICDDR/B. In the past, U.S. Public Health Service workers were sent to the ICDDR/Bfor training, although no funds are presently available for thispurpose.

In addition,

  • All agencies could build upon the in-country research andtraining capacity established through Fogarty-supportedprograms.
  • All agencies could benefit from USAID's experience withmulti-disciplinary research and training projects in developingcountries.
  • More foreign nationals could be trained in epidemiology andexperimental microbiology along with American students in U.S.academic centers funded by Government grants and contracts.
  • International collaborations with NOAA's scientists couldincorporate climate forecasting into disease surveillancetraining.
  • 3. Encourage networking among the international research andpublic health communities that support the surveillance andresponse system for emerging diseases.

Several disease-specific "vertical" surveillance networksoperated by WHO (see "International Resources Related toInternational Diseases,") receive technical assistancefrom CDC, NIH, DoD, USAID, WHO and various non-governmentalorganizations.

Connections can be encouraged among the participants in thesenetworks and among participants in research training programssupported by Fogarty, all of whom are well-placed to shareinformation on research and on public health, as well as amongparticipants in research training programs supported by theNIH/Fogarty.

  • 4. Strengthen the training of American physicians andmicrobiologists in the recognition of "tropical" diseases andtravel medicine.

The identification of persons carrying pathogens capable ofcausing serious disease outbreaks is made difficult by the verylarge number of people entering the United States fromincreasingly remote locations. There is a constant influx ofAmerican civilians and solders, foreign nationals (includingtourists, business travelers, long-term visitors), andimmigrants. It is imperative that American medical students betrained to identify infectious diseases that are common in othercountries.

  • 5. Strengthen resources for the education of laboratory andfield-based scientists and physicians.

Current facilities operated or supported by CDC, NIH, DoD, andUSAID overseas could serve as excellent training facilities formedical or graduate student rotations in laboratory research orfield work, or for overseas training details for employees.

Scientific Research

Numerous examples illustrate the role that research plays inprotecting the public against infectious diseases. In recentyears, the techniques of modern molecular biology have been usedto study new pathogens (e.g., the agents causing AIDS and Lymedisease) and to define their geographical spread (for example,hantavirus in the Southwest and other parts of the UnitedStates). Biomedical researchers have also uncovered newrelationships between disease causing microbes and disease. Forinstance, a previously unrecognized herpesvirus has been detectedin Kaposi's sarcoma, a tumor most often associated with AIDS inthe United States. Scientists have also applied insights frombasic research in physiology to devise life-saving therapies,such as oral rehydration therapy for the treatment of cholera.

In many areas, the lack of basic research has hampered ourability to cope effectively with disease threats. For example, the lack ofadequate information about the Cryptosporidium parvum, anintestinal parasite, has made the development of new diagnosticreagents and therapies very difficult. Without reliablediagnostic tests, it has been difficult to assess the level ofrisk during a given outbreak and to design appropriate controlmeasures.

Scientific research is also needed to guide public policy. Forinstance, scientific information is needed to formulate policy onthe use of antibiotics in agriculture and aquaculture, as well asin the treatment of human illness. Similarly, research on theimpact of environmental change and climatic variability on theemergence of microbes can inform policy discussions on land use,waste disposal, water resources management, and agriculturalpolicy.

Final OMB/OSTP Caveat

The purpose of this report is to highlight ongoing Federalresearch efforts in this science and technology (S&T) field andto identify new and promising areas where there might be gaps inFederal Support. The report is intended for internal planningpurposes within the Federal agencies and as a mechanism to conveyto the S&T community the types of research and researchpriorities being sponsored and considered by the Federalagencies. The Administration is committed to a broad range ofhigh priority investments (including science and technology), todeficit reduction, and to a smaller, more efficient Federalgovernment. These commitments have created a very challengingbudget environment-requiring difficult decisions and a wellthought-out strategy to ensure the best return for the nation'staxpayer. As part of this strategy, this document does notrepresent the final determinant in an overall Administrationbudget decision making process. The research programs presentedin this report will have to compete for resources against manyother high priority Federal programs . If these programs competesuccessfully, they will be reflected in future Administrationbudgets.

This document was prepared under the guidance of the National Science and Technology Council (NSTC). The NSTC, chaired by the President, is a cabinet-level council charged with coordinating science, space, and technology policies throughout the federal government. An important objective of the NSTC is to establish clear national goals for federal science and technology investments. The NSTC includes the Vice President, the Assistant to the President for Science and Technology, the Cabinet Secretaries and agency heads with responsibility for significant science and technology programs,and other key White House officials.

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Report on International Science - Table of Contents


Executive Summary

Section I. Introduction

Section II.

Section III.

Section IV.

Section V.

Section VI.

Section VII.