The American Society for Microbiology (ASM) is pleased to submit the following testimony on the Fiscal Year (FY) 2011 appropriation for the Centers for Disease Control and Prevention (CDC). The ASM is the largest single life science organization in the world with more than 40,000 members.
The ASM is very concerned that the proposed CDC budget of $6.6 billion for FY 2011 is 2 percent below the FY 2010 appropriation. The Administration’s proposed budget is inconsistent with the need to adequately fund the agency acknowledged to be the principal federal driver in meeting our nation’s goals for enhanced prevention and wellness. Focusing only on the infectious disease component of the CDC budget, the ASM notes that the Administration has proposed a $19.6 million increase in this area. However, such a modest increase does not adequately address the growing complexity and challenges of emerging infectious diseases. These challenges have been abundantly evident over the past year with the H1N1 influenza pandemic. Furthermore, the proposed budget substantially decreases two priority program areas: the CDC’s vector-borne diseases program (by $26.7 million, which will essentially eliminate the program), and the CDC’s antimicrobial resistance program (by $8.6 million). In the FY 2011 budget, both programs are to be supported out of emerging infectious disease funds. Therefore, the proposed increase of $19.6 million for emerging infectious diseases is insufficient to offset the $35 million in proposed reductions for vector-borne diseases and antimicrobial resistance, resulting in a net decrease of $15 million for emerging infectious diseases.
Eliminating funding for the vector-borne diseases program will impair CDC’s collaborations with state and local partners consisting of vector-borne disease surveillance, outbreak response, the development of new diagnostics, diagnostic training and proficiency testing, as well as applied research and prevention efforts to address arboviral diseases. In the proposed budget, it is unclear what, if any, support will be available in FY 2011 for prevention and control of vector-borne pathogens. This funding reduction will essentially destroy the infrastructure developed in the past decade in response to the importation of West Nile virus in 1999 and its subsequent spread across the United States, and will leave the country vulnerable to similar importation of other vector-borne diseases.
In view of the net reduction for infectious diseases of approximately $15 million, the ASM recommends that Congress increase the budget for emerging infectious diseases and for CDC by at least 8 to 10 percent, to restore and strengthen funding for infectious disease prevention and control and other priority public health programs.
Vector-borne Diseases. The Administration’s proposed elimination of funding (-$26.7 million) for vector-borne diseases, including West Nile virus, in its FY 2011 budget will have serious repurcussions. Many emerging or reemerging infectious diseases are tied to pathogens transmitted from animals to humans, often through insect vectors. CDC programs protect public health through “one health” strategies, based on the understanding that human health is intertwined with the health of animals and the environment. The vector-borne program not only supports the West Nile virus activities, but also supports work on agents like plague, tularemia, Lyme disease, dengue fever, and Japenese encephalitis. Lyme disease is by far the most common tickborne infection in the United States and exacts an enormous toll in health care costs and lost productivity. The US mainland is constantly threatened by the potential for establishment of dengue virus, as occurred last year in the Florida keys. Emerging public health risks like chikungunya virus in south Asia and the Indian Ocean are an ongoing concern similar to West Nile. To appropriately address vector-borne infections requires a vibrant infrastructure for detection, diagnosis, response and prevention at the national, state and local level. The proposed budget cuts will substantially dismantle the system developed in response to West Nile virus, causing much of the $200 million investment over the last decade to disappear. The ASM urges the Administration to restore the vector-borne disease funding.
Antimicrobial Resistant Infections. The Administration’s proposed budget reduces the antimicrobial resistance program by $8.6 million. The ASM disagrees with the proposed FY 2011 decreases for crucial CDC efforts at a time when drug-resistant pathogens continue to emerge in both the community and healthcare setting. The decrease will, among other negative outcomes, substantially cut funding to states for surveillance and control programs. As a partner in the Federal Interagency Action Plan to Combat Antimicrobial Resistance, the CDC has been instrumental in tracking the grim increase in microbial pathogens resistant to antimicrobial drugs, like methicillin-resistant Staphylococcus aureus (MRSA). Invasive MRSA infections attack about 94,000 Americans annually, contributing to 19,000 deaths. MRSA is an increasing problem in community settings where different control strategies are necessary than in the hospital environment. A similar trend is being seen with Clostridium difficile, an organism once largely confined to hospital and nursing home settings but now associated with increasing severity in the community. Microbial drug resistance is driven by various factors, from pathogens’ natural evolution to the growing use of antimicrobials in human and animal healthcare. One estimate suggests that between 5 and 10 percent of all hospitalized US patients acquire a drug-resistant infection, adding $5 billion in annual healthcare costs. CDC either leads or collaborates in multiple projects against antimicrobial resistance, like the World Health Organization (WHO) effort to reduce the global spread of cephalosporin-resistant gonorrhea. Reduced funding would seriously impact the ability to mount and sustain programs to confront the problem of antimicrobial resistant pathogens.
CDC Funding: The Need for Increased Resources
Preventable diseases persist as major causes of illness and death in the United States. While life expectancy has steadily increased, influenza, pneumonia and septicemia caused by microbial pathogens remain among the top ten causes of death. The sudden emergence of pandemic H1N1 in the spring of 2009 in Mexico, California and Texas highlights the profound impact infectious diseases can have on our well being and economy. In addition to such emergent threats, other infectious diseases are on the rise. Reported cases of sexually transmitted Chlamydia infections have more than tripled since 1990, making it the most commonly reported infectious disease in the United States. Each year, children are absent 38 million school days due to influenza. About 43,000 Americans still develop acute hepatitis B annually, despite effective vaccines. The estimated annual cost to US hospitals of treating healthcare associated infections ranges from $28.4 billion to $45 billion. Foodborne illnesses continue to produce tens of millions of infections annually. And each year, Americans visit physician offices, hospital outpatient units or emergency rooms for infectious and parasitic diseases an estimated 30 million times.
Infectious disease prevention saves lives and dollars. The CDC Office of Infectious Diseases (OID) has three programs to prevent numerous microbial diseases: the National Center for Immunization and Respiratory Diseases, the National Center for Emerging and Zoonotic Infectious Diseases and the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. The CDC’s Center for Global Health and other agency offices add expertise to the fight against disease pathogens here and abroad. In the past year, CDC personnel have contributed to the fight against H1N1 influenza and identified or confirmed the causes of disease outbreaks nationwide, like the two recent salmonellosis episodes tied to pet frogs and to black pepper. They also watched for drug-resistant tuberculosis and other communicable diseases at US ports of entry, and collaborated with local, state, federal and international partners to protect and promote good health in all 50 states, as well as nations like Haiti in response to the recent catastrophic earthquake.
Monitoring Disease, Protecting Public Health
HIV/AIDS. CDC estimates that about 1.1 million persons in the United States are living with HIV or AIDS; an estimated 21 percent do not know that they are infected. With life saving antiretroviral treatments now available, earlier diagnosis is the goal of recent CDC guidances on opt-out testing in correctional institutions and other settings and for routine screening in all health care settings for those aged 13–64 years and pregnant women, and retesting at least annually for all at high risk. In November, CDC reported that HIV incidence among intravenous drug users had declined by nearly 80 percent since the late 1980s, a positive public health outcome, yet late diagnosis of new infections persists. The FY 2011 budget increases funds for a National HIV/AIDS strategy under development, to include renewed efforts toward HIV risk reduction.
Hepatitis. Two percent of the US population or an estimated 5.3 million are living with chronic hepatitis B (HBV) or hepatitis C (HCV), most unaware of their infection unless they later develop liver disease or cancer. Last year, a CDC study concluded that in the previous decade, failures by health care workers to follow basic infection control practices had placed more than 60,000 US patients at risk for HBV or HCV infection. In January, the Institute of Medicine called for a new, improved national strategy to prevent and control these infections. Each year an estimated 25,000 persons become infected with hepatitis A (HAV), even though rates of acute symptomatic cases have declined by 92 percent since a vaccine first became available in 1995. CDC now recommends HAV vaccine for all children at age one, since children are a major source of infection for adults who can develop more serious symptoms. CDC reported last year that vaccination among US children increased from about 26 percent in 2006 to over 47 percent in 2007, but this means that still over half of our children are needlessly at risk of a fully preventable disease like hepatitis A. They also serve as a source of infection to vulnerable adults.
Tuberculosis. In a new CDC report, preliminary statistics from the agency’s National TB Surveillance System reveals that 2009 saw the largest single year decrease in US cases since data collection began in 1953. The 11,540 cases reported last year were roughly 11 percent fewer than the previous year, with declines in both US and foreign born persons, although the TB rate among foreign born was still nearly 11 times higher. Possible explanations for the unprecedented drop, which CDC is investigating, include failure to recognize, diagnose, or report the disease due to weakening infrastructure or diversion of public health resources to the H1N1 response. This would represent a serious setback to TB disease control and elimination efforts in the United States. The emergence of tuberculosis bacteria resistant to available antimicrobial drugs has alarmed health organizations worldwide. CDC scientists identified genetic mutations associated with drug resistance in tuberculosis bacteria, which are now included in CDC laboratory testing available to state public health laboratories. CDC also is working with international partners in clinical trials of alternative drug treatments, and field trials of newer molecular-based diagnostic tests for resistance that provide results in hours to days, rather than the current weeks to months.
Foodborne/Waterborne Illness. A recent study estimates that the total economic impact of foodborne illness in the United States reaches $152 billion annually. Last April, CDC reported that progress in foodborne illness prevention had reached a plateau, with the incidence of the most common foodborne illnesses stagnating over the previous three years after several years of decline in the late 1990s and early 2000s. Data came from the FoodNet surveillance network, a collaborative project of CDC, 10 state sites and the nation’s two food safety regulatory agencies (the Food and Drug Administration and the Department of Agriculture). Of particular concern is the incidence of Salmonella infections, which persists at 14–16 cases per 100,000 Americans and periodically causes well-publicized disease outbreaks. This rate is stubbornly above the Healthy People 2010 target. Shortly thereafter, CDC released another report on illnesses linked to specific types of foods. Results included the following: 1) of the 1,270 outbreaks in 2006, 621 had a confirmed single cause, most often norovirus (54 percent), followed by Salmonella (18 percent); and 2) foods tied to the largest number of outbreak cases were poultry (21 percent), leafy vegetables (17 percent) and fruits-nuts (16 percent). Extensive CDC surveillance, done with multiple public health partners, has helped shape the current federal food safety initiative.
The ASM commends the appreciable increases in FY 2011 funding for food safety activities that will boost CDC capabilities, such as expanded outbreak surveillance and standardized investigations at the state and local level. The proposed FY 2011 budget specifically supports CDC water quality programs, including expansion of its Safe Water System and Water Safety Plan to additional countries to reduce waterborne diseases like cholera, giardiasis and cryptosporidioisis. The agency sustains multiple water quality projects, both domestically and elsewhere, ensuring safe drinking water and clean recreational waters free from microbial contamination.
Preventing Disease, Protecting Public Health
Collaborations with multiple stakeholders greatly increase the impact of CDC prevention programs. CDC grants to states and universities help build public health infrastructures against preventable illness; for instance, last fall the agency awarded over $4 million to fund new Centers of Excellence in Public Health Informatics, and another $5 million for biomonitoring programs in three states. In 2009, CDC joined other units of HHS in a new national initiative against healthcare-associated infections (HAI). It also announced plans last fall to distribute $40 million in Recovery Act funding to state health departments to reduce HAIs, and is collaborating with states to demonstrate that implementing CDC’s HAI prevention guidelines can achieve major improvement. CDC estimates that every year US patients acquire 1.7 million infections while being treated in hospitals, the cause of approximately 99,000 deaths annually and an estimated $30 billion in added healthcare costs.
Over the past year, considerable CDC resources focused on preventing H1N1 influenza, the agency’s top priority in 2009. Americans have received 97 million doses of H1N1 vaccine via distribution systems established by CDC and its public health partners. Although the pandemic has been less severe than originally feared, it has still resulted in an estimated 55 million US cases since April 2009, 246,000 hospitalizations and 11,000 deaths, many in infants, children and young adults. In addition to its extensive vaccine related efforts, CDC’s influenza program identified higher H1N1 death rates among American Indians and Alaska Natives, and more serious illness among pregnant women in the United States. CDC testing determined that many Americans who died from H1N1 had co-infections with the common pneumonia bacterium, Streptococcus pneumoniae, which likely contributed to their death. Unfortunately, vaccine preventable pneumococcal infections still kill an estimated 40,000 Americans each year. CDC officials are currently assessing the lessons learned during the 2009–2010 influenza season.
In February, CDC recommended universal use in children of an updated pneumococcal vaccine just approved by the Food and Drug Administration, which should greatly reduce S. pneumoniae infections and stop a leading cause of bacteremia, meningitis and pneumonia. Pneumonia kills nearly 2 million children each year, most in impoverished nations. CDC is active globally in the detection, prevention and treatment of pneumonia and other childhood infectious diseases, collaborating with WHO and dozens of nations to reduce child mortality by two thirds by 2015. WHO estimates that if all currently available vaccines against childhood diseases were widely administered, an additional two million deaths could be prevented per year.
Improving Preparedness and Response
Being prepared for the unexpected is one of CDC’s primary responsibilities in protecting health and well-being. During an emergency, CDC can quickly convene expert teams and deploy both personnel and medical supplies anywhere in the world. CDC leads federal efforts to detect and contain biothreats and to ensure availability of medical countermeasures. It operates the Strategic National Stockpile, a repository of countermeasures for rapid deployment, as well as its quarantine stations at the nation’s borders. It distributes grants to state and local health departments to build capacity against public health emergencies. The ASM supports additional FY 2011 funds to improve CDC’s preparedness and response efforts, including the Laboratory Response Network and Select Agent Program.
In light of the significant role played by the CDC as the nation’s first line of defense against a host of infectious disease threats and its leadership in national efforts to promote wellness and prevention, these efforts should not be handicapped by a funding reduction as proposed in the 2011 budget. The ASM supports an 8 to 10 percent increase in infectious disease activities to assure critical programs are not reduced or eliminated and that opportunities to prevent and control infectious diseases are not curtailed. The ASM appreciates the opportunity to comment on the FY 2011 budget for the CDC.