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PUBLIC HEALTH SYSTEMS
AND
MERGING INFECTIONS
Assessing the
Capabilities of the
Public and Private Sectors
Workshop Summary
Jonathan R. Davis and Joshua Lederberg, Editors
Based on a Workshop of the
Forum on Emerging Infections
Division of Health Sciences Policy
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
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NATIONAL ACADEMY PRESS · 2101 Constitution Avenue, N.W. · Washington, DC 20418
NOTICE: The project that is the subject of this workshop summary was approved by the
Governing Board of the National Research Council, whose members are drawn from the
councils of the National Academy of Sciences, the National Academy of Engineering,
and the Institute of Medicine.
Support for this project was provided by the U.S. Department of Health and Human
Services' National Institutes of Health, Centers for Disease Control and Prevention, and
Food and Drug Administration; U.S. Department of State, Bureau of Oceans and Interna-
tional Environmental and Scientific Affairs; U.S. Department of Veterans Affairs; Abbott
Laboratories; American Society for Microbiology; Applied Microbiology, Inc.; Bristol-
Myers Squibb Company; Burroughs Wellcome Fund; Eli Lilly & Company; Glaxo Well-
come; F. Hoffmann-La Roche, AG; Merck; Pfizer, Inc.; SmithKline Beecham Corpora-
tion; and Wyeth-Ayerst Laboratories. The views presented are those of the editors and
workshop participants, and are not necessarily those of the funding organizations.
This report is based on the proceedings of a workshop that was sponsored by the Fo-
rum on Emerging Infections. It is prepared in the form of a workshop summary by and in
the name of the editors with the assistance of staff and consultants, as an individually
authored document. Sections of the workshop summary not specifically attributed to an
individual reflect the views of the editors and not those of the Forum on Emerging Infec-
tions. The content of those sections is based on the presentations and the discussions that
took place during the workshop.
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with the kind permission of the Society.
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INSTITUTE OF MEDICINE
Shoplng the Future for Health
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National Academy of Sciences
National Academy of Engineering
Institute of Medicine
National Research Council
.. -: ~
... `~
.~ I. .
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of
distinguished scholars engaged in scientific and engineering research, dedicated to the
furtherance of science and technology and to their use for the general welfare. Upon the
authority of the charter granted to it by the Congress in 1863, the Academy has a mandate
that requires it to advise the federal government on scientific and technical matters. Dr.
Bruce M. Alberts is president of the National Academy of Sciences.
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to secure the services of eminent members of appropriate professions in the examination
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Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf
are chairman and vice chairman, respectively, of the National Research Council
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FORUM ON EMERGING INFECTIONS
JOSHUA LEDERBERG (Chair), Sackler Foundation Scholar, The Rockefel-
ler University
VINCENT I. AHONKHAI, Vice President and Director, Anti-Infectives and
Biologicals, SmithKline Beecham Corporation, Collegeville, Pennsylvania
STEVEN J. BRICKNER, Manager of Medicinal Chemistry, Central Research
Division, Pfizer, Inc., Groton, Connecticut
GAIL H. CASSELL, Vice President for Infectious Diseases Research, Drag
Discovery Research, and Clinical Investigation, Eli Lilly & Company, Indi-
anapolis, Indiana
GARY CHRISTOPHERSON, Principal Deputy Assistant Secretary for Health
Affairs and Senior Advisor for Force Health Protection, U.S. Department of
Defense Reserve Affairs, Washington, D.C.
GORDON H. DeFRIESE, Director and Professor of Social Medicine, Epide-
miology, Health Policy, and Administration, Sheps Center for Health Serv-
ices Research, University of North Carolina, Chapel Hill
CEDRIC E. DUMONT, Medical Director, Office of Medical Services, U.S.
Department of State, Washington, D.C.~
NANCY CARTER-FOSTER, Director, Program for Emerging Infections and
HIVlAIDS, U.S. Department of State, Washington, D.C.2
JESSE GOODMAN, Acting Deputy Director, Center for Biologics Evaluation
and Research, U.S. Food and Drug Administration, Washington, D.C.i
RENU GUPTA, Vice President, Medical Safety and Therapeutics, Covance,
Inc., Princeton, New Jersey
MARGARET A. HAMBURG, Assistant Secretary for Planning and Evalua-
tion, U.S. Department of Health and Human Services, Washington, D.C.
CAROLE A. HEILMAN, Director, Division of Microbiology and Infectious
Disease, National Institutes of Allergy and Infectious Diseases, National In-
stitutes of Health, Bethesda, Maryland
DIETER HINZEN, Professor and Head of Preclinical Research, F. Hoffmann-
La Roche, AG, Basel, Switzerland2
JAMES M. HUGHES, Assistant Surgeon General, and Director, National
Center for Infectious Diseases, Centers for Disease Control and Prevention,
Atlanta, Georgia
J. STANLEY HULL, Vice President, Global Commercial Development, Glaxo
Wellcome, Research Triangle Park, North Carolina
~Forum member as of October 1999.
2Forum member at time of workshop.
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SAMUEL L. KATZ, Chairman of the Board, Burroughs Wellcome Fund, and
Wilburt C. Davison Professor, Department of Pediatrics, Duke University
Medical Center
KENNETH W. KIZER, Undersecretary for Health, Veterans Health Admini-
stration, U.S. Department of Veterans Affairs, Washington, D.C.2 3
WILLIAM KOHLBRENNER, Director, Antiviral Research, Abbott Laborato-
ries, Abbott Park, Illinois2
JOHN R. LaMONTAGNE, Deputy Director, National Institute of Allergy and
Infectious Diseases, National Institutes of Health, Bethesda, Maryland2
MARCELLE LAYTON, Bureau of Communicable Diseases, New York City
Department of Health
CARLOS LOPEZ, Executive Director, Infectious Disease Research, Eli Lilly
Research Laboratories, Indianapolis, Indiana
STEPHEN S. MORSE, Assistant Professor of Epidemiology, Columbia Uni-
versity School of Public Health, and Defense Advanced Research Projects
Agency/Defense Sciences Office, Washington, D.C.
SOLOMON MOWSHOWITZ, Vice President, Research and Development,
Applied Microbiology, Inc., Tarrytown, New York2 4
STUART L. NIGHTINGALE, Associate Commissioner for Health Affairs,
U.S. Food and Drug Administration, U.S. Department of Health and Human
Services, Rockville, Maryland2
MICHAEL T. OSTERHOLM, State Epidemiologist and Chief, Acute Disease
Epidemiology Section, Minnesota Department of Health, Minneapolis5
MARC RUBIN, Vice President of Infectious Diseases Therapeutic Develop-
ment Group, Glaxo Wellcome, Research Triangle Park, North Carolinas
DAVID M. SHLAES, Vice President, Infectious Disease Research, Wyeth-
Ayerst Research, Pearl River, New York City
JANET SHOEMAKER, Director, Public Affairs, The American Society for
Microbiology, Washington, D.C.~
JOHN D. SIEGFRIED, Deputy Vice-President, Science and Regulatory Affairs,
Pharmaceutical Research and Manufacturers of America, Washington, D.C.
P. FREDERICK SPARLING, Chair of Medicine, University of North Caro-
lina at Chapel Hill, and President, Infectious Diseases Society of America,
Washington, D.C.
C. DOUGLAS WEBB JR., Senior Medical Director, Infectious Diseases
Global Marketing, Bristol-Myers Squibb, Princeton, New Jersey
CATHERINE E. WOTEKI, Undersecretary for Food and Safety, U.S. De-
partment of Agriculture, Washington, D.C.~
3At time of printing, President and Chief Executive Officer, National Quality Fo-
rum, Washington, D.C.
4At time of printing, President, Diligen, New York City.
sAt time of printing, Chairman and Chief Executive Officer, Infectious Control Ad-
visory Network, Eden Prairie Minnesota.
V1
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Liaisons to the Forum
BARRY R. BLOOM, Investigator, Howard Hughes Medical Institute, and A1-
bert Einstein College of Medicine, Yeshiva University
ENRIQUETA C. BOND, President, Burroughs Wellcome Fund, Morrisville,
North Carolina
MICHAEL HUGHES, Office of the Undersecretary, Veterans Health Adrnini-
stration, U.S. Department of Veterans Affairs, Washington, D.C.
STEPHANIE JAMES, Parasitology and International Programs Branch, Divi-
sion of Microbiology and Infectious Diseases, National Institute of Allergy
and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
PATRICK W. KELLEY, Colonel, U.S. Army, and Director, Division of Preven-
tive Medicine, Walter Reed Army Institute of Research, Washington, D.C.6
STEPHEN M. OSTROFF, Acting Deputy Director, and Associate Director for
Epidemiologic Science, National Center for Infectious Diseases, Centers for
Disease Control and Prevention, Atlanta, Georgia
GARY ROSELLE, Program Director for Infectious Disease, Veterans Health
Administration, U.S. Department of Veterans Affairs, Cincinnati, Ohio
JAMES M. SIGG, Contract Liaison Officer, Office of Management and Con-
tract, Centers for Biologics Evaluation and Research, U.S. Food and Drug
Administration, Washington, D.C.6
FRED TENOVER, Chief, Nosocomial Pathogens Laboratory Branch, National
Center for Infectious Diseases, Centers for Disease Control and Prevention,
Atlanta, Georgia
KAYE WACHSMUTH, Deputy Administrator, Office of Public Health and
Science, Food Safety Insection Service, U.S. Department of Agricultures
Study Staff
JONATHAN R. DAVIS, Senior Program Officer
VIVIAN P. NOLAN, Research Associate
NICOLE AMADO, Project Assistant
KATHI MANNA, Consultant
MICHAEL HAYES, Copy Editor
Division Staff
ANDREW M. POPE, Division Director
SARAH PITLUCK, Research Assistant
ALDEN CHANG, Project Assistant
THELMA COX, Project Assistant
CARLOS GABRIEL, Financial Associate
6Liaison to the Forum as of October 1999
. .
V11
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REVIEWERS
All presenters at the workshop have reviewed and approved their respective
sections of this report for accuracy. In addition, this workshop summary has
been reviewed in draft form by independent reviewers chosen for their diverse
perspectives and technical expertise, in accordance with procedures approved by
the National Research Council's Report Review Committee. The purpose of this
independent review is to provide candid and critical comments that will assist
the Institute of Medicine (IOM) in making the published workshop summary as
sound as possible and to ensure that the workshop summary meets institutional
standards. The review comments and draft manuscript remain confidential to
protect the integrity of the deliberative process.
The Forum and IOM thank the following individuals for their participation
in the review process:
Kenneth Bart, San Diego State University Graduate School of Public Health
Donna Crane, American Public Health Association
Walter R. Dowdle, Emory University School of Public Health Task Force for
Child Survival and Development
Laura Efros, White House Office of Science and Technology Policy
Adel Mahmoud, Merck Vaccines, Inc.
David Smith, Texas Tech University Health Sciences Center
Although the independent reviewers have provided many constructive
comments and suggestions, responsibility for the final content of this workshop
summary rests solely with the editors.
. . .
vail
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Preface
The Forum on Emerging Infections was created in 1996 in response to a re-
quest from the Centers for Disease Control and Prevention and the National In-
stitutes of Health. The goal of the Forum is to provide structured opportunities
for representatives from academia, industry, professional and interest groups,
and government* to examine and discuss scientific and policy issues that are of
shared interest and that are specifically related to research and prevention, de-
tection, and management of emerging infectious diseases. In accomplishing this
task, the Forum provides the opportunity to foster the exchange of information
and ideas, identify areas in need of greater attention, clarify policy issues by
enhancing knowledge and identifying points of agreement, and inform decision
makers about science and policy issues. The Forum seeks to illuminate issues
rather than resolve them directly, hence it does not provide advice or recom-
mendations on any specific policy initiative pending before any agency or or-
ganization. Its strengths are the diversity of its membership and the commitment
of individual members expressed throughout the activities of the Forum.
A critical part of the work of the Forum is a series of workshops. The first
of these, held in February 1997, addressed the theme of public- and private-
sector collaboration (IOM, 1997b). The second workshop took place in July
1997 and explored aspects of antimicrobial resistance (IOM, 1998~. The third
workshop (IOM, 2000), examined the implications of managed care systems and
Representatives of federal agencies serve in an ex officio capacity. An ex officio
member of a group is one who is a member automatically by virtue of holding a particu-
lar office or membership in another body.
1X
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x
PREFACE
the ability to address emerging infectious diseases in the age of managed care.
The fourth workshop, which this document summarizes, examined the core ca-
pacities of the public and private health sectors in emerging infectious disease
surveillance and response. The fifth workshop, October 1999, examined the in-
ternational aspects of emerging infections. The summary of that workshop is in
production. The topic of zoonotic diseases will be the focus for the Forum's
sixth workshop, to be held in June 2000.
ABOUT THE WORKSHOP
The changing face of health care poses new challenges for the detection,
treatment, and prevention of infectious diseases. Historically, local public health
departments, hospitals, and clinics have been at the forefront of infectious dis-
ease outbreak detection and treatment. However, the health care system has
changed, and managed care organizations and privatized public health laborato-
ries (often privatized for political reasons) continue to grow in response to the
needs of the communities they serve. Yet, simultaneously, many of the system's
abilities to perform its functions of public health laboratories and epidemiologi-
cal services may be eroding. Along with that erosion, local public health systems
may have a diminished capacity to detect and respond to an emerging infectious
disease.
In an effort to increase our knowledge and understanding of the role of the
private and public health sectors in emerging infectious disease surveillance and
response, this workshop, entitled Public Health Systems: Assessing Capacities to
Respond to Emerging Infections, explored how the privatization of public health
laboratories and the modernization of public health care may effect infectious
disease surveillance and outbreak detection. A central theme running throughout
the workshop was the problematical capacity of public health systems at the state
and local levels to detect and respond to an infectious disease outbreak. The
workshop served to open a dialogue on public health systems to identify and dis-
cuss issues of mutual concern among representatives from the affected parties
and groups. These issues were broken down into the following four thematic ar-
eas, which addressed various components of the public health system:
1. epidemiological investigation;
2. surveillance;
3. communication, coordination, and education and outreach; and
4. strategic planning, resource allocation, and economic support.
Representatives from the public health community, hospitals, government
agencies, pharmaceutical companies, and academia were invited to give panel
presentations moderated by Forum members. Each panelist was asked to high-
light important issues, suggest possible practical solutions, and indicate impedi-
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PREFACE
X1
meets that must be overcome to improve infectious disease surveillance and
response, communication and coordination, and education and outreach.
ORGANIZATION OF THE WORKSHOP SUMMARY
This report of the Forum-sponsored workshop is prepared in the form of a
workshop summary by and in the name of the editors with the assistance of staff
and consultants, as an individually authored document. Sections of the workshop
summary not specifically attributed to an individual reflect the views of the edi-
tors and not those of the Forum on Emerging Infections, nor its sponsors. The
content of those sections is based on the presentations that took place during the
workshop.
The workshop summary is organized as a topic-by-topic description of the
presentations and discussions that occurred during the workshop. Its purpose is
to present lessons from relevant experience, delineate a range of pivotal issues
and their respective problems, and put forth some potential responses as de-
scribed by the workshop participants. The Summary and Assessement chapter
discusses the core messages that emerged from the speaker presentations and
ensuing discussions. Chapter 1 is an introduction to the topic and overview of
the main issues confronting public health systems. Chapters 2 to 5 begin with
opening statements that provide context and background information by the
editors, followed by descriptions of the presentations that were made by the in-
vited participants. Appendix A is a glossary and list of acronyms useful for the
topics. Appendix B presents the workshop agenda. A summary of the GAO re-
port on Emerging Infectious Diseases is found in Appendix C. Forum members
and staff biographies are presented in Appendix D.
Although this workshop summary provides an account of the individual
presentations, it also reflects a very important aspect of the Forum philosophy.
The workshop functions as a dialogue among representatives from different
sectors and presents their beliefs on which areas may merit further attention.
However, the reader should be aware that the material presented here expresses
the views and opinions of those participating in the workshop and not the delib-
erations of a formally constituted Institute of Medicine study committee. These
proceedings summarize only what participants stated in the workshop and are
not intended to be an exhaustive exploration of the subject matter.
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X11
PREFACE
ACKNOWLEDGMENTS
The Forum and the Institute of Medicine wish to express their warmest ap-
preciation to the individuals and organizations who gave valuable time to pro-
vide information and advice to the Forum through participation in the workshop.
Each of the following contributed greatly: Scott Becker, Association of Public
Health Laboratories (APHL); Cheryl Beversdorf, Association of State and Ter-
ritorial Health Officials (ASTHO); Eric Blank, APHL; Judy Buckalew, Office of
Senator Lauch Faircloth; Jack Chow, Senate Appropriations Committee, Labor,
Health, and Human Services Subcommittee; Donna Crane, American Public
Health Association; Ellen Gadbois, Office of Senator Edward Kennedy; Mary
Gilchrist, University of Iowa Hygienic Laboratory; JoAnne Glisson, American
Clinical Laboratory Association; James Hadler, Connecticut Department of
Health; Peggy Hamburg, Assistant Secretary for Planning and Evaluation, U.S.
Department of Health and Human Services; Tracey Hooker, National Confer-
ence of State Legislators; Eileen Koski, Quest Diagnostics; Marsha Lillie-
Blanton, U.S. General Accounting Office; Laurence McCarthy, MRL Pharma-
ceuticals, Inc.; Joe McDade, Centers for Disease Control and Prevention; Linda
Miller, SmithKline, Beecham; Ellen Morrison, U.S. Food and Drug Administra-
tion; Steve Ostroff, National Center for Infectious Diseases (NCID), CDC;
Patricia Quinlisk, Iowa Department of Health, Council of State and Territorial
Epidemiologists; James Pearson, Division of Consolidated Laboratory Services,
Commonwealth of Virginia; Gianfranco Pezzino, Kansas Department of Health
and Environment; Robert Pinner, NCID/CDC; William L. Roper, Dean, School
of Public Health, University of North Carolina; Robert Rubin, The Lewin
Group; Ted Shortliffe, Stanford University; Catherine Slemp, West Virginia
Department of Health; Larry Strausbaugh, Portland VA Medical Center; Bala
Swaminathan, NCID/CDC; Fred Edgar Thompson, Jr., Mississippi Department
of Health, ASTHO; Helene Toiv, GAO; and Kathleen Young, Alliance for the
Prudent Use of Antibiotics.
The Forum is indebted to the IOM staff who contributed during the course
of the workshop and the production of this workshop summary. On behalf of the
Forum, I gratefully acknowledge the efforts led by Jonathan Davis, study direc-
tor for the Forum and co-editor of this report, who dedicated much effort and
time to developing this workshop's agenda and for his thoughtful and insightful
approach and skill in translating the workshop proceedings and discussion into
this workshop summary. I would also like to thank the following IOM staff for
their valuable contributions to this activity: Vivian Nolan assisted with the de-
velopment of the workshop agenda, provided detailed support to facilitate the
development of the workshop summary, and assisted with editing various sec-
tions of the workshop summary in response to the review process; Nicole
Amado assisted in developing the Glossary and Acronyms list and provided
comprehensive administrative support; and Sarah Pitluck, Alden Chang, Thelma
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PREFACE
X111
Cox, and Hattie Wilfert provided expert support at various developmental stages
of the workshop summary. Other IOM staff also provided invaluable help: Sue
Barron, Clyde Behney, Claudia Carl, Michael Edington, Carlos Gabriel, and
Andrew Pope. Consultant and technical writer, Kathi Hanna, contributed signifi-
cantly to writing many sections of the workshop summary. The extensive com-
mentary and suggestions made by the copy editor, Michael Hayes, are gratefully
acknowledged.
Finally, the Forum also thanks its sponsors that supported this activity. Fi-
nancial support for this project was provided by the U.S. Department of Health
and Human Services' National Institutes of Health, Centers for Disease Control
and Prevention, and Food and Drug Administration; U.S. Department of State,
Bureau of Oceans and International Environmental and Scientific Affairs; U.S.
Department of Veterans Affairs; Abbott Laboratories; American Society for
Microbiology; Applied Microbiology, Inc.; Bristol-Myers Squibb Company;
Burroughs Wellcome Fund; Eli Lilly & Company; Glaxo Wellcome; F. Hoff-
mann-La Roche; Merck Co., Inc.; Pfizer; SmithKline Beecham; and Wyeth-
Ayerst Laboratories.
Joshua Lederberg
Chair
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Contents
SUMMARY AND ASSESSMENT
Assessing the Capability, 3
Strengthening the Capability, 11
Concluding Remarks, 22
1 INTRODUCTION 24
Background, 24
Changing Landscape of Public Health, 26
EPIDEMIOLOGICAL INVESTIGATION 29
Overview, 29
National Perspective on Outbreak Investigations, 30
State Perspectives on Outbreak Investigations, 33
County-Level Perspective on Outbreak Investigations, 36
Perspectives of Physicians' Community, 37
Public Health Practice and the Role of Academic Public Health, 39
3 SURVEILLANCE
Overview, 42
GAO Report on Public Health Surveillance of Emerging Infectious
Diseases, 43
Emerging Infections Program Cooperative Agreement, 44
Large National Commercial Laboratories, 50
xv
42
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XVI
CONTENTS
Role of the Public-Sector Laboratory at the National Level, 52
Role of the Public-Sector Laboratory at the State Level, 54
4 COMMUNICATION, COORDINATION, AND EDUCATION
AND OUTREACH 57
Overview, 57
Communication and Coordination at the National Level:
The Pulsenet Model, 57
Communication and Coordination at the State Level, 60
Nongovernmental Organizations and State Partnerships, 62
Continuing Education: The Role of Professional Organizations, 64
Role of Medical Information in Detection and Management of
Emerging Infections, 65
STRATEGIC PLANNING, RESOURCE ALLOCATION,
AND ECONOMIC SUPPORT
Overview, 68
Legislation and Mandates at the Federal Level, 68
Congressional Response to the Threat of Infectious Diseases, 70
State Health Official Perspective, 71
Laboratory-Based Reporting Issues, 72
REFERENCES
APPENDIXES
A Glossary and Acronyms, 77
B Workshop Agenda, 84
C Emerging Infectious Diseases: Consensus on Needed
Laboratory Capacity Could Strengthen Surveillance, 90
D Forum Member and Staff Biographies, 97
68
75
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PUBLIC HEALTH SYSTEMS
AND
EMERGING INFECTIONS
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