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APPENDIX C
Emerging infectious Diseases
.
O O
Consensus on Needed Laboratory
Capacity Could Strengthen Surveillance
SUMMARY
Pursuant to a congressional request, GAO reviewed the nation's infectious
diseases surveillance network, focusing on the: (1) extent to which states con-
duct public health surveillance and laboratory testing of selected emerging in-
fectious diseases; (2) problems state public health officials face in gathering and
using laboratory-related data in the surveillance of emerging infectious diseases;
and (3) assistance that the Department of Health and Human Services' Centers
for Disease Control and Prevention (CDC) provides to states for laboratory-
related surveillance and the value of this assistance to state officials.
GAO noted that: (1) surveillance and testing for important emerging infec-
tious diseases are not comprehensive in all states, leaving gaps in the nation's
infectious diseases surveillance network; (2) GAO's survey found that most
states conduct surveillance of five of the six emerging infectious diseases GAO
asked about, and state public health laboratories conduct tests to support state
surveillance of four of the six; (3) over half of the state laboratories do not con-
duct tests for surveillance of hepatitis C and penicillin-resistant S. pneumonias;
(4) many state epidemiologists believe that their infectious diseases surveillance
programs should expand, and they cited a need to gather more information on
antibiotic-resistant diseases; (5) just over half of the state public health laborato-
This Appendix reprints material extracted from the U.S. General Accounting Office
Report, Emerging Infectious Diseases: Consensus on Needed Laboratory Capacity Could
Strengthen Surveillance, Report to the Chairman, Subcommittee on Public Health, Com-
mittee on Health, Education, Labor, and Pensions, U.S. Senate (February 1999, Rep. No.
GAO/HEHS-99-26).
90
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APPENDIX C
91
ries have access to advanced molecular technology, which could be valuable to
all states' diseases surveillance efforts; (6) few states require the routine submis-
sion of specimens or isolated quantities of a pathogen from patients with certain
diseases for testing in state laboratories—a step CDC has urged them to adopt to
improve the quality of surveillance information; (7) many state laboratory di-
rectors and epidemiologists reported that inadequate staffing and information-
sharing problems hinder their ability to generate and use laboratory data to con-
duct infectious diseases surveillance; (8) participants in the surveillance network
often lack basic computer hardware or integrated systems to allow them to rap-
idly share information; (9) many state officials told GAO that they did not have
sufficient staffing and technology resources, and public health officials have not
agreed on a consensus definition of the minimum capabilities that state and local
health departments need to conduct infectious diseases surveillance; (10) this
lack of consensus makes it difficult to assess resource needs; (11) most state
laboratory directors and epidemiologists placed high value on CDC's testing and
consulting services, training, and grant funding and said these services were
critical to their ability to use laboratory data to detect and monitor emerging
infections; (12) state officials said CDC needs to better integrate its data systems
and help states build systems that link them to local and private surveillance
partners; and (13) state officials would like CDC to provide more hands-on
. . .
training experience.
Continued on next page
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92
PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
LETTER
United States General Accounting Office
Health, Education, and Human Services Division
Washington, DC 20548
B-280933
February 5, 1999
The Honorable Bill Frist
Chairman, Subcommittee on Public Health
Committee on Health, Education, Labor, and Pensions
United States Senate
Dear Mr. Chairman:
The spread of infectious diseases is a public health problem once thought to
be largely under control. However, outbreaks over the last decade illustrate that
infectious diseases remain a serious public health threat. For example, in 1993,
more than 400,000 people became ill from a city's drinking water contaminated
with Cryptosporidium parvam a common parasite resistant to chlorination and
other water treatment measures. Over 4,000 people were hospitalized, and 55
died. In 1996, drinking apple juice contaminated with a virulent strain of E. cold
bacteria made more than 60 people seriously ill and caused the death of one per-
son. And in 1998, 26 children became ill from playing in a swimming pool con-
taminated by a virulent strain of E. coli. Four of the children developed a serious
complication that affects the blood and kidneys.
The resurgence of some infectious diseases is particularly alarming because
previously effective forms of control are breaking down. For example, some
pathogens (disease-causing organisms) have become resistant to antibiotics used
to bring them under control or have developed strains that no longer respond to
the antibiotics.
Monitoring infectious diseases identifying diseases and their sources is
critical for determining control and prevention efforts. Public health officials
refer to this activity as surveillance the ongoing collection, analysis, and inter-
pretation of disease-related data to plan, implement, and evaluate public health
actions. Many public health experts have raised concerns about the adequacy of
the nation's infectious diseases surveillance network, especially for those dis-
eases considered to be emerging that is, ones more prevalent now than 20
years ago or ones that show signs of becoming more prevalent in the near future.
In light of these concerns, you asked us to examine the nation's surveillance
network and to focus on the contribution of laboratories, since new technology
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APPENDIX C
93
gives them an increasingly important role in identifying pathogens and the
sources of outbreaks. Specifically, you asked us to (1) determine the extent to
which states conduct public health surveillance and laboratory testing of selected
emerging infectious diseases, (2) identify the problems state public health offi-
cials face in gathering and using laboratory-related data in the surveillance of
emerging infectious diseases, and (3) describe the assistance that the Department
of Health and Human Services' (HHS) Centers for Disease Control and Preven-
tion (CDC) provides to states for laboratory-related surveillance and the value of
this assistance to state officials.
To provide information on the contribution of laboratories to the surveil-
lance network, we surveyed the directors of all state public health laboratories
and infectious diseases epidemiology programs that report disease-related in-
formation directly to CDC, including officials in all 50 states, 5 territories, the
District of Columbia, and New York City.2 We also conducted case studies in
Kentucky, New York, and Oregon; spoke with additional state and local public
health officials around the country; and interviewed CDC officials. We focused
our work on six specific emerging infectious diseases or pathogens: tuberculo-
sis, Shiga-like toxin-producing E. cold (including E. cold 0157:H7~3 pertussis,
Cryptosporidium parvum, hepatitis C virus, and penicillin-resistant Streptococ-
cus pneumonias. Our methodology is described in more detail in appendix I, the
results from our surveys are in appendixes II and III, and details on the six dis-
eases are in appendix IV. Our work was conducted from December 1997
through December 1998 in accordance with generally accepted government
auditing standards.
Results in Brief
Surveillance and testing for important emerging infectious diseases are not
comprehensive in all states, leaving gaps in the nation's infectious diseases sur-
veillance network. Our survey found that most states conduct surveillance of
five of the six emerging infectious diseases we asked about, and state public
health laboratories conduct tests to support state surveillance of four of the six.
However, over half of the state laboratories do not conduct tests for surveillance
of hepatitis C and penicillin-resistant S. pneumo7~iae. Many state epidemiolo-
gists believe that their infectious diseases surveillance programs should expand,
and they frequently cited a need to gather more information on antibiotic-
resistant diseases. Just over half of the state public health laboratories have ac-
~Epidemiology is the study of the distribution and causes of disease or injury in a
population.
2Throughout this report, we refer to this group collectively as "states."
3Shiga-like toxin-producing E. cold belong to a group of virulent E. cold that can
produce severe intestinal bleeding. Throughout this report, we will refer to the group by
the name of its most well-known member, E. cold 0157:H7.
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PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
cess to advanced molecular technology, which many experts believe could be
valuable to all states' diseases surveillance efforts. Furthermore, few states re-
quire the routine submission of specimens or isolated quantities of a pathogen
from patients with certain diseases for testing in state laboratories a step CDC
has urged them to adopt to improve the quality of surveillance information.
Many state laboratory directors and epidemiologists reported that inade-
quate staffing and information-sharing problems hinder their ability to generate
and use laboratory data to conduct infectious diseases surveillance. For example,
they believe that the number of laboratory staff to perform tests and the number
of epidemiology staff who can analyze data and translate surveillance informa-
tion into disease prevention and control activities are insufficient. They also
cited a need for training to ensure that their staffs have the skills to take advan-
tage of technological advances in laboratory methods, information-sharing sys-
tems, or both. Participants in the surveillance network, particularly at the local
level, often lack basic computer hardware or integrated systems to allow them to
rapidly share information. State officials also expressed concerns about CDC's
many separate data reporting systems, which result in duplication of effort and
drain scarce staff resources. Although many state officials told us that they did
not have sufficient staffing and technology resources, public health officials
have not agreed on a consensus definition of the minimum capabilities that state
and local health departments need to conduct infectious diseases surveillance.
This lack of consensus makes it difficult to assess resource needs. We are rec-
ommending that the Director of CDC lead an effort to help federal, state, and
local public health officials create consensus on the core capacities needed at
each level of government.
CDC provides state and local health departments with a wide range of tech-
nical, financial, and staff resources to help maintain or improve their ability to
detect and respond to emerging infectious disease threats. Most state laboratory
directors and epidemiologists placed high value on CDC's testing and consulting
services, training, and grant funding and said these services were critical to their
ability to use laboratory data to detect and monitor emerging infections. How-
ever, they identified a number of ways in which these services could be im-
proved. Specifically, most state officials said CDC needs to better integrate its
data systems and help states build systems that link them with local and private
surveillance partners. Many state officials would also like CDC to provide more
hands-on training experience. State officials also pointed out that obtaining as-
sistance with problems that cut across programmatic boundaries could be im-
proved if CDC's departments that focus on specific diseases communicated
better with one another.
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APPENDIX C
95
Conclusions
Public health officials agree that the importance of infectious diseases sur-
veillance cannot be overemphasized. The nation's surveillance network is con-
sidered the first line of defense in detecting and identifying emerging infectious
diseases and providing essential information for developing and assessing pre-
vention and control efforts. Laboratories play an increasingly vital role in infec-
tious diseases surveillance, as advances in technology continually enhance the
specificity of laboratory data and give public health officials new techniques for
monitoring emerging infections.
Public health officials who spoke with us said that the nation's surveillance
system is essentially sound but in need of improvement. They point to outbreaks
rapidly identified and contained as visible indications of the system's strength.
Our survey results tend to support this view: surveillance of five of the six
emerging infectious diseases we asked about is widespread among states, and
surveillance of four of the six is supported by testing in state public health labo-
ratories. Officials also view CDC's support as essential and are generally very
satisfied with both the types and levels of assistance CDC provides.
However, our survey also revealed gaps in the infectious diseases surveil-
lance network. Just over half of the state public health laboratories have access
to molecular technology that many experts believe all states could use, and few
states require the routine submission of specimens to their state laboratories for
testing a step urged by CDC. In addition, many state epidemiologists believe
their surveillance programs do not sufficiently study all infectious diseases they
consider important, including antibiotic-resistant conditions and hepatitis C.
Both laboratory directors and epidemiologists expressed concerns about the
staffing and technology resources they have for surveillance and information
sharing. They were particularly frustrated by the lack of integrated information
systems within CDC and the lack of integrated systems linking them with other
public and private surveillance partners. CDC's continued commitment to inte-
grating its own data systems and to helping states and localities build integrated
electronic data and communication systems could give state and local public
health agencies vital assistance in carrying out their infectious diseases surveil-
lance and reporting responsibilities.
The lack of a consensus definition of what constitutes an adequate infec-
tious diseases surveillance system may contribute to some of the shortcomings
in the surveillance network. For example, state public health officials assert that
they lack sufficient trained epidemiologic and laboratory staff to adequately
study infectious diseases, as well as sufficient resources to take full advantage of
advances in laboratory and information-sharing technology. Without agreement
on the basic surveillance capabilities state and local health departments should
have, however, it is difficult for policymakers to assess the adequacy of existing
resources or to identify what new resources are needed to carry out state and
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PUBLIC HEALTH SYSTEMS AND EMERGING INFECTIONS
local surveillance responsibilities. Moreover, public health officials make deci-
sions about how to spend federal dollars to enhance state surveillance activities
without such criteria to evaluate where investments are needed most.
Recommendation to the Director of CDC
To improve the nation's public health surveillance of infectious diseases
and help ensure adequate public protection, we recommend that the Director of
CDC lead an effort to help federal, state, and local public health officials create
consensus on the core capacities needed at each level of government. The con-
sensus should address such matters as the number and qualifications of labora-
tory and epidemiologic staff, laboratory and information technology, and CDC's
support of the nation's infectious diseases surveillance system.
Agency Comments
CDC officials reviewed a draft of this report. They generally concurred with
our findings and recommendation and provided technical or clarifying com-
ments, which we incorporated as appropriate. Specifically, CDC agreed that a
clearer definition of the needed core epidemiologic and laboratory capacities at
the federal, state, and local levels would be useful and that integrated surveil-
lance systems are important to comprehensive prevention programs. CDC noted
that it is working with other HHS agencies to address these critical areas.
We also provided the draft report to APHL and CSTE. APHL officials said
the report was comprehensive and articulated the gaps in the current diseases
surveillance system well. They also provided technical comments, which we
incorporated as appropriate. CSTE officials did not provide comments.
As agreed with your office, unless you publicly announce its contents ear-
lier, we plan no further distribution of this report until 30 days from the date of
this letter. At that time, we will send copies to the Secretary of HHS, the Direc-
tor of CDC, the directors of the state epidemiology programs and public health
laboratories included in our survey, and other interested parties. We will make
copies available to others upon request.
If you or your staff have any questions, please contact me or Helene Toiv,
Assistant Director, at (202) 512-7119. Other major contributors are included in
appendix V.
Sincerely yours,
Bernice Steinhardt
Director Health Services Quality and Public Health Issues
Representative terms from entire chapter:
diseases surveillance
