    Global Health: Challenges in Improving Infectious Disease
    Surveillance Systems (31-AUG-01, GAO-01-722).

    According to the World Health Organization, infectious diseases
    account for more than 13 million deaths every year, including
    nearly two-thirds of all deaths among children under age 5.
    Infectious diseases present a substantial threat to people in all
    parts of the world and this threat has grown in volume and
    complexity. New diseases have emerged, others once viewed as
    declining in significance have resurged in importance, and many
    have developed substantial resistance to known antimicrobial
    drugs. Infectious disease surveillance provides national and
    international public health authorities with information that
    they need to plan and manage efforts to control these diseases.
    In the mid-1990s, public health experts in the United States and
    abroad determined that global infectious disease surveillance was
    inadequate, and both the World Health Assembly and the President
    of the United States called for concerted action to develop an
    effective global infectious disease surveillance and response
    system. The strongest influence on the evolution of the current
    global infectious disease surveillance framework has been the
    international community's focus on specific diseases or groups of
    diseases. The international community has created diverse
    surveillance programs to support global and regional efforts to
    control particular diseases. Surveillance systems in all
    countries suffer from a number of common constraints. However,
    these constraints have their greatest impact in the poorest
    countries, where per capita expenditure on all aspects of health
    care amounts to only about three percent of expenditures in
    high-income countries. Surveillance in developing countries is
    often impaired by shortages of human and material resources. The
    international community has recently launched a number of
    initiatives that may improve global surveillance. The community
    has committed itself to achieving specific reductions in the
    global burdens imposed by three diseases--tuberculosis, human
    immunodeficiency virus/acquired immunodeficiency syndrome, and
    malaria--that present complex challenges. Also, the community has
    launched more broadly targeted initiatives to upgrade
    laboratories, strengthen epidemiological capacity, and otherwise
    improve surveillance for infectious diseases as a group.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-01-722
        ACCNO:   A01703
        TITLE:   Global Health: Challenges in Improving Infectious Disease
                 Surveillance Systems
         DATE:   08/31/2001
      SUBJECT:   Disease detection or diagnosis
    	     Infectious diseases
    	     International cooperation
    	     International organizations
    	     Public health research
    	     UN Expanded Program on Immunization
    	     CDC Epidemic Intelligence Service
    	     Program
    	     DOD Global Emerging Infections
    	     Surveillance and Response System
    	     Joint United Nations Programme on
    	     HIV/AIDS
    	     UN Children's Fund
    	     West Nile Virus

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    GAO-01-722

    Report to Congressional Requesters

    United States General Accounting Office

    GAO

    August 2001 GLOBAL HEALTH Challenges in Improving Infectious Disease
    Surveillance Systems

    GAO- 01- 722

    Page i GAO- 01- 722 Global Health Letter 1

    Results in Brief 2 Background 4 Global Surveillance Varies by Disease 8
    Global Framework?s Performance Constrained by Weaknesses in

    Developing Countries 16 Impact of Improvement Initiatives Remains to Be
    Demonstrated 26 Concluding Observations 40 Agency Comments and Our
    Evaluation 41

    Appendix I Objectives, Scope, and Methodology 44

    Appendix II Disease Information 47

    Appendix III Comments From the Department of Health and Human Services 55

    Appendix IV Comments From the World Health Organization 58

    Appendix V Comments From the United States Agency for International
    Development 60

    GAO Comments 66

    Appendix VI Comments From the National Aeronautics and Space Administration
    67

    Appendix VII Comments From the World Bank 68

    Appendix VIII Comments From the Department of Defense 69 Contents

    Page ii GAO- 01- 722 Global Health Appendix IX GAO Contact and Staff
    Acknowledgments 70

    GAO Contact 70 Acknowledgments 70

    Tables

    Table 1: Health Expenditures by National Income Level 17

    Figures

    Figure 1: The Global Infectious Disease Surveillance Framework: A Network of
    Networks 7 Figure 2: Distribution of WHO Collaborating Centers for
    Infectious

    Disease Surveillance and Control 36

    Abbreviations

    CDC Centers for Disease Prevention and Control HIV/ AIDS Human
    Immunodeficiency Virus/ Acquired

    Immunodeficiency Syndrome IDS Integrated Disease Surveillance and Response
    UNICEF United Nations Children?s Fund USAID United States Agency for
    International Development WHO World Health Organization

    Page 1 GAO- 01- 722 Global Health

    August 31, 2001 The Honorable Patrick Leahy Chairman The Honorable Mitch
    McConnell Ranking Minority Member Subcommittee on Foreign Operations
    Committee on Appropriations United States Senate

    The Honorable Russell Feingold Chairman The Honorable Bill Frist Ranking
    Minority Member Subcommittee on African Affairs Committee on Foreign
    Relations United States Senate

    According to the World Health Organization, infectious diseases account for
    more than 13 million deaths every year, including nearly two- thirds of all
    deaths among children under age 5. Although the great majority of these
    deaths occur in developing countries, infectious diseases do not recognize
    international boundaries. They present a substantial threat to people in all
    parts of the world. In recent years, this threat has grown in volume and
    complexity. New diseases have emerged, others once viewed as declining in
    significance have resurged in importance, and many have developed
    substantial resistance to known antimicrobial drugs. This picture is
    complicated by the potential deployment of infectious disease pathogens as
    weapons of war or instruments of terror.

    Infectious disease surveillance provides national and international public
    health authorities with information that they need to plan and manage
    efforts to control these diseases. In the mid- 1990s, public health experts
    in the United States and abroad determined that global infectious disease
    surveillance was inadequate, and both the World Health Assembly and the

    United States General Accounting Office Washington, DC 20548

    Page 2 GAO- 01- 722 Global Health

    President of the United States called for concerted action to develop an
    effective global infectious disease surveillance and response system. 1

    In response to your concern about current arrangements for infectious
    disease surveillance, we reported in July 2000 2 that global surveillance is
    carried out through a loose framework of formal, informal, and ad hoc
    arrangements that World Health Organization (WHO) officials characterize as
    a ?network of networks.? In this second report, we (1) examine the
    framework?s evolution and current operations, (2) identify factors that
    constrain its performance, and (3) assess several initiatives designed to
    improve global infectious disease surveillance and response.

    In doing this work, we collected data from and consulted with experts in the
    international public health community, including officials of WHO, the
    Centers for Disease Control and Prevention (CDC), the U. S. Agency for
    International Development (USAID), the World Bank, and prominent
    nongovernmental organizations in the health sector. As you requested, we
    emphasized surveillance operations in sub- Saharan Africa, visiting Malawi,
    Tanzania, Uganda, and Zimbabwe to discuss relevant issues with public health
    officials at every level. More detailed information about our scope and
    methodology is in appendix I. Information on each of the diseases mentioned
    in this report is in appendix II.

    The strongest influence on the evolution of the current global infectious
    disease surveillance framework has been the international community?s focus
    on specific diseases or groups of diseases. The international community has
    created diverse surveillance programs to support global and/ or regional
    efforts to control particular diseases. The longest standing of these is the
    global influenza program, which was launched prior to the WHO?s founding in
    1948. The success of the intensified smallpox

    1 See World Health Assembly Resolution 48. 13, Communicable Disease
    Prevention and Control: New Emerging and Re- Emerging Infectious Diseases
    (Geneva, Switzerland: May 12, 1995); Emerging Infections: Microbial Threats
    to Health in the United States, Institute of Medicine (Washington, D. C.
    1992); Infectious Disease- A Global Health Threat, Report of the National
    Science and Technology Council, Committee on International Science,
    Engineering, and Technology, Working Group on Emerging and Re- emerging
    Infectious Diseases (Washington, D. C.: Sept. 1995); and Presidential
    Decision Directive NSTC- 7, Emerging Infectious Diseases (Washington, D. C.:
    June 1996).

    2 Global Health: Framework for Infectious Disease Surveillance (GAO/ NSIAD-
    00- 205R, July 20, 2000). Results in Brief

    Page 3 GAO- 01- 722 Global Health

    eradication effort, which began in 1966 and identified the last naturally
    occurring case in 1977, spurred initiation of other eradication/ elimination
    efforts during the late 1980s and early 1990s, including the current
    campaign to eradicate polio. International public health officials also
    operate a number of programs directed at controlling noneradicable diseases
    such as dengue. Under some circumstances, such as when a disease can be
    eradicated with comparative ease or when it poses a high risk of a global
    pandemic, disease- specific programs have attracted broad support and
    substantial funding. In such situations public health officials have been
    able to establish specific goals and create comparatively highperforming
    systems- including surveillance systems- to support achievement of those
    goals. Surveillance for other diseases has received less international
    support and is more limited.

    Surveillance systems in all countries suffer from a number of common
    constraints. However, these constraints have their greatest impact in the
    poorest countries, where per capita expenditure on all aspects of health
    care amounts to only about 3 percent of expenditure in high- income
    countries. Surveillance in developing countries is often impaired by
    shortages of human and material resources. Key positions in laboratories and
    clinics often are filled by people who do not possess the necessary
    qualifications. According to WHO, staff in over 90 percent of developing
    country laboratories are not familiar with quality assurance principles, and
    more than 60 percent of laboratory equipment is outdated or not functioning.
    Sixteen of 19 WHO- sponsored assessments of sub- Saharan African systems
    that we reviewed reported weaknesses in laboratory capacity, ranging from a
    lack of trained technicians to deteriorating buildings. In addition, poor
    roads and communications make it difficult for health care workers to alert
    higher authorities about outbreaks or quickly transport specimens to
    laboratories. Ten of the assessments found that less than half of the local
    health facilities surveyed had operating telecommunications equipment or
    vehicles for transport. In addition, multiple surveillance systems are often
    poorly coordinated and not firmly linked to response measures. The absence
    of a clear response discourages lower level officials from investing effort
    in surveillance, and this leads to many cases of disease going unrecorded
    and unreported. These weaknesses limit the effectiveness of even the most
    widely supported international disease control programs. They also impair
    routine surveillance for other diseases and efforts to investigate and
    respond to outbreaks, newly emerging diseases, and growth in antimicrobial
    resistance.

    Page 4 GAO- 01- 722 Global Health

    The international community has recently launched a number of initiatives
    that may improve global surveillance. First, the community has committed
    itself to achieving specific reductions in the global burdens imposed by
    three diseases- tuberculosis, human immunodeficiency virus/ acquired
    immunodeficiency syndrome (HIV/ AIDS), and malaria- that present complex
    challenges. Improving surveillance for these three diseases will be an
    essential part of the global response to these new commitments. Second, the
    community has launched more broadly targeted initiatives to upgrade
    laboratories, strengthen epidemiological capacity, and otherwise improve
    surveillance for infectious diseases as a group. The eventual impact of both
    the disease- specific and the more broadly targeted initiatives remains to
    be demonstrated. Public health experts observed that major reductions in
    tuberculosis, HIV/ AIDS, and malaria cannot be achieved without substantial
    overall improvements in developing country health systems, including
    surveillance operations of these systems. These new disease- specific
    initiatives may therefore facilitate efforts to improve surveillance for
    infectious diseases as a group. Nonetheless, efforts to make broad
    improvements in developing country systems will be proceeding in an
    environment wherein the priority will be to achieve measurable results
    against HIV/ AIDS, malaria, and tuberculosis, in particular. The extent to
    which the global public health community?s response to the new disease-
    specific commitments will improve surveillance for all infectious diseases
    remains to be seen.

    We received comments on a draft of this report from the Department of Health
    and Human Services (which includes CDC), and the Departments of Defense and
    State, as well as from WHO, USAID, the National Aeronautics and Space
    Administration, and the World Bank. These agencies generally concurred with
    our findings. The Department of Health and Human Services and USAID
    elaborated upon the challenges to be faced in developing programs to improve
    surveillance and response capacity for specific diseases and for infectious
    diseases as a group, while USAID and the Department of Defense commented
    that the report did not adequately describe their contributions to improving
    global surveillance. We modified this report to respond to these comments
    and to other matters raised by the agencies.

    Dramatic increases in the volume and speed of international travel and trade
    in recent years have increased opportunities for diseases to spread across
    international boundaries. The global reach of the ongoing HIV/ AIDS pandemic
    and the recent appearance in the United States of West Nile virus- a
    pathogen never before identified in the Western Hemisphere- Background

    Page 5 GAO- 01- 722 Global Health

    demonstrate this point. Diseases once regarded as declining in significance
    have also reemerged in recent years to once again become major global health
    threats. For example, according to WHO, global reports of yellow fever have
    dramatically increased over the last 2 decades.

    The emergence of previously unknown diseases and the development of disease
    strains resistant to antimicrobial drugs further complicate international
    disease control efforts. Over the past 3 decades, more than 30 previously
    unknown diseases have been identified. Many, including Ebola hemorrhagic
    fever, Rift Valley fever, and Lyme disease, appear to have become threats to
    human health because of increased human movement into or alteration of the
    habitats of disease- carrying insects and animals. Excessive, uncontrolled
    use of antimicrobial drugs has contributed to the evolution of disease
    strains that are highly resistant to available medications.

    Infectious diseases can be a substantial obstacle to economic and social
    advancement in developing countries, where the great majority of cases of
    such diseases occur. For example, WHO has concluded that Africa?s gross
    domestic product would be nearly one- third higher than it is today if
    malaria alone had been eliminated 35 years ago. Development experts believe
    that the HIV/ AIDS pandemic will have a similar impact on African economies.

    Surveillance provides information for action against infectious disease
    threats. Basic surveillance functions include detecting and reporting cases
    of disease, analyzing and confirming this information to identify outbreaks
    and clarify longer- term trends, and applying the information to inform
    public health decisionmaking. When effective, surveillance can facilitate
    (1) timely action to control outbreaks, (2) informed allocation of resources
    to meet changing disease conditions, and (3) adjustment of disease control
    programs to make them more effective. According to CDC, factors that can be
    taken into account in evaluating surveillance systems include their ease of
    operation; the extent to which health care providers and laboratory
    personnel actually provide the system with information; and the system?s
    ability to identify cases of disease, accurately diagnose them, and generate
    timely and accurate information on disease events and trends.

    Basic responsibility for disease surveillance and response lies with
    individual countries. The legal underpinnings for cooperation among
    countries to control infectious diseases are limited in scope. The primary
    function of the International Health Regulations- the most important and

    Page 6 GAO- 01- 722 Global Health

    only binding international agreement on disease control- is to delineate
    measures that countries may take to protect themselves against epidemics of
    three diseases: cholera, plague, and yellow fever. 3 To provide national
    authorities with a basis for applying protective measures, the regulations
    require countries that record cases of these three diseases to report to
    WHO, which then makes that information available to other countries. The
    Regulations do not provide an international framework for addressing
    threatening epidemics at their source- within countries.

    At the global level, surveillance functions are carried out through a loose
    framework that links elements of national health care systems with various
    entities, including media channels, nongovernmental organizations active in
    health, and laboratories and other institutions participating in networks
    focusing on particular diseases and/ or regions. Figure 1 presents one
    illustration of this global ?network of networks.? The groupings presented
    in this figure are not mutually exclusive. For example, national public
    health authorities may operate WHO Collaborating Centers, participate in
    epidemiology training networks, and maintain Internet discussion sites.

    3 The origins of the International Health Regulations can be traced back to
    the 1892 adoption of the first International Sanitary Convention, which only
    addressed cholera. The original convention has been revised and replaced on
    several occasions, with the term ?International Health Regulations?
    introduced in 1969. The Regulations were last revised in 1981 when smallpox
    reporting was eliminated due to the success of the global smallpox
    eradication program. A total of 187 countries have agreed to comply with the
    Regulations in full. Australia is the only WHO member country that has not
    accepted the Regulations. Seven countries- Egypt, India, Iran, Libya,
    Madagascar, Pakistan, and Papua New Guinea- have accepted them in part, or
    with reservations.

    Page 7 GAO- 01- 722 Global Health

    Figure 1: The Global Infectious Disease Surveillance Framework: A Network of
    Networks

    UNHCR and UNICEF

    country offices

    Formal Informal

    WHO collaborating

    centers/ laboratories

    Epidemiology training networks

    Military laboratory

    networks Global Public

    Health Intelligence

    Network Internet discussion

    sites Media, press Non-

    governmental organizations WHO

    regional and country

    offices National

    public health authorities

    Note 1: UNHCR represents the United Nations High Commissioner for Refugees.
    Note 2: UNICEF represents the United Nations Children?s Fund. Source: WHO.

    WHO plays a central role in the surveillance framework by working to
    strengthen national and international surveillance capacity and coordinating
    international efforts to monitor disease trends, detect and respond to
    outbreaks, and carry out disease control programs. Foreign assistance
    agencies such as the World Bank and USAID, as well as private foundations,
    are important sources of support for strengthening surveillance operations,
    particularly those taking place in developing

    Page 8 GAO- 01- 722 Global Health

    countries. For example, in commenting on a draft of this report, the World
    Bank noted that it is actively working with a number of developing country
    governments to strengthen their national surveillance systems, within the
    context of the Bank?s overall emphasis on health. While many technical
    agencies contribute to framework operations, CDC is the single largest
    source of expertise and resources available to the international
    surveillance and response system. The Department of Defense also contributes
    to global surveillance through its Global Emerging Infections Surveillance
    and Response System. 4 In commenting on a draft of this report, for example,
    the department cited its contributions to global surveillance for drug-
    resistant malaria and influenza.

    The global surveillance framework?s capacity for serving the public interest
    varies according to the level of commitment that the international community
    has made to controlling individual diseases or groups of diseases. The most
    significant influence on the framework?s development has been the
    international public health community?s focus on controlling specific
    diseases. In some circumstances- when a disease can be eradicated with
    comparative ease or when it poses a high risk of a global pandemic- these
    programs have attracted broad support and substantial funding. In such
    situations, public health officials have been able to establish specific
    goals and create comparatively high- performing systems- including
    surveillance systems- to support achievement of those goals. Surveillance
    for other diseases is more limited.

    The strongest influence on the evolution of the existing surveillance
    framework has been the collaboration among medical professionals, national
    governments, and foreign assistance agencies to develop control programs and
    associated surveillance efforts that focus on specific diseases or groups of
    diseases. The longest standing of these diseasespecific efforts is the
    global influenza program, which was launched prior to WHO?s founding in
    1948. Later, the success of the global effort to eradicate smallpox (1966
    through 1977) spurred the creation of other programs designed to eradicate
    or eliminate global disease threats, such as polio and leprosy, and diseases
    found in specific regions, such as guinea

    4 For more information on this system, see http:// www. geis. ha. osd. mil/.
    Global Surveillance

    Varies by Disease Multiple Surveillance Systems Created to Support Disease-
    Specific Control Programs

    Page 9 GAO- 01- 722 Global Health

    worm and river blindness, which are both found primarily in Africa. 5 Global
    consensus in favor of these eradication/ elimination campaigns was achieved
    during the late 1980s and early 1990s, after reduction programs had achieved
    substantial progress. WHO also collaborates with numerous institutions
    around the world to maintain programs to control noneradicable infectious
    diseases such as HIV/ AIDS, cholera, tuberculosis, malaria, and dengue.
    National disease- control programs reflect this focus on specific diseases.
    They are generally managed through separate programs aimed at specific
    diseases, such as polio and tuberculosis, or groups of diseases, such as
    those covered by the Expanded Program on Immunization. 6

    Variation in the quality of global surveillance systems can be attributed in
    large measure to disease characteristics. Under certain circumstances- for
    example, if a disease can be eradicated or if it poses a high risk of a
    global pandemic- disease- specific control programs have attracted broad
    support and have employed this support to create comparatively effective
    surveillance systems. Surveillance for other diseases, including emerging
    infections, has received less international support and is more limited.

    The best surveillance systems have been established to support international
    campaigns aimed at eradicating or eliminating certain diseases, including
    polio and guinea worm, and at protecting the global community against
    influenza- a disease that has the potential to inflict global pandemics. 7

    5 Disease control initiatives can be designed to reduce the number of cases
    below current levels, or they may be directed at eliminating or eradicating
    a disease. Elimination initiatives seek to reduce the number of cases in a
    particular area to zero and/ or to reduce morbidity to a level that does not
    constitute a major public health problem. Eradication initiatives seek to
    reduce worldwide incidence of a disease to zero, obviating the need for
    further control measures.

    6 In addition to serving as the vehicle for the polio initiative, the
    Expanded Program on Immunization generally provides vaccinations against
    tuberculosis, measles, tetanus, diphtheria, and pertussis (whooping cough),
    and can provide vaccines against other diseases such as haemophilus
    influenzae type B (HIB), rubella, hepatitis B, and yellow fever.

    7 For more information on influenza preparedness, see Influenza Pandemic:
    Plan Needed for Federal and State Response (GAO- 01- 4, Oct. 27, 2000).
    Disease Characteristics,

    International Commitment Affect Surveillance Quality

    High- Quality Surveillance for Some Diseases

    Page 10 GAO- 01- 722 Global Health

    The international community has been supportive of eradication/ elimination
    campaigns because they promise dramatic results- the removal of targeted
    diseases as public health threats- after relatively short periods of
    concentrated effort. However, only diseases with certain characteristics can
    be eradicated or eliminated. In addition to imposing substantial disease
    burdens- a trait common to many illnesses- diseases that the global
    community has targeted for eradication or elimination tend to share other
    characteristics that have encouraged consensus in favor of concerted action.
    Although the international community has targeted other diseases for
    eradication or elimination, polio and guinea worm are discussed below to
    illustrate the characteristics of eradicable diseases and the comparatively
    high quality of surveillance systems that are created to support
    international eradication/ elimination campaigns. 8

    The polio virus and the guinea worm parasite both require human hosts to
    complete their reproductive life cycles. Both can be controlled by
    interrupting their transmission from infected to uninfected individuals.
    Also, available diagnostic tools and approaches make these diseases
    relatively easy to identify and differentiate from other illnesses. For
    example, a small but predictable number of polio victims (less than 1
    percent) develop acute flaccid paralysis- a condition in which those
    infected suddenly lose control of the muscles in their limbs. This makes it
    possible to readily identify communities where intervention may be required.
    Guinea worm is easily detected when mature worms emerge from infected
    people?s bodies. Moreover, these diseases generally can be controlled
    through application of effective, comparatively inexpensive, and easily
    applied interventions. Polio, for example, can be prevented through
    immunization with vaccines that are available to developing countries at
    very low prices. Guinea worm transmission can be dramatically reduced
    through education and relatively cheap and simple water filtration systems.

    These characteristics have allowed disease experts to develop clearly
    stated, technically feasible, time- limited goals and indicators for
    measuring progress. Advocates for campaigns against these diseases have been
    able

    8 Global commitments to eradicating these two diseases are of longest
    standing. Campaigns to eliminate river blindness, leprosy, and Chagas
    disease have also been under way for a decade or more. An initiative against
    lymphatic filiariasis was launched in 1997, and the international community
    is considering other global initiatives, including measles eradication.

    Page 11 GAO- 01- 722 Global Health

    to obtain political commitment and financial support from countries with
    these diseases and from public and private sources of foreign assistance.
    For example, the global polio eradication effort has received financial and/
    or technical support from the governments of the United States, Japan,
    Norway, Australia, Canada, Denmark, the United Kingdom, and other
    industrialized countries; Rotary International and other private
    organizations; and developing country governments.

    With major financial resources 9 and support from all concerned governments,
    these campaigns have developed comparatively highperforming surveillance
    systems. For example, donors and developing country governments have
    combined their efforts to create a system of active surveillance 10 for
    acute flaccid paralysis that can promptly identify potential polio cases.
    This surveillance system has helped reduce the global incidence of polio by
    99 percent since 1988. The surveillance effort is ambitious- most countries
    employ multiple surveillance officers to conduct active surveillance for
    cases of acute flaccid paralysis. According to CDC officials, most countries
    in Africa dedicate at least one motor vehicle and significant financial
    resources to polio surveillance. The ability to confirm the presence of the
    disease has been helped by creation of a global network of 148 laboratories
    at the national, regional, and global levels to ensure accurate diagnosis
    and differentiation among strains. 11 These laboratories participate in an
    annual accreditation program to ensure the accuracy of their analyses.

    Surveillance efforts to eradicate guinea worm have been similarly ambitious.
    This eradication program began with comprehensive village- byvillage surveys
    in endemic countries to identify every afflicted locality. To use these data
    effectively, WHO and the U. N. Children?s Fund (UNICEF)

    9 In September 2000, for example, WHO reported that donor nations and
    agencies had indicated that they would provide approximately $550 million
    dollars in support for the polio eradication campaign through 2005.
    According to the World Bank and the Carter Center, the guinea worm
    eradication campaign received more than $87 million in donor support from
    1987 through 1998.

    10 Passive surveillance systems rely on local health care providers to
    submit periodic reports on infectious disease incidence. Active surveillance
    is often employed to help compensate for the reporting shortfalls that are
    commonly encountered in passive systems. In active surveillance systems,
    health workers from district or national levels ?make the rounds? to seek
    out possible cases.

    11 Differentiation among strains is valuable in determining the origins of
    specific cases so that response measures can be directed where needed.

    Page 12 GAO- 01- 722 Global Health

    created a Joint Program on Health Mapping. The ?HealthMapper? project
    generated national and international maps of guinea worm incidence that were
    used to target interventions and plot progress in interrupting transmission.
    Endemic countries created networks of community workers in every village to
    report guinea worm cases so that response measures could be delivered in a
    timely fashion. This surveillance effort facilitated reduction of the global
    incidence of this disease from an estimated 10 million to 15 million cases a
    year in the early 1980s to about 75,000 cases in 2000 (more than two- thirds
    of them occurring in war- torn Sudan).

    Although influenza cannot be eradicated due to its presence in a variety of
    animal hosts and its constantly evolving character, the international
    community has created an extensive surveillance system for this disease.
    Factors leading to the considerable level of investment in this system
    include the disease burdens imposed by influenza and the character of
    available interventions. Although often perceived as a comparatively
    lowlevel threat, the viruses that cause influenza are continually evolving
    and occasionally appear in highly virulent forms. For example, the 1918 to
    1919 influenza pandemic killed more than 20 million people in locations as
    diverse as China, Spain, the United States, and Samoa. Although not as
    severe, influenza pandemics in 1957 and 1968 killed a total of 1.5 million
    people and caused an estimated $32 billion in economic losses worldwide,
    according to WHO. While influenza?s adverse impacts can be reduced via
    immunization, vaccines have to be re- engineered each year to target the
    strains considered likely to be most prevalent in the upcoming ?flu season.?
    12 Worldwide surveillance is necessary to permit continuous updating of the
    information that manufacturers use to reformulate these vaccines.

    Since the late 1940s, WHO has created a global network of 111 national
    influenza centers in 83 countries, supported by 4 international reference
    laboratories. 13 These centers collaborate in collecting and analyzing
    influenza strains to identify those that appear most likely to spread around
    the globe and present major risks to public health. According to CDC, the
    system produced vaccines that precisely or substantially targeted 12 of 13
    virus strains that circulated widely between 1988 and 1997. WHO has also

    12 In temperate countries, influenza cases are concentrated in the winter
    months. 13 The international reference laboratories are operated by CDC and
    institutions in the United Kingdom, Japan, and Australia.

    Page 13 GAO- 01- 722 Global Health

    created ?FluNet,? an Internet site devoted to monitoring global influenza
    activity.

    Although diseases such as yellow fever, cholera, and dengue also present
    substantial public health threats, surveillance for these diseases tends to
    be more limited. These diseases have characteristics that work against
    international commitment in favor of ambitious, goal- directed control
    campaigns. Cholera, dengue, and yellow fever do not appear to be good
    candidates for eradication because the pathogens that cause them can live
    and reproduce without human hosts. Advocates for addressing these diseases
    cannot therefore hold out the prospect of eradication or elimination as an
    incentive for investing in control efforts. 14 Without laboratory
    confirmation, all three can be confused with other diseases causing similar
    symptoms. They are therefore comparatively difficult to identify, especially
    in developing country conditions. Although effective yellow fever vaccines
    are available, many developing country governments do not administer them
    routinely. 15 Cholera vaccines are infrequently employed, 16 and there is
    currently no vaccine for dengue. No specific treatment exists for any of the
    three diseases; all are treated primarily by ensuring that patients are
    hydrated. Therefore, although all three cause periodic outbreaks that
    require an organized response, health care providers may simply address
    patient needs without seeking laboratory confirmation of possible cases or
    reporting cases to higher level authorities. This reduces the likelihood
    that surveillance reports will accurately reflect disease incidence or
    trends and makes it difficult for disease campaign advocates to set specific
    objectives for reductions in these diseases. Finally, although all three
    diseases are quite serious and can spread across international borders, they
    do not threaten to cause rapidly spreading global pandemics like those that
    can be caused by influenza.

    14 The bacteria that cause cholera thrive in fresh or brackish estuarine
    waters and do not rely on human hosts. Yellow fever is passed among monkeys,
    mosquitoes, and humans. According to WHO, studies have shown that in some
    parts of the world monkeys may also become infected with dengue, and may
    serve as a source of virus for uninfected mosquitoes.

    15 Many countries, especially in Africa, prefer to administer the vaccine on
    an emergency basis when yellow fever outbreaks are identified. 16 Cholera
    vaccines are infrequently employed because they are less than 100 percent
    effective and provide protection only for limited periods of time. More
    Limited Surveillance

    for Other Diseases

    Page 14 GAO- 01- 722 Global Health

    Global surveillance for yellow fever is quite limited. Efforts by WHO,
    UNICEF, and others to encourage greater investment in controlling this
    disease, including more widespread employment of yellow fever vaccines, have
    met with limited success. Ongoing laboratory training organized by WHO for
    the polio laboratory network in Africa has been expanded to include yellow
    fever but the global community has not established any specific targets for
    yellow fever reduction. According to WHO, countries that report information
    on yellow fever immunization coverage typically reach 50 percent or less of
    eligible children. Despite the fact that the International Health
    Regulations require reporting on yellow fever, WHO officials estimate that
    actual caseloads are up to 500 times greater than reported.

    Surveillance for cholera is also problematic. While WHO and multiple partner
    organizations established a Global Task Force on Cholera Control in 1991,
    the task force was not given specific targets. Seven years later, a U. N.
    review found that the global community?s approach focused on outbreak
    response and that, while this approach can reduce cholera death rates, it
    failed to prevent cholera from occurring. 17 Developing countries have had
    little incentive to improve surveillance beyond the detection of outbreaks.
    Although the International Health Regulations require reporting on cholera,
    a WHO official estimated that the numbers of cholera cases and deaths
    occurring in the world are 10 times higher than official reports indicate.
    In 1999, WHO was officially notified of approximately 9,200 cholera deaths,
    but disease experts believe that the annual number of deaths from cholera is
    closer to 120,000.

    Surveillance for dengue is similarly limited. WHO developed a Global
    Strategy for Prevention and Control of Dengue Fever and Dengue Hemorrhagic
    Fever in 1995 and has, with USAID support, held two international meetings
    to focus attention on this disease. In collaboration with the French
    National Institute for Medical Research and Health and other partners, WHO
    has also created ?DengueNet,? an Internet site dedicated to gathering and
    sharing dengue- related information. However, without the incentive that
    would be provided by a clear, goal- directed international commitment to
    responding to the threat posed by this disease, surveillance for dengue
    remains limited. For example, although

    17 See Preventive Action and Intensification of the Struggle Against Malaria
    and Diarrheal Diseases, in Particular Cholera, Report by the Secretary
    General to the Economic and Social Council, E/ 1998/ 20.

    Page 15 GAO- 01- 722 Global Health

    WHO officials pointed out that progress has been made in the Americas, no
    organized surveillance for dengue exists in Africa, even though disease
    experts are certain that the illness is present there. Countries use
    different definitions of what constitutes a reportable case of dengue and
    different procedures for deciding when to report cases (that is, with or
    without laboratory confirmation) and for reporting on dengue versus dengue
    hemorrhagic fever. WHO officials highlighted the general inadequacy of
    laboratory support for dengue surveillance and observed that epidemiological
    data on dengue is ?frequently incomplete, delayed, and not used for
    decisionmaking purposes.? 18 While national authorities are officially
    reporting just over 1 million cases per year, WHO estimates the actual
    number of cases at more than 50 million per year.

    In addition, public health experts observe that global surveillance for
    identifying and investigating emerging infections is weak. Sizable,
    apparently sudden outbreaks of unknown diseases, such as the 1976 Ebola
    outbreak in Zaire, often occur after the disease has been infecting local
    populations for weeks or months. Health authorities are frequently unaware
    of the problem until sick people begin showing up at hospitals, where
    concentration of infected individuals and reuse of unsterile equipment can
    dramatically increase the spread of the disease. Isolated cases or small
    clusters of cases of such diseases can be easily missed, and diseases that
    closely resemble others may spread before they are detected and identified.
    Disease experts believe, for example, that HIV/ AIDS began to appear in
    humans decades before WHO called for its worldwide surveillance in 1981.
    However, these early cases were isolated and those contracting the disease
    tended to die from other infections, which forestalled identification and
    investigation of the disease. Similarly, isolated Ebola cases may have been
    occurring for many years, only to be diagnosed as shigella or other
    diseases.

    18 See Strengthening Implementation of the Global Strategy for Dengue Fever/
    Dengue Hemorrhagic Fever Prevention and Control, Report of the Informal
    Consultation, Oct. 18- 20, 1999 (WHO/ CDS/( DEN)/ IC/ 2000.1).

    Page 16 GAO- 01- 722 Global Health

    Developing country systems are a weak link in the global surveillance
    framework. Surveillance systems in industrialized and developing countries
    suffer from a number of common constraints, including a lack of human and
    material resources, weak infrastructure, poor coordination, and uncertain
    linkages between surveillance and response. 19 However, these constraints
    are more pronounced in developing countries, which bear the greatest burden
    of disease and are where new pathogens are more likely to emerge, old ones
    to reemerge, and drug- resistant strains to propagate. Weaknesses in these
    countries thus substantially impair global capacity to understand, detect,
    and respond to infectious disease threats.

    Several disease experts we met with observed that health care systems
    typically emphasize the care and treatment of sick people and that support
    systems such as surveillance are generally assigned a lower priority and
    receive comparatively few human and material resources. A 2000 report by the
    National Intelligence Council 20 concluded that, with some exceptions, such
    as Thailand and South Africa, developing country governments throughout
    Africa and Asia assigned health care a comparatively or extremely low
    priority. The report observed that, as a result, these countries have
    rudimentary or no domestic systems for disease surveillance, response, or
    prevention. As shown in table 1, both overall health care spending and
    government health expenditures tend to decline along with national income
    levels. For example, total health care spending per capita in low income
    countries amounts to about 3 percent of per capita spending in high income
    countries. With the fewest resources to call upon and intense pressure to
    provide care and treatment services, public health authorities in the
    poorest countries are likely to spend the least amount of resources on
    surveillance.

    19 For perspectives on difficulties in the United States, see Emerging
    Infectious Diseases: Consensus on Needed Laboratory Capacity Could
    Strengthen Surveillance

    (GAO/ HEHS- 99- 62, Feb. 5, 1999); and Emerging Infectious Diseases:
    National Surveillance System Could be Strengthened (GAO/ T- HEHS- 99- 62,
    Feb. 25, 1999). For perspectives on surveillance in Canada, see Report of
    the Auditor General of Canada- September 1999, ?Chapter 14: National Health
    Surveillance: Diseases and Injuries.?

    20 The Global Infectious Disease Threat and Its Implications for the United
    States, No. NIE- 99- 17 of the National Intelligence Estimates, National
    Intelligence Council (Washington, D. C.: Jan. 2000). Global Framework?s

    Performance Constrained by Weaknesses in Developing Countries

    Surveillance Systems Lack Qualified People and Equipment

    Page 17 GAO- 01- 722 Global Health

    Table 1: Health Expenditures by National Income Level Country category

    Government expenditures on

    health as percentage of gross

    domestic product a Total expenditures on

    health as percentage of gross domestic

    product a Total annual health

    expenditures per capita a in international dollars b

    High income 6.0 9. 7 2,587 Upper- middle income 3.4 6. 2 549 Lower- middle
    income 2.3 4. 7 190 Low income 1.2 4. 5 74

    Source: Data from 2001 World Development Indicators (The World Bank,
    Washington, D. C., 2001). a These numbers represent the most recent annual
    figures available from the period 1990 through1998. b The term
    ?international dollars? means that data on expenditures at the official
    dollar- exchange rate

    have been adjusted to reflect real differences in relative prices, using
    price surveys conducted by the United Nations? International Comparison
    Program.

    The human resources necessary to perform surveillance activities are at a
    premium in developing countries. In the United States, surveillance
    officials at the state level report that inadequate staffing and training
    hinder their ability to operate. In developing countries, human resources
    are an even more pressing concern. Many African officials with whom we spoke
    said that poor salaries and working conditions drive many qualified public
    health workers abroad in search of work. One CDC official observed that, in
    Zimbabwe, only two people are devoted to surveillance at the national level.

    Key positions in developing countries, including laboratory technicians and
    health care workers, are often filled by people who do not possess the
    necessary qualifications. In Uganda, for example, officials charged with
    assessing the national surveillance system found that a shortage of trained
    health care workers at peripheral health units contributed to inadequate
    analysis and application of data for decisionmaking, incomplete and untimely
    reports sent to higher levels, and a lack of laboratory confirmation or
    accurately validated diagnoses. WHO officials stated that laboratory
    personnel in developing countries often cannot competently test blood
    samples for malaria because they are not properly trained. WHO also observed
    that, although quality assurance programs are an important means of ensuring
    laboratory competence, staff in more than 90 percent of developing country
    laboratories are not familiar with quality control or quality assurance
    principles. Few surveillance workers in developing countries possess the
    epidemiological skills that make CDC so effective at

    Page 18 GAO- 01- 722 Global Health

    clarifying and resolving infectious disease challenges. For example, one WHO
    official commented that many of those assigned responsibility for analyzing
    disease information in developing countries are able to produce accurate
    tables and graphs but cannot probe the data to identify discrepancies that
    bear investigation.

    Equipment shortages also constrain surveillance. In the United States,
    public health departments often lack computers and fax machines or
    integrated data systems that allow surveillance data to be immediately
    shared with public and private partners. Developing country health
    departments have little access to such equipment. The ability of developing
    country health officials to provide accurate disease information is further
    compromised by their frequent lack of clear and accurate diagnostic tests
    that they can perform themselves or ready access to functioning
    laboratories. As a result, they have difficulty making appropriate decisions
    about disease control measures and may waste valuable resources, such as
    antibiotics and vaccines. Inexpensive, rapid diagnostic tests are available
    for some diseases, including hepatitis B and HIV, but many other diseases,
    including cholera and yellow fever, can only be confirmed by a laboratory.
    CDC and WHO officials observed that public health laboratories in Africa are
    generally poorly funded, understaffed, and underequipped. According to WHO,
    more than 60 percent of laboratory equipment in developing countries is
    outdated or not functioning. Sixteen of the 19 WHO- sponsored assessments of
    African national surveillance systems that we reviewed reported weaknesses
    in laboratory capacity, ranging from a lack of trained technicians to
    deteriorating buildings, and 9 specifically cited a lack of laboratory
    equipment or poorly maintained equipment as reasons for difficulty in
    confirming cases. During fieldwork in Malawi, for example, we were told that
    all clinics should have a microscope to scan blood for malaria parasites,
    but at the clinic we visited, the only microscope was broken.

    Weaknesses in transportation and communications infrastructure in developing
    countries substantially impair surveillance in these countries. Many people
    in developing countries live in remote areas that are not served by
    organized health care facilities. Several national surveillance system
    assessments we reviewed specifically cited this as a problem or identified
    large portions of their populations as not having access to health care. In
    Uganda, for example, less than half the population lives within a 3mile walk
    of a health facility. Weak Infrastructure

    Exacerbates Surveillance Difficulties in Developing Countries

    Page 19 GAO- 01- 722 Global Health

    Many cases of disease thus go unrecorded. As an epidemiologist with the
    Armed Forces Medical Intelligence Center commented, because the effective
    reach of the formal health care systems in most developing countries extends
    to so little of the population, patients seen at clinics represent merely
    the ?the tip of the iceberg? in terms of disease trends and events. For
    example, research conducted by the Tanzanian health ministry found that,
    from 1992 through 1995, 46 percent of all deaths in one district occurred
    without prior contact with a health facility and 90 percent of all children
    under age 5 with high fever and seizures- a key symptom of malaria- died at
    home. Because local health authorities had not previously had a full
    understanding of disease burdens in their district, they had not chosen to
    focus on malaria as a top priority. However, according to national
    officials, the local authorities made malaria a high priority and quintupled
    the share of resources dedicated to controlling this disease after they
    learned of the data generated by this research project.

    Poor roads and communications in many developing countries make it difficult
    for health care workers to alert higher authorities about outbreaks or
    quickly transport specimens to laboratories. At least 10 of the 19
    assessments of African national surveillance systems that we reviewed found
    that less than 50 percent of the local health facilities surveyed had either
    telephones (or other means of communication) or vehicles for transport. 21
    Even in facilities that had these resources, performance was hampered by
    breakdowns and insufficient funds for fuel. One clinic official in Tanzania,
    who did not have access to a vehicle or telecommunications equipment,
    informed us that in the event of an emergency, such as the need to report a
    suspected case of polio or cholera, he hitches a ride on one of the trucks
    that occasionally pass through his village. He observed that this was a
    workable alternative for him because his clinic was only about an hour?s
    drive from the district health office but that his colleagues operated
    clinics much further away from district headquarters. These obstacles also
    affect the ability of higher- level officials to give feedback to the health
    care workers they supervise on the quality of the data being collected. Such
    feedback, according to public health experts, is critical to motivating
    health workers to continue investing time and energy in surveillance
    activities.

    21 This is a conservative figure because the assessments do not indicate if
    some or all of the sites with telephones also had radio call boxes, or if
    some or all of the sites with cars also had motorbikes, bicycles, etc.

    Page 20 GAO- 01- 722 Global Health

    Global disease surveillance is also constrained by poor coordination of
    surveillance activities. Multiple reporting systems, unclear lines of
    authority in the event of an outbreak, poor integration of laboratories into
    public health systems, and nonparticipation among private health care
    providers have combined to further hamper surveillance efforts. While these
    problems exist in industrialized countries, they are particularly severe in
    the developing world.

    The disease- specific focus of control efforts has resulted in the creation
    of multiple surveillance systems at the national and global levels. The
    WHOsponsored assessments of surveillance systems in sub- Saharan Africa
    found that many countries maintained at least five separate surveillance
    systems and that two countries had as many as nine systems. For example, in
    addition to maintaining separate routine surveillance systems for multiple
    diseases within the country and at the border, Madagascar maintains
    surveillance systems to support independent programs to control malaria;
    tuberculosis and leprosy; HIV/ AIDS and other sexually transmitted diseases;
    plague, schistosomiasis, and cysticercosis; and diseases targeted by the
    Expanded Program on Immunization. While industrialized countries have more
    resources and expertise to cope with the resulting duplication of effort,
    multiple reporting systems tax developing countries? weak public health
    systems. As we observed during our fieldwork in Africa and our review of the
    19 WHO- sponsored assessments, overburdened individuals at the lowest levels
    of the health system are frequently required to do everything from caring
    for patients to filling out reporting forms for several disease surveillance
    programs. These individuals may often have to choose between their
    responsibilities for patient care and filling out reporting forms. The
    accuracy, timeliness, and completeness of the disease surveillance data
    collected and reported may therefore be compromised. The disease- specific
    nature of these programs also impairs the ability of national governments to
    analyze overall disease trends. In Madagascar, for example, the WHO-
    sponsored assessment of the national surveillance system found that there
    was no central point for analyzing (or responding to) disease information;
    each of the country?s multiple surveillance programs maintained its own
    reporting chain.

    Unclear lines of authority make it difficult to know whom to contact and who
    is responsible for which tasks in the event of an outbreak. Such problems
    exist in both industrialized and developing countries. For example, a
    Canadian government report critiquing the national response to a 1998
    salmonella outbreak in that country noted that a key local official did not
    know who to contact at the national level and that national officials were
    not sure who at their agency was responsible for handling Surveillance
    Activities Are

    Poorly Coordinated

    Page 21 GAO- 01- 722 Global Health

    the issue. As a result, vital information about the scope of the outbreak
    was delayed. 22 Uncertainty about what to report, when, and to whom was also
    evident in the 1999 West Nile virus outbreak in New York City. 23 Many of
    the assessments of African surveillance systems that we reviewed cited
    weakness in this area as an important problem, as did World Bank and WHO
    officials.

    Disease surveillance systems in developing countries do not take full
    advantage of nor do they coordinate the contributions that laboratories can
    make to surveillance. Few developing countries have public health
    laboratories, which means that testing to confirm outbreaks must compete
    with testing to support individual patient- care decisions. Laboratories and
    epidemiologists often report to separate sections of a nation?s health
    ministry, resulting in poor communication between those who test disease
    specimens to confirm diagnoses and those who analyze disease outbreaks and
    trends.

    Finally, private health care providers, who play an increasingly important
    role in many developing countries, often do not participate in surveillance
    programs. One health official in an urban area in Tanzania noted, for
    example, that her efforts to monitor local disease trends were substantially
    handicapped by the fact that more than 80 percent of the population in the
    area now seek care through private clinics. Her efforts to obtain
    surveillance information from these clinics had met with limited success.
    Another Tanzanian official working in a rural area noted that he had exerted
    considerable effort in building relationships with traditional healers to
    improve his awareness of local trends and events and had had some success,
    but that not all public health officials could be expected to do the same.

    Surveillance is further constrained by uncertain linkages between data
    collection, analysis, and response. In the United States, physicians are
    often unaware of the need to gather information necessary for surveillance
    efforts and may not have had any education regarding the criteria used to
    launch a public health investigation. One WHO official observed that

    22 Report of the Auditor General of Canada- September 1999, ?Chapter 15:
    Management of a Food- Borne Disease Outbreak.? 23 For more information, see
    West Nile Virus Outbreak: Lessons for Public Health Preparedness (GAO/ HEHS-
    00- 180, Sept. 11, 2000). Uncertain Linkages

    Between Surveillance and Response

    Page 22 GAO- 01- 722 Global Health

    overburdened health care workers in developing countries are frequently not
    motivated to collect disease data because they do not see any evidence that
    the information is being applied or because no one has explained to them why
    it is valuable. A Malawi health official said that some health workers had
    simply thrown away the registers in which they were supposed to record data
    on their patients. In Zimbabwe, according to a national health official,
    clinic data on surges in malaria incidence often do not reach the
    appropriate authorities until many people have become sick or died because
    the clerks responsible for transmitting this information are unaware of its
    urgency.

    The information generated by many developing country systems often does not
    produce a response because it is not timely or reliable enough to be useful.
    For example, during the 1990s, several sub- Saharan African countries
    introduced broadly targeted health management information systems to
    consolidate data collection and analysis on disease incidence and a variety
    of other health issues such as vaccination rates. World Bank and WHO
    officials commented that, while useful for other purposes, these information
    systems had often proven too broad in scope, cumbersome in detail, and slow
    to be used as effective surveillance tools. In fact, many national
    surveillance assessments we reviewed indicated that, despite attempts to use
    these systems as a means of simplifying disease reporting, they had become
    yet another parallel disease reporting system. Several officials with whom
    we spoke said that routine reporting systems often do not provide data that
    can be used to make long- term disease control management decisions, even
    though they were designed with this purpose in mind. For example, an
    official at the Tanzanian health ministry said that data from the country?s
    health management information system are not reliable enough to be used for
    this purpose. Tanzanian government officials also observed that limitations
    in the routine reporting system have led them to create a separate system
    for gathering information on disease outbreaks through weekly telephone
    calls to regional- level officials within the country.

    In addition, the surveillance systems that developing countries rely upon
    most heavily (routine reporting by health care providers) cannot, by
    themselves, fully inform health care decision- makers about disease trends
    and events. Experts at WHO, CDC, and USAID commented that supplementary
    efforts, such as long- term demographic surveys and analyses of vital
    statistics (births and deaths), can make major

    Page 23 GAO- 01- 722 Global Health

    contributions to understanding disease trends. 24 CDC officials stated that
    the recordation and use of vital statistics should be a priority for every
    country and that such activities should be linked to disease surveillance.
    However, developing countries seldom invest funds in supplementary studies
    25 and often do not record vital statistics. Effective outbreak
    investigations also can make substantial contributions to understanding
    disease trends. For example, mapping the location of infected households and
    tracing the contacts of sick people help identify modes of transmission and
    risk factors. Health authorities can use this information to formulate an
    appropriate response to the current outbreak and forestall future outbreaks
    of the same illness. However, developing countries often lack the capacity
    to conduct thorough outbreak investigations.

    Weaknesses in developing country systems reduce the ability of public health
    authorities at every level to understand and control infectious disease
    threats. These shortcomings limit the success of ambitious international
    programs such as the polio eradication effort, and impair the routine
    surveillance of other diseases and the identification and control of
    outbreaks, newly emerging diseases, and antimicrobial resistance.

    The surveillance achievements recorded by programs such as the polio
    eradication effort have been possible only because intensive international
    assistance has been given to developing countries so that they can
    participate in these programs. In spite of this assistance, poor
    surveillance in developing countries has continued to limit the ability of
    these programs to achieve their goals. For example, according to CDC, four
    countries in southern Africa were unable to meet international expectations
    in 1999 for detecting cases of acute flaccid paralysis, a key indicator of
    polio surveillance quality. 26 Seven countries in the region fell

    24 Other types of surveillance information that developing country systems
    do not typically generate can be used in disease control efforts. These
    include data on the use of drugs or other remedies that can indicate the
    prevalence of a disease in a given area, and on weather and drought patterns
    affecting populations of disease- bearing insects or animals.

    25 The Tanzania research that resulted in increased resources for
    controlling malaria was funded primarily by the United Kingdom?s Department
    for International Development and the Canadian International Development
    Agency.

    26 Acute flaccid paralysis can be brought on by a number of causes. Even
    when polio is believed to have been eliminated from a country, polio
    officials continue to monitor surveillance systems to ensure that they
    report at least 1 case of acute paralysis for every 100, 000 children, thus
    preserving the system?s ability to detect cases of paralysis caused by
    polio. Weaknesses in Developing

    Country Systems Impair All Facets of Global Surveillance

    Page 24 GAO- 01- 722 Global Health

    short of the targeted 80- percent rate for collecting stool samples from
    suspected cases. The African region as a whole performed more poorly than
    any other, detecting less than the target number of potential polio cases
    and attaining less than the 90- percent goal for completeness of reporting.
    According to CDC, completing the global eradication effort is complicated by
    systemic weaknesses in the remaining endemic areas, which are located
    primarily in sub- Saharan Africa and South Asia. 27

    Ineffective routine surveillance seriously compromises the international
    community?s ability to understand global disease burdens and trends. As
    already indicated with regard to yellow fever, cholera, and dengue, the
    global incidence of many diseases is unknown. One WHO official noted that
    health authorities in Equatorial Guinea, which lies within the yellow fever
    endemic zone of Africa, had informed him that their country has never
    experienced an outbreak of yellow fever. This statement cannot be disproved
    because no surveillance for yellow fever exists in Equatorial Guinea. Even
    when adequate data exist to identify gross trends, the data generally are
    not adequate for in- depth analyses or informed decisions about targeting
    resources to achieve specific control objectives.

    Developing countries often cannot investigate or address outbreaks on their
    own. CDC?s investigative expertise, including laboratory support, is
    comparatively rare in the rest of the world. Many of the African
    surveillance assessments we reviewed indicated that outbreaks there are
    often not thoroughly investigated, if they are investigated at all. Health
    officials in countries we visited and at WHO headquarters in Geneva noted
    that serious outbreaks strain developing countries? relatively weak public
    health systems, requiring them to request international assistance to cope.
    For example, India experienced an outbreak of plague in 1994 that resulted
    in hundreds of cases across the country, 56 deaths, 28 and over a billion
    dollars in economic damage from the travel restrictions and trade embargoes
    imposed by other countries. The outbreak was severe in part because India
    had largely discontinued surveillance for plague. Health authorities did not
    respond to initial complaints of flea infestation and did not take
    appropriate measures to contain the outbreak. The disease spread

    27 CDC also noted that armed conflict in several of these areas presents a
    major obstacle to completing the eradication program. 28 This is the number
    reported in Morbidity and Mortality Weekly Report (Oct. 21, 1994), the
    official weekly publication of the CDC. Unofficial estimates put the death
    toll at several hundred.

    Page 25 GAO- 01- 722 Global Health

    to crowded urban slums where it progressed unchecked to its highly
    contagious, pneumonic form and became a serious national problem.

    Shortcomings in developing country systems also limit the global community?s
    ability to identify and effectively control newly emerging and reemerging
    diseases. Several factors combine to make the emergence of new pathogens
    more likely in developing countries. These include accelerating urbanization
    and overcrowding without benefit of adequate water supply and sewage
    systems, population displacement due to civil wars and other disasters, and
    increased human incursion into ecosystems where contact with pathogens that
    previously affected only animals or insects is more likely to occur.
    Developing countries are poorly equipped to conduct surveillance for such
    pathogens. For example, during the 1980s a bacteria long recognized as a
    cause of routine eye infections evolved into a pathogen capable of causing
    an extremely serious disease- Brazilian Purpuric Fever. 29 Since its first
    appearance, cases of this disease have been documented in Brazil and
    Australia. Experts observe that other cases may have occurred, only to be
    misdiagnosed as meningococcal disease. According to experts at the State
    University of New York at Buffalo and CDC, outbreaks of Brazilian Purpuric
    Fever appear to have waned. However, no organized surveillance exists for
    this disease, and its actual global distribution is unknown. In Uganda,
    local health professionals at the scene of the fall 2000 Ebola outbreak did
    not at first suspect the disease, despite the fact that Ebola outbreaks had
    previously occurred in two neighboring countries.

    Although antimicrobial resistance problems have emerged in industrialized
    countries, such problems are more likely to escape immediate attention and
    become severe in developing countries. Impoverished developing countries are
    particularly ripe breeding grounds for the unchecked spread of drug-
    resistant strains due to their citizens? poor access to medical facilities;
    high rates of self- medication; economic, educational, and logistical
    difficulties in completing full courses of drug treatment; and limited drug
    oversight by governments. While disease experts generally regard global
    surveillance for antimicrobial resistance as

    29 All 10 children known to have contracted this disease in the first known
    outbreak died.

    Page 26 GAO- 01- 722 Global Health

    inadequate, developing countries conduct the least ambitious programs in
    this area. These countries? weak laboratories are a key constraint. 30

    The international community has recently launched a number of initiatives
    that may improve global surveillance. First, the international community has
    made unprecedented commitments to achieving specific reductions in the
    burdens imposed by HIV/ AIDS, malaria, and tuberculosis. These diseases
    present complex challenges, and substantial effort will be required to
    create surveillance systems for these diseases that will permit these
    initiatives to move forward as their sponsors intend. Second, WHO and other
    members of the global public health community have launched a number of
    broader initiatives intended to strengthen global capacity for surveillance
    of infectious diseases as a group. The impact of both sets of initiatives
    remains to be seen.

    Malaria, tuberculosis, and HIV/ AIDS have continued to grow as public health
    threats, especially in developing countries, despite years of organized
    international control efforts. All three diseases have their most severe
    impacts in sub- Saharan Africa. Disease experts estimate that about 90
    percent of malaria cases and 70 percent of HIV cases occur in subSaharan
    Africa. They believe that if current trends continue, Africa will also have
    more cases of tuberculosis than any other region by 2005.

    These diseases share several characteristics that make surveillance and
    response comparatively difficult. First, they are relatively difficult to
    identify; laboratory confirmation is required for certainty in diagnosing
    all three. Malaria, in particular, is easily confused with other febrile
    illnesses in the absence of laboratory analysis. HIV- positive people often
    become sick- and die- from ?opportunistic? infections. The underlying cause
    of the patient?s illness may never be recognized. Further, humans can carry
    the pathogens that cause these diseases for extended periods without
    exhibiting overt symptoms. This is particularly problematic for HIV

    30 For more information on the complex challenges that must be faced in
    conducting surveillance for antimicrobial resistance, see Antimicrobial
    Resistance: Data to Assess Public Health Threat From Resistant Bacteria Are
    Limited

    (GAO/ HEHS/ NSIAD/ RCED- 99- 132, Apr. 28, 1999); Containing Antimicrobial
    Resistance,

    WHO/ CDC/ CSR/ DRS/ 99. 2, WHO, Geneva; and A Public Health Action Plan to
    Combat Antimicrobial Resistance, U. S. Interagency Task Force on
    Antimicrobial Resistance, June 2001. Impact of

    Improvement Initiatives Remains to Be Demonstrated

    Recent International Commitments to Control HIV/ AIDS, Malaria, and
    Tuberculosis Will Require Improved Surveillance

    Page 27 GAO- 01- 722 Global Health

    positive persons, who can infect others despite their apparent lack of
    disease.

    Second, none of these three diseases elicits a clear and effective response
    from the human immune system. These immunological complexities have hampered
    the development of easily applied, effective, and comparatively inexpensive
    diagnostic tools, preventive measures, or treatments that would simplify
    surveillance and encourage commitment to control efforts. 31 Vaccines that
    could effectively prevent these diseases have not yet been developed. 32
    Extended multidrug medication regimens are required to cure active
    tuberculosis, and retard the development of AIDS symptoms in HIV- positive
    patients. In the case of tuberculosis these regimens take months to complete
    while, in the case of HIV patients, they must be followed for the life of
    the patient. In the case of malaria, the limited ability of the human body
    to develop effective immunity means that persons living in endemic areas may
    become sick with this disease on repeated occasions throughout their lives
    and must therefore be treated repeatedly. 33

    Notwithstanding these difficulties, the international community has, over
    the last few years, moved to adopt specific objectives for controlling these
    three diseases. In 1998, several organizations, including WHO, other U. N.
    organizations, and the World Bank, inaugurated campaigns to ?Roll Back
    Malaria? and ?Stop TB.? Since that time, effective advocacy by many parties
    has increased support for these initiatives and for international

    31 The diseases occur in different forms within the body, presenting
    multiple challenges to the immune system. For example, the HIV virus evolves
    at such a high rate that HIVpositive patients often carry multiple strains.
    The malaria parasite passes through several life stages within the human
    body, each of which elicits a different reaction from the body?s immune
    system.

    32 Research is proceeding to develop vaccines against malaria and HIV/ AIDS
    and to provide an improved antituberculosis vaccine. The available vaccine
    against tuberculosis has been effective in preventing the disease in young
    children in many parts of the world. However, according to the National
    Institutes of Health, the vaccine has shown highly variable efficacy in
    preventing tuberculosis in adults and has not been effective in controlling
    the disease in most countries of the Southern Hemisphere.

    33 In areas where there is continuous transmission of malaria (e. g., no
    break during a dry season), most people who survive initial infection during
    childhood continue to have asymptomatic reinfections throughout their lives.

    Page 28 GAO- 01- 722 Global Health

    collaboration to combat HIV/ AIDS. In July 2000, at the G8 34 summit in
    Okinawa, leaders of the major industrialized countries pledged to work
    toward achieving the following goals by 2010:

     Under ?Roll Back Malaria,? to reduce global burdens of malaria by 50
    percent;  Under ?Stop TB,? to reduce tuberculosis deaths and prevalence by
    50

    percent;  As proposed by the U. N. Secretary General, to reduce the number
    of

    HIV/ AIDS- infected young people (15 to 24 years old) by 25 percent. 35 In
    commenting on a draft of this report, the Department of Health and Human
    Services and the Department of State pointed out that at the July, 2001 G8
    summit in Italy, the industrialized countries pledged to provide at least
    $1.3 billion to support a new Global AIDS and Health Fund that would provide
    support for achieving these objectives.

    Public health experts observed that substantial improvements are needed to
    create the surveillance support necessary to achieve these and other
    targets. 36 Since baseline estimates of the incidence of these diseases are
    subject to wide margins of error, the initiatives do not have a firm
    starting point from which to measure progress. For example, WHO estimates of
    the global incidence of tuberculosis are based on the work of a panel of
    disease experts that the organization called upon to analyze available data
    from 1997. The panel observed that the number of new cases occurring could
    have been as much as 21 percent lower or 40 percent higher than estimated.
    37 Malaria experts observe that, because of the large margin of error in
    estimates of malaria incidence- which range from 300 million to

    34 The Group of Eight consists of the heads of state of Canada, France,
    Germany, Italy, Japan, Russia, the United Kingdom, and the United States.
    The President of the European Commission also participates in G8
    deliberations.

    35 The U. N. General Assembly had previously expressed support for this goal
    (see ?Report of the Ad Hoc Committee of the Whole of the Twenty- First
    Special Session of the General Assembly,? A/ S- 21/ 5/ Add. 1, July 1999),
    and reaffirmed its support in a ?Declaration of Commitment on HIV- AIDS? on
    June 27, 2001. The World Health Assembly has also supported an intensified
    effort against HIV/ AIDS. See ?Scaling up the Response to HIV/ AIDS,? World
    Health Assembly Resolution 54. 10, May 2001.

    36 Other targets include a plan developed by WHO, UNICEF, and CDC to reduce
    measles deaths by 50 percent by 2005. 37 See ?Global Burden of
    Tuberculosis,? The Journal of the American Medical Association,

    Vol. 282 (Aug. 18, 1999).

    Page 29 GAO- 01- 722 Global Health

    500 million cases- and the fact that many malaria cases and deaths are never
    diagnosed or reported, the Roll Back Malaria campaign also does not have a
    reliable baseline. HIV/ AIDS data are similarly limited. For example,
    because AIDS typically appears in HIV- positive individuals years after they
    have been infected, HIV/ AIDS surveillance systems commonly rely not only on
    surveillance for AIDS but on the administration of blood tests to specific
    populations, such as pregnant women, to provide information on HIV infection
    rates. However, according to the Joint United Nations Programme on HIV/ AIDS
    and WHO, more than 40 percent of these national ?sero- surveillance?
    systems, especially those in Africa, are of poor quality or completely
    nonfunctional.

    Surveillance shortcomings also make it difficult to implement control
    programs. For example, developing country surveillance systems often cannot
    identify people who need treatment for these diseases. WHO estimates that,
    in 1999, the 23 countries with the highest burden of tuberculosis
    successfully detected only about 44 percent of the active cases in their
    countries. WHO experts also commented that laboratories in developing
    countries frequently cannot be relied upon to provide accurate diagnostic
    tests for malaria. The WHO- sponsored assessment of Uganda?s surveillance
    system found that almost half of local health facilities could not
    accurately diagnose this disease. All three diseases tend to be unevenly
    distributed by region and population group, thus requiring improved
    surveillance to effectively target control efforts. HIV/ AIDS experts, in
    particular, commented that more surveillance will be required to understand
    the character of HIV infection patterns and how they vary among disparate
    populations, including high- risk groups such as sex workers and their
    clients. HIV experts also observed that more surveillance information is
    needed on behaviors such as condom use so that effective strategies for
    limiting HIV transmission can be prepared. 38

    Because all three diseases have demonstrated a capacity for developing
    resistance to drugs, surveillance for antimicrobial resistance is also
    critically important. In fact, the international effort to eradicate malaria
    was abandoned in the late 1960s when it became apparent that both the
    malaria parasites and the mosquitoes that carry them were becoming resistant
    to the chemicals used for their control. WHO and the International Union
    Against Tuberculosis and Lung Disease, with support

    38 See Second Generation Surveillance for HIV: The Next Decade,

    WHO/ CDS/ CSR/ EDC/ 2000. 5- UNAIDS/ 00. 03E.

    Page 30 GAO- 01- 722 Global Health

    from other organizations, launched a Global Project to monitor
    AntiTuberculosis Drug Resistance in 1994. Under this project, a global
    laboratory network was created, with internationally recognized laboratories
    providing support (including quality assurance testing) for lower- capacity
    facilities. This project has produced information on the magnitude of the
    threat posed by resistant strains of tuberculosis. However, the most recent
    report on the project?s results includes data from geographic areas that
    include only about 28 percent of the reported tuberculosis cases in the
    world and two- thirds of the 23 high- burden countries targeted by the Stop
    TB campaign. 39 A WHO tuberculosis expert commented that he would like to
    see the project?s geographic reach extended. Surveillance for antimicrobial
    resistance in malaria and AIDS patients is less organized. One malaria
    expert observed that data on resistance to malaria drugs are scarce, often
    outdated, and collected in ways that make data comparison and analysis
    difficult.

    WHO and CDC officials observed that developing country public health systems
    need substantial strengthening in multiple areas to permit them to
    participate effectively in ambitious campaigns such as Roll Back Malaria and
    Stop TB. These officials observed that programs that are developed to
    support the new disease- specific commitments should therefore be broadly
    targeted. Such broadly targeted efforts could facilitate across- theboard
    improvements in surveillance for all infectious diseases.

    The international community has introduced a number of initiatives to
    strengthen overall global capacity for surveillance of infectious diseases
    as a group. These include efforts to (1) strengthen global outbreak
    management, (2) strengthen surveillance capacity within developing
    countries, and (3) improve surveillance coordination and cooperation at
    national and regional levels. While available evidence suggests that these
    initiatives have merit, they are still in their early stages.

    Prior to the mid- 1990s, the international public health community?s
    approach to identifying and responding to major disease outbreaks was ad hoc
    in nature, resulting in poor responses to several significant outbreaks,
    including the 1994 plague epidemic in India and the 1995 Ebola outbreak in
    Zaire. WHO has since established a system for verifying outbreak

    39 Anti- Tuberculosis Drug Resistance in the World, Report No. 2: Prevalence
    and Trends

    (Geneva, Switzerland: WHO, 2000). Broader Initiatives Aimed

    at Strengthening Global Surveillance

    Strengthening Global Outbreak Management

    Page 31 GAO- 01- 722 Global Health

    reports, inaugurated a network to organize and coordinate outbreak
    responses, and is coordinating a process to revise the International Health
    Regulations to provide a firmer foundation for international collaboration
    in identifying and responding to threatening outbreaks.

    WHO launched an outbreak verification process in 1997 to help identify
    significant disease outbreaks around the world. This process involves
    collecting and verifying outbreak reports with national health authorities
    and others, assessing their significance, and disseminating information. To
    further this effort, WHO worked with the Canadian government to develop the
    Global Public Health Intelligence Network, an electronic surveillance system
    that scans the Internet for reports of infectious disease in news sources,
    Internet discussion groups, biomedical journals, and elsewhere. WHO
    officials stated that they do not receive prompt information about every
    important outbreak because some countries control that information, and the
    Network only searches the Internet in a few languages. 40 Given that
    outbreak reports vary in quality, WHO tries to verify reports to ensure that
    they present issues of potential international importance before calling
    attention to them. WHO generally focuses on outbreak reports from developing
    countries, where public health systems are weaker and more likely to require
    outside assistance. During the verification process, WHO may offer technical
    assistance, supplies, transport of specimens, or training on control
    measures, or help organize vaccination programs. Between November 1999 and
    October 2000, WHO investigated 228 outbreak reports, eventually confirming
    169 significant outbreaks. The vast majority of these outbreaks occurred in
    developing countries; more than 40 percent occurred in sub- Saharan Africa.

    In April 2000, WHO inaugurated the Global Outbreak Alert and Response
    Network to help organize and coordinate international outbreak response. 41
    Various organizations have volunteered to participate, including national
    public health institutions such as CDC, as well as U. N.

    40 As of November 2000, searches were done in English and French and plans
    to use Spanish were under way. 41 The World Health Assembly officially
    endorsed this effort in its Resolution 54.14, adopted May 2001, entitled
    ?Global Health Security: Epidemic Alert and Response.? In commenting on a
    draft of this report, WHO stated that its effort to develop a coordinated
    outbreak response system, as well as affiliated efforts to improve
    laboratory and epidemiological capacity in developing countries and obtain
    agreement on revisions to the International Health Regulations, are now
    being managed as an overall ?Global Health Security? initiative.

    Page 32 GAO- 01- 722 Global Health

    and nongovernmental organizations. While Network procedures for rapidly
    mobilizing technical and financial support and for governing response teams
    are still being finalized, WHO officials believe that their efforts have
    improved international outbreak coordination and response. There is now a
    central source of verified information on outbreaks, and rapid response
    teams have been deployed to countries that need assistance in investigating
    and controlling outbreaks. For example, WHO reported that its request for
    assistance in an investigation of an apparent acute hemorrhagic fever
    outbreak in Afghanistan in June 2000 produced offers from five institutions
    within 12 hours and the placement of a team in- country within a week of the
    outbreak being verified. A major test of Network operations occurred during
    the Ebola hemorrhagic fever outbreak in Uganda in the fall of 2000. At the
    request of the Ugandan government, WHO coordinated the international
    response, which included more than 20 Network partners. While this system
    can provide effective assistance when requested by countries experiencing
    outbreaks, the Network partners cannot require countries experiencing
    outbreaks to request assistance or to take recommended measures.

    In 1995, WHO initiated an effort to revise the International Health
    Regulations to create a firmer legal footing and a stronger institutional
    commitment to outbreak surveillance and response. WHO plans to have a draft
    revision ready for international review in late 2002, to be followed by
    World Health Assembly approval and acceptance by individual countries. Full
    implementation is projected for 2005. In launching this initiative, WHO
    officials noted that, for several reasons, the existing regulations? disease
    reporting requirements (for cholera, plague, and yellow fever) have been
    widely ignored. Among other things, the regulations provide little incentive
    for reporting. Although WHO often organizes international assistance to help
    countries investigate or control significant outbreaks, the regulations do
    not commit WHO or the international community to provide such assistance. In
    addition, the regulations do not protect reporting countries against trade
    and travel restrictions that national governments may impose against
    countries affected by serious disease outbreaks. While such restrictions may
    be justified in some cases, disease experts have found that the restrictions
    are sometimes excessive. For example, in 1998, the European Commission
    banned imports of fresh fish from four countries in East Africa during a
    cholera epidemic despite WHO and U. N. Food and Agriculture Organization
    statements that the fish posed no health risk if cooked, dried, or canned
    properly. Although the two organizations advised the Commission that trade
    restrictions were not necessary or effective in protecting consumers, the
    ban continued for 6 months.

    Page 33 GAO- 01- 722 Global Health

    Key changes to the International Health Regulations would include the
    following:

     Redefining reporting requirements to replace the focus on identifying all
    occurrences of a few specific diseases (no matter how minor) with a new
    focus on identifying all ?events of urgent international health importance?
    (i. e. outbreaks of any disease that may impose adverse consequences on
    other countries).  Authorizing WHO to define a range of acceptable
    protective measures that

    may be employed by countries in response to outbreaks. This provision is
    directed at providing reporting governments with some assurance that they
    will not be harmed by unreasonable trade sanctions. 42 For example, WHO
    would provide guidance as to whether goods entering a country from an area
    experiencing an outbreak should be inspected, treated, destroyed, or refused
    entry.  Obligating WHO- and by extension, the international community- to

    respond to outbreak reports by helping reporting countries assess and
    control outbreaks that may have adverse impacts beyond their borders.
    Defining a set of core requirements for countries in carrying out

    surveillance, notification, and response. In commenting on a draft of this
    report, the Department of Health and Human Services stated that the proposed
    revisions offer an important channel for pursuing improvements in global
    surveillance; but the department added that many countries will need
    assistance to achieve basic surveillance, notification, and response
    capabilities. WHO added that the revision exercise has recently gained
    impetus through endorsement from the World Health Assembly in its spring
    2001 session 43 and that the number of countries actively involved in the
    negotiations has increased.

    WHO, CDC, USAID, other foreign assistance agencies, and developing country
    governments are collaborating in a number of efforts to improve developing
    country surveillance and response capacity. These include

    42 Binding measures would have more of an impact in limiting trade
    sanctions. However, WHO and World Trade Organization experts agreed that
    national governments would be reluctant to accept in advance such
    restrictions on their ability to protect themselves under emergency
    conditions.

    43 World Health Assembly Resolution 54. 14 included an expression of support
    for the ongoing revision effort and called on member countries to designate
    focal points for the negotiations. Initiatives to Strengthen

    Surveillance Capacity in Developing Countries

    Page 34 GAO- 01- 722 Global Health

    efforts to improve laboratory and epidemiological capacity and to increase
    disease- mapping capability.

    Upgrading Laboratory Capacity

    While the global health community has focused on creating laboratory systems
    that can provide reliable support for high- priority efforts such as polio
    eradication and influenza control, comparatively less effort has been
    devoted to broader laboratory improvements. Well- functioning laboratory
    systems need trained personnel, adequate facilities and equipment, quality
    assurance programs to ensure accurate test results, and participation from
    laboratories with greater levels of expertise to answer complex or unusual
    questions.

    WHO coordinates several broadly targeted training and quality assurance
    programs designed to strengthen national public health laboratories, make
    cost- effective laboratory technology available, and develop and refine
    laboratory standards and reference materials. For example, WHO has organized
    voluntary quality assessment programs to monitor and improve the quality of
    laboratory performance in areas such as hematology and bacteriology. These
    programs, administered by various prominent disease laboratories around the
    world, periodically send out samples for participating national laboratories
    to examine and identify. The testing results are scored and feedback is
    provided to participating laboratories. While the programs involve about 450
    laboratories around the world, they do not reach all countries or all
    laboratories. Further, they are not fully funded by WHO, and the various
    laboratories charged with operating them have had to cover most of the costs
    of operating these programs. Some of WHO?s regional offices have also begun
    investing in programs to strengthen national laboratories in their regions.

    In 2001, WHO, with support from the city of Lyon, the Government of France,
    and the Merieux Foundation, established a new program to strengthen
    laboratory and epidemiological capacities for handling disease outbreaks in
    developing countries. Intended to serve 45 developing countries over the
    next 5 years, the program?s first phase began in April 2001, with 15 senior
    staff from national public health laboratories in 7 French- speaking African
    countries. During their 2- year course of study, participants will be
    expected to develop detailed plans for addressing the needs of their
    laboratories. Plans are for later trainees to come from the Middle East and
    North Africa, the Baltics and Central Asia, and possibly South Asia and
    additional African countries. In commenting on a draft of this report, USAID
    pointed out that it is working with the new program in

    Page 35 GAO- 01- 722 Global Health

    Lyon to develop a Quality Control/ Quality Assurance Program for national
    laboratories in Africa.

    International networking is an effective way to provide developing countries
    with access to more highly specialized laboratory services as well as
    assistance in improving the quality of their own laboratory services. Such
    international networks are a prominent feature of some disease- specific
    initiatives, including polio eradication and influenza control. WHO has
    created a system of Collaborating Centers, in part to ensure that developing
    countries can access support services when needed. WHO currently maintains a
    worldwide system of more than 270 Centers that focus on infectious diseases.
    However, as shown in figure 2, Collaborating Centers tend to be concentrated
    in industrialized countries. Relatively few are located in Africa, despite
    the high burden of infectious diseases on that continent. With 38
    Collaborating Centers, CDC is the single largest contributor of expertise
    and resources to this system.

    Page 36 GAO- 01- 722 Global Health

    Figure 2: Distribution of WHO Collaborating Centers for Infectious Disease
    Surveillance and Control

    Source: Prepared by GAO using list of Collaborating Centers provided by WHO.

    In 1999, WHO issued a report that identified a number of shortcomings in the
    Collaborating Centers system, including a lack of consistency in the
    criteria for selecting centers and the absence of a systematic means for
    evaluating their activities. WHO found that some Collaborating Centers
    contribute little to international disease control efforts. WHO is amending
    its procedures for working with the Centers to address these shortcomings
    through a more rigorous and consistent designation process, joint
    preparation of Center work plans, closer monitoring and evaluation, and the
    development of a global database to meet the needs of national and
    international health authorities. WHO also continues to work with
    Collaborating Centers and other institutions to encourage the growth of

    Page 37 GAO- 01- 722 Global Health

    existing networks for sharing information on particular diseases and
    initiatives to establish additional networks.

    Improving Epidemiological Capacity

    International public health officials have long recognized the need to
    develop strong epidemiological skills in countries and institutions around
    the world. CDC is widely acknowledged as having the strongest institutional
    capabilities for investigating and resolving complex disease management
    challenges. Since its founding in 1951, CDC?s Epidemic Intelligence Service
    has provided approximately 2,300 health professionals from the United States
    and elsewhere with the skills to investigate disease events and trends and
    improve surveillance systems. At the request of national governments, CDC,
    WHO, USAID, the Rockefeller Foundation, and the European Union have helped
    establish 27 additional training programs in applied epidemiology worldwide,
    which are modeled after CDC?s Epidemic Intelligence Service. According to
    CDC, non- U. S. programs, about half of which are located in lower- income
    countries, had trained over 900 people as of January 2001. 44

    The common goals of these programs include (1) developing a cadre of
    national public health professionals, (2) providing essential
    epidemiological and public health services to the country during and after
    training, and (3) building regional and international linkages between
    countries to support public health response and training. According to
    public health experts, an underlying goal is to develop an informationbased
    culture for public health decisionmaking in every country.

    A CDC- sponsored evaluation of five of these programs in 1998 found that
    epidemiologists trained by the programs have had a positive impact on the
    quality of their national public health programs. For example, graduates
    have helped (1) improve surveillance system procedures and outbreak
    investigations, (2) develop local surveillance capacity, and (3) design
    research programs that influenced national health policy decisions.
    According to CDC and WHO staff, graduates of these programs made important
    contributions to addressing recent outbreaks of Ebola in Uganda and Rift
    Valley fever in Yemen and Saudi Arabia.

    44 Programs in lower income countries include those located in Colombia,
    Cote d?Ivoire, Egypt, Ghana, Indonesia, Jordan, Peru, the Philippines,
    Thailand, Uganda, Vietnam, and Zimbabwe, as well as a regional program in
    Central America.

    Page 38 GAO- 01- 722 Global Health

    Many of the disease experts we spoke with cited continued expansion of these
    programs as a key element in global efforts to improve surveillance capacity
    and performance.

    However, a low mentor- student ratio is one key factor in the success of
    applied epidemiology training programs, and this places a limit on the speed
    at which such programs can be expanded. Twenty of the programs currently in
    existence were inaugurated within the last decade. For example, programs in
    Brazil and the Indian state of Tamil Nadu have just begun, while a program
    in China is still in the planning stages. These programs will take many
    years to have a significant impact.

    Increasing capacity for mapping disease information

    CDC, the WHO Regional Office for the Americas, and WHO headquarters (in
    collaboration with UNICEF) have all developed computer software to generate
    maps of disease conditions in specific geographic areas that can help inform
    decisionmaking. Over the past decade, these disease- mapping systems have
    had a positive effect on surveillance in developing countries, especially in
    supporting disease- specific initiatives. For example, the WHO/ UNICEF
    HealthMapper application was used to support the guinea worm eradication and
    river blindness elimination efforts and is beginning to be used in global
    efforts against malaria and HIV/ AIDS. Experts believe that there is great
    potential for employing such systems to predict disease outbreaks and trends
    in relation to climate and weather patterns. However, they note that such
    systems are constrained by the quality of available data on diseases and
    underlying features such as population distribution and the locations of
    health facilities and water supplies, as well as limited access to
    satellite- generated information.

    The international community has initiated efforts to expand coordination of
    surveillance at the national level, especially in developing countries, and
    within regions. These efforts can help reduce reporting burdens and make
    better use of limited resources.

    With assistance from CDC, WHO?s Regional Office for Africa launched the
    Integrated Disease Surveillance and Response (IDS) initiative in 1998 to
    improve linkages between surveillance and response by generating more
    accurate, timely, relevant, and complete data. In commenting on a draft of
    this report, USAID added that it has also assisted in launching this
    initiative, making several grants to WHO?s Regional Office for Africa to
    support relevant activities. Although the World Health Assembly has not
    Coordinating Surveillance

    Operations

    Page 39 GAO- 01- 722 Global Health

    officially endorsed IDS, a number of countries and regions of the world are
    also seeking greater integration of their surveillance operations.

    IDS is not intended to replace disease- specific programs. Rather, it seeks
    opportunities for pooling funds and personnel to improve surveillance for
    multiple diseases. While the long- term goal is to improve coordination
    among all surveillance programs, the initiative is presently directed
    primarily at encouraging greater cooperation in surveillance for
    epidemicprone diseases such as cholera and vaccine- preventable diseases,
    such as measles.

    Evidence suggests that the initiative may have a favorable impact. For
    example, according to WHO, IDS planning has enhanced coordination and
    support for surveillance within public health ministries in at least three
    African countries. CDC found that 26 African countries had already begun to
    employ polio eradication resources to perform surveillance for other
    diseases, without impairing the quality of polio surveillance. However,
    implementing IDS presents significant challenges and will require
    substantial time and effort. For example, baseline assessments of African
    surveillance systems began in late 1998. As of April 9, 2001, only 10 of 46
    countries in WHO?s Africa region had both completed assessments and
    developed plans for addressing weaknesses. CDC and WHO took several years to
    develop generic surveillance guidelines that can be used to put these plans
    into action. The guidelines were sent to WHO?s Africa Regional Office in the
    summer of 2001. CDC officials observed that this slow pace reflects the
    inherent difficulties in creating manageable systems that satisfy multiple
    stakeholders. For example, IDS requires agreement on issues such as how to
    reduce reporting burdens by requiring routine reporting of only ?essential
    information.? However, disease- specific program managers typically have a
    very broad definition of the term ?essential information? when it comes to
    diseases for which they are responsible. CDC officials also noted that the
    IDS negotiations have required national officials to agree on issues that
    they have never before addressed, such as defining threshold levels to
    determine what constitutes an outbreak and creating procedures for outbreak
    response.

    Public health authorities and others are also working on creating regional
    surveillance networks. For example:

    Page 40 GAO- 01- 722 Global Health

     The Pacific Public Health Surveillance Network was established in 1996 to
    improve surveillance and response among the Pacific Community?s 22 member
    states and territories. 45 Network activities include (1) an Internet system
    for sharing information on disease trends and events, and (2) diagnostic and
    other types of assistance to isolated health care facilities. The network
    has begun to function as an outbreak response coordinator and is working to
    assemble a regional laboratory system to support timely and appropriate
    outbreak response.  Countries in the Amazon basin and the ?Southern Cone?
    of South

    America 46 have been working since 1998 to create laboratory networks to
    improve surveillance of new, emerging, and reemerging infectious diseases.
    Because of these efforts, participating laboratories have identified an
    increasing number of Hantavirus pulmonary syndrome cases, including in areas
    where the disease had not previously been recognized. Participating
    countries are emphasizing integration of epidemiologists and laboratory
    personnel to advance network goals.  With CDC and Department of Defense
    support, several countries in

    Southeast Asia are working to establish a regional network to improve
    outbreak detection and response.

    The global disease surveillance framework is dominated by networks directed
    at providing information on specific disease threats. The framework supplies
    comparatively good information when demanded by well- supported, goal-
    oriented disease control initiatives. Surveillance capacity for other
    diseases is comparatively weak, and these weaknesses are most acute in
    developing countries. The continued weakness of developing country
    surveillance systems not only impairs global surveillance operations, but
    necessitates the application of substantial resources to create effective
    global systems each time the international community identifies an
    additional priority disease target. It also requires institutions such as
    CDC to devote resources to respond to outbreaks in developing countries that
    exceed local authorities? capacity. To date, while facilitating the
    relatively rapid achievement of disease- specific results, the

    45 The members of the Community are the Cook Islands, the Federated States
    of Micronesia, Fiji, Guam, Kiribati, the Northern Marianas, the Marshall
    Islands, Nauru, Niue, New Caledonia, Palau, Papua New Guinea, Pitcairn
    Island, French Polynesia, the Solomon Islands, Samoa, American Samoa,
    Tokelau, Tonga, Tuvalu, Vanuatu, and Wallis and Futuna.

    46 Countries participating in the Amazon regional effort are Bolivia,
    Brazil, Colombia, Peru, and Venezuela. Countries participating in the
    Southern Cone regional effort are Argentina, Bolivia, Brazil, Chile,
    Paraguay, and Uruguay. Concluding

    Observations

    Page 41 GAO- 01- 722 Global Health

    creation of additional surveillance systems to serve new initiatives has
    left developing countries? underlying surveillance problems unresolved.

    International public health officials concerned about the overall threat of
    infectious disease are seeking to take advantage of the global community?s
    apparent willingness to commit itself to achieving measurable progress
    against three major disease threats- HIV/ AIDS, tuberculosis, and malaria-
    to support broader systemic improvements in developing country surveillance
    and response capacity. These broad improvements may eventually reduce the
    need for disease- specific campaigns. However, given the need to demonstrate
    progress against these three diseases in particular, the extent to which the
    global public health community can manage the new disease- specific
    initiatives in a manner that significantly improves surveillance for all
    infectious disease threats, remains to be demonstrated.

    USAID?s and the Department of Health and Human Services? comments on a draft
    of this report offer additional perspectives on the challenges to be faced
    in developing strategies for responding to specific disease threats while
    also addressing overall weaknesses in surveillance capacity. USAID noted the
    failure of past disease- specific initiatives (like smallpox eradication) to
    leave a lasting positive impact on surveillance capacity in developing
    countries. The agency is attempting to insure that its ongoing polio-
    eradication activities advance the eradication program while also upgrading
    developing countries? capacity for monitoring and responding to other
    diseases. USAID also observed that many of the weaknesses in developing
    country systems documented in this report require donor attention outside
    the range of disease specific programs. The Department of Health and Human
    Services observed that while expanded efforts to improve surveillance and
    response capacity for HIV/ AIDS, malaria, and tuberculosis are clearly
    warranted, other significant infectious disease threats also need attention.
    The department concluded that both diseasespecific and cross- cutting
    programs are needed, and that these programs can and should be carried
    forward in ways that are mutually supportive.

    We received written comments on a draft of this report from the Department
    of Health and Human Services, the Department of Defense, WHO, USAID, the
    National Aeronautics and Space Administration, and the World Bank. The World
    Bank?s letter was transmitted through the Department of the Treasury. These
    comments are reprinted in appendixes III through VIII, along with our
    evaluations, where appropriate. The Department of State provided oral
    comments. In addition, WHO?s Agency Comments

    and Our Evaluation

    Page 42 GAO- 01- 722 Global Health

    Department of Communicable Disease Surveillance and Response and CDC
    provided technical comments, which we have incorporated where appropriate.

    In general, the agencies concurred with the report?s findings. The
    Department of Health and Human Services commented that the report presents
    an accurate and thorough evaluation of global infectious disease
    surveillance. In their oral comments, officials from the State Department?s
    Bureaus for International Organization Affairs and Oceans and International
    Environmental and Scientific Affairs stated that the report accurately
    portrayed the issues and obstacles that the international community faces in
    dealing with infectious disease surveillance. The Department of Health and
    Human Services and USAID elaborated upon the reports? concluding
    observations concerning the challenges to be faced in pursuing both disease-
    specific and more- broadly focused improvements in surveillance capacity. We
    expanded our concluding observations to reflect these comments.

    USAID, the Department of Defense and, to a lesser extent, the World Bank,
    WHO, and the Department of Health and Human Services provided additional
    information on their contributions to building global surveillance capacity.
    USAID and the Department of Defense, in particular, said that the draft
    report did not adequately describe their efforts to improve global
    surveillance. USAID highlighted its efforts to assist developing countries
    in developing surveillance capacity outside the bounds of disease- specific
    initiatives. The Department of Defense cited relevant activities being
    undertaken through the Department?s Global Emerging Infections Surveillance
    and Response System. The World Bank pointed out that as part of its emphasis
    on health, it is actively working with a number of governments to strengthen
    national surveillance system. The Department of Health and Human Services
    cited CDC?s global strategy paper Working with Partners to Improve Global
    Health: A Strategy for CDC and ATSDR 47 -a document which provides extensive
    information on CDC activities that contribute to strengthening global
    surveillance capacity. Where appropriate, we added information on these
    agencies? efforts to the report. However, the report was not designed to
    provide a comprehensive accounting of all worldwide efforts. We refer the
    reader to the appendixes for additional information as provided by the
    agencies.

    47 The Agency for Toxic Substances and Disease Registry.

    Page 43 GAO- 01- 722 Global Health

    We are sending this report to interested congressional committees, the
    Secretary of the Treasury, the Secretary of State, the Secretary of Health
    and Human Services, the Secretary of Defense, the Administrator of USAID,
    the Administrator of the National Aeronautics and Space Administration, and
    the Director General of the World Health Organization. We will also make
    copies available to other interested parties on request.

    Please contact me on (202) 512- 8979 if you or your staff have any questions
    concerning this report. An additional GAO contact and staff acknowledgements
    are listed in appendix IX.

    Joseph A. Christoff, Director International Affairs and Trade

    Appendix I: Objectives, Scope, and Methodology

    Page 44 GAO- 01- 722 Global Health

    At the request of the Chairmen and Ranking Members of the Senate
    Subcommittee on Foreign Operations, Committee on Appropriations, and the
    Senate Subcommittee on African Affairs, Committee on Foreign Relations, we
    evaluated the global infectious disease surveillance framework.
    Specifically, we (1) examined the surveillance framework?s evolution and
    current operations, (2) identified factors that constrain its performance,
    and (3) assessed several initiatives designed to improve global infectious
    disease surveillance and response.

    To determine the surveillance framework?s evolution and current operations,
    we interviewed officials responsible for international surveillance- related
    activities at World Health Organization (WHO) offices, including WHO
    headquarters in Geneva, Switzerland; the Pan- American Health Organization
    (the WHO Regional Office for the Americas) in Washington, D. C.; and the
    Regional Office for Africa in Harare, Zimbabwe. We interviewed officials at
    various U. S. agencies, including the Centers for Disease Control and
    Prevention (CDC), the National Institutes of Health (both of which are
    constituent elements of the Department of Health and Human Services), the U.
    S. Agency for International Development (USAID), the Armed Forces Medical
    Intelligence Center, the Walter Reed Army Institute of Research, the
    National Aeronautics and Space Administration, and the White House Office of
    Science and Technology Policy; and at multilateral development institutions,
    including the World Bank. We interviewed disease experts in academia and
    officials at nongovernmental organizations such as the Association of Public
    Health Laboratories. We reviewed the International Health Regulations, as
    well as documents and studies from WHO and other sources pertaining to
    international efforts to control specific diseases and guide surveillance.
    We also attended conferences dealing with international infectious disease
    control and surveillance issues.

    To identify factors that constrain the performance of the global disease
    surveillance framework, we interviewed the officials listed above and
    conducted fieldwork in four African countries- Malawi, Tanzania, Uganda, and
    Zimbabwe. We selected these countries from a larger group of African
    countries that had recently conducted assessments of their national disease
    surveillance systems. We limited our fieldwork to Africa because of interest
    expressed in this region by the requesters of this work, as well as Africa?s
    infectious disease burden, the weak condition of most African health care
    systems, and the concerted efforts under way to improve surveillance in this
    region. While in Africa, we interviewed officials at national health
    ministries; multilateral agencies, including WHO country and regional
    offices, the World Bank, and the African Appendix I: Objectives, Scope, and

    Methodology

    Appendix I: Objectives, Scope, and Methodology

    Page 45 GAO- 01- 722 Global Health

    Development Bank; foreign assistance and technical agencies from the United
    States and other countries, including USAID and CDC; and nongovernmental
    organizations active in the health sector. We reviewed documentation on
    surveillance systems in each country and discussed these countries?
    experiences with recent disease outbreaks. We also visited health facilities
    in each country, including central and district hospitals and laboratories,
    research institutions, local clinics, and designated surveillance sites for
    specific diseases such as malaria. At each site, we observed conditions and
    discussed with knowledgeable officials the ways in which surveillance is
    conducted, the extent to which surveillance data are analyzed and used, and
    factors that constrain surveillance activities. In addition, we
    systematically reviewed the 19 assessments of surveillance systems in
    African countries that WHO, together with CDC and national health
    authorities, had completed as of April 2001. We also reviewed studies of
    surveillance problems in developing and industrialized countries, including
    the United States and Canada.

    To assess initiatives designed to improve global infectious disease
    surveillance and response, we interviewed WHO, World Bank, CDC, USAID, and
    other officials to identify and discuss key initiatives currently under way
    to improve regional and global surveillance. When pertinent, we also asked
    national officials we met during our fieldwork about their involvement in
    these initiatives, particularly WHO?s Integrated Disease Surveillance and
    Response effort in the Africa region. We reviewed documents describing the
    purpose, status, and outcomes to date (where appropriate) of these programs.
    For our review of WHO efforts to improve international outbreak detection
    and response, we collected and analyzed information from WHO on disease
    outbreaks that had been entered in its Outbreak Verification List database
    from November 1999 through October 2000, including detailed case histories
    of the international response to a small number of these outbreaks. We also
    collected and reviewed information on outbreaks from other sources-
    including ProMED, an Internet service of the International Society for
    Infectious Diseases.

    We did not address specific surveillance problems that arise in countries or
    regions affected by armed conflict or the complex humanitarian emergencies
    that such conflicts often produce. As noted in our July 2000 report on
    surveillance, health care to populations affected by such emergencies is
    typically provided by international and nongovernmental organizations rather
    than by national governments, and these organizations face obstacles and
    pressures that are not faced by public health systems functioning in
    nonemergency conditions. Since this report

    Appendix I: Objectives, Scope, and Methodology

    Page 46 GAO- 01- 722 Global Health

    focused on the development and application of surveillance information, we
    did not explore the feasibility of improvements in diagnostic, preventive,
    or treatment technologies.

    We conducted our work from July 2000 through June 2001 in accordance with
    generally accepted government auditing standards.

    Appendix II: Disease Information Page 47 GAO- 01- 722 Global Health

    This appendix provides descriptive information on the diseases mentioned in
    the body of this report. The information is derived primarily from WHO and
    CDC documents.

    Brazilian purpuric fever, first observed in 1984, is caused by an evolved
    form of a bacterium that causes a common eye infection, conjunctivitis. In
    its evolved form, this pathogen can invade the bloodstream and cause a
    lethal infection characterized by high fever, shock, and a severe bleeding
    disorder. Outbreaks of the disease have appeared to wane. The factors that
    caused the disease to suddenly appear and then seem to disappear have yet to
    be determined. According to disease experts, northern Africa and other parts
    of the world where the original form of the bacterium in question is common
    are potentially at risk for epidemics of this disease.

    Chagas disease is caused by a parasite transmitted by insects, by
    transfusions of contaminated blood, or from mother to fetus. The acute phase
    of the disease often has no symptoms or an inflammation at the site of the
    infection and flu- like symptoms. If caught in its early stages, the
    parasite can be seen in the blood and the disease can be cured with drugs.
    After that, the parasite moves into body tissue, where it cannot be treated
    and can cause severe, life- threatening conditions 10 to 30 years later,
    including heart disease. Up to 18 million people in 18 countries in South
    and Central America are infected. As many as 100,000 infected people, mostly
    immigrants, are estimated to reside in the United States.

    Cholera is caused by a water- and food- borne bacterium. Infection results
    in acute watery diarrhea, leading to extreme dehydration and death if not
    addressed. Known vaccines and antibiotics have only limited impact on the
    disease; treatment focuses on rehydration. According to WHO, recent cholera
    outbreaks have killed 3.6 percent of those who become ill worldwide. Cholera
    is endemic in more than 80 countries. During the 1990s, global cholera
    reports varied from about 100,000 to about 600,000 cases per year.

    Cysticercosis is a parasitic infection caused by the pork tapeworm, whose
    eggs may be ingested in contaminated food and water. Inside the human body,
    the larvae hatch and form cysts in the organs, particularly the muscles,
    eyes, and brain. Although most cases are asymptomatic or mild, patients may
    experience vision problems, headaches, seizures, and brain swelling. The
    infection can be treated with drugs and sometimes surgery. The disease
    occurs worldwide but is found most often in rural, developing countries with
    poor sanitary conditions and where pigs are allowed to roam freely. Appendix
    II: Disease Information

    Appendix II: Disease Information Page 48 GAO- 01- 722 Global Health Dengue
    fever, a mosquito- borne infection caused by four distinct but

    closely related viruses, is a severe, flu- like illness with specific
    symptoms that vary based on the age of the victim. Dengue hemorrhagic fever
    is a potentially lethal complication that may include convulsions. There is
    no vaccine for dengue fever, nor is there any treatment beyond supportive
    therapy. With treatment, fatality rates can be less than 1 percent; without
    it, they can exceed 20 percent. Dengue is endemic in more than 100
    countries.

    Diphtheria is a respiratory disease caused by a virus- infected bacterium.
    Occurring worldwide, the disease is spread through human- to- human contact.
    Symptoms range from mild to severe. Diphtheria can be complicated by damage
    to the heart muscle or peripheral nerves. An effective vaccine is typically
    provided through national childhood vaccination programs. The disease is
    fatal 5 to 10 percent of the time, even when treated by administration of
    antibiotics and diphtheria antitoxin. Untreated, the fatality rate can be
    much higher.

    Ebola hemorrhagic fever, a viral disease, is transmitted by direct contact
    with the body fluids of infected individuals, causing acute fever, diarrhea
    that can be bloody, vomiting, internal and external bleeding, and other
    symptoms. There is no known cure, although some measures, including
    rehydration, can improve the odds of survival. Ebola kills more than half of
    those it infects. Identified for the first time in 1976, the Ebola virus is
    still considered rare, but there have been a number of outbreaks in central
    Africa.

    Guinea worm disease, formally known as dracunculiasis, is transmitted by
    drinking water contaminated with parasite larvae. The mature parasite
    travels through the body, usually emerging through the foot or leg.
    Perforation of the skin is accompanied by fever, extreme pain, nausea, and
    vomiting, and an infected person can stay ill for several months. Fatalities
    are rare, but secondary infection and permanent deformity can occur. There
    is no vaccine or drug to prevent infection or kill the worms; however,
    transmission of the disease can be halted through education and the
    provision of safe drinking water. The disease has been eradicated from
    several countries, but remains present in 13 African nations, according to
    CDC.

    Hantavirus pulmonary syndrome is caused by several strains of a virus that
    is transmitted by exposure to infected rodents. Symptoms include fever,
    fatigue, muscle aches, coughing, and shortness of breath; the onset of
    respiratory distress often leads to death. There is no specific treatment

    Appendix II: Disease Information Page 49 GAO- 01- 722 Global Health

    for the disease, other than appropriate management of respiratory problems.
    The virus was first identified in the southwestern United States in 1993,
    but several hundred cases have since been confirmed in other U. S.
    locations, Canada, and several countries in South America.

    Hepatitis B is a viral infection of the liver that is readily transmitted by
    contact with the body fluids of an infected person. In many developing
    countries, most children become infected. The virus may cause an acute
    illness, as well as a life- long infection that carries a high risk of
    serious illness or eventual death from liver cancer or cirrhosis. An
    effective vaccine is available, and WHO has recommended that it be added to
    routine childhood immunization programs in all countries. About 2 billion
    people worldwide have been infected with the virus, and about 350 million
    people remain chronically infected.

    Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome
    (AIDS), a disease of the immune system. HIV is transmitted through contact
    with the body fluids of an infected person or from mother to baby. Infected
    adults may be asymptomatic for 10 years or more. Because the immune system
    is weakened, there is eventually greater susceptibility to opportunistic
    diseases such as pneumonia and tuberculosis. Drugs are available that can
    prevent transmission from pregnant mothers to their unborn children and can
    help slow the onset of AIDS. As of December 2000, an estimated 36.1 million
    people worldwide were living with HIV/ AIDS and about 21.8 million had died.

    Influenza, or flu, is a highly contagious respiratory infection caused by
    three types of virus, of which two (types A and B) can reach epidemic
    proportions and are found worldwide. Symptoms include fever, cough, sore
    throat, runny or stuffy nose, headache, muscle aches, and often extreme
    fatigue that may last 1 to 2 weeks. Severe complications such as pneumonia
    sometimes occur in children, the elderly, and other vulnerable populations.
    There is an influenza vaccine, but the viruses change so quickly that the
    vaccine must be updated every year. Several drugs exist to prevent and treat
    influenza.

    Leprosy is a chronic bacterial infection. The exact mode of transmission is
    not fully understood. Primarily affecting the skin, nerves, and mucous
    membranes, leprosy causes deformities of the face and extremities after many
    years but can be cured with drugs. About 680,000 new cases were reported in
    1999. India, Myanmar, and Nepal account for about 70 percent of all leprosy
    cases.

    Appendix II: Disease Information Page 50 GAO- 01- 722 Global Health Lyme
    borellosis, or Lyme disease, is a bacterial illness transmitted by

    ticks. The pathogen was first detected in the United States in 1982 and
    identified as the cause of the disease. The area around the tick bite
    sometimes develops a ?bull?s eye? rash, typically accompanied by fever,
    headache, and musculoskeletal aches and pains. There is an effective vaccine
    for adults at high risk. If untreated by antibiotics, arthritis, neurologic
    abnormalities, and- rarely- cardiac problems follow. The disease is rarely
    if ever fatal and is endemic in North America and Europe.

    Lymphatic filariasis is a parasitic disease transmitted by mosquitoes. The
    infection causes severe pathology of the lymph system resulting in
    elephantiasis, or gross swelling, of the limbs and genitals and organ
    damage. Diagnostic tools have improved, and more recently drug treatment
    options have replaced mosquito control as a strategy for eliminating the
    disease. At least 120 million people in 80 countries worldwide are infected
    in both rural areas and densely populated urban slums.

    Malaria is a parasitic disease, transmitted by mosquitoes and endemic in 101
    countries and territories. Symptoms include fever, shivering, joint pain,
    headache, repeated vomiting, severe anemia, convulsions, coma, and in severe
    cases death. Malaria is becoming increasingly resistant to known primary
    drug treatments. About 40 percent of the world population is considered at
    risk for malaria. Ninety percent of malaria cases are in subSaharan Africa,
    but the disease is now reemerging in countries where it was once under
    control.

    Measles, a highly contagious viral disease, often strikes children and
    causes fever, conjunctivitis, congestion, and cough, followed by a rash.
    This disease is transmitted by human- to- human contact, and secondary
    infections often cause further complications. Sustained efforts to immunize
    children have reduced the prevalence of this disease, but it still occurs
    worldwide, with an estimated 30 million cases leading to approximately
    900,000 deaths every year.

    Meningitis, a condition that may be caused by several disease agents, is an
    infection and severe inflammation of the fluid membranes surrounding the
    brain and spinal cord.

    Meningococcal meningitis, caused by a particular type of bacteria, is
    transmitted by human- to- human contact and is characterized by sudden onset
    of fever, headache, neck stiffness, and altered consciousness. There is a
    vaccine for this disease, but it loses its effectiveness over time and

    Appendix II: Disease Information Page 51 GAO- 01- 722 Global Health

    must be repeated. Untreated epidemics can incur fatality rates of over 50
    percent but epidemic fatality rates in the last 30 years have generally been
    in the 8 to 12 percent range. Epidemics of meningococcal meningitis are a
    frequent occurrence in Africa?s ?meningitis belt,? which stretches from
    Senegal to Ethiopia. An estimated 500,000 cases and 50,000 deaths occur each
    year due to meningococcal meningitis.

    Pertussis, or whooping cough, is a highly contagious bacterial disease
    spread through respiratory droplets from an infected person. Symptoms
    include runny nose and sneezing, a mild fever, and a cough that gradually
    becomes more severe, turning into paroxysms of coughing that end in vomiting
    and exhaustion. Pertussis is treatable with antibiotics, and the pertussis
    vaccine is commonly administered as part of routine childhood immunization
    programs. Twenty million to 40 million cases with 200,000 to 300,000 deaths
    are reported worldwide every year. Most occur in developing countries.

    Plague, a severe bacterial infection, is usually transmitted to humans by
    infected rodent fleas (bubonic plague) and uncommonly by person- toperson
    respiratory exposure (pneumonic plague). Symptoms of bubonic plague include
    swollen, painful lymph glands (buboes), fever, chills, headache, and
    exhaustion. People with pneumonic plague develop cough, bloody sputum, and
    breathing difficulty. Plague is treatable with antibiotics. However, unless
    diagnosed and treated early, it is highly fatal. Approximately 1,000 to
    4,000 cases of plague are reported each year, but these figures represent
    only a portion of the actual number of cases.

    Poliomyelitis, or polio, is a virus transmitted through human- to- human
    contact. In most cases, there are no symptoms or only mild, flu- like
    symptoms. Five to 10 percent of cases can lead to aseptic meningitis, while
    only 1 percent of infections lead to the acute flaccid paralysis associated
    with polio. Although there is no cure, an effective vaccine is included as
    part of routine childhood immunizations. Fewer than 3, 500 confirmed cases
    were reported in 2000, with transmission still occurring in up to 20
    countries.

    Rift Valley fever is a viral disease that primarily affects animals-
    including domesticated livestock- but can be transmitted to people by
    mosquitoes or contact with the body fluids of infected animals. Rift Valley
    fever usually causes a flu- like illness lasting 4 to 7 days, but about 1
    percent of cases develops into a more severe hemorrhagic fever that has an
    approximately 50- percent fatality rate. An antiviral drug has been
    identified and is being tested, and vaccines are under development. The

    Appendix II: Disease Information Page 52 GAO- 01- 722 Global Health

    disease has occurred in many parts of Africa and, in September 2000, was for
    the first time reported outside of Africa, in Saudi Arabia and Yemen.

    River blindness, or onchocerciasis, is a parasitic disease. Blackflies
    transmit the larvae of parasitic worms to humans, where they grow into adult
    worms with a lifespan of 12 to 15 years. These worms spawn millions of
    microscopic parasites that travel throughout the body causing unbearable
    itching, skin disfigurement, and vision impairment or blindness. Treatment
    with the drug ivermectin kills the infant parasites but has very limited if
    any effect on adult worms. The disease is endemic in 37 countries, with
    nearly all cases in Africa.

    Salmonella infection, or salmonellosis, is caused by a group of bacteria
    that may be present in contaminated foods- often raw or undercooked foods of
    animal origin. It causes acute diarrheal illness, for which treatment is
    usually not required. In some cases, however, the infection can spread in
    the bloodstream and cause death unless antibiotics are used. Over 2,200
    strains of Salmonella bacteria have been identified, including some that
    have developed antibiotic resistance and are hence more difficult to
    control. The disease is common in both developed and developing countries.

    Schistosomiasis, known in some regions as Bilharzia, is caused by five
    species of parasitic flatworms, called schistosomes. The flatworms, which
    are carried during part of their lifecycle by fresh water snails, penetrate
    the skin when people swim or wade in contaminated water. The flatworms grow
    inside the blood vessels and produce eggs that can damage the intestines,
    bladder, and other organs and eventually cause bladder cancer, kidney
    failure, or serious complications of the liver and spleen. Safe,
    costeffective drugs are available to treat the disease. Schistosomiasis is
    endemic in more than 70 developing countries, infecting an estimated 200
    million people, 20 million of whom have severe illness. Over 80 percent of
    the cases are found in Africa.

    Shigellosis is a highly contagious, diarrheal disease caused by four strains
    of bacteria. One of these strains, an unusually virulent pathogen, causes
    large- scale, regional outbreaks of dysentery (bloody diarrhea) with
    mortality rates of 5 to 15 percent. Transmitted by human- to- human contact
    and contaminated food and water, this disease is common in crowded areas
    with poor sanitation and unsafe water supplies. In addition to diarrhea,
    patients experience fever, abdominal cramps, and rectal pain. The disease is
    treatable by rehydration and antibiotics, but antimicrobial

    Appendix II: Disease Information Page 53 GAO- 01- 722 Global Health

    resistance has become widespread. All types of shigellosis together cause an
    estimated 600,000 deaths per year, mostly in developing countries.

    Smallpox is a highly contagious viral disease transmitted from person to
    person, with a high mortality rate and a history of epidemics throughout the
    world. Patients experience fever, aching, and prostration, followed by a
    painful rash that spreads over the entire body and eventually leaves pitted
    scars and sometimes causes blindness. There is no effective treatment for
    the disease; however, the development of a vaccine enabled the worldwide
    eradication of smallpox by 1977. At the start of the eradication campaign in
    1966, an estimated 10 million to 15 million cases occurred globally each
    year, resulting in more than 2 million deaths.

    Tetanus, or lockjaw, is caused by a bacterium found in the intestines of
    many animals and in the soil. It is transmitted to humans through open
    wounds. Neonatal tetanus is a particular problem in newborn infants due to
    unsanitary birthing practices. Symptoms include generalized rigidity and
    convulsive spasms of the skeletal muscles. Tetanus can be treated with an
    antitoxin, and there is an effective vaccine, commonly included in childhood
    vaccination programs. It is fatal about 30 percent of the time and occurs
    worldwide. Neonatal tetanus causes an estimated 270,000 deaths each year,
    mostly in developing countries.

    Tuberculosis is a bacterial disease that is usually transmitted by contact
    with an infected person. People with healthy immune systems can become
    infected but not fall ill- more than one- third of the world?s population is
    thought to be infected. Symptoms of tuberculosis can include a bad cough,
    coughing up blood, pain in the chest, fatigue, weight loss, fever, and
    chills. Several drugs can be used to treat tuberculosis, but the disease is
    becoming increasingly drug resistant. The available vaccine, commonly
    administered to children, has a limited effect. The disease is estimated to
    kill 2 million people each year.

    West Nile fever is a mosquito- borne viral disease. Symptoms include fever,
    head and body aches, rash, and, in more serious cases, stupor, coma,
    convulsions, and paralysis. Death occurs in 3 to 15 percent of cases. There
    is no vaccine for the West Nile virus, and no specific treatment besides
    supportive therapies. The disease occurs in Africa, Eastern Europe, West
    Asia, the Middle East, and, since 1999, the United States.

    Appendix II: Disease Information Page 54 GAO- 01- 722 Global Health Yellow
    fever is a mosquito- borne viral disease whose symptoms include

    fever, muscle pain, headache, loss of appetite, and nausea. Fifteen percent
    of patients progress to a toxic phase, which can include jaundice, abdominal
    pain, and bleeding from the mouth, nose, eyes, or stomach. The kidneys
    deteriorate and may fail. Half of patients who enter this phase die. There
    is no treatment for yellow fever beyond supportive therapies. A safe and
    highly effective vaccine for yellow fever is available but is often not
    included in national vaccination programs. Yellow fever is endemic in more
    than 40 countries in Africa and Central and South America and causes an
    estimated 200,000 cases of illness and 30,000 deaths each year.

    Appendix III: Comments From the Department of Health and Human Services

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    Appendix III: Comments From the Department of Health and Human Services

    Appendix III: Comments From the Department of Health and Human Services

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    Appendix III: Comments From the Department of Health and Human Services

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    Appendix IV: Comments From the World Health Organization

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    Appendix IV: Comments From the World Health Organization

    Appendix IV: Comments From the World Health Organization

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    Appendix V: Comments From the United States Agency for International
    Development

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    Appendix V: Comments From the United States Agency for International
    Development

    Note: GAO comments supplementing those in the report text appear at the end
    of this appendix.

    See comment 2. See comment 1.

    Appendix V: Comments From the United States Agency for International
    Development

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    Appendix V: Comments From the United States Agency for International
    Development

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    Appendix V: Comments From the United States Agency for International
    Development

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    Appendix V: Comments From the United States Agency for International
    Development

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    Appendix V: Comments From the United States Agency for International
    Development

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    See comment 4. Now on p. 39. See comment 3.

    Appendix V: Comments From the United States Agency for International
    Development

    Page 66 GAO- 01- 722 Global Hea

    1. We reviewed the examples of relevant USAID activities provided on pages
    3- 5 of the agency?s written comments and inserted into the report
    references to those activities that could be included in the text. For
    example, we added a reference to USAID support to our existing discussion on
    ?Coordinating Surveillance Operations.?

    2. We revised the draft report?s concluding observations to reflect USAID?s
    subsequent comments that past disease- specific initiatives have failed to
    improve overall developing country surveillance capacity, many of the
    weaknesses of developing country programs identified in the report require
    donor attention outside the range of disease specific programs, if the
    balance of resource flows between disease- specific surveillance initiatives
    and routine surveillance remains heavily in favor of the former, then the
    ability of the donor community to support overall system strengthening will
    continue to be severely inhibited.

    3. We retained the original language after consulting with experts on these
    diseases at CDC and the Case Western Reserve University School of Medicine.

    4. We retained the original wording, with the qualification that the
    information cited was accurate as of April 9, 2001. As of this date, after
    detailed communications with WHO?s Africa Regional Office, we had received
    19 completed assessments and 10 completed plans of action. We were informed,
    in addition, that health officials had conducted fieldwork in a 20th
    country, Kenya, but that their assessment report was not yet available.

    No change was made to reflect the comment that the goal of the Integrated
    Disease Surveillance and Response initiative ?involved only 23 countries
    that requested inclusion in the initiative.? No reference to such requests
    was made to us during the course of our work with WHO or the countries
    involved in the initiative. GAO Comments

    Appendix VI: Comments From the National Aeronautics and Space Administration

    Page 67 GAO- 01- 722 Global Health

    Appendix VI: Comments From the National Aeronautics and Space Administration

    Appendix VII: Comments From the World Bank Page 68 GAO- 01- 722 Global
    Health

    Appendix VII: Comments From the World Bank

    Appendix VIII: Comments From the Department of Defense

    Page 69 GAO- 01- 722 Global Health

    Appendix VIII: Comments From the Department of Defense

    Appendix IX: GAO Contact and Staff Acknowledgments

    Page 70 GAO- 01- 722 Global Health

    Michael McAtee (202) 512- 8978 In addition to the person named above, key
    contributors to this report were Ann Baker, Lynn Cothern, Kay Halpern, Lynne
    Holloway, John Hutton, Bruce Kutnick, and Tom Zingale. Appendix IX: GAO
    Contact and Staff

    Acknowledgments GAO Contact Acknowledgments

    (711544)

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