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

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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

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Appendix VIII: Comments From the Department of Defense

Appendix IX: GAO Contact and Staff Acknowledgments

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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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