Global Health: U.S. Agencies Support Programs to Build Overseas  
Capacity for Infectious Disease Surveillance (04-OCT-07,	 
GAO-08-138T).							 
                                                                 
The rapid spread of severe acute respiratory syndrome (SARS) in  
2003 showed that disease outbreaks pose a threat beyond the	 
borders of the country where they originate. The United States	 
has initiated a broad effort to ensure that countries can detect 
outbreaks that may constitute a public health emergency of	 
international concern. Three U.S. agencies--the Centers for	 
Disease Control and Prevention (CDC), the U.S. Agency for	 
International Development (USAID), and the Department of Defense 
(DOD)--support programs aimed at building this broader capacity  
to detect a variety of infectious diseases. This testimony	 
describes (1) the obligations, goals, and activities of these	 
programs and (2) the U.S. agencies' monitoring of the programs'  
progress. To address these objectives, GAO reviewed budgets and  
other funding documents, examined strategic plans and program	 
monitoring and progress reports, and interviewed U.S. agency	 
officials. GAO did not review capacity-building efforts in	 
programs that focus on specific diseases, namely polio, 	 
tuberculosis, malaria, avian influenza, or HIV/AIDS. This	 
testimony is based on a report (GAO-07-1186), which is being	 
released with this testimoy. GAO did not make recommendations.	 
The agencies whose programs we describe reviewed our report and  
generally concurred with our findings. We incorporated their	 
technical comments as appropriate.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-138T					        
    ACCNO:   A77050						        
  TITLE:     Global Health: U.S. Agencies Support Programs to Build   
Overseas Capacity for Infectious Disease Surveillance		 
     DATE:   10/04/2007 
  SUBJECT:   Developing countries				 
	     Disease control					 
	     Disease detection or diagnosis			 
	     Disease surveillance				 
	     Emerging infectious diseases			 
	     Health care programs				 
	     Infectious diseases				 
	     International relations				 
	     Laboratories					 
	     Program evaluation 				 
	     Public health					 
	     Public health research				 
	     Zoonotic diseases					 
	     Program goals or objectives			 
	     Field Epidemiology Training Programs		 
	     Global Disease Detection				 
	     Global Emerging Infections Surveillance		 
	     and Response System				 
                                                                 
	     Integrated Disease Surveillance and		 
	     Response						 
                                                                 

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GAO-08-138T

   

     * [1]Summary
     * [2]Background
     * [3]Four U.S.-funded Programs Help Build Capacity for Overseas I

          * [4]Global Disease Detection
          * [5]Field Epidemiology Training Programs
          * [6]Integrated Disease Surveillance and Response
          * [7]Global Emerging Infections Surveillance and Response
          * [8]Additional Capacity-Building Activities

     * [9]Agencies Monitor Surveillance Capacity- Building Activities
     * [10]GAO Contact and Staff Acknowledgment
     * [11]GAO's Mission
     * [12]Obtaining Copies of GAO Reports and Testimony

          * [13]Order by Mail or Phone

     * [14]To Report Fraud, Waste, and Abuse in Federal Programs
     * [15]Congressional Relations
     * [16]Public Affairs

Testimony

Before the Subcommittee on Oversight of Government Management, the Federal
Workforce, and the District of Columbia, Senate Committee on Homeland
Security and Governmental Affairs

United States Government Accountability Office

GAO

For Release on Delivery Expected at 2:30 p.m. EDT

Thursday, October 4, 2007

GLOBAL HEALTH

U.S. Agencies Support Programs to Build Overseas Capacity for Infectious
Disease Surveillance

Statement of David Gootnick, Director

International Affairs and Trade

GAO-08-138T

Mr. Chairman and Members of the Subcommittee:

Thank you for this opportunity to discuss GAO's recent work on U.S.
efforts to strengthen international surveillance of infectious diseases.

Infectious diseases are a leading cause of deaths worldwide and represent
the third most common cause of death in the United States. As the recent
outbreaks and rapid spread of severe acute respiratory syndrome (SARS) and
avian influenza^1 have shown, disease outbreaks pose a threat beyond the
borders of the country where they originate. The United States thus has a
clear interest in building capacity abroad to identify and respond to
outbreaks of infectious disease. Effective disease surveillance systems in
other countries contribute to lower morbidity and mortality rates and
improved public health outcomes, both in those countries and elsewhere in
the world.

Earlier efforts to improve surveillance worldwide focused on individual
diseases, beginning with global influenza surveillance in the 1940s and
followed by surveillance systems for smallpox and polio, among others. In
the mid-1990s, recognizing the threat posed by previously unknown
infectious diseases, the United States and other countries initiated a
broader effort to ensure that countries can detect any disease outbreak
that may constitute a public health emergency of international concern.
Three U.S. agencies--the Department of Health and Human Services' Centers
for Disease Control and Prevention (CDC), the U.S. Agency for
International Development (USAID), and the Department of Defense
(DOD)--have programs aimed at building this broader capacity to detect a
variety of infectious diseases.

Today I will describe U.S. efforts to build developing countries' broader
capacity for infectious disease surveillance, specifically: (1) the
obligations, goals, and activities of key U.S. programs to develop
epidemiology and laboratory capacity and (2) U.S. agencies' monitoring of
the progress achieved by these programs. My statement--based on our report
released today^2--does not address U.S. efforts to build international
capacity for surveillance of specific diseases, namely polio,
tuberculosis, malaria, HIV/AIDS, or avian influenza. However, we recently
issued reports on domestic preparedness for avian influenza outbreaks and
on international efforts to prevent pandemic influenza.^3 In addition, we
are beginning to examine, at the subcommittee's request, U.S. capacity to
protect against naturally or intentionally introduced outbreaks of
zoonotic diseases as well as lessons that can be learned from previous
outbreaks in other countries.^4

^1In this report, "avian influenza" refers to the highly pathogenic form of
this disease, which can cause nearly 100 percent mortality in infected
poultry. The disease can also occur in low pathogenic forms that cause
only mild symptoms in infected birds.

^2GAO, Global Health: U.S. Agencies Support Programs to Build Overseas
Capacity for Infectious Disease Surveillance, [17]GAO-07-1186 (Washington,
D.C.: Sept. 28, 2007).

For our September 2007 report, we reviewed annual budgets, grants, and
project funding for four infectious disease surveillance programs--Global
Disease Detection (GDD), Field Epidemiology Training Programs (FETP),
Integrated Disease Surveillance and Response (IDSR), and Global Emerging
Infections Surveillance and Response System (GEIS)--and examined U.S.
agencies' budget, planning, and reporting documents. In addition, we
interviewed U.S. and World Health Organization (WHO) officials responsible
for implementing capacity-building activities. We determined that the
budget and performance data that we obtained had some limitations but were
sufficiently reliable for our purposes. We did not make recommendations in
our report. We conducted our work from October 2006 through July 2007 in
accordance with generally accepted government auditing standards.

DOD, HHS, and USAID provided written comments on a draft of our September
2007 report, generally concurring with our findings. DOD provided
information to clarify the extent of GEIS's global involvement, goals, and
priorities. HHS provided additional information regarding GDD operations,
noting that the GDD centers bring together CDC's existing international
expertise in public health surveillance, training, and laboratory methods.
Additionally, HHS indicated that disease-specific programs contribute to
building surveillance capacity. USAID's comments also focused mainly on
the support it provides to disease-specific and other activities that
contribute to building surveillance capacity.^5

^3GAO, Avian Influenza: USDA Has Taken Important Steps to Prepare for
Outbreaks, but Better Planning Could Improve Response, [18]GAO-07-652
(Washington, D.C.: June 11, 2007); Influenza Pandemic: Efforts to
Forestall Onset Are Under Way; Identifying Countries at Greatest Risk
Entails Challenges, [19]GAO-07-604 (Washington, D.C.: June 20, 2007);
Influenza Pandemic: DOD Combatant Commands' Preparedness Could Benefit
from More Clearly Defined Roles, Resources, Risk Mitigation,
[20]GAO-07-696 (Washington, D.C.: June 20, 2007).

^4Zoonotic infections are infections transmitted from animals to humans;
examples include human cases of avian influenza, Ebola hemorrhagic fever,
and rabies. According to the CDC, approximately 60 percent of all human
pathogens are zoonotic.

Summary

In 2004-2006,^6 CDC, USAID, and DOD obligated about $84 million for four
key programs, as well as additional activities, to develop capacity for
the surveillance and detection of infectious diseases abroad.

           o Global Disease Detection (GDD). CDC obligated about $31 million
           for capacity-building activities at GDD centers in China, Egypt,
           Guatemala, Kenya, and Thailand. GDD centers seek to enhance
           surveillance, conduct research, respond to outbreaks, facilitate
           networking, and train epidemiologists and laboratorians overseas.
           o Field Epidemiology Training Programs (FETPs). CDC and USAID
           obligated approximately $19 million to support FETPs in 24
           countries, in collaboration with host-country governments. In
           2004-2006, these 2-year programs trained approximately 351
           epidemiologists and laboratorians in infectious disease
           surveillance.
           o Integrated Disease Surveillance and Response (IDSR). USAID
           obligated approximately $12 million to support CDC in designing
           and implementing the IDSR strategy with WHO's Regional Office for
           Africa (WHO/AFRO) in 46 African countries and in providing
           technical assistance to 8 of these countries. The IDSR strategy
           aims to integrate countries' existing disease-specific
           surveillance and response systems and link surveillance,
           laboratory confirmation, and other data to public health actions.
           o Global Emerging Infections Surveillance and Response System
           (GEIS). For 2005-2006,^7 DOD obligated approximately $8 million
           through GEIS for more than 60 infectious disease surveillance
           projects to help build capacity in 32 countries where the projects
           were conducted. DOD's GEIS conducts surveillance of infectious
           diseases abroad to protect military health and readiness; capacity
           building occurs through its surveillance activities that focus on
           this goal.
           o Additional activities. USAID's Bureau for Global Health and
           USAID missions obligated about $14 million in 2004-2006 for
           additional activities to build infectious disease surveillance
           capacity.
			  
^5For more information on our scope and methodology and to review agency
comments, see [21]GAO-07-1186 .

^6In this testimony, all years cited are fiscal years unless otherwise
noted.

^7Prior to 2005, GEIS funded the overseas laboratories directly, without a
project-by-project breakdown.			  

           U.S. agencies monitor activities for the four key surveillance
           capacity-building programs, including activities such as the
           numbers of epidemiologists trained, numbers of outbreak
           investigations conducted, and development of laboratory diagnostic
           capabilities. To systematically measure their programs' impact on
           disease surveillance capacity, CDC and USAID recently developed
           frameworks linking these activities to program goals. For example,
           in 2006, CDC developed frameworks for evaluating both the FETP and
           GDD efforts. However, because no evaluations had been completed as
           of July 2007, it is too early to assess whether these monitoring
           and evaluation efforts will demonstrate progress in building
           surveillance capacity. DOD does not plan to evaluate the GEIS
           program's impact on host countries' surveillance capacity, because
           it does not consider capacity building to be a primary program
           goal.
			  
			  Background

           Dramatic growth in the volume and speed of international travel
           and trade in recent years have increased opportunities for
           diseases to spread across international boundaries with the
           potential for significant health and economic implications.
           International disease control efforts are further complicated by,
           for instance, the emergence of previously unknown zoonotic
           diseases, such as Ebola hemorrhagic fever and avian influenza.^8

           Surveillance provides essential information for action against
           infectious disease threats. Basic surveillance involves four
           functions: (1) detection, (2) interpretation, (3) response, and
           (4) prevention. (See fig. 1.)
			  
^8Outbreaks of Ebola hemorrhagic fever, which have occurred in several
African countries, are thought to originate from human contact with
infected monkeys and spread among humans primarily through contact with
infected persons. Outbreaks of avian influenza--spread by birds and
sometimes infecting humans--have occurred in nearly 60 countries, killing
millions of birds and more than 170 humans in 12 countries throughout
Southeast Asia, the Middle East, and Africa as of 2007.

           Figure 1: Elements of a Disease Surveillance System

           Global efforts to improve disease surveillance have historically
           focused on specific diseases or groups of diseases. For example,
           as we reported in 2001, the international community has set up
           surveillance systems for smallpox, polio, influenza, HIV/AIDS,
           tuberculosis, and malaria, among others, with the goal of
           eradicating (in the case of smallpox and polio) or controlling
           these diseases.^9 In 2006, the United States adopted a national
           strategy to prepare for pandemic influenza outbreaks both
           domestically and internationally, which included planned funding
           by U.S. agencies to support influenza surveillance and
           detection.^10 Such disease-specific efforts can build capacity for
           surveillance of additional diseases as well.
			  
^9GAO, Global Health: Challenges in Improving Infectious Disease
Surveillance Systems, [22]GAO-01-722 (Washington, D.C.: Aug. 31, 2001).

^10 [23]GAO-07-604 . Planned funding levels indicate agency budget
projects for planning purposes.

           The United States acknowledged the need to improve global
           surveillance and response for emerging infectious diseases in
           1996, when the President determined that the national and
           international system of infectious disease surveillance,
           prevention, and response was inadequate to protect the health of
           U.S. citizens. Addressing these shortcomings, the 1996
           Presidential Decision Directive NSTC-7 enumerated the roles of
           U.S. agencies--including CDC, USAID, and DOD--in contributing to
           global infectious disease surveillance, prevention, and response.

           Enhancing capacity for detecting and responding to emerging
           infectious disease outbreaks is also a key focus of the revised
           International Health Regulations (IHR). For many years, the IHR
           required reporting of three diseases--cholera, plague, and yellow
           fever--and delineated measures that countries could take to
           protect themselves against outbreaks of these diseases. In May
           2005, the members of WHO revised the IHR, committing themselves to
           developing core capacities for detecting, investigating, and
           responding to other diseases of international importance,
           including outbreaks that have the potential to spread. The
           regulations entered into force in June 2007; member states are
           required to assess their national capacities by 2009 and comply
           with the revised IHR by 2012.^11
			  
^11The revised regulations specify that each state party shall assess its
systems within 2 years of the regulations entering into force on June 15,
2007. They also specify that each state party shall develop systems that
meet the new requirements as soon as possible but no later than 5 years
from the date the regulations enter into force. In certain circumstances,
the revised regulations allow countries to request an extension of up to 4
years to develop systems that meet the requirements.
			  
           Four U.S.-funded Programs Help Build Capacity for Overseas Infectious
			  Disease Surveillance			  

           U.S. agencies operate or support four key programs aimed at
           building overseas surveillance capacity for infectious diseases:
           Global Disease Detection (GDD), operated by CDC; Field
           Epidemiology Training Programs (FETP), supported by CDC and USAID;
           Integrated Disease Surveillance and Response (IDSR), supported by
           CDC and USAID; and Global Emerging Infections Surveillance and
           Response System (GEIS), operated by DOD. USAID also supports
           additional capacity-building projects.

           In 2004-2006, the U.S. government obligated about $84 million for
           these four programs (see table 1). Funding for these programs is
           obligated to support the ability of laboratories to confirm
           diagnosis of disease as well as the training of public health
           professionals who will work in their countries to improve capacity
           to detect, confirm, and respond to the outbreak of infectious
           diseases.

Table 1: U.S. Obligations for Programs Supporting Capacity Building for
Infectious Disease Surveillance, 2004-2006

Program: GDD; 
Agency: CDC; 
Obligations: 2004: $6; 
Obligations: 2005: $11; 
Obligations: 2006: $14; 
Obligations: Amounts provided only as 2004-2006 aggregates: [Empty]; 
Obligations: Total: $31.

Program: FETP; 
Agency: CDC[A]; 
Obligations: 2004: 2; 
Obligations: 2005: 2; 
Obligations: 2006: 3; 
Obligations: Amounts provided only as 2004-2006 aggregates: [Empty]; 
Obligations: Total: $7.

Program: FETP; 
Agency: : USAID; 
Obligations: 2004: 2; 
Obligations: 2005: 3; 
Obligations: 2006: 1; 
Obligations: Amounts provided only as 2004-2006 aggregates: $6; 
Obligations: Total: : $12.

Program: IDSR[B]; 
Agency: USAID[C]; 
Obligations: 2004: 3; 
Obligations: 2005: 3; 
Obligations: 2006: 2;
Obligations: Amounts provided only as 2004-2006 aggregates: 4; 
Obligations: Total: $12.

Program: GEIS; 
Agency: DOD; 
Obligations: 2004: NA[D]; 
Obligations: 2005: 5; 
Obligations: 2006: 3; 
Obligations: Amounts provided only as 2004-2006 aggregates: [Empty]; 
Obligations: Total: $8.

Program: Additional capacity-building activities[E]; 
Agency: USAID; 
Obligations: 2004: 4;
Obligations: 2005: 4; 
Obligations: 2006: 2; 
Obligations: Amounts provided only as 2004-2006 aggregates: 4; 
Obligations: Total: $14.

Sources: GAO analysis of CDC data, USAID grant awards, DOD project
reports.

Note: There are two main limitations to the reliability of these data.
First, the agencies do not track capacity building in their budget
systems, and therefore we developed a methodology to identify activities
that involved capacity building. The agencies concurred with this
methodology and its results. Second, more than half (56 percent) of the
$38 million identified as USAID obligations--about 25 percent of total
identified obligations--are self-reported estimates by some of the USAID
missions and bureaus. We were able to verify the remaining obligations,
including obligations from other USAID missions, with documentation, and
we determined that the data are sufficiently reliable. For additional
information on data reliability, see [24]GAO-07-1186 .

[a]CDC also received approximately $2 million from non-U.S. government
sources such as private foundations and the World Bank to assist with
establishing FETPs. CDC treats these funds as core funds supporting its
operations; however, we did not include them in our analysis, because they
are not U.S.-appropriated funds.

[b]CDC received funds from the United Nations Foundation to support its work
with IDSR. We did not include these funds in our analysis, because they
are not U.S.-appropriated funds.

[c]USAID provides funding to CDC to support IDSR efforts.

[d]NA = not applicable. DOD's project reporting system was not in place
until 2005.

[e]Additional capacity-building activities include projects supported by
USAID's missions in country. This amount does not include obligations from
USAID's Egypt mission, which conducted capacity-building activities for
infectious disease surveillance from 2004 through 2006 but was not able to
determine specifically how much funding went to these activities.

Collectively, these four programs operate in 26 developing countries. (See
fig. 2.) To limit duplication and leverage resources in countries where
some or all of the capacity-building programs operate, CDC, DOD, and USAID
coordinate their efforts by colocating activities, detailing staff to each
other's programs, participating in working groups, and communicating by
phone.^12

Figure 2: Countries with GDD-, FETP-, IDSR-, or GEIS-Related Activities
Supported by U.S. Agencies, 2004-2006

[a]Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras,
Nicaragua, and Panama participated in the Central America FETP in
2004-2006.

[b]Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan participated in the
Central Asia FETP in 2004-2006.

[c]CDC and USAID provided direct assistance to these countries in
implementing WHO/AFRO's IDSR; in addition, WHO/AFRO is working with other
countries in Africa to implement IDSR.

[d]CDC support for IDSR implementation in Guinea and southern Sudan was
funded by the United Nations Foundation.

^12GAO has identified eight practices that agencies can use to enhance and
sustain their collaborative efforts, including developing mechanisms to
monitor, evaluate, and report on them. See GAO, Results-Oriented
Government: Practices That Can Help Enhance and Sustain Collaboration
among Federal Agencies, [25]GAO-06-15 (Washington, D.C.: Oct. 21, 2005).

Global Disease Detection

GDD is CDC's primary effort to build public health capacity to detect and
respond to existing and emerging infectious diseases in developing
countries, according to CDC officials.^13 In 2004-2006, CDC obligated
about $31 million to support GDD capacity-building efforts. GDD's goals
are to

           o enhance surveillance,
           o conduct research,
           o respond to outbreaks,
           o facilitate networking, and
           o train epidemiologists and laboratorians.

Established in 2004, GDD aims to set up a total of 18 international
centers that would collaborate with partner countries, surrounding
regions, and WHO to support epidemiology training programs and national
laboratories and conduct research and outbreak response around the world.
Two GDD centers were established in Kenya and Thailand in 2004, and three
centers are currently under development in Egypt, China, and Guatemala.^14
In addition, CDC established a GDD Operations Center in Atlanta to
coordinate information related to potential outbreaks.

According to CDC officials, GDD capacity-building activities consist of
strengthening laboratories, providing epidemiology training, and
conducting surveillance activities. CDC aims to establish laboratories
with advanced diagnostic capacity--for example, in Kenya, CDC established
several laboratories with biosafety levels 2 and 3.^15 GDD centers conduct
formal, 2-year training programs in analyzing epidemiological data,
responding to outbreaks, and working on research projects.^16 The centers
also conduct short-term training--for example, in 2006, GDD centers
trained more than 230 participants from 32 countries to respond to
pandemics. In addition, the centers provide opportunities for public
health personnel in host countries to work with CDC to evaluate existing
surveillance systems, develop new systems, write and revise peer-reviewed
publications, and use surveillance data to inform policy decisions.

^13In developing GDD, CDC drew on its existing international expertise in
public health surveillance, training, and laboratory methods and brought
together three previously established programs: FETPs, the International
Emerging Infections Program (IEIP), and influenza activities.

^14The long-term applied epidemiology training program in Guatemala is
referred to as the Central America FETP.

Field Epidemiology Training Programs

Assisted by USAID and WHO, and at the request of national governments, CDC
has helped countries establish their own FETPs to strengthen their public
health systems by training epidemiologists and laboratorians in infectious
disease surveillance.^17 CDC and USAID obligated approximately $19 million
to support these programs in 2004-2006. Each FETP is customized in
collaboration with country health officials to meet the country's specific
needs, emphasizing

           o applied epidemiology and evidence-based decision making for
           public health actions;
           o effective communication with the public, public health
           professionals, and the community; and
           o health program design, management, and evaluation.

^15Biosafety addresses the safe handling and containment of infectious
microorganisms and hazardous biological materials. Levels of containment
range from 1 (lowest) to 4 (highest) and depend on the risk of infection,
severity of disease, likelihood of transmission, nature of work being
conducted, and origin of the infectious disease agent.

^16These long-term programs are FETPs that existed prior to the
establishment of the GDD centers and are now operating as part of the
centers. The FETPs in GDD countries are implemented and supported by CDC
in a manner similar to the FETPs in non-GDD countries.

^17The FETP model is based on CDC's Epidemic Intelligence Service, which
began in 1951. In addition to the FETPs, there are also three Field
Epidemiology and Laboratory Training Programs in Kenya, Pakistan, and
South Africa. These are included in our discussion of FETPs.

CDC and USAID collaborate with host-country ministries of health in
Brazil, Central America,^18 Central Asia,^19 China, Egypt, Ghana, India,
Jordan, Kenya, Pakistan, South Africa, Sudan, Thailand, Uganda, and
Zimbabwe to build surveillance capacity through the FETPs. In addition to
receiving formal classroom training in university settings, FETP students
and graduates participate in surveillance and outbreak response
activities, such as analyzing surveillance data and performing economic
analysis, and publish articles in peer-reviewed bulletins and scientific
journals. At the end of the 2-year program, participants receive a
postgraduate diploma or certificate.

According to CDC, these programs graduated 351 epidemiologists and
laboratorians in 2004-2006. As of February 2007, according to CDC, six
programs established between 1999 and 2004^20 tracked their graduates and
found that approximately 92 percent continued to work in the public health
arena after the training. For example, in Jordan, 21 of 23 graduates of
its FETP are working as epidemiologists at the central and governorate
levels.

Integrated Disease Surveillance and Response

USAID has supported CDC in (1) designing and implementing IDSR, with
WHO/AFRO, in 46 African countries and (2) providing technical assistance
to 8 of these countries. In 2004-2006, USAID obligated approximately $12
million to support IDSR, transferring about one-quarter of this amount to
CDC through interagency agreements and participating agency service
agreements. IDSR's goal is to use limited public health resources
effectively by integrating the multiple disease-specific surveillance and
response systems that exist in these countries and linking surveillance,
laboratory confirmation, and other data to public health actions.

CDC has collaborated with WHO/AFRO in developing tools and guidelines,
which are widely disseminated in the region to improve surveillance and
response systems. CDC's assistance has included

           o developing an assessment tool to determine the status of
           surveillance systems throughout Africa,
           o developing technical guidelines for implementing IDSR,
           o working to strengthen the national public health surveillance
           laboratory systems, and
           o conducting evaluations of the cost to implement IDSR in several
           African countries.

^18In 2004-2006, the Central America FETP, based in Guatemala, trained
students from Costa Rica, the Dominican Republic, El Salvador, Guatemala,
Honduras, Nicaragua, and Panama. Panama's participation is funded by CDC's
Global AIDS Program.

^19Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan participated in the
Central Asia FETP in 2004-2006.

^20The six programs are in Brazil, Central Asia, Central America, India,
Jordan, and Kenya.

In addition, CDC is providing technical assistance to eight countries in
Africa,^21 which CDC and USAID selected as likely to become early adopters
of surveillance best practices and therefore to be models for other
countries in the region. With funding from USAID, CDC has undertaken
activities in these countries such as evaluating the quality of national
public health laboratories in conjunction with WHO, developing a
district-level training guide (published in English and French) for
analyzing surveillance data, and developing job aids for laboratories to
train personnel in specimen-collection methods.

Global Emerging Infections Surveillance and Response

DOD established GEIS in response to the 1996 Presidential Decision
Directive NSTC-7 on emerging infectious diseases, which called on DOD to
support global surveillance, training, research, and response to
infectious disease threats. In 2005-2006, DOD obligated approximately $8
million through GEIS to build capacity for infectious disease
surveillance. GEIS, as part of its mission, provides funding to DOD
research laboratories in Egypt, Indonesia, Kenya, Peru, and Thailand^22 as
well as to other military research units for surveillance projects located
in 36 countries, according to DOD officials,. GEIS conducts many projects
jointly with host-country nationals, providing opportunities to build
capacity through their participation in disease surveillance projects.
GEIS officials noted that they view its primary goal as providing
surveillance to protect the health of U.S. military forces and consider
capacity building a secondary goal that occurs as a result of surveillance
efforts.

^21CDC and USAID have supported the implementation of IDSR in Burkina
Faso, Ethiopia, Ghana, Kenya, Mali, Tanzania, Uganda, and Zimbabwe. In
addition, CDC has supported the implementation of IDSR in Guinea and
southern Sudan, funded by the United Nations Foundation.

^22The laboratories are under the command of the U.S. Army in Kenya and
Thailand and the U.S. Navy in Egypt, Indonesia, and Peru.

GEIS funded more than 60 capacity-building projects in 2005 and 2006,^23
supporting activities such as establishing laboratories in host countries,
training host-country staff in surveillance techniques, and providing
advanced diagnostic equipment. For example, in Nepal, GEIS funded
surveillance of febrile illnesses, such as dengue fever, and through this
project provided a field laboratory with training and equipment to conduct
advanced diagnostic techniques. GEIS has also funded more direct training;
for example, the laboratory in Peru conducted an outbreak-investigation
training course for public health officials from Peru, Argentina, Chile,
and Suriname in 2006 with GEIS funding.

Additional Capacity-Building Activities

Funding provided by USAID's Bureau for Global Health and USAID missions
has supported additional activities to build basic epidemiological skills
in developing country health personnel. In 2004-2006, USAID obligated
about $14 million for these activities. For example, USAID funded a WHO
effort to assist the government of India in improving disease
surveillance, including strengthening laboratories, developing tools for
monitoring and evaluating surveillance efforts, and creating operational
manuals for disease surveillance.

Agencies Monitor Surveillance Capacity- Building Activities and Have Begun to
Evaluate Programs' Impact

The U.S. agencies operating or supporting the disease surveillance
capacity building programs collect data to monitor the programs'
activities. CDC and USAID also recently began systematic efforts to
evaluate program impact, but it is too early to assess whether the
evaluations will demonstrate progress in building surveillance capacity.

           o GDD. Since 2006, CDC has monitored the number of outbreaks that
           GDD has investigated, the numbers of participants in GDD long-term
           and short-term training, and examples of collaboration among GDD
           country programs. In addition, in 2006, CDC developed a framework
           for evaluating progress toward GDD's five goals^24 and collected
           data for 8 of 14 indicators. (Fig. 3 shows the GDD evaluation
           framework.) However, as of July 2007, the agency had not collected
           data on the two surveillance indicators to evaluate the program's
           contribution to improved surveillance.

^23A breakdown of individual project data is not available prior to 2005,
which is when GEIS began awarding funding for individual projects to the
DOD overseas laboratories. Prior to that, GEIS obligated a fixed amount to
each laboratory.

^24GDD's five goals are surveillance, research, outbreak response,
networking, and training.

Figure 3: Framework for Evaluating Impact of GDD

           o FETP. CDC has collected data such as the numbers of FETP
           trainees and graduates, the numbers of FETP graduates hired by
           public health ministries, the number of outbreak investigations
           conducted, and the number of surveillance evaluations conducted.
           In 2006, CDC developed a framework for monitoring and evaluating
           FETPs' impact on countries' health systems, with 13 indicators
           related to FETP activities (see fig. 4 for the FETP indicators).
           CDC hopes to implement the framework fully by 2009, but because
           FETPs are collaborations between CDC and the host countries, the
           framework's implementation depends on country cooperation.

Figure 4: Indicators for Evaluating Impact of FETPs

           o IDSR. Since 2000, CDC has collected data on activities completed
           under its IDSR assistance program, including the number of job
           aids developed, the training materials adopted, and the number of
           training courses completed, and it reports on these activities
           annually to USAID. In 2003, WHO/AFRO adopted 11 indicators,
           developed with input from CDC and USAID, to monitor and evaluate
           progress in implementing IDSR in Africa (see fig. 5 for the IDSR
           indicators). According to WHO/AFRO, 19 of 46 African countries
           reported data in 2006 for at least some of these indicators,
           showing some success in IDSR implementation; however, U.S.
           agencies cannot require the collection of data in the remaining
           countries that did not report on the indicators, because IDSR is a
           country-owned program. Separately, in 2005, CDC completed an
           evaluation of IDSR implementation in 4 of the 8 countries where it
           assists with IDSR--Ghana, Tanzania, Uganda, and Zimbabwe--and,
           using a set of 40 indicators based on WHO guidance,^25 found that
           these countries had implemented most of the elements of IDSR.

^25World Health Organization, Protocol for the Assessment of National
Communicable Disease Surveillance and Response Systems: Guidelines for
Assessment Teams, WHO/CDS/CSR/ISR/2001.2 (Geneva: 2001).

Figure 5: Indicators for Evaluating Impact of IDSR

           o GEIS. Since 2005, DOD has monitored GEIS capacity-building
           activities through individual project reports that detail each
           activity completed, such as training for staff involved in
           surveillance studies and development of laboratory diagnostic
           capabilities. According to GEIS officials, DOD does not plan to
           develop a framework to monitor and evaluate the impact of GEIS on
           countries' surveillance capacity, because capacity building in
           host countries is not GEIS's primary purpose. Rather, GEIS's goal
           is to establish effective infectious disease surveillance and
           detection systems with the ultimate aim of ensuring the health of
           U.S. forces abroad. However, GEIS has reviewed some of its
           surveillance projects,^26 and GEIS officials stated that the
           program's activities in the host nations have led to improved
           surveillance capacity for infectious diseases.

Mr. Chairman, this concludes my statement. I would be happy to respond to
any questions you or other members of the subcommittee may have at this
time.

^26In addition, the Institute of Medicine completed a review of GEIS in
2001 and DOD officials told us that IOM was nearing completion of a second
evaluation of GEIS pandemic influenza activities as of September 2007.

GAO Contact and Staff Acknowledgment

For further information about this testimony, please contact David
Gootnick at (202) 512-3149 or [email protected]. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on the
last page of this statement. Audrey Solis, Julie Hirshen, Reid Lowe,
Diahanna Post, Elizabeth Singer, and Celia Thomas made key contributions
to this testimony and the report on which it was based. David Dornisch,
Etana Finkler, Grace Lui, Susan Ragland, and Eddie Uyekawa provided
technical assistance.

(320550)

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Highlights of [33]GAO-08-138T , a testimony before the Subcommittee on
Oversight of Government Management, the Federal Workforce, and the
District of Columbia, Senate Committee on Homeland Security and
Governmental Affairs

October 4, 2007

GLOBAL HEALTH

U.S. Agencies Support Programs to Build Overseas Capacity for Infectious
Disease Surveillance

The rapid spread of severe acute respiratory syndrome (SARS) in 2003
showed that disease outbreaks pose a threat beyond the borders of the
country where they originate. The United States has initiated a broad
effort to ensure that countries can detect outbreaks that may constitute a
public health emergency of international concern. Three U.S. agencies--the
Centers for Disease Control and Prevention (CDC), the U.S. Agency for
International Development (USAID), and the Department of Defense
(DOD)--support programs aimed at building this broader capacity to detect
a variety of infectious diseases.

This testimony describes (1) the obligations, goals, and activities of
these programs and (2) the U.S. agencies' monitoring of the programs'
progress. To address these objectives, GAO reviewed budgets and other
funding documents, examined strategic plans and program monitoring and
progress reports, and interviewed U.S. agency officials. GAO did not
review capacity-building efforts in programs that focus on specific
diseases, namely polio, tuberculosis, malaria, avian influenza, or
HIV/AIDS.

This testimony is based on a report (GAO-07-1186) being released today in
conjunction with the hearing. GAO did not make recommendations. The
agencies whose programs we describe reviewed our report and generally
concurred with our findings. We incorporated their technical comments as
appropriate.

The U.S. government operates or supports four key programs (as shown in
the graphic below) aimed at building overseas surveillance capacity for
infectious diseases. In fiscal years 2004-2006, U.S. agencies obligated
approximately $84 million for these programs, which operate in developing
countries around the world. Global Disease Detection is CDC's main effort
to help build capacity for infectious disease surveillance in developing
countries. The Field Epidemiology Training Programs, which CDC and USAID
support, are another tool used to help build infectious disease
surveillance capacity worldwide. Additionally, USAID supports CDC and the
World Health Organization's Regional Office for Africa in designing and
implementing Integrated Disease Surveillance and Response in 46 countries
in Africa, with additional technical assistance to 8 African countries.
DOD's Global Emerging Infections Surveillance and Response System also
contributes to capacity building through projects undertaken at DOD
overseas research laboratories. USAID supports additional
capacity-building projects in various developing countries.

For each of the four key surveillance capacity-building programs, the U.S.
agencies monitor activities such as the number of epidemiologists trained,
the number of outbreak investigations conducted, and types of laboratory
training completed. In addition, CDC and USAID recently began systematic
efforts to evaluate the impact of their programs; however, because no
evaluations had been completed as of July 2007, it is too early to assess
whether these evaluation efforts will demonstrate progress in building
surveillance capacity.

Four U.S.-Supported Programs to Build Overseas Capacity for Surveillance
of Infectious Disease

References

Visible links
  17. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1186
  18. http://www.gao.gov/cgi-bin/getrpt?GAO-07-652
  19. http://www.gao.gov/cgi-bin/getrpt?GAO-07-604
  20. http://www.gao.gov/cgi-bin/getrpt?GAO-07-696
  21. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1186
  22. http://www.gao.gov/cgi-bin/getrpt?GAO-01-722
  23. http://www.gao.gov/cgi-bin/getrpt?GAO-07-604
  24. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1186
  25. http://www.gao.gov/cgi-bin/getrpt?GAO-06-15
  26. http://www.gao.gov/
  27. http://www.gao.gov/
  28. http://www.gao.gov/fraudnet/fraudnet.htm
  29. mailto:[email protected]
  30. mailto:[email protected]
  31. mailto:[email protected]
  32. http://www.gao.gov/cgi-bin/getrpt?GAO-08-138T
  33. http://www.gao.gov/cgi-bin/getrpt?GAO-08-138T
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