IV. Infectious Diseases

FY 2000 Performance Plan - Revised Final FY 1999 Performance Plan

• Emerging Infections
• Tuberculosis
• HIV/AIDS
• Sexually Transmitted Diseases

Once expected to be eliminated as a public health problem, infectious diseases remain the leading cause of death worldwide. In the U.S. and elsewhere, infectious diseases increasingly threaten public health and contribute significantly to the escalating costs of health care. They are a continuing menace to all segments of society, regardless of age, gender, lifestyle, ethnic background and socioeconomic status. Earlier predictions of the elimination of infectious disease did not take into account changes in demographics and human behaviors and the extraordinary ability of microbes to adapt, evolve, and develop resistance to drugs. As early as the 1950s, penicillin began to lose its power to cure infections caused by Staphylococcus aureas, a common bacterium that can cause serious illness. In 1957 and 1968, new strains of influenza emerged in China and spread rapidly around the globe, and in the 1970s there was a resurgence of sexually transmitted diseases. Also during the 1970s, several new diseases were identified including Legionnaires' disease, Lyme disease, toxic shock syndrome, and Ebola hemorrhagic fever. Between 1973 and 1995, thirty newly emerging infectious diseases were identified, including hepatitis C virus (HCV) infection, now shown to be the most common bloodborne infection in the U.S. The re-emergence of diseases such as TB, malaria, rabies, dengue, and growing drug resistance of many pathogens continued to dramatically change the global and domestic landscape of infectious diseases. By the early 1990s, it had been demonstrated that the threat of infectious diseases was increasing in the United States and elsewhere.

Emerging Infections

In 1994, CDC began working with other federal agencies, state and local health departments, and other partners to strengthen our Nation's capacity to recognize and respond to infectious disease threats through implementation of the CDC plan, Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States. The effort to build U.S. capacity to combat infectious diseases is well underway. However, the fulfillment of CDC's vision of a safer world in the next millennium requires a long-term commitment and sustained effort. The second phase of CDC's effort, Preventing Emerging Infectious Diseases: A Strategy for the 21st Century, has involved taking into account new challenges and building on experience, success, and knowledge gained from the initial plan.

The National Center for Infectious Diseases' (NCID's) performance plan continues to evolve, not only to reflect updated strategies, but to address the challenges posed by new and resurgent infectious disease threats. For example, the recent recognition of an avian strain of influenza in Hong Kong raised the specter of an influenza pandemic. Such a pandemic will have a high death rate, carry with it a huge economic burden, and create massive disruption of public life. A Hepatitis C Virus (HCV) epidemic affecting almost 4 million Americans of whom about 7% may have acquired their infection through blood

transfusion, has also been recognized. The emergence of drug resistance in bacteria, parasites, viruses, and fungi is swiftly reversing advances of the previous 50 years. As we approach the 21st century, many important drug choices of the treatment of common infections are becoming increasingly limited and expensive, and in some cases, nonexistent. This year's performance plan has been updated to include major program efforts for HCV infection, antimicrobial resistance, and bioterrorism. The bioterrorism component of infectious diseases builds on the epidemiologic and laboratory enhancements for emerging diseases, focusing on targeted bioterrorism and unknown threat agents, including weapons of mass destruction (WMD). It strengthens surveillance through a national network of State and major metropolitan area laboratories for early identification and characterization of disease outbreaks.

CDC's efforts focus on building epidemiology and laboratory capacity, recognizing that at STRONGpublic health infrastructure will lead to improved surveillance, a better understanding of disease determinants, interventions, that will prevent and control disease outbreaks, and ultimately , reduced morbidity and mortality (Figure 2). The updated objectives focus on intramural activities (objective 1) and technology transfer to state and local health departments and internationally (objective 2) that will result in an improved public health infrastructure to combat infectious disease threats.

Although ultimately the goal for infectious diseases is reduced morbidity and mortality, before this can occur, our nation's public health infrastructure must be rebuilt before we will see reductions in disease. For many infectious disease programs, including CDC's food safety activities, improvements in our ability to recognize and track these diseases and improved "early warning" surveillance systems will result in an increase in the number of reported cases and outbreaks before there is a downward trend resulting from effective prevention programs. As the capacity for surveillance and response becomes established, such as it is for Group B streptococcus, measures of success will be reflected by reductions in the number of cases.

Performance Goals and Measures

Performance Goal: Develop and strengthen epidemiologic and laboratory methods for detecting, controlling, and preventing infectious diseases.

Performance Measures:

FY Baseline	FY 1999 Appropriated	FY 2000 Estimate
Assays are not currently available for public health use (FY 1998).		Assays to detect HIV mutations that are resistant to commonly used therapeutic agents will be developed and optimized.
Assays are not currently being applied in public health settings. (FY 1998).		Assays for assessment of the duration, severity, and prognosis of HIV infection will be developed, optimized, and evaluated.
0 state/local health departments provided with support for Hepatitis C Virus (HCV) counseling, testing and referral demonstration sites (FY 1998).		9 State/local health departments provided with support for HCV counseling, testing, and referral demonstration sites.
0 sentinel surveillance systems for acute and chronic Hepatitis C Virus (FY 1998).	Sentinel surveillance system for acute and chronic HCV will be developed and pilot tested.	Sentinel surveillance system for acute and chronic HCV will be established in select sites.
15 large or unusual outbreaks of diarrheal and/or foodborne illness will be detected and investigated. (FY 1997).	23 large or unusual outbreaks of diarrheal and/or foodborne illness will be detected and investigated.	24 large or unusual outbreaks of diarrheal and/or foodborne illness will be detected and investigated.
40% of reported foodborne outbreaks with identified toxin or causative organism (FY 1998).	The proportion of reported foodborne outbreak investigations in which the causative organism or toxin is identified will be increased to 45%.	The proportion of reported foodborne outbreak investigations in which the causative organism or toxin is identified will be maintained at 50%.
The proportion of reported foodborne outbreak in which the food that caused the outbreak is identified is 45% (FY 1998).	The proportion of reported foodborne outbreaks in which the food that caused the outbreak is identified will be increased to 50%.	The proportion of reported foodborne outbreaks in which the food that caused the outbreak is identified will be greater than 50%.
3 extramural surveillance networks (1997).	4 extramural domestic and global surveillance networks will monitor conditions including antimicrobial resistance, threats from transfusion of blood and blood products; infectious diseases among travelers and immunosuppressed and under-served populations.	5 extramural domestic and global surveillance networks will monitor conditions including antimicrobial resistance, threats from transfusion of blood and blood products; infectious diseases among travelers and immunosuppressed and under-served populations.
Baselines are being collected.		Develop baseline data to better estimate the number of occupationally acquired blood borne infections (i.e., hepatitis B virus, HCV, HIV, varicella, and TB).
17 extramural awards will be provided to conduct enhanced research investigation to assist in development and improvement of diagnostic tests (FY 1997).	22 extramural awards will be provided to conduct enhanced research investigations to assist in development and improvement of diagnostic tests for use in areas such as antimicrobial resistance, sexually transmitted diseases, malaria, Lyme disease, health-care associated infections, and blood safety.	22 extramural awards will continue to be provided to conduct enhanced research investigations to assist in development and improvement of diagnostic tests for use in areas such as antimicrobial resistance, sexually transmitted diseases, malaria, Lyme disease, health-care associated infections, and blood safety.

Performance Goal: Strengthen domestic and global epidemiologic and laboratory capacity for surveillance and response to infectious disease and bioterrorist threats.

Performance Measures:

FY Baseline	FY 1999 Appropriated	FY 2000 Estimate
0 States electronically linked (1998)		6 State health departments will be electronically linked with CDC to provide TB results from overseas screening and U.S. follow-up assessments of both immigrants and refugees.
30 States supported (FY 1998).	33 States will have increased epidemiologic and laboratory capacity for surveillance and response.	43 states will have increased epidemiologic and laboratory capacity for surveillance and response.
Within 24 hours urgent results reported (FY 1997). Within 2 weeks routine requests reported (FY 1997).	The time for providing parasitic diseases reference laboratory diagnostic results to state laboratories will be improved in urgent situations, from 24 hours to 2 hours, and in routine cases, from 2 weeks to 2 days, in 90% of the requests.	Reduced time for providing reference laboratory diagnostic results in 90% of requests received will be maintained as 5 additional state/local laboratories are added to DPDx, CDC's Website for the diagnosis of parasitic diseases.
10 states provided training in Calicivirus, Bartonella, and Ehrlichia diagnostics (1999)		Training will be provided to at least 18 states in Calicivirus, Bartonella, and Ehrlichia diagnostics.
13 Fellows trained (1997)	40 Public Health Fellows will be trained and available for employment in local, state, and federal public health laboratories.	70 Public health microbiology fellows will be trained and available for employment in local, state and federal public health laboratories.
0% Countries with antimalArial drug resistance surveillance system (FY 1999).		Consistent with the Multilateral Initiative on Malaria, and in collaboration with WHO and participating countries, a surveillance system will be established to collect data on antimalArial drug resistance in 50% of sub-Saharan African countries.
10% participation by federally supported U.S. hemophilia treatment centers (1999).		Participation by federally supported U.S. hemophilia treatment centers (HCTs) in CDC's newly implemented Universal Data Collection (UDC) system, which is designed to monitor the safety of blood products and to track the health of persons with bleeding disorders, will be 60%.
2 countries with surveillance of unusual HIV variants (1999).		Surveillance for unusual HIV variants will be expanded from the current two countries to an additional six countries.
7 Emerging Infections Programs conducted early warning investigations (FY 1997).	9 regional population-based Emerging Infections Programs will conduct early warning investigations of agents of infectious diseases.	10 regional population-based Emerging Infections Programs will conduct early warning investigations of agents of infectious diseases.
0 enhanced surveillance for influenza in 45 state and local health departments.		Enhanced surveillance for influenza will be initiated in 45 state and local departments.
0 states with enhanced foodborne surveillance and control activities for E. coli 0157:H7 (FY 1997).	Enhanced basic foodborne disease surveillance and control activities, for E. coli 0157:H7, will be available in 29 states and will be expanded to include Salmonella Typhimurium in 7 states.	Establish and enhance 8 active FoodNet foodborne surveillance sites. Expand state health department capacity to subtype and rapidly exchange information using PulseNet for E. coli (currently 29 Labs) and Salmonella Typhimirium (currently 7 labs) to 40 labs for each.
0 state/local health departments and hospitals provided support for surveillance, prevention, and control of antimicrobial resistance (FY 1998).		15 state/local health departments and hospitals provided support for surveillance, prevention and control of antimicrobial resistance.
17 Health Care Facilities conducted surveillance of occupation exposures and infections (FY 1998).	The number of health care facilities that conduct surveillance of occupation exposures and infections using the national Surveillance System for Health Care Workers (NaSH) will be increased to 50.	The number of health care facilities that conduct surveillance of occupation exposures and infections using the national Surveillance System for Health Care Workers (NaSH) will be increased to 100.
0 Laboratory-based surveillance for Helicobacter pylori.	Laboratory -based surveillance for Helicobacter pylori will be established at three Alaska Native regional hospitals.	Laboratory -based surveillance for Helicobacter pylori will be maintained at three Alaska Native regional hospitals.
The baseline incidence of	The incidence of perinatal	The incidence of perinatal Group B streptococcal infections
150 Daily dose per 1000 patient days (FY 1998).		The rate of inappropriate antimicrobial use will be reduced to < 100 daily doses per 1000 patient days as measured through the National Nosocomial Infections Surveillance (NNIS) System.
The scope of the active surveillance network for foodborne diseases (FoodNet) is 7 sites (FY 1997).	The scope of the active surveillance network for foodborne diseases (FoodNet) will be expanded to 8.	The scope of the active surveillance network for foodborne diseases (FoodNet) will be maintained at 8.
0 national state-based laboratory network for detection of bioterrorist agents (FY 1998).		Establish a national state-based laboratory network for detection of bioterrorist agents.
0 Training/technology transfer programs for state-of-art diagnostics for use in bioterrorism (FY 1998).		10 Training/technology transfer programs for state-of-art diagnostics for use in bioterrorism.
		Increase the number of state and local health departments that have integrated various electronic surveillance systems and have electronic linkages to the medical community. These electronic systems include: Emerging Infectious Diseases , food safety, and bioterrorism surveillance systems, as well as the National Electronic Telecommunications System for Surveillance, the Sexually Transmitted Diseases Management Information System, and the HIV/AIDS surveillance systems.
Program Activity Funding	$137,636	$181,926

Verification/Validation of Performance Measures: Successful accomplishment of these objectives will, in part, be verified using data submitted from funded states. Performance, in these instances, will be verified through on-site technical assistance and periodic visits and progress reviews. Other data are monitored using published and unpublished studies and recommendations.

Links to DHHS Strategic Plan

These performance measures are related to the DHHS Goal 1: To promote health and reduce major threats to health and productive lives for all Americans; DHHS Goal 5: Improve public health and safety systems; and DHHS Goal 6: Strengthen the Nation's science base for health and human services. To accomplish these objectives, CDC collaborates with a number of agencies and organizations including: Council of State and Territorial Epidemiologists, Association of State and Territorial Public Health Laboratory Directors, National Institutes of Health, Food and Drug Administration, Department of Agriculture, Department of Interior (U.S. Fish and Wildlife), Department of Justice (U.S. Immigrations and Naturalization Service), Department of State, Department of Treasury (U.S. Customs), and the GeoSentinel project.

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