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entitled 'Global Health: U.S. Agencies Support Programs to Build 
Overseas Capacity for Infectious Disease Surveillance' which was 
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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

September 2007: 

Global Health: 

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

Global Health: 

GAO-07-1186: 

GAO Highlights: 

Highlights of GAO-07-1186, a report to congressional requesters. 

Why GAO Did This Study: 

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

This report describes (1) the obligations, goals, and activities of 
these programs and (2) the U.S. agenciesí monitoring of the programsí 
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. GAO is not making any recommendations. 

The U.S. agencies whose programs we describe reviewed a draft of this 
report and generally concurred with our findings. They also provided 
technical comments, which we incorporated as appropriate. 

What GAO Found: 

The U.S. government operates or supports four key programs 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 CDCís main effort to 
build capacity for infectious disease surveillance in developing 
countries. The Field Epidemiology Training Programs, which CDC and 
USAID support, are another tool used to build infectious disease 
surveillance capacity worldwide. Additionally, USAID supports CDC and 
the World Health Organizationís 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. DODís 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. 
The responsible agencies coordinate with each other to limit 
duplication of their overseas efforts. 

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. 

Figure: U.S.-Supported Programs for Build Overseas Capacity for 
Surveillance of Infectious Disease: 

[See PDF for image] 

Source: GAO; Map Resources (map clip art). 

[End of figure] 

To view the full product, including the scope and methodology, click on 
GAO-07-1186. For more information, contact David Gootnick at (202) 512-
3149 or gootnickd@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Four Programs Support Capacity Building for Overseas Surveillance of 
Infectious Diseases: 

Agencies Monitor Surveillance Capacity-Building Activities, and CDC and 
USAID Have Begun Efforts to Evaluate Programs' Impact: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: GDD: 

Appendix III: FETP: 

Appendix IV: IDSR: 

Appendix V: GEIS: 

Appendix VI: Comments from the Department of Defense: 

Appendix VII: Comments from the Department of Health and Human 
Services: 

Appendix VIII: Comments from the U.S. Agency for International 
Development: 

Appendix IX: GAO Contact and Staff Acknowledgments: 

Tables: 

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

Table 2: Overview of GDD Center Activity Data: 

Table 3: FETP Trainees and Graduates by Country, 2004-2006: 

Table 4: Examples of Country-Specific IDSR Activities Supported by CDC 
and USAID, 2004-2006: 

Table 5: GEIS Projects with Capacity-Building Components, 2005: 

Table 6: GEIS Projects with Capacity-Building Components, 2006: 

Figures: 

Figure 1: Elements of a Disease Surveillance System: 

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

Figure 3: Framework for Evaluating Impact of GDD: 

Figure 4: Indicators for Evaluating Impact of FETPs: 

Figure 5: Indicators for Evaluating Impact of IDSR: 

Abbreviations: 

CDC: Centers for Disease Control and Prevention: 

DOD: Department of Defense: 

FETP: Field Epidemiology Training Program: 

GDD: Global Disease Detection: 

GEIS: Global Emerging Infections Surveillance and Response System: 

HHS: Department of Health and Human Services: 

IDSR: Integrated Disease Surveillance and Response: 

IEIP: International Emerging Infections Program: 

IHR: International Health Regulations: 

USAID: U.S. Agency for International Development: 

WHO: World Health Organization: 

WHO/AFRO: World Health Organization's Regional Office for Africa: 

United States Government Accountability Office: 

Washington, DC 20548: 

September 28, 2007: 

The Honorable Daniel K. Akaka: 

Chairman: 

Subcommittee on Oversight of Government Management, the Federal: 

Workforce, and the District of Columbia: 

Committee on Homeland Security and Governmental Affairs: 

United States Senate: 

The Honorable Dianne Feinstein: 

United States Senate: 

Infectious diseases are a leading cause of deaths worldwide and 
represent the third most common cause of death in the United States. As 
the rapid spread of severe acute respiratory syndrome (SARS) showed in 
2003, 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 outbreaks that may constitute a public health 
emergency of international concern. Three U.S. agencies--the Department 
of Health and Human Services' (HHS) 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. 

You asked us to describe U.S. efforts to build developing countries' 
broader capacity for infectious disease surveillance. This report 
examines (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. We did 
not review capacity-building efforts in programs that focus on specific 
diseases, namely polio, tuberculosis, malaria, avian influenza, and 
HIV/AIDS. 

To describe the obligations, goals, and activities of the key U.S. 
programs to develop epidemiology and laboratory capacity for 
surveillance of infectious diseases in 2004-2006,[Footnote 1] 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 the Global Emerging Infections 
Surveillance and Response System (GEIS). We also identified funding 
from USAID missions for these activities; examined CDC, DOD, and USAID 
strategic plans for combating infectious diseases abroad; and reviewed 
annual, progress, and accomplishment reports. In addition, we 
interviewed CDC, DOD, Department of State, USAID, and World Health 
Organization (WHO) officials responsible for implementing capacity- 
building activities. To assess how agencies were measuring the progress 
of their programs in building infectious disease surveillance capacity, 
we analyzed progress and accomplishment reports for all four programs, 
GDD and FETP frameworks for monitoring and evaluation, IDSR indicators 
to evaluate the success of the program, and assessments of the FETPs. 
Additionally, we interviewed officials from the respective programs and 
from WHO to understand how they monitored program progress. We 
determined that the budget and performance data that we obtained had 
some limitations, which are described in appendix I, but were 
sufficiently reliable for our purposes. We conducted our work from 
October 2006 through July 2007 in accordance with generally accepted 
government auditing standards. (For additional details on our 
objectives, scope, and methodology, see app. I.) 

Results in Brief: 

In 2004-2006, CDC, USAID, and DOD obligated about $84 million for four 
key programs and additional activities to develop capacity for the 
surveillance and detection of infectious diseases abroad.[Footnote 2] 

* GDD. CDC obligated about $31 million for GDD capacity-building 
activities conducted at GDD centers in five countries.[Footnote 3] The 
program's priorities are enhancing surveillance, conducting research, 
responding to outbreaks, facilitating networking, and training 
epidemiologists and laboratorians. Activities undertaken at GDD centers 
include laboratory-strengthening efforts in Kenya and Thailand and long-
term and short-term programs providing epidemiology training. 

* FETPs. CDC and USAID obligated approximately $19 million to support 2-
year training programs, in collaboration with host-country governments, 
aimed at building infectious disease surveillance capacity in 24 
countries. In 2004-2006, the programs trained approximately 351 
epidemiologists and laboratorians. 

* IDSR. USAID obligated approximately $12 million, transferring about 
one-quarter of this amount to CDC through interagency agreements and 
participating agency service agreements, to support CDC and WHO's 
Regional Office for Africa (WHO/AFRO) in designing and implementing 
IDSR in 46 countries in the African region, with additional technical 
assistance to 8 African countries. The program's goal is to integrate 
countries' existing disease-specific surveillance and response systems 
and link surveillance, laboratory confirmation, and other data to 
public health actions. CDC's activities included, among others, 
evaluating the quality of laboratories, 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. 

* GEIS. For 2005-2006,[Footnote 4] DOD obligated approximately $8 
million through GEIS to more than 60 projects for infectious disease 
surveillance that helped build capacity in five developing countries 
where the department has overseas research laboratories. Many of the 
GEIS projects are conducted jointly with host-country nationals. The 
primary goal of the GEIS program is conducting surveillance of 
infectious diseases abroad to protect military health and readiness; 
capacity building occurs through its surveillance activities that focus 
on this goal. GEIS activities include, for example, establishing 
laboratories in host countries, training host-country staff in 
surveillance techniques, and providing advanced diagnostic equipment. 

* Additional activities. USAID's Bureau for Global Health and USAID 
missions obligated about $14 million in 2004-2006 for a number of 
additional activities that support the agency's strategy to build 
infectious disease surveillance capacity. The missions have supported 
activities such as a WHO-India effort to assist the government of India 
in strengthening disease surveillance--including building laboratory 
capacity, developing tools for monitoring and evaluation, and creating 
operational manuals for disease surveillance--and training public 
health personnel in epidemiological surveillance in yellow and dengue 
fever in Bolivia. 

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 various working group meetings, 
and communicating by phone. 

The U.S. agencies monitor activities for the four key surveillance 
capacity-building programs, and CDC and USAID recently developed 
frameworks linking these activities to program goals in order to 
systematically measure their programs' impact on disease surveillance 
capacity. The three agencies monitor activities such as the number of 
epidemiologists trained, the number of outbreak investigations 
conducted, and development of laboratory diagnostic capabilities. In 
addition, CDC and USAID recently developed frameworks to evaluate their 
capacity-building programs. For example, CDC developed frameworks in 
2006 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. 

DOD, HHS, and USAID provided written comments on a draft of this 
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. 

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. The potential threat of 
bioterrorism and the emergence of previously unknown diseases, such as 
Ebola hemorrhagic fever and SARS, as well as the development of strains 
resistant to antimicrobial drugs,[Footnote 5] such as multidrug- 
resistant tuberculosis, further complicate international disease 
control efforts. The U.S. government's reaction to the recent case of a 
U.S. citizen with multidrug-resistant tuberculosis boarding several 
planes, crossing a number of international borders, and entering 
several countries illustrates the government's increasing concern 
regarding the spread of infectious disease. Moreover, the global reach 
of avian influenza--spread by birds and sometimes infecting humans--is 
now confirmed, with human outbreaks in 12 countries throughout 
Southeast Asia, the Middle East, and Africa as of 2007. The spread of 
infectious diseases also has economic consequences: for instance, in 
2004, the SARS crisis cost Asian economies from $11 billion to $18 
billion.[Footnote 6] 

Surveillance provides essential information for action against 
infectious disease threats. Basic surveillance involves four functions: 
(1) detecting cases of disease in a population and reporting the 
information, (2) analyzing and confirming reported information to 
detect outbreaks, (3) providing timely and appropriate response to 
disease outbreaks, and (4) providing information to assist in longer- 
term management of health care policies and programs. (See fig. 1.) 

Figure 1: Elements of a Disease Surveillance System: 

[See PDF for image] 

Source: GAO analysis. 

[End of figure] 

Disease surveillance is commonly performed through passive surveillance 
or active surveillance. In a passive surveillance system, national or 
district-level authorities prepare a list of "notifiable" diseases and 
guidelines for their diagnosis and then rely on local health care 
providers to detect and report cases of these diseases. In the United 
States, more than 50 diseases are considered notifiable at the national 
level. In an active surveillance system, health workers canvass the 
population, seeking possible cases of notifiable diseases. For example, 
active surveillance has been a prominent feature of the international 
campaign to eradicate polio. For both passive surveillance and active 
surveillance systems, public health officials at the district, 
national, and, sometimes, international levels aggregate and conduct 
epidemiological analyses of the collected data, looking for trends and 
examining how diseases may be clustered in certain locations or certain 
groups of people, to determine if an outbreak is occurring that 
requires a response. For greater accuracy, public health officials 
often require laboratory analysis of a disease to confirm or clarify 
initial diagnoses made by individual health care providers and to 
initiate a relevant and appropriate response. This is particularly 
important in developing countries, where local diagnostic capacity is 
often quite limited. 

Global efforts to improve disease surveillance have historically 
focused on specific diseases or groups of diseases. We previously found 
that the international community had 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.[Footnote 7] More recently, in 
2005-2006, USAID planned $15 million in funding for surveillance of 
pandemic strains of influenza in humans. These disease-specific efforts 
can build capacity for surveillance of additional diseases as well; a 
study of the polio eradication initiative in Africa found that at least 
25 countries expanded their polio surveillance systems to include 
additional diseases, such as measles, neonatal tetanus, cholera, 
meningitis, and yellow fever.[Footnote 8] But surveillance for diseases 
not targeted on a specific list is weaker than disease-specific 
surveillance, leaving populations potentially vulnerable to emerging, 
previously unknown infections.[Footnote 9] For instance, disease 
experts believe that decades before WHO called for worldwide 
surveillance of HIV/AIDS in 1981, the virus was appearing, unrecognized 
and undetected, in humans. 

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. In 2003, the National Academy of Sciences emphasized the 
role of building capacity for disease surveillance in other countries, 
recommending that "the United States should seek to enhance the global 
capacity for response to infectious disease threats, focusing in 
particular on threats in the developing world." Among the critical 
deficiencies the report documented was the need to strengthen national 
and regional technical capacities for infectious disease 
surveillance.[Footnote 10] 

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.[Footnote 11] 

Four Programs Support Capacity Building for Overseas Surveillance of 
Infectious Diseases: 

U.S. agencies operate or support four key programs aimed at building 
overseas surveillance capacity for infectious diseases. In 2004-2006, 
the agencies obligated approximately $84 million for these programs in 
developing countries around the world. GDD is CDC's main effort to 
build public health capacity for infectious disease surveillance in 
developing countries. FETPs, which CDC and USAID support, are used to 
build infectious disease surveillance capacity worldwide. Additionally, 
USAID supports CDC and WHO/AFRO in designing and implementing IDSR in 
46 countries in the African region with additional technical assistance 
to 8 countries. DOD's GEIS also contributes to capacity building 
through projects undertaken at DOD overseas research laboratories. 
USAID supports additional capacity-building projects in various 
developing countries. To limit duplication, the agencies responsible 
for the various programs coordinate their overseas efforts. 

U.S. Obligations to Build Capacity for Infectious Disease Surveillance: 

In 2004-2006, the U.S. government obligated about $84 million for 
programs and activities to build capacity for surveillance of 
infectious diseases in developing countries (see table 1). Funding for 
the four key programs supports 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: 

Dollars in millions. 

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

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

Program: [Empty]; 
Agency: USAID; 
2004: 2; 
2005: 3; 
2006: 1; 
Obligations: Amounts Provided only as 2004-2006 aggregates: $6; 
Obligations: Total: $12. 

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

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

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

Total; 
Agency: [Empty]; 
2004: $17; 
2005: $28; 
2006: $25; 
Obligations: Amounts Provided only as 2004-2006 aggregates: $14; 
Obligations: Total: $84. 
 
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 app. I. 

[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. 

[End of figure] 

Collectively, these four programs operate in 26 developing countries. 
(See fig. 2.) 

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

[See PDF for image] 

Sources: GAO; Map Resources (map clip art). 

[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. 

[End of figure] 

Global Disease Detection: 

CDC obligated about $31 million for GDD capacity-building activities in 
2004-2006. According to CDC, GDD is its primary effort to build public 
health capacity to detect and respond to existing and emerging 
infectious diseases in developing countries.[Footnote 12] GDD's goals 
are to: 

* enhance surveillance, 

* conduct research, 

* respond to outbreaks, 

* facilitate networking, and: 

* train epidemiologists and laboratorians. 

GDD, established in 2004, aims to set up a total of 18 international 
centers[Footnote 13] 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. Five GDD centers already exist: 2 were established in 
Kenya and Thailand in 2004,[Footnote 14] and 3 more are currently under 
development in Egypt, China, and Guatemala.[Footnote 15] In addition, 
CDC established a GDD Operations Center in Atlanta to coordinate 
information related to potential outbreaks.[Footnote 16] Funds that CDC 
obligated for GDD have been used for capacity building as well as for 
conducting outbreak response, research, and networking. 

According to CDC officials, GDD capacity-building activities include 
laboratory-strengthening efforts in countries where GDD centers are 
located, long-term and short-term activities providing epidemiology 
training,[Footnote 17] and participation in surveillance activities. 

* Laboratory-strengthening efforts. Efforts to build laboratory 
capacity in Kenya and Thailand have focused on establishing 
laboratories[Footnote 18] with advanced diagnostic capabilities, which 
can be used to support outbreak investigations and facilitate training. 
For example, in Kenya, CDC established biosafety level 2 and 3 
laboratories in Nairobi and a biosafety level 2 laboratory in 
Kisumu.[Footnote 19] Supporting the need for specialized training in 
Thailand, CDC, in collaboration with WHO's Southeast Asia Regional 
Office and the Thai Ministry of Health, conducted a workshop focused on 
diagnosing, treating, and preventing exposure to anthrax. 

* Epidemiology training programs and activities. Training at the GDD 
centers occurs formally through long-term applied epidemiology training 
programs[Footnote 20] and informally through the participation of host- 
country nationals in short-term activities focused on outbreak 
response, surveillance, and research. 

* Long-term programs. Trainees in the formal, 2-year epidemiology 
training programs[Footnote 21] get hands-on experience in analyzing 
data, responding to outbreaks, and working on research projects that 
provide capacity-building opportunities through experience-based 
training. Graduates of these programs are counted under the FETPs. 

* Short-term activities. Host-country nationals participated in short- 
term GDD training activities. For example, in 2006, GDD centers trained 
230 participants from 32 countries to respond to pandemics and trained 
90 staff to diagnose avian influenza. Also in 2006, host-country 
nationals, in collaboration with CDC, responded to more than 144 
outbreaks in China, Kenya, and Thailand. CDC officials told us that 
these collaborative efforts build capacity as host-country nationals 
work alongside CDC experts, learning new methods and techniques that 
can later be applied to future emerging diseases. 

Surveillance activities. Host-country nationals work with CDC to 
evaluate existing surveillance systems, develop new surveillance 
systems, write and revise peer-reviewed publications, and use 
surveillance data to inform policy decisions. For example, in 2002, CDC 
and Thai officials evaluated rural Thailand's pneumonia surveillance 
system. Through this effort, Thai health officials were involved in the 
collection of data related to the existing passive surveillance system, 
which demonstrated weaknesses in the training of personnel, the lack of 
a standard case definition, and an underreporting of deaths. 

Field Epidemiology Training Programs: 

With assistance from 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.[Footnote 22] 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. The programs emphasize: 

* applied epidemiology and evidence-based decision making for public 
health actions; 

* effective communication with the public, public health professionals, 
and the community; and: 

* health program design, management, and evaluation. 

CDC and USAID collaborate with host-country ministries of health in 
Brazil, Central America,[Footnote 23] Central Asia,[Footnote 24] China, 
Egypt, Ghana, India, Jordan, Kenya, Pakistan, South Africa, 
Sudan,[Footnote 25] Thailand, Uganda, and Zimbabwe[Footnote 26] 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, performing economic analysis, and 
describing health problems and initiating actions. They also publish 
articles in peer-reviewed bulletins and scientific journals. At the end 
of the 2-year program, which includes both classroom and on-the-job 
training in applied epidemiology and laboratory science, participants 
receive a postgraduate diploma or certificate. 

According to CDC, these programs graduated 351 epidemiologists and 
laboratorians in 2004-2006. As of February 2007, CDC reported, six 
programs established in 1999-2004[Footnote 27] 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 FETP 
graduates are working as epidemiologists at the central and governorate 
levels, and graduates from Brazil's FETP hold supervisory and staff 
epidemiology positions at the Ministry of Health. 

Integrated Disease Surveillance and Response: 

USAID has supported CDC and WHO/AFRO in designing and implementing IDSR 
in 46 African countries and providing technical assistance to 8 of 
these countries. USAID obligated approximately $12 million in 2004-2006 
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 utilize 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[Footnote 28]. 

CDC has collaborated with WHO/AFRO in developing tools and guidelines, 
which WHO/AFRO then disseminates for widespread use in the region to 
improve surveillance and response systems. CDC's assistance has 
included: 

* developing an assessment tool to determine the status of surveillance 
systems throughout Africa, 

* developing technical guidelines for implementing IDSR, 

* working to strengthen the national public health surveillance 
laboratory systems, and: 

* conducting evaluations of the cost to implement IDSR in several 
African countries. 

In addition, CDC is providing technical assistance to eight countries 
in Africa,[Footnote 29] 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 System: 

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 2004-2006, DOD obligated approximately 
$8 million through GEIS to build capacity for infectious disease 
surveillance. GEIS, as part of its mission, provides funding to the 
five DOD overseas research laboratories in Egypt, Indonesia, Kenya, 
Peru, and Thailand,[Footnote 30] as well as other military research 
units, for specific surveillance projects. DOD officials told us that 
these projects are located in 36 countries. GEIS officials 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. 

Although capacity building is not GEIS's primary goal, it conducts many 
projects jointly with host-country nationals, providing opportunities 
to build capacity through their participation in disease surveillance 
projects. GEIS funded more than 60 capacity-building projects in 2005 
and 2006,[Footnote 31] 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. According to DOD, this effort, along with several other 
projects at the site, transformed the laboratory from a facility for 
shipping specimens into a fully functional infectious disease 
surveillance laboratory. In Egypt, GEIS funded a surveillance system 
for the rotavirus, the most common cause of severe diarrhea among 
children. As part of this effort, clinicians and laboratorians in 
Libya, Bahrain, Jordan, Sudan, Syria, and Yemen were trained in 
conducting surveillance for this disease. 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 Activities Supporting Capacity Building: 

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. These activities 
include, for example, a WHO laboratory quality control effort in WHO's 
Africa and Eastern Mediterranean regions; a WHO-India 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; and training for public health personnel in 
epidemiological surveillance in yellow and dengue fever in Bolivia. 

Interagency Coordination of Overseas Efforts: 

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.[Footnote 32] 

* Colocation. CDC and DOD have colocated some programs to enhance 
coordination and communication and to facilitate information and 
resource sharing. For instance, CDC's GDD is colocated with DOD's 
research laboratory in Egypt, and CDC and DOD efforts are also 
colocated in Kenya. 

* Staff details. CDC has detailed staff to DOD facilities overseas--for 
example, in Peru and Cambodia--and both agencies have detailed staff to 
WHO in Geneva. Detailees provide technical assistance and facilitate 
information sharing, both between and within their own agencies, about 
activities to build infectious disease surveillance capacity. 

* Working groups. U.S. agencies also share information by participating 
in working groups focused on issues such as pandemic influenza. For 
example, CDC has participated in DOD's influenza working group for 
South East Asia since 2005. Topics discussed at these meetings include 
interagency collaboration and preventing overlap in the agencies' 
pandemic surveillance efforts. Likewise, representatives of USAID and 
CDC meet regularly to plan and define their appropriate roles and 
responsibilities, coordinate their approach to IDSR in Africa, and 
support FETP and the African Field Epidemiology Network. 

* Phone communication. USAID and CDC share information regularly by 
phone to ensure coordination of activities and achievement of common 
goals. 

Agencies Monitor Surveillance Capacity-Building Activities, and CDC and 
USAID Have Begun Efforts to Evaluate Programs' Impact: 

For each of the four key surveillance capacity-building programs they 
support, U.S. agencies monitor activities by, for example, tracking 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 
the evaluations will demonstrate progress in building surveillance 
capacity. 

Agencies Monitor Program Activities: 

CDC, DOD, and USAID collect data on activities in the four surveillance 
capacity-building programs. For example: 

* GDD. Since 2006, CDC has monitored the number of outbreaks that GDD 
has investigated, the numbers of participants in GDD short-term and 
long-term training, and examples of collaboration among GDD country 
programs. (See app. II for more information on GDD activities.) 

* FETP. CDC has monitored the numbers of FETP trainees and graduates, 
the numbers of FETP graduates hired by public health ministries, the 
number of graduates' journal articles in peer-reviewed publications, 
graduates' participation in international scientific meetings, the 
number of outbreak investigations conducted, and the number of 
surveillance evaluations conducted. (See app. III for more information 
on FETP activities.) 

* 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. (See app. IV for more information on IDSR activities.) 

* 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. (See app. V for more 
information on GEIS activities.) 

In addition, USAID has monitored programs or projects supported by its 
missions through reports describing completed activities. 

CDC and USAID Have Begun Efforts to Evaluate Impact of Surveillance 
Capacity-Building Programs: 

CDC and USAID recently began developing frameworks for systematically 
evaluating the impact of GDD, FETP, and IDSR on countries' surveillance 
capacity. However, the agencies have not yet collected sufficient 
information to evaluate the programs' contribution to improved 
surveillance. DOD does not plan to evaluate its capacity-building 
efforts, because it does not view surveillance capacity building in 
host countries as a primary goal of GEIS. 

* GDD. In 2006, the first year of GDD center operations, CDC developed 
an evaluation framework that includes indicators for each of GDD's five 
goals.[Footnote 33] For example, for training, indicators include the 
number of graduates of long-term training programs, number of 
participants in short-term training programs, and number and proportion 
of trained graduates who hold public health leadership positions. (See 
fig. 3.) CDC collects data for these indicators while monitoring GDD 
activities.[Footnote 34] After finalizing the framework, CDC plans to 
evaluate all GDD centers against these performance measures and 
indicators. This will enable comparisons between centers and 
assessments of the centers' capabilities and is intended to evaluate 
progress toward intended outcomes, including building surveillance 
capacity. CDC collected data in 2006 for 8 of the 14 indicators but, as 
of July 2007, had not collected data on the two surveillance indicators 
to evaluate the program's contribution to improved surveillance. 

Figure 3: Framework for Evaluating Impact of GDD: 

[See PDF for image] 

Source: Centers for Disease Control and Prevention. 

[End of figure] 

* FETP. In 2006, CDC developed a framework for monitoring and 
evaluating FETPs' impact on countries' health systems by measuring 13 
indicators related to FETP activities.[Footnote 35] Some of these 
indicators measure a specific activity, such as the number of 
graduates, while others focus more on program impact, such as whether a 
country's surveillance system was improved or expanded by an FETP or 
its trainees. (Fig. 4 shows the relevant FETP indicators.) Prior to 
developing its formal monitoring and evaluation system, CDC collected 
information on program activities but did not systematically evaluate 
the impact of FETPs on improving surveillance capacity. CDC hopes to 
implement the framework fully by 2009, but this depends on country 
cooperation; because FETPs are collaborations between CDC and the host 
countries, CDC's FETP handbook presents the framework as guidance to 
the countries rather than as a requirement. In addition to establishing 
program indicators, CDC developed a database, which it is sharing with 
FETP countries, for collecting and evaluating data for the 
indicators.[Footnote 36] 

Figure 4: Indicators for Evaluating Impact of FETPs: 

[See PDF for image] 

Source: Centers for Disease Control and Prevention. 

[End of figure] 

* IDSR. In 2003, WHO/AFRO adopted 11 indicators, developed with input 
from CDC and USAID, to monitor and evaluate progress in implementing 
IDSR in Africa. The indicators are intended to help identify problems 
in implementing IDSR, evaluate progress, and advocate for resources for 
IDSR. The indicators also enable comparisons across countries. (See 
fig. 5 for a complete list of the IDSR indicators.) According to WHO/ 
AFRO, 19 of 46 African countries reported on at least some of these 
indicators in 2006. For example, 18 countries reported that an average 
of 79 percent of their districts filed timely surveillance reports, 
which indicates the speed with which surveillance information is 
transmitted, and 16 countries reported that an average of 78 percent of 
outbreaks were confirmed with laboratory evidence, which indicates the 
use of laboratories in outbreak detection, confirmation, and response. 
A CDC official noted that the agency prompts countries to collect data 
on the indicators, by inquiring during meetings with country officials 
whether the indicators are being used to evaluate progress. However, 
U.S. agencies cannot require countries to collect data on the 
indicators, because IDSR is a country-owned program. In addition to the 
ongoing collection of data for these 11 indicators, WHO/AFRO conducts, 
in conjunction with the countries, periodic in-depth assessments of 
country progress in IDSR implementation.[Footnote 37] CDC also 
completed an evaluation in 2005 of the implementation of IDSR in Ghana, 
Tanzania, Uganda, and Zimbabwe and, using a set of 40 indicators based 
on WHO guidance,[Footnote 38] found that these countries had 
implemented most of the elements of IDSR. Although the results of CDC's 
evaluation effort were positive, the effort represents only 4 of the 8 
countries that CDC is assisting directly in implementing IDSR. 

Figure 5: Indicators for Evaluating Impact of IDSR: 

[See PDF for image] 

Source: World Health Organization. 

[End of figure] 

* GEIS. 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, 
DOD reviewed two GEIS surveillance projects and found that they 
resulted in improvements in disease surveillance.[Footnote 39] GEIS 
officials asserted that the program's activities in the host nations 
have led to improved surveillance capacity for infectious diseases. For 
example, according to these officials, GEIS helped to establish an 
electronic surveillance system in Indonesia, Laos, Cambodia, and 
Vietnam, as well as another version of the system in Peru, that 
improved timely detection of, and response to, infectious disease 
epidemics. 

Agency Comments and Our Evaluation: 

DOD, HHS, and USAID provided written comments on a draft of this 
report, generally concurring with our findings. We have reprinted these 
comments in appendixes VI, VII, and VIII and incorporated the agencies' 
technical comments as appropriate. 

DOD clarified the extent of GEIS's global involvement, noting that DOD 
overseas laboratories develop regional projects, which DOD refers to as 
programs and each of which serves many countries. We accordingly added 
a reference in our report to the number of countries that GEIS serves. 
Regarding our map's lack of inclusion of locally operated and fixed 
laboratories, these are small activities relative to the five DOD 
laboratories operating in Egypt, Kenya, Indonesia, Peru, and Thailand. 
For instance, the budget for the laboratory in Nepal in 2006 was 
$175,000, compared with $1,340,000 that GEIS obligated to projects at 
the DOD laboratory in Indonesia. DOD also clarified that although 
GEIS's highest priority goals are surveillance, detection, response, 
and readiness, its goal of capacity building is important to the 
success of these goals. Additionally, DOD provided information 
regarding evaluations of surveillance projects that GEIS has 
undertaken, and in response we included in the report information 
pertaining to GEIS program reviews. 

HHS provided additional information regarding the operations of GDD, 
noting that the centers bring together CDC's existing international 
expertise in public health surveillance, training, and laboratory 
methods and build on three previously established programs: FETP, 
International Emerging Infections Program, and influenza activities. We 
have incorporated this information into the report. In an effort to 
more accurately characterize GDD's structure, we had several 
discussions with CDC officials, who emphasized that GDD brought these 
programs together. Additionally, HHS indicated that disease-specific 
programs contribute to capacity building. We agree that these programs 
contribute to capacity building, but they are outside the scope of this 
report. GAO has conducted numerous reviews on disease-specific 
activities, such as those for avian influenza, HIV/AIDS, and 
malaria.[Footnote 40] 

USAID's comments expanded on its funding for capacity-building 
activities specific to diseases such as avian influenza, HIV/AIDS, 
malaria, polio, and tuberculosis, a point that we acknowledge in the 
report's background. USAID also provided additional examples of 
capacity building. All of these activities were included in our 
accounting of obligations provided by USAID. 

As agreed with your offices, unless you publicly announce its contents 
earlier, we plan no further distribution of this report until 6 days 
from its date. At that time, we will send copies to the Secretaries of 
Defense and Health and Human Services, the Administrator of the U.S. 
Agency for International Development, appropriate congressional 
committees, and other interested parties. We will also make copies 
available to others upon request. In addition, the report will be 
available at no charge on GAO's Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions regarding this report, please 
contact me at (202) 512-3149 or gootnickd@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major contributions 
to this report are listed in appendix IX. 

Signed by: 

David Gootnick: 

Director: 

International Affairs and Trade: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

We examined (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. 

To describe the obligations of the key U.S. programs to develop 
epidemiology and laboratory capacity for surveillance of infectious 
diseases in 2004-2006, we reviewed annual budgets for the Centers for 
Disease Control and Prevention's (CDC) Global Disease Detection (GDD) 
and International Emerging Infections Program (IEIP), the Department of 
Defense's (DOD) Global Emerging Infections Surveillance and Response 
System (GEIS), and the five Army and Navy overseas laboratories; U.S. 
Agency for International Development (USAID) grants to CDC and the 
World Health Organization (WHO) for support of Integrated Disease 
Surveillance and Response (IDSR) and other programs; CDC's obligations 
for Field Epidemiology Training Programs (FETP); and DOD's GEIS project 
funding reports. In addition, we interviewed USAID officials in the 
Africa, Asia, Eastern Europe, and Latin America bureaus to identify 
funding for mission activities intended to build crosscutting capacity 
for surveillance of infectious diseases, excluding capacity building 
funded by appropriations for polio, tuberculosis, malaria, HIV/AIDS, 
and avian influenza. We also interviewed officials at CDC, DOD, and 
USAID's Bureau of Global Health and regional bureaus. 

To describe the goals of these programs, we examined the Presidential 
Decision Directive NSTC-7 on emerging infectious diseases, CDC and 
USAID guidance documents for combating infectious diseases abroad, 
strategic plans for DOD's GEIS and CDC's GDD, strategic goals for CDC's 
Coordinating Office of Global Health, WHO's Regional Office for 
Africa's (WHO/AFRO) plan for integrated disease surveillance in Africa, 
GEIS project objectives, and work plans for CDC's assistance to IDSR as 
well as for individual country FETPs. 

To determine the activities of these programs, we reviewed annual 
reports on GEIS and CDC's Division of Epidemiology and Surveillance 
Capacity Development in the Coordinating Office of Global Health, CDC's 
and WHO's progress reports to USAID on FETPs and IDSR, GDD 
accomplishment reports, and project reports from DOD's GEIS. We also 
interviewed CDC, DOD, Department of State, USAID, and WHO officials 
responsible for implementing capacity-building activities, including 
CDC's Coordinating Office for Global Health and Coordinating Center for 
Infectious Diseases, as well as key personnel managing the Thailand and 
Kenya GDD centers. To assess coordination among the agencies and 
programs, we observed a GDD coordination meeting and a biweekly GDD 
country team meeting at CDC and conducted interviews with agency 
officials at CDC, DOD, USAID, and WHO. 

To learn how agencies were measuring the programs' progress in building 
infectious disease surveillance capacity, we analyzed reports from GDD, 
GEIS, FETP, IEIP, and IDSR regarding these programs' progress and 
accomplishments. We also reviewed frameworks for monitoring and 
evaluation, including quantitative measures, for GDD and FETP; reports 
from WHO that established measures for evaluating the success of IDSR 
in Africa; and annual reports and assessments of individual country 
FETPs, including the Epi-Track database used in some countries to 
monitor FETP achievements. Additionally, we interviewed officials from 
the respective programs and from WHO to understand how they monitored 
program progress. 

We identified two limitations in the reliability of the data that the 
agencies provided. First, agencies did not track obligations for 
infectious disease surveillance capacity-building, and thus we 
developed a methodology, based on program documentation and discussions 
with program officials, to categorize the obligations. The methodology 
involved reviewing descriptions of program activities to identify 
whether a particular surveillance activity included capacity building 
and which program it supported. The agencies concurred with this 
methodology and the capacity-building activities we identified. Second, 
about 25 percent of the total obligations we identified are self- 
reported amounts from some of USAID's missions and bureaus. According 
to USAID, the self-reported obligations represent the missions' and 
bureaus' best estimates of how much was obligated. For the other 
approximately 75 percent of the obligations, we obtained documentation 
such as grant amendments and scopes of work to verify the obligated 
amounts. Based on our interviews with knowledgeable officials at USAID, 
and the fact that we were able to verify the majority of the 
obligations, we determined that the data were sufficiently reliable for 
our purpose of describing the agencies' obligations for the key 
programs we identified as well as for additional capacity-building 
activities for infectious disease surveillance. However, we rounded to 
the nearest million dollars the funding information that the agencies 
provided. 

We conducted our work from October 2006 through July 2007 and in 
accordance with generally accepted government auditing standards. 

[End of section] 

Appendix II: GDD: 

Table 2: Overview of GDD Center Activity Data: 

Country: China; 
Activity: 
* 30 graduates from long-term epidemiology training, 2004-2006[A]; 
- 20 graduates in key positions in 14 provinces
* 100 city-level public health doctors participated in 4-day training 
course in surveillance and epidemiology; 
* Conducted 90 outbreak responses, 23 of which were human avian 
influenza cases; 
* Conducted outbreak investigation of Streptococcus suis that led to 
drop in number of cases; 
- 215 cases, 39 deaths in 2005; 
- Investigation indicated strict ban on pig slaughter; 
- In 2006, 83 percent fewer cases and zero deaths. 

Country: Guatemala; 
Activity: 
* 20 graduates from long-term epidemiology training, 2004-2006[A]; 
* 150 graduates of 3-month epidemiology course in Guatemala, and 192 
graduates in Costa Rica; 
* Conducted outbreak response to methanol intoxication in Nicaragua; 
- Over 700 cases; 41 deaths; 
- Identified contaminated alcohol as the cause; outbreak contained; 
* Collaborated with local institutions to strengthen regional 
laboratory capacity; 
* Developed rapid-response capacity through workshop attended by 70 
participants from eight countries in November 2006; 
* Synchronized community-based surveillance protocols with sites in 
Thailand and Kenya to enable cross-country comparison of data. 

Country: Egypt; 
Activity: 
* 15 graduates from long-term epidemiology training, 2004-2006[A]; 
* Rapid-response capacity being established through rapid response 
training in Cairo; 
* Laboratory avian influenza capacity strengthened; instituted advanced 
laboratory testing for bacterial meningitis and for rickettsioses; 
* Collaborated with Kenya GDD program to provide laboratory team and 
entomologist to assist with Rift Valley fever outbreak in Kenya. 

Country; Kenya; 
Activity: 
* 7 graduates from long-term epidemiology training, 2004-2006[A]; 
* Trained district health surveillance teams from eight provinces on 
IDSR; 
* Developed avian influenza training and rapid-response training 
capacity in Africa; 
* Predicted and confirmed Rift Valley fever outbreak; 
- Fewer than 200 human cases and 50 deaths; 
- Containment efforts ongoing to address its spread to Somalia and 
Tanzania; 
* Established previously unavailable testing for more than five 
pathogens; 
- Tested 786 humans and animals for avian influenza, meningococcal 
meningitis, and yellow fever; provided extensive laboratory support to 
countries within the region; 
* Collaborated with Kenya Ministry of Health and WHO to establish IDSR. 

Country: Thailand; 
Activity: 
* 8 graduates from long-term epidemiology training, 2004-2006[A]; 
* 40-45 participants in field epidemiology short course in 2006; 
* Led and hosted the model rapid response training; all five GDD 
centers participated; 
* Helped build avian influenza laboratory capacity in Bangkok and in 14 
Thai regions; 
* Responded to botulism outbreak; 
- Largest reported outbreak of botulism; 
- 232 cases, 45 ventilated patients; 
- 50 vials of antitoxin delivered within 48 hours; no deaths; 
* Expanded an ongoing population-based pneumonia surveillance system in 
two provinces by adding microbiology diagnostic capacity; 
- Within 10 months of implementation, obtained 26 isolates of 
Streptococcus pneumoniae; 
* Conducted regional drills with WHO, the Asian Development Bank, and 
other national and international partners. 

Source: CDC. 

[A] These are graduates of the FETP. 

[End of table] 

[End of section] 

Appendix III: FETP: 

The United States assists countries in improving and strengthening 
their public health system and infrastructure through FETPs. The 
program, established in 1980,  provides 2 years of classroom 
instruction and field assignments.  Field assignments include 
conducting epidemiologic investigations and field surveys; evaluating 
various components of domestic surveillance systems; performing disease 
control and prevention measures, such as identifying risk factors 
associated with pulmonary tuberculosis in Kazakhstan; reporting their 
findings to decision makers and policymakers; training other health 
care workers; building professional networks through participating in 
international conferences; and enhancing professional stature by 
publishing in peer-reviewed journals. From 2004 through 2006, FETPs in 
15 programs graduated 351 participants (see table 3). As of February 
2007, according to CDC, six programs established from 1999 through 
2004  tracked their graduates and found that 92 percent continued to 
work in the public health arena following the training. 

Table 3: FETP Trainees and Graduates by Country, 2004-2006: 

Country Region: Brazil;	
2004: Trainees [A]: 11;	
2004: Graduates: 0; 
2005: Trainees [A]: 25;	
2005: Graduates: 0; 
2006: Trainees [A]: 24; 
2006: Graduates: 11. 

Country Region: Central America; 
2004: Trainees [A]: 53;	
2004: Graduates: 5; 
2005: Trainees [A]: 45;	
2005: Graduates: 15; 
2006: Trainees [A]: 29; 
2006: Graduates: 0. 

Country Region: Central Asia; 
2004: Trainees [A]: 15;	
2004: Graduates: 0; 
2005: Trainees [A]: 18;	
2005: Graduates: 7; 
2006: Trainees [A]: 19; 
2006: Graduates: 8. 

Country Region: China; 
2004: Trainees [A]: 22;	
2004: Graduates: 10; 
2005: Trainees [A]: 21;	
2005: Graduates: 10; 
2006: Trainees [A]: 24; 
2006: Graduates: 10. 

Country Region: Egypt; 
2004: Trainees [A]: 15;	
2004: Graduates: 0; 
2005: Trainees [A]: 25;	
2005: Graduates: 9; 
2006: Trainees [A]: 25; 
2006: Graduates: 6.

Country Region: Ghana [B];	
2004: Trainees [A]: 35;	
2004: Graduates: 35; 
2005: Trainees [A]: 40;	
2005: Graduates: 40; 
2006: Trainees [A]: 35; 
2006: Graduates: 35.

Country Region: India;	
2004: Trainees [A]: 14;	
2004: Graduates: 6; 
2005: Trainees [A]: 14;	
2005: Graduates: 7; 
2006: Trainees [A]: 25; 
2006: Graduates: 6. 

Country Region: Jordan;	
2004: Trainees [A]: 11;	
2004: Graduates: 5; 
2005: Trainees [A]: 6; 
2005: Graduates: 5; 
2006: Trainees [A]: 10; 
2006: Graduates: 0. 

Country Region: Kenya;	
2004: Trainees [A]: 7;	
2004: Graduates: 0; 
2005: Trainees [A]: 14;	
2005: Graduates: 0; 
2006: Trainees [A]: 16; 
2006: Graduates: 7. 

Country Region: Pakistan [C]; 
2004: Trainees [A]: 0;	
2004: Graduates: 0; 
2005: Trainees [A]: 0;	
2005: Graduates: 0; 
2006: Trainees [A]: 0; 
2006: Graduates: 0. 

Country Region: South Africa [C]; 
2004: Trainees [A]: 0;	
2004: Graduates: 0; 
2005: Trainees [A]: 0;	
2005: Graduates: 0; 
2006: Trainees [A]: 0; 
2006: Graduates: 0. 

Country Region:  Sudan [D]; 
2004: Trainees [A]: 0; 
2004: Graduates: 0; 
2005: Trainees [A]: 0; 
2005: Graduates: 0; 
2006: Trainees [A]: 4; 
2006: Graduates: 0. 

Country Region: Thailand; 
2004: Trainees [A]: 8; 
2004: Graduates: 0; 
2005: Trainees [A]: 18;	
2005: Graduates: 0; 
2006: Trainees [A]: 33; 
2006: Graduates: 8. 

Country Region: Uganda;	
2004: Trainees [A]: 23;	
2004: Graduates: 31; 
2005: Trainees [A]: 18;	
2005: Graduates: 23; 
2006: Trainees [A]: 22; 
2006: Graduates: 23. 

Country Region: Zimbabwe; 
2004: Trainees [A]: 7; 
2004: Graduates: 4; 
2005: Trainees [A]: 13;	
2005: Graduates: 15; 
2006: Trainees [A]: 8; 
2006: Graduates: 10. 

Total; 
2004: Trainees [A]: 221; 
2004: Graduates: 96; 
2005: Trainees [A]: 257; 
2005: Graduates: 131; 
2006: Trainees [A]: 274; 
2006: Graduates: 124. 

Source: CDC. 

[A] CDC was unable to determine whether the number of trainees each 
year includes trainees from previous classes or represents only new 
trainees. Therefore, we are unable to total the number of trainees 
across all 3 years. 

[B] The Ghana FETP is a 1-year program. 

[C] Program began enrolling trainees in 2007, although CDC provided 
support in 2006. 

[D] The south Sudan FETP began in 2006. 

[End of table] 

[End of section] 

Appendix IV: IDSR: 

WHO/AFROís IDSR aims to develop a comprehensive, functional system for 
disease surveillance that links epidemiologic surveillance with 
laboratory functions. CDC has provided technical assistance in support 
of IDSR in Africa since its inception in 1998. With funding from USAID, 
CDCís assistance has supported a variety of IDSR activities, including 
designing the overall framework for guiding the implementation of IDSR, 
developing national guidelines for strengthening public health 
laboratory networks in Africa, developing technical guidelines aimed at 
the district level for implementing IDSR, supporting regional training 
materials, supporting development of indicators for monitoring and 
evaluating IDSR implementation, and conducting an economic evaluation 
of the cost to implement IDSR. CDC has also provided assistance for a 
number of country-specific activities with USAIDís support. Table 4 
presents examples of country-specific IDSR activities supported by CDC 
and USAID from 2004 through 2006. 

Table 4: Examples of Country-Specific IDSR Activities Supported by CDC 
and USAID, 2004-2006: 

Country: Tanzania; 
Activity: Undertook laboratory strengthening, including development and 
implementation of 23 job aids that were designed to support the 
collection, packaging, handling, labeling, and transporting of 
specimens; conducted outbreak investigation courses; maintained 
surveillance team. 

Country: Mali; 
Activity: Conducted a workshop on outbreak response and how to use the 
district-level IDSR materials; undertook laboratory training; supported 
the production of feedback bulletins on infectious disease 
surveillance; provided technical assistance for meningitis epidemic 
preparedness and response. 

Country: Kenya; 
Activity: Conducted training workshops for individuals who then 
returned to their districts and trained others thereótraining of 
trainers. 

Country: Burkina Faso; 
Activity: Collaborated on strengthening IDSR and conducted evaluation 
for meningitis surveillance system; provided technical assistance and 
materials support for laboratory surveillance; provided technical 
assistance for meningitis epidemic preparedness and response. 

Country: Ethiopia; 
Activity: Supported training on IDSR at regional levels; supported 
monitoring of timeliness and completeness of data reporting. 

Country: Ghana; 
Activity: Maintained and provided communications training to 
surveillance team; conducted outbreak investigation courses. 

Country: Uganda; 
Activity: Conducted outbreak investigation courses; supported 
laboratory specimen transportation system; maintained surveillance 
team. 

Country: Zimbabwe; 
Activity: Conducted outbreak investigation courses; maintained 
surveillance team. 

Source: GAO analysis of DOD data. 

End of table] 

[End of section] 

Appendix V: GEIS: 

Since 1996, DODís GEIS has provided funding and professional support to 
a network of domestic and overseas military laboratories and medical 
organizations. GEIS began providing funding in 2005 on a project-by-
project basis to five DOD overseas laboratories.  We identified 33 
projects conducted in 2005 and 32 projects conducted in 2006 that had 
capacity-building components, including epidemiology and laboratory 
training, in conjunction with conducting surveillance and outbreak 
response.  (Tables 5 and 6 show the GEIS projects we identified as 
having capacity-building components in 2005 and 2006, respectively.) 
These projects were primarily conducted at the DOD overseas 
laboratories, although in 2005 and 2006, three projects each year were 
run out of the U.S. military health system. The funding obligated to 
all of the capacity-building projects constituted 47 percent of the 
GEIS budget in 2005 and 27 percent of the GEIS budget for 2006. These 
figures do not include funds designated for avian and pandemic 
influenza. 

Table 5: GEIS Projects with Capacity-Building Components, 2005: 

[See PDF for image] 

Source: GAO analysis of DOD data. 

[End of table] 

Table 6: GEIS Projects with Capacity-Building Components, 2006: 

[See PDF for image] 

Source: GAO analysis of DOD data. 

[End of table] 

[End of section] 

Appendix VI: Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 

1200 Defense Pentagon: 
Washington, DC 20301-1200: 

September 18, 2007: 

Mr. David Gootnick: 
Director, International Affairs and Trade: 
U.S. Government Accountability Office: 
441 G Street, N.W.: 
Washington, DC 20548: 

Dear Mr. Gootnick: 

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) Draft Report, GAO-07-1186 "Global Health: 
U.S. Agencies Support Several Programs to Build Overseas Capacity for 
Infectious Disease Surveillance," dated August 17 (GAO Code 320459). 

Thank you for the opportunity to review and comment on the draft 
report. I appreciate the collaborative, insightful, and thorough 
approach that your team has taken with this important issue. This 
report provides a concise, comprehensive overview of the collaborative 
efforts of the Centers for Disease Control and Prevention, United 
States Agency for International Development and the DoD to build 
overseas capacity for infectious disease surveillance. 

However, it is necessary to provide clarification on the extent of 
global involvement, and the goals and priorities, of the DoD-Global 
Emerging Infections System (DoD-GEIS). As presented in the report, the 
great majority of the DoD-GEIS overseas programs are conducted out of 
the DoD overseas laboratories in Egypt, Kenya, Indonesia, Peru, and 
Thailand. What is not clear in the GAO report is that these 
laboratories develop regional programs that include many countries in 
their geographic areas. Additionally, the report notes that DoD-GEIS 
does not consider capacity building a primary goal. Capacity building 
is contained in DoD-GEIS 3rd and 4th Priority Goals. In addition, DoD-
GEIS has always been interested in the lasting impact of its programs 
on host nation surveillance capacity. More details on DoD-GEIS are 
included in the attachment. 

Again, thank you for the opportunity to provide these comments. My 
points of contact for additional information are Ms. Dee Dodson Morris 
(Functional) at (703) 845 8339, or Dee.Morris@ha.osd.mil; and Mr. 
Gunther Zimmerman (Audit Liaison) at (703) 681-3492, or 
Gunther.Zimmerman@tma.osd.mil. 

Sincerely,

Signed by: 
S. Ward Casscells, MD: 

Enclosure: 
As stated: 

Government Accountability Office: 
Draft Report Dated August 17, 2007: 
GAO-07-1186 (GAO CODE 320459): 

"Global Health: US Agencies Support Several Programs To Build Overseas 
Capacity For Infectious Disease Surveillance": 

Department Of Defense Comments: 

General Comments: 

As presented in the report, the great majority of the Department of 
Defense-Global Emerging Infectious System (DoD-GEIS) overseas programs 
are conducted out of the DoD overseas laboratories in Egypt, Kenya, 
Indonesia, Peru, and Thailand. What is not clear in the Government 
Accountability Office report is that these laboratories develop 
regional programs that include many countries in their geographic 
areas. The DoD-GEIS staff estimates that during the time period 
reviewed by the GAO, DoD-GEIS programs were in operation or under 
consideration in at least 36 different countries. For example, the 
Early Warning Outbreak Recognition System (EWORS), a disease 
surveillance system operated out of the lab in Indonesia, was operating 
in Indonesia and three other countries in Southeast Asia (Laos, 
Cambodia, and Vietnam). Additionally, the GAO identifies DoD-GEIS-
supported, locally operated, fixed laboratories in Nepal, Cambodia, and 
Ghana, in their report, but these countries are not identified as GEIS 
areas of operation on Figure 2. 

The report notes that the DoD does not plan to evaluate the DoD-GEIS 
program's impact on host countries' surveillance capacity since DoD-
GEIS does not consider capacity building a primary program goal. The 
DoD-GEIS operates on four goals: 

1. Surveillance and Detection, 
2. Response and Readiness, 
3. Integration and Innovation, and: 
4. Cooperation and Capacity Building. 

The first two goals are given the highest priority, with Surveillance 
and Detection the first priority. The third and fourth goals are 
important and success of the first two goals could not be achieved if 
these were neglected. 

The DoD-GEIS core program (exclusive of avian influenza/pandemic 
influenza appropriated monies, approximately $12 million/year) is 
modest and directed at developing, maintaining, and upgrading 
surveillance systems and programs that can detect threats reliably and 
early. Since the beginning of DoD-GEIS, the program staff has been 
interested in the lasting impact of its programs on host nation 
surveillance capacity. A peer-reviewed 2003 publication (Military 
Medicine, Vol. 168, pages 843- 848, October 2003) provides an 
evaluation of a DoD-GEIS-sponsored, collaborative Caribbean public 
health laboratory project. In 2006, DoD-GEIS initiated and sponsored 
ongoing, well-defined reviews of surveillance systems in South America 
and Southeast Asia that is host nation operated with assistance from 
the DoD laboratories in those areas. 

These reviews will provide information on how well these programs have 
improved local capacity for disease surveillance. The above two 
examples are outside of the parameters addressed by the GAO (the 
Caribbean project preceded the GAO period of interest and the recent 
surveillance system reviews are funded by avian influenza/pandemic 
influenza money). However, these examples demonstrate DoD- GEIS 
interest in evaluating the impact of its programs on host nation 
capacity and its willingness to initiate further evaluative programs if 
resources are available.

The following are GAO's comments on DOD's letter dated September 18, 
2007. 

GAO Comments: 

1. As DOD noted, in addition to maintaining overseas laboratories in 
five countries, it also funds projects, which it refers to as programs, 
in many countries. Appendix V identifies all GEIS projects with 
capacity-building elements. These projects are generally small-scale 
efforts; for instance, in 2006, GEIS provided funding ranging from 
$3,000 to $250,000 for the projects listed in table 6, with the median 
level of project funding at $88,500. 

2. We clarified that DOD and others have conducted reviews of some of 
the individual GEIS projects. 

[End of section] 

Appendix VII: Comments from the Department of Health and Human 
Services: 

Department Of Health & Human Services: 

Office of the Assistant Secretary for Legislation: 
Washington D.C. 20201: 

September 14, 2007: 

David Gootnick: 
Director, International Affairs and Trade: 
U.S. Government Accountability Office: 
Washington, DC 20548: 

Dear Mr. Gootnick:

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled, " Global Health: 
U.S. Agencies Support Several Programs to Build Overseas capacity for 
infectious Disease Surveillance" (GAO 07-1186) 

The Department has provided several technical comments directly to your 
staff. 

The Department appreciates the opportunity to review and comment on 
this draft before its publication.

Sincerely, 

Signed by: 

Vincent J. Ventimiglia
Assistant Secretary for Legislation: 

HHS Comments On U.S. Government Accountability Offices Draft 
Correspondence "Global Health: U.S. Agencies Support Several Programs 
To Build Overseas Capacity For Infectious Disease Surveillance (GAO-07-
1186): 

HHS appreciates GAO for the review and synthesis of complex information 
on surveillance efforts across the U.S. Government. This type of review 
is useful as investments continue in these programs. In order to 
enhance the value of the final report, HHS recommends that GAO make the 
following changes: 

The component parts of the Global Disease Detection Program (GDD) are 
not adequately described and need to be clarified throughout the draft. 
The primary components of CDC's GDD program are the five GDD Centers, 
located in Thailand, Kenya, Egypt, Guatemala, and China. The GDD 
program was built on CDC's existing international expertise in public 
health surveillance, training, and laboratory methods, and brought 
together three previously established and proven programs: the Field 
Epidemiology Training Program (FETP), the International Emerging 
Infections Program (IElP), and influenza activities. This should be 
clearly stated (in both the Highlights page, and also in the draft 
introduction where the programs are described) to show the relationship 
among these programs. 

The draft states on the Highlights page, on page 3 and page 8 that U.S. 
agencies spent approximately $85M for global infectious disease 
surveillance capacity. The draft (pg. 5) also states that SARS was 
estimated to cost between $11 billion and $18 billion on Asian 
economies. CDC recommends this overall figure of $85M over 3 years (or 
approximately $30M per year) be placed directly in the context of 
potential economic costs of a poorly detected or contained emerging 
infectious disease. Specifically, CDC suggests two changes to emphasize 
this point: 

1. Add another example (in addition to the SARS example) to show 
economic impact, - "In addition, the cost to the US economy of a modest 
influenza pandemic is estimated at $100 billion to $200 billion 
(Brahmbhatt, World Bank)." 

2. Include the $85M figure and the economic estimates of SARS and 
influenza pandemic within the same section (ideally a "conclusions" 
section) of the draft to show context and better frame *the investment 
of these programs. CDC's investment in programs that build capacity for 
non-specific threats or emerging infectious diseases is minimal when 
considering the potential economic impact of such a disease. 

The scope of the review is limited to capacity building for infectious 
disease surveillance, but the definition of capacity building is not 
clearly articulated. As noted above, the investment in the specific 
types of capacity building included in the draft (capacity building for 
emerging infectious threats, not including disease-specific efforts) is 
relatively small in comparison to the potential impact. However, the 
draft does not recognize the contributions of other disease- specific 
programs in capacity building. 

HHS Comments On U.S. Government Accountability Offices Draft 
Correspondence "Global Health: U.S. Agencies Support Several Programs 
To Build Overseas Capacity For Infectious Disease Surveillance (GAO-07-
1186): 

One page 2, the draft states that GAO did not review capacity-building 
efforts in programs that focus on specific diseases (such as polio, TB, 
malaria, avian influenza, and HIV/AIDS) but does not state why these 
programs were omitted from the review. In addition, the draft would 
benefit from stating clearly in the text, rather than in the footnotes, 
that there are other important components to international surveillance 
not described in this draft (see technical comments, page 5, paragraph 
1, line 2). 

CDC believes disease-specific programs are important to building 
capacity and recognizes that other capacity-building efforts are also 
being built through other programs such as Global AIDS program, Global 
Immunization Division, President's Malaria Initiative, etc. 

In addition, GAO included the Global Emerging Infections Surveillance 
Response System (GEIS) in the review, even though GEIS stated (pg 16 
and 22) that capacity building is not its primary purpose. Because the 
draft excludes some important capacity-building programs while 
including others (less focused on capacity-building), it presents an 
incomplete and potentially misleading representation of all overseas 
capacity-building investments by the US Government. 

As stated in the draft, GDD and FETP evaluation frameworks have 
recently been implemented. Although CDC is in the early stages of data 
collection on performance indicators, it is too early at this time to 
make conclusions on the progress of these programs. Therefore, CDC 
suggests that the final report include a recommendation to the 
Secretary of Health and Human Services (HHS) that CDC provide a Report 
to Congress on the progress of these programs within 1-3 years of the 
report release date. 

The following are GAO's comments on HHS's letter dated September 14, 
2007. 

GAO Comments: 

1. Our description of GDD focused on the types of capacity-building 
activities undertaken by GDD from 2004 to 2006, not on GDD's history. 
However, in response to CDC's comments, we have added information 
regarding the preexisting programs that make up GDD. Additionally, we 
describe the FETPs in detail and also refer to them under our 
description of GDD. As we stated in our introduction, we did not focus 
on efforts funded by appropriations for specific diseases, including 
influenza activities, although the report does acknowledge that disease-
specific activities have improved surveillance. Furthermore, during the 
timeframe of our review, the IEIP was established in only one location, 
Thailand, prior to the establishment of the GDD centers. 

2. The report includes an estimate of the economic cost of severe acute 
respiratory syndrome (SARS). 

3. The report's objectives clearly state that our focus was 
epidemiology and laboratory capacity-building programs. The report 
acknowledges the contribution of surveillance systems for specific 
diseases to overall disease surveillance efforts. 

4. As our rationale for excluding disease-specific programs clearly 
states, although earlier efforts to improve surveillance worldwide 
focused on individual diseases, the United States and other countries 
initiated a broader effort in the mid-1990s to ensure that countries 
can detect outbreaks of previously unknown infectious diseases. As 
noted, our review focused on these broader efforts. Regarding other 
components of international surveillance, see comment 3. 

5. We disagree that our report presents an incomplete picture of 
capacity-building programs. We identified and evaluated the key U.S. 
programs to build developing countries' broader capacity for infectious 
disease surveillance and specifically excluded programs for disease- 
specific efforts from our review. Regarding GEIS, capacity building is 
one of its goals, and our review showed that DOD's overseas 
laboratories, where many of the GEIS projects are run, also house CDC's 
GDD efforts, specifically in Egypt and Kenya. 

6. As noted in our report, we were unable to assess CDC's program 
evaluation efforts because these activities had just begun in 2006. 
However, we support CDC's interest in keeping Congress informed of the 
progress and impact of the FETP and GDD programs. 

[End of section] 

Appendix VIII: Comments from the U.S. Agency for International 
Development: 

U S. Agency for International Development: 
1300 Pennsylvania Avenue. NW: 
Washington, DC 20523: 
[hyperlink, http://www.usaidgov] 

September 7, 2007: 

David Gootnick: 
Director: 
International Affairs and Trade: 
U.S. Government Accountability Office: 
441 G. Street, N.W.: 
Washington, D.C. 20548: 

Dear Mr. Gootnick: 

I am pleased to provide the U.S. Agency for International Development's 
(USAID) formal response to the Government Accountability Office (GAO) 
draft report titled "Global Health: U.S. Agencies Support Several 
Programs to Build Overseas Capacity for Infectious Disease 
Surveillance" (GA()-07-1186). 

First, we would like to take this opportunity to congratulate the GAO 
on the outstanding, job of responding to a Congressional inquiry on the 
status of building overseas capacity for infectious disease 
surveillance. USAID fully recognizes the complexity of this subject and 
believes that this draft report provides valuable insights into the 
issues concerning the ability of public health officials to detect and 
report infectious diseases. 

This issue is clearly of global significance, given the potential for 
the global spread of disease and the ability of surveillance to 
contribute to significant reductions in morbidity and mortality within 
developing countries. As such, USAID has been a strong supporter of 
programs to build surveillance capacity at the local level. We are 
proud to work closely with our U.S. Government partners, particularly 
the Centers for Disease Control and Prevention (CDC) and our 
international partners, particularly the World Health Organization 
(WHO). 

Further comments on the significant level of investment USAID's 
disease- specific programs make to capacity building for surveillance 
are enclosed. you for the opportunity to respond to the GAO draft 
report and for the courtesies extended by your staff in the conduct of 
this review. 

Sincerely, 

Signed by: 
Mosina H. Jordan: 

Counselor to the Agency: 
Enclosure: a/s: 

Enclosure: USAID Comments on the GAO report entitled "Global Health: 
U.S. Agencies Support Several Programs to Build Overseas Capacity for 
Infectious Disease Surveillance" (GAO-07-1186): 

As the draft report indicates, the GAO did not review capacity-building 
efforts in programs that focus on specific diseases. USAID fully 
understands that such a comprehensive review would have been a massive 
undertaking. Furthermore, USAID recognizes that there are limitations 
as to what can be done to strengthen overall disease surveillance 
capability through a disease-specific approach. However, at the same 
time, USAID's expenditure levels in the areas of disease surveillance 
are determined by appropriation patterns and the majority of our 
funding is disease-specific. Therefore, excluding USAID's disease-
specific programs overlooks the significant level of investment these 
programs make to capacity building for surveillance. As a result, USAID 
would like to emphasize the important contributions of its disease-
specific programs in this area, namely polio, tuberculosis (TB). avian 
influenza (AI), malaria, and HIV/AIDS. For example: 

* TB: In the area of TB, USAID's Bureau for Global Health has invested 
approximately $10 million since FY 1999 in computerized electronic TB 
registries, global TB monitoring surveillance, multi-drug resistant TB 
(MDR- TB) surveillance, and TB monitoring and evaluation. The Global TB 
surveillance program collects data from over 200 countries and releases 
the information in an annual report. The means for collecting and 
reporting that information at the country level has contributed 
significantly to local capacity to collect data and use it to manage 
patients and programs. USAID has made a significant contribution to 
this effort. 

* AI: In FY 2005 and FY 2006 the USAID Avian Influenza Program 
obligated just over $8 million in support of human infectious disease 
surveillance activities in Asia, Europe and Eurasia, Africa and Latin 
America. These activities are focused on strengthening laboratory and 
diagnostic capacity, as well as active field surveillance for influenza-
like illnesses. While currently focused on H5N 1 influenza, this work 
will strengthen overall surveillance for zoonotic diseases in 
developing countries around the world. 

* Polio: Since 1985, USAID has provided approximately $290 million for 
polio surveillance in over 40 countries in Africa, South Asia. the Near 
East, and former Newly Independent States. These funds have created a 
global network made up of 148 national and regional laboratories 
capable of isolating, serotyping and, in many cases, genetic sequencing 
of polio viruses. Many are also expanding their analysis to other 
vaccine-preventable diseases, such as measles and rubella. These funds 
also support a network of several hundred medical surveillance officers 
and community-disease detection informants trained to detect, report 
and investigate cases of polio, and, increasingly, other diseases of 
health importance. 

The GAO draft report notes in several sections, including page 1 
paragraph 2 and Appendix I, that the authors examined the costs of key 
U.S. programs to develop epidemiology and laboratory capacity. However, 
the data gathered from USAID on its investments in these areas was 
obligation data, not cost data. The actual cost of developing 
epidemiology and laboratory capacity are not quantified in the draft 
report and are significantly greater than the amount USAID has been 
able to invest, based on Congressional appropriations. 

Further, the GAO draft report briefly mentions "additional activities 
supporting capacity building" on page 17 and includes a short list of 
example activities carried out in this category. However, the work 
completed under this category represents a substantial proportion of 
USAID`s obligations in FY 2004- 2006 for capacity building for 
surveillance. Taking this into account, USAID would like to recognize 
the following additional activities in this category: 

* The GAO draft report makes reference to the development of tools and 
guidelines for Integrated Disease Surveillance and Response (IDSR). 
However, the draft report does not fully describe the significant level 
of investment and the activities undertaken by the Partners for Health 
Reformplus (PHRplus) project. Implemented by Abt Associates with 
support from USAID, this project worked closely with the W HO African 
Regional Office (AFRO) and the Government of Tanzania to develop the 
initial training manuals for IDSR, complete a cost analysis, evaluate 
community surveillance systems in Africa, and establish a model program 
in Tanzania. This initial work provided the foundation and support for 
the activities outlined in paragraph 2 on page 15 of the draft report. 

* USAID provided support to WHO to strengthen national capacity for 
surveillance, early warning and response through the provision of 
technical guidance and support for the development and implementation 
of these systems. These activities included surveillance system 
assessments, plans of action, development of standards, guidelines and 
tools for early warning and response, development of an early warning 
and response tool kit, support to human capacity building, and 
strengthening post-outbreak capabilities. 

* USAID provided funding to WHO to support biosafety activities in 
storage, handling and transport of dangerous pathogens. These 
activities addressed the need for enhancement of biological safety and 
laboratory biosecurity procedures and practices in facilities handling 
infectious substances. 

* USAID supported WI 10 regional offices for Africa and Europe to 
strengthen public health laboratory capacities. These activities 
assisted WHO to identify sustainable ways of meeting national 
laboratory requirements for maintenance of diagnostic capacity for 
epidemic-prone diseases. 

* USAID provided support to WHO to establish National External Quality 
Assessment Units. These activities engaged national public health 
laboratories in the evaluation of diagnostic performance within their 
countries. 

Finally, as the GAO draft report indicates, surveillance provides 
essential information for action against infectious disease threats. 
USAID would like to emphasize the importance of "routine" surveillance, 
which, while not as visible on the global stage as disease-specific 
surveillance activities, has the potential for significant improvements 
in health status and mortality reduction. Activities for routine 
disease surveillance are usually not within the range of disease-
specific surveillance programs and need to be strengthened to allow 
countries to utilize their limited resources more effectively, promote 
better policy decisions, and organize health services in a way that 
best promotes the population's overall health.

The following are GAO's comments on USAID's letter dated September 7, 
2007. 

GAO Comments: 

9. As USAID noted, our draft report used the terms "obligations" and 
"costs" interchangeably, and the cost of implementing these activities 
is greater than the amounts obligated to capacity building for 
infectious disease surveillance. We have revised the report where 
appropriate to make it clear that our work refers only to "obligations" 
rather than "costs." 

10. Regarding additional capacity-building activities supported by 
USAID obligations to entities such as Partners for Health Reformplus 
project and WHO, table 1 of our report includes funds obligated to 
these entities in fiscal years 2004 through 2006 in support of these 
capacity-building activities. 

[End of section] 

Appendix IX: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

David Gootnick, (202) 512-3149 or gootnickd@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Audrey Solis, Assistant 
Director; Julie Hirshen; Diahanna Post; Elizabeth Singer; and Celia 
Thomas made key contributions to this report. David Dornisch, Etana 
Finkler, Reid Lowe, Grace Lui, Susan Ragland, and Eddie Uyekawa 
provided technical assistance. 

[End of section] 

Footnotes: 

[1] In this report, all years cited are fiscal years, unless otherwise 
noted. 

[2] This amount does not include U.S. agency obligations to build 
surveillance capacity for specific diseases, namely polio, malaria, 
tuberculosis, avian influenza, and HIV/AIDS. 

[3] China, Egypt, Guatemala, Kenya, and Thailand. 

[4] Prior to 2005, GEIS funded the overseas laboratories directly, 
without a project-by-project breakdown. 

[5] Disease strains resistant to antimicrobial drugs are the result of 
excessive, uncontrolled use of these drugs. 

[6] GAO, Emerging Infectious Diseases: Asian SARS Outbreak Challenged 
International and National Responses, GAO-04-564 (Washington, D.C.: 
Apr. 28, 2004). 

[7] GAO, Global Health: Challenges in Improving Infectious Disease 
Surveillance Systems, GAO-01-722 (Washington, D.C.: Aug. 31, 2001). 

[8] Peter Nsubuga et al., "Polio Eradication Initiative in Africa: 
Influence on Other Infectious Disease Surveillance Development," BMC 
Public Health, vol. 2 no. 27 (2002) [hyperlink, 
http://www.biomedcentral.com/] 1471-2458/2/27 (downloaded July 30, 
2007). 

[9] Emerging infections are "infections that have newly appeared in a 
population or have existed previously but are rapidly increasing in 
incidence or geographic range." See S.S. Morse, "Factors in the 
Emergence of Infectious Diseases," Journal of Emerging Infectious 
Diseases, vol. 1 no. 1 (1995): 7-15. 

[10] See Institute of Medicine, Microbial Threats to Health: Emergence, 
Detection, and Response (Washington, D.C.: National Academies Press, 
2003). 

[11] The 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. 

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

[13] CDC officials told us that the GDD centers are typically 
incorporated into ministry of health facilities or colocated with 
universities. 

[14] The Thailand center incorporated an IEIP, which is a program for 
research and outbreak response to emerging infectious diseases. 

[15] The long-term applied epidemiology training program in Guatemala 
is referred to as the Central America FETP. 

[16] The outbreak center receives information from the GDD centers, as 
well as from other entities that collect and disseminate reports on 
disease outbreaks, such as the Global Public Health Intelligence 
Network, Epidemic Information Exchange, ProMED Mail, DOD, the 
intelligence community, and the Department of State. 

[17] GDD centers also receive supplemental avian and pandemic influenza 
funding from the Department of Health and Human Services (HHS). As of 
December 2006, HHS received planned funding of $150 million for avian 
influenza-related activities, some of which was used by the GDD centers 
to conduct rapid-response training for the disease. The skills acquired 
during these training sessions can be applied to detecting and 
investigating other diseases. 

[18] CDC officials told us that these efforts generally support 
national and district-level public health laboratories. 

[19] Biosafety 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. 

[20] These 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. 

[21] The programs typically include both classroom training as well as 
on-the-job training in conducting surveillance and outbreak 
investigations. CDC officials told us that classes are held variously 
in local universities or in ministry of health facilities. 

[22] The 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. 

[23] In 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. 

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

[25] CDC supports an advisor for the Sudan program, but the students 
receive their training in the Kenya program. 

[26] The programs in Ghana, Uganda, and Zimbabwe are Public Health 
Schools without Walls (PHSWOW). This program was established by the 
Rockefeller Foundation and is another type of applied epidemiology 
training program. CDC supported the PHSWOWs in these three countries 
through the Global Surveillance Project, funded by USAID. 

[27] The six programs are in Brazil, Central Asia, Central America, 
India, Jordan, and Kenya. 

[28] According to CDC, WHO/AFRO is also working through IDSR to improve 
African countries' abilities to meet the requirements of the revised 
IHR. 

[29] CDC 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. 

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

[31] A 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. 

[32] GAO 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, GAO-06-15 (Washington, D.C.: Oct. 
21, 2005). 

[33] GDD's five goals are surveillance, research, outbreak response, 
networking, and training. 

[34] Because CDC's and USAID's evaluation frameworks are under 
development or in early implementation, we did not assess the adequacy 
of these efforts to demonstrate progress in building surveillance 
capacity. 

[35] CDC sought input on the indicators from USAID, FETPs, and members 
of the Training Programs in Epidemiology and Public Health Intervention 
Network, a professional alliance of FETPs located in 32 countries 
around the world. In total there are 21 indicators; however, some of 
them are related to the process of institutionalizing the program in 
country. 

[36] The database is called Epi-Track. 

[37] For example, assessments have been completed in the Gambia, 
Ethiopia, Malawi, and Uganda. 

[38] World 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). 

[39] In addition, the Institute of Medicine (IOM) completed a review of 
the GEIS program in 2001, and DOD officials told us that IOM was 
nearing completion of a second evaluation of GEIS's pandemic influenza 
activities as of September 2007. 

[40] See GAO, Influenza Pandemic: Efforts to Forestall Onset Are Under 
Way; Identifying Countries at Greatest Risk Entails Challenges, GAO-07-
604 (Washington, D.C.: June 20, 2007); Global Health: Spending 
Requirement Presents Challenges for Allocating Prevention Funding under 
the President's Emergency Plan for AIDS Relief, GAO-06-395 (Washington, 
D.C.: April 4, 2006); and Global Malaria Control: U.S. and 
Multinational Investments and Implementation Challenges, GAO-06-147R 
(Washington, D.C.: Nov. 16, 2005). 

[41] The first FETP was established in Thailand. 

[42] FETP is a 2-year program and during any given year there are 
usually two cohorts of trainees, first year and second year. 
 
[43] Brazil, Central Asia, Central America, India, Jordan, and Kenya. 

[44] Prior to 2005, GEIS funded the overseas laboratories directly, 
without a project-by-project breakdown. 

[45] Consistent with the scope of our engagement, we did not include 
projects funded from appropriations designated for avian influenza. 

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