Mar. 21, 2003 WASHINGTON -- The nation should take decisive steps to fortify its public health system to tackle microbes that trigger infectious diseases such as West Nile encephalitis, AIDS, and tuberculosis, says a new report from the Institute of Medicine of the National Academies. In addition, the U.S. government should play a significant role in building the capacity of poor countries to monitor, prevent, and respond to disease outbreaks. In the developing world, infectious diseases kill one in every two people.
Microbial threats endanger public health across the globe. Moreover, the potential use of biological agents in terrorist attacks or warfare underscores the urgent need for better strategies and tools to grapple with infectious diseases, the report notes.
"Infectious diseases cross national borders and require a global response, but the United States should help lead efforts to reverse the complacency in industrialized countries regarding this problem," said Margaret Hamburg, vice president for biological programs, Nuclear Threat Initiative, Washington, D.C., and co-chair of the committee that wrote the report. "On the whole, aggressively responding to microbial threats is in America's economic, humanitarian, and security interests, and should be a national priority."
At the outset, America has a lot of work to do domestically. Its ability to track and respond quickly to infectious diseases rests on a public health infrastructure that has suffered from years of neglect, the report says. Efforts to prevent and control microbial threats must be enhanced and expanded at all levels of government. Upgrades in everything from laboratory facilities to training programs will require much larger, and sustained, investments. The National Institutes of Health, working with other federal research institutions, also should develop a comprehensive research agenda for infectious-disease prevention and control.
The committee pointed out several major areas of concern. Reporting of infectious diseases by health care providers and clinical laboratories to both state and local health officials remains inadequate, for instance. Open lines of communication and solid working relationships among providers, laboratories, and public health authorities are critical to maintaining effective infectious-disease surveillance systems – and successfully carrying out response activities. The Centers for Disease Control and Prevention should craft innovative strategies to improve communication among these groups.
Likewise, a skilled health care work force is essential. Knowledge of how to confront microbial threats should be fully integrated into training programs for all health care professionals, the committee said. Specifically, CDC, NIH, and the U.S. Department of Defense should expand existing programs and develop new ones that educate health care workers about field-based and laboratory approaches to preventing infectious disease in this country and abroad.
Also, health care professionals also should heed the importance of etiologic diagnosis, which identifies the microbial causes of infectious diseases, the report says. Along with surveillance, such diagnoses are the cornerstone of control and prevention measures. For various reasons, etiologic diagnoses have decreased significantly over the past decade. The result has been a dangerous overuse of broad-spectrum antibiotics to treat illness, fueling microbial resistance to therapeutic drugs. Public health agencies and professional societies should disseminate and publicize guidelines calling for widespread use of etiologic diagnostic tools. Also, CDC and other federal agencies should work together with private industry to develop and assess new diagnostic tests.
At the same time, efforts to educate practitioners and the public about inappropriate uses of therapeutic drugs should be strengthened. A steady, global increase in the number of microbial agents that are resistant to available therapies has made it difficult to treat infections, the committee said. This problem is compounded by the pharmaceutical industry's decreased development and production of new anti-microbials, compared with previous years.
The report also urges the Food and Drug Administration to ban the use of certain anti-microbials for growth promotion in animals if those same drugs may be used to treat illness in humans. The goal should be to reduce the chances of developing drug-resistant organisms in animals that could eventually spread to people.
Concerns about vaccines have mounted, too. Research and development initiatives have been inadequate. Periodic shortages of existing vaccines have occurred. And there is a lack of vaccines against infectious diseases that disproportionately affect people in developing countries, such as malaria. Looking at the big picture, the report calls for high-level federal leadership to accelerate the development of new anti-microbials, maintain adequate vaccine supplies, and implement a U.S. national vaccine strategy to resolve the concerns. The secretaries of Health and Human Services and Defense and the director of Homeland Security should join together with other top officials from the public and private sectors to take immediate action in all of these areas. Their work should include partnerships with global organizations to promote the creation and distribution of vaccines against the diseases that are devastating the developing world. An aggressive campaign to produce new pesticides and repellents to combat mosquitoes and other carriers of infectious diseases also is needed.
As for U.S. disease-surveillance systems, they are fragmented and have not kept up with technological advances that could improve the timeliness and integration of data, the report notes. The CDC should set up a national electronic reporting system that feeds data from major clinical laboratories to state health departments, including information about patterns of microbial resistance. And the federal government should support research on innovative surveillance approaches that take advantage of cutting-edge information technology. Any new processes should be carefully evaluated before they are put in place, however. Similarly, global surveillance is key to responding to and containing microbial threats before isolated outbreaks mushroom into regional or worldwide pandemics. The United States should work with key international agencies, such as the World Health Organization, to build up existing surveillance initiatives around the world – focusing on microbial threats in developing nations. Assistance should include financial and technical support. In the long run, America should take a leadership role in promoting a comprehensive system of surveillance for global infectious diseases. "Still, this effort should be multinational because it will require regional and global coordination, advice, and resources from participating nations," said committee co-chair Joshua Lederberg, professor emeritus and Sackler Foundation Scholar, Rockefeller University, New York City. "In the context of infectious diseases, we all share the same landscape."
The human element plays a critical role in interactions that result in disease emergence, the report says. Increases in the size and density of populations can promote the spread of disease, for example. Land development may situate people close to wild animals that carry pathogens. And individual behavior, such as unprotected sexual activity or use of intravenous drugs, can lead to the transmission of a number of diseases.
Several other factors contribute to the emergence of disease. In shipping goods from one place to another, people may unknowingly transport a disease carrier, and they can carry diseases during travel to and from international destinations. Breakdowns in public health measures – especially a lack of potable water or basic sanitation – have dramatically raised the persistence of infectious diseases throughout the world. The risk of intentional biological attacks also remains high.
The study was sponsored by the U.S. Centers for Disease Control and Prevention, National Institutes of Health, Ellison Medical Foundation, U.S. Department of Agriculture, U.S. Agency for International Development, U.S. Department of Defense, U.S. Food and Drug Administration, and the Joint Institute for Food Safety Research. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.
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