The United States is part of the international plan to prevent the naturally occurring, accidental or deliberate spread of infectious diseases, but remains among many countries hampered by the inadequate or underprepared systems around the world that can’t effectively deal with rapidly emerging unexpected threats.
As a contributor to the Global Health Security Agenda (GHSA), a multilateral, multisector effort that includes 60 participating countries and numerous private and public international organizations focused on building up worldwide health security capabilities toward meeting such threats, the United States has committed to improving its own preparedness, as well as that of other nations.
On March 26-28, the United States will participate in the next GHSA high-level meeting being held in Tbilisi, Georgia on biosurveillance of infectious disease threats, which include such modern-day examples as HIV/AIDS, severe acute respiratory syndrome (SARS), H1N1 influenza, multi-drug resistant tuberculosis — any emerging or reemerging disease that threatens human health and global economic stability.
“Emerging infectious diseases affect developing countries, but they also affect wealthy countries. No country is immune,” Dr. Anne Schuchat, acting director of the U.S. Centers for Disease Control and Prevention (CDC), said last week. “Just ask South Korea about MERS; just ask Canada and Singapore about SARS; just ask Brazil about yellow fever and Zika.
“Today’s world of increasing interconnectivity and mobility accelerates the shared global risk to human health and well-being,” Schuchat said. “An outbreak anywhere can be anywhere within 36 hours.”
So says the GHSA February 2018 report, “Implementing the Global Health Security Agenda: Progress and Impact from U.S. Government Investments,” which notes that many new and reemerging pathogens are spreading quickly resulting in epidemics and outbreaks having the potential to overwhelm and devastate global systems across health care, financial and research and development markets.
Among the many pathogens cited in the report as being of global health security concern are zoonotic diseases — which are those transmitted between animals and humans — antimicrobial resistance in pathogens that infect humans and animals, and biological weapons development.
The information in this second-annual report, which focuses on activities during the third year of the five-year U.S. government GHSA commitment, highlights how U.S. and other partner investments in the GHSA have continued to build capacities across each of the GHSA 11 Action Packages.
The Action Packages have been identified and agreed upon by GHSA member countries to provide focus and structure to priority technical areas that will help achieve the overall GHSA goal to prevent, detect and respond to infectious disease outbreaks. Each Action Package includes a five-year target, indicators to measure progress, and lists of baseline assessment, planning, monitoring, and evaluation activities to support successful implementation. All GHSA member countries participate in one or more Action Packages and may choose to fulfill commitments by building capacity at a national, regional and/or global level, according to GHSA.
“The United States is committed to working with 31 countries and the Caribbean Community toward achieving GHSA targets across the 11 Action Packages,” according to the GHSA report, and in July 2015 committed to investing $1 billion in new resources across several countries to build capacity to prevent, detect and respond to infectious disease outbreaks.
As of Dec. 31, 2017, the CDC had obligated $453.8 million, and USAID obligated $245.5 million in support of the U.S. commitment to GHSA, with the funding and technical assistance helping these countries design and implement five-year GHSA plans to address specific gaps in health security capability across the GHSA Action Packages.
But according to Jen Kates, vice president and director of global health and HIV policy at the Henry J. Kaiser Family Foundation (KFF), this isn’t typical global health security funding.
“We are at a critical time,” Kates said during a March 12 KFF event to take stock thus far of the U.S. government’s support of global health security.
The United States, which has been instrumental in launching the GHSA and in helping to build the capacity of countries to prevent, detect and respond to emergent health threats, now faces a major funding challenge, she said, pointing to historical U.S. funding data dating back to 2006 showing that, on average, the nation spent about $400 million annually on global health security activities.
However, in 2015 the United States had a significant funding spike from $433 million allocated to $1.34 billion with supplemental funds to fight the Ebola outbreak and pay for costs associated with related GHSA efforts, according to Kates. In 2016, there was another small jump in global health security spending to $552 million from $407 million allocated due to the Zika virus and related GHSA efforts. In 2017, spending returned to $402 million and in 2018, $353 million has been requested.
“What we have is a situation where there is episodic and non-permanent influxes when there’s an outbreak and a return to these normal levels that many experts say are insufficient,” Kates said. “There’s no surge capacity and there’s no preparedness bank to draw on both to respond as well as to prepare.”
In fact, much of the Ebola funding for the GHSA — which primarily went to the CDC — is due to expire at the end of fiscal year (FY) 2019, she added.
“So the funding is ending with really no replenishment in sight, and we’re already learning that this could result in a really significant scaling back of U.S. government efforts,” said Kates.
It’s important to note, she added, that President Donald Trump in his FY 2019 budget request seeks additional funding for the CDC in recognition of the fact that the money would be expiring at the end of 2019, “essentially a doubling of the amount that has been going to the CDC on an annual basis.”
But that request appears to come at the expense of other global health security initiatives, Kates said, in this case global HIV-related funding, which seems to go down about the same amount as CDC funding increases.
“It’s not clear what the solution is,” said Kates. “I think this challenge is not really something that’s about partisanship. It’s more about the willingness of governments to spend on things that haven’t happened yet, even though we know that they will happen, and that the response to an event costs more than preventing it.”
Investing in global health security also saves lives here in the U.S. and across the globe, she added, and produces economic benefits, as well.
Action-packed meeting
Despite the encroaching funding cliff, GHSA efforts continue and the U.S. will participate in the upcoming meeting in Georgia, which is the lead country for the Real-Time Surveillance Action Package, one of the 11 GHSA Action Packages.
The topic for Georgia’s meeting is “Accelerating progress in the Real-Time Biosurveillance Action Package of GHSA,” and objectives, according to the GHSA Georgia Team of the National Center for Disease Control and Public Health, include:
- Strengthening partnerships with GHSA partner/contributing countries of the Real-Time Surveillance Action Package and engaging with and boosting collaborations with non-governmental organizations and international partners;
- Exchanging best practices and experiences on building capacity to meet compliance with International Health Regulations, such as implementing integrated electronic systems for regional communicable disease surveillance or community-based surveillance, using biosurveillance data for public health action, and bolstering integrated disease surveillance systems that facilitate a ‘One Health’ approach to disease detection and control; and
- Providing funding to sustain surveillance as a cost-effective investment.
Among the expected outcomes from the meeting, GHSA Georgia Team members hope to gain insights into disease surveillance, update best practices, develop recommendations for better planning and operationalization of disease surveillance systems, and define their next steps for the Real-Time Surveillance Action Package.
In addition to the United States, contributing countries participating in Georgia’s upcoming Real-Time Surveillance Action Package — which will include two technical experts from each country; one from the human and one from the animal health sectors — are: Argentina, Azerbaijan, Bangladesh, Cote d’Ivoire, Ethiopia, Finland, Ghana, Guinea-Bissau, Indonesia, Israel, Italy, Kenya, Mexico, Mongolia, Norway, South Africa, the United Kingdom, Yemen, and Zimbabwe.
The contributing international organizations are the World Health Organization (WHO), the Food and Agriculture Organization (FAO) of the United Nations, and the World Organisation for Animal Health (OIE).
Worldwide importance
Such ongoing global health security collaboration is vital, CDC’s Schuchat said in her keynote address during the March 12 KFF event in Washington, D.C.
“In 2018, despite the Global Health Security Agenda, most of the world is still underprepared to efficiently prevent, detect and respond to urgent infectious disease threats,” Schuchat said. “And we can’t protect America if other countries can’t protect their own nations.”
As of today, the CDC has about 35 public health events of international importance under surveillance all around the world, she said, adding that the U.S. public health system is dependent upon other nations being able to effectively operate their own systems. Some countries, however, may not have a public health system or are in various stages of developing them.
“In the United States, we rely on a trained public health staff, a national laboratory response effort, on emergency operations centers to detect and prevent, on effective disease surveillance programs, and more than anything we rely on speed,” Schuchat said. Quick response is slowed and the consequences more dire when systems aren’t well-equipped to handle outbreaks.
Through GHSA and CDC-specific programs, she said CDC is focused on building strong, capable systems around the world that have the same core capabilities as those of the United States. But based on CDC and GHSA assessments, known as joint external evaluations (JEEs), many countries still have significant gaps in their efforts to find, stop and prevent epidemics, Schuchat said.
But the landscape is changing.
“The JEEs are critical for knowing where the gaps are so we can most effectively target our resources,” she said. “We have seen measurable success.”
CDC, working in partnership with myriad groups, including ministries of health, civil societies, academic institutions and other partners, is on the ground in more than 60 countries, said Schuchat, who highlighted a recent success related to U.S. investments in GHSA. The report summarizes others.
In July 2014, for instance, a Liberian businessman flew to Lagos, Nigeria. He became sick en route and it was determined he had brought Ebola to Nigeria. “But because there was a public health infrastructure there, the Nigerians were able to stop the Ebola outbreak after 19 cases,” said Schuchat.
GHSA program-supported government experts and field workers logged some 20,000 home visits to trace contacts and follow up with patients, she added, and “because they stopped it, they protected Lagos, they protected Nigeria and they protected the continent of Africa. It still took too long to stop Ebola in the three hardest-hit African countries, but because Nigeria has public health capacity, it was able to stop the outbreak there.”
Meanwhile, of the more than 28,600 total Ebola cases CDC reported in Liberia, New Guinea and Sierra Leone during that outbreak, more than 11,300 people in those West African nations died, according to the agency.
“Ebola just festered there … and was very, very difficult to stop,” Schuchat said.
To put in perspective what it would cost today to fight a 1918-like influenza pandemic, which 100 years ago killed 50 million people, Schuchat estimated the price tag at $6 trillion.
“But the economic costs of these smaller outbreaks and events are substantial, as well,” she said, and include deaths of second-order effects in which trained healthcare workers die from an infectious disease, resulting in more deaths of other people because there’s no trained help.
Additionally, CDC has found that 1.6 million American jobs across a variety of sectors are threatened by these overseas outbreaks of infectious diseases, Schuchat said.
“This is a critical time in global health security,” she said. “The issues are evergreen. It’s very important that these issues get the world’s attention.”