Global Health: U.S. Agencies Support Programs to Build Overseas
Capacity for Infectious Disease Surveillance (28-SEP-07,
GAO-07-1186).
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. agencies--the Centers for Disease Control and
Prevention (CDC), the U.S. Agency for International Development
(USAID), and the Department of Defense (DOD)--support programs
aimed at building this broader capacity to detect a variety of
infectious diseases. This report describes (1) the obligations,
goals, and activities of these programs and (2) the U.S.
agencies' monitoring of the programs' progress. To address these
objectives, GAO reviewed budgets and other funding documents,
examined strategic plans and program monitoring and progress
reports, and interviewed U.S. agency officials. GAO did not
review capacity-building efforts in programs that focus on
specific diseases, namely polio, tuberculosis, malaria, avian
influenza, or HIV/AIDS. 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.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-07-1186
ACCNO: A76811
TITLE: Global Health: U.S. Agencies Support Programs to Build
Overseas Capacity for Infectious Disease Surveillance
DATE: 09/28/2007
SUBJECT: Developing countries
Disease control
Disease detection or diagnosis
Disease surveillance
Emerging infectious diseases
Health care programs
Infectious diseases
International relations
Laboratories
Program evaluation
Public health
Public health research
Program goals or objectives
Field Epidemiology Training Programs
Global Disease Detection
Global Emerging Infections Surveillance
and Response System
Integrated Disease Surveillance and
Response
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GAO-07-1186
* [1]Results in Brief
* [2]Background
* [3]Four Programs Support Capacity Building for Overseas Surveil
* [4]U.S. Obligations to Build Capacity for Infectious Disease Su
* [5]Global Disease Detection
* [6]Field Epidemiology Training Programs
* [7]Integrated Disease Surveillance and Response
* [8]Global Emerging Infections Surveillance and Response System
* [9]Additional Activities Supporting Capacity Building
* [10]Interagency Coordination of Overseas Efforts
* [11]Agencies Monitor Surveillance Capacity-Building Activities,
* [12]Agencies Monitor Program Activities
* [13]CDC and USAID Have Begun Efforts to Evaluate Impact of Surve
* [14]Agency Comments and Our Evaluation
* [15]GAO Comments
* [16]GAO Comments
* [17]GAO Comments
* [18]GAO Contact
* [19]Acknowledgments
* [20]GAO's Mission
* [21]Obtaining Copies of GAO Reports and Testimony
* [22]Order by Mail or Phone
* [23]To Report Fraud, Waste, and Abuse in Federal Programs
* [24]Congressional Relations
* [25]Public Affairs
* [26]PDF6-Ordering Information.pdf
* [27]Order by Mail or Phone
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
GAO-07-1186
Contents
Letter 1
Results in Brief 2
Background 4
Four Programs Support Capacity Building for Overseas Surveillance of
Infectious Diseases 8
Agencies Monitor Surveillance Capacity-Building Activities, and CDC and
USAID Have Begun Efforts to Evaluate Programs' Impact 18
Agency Comments and Our Evaluation 23
Appendix I Objectives, Scope, and Methodology 26
Appendix II GDD 28
Appendix III FETP 30
Appendix IV IDSR 32
Appendix V GEIS 33
Appendix VI Comments from the Department of Defense 37
Appendix VII Comments from the Department of Health and Human Services 41
Appendix VIII Comments from the U.S. Agency for International Development
45
Appendix IX GAO Contact and Staff Acknowledgments 51
Tables
Table 1: U.S. Obligations for Programs Supporting Capacity Building for
Infectious Disease Surveillance, 2004-2006 9
Table 2: Overview of GDD Center Activity Data 28
Table 3: FETP Trainees and Graduates by Country, 2004-2006 30
Table 4: Examples of Country-Specific IDSR Activities Supported by CDC and
USAID, 2004-2006 32
Table 5: GEIS Projects with Capacity-Building Components, 2005 34
Table 6: GEIS Projects with Capacity-Building Components, 2006 35
Figures
Figure 1: Elements of a Disease Surveillance System 6
Figure 2: Countries with GDD-, FETP-, IDSR-, or GEIS-Related Activities
Supported by U.S. Agencies, 2004-2006 10
Figure 3: Framework for Evaluating Impact of GDD 20
Figure 4: Indicators for Evaluating Impact of FETPs 21
Figure 5: Indicators for Evaluating Impact of IDSR 22
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
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separately.
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. 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. 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,^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.^2
o GDD. CDC obligated about $31 million for GDD capacity-building
activities conducted at GDD centers in five countries.^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.
o 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.
o 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.
o GEIS. For 2005-2006,^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.
o 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.
^1In this report, all years cited are fiscal years, unless otherwise
noted.
^2This amount does not include U.S. agency obligations to build
surveillance capacity for specific diseases, namely polio, malaria,
tuberculosis, avian influenza, and HIV/AIDS.
^3China, Egypt, Guatemala, Kenya, and Thailand.
^4Prior to 2005, GEIS funded the overseas laboratories directly, without a
project-by-project breakdown.
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,^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.^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.)
^5Disease strains resistant to antimicrobial drugs are the result of
excessive, uncontrolled use of these drugs.
^6GAO, Emerging Infectious Diseases: Asian SARS Outbreak Challenged
International and National Responses, [28]GAO-04-564 (Washington, D.C.:
Apr. 28, 2004).
Figure 1: Elements of a Disease Surveillance System
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.^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.^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.^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.^10
^7GAO, Global Health: Challenges in Improving Infectious Disease
Surveillance Systems, [29]GAO-01-722 (Washington, D.C.: Aug. 31, 2001).
^8Peter Nsubuga et al., "Polio Eradication Initiative in Africa: Influence
on Other Infectious Disease Surveillance Development," BMC Public Health,
vol. 2 no. 27 (2002) [30]http://www.biomedcentral.com/1471-2458/2/27
(downloaded July 30, 2007).
^9Emerging 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.
Enhancing capacity for detecting and responding to emerging infectious
disease outbreaks is also a key focus of the revised International Health
Regulations (IHR). For many years, the IHR required reporting of three
diseases--cholera, plague, and yellow fever--and delineated measures that
countries could take to protect themselves against outbreaks of these
diseases. In May 2005, the members of WHO revised the IHR, committing
themselves to developing core capacities for detecting, investigating, and
responding to other diseases of international importance, including
outbreaks that have the potential to spread. The regulations entered into
force in June 2007; member states are required to assess their national
capacities by 2009 and comply with the revised IHR by 2012.^11
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.
^10See Institute of Medicine, Microbial Threats to Health: Emergence,
Detection, and Response (Washington, D.C.: National Academies Press,
2003).
^11The revised regulations specify that each state party shall assess its
systems within 2 years of the regulations entering into force on June 15,
2007. They also specify that each state party shall develop systems that
meet the new requirements as soon as possible, but no later than 5 years
from the date the regulations enter into force. In certain circumstances,
the revised regulations allow countries to request an extension of up to 4
years to develop systems that meet the requirements.
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 Agency Obligations
Amounts provided only as
2004 2005 2006 2004-2006 aggregates Total
GDD CDC $6 $11 $14 $31
FETP CDC^a 2 2 3 $7
USAID 2 3 1 $6 $12
IDSR^b USAID^c 3 3 2 4 $12
GEIS DOD NA^d 5 3 $8
Additional USAID 4 4 2 4 $14
capacity-building
activities^e
Total $17 $28 $25 $14 $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.
^aCDC 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.
^bCDC 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.
^cUSAID provides funding to CDC to support IDSR efforts.
^dNA = not applicable. DOD's project reporting system was not in place
until 2005.
^eAdditional capacity-building activities include projects supported by
USAID's missions in country. This amount does not include obligations from
USAID's Egypt mission, which conducted capacity-building activities for
infectious disease surveillance from 2004 through 2006 but was not able to
determine specifically how much funding went to these activities.
Collectively, these four programs operate in 26 developing countries. (See
fig. 2.)
Figure 2: Countries with GDD-, FETP-, IDSR-, or GEIS-Related Activities
Supported by U.S. Agencies, 2004-2006
^aCosta Rica, Dominican Republic, El Salvador, Guatemala, Honduras,
Nicaragua, and Panama participated in the Central America FETP in
2004-2006.
^bKazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan participated in the
Central Asia FETP in 2004-2006.
^cCDC 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.
^dCDC support for IDSR implementation in Guinea and southern Sudan was
funded by the United Nations Foundation.
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.^12 GDD's goals are to
o enhance surveillance,
o conduct research,
o respond to outbreaks,
o facilitate networking, and
o train epidemiologists and laboratorians.
GDD, established in 2004, aims to set up a total of 18 international
centers^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,^14 and 3 more are currently under development in Egypt, China,
and Guatemala.^15 In addition, CDC established a GDD Operations Center in
Atlanta to coordinate information related to potential outbreaks.^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,^17 and participation in surveillance activities.
^12In 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.
^13CDC officials told us that the GDD centers are typically incorporated
into ministry of health facilities or colocated with universities.
^14The Thailand center incorporated an IEIP, which is a program for
research and outbreak response to emerging infectious diseases.
^15The long-term applied epidemiology training program in Guatemala is
referred to as the Central America FETP.
^16The 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.
o Laboratory-strengthening efforts. Efforts to build laboratory
capacity in Kenya and Thailand have focused on establishing
laboratories^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.^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.
o Epidemiology training programs and activities. Training at the
GDD centers occurs formally through long-term applied epidemiology
training programs^20 and informally through the participation of
host-country nationals in short-term activities focused on
outbreak response, surveillance, and research.
o Long-term programs. Trainees in the formal, 2-year epidemiology
training programs^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.
o 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.
^17GDD 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.
^18CDC officials told us that these efforts generally support national and
district-level public health laboratories.
^19Biosafety 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.
^20These 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.
^21The 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.
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.^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
o applied epidemiology and evidence-based decision making for
public health actions;
o effective communication with the public, public health
professionals, and the community; and
o health program design, management, and evaluation.
^22The FETP model is based on CDC's Epidemic Intelligence Service, which
began in 1951. In addition to the FETPs, there are also three Field
Epidemiology and Laboratory Training Programs in Kenya, Pakistan, and
South Africa. These are included in our discussion of FETPs.
CDC and USAID collaborate with host-country ministries of health in
Brazil, Central America,^23 Central Asia,^24 China, Egypt, Ghana, India,
Jordan, Kenya, Pakistan, South Africa, Sudan,^25 Thailand, Uganda, and
Zimbabwe^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 1999-2004^27 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.^28
^23In 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.
^24Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan participated in the
Central Asia FETP in 2004-2006.
^25CDC supports an advisor for the Sudan program, but the students receive
their training in the Kenya program.
^26The 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.
^27The six programs are in Brazil, Central Asia, Central America, India,
Jordan, and Kenya.
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
o developing an assessment tool to determine the status of
surveillance systems throughout Africa,
o developing technical guidelines for implementing IDSR,
o working to strengthen the national public health surveillance
laboratory systems, and
o conducting evaluations of the cost to implement IDSR in several
African countries.
In addition, CDC is providing technical assistance to eight countries in
Africa,^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,^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.
^28According to CDC, WHO/AFRO is also working through IDSR to improve
African countries' abilities to meet the requirements of the revised IHR.
^29CDC 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.
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,^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.
^30The laboratories are under the command of the U.S. Army in Kenya and
Thailand and the U.S. Navy in Egypt, Indonesia, and Peru.
^31A 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.
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.^32
o 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.
o 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.
o 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.
o Phone communication. USAID and CDC share information regularly
by phone to ensure coordination of activities and achievement of
common goals.
^32GAO 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, [31]GAO-06-15 (Washington, D.C.: Oct. 21, 2005).
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:
o 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.)
o 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.)
o IDSR. Since 2000, CDC has collected data on activities completed
under its IDSR assistance program, including the number of job
aids developed, the training materials adopted, and the number of
training courses completed, and it reports on these activities
annually to USAID. (See app. IV for more information on IDSR
activities.)
o GEIS. Since 2005, DOD has monitored GEIS capacity-building
activities through individual project reports that detail each
activity completed, such as training for staff involved in
surveillance studies and development of laboratory diagnostic
capabilities. (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.
o 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.^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.^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.
^33GDD's five goals are surveillance, research, outbreak response,
networking, and training.
^34Because 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.
Figure 3: Framework for Evaluating Impact of GDD
o 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.^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.^36
^35CDC 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.
Figure 4: Indicators for Evaluating Impact of FETPs
o 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.^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,^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.
^36The database is called Epi-Track.
Figure 5: Indicators for Evaluating Impact of IDSR
o 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.^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.
^37For example, assessments have been completed in the Gambia, Ethiopia,
Malawi, and Uganda.
^38World 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).
^39In 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.
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.^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 [32]http://www.gao.gov .
^40See GAO, Influenza Pandemic: Efforts to Forestall Onset Are Under Way;
Identifying Countries at Greatest Risk Entails Challenges, [33]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, [34]GAO-06-395 (Washington,
D.C.: April 4, 2006); and Global Malaria Control: U.S. and Multinational
Investments and Implementation Challenges, [35]GAO-06-147R (Washington,
D.C.: Nov. 16, 2005).
If you or your staff have any questions regarding this report, please
contact me at (202) 512-3149 or [36][email protected] . 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.
David Gootnick
Director
International Affairs and Trade
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.
Appendix II: GDD
CDC's GDD has established five centers around the world to develop public
health capacity to detect and respond to emerging infectious diseases and
bioterrorist threats. Congress made its initial appropriations for the
program in 2004, and GDD's first report on the centers' progress covers
accomplishments for 2006. Table 2 presents an overview of activity data
collected for individual GDD centers.
Table 2: Overview of GDD Center Activity Data
Country Activity
China o 30 graduates from long-term epidemiology training,
2004-2006^a
o 20 graduates in key positions in 14
provinces
o 100 city-level public health doctors participated
in 4-day training course in surveillance and
epidemiology
o Conducted 90 outbreak responses, 23 of which were human
avian influenza cases
o Conducted outbreak investigation of Streptococcus suis that
led to drop in number of cases
o 215 cases, 39 deaths in 2005
o Investigation indicated strict ban on pig slaughter
o In 2006, 83 percent fewer cases and zero deaths
Guatemala o 20 graduates from long-term epidemiology training,
2004-2006 ^a
o 150 graduates of 3-month epidemiology course in
Guatemala, and 192 graduates in Costa Rica
o Conducted outbreak response to methanol intoxication in
Nicaragua
o Over 700 cases; 41 deaths
o Identified contaminated alcohol as the cause;
outbreak contained
o Collaborated with local institutions to strengthen regional
laboratory capacity
o Developed rapid-response capacity through workshop attended
by 70 participants from eight countries in November 2006
o Synchronized community-based surveillance protocols with
sites in Thailand and Kenya to enable cross-country
comparison of data
Egypt o 15 graduates from long-term epidemiology training,
2004-2006 ^a
o Rapid-response capacity being established through rapid
response training in Cairo
o Laboratory avian influenza capacity strengthened;
instituted advanced laboratory testing for bacterial
meningitis and for rickettsioses
o Collaborated with Kenya GDD program to provide laboratory
team and entomologist to assist with Rift Valley fever
outbreak in Kenya
Kenya o 7 graduates from long-term epidemiology training,
2004-2006 ^a
o Trained district health surveillance teams from
eight provinces on IDSR
o Developed avian influenza training and rapid-response
training capacity in Africa
o Predicted and confirmed Rift Valley fever outbreak
o Fewer than 200 human cases and 50 deaths
o Containment efforts ongoing to address its spread
to Somalia and Tanzania
o Established previously unavailable testing for more than
five pathogens
o Tested 786 humans and animals for avian influenza,
meningococcal meningitis, and yellow fever; provided
extensive laboratory support to countries within the
region
o Collaborated with Kenya Ministry of Health and WHO to
establish IDSR
Thailand o 8 graduates from long-term epidemiology training,
2004-2006 ^a
o 40-45 participants in field epidemiology short
course in 2006
o Led and hosted the model rapid response training; all five
GDD centers participated
o Helped build avian influenza laboratory capacity in Bangkok
and in 14 Thai regions
o Responded to botulism outbreak
o Largest reported outbreak of botulism
o 232 cases, 45 ventilated patients
o 50 vials of antitoxin delivered within 48 hours; no
deaths
o Expanded an ongoing population-based pneumonia surveillance
system in two provinces by adding microbiology diagnostic
capacity
o Within 10 months of implementation, obtained 26
isolates of Streptococcus pneumoniae
o Conducted regional drills with WHO, the Asian Development
Bank, and other national and international partners
Source: CDC.
^aThese are graduates of the FETP.
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,^1 provides 2 years of classroom instruction and field
assignments.^2 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 2004^3 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
2004 2005 2006
Country/region Trainees^a Graduates Trainees^a Graduates Trainees^a Graduates
Brazil 11 0 25 0 24 11
Central 53 5 45 15 29 0
America
Central Asia 15 0 18 7 19 8
China 22 10 21 10 24 10
Egypt 15 0 25 9 25 6
Ghana^b 35 35 40 40 35 35
India 14 6 14 7 25 6
Jordan 11 5 6 5 10 0
Kenya 7 0 14 0 16 7
Pakistan^c 0 0 0 0 0 0
South Africa^c 0 0 0 0 0 0
Sudan^d 0 0 0 0 4 0
Thailand 8 0 18 0 33 8
Uganda 23 31 18 23 22 23
Zimbabwe 7 4 13 15 8 10
Total 221 96 257 131 274 124
^aCDC 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.
^bThe Ghana FETP is a 1-year program.
^cProgram began enrolling trainees in 2007, although CDC provided support
in 2006.
^dThe south Sudan FETP began in 2006.
^1The first FETP was established in Thailand.
^2FETP is a 2-year program and during any given year there are usually two
cohorts of trainees, first year and second year.
^3Brazil, Central Asia, Central America, India, Jordan, and Kenya.
Source: CDC.
Appendix IV: IDSR
WHO/AFRO's 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, CDC's
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 USAID's 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 Activity
Tanzania 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.
Mali 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.
Kenya Conducted training workshops for individuals who then
returned to their districts and trained others
there--training of trainers.
Burkina Faso 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.
Ethiopia Supported training on IDSR at regional levels; supported
monitoring of timeliness and completeness of data reporting.
Ghana Maintained and provided communications training to
surveillance team; conducted outbreak investigation courses.
Uganda Conducted outbreak investigation courses; supported
laboratory specimen transportation system; maintained
surveillance team.
Zimbabwe Conducted outbreak investigation courses; maintained
surveillance team.
Source: CDC.
Appendix V: GEIS
Since 1996, DOD's 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.^1 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.^2 (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.
^1Prior to 2005, GEIS funded the overseas laboratories directly, without a
project-by-project breakdown.
^2Consistent with the scope of our engagement, we did not include projects
funded from appropriations designated for avian influenza.
Table 5: GEIS Projects with Capacity-Building Components, 2005
Projects with capacity-building
DOD implementing unit components
DOD overseas laboratories
Naval Medical Research Unit Surveillance and outbreak response in
No. 2 (NAMRU-2), Jakarta, the emerging diseases program
Indonesia Surveillance in the viral diseases program
Surveillance in the enteric diseases
program
Surveillance and outbreak response in the
parasitic diseases program
Naval Medical Research Unit Hospital and laboratory-based
No. 3 (NAMRU-3), Cairo, Egypt surveillance for hemorrhagic fever
viruses in Ukraine
Regional surveillance for influenza in the
Middle East, Africa, and Eastern Europe and
in overseas military populations
Response to outbreaks in the eastern
Mediterranean and other support for WHO's
Eastern Mediterranean Regional Office,
including training and evaluation
Laboratory information management,
accessioning, and archiving system
Maintain/broaden Egyptian disease
surveillance network to include acute
febrile illness, meningitis, and viral
hepatitis
Etiology of diarrhea in hospital-based
(urban) system versus active
community-based (rural) system
Establish a regional network in eastern
Mediterranean region for meningitis
Naval Medical Research Center Outbreak response, classroom training,
Detachment (NMRCD), Lima, Peru and electronic surveillance of
infectious disease
Surveillance of diarrhea in the bacterial
diseases program
Surveillance of dengue in the vectors of
disease program
Armed Forces Research Influenza surveillance
Institute of Medical Sciences Febrile illness surveillance and Thai field
(AFRIMS), Bangkok, Thailand site for training DOD personnel
Zoonotic disease surveillance
Drug resistance surveillance and pathogen
identification
Cambodia surveillance site development and
capacity building
Philippines site development and capacity
building
Response and readiness surge capacity
Public health capacity building in Nepal
Public health capacity building in
partnership with the Royal Thai Army
Maintain HIV serum repository in
collaboration with the Royal Thai Army
United States Army Medical Epidemiology of diarrheal illness in
Research Unit-Kenya Kenya
(USAMRU-K), Nairobi, Kenya Influenza surveillance in Kenya
Infrastructure, including student
attachment program
Outbreak response
Surveillance sites network
Acute febrile illness surveillance in Kenya
U.S. Military Health System
Air Force Institute for Operation and expansion of DOD
Operational Health (AFIOH) influenza surveillance system
United States Army Center for Laboratory surveillance in the Central
Health Promotion and America Military Health System
Preventive Medicine-West
(USACHPPM-West)
Walter Reed Army Institute of Establishing a Plasmodium vivax
Research (WRAIR) surveillance network in the
Asia-Pacific region
Source: GAO analysis of DOD data.
Table 6: GEIS Projects with Capacity-Building Components, 2006
DOD implementing unit Projects with capacity-building components
DOD overseas
laboratories
NAMRU-2 (Jakarta, Syndromic surveillance in Vietnam
Indonesia) Influenza surveillance and virus characterization
in Indonesia
Resistance to chloroquine or primaquine in
Plasmodium vivax, and markers of resistance to
artemisinin combined therapies in Indochina and
East Timor
Outbreak investigation and outbreak support
NAMRU-3 (Cairo, Egypt) Development of the eastern Mediterranean
regional rotavirus surveillance network
Regional surveillance for respiratory viruses in
the Middle East, Africa, and Eastern Europe
Hospital and laboratory-based surveillance for
hemorrhagic fever viruses and arboviruses
Surveillance for avian influenza viruses
Enhanced laboratory-based surveillance for patients
with meningitis and pneumonia in the eastern
Mediterranean region
Regional response to outbreaks in the Middle East,
Africa, and the Eurasian region, with relevant
training support and program evaluation
NMRCD (Lima, Peru) Molecular and epidemiological surveillance of
Leishmaniasis in Peru
Surveillance for the dengue vector, Aedes aegypti,
in urban Lima
Respiratory illness surveillance in Central and
South America
Bacterial etiologies of febrile syndromes in a
variety of populations throughout Peru
Electronic disease surveillance systems in
Peru--Alerta and Early Warning Outbreak Recognition
System
Epidemiological training in the Americas
AFRIMS (Bangkok, Unit-based infectious disease surveillance in
Thailand) Thai border areas
Infectious disease surveillance among Royal Thai
Army recruits
Multi-nation surveillance of diarrhea etiology and
antimicrobial-resistant enteric pathogens
Detection of artemisinin resistance and
surveillance of antimalarial drug resistance in
Asia
Establishing antimalarial drug resistance research
at Walter Reed/AFRIMS Research Unit-Nepal
Sentinel human influenza surveillance in Asia
Sentinel surveillance for emerging diseases causing
dengue-like or acute encephalitis syndrome in the
Philippines
Febrile illness surveillance and characterization
in Nepal
USAMRU-K (Nairobi, Education, capacity building, and training
Kenya) Study site network and laboratory support
Epidemiology of malaria and drug sensitivity
patterns in Kenya
Epidemiology of diarrheal illness in Kenya
Acute febrile illness surveillance in Kenya
U.S. Military Health
System
AFIOH and Collaboration for laboratory-based
USACHPPM-West respiratory surveillance in Central America
USACHPPM-West Disease outbreak surveillance program in
Central America Military Health System
WRAIR Malaria microscopy center for excellence in
Kisumu, Kenya
Source: GAO analysis of DOD data.
Appendix VI: Comments from the Department of Defense
Note: GAO comments supplementing those in the report text appear at the
end of this appendix.
See comment 1.
See comment 2.
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.
Appendix VII: Comments from the Department of Health and Human Services
Note: GAO comments supplementing those in the report text appear at the
end of this appendix.
See comment 3.
See comment 2.
See comment 1.
See comment 6.
See comment 5.
See comment 4.
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.
Appendix VIII: Comments from the U.S. Agency for International Development
Note: GAO comments supplementing those in the report text appear at the
end of this appendix.
See comment 2.
See comment 1.
The following are GAO's comments on USAID's letter dated September 7,
2007.
GAO Comments
1. 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."
2. 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.
Appendix IX: GAO Contact and Staff Acknowledgments
GAO Contact
David Gootnick, (202) 512-3149 or [37][email protected]
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.
(320459)
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Highlights of [45]GAO-07-1186 , a report to congressional requesters
September 2007
GLOBAL HEALTH
U.S. Agencies Support Programs to Build Overseas Capacity for Infectious
Disease Surveillance
The rapid spread of severe acute respiratory syndrome (SARS) in 2003 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. agencies--the Centers for Disease Control and
Prevention (CDC), the U.S. Agency for International Development (USAID),
and the Department of Defense (DOD)--support programs aimed at building
this broader capacity to detect a variety of infectious diseases.
This report describes (1) the obligations, goals, and activities of these
programs and (2) the U.S. agencies' monitoring of the programs' progress.
To address these objectives, GAO reviewed budgets and other funding
documents, examined strategic plans and program monitoring and progress
reports, and interviewed U.S. agency officials. GAO did not review
capacity-building efforts in programs that focus on specific diseases,
namely polio, tuberculosis, malaria, avian influenza, or HIV/AIDS. 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.
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 CDC's 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 Organization's
Regional Office for Africa in designing and implementing Integrated
Disease Surveillance and Response in 46 countries in Africa, with
additional technical assistance to 8 African countries. DOD's Global
Emerging Infections Surveillance and Response System also contributes to
capacity building through projects undertaken at DOD overseas research
laboratories. USAID supports additional capacity-building projects in
various developing countries. 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.
U.S.-Supported Programs to Build Overseas Capacity for Surveillance of
Infectious Disease
References
Visible links
28. http://www.gao.gov/cgi-bin/getrpt?GAO-04-564
29. http://www.gao.gov/cgi-bin/getrpt?GAO-01-722
30. http://www.biomedcentral.com/1471-2458/2/27
31. http://www.gao.gov/cgi-bin/getrpt?GAO-06-15
32. http://www.gao.gov/
33. http://www.gao.gov/cgi-bin/getrpt?GAO-07-604
34. http://www.gao.gov/cgi-bin/getrpt?GAO-06-395
35. http://www.gao.gov/cgi-bin/getrpt?GAO-06-147R
36. mailto:[email protected]
37. mailto:[email protected]
38. http://www.gao.gov/
39. http://www.gao.gov/
40. http://www.gao.gov/fraudnet/fraudnet.htm
41. mailto:[email protected]
42. mailto:[email protected]
43. mailto:[email protected]
44. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1186
45. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1186
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