Breakthroughs Blog: CDC

Today, the Senate appropriations committee approved a fiscal year (FY) 2014 appropriations bill that outlines funding levels for the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). The Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) Appropriations Bill would take the positive step of restoring sequestration cuts to CDC and NIH, although there is mixed news for global health programs at the agencies. NIH The bill would fund the NIH at a total of $30.9 billion in FY 2014, restoring this year’s five percent sequestration cut and providing a small increase over last year’s budget. Science Insider reports that the NIH had “strong support” from Senate Appropriations Committee Chair Barbara Mikulski (D-MD), who recently said that she is determined to reverse "reckless cuts to American biomedical research." In her opening remarks earlier today, Sen. Mikulski said, “Because of the investments we have made in NIH over the past decades, … HIV and AIDS is no longer a death sentence, and polio and small pox are essentially eradicated in this country. These medical breakthroughs didn’t just happen, they occurred because this Committee supported NIH, and the NIH supported dedicated scientists who sought knowledge and medical breakthroughs. We must keep up this support.” The bill includes $50 million, five times the FY 2013 level, for NIH’s Cures Acceleration Network, which aims to speed the translation of medical research discoveries in the laboratory that have not advanced far enough to attract significant investments from the private sector. According to Nature, in order to approve a new NIH budget—as opposed to passing yet another continuing resolution for FY 2014—the House and Senate must agree on a common figure for the agency. As a comparison, the House FY 2014 Labor-HHS bill would provide $8 million less for NIH compared with the Senate version. The Senate Labor-HHS appropriations bill for FY2014 would fund the NIH at $30.9 billion and the CDC at $7.022 billion. Credit: PATH/Evelyn Hockstein CDC The Senate bill would provide CDC with $7.022 billion in funding for FY 2014. The bill would restore the $800 million cut from CDC’s budget by sequestration and add a $22 million funding increase. The bill would provide $391.9 million for CDC’s Center for Global Health. This would include $116.9 million for CDC’s Global AIDS Program, which is equivalent to the FY 2013 level, but $15 million below President Obama’s FY 2014 request. The bill would provide $19.3 million for CDC’s Parasitic Diseases and Malaria program, which is comparable to FY 2013 levels, but less than the $22.2 million requested by Obama. CDC’s Division of Tuberculosis Elimination would receive flat funding at the FY 2013 funding level of $140 million. No additional funding for the division’s research programs was allocated. Finally, the bill also contains a total of $19.2 million for Global Public Health Capacity Development. These funds are for a new initiative to support public health capacity building in at least five developing countries over a two-year period to be overseen by CDC. The fate of the Labor-HHS appropriations bill is unclear from this point on. There is a $91 billion funding gap between the House and Senate overall budgets for FY 2014. And while the House Labor-HHS subcommittee has its overall budget, the subcommittee has not announced a date for consideration of a bill. Whatever happens, both the House and Senate must work to protect funding levels at the NIH, CDC, and all federal agencies that support global health and research programs.

In this guest post, Jessie L. Dyer, MSPH, in the Centers for Disease Control and Prevention’s (CDC) Rabies Program, writes about the agency’s work with partners in Haiti to fight the disease. She focuses here on the implementation of a low-cost rabies diagnostic test that could make better use of scarce resources and save lives in this developing Caribbean nation. This is the third in a four-part series by experts from CDC’s National Center for Emerging and Zoonotic Infectious Diseases. Often the shred of truth behind legends, rabies is an ancient disease that has inspired countless stories and cautionary tales throughout the world. The Caribbean island nation of Haiti is no different. Historical records warn of rabid man-eating dogs brought to the island by French colonist as early as 1791. Fast-forward more than 200 years, and you’ll find that rabies is now endemic in Haiti—meaning it is commonly found in dogs, mongooses, and possibly bats. Haiti also reports the highest number of suspected human rabies cases of all Latin American and Caribbean countries. Children are the most vulnerable age group for rabies exposure throughout the world. Credit: Michael Niezgoda, CDC. For the past 2 years, while working with the CDC’s Rabies Program in Haiti, I’ve heard many personal stories about “mad” dogs and learned first-hand about the large-scale collaborative effort that is needed to prevent and control rabies. Rabies is a terrifying disease, and once symptoms present, death is inevitable. Yet, most people do not know how to protect themselves. Without the appropriate post-exposure prophylaxis (PEP) after a suspected rabies exposure (usually a dog bite), rabies is almost always fatal.PEP consists of: Wound care (washing with soap) Administration of rabies immune globulin (antibodies that protect you until your body can produce its own antibodies against the rabies virus) Multiple doses of the rabies vaccine (given in the arm). Proper application of PEP can prevent the onset of rabies and death. CDC is one of many partners collaborating with the Haitian government to develop and implement a One Health approach to rabies prevention and control—an approach that encourages physicians, veterinarians, community workers, laboratory professionals, and public health and agriculture officials to work together to prevent and control this horrifying disease. Because rabies is a zoonotic disease, a disease spread between animals and humans, partnerships between human and animal health agencies are vital for successful implementation. For example, we work with Haiti’s Ministry of Public Health and Population (for human rabies prevention) and the Ministry of Agriculture, Natural Resources, and Rural Development (for animal rabies prevention and laboratory diagnostics). Our goal is to cut the incidence of human and canine rabies cases in half by 2015. We know we cannot do it alone, and that it will require efforts in many different areas, including laboratory diagnostics, surveillance, and community outreach. A crucial part of our efforts in Haiti is a push to expand laboratory capacity to quickly and accurately diagnose rabies. One promising new tool is the direct rapid immunohistochemistry test (DRIT), a low-cost test developed at CDC that can be used for initial diagnosis of rabies. The DRIT requires a light microscope, which is far less expensive than the fluorescence microscopes needed to perform the current world standard for rabies laboratory diagnoses—the direct fluorescent antibody test. Research has also shown that the DRIT has a higher specificity for the rabies virus than the test routinely used in Haiti—the Sellers staining method—which was developed in the 1920s and cannot confirm that the resulting stained inclusion is, for sure, the rabies virus (for example, it also stains inclusions caused by the canine distemper virus). Another benefit of accurate diagnostics is that it will strengthen rabies surveillance, which is a critical component for the control and elimination of canine rabies in Haiti. Our hope is that one day, through improved laboratory diagnostics, enhanced surveillance, and growing partnerships, we will better understand the true impact of this tragic and deadly disease in Haiti. The enormous potential of the DRIT gives hope for rabies prevention and control programs in resource-scarce countries such as Haiti.

In this guest post, Dr. Martin Schriefer, chief of the Diagnostic and Reference Activity in the Bacterial Diseases Branch of the Division of Vector-Borne Diseases (DVBD) in Fort Collins, Colo., writes about his laboratory’s development of a new diagnostic tool, the plague dipstick. DVBD is one of seven divisions in the Centers for Disease Control and Prevention’s (CDC) National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). His blog is the second in a four-part series from experts at NCEZID. Uganda is considered a “hot zone” for emerging infectious diseases that have the potential for far- ranging impact. These diseases include Ebola and Marburg hemorrhagic fevers, yellow fever, chikungunya, West Nile virus disease, and plague. The NCEZID has a number of field programs in Uganda to study this unique ecological environment. I have traveled there several times, learning about the health infrastructure and a critical gap in plague diagnostics that was putting people's lives at risk. Plague is an acute and potentially fatal febrile illness that is harbored in rodents and transmitted by fleas. In its pneumonic form, plague can be transmitted by aerosol from person to person, resulting in local outbreaks and the risk for global spread. Now rare in the United States, plague remains a real threat to human health in sub-Saharan Africa and Madagascar. These regions account for more than 95 percent of the world’s reported plague cases. Fatality rates for untreated infections range from 50 percent to 60 percent for bubonic plague to nearly 100 percent for pneumonic infections. A convalescing plague patient in Uganda. Photo Credit: NCEZID In my laboratory, a team of CDC researchers has developed, manufactured, and field-tested a rapid, affordable diagnostic tool—the plague dipstick. The point-of-care plague dipstick, which works like a pregnancy test, brings the laboratory to the bedside. In September 2012, we delivered a supply of dipsticks to Uganda in anticipation of the 2012-2013 plague season. At the plague field station and several local health clinics, the plague dipsticks are providing significant improvements in terms of time, ease of use, storage, and handling. Healthcare workers have been trained in the collection of blood, lymph node aspirate, or sputum from suspected plague patients and the application of these samples to the dipstick. Results are visualized in 15 minutes. During a recent outbreak involving four patients and three deaths, the dipstick successfully diagnosed a pneumonic plague patient, allowing rapid prevention measures to 130 contacts—as a result, no further cases occurred. Before the dipstick was introduced, early clinical diagnosis of plague was difficult and could delay life-saving treatment. Sending samples away for laboratory verification took weeks. Overcoming barriers to effective diagnosis and timely treatment is a priority for CDC laboratory technicians. Plague dipsticks do not require electricity or refrigeration—a critical issue in an environment where electricity is sporadic. And each test costs less than $1.00 to produce. However, better diagnostics are not useful in Uganda unless people can access and use them with confidence. Many Ugandans living in more rural, remote areas are unable to trek long distances to find a health clinic and visit “traditional healers” instead. CDC has been working with field staff to train local healers to recognize plague symptoms and its effects on rats and to refer cases of plague to local clinics as necessary. Healthcare workers can be quickly trained to apply blood or lymph node aspirate to the dipstick, which yields results in 15 minutes. The dipsticks do not require electricity or refrigeration— important in an environment where electricity is sporadic. Photo Credit: NCEZID By educating healers in plague recognition, CDC is helping them to better protect their villages from this deadly disease. NCEZID’s highly innovative programs in Uganda are saving lives with early detection and response. They serve as an important source to strengthen the country’s public health capacity and better prepare for potential bioterrorism events in the United States. The plague dipstick is now being submitted to the US Food and Drug Administration for 510(k) clearance, which is the next step in showing the dipstick to be a clinically validated, sensitive, and specific test.

In this guest post, Dr. Beth P. Bell, director of the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) at the Centers for Disease Control and Prevention (CDC), describes some of her center’s active engagement in global health work. She also highlights an important technology initiative called Advanced Molecular Detection that is proposed in the President’s fiscal year (FY) 2014 budget. This is the first in a four-part series about NCEZID’s global activities focused on the prevention of illnesses and death from infectious diseases. I am pleased to write this inaugural blog from NCEZID for the Global Health Technologies Coalition. We work closely with other CDC centers, federal agencies, and domestic and international partners to protect people from infectious diseases and enhance global health security.We’re excited to have the opportunity to showcase our portfolio of global activities that evidence NCEZID’s research, technology, and program priorities. One example is our work in Uganda, where we helped build laboratories and train staff at the Uganda Virus Research Institute (UVRI). The main UVRI facility is based in Entebbe in central Uganda, and it has a satellite laboratory about 320 miles northwest in the town of Arua, near the border with the Democratic Republic of the Congo (DRC). NCEZID staff based at UVRI in Entebbe collaborates with other UVRI scientists to deliver in-country expertise in diagnosing and preventing viral hemorrhagic fevers, plague, and other infectious diseases.For instance, UVRI staff last year used modern diagnostic technologies while working closely with Atlanta-based CDC response teams, local public health authorities, and other experts to contain four near-simultaneous outbreaks of filovirus disease (caused by Ebola and Marburg viruses) in Uganda and the DRC. Separately, I learned first-hand about the benefit of building local diagnostic capacity in Uganda when I traveled there last fall and spoke with scientists and residents about the successful use of a new plague dipstick test (more on this in our next guest blog).In October 2012, Dr. Bell (far right) visited Uganda and met a farmer (third from left) who had developed symptoms of plague. He was promptly tested with the plague dipstick test and learned within 15 minutes that he had tested positive for plague. He was treated with antibiotics,fully recovered, and was back working in 3 days. Also pictured is Ugandan clinical coordinator Dr. Titus Apangu (center, wearing a tie).  Photo credit: NCEZIDOther examples of NCEZID’s commitment to using innovative technology in response to infectious diseases on the global front include our efforts to develop vaccines for dengue and Rift Valley fever, and to establish safe water projects in places like Malawi and Haiti. And in just the past few months, we’ve helped with a Japanese encephalitis immunization campaign in western Cambodia (with support from the Bill & Melinda Gates Foundation) and assisted India in the development of a pilot outbreak investigation and surveillance for enteric diseases in several states.But as we anticipate new and evolving global challenges in infectious disease, we also recognize the need to strengthen our capacity in using next-generation public health tools. This step is crucial if we are to successfully confront what CDC Director Dr. Tom Frieden calls the “perfect storm of vulnerability: emerging microbes, resistant microbes that outsmart the drugs used to treat them, globalization of travel and trade, and the greater ease of making deadly organisms in a laboratory.”Of particular importance is the need to implement new approaches for strengthening our expertise and capacity in molecular-based sequencing and bioinformatics and applying these advances to public health—both domestically and internationally. Real-time genomic sequencing of pathogens rapidly generates massive amounts of information, and bioinformatics helps us interpret these data and apply the results to public health. To be sure, CDC and its public health partners have had some success with the global application of genetic sequencing and molecular epidemiology—the global polio eradication effort being one example. But much more remains to be done. Advances in these evolving areas will help us to more rapidly and accurately diagnose infectious diseases, investigate and control outbreaks, understand transmission patterns, determine antimicrobial resistance, and develop and target prevention measures, including vaccines.The President’s FY 2014 budget contains an initiative called the “Advanced Molecular Detection (AMD) and Response to Infectious Disease Outbreaks,” which would provide CDC an unprecedented opportunity to build our expertise across all infectious diseases. This initiative can help us move beyond older methods of detecting a microbe and determining its threat to human health. Strengthening our detection and response capabilities with these technologies will help us take bold new steps in protecting the public’s health, both here and abroad. You can read more about the AMD initiative on CDC’s website (see link below).In our next three guest blog posts for Breakthroughs, we intend to show you how technology enables us to extend our reach of work around the globe. For example, one of our scientists who developed the plague dipstick will give a first-hand account of creating this tool that diagnoses plague easily, rapidly, and inexpensively. Other blogs will detail recent efforts to combat rabies in Haiti and the ever-growing challenge of controlling the spread of dengue. I hope you enjoy reading them.For more information about the AMD initiative, click hereTo learn more about NCEZID, click here