Viewpoint

Global health and the US Centers for Disease Control

and Prevention
Anne Schuchat, Jordan Tappero, John Blandford

Lancet 2014; 384: 98–101 Why is an article about global health included in a special (PEPFAR) targets resource-constrained countries that
Published Online issue on health in the USA? About half the produce that are hardest hit by the HIV epidemic. CDC has played a
July 3, 2014 Americans consume is cultivated in other countries, central role in PEPFAR since its inception, bringing
http://dx.doi.org/10.1016/
60 million Americans travel or work outside the USA, more than 30 years of experience of work in HIV/AIDS.
S0140-6736(14)60570-5
and most patients with measles and tuberculosis in the CDC staff work with peers in Ministries of Health and
Center for Global Health,
Centers for Disease Control and USA acquired their infection elsewhere. Emerging other host country entities to implement effective
Prevention, Atlanta, GA, USA diseases, globalisation of foods and medicines, the rise in national programmes in HIV care and treatment,
(A Schuchat MD, J Tappero MD, antimicrobial resistance, and the ease with which tuberculosis–HIV integration, maternal and child health,
J Blandford PhD)
pathogens can be manipulated for good or harm increase HIV prevention, and HIV counselling and testing.
Correspondence to:
each nation’s vulnerability and interdependence. Through PEPFAR, CDC is also strengthening public
Dr Anne Schuchat, National
Center for Immunization and The Centers for Disease Control and Prevention (CDC) health systems through focused investments in local
Respiratory Diseases, Centers for has engaged in global health for more than 60 years. workforce capacity and health systems that are essential
Disease Control and Prevention, Although tackling infectious disease threats has been a to the scale-up and sustainability of priority PEPFAR
Mailstop A-27, 1600 Clifton Rd,
constant, the agency has also provided humanitarian programmes and to the strengthening of the broader
NE, Atlanta, GA 30333, USA
[email protected] assistance in natural disasters, refugee crises, and public health system. For example, growing HIV
famines; improved child survival; and strengthened treatment programmes were shown to be positively
scientific measurement of health metrics. CDC’s work- correlated with increased rates of facility deliveries by
force includes more than 300 internationally deployed non-HIV infected women.2
public health professionals in addition to around In late 2011, President Obama and then-Secretary of
1330 locally employed staff working in about 60 countries State Hillary Clinton advanced the vision of an AIDS-free
(figure). CDC’s global health strategy aims to: achieve generation, defined as almost complete elimination of
optimum health effects; strengthen global health capacity; vertical transmission of HIV, greatly reduced incidence of
improve global health security; and strengthen the sexual transmission of HIV in adults and adolescents, and
organisation’s capacity.1 This report describes selected universal access to antiretroviral therapy (ART) to people
programmes that illustrate these goals. who become infected. President Obama announced in
Leveraging the strengths of the US-implementing December, 2011, ambitious new targets for priority
agencies for a whole-of-government approach, the evidence-based interventions that were to be realised in
US  President’s Emergency Plan for AIDS Relief just 2 years’ time: PEPFAR, in 2013, was committed to

CDC Headquarters

CDC staff overseas, including those assigned to international organisations

Current CDC global activities (but no staff)
CDC headquarters-based staff deployed for outbreak response in 2013

Figure: Location of CDC’s global programmes and personnel, 2013

CDC=Centers for Disease Control and Prevention.

98 www.thelancet.com Vol 384 July 5, 2014

 Viewpoint

directly support 6 million patients receiving treatment, an CDC’s influenza programme contributes to strengthened
increase of 50% over the previous target; provision of global health security. Influenza viruses spread rapidly
therapy to 1·5 million pregnant women to prevent vertical without respect to geographical borders. Control of disease
infection of HIV; and to cumulatively reach 4·7 million caused by these viruses requires accurate laboratory
men with voluntary medical male circumcisions.3,4 CDC detection, epidemiological response, and development and
and its partners worked to make these bold targets a reality. delivery of appropriately targeted vaccines and other
PEPFAR has directly supported 6·7 million patients countermeasures. Efforts that focus on seasonal influenza
receiving treatment; provided more than 1·5 million strengthen preparedness for pandemics. Addressing avian
pregnant women with antiretroviral prophylaxis to prevent influenza has assumed greater priority since emergence of
mother-to-child transmission of HIV during the preceding H5N18 and more recently H7N9 influenza viruses.9
2 years; and with cumulative support of 4·2 million The CDC is the National Influenza Center for the USA
medical male circumcisions, was on track to achieve that and one of five WHO International Collaborating
target by the end of 2013.5 Centers for surveillance, epidemiology, and control of
CDC implemented an innovative approach to prevent influenza. CDC scientists participate in strain selection
mother-to-child transmission of HIV in Malawi by for seasonal vaccines and prepare candidate vaccine
working with the Ministry of Health and local partners.6 virus strains for vaccine manufacturers. Since the
The new approach, called Option B+, offers all pregnant emergence of cases of H5N1 avian influenza in people
or breastfeeding women infected with HIV lifelong ART. more than a decade ago, CDC has expanded support to
1 year after this approach was implemented in 2011, the and collaborations on influenza with dozens of
number of HIV-positive pregnant and breastfeeding countries.
women receiving ART increased by more than 700%, After a local outbreak in 1997 in Hong Kong,10,11 avian
from 1257 to 10 663. Option B+ not only reduces mother- H5N1 influenza resurfaced in 2003, initiating a decade of
to-child transmission to less than 5% but also maintains major epizootics affecting birds in Asia, northern Africa,
the mother’s health, provides lifelong reduction of HIV and Europe, prompting intensified national, regional, and
transmission to uninfected sexual partners, and prevents global responses.12 To date, animal-to-human transmission
mother-to-child transmission in future pregnancies. has caused nearly 400 human fatalities, and millions of
Other African and Caribbean countries are now initiating poultry have been culled in affected areas. The CDC
this approach. Although each country must weigh the contributed to a comprehensive US Government response
potential effect and costs of Option B+ in reaching the to H5N1 avian influenza. It established cooperative
goal of elimination of mother-to-child HIV transmission, agreements with ministries of health in more than
this approach could overcome barriers such as inadequate 30 countries to strengthen capacity for epidemiological
immunological testing capacity, substantial distances response, laboratory detection, and emergency prepared-
between antenatal clinic and ART-initiation sites, and ness; seconded staff to WHO, World Animal Health
human resource constraints.6 Organization, and UN Food and Agriculture Organization;
Further, CDC and the US Health Resources and Services collaborated on vaccine and diagnostic studies with the US
Administration initiated the Track 1·0 programme in National Institutes of Health, the Food and Drug
2004, to rapidly scale up ART delivery initially through Administration, the Biomedical Research and Advanced
US-based partners.7 In its first phase, PEPFAR was Development Authority, academic investigators, and
undertaken as an emergency response to provide industry; and established a strategic national stockpile of
accelerated access to crucial, lifesaving services and antiviral drugs and other emergency supplies.
programmes. With PEPFAR’s reauthorisation in 2008, By April, 2009, when CDC first detected a novel strain
CDC worked to further strengthen programme of influenza A H1N1, CDC had already enhanced capacity
sustainability, country stewardship, and local imple- for pandemic response. An Influenza Reagent Repository
mentation of core programmes. CDC worked with facilitated the surge in laboratory testing in the USA and
Ministries of Health to transition service delivery of HIV/ other countries. CDC shipped reagents for the detection
AIDS care and treatment to local stewardship in of novel 2009 H1N1 influenza virus beginning May 1,
13 countries. As of February, 2012, these countries had 2009.13 In addition to 1500 kits shipped to public health
contracts or awards in place with indigenous partners to laboratories in all 50 states, 1400 diagnostic kits were
establish local country ownership of their ART shipped to laboratries in 153 countries. CDC’s
programmes. The transition of treatment programmes to investments in strengthening countries’ surveillance for
indigenous partners is consistent with CDC’s approach severe acute respiratory illness (SARI)14 provided
across programme areas of working through partner recognition of severe disease in many countries caused
Ministries of Health and other local entities. 61% of CDC’s by the new influenza strain and helped to monitor
PEPFAR programme funding goes through indigenous changes in clinical severity that might signal viral
entities, and this share should continue to grow as CDC mutations of concern. In 2013, the SARI surveillance
provides the technical support and capacity building to systems monitored the spread of the new Middle East
maintain continuity and quality of treatment services. respiratory syndrome (MERS) coronavirus.

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On March 31, 2013, Chinese authorities reported to WHO and non-governmental organisation implementation
their detection of a novel H7N9 avian influenza virus that platforms established under PEPFAR in 2002.20 HIV
caused severe pneumonia in three people in Shanghai and services recovered to baseline rapidly.21 Yet an urgent need
Anhui.9,15 From Oct 1, 2013, to March 12, 2014, 384 human remained to strengthen reportable disease surveillance
cases and 123 deaths had been reported by China’s National because of overcrowding and poor living conditions,22,23
Health and Family Planning Commission, and the novel expand capacity to identify reportable pathogens at the
virus had been isolated from live bird markets.16 The national public health laboratory,24 and train a public
Chinese rapidly completed whole genome sequencing of health workforce. The US Government committed more
several viral isolates, posted their sequence data, closed live than US$3 billion in new funds for post-earthquake relief,
bird markets in several cities, and initiated targeted culling recovery, and reconstruction; facilitated MSPP’s rapid
of birds. The virus is of low pathogenicity in poultry, and detection of Vibrio cholerae within days of its introduction;
subclinical avian infection has complicated animal control and contributed to an effective emergency response20 to
efforts. Although no sustained human-to-human trans- the worst national cholera epidemic in the modern era.25
mission has occurred, it is too early to be certain of the full After these back-to-back crises, in early 2011 MSPP, CDC,
effect that this novel virus will have on human or animal and other organisations identified seven measurable
populations. The Chinese authorities responded rapidly public health effect goals to transform health services and
and shared information about human disease and genetic disease outcomes.26
sequence data openly.17 With the aim to achieve an AIDS-free generation, in
The US CDC has collaborated with China’s influenza 2011, MSPP and PEPFAR-Haiti expanded HIV
scientists and public health authorities for decades. CDC counselling and testing sites for pregnant women,
provided substantial technical assistance, several visiting implemented a case management programme for all
scientists from China completed training and research HIV-infected women to reduce loss to follow-up, and in
projects in Atlanta, and senior scientists from the US CDC 2012 adopted the B+ option that provides all HIV-infected
provided onsite technical support in China. A major pregnant and breastfeeding women with lifelong ART
milestone was achieved in 2010, when China was irrespective of CD4 cell count.6,27 HIV testing of pregnant
designated as the fifth WHO International Collaborating women has increased by 74%, from 128 540 in 2010, to
Center for Reference and Research on Influenza in 223 626 in 2013.28 The proportion of identified HIV-
human beings. China is also the location of one of CDC’s infected pregnant women who received prophylaxis or
Global Disease Detection (GDD) Regional Centers. At ART increased from 61% to 92% during this period.28
GDD sites, US CDC epidemiology, laboratory, and Since the earthquake, overall access to ART has nearly
veterinary staff work closely with counterparts from the doubled;29,30 in 2013, more than 75% of all eligible HIV-
ministries of health to strengthen early detection and infected Haitians were receiving ART.28
For more on the Field response to public health threats. China also hosts a Field From Oct 20, 2010, to April 28, 2014, Haiti reported
Epidemiology Training Epidemiology Training Program (FETP), at which a US 701 961 cases of cholera and 8555 deaths.31 The inadvertent
Program (FETP) see
http://www.cdc.gov/
CDC Resident Advisor works closely with epidemiology introduction of cholera, which had not been seen in Haiti
globalhealth/fetp/history.html trainees in a 2 year programme modelled after the CDC’s in more than a century, accounted for 57% of the reported
elite Epidemic Intelligence Service. In recognition of these global cholera burden in 2010 and 2011.25 Although the
broad partnerships, China designates national, provincial, annual case fatality rate has been sustained at the
and district public health departments as CDCs. international standard of 1% or less since 2011, elimination
Influenza events highlight the importance of strengthen- will need substantial investment in infrastructure to
ing global health security worldwide. Emerging threats address inadequate access to improved drinking water
such as avian influenza or severe acute respiratory (62%) and sanitation (24%).32,33 MSPP and the National
syndrome can occur anywhere.18 Acceleration of improve- Directorate for Potable Water and Sanitation, with technical
ments in the capacity for each nation to protect its own support from PAHO, UNICEF, and CDC, developed a
citizens and detect and report public health threats of 10 year national elimination plan that calls for increased
international concern promptly to the global community investment in infrastructure and interim measures, such
is urgently needed.19 as the scale-up of a new national strategy for household
CDC’s experience in Haiti addresses how programmes water treatment and storage, the deployment of 264 trained
designed for health effect can strengthen capacity and potable water and sanitation technicians to 133 rural
improve preparedness for health security threats. On communes, and targeted use of oral cholera vaccine.
Jan 12, 2010, a devastating earthquake struck Port-au- One of the most important legacy goals for Haiti was to
Prince, Haiti, killing an estimated 230 000 people, injuring establish a functioning, sustainable, self-correcting public
300 000 more, displacing more than 20% of the country’s health system. Integration of MSPP’s reportable disease
10 million residents, and destroying much of the capital’s surveillance systems,22,23,25 expansion of laboratory
infrastructure.20 The public health response benefited capacity,20 and the establishment in 2011 of a competency-
from CDC’s partnership with the Ministry of Public based, mentor-facilitated FETP have bolstered national
Health and Population (MSPP), and the administrative public health capacity to detect and monitor disease

100 www.thelancet.com Vol 384 July 5, 2014

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outbreaks, and use data to drive public health policy. CDC 12 Uyeki TM. Human infection with highly pathogenic avian influenza
has helped to establish 50 FETPs that have trained nearly A (H5N1) virus: review of clinical issues. Clin Infect Dis 2009;
49: 279–90.
3000 graduates from 69 countries. 13 Jernigan DB, Lindstrom SL, Johnson JR, et al. Detecting 2009
The world is more interconnected than ever, and weak pandemic influenza A (H1N1) virus infection: availability of
links in public health capacity anywhere can have diagnostic testing led to rapid pandemic response. Clin Infect Dis
2011; 52 (suppl 1): 36–43.
profound effects at distant locations. Governments have 14 Radin JM, Katz MA, Tempia S, et al. Influenza surveillance in
responsibilities to their citizens and other nations to 15 countries in Africa, 2006–2010. J Infect Dis 2012;
detect problems rapidly, communicate promptly, and 206 (suppl 1): S14–21.
15 Centers for Disease Control and Prevention. Emergence of avian
respond effectively. The CDC focuses on the protection influenza A (H7N9) virus causing severe human illness—China,
of Americans and improvements in the health and February-April 2013. MMWR Morb Mortal Wkly Rep 2013;
capacity of people worldwide through partnerships with 62: 366–71.
ministries of health, other US Government agencies, 16 Chen Y, Liang W, Yang S, et al. Human infections with the
emerging avian influenza A H7N9 virus from wet market poultry:
non-governmental organisations, and multilateral clinical analysis and characterisation of viral genome. Lancet 2013;
organisations. The goal of these efforts is to improve 381: 1916–25.
health and strengthen capacity while striving for a world 17 Uyeki TM, Cox NJ. Global concerns regarding novel influenza A
(H7N9) virus infections. N Engl J Med 2013; 368: 1862–64.
more secure from emerging threats. 18 Fischer JE, Katz R. Moving forward to 2014: global IHR (2005)
Contributors implementation. Biosecur Bioterror 2013; 11: 153–56.
AS contributed to the overall planning and writing of the manuscript, 19 Ijaz K, Kasowski E, Arthur RR, Angulo FJ, Dowell SF. International
the literature search, and the development of the figure. JT contributed Health Regulations—what gets measured gets done. Emerg Infect Dis
to the writing of the manuscript, the literature search, and the 2012; 18: 1054–07.
development of the figure. JB contributed to the writing of the 20 Tappero JW, Tauxe RV. Lessons learned during public health
manuscript and the literature search. response to cholera epidemic in Haiti and the Dominican Republic.
Emerg Infect Dis 2011; 17: 2087–93.
Declaration of interests 21 Walldorf JA, Joseph P, Valles JS, et al. Recovery of HIV service
We declare no competing interests. provision post-earthquake. AIDS 2012; 26: 1431–36.
Acknowledgments 22 Centers for Disease Control and Prevention. Launching a National
We thank Ezra Barzilay, Sally Ezra, Barbara Marston, and Ann Moen for Surveillance System after an earthquake—Haiti, 2010.
MMWR Morb Mortal Wkly Rep 2010; 59: 933–38.
assistance with manuscript and figure preparation; and Harold Jaffe and
Tom Frieden for review of the manuscript. The findings and conclusions 23 Centers for Disease Control and Prevention. Rapid establishment of
an internally displaced persons disease surveillance system after an
of this report are those of the authors and do not necessarily reflect the
earthquake—Haiti, 2010. MMWR Morb Mortal Wkly Rep 2010;
official position of the Centers for Disease Control and Prevention. 59: 939–45.
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