Laboratory and epidemiologic research are the essential foundation upon which a sound disease surveillance and response system is based. This is especially true in regard to emerging and unknown infectious diseases. To combat new diseases for which no treatments are known, it is essential to maintain an active community of epidemiologists and experimental scientists ready and able to seek new solutions for new disease threats. In addition, continued emphasis on effective social and behavioral science methods to enhance health promoting behavior should be maintained. To meet the challenge of emerging and re-emerging infectious diseases requires critical knowledge of the fundamental biology of infectious agents and the clinical disease processes they induce. Scientific studies of infectious agents and the diseases they cause provide the fundamental knowledge base used to develop diagnostic tests to identify diseases, drugs to treat them, and vaccines to prevent them. In addition, the ability to intervene effectively in an outbreak or epidemic, or to implement a successful prevention strategy, requires a thorough understanding of the epidemiology of the disease. An especially important research challenge that may require the combined efforts of epidemiologists, microbiologists, pharmacologists, and others is to find new ways to combat antibiotic resistance, either by preventing its development or by designing vaccines or new classes of drugs effective against bacteria, viruses, fungi, and parasites. Further, the establishment of an infrastructure of researchers trained in epidemiology and laboratory research provides a sound basis for a global network for surveillance and response.
At the present time, major gaps exist in U.S. research and training programs concerned with infectious diseases. The level of support for research on infectious diseases other than AIDS and TB is extremely limited. At NIH, funding for work related to infectious diseases, excluding AIDS and TB represents only about 5% of their total budgets. At CDC, although approximately 65% of the budget is dedicated to the prevention and control of infectious diseases, about 95% of these funds are earmarked for AIDS, TB, and sexually transmitted and vaccine preventable diseases. Furthermore, the number of individuals receiving infectious disease training at NIH and CDC is extremely low, and the number receiving field training overseas is even lower. The training capacity of the DoD in this area has also been eroded. Few individuals in the United States, for example, had the necessary expertise in the diagnosis and treatment of plague to provide assistance during the recent plague outbreak in India. For these reasons, it is imperative that an active scientific community focus on infectious diseases be maintained and supported.
It is likely that many new infectious diseases will emerge in other parts of the world. The earliest possible detection of such emerging problems is in our nations' best interest to anticipate them and respond in an effective manner. To develop effective prevention and control strategies for new and emerging pathogens, research is required on the complex interaction between humans and microbes and the evolutionary and genetic factors that cause epidemics.
Currently, there exist a number of international research and training programs funded by USAID, NIH, NIAID, Fogarty and CDC, that offer a base for studies of infectious diseases and are also well-situated to detect arising infectious diseases. These include the NIAID's TMRC and ICIDR and Fogarty's AIDS International Training and Research Programs, and CDC's FETP. Optimal utilization of these research teams will strengthen recognition and identification of emerging infectious pathogens at their sites of origin. These teams are positioned to develop new prevention strategies through the discovery of those epidemiologic and biological principles that determine the emergence of new and re-emerging microbial diseases.
Encourage the development of tools to monitor, investigate, and intervene in public health problems involving emerging or antibiotic resistant microbes. Also, ensure that facilities are made available to test these products under field conditions.
These interactions need to be fostered both between agencies and between scientific and public health disciplines. For example, CDC and NIH need to expand and strengthen exchange programs between the epidemiologic and laboratory based science, at the doctoral, post-doctoral, and mid-career levels. Maintaining a cadre of trained investigators who can deal with new disease problems is an essential part of U.S. preparedness. The establishment of an international training program on emerging infectious diseases as outlined by Fogarty in its long-range plan would help to maintain this cadre.
Several disease-specific "vertical" surveillance networks operated by WHO (see "International Resources Related to International Diseases,") receive technical assistance from CDC, NIH, DoD, USAID, WHO and various non-governmental organizations.
Connections can be encouraged among the participants in these networks and among participants in research training programs supported by Fogarty, all of whom are well-placed to share information on research and on public health, as well as among participants in research training programs supported by the NIH/Fogarty.
The identification of persons carrying pathogens capable of causing serious disease outbreaks is made difficult by the very large number of people entering the United States from increasingly remote locations. There is a constant influx of American civilians and solders, foreign nationals (including tourists, business travelers, long-term visitors), and immigrants. It is imperative that American medical students be trained to identify infectious diseases that are common in other countries.
Current facilities operated or supported by CDC, NIH, DoD, and USAID overseas could serve as excellent training facilities for medical or graduate student rotations in laboratory research or field work, or for overseas training details for employees.
Numerous examples illustrate the role that research plays in protecting the public against infectious diseases. In recent years, the techniques of modern molecular biology have been used to study new pathogens (e.g., the agents causing AIDS and Lyme disease) and to define their geographical spread (for example, hantavirus in the Southwest and other parts of the United States). Biomedical researchers have also uncovered new relationships between disease causing microbes and disease. For instance, a previously unrecognized herpesvirus has been detected in Kaposi's sarcoma, a tumor most often associated with AIDS in the United States. Scientists have also applied insights from basic research in physiology to devise life-saving therapies, such as oral rehydration therapy for the treatment of cholera.
In many areas, the lack of basic research has hampered our ability to cope effectively with disease threats. For example, the lack of adequate information about the Cryptosporidium parvum, an intestinal parasite, has made the development of new diagnostic reagents and therapies very difficult. Without reliable diagnostic tests, it has been difficult to assess the level of risk during a given outbreak and to design appropriate control measures.
Scientific research is also needed to guide public policy. For instance, scientific information is needed to formulate policy on the use of antibiotics in agriculture and aquaculture, as well as in the treatment of human illness. Similarly, research on the impact of environmental change and climatic variability on the emergence of microbes can inform policy discussions on land use, waste disposal, water resources management, and agricultural policy.
The purpose of this report is to highlight ongoing Federal research efforts in this science and technology (S&T) field and to identify new and promising areas where there might be gaps in Federal Support. The report is intended for internal planning purposes within the Federal agencies and as a mechanism to convey to the S&T community the types of research and research priorities being sponsored and considered by the Federal agencies. The Administration is committed to a broad range of high priority investments (including science and technology), to deficit reduction, and to a smaller, more efficient Federal government. These commitments have created a very challenging budget environment-requiring difficult decisions and a well thought-out strategy to ensure the best return for the nation's taxpayer. As part of this strategy, this document does not represent the final determinant in an overall Administration budget decision making process. The research programs presented in this report will have to compete for resources against many other high priority Federal programs . If these programs compete successfully, they will be reflected in future Administration budgets.
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