The President′s FY 2008 Budget Request for the Centers for Disease Control and Prevention

CDC Congressional Testimony

Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education and Related Agancies, United States House of Representatives

Statement of:
Julie L. Gerberding, M.D., M.P.H.
Director, Centers for Disease Control and Prevention,
U.S. Department of Health and Human Services
Accompanied by:
Bill Nichols, MPA, Director, Financial Management Office, CDC
Richard Turman, Deputy Assistant Secretary for Budget, HHS

Good morning Mr. Chairman, Congressman Walsh, and other distinguished members of the Subcommittee. It is a pleasure to appear before you again as Director of the Centers for Disease Control and Prevention (CDC), the nation′s leading public health protection agency located within the Department of Health and Human Services. Thank you for the opportunity to present the President′s budget request for CDC for fiscal year (FY) 2008. I would like to highlight just a few examples of what we have achieved with the Subcommittee′s support over the past year and introduce the priority public health initiatives we plan to pursue in FY 2008 in accordance with the President′s request.

The FY 2008 budget request for CDC addresses a balanced portfolio of health protection activities, emphasizing both urgent threats we must be prepared to face tomorrow and the urgent realities we are confronting today. This dual emphasis reflects CDC′s complex mission in the 21st century to protect the public′s health against major calamities such as pandemic influenza, natural disasters, and terrorism, while remaining focused on the threats to health and well-being that Americans face each day, including chronic diseases, injuries and disabilities. CDC′s Health Protection Goals address both categories of activity in equal measure, and are designed to accelerate health impact, reduce health disparities, and protect people at home and abroad from current and imminent health threats. Organized in four thematic areas, these goals serve to focus our programmatic efforts and financial investments:

• Healthy People in Every Stage of Life
• Healthy People in Healthy Places
• People Prepared for Emerging Health Threats
• Healthy People in a Healthy World

Over the course of the past 18 months, CDC has engaged in an intensive effort to bring together experts from inside and outside the agency to agree on a set of objectives to help us achieve these overarching goals. We have solicited external input through a series of public meetings around the country, and we will continue to be responsive to internal concerns among parts of CDC′s workforce about the new, goal-oriented approach to our mission. As the goals are refined and implemented, CDC will be better equipped to measure and demonstrate the impact of our health protection activities and the benefit that accrues to the public as a result of the agency′s efforts. These measures are intended to target our resources and enhance accountability to our most valued customers Congress, our partners, and the public.

I am pleased to report that the public perception of CDC continues to be positive, as measured by a nationwide Harris Poll conducted in January 2007 in which CDC was again ranked the top agency in government. CDC received the most positive votes of the thirteen agencies included in the poll, with ninety percent of adults saying they understand what the agency does and 84 percent giving us high marks for our work. We are gratified by this public endorsement, yet we remain committed to improving and refining our capacity to address urgent public health challenges. The strategic realignment CDC embarked upon in 2005 and the goals planning process in which we are currently engaged illustrate our commitment to be an integrated, adaptive, and highly effective organization, and we are well on our way to achieving that vision.

For FY 2008, CDC′s budget request includes a total funding level of $8.8 billion, reflecting a $143 million adjustment to the estimate for the Vaccines for Children mandatory budget, and a discretionary funding reduction of $20 million below the FY 2007 estimate. The request includes the following increases: $158.3 million for a range of pandemic influenza preparedness activities, $93.0 million for the HIV/AIDS Testing Initiative, $89.9 million for the Strategic National Stockpile, $17.3 million for the Adolescent Health Promotion Initiative, $5.2 million to improve special pathogens laboratory capacity, and several smaller additional increases. Within the total funding level, CDC balances increased investments in these high priority areas with targeted reductions in other areas. Specific reductions include the following: -$125.4 million for upgrading state and local capacity activities, -$113.6 million for Buildings and Facilities, -$99.0 million for the Preventive Health and Health Services Block Grant, -$17.2 million for Steps to a HealthierUS, -$16.9 million for West Nile virus, -$13.9 million for the anthrax research study, as well as several smaller additional reductions.

We are committed to serving as responsible stewards of the public dollars with which we are entrusted each year and will continue to strive to maintain our position as the most trusted agency in government. Prioritizing the agency′s activities within the four overarching health protection goals described above assures that we are focused on optimizing health impact in every laboratory on our campus, in every program we fund, in all our health protection research, and in every outbreak we contain. With sustained focus and continued investment, we will continue to be prepared for the next public health emergency, and we will begin to roll back the impact of a sedentary lifestyle and stop the spread of HIV/AIDS. The President′s budget request makes a number of investments in the coming fiscal year to help us prepare for urgent threats on the horizon and bolster our efforts to address the urgent realities our communities face today.

Preparing for Urgent Threats

Preparedness for a wide array of health threats and emergencies remains a central priority for CDC and our public health partners. In the last five years CDC has responded to a variety of public health emergencies, ranging from the anthrax attacks of 2001 to SARS in 2003, Hurricane Katrina in 2005, and preparing for pandemic influenza in 2007. Since 2001, Congress has greatly expanded the resources available for public health preparedness efforts and we are seeing a return on that investment at the state and local level, as well as at CDC. To offer one example, CDC has increased the number of Laboratory Response Network labs to 152 (up from 91 in 2001), with a presence in all 50 states and abroad, and with 100 percent able to confirm anthrax, tularemia and plague. In addition, CDC has trained more than 9,000 clinical laboratorians to date to play a role in the detection, diagnosis, and reporting of public health emergencies.

We continue to make progress in the preparedness arena, but the combined capacity of federal, state and local public health partners is not yet where it should be. The FY 2008 budget contains a number of investments that will augment our capacity to address urgent health threats, in close alignment with our preparedness and global health protection goals. These include upgrades to the Strategic National Stockpile (SNS), laboratory capacity enhancements, and pandemic influenza readiness activities. As noted earlier, the request also contains targeted reductions in areas such as the anthrax vaccine research program, West Nile virus activities, and funding for general state and local preparedness activities. CDC remains committed to allocating preparedness dollars in a way that maximizes our ability to enhance federal, state and local response capabilities.

People Prepared for Emerging Health Threats

In an effort to achieve the goal of People Prepared for Emerging Health Threats, we continue to upgrade our response capacity for natural disasters, intentional attacks, and infectious disease outbreaks at home and abroad. CDC′s management of the Strategic National Stockpile (SNS) a national repository of lifesaving pharmaceuticals, medical supplies and equipment that can be deployed within 12 hours to any point in the U.S. exemplifies the agency′s engagement in frontline preparedness activities. The request of $581 million for SNS will expand our capacity to respond to mass trauma events, including natural disasters and intentional attacks, by including selected pharmaceuticals and special needs items in the SNS that are essential for a broad range of public health emergencies.

CDC also serves as an international leader for identifying and containing infectious disease threats. The agency′s trademark contribution in this arena resides in the integration of our extensive laboratory capacity with subject matter and epidemiologic expertise to identify and respond to virulent outbreaks. Increased funding for CDC′s special pathogens laboratory capacity in the amount of $5.2 million will build our basic science program for high hazard pathogens (such as Ebola and Marburg virus), our cadre of elite scientists who work in this area, and our capacity for rapid and effective outbreak response. The budget request will greatly augment our capacity to predict and mediate the public health impact of natural disasters and other urgent health threats.

Healthy People in a Healthy World

Although much progress has been made toward preventing and controlling infectious disease, it remains clear that a disease, such as pandemic influenza, emerging in one country can rapidly become a worldwide threat. The ability to identify and contain such an outbreak is critical to assuring a healthy and prosperous international community. Thus pandemic influenza readiness is central to our goal of achieving Healthy People in a Healthy World.

CDC has accomplished a great deal in this regard with the supplemental resources Congress has allocated to pandemic preparedness since FY 2006, including preparing and disseminating guidance, information, and initial funding to 62 states, localities, territories, and tribal nations. The guidance contains templates for operational drills of influenza immunization clinics and tabletop exercises for community-based school closing decision processes, as well a model contract for engaging pertinent private sector entities in the emergency distribution of antiviral drugs. At an international level, CDC and partners released a one-week standard curriculum last summer in Bangkok, Thailand to provide essential skills to Rapid Response Teams composed of medical doctors, epidemiologists, communications specialists and other health responders. The public health community has become better prepared for a pandemic in the past year, thanks to the support of this Subcommittee and the Congress, but there is more to be done.

We need four things to achieve an optimal state of readiness: people, products, plans, and practice. Within the total increase for pandemic influenza activities of $158.3 million, we have requested a number of increases to expand capacity in these four broad areas. First, the budget request includes an increase of $10.0 million to expand the number of quarantine stations at major ports of entry around the country to assure that we have trained people on the frontline to identify and contain a pandemic. Quarantine station expansion has enhanced the systematic collection, analysis and dissemination of data related to public health events at U.S. ports of entry, improving CDC′s capacity to respond. Secondly, in terms of products, we need to continue our efforts to increase demand for annual influenza vaccine (+$19.8 million), a critical factor in stimulating production. CDC is working to establish a reference library of circulating influenza viruses and to identify suitable vaccine candidates (+$19.8 million). We also need to increase the stock of diagnostic reagents for influenza (+$14.9 million) to improve our capability to detect a pandemic.

With regard to planning, the President′s request includes an increase of $9.9 million to develop real-time assessment models and other decision tools to analyze influenza patterns and to plan accordingly. It also contains an increase of $14.6 million to enhance CDC′s vaccine registry, which monitors distribution of influenza vaccine and other countermeasures to allow for continuing identification of plans to fill gaps in coverage. Finally, with respect to practice, an increase of $69.0 million is requested for a group of activities: human-animal interface studies for domestic grantees, international and domestic surveillance, and rapid outbreak response actions in the U.S. and in high priority countries abroad to assure that local practitioners are as prepared as possible to confront pandemic outbreaks. The President′s request for these resources will allow CDC to continue vital activities begun with your support for supplemental funding in FY 2006.

CDC continues to work with state and local public health agencies and with international partners to prepare for an influenza pandemic. We recognize the long-term value of this investment and are committed to leveraging these resources to maximize preparedness for all manner of public health emergencies.

Combating Urgent Realities

While CDC is making great strides to prepare for myriad health threats that loom on the horizon, we remain focused on battling the urgent health realities of diseases, injuries and disabilities that affect the lives of Americans each and every day. The threat of pandemic influenza is real and our nation is making a major investment in preparing for it. But urgent realities such as diabetes, heart disease and asthma are more than a threat; they are with us right now. Moreover, the actual burden of these current health realities parallels the projected impact for many of the urgent threats we face. The annual burden of cardiovascular disease in this country (79 million ill), for example, is the same order of magnitude as the projected impact of an isolated influenza pandemic (90 million ill). While suffering from a potential influenza pandemic is a one time toll, we tolerate the impact of cardiovascular disease at these levels every single year.

Complacency is not an option when one in three Americans is obese, one in four of those living with HIV is unaware of his infection, and one in 33 infants is born with a birth defect. The FY 2008 budget request reflects the fundamental challenge of balancing urgent threats and urgent realities, and illustrates CDC′s commitment to strong and effective programs in both arenas.

Healthy People in Every Stage of Life

CDC is focused on maximizing health impact and reducing health disparities through programs that address key prevention and health promotion factors across every life stage. Our childhood immunization programs and adult cancer screening services are two examples of life stage-focused efforts. CDC awards grants through Section 317 of the Public Health Service Act and the Vaccines for Children (VFC) program to assist state and local health departments in purchasing safe and effective childhood vaccines and in conducting immunization programs. A recent economic evaluation of seven routine childhood immunizations found that the vaccines resulted in annual savings of $9.9 billion in direct medical costs and over $33.4 billion in indirect societal costs. These immunizations prevent more than 14 million cases of disease and over 33,000 deaths over the lifetime of children born in any given year. CDC continues to aim for maximum impact in the management of these essential immunization programs.

The National Breast and Cervical Cancer Early Detection Program is an important component of the agency′s preventive services for adults, providing access to critical cancer screening for underserved women in the U.S. since 1991. To date, almost three million women have been screened who otherwise would not have had access to these services. The program has provided more than 6.5 million screening examinations and diagnosed almost 27,000 breast cancers, over 88,000 mild to severe cervical precancerous lesions, and more than 1,700 invasive cervical cancers. CDC is proud of this record of assisting state and local health departments to deliver vaccines to underserved children and to conduct preventive screenings for underserved women, and will uphold this leadership role in promoting health across life stages.

The prevalence of HIV/AIDS is an urgent reality that has been with us for over two decades, and CDC continues to search for ways to stop the spread of the virus at home and abroad. CDC plays a vital role in implementing the President′s Emergency Plan for AIDS Relief, an international effort that in 2006 supported HIV/AIDS treatment for 822,000 men, women and children in 15 countries. On the domestic front, the FY08 budget request includes funding for an initiative to increase testing and treatment for HIV. Yesterday (March 8) CDC hosted a partner meeting in Atlanta to call attention to the urgency of addressing high rates of HIV/AIDS among African-Americans. Participants included African-American leaders representing a wide range of sectors such as business, philanthropy, education, entertainment and civic organizations. The meeting is intended to launch a widespread community mobilization effort aimed at encouraging a heightened response to HIV/AIDS among African-Americans in communities around the country.

In the FY 2008 budget request, an increase of $63.0 million is included to expand the number of people who are aware of their HIV status in the U.S., with a focus on populations, jurisdictions and venues with the highest prevalence of disease. This funding will support testing programs primarily in 10 jurisdictions with the greatest rates of new infections, in addition to incarcerated persons and intravenous drug users. We estimate that over two million people, mostly African-Americans, will be tested and over 31,000 new infections will be diagnosed through this initiative. Because individuals who are aware of their infection are less likely to transmit the virus, this effort is expected to avert 1,500 infections in the first year alone, thereby saving $1.5 billion in lifetime medical care and lost productivity costs.

An additional $30.0 million included in the request will provide support for HIV testing and treatment in states with policies for voluntary opt-out testing for pregnant women and high risk populations, as well as universal testing of newborns, as authorized in the Ryan White HIV/AIDS Treatment Modernization Act. These combined resources will allow those who are infected to learn of their infection earlier, stay in better health longer, and take steps to protect others, resulting in decreased overall cost to the health care system and improved health across life stages.

Healthy People in Healthy Places

In addition to encouraging healthy behaviors and actions in all life stages, CDC seeks to assure that places where people live, work, learn, and play will protect and promote their health and safety, especially those at greater risk of health disparities. In particular, home, school and workplace are three places that have a tremendous impact on health. CDC is pushing forward with a variety of efforts to improve health outcomes in each of these places, including an initiative to expand adolescent health promotion in schools as part of the President′s budget request.

In the home, for example, CDC takes a lead role in preventing residential fire deaths. A review of homes participating in CDC-funded smoke alarm installation and fire safety education programs found that more than 1,100 lives have been saved to date as a result of these programs. In the workplace, CDC and partners received the prestigious R&D 100 Award in 2006 for creation of the first device that can immediately determine whether coal dust concentrations in active areas of underground mines have been sufficiently mixed with rock dust to prevent risk of explosion. This represents a significant step forward for mine safety, as current technologies used to assess coal dust concentrations require lab analysis that may take as long as two weeks to complete.

Promotion of healthy schools is another area of emphasis for CDC, and a key component of the President′s FY 2008 budget request. In recognition of CDC′s leading role in health promotion, the President has requested $17.3 million for an Adolescent Health Initiative to promote physical activity, healthy eating, and injury prevention through funding and technical assistance to 3,600 schools across the country. The ultimate goal is to help encourage a culture of wellness among our young people, which would go a long way toward addressing the long-term urgent health realities we face as a country.

Schools can play a critically important role in fostering wellness by teaching children and adolescents essential knowledge and skills for healthy eating, physical activity, and personal safety, and providing plenty of opportunities to practice those skills. Today almost eight out of ten high school students do not eat the recommended five servings of fruits and vegetables a day, and only 33 percent participate in daily physical education classes. Given the importance of establishing healthy habits early in life, it can be no surprise that nearly one in three children and adolescents are overweight or at risk of becoming overweight. In addition, one-third of high school students reported being in a physical fight in the 12 months preceding a 2004 CDC survey, and nearly one in five students reported carrying a weapon in the 30 preceding days. These data represent an unacceptable state of adolescent health in this country. By directly reaching more than three million young people and their families, CDC′s Adolescent Health Initiative aims to improve these conditions. If these young people can be taught strong and effective health promotion messages while they are still in school, and if schools are models of healthy and safe environments, we may be able to begin to reverse the trend toward sedentary behavior and unhealthy habits in adulthood. This is health promotion at its most promising and CDC is proud to be leading this initiative on behalf of HHS.

Thank you for the opportunity to appear here today to discuss the support CDC has received in the President′s FY 2008 budget request. In an era of limited fiscal resources and many competing priorities, the FY 2008 budget strikes a balance between preparing for urgent threats and confronting urgent realities, and we are committed to leveraging these resources to achieve maximum health impact and reduce health disparities. In the coming fiscal year, CDC will sustain our leadership role in promoting health among young people and adults, across all life stages, and in schools and communities around the country. We will continue our investment in preparedness for urgent health threats and will work with partners at home and abroad to assure a healthy international community. In closing, I would like to express particular thanks to you, Mr. Chairman, and to the members of this Subcommittee, for your continued support. I look forward to working with Congress over the course of this next fiscal year to fulfill our public health mission, and I would be happy to answer any questions you might have.

⊃1;Z Fangjun, Santoli J, Messonier M, Hussain Y, et al.; Economic Evaluation of the 7-Vaccine Routine Childhood Immunization Schedule in United States, 2001; Archives of Pediatrics and Adolescent Medicine; 2005;159:1136-1144