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A Safer, Healthier U.S.: The Centers for Disease Control and Prevention, 2009–2016

Published:January 14, 2017DOI:https://doi.org/10.1016/j.amepre.2016.12.024

      Introduction

      The Centers for Disease Control and Prevention (CDC) has a unique mandate, reach, and breadth and depth of expertise. As CDC Director since 2009, the author has had the opportunity to work with and learn from public health partners at CDC, throughout the U.S., and globally. This article summarizes major initiatives, lessons, and remaining challenges. CDC has helped make Americans safer and healthier by strengthening public health systems, addressing health threats effectively, and protecting health both in our country and around the world (Table 1).
      Table 1CDC Initiatives 2009-2016; Progress and Future Directions
      InitiativeProgressFuture directions
      Strengthen public health systems
       Data collection and dissemination more quickly and more widely to increase use of information for action
      • Increased from <10% to 50% certificates submitted electronically to the National Center for Health Statistics (NCHS) within 10 days of death.
      • Increase to ≥80% of deaths reported to NCHS within 10 days, with real-time analysis of trends.
      • Through the National Health Interview Survey (NHIS), number of states with accurate estimates increased from 32 in 2011 to all 50 states and Washington, DC, in 2014.
      • Explore collection of biometric information (e.g., blood pressure) and measurements (e.g., cholesterol).
      • Modernized MMWR with faster review and publication of articles, summary box with implications, indexed with high metrics for impact, and new Vital Signs series of monthly reports on leading public health challenges and what can be done about them, each of which generates more than 650 news stories with an earned media value of about $1 million and average potential reach of over 1 billion audience impressions.
      • Improve data visualization and use social media more effectively.
      • Established globally webcast Public Health Grand Rounds to foster discussion on major public health issues and encourage action based on latest scientific findings.
      • Established strong social media presence on Twitter, with more than 1 million followers, Facebook, and other channels to communicate timely information to the public.
      • Evaluate impact and optimize to foster healthier knowledge, attitudes, practices, and policies.
      • Developed or upgraded websites to increase data accessibility, including Sortable Stats, Community Health Status Indicators (CHSI 2015), Motor Vehicle Prioritizing Interventions and Cost Calculator for States (MV PICCS), Office of Smoking and Health’s State Tobacco Activities Tracking and Evaluation (STATE) system, Alcohol-Related Disease Impact (ARDI) tool, Behavioral Risk Factor Surveillance System Web Enabled Analysis Tool (BRFSS WEAT) and Selected Metropolitan Area Risk Trends project (SMART BRFSS), Wide-ranging Online Data for Epidemiologic Research (WONDER) database, Web-based Injury Statistics Query and Reporting System (WISQARS), Youth Online, and others.
      • Further improve data dissemination and use, both through social media and more geographically resolved data that is of use to affected communities.
      • Increased availability of CDC datasets in machine-readable formats for use by public health practitioners, researchers, and developers. Datasets are publically available via https://data.cdc.gov/, and CDC WONDER includes an API for machine-to-machine data transfer. The WONDER site has 7 million page views, and 4.5 million custom data reports are generated each year.
      • While maintaining appropriate safeguards, continue to increase availability of data to expand data use and increase its impact.
      • Improved information on clinical care through expanded health care surveys, collaboration with Centers for Medicare & Medicaid Services (CMS) to analyze Medicare claims data, use of commercial pharmaceutical databases, and more.
      • Work with partners to further improve information from electronic health records and other sources (e.g., blood pressure control, HIV viral load suppression), about clinical systems (e.g., healthcare-associated infections, opiate- and antibiotic-prescribing practices), impact of clinical care (e.g., self-rated health status, vital statistics), availability of core services (e.g., immunization, tuberculosis and STD control, newborn screening), and community–clinical linkages (e.g., diabetes prevention program, quitlines, dental sealants, asthma case management).
      • Increase geographic coverage of environmental information and its use in setting and monitoring interventions to reduce illness and death.
       Laboratory techniques to find and stop outbreaks
      • Many parts of CDC now increasingly use whole genome sequencing (WGS) (e.g., emerging diseases, food safety, healthcare-associated infections, HIV, hepatitis, influenza, tuberculosis control).
      • All of PulseNet, other national laboratory-based systems, and an increasing number of state and municipal public health laboratories use WGS and integrate with epidemiologic data to maximize public health impacts.
       Information on health status of diverse populations
      • Published reports, such as the MMWR Supplement on Strategies for Reducing Health Disparities on health disparities and inequalities with information by income, education level, sex, race, ethnicity, employment status, and sexual orientation. Provided national-level information on health of LGBTQ youth (YRBS) and adults (NHIS). Increased reporting on health status by urban/rural status. Created CDC Social Determinants of Health website, providing resources, data, tools for action, programs, and policy to improve community well-being. NHIS added 4,000 extra households to the survey containing one or more Native Hawaiian and Pacific Islander (NPHI) to better understand the health status of this group.
      • Report on disparities regularly and increase specificity of data (e.g., on different Hispanic groups, American Indian/Alaskan Native groups, and different patterns of health in different types of rural areas, correctional health, and other populations) and use the information to better address health disparities.
       Public health laboratory workforce
      • Established 2-year Laboratory Leadership Service (LLS), analogous to and in partnership with CDC’s Epidemic Intelligence Service, to prepare early-career laboratory scientists to become future public health laboratory leaders.
      • Increase number of Fellows, at the master’s and doctoral levels, place them in state and local health departments, and ensure career track for graduates.
       Notifiable disease surveillance
      • National Notifiable Diseases Surveillance System (NNDSS) established a standard set of data elements with core information for all nationally notifiable diseases; established modern, standard format reporting from 10 states with approximately 25% of U.S. population.
      • Implement new data standards and data exchange systems so 90% of data are reported through this system.
      • Test and incorporate novel data sources and flows including big data and more efficient and automated reporting formats.
      • Reduce variability in reporting systems to establish core set of variables and data dictionary.
       Support and collaborate with state, tribal, local, and territorial public health agencies
      • Increased proportion and amount of budget provided to state and local health departments, increased number of embedded CDC staff in public health agencies, and established New Health Officials Orientation for new big city and state health officials.
      • Ensure budget support for federal funding of state and local public health.
      • Increase state and local self-funding of public health initiatives.
      • Increase accountability for and documentation of outcomes of funds provided.
       Epidemic Intelligence Service
      • CDC Epidemic Intelligence Service (EIS) surged to protect the U.S. population from emerging global threats while continuing to respond to domestic threats. The Ebola response was the largest international response in CDC’s history: all 164 EIS officers contributed to the response. Their work in remote and austere environments helped to stop the spread of the epidemic and made lasting improvements in local public health infrastructure. The EIS program then surged to support the Zika virus response. CDC has also placed Epidemic Intelligence Service Officers within the agencies of CDC’s partners to enhance coordination and efficiency and further support state, tribal, local, and territorial needs. Since 2009, EIS Officers have been placed in the National Park Service, the Department of Veteran’s Affairs, SAMHSA, and the Northwest Portland Area Indian Health Board.
      • Continue to assess current needs in public health and recruit clinicians and scientists into EIS who have training in skills most needed in today’s environment. Continue to work with States to adapt training to ensure that EIS Officers and other fellows bring the skills most needed to support state and local capacity and contribute to the public health workforce.
       Initiated Good Health and Wellness in Indian Country program
      • Initiated a 5-year, $16-million/year program to reduce death and disability from tobacco use, obesity, diabetes, heart disease, and stroke.
      • Continue to invest in programs to improve health of American Indian and Alaska Native populations and identify and scale up effective approaches that build on community strengths.
       Strengthen, rejuvenate, and increase diversity of public health workforce
      • Public Health Associate Program (PHAP) attracts more than 3,000 applicants a year for 200 two-year positions. Nearly 400 PHAP associates, of whom more than half are non-white, including approximately one third African American and one sixth Hispanic, are deployed throughout the U.S. and territories. The CDC Undergraduate Public Health Scholars (CUPS) internship program trains and sponsors undergraduate students interested in minority health and public health careers. Over the past 5 years the program has received 16,141 applicants and sponsored 910 students. More than two thirds of graduates work in public health, including CDC, departments of public health, and community-based organizations.
       Provide information on policies and programs that save lives and money
      • Prevention Status Reports (PSRs) highlight status of key public health policies and practices for all 50 states and the District of Columbia. Reports document the burden of the problem, identify evidence-based approaches to reduce this burden, and report the status of interventions.
      • Expansion of PSRs to include American Indian/Alaskan Native populations and Territories.
       Improve health department capacity
      • As of November 2016, 130 local, 19 state, and 1 tribal health departments, covering a population of more than 170 million, were accredited. The National Leadership Academy for the Public’s Health, established in 2011, trains four-person multi-sector teams from across the country to advance leadership skills and health equity.
      • Support accreditation of all public health departments and continue refining the accreditation process to better correlate with safer, healthier communities.
       Build and strengthen partnerships to address health issues
      • CDC supports FDA’s tobacco control work with laboratory, epidemiology, and program expertise. CDC, FDA, and USDA worked closely together on food safety and nutrition, and CDC supported USDA in revising the food pyramid to a plate to help inform healthy eating habits. CDC also supported the ongoing work of the Surgeon General to author reports on tobacco, suicide, and many other issues facing Americans.
      • Continue to identify areas where focused collaboration can achieve significant health improvement.
       Expanded and strengthened partnerships with CMS
      • CDC and CMS have developed broad and deep collaboration. For example, CMS provided incentives for hospitals to participate in CDC’s National Healthcare Surveillance Network (NHSN), CDC supported CMS in extending coverage for the Diabetes Prevention Program to Medicare beneficiaries, and CDC worked with the CMS Innovation Center to provide input on population health outcomes for new payment and service demonstration delivery models. With the support of CDC technical assistance, State health departments and Medicaid agencies have similarly strengthened partnerships and undertaken joint initiatives.
      • Continue to build on strong relationship, scale up effective programs, innovate, and rigorously evaluate. State public health agencies and Medicaid departments can also innovate and share best practices across states. Data systems for health care and public health should provide accountability of population-wide health improvement. Change policies (e.g., on scope of practice) and practices to reduce costs and increase access. Improve clinical laboratory quality.
      Protect Americans from health threats
       Emergency response to control outbreaks and respond to disasters
      • 2009 H1N1 influenza pandemic. CDC’s work to rapidly distribute vaccine as soon as it became available and encourage use of antiviral medications prevented at least 1 million cases of influenza, 18,000 hospitalizations, and 600 deaths. CDC increased capacity of Strategic National Stockpile to mitigate catastrophic health events (e.g., reduced time to delivery of materials; stocked ventilators in case needed for severe influenza or other respiratory event).
      • Continue to improve surveillance to detect novel influenza faster, innovate to produce better, widely immunogenic influenza vaccines, and continue planning for mitigation of worst-case scenarios.
      • Haiti earthquake and cholera epidemic. Since the 2010 earthquake, CDC introduced new vaccines against H. influenza, pneumococcus, and rotavirus, preventing tens of thousands of deaths per year; health facilities participating in the national surveillance system increased from 51 to 357; increased annual laboratory testing for infectious diseases from 2,645 to 20,654; increased case notification of smear-positive TB from 86 cases/100,000 to 106 cases/100,000; mass drug administration for lymphatic filariasis increased from 53 communities to 139 communities; elimination of measles and rubella was declared in 2014; began use of oral cholera vaccine.
      • Continue progress to eliminate lymphatic filariasis, maternal-to-infant transmission of HIV, and malaria. Establish stable funding and staffing for core public health programs. Implement programs to improve water and sanitation.
      • Ebola epidemic. CDC staff led identification of and response to West Africa Ebola epidemic and restoration of health systems, deploying to nearly every community where Ebola was spreading in Liberia, Sierra Leone, Guinea, Nigeria, Senegal, and Mali. Staff supported incident management systems, contact tracing, infection control, laboratory testing, rapid response, border health, and more. More than 4,000 CDC staff responded, including more than 1,400 who deployed for more than 75,000 person-workdays in West Africa. In the U.S., health departments monitored more than 63,000 returning travelers.
      • Build on Ebola response infrastructure and implementation of Global Health Security Agenda including surveillance, laboratory capacity, workforce training, and emergency response capability. Accurate, timely, ongoing surveillance is critical to find and stop flare-ups of Ebola and emergence of other health threats.
      • Zika virus pandemic. Prevented fetal malformations by advising pregnant women not to travel to affected areas, identifying risk of sexual transmission, developing and disseminating diagnostic tests, and supporting Miami to curtail transmission. More than 2,000 CDC staff involved in response. From January to November 2016, CDC Zika website was viewed more than 71 million times and CDC published more than 200 guidance documents and scientific publications, posted 58 travel notices, and responded to more than 5,700 clinical inquiries to limit risk of acquiring Zika and to support travelers, patients, and clinicians.
      • Complete studies to better define range of congenital Zika syndrome. Develop additional diagnostics to differentiate antibody reactions of Zika from dengue and other related viruses; develop innovative insecticides; strengthen vector control through assessment of current and new technologies.
      • Strengthen informatics systems to improve communication of diagnostic results between laboratories and healthcare providers.
      • HIV/HCV outbreak. Staff from two CDC centers worked with the state to respond to an unprecedented outbreak of HIV and HCV infections in rural Indiana in 2015 associated with Opana injection; rapidly curtailed spread. Identified other counties that may be vulnerable to rapid dissemination of HIV.
      • Address epidemic of opioid use, prevent injection drug use, and increase access to addiction treatment and syringe service programs.
      • Flint, MI lead contamination. Responded to lead contamination as well as Legionella and Shigella outbreaks in Flint, MI in 2015–2016. CDC Identified and located 9,622 children in need of blood lead testing and continuing care. CDC monitored blood lead levels in the community’s children under 6 years of age, connected more than 90% of children with elevated blood lead levels to case management.
      • Maintain and improve public health infrastructure. Reduce blood lead levels in children.
      • Fungal meningitis outbreak. In September 2012, CDC and FDA began investigating a multistate outbreak of fungal meningitis associated with steroid injections in which more than 750 people were sickened and more than 60 died. Through laboratory testing, CDC identified bacterial and/or fungal contamination in unopened vials of betamethasone, cardioplegia, and triamcinolone solutions distributed and recalled from a compounding pharmacy. CDC provided clinical resources and advice regarding the contamination and clinical care.
      • Further improve practices to reduce risk of contamination of materials that should be sterile; expand WGS and outbreak investigations to rapidly identify contamination when it occurs.
      • Deepwater Horizon response 2010. CDC rapidly conducted health hazard evaluations and surveillance of reported illnesses among workers and developed a voluntary roster of more than 55,000 workers to obtain record of those who participated and a mechanism to contact them about possible related symptoms of illness or injury. Analyzed occupational injury and illness data to increase awareness of the risks associated with Gulf oil response work. Initiated laboratory studies on the dispersant and crude oil. Developed guidance and educational materials in partnership with other federal agencies to protect response workers.
      • Improve occupational injury and illness surveillance during disasters. Promote policies and systems to roster response workers and enable real-time health surveillance and long-term follow-up of health status. Contribute to the science on the potential health effects of exposures to crude oil, dispersant, and mixtures.
       Strengthen response to global health workforce emergencies
      • Created CDC Global Rapid Response Team (GRRT), with more than 350 staff ready to mobilize in response to global health threats. In its first year, GRRT staff had spent 3,000 person-days in more than 90 responses to cholera, yellow fever, Ebola, measles, polio, mass gatherings, and wildfires.
      • Need for emergency response fund with authorities to surge in quickly and stop health threats before they grow.
      • Sustainable funding and career support for GRRT.
      Winnable Battles initiative to address leading causes of morbidity and mortality in the U.S.
      • Identified leading public health challenges and developed technical packages to address them. This approach has been adopted by many state and local health departments and used as a framework for action within CDC, including improving medication use in attention deficit hyperactivity disorder, strengthening water system management in buildings for Legionella control, and preventing human papilloma virus infection through vaccination and improved cancer screening.
      • Apply Winnable Battles approach to other leading public health issues to increase impact and determine next stage to further reduce burden of problems being addressed. Address problem alcohol use. Reduce disability during aging, including reducing falls among seniors.
      • Healthcare-associated infections. Combination of CDC data systems, guidelines, and programs has contributed to significant reductions of healthcare-associated infections, including 50% reduction in central line-associated bloodstream infections between 2008 and 2014.
      • Further reduce healthcare-associated infections, and rapidly identify novel sources of infections and new pathogens. Combat antibiotic-resistant infections in health care.
      • HIV. Number of annual HIV diagnoses decreased from 48,366 in 2008 to 39,718 in 2014; proportion of people with HIV who know their status increased from 80.9% in 2006 to 87.0% in 2013.
      • Increase proportion of those with HIV who know their status and increase proportion of those with HIV who are virally suppressed in order to further reduce the number of new HIV infections.
      • Nutrition, physical activity, and obesity. Reductions in early childhood obesity among WIC populations in some states. Percentage of U.S. hospitals using majority of Ten Steps to Successful Breastfeeding increased from 29% in 2007 to 54% in 2013; 81% of babies born in 2013 started out breastfeeding, up from 76% in 2009.
      • Innovate, evaluate, and scale up programs to prevent obesity.
      • Food safety. CDC, FDA, and USDA worked together closely to improve food safety. CDC and partners used whole genome sequencing to identify novel food vehicles, solve outbreaks faster, and implement effective control measures. Foodborne illness caused by Shiga toxin-producing Escherichia coli (STEC) O157:H7 decreased from 1.2/100,000 in 2006–2008 to 0.9/100,000 in 2015.
      • Further progress needed to reduce burden of foodborne illness, including from Salmonella and Listeria, and to reduce multi-state outbreaks, which cause more than half of all deaths associated with foodborne outbreaks.
      • Tobacco. Cigarette smoking is at an all-time low; there were 10 million fewer adult cigarette smokers in 2015 than 2009. Tips from Former Smokers, the first-ever paid national anti-tobacco campaign, helped 400,000 smokers quit from 2012 to 2015 at a cost per life saved of less than $3,000.
      • Further reduce tobacco use by increasing cost of cigarettes, expanding smokefree environments, increasing access to barrier-free tobacco-cessation treatment, investing in year-round anti-tobacco ad campaigns, and supporting state and local tobacco control programs. Innovate to reduce harm of addictive products without facilitating sustained use of harmful products. Address increasing use of e-cigarettes among youth.
      • Teen pregnancy. Teen birth rate decreased from 37.9/1000 females aged 15–19 years in 2009 to 22.3/1,000 in 2015, lowest rate ever recorded, exceeding Winnable Battle target.
      • Reduce disparities in teen birth rates. Increase access to long-acting reversible contraception to reduce unintended pregnancies among women of all ages.
      • Motor vehicle safety. Motor vehicle fatalities decreased from 13.8/100,000 in 2007 to 10.9/100,000 in 2015.
      • Further reduce motor vehicle crash deaths by addressing driving while intoxicated or distracted, teen driving, and further support safe vehicles and transportation systems. Continue to partner with tribal nations to reduce death rates of motor vehicle crashes among American Indian/Alaska Native adults.
       Opioid epidemic
      • CDC supports states to improve surveillance of opioid-related morbidity and mortality. CDC implemented and scaled up new state prevention program, which grew from five in Fiscal Year 2014 to 42 states in Fiscal Year 2016, to maximize Prescription Drug Monitoring Programs, enhance community and insurer/health system innovation, evaluate policy interventions, and conduct rapid response projects. CDC issued guideline to improve opioid prescribing for chronic pain outside of the end-of-life setting.
      • Improve prescribing practices, including through implementation of CDC opioid-prescribing guideline, and increase access to medication-assisted treatment and naloxone. Work with law enforcement to reduce supply and decrease overdoses involving heroin, illicitly produced fentanyl and other opioids.
       Combatting antibiotic resistance
      • Better track resistance patterns; improve prescribing and promote appropriate antibiotic use; reduce spread of organisms in hospitals; support development of new antibiotics and diagnostic tests. Increase awareness of sepsis among the public, healthcare providers, and healthcare facilities.
       Launched Million Hearts with CMS and other partners to prevent 1 million heart attacks and strokes in 5 years
      • In its first 2 years, the Million Hearts initiative prevented an estimated 115,000 events and it is projected that approximately 500,000 events will be prevented in the 5 years of the initiative. As of 2015, the Million Hearts Hypertension Control Challenge recognized nearly 60 public and private healthcare practices and systems, reaching almost 14 million adult patients in 29 states for achieving at least 80% hypertension control. Thousands of additional adults are covered by systems reporting Million Hearts quality measures for the ABCS (aspirin use, blood pressure control, cholesterol management, and smoking cessation). The FDA finalized determination that artificial trans fats are no longer generally recognized as safe and will phase them out of foods by 2018. Cigarette smoking is at an all-time low among adults and youth.
      • Continued focus on improving care of the ABCS.
      • Population-wide sodium reduction, which will save lives and money and put choice back into consumers’ hands.
       Developed 6|18 initiative to accelerate evidence into action
      • CDC identified six common and costly health conditions—tobacco use, high blood pressure, healthcare-associated infections, asthma, unintended pregnancies, and diabetes—and 18 proven interventions for purchasers, payers, and providers to consider as they improve health and control costs. Multiple state Medicaid programs, commercial payers, and large employers are adapting covered benefits to provide access to specific 6|18 interventions.
      • Work with purchasers, payers, and providers to implement 6|18 interventions and evaluate impact on health outcomes and healthcare costs.
       Developed the HI-5 initiative to improve population health
      • Health Impact in 5 Years (HI-5) initiative highlights community-wide (non-clinical) approaches that have evidence of (1) positive health impacts, (2) results within 5 years, and (3) cost effectiveness and/or cost savings over the lifetime of the population or earlier.
      • Continue to implement proven interventions and build evidence base for additional community interventions that save lives and money and share best practices.
       Detection and response to emerging non-communicable disease threats
      • Tobacco and e-cigarettes. Supported FDA tobacco regulation by producing 627,000 results for over 100 addictive and toxic substances in studies characterizing exposure in the U.S. population and in users of various tobacco products, including analysis of cigarettes, e-cigarettes, and other nicotine delivery devices.
      • Newborn screening. Ensured accurate newborn screening tests for early detection of serious, treatable diseases in all 50 states and 81 countries, directly impacting 654 laboratories. Since 2008, CDC-funded programs have screened more than two million babies for severe combined immunodeficiency (SCID), a deadly but curable disease.
      • Reduce risk that youth will become nicotine addicted, whether from e-cigarettes or other products.
      • Disseminate information on known harms of marijuana use and research gaps. Support rigorous analysis to determine causality of other health consequences.
      Protect Americans by strengthening health systems around the world
       Reduce risk of future health threats spreading avoidably
      • Piloted and implemented Global Health Security Agenda (GHSA) to improve capacity of low- and middle-income countries to find, stop, and prevent health threats. Fifty countries have completed or planned Joint External Evaluations with objective, transparent, independent information on preparedness with results available online. Since 2009, CDC has responded to more than 1,640 outbreaks globally, including providing laboratory support for more than 1,240. Laboratory capacity is a key component of GHSA and 10 GHSA countries trained technicians in 2015 to detect global emerging threats
      • All countries complete Joint External Evaluation (more than 70 have committed to conducting JEE assessments by end of 2017).
      • Increase speed of detection and response to outbreaks by building in-country capacity for effective disease surveillance, diagnosis, and response.
      • Increase technical and operational capacity of WHO to support country action and prevent spread of health threats.
      • Field Epidemiology Training Program (FETP), which trains field epidemiologists, has trained more than 7,400 graduates from 72 countries, including more than 4,600 since 2009, 80% of whom continue to work in their home countries. Over the past 2 years, CDC has expanded the FETP Frontline program, bringing the training to local surveillance officers in 27 countries.
      • Continue to expand reach of FETP and provide training on a wider range of public health issues and to a broader range of health workers.
      • Established and strengthened international laboratories for rapid, effective disease response. CDC has supported the discovery of 12 new pathogens since 2009, and detected an additional 31 for the first time in a country/region. PEPFAR supported HIV testing and counseling for more than 74.3 million people, including 11.5 million pregnant women, in Fiscal Year 2016. Through PEPFAR, CDC developed more than 16,500 HIV testing sites, supported continuous quality improvement in more than 700 laboratories, and trained specialists in close to 500 labs across 23 countries. CDC also helped establish the African Society for Laboratory Medicine (ASLM) to guide and strengthen laboratory networks throughout Africa and helped launch Africa’s first accreditation and preparedness program, supporting more than 1,000 labs towards accreditation.
      • Accelerate the discovery of potential public health threats to facilitate containment and emergency preparedness.
       Polio eradication
      • There were 350,000 cases in 1988 compared with fewer than 40 in 2016; 15 million people are walking today who would have been paralyzed. Since 2009, India has become polio-free, and Nigeria, Pakistan, and Afghanistan are close to being polio-free.
      • Eradicate and confirm eradication through rigorous surveillance, even in areas with conflict.
       Prevention, treatment, and care for people with HIV/AIDS
      • In 2015, through PEPFAR, CDC supported: lifesaving antiretroviral therapy (ART) for 5.8 million HIV-infected people; anti-retroviral treatment for more than 400,000 pregnant women to prevent mother-to-child transmission, and 1.3 million voluntary male medical circumcision procedures. CDC also conducted epidemiologic and program research and economic analyses to maximize impact of the U.S. Government’s investments. Improved infection control for tuberculosis through Building and Strengthening Infection Control Strategies (TB BASICS), and provided guidelines on TB/HIV co-infection.
      • Continue to scale up the use of ART, strengthen the ability of national governments to provide HIV services, deliver effective prevention tools to individuals at high risk for HIV infection, and use data to reach high-risk groups, inform public health policies and strategies, and measure impact.
       Malaria
      • President’s Malaria Initiative (PMI) has increased use of insecticide-treated nets, rapid diagnostic tests, antimalarial treatment, monitoring of therapeutic efficacy, and preventive treatment for pregnant women. This scale-up of interventions has saved 3.3 million lives globally and contributed to a global reduction of malaria mortality by 45%. CDC brings technical expertise to support these efforts with its collaborative work in malaria-endemic countries and regions.
      • Further strengthen national technical leadership and capacity to implement effective prevention and control.
      • Innovate for new means to control mosquitoes and reduce the burden of malaria.
       Immunization
      • Immunization saves 2 to 3 million lives every year. CDC partners with countries to strengthen immunization systems and expand comprehensive delivery of immunizations.
      • Leverage polio eradication progress to increase healthcare system vaccine coverage, eliminate measles, and reduce deadly illnesses from vaccine-preventable diseases.
       Support partners to address leading causes of death
      • Lead technical agency for Global Tobacco Surveillance System (GTSS). With funding from Bloomberg Philanthropies, the Global Adult Tobacco Survey (GATS) has released data from 31 countries, where more than 80% of the world’s smokers live, trained nearly 9,000 staff, completed more than 575,000 household interviews, collected 110 million data points, and conducted survey in over 50 languages/dialects.
      • Launched Global Hearts initiative to address growing burden of cardiovascular disease, incorporating technical packages for tobacco (MPOWER), sodium reduction (SHAKE), and cardiovascular disease management in primary care (HEARTS).
      • Monitor tobacco product use through repeat tobacco surveys and incorporate tobacco questions into other routine demographic or health surveys. Work with partners to support implementation and evaluation of MPOWER interventions.
      • Implement, optimize, and expand Global Hearts initiative.
      • Support partner countries to address other leading causes of poor health, including indoor and outdoor air pollution, lead poisoning, unsafe water and sanitation, and unsafe and unhealthy food.
       Stop violence against children
      • CDC’s Violence against Children Surveys (VACS) measure physical, emotional, and sexual violence against girls and boys. VACS have been completed or are in progress in 22 countries in collaboration with the Together for Girls partnership. CDC, WHO, and global partners developed the INSPIRE technical package which provides evidence-based strategies to end violence against children.
      • Repeat VACS to establish ongoing surveillance; implement, evaluate, and optimize INSPIRE technical package.
      ABCS, aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation treatment; FDA, U.S. Food and Drug Administration; H1N1, Influenza A virus subtype; HCV, Hepatitis C virus; JEE, Joint External Evaluation; MMWR, Morbidity and Mortality Weekly Report; PEPFAR, President’s Emergency Plan for AIDS Relief; SAMHSA, Substance Abuse and Mental Health Services Administration; USDA, U.S. Department of Agriculture; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

      Stronger Public Health Systems

       Surveillance and Laboratory Science

      Surveillance is the basis for effective action. CDC has improved data timeliness, completeness, utility, and dissemination using new technologies, analytic tools, and sources. In 2015, PulseNet, a state health department laboratory network to find outbreaks of foodborne disease, began replacing pulsed-field gel electrophoresis with whole genome sequencing to enhance disease investigation. A pilot project on Listeria initiated in 2013 provided proof of principle and a foundation for PulseNet modernization, resulting in more timely and definitive identification of clusters of illness and improved source identification, reducing the size of outbreaks and preventing infections and deaths.
      Dissemination of data was increased by CDC through publications, traditional and new media outlets, making data available online, and partner organizations. With more than 1 billion page views a year, the CDC website is one of the world’s most visited health sites, and CDC is one of the most trusted federal agencies.

      Most view the CDC favorably; VA’s image slips. Pew Research Center. January 22, 2015. www.people-press.org/2015/01/22/most-view-the-cdc-favorably-vas-image-slips. Accessed November 15, 2016.

      Although surveillance has improved, survey participation rates are falling, costs are increasing, reporting is not standardized, and new tools including electronic health records are not adequately incorporated. More rapid data collection, analysis, and dissemination are needed. Data are now available in larger quantities, more quickly, and from more sources, but analytics (both machine learning and rigorous human analysis) and dissemination lag. CDC is working to make data available more promptly and in more-usable formats.

       U.S. Public Health System

      Many state and local health departments experienced large budget cuts during 2008 and 2009, and few had subsequent budget restorations. CDC increased the proportion and amount of funding to state, tribal, local, and territorial health departments and developed new tools to help health agencies enhance their capacity and increase impact. These include status reports on public health policies and practices addressing food safety, healthcare-associated infections, heart disease and stroke, tobacco and alcohol use, HIV prevention, motor vehicle injuries, nutrition and physical activity, prescription drug overdose, and teen pregnancy.
      Since 2010, CDC has developed the Public Health Associate Program to train the next generation of public health leaders, assigning them to local and state health departments for 2 years of service learning. The nearly 400 current associates are drawn from more than 6,000 master’s- or bachelor’s-level applicants; about half are African American or Hispanic. Most graduates continue careers in public health.

      Protecting Americans from Health Threats

       Response to Emergencies

      Over the past 8 years, CDC has responded to an unprecedented series of domestic and global emergencies; these emergencies have required activation of CDC’s Emergency Operations Center for more than 90% of this time. In addition to these large-scale responses, individual centers of CDC have also implemented incident management systems to better respond to complex situations such as the HIV/HCV outbreak in Scott County, Indiana, hurricanes, and yellow fever outbreaks.
      The response of CDC to the H1N1 influenza pandemic of 2009–2010 showed the importance of robust everyday systems. To distribute H1N1 influenza vaccine, CDC scaled up the Vaccines for Children centralized distribution infrastructure; more than 330,000 shipments were sent to more than 75,000 healthcare providers without delay or error. By contrast, without a system to distribute antiviral medication, shipments of Oseltamivir to states did not result in a sufficient increase in use. Despite delayed production of vaccine contracted by the Biomedical Advanced Research and Development Authority within the Office of the Assistant Secretary for Preparedness and Response, CDC’s work to rapidly distribute vaccine as soon as it became available and encourage use of antiviral medications prevented at least 1 million cases of influenza, 18,000 hospitalizations, and 600 deaths.
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      • et al.
      Influenza illness and hospitalizations averted by influenza vaccination in the United States, 2005-2011.
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      • et al.
      Estimating effect of antiviral drug use during pandemic (H1N1) 2009 outbreak, United States.
      The world’s first Ebola epidemic spread widely and rapidly through Guinea, Liberia, and Sierra Leone, explosively in urban areas, and began spreading to neighboring countries. CDC, affected countries, and partners were able to end the epidemic and prevent a global catastrophe.
      • Frieden T.R.
      • Damon I.K.
      Ebola in West Africa—CDC’s role in epidemic detection, control and prevention.
      Ebola showed the importance of further strengthening the capacity of countries around the world to find, stop, and prevent health threats, and the need to have rapid mechanisms for global response when country capacity is overwhelmed. CDC created the Global Rapid Response Team, which in its first year spent 3,000 person-days responding to more than 90 emergencies around the world. CDC responded rapidly to the Zika epidemic, advising pregnant women not to travel to affected areas, developing diagnostic tests, supporting mosquito control activities, and responding to outbreaks.

       Targeted Efforts to Address the Leading Causes of Disease, Disability, and Death

      In 2010, CDC identified six “winnable battles” for which progress is possible but not ensured: nutrition and food safety, healthcare-associated infections, HIV, tobacco, teen pregnancy, and motor vehicle safety. CDC and partners have made progress on most of these ambitious targets, though not all are on track to be met.
      Rates of cigarette smoking among adults and youth are at all-time lows, with 10 million fewer adult smokers in 2015 than in 2009. CDC’s Tips from Former Smokers campaign, the first paid, national tobacco education campaign, has helped at least 400,000 Americans quit smoking since the campaign began in 2012 and is highly cost effective. However, smoking remains the leading preventable cause of death, e-cigarette use by youth threatens to get another generation addicted, and much more progress is possible and needed.
      • Fiore M.C.
      Tobacco control in the Obama era—substantial progress, remaining challenges.
      Rates of opioid prescriptions have quadrupled, causing an epidemic of addiction, overdose, and death; this epidemic has evolved to include heroin and illicitly produced fentanyl. In 2016, CDC released a guideline on opioid prescribing for chronic pain for primary care providers and supporting states to improve prescribing and response; drastic improvements in management of both pain and addiction are needed.
      Collaboration between public health and the healthcare delivery system has been increased by CDC, including projects with the Centers for Medicare and Medicaid Services that reduce healthcare-associated infections, teen pregnancy, and cardiovascular events and improve the quality of clinical laboratory testing. The Million Hearts initiative set a goal of preventing a million heart attacks and strokes in 5 years through public heath action to reduce smoking, sodium consumption, and artificial trans fat use, and in clinical settings to improve aspirin use, smoking cessation treatment, and management of hypertension and high cholesterol.
      • Frieden T.R.
      • Berwick D.M.
      The “Million Hearts” initiative—preventing heart attacks and strokes.
      Although the initiative is not likely to reach the 1 million mark, it appears on track to prevent approximately 500,000 cardiovascular events by the end of the 5 years, in 2016.
      • Ritchey M.D.
      • Loustalot F.
      • Wall H.
      • et al.
      Abstract 15862: Million Hearts—estimating the number of cardiovascular events prevented during 2012–2016.
      The two major limitations were lack of action on sodium reduction and slow clinical improvement; healthcare system incentives are not yet well aligned with health improvement. Increasing antimicrobial resistance shows the urgent need for clinical improvement by improving both monitoring of drug resistance and prescribing, and through more rapid outbreak detection and response.

      Protecting Americans by Strengthening Global Health Security

      To both protect Americans from external threats and support health progress around the world, CDC has staff in more than 60 countries. As a result of a 2012 CDC proposal and pilot projects and in collaboration with partners, in 2014, the U.S. Government launched the Global Health Security Agenda to accelerate progress toward a world safe and secure from infectious disease threats. Dozens of countries have expanded laboratory networks, trained epidemiologists, improved surveillance systems, and responded rapidly to health threats. These systems protect the countries that build them, their neighbors, and the U.S.
      Ebola demonstrated the importance of accelerated progress on global health security and also showed that when national capacity is overwhelmed, the world must be able to mobilize surge capacity rapidly. The Joint External Evaluation is an independent assessment of countries’ ability to prevent, detect, and respond to infectious disease threats. By identifying capacities and gaps with numerical scores, the Joint External Evaluation establishes accountability for progress.
      The spearheading partners of the Global Polio Eradication Initiative are CDC, Rotary International, WHO, the U.N. Children’s Fund, and the Bill and Melinda Gates Foundation. In 2016, there were fewer than 40 cases of wild poliovirus worldwide; the world is closer to polio eradication than ever. CDC also plays pivotal roles in government-wide global health initiatives. In the President’s Emergency Plan for AIDS Relief, CDC provides half of all treatment, has established laboratory networks in countries lacking them, and has made substantial progress reducing mother-to-child HIV transmission. Progress reducing HIV incidence around the world will require faster expansion of treatment, particularly in areas with high HIV prevalence. The President’s Malaria Initiative and partners have saved more than 6 million lives over the past decade and reduced the enormous burden of malaria on healthcare systems, workplaces, and societies. Core President’s Malaria Initiative interventions were developed in whole or in part at CDC; all have important limitations. To maintain progress and further reduce the more than 1,000 deaths a day that malaria continues to cause, both innovative use of current tools and new technologies are needed.
      Non-communicable diseases now kill more people than infectious disease. CDC has also worked with WHO and others to establish guidelines for the control of hypertension

      HEARTS: technical package for cardiovascular disease management in primary health care. Geneva: WHO, 2016. www.who.int/cardiovascular_diseases/hearts/Hearts_package.pdf. Accessed November 15, 2016.

      and reduce violence against children.
      INSPIRE: seven strategies for ending violence against children
      Better addressing non-communicable diseases and their causes, including tobacco use, excess sodium consumption, and air pollution, would save lives and yield economic dividends.

      Conclusions

      CDC plays an essential role making the U.S. and the world safer and healthier and implementing and documenting cost-effective interventions. Over the past seven and a half years, the CDC has strengthened public health capacity internally throughout CDC and globally. At the same time, agency morale has improved, increasing from the bottom 25% of agencies to the top 15% in the federal Best Places to Work index.

      Best Places to Work in the Federal Government. Agency report: Centers for Disease Control and Prevention (HHS). Partnership for Public Service. 2016. http://bestplacestowork.org/BPTW/rankings/detail/HE39. Accessed December 21, 2016.

      Future progress will require rapid emergency responses and effective communication, policy decisions that prioritize maximizing health, and maintenance of CDC’s scientific independence.

      Acknowledgments

      The author thanks the senior leadership of the Centers for Disease Control and Prevention for comments on this article and their work leading the described initiatives; Drew Blakeman, Kathryn Foti, and Hugh Green for assistance with manuscript preparation; and the dedicated professionals throughout the Centers for Disease Control and Prevention for their hard and effective work protecting Americans and promoting health.
      No financial disclosures were reported by the author of this paper.

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