CDC Year in Review: Working 24/7/365

Through CDC’s Antibiotic Resistance Solutions Initiative, the agency is transforming the nation’s capacity to further detect, respond, and prevent antibiotic-resistant threats across healthcare settings and in communities to protect Americans and save lives. This effort includes work to improve antibiotic use and misuse, a main cause of antibiotic resistance. At least 30 percent of antibiotics prescribed in outpatient settings are unnecessary.

• Emerging resistance. In 2016, five patients in the United States tested positive for the mcr-1 gene, which can make bacteria resistant to the last-ditch antibiotic used to treat resistant infections. In November, 13 cases of Candida auris, a drug-resistant fungus, were reported, adding to the list of emerging threats. CDC is tracking and identifying emerging resistant genes and infections caused by resistant microbes like these. By knowing where and how changes in resistance are occurring, we can inform solutions—like outbreak response, drug development, and diagnostic development—to contain spread and slow resistance.
• Healthcare-associated infections (HAIs). America is doing a better job at preventing HAIs, but more work is needed, especially in preventing antibiotic-resistant infections and their spread. CDC has found that 1-in-7 catheter- and surgery-related HAIs are caused by an antibiotic-resistant bacteria. That number increases to 1-in-4 infections in long-term acute care hospitals—facilities that treat patients who are generally very sick and stay, on average, more than 25 days.
• Resistance in the community. In 2016, CDC expanded the use of whole genome sequencing (WGS) to screen 100% of Salmonella isolates for resistance (currently, only 1-in-20 isolates are tested). Sequencing efforts will protect communities by rapidly identifying drug-resistant foodborne bacteria, like E. coli, Shigella, and Campylobacter, to stop and solve outbreaks and improve prevention. In addition, CDC is developing local and state health department epidemiological and laboratory capacity to more rapidly detect and effectively respond to antibiotic-resistant gonorrhea in high-risk communities. Gonorrhea is one of the most commonly reported infectious diseases in the United States and increasingly resistant to most antibiotics. In April and May 2016, through rapid identification and response, public health efforts stopped further spread of a gonorrhea cluster that showed high levels of resistance and decreased susceptibility to the primary drugs used for treatment.
• More labs identifying antibiotic resistance. CDC provided funding to health departments in July 2016 to help tackle antibiotic resistance and patient safety threats nationwide, including HAIs and “nightmare bacteria” carbapenem-resistant Enterobacteriaceae (CRE), through the Antibiotic Resistance Laboratory Network (ARLN). State public health laboratories in the ARLN can detect new forms of antibiotic resistance, like mcr-1, and report these findings to CDC to inform response and prevention activities. Additionally, all state public health labs will have enhanced CRE testing capabilities.
• Timely antibiotic resistance data. CDC released the Antibiotic Resistance Patient Safety Atlas web app in 2016 that provides indicators for the types of resistance most common in individual states and regions. It allows users to look up antibiotic resistance patterns in HAIs by state and region. This expands on the public access to antibiotic resistance data. In 2015, CDC introduced NARMS Now: Human Data, an interactive tool that shows how antibiotic resistance has changed over the past 20 years for four bacteria transmitted commonly through food. In 2016, for the first time, NARMS Annual Human Isolates Surveillance Report includes human WGS data of resistant Salmonella infections.
• Antibiotic resistance research. In 2016, CDC awarded funds to support applied research at five academic medical centers as part of a patient safety effort known as Prevention Epicenters Program. The new funding more than doubles previous awards and expands and extends the Prevention Epicenters program to 2020. CDC also awarded funds for new approaches to combat antibiotic resistance. Research will include how microorganisms naturally present in the human body (referred to as a person’s microbiome) can be used to predict and prevent infections caused by antibiotic-resistant organisms. This research will work to identify effective public health approaches that protect people, their microbiomes, and the effectiveness of antibiotics.
• Global efforts. Under the Global Health Security Agenda, CDC is engaging 17 countries to support and measure progress toward strengthening laboratories and to develop action plans to establish or strengthen laboratory surveillance networks. To fight drug-resistant tuberculosis (TB)—now the leading infectious disease killer worldwide—CDC is developing innovative strategies to find, cure, and prevent TB, including multidrug-resistant TB, and working with highest burden countries of origin for TB among foreign-born U.S. residents to strengthen surveillance and laboratory systems. CDC is also working with partners from the Transatlantic Taskforce for Antimicrobial Resistance and the World Health Organization to develop a portal for rapid global communication of antibiotic resistance findings requiring international attention.

CDC continues to play a key role in supporting the National Strategy to Combat Antibiotic-Resistant Bacteria, which outlines ways to effectively track, detect, and slow antibiotic resistance. A new interactive map, expected for release in early 2017, shows CDC’s strategic investments in state and local health departments, laboratories, and university and healthcare partners, and describes nationwide activities toward combating antibiotic resistance. Moving forward, CDC continues to focus on steps to keep Americans safe from one of the most urgent threat of antibiotic resistant superbugs.

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CDC and physicians are making it easier to protect adolescents from cancer. Updated guidelines were released in 2016 recommending teens 11- to 12-years-old receive two doses of HPV vaccine at least six months apart rather than the previously recommended three doses to protect against cancers caused by human papillomavirus (HPV) infections.

• Decrease in HPV infections and HPV-associated cancers and disease. After 10 years of HPV vaccination in the United States, evidence suggests that HPV vaccination is making a significant impact on HPV infection and HPV-associated cancers and disease. Since the introduction of HPV vaccine, prevalence of HPV infection, genital warts, and cervical precancers has decreased in the United States. A study published earlier this year found a 64 percent drop in infections with the four HPV types targeted by the quadrivalent vaccine among teen girls (ages 14-19). A 2012 study found a 38 percent drop in genital warts among teen girls (ages 15-19). A study published earlier this year found a significant drop in high-grade cervical lesions detected through cervical cancer screening and cervical precancers diagnosed from biopsy specimens among teen girls (ages 15-19), decreasing by 8.3 percent and 14.4 percent per year, respectively.

In 2017, CDC will continue to enhance HPV disease prevention by improving vaccination coverage through public policy and clinical practice.

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America’s prescription drug overdose epidemic is affecting small towns and big cities alike. Drug-related overdose deaths have increased among people of both sexes, all races, and nearly all ages. This year, CDC issued the Guideline for Prescribing Opioids for Chronic Pain to reduce risk of opioid addiction and overdose. The Guideline provides careful consideration of risks and benefits of long-term opioid therapy, recommendations about appropriate prescribing of opioids, and effective non-opioid and non-pharmacologic pain management options. CDC is funding 44 states and Washington, D.C., through CDC’s Overdose Prevention in States efforts, which partners with and supports state health departments in implementing key prevention and surveillance activities addressing both prescription and illicit opioids.

• Enhanced surveillance funding. The program improves surveillance of opioid overdoses by increasing the timeliness of nonfatal and fatal opioid-involved overdose reporting, identifying associated risk factors with fatal overdoses, and disseminating surveillance findings to key stakeholders working to prevent opioid-involved overdoses. The 12 funded states are: Kentucky, Maine, Massachusetts, Missouri, New Hampshire, New Mexico, Ohio, Oklahoma, Pennsylvania, Rhode Island, West Virginia, and Wisconsin.
• Frontline funding. In 2016, 14 of the 29 Prevention for States programs received supplemental funding to support their work: California, Colorado, Indiana, Kentucky, New Mexico, New York, Ohio, Oregon Pennsylvania, Rhode Island, Tennessee, Utah, Washington, and Wisconsin.
• Investing in communities. The newly created Prescription Drug Overdose Data-Driven Prevention Initiative will award funds during the next three years to 13 states and the District of Columbia. These funds will help American communities develop opioid overdose prevention programs that work for them.

Activities in the selected states will include making prescription drug monitoring programs easier to use and access, supporting health system and insurer efforts to improve opioid use, and evaluating interventions to understand and scale up what works to prevent opioid overdose.

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As the CDC was winding down its historic Ebola response in March 2016, the Emergency Operations Center was already fighting Zika: one of the most complex outbreak responses in CDC history. These two outbreaks serve as stark reminders that keeping America safe means stopping – or better still, preventing – health threats everywhere.

In 2016, CDC made critical advances toward global health security. Some highlights:

• The global Joint External Evaluation (JEE) tool advances progress and accountability by identifying the most urgent gaps in public health systems around the world. To date, 40 countries have completed or are in the process of undergoing a Joint External Evaluation−a mechanism which, for the first time ever, objectively and transparently identifies gaps in global preparedness. More than 20 more are planned for the coming months.
• Hurricane Matthew. CDC’s Center for Global Health is leading public health efforts to support countries affected by Hurricane Matthew. This includes coordinating with the US Office of Foreign Disaster Assistance (OFDA), the CDC Haiti Country Office, and other governmental and humanitarian partners to support response efforts. CDC’s country office in Haiti and teams of public health responders from CDC Atlanta are focusing their efforts on assessing the public health impact of the storm and working with our Haitian partners to repair damaged public health systems.
• Labs for life. This innovative public-private partnership is transforming laboratory health care in developing countries around the world including an initial phase in Kenya, Mozambique, Ethiopia, and Uganda. The burden of HIV and TB in these four African countries is among the greatest in the world. CDC provides lab-specific expertise, such as training and technical support in diagnosing disease, monitoring patients, and training healthcare workers. In addition, CDC is strengthening labs in more than 50 countries around the world and has supported lab quality improvements in more than 1,000 labs worldwide.
• The CDC Global Rapid Response Team (Global RRT) surged to address a significant yellow fever outbreak in Angola and Democratic Republic of Congo. Global RRT is a highly trained and ever-ready multidisciplinary workforce with more than 50 CDC staff ready to deploy anywhere in the world. By its first-year anniversary, the Global RRT staff had supported 18 countries, spending 5,000 person-days in more than 140 responses to cholera, yellow fever, Ebola, measles, polio, Zika, mass gatherings and natural disasters.

Just as CDC works with state and local health departments, the agency also partners with other nations’ ministries of health to prevent disease and save lives. In 2017, CDC has committed to the milestones laid out in the Global Health Security Agenda.

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Powerful new ads telling the moving personal stories of Americans suffering from smoking-related illnesses were part of the 2016 Tips From Former Smokers™ campaign. The national tobacco education campaign is in its fifth year but evaluation of its impact shows it’s as effective now as in its first year, saving lives for less than $3,000 each.

• Adult cigarette smoking is down. According to the November 2016 MMWR, current cigarette smoking among U.S. adults declined from 20.9 percent (45.1 million) in 2005 to 15.1 percent (36.5 million) in 2015. Due to the Tips campaign and other interventions, there are now 10 million fewer smokers in the U.S. since 2009. Disparities in cigarette smoking remain among racial and ethnic population groups, according to the August 2016 MMWR.
• No decline in overall youth tobacco use. In the April 2016 MMWR, new data showed that overall tobacco use by middle and high school students has not changed since 2011. Three million middle and high school students were current users of e-cigarettes in 2015, up from 2.46 million in 2014. Most e-cigarettes contain nicotine, which causes addiction, may harm brain development, and could lead to continued tobacco product use among youth.
• Most U.S. adults believe pharmacies should not sell tobacco. Two-thirds of American adults believe pharmacies should not be allowed to sell tobacco products. As of January 2016, 134 municipalities in California and Massachusetts have enacted tobacco-free pharmacy laws. Preliminary data suggest that eliminating tobacco product sales in pharmacies does not hurt business.
• Secondhand smoke exposure. CDC researchers found about 34 percent of multi-unit housing residents who have adopted voluntary smoke-free home rules have recently been exposed to secondhand smoke that entered their living unit from nearby living units or shared areas.

In 2017, CDC will launch the next round of compelling and effective Tips From Former Smokers™ ads to help people quit and save lives.

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CDC’s investments in advanced molecular detection (AMD) are transforming pathogen characterization and detection in the U.S. public health system. In 2016, CDC employed AMD to sequence the DNA of pathogens (i.e., bacteria, viruses, parasites, and fungi) and plug that information into supercomputers to quickly detect molecular patterns that help us understand diseases and their spread.

• Identifying the source of a Legionnaires’ disease outbreak. In fall 2016, CDC supported a state public health laboratory’s investigation of a cooling tower-related outbreak of Legionnaires’ disease. The state public health laboratory performed whole genome sequencing analysis on clinical and environmental samples. CDC quickly compared these genomes using a database comprising hundreds of genomes of Legionella. This allowed the state to identify the cooling tower that needed to be remediated to control the outbreak. Legionnaires’ disease is on the rise; in recent years about 5,000 people were diagnosed and at least 20 outbreaks were reported in the United States. AMD technologies will improve the ability to quickly identify outbreak sources and prevent more disease.
• Two Listeria strains linked to facility. In March 2016, CDC along with public health officials in several states and the U.S. Food and Drug Administration, investigated Listeria in environmental and food samples from a Washington State company that produces frozen vegetables. Nine people were infected and three died. Investigators used the PulseNet system, the national subtyping network of public health and food regulatory agency laboratories coordinated by CDC, to identify illnesses that may have been part of this outbreak. At the end of the investigation 350 consumer products sold under 42 separate brands were recalled, as well as at least 100 other products prepared by other companies that contained recalled ingredients from the company. CDC estimates that 1 in 6 Americans — 48 million people — get sick from contaminated food each year. By expanding advanced molecular detection methods, we can get contaminated products off store shelves and save lives sooner.
• Mapping Zika strains. In January 2016, CDC investigators confirmed the presence of Zika virus in babies born with microcephaly and other poor pregnancy outcomes in Brazil. Within three weeks of receiving the first Zika virus-positive samples, CDC used AMD to rapidly develop, validate, and distribute a molecular diagnostic test protocol to identify Zika virus strains. Older laboratory methods would have required 3-4 months to develop a new diagnostic test protocol.

Moving forward, CDC is working to build AMD capacity in state and local public health laboratories to further speed detection and surveillance of infectious pathogens in the United States.

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