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On September 30, 2014, the Centers for Disease Control and Prevention (CDC) received a report of a laboratory-confirmed case of Ebola virus disease (Ebola) in a man who had traveled from Liberia to Dallas, Texas. Two nurses who cared for him were eventually confirmed as having Ebola. Three weeks later, a physician who had recently returned from West Africa to New York City developed symptoms and had laboratory confirmation of Ebola infection. These 4 cases placed an astounding burden of work on the state and local health departments involved and required the efforts of hundreds of health care workers.1–3 The economic impact was steep; Congress allocated more than $570 million to CDC for the US domestic Ebola response as part of a larger $5.4 billion appropriation for Ebola and health security.4 The 4 cases of Ebola illustrate how the interconnectedness of today’s world brings an increased risk for disease acquisition, both in the United States and abroad.
The United States has long recognized the risks posed by global infectious diseases and public health threats and has supported efforts to enhance global health security. In 2005, 196 countries, including all World Health Organization member states and the United States, signed the International Health Regulations and agreed to build their capacities to detect, assess, and report public health events.5 However, progress in achieving compliance has been slow. In 2014, the United States joined other nations, international organizations, and key global stakeholders to launch the Global Health Security Agenda (GHSA) to accelerate progress toward full implementation of the International Health Regulations.6 The GHSA now has more than 60 member countries. In 2014, Congress appropriated $1.2 billion to CDC to contain Ebola in West Africa and to support GHSA goals.4 To advance the GHSA, the US Department of Health and Human Services (HHS), working primarily through the Office of Global Affairs and CDC, has collaborated closely with US government agencies, government agencies of other nations, and external partners. CDC is a lead technical agency for the GHSA and works with governments and other partners in key countries to build surveillance and laboratory systems, train people in disease detection and response skills, and create emergency management capacities.7
CDC’s work in global health security provides health protection for the United States, but it also protects US economic interests. For example, by helping to stop disease outbreaks at their source, CDC’s programs help to safeguard the US export economy from disruptions to local, regional, and international markets and to national and state employment, trade, agriculture, travel, and tourism.8–10 One such program is CDC’s Field Epidemiology Training Program, which, since 1980, has trained more than 11 000 field epidemiologists, or “disease detectives,” around the world to recognize and stop disease outbreaks.11 Another program is CDC’s Global Disease Detection Program, which, since its founding in 2004, has established 10 centers that have identified new pathogens and built laboratory capacities around the world.8
CDC’s global health security work focuses primarily on countries with weaknesses in their health systems, because these countries are vulnerable to global disease threats that could adversely affect the health and economy of the United States at the national, state, and local levels. To help inform preparedness efforts in the United States and in partner countries, we review areas of global interconnectivity that make US states and localities vulnerable to the health and economic repercussions of global public health threats.
Travel Connections
More than 8 million people travel globally by airplane every day.12 Approximately 38.3 million people in the United States traveled overseas in 2017, of whom 4.8 million traveled for business.13 This rapid movement of people means that a communicable disease pathogen can be transported from a remote setting anywhere in the world to cities on 6 continents within 36 hours.14 For example, approximately 1700 cases of malaria are reported annually in the United States, mostly among returning travelers and immigrants.15 This global interconnectedness has important implications for health authorities in the United States who are responsible for treating and containing the spread of imported diseases.
Once a disease has been imported, it may be transmitted locally, as has occurred for Zika virus. Since 2015, more than 5700 cases of Zika virus have been reported in the continental United States, including 231 cases acquired through presumed local mosquito-borne transmission. More than 37 000 cases of Zika were reported in US territories during the same period, most of which resulted from local mosquito-borne transmission.16 The globally emerging invasive and multidrug-resistant fungus Candida auris provides another example. The fungus has rapidly gained a foothold in the United States and was isolated from 122 patients during a 2016-2017 outbreak.17 Other recent examples of imported pathogens with documented local transmission within the United States are West Nile virus, dengue, and chikungunya.18–20
Once local transmission has occurred and imported pathogens have been established, preventing and treating them can place additional burdens on local US jurisdictions. Examples of such pathogens include West Nile virus and multidrug-resistant tuberculosis. These imported diseases are costly. The estimated average cost of all hospitalized West Nile virus cases from 1999 through 2012 was more than $750 million, including long-term costs and loss of productivity.21 Similarly, 1 case of multidrug-resistant tuberculosis can cost nearly $300 000 for treatment, including loss of productivity.22
Infectious disease outbreaks have increased not only because of global interconnectivity, but also because of epidemiological, ecological, environmental, sociocultural, and economic factors.23–25 Most outbreaks since 1980 have been caused by bacteria, viruses, zoonotic diseases, and vector-transmitted diseases. An analysis of infectious diseases in 219 countries found substantial increases (controlled for surveillance, communications, and geography) in the number and diversity of outbreaks. Increases have occurred for diseases with human and zoonotic hosts, for vector-borne and non–vector-borne modes of transmission, and across pathogen taxonomies.25
Economic Implications of Rapid Global Disease Spread
Aside from the human toll measured in morbidity, mortality, suffering, and health costs, outbreaks of imported diseases and public health emergencies can disrupt local and international markets, creating economic instability in the United States and globally.26,27 Outbreaks can affect the large export economy of the United States. Total goods and services exports from all US states and territories exceeded $2.21 trillion in 2016, including $1.45 trillion for goods alone (Table), and involved more than 295 000 US-based companies.28 More than 10.7 million US jobs support these exported US goods and services, including 6.3 million jobs for goods alone (Figure), highlighting the important role of exports to the US economy and workforce.29 Jobs may be jeopardized when global outbreaks lead to a decrease in demand for exported US goods and services, disrupting the export economy.26
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Table. Annual revenue from exported goods and number of export-supporting jobs, by state, United States, 2016a
Figure. Number of jobs supported by global exported goods, by state, United States, 2016. Data source: Hall.32
The effect of an outbreak on exports often depends on its size, scope, and location. For example, modeling of a hypothetical infectious disease outbreak in Asia suggested that, as the outbreak spread from 1 country to 9 countries, the impact on US exports could grow from $13 million to $41 billion, placing 1500 to more than 1.3 million export-related US jobs at risk.26 Impacts in the United States at the state level depend on the amount of revenue a state generates from exports and the number of jobs supported by goods in a given state. Although export revenue and the number of jobs and companies supporting exports vary by state, jobs in any US state may be jeopardized when a global disease outbreak disrupts economies and could lead to a decrease in demand for exported US goods and services. All US states have jobs supported by exports (Table). Texas has been the lead state exporter since 2010, with $231.3 billion in goods exported annually and more than 900 000 export-supported jobs from approximately 30 000 businesses; Texas is followed by California and Washington State.30–32
Global disease outbreaks and subsequent disruptions can also affect imports to the United States, including raw materials used for exports. Difficulties with the international supply chain can also inhibit the import of critical supplies (eg, medical equipment, pharmaceutical commodities) from reaching US hospitals and public health departments. In 2017, the United States imported $89.8 billion in medicinal and pharmaceutical products; decreased availability of these items caused by public health crises in source countries could affect clinical care across the United States.33–35
The US Poultry Industry
One US industry in which global disease transmission may have a large effect is poultry production. The United States is the world’s largest producer and second-largest exporter of poultry meat, as well as a major egg producer and exporter.36 The United States, led by Georgia, Alabama, Arkansas, North Carolina, and Mississippi, produced more than 8.7 billion broiler chickens in 2016, valued at $25.9 billion. In 2016, Iowa, Ohio, Indiana, Pennsylvania, and Texas led US egg production, which totaled 102 billion eggs, worth $6.5 billion. In addition, in 2016, the United States produced more than 244 million turkeys valued at $6.2 billion; 58% of turkeys were raised in the top 5 turkey-producing states (Minnesota, North Carolina, Arkansas, Indiana, and Missouri).37 In 2016, the overall poultry industry in the United States provided 1.6 million jobs, $96 billion in wages, $441.2 billion in economic activity, and $34 billion in government revenue.38
The US poultry industry is particularly vulnerable to disease threats from outside the United States. During the 2014-2015 avian influenza outbreak in the United States, more than 48 million chickens, turkeys, and other poultry were euthanized to contain the highly pathogenic H5 avian influenza thought to have been introduced by migrating wild birds from Asia.39,40 Turkey farms in Minnesota and egg-laying hen farms in Iowa were hardest hit. After this outbreak, more than 50 countries imposed full or partial bans on US poultry exports, resulting in an estimated loss of $1.6 billion from euthanized turkeys and egg-laying hens. Other sectors of the economy (eg, feed and trucking) also lost business as a result of the bans. The impact of the outbreak on the entire US economy was estimated at $3.3 billion during 2014-2015.39 Public health efforts that detect and contain avian influenza at its source are particularly important in states that produce substantial numbers of broiler chickens that are raised for meat production: Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Maryland, Minnesota, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Wisconsin.41
US Tourism
Another example of a US industry that is susceptible to global disease threats is tourism. The tourism industry is large: 77.5 million international visitors traveled to the United States in 2015, and more than 829.3 million enplanements occur annually across 506 commercial US airports.42,43 Approximately 7.6 million jobs are supported by the travel and tourism industry, which employs 1 of 18 persons aged 16 or older in the United States.44 Global outbreaks of disease can adversely affect tourism. For example, cases of Zika virus in Florida and Texas resulted in a downturn of revenue for local businesses in 2016.45 Tourism effects can spread quickly across the globe. For example, the SARS (severe acute respiratory syndrome) outbreak in 2003 disrupted the tourism, service, aviation, and restaurant industries, resulting in a $40 billion cumulative economic loss globally.46 Travel hubs in the United States may expose large populations of domestic and international travelers to infectious diseases. In part to help reduce such threats to the US tourism industry, CDC Quarantine Stations are located at 20 US ports of entry and collaborate with partners to facilitate health screenings at more than 300 US ports of entry.47
Preparedness in the United States at State and Local Levels
The answer to global disease threats is preparedness at several levels—global, national, state, and local. Preparedness in the United States at the state and local level can be tracked with the National Health Security Preparedness Index.48 This index has been used since 2013 to summarize “the nation’s progress in preparing for, responding to, and recovering from the health consequences of disasters, disease outbreaks, and other large-scale emergencies” for all 50 US states, the District of Columbia, and the nation as a whole.49 The index includes 140 measures from more than 60 sources and aggregates data from national household surveys, medical records, safety inspection results, and surveys of health agencies and facilities. Measures are grouped into 6 broad domains: health security surveillance, community planning and engagement, information and incident management, health care delivery, countermeasure management, and environmental and occupational health. Each domain is rated on a scale from 0 to 10, with 10 indicating the highest level of preparedness. The index indicates that domestic preparedness in the United States has been improving steadily since 2013, reaching 7.1 of 10 in 2017—a percentage increase of 2.9% from 2016 (score of 6.9) and an increase of 10.9% from 2013 (score of 6.4).49 However, no state has yet achieved a score of 9 or higher, which is considered a strong health security score. Inequalities in protection are clear: a 25% difference in index scores exists between the highest-scoring state (Maryland, 8.0) and the lowest-scoring states (Alaska and Nevada, 6.4).50 In addition, the percentage of people in the United States living in states with below-average scores has steadily increased from 20% in 2014 to 43% in 2017. Currently, 30% more people in the United States live in regions with below-average scores than in regions with above-average scores, and the remainder live in regions with average scores.49
Resources to improve state preparedness are limited. To contain the spread of disease during emergencies, states often must divert resources from other disease-control activities.10,14 For example, until the US Congress appropriated supplemental funding for Zika virus in 2016, at-risk states were obliged to redirect substantial portions of their preparedness funds to conduct mosquito studies, develop prevention messages, establish vector-control efforts, and provide personal protection.51,52 As a result, states were less able to respond to other outbreaks or natural disasters. If global threats can be identified and contained before they reach the United States, the economic burden on state and local health departments will be reduced. However, global capabilities, although improving, are fragile, and containment cannot always be achieved in a timely manner. As such, state and local jurisdictions are vulnerable to the effects of global disease threats and must continue to invest in preparedness.
Preparedness at the National and International Levels
CDC has long been charged with protecting the United States against the importation of infectious diseases. The 1965 Immigration and Nationality Act and the 1944 Public Health Service Act authorize HHS and CDC to design and monitor the required medical screening examination for immigrants and refugees and to define inadmissible conditions, such as tuberculosis and other diseases of public health importance.53,54 Screening and treatment of these diseases are completed overseas by 1 of more than 600 panel physicians in 159 countries before the examinee is permitted to enter the United States.55
In addition to this screening role, the US government prepares strategies and other documents to guide federal planning and response to global disease threats. The president’s US National Security Strategy, which was released in December 2017, states that combatting bio-threats and pandemics is important to prevent loss of life, preserve economic productivity, and maintain confidence in institutions. It emphasizes that biological threats must be contained at their source, which requires biomedical innovation, stronger emergency response systems, and effective partnerships with other countries.56
In concert with the US National Security Strategy is CDC’s mission for global health security. To reduce the risk and impact of outbreaks globally, CDC works through extensive collaborations with international partners to prevent, detect, respond to, and contain health threats at their sources. This global work complements the domestic work of state, territorial, and local health departments to prevent outbreaks in their jurisdictions. CDC also works closely with state and local health departments to prepare for and respond to global outbreaks of disease. For example, during the 2014-2016 Ebola response, CDC worked with the Council of State and Territorial Epidemiologists to recruit more than 30 volunteers who joined CDC responders in West Africa.57 Other professional organizations, such as the Association of State and Territorial Health Officials and the National Association of County and City Health Officials, were instrumental in promoting domestic preparedness and supporting the global Ebola response.58 During responses to Ebola and Zika viruses, these public health partners further assisted CDC by aligning their risk communications with CDC and augmenting CDC efforts to support states and localities with effective and timely interventions. In addition, a range of US government agencies, interagency groups, and public health departments assisted with global preparedness and response work.58–62 In the future, technical exchanges and partnerships could be important strategies for supporting efforts in other countries. Expertise that has developed through state and local preparedness work could be a valuable resource for global capacity-building efforts.
Ultimately, to be successful, global health security work must translate into functional capacities in countries around the world to identify and contain outbreaks before they spread across borders. CDC’s programs and technical assistance have already supported numerous advances in capabilities in partner countries. Improved capabilities include surveillance at the subnational level, trained disease detectives, laboratory specimen transport systems, expanded laboratory testing capabilities, biosecurity measures, and emergency operations centers.9 These new capabilities have already contributed to the rapid containment of several recent outbreaks, including meningitis in Liberia, cholera in Cameroon, and Marburg virus disease in Uganda.63–65
Going forward, momentum for global health security work will depend on success in containing disease threats and commitments from key partners and countries. In the United States, the Blue Ribbon Study Panel on Biodefense, the Institute of Medicine, and the National Academies of Sciences, Engineering, and Medicine all call for enhanced global health security work, reflecting global consensus on the importance of continued progress.66–68 HHS Secretary Alex Azar recently wrote, “We are committed to investing in infectious disease preparedness at home and across the globe, including through the Global Health Security Agenda, and these tasks must be the focus of our global health work.”69 CDC’s work to fulfill this global health security mandate depends on partnerships at all levels, including with state and local jurisdictions. In our increasingly interconnected world, continued advancement of global health security can help protect people in the United States and around the world from the devastating health and economic consequences of infectious disease threats and public health emergencies.
Authors’ Note
The views represented in this article are those of the authors and do not represent the official position of the Centers for Disease Control and Prevention.
Acknowledgments
The authors appreciate James S. Blumenstock, Chief of Health Security, Association of State and Territorial Health Officials, for providing insightful review and suggestions.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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