Detailed Information on the
CDC: Sexually Transmitted Diseases and Tuberculosis Assessment

The program will track performance on the new long-term and annual performance measures this year and will also develop a measure to track its efficiency.

Over the next few years, the program will support evaluations of sufficient scope and quality to improve program performance.

The program will work to better target resources to directly address the program??s purpose.

Hold Federal managers and program partners accountable for cost schedule and performance results.

Measure: The incidence of pelvic inflammatory disease as measured by initial visits to physicians by women ages 15 - 44

Explanation:Pelvic inflammatory disease is a serious consequence of chlamydia and indicator of chlamydia prevalence.

Measure: Incidence of syphilis, as measured by number of cases per 100,000.

Explanation:The program's goal is to eliminate syphilis by 2008.

Measure: Number of persons per 100,000 population with TB among US-born persons, foreign-born persons, and overall.

Explanation:The program's ultimate aim is to eliminate TB in the US, as defined by less than 1 case per 1,000,000. This measure is the interim TB rate per 100,000 persons.

Measure: Prevalence of chlamydia in women aged 25 or younger in high risk females.

Explanation:The program's goal is to reduce the prevalence of chlamydia, especially among high risk women under age 25.

Measure: Incidence of primary and secondary syphilis, as measured by number of cases per 100,000.

Explanation:The program's goal is to eliminate syphilis by 2008. *In FY 2002, the incidence of P&S syphilis in men was 3.8/100,000 (initial FY 2002 baseline). However, due to an outbreak of syphilis among men who have sex with men that occurred after 2002, CDC will report a new baseline for FY 2006. The overall goal for 2010 is a decrease in incidence to 2.2/100,000 as compared to the FY 2006 baseline. The FY 2007 target of 2.5 is an average of targets for male and female incidence: M - 4.5/100,000; F - 0.53/100,000.

Measure: An efficiency measure is under development.

Explanation:An efficiency measure has been developed for TB and will be presented to OMB for approval.

Measure: Reduce the amount of time it takes to award grantees' unobligated funds by meeting the Procurement and Grant Office's (PGO) key performance targets without increased funding.

Explanation:

Is the program purpose clear?

Explanation: The Sexually Transmitted Diseases (STD) activity at the Centers for Disease Control and Prevention within the Department of Health and Human Services has a clear purpose. The purpose is to control STD disease, transmission, and the consequences of disease. Focuses within that purpose include preventing infertility and reproductive tract cancer associated with STDs and prevention of disease facilitation of HIV. While HIV is an STD, HIV-specific activities are the responsibility of the HIV/AIDS program at CDC. The purpose of the tuberculosis (TB) activity at CDC is to promote health and quality of life by preventing, controlling, and eventually eliminating TB from the United States and helping to control TB worldwide by collaborating with other nations and partners.

Evidence: The STD and TB programs are in the National Center for HIV, STD and TB Prevention at the Centers for Disease Control and Prevention. The program is authorized in sections 317 and 318 of the Public Health Service Act. Of the 160 TB staff, 17 work on international issues. A division of TB control was first established in the Public Health Service in 1944 and moved to CDC in 1960. The program purpose is confirmed in program mission statements.

Does the program address a specific and existing problem, interest or need?

Explanation: STDs are a collection of 25 infectious agents transmitted primarily through sexual activity. Five of the top 10 most frequently reported infectious diseases in the U.S. are STDs. If untreated, syphilis in pregnant women can lead to severe adverse outcomes such as spontaneous abortions and stillbirths, up to 40% of congenital cases result in fetal death; chlamydia leads to pelvic inflammatory disease (PID) 20%-50% of the time; gonhorrhea leads to PID 10%-40% of the time. PID causes infertility 20% of the time, ectopic pregnancy 9% of the time and chronic pelvic pain 18% of the time. Neonatal pneumonia or eye infections occur 60%-70% of the time in infants born to untreated mothers and there is a two to five fold increased risk of HIV infection. Median chlamydia screening coverage for sexually active females aged 15-19 is 60%.The syphilis rate among African Americans was 8 times greater than among whites; more than double among Hispanics. In 2003, there were over 14,000 cases of active TB in the U.S., 29% were in black, non-hispanic persons, 53.3% are foreign born.

Evidence: Additional evidence from CDC data and the Hidden Epidemic IOM report includes more than 65 million people in the US live with an incurable STD. There were an estimated 18.9 million new cases of STDs in 2000, 9.1 million among persons aged 15-24. In 2002, cases reported to CDC included 834,555 chlamydial infections, 351,852 cases of gonorrhea, 6,682 cases of primary and secondary syphilis and 412 cases of congenital syphilis. In 1998, over 50% of infectious syphilis cases were reported in 28 counties. With over 50% of TB cases from foreign born persons (especially from Mexico, the Phillipines and Vietnam), the highest rates are in the south, along the US Mexico border, and in Hawaii, Alaska, Maryland, Indiana, New York and New Jersey. Two million people per year die of TB worldwide. HIV is the leading risk factor for progressing from latent to active TB disease and pulmonary TB is an AIDS-defining condition.

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: While states and the federal government share costs of these activities, the program is designed so that it is not redundant of other Federal, state, local or private efforts. Other Federal agencies serving a different role in TB include OSHA, Justice, State, Veterans Affairs, NIH, HRSA, USAID. The program funds state health departments and other entities, supports laboratory and other research. States and local entitites do combine federal funding with state and local funding, such as to support the activities of public STD clinics. The program's grant agreements with states gaurd against supplantation of funds by monitoring state expenditures. The awards do not require matching funds. The majority of funds to states pay to support staffing. The research work differs from that supported by the National Institutes of Health by focusing more on applied research, such as in the area of diagnostics. The program also works with the Federal TB Task Force, which works to define agency roles and avoid duplication of effort.

Evidence: Data on state spending on TB and STDs are not available. Public STD clinics receive funding from the program, Title X, states and local entities. According to a needs assessment report of the National Coalition of STD Directors by the Policy Resource Group, 43% of sampled STD state programs are combined with HIV; Federal public health advisors made up between 5%-9% of total STD staff in 2000, down from 7%-14% in 1995. A non-representative sample from the report indicates a mean Federal funding for STD programs of $2 million in 2000 and state and local funding for these programs of $2.2 million. Of the roughly 4,000 STD clinics, 1,800 provide more than one day per week of service. Since the 1960s, the program has supported clinical trials for TB, though NIH can include TB related research in that program's HIV/AIDS clinical trials. The program has standing meetings for the TB labs to avoid duplication of research. The Federal TB Task Force response to the IOM report provides an example of agency roles.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: There is no direct evidence that a different mechanism, such as regulatory action, would be more effective in meeting the program purpose. The STD program provides funds to states through an umbrella Comprehensive STD Prevention Systems grant. At roughly $101 million, the comprehensive grant goes to every state and includes $30 million for an infertility subgrant to every state and $37 million for a targeted syphilis grant to specific states. The syphilis grant targets cities and counties with high morbidity. The TB grant goes to every state. Within TB, there are cost effectiveness studies on directly observed therapy, that is in part carried out by states through federal support. Both the STD and TB grants outline specific activities and guidance to grant recipients based on best practices. Program staff also support and engage in considerable research activity in both areas. As is described in the following question, there are weaknesses with the targeting of resources.

Evidence: Of the program's $168 million current STD budget, $101 million supports general STD work, $30 million supports infertility targeted activities, and $37 million supports targeted syphilis elimination efforts. The program supports 65 STD projects, including 50 states, seven cities and eight territories. In addition, the program supports national leadership, surveillance, training, and outbreak response at the federal level. The program recently reorganized the laboratory components from the National Center for Infectious Diseases to NCHSTP. The rationale for the transfer was to better align management and funding with the offices directing the mission of the laboratories and holding the majority of subject matter expertise. The program supports 68 health departments for TB control and surveillance with $98 million. The program also supports three model TB centers, supports clinical and epidemiologic research and works along the US Mexico border. Roughly 65% of STD basic grants pay for personnel for surveillance, partner notification and other activities.

Is the program effectively targeted, so that resources will reach intended beneficiaries and/or otherwise address the program's purpose directly?

Explanation: The program distributes funding to states through the core grants based on historical distributions, which were based on morbidity and other factors, and does not currently target the majority of funds based on current need. TB funding per case ranges from $2K to $14K by area. As is discussed more thoroughly below, TB is proposing to redistribute 20 percent of financial assistance in FY 2005 based on five-year average reported cases and case characteristics that complicate treatment, such as drug resistance, and binational cases and will examine increasing the proportion of targeted funds in subsequent years. The program directs syphilis-targeted funding to populations with increased risk of syphilis and requires states to contract 30% of these targeted funds to community organizations that serve the most affected populations. The program targets the infertility subgrant to chlamydia screening and treatment in Title X family planning programs and distributes these funds using a population based formula tied to the number of females aged 15-34 and low income females aged 10-44.

Evidence: The program's syphilis elimination strategies target high burden areas through enhanced surveillance, partnerships, response, clinical and lab services and prevention activities, but funding overall has not been similarly targeted. The program is considering historical funding levels, current morbidity, and factors that complicate the care of patients with TB or add to the workload of the recipient program, including binational cases for targeting resources. The program has made significant advances in targeting syphillis in heterosexual and especially minority communities and is now turning to address increased rates of syphilis in urban homosexual males. The IOM noted Federal TB funding should be structure to provide maximum flexibility and efficiency. Directly observed therapy has been shown effective in reducing TB and the program promoted targeted TB testing through MMWR and does target some efforts along the US Mexico border and among African American communities in the Southeastern US. Patients of public STD clinics tend to be young, minority, low-income, and uninsured.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The program has adopted specific long-term performance measures that focus on outcomes. The program adopted two measures for STD activites, one in pelvic inflammatory disease and one in syphilis, and one for TB elimination. The program has had outcome oriented annual goals in GPRA plans and reports and in a 1999 elimination report, the program set a national goal of 1,000 or fewer cases of syphilis and 90% of US counties syphilis free by 2005. The program has adopted the new long-term measures in part because they are consistent with the program's GPRA measures and responsive to the Healthy People 2010 objectives for STDs.

Evidence: The program's long-term measures for STD are reducing the incidence of pelvic inflammatory disease as measured by the initial physician visits for PID by 15% by 2006; and eliminating syphilis by 2008. The program's long-term measure for TB is progress towards elimination in the United States by achieving an interim TB rate of 1 case per 100,000 population in U.S.-born persons, 20 cases per 100,000 population in foreign-born persons residing in the United States, and 3 per 100,000 cases overall, by 2010. The incidence of PID is principally evaluated by the number of initial physician visits made by women 15-44 years of age for pelvic inflammatory disease, as measured by the National Disease and Therapeutic Index. There were 197,000 initial physician visits for PID in 2002. TB elimination is defined as less than 1 case per 1,000,000 population.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program has adopted associated targets that are ambitious and a baseline from which to measure progress.

Evidence: The targets for STD are to reduce visits for PID by 15% by 2006 and reduce syphilis to a rate of 2.2 cases per 100,000 in 2010 from a current baseline of 2.4 cases in 2002 and a projected peak of 2.5 cases by 2006. The target for TB is to achieve 3 cases of overall TB per 100,000 and 20 cases of foreign born per 100,000 by 2010.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The program has adopted annual measurs that are focused on outcomes and that contribute to the long-term objectives of the program. The program will need to continue work on developing an efficiency measure.

Evidence: The annual measure for the goal of reducing PID is the prevalence of chlamydia among women under age 25 who are high risk. The annual measure for syphilis elimination for 2006 is 2.5 cases per 100,000. The annual measure for TB is to reduce TB among the foreign born, US-born and total US population.

Does the program have baselines and ambitious targets for its annual measures?

Explanation: The program has adopted associated targets that are ambitious and a baseline from which to measure progress.

Evidence: The baseline for chlamydia diagnosis among high risk females is 10.1% in 2002 and the target is 9.3% by 2006. The current baseline for syphilis elimination is 2.4 per 100,000 in 2002 and the target is 2.5 by 2006. The baseline for TB cases among foreign born is 23.1, among US born is 2.9 and among total US population is 5.2, the targets respectively for 2006 are 21.61, 1.60, and 3.97.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: Program managers take steps to ensure cooperative agreement partners support the overall goals of the program and report on their performance. Partners identify objectives and goals that contribute to the program's overall objectives and report on them on an annual basis and at the end of the five year project period. The program's memoranda of understanding and inter-agency agreements are used to ensure the commitment of partners to the program's objectives. The program's awards include language specifying grant activities will align with the program's performance goals. Partners are to provide data to reflect performance as it relates to the objectives of the program. The awards include guidance on measures that are specific, measurable, ambitious and relevant. The program also maintains a comprehensive surveillance system with state-specific data and enters into specific inter agency agreements with federal partners that tie to the purpose of the program.

Evidence: Evidence includes the cooperative agreement announcement for FY 2004 for Comprehensive STD Prevention Systems, Prevention of STD-related Infertility, and Syphilis Elimination. Examples of measures include the percentage of females admitted to large juvenile detention facilities tested for chlamydia, proportion of syphilis cases interviewed within a certain time period, number of contacts tested and treated and the proportion of providers delivering care for HIV positive individuals that have written protocols for screening those clients for syphilis. The program held external consultants meetings on genital HPV in December 1999 and on future directions to control gonorreah in October 2001 that were broadly representative and produced specific recommendations. An example of an interagency agreement includes with the Indian Health Service on STD prevention and control among American Indian and Alaska Native populations.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: The program has not had regular evaluations or targeted evaluations as needed to fill gaps in performance information, including by GAO or the HHS Inspector General. The program has supported some external evaluations on select issues and has published numerous research findings related to the effectiveness of specific interventions. A comprehensive IOM report and Congressional report from the Office of Technology Assessments provided information on many facets of the disease, but were not comprehensive evaluations of the program. GAO has reviewed the nation's progress in eliminating TB (01-82). The Advisory Committee for the Elimination of TB is appointed by the Secretary and provides objective assessments on the progress of TB elimination through meetings three times a year. Planned evaluations include a Batelle review of the faculty expansion program to promote STD training in medical schools, an evaluation of STD services in large HIV care clinics among men who have sex with men, and an ongoing report by LTD Associates on syphilis elimination.

Evidence: Evaluations were conducted by Batelle on STD clinics in 1990 and local-level syphilis prevention in 1997, the Institute of Medicine on confronting STDs in 1997 and the Alliance of Community Health Plans on use of CDC's STD guidelines in 1998. Members of the TB advisory committee that are grantees recuse themselves on discussions related to grant awards. GAO has cited the group as a model advisory committee. The committee is to provide direct feedback on program progress. Sources of data include NHANES and National Disease and Therapeutic Index (herpes simplex type two), the National Survey of Family Growth (PID diagnoses/infertility) and National Hospital Discharge Survey (PID hospitalizations). According to the National Coalition of STD Directors, Policy Resource Group, most state STD programs need technical assistance for evaluations, 87% want examples. CDC research in areas such as syphilis partner notification, recommendations in managed care, community based screening and treatment guide the program but are not evaluations as outlined in the guidance.

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: While the program has made some progress in this area, it has not yet met the criteria specified for this question to show resource allocation decisions are made in order to accomplish specific targeted performance levels and the effects of funding on results. The program is basing program spending plans based on where there is burden and opportunity for the greatest impact. Recently budget initiatives have not been as frequently initiated at the program level and have not been built to achieve a specific level of performance.

Evidence: Evidence includes the GPRA plans and reports and annual Congressional Justifications and budget documents provided to OMB. Additional evidence includes program documents used to establish annual spending plans.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The remaining deficiencies included in this area are budget and performance integration and evaluations. The program is supporting new evaluations, including a project by Battelle to determine whether the CDC-funded Faculty Expansion Program is meeting its objectives. As noted above and explained in further detail in evidence, the program is adjusting the funding formula for TB. The program is also serving as a pilot for the agency for measuring marginal cost of STD reduction, which may help move the program and the agency toward a more meaningful integration of budget and performance information by helping the program anticipate changes in outcome associated with changes in funding level. The agency's Future's Initiative can improve strategic planning and is focused on orientating the agency toward having a measurable impact. The program has reacted to the IOM report on STDs by facilitating a national partnership group to provide leadership and revising grantee guidance. As described below, the program is also working with Cap Gemini Ernst and Young to improve program processes.

Evidence: Assuming a level appropriation in FY 2005, a TB grantee will receive 80% of their FY 2004 funding (excluding direct assistance, laboratory, supplemental funding). The remaining 20% will be re-distributed based on a five year average of TB morbidity and the number of TB cases reported in their jurisdictions with weighted factors. Factors include: 1) Number of incident cases, 40%; 2) Number of US-born Minority cases, 15%; 3) Number of Foreign-born cases, 15%; 4) Number of A/B1/B2 notifications, 10%; 5) Number of Homeless cases, 5%; 6) Number of MDR-TB cases, 5%; 7) Number of Substance Abuse cases, 5%; 8) Number of HIV/TB cases, 5%. In FY 2008, another re-distribution will be implemented. A program will receive 65% of their FY 2007 funding for financial assistance and the remaining 35% will be re-distributed to programs based on an updated five year average of TB morbidity and these eight factors. Programs receiving less than $220,000 would continue to be funded at FY 2004 levels. The program considers this level to be a minimal infrastructure needed for TB surveillance and to respond an occasional report of TB.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: The program collects performance information and uses it to change program direction and guidelines. The program could improve further in using performance information to make resource decisions, despite determining that it is restricted in its ability to withhold funds for poor performance. The program makes recommendations to grantees following a site visit. If increases in disease are detected, the program will send rapid response teams or Epidemic Intelligence Service officers. Considerable data are collected in epi-aid trip reports and used to help grantees make improvements. The program has used an IOM report on STD to develop new program guidelines and commissioned an IOM report on TB elimination and devised a process for responding to the recommendations, and developed a Federal TB Task Force plan in response to the IOM report. The program also uses feedback from the federal TB taskforce to guide strategic planning. The program does set aside a small amount of TB funding at the beginning of the year to allocate to high performing programs.

Evidence: The program responded to TB prevalence data and information about the difficulty of tracking cases along the US Mexico border by developing and issuing binational health cards. The program responded to a study of adherence to CDC STD treatment guidelines in two managed care organizations by highlighting potential areas of improvement and recommending new areas of research. Examples of program guidance includes treatment guidelines published in MMWR, such as April 30, 2004 revised recommendations for gonorrhea treatment, and "Program Operations: Guidelines for STD Prevention," CDC. The program will also support an analysis of the program's syphilis elimination assessment reports to develop a guidance document. Grantees do not yet report on a set of performance measures, but the FY 2004 announcements include this requirement. For a state example, in Mississippi, the program has responded to challenges in completing treatment for latent TB infection by conducting focus groups and has used this information to try new approaches.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: Accountability for cost, schedule and specific outputs is established through performance appraisals, but there is not currently a consistent method of accountability for program results. Senior managers have some elements of accountability built into performance evaluation systems, including for the Commissioned Corps, and employees now incorporate one or more general performance measures from the agency or department level into their workplans. These measures may not be specific or traceable to the employee's position. State awards technically can be reduced for failed performance, but this action is seldom, if ever, taken. The program has restricted research projects and awards to a national prevention training center for failure to perform. The program has restricted two non-performing TB cooperative agreement sites and de-funded three non-performing TB contract sites in the last five years. State assignees are evaluated by supervisors in the field and headquarters.

Evidence: Examples of accountability of grantees include the CSPS draft program announcement and correspondence between the program and select grantees regarding steps taken for faults in performance, including restrictions on funds. STD project officers are responsible for knowing fiscal matters that impact the program and are accountable for grantee use of CDC guidelines, policies and strategies. If grantees do not achieve the targets they established, CDC works with the grantee to identify and remove barriers through technical assistance and may ultimately place conditions or restrictions on awards. The 2005 TB cooperative agreement award will measure state outcomes against seven indicators of progress that include increases in appropriate treatment, evaluation and treatment of immigrants and refugees and decreases in case rates among African Americans.

Are funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: The program obligates virtually all of the funds in its ceiling and monitors how funds are being used through operations and spending plans. Methods of tracking intended use include the Grants Management Information System and interim financial status reports from grantees.

Evidence: For FY 2004, CDC will close out September 1 and the program will complete its closing ten to 15 days before then. STD program grantees can redirect up to 10 percent of funds within the program.

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The agency has numerous procedures in place to improve the efficiency of program execution. At the program level, the program could adopt more systematized procedures to improve efficiency of federal operations, but has a number of actions underway. The program is funding a Cap Gemini Ernst and Young business process management model to develop STD prevention processes that state and local health departments can adopt. In 2004, the program will reassess the functions in the office of the director to determine whether support staff can be reassigned to support front-line activities by consolidating secretarial functions and reviewing outsourcing options. The program reviewed its desk top publishing and developed a resource allocation software program to help programs make the most out of resources for chlamydia screening. The program holds management meetings to avoid duplication of TB research. At the center level, the program has automated time and attendance and travel.

Evidence: The agency consolidated information technology services and is consolidating budget execution, travel processing, training and graphics and has delayed to no more than four management levels. The agency now has a supervisory ratio of one to ten, up from one to seven at the end of FY 2002. The agency is conducting competitive sourcing studies. The agency has used FedBizOpps to post all contracts electronically. The agency is reviewing migration to two enterprise grant management systems. The Cap Gemini Ernst and Young proposal was submitted in July 2003. The 18 month review is focused on the surveillance systems used by state and local programs and will provide feedback on case management, performance monitoring, training and policy development and will help state and local grantees automate STD prevention activities. The program's STD structure was simplified in 2003 and the program converted multiple supervisory positions to team leads.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The program collaborates with the Department of Veterans Affairs on TB and has begun to discuss possible distribution of a vaccine for HPV with the Advisory Committee on Immunization Practices. The program works with national organizations on STD efforts and collaborated with other federal and non-federal partners in developing a national plan for syphilis elimination and recommendations for surveillance of syphilis. The program collaborates in TB surveillance and works with the federal TB task force and internationally with WHO, the US Agency for International Development and offices within CDC. The program holds interagency agreements in areas of common interest with other entities in the Department of Health and Human Services. The program collaborates with other CDC offices, such as on HPV and gonorrhea, and with external researchers on publications.

Evidence: Evidence includes interagency agreements, publications, and funding awards. Examples of HHS interagency agreements include the Office of Population Affairs, Health Resources and Services Administration, Indian Health Service and the Substance Abuse and Mental Health Services Administration. Examples of more external collaborations include the National Coalition of STD Directors, National Conference of State Legislators and National Black Caucus of State Legislators to reach state legislators and STD program directors. The program also collaborates with the National Committee for Quality Assurance to add a chlamydia screening measure to the Health Plan Employer Data and Information Set and with the US Preventive Services Task Force to review chlamydia screening recommendations. An example of an interagency agreement is with SAMHSA on a cross training collaboration targeting disease intervention specialists and substance abuse treatment staff that began in FY 2001.

Does the program use strong financial management practices?

Explanation: An independent auditor's report in Section IV of the FY 2003 HHS Performance and Accountability Report concludes the CDC/ATSDR central financial system lacks the ability to generate financial statements, trian balance and financial statements need to be created offline, which is manually intensive, inefficient and increases the risk of error. The FY 2002 report noted reportable conditions relating to information systems; the internal controls over preparation, analysis and monitoring of financial information, including manually intensive procedures; reimbursable agreements; and grants accounting and oversight. None of the reportable conditions are considered material internal control weaknesses. CDC automated reimbursable billings, enhanced year end closing transactions and implemented a new indirect cost methodology. CDC is also addressing staffing needs, including core accounting competencies, professional staff recruitment, financial systems, training and customer service. The program uses the Integrated Resource Information System to adminster and track funding.

Evidence: Evidence includes the FY 2002 Chief Financial Officers annual report, including summary of reportable conditions, summary documents on end of year balances, IRIS reports. Four areas of findings were also documented the prior year. CDC has received five consecutive unqualified opinions on the agency's financial statements. Additional data include that CDC issued 64 duplicate or erroneous payments in FY 2002, or 0.042% of all payments and has a 97% compliance rate for prompt payments.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: The agency has taken numerous steps to improve the financial management system and oversight of resources. The Department expects the financial system used by CDC to be significantly enhanced by the end of FY 2005. The agency is extending the incorporation of performance measures into employee evaluations and work contracts. The agency is also putting considerable effort into setting priorities and reorganizing operations through the Future's Initiative. The initiative has as one of the areas of focus to improve CDC's business practices. The program is developing a set of performance measures for grantees to report on beginning in FY 2005. In response to IOM recommendations, the program reorganized TB activities. The program is taking important steps to introduce more competition and targeting into state awards. While difficult, this process has the potential to improve the distribution of funds for the greatest national impact.

Evidence: Management changes at the agency level were also documented in a January 2004 GAO report (04-219). The FY 2003 PAR cites improvements in preparing financial statements. The new announcement for FY 2005 with performance measures will be released in June of this year with a September application deadline and January 2005 award. Further collaboration with Medicaid may be needed to advance TB control through directly observed therapy, skin testing and treatment of latent infection.

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: The core activities of the cooperative agreements for TB elimination correlate to the state public health mandates to control infectious diseases and every state receives a financial award to conduct surveillance and basic control activities. Supplemental projects are announced, competed, and awarded through these same cooperative agreements. These are generally demonstration projects, with limited eligibility criteria. These applications undergo an objective review process. In the objective review process, a TB staff person provides a technical review of each application. CDC staff from other Centers are members the objective review panel and serve as a primary and/or secondary reviewer of each application. Each application is then voted on and scored by each panel member. The scores are totaled by Procurement and Grants Office staff and applications are ranked by score and applicants with a specific score will receive an award.

Evidence: Evidence includes the cooperative agreement announcement for FY 2004 for Comprehensive STD Prevention Systems, Prevention of STD-related Infertility, and Syphilis Elimination. Evidence of intramural research practices is included in the DSTDP research programs review. The STD program was unique in using special emphasis panels early on and continues to convene panels for each research request for applications. However, intramural research is reviewed internally by three administrative leaders. For the TB clinical trials, new sites are competed every 10 years, sub-contracts are issued within the consortium, and reviews are done by an objective review panel.

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: In addition to technical reviews for progress reports and annual and end of project reports from grantees, the program conducts site visits of STD projects. Grantees respond to technical review comments from project officers within 30 days. Grantee spending is monitored by the grants management information system and grantees submit interim financial status reports within 90 days of the end of the calendar year. The program conducts external peer review of STD intramural and extramural research. Trip reports from epi-aids, rapid response teams and site visits provide an impressive amount of detail on disease burden and program performance.

Evidence: The program conducts site visits of all 68 TB cooperative agreement recipients at least once every year and often visits larger and more complex projects more frequently. The site visits enable the program to review the project's activities and progress toward meeting agreed upon goals and objectives. The consultants then send a letter to recipients within 30 days to provide findings and recommendations. The program also uses more frequent and informal communication with recipients and staff in the field for oversight and technical assistance. Technical reviews provide detailed information on disease burden and interventions. TB cooperative agreement applications and end of year progress reports also provide information for oversight, as do the program's national surveillance systems.

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: In this case, the program's national surveillance systems provide state and local level data on the incidence and prevalence of disease that is readily available to the public. Because they are not merely on the burden of disease but track progress in prevention and control, these data can be used to compare state performance and provide a proxy for performance of the use of federal funds. The program does not yet provide other performance data at the grantee level on the internet. CDC is working at the agency level to develop a new policy on sharing information with the states that may expand information on performance that is available to the public in the future.

Evidence: Evidence in the STD area includes the Sexually Transmitted Disease Surveillance Report, 2002, and the CDC Syphilis Surveillance Report, 2002, and Chlamydia Prevalence Monitoring Project Annual Report, 2002, and associated state profiles. Evidence in the TB area includes Trends in Tuberculosis, United States, 1998-2003, March 19, 2004, MMWR. Data reported by CDC that provide information on state performance include CDC's TB cases and case rates per 100,000 population; TB cases by case verification criterion and site of disease; use of directly observed therapy and completion of therapy; TB cases by age, risk group, occupation and other breakdowns; special sections for STDs among all states, including racial and ethnic groups; progress on syphilis elimination; state level data.

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: A large extent is given because the program has adopted specific long-term performance measures that focus on outcomes and has data available that indicates considerable progress in meeting the long-term outcomes. The number of physician visits for pelvic inflammatory disease has declined from a high of 254,000 in 2000 to 197,000 in 2002. The number of cases of syphilis has also declined. The rate of cases of TB has continued to decline among US persons and overall and has held more steady recently among the foreing born.

Evidence: Evidence incudes the 2005 GPRA plan and 2003 GPRA report. After a dramatic and well documented upsurge from 1985 to 1992, TB rates declined again and from 1993 to 2002 the average annual decrease in the overall TB rate was 6.8%. TB rates among foreign born have declined from 29.2 among 100,000 in 1999 to 23.1 in 2002, and overall rates have declined from 6.4 to 5.2 over the same time period. The decline slowed in 2003, which is raising concerns.

Does the program (including program partners) achieve its annual performance goals?

Explanation: A large extent is given because the program has adopted specific annual performance measures that also focus on outcomes and has data available that indicate considerable progress in meeting the annual targets. The prevalence of chlamydia in women aged 25 or younger in high risk females has declined from a recent high of 11.9% in 2000 to 10.1% in 2002. As noted above, TB rates have largely declined.

Evidence: Evidence incudes the 2005 GPRA plan and 2003 GPRA report. TB rates among foreign born have declined from 29.2 among 100,000 in 1999 to 23.1 in 2002, and overall rates have declined from 6.4 to 5.2 over the same time period.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: A small extent is given for this assessment because the program has taken steps to improve efficiencies but has limited data data that show an increase in program efficiency. As program changes that are currently being put in place develop, including perhaps efforts that develop from the Cap Gemini Ernst & Young review, the program should be able to show increased efficiency over time. The program has used the IOM report to encourage health departments to focus less on direct provision of services and adjust to changes in the health care system by building partnerships and improving services provided by private care systems and other external entities. The program has also steared away from free-standing syphilis elimination programs, but focused instead on closing gaps and targeting efforts. National rates of TB have declined significantly since the early 1990s while funding has been more level.

Evidence: Outside of increased use of the internet and changes in organization, there is little specific evidence of improvements in program efficiency over the prior year. The program has reassigned 50 supervisors from supervisory to lead positions to decrease the ratio of supervisors to staff and eliminated four administrative positions from 2002 to 2003. The program is also streamlining administrative and programmatic functions for STD by eliminating eight sections with the six STD branches and in 2003 converted the STD surveillance program to electronic reporting. In 1990, CDC published case definitions for STD to improve the effectiveness and efficiency of surveillance. Evidence of syphilis approach is included in the national plan and annual grant awards.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: There are no other federal programs that share the role of the program and the program's activities cannot be compared directly with other federal, state or private entities. Other nations have had success in nearly eradicating gonorrhea and syphilis, such as Sweden, but no direct comparison of program effectiveness can be drawn.

Evidence: There is insufficient evidence of comparable programs to draw an affirmative conclusion for this question.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: A small extent is given for this question because as is noted in Section II, there are only a few evaluations of the program. A 1993 report by Battelle found there is a range of workload among STD clinics with various impacts on patient retention and satisfaction and that some clinics do not test for chlamydia. The GAO TB report does cite progress. A 1997 case study in eight southern communities by Battelle found local health departments are the only local entities that focus on syphilis and public health agencies supported little prevention activities. A 2000 IOM report on TB, Ending Neglect, reached multiple conclusions on resource investments and found CDC should develop and use program standards to evaluate program performance and action plans to guide resources. A 2003 NAS report found an effective national system for STD prevention is lacking, but asserts for every $1 spent on early detection and treatment for chlamydia and gonorrhea, $12 in associated costs could be saved and notes that CDC has a critical leadership role and points to the importance of CDC guidelines.

Evidence: The NAS study is The Hidden Epidemic: Confronting Sexually Transmitted Diseases. The chlamydia study was published in Sexually Transitted Diseases, January 2003. Key findings from the IOM report on STD include that clinics have not been oriented toward prevention, physicians lack skills in this area, barriers to effective STD campaigns have not been addressed. The American Social Health Association evaluation of national STD and AIDS hotlines found a range of areas covered with callers reporting satisfaction in the general areas of expertise and politeness. The LTG Associates report on lessons learned for syphilis elimination is not yet completed. A report on CDC's STD treatment guidelines in two managed care organizations in 1998 found varying results in the two organizations in awareness and adherence. While informative, the study was not a comprehensive evaluation. As noted in Section III, the program has used the report to suggest other research and inform the development of program guidelines.