Centers for Disease Control and Prevention (CDC): History, Overview of Domestic Programs, and Selected Issues
Congressional research reportMar 22, 2024
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Centers for Disease Control and Prevention
(CDC): History, Overview of Domestic
Programs, and Selected Issues
March 22, 2024
Congressional Research Service
https://crsreports.congress.gov
R47981
SUMMARY
Centers for Disease Control and Prevention
(CDC): History, Overview of Domestic
Programs, and Selected Issues
R47981
March 22, 2024
Kavya Sekar
Analyst in Health Policy
The Coronavirus Disease 2019 (COVID-19) pandemic shined a spotlight on the Centers
for Disease Control and Prevention (CDC), one of nine Public Health Service (PHS)
agencies in the Department of Health and Human Services (HHS). CDC’s role in and
response to the pandemic have been the subject of numerous congressional hearings and oversight investigations.
History
CDC began as the Communicable Disease Center in 1946 focused on assisting states and localities in controlling
communicable disease outbreaks. CDC’s role has expanded over the decades to include programs aimed at
disease prevention and health promotion more broadly. In 1980, when CDC was renamed the Centers for Disease
Control (after two prior name changes), its official mission was to serve as HHS’s “focus for developing and
applying disease prevention and control, environmental health, and health promotion and health education
activities designed to improve the health of the people of the United States.” Over time, CDC evolved in response
to an epidemiologic transition that occurred throughout the 20th century, in which the leading causes of death in
the United States shifted from infectious diseases to chronic diseases and injuries. CDC also evolved as the field
of epidemiology developed and scientists identified the preventable causes of a wide range of health challenges.
Within the context of these developments, CDC was positioned to study preventable health challenges and to
support programs to address them. CDC retains a dual responsibility for responding to emerging health threats,
such as disease outbreaks, and for supporting ongoing disease prevention and health promotion efforts.
Organization and Programs
In FY2023, CDC and the Agency for Toxic Substances and Disease Registry had a program level of $14.5 billion,
consisting of $9.3 billion for core public health programs and $5.2 billion for other programs funded by
mandatory budget authorities such as the Vaccines for Children program and the World Trade Center Health
Program. CDC currently comprises 23 centers, institutes, and offices (CIOs). Some of these CIOs focus on
specific health areas (e.g., immunization and respiratory diseases), whereas others focus on specific functions and
capabilities (e.g., laboratory science and safety). Within these CIOs, CDC’s domestic public health activities
generally fall within three categories: (1) support to state, local, tribal, and territorial (SLTT) health agencies,
including assistance in investigating health threats and grant funding for health programs; (2) science and data,
including CDC support for networks of laboratories and surveillance systems to monitor health threats and
changes; and (3) health education and guidance. These activities cover a wide range of health topics, including
infectious diseases, chronic diseases, injury, disability, occupational health, environmental health, and public
health emergency preparedness and response. This CRS report does not focus on CDC’s global health programs.
Authorization
CDC does not have a single, overarching statute that defines its overall mission, structure, and programs.
Congress in 2022 codified the position of the CDC Director and its responsibilities through the PREVENT
Pandemics Act (P.L. 117-238, Division FF, Title II). CDC as an agency has been shaped by reorganizations carried
out under HHS departmental reorganization authorities. Many CDC programs cite general program authorizations
in the Public Health Service Act (PHSA) as their statutory basis. Congress has often shaped CDC’s programmatic
focus areas through the annual appropriations process, in which CDC has received its funding through disease and
program-specific accounts and line items. Some CDC programs are explicitly authorized in law, mostly in the
PHSA. CDC also administers some federal public health regulations, though it is not primarily a regulatory
agency. In addition, the CDC Director oversees the Agency for Toxic Substances and Disease Registry (ATSDR),
a separate HHS operating division.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Reorganization and Reform
CDC has recently undertaken its own reorganization and reform effort through the Moving Forward initiative.
Committee members in both the House and the Senate have solicited input on potential CDC reform. If Congress
considers further legislative reform, Congress may contemplate the appropriate scope of the agency’s mission and
activities. Congress faces many policy options for CDC reform, including (1) awaiting results from the Moving
Forward initiative, (2) establishing a process for CDC reform, and (3) further codifying the agency in statute.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Contents
History and Context......................................................................................................................... 3
Brief History.............................................................................................................................. 3
Public Health Service Act of 1944 ...................................................................................... 4
1946-1950: Establishment and Initial Years ....................................................................... 5
1950s-1960s: Expansion in Epidemiology, Communicable Disease, and
Vaccination Programs ...................................................................................................... 6
1970s: Becoming the Center for Disease Control and Expanding Scope ........................... 8
1980s: The Centers for Disease Control, Lead Disease Prevention Agency, and
the HIV/AIDS Epidemic................................................................................................ 10
1992-Present: Centers for Disease Control and Prevention .............................................. 12
Current Status: The COVID-19 Pandemic and CDC’s Moving Forward Initiative ......... 15
CDC’s Evolution in Context ................................................................................................... 17
Congress’s Role in Shaping CDC ........................................................................................... 19
Appropriations .................................................................................................................. 19
Authorizing Legislation: Case Studies.............................................................................. 20
Agency Overview Today ............................................................................................................... 22
Mission .................................................................................................................................... 22
Organization ............................................................................................................................ 23
Statutory Authorizations.......................................................................................................... 25
CDC Director Authorization ............................................................................................. 25
General Program Authorizations....................................................................................... 25
Program-Specific Authorizations ...................................................................................... 27
Appropriations......................................................................................................................... 29
Activities ................................................................................................................................. 29
Support to SLTT Public Health Agencies ......................................................................... 29
Science and Data ............................................................................................................... 34
Health Education and Guidance........................................................................................ 39
Regulations.............................................................................................................................. 40
Mandatory Health Services Programs ..................................................................................... 41
Vaccines for Children ........................................................................................................ 41
World Trade Center Health Program ................................................................................ 42
Considerations and Options for Reform ........................................................................................ 43
Defining the Mission ............................................................................................................... 43
Scoping CDC by Disease and Health Area ....................................................................... 43
Scoping CDC by Function ................................................................................................ 44
Scoping CDC by Role....................................................................................................... 45
Selected Policy Options .......................................................................................................... 45
Await Results from the Moving Forward Initiative .......................................................... 45
Establish a CDC Reform Process ..................................................................................... 46
Further Authorize CDC ..................................................................................................... 47
Figures
Figure 1. CDC Organizational History: A Timeline ...................................................................... 17
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Figure 2. How Congress Shapes CDC Programs Through Appropriations:
Illustrative Example ................................................................................................................... 20
Figure 3. CDC Organization Chart ................................................................................................ 24
Tables
Table 1. Selected CDC Program Authorizations ........................................................................... 28
Table 2. Top 10 CDC Grant Programs, by Funding Amount in FY2022 ...................................... 31
Table 3. Selected CDC Surveillance Systems ............................................................................... 36
Table 4. Selected CDC Surveys..................................................................................................... 38
Contacts
Author Information........................................................................................................................ 48
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
T
he Coronavirus Disease 2019 (COVID-19) pandemic shined a spotlight on the Centers for
Disease Control and Prevention (CDC), one of nine Public Health Service (PHS) agencies
in the Department of Health and Human Services (HHS). CDC’s role in and response to
the pandemic have been the subject of numerous congressional hearings and oversight
investigations.
With CDC the nation’s lead agency for disease prevention and health promotion, CDC’s primary
domestic activities include providing support to state, local, tribal, and territorial (SLTT) health
agencies, which are often at the forefront of public health. CDC also supports public health
research, investigation, and data collection and provides public health education, guidance, and
outreach to various audiences, including the general public, clinicians, and public health
practitioners. These activities cover a wide range of health topics, including infectious diseases,
chronic diseases, injury, disability, occupational health, environmental health, and public health
emergency preparedness and response. In addition, the agency exercises regulatory authority in a
few limited areas, such as in federal quarantine and inspection and occupational health and safety.
CDC also administers a few mandatory health services programs, such as the Vaccine for
Children program. Through its global health programs, CDC provides public health assistance to
foreign governments (these activities are not a focus of this report).
Initially established in 1946 as a small center focused on controlling malaria and other vectorborne diseases, CDC evolved into the federal government’s lead agency for disease prevention
and health promotion in 1980. The agency grew through acquisition when many other preexisting
federal public health programs, such as programs for tuberculosis and vital statistics, were
transferred to CDC. In addition, Congress shaped CDC by enacting legislation aimed at
strengthening its programs in certain areas, such as in injury prevention and control and public
health emergency preparedness and response. Throughout CDC’s history, CDC Directors have
undertaken comprehensive reviews of the agency that informed subsequent reorganizations, for
example in the late 1970s and most recently through the Moving Forward initiative, which began
in 2022.1
All of this occurred against the backdrop of changing health concerns and a growing health
prevention science field. Throughout the 20th century, an epidemiologic transition occurred in
which the leading causes of death in the United States shifted from mostly infectious diseases to
mostly chronic diseases and injuries. Epidemiologists adapted the methods developed for
controlling communicable diseases to learn the preventable causes of a wide range of diseases
and health problems. At the beginning of the 20th century, most diseases were viewed as a matter
of fate. By the end of the 20th century, it was widely understood that many health problems could
be prevented, whether through vaccines, bug spray, seatbelts, helmets, condoms, diet, exercise, or
other measures. CDC positioned itself to study how to prevent health problems and to support
prevention and control programs to address such challenges.2
During the 118th Congress, some Members of Congress have contemplated legislative reform of
CDC following the agency’s perceived performance during the COVID-19 pandemic.3 In
particular, CDC has received scrutiny for its development and distribution of an initial laboratory
1 See Brief History section of this report.
2 See CDC’s Evolution in Context section of this report.
3 See for example, Representative Mariannette Miller-Meeks, “Miller-Meeks Seeks Stakeholder Feedback to Reform
CDC Following Years of Consistent Failures and Broken Trust,” press release, April 5, 2023,
https://millermeeks.house.gov/media/press-releases/miller-meeks-seeks-stakeholder-feedback-reform-cdc-followingyears-consistent.
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test for COVID-19, as well as for its COVID-19 related health guidance, which critics perceived
as confusing or favorable to certain interest groups.4 Some have asserted that CDC has lost public
trust, citing polls showing declining favorable public views of CDC and other public health
agencies.5 One independent investigative report characterized CDC’s culture as academic and
slow to respond to the urgent and changing emergency health situation posed by the pandemic.6
CDC has acknowledged some of these challenges in its own internal Moving Forward evaluation,
and has since begun an internal reform process.7
There are many current views and proposals regarding potential CDC reform. Some have called
for Congress to formally authorize CDC in statute.8 Although Congress shapes CDC’s funded
programs through appropriations each year, CDC does not currently have a single, overarching
statute that defines the agency’s mission, structure, and programs. As Representative Guthrie,
chair of House Energy and Commerce Health Subcommittee (committee of jurisdiction for CDC)
put it, “Congress has never, in a single voice, told the CDC what its mission is and is not.”9
Others have called for Congress to establish a more formal process for considering potential CDC
reform, for example, by establishing an external advisory group to evaluate the agency and
propose reforms.10 Still others have called for patience, arguing that Congress should allow CDC
to continue with its Moving Forward reform effort before considering any major legislative
reform.11
This CRS report (1) provides an overview of CDC and presents selected issues for potential
legislative reform; (2) describes CDC’s history and contextualizes its evolution into the agency it
4 See, for example, HHS Office of the Inspector General, CDC’s Internal Control Weaknesses Led to Its Initial
COVID-19 Test Kit Failure But CDC Ultimately Created a Working Test Kit, A-04-20-02027, October 2023,
https://oig.hhs.gov/oas/reports/region4/42002027.pdf; and U.S. Congress, House Committee on Oversight and
Accountability, Oversight of CDC Policies and Decisions During the COVID-19 Pandemic, 118th Cong., 1st sess., June
7, 2023.
5 J. Stephen Morrison and Tom Inglesby, Building the CDC the Country Needs, Center for Strategic and International
Studies, January 2023, https://csis-website-prod.s3.amazonaws.com/s3fs-public/publication/
230112_Morrison_Building_CDC.pdf?VersionId=kTKB3urWn1bfZpXuCqixfxzHfT8AUcIM.
6 The COVID Crisis Group, Lessons from the COVID War: An Investigative Report (New York, NY: PublicAffairs,
2023), pp. 64, 166.
7 CDC, “CDC Moving Forward Summary Report,” September 2022, https://www.cdc.gov/about/organization/cdcmoving-forward-summary-report.html.
8 Dr. Joel M. Zinberg and Drew Keyes, Unauthorized and Unprepared: Refocusing the CDC After COVID-19, Paragon
Health Institute, July 2023, https://paragoninstitute.org/wp-content/uploads/2023/07/Unauthorized-and-UnpreparedRefocusing-the-CDC-after-COVID-19_Zinberg-Keyes_FOR-RELEASE_V1.pdf and Letter from Academy of General
Dentistry ( to The Honorable Mariannette Miller-Meeks, M.D., Representative, House Committee on Energy and
Commerce, April 23, 2023, https://www.agd.org/docs/default-source/advocacy-papers/agd-miller-meeks-letterheadcdc-rfi_.pdf?sfvrsn=1904d33c_0.
9 U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations, Looking
Back Before Moving Forward: Assessing CDC’s Failures in Fulfilling its Mission, 118th Cong., 1st sess., June 7, 2023.
10 J. Stephen Morrison and Tom Inglesby, Building the CDC the Country Needs, Center for Strategic and International
Studies, January 2023, https://csis-website-prod.s3.amazonaws.com/s3fs-public/publication/
230112_Morrison_Building_CDC.pdf?VersionId=kTKB3urWn1bfZpXuCqixfxzHfT8AUcIM and Brian J. Miller,
Niraj Gowda, and Padmini Ranasinghe, et al., “A Vision for Supporting and Reforming The CDC,” Health Affairs,
June 10, 2022.
11 American Public Health Association, Testimony of Georges C. Benjamin, Executive Director at Looking Back
Before Moving Forward: Assessing CDC’s Failures in Fulfilling its Mission, House Energy and Commerce Committee,
Subcommittee on Oversight and Investigations, June 7, 2023, p. 32 and Letter from Michael R. Fraser, CEO,
Association of State and Territorial Health Officials to Senator Bill Cassidy, Ranking Member, Senate Committee on
Health, Education, Labor, and Pensions, October 20, 2023, https://www.astho.org/globalassets/pdf/government-affairs/
astho-responds-to-senate-help-rfi-on-cdc-reform-october-2023.pdf.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
is today, including a discussion of Congress’s role in that evolution; and (3) outlines the CDC’s
current mission, organization, statutory authorizations, appropriations, and major domestic
programs and activities. Information on the Agency for Toxic Substances and Disease Registry
(ATSDR)—a separate HHS operating division authorized by Comprehensive Environmental
Response, Compensation, and Liability Act of 1980 (CERCLA)—is included within the overall
discussion of CDC programs.12 This CRS report does not focus on CDC’s international programs
and activities.
What Is “Public Health”?
In 1920, professor C.-E.A. Winslow defined the nascent concept of public health as
[t]he science and art of preventing disease, prolonging life, and promoting physical health and efficiency
through organized community efforts for the sanitation of the environment, the control of community
infections, the education of the individual in the principles of personal hygiene, the organization of medical
and nursing services for the early diagnosis and preventive treatment of disease, and the development of
social machinery which will ensure to every individual in the community a standard of living adequate for the
maintenance of health.
CDC still uses this quote in its online Public Health 101 course today.
Other definitions of public health are similarly broad. For example, in 1988, the Institute of Medicine (today the
National Academy of Medicine) defined public health as “fulfilling society’s interest in assuring people can be
healthy.”
There are two key themes to definitions and ideas about public health. One is that public health focuses on
preventing adverse health outcomes and promoting health more generally. Health promotion seeks to achieve an
optimal state of wellness. The second is that public health focuses on efforts to improve health on a population and
community-wide basis rather than on an individualized basis.
Sources: CDC, “Introduction to Public Health,” https://www.cdc.gov/training/publichealth101/public-health.html,
and C.-E.A. Winslow, “The Untilled Fields of Public Health,” 1920, Science, vol. 51, no. 1306, pp. 23-33.
History and Context
Brief History
The public health system in the United States grew out of the sanitary reform movement of the
19th century, which was premised on the view that disease was caused by environmental
conditions and lack of sanitation.13 Throughout the 1880s, states and cities established Boards of
Health, often with broad powers to protect their residents’ health.14 These boards generally
focused on tackling potential sources of disease in the physical environment. They conducted
surveys on the health conditions of their populations, performed inspections, investigated
outbreaks, and disinfected possessions and locations thought to cause disease. By the end of the
19th century, 40 of the 45 states then in existence and many localities had established health
departments. In the late 19th century, as scientific understanding of the germ theory of disease
developed, many of these health departments established laboratories to identify and investigate
the germs that caused disease. State and local public health agencies then expanded their roles,
12 42 U.S.C. §§9601 et seq., at §9604(i)
13 Institute of Medicine, Chapter 3: A History of the Public Health System, The Future of Public Health., 1988,
https://www.ncbi.nlm.nih.gov/books/NBK218224/; and Bernard J. Turnock, “Chapter 1: What is Public Health?” in
Public Health: What it is and How it Works, 5th ed. (Jones and Bartlett Learning, LLC, 2012), p. 5.
14 Bernard J. Turnock, “Chapter 1: What is Public Health?” in Public Health: What it is and How it Works, 5th ed.
(Jones and Bartlett Learning, LLC, 2012), p. 6.
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moving into surveillance (i.e., disease data reporting and monitoring), clinical care, and health
education.15
Some trace the federal government’s role in public health to the Marine Hospital Service (MHS),
a system of federally run hospitals for merchant seamen first established in 1798.16 By the late
1800s the MHS began to play a role in preventing the introduction and spread of infectious
diseases into the United States by ship—including smallpox, yellow fever, and cholera. In 1878,
Congress enacted the first federal quarantine law to prevent and control the introduction of
infectious diseases into the United States.17 The MHS’s role then expanded to include public
health activities, for example, federal quarantine, vaccination efforts, epidemic investigations, and
medical examinations of immigrants.18 MHS was renamed the Public Health and Marine Hospital
Service in 1902 and then the Public Health Service in 1912.19
Public Health Service Act of 1944
Even before CDC existed, Congress enacted the Public Health Service Act of 1944 (PHSA),
which established the general set of federal public health authorities that, as amended, remain the
basis of many CDC programs and regulations today.20 The PHSA consolidated and revised all
preexisting federal laws pertaining to the U.S. Public Health Service (PHS), which had become
part of the Federal Security Agency.21
As explained below in the “Statutory Authorizations” section, Title III of PHSA established a
general set of federal public health authorities, including the authority to engage in research and
investigations, to regularly publish health statistics and reports, and to assist states in preventing
and controlling diseases.22 PHSA Title III also established the federal legal authorities for foreign
and interstate quarantine and isolation to control communicable diseases. At the outset, the
Surgeon General envisioned the federal government’s role in public health as focused primarily
on assisting the states with implementation of their public health programs. According to the
statement of the Surgeon General, then head of the PHS, after its enactment:
[T]he new law will facilitate the smooth operation of the Federal-State public health
programs and will make it possible to expand State and local health services to the people.
With a minimum of Federal administrative control to insure efficient and economical
15 Institute of Medicine, Chapter 3: A History of the Public Health System, The Future of Public Health., 1988,
https://www.ncbi.nlm.nih.gov/books/NBK218224/.
16 “An Act for the Relief of Disabled Seamen,” 5th Congress, https://memory.loc.gov/cgi-bin/ampage?collId=llsl&
fileName=001/llsl001.db&recNum=728, and National Library of Medicine (NLM), “History of the Public Health
Service: Disease Control and Prevention- Health Care for Seamen,” https://www.nlm.nih.gov/exhibition/phs_history/
seamen.html.
17 National Quarantine Act of 1878, P.L. 45-66. See Centers for Disease Control and Prevention (CDC), “History of
Quarantine (Port Health),” https://www.cdc.gov/quarantine/historyquarantine.html.
18 National Library of Medicine, “History of the Public Health Service: Disease Control and Prevention- Fighting the
Epidemic Spread of Disease,” https://www.nlm.nih.gov/exhibition/phs_history/seamen.html.
19 National Library of Medicine, “History of the Public Health Service: Two Centuries of Health Promotion,”
https://www.nlm.nih.gov/exhibition/phs_history/seamen.html, and CDC, “The Roots of Public Health and CDC,”
https://www.cdc.gov/museum/online/story-of-cdc/roots/index.html.
20 P.L. 78-184.
21 The Federal Security Agency was established by Reorganization Plan No. 1 of 1939. In addition to the U.S. Public
Health Service, it included as subunits the Social Security Board, the U.S. Employment Service, the Office of
Education, and other public welfare-related entities. The Federal Security Agency later became the Department of
Health, Education, and Welfare, which in turn became the Department of Health and Human Services.
22 Alanson W. Willcox, “The Public Health Service Act, 1944,” Public Health Service, Federal Security Agency
Bulletin, August 1944.
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expenditure of Federal funds, State health authorities develop, organize, and administer
their own programs; but on technical problems, planning and administration of
comprehensive programs, and training of personnel they look to the Public Health Service
for leadership and expert advice. 23
1946-1950: Establishment and Initial Years
The modern-day CDC began as the Communicable Disease Center in 1946.24 The center grew out
of the Office of Malaria Control in War Areas (MCWA), which had been established in 1942 to
prevent and control the spread of malaria around military training centers in the U.S. South.25
MCWA had been headquartered in Atlanta, GA, and CDC has been headquartered there since. By
1946, most of the military training centers had closed, but federal officials saw value in
maintaining the expertise and capabilities of the office to prevent and control communicable
diseases in the United States more generally.26 CDC was established administratively within the
U.S. Public Health Service. Congress subsequently provided an appropriation in support of the
new center.27
Initially, CDC was focused on vector-borne communicable diseases such as malaria.28 (Vectorborne diseases are caused by “vectors” such as mosquitoes, ticks, and fleas.29) In the following
years, CDC’s role expanded to assist states in addressing other outbreaks and health threats,
including diarrheal diseases and polio.30 By 1949, the center had become a division of the Bureau
of State Services within the PHS and had the following responsibilities:
23 Alanson W. Willcox, “The Public Health Service Act, 1944,” Public Health Service, Federal Security Agency
Bulletin, August 1944.
24 CDC, “Our History-Our Story,” https://www.cdc.gov/museum/history/our-story.html. In a 1946 supplement to the
Code of Federal Regulations, CDC was listed as a field station of the States Relations Division within the Bureau of
State Services of the U.S. Public Health Service. (U.S. National Archives, Division of the Federal Register, 1946
Supplement to the Code of Federal Regulations of the United States of America [Washington: GPO, 1947], p. 61496153.)
25 Federal Security Agency, U.S. Public Health Service, Development of the Communicable Disease Center, 1946,
https://globalhealthchronicles.org/files/original/151a6159652008b3bf2ce2f158a5cdc1.pdf.
26 Federal Security Agency, U.S. Public Health Service, Development of the Communicable Disease Center, 1946,
https://globalhealthchronicles.org/files/original/151a6159652008b3bf2ce2f158a5cdc1.pdf; Helen Neff, “The Center for
Disease Control—1946-1976,” Connecticut Medicine, 1979; and William Foege, “Centers for Disease Control,”
Journal of Public Health Policy, 1981.
27 Elizabeth W. Etheridge, “Chapter 1: War and the Mosquito,” in Sentinel for Health: A History of the Centers for
Disease Control and Prevention (University of California Press, 1992), pp. 16-17. According to the book, “the U.S.
Public Health Service had all the authority it needed to set up the new center, however, it needed funding from
Congress.” FY1946 appropriations (P.L. 79-124) for the Public Health Service included a new line item for
“communicable diseases” with a funding level of $1.04 million (the FY1945 appropriations law [P.L. 78-373] did not
include a similar line item.) For examples of discussions of related appropriations, see U.S. Congress, House
Committee on Appropriations, Subcommittee on Labor Department and Federal Security Appropriations, Department
of Labor—Federal Security Agency Appropriation Bill for 1946, hearings, 79th Cong., 1st sess., April 19, 1945
(Washington: GPO, 1945), pp. 335-341; U.S. Congress, House Committee on Appropriations, Subcommittee on Labor
Department and Federal Security Appropriations, Department of Labor—Federal Security Agency Appropriation Bill
for 1947, hearings, 79th Cong., 2nd sess., April 15, 1946 (Washington: GPO, 1946), pp. 230-237; and U.S. Congress,
House Appropriations, Labor Department and Federal Security Appropriations, Department of Labor—Federal
Security Agency Appropriations Bill for 1948, hearings, 80th Cong., 1st sess., February 7 and 18, 1947 (Washington:
GPO, 1947), pp. 273 and 368-377.
28. Federal Security Agency, U.S. Public Health Service, Development of the Communicable Disease Center, 1946,
https://globalhealthchronicles.org/files/original/151a6159652008b3bf2ce2f158a5cdc1.pdf.
29 CDC, “About the Division of Vector-Borne Diseases,” https://www.cdc.gov/ncezid/dvbd/index.html.
30 Elizabeth W. Etheridge, “Chapter 2: The Lengthened Shadow of a Man,” in Sentinel for Health: A History of the
(continued...)
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This center … provides through the regional offices to State and local health agencies
consultation and training in the development and operation of communicable disease
control programs and public health laboratory practices. It plans, directs and evaluates in
cooperation with State and local health agencies programs for the control of selected
communicable disease; provides professional leadership, and makes available the latest
professional techniques in connection therewith. The center conducts and evaluates studies
and investigations in the development of new and improved procedural techniques for the
prevention, detection, diagnosis, control and treatment of communicable disease, and
enforces the medical aspects of the interstate quarantine regulations. 31
1950s-1960s: Expansion in Epidemiology, Communicable Disease, and
Vaccination Programs
In its early years, CDC became known for the Epidemic Intelligence Service (EIS), which was
established in 1951 to respond to the threat of potential biological warfare.32 EIS remains a core
CDC program today.33 In the early 1950s, EIS was composed of early-career medical
professionals who were trained by CDC to use epidemiology to control communicable diseases.
Epidemiology uses statistical methods to study how often diseases occur in specific groups of
people and to help trace the factors that contribute to disease. Epidemiology commonly relies on
surveillance, or systematic and ongoing disease tracking and analysis. After training, EIS officers
were available on-call to assist states with controlling communicable disease outbreaks. From the
beginning, CDC received frequent requests for EIS assistance and the center became known for
its ability to use applied epidemiology to help control disease spread.34
Reorganization Plan No. 1 of 1953 dissolved the Federal Security Agency and established the
Department of Health, Education, and Welfare (HEW) in its stead (see textbox below). CDC was
transferred to the new department. Throughout the early decades of its existence, CDC absorbed
other programs and divisions within the PHS, for example, the Venereal Disease Division in
1957, the Tuberculosis program in 1960, the Morbidity and Mortality Weekly Report in 1961, and
the Quarantine Service in 1967.35 As the Venereal Disease Division was absorbed into CDC,
along with it came the public health advisors (PHAs), a cadre of early career health workers
assigned to states who investigated sexually transmitted disease (STD) cases (then known as
venereal disease). These young professionals implemented mass testing programs, interviewed
Centers for Disease Control and Prevention (University of California Press, 1992), p. 35; and John Parascandola,
“From MCWA to CDC—The Origins of the Centers for Disease Control and Prevention,” Public Health Reports, vol.
111 (November 1996), pp. 549-551.
31 Federal Security Agency, “Public Health Service: Organization and Delegations of Authority,” 14 Federal Register
2667, at 2672, May 20, 1949.
32 Elizabeth W. Etheridge, “Historical Perspectives: History of CDC,” Morbidity and Mortality Weekly Report, vol. 45
(June 1996), pp. 526-30; and Helen Neff, “The Center for Disease Control—1946-1976,” Connecticut Medicine, 1979.
33 CDC, “Epidemic Intelligence Service,” September 2023, https://www.cdc.gov/eis/index.html.
34 Elizabeth W. Etheridge, “Chapter 3: The Disease Detectives,” in Sentinel for Health: A History of The Centers for
Disease Control, ed. University of California Press (1992), pp. 36-66; and Jeffrey Koplan and Stephen B. Thacker,
“Fifty Years of Epidemiology at the Centers for Disease Control and Prevention: Significant and Consequential,”
American Journal of Epidemiology, vol. 154, no. 11 (2001).
35 CDC, “CDC Timeline 1940s-1970s,” https://www.cdc.gov/museum/timeline/1940-1970.html; and Elizabeth W.
Etheridge, “Chapter 8: Call to Arms,” in Sentinel for Health: A History of The Centers for Disease Control, ed.
University of California Press (1992), p. 115.
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patients, and traced patients’ contacts—functions that remain core parts of public health programs
today.36
In 1955, CDC responded to its first national health crisis. After the Salk polio vaccine became
available, the PHS began to receive reports of polio cases among children who received the
vaccine. CDC established a surveillance unit to monitor and investigate the cases and provide
regular summaries of findings to state health officers and others involved in disease control. CDC
eventually learned that 80% of the reported cases were associated with one product that
constituted 10% of the total vaccine supply. A manufacturing issue was found and the product
was pulled from the market. This incident, often called “the Cutter incident” (attributed to vaccine
producer Cutter Laboratories), set a precedent for CDC to take a leadership role in national
response during future emerging health threats and outbreaks, especially by leading national
disease tracking and surveillance.37 CDC subsequently played a similar role in coordinating U.S.
national disease tracking during the 1957-1958 Asian influenza pandemic, which caused several
U.S. outbreaks.38
In the 1960s, CDC began to play a key role in federal immunization programs. Following the
licensure of the Sabin oral polio vaccine in 1961, Congress enacted the Vaccination Assistance
Act of 1962,39 which established the first federal grant program focused on immunization.40 The
law added a new PHSA Section 317, which authorized a state grant program for intensive
community vaccination programs against polio, diphtheria, whooping cough, and tetanus—a
program that remains in place today and is commonly known as the “Section 317 Immunization
Program.”41 CDC became responsible for administering the new grant program. The agency
provided funding and vaccines to states, and PHAs helped with program implementation. As the
measles and rubella vaccines were licensed in 1963 and 1969, respectively, the two types of
vaccines were integrated into the program. Incidence of vaccine-preventable disease fell
throughout the 1960s.42
In the late 1950s, CDC began to provide public health assistance to other countries. At first, CDC
provided periodic assistance during disease outbreaks. During the global Asian influenza
pandemic in 1957-1958, CDC helped distribute testing supplies throughout the world, informed
global laboratory practices, and tracked and summarized disease cases.43 In 1966, an international
36 Elizabeth W. Etheridge, “Chapter 6: Building the Temple,” in Sentinel for Health: A History of The Centers for
Disease Control, ed. University of California Press (1992), pp. 89-91.
37 Helen Neff, “The Center for Disease Control—1946-1976,” Connecticut Medicine, 1979; Elizabeth W Etheridge,
“Historical Perspectives: History of CDC,” Morbidity and Mortality Weekly Report, vol. 45 (June 1996), pp. 526-30;
and D.A. Henderson, “The Development of Surveillance Systems,” American Journal of Epidemiology, vol. 183, no. 5
(February 26, 2016), pp. 381-386.
38 D.A. Henderson, “The Development of Surveillance Systems,” American Journal of Epidemiology, vol. 183, no. 5
(February 26, 2016), pp. 381-386.
39 P.L. 87-868.
40
R. Hinman, Walter A. Orenstein, and Anne Shuchat, “Vaccine-Preventable Diseases, Immunizations, and MMWR—
1961—2011,” Morbidity and Mortality Weekly Report, vol. 60, no. 4 (October 7, 2011), pp. 49-57. Prior to enactment
of this law, vaccines were administered in private medical practices or by state and local health departments, generally
using state and local funds with some support from the Maternal and Child Health Block grant program.
41 Paul Jarris and Virginia Dolen, “Section 317 Immunization Program: Protecting a National Asset,” Public Health
Reports, vol. 128, no. 2 (March 2013), pp. 96-98.
42 Alan R. Hinman, Walter A. Orenstein, and Anne Shuchat, “Vaccine-Preventable Diseases, Immunizations, and
MMWR—1961—2011,” Morbidity and Mortality Weekly Report, vol. 60, no. 4 (October 7, 2011), pp. 49-57.
43 Helen Neff, “The Center for Disease Control—1946-1976,” Connecticut Medicine, 1979, and David J. Sencer,
“CDC’s 60th Anniversary: Director’s Perspective—David J. Sencer, M.D., M.P.H., 1966-1977,” Morbidity and
Mortality Weekly Report, vol. 55, no. 27 (July 14, 2006), pp. 745-49.
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malaria eradication program was transferred from the Agency for International Development to
CDC. CDC’s international work subsequently expanded to include a smallpox eradication
program and a famine relief initiative.44
CDC was briefly renamed the National Communicable Disease Center in 1967.45 By 1968, it
became a center within the broader Health Services and Mental Health Administration agency. Its
responsibilities were to support “a national program for the prevention and control of
communicable and other preventable diseases.”46
Reorganization Plans in 1953 and 1966
Both CDC and the U.S. Public Health Service (PHS) underwent several major reorganizations in the 1960s and
1970s. These reorganizations were underpinned by two federal reorganization plans submitted to Congress in
accordance with the Reorganization Act of 1949:
•
April 1953: Reorganization Plan No. 1 of 1953 (67 Stat. 631) created the Department of Health, Education,
and Welfare and transferred all functions and agencies of the Federal Security Agency, including the PHS and
its CDC subunit, to the new department. At the time of the reorganization, the Surgeon General oversaw
the PHS agencies. The plan also stated, “The [HEW] Secretary may from time to time make such provisions
as the Secretary deems appropriate authorizing the performance of any of the functions of the Secretary by
any other officer, or by any agency or employee, of the Department.”
•
June 1966: Reorganization Plan No. 3 of 1966 (80 Stat. 1610) transferred the PHS from under the Surgeon
General to the HHS Secretary. The plan “transferred to the Secretary of Health, Education, and Welfare …
all functions of the Public Health Service, of the Surgeon General of the Public Health Service, and of all other
officers and employees of the Public Health Service, and all functions of all agencies of or in the Public Health
Service.” It provided further that the Secretary “may from time to time make such provisions as he shall
deem appropriate authorizing the performance of any of the functions transferred to him by the provisions of
this reorganization plan by any officer, employee, or agency of the Public Health Service or of the
Department of Health, Education, and Welfare.” The plan abolished several PHS subunits, including the
Bureau of State Services, which had been the home of the Communicable Disease Service since 1946. With
regard to implementation of these abolishments, the plan stated that the “Secretary shall make such
provisions as he shall deem necessary respecting the winding up of any outstanding affairs of the agencies
abolished.”
Following the Supreme Court ruling in INS v. Chadha, which cast doubt over the validity of reorganization plans,
Congress enacted P.L. 98-532, which stated, “Congress hereby ratifies and affirms as law each reorganization plan
that has, prior to the date of enactment of this Act, been implemented pursuant to the provisions of chapter 9 of
title 5, United States Code, or any predecessor Federal reorganization statute.” Thus, the 1953 and 1966
reorganization plans and the authorities they provided were ratified as law (42 U.S.C. §3501 and 42 U.S.C. §202,
note, respectively) at that time. These authorities remain in place today.
1970s: Becoming the Center for Disease Control and Expanding Scope
In 1970, CDC was renamed the Center for Disease Control. CDC’s official responsibilities had
widened to encompass “a national program for the prevention and control of communicable and
vector-borne diseases and other preventable conditions, including those related to malnutrition.”47
At the time, CDC’s program areas consisted of (1) ecological investigations, (2) epidemiology,
44 Elizabeth W. Etheridge, “Chapter 13: Over Oceans and Into Space,” and “Chapter 14: The Crusade Against
Smallpox,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press
(1992), pp. 178-187 and 188-210; and William Foege, “Centers for Disease Control,” Journal of Public Health Policy,
1981.
45 CDC, “CDC Timeline 1940s-1970s,” https://www.cdc.gov/museum/timeline/1940-1970.html.
46 Public Health Service, “Health Services and Mental Health Administration: Statement of Organizations, Functions,
and Delegations of Authority,” 33 Federal Register 15957, October 30, 1968.
47 Public Health Service, “Health Services and Mental Health Administration: Statement of Organizations, Functions,
and Delegations of Authority,” 35 Federal Register 10797, July 1, 1970.
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(3) foreign quarantine, (4) malaria, (5) nutrition, (6) small pox eradication, (6) training, (7)
laboratory, and (8) state and community services (including those related to tuberculosis, other
respiratory diseases, and STDs).48 This marked the first time that CDC’s official responsibilities
included noncommunicable health conditions. However, even before this change—as early as the
1950s—the CDC Director had assigned staff to study the epidemiology of noncommunicable
health issues, such as cancer, malnutrition, and family planning.49
In 1973, after a series of PHS reorganizations, CDC officially became one of the service’s five
main agencies (instead of a division within a larger program).50 Throughout the 1970s, the scope
of CDC’s work expanded as the agency established programs in the areas of nutrition,
environmental health (e.g., lead exposure), smoking tobacco and health, occupational safety and
health, oral health, cancer, health education, family planning, and birth defects.51 CDC acquired
the PHS nutrition survey in 1971 (today known as the National Health and Nutrition Examination
Survey, NHANES), the National Clearinghouse on Smoking and Health in 1972, and the National
Institute for Occupational Safety and Health, along with lead paint poisoning prevention and
urban rat control programs, in 1973.52
During the 1970s, CDC was credited with some public health successes. With assistance from
CDC’s global smallpox program, which relied on a strategy of surveillance and containment,
smallpox was announced officially eradicated from the globe in 1979.53 By the end of the decade,
the last human case of wild poliovirus (rather than vaccine-induced) was reported in the United
States. Using NHANES data, CDC’s environmental services division helped determine that blood
lead levels were associated with lead concentration in gasoline, which led to regulations that
decreased the amount of lead in gasoline and subsequently reduced blood lead levels in the
population.54
CDC also faced scrutiny in the 1970s. In 1972, CDC was criticized for the so-called Tuskegee
study begun in 1932 that left untreated syphilis in Black male patients for decades, even when
48 Public Health Service, “Health Services and Mental Health Administration: Statement of Organizations, Functions,
and Delegations of Authority,” 35 Federal Register 10797, July 1, 1970.
49 Jeffrey Koplan and Stephen B. Thacker, “Fifty Years of Epidemiology at the Centers for Disease Control and
Prevention: Significant and Consequential,” American Journal of Epidemiology, vol. 154, no. 11 (2001); Stephen B.
Thacker, “Epidemiology and Public Health at CDC,” MMWR, vol. 55, no. SUP02 (December 22, 2006), pp. 3-4;
Elizabeth W. Etheridge, “Chapter 3: The Disease Detectives,” and “Chapter 9: The Candidate for Surgeon General,” in
Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 47 and
135-136; and David J. Sencer, “CDC’s 60th Anniversary: Director’s Perspective—David J. Sencer, M.D., M.P.H.,
1966-1977,” Morbidity and Mortality Weekly Report, vol. 55, no. 27 (July 14, 2006), pp. 745-49.
50 At the time, the U.S. Public Health Service consisted of (1) the Center for Disease Control, (2) the Food and Drug
Administration, (3) the Health Resources Administration, (4) the Health Services Administration, and (5) the National
Institutes of Health. Public Health Service, “Reorganization Order,” 38 Federal Register 18261, July 9, 1973; and
William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981.
51 CDC, “CDC Timeline 1940s-1970s,” https://www.cdc.gov/museum/timeline/1940-1970.html; William Foege,
“Centers for Disease Control,” Journal of Public Health Policy, 1981; and Helen Neff, “The Center for Disease
Control—1946-1976,” Connecticut Medicine, 1979.
52 Elizabeth W. Etheridge, “Chapter 16: Acquisitions,” in Sentinel for Health: A History of The Centers for Disease
Control, ed. University of California Press (1992), pp. 224-234.
53 Elizabeth W. Etheridge, “Chapter 14: The Crusade Against Smallpox,” in Sentinel for Health: A History of The
Centers for Disease Control, ed. University of California Press (1992), pp. 188-210; Elizabeth W Etheridge, “Historical
Perspectives: History of CDC,” Morbidity and Mortality Weekly Report, vol. 45 (June 1996), pp. 526-30; D.A.
Henderson, “Smallpox Eradication,” Public Health Reports, vol. 95, no. 5 (September 1980), pp. 423-426; and D.A.
Henderson, “The Development of Surveillance Systems,” American Journal of Epidemiology, vol. 183, no. 5 (February
26, 2016), pp. 381-386.
54 CDC, “CDC Timeline 1940s-1970s,” https://www.cdc.gov/museum/timeline/1940-1970.html; and Karen K.
Steinberg, “Laboratory Science and Public Health at CDC,” MMWR, vol. 55, no. SUP02 (December 22, 2006), pp. 5-6.
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treatment became available, in order to study progression of the disease. The agency had inherited
the study with the transfer of the Venereal Diseases Division in 1957.55 CDC was also criticized
for taking years to determine the cause of Legionnaires’ disease, a severe form of pneumonia that
caused several deadly outbreaks at the time. In addition, a 1976 mass immunization campaign to
protect against a potential swine flu epidemic was suspended early when no influenza outbreak
occurred and the vaccines were found to be associated with a rare but increased risk of GuillainBarre syndrome, a severe neurological disorder.56 A subsequent review at the government’s
request found that the “program was marked by controversy, delay, administrative troubles, legal
complications, unforeseen side effects and a progressive loss of credibility for public health
authorities,” and the review implicated the CDC Director in many of the challenges faced.57 Some
have since defended the CDC Director’s decisions, arguing that he made the right decisions based
on available information.58
1980s: The Centers for Disease Control, Lead Disease Prevention Agency, and
the HIV/AIDS Epidemic
In the late 1970s, CDC Director William Foege sought to shape CDC’s future direction by
soliciting public input and convening an advisory committee of outside experts and members of
the public.59 The committee published a report in 1978 that identified the highest priority
preventable health problems at the time, recommended strategies to address those problems, and
made recommendations regarding CDC’s role. The report recommended that CDC become the
lead federal agency for disease prevention to address the full range of health problems facing the
nation and the globe.60
The following year, the Surgeon General, with input from CDC, published the first Healthy
People report, which laid out the major preventable health challenges facing the country and
marked a national commitment to prevention.61 This report also set the stage for CDC to take a
holistic approach to disease prevention and health promotion in the 1980s.
The Department of Education Organization Act,62 enacted in 1979, created the Department of
Education as a separate department and renamed the Department of Health, Education, and
Welfare as the Department of Health and Human Services. The following year, CDC was
reorganized and renamed the Centers for Disease Control (with the “s” added) and its official
mission (which remains in place today) became as follows:
55 Elizabeth W. Etheridge, “History of CDC,” Morbidity and Mortality Weekly Report, vol. 45 (June 1996), pp. 526-30.
In 1997, the President offered an apology for the study conducted in Tuskegee to its survivors, and the wives, family
members, children, and grandchildren of the men subjected to the government’s research
(https://clintonwhitehouse4.archives.gov/textonly/New/Remarks/Fri/19970516-898.html).
56 Elizabeth W. Etheridge, “Chapter 18: 1976,” and “Chapter 19: Aftermath,” in Sentinel for Health: A History of The
Centers for Disease Control, ed. University of California Press (1992), pp. 247-275.
57 Richard E. Neustadt and Harvey V. Fineberg, The Swine Flu Affair: Decision Making on a Slippery Disease, 1978,
https://nap.nationalacademies.org/catalog/12660/the-swine-flu-affair-decision-making-on-a-slippery-disease.
58 Rita Rubin, “US CDC Celebrates 70 Years,” The Lancet, vol. 388, no. 10057 (November 5, 2016), pp. 2224-2225.
59 William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981.
60 CDC Programs and Policies Advisory Committee, Recommendations for a National Strategy for Disease Prevention,
Atlanta, GA, June 30, 1978, https://stacks.cdc.gov/view/cdc/131521.
61 United States Public Health Service, Healthy People: The Surgeon General’s Report on Health Promotion and
Disease Prevention, 1979, https://profiles.nlm.nih.gov/spotlight/nn/catalog/nlm:nlmuid-101584932X94-doc; and
William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981.
62 P.L. 96-88.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
The Centers for Disease Control (CDC) serves as the Department’s focus for developing
and applying disease prevention and control, environmental health, and health promotion
and health education activities designed to improve the health of the people of the United
States. 63
At the time, CDC consisted of programs and offices focused on (1) epidemiology, (2) biosafety,
(3) international health, (4) laboratory improvement, (5) prevention services, (6) environmental
health, (7) occupational safety and health, (8) health promotion and education, (9) professional
development and training, and (10) infectious diseases.64 The key new additions included the
Center for Health Promotion and Education and Center for Environmental Health, both of which
incorporated preexisting CDC programs.65
Most prominently, the 1980s were marked by the HIV/AIDS epidemic.66 CDC first received
reports of the new disease in 1981 and then conducted further epidemiologic and laboratory
investigations. CDC quickly learned that the disease spread primarily among men who had sex
with men and was likely caused by a blood-borne virus. CDC formed a taskforce on the disease
and warned that it could become a major health issue.67
Budgetary constraints of the early 1980s limited CDC’s ability to direct resources to the
problem.68 By the mid to late 1980s, as the disease spread more widely, Congress had begun to
dedicate more resources to HIV/AIDS programs. CDC’s HIV prevention budget grew from $200
thousand in FY1981 to over $300 million in FY1988 (not inflation adjusted).69 CDC used its
established methods of assessing risks and developing preventive programs in its efforts to
control the epidemic. Throughout the 1980s, CDC established several new grant programs to fund
HIV/AIDS prevention and control programs at the state and local level and spearheaded several
informational campaigns on the disease.70 By FY1991, HIV/AIDS funding represented 37% of
the agency’s budget.71
Defining Public Health in America: Public Health in America Statement, 1994
In 1988, an Institute of Medicine report on the U.S. public health system found that it had fallen into “disarray.”
The report found general lack of agreement within the field on public health’s mission and appropriate role. While
63 Public Health Service, “Center for Disease Control; Office of the Assistant Secretary for Health Statement of
Organization, Functions and Delegations of Authority,” 45 Federal Register 67772, October 8, 1980. For the current
official mission statement, see CDC, “Immediate Office of the Director (IOD): Mission Statement,”
https://www.cdc.gov/about/organization/cio-orgcharts/iod.html.
64 Public Health Service, “Center for Disease Control; Office of the Assistant Secretary for Health Statement of
Organization, Functions and Delegations of Authority,” 45 Federal Register 67772, October 8, 1980.
65 Elizabeth W. Etheridge, “Chapter 23: Toward the 21 st Century,” in Sentinel for Health: A History of The Centers for
Disease Control, ed. University of California Press (1992), pp. 314-315.
66 CDC, “CDC Timeline 1980s,” https://www.cdc.gov/museum/timeline/1980.html.
67 Elizabeth W. Etheridge, “Chapter 24: Discovery of the AIDS Epidemic,” in Sentinel for Health: A History of The
Centers for Disease Control, ed. University of California Press (1992), pp. 321-340.
68 Elizabeth W. Etheridge, “Chapter 24: Discovery of the AIDS Epidemic,” in Sentinel for Health: A History of The
Centers for Disease Control, ed. University of California Press (1992), pp. 321-340; and U.S. Congress, House
Committee on Government Operations, The Federal Response to AIDS, committee print, 98th Cong., 1st sess.,
November 30, 1983, H. Rept. 98-582.
69 Gary R. Noble, William C. Parra, and Priscilla B. Holman, “Organizational Structure and Resources of CDC’s HIVAIDS Prevention Program,” Public Health Reports, vol. 106, no. 6 (November 1991), pp. 664-667.
70 Bernard J. Turnock, “Chapter 4: Law, Government, and Public Health,” in Public Health: What it is and How it
Works, 5th ed. (Jones and Barlett Learning, 2012), pp. 206-207.
71 Gary R. Noble, William C. Parra, and Priscilla B. Holman, “Organizational Structure and Resources of CDC’s HIVAIDS Prevention Program,” Public Health Reports, vol. 106, no. 6 (November 1991), pp. 664-667.
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the report made some initial recommendations, federal public health agencies then worked to further define
public health’s mission and scope. In 1994, the CDC Director and the Deputy Assistant Secretary for Disease
Prevention and Health Promotion led a working group of PHS agency representatives and outside stakeholders to
develop a consensus list of essential public health services. Ultimately, in fall 1994, HHS leadership and U.S. public
health organizations adopted a Public Health in America statement that drew from the list, shown below. This
framework, revised since 1994, has continued to serve as a basic foundation for public health practice in the
United States.
Public Health in America Statement:
Vision: Healthy people in healthy communities
Mission: Promote physical and mental health and prevent disease, injury, and disability
Public Health:
•
Prevents epidemics and the spread of disease
•
Protects against environmental hazards
•
Prevents injuries
•
Promotes and encourages healthy behaviors
•
Responds to disasters and assists communities in recovery
•
Assures the quality and accessibility of health services
Essential Public Health Services:
•
Monitor health status to identify community health problems
•
Diagnose and investigate health problems and health hazards in the community
•
Inform, educate, and empower people about health issues
•
Mobilize community partnerships to identify and solve health problems
•
Develop policies and plans that support individual and community health efforts
•
Enforce laws and regulations that protect health and ensure safety
•
Link people to needed personal health services and assure the provision of health care when otherwise
available
•
Assure a competent public health and personal health care workforce
•
Evaluate effectiveness, accessibility, and quality of personal and population-based health services
•
Research for new insights and innovative solutions to health problems
Sources: Institute of Medicine Committee for the Study of the Future of Public Health, The Future of Public Health,
1988, https://www.ncbi.nlm.nih.gov/books/NBK218215/; James A. Harrell and Edward L. Baker, “The Essential
Services of Public Health,” Leadership in Public Health, vol. 3, no. 3 (1994), pp. 27-30; The Public Health National
Center for Innovations and the de Beaumont Foundation, Defining Public Health Practice: 25 Years of the 10 Essential
Public Health Services, August 2019, https://www.astdd.org/docs/defining-public-health-practice-25-years-of-the-10essential-public-health-services.pdf; and Bernard J. Turnock, "Chapter 5: Core Functions and Public Health
Practice,” in Public Health: What it is and How it Works, 5th ed. (Jones and Bartlett Learning, 2012), pp. 217-264.
1992-Present: Centers for Disease Control and Prevention
The Preventive Health Amendments of 1992 changed all statutory references to CDC in law to
“Centers for Disease Control and Prevention,” the name of the agency today.72 Since the early
1990s, CDC’s programs have continued to evolve. As shown in the textbox above, discussions
about the appropriate role and scope of public health in the late 1980s and early 1990s set the
stage for issues on which CDC would focus in the following decades. This section discusses some
of the agency’s major areas of focus.
Vaccines for Children and other immunization programs. Following a measles epidemic from
1989 to 1991, where half of all cases occurred among unvaccinated preschool children, the
72 P.L. 102-531.
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Omnibus Budget Reconciliation Act of 199373 established the Vaccines for Children (VFC)
program in Section 1928 of the Social Security Act.74 Through this Medicaid-financed program,
CDC purchases recommended childhood vaccines in bulk at a federally negotiated discounted
rate and distributes them to SLTT agencies to allow participating providers to furnish them at no
cost to eligible children (see the “Vaccines for Children” section). Together with the longstanding PHSA Section 317 immunization program (see the “1950s-1960s” section), the VFC
program helped expand CDC’s role in supporting the infrastructure for immunization safety-net
programs across the country. Starting in the 1990s, CDC also began to expand other
immunization programs; for example, it invested in the nation’s network of Immunization
Information Systems, population-based data systems that help record and track immunizations
received.75
Chronic disease. Since the 1990s, CDC’s chronic disease prevention and control programs have
expanded. In the early 1990s, Congress enacted several laws authorizing cancer programs at
CDC. For example, in 1992, Congress enacted the Cancer Registries Amendment Act,76 which
established the National Program of Cancer Registries—state-based systems to collect and track
data on cancer.77 In addition, in 1990, Congress enacted the Breast and Cervical Cancer Mortality
Prevention Act of 1990,78 which established a CDC state grant program to fund cancer screening
among uninsured and underinsured women, the National Breast and Cervical Cancer Early
Detection Program (NBCCEDP). More recently, starting in 2008, CDC also funded heart disease
and stroke risk factor screenings for the population served by NBCCEDP, known as the
WISEWOMAN program.79 In FY2023, CDC’s Chronic Disease Prevention and Health
Promotion program funded 30 separate grant programs.80
Firearm injury and mortality prevention research and the “Dickey amendment”: In the mid1990’s, some concerns arose surrounding perceived political biases of CDC research related to
firearms and violence.81 Starting in FY1997, Congress added a new appropriations limitation that,
at the time read, “none of the funds made available for injury prevention and control at the
Centers for Disease Control and Prevention may be used to advocate or promote gun control.”82 A
version of this amendment, commonly known as the “Dickey amendment,” has been included in
annual appropriations every year since FY1997.83 While the language does not specifically
73 P.L. 103-66.
74 42 U.S.C. §1396s.
75 CRS Report R47024, Immunization Information Systems: Overview and Current Issues.
76 P.L. 102-515.
77 See CDC, “National Program of Cancer Registries,” cdc.gov/cancer/npcr/index.htm.
78 P.L. 101-354.
79 CDC, “WISEWOMAN Frequently Asked Questions (FAQs),” cdc.gov/wisewoman/faqs.htm. The program’s name is
an acronym for “Well-Integrated Screening and Evaluation for WOMen Across the Nation.”
80 CDC, “National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP): Our Budget,”
https://www.cdc.gov/chronicdisease/programs-impact/budget/index.htm.
81 See statements made at 1996 hearing: S. Congress, House Committee on Appropriations, Subcommittee on Labor,
Health and Human Services, and Education, Hearing on Centers for Disease Control and Prevention Budget, 104 th
Cong., 2nd sess., May 1, 1996, H.Hrg 24-955 (Washington: GPO, 1996), pp. 111-392.
82 P.L. 104-208.
83 Found in the annual Departments of Labor, Health and Human Services, and Education, and Related Agencies
(LHHS) appropriations bill. In FY2023 (P.L. 117-328), the provision read, “None of the funds made available in this
title may be used, in whole or in part, to advocate or promote gun control.” The title refers to the entire title that
provides HHS appropriations in the LHHS law. The limitation has applied to all of HHS appropriations in the LHHS
act since FY2012. Although the amendment is commonly referred to as the “Dickey amendment,” Representative Jay
(continued...)
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mention research, CDC responded to the amendment and the surrounding political controversy by
limiting its research related to firearms and violence.84 Some studies have found that since the
limitation has been in effect, firearm-related violence has been underfunded and understudied
relative to other leading causes of death based on mortality rates.85
Starting in FY2020 (P.L. 116-94), following several high-profile mass shootings, Congress has
provided $12.5 million annually to CDC for “firearm injury and mortality prevention research.”
These amounts have been directed in appropriations report language for each of FY2020 through
FY2023.86 During a 2019 House Appropriations subcommittee hearing, some Members of both
parties expressed support for keeping the Dickey amendment in place as a “guardrail,” while
funding CDC research related to firearms and violence.87
Public health emergency and bioterrorism. In 1999, CDC established several new major public
health emergency programs. For example, CDC launched the National Pharmaceutical Stockpile,
now known as the Strategic National Stockpile (SNS), a federal stockpile of drugs, vaccines, and
other medical products intended for emergency responses (SNS is now housed at the
Administration for Strategic Preparedness and Response).88 In the same year, CDC established
the Laboratory Response Network, a coordinated network of laboratories at the federal, state, and
local level with specialized capabilities to detect biological, chemical, and other health threats.89
As discussed in greater detail in the “Example 3: Public Health Emergency Activities” section,
Congress has enacted a series of statutes since 2000 that have likewise expanded CDC’s role and
programs in public health emergency management and response.
Major infectious disease outbreaks and epidemics. Since the early 2000s, CDC has responded
to several major global and domestic infectious disease outbreaks. These have included the severe
acute respiratory syndrome outbreak (SARS; 2003), H5N1 avian influenza (2005), H1N1
pandemic influenza (2009), Ebola virus (2014-2015 and 2018-present), Zika virus (2016), the
Coronavirus Disease 2019 pandemic (COVID-19; 2020-2023), and mpox outbreak (2022). In
particular, concerns about a potential avian influenza pandemic in 2005 prompted many
congressional hearings, plans, and policy assessments on national preparedness for a pandemic
Dickey did not introduce the amendment. Representative Dickey proposed a different amendment that did not pass in
committee markup. See CQ Almanac, 104th Congr., 2nd Sess., 1997, 52nd ed., 10-59-10-66., http://library.cqpress.com/
cqalmanac/cqal96-841-24596-1091627.
84 From a 2017 GAO report, “CDC officials said that after the restriction was enacted, the agency interpreted it as a
prohibition of activities related to gun control advocacy, but not as a restriction of activities that supported firearm
injury-related data collection and scientific research. However, CDC officials added that the agency has limited its
firearm-related research over time because, in 1997, its budget was reduced by an amount equal to what the agency had
spent on such research, and because it learned that further reductions were possible if the research continued.” See
GAO, Personal Firearms: Programs that Promote Safe Storage and Research on their Effectiveness, GAO-17-665,
September 2017, p. 20, https://www.gao.gov/assets/690/687239.pdf.
85The appropriations limitation has applied to all HHS research since FY2012, therefore some of the studies examine
effects on National Institutes of Health (NIH), CDC, and other HHS health research. David E. Stark and Nigam H.
Shah, “Funding and Publication of Research on Gun Violence and Other Leading Causes of Death,” Journal of the
American Medical Association, vol. 317, no. 1 (January 3, 2017), pp. 84-85 and Joseph A. Ladapo, Benjamin A.
Rodwin, and Andrew M. Ryan, “Scientific Publications on Firearms in Youth Before and After Congressional Action
Prohibiting Federal Research Funding,” Journal of the American Medical Association, vol. 310, no. 5 (August 7, 2013),
pp. 532-34.
86 CRS review of appropriations reports accessible from the CRS Appropriations Status table.
87 House Subcommittee on LHHS Appropriations, Addressing the Public Health Emergency of Gun Violence, 116th
Cong., 1st sess., March 7, 2019.
88 See CRS Report R47400, The Strategic National Stockpile: Overview and Issues for Congress.
89 CDC, “CDC Timeline 1990s,” https://www.cdc.gov/museum/timeline/1990.html.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
that informed CDC’s subsequent responses.90 Many of these infectious disease responses—
especially the COVID-19 pandemic—have tested CDC’s role as a lead public health agency with
expertise in infectious disease control and response, as explained further in the next section.
The Affordable Care Act and public health programs. The Patient Protection and Affordable
Care Act (ACA91), enacted in 2010, was landmark health policy legislation that made many
changes across federal health policy areas, including public health prevention and health
promotion programs. The ACA authorized several new programs at CDC and codified several
existing programs, including programs related to infectious diseases, diabetes prevention, and oral
health.92
The ACA established a new mandatory budget authority for public health, the Prevention and
Public Health Fund, “to provide for expanded and sustained national investment in prevention
and public health programs to improve health and help restrain the rate of growth in private and
public sector health care costs.”93 That ACA section has appropriated funding annually, and as
directed through annual appropriations, CDC has received the majority of this funding in recent
years (e.g., $903 million to CDC in FY2023 out of $943 million total). This PPHF, combined
with annual discretionary appropriations, serves as one of CDC’s main sources of budget
authority for public health programs.94
Current Status: The COVID-19 Pandemic and CDC’s Moving Forward
Initiative
During the COVID-19 pandemic, CDC took a highly visible role in educating the public about
the virus and disease, collecting and tracking COVID-19 data, informing COVID-19 research and
science, and issuing health guidance aimed at prevention and control. CDC also advised and
coordinated many national public health programs, for example, testing, contact tracing, and
vaccination efforts.95 The agency also used its regulatory authorities to issue public health orders
during the pandemic, for example, an order requiring vaccination for international travelers to the
United States and an order restricting the entry of certain noncitizens into the United States,
commonly known as the “Title 42” entry restrictions.96
90 The COVID Crisis Group, Lessons from the COVID War: An Investigative Report (New York: Public Affairs, 2023),
pp. 73-74. See, for example, U.S. Congress, House Committee on Government Reform, The National Pandemic
Influenza Preparedness and Response Plan: Is the United States Ready for Avian Flu? 109th Cong., 1st sess., November
4, 2005, 109-94; and CDC, “National Pandemic Strategy,” https://www.cdc.gov/flu/pandemic-resources/nationalstrategy/index.html.
91 P.L. 111-148, as amended.
92 See CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in ACA: Summary and
Timeline.
93
P.L. 111-148, §4002.
94 For more information, see CRS Report R47895, Prevention and Public Health Fund: In Brief.
95 CDC, “CDC in Action: Working 24/7 to Stop the Threat of COVID-19,” February 4, 2021, https://www.cdc.gov/
budget/documents/covid-19/CDC-247-Response-to-COVID-19-fact-sheet.pdf.
96 CDC, “Amended Order Implementing Presidential Proclamation on Advancing the Safe Resumption of Global
Travel During the COVID-19 Pandemic,” https://www.cdc.gov/quarantine/cruise/pdf/Vax-Order-10-30-21-p.pdf, and
CRS Legal Sidebar LSB10874, COVID-Related Restrictions on Entry into the United States Under Title 42: Litigation
and Legal Considerations. CDC also issued other public health orders, such as an eviction moratorium and a
transportation mask mandate, that were subject to litigation and enjoined by courts. See CRS Legal Sidebar LSB10638,
Supreme Court Blocks Enforcement of the CDC’s Eviction Moratorium, by David H. Carpenter, and CRS Legal
Sidebar LSB10589, Legal Issues Related to Transportation Mask-Wearing Mandates, by Bryan L. Adkins.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
CDC and its actions during the pandemic have been the subject of numerous congressional
hearings, oversight reports, and independent evaluations. In particular, CDC received scrutiny for
its development and distribution of an initial laboratory test for COVID-19, as well as for its
COVID-19 related health guidance, which critics perceived as confusing or favorable to certain
interest groups.97 Some have asserted that CDC has lost public trust, citing polls showing
declining favorable public views of the agency.98 One independent investigative report
characterized CDC’s culture as academic and slow to respond to the urgent and changing
emergency health situation posed by the pandemic.99 Some have argued that the challenges CDC
faced during the pandemic are attributable to a general lack of funding and capacity at CDC and,
more broadly, in the public health system.100
In April 2022, CDC’s leadership began a review and reform process, entitled Moving Forward,
aimed at modernizing the agency to better achieve its mission. The initial review consisted of two
components: a scientific and programmatic review and an organizational structure review.
Broadly, the structural review found that CDC’s academic approach sometimes hindered its
ability to rapidly respond to an evolving threat such as the COVID-19 pandemic. In particular, the
review found that the agency’s incentive structures rewarded scientific publications over impact
and actions. The review also found that the agency could benefit from becoming more flexible
and less siloed by health area or program.101 In February 2023, CDC finalized an agency
reorganization following recommendations from the evaluations (see the “Organization” section
for more details).102 The agency stated that, as a result of the initiative, it was working through
160 reform actions targeted to be completed by January 2024. These included, for example,
website changes, laboratory capacity reforms, CDC-wide response training, and data
modernization.103
97 See, for example, HHS Office of the Inspector General, CDC’s Internal Control Weaknesses Led to Its Initial
COVID-19 Test Kit Failure But CDC Ultimately Created a Working Test Kit, A-04-20-02027, October 2023,
https://oig.hhs.gov/oas/reports/region4/42002027.pdf; and U.S. Congress, House Committee on Oversight and
Accountability, Oversight of CDC Policies and Decisions During the COVID-19 Pandemic, 118th Cong., 1st sess., June
7, 2023.
98 J. Stephen Morrison and Tom Inglesby, Building the CDC the Country Needs, Center for Strategic and International
Studies, January 2023, https://csis-website-prod.s3.amazonaws.com/s3fs-public/publication/
230112_Morrison_Building_CDC.pdf?VersionId=kTKB3urWn1bfZpXuCqixfxzHfT8AUcIM.
99 The COVID Crisis Group, Lessons from the COVID War: An Investigative Report (New York, NY: PublicAffairs,
2023), pp. 64, 166.
100 American Public Health Association, Testimony of Georges C. Benjamin, Executive Director at Looking Back
Before Moving Forward: Assessing CDC’s Failures in Fulfilling its Mission, House Energy and Commerce Committee,
Subcommittee on Oversight and Investigations, June 7, 2023; Letter from Association of American Medical Colleges
to The Honorable Mariannette Jane Miller-Meeks, M.D., House Representative, April 21, 2023, https://www.aamc.org/
media/66591/download?attachment; and Richard Besser, Comments from Richard Besser, MD on Ways to Support and
Strengthen the Centers for Disease Control and Prevention, Robert Wood Johnson Foundation, April 10, 2023,
https://www.rwjf.org/en/insights/advocacy-and-policy/regulatory-comments/2023/04/comments-from-richard-besseron-ways-to-support-and-strengthen-the-cdc.html.
101 CDC, “CDC Moving Forward Summary Report,” September 2022, https://www.cdc.gov/about/organization/cdcmoving-forward-summary-report.html.
102 CDC, “CDC Moving Forward Reorganization,” 88 Federal Register 9290-9291, February 13, 2023.
103 CDC, “CDC Moving Forward,” https://www.cdc.gov/about/organization/cdc-moving-forward.html.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Figure 1. CDC Organizational History: A Timeline
Source: See the sources in the “History and Context” section of this report.
CDC’s Evolution in Context
As shown in CDC’s organizational history in Figure 1, the scope of the agency has greatly
expanded since it was first established. CDC evolved and grew as an agency as the fields of
public health and prevention science grew. In the first half of the 20th century, a greater scientific
understanding of the germ theory of disease helped facilitate the communicable disease control
science and methods for which CDC became known.104 CDC cultivated specialized expertise
104 Nancy Krieger, “Epidemiology Expands: Germs, Genes and the (Social) Environment (1900-1950),” in
Epidemiology and the People’s Health: Theory and Context (Oxford University Press, 2011), pp. 95-101; and Mervyn
Susser, “Epidemiology in the United States After World War II,” Epidemiologic Reviews, vol. 7 (1985), pp. 147-173.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
within the federal government in disease control, specifically in the developing fields of
epidemiology and surveillance.105
Throughout the 20th century, the field of public health became more specialized, and
distinguished itself from the field of medicine. Public health grew to encompass research into the
social, environmental, and biological determinants of health, broadly, along with the practice of
addressing those determinants.106 The 20th century also saw a shift in the burden—or overall
health impact—of diseases. In the early 1900s, infectious diseases were the major causes of death
in the United States. By midcentury—including by the time CDC was established in 1946—
chronic conditions such as cancer and heart disease became the leading causes of death (often
called the epidemiologic transition). Throughout the 20th century, even after 1946, mortality rates
from infectious diseases fell, except during epidemics such as the HIV/AIDS epidemic and the
COVID-19 pandemic. 107 As the major health concerns changed, so too did the field of public
health and its focus areas. 108
In particular, evolution in the field of epidemiology—in which CDC cultivated distinct
expertise—helped expand the scope of public health.109 Throughout the 20th century,
epidemiologists learned to apply the scientific methods developed for communicable diseases to a
wide range of diseases and conditions, including chronic diseases and injuries. Epidemiologists
helped scientifically determine the risk factors that led to poor health; for example, the scientific
relationships between smoking tobacco and lung cancer, folic acid intake and birth defects, and
seat belt use and motor vehicle fatalities.110 This scientific understanding could then be used to
develop public health interventions to address risk factors, such as health education and
promotion campaigns.111 CDC was in a position to support both the data collection and research
into risk factors, as well as some of the programmatic interventions to address them.
Within this context, CDC expanded in scope as an agency. As recounted in the brief history here,
CDC sometimes expanded through acquiring existing programs and through departmental
reorganizations. CDC fit these diverse programs under the broad umbrella of public health such
that by the 1980 reorganization, CDC became HHS’s focus for developing and applying disease
105 Jeffrey Koplan and Stephen B. Thacker, “Fifty Years of Epidemiology at the Centers for Disease Control and
Prevention: Significant and Consequential,” American Journal of Epidemiology, vol. 154, no. 11 (2001); and Stephen
B. Thacker, “Epidemiology and Public Health at CDC,” MMWR, vol. 55, no. SUP02 (December 22, 2006).
106 Allan M. Brandt and Martha Gardner, “Antagonism and Accommodation: Interpreting the Relationship Between
Public Health and Medicine in the United States During the 20 th Century,” American Journal of Public Health, vol. 90,
no. 5 (May 2000), pp. 707-715.
107 David S. Jones, Scott H. Podolsky, and Jeremy A. Greene, “The Burden of Disease and the Changing Task of
Medicine,” New England Journal of Medicine, vol. 366 (2012), pp. 2333-2338, and CDC National Center for Health
Statistics, “Leading Causes of Death,” https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.
108 Mervyn Susser, “Epidemiology in the United States After World War II,” Epidemiologic Reviews, vol. 7 (1985), pp.
147-173.
109 Jeffrey Koplan and Stephen B. Thacker, “Fifty Years of Epidemiology at the Centers for Disease Control and
Prevention: Significant and Consequential,” American Journal of Epidemiology, vol. 154, no. 11 (2001).
110 Allan M. Brandt and Martha Gardner, “Antagonism and Accommodation: Interpreting the Relationship Between
Public Health and Medicine in the United States During the 20 th Century,” American Journal of Public Health, vol. 90,
no. 5 (May 2000), pp. 707-715. Krista S. Crider, Yan Ping Qi, Lorraine F. Yeung, et al., “Folic Acid and the Prevention
of Birth Defects: 30 Years of Opportunity and Controversies,” Annual Review of Nutrition, vol. 42 (August 22, 2023),
pp. 423-452; and CDC National Center for Injury Prevention and Control, “Achievements in Public Health, 1900-1999
Motor-Vehicle Safety: A 20th Century Public Health Achievement,” Morbidity and Mortality Weekly Report, vol. 48,
no. 18, (May 14, 1999), https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.htm.
111 Mervyn Susser, “Epidemiology in the United States After World War II,” Epidemiologic Reviews, vol. 7 (1985), pp.
147-173; Safety: A 20th Century Public Health Achievement,” Morbidity and Mortality Weekly Report, vol. 48, no. 18
(May 14, 1999).
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
prevention and control and for promoting health more broadly.112 The 1980 reorganization was
also preceded by a broader reassessment of CDC’s role in addressing preventable health
challenges. In addition, as illustrated in the next section, Congress has at times facilitated new or
enhanced programs and roles for CDC through both the authorizations and the appropriations
process.
Congress’s Role in Shaping CDC
As noted above, CDC has been substantially shaped by a series of administrative reorganizations
throughout the 20th century. Congress has also played a role in shaping the agency. Much of this
role has been to provide the agency with annual appropriations, often through disease- or
program-specific accounts and budget lines, that have shaped CDC’s programmatic focus
areas.113 In addition, Congress has at times enacted authorizing legislation aimed at shaping
CDC’s programs and functions. Examples of each of these methods of shaping CDC are included
below. Most recently, Congress formally authorized the position of the CDC Director and
required agency-wide strategic planning through the PREVENT Pandemics Act.114
Appropriations
Congress has provided annual appropriations for CDC programs since the agency was first
established (see the “1946-1950: Establishment and Initial Years” section). Through this process,
Congress has often appropriated funding based on certain health or program areas. Earlier in its
history, the entire U.S. Public Health Service received appropriations for specific public health
functions; the appropriations laws did not specify the specific operating divisions or units to carry
out such activities. For example, in the appropriations act for FY1960,115 the Public Health
Service received appropriations for “Assistance to States,” “Control of Venereal Diseases,”
“Control of Tuberculosis and Communicable Disease Activities,” among other purposes.
In 1974, after CDC became one of five main PHS agencies, appropriations laws began to
appropriate funds to CDC more directly.116 In recent decades, Congress has appropriated funds to
specific accounts within CDC aligned with certain broad health areas (e.g., immunization) or
activity areas (e.g., epidemic services). Within these accounts, Congress often specifies funding
for particular programs through appropriations report language (see Figure 2). The number and
specificity of CDC’s programmatic budget lines within accounts have grown over the past several
decades. To illustrate, in FY1990, the conference report accompanying CDC appropriations
specified funding levels for 18 programs within CDC accounts.117 In FY2023, the explanatory
statement accompanying CDC appropriations specified funding levels for more than 140 lineitems within CDC accounts (in both accompanying tables and text).118
112 Public Health Service, “Center for Disease Control; Office of the Assistant Secretary for Health Statement of
Organization, Functions and Delegations of Authority,” 45 Federal Register 67772, October 8, 1980.
113 For a general discussion of the interplay between congressional appropriations and administrative reorganizations,
see “Appropriations as a Tool of Reorganization” and “Congressional Responses to Particular Agency Head Actions”
in CRS Report R44909, Executive Branch Reorganization, by Henry B. Hogue.
114 P.L. 117-328, Division FF, Title II; 136 Stat. 5706; 42 U.S.C. §242c.
115 P.L. 86-158.
116 See P.L. 93-517.
117 U.S. Congress, House Committee on Appropriations, Conference Report to Accompany H.R. 29909, 101st Cong., 1st
sess., October 6, 1989, pp. 18-19.
118 Congressional Record, vol. 168, no. 198, book II, December 20, 2022, pp. S8877-S8881. See also CDC Operating
Plan FY2023 for a summary.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Figure 2. How Congress Shapes CDC Programs Through Appropriations:
Illustrative Example
Source: CRS analysis of CDC appropriations.
Authorizing Legislation: Case Studies
At times, Congress has enacted legislation that has created new programs or changed CDC’s
authorities and functions. Three illustrative examples are explained in the following case studies.
In the first example (injury prevention and control), Congress authorized a specific type of
activity at CDC. In the second example (the National Center on Birth Defects and Developmental
Disabilities), Congress explicitly established a new center at CDC by statute. In the third example
(public health emergency activities), Congress established and shaped CDC’s roles and programs
in public health emergency preparedness and response through a series of laws that have been
periodically reauthorized since 2000.
Example 1: Injury Prevention and Control
A 1985 report requested by Congress, Injury in America: A Continuing Public Health Problem,
called for addressing injuries—including traffic-related injuries, falls, drowning, poisoning,
violence, and other injuries—as public health problems, including by increasing research into the
causes of injuries and the means to prevent them. The report recommended that a Center for
Injury Control be established within CDC.119 Congress then enacted the Injury Prevention Act of
1986,120 which formally authorized CDC injury prevention and control activities in the Public
119 Institute of Medicine and National Research Council, Injury in America: A Continuing Public Health Problem,
1985, https://nap.nationalacademies.org/catalog/609/injury-in-america-a-continuing-public-health-problem. See
especially page 116.
120 P.L. 99-649.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Health Service Act.121 CDC’s budget for injury prevention and control grew from $10 million in
1985 to $49.2 million in 1997 (not inflation adjusted). CDC established the National Center for
Injury Prevention and Control in 1992.122
Example 2: National Center on Birth Defects and Developmental Disabilities
The Children’s Health Act of 2000123 amended the PHSA to establish, in statute, the National
Center on Birth Defects and Developmental Disabilities (NCBDDD) within CDC.124 According
to CDC, the center was created in response to “strong advocacy efforts by external organizations
whose view was that children’s health issues were not being adequately addressed by CDC.”125 In
2001, CDC moved the staff and resources of the preexisting Division of Birth Defects and
Developmental Disabilities out of the National Center for Environmental Health, where it had
been located for over 30 years, to become the new NCBDDD.126
Example 3: Public Health Emergency Activities
Beginning in 2000, Congress enacted a series of laws aimed at strengthening public health
emergency capabilities within CDC and other HHS agencies. The Public Health Threats and
Emergencies Act, enacted in 2000, included several provisions that required assessments of
national public health emergency capacity and needs.127 The law also authorized grants to support
state and local capacity to address health threats. In addition, the law authorized CDC to improve
its laboratories and other facilities to support public health emergency capacity. It included a
section that stated,
Congress finds that the Centers for Disease Control and Prevention have an essential role
in defending against and combatting public health threats of the 21 st century and requires
secure and modern facilities that are sufficient to enable such Centers to conduct this
important mission.128
The committee report accompanying the Senate bill expressed concern that many state and local
health departments would not be able to rapidly and effectively respond to a major outbreak in
their communities. The report also noted that federal agencies, such as CDC, needed updated
laboratories, facilities, and technologies for public health emergency response. In particular, many
buildings at CDC had not been updated since just after World War II, and many of CDC’s
laboratories lacked capabilities required for research with dangerous infectious agents.129
121 See Title III, Part J.
122 David A. Sleet, Grant Baldwin, and Angela Marr, “History of Injury and Violence as Public Health Problems and
Emergence of the National Center for Injury Prevention and Control at CDC,” Journal of Safety Research, vol. 43, no.
4 (September 2012), pp. 233-47.
123 P.L. 106-310.
124 PHSA §317C.
125 CDC, “CDC’s National Center on Birth Defects and Developmental Disabilities Strategic Plan,” February 2011,
https://stacks.cdc.gov/view/cdc/11701.
126 CDC, “Statement of Organization, Functions, and Delegations of Authority,” 66 Federal Register 20148, April 19,
2001.
127 P.L. 106-505, Title I.
128 P.L. 106-505, §102. In 2001, anthrax spores were deliberately released through U.S. postal mail. In total, 22 people
got sick and, of these, five died. See CDC, “History of Anthrax,” 2020, https://www.cdc.gov/anthrax/basics/anthraxhistory.html.
129 S.Rept. 106-505.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Following the 9/11 terrorist attacks and the anthrax incident of 2001, Congress enacted the Public
Health Security and Bioterrorism Preparedness and Response Act of 2002,130 which sought to
further enhance public health emergency capacity. The law enhanced CDC’s authorities to
improve its laboratory facilities and surveillance networks to respond to public health threats. The
law also authorized CDC’s Public Health Emergency Preparedness (PHEP) cooperative
agreement program in PHSA Section 319C-1, a grant program that funds public health emergency
preparedness and response capacity in state and local health departments. This law set the stage
for the Pandemic and All Hazards Act of 2006 (PAHPA),131 which reauthorized and further
amended the CDC provisions enacted in 2002. PAHPA has since been reauthorized twice, in
2013132 and 2019,133 and both times included additional provisions that addressed CDC programs
related to public health threats.
The programs authorized by these laws have helped develop the field of public health emergency
preparedness and response across the country. CDC has established 15 foundational capabilities
that SLTT health agencies should have in order to prevent, protect against, respond to, and
recover from public health emergencies such as infectious disease outbreaks and chemical,
biological, nuclear, and radiological threats.134 These include functions such as emergency
coordination, public health laboratory testing, and medical countermeasure (e.g., vaccines,
treatments) dispensing and administration. SLTT health agencies are required to invest in these
capabilities as a condition of receiving CDC PHEP grants. These programs have brought
frameworks from the emergency management field into public health responses to various health
threats, such as infectious diseases. Much of the evolution in the field of public health emergency
management was driven by legislation enacted by Congress.135
Agency Overview Today
The following sections provide an overview of CDC as an agency today, including its mission,
organization, authorizations, funding, and key activities.
Mission
Like several other agencies established by executive action, CDC does not have an overall
mission or purpose defined in statute. In 2022, Congress articulated the breadth of the agency’s
work in the PREVENT Pandemics Act.136 The act codified the position of the CDC Director and
provided that the Director is to implement responsibilities and authorities that are
related to the investigation, detection, identification, prevention, or control of diseases or
conditions to preserve and improve public health domestically and globally and address
injuries and occupational and environmental hazards, as appropriate.137
130
P.L. 107-188.
131 P.L. 106-417.
132 P.L. 113-5.
133 P.L. 116-22.
134 CDC, “Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local,
Tribal, and Territorial Public Health,” https://www.cdc.gov/orr/readiness/capabilities/index.htm.
135 Dale A. Rose, Shivani Murthy, and Jennifer Brooks, “The Evolution of Public Health Emergency Management as a
Field of Practice,” American Journal of Public Health, vol. 107, no. 2 (September 2017), pp. S126-S133.
136 P.L. 117-328; Division FF, Title II.
137 Public Health Service Act Section 305(b)(1); 42 U.S.C. §242c(b)(1).
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
As established in Federal Register notices, CDC’s official mission statement is as follows:138
The Centers for Disease Control and Prevention (CDC) serves as the national focus for
developing and applying disease prevention and control, environmental health, and health
promotion and health education activities designed to improve the health of the people of
the United States.
In addition, CDC’s stated mission on its website is as follows:
CDC works 24/7 to protect America from health, safety and security threats, both foreign
and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or
preventable, human error or deliberate attack, CDC fights disease and supports
communities and citizens to do the same.
CDC increases the health security of our nation. As the nation’s health protection agency,
CDC saves lives and protects people from health threats. To accomplish our mission, CDC
conducts critical science and provides health information that protects our nation against
expensive and dangerous health threats, and responds when these arise.139
CDC’s mission statements comprise two predominant themes. First, the agency is responsible for
overall health promotion and disease prevention. Second, the agency is responsible for health
security and response to specific health threats.
Organization
As shown in Figure 3, CDC is organized into many centers, institutes, and offices (CIOs). Some
of these CIOs focus on specific public health challenges (e.g., injury prevention and control),
while others focus on general public health capabilities (e.g., state, tribal, local, and territorial
public health infrastructure and workforce).
138 CDC, “Immediate Office of the Director (IOD): Mission Statement,” https://www.cdc.gov/about/organization/cio-
orgcharts/iod.html. For Federal Register notices, see for example, Public Health Service, “Center for Disease Control;
Office of the Assistant Secretary for Health Statement of Organization, Functions and Delegations of Authority,” 45
Federal Register 67772.
139 CDC, “Mission, Role and Pledge,” https://www.cdc.gov/about/organization/mission.htm.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Figure 3. CDC Organization Chart
Source: Adapted by CRS from CDC, “CDC Organization Chart,” https://www.cdc.gov/about/pdf/organization/
cdc-org-chart.pdf, updated as of February 23, 2023.
Notes: HIV = Human Immunodeficiency Virus; STD = Sexually Transmitted Disease; TB = Tuberculosis.
CDC most recently underwent a reorganization in 2023 as a part of its Moving Forward
initiative.140 According to CDC, the reorganization was informed by feedback from staff and
partners on how CDC could change its structure to better respond to public health challenges. The
reorganization included the following key changes:141
140 For more on this initiative, see “Current Status: The COVID-19 Pandemic and CDC’s Moving Forward Initiative.”
141 CDC, “CDC Moving Forward,” https://www.cdc.gov/about/organization/cdc-moving-forward.html.
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
•
•
CDC created the new National Center for State, Tribal, Local, and Territorial
Public Health Infrastructure and Workforce, intended to improve collaboration
with local health departments and public health partners.
To align with its “core capabilities,” CDC established new offices within the
Office of the Director: the Office of Health Equity; the Office of Public Health
Data, Surveillance, and Technology; the Office of Laboratory Science and Safety;
and the Office of Readiness and Response.
Statutory Authorizations
As discussed above, CDC is an administratively established agency that has been shaped by
congressional appropriations and some program authorization statutes. Congress has mostly
shaped CDC’s programs through specifying and directing funding through the annual
appropriations process. The agency, like several other agencies established by executive action,
does not have a single, overarching statute that defines its overall mission, structure, or
programs.142 CDC’s programs are authorized by general and program-specific laws, mostly in the
PHSA. The position of the CDC Director and its responsibilities were codified into law in
December 2022.143
CDC Director Authorization
Authorized in PHSA Section 305,144 added in December 2022, the CDC Director is responsible
for the overall direction of CDC and the Agency for Toxic Substances and Disease Registry, as
well as the management and operation of its programs.145 This law made the CDC Director a
presidentially appointed and Senate-confirmed position, effective January 20, 2025. The
authorization does not define the specific programs for which the CDC Director is responsible;
instead, the law defines the general scope of the Director’s authorities and responsibilities (see the
“Mission” section).
PHSA Section 305 also requires the CDC Director to develop a strategic plan every four years to
identify overall priorities and objectives for the agency.
General Program Authorizations
The general public health authorities of the Public Health Service Act, many of which were
established in 1944, have long underpinned CDC’s activities (see the “Public Health Service Act
of 1944” section). CDC’s current programs and structure evolved from a series of reorganizations
and acquisitions, as discussed in the “Brief History” section. Many CDC programs across a wide
range of health areas cite general and permanent PHSA Title III authorities of the HHS Secretary
as their statutory basis, including the following:
PHSA Section 301 (42 U.S.C. §241): Research and Investigation. This section allows PHS
agencies, including CDC and the National Institutes of Health (NIH), to conduct, coordinate, and
142 According to one analysis by political science scholars, 40% of federal agencies established from 1946 through
1995 were established by executive action rather than legislation; see William G. Howell and David E. Lewis,
“Agencies by Presidential Design,” The University of Chicago Press Journals, vol. 64, no. 4 (November 2002), pp.
1095-1114.
143 The PREVENT Pandemics Act, P.L. 117-238, Division FF, Title II.
144 42 U.S.C. §242c.
145 The PREVENT Pandemics Act, P.L. 117-238, Division FF, Title II. Prior to the enactment of this statute, the CDC
Director was an administratively established position.
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fund research and investigations “relating to the causes, diagnosis, treatment, control, and
prevention of physical and mental diseases and impairments of man.” Under this authorization,
PHS agencies may award grants and contracts for research, publish studies and research-based
health information, and make available PHS facilities for research, among other research
activities. CDC cites PHSA Section 301 as one authorizing statute for all of its CIOs and
accounts.146
PHSA Section 307 (42 U.S.C. §242l): International Cooperation. This section authorizes the
HHS Secretary to engage in international cooperation in health research, health statistics, health
care technology, health care services, and other activities, especially for HIV/AIDs, tuberculosis,
malaria, and other preventable infectious diseases. The section authorizes participation in
international meetings, the award of grants, and the exchange of scientists and other fellows with
other countries, among other cooperative activities. CDC cites PHSA Section 307 as one
authorizing statute for all of its CIOs and accounts.147
PHSA Section 310 (42 U.S.C. §242o): Health Conferences and Health Education
Information. This section requires the HHS Secretary to call annually a conference among state
health authorities. The section also authorizes the Secretary to periodically issue information
related to public health and requires the Secretary to publish weekly reports on the health
conditions in the United States and other countries and other health information. CDC cites PHSA
Section 310 as one authorizing statute for all of its CIOs and accounts.148
PHSA Section 311 (42 U.S.C. §243): Federal-State Cooperation in Communicable Disease
Control and Public Health Matters. This section authorizes the HHS Secretary to provide and
accept assistance in enforcing quarantine and other health authorities at the federal and state level,
and to assist states (and their political subdivisions) in controlling communicable diseases and in
other public health matters. The Secretary may provide related assistance and training to states,
and may make available resources, such as personnel and medical supplies, to the states that
“may be effectively used to control epidemics of any disease or condition and to meet other
health emergencies or problems.” CDC cites PHSA Section 311 as one authorizing statute for all
of its CIOs and accounts, except “Public Health Scientific Services” and “Global Health.”149
PHSA Section 317 (42 U.S.C. §247b): Project Grants for Preventive Health Services. This
section allows the HHS Secretary to award grants for preventive health service programs to
states, their political subdivisions, and other public health entities. Recipients may receive
supplies, including vaccines and other preventive agents, in lieu of grant funds. Subsection (k)(1)
specifically authorizes vaccination grant programs. Subsection (k)(2) authorizes grant programs
for the prevention and control of diseases and conditions more broadly, including for research,
demonstration projects, public information and education programs, and other programs aimed at
health professionals. Subsection (l) provides authority to purchase recommended adult vaccines at
a negotiated rate, to be provided in lieu of grant funds at the recipient’s request. CDC cites PHSA
146 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/
documents/fy2025/FY-2025-CDC-congressional-justification.pdf.
147 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/
documents/fy2025/FY-2025-CDC-congressional-justification.pdf.
148 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/
documents/fy2025/FY-2025-CDC-congressional-justification.pdf.
149 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/
documents/fy2025/FY-2025-CDC-congressional-justification.pdf.
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Section 317 as one authorizing statute for all of its CIOs and accounts, except “Global Health”
and “Public Health Preparedness and Response.”150
Program-Specific Authorizations
Three CDC centers and institutes and ATSDR are explicitly authorized in law:
•
•
•
•
National Institute for Occupational Safety and Health (NIOSH), authorized
by the Occupational Safety and Health Act of 1970 (29 U.S.C. §§651 et seq.).
National Center on Birth Defects and Developmental Disabilities (NCBDD),
established in PHSA Section 317C (42 U.S.C. §247b-4).
National Center for Health Statistics (NCHS), established in PHSA Section
306 (42 U.S.C. §242k).
ATSDR, established by the Comprehensive Environmental Response,
Compensation and Liability Act of 1980 (CERCLA; 42 U.S.C. §§9601 et seq., at
§9604(i)).151
Some of these components were initially established separately from CDC—NIOSH and NCHS,
in particular—and were then later transferred to CDC (see the “History and Context” section).
Some CDC offices, such as the Office of Women’s Health (PHSA Section 310A152), are also
authorized in law.
CDC also administers program-specific statutes throughout the PHSA and other laws.153 Some of
these statutes are directed at CDC, for example, the authorization for the Epidemiology and
Laboratory Capacity grant program in PHSA Section 2821.154 Others are directed at the HHS
Secretary but carried out by CDC by delegation, for example, an authorization for activities
related to the prevention and control of sexually transmitted diseases in PHSA Section 318.155
The program-specific authorizations that CDC administers vary in terms of specificity, as
illustrated in Table 1. Some, such as PHSA Section 318, authorize a general set of public health
activities (e.g., research, demonstration projects, and education) with respect to a certain health
area (e.g., sexually transmitted diseases). Others authorize and delineate a specific program to be
administered by CDC, such as the authorization for the Public Health Emergency Preparedness
cooperative agreement in PHSA Section 319C-1, which sets forth eligible awardees, a program
funding formula, and other requirements for the grant program.
Many of CDC’s specific program authorizations have expired authorizations of appropriations.
CDC’s FY2025 Congressional Budget Justification lists 29 programs with authorizations of
150 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/
documents/fy2025/FY-2025-CDC-congressional-justification.pdf.
151 HHS initially established ATSDR to be headed by an Administrator who reported directly to the Assistant Secretary
for Health on April 25, 1983 (42 FR 17652). On May 12, 1983, the then CDC Director became the first Administrator
of ATSDR following litigation that compelled the federal government to carry out certain provisions of the
Comprehensive Environmental Response, Compensation and Liability Act of 1980. See Richard G. Stoll, “Resolution
of EDF/CMA Suit to Promote Government Health Studies,” National Resources Law Newsletter (1983).
152 42 U.S.C. §242s
153 For a full list of current CDC authorizations, see CDC, “Authorizing Legislation,” Congressional Justification:
FY2025, pp. 49-56, https://www.cdc.gov/budget/documents/fy2025/FY-2025-CDC-congressional-justification.pdf.
154 42 U.S.C. §300hh–31.
155 42 U.S.C. §247c.
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appropriations that have expired in FY2023 or earlier.156 In general, when Congress appropriates
funds for a program whose funding authorization has expired, that appropriation provides
sufficient legal basis to continue the program during that period of availability absent indication
of congressional intent to terminate the program.157
Table 1. Selected CDC Program Authorizations
Title
Projects and programs for the
prevention and control of
sexually transmitted diseases
PHSA and U.S. Code
Section
PHSA §318; 42 U.S.C. §247c
Epidemiology-laboratory capacity
grants
PHSA §2821; 42 U.S.C.
§300hh-31
Oral health promotion and
disease prevention
PHSA §317M; 42 U.S.C.
§247b–14
Compilation of data on asthma
PHSA §317I; 42 U.S.C.
§247b-10
Improving state and local public
health security
PHSA §319C-1; 42 U.S.C.
247d-3a
Summary
Allows the HHS Secretary to conduct many
activities related to the prevention and
control of sexually transmitted diseases,
including, among others, technical assistance
and training; research and demonstration
grants; prevention and control program
grants; and fostering innovative
interdisciplinary approaches.
Requires the CDC Director to establish an
Epidemiology and Laboratory Capacity Grant
Program for state, local, and tribal health
departments to strengthen epidemiologic and
laboratory capacity for response to infectious
diseases and other conditions of public health
importance.
Authorizes CDC grants to states and tribes
for oral health purposes, including community
water fluoridation, school-based dental
sealant programs, and oral health program
leadership and data collection.
Requires CDC to conduct surveillance
activities to collect and publish data related to
asthma’s health impact and clinical
management.
Authorization for the Public Health
Emergency Preparedness cooperative
agreement program. Authorizes CDC to
award cooperative agreements to state and
local jurisdictions for public health emergency
preparedness and response. Requires
awardees to submit preparedness and
response plans, report annually on progress
against health security goals, and to conduct
certain activities, such as drills and trainings
for staff. Specifies a funding formula and
requires states to maintain public health
security expenditures.
Source: Selected from CDC, “Authorizing Legislation,” Congressional Justification: FY2024, pp. 54-61,
https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC-congressional-justification.pdf.
Note: CRS selected a sample of CDC program authorizations to provide an illustrative view of how the
agency’s programs are authorized.
156 CDC, “Appropriations not Authorized by Law,” Congressional Justification: FY2025, pp. 58-59,
https://www.cdc.gov/budget/documents/fy2025/FY-2025-CDC-congressional-justification.pdf.
157 CRS Report R46497, Authorizations and the Appropriations Process
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Appropriations
In FY2023, CDC/ATSDR had a total program level of $14.5 billion, consisting of $9.3 billion in
core public health program funding for CDC and ATSDR and an estimated $5.2 billion for other
mandatory spending programs.158 CDC receives most of its core program funding through the
annual Departments of Labor, HHS, and Education, and Related Agencies (LHHS)
Appropriations Act. CDC receives LHHS appropriations through accounts that align mostly with
the titles of its CIOs. ATSDR is funded by the Departments of the Interior, Environment, and
Related Agencies Appropriations Act. CDC also administers several programs that are funded by
mandatory spending authorities, such as the Vaccines for Children program and the World Trade
Center Health Program (see the “Mandatory Health Services Programs” section). Congress has
also provided CDC with supplemental emergency funding during public health emergencies and
other incidents.
Given that many CDC programs are based in general authorities, Congress often uses the
appropriations process to inform CDC’s programs. Appropriations reports accompanying CDC
annual appropriations usually specify programmatic funding levels within CDC accounts, though
to varying levels of detail depending on the program and account. For more information on CDC
funding, see CRS Report R47207, Centers for Disease Control and Prevention (CDC) Funding
Overview.
Activities
CDC uses its general and specific program authorizations, as well as the appropriated funds it
receives, to administer programs focused on a wide array of health topics, including infectious
diseases, chronic diseases, injury, disability, occupational health, environmental health, and public
health emergency preparedness and response. Most of CDC’s domestic programs fall within three
main categories: (1) support to SLTT health agencies; (2) science and data; and (3) health
education and guidance. The discussion below is not exhaustive of all CDC programs but is
intended to provide an illustrative view of CDC programs and their scope.
CDC also provides assistance to international governments and organizations through its global
health programs, which are not a focus of this report. For more information on CDC global health
programs, see CRS In Focus IF11758, U.S. Global Health Funding: FY2020-FY2023
Appropriations.
Support to SLTT Public Health Agencies
Since CDC’s inception, one of its primary functions has been to support public health agencies at
the SLTT levels. CDC supports these agencies in all areas of public health through technical
assistance, guidance, leadership, convenings, funding (primarily through grants, as discussed in
the next section), and other material assistance. CDC staff can provide support during outbreaks
and other emergencies, including by investigating and responding to threats. For example,
through CDC’s Epidemiologic Assistance program, SLTT public health agencies can request that
EIS officers help investigate public health problems such as “infectious and noninfectious disease
outbreaks, unexplained illnesses, or natural or manmade disasters.”159 CDC also administers
158 CDC, “FY2024 President’s Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC-
Budget-Detail.pdf.
159 CDC, “Epidemiologic Assistance,” https://www.cdc.gov/eis/request-services/epiaids.html.
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several fellowship and workforce programs to fund staff at SLTT agencies. CDC staff may also
take temporary placement positions within SLTT agencies.
Major Grant and Assistance Programs
CDC administers numerous programs that provide funding or other assistance to SLTT health
agencies. In FY2022, CDC obligated a total of $10.3 billion in financial assistance to states and
territories. This total includes some direct funding to local governments or organizations within
states and some American Rescue Plan Act and other supplemental funding.160 Of this total, $4.2
billion was spent on direct assistance through the Vaccines for Children program.
Under this Medicaid-financed program, CDC
purchases recommended childhood vaccines at
a negotiated discounted rate and then
distributes them to SLTT public health
agencies to provide to eligible children (see
the “Vaccines for Children” section).161
Resources for CDC Grants
CDC’s grant funding profiles webpage provides
summaries of CDC grant funding by state:
https://fundingprofiles.cdc.gov/.
HHS also makes available detailed grant data in its
Tracking Accountability in Government Grants System
(TAGGS). Users can explore HHS grant data by agency
(operating division), state, recipient, activity type, and
other criteria: https://taggs.hhs.gov/.
Available CDC grant opportunities are posted at
grants.gov. See CDC, “Grants: How to Apply,”
https://cdc.gov/grants/applying/index.html.
CDC also funds many grant programs that
finance the public health programs of SLTT
government agencies. Some grant programs,
such as the Public Health Emergency
Preparedness (PHEP) cooperative agreement
program and the Preventive Health and Health
Services Block Grant program, provide public health funding to all states, territories, and selected
local jurisdictions. Others provide funding on a competitive basis to a subset of SLTT agencies.
Most CDC grants are awarded to states or territories that are then responsible for distributing
funds within their jurisdictions, although some CDC grants are awarded directly to local or tribal
agencies. CDC administers many of its grant programs with SLTT agencies as cooperative
agreement programs, where CDC staff have substantial involvement with the grantee in program
implementation.
Table 2 summarizes the 10 largest CDC grant programs by funding amount in FY2022. These
grant awards were funded by both regular and supplemental appropriations (especially American
Rescue Plan Act appropriations). In many cases, CDC used appropriations from several different
appropriations accounts and budget lines to fund a single program.
160 CDC, “CDC Fiscal Year 2022 Grant Funding by State,” https://fundingprofiles.cdc.gov/.
161 Amount based on CRS analysis of CDC funding data.
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Table 2. Top 10 CDC Grant Programs, by Funding Amount in FY2022
Funded by regular and supplemental appropriations
Program Name and Description
2022 Recipients
Epidemiology and Laboratory
Capacity for Prevention and
Control of Emerging Infectious
Diseases (ELC) Cooperative
Agreement: Supports SLTT health
department capacity to detect, prevent,
and respond to infectious diseases.
Grant programs consists of several
components, including subprojects to
specific jurisdictions focused on specific
topics (e.g., parasitic diseases, mycotic
diseases). A large portion of COVID-19
relief grant funding was awarded
through this mechanism.
64 total: 50 states, eight
territories and freely
associated states (T/FAS), the
District of Columbia (DC), and
five cities (recipients vary by
subaward within larger grant
program).
Public Health Emergency
Preparedness (PHEP)
Cooperative Agreement:
Strengthens public health preparedness
and response capabilities of SLTT
public health departments, including,
for example, coordination of
emergency response, distribution of
medical countermeasures (e.g.,
vaccines), and sharing of emergency
information.
62 total: 50 states, eight T/FAS, PHSA §319C-1 [42
DC, and three cities.
U.S.C. §247d-3a]
$649 million
Immunization Cooperative
Agreements: Supports infrastructure
for immunization programs, including
vaccination clinic operations; education
and awareness; vaccine storage and
delivery systems; data systems;
provider outreach and training; and
some vaccine purchase for the
uninsured and underinsured.
64 total: 50 states, eight T/FAS, PHSA §317 [42 U.S.C.
DC, and five cities.
§247b] and SSA §1928
(Vaccines for Children
program) [42 U.S.C.
§1396s]
$462 million
Integrated HIV Surveillance and
Prevention Programs for Health
Departments: Supports
comprehensive HIV surveillance and
prevention programs aimed at
preventing new infections and
improving health outcomes for those
with HIV. Funded activities can include
HIV testing and case reporting;
investigation of clusters and outbreaks;
linkage to HIV care and services; and
other prevention programs (e.g.,
condom distribution, education and
awareness).
60 total: 50 states, DC, Puerto
Rico, and the U.S. Virgin
Islands, and six local health
departments.
$378 million
Congressional Research Service
Authorizationsa
FY2022
Funding
(rounded)
General: PHSA
$1.018 billion
§§301(a) and 317(k)(2)
[42 U.S.C. §§241(a) and
247b(k)(2)]
ELC-specific: PHSA
§2821 [42 U.S.C.
§300hh-31]
Prevention and Public
Health Fund: ACA
§4002 [42 U.S.C.
§300u–1]
PHSA §318 [42 U.S.C.
§247c]
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Program Name and Description
2022 Recipients
Strengthening Public Health
Systems and Services through
National Partnerships to Improve
and Protect the Nation’s Health:
Funds national organizations to provide
capacity-building assistance to the U.S.
public health system.
39 national organizations
(mostly nonprofit
organizations).
Strengthening STD Prevention
and Control for Health
Departments: Supports sexually
transmitted disease prevention and
control activities, including screening,
surveillance, outbreak response, linkage
to care, and other prevention and
control activities.
59 total: 50 states, DC, Puerto
Rico, the U.S. Virgin Islands,
and six local health
departments.
PHSA §318 [42 U.S.C.
§247c]
$298 million
Overdose Data to Action: Supports
surveillance on fatal and nonfatal drug
overdoses, along with activities to use
data to inform outreach and
prevention.
66 total: 48 states, DC, 15
localities, and two territories.
PHSA §311 [42 U.S.C.
§243]
$251 million
Cancer Prevention and Control
Programs for State, Territorial,
and Tribal Organizations: Funds
several CDC cancer prevention and
control programs, including (1)
National Breast and Cervical Cancer
Early Detection Program (NBCCEDP),
which supports breast and cervical
cancer screenings and other clinical
services for women who are uninsured
or underinsured; (2) the National
Comprehensive Cancer Control
Program (NCCCP), which supports
jurisdiction-based cancer programs in
formulating and implementing
jurisdiction-wide cancer plans; and (3)
the National Program of Cancer
Registries (NCPR), which funds and
supports cancer registries that collect
data on cancer cases.
NBCCEDP (71 total): 50
states, DC, seven T/FAS, and
13 tribes.
NBCCEDP; PHSA
§§1501-1508 and 1510
[42 U.S.C. §§300k300n-4 and 300n-5]
$214 million
NCCCP (66 total): 50 states,
DC, eight T/FAS, and seven
tribes.
NCCCP: PHSA §317
[42 U.S.C. §247b]
NCPR: 47 states, DC, and
three T/FAS.
NPCR: PHSA §§399B399F(a) [42 U.S.C.
§§280e-280e-4(a)]
Preventive Health and Health
Services Block Grant: Block grant
program allows jurisdictions to use
flexible funding to meet their own
unique public health needs and
challenges. Some block grant funding is
reserved for rape prevention and
education activities.
61 total: 50 states, DC, eight
T/FAS, and two tribes.
PHSA Title XIX, part A $146 million
[42 U.S.C. Chapter 6A,
Subchapter XVII, Part
A]
Congressional Research Service
Authorizationsa
FY2022
Funding
(rounded)
General: PHSA
$375 million
§§317(k)(2) and 307 [42
U.S.C. §§247b(k)(2) and
242l]
Prevention and Public
Health Fund: ACA
§4002 [42 U.S.C.
§300u–1]
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Centers for Disease Control and Prevention (CDC): History, Overview, and Issues
Program Name and Description
2022 Recipients
Authorizationsa
Integrated HIV Programs for
Health Departments to Support
Ending the HIV Epidemic in the
United States: Funds mostly local
jurisdictions as a part of the Ending the
HIV Epidemic initiative. The grants are
meant to complement other CDC HIV
grants and specifically support
increased testing, linkage to HIV
treatment, and prevention, such as
facilitating pre-exposure prophylaxis
treatment in local areas that account
for more than half of new HIV
diagnoses.
57 total: 48 counties, DC, San
Juan, Puerto Rico, and seven
states.
PHSA §318 [42 U.S.C.
§247c]
FY2022
Funding
(rounded)
$120 million
Source: Funding data from CDC, “Grant Funding Profiles,” https://fundingprofiles.cdc.gov/. Other table
information from cdc.gov webpages and from grants.gov.
a. For consistency, CRS excluded appropriations laws when cited as a statutory basis for a particular program
(not all source materials cited appropriations consistently).
Public Health Workforce
CDC offers a variety of internships, fellowships, and training opportunities for students and
professionals in public health. Programs include fellowships for public health laboratory
professionals, epidemiologists, informaticians, and other public health disciplines. These fellows
often serve in SLTT health departments and other public health organizations. Prominent CDC
fellowship and workforce programs include the EIS and CDC’s Public Health Associate
Program.162
CDC program grants are also commonly used to pay for SLTT public health staffing and
workforce development. The American Rescue Plan Act of 2021 (ARPA)163 provided $7.7 billion
for public health workforce programs.164 HHS allocated these funds for many purposes, including
to support several new and existing CDC programs.165 CDC used a large portion of this funding,
combined with regular appropriations, to fund a new Public Health Infrastructure Grant program
in FY2023. Through this program, CDC awarded $3.7 billion to 107 health departments in all 50
states, Washington, DC, eight territories and freely associated states, and 48 large localities.166
Recipients are to use this award to hire and retain public health staff, strengthen organization
systems and processes, and modernize public health data systems.167 State health department
recipients are expected to distribute a portion of grant funds for public health workforce among
162 CDC, “Fellowships and Training Opportunities,” https://www.cdc.gov/fellowships/index.html.
163 P.L. 117-2
164 P.L. 117-2 § 2501
165 The White House, “FACT SHEET: Biden-Harris Administration to Invest $7 Billion from American Rescue Plan to
Hire and Train Public Health Workers in Response to COVID-19,” press release, May 13, 2021,
https://www.whitehouse.gov/briefing-room/statements-releases/2021/05/13/fact-sheet-biden-harris-administration-toinvest-7-billion-from-american-rescue-plan-to-hire-and-train-public-health-workers-in-response-to-covid-19/.
166 CDC, “Public Health Infrastructure Grant: Recipients,” https://www.cdc.gov/infrastructure/phig/fundedjurisdictions.html.
167 CDC, “Public Health Infrastructure Grant: Grant Overview,” https://www.cdc.gov/infrastructure/phig/programoverview.html.
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local health departments that did not receive direct grant funding from CDC.168 Given this fiveyear grant is funded by a one-time appropriation from the ARPA, funds may no longer be
available to support hired staff at the end of the five-year period.
CDC and the U.S. Public Health System
In the U.S. federalist system of government, SLTT governments are often at the forefront of public health. One of
CDC’s primary functions is to support the U.S. public health system at the SLTT level. State law provides the basis
for many public health authorities in the United States, such as authorities to require quarantine and isolation or
to mandate reporting of certain disease cases. Many public health programs are based at the local level, including,
for example, vaccination programs and programs to inspect the health and safety of food service establishments.
Over the course of the 20th and 21st centuries, the scope of SLTT public health agencies evolved similarly to how
CDC evolved (sometimes as funded by CDC grants). U.S. jurisdictions vary considerably in how public health
functions are organized among state and local governments, as do the scope of their public health activities.
Today, all states (including territories and DC) have a state health agency led by a state health official. All state
health agencies engage in public health activities, some through a freestanding public health agency and others as a
part of a combined health and human services agency. In addition, as of 2019, there were approximately 2,800
local health departments in the United States. U.S. public health agencies vary in terms of their governance
structures. Some states have a centralized public health system, where the state government has primary authority
and responsibility for public health throughout the state. The majority of states have a decentralized public health
system, where local governments have primary authority and responsibility for public health (but are often still
responsible for implementing state laws). Other states have mixed or shared governance arrangements for public
health, where state and local governments share responsibility and authority in public health. In many cases, CDC
has a primary funding and programmatic relationship with state health agencies. Local agencies can receive passthrough CDC grant funding from their states.
State and local public health agencies vary considerably in the scope of their activities. Virtually all state public
health agencies engage in population health activities such as infectious disease control, public health emergency
preparedness and response, epidemiology, surveillance, and prevention programs. Some state and local health
agencies have a significant health care safety net mission, and therefore they have a large focus on supporting
health care services for uninsured and underinsured populations. In other states, the health department may rely
other types of providers to provide safety net services, such as community health centers. State and local
jurisdictions also vary in terms of their priorities, especially the types of health problems that public health
agencies are funded and empowered to address.
Sources: CDC, “Health Department Governance,” https://www.cdc.gov/publichealthgateway/sitesgovernance/
index.html; Association of State and Territorial Health Officials (ASTHO), “State Health Agency Activities: Why
Agencies May Not Provide the Same Services,” 2019, https://www.astho.org/globalassets/pdf/state-health-agencyactivities-why-agencies-may-not-provide-the-same-services.pdf; and National Association of County and City
Health Officials (NACCHO), “National Profile of Local Health Departments: 2019,” https://www.naccho.org/
uploads/downloadable-resources/Programs/Public-Health-Infrastructure/NACCHO_2019_Profile_final.pdf.
Science and Data
CDC supports research and investigation into health challenges, generally with a focus on how
they can be prevented and controlled. CDC research explores the distribution and prevalence of
health problems and contributing risk factors within populations. CDC research also commonly
evaluates the potential interventions to address those risk factors. CDC researchers and scientists
come from diverse disciplines, including, for example, epidemiology, veterinary science,
microbiology, engineering, economics, social and behavioral sciences, and statistics.169 Many
CDC research articles are published in the agency’s Morbidity and Mortality Weekly Report. CDC
also awards some research grants and contracts to universities and other research institutions.
168 CDC, Strengthening U.S. Public Health Infrastructure, Workforce, and Data Systems (CDC-RFA-OE22-2203),
CDC-RFA-OE22-2203, August 15, 2022.
169 Lisa M. Lee and Tanja Popovic, “Preface: 60 Years of Public Health Science at CDC,” MMWR, vol. 55 (SUP02),
no. 1 (December 22, 2006).
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In addition, CDC supports laboratory science to aid with detecting and investigating infectious
diseases and other health threats. CDC manages federal laboratories that can perform specialized
testing to detect new or unusual diseases. CDC also plays a significant role in informing the
practices and capacities of the nation’s network of public health laboratories. This includes CDC’s
role in overseeing the Laboratory Response Network (LRN)—a network of laboratories at the
federal, state, and local levels that can detect biological, chemical, and other threats, including
emerging infectious diseases. (Not all public health laboratories are LRN laboratories.) CDC
develops laboratory test kits, protocols, and best practices, and it distributes test kits and supplies
to LRN and other public health laboratories. Several grant programs can also support public
health laboratory operations and testing.170
To facilitate public health research and science, CDC has many programs for collecting and
analyzing health data. CDC uses the data in its own research and makes data available to outside
researchers and sometimes the general public. CDC’s data collection programs generally fall into
two categories: surveillance systems and surveys.
Surveillance Systems
Public health surveillance is “the ongoing, systematic collection, analysis, and interpretation of
health-related data essential to planning, implementation, and evaluation of public health
practice.” CDC operates over 100 surveillance systems that collect data on an ongoing basis.171
Table 3 provides an illustrative summary of selected CDC surveillance systems. CDC often
receives its data from SLTT health departments, mostly on a voluntary basis through data-sharing
agreements with those agencies.172 SLTT health agencies generally collect public health data
based on their own legal requirements and policies.173 Many CDC grants support SLTT
surveillance activities. The data CDC receives, which typically do not include personally
identifiable information, help inform an understanding of when, how, where, and to whom
disease cases and other health events occur at a population level.
170
For an overview of public health laboratory systems, see Jay K. Varma, Jill Taylor, and Joshua M. Sharfstein,
“Planning for The Next Pandemic: Lab Systems Need Policy Shift To Speed Emerging Infectious Disease Warning
And Tracking,” Health Affairs, vol. 42, no. 3 (March 2023).
171 CDC, Public Health Surveillance: Preparing for the Future, September 2018, https://stacks.cdc.gov/view/cdc/
58736.
172 CDC, “Public Health Surveillance and Data: Where Does our Data Come From?” 2023, https://www.cdc.gov/
surveillance/data-modernization/basics/where_does_our_data_come_from.html?CDC_AA_refVal=
https%3A%2F%2Fwww.cdc.gov%2Fsurveillance%2Fprojects%2Fdmiinitiative%2Fwhere_does_our_data_come_from.html.
173 Association of State and Territorial Health Officials (ASTHO), Legal Landscape of Public Health Data, March
2023, https://www.astho.org/globalassets/report/legal-landscape-of-ph-data-scan-of-state-laws.pdf.
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Table 3. Selected CDC Surveillance Systems
Surveillance
System
Statutory
Authorizations
Type of
Primary Data
Reporting
Mechanism
National Notifiable
Diseases
Surveillance System
Public Health
Service Act (PHSA)
Section 301 [42
U.S.C. §241]
Nationally notifiable
disease cases
(infectious and
noninfectious
conditions)
reported using a
standardized case
definition.
SLTT health
departments report
de-identified cases
to CDC.
(Laboratories and
health care
providers report to
health departments
pursuant to state
reporting laws.)
System allows for
monitoring and
control of certain
infectious and some
noninfectious
diseases and
conditions. Data
include
demographic, health
information, and
exposure history
for confirmed cases.
National Syndromic
Surveillance
Program
PHSA Section 319D
[42 U.S.C. §247b]
Algorithms analyze
de-identified
electronic health
record data on
patient symptoms
and other health
indicators to
monitor health
trends (does not
require reporting of
specific cases).
Systems operated
by state and local
health departments,
as well as the
Department of
Defense (DOD) and
the Department of
Veterans Affairs
(VA), that report to
CDC using
BioSense platform.
System allows for
real-time
monitoring and
control of a variety
of diseases and
conditions.
Currently used for
diverse purposes,
including responses
to the COVID-19
pandemic, influenza,
drug overdoses,
suicide, health
effects of natural
disasters, and
foodborne illness
outbreaks, among
others.
(Data provided
from outpatient
health care
providers in all 50
states, Puerto Rico,
the District of
Columbia, and the
U.S. Virgin Islands.)
Purpose
National Vital
Statistics System
PHSA Section 306
[42 U.S.C. §242k]
Records of deaths,
births, and fetal
deaths.
SLTT vital records
offices report to
CDC.
Records include
information that is
used in national
health statistics. For
example, death
records include
information on
underlying cause of
death and
contributing causes
of death.
National Violent
Death Reporting
System
PHSA Section 301
[42 U.S.C. §241]
and PHSA Section
392(a)(1) [42 U.S.C.
§280b-0(a)(1)]
Data on violent
deaths, including
type of death (i.e.,
homicide, suicide),
method,
relationship
between
perpetrator and
victim, demographic
information, and
more.
State-based
programs compile
data based on death
certificates, law
enforcement
records, and
medical
examiner/coroner
reports for
submission to
CDC’s database.
Data help provide
greater
understanding of
violent deaths and
the circumstances
surrounding them in
order to inform
prevention and
research at national,
state, and local
levels.
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Surveillance
System
Statutory
Authorizations
Type of
Primary Data
Reporting
Mechanism
Behavioral Risk
Factor Surveillance
System
PHSA Section 301
[42 U.S.C. §241]
Survey data on
health-related risk
behaviors, chronic
health conditions,
use of preventive
health services, and
other health issues.
States administer
BFRSS survey
collection from
households in
accordance with
program guidelines.
All states administer
core questionnaire
annually. Certain
survey modules are
optional. States use
data to inform their
public health
planning. National
data measures
progress against
national health goals
(Healthy People)
and used for
research.
National
Respiratory and
Enteric Virus
Surveillance System
PHSA Section 301
[42 U.S.C. §241]
Data on testing for
viruses, including
coronaviruses,
rotavirus, norovirus,
respiratory syncytial
virus (RSV), and
others.
Participating
laboratories,
including clinical and
public health
laboratories,
voluntarily share
data.
System helps
monitor the spread
of viruses and types
circulating.
National Program of
Cancer Registries
PHSA Section 301
[42 U.S.C. §241]
and Part M of PHSA
Title III [42 U.S.C.
§280e et. seq.]
Cancer registry data
include information
on patient
demographics,
occupational
history, health
history, cancer type,
treatment(s)
received, and
patient outcomes,
among other
information.
Health department
cancer registries
report de-identified
data to CDC.
Cancer registry data
allows for
monitoring cancer
trends and
informing research
about cancer,
including its cause,
prevention, and
appropriate
treatment.
(Health care facility
cancer registrars
report data to
health departmentrun cancer
registries.)
Purpose
Source: CRS analysis based on CDC websites and grant guidance documents, the Office of Management and
Budget’s Information Collection Review, Federal Register notices, and other public health literature and policy
publications.
Health Surveys
CDC also administers many surveys, including national population health surveys such as the
National Health Interview Survey and surveys of health care providers. CDC’s National Center
for Health Statistics is one of 13 principal federal statistical agencies (or units).174
In a population-based health survey, respondents (or a knowledgeable proxy) report information
about themselves or about all the people in a household.175 Population-based surveys can include
biological samples for testing, such as blood samples. There is overlap between surveillance
174 Office of Management and Budget, “Statistical Programs of the United States Government: Fiscal Years,
2021/2022,” https://www.whitehouse.gov/wp-content/uploads/2024/02/statistical-programs-20212022.pdf.
175 See section “Implementation Guidance” in HHS Office of the Assistant Secretary for Planning and Evaluation,
“HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and
Disability Status,” https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicitysex-primary-language-disability-0.
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systems and surveys. Some surveillance systems involve population-based surveys (e.g., BRFSS).
However, not all CDC health surveys are considered surveillance systems.
Table 4. Selected CDC Surveys
Survey
CDC CIO
Design
Summary
National Health
Interview Survey
National Center
for Health
Statistics
Household
interview survey.
Nationally
representative
sample.
Survey provides the “[p]rincipal source of
information on the health of the civilian
noninstitutionalized population of the United
States.” Includes questions on a broad range of
health topics along with demographic and
socioeconomic characteristics of the
respondents.
National Health
and Nutrition
Examination Survey
National Center
for Health
Statistics
Survey on adults
and children that
includes interviews
and physical
examinations and
clinical tests.
Nationally
representative
sample.
Survey assesses chronic and other conditions,
health behaviors, risk factors, and
demographic characteristics. Physical
examinations include body measurements,
blood samples, and dental screenings, along
with other tests and procedures depending on
interviewee characteristics (e.g., sex and age).
National Survey of
Family Growth
National Center
for Health
Statistics
Interview-based
survey of adult
women and men
(aged 15-49).
Nationally
representative
sample.
Survey gathers information on pregnancy,
births, marriage and cohabitation, and
reproductive health.
National PostAcute and LongTerm Care Study
National Center
for Health
Statistics
Mail, web, and
telephone surveys
of directors of
adult day care and
residential care
facilities, along with
administrative data.
Survey assesses geographic and operating
characteristics, services, practices, and staffing.
Also includes characteristics of population
served.
Behavioral Risk
Factor Surveillance
System
National Center
for Chronic
Disease Prevention
and Health
Promotion
Telephone-based,
state-administered
survey. All 50
states, D.C. and
three territories
participate.
Survey collects information on health-related
risk behaviors, chronic health conditions, use
of preventive health services, and other health
issues.
National Youth
Tobacco Survey
National Center
for Chronic
Disease Prevention
and Health
Promotion
School-based
survey of middle
and high school
students.
Nationally
representative
sample.
Survey includes measures on tobacco-related
behaviors, attitudes, beliefs, and exposure to
related influences.
Youth Risk
Behavior
Surveillance System
National Center
for HIV/AIDS, Viral
Hepatitis, STD, and
TB Prevention
CDC- and SLTTadministered,
school-based
survey of high
school students.
Nationally
representative
sample.
Survey collects information on, among other
topics, health risk behaviors, including tobacco
use; dietary behaviors; physical activity; alcohol
and other drug use; sexual behaviors; and
violence-related behaviors, along with
demographic information on students.
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Survey
CDC CIO
Design
Summary
Pregnancy Risk
Assessment
Monitoring System
National Center
for Chronic
Disease Prevention
and Health
Promotion
Participating SLTT
agencies conduct a
mail- and
telephone-based
survey of women
who have had a
recent live birth
(according to birth
certificate files).
Currently, 46
states, DC, New
York City,
Northern Mariana
Islands, and Puerto
Rico participate.
Survey asks new mothers about their
behaviors and experiences before, during, and
after pregnancy, as well as the health of their
infant.
Source: CRS analysis based on CDC and HHS websites, the Office of Management and Budget’s Information
Collection Review, Federal Register notices, and other public health literature and policy publications.
Health Education and Guidance
CDC conducts education and outreach to many audiences, including the general public,
clinicians, and public health practitioners, among others. For example, through its Health Alert
Network (HAN), CDC can rapidly share information about urgent public health threats with
public information officers, federal and SLTT public health practitioners, and clinicians and
public health laboratories.176 CDC has used the HAN system to issue alerts about diverse health
issues, including, but not limited to, rising fentanyl deaths, emerging infectious diseases,
recommended health care sanitation procedures, medical product shortages (and associated
clinical practice recommendations), and the health effects of natural disasters.177
CDC also regularly develops educational materials for SLTT agencies, health care providers, and
the general public. Health education is a component of almost all of CDC’s programs related to
specific diseases and health issues.178 CDC informs the science and practice of public health
communication as a part of its mission as well.179
In addition, CDC develops public health and clinical guidelines based on its expertise in health
science and practice. As official recommendations, CDC guidelines are generally not legally
binding. Some of CDC’s guidelines play a significant role in federal health policy. For example,
CDC’s Advisory Committee on Immunization Practices (ACIP), made up of nonfederal experts
and representatives, makes guidelines and recommendations regarding the use of vaccines and
related agents. Based on these recommendations, CDC develops the child and adult immunization
schedules of routinely recommended vaccines. ACIP recommendations also inform which
vaccines are provided through the Vaccines for Children program (see the “Vaccines for
Children” section). ACIP’s recommendations also serve as the basis for several statutory health
176 CDC, “Health Alert Network (HAN),” https://emergency.cdc.gov/han/index.asp.
177 See CDC, “Health Alert Network (HAN) Archive,” https://emergency.cdc.gov/han/dir.asp.
178 See program descriptions in CDC, FY2024 Congressional Justification, https://www.cdc.gov/budget/documents/
fy2024/FY-2024-CDC-congressional-justification.pdf.
179 See, for example, CDC, “Crisis & Emergency Risk Communication (CERC),” https://emergency.cdc.gov/cerc/.
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care coverage requirements for vaccines, including for private health insurance, Medicaid,
Medicare Part D, and the State Children’s Health Insurance Program.180
CDC also develops and disseminates information on public health and clinical best practices, for
example, for youth violence prevention programs or for health care provider conversations about
vaccines with patients.181
Regulations
CDC is not primarily a regulatory agency. Administering and enforcing regulations is not a main
activity for the agency. As discussed below, however, CDC administers regulations in a few areas:
Medical examination of immigrants
and refugees. In 42 C.F.R. Part 34,
CDC has developed the medical
examination and vaccination
requirements for noncitizens seeking
to enter the United States as
immigrants or refugees. These
regulations are based on provisions of
the PHSA and the Immigration and
Nationality Act.
Quarantinable Communicable Diseases
The below list of quarantinable communicable diseases is
established by Executive Order (E.O.) 13295:
•
Cholera
•
Diphtheria
•
Infectious tuberculosis
•
Plague
•
Smallpox
•
Yellow fever
•
Viral hemorrhagic fevers
Interstate and foreign quarantine of
people. PHSA Sections 361 through
•
Severe acute respiratory syndromes
369 grant the HHS Secretary certain
•
Flu that can cause a pandemic
authorities to control the spread of
•
Measles
communicable diseases, including
This E.O. was first established by President Bush in 2003 and
through federal quarantine and
then amended in 2005 (E.O. 13375), in 2014 (E.O. 13674), and in
inspection. Based on these provisions,
2021 (E.O. 14047).
CDC administers separate regulations
for interstate and foreign quarantine in 42 C.F.R. Parts 70 and 71, respectively.182 These
regulations, for instance, specify the conditions under which the CDC Director may authorize the
apprehension, medical examination, quarantine, or isolation of an individual with or exposed to
certain communicable diseases—known as quarantinable communicable diseases—who is
traveling into the United States or between states.183 Quarantinable communicable diseases are
established by executive order, as explained in the text box above. The regulations also authorize
CDC to take action in the event that state or local control of a communicable disease is deemed
inadequate to prevent its spread. Such actions may include “measures to prevent such spread of
the diseases as [the CDC Director] deems reasonably necessary, including inspection, fumigation,
180 CRS In Focus IF12317, The Advisory Committee on Immunization Practices (ACIP).
181 See CDC, “Violence Prevention in Practice,” https://vetoviolence.cdc.gov/apps/violence-prevention-practice/#!/;
and CDC, “Talking with Patients about COVID-19 Vaccination,” https://www.cdc.gov/vaccines/covid-19/hcp/
engaging-patients.html.
182 Part of the federal quarantine and isolation authority over animals and other products that may transmit or spread
communicable diseases is delegated to the Food and Drug Administration. See 65 Federal Register 49,906 (Aug. 16,
2000).
183 42 C.F.R. §§70.12–70.17.
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disinfection, sanitation, pest extermination, and destruction of animals or articles believed to be
sources of infection.”184
Importation of human remains, certain animals, and infectious biological materials. CDC
administers several regulations aimed at preventing and controlling the spread of infectious
diseases from imported materials, including from human remains, certain animals, and infectious
biological materials.185 These regulations are all part of 42 C.F.R. Part 71, the foreign quarantine
regulations mentioned above.
Federal Select Agent Program. CDC, along with the U.S. Department of Agriculture,
administers the Federal Select Agent Program (FSAP), which regulates the possession, use, and
transfer of select biological agents and toxins that have potential to pose a public health
threat.186As part of the FSAP, CDC publishes and updates a list of select agents and toxins
regulated under the program. Regulated entities are typically laboratories that use these select
agents in research. The statutory authorization for the program was established in the Public
Health Security and Bioterrorism Preparedness and Response Act of 2002.187
Occupational Safety and Health Regulations. CDC’s NIOSH administers several regulations
related to occupational health. For example, 42 C.F.R. Part 37 requires coal mine operators to
provide medical examinations to coal miners, as authorized in the Federal Mine Safety and
Health Act of 1977.188 As another example, NIOSH regulates respiratory protective devices, such
as N95 respirators, in 42 C.F.R. Part 84.189
Mandatory Health Services Programs
CDC administers two large health services programs funded by mandatory budget authorities: the
Vaccines for Children program and the World Trade Center Health Program.
Vaccines for Children
The Vaccines for Children (VFC) program is a Medicaid-financed and CDC-administered
program to provide recommended childhood vaccines at no cost to eligible children.190 The
Advisory Committee on Immunization Practices determines the list of VFC vaccines through
VFC-ACIP Vaccine Resolutions.191
Through VFC, CDC purchases recommended childhood vaccines at a federally negotiated
discounted rate. These vaccines are then distributed to SLTT health agencies to further distribute
to participating providers.192 CDC also provides a portion of VFC funding to states for program
184 42 C.F.R. §70.2.
See CDC, “Importation: Laws and Regulations,” https://www.cdc.gov/importation/laws-and-regulations/index.html,
and, for example, 42 C.F.R. §71.32, 42 C.F.R. §71.53, 42 C.F.R. §71.54 42 C.F.R. §71.55, 42 C.F.R. §71.56.
186 See 42 C.F.R. Part 73 for CDC’s FSAP regulations.
187 P.L. 107-188, which added PHSA Section 351A (42 U.S.C. §262a).
188 P.L. 95-164, as amended.
189 For a full list of NIOSH regulations, see https://www.cdc.gov/niosh/regulations.html.
190 The program is authorized in Social Security Act Section 1928 (42 U.S.C. §1396s).
191 These resolutions are separate from other ACIP recommendations. See CDC, “VFC-ACIP Vaccine Resolutions,”
https://www.cdc.gov/vaccines/programs/vfc/providers/resolutions.html.
192 CDC, “About VFC,” https://www.cdc.gov/vaccines/programs/vfc/about/index.html.
185
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administration through the Immunization Cooperative Agreement program (in addition to
discretionary funding), a grant program that supports state immunization programs.193
Children eligible to receive VFC vaccines include those who are (1) Medicaid eligible; (2) not
insured; (3) without adequate insurance and who are receiving a vaccine at a federally qualified
health center or a rural health clinic; and (4) American Indian or Alaska Native.194 Participating
providers cannot charge patients for the cost of VFC vaccines. Providers may charge patients a
fee for vaccine administration as determined by the HHS Secretary, but they cannot deny a
vaccine due to inability to pay the fee.195
Like other Medicaid programs, VFC is an appropriated entitlement program, meaning that funds
are provided through annual appropriations but actual program spending is based on need and
eligibility. In FY2022, the VFC program spent a total of $5.54 billion.196
World Trade Center Health Program197
The World Trade Center Health Program (WTCHP), administered by NIOSH, provides medical
monitoring and treatment for certain conditions related to health exposures from the September
11, 2001, terrorist attacks in New York City, at the Pentagon, and in Shanksville, PA. The
program currently serves over 110,000 responders and survivors from the attacks. In addition, the
program supports some medical research related to 9/11 health exposures.198
To be covered by the program, individuals must meet eligibility criteria and be certified as having
a covered condition related to 9/11 exposure. Current categories of covered conditions include (1)
acute traumatic injuries, (2) airway and
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