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suitable matrix for every situation, but it seems to me like the innovative use of some of those facilities on Saturdays periodically would make a lot of sense.

Now in that connection you and I also had a discussion about something that the President of the United States himself brought up yesterday and something I have been talking about, and it will be something that will not be without controversy but I think just based on a superficial examination of it, it makes sense.

The President said yesterday that if we are going to stop the development of these pools of the measles virus, for example, that one way to do it is to say to the mother before you are entitled to draw AFDC payments or food stamps you must certify that this child has been immunized?

Now there are a lot of people who would take strong exception to that and argue that you are going to starve these mothers of food and so on simply because you are holding their children hostage to these vaccines. As you and I know, we do not deprive children of an education, and yet we require them to be immunized before they start to school.

It seems to me that we are going to have to use some kind of a mechanism here to get to the people who do not have transportation, who cannot get to the clinics when they are open, all those problems they have—and I recognize they are big problems. If we are ever going to do that, we are also going to have to provide easy access to the clinics for those people.

What are your thoughts about this? Have you communicated this to the President? Is that the reason he mentioned it yesterday?

Dr. ROPER. I am delighted to have your question, sir. Thank you.

On your first point about the need to have immunization programs available to parents, it is surely the case. Just to give you a personal example, my little boy who is 25 months old is getting immunized today back in Atlanta. My wife is taking off from work to take him, and she has the capability since she works less than full time to do that. But that is a real burden, a real obstacle for a lot of people.

Public programs need to offer weekend and night services, the sort of things you have outlined, because we have an obligation to make vaccines available without barriers, whether timeliness or financial barriers or whatever. We need to make sure parents can immunize their children.

Then there is the other part of your question. We need to make sure this is a priority for parents. I had the opportunity to testify before Mr. Waxman over in the House yesterday on the very point you made. Rather than restate our position, you stated it very eloquently and I will just say it makes good sense to me. I think the American people would have a hard time understanding why we do not use these other public programs as avenues to get young children immunized.

We need to do our part and make sure that the vaccine is there and that transportation is available at a time that is convenient and all those kind of things, but I have no problem saying we expect parents to immunize their children.

If I could stick my neck out on your earlier point, I think we ought to demand that parents immunize their children. I think, as a pediatrician, that ought to be society's expectation, that all children are immunized.

Senator BUMPERS. I could not agree with you more. The measles cases in this country, I do not want to call it an outrage but it is shameful for a Nation as rich as ours to allow these outbreaks to happen, and particularly to allow them to continue.

Dr. ROPER. Let me just say, sir, CDC and I personally appreciate your leadership in the Congress on the immunization programs, and I am delighted to hear your sentiments on this issue. We want to take the ball and run with it.

H FLU VACCINES

Senator BUMPERS. Thank you very much. Are we going to have a shortfall on H flu vaccines? Are you going to have enough money to buy H flu vaccines? We have moved from a one-dose to a fourdose regimen.

Dr. ROPER. This is a newly available vaccine, and it is becoming more widely used. We do not have the resources fully to immunize all children in the public sector within the current framework of the budget, but the field is changing as this vaccine now is more widely available. I am told it will take us

Senator BUMPERS. Staff tells me you are $5.8 million short in fiscal year 1991.

Dr. ROPER. Yes, sir; that is the figure I have just been given. That is how much we would be short.

Senator BUMPERS. If Congress provided that, could we use it?
Dr. ROPER. Yes, sir.
Senator BUMPERS. Do you think that would be highly desirable?

Dr. ROPER. It would be desirable. I would just have to give you a sense of priorities to say that our No. 1 priority is delivery of current vaccines. It is important to add new ones, but we need to get access to children and get the shots in their arm, and we are not doing that yet, as measles typifies.

HEPATITIS B Senator BUMPERS. As you know, I have also been strongly urging CDC along with the hepatitis B vaccines.

Dr. ROPER. Yes, sir.

Senator BUMPERS. We started this program, an incremental implementation, 2 years ago, I guess. You have been concentrating on high-risk mothers, notably those-is it the Pacific Islanders who are most susceptible to this? Is that correct?

Dr. ROPER. We have initiated a universal screening and vaccination program to reduce the perinatal transmission of hepatitis B. It is the populations from Asia typically who carry the virus more, and that is why they are at greatest risk and we have focused the program there, yes, sir.

COST OF IMMUNIZATION FOR HEPATITIS B Senator BUMPERS. You say it will cost $1 million to reach the highest risk infants, namely the Pacific Islanders, and $5 million for each additional 10 percent of the infant population that you want to immunize with hepatitis B. Is that correct?

Dr. ROPER. Yes, sir.
Senator BUMPERS. Do you have the money to do that?

Dr. ROPER. We have the money to do the beginning part of the program but not the further parts that you outlined.

Senator BUMPERS. How quickly could you move to implement the advisory committee's recommendation?

Dr. ROPER. The Advisory Committee on Immunization Practice has made a preliminary recommendation which we expect them to finalize in June on universal immunization of all American children against hepatitis B. If we were to begin on such a venture, it would take us, we project, 3 to 5 years fully to implement such an activity.

It is something that we want to be able to do. It will take additional resources, and, again, it requires us to construct an infrastructure that gets hold of the children so that we can immunize them. I do not know how to put it more eloquently, but we have just not yet figured a way to round up all the children in the country. Senator BUMPERS. At what age do you immunize for hepatitis B. Dr. ROPER. This would be newborns, sir. Senator BUMPERS. Newborns? Dr. ROPER. Yes, sir.

Senator BUMPERS. They should be immunized before they leave the hospital?

Dr. ROPER. Vaccinations could begin in the hospitals or at 2 months of age, along with their other infant vaccines.

Senator BUMPERS. Do you have any idea what the cost of that would be?

Dr. ROPER. We estimate that the first year cost of this universal infant immunization program would be about $ 15 million. As I indicated earlier, as a phased-in process over 3 to 5 years, first full year cost would be probably $50 or $60 million.

Senator BUMPERS. Do you agree that we should be moving in that direction?

Dr. ROPER. Yes, sir; I do. It is a sound recommendation that the advisory committee has given us. I have to say it will be a challenge for us to convince all new parents that their child has to be immunized against a disease that most of them have never heard of. So we have a real public education task ahead of us.

Senator BUMPERS. When you look at the incidence of that, it really is pretty staggering. When I started delving into that, I was amazed how many cases there were of it.

Dr. ROPER. The long-term toll of hepatitis B is very great, and it is preventable.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE Senator BUMPERS. Dr. Roper, thank you. Gentlemen, thank you very much for being with us this morning. Dr. ROPER. Thank you for your time. We appreciate it.

[The following questions were not asked at the hearing, but were submitted to the Department for response subsequent to the hearing:)

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

FARM HEALTH AND SAFETY / EDUCATION IN SCHOOLS

Question. states?

Should Surveillance be expanded to more rural

Answer. CDC is currently supporting six states to conduct surveillance identifying hazards to which agricultural workers are exposed, the circumstances of exposures, and the health status of these workers and their families. On April 30-May 3, 1991, CDC is sponsoring the "Surgeon General's Conference: Agricultural Safety and Health" to discuss these topics.

SMOKING AND HEALTH

Question. The FY 1992 budget requests $6,842,000 for smoking cessation programs, an increase of $3,503,000 over FY 1991. Approximately 50 million, or nearly 1 of every 3 American adults smoke. Moreover, there are 300,000 smoking related deaths each year and economic losses of smoking this year will exceed $65 billion. Do you think that this increase is adequate to meet your goals of reducing the incidence of smoking by the Year 2000?

Answer. This 105% increase in the 1992 budget request will enable activities to be undertaken in key areas that will substantially reduce the incidence of smoking by the Year 2000. These additional activities include:

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Strengthening the public health infrastructure to take
action against tobacco use. This includes, but is not
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Initiating target group-specific studies--to identify
and promote effective tobacco control approaches for
high-risk populations, such as minorities, women,
children, and adolescents, and blue collar workers.

Publicizing critical and needed information about
tobacco control.

As a society, we should be doing more to prevent tobacco use. Broad social and environmental changes are needed to reinforce the point that tobacco use is damaging to health--and for that reason, tobacco use is not acceptable in our society. Federal dollars alone will not achieve such change.

Question. This budget also includes $16,500,000 for infant mortality programs. One of the programs cited in your budget is technical assistance to reduce infant mortality rates associated with low birthweight. In as much as smoking doubles the risk of low-birth weight and increases the risk of still birth by up to 100%, would it not make sense to increase funding for smoking cessation programs to target women who smoke?

Answer. Smoking remains the single most preventable cause of death in the United States and causes 10 percent of infant mortality. In an attempt to reduce infant mortality rates associated with low birthweight, in FY 1991, we have increased our work in prenatal smoking cessation (PSC) activity by expanding the program to more states and providing technical assistance to others. In addition, HRSA is increasing its activities in this area. While smoking cessation programs can help in reducing infant mortality rates associated with low birthweight, we are also excited about the opportunity for our increased smoking cessation education activities to improve women's health as well as the health of low-income persons, teens, minorities, and others.

We believe these substantial increases indicate our high level of concern and intent in this area. The new monies available in the FY 1992 budget for CDC's infant mortality initiative are being targeted towards the other high priority activities of assisting the states to better understand the extent of their infant mortality problem, through improved surveillance. This is an area that has been highlighted as a need in both the White House Task Force report and the Interagency Committee on Infant Mortality recommendations for future activity.

IMMUNIZATION/INCENTIVE GRANTS

Question. Many state and local health departments have stated that they do not have the resources to improve immunization levels of children less than 24 months of age. Yet, the FY 1992 budget requests $20 million for Immunization Incentive Grants which will be awarded to those states that are doing a good job of immunization. Dr. Roper, do you think this is a good idea

it would seem to me that $20 million would be better spent in either helping states improve their immunization program or in increasing support for additional doses. What is the primary need?

Answer. While investigating outbreaks of measles in 1989 and 1990, we found the principal cause for the measles epidemic was failure to deliver vaccinations to at-risk preschool-aged children at the appropriate age, particularly in inner cities. In 1990, the proportion of cases in preschool-aged children increased to almost half, the highest proportion since the start of national data collection in 1973. Most of these preschool children were unvaccinated. CDC believes a number of policy and resource barriers are disincentives to the immunization of preschool-aged children by age 2 and that these incentive grants will be successful in encouraging the removal of those barriers. The primary need is to make sure that vaccine can be delivered to the population most at need.

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