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emphasis on infectious disease surveillance, is necessary to forestall the potential threat of new, emerging, and reemerging infectious diseases, and to protect the public health. Erosion of this base in the past 10 years has reduced our capability to react. Additional resources would be needed to strengthen CDC's ability to deal with specific prevention and control activities, vaccine and evaluation, and emergency outbreak control. However, any such increases would require a reduction of other programs within the domestic discretionary spending cap.

DISABILITIES PREVENTION

Question. The principal focus of the disabilities prevention program since its inception in 1988 has been to provide grants to States to develop programs for the prevention of disabilities. States have focused on the prevention of developmental disabilities, prevention of injuries, and the prevention of secondary disabilities. We increased the appropriation for this program from about $4.5 million to $9.7 million last year for the expressed purpose of expanding the number of grants to States from 9 to 20. It was our intent that the new States would carry out similar activities. I understand that your plan would put only $5.8 million of the total into grants to the States. The figure I have is that more than a quarter of the appropriation is going to "program operations." What is included in this $2.4 million category for "program operations?" Why isn't the increase going to increase funding to the States?

Answer. Only 19.5% ($1.9 million rather $2.4 million) of the appropriation for the disabilities prevention program in fiscal year 1991 is being directed toward program operations including personnel, travel, supplies, and other operating categories. It is essential that CDC enhance the knowledge base for developing effective interventions for the prevention of primary and secondary disabilities. With this approach in mind, additional resources are being directed into extramural programs in addition to grants to States. These other extramural activities include ma jor elements necessary to the design and implementation of a national plan for the prevention of disabilities in collaboration with the National Council on Disability.

For Fiscal Year 1991, these other extramural activities include: a national conference on the prevention of primary and secondary disabilities co-sponsored by the National Council on Disability, the Minority Health Professions Foundation, and CDC; development of pre-conference working papers for presentation and discussion at the conference and as an elements in the development of the national plan; costs associated with the completion and dissemination of the Institute of Medicine Report, Disability in America; a national conference on the prevention of congenital alcohol disorders which will become a priority area for State interventions projects this year; support of a study in collaboration with other CDC Centers on the incidence and prevalence of post-polio in the United States which will have future impact on State prevention programs; an initiative with the Indian Health Service and the State of Alaska in the surveillance and evaluation of fetal alcohol syndrome in Native Americans including surveillance for other developmental disabilities and

birth defects in the population in general; and partial support for a randomized controlled trial in China of periconceptional vitamin supplementation on the occurrence risk for spina bifida and anencephaly, a project that may have significant value in prevention of lifelong morbidity and infant mortality.

These additional extramural activities will total approximately $1.9 million in Fiscal Year 1991, or 19.5% of the $9.739 million Congressional appropriation. Therefore, the balance of $5.9 million ($9.739 less $1.9 program ope rations and $1.9 additional extramural activities) will be directed to approximately 19-21 State capacity building projects. These projects will take advantage of the knowledge base and interventions developed through these other substantial extramural events that will improve surveillance and epidemiology and enhance the development of a well conceived national plan for the prevention of primary and secondary disabilities. We believe this approach will meet both the requirements of States in their capacity building projects and also meet epidemiologic and scientific needs of states which the Congress recognizes are critical components of a national program to prevent disabilities.

CHILD DAY CARE

Question. By the Year 2000, it is estimated that more than 75% of mothers with children under six years of age will be working outside the home. What is CDC doing about prevention of infectious diseases and injuries in child care settings, and in your professional judgment, what additional resources will be required to allow CDC to move forward more quickly in meeting child day care prevention activities?

Answer. Infectious diseases are the most important causes of morbidity in day-care centers, with respiratory and diarrheal illnesses being most common. Depending on the disease, children attending daycare are estimated to have a 2 to 18 fold increased risk of specific infectious diseases compared with children not attending daycare. The most common diarrheal pathogens in children in day care are Giardia, Shigella, and rotavirus, agents which require a relatively small inoculum and are spread by person-toperson transmission. The vast majority of respiratory infections are viral infections of the upper respiratory tract. Risk factors for infectious diseases in the day-care setting are not well understood. The appropriate management of ill children in childcare settings, including the practice of excluding sick children, is the subject of enormous controversy. Current criteria for excluding sick children vary widely and reflect the paucity of data upon which to base recommendations. The importance of this issue is indicated by recent estimates which suggest that 1-year-old children in day care can be expected to be excluded for up to 20% of working days. CDC has completed a study to determine the prevalence of Giardia and other parasitic infections in day-care centers, completed phase I of a two year study to evaluate policy regulation of day-care throughout the United States, and continued collaborations with the American Academy of Pediatrics, the American Public Health Association and the Council of State and Territorial Epidemiologists to draft national performance standards for the prevention of infectious diseases in day-care. In 1992 CDC will sponsor the first international conference on child day-care health.

The CDC Injury Control program has conducted a series of related studies focused on injuries in day care. CDC's first such study showed that during a one-year period, 3.5% of children were injured severely enough to require medical or dental attention. The pattern of these injuries suggested that many are preventable. Climbing equipment 6 feet or taller generally had inadequate impact-absorbing undersurfacing and had twice the injury rate as climbers less than 6 feet tall. Since the most severe injuries occurred from falls on the playground, impact-absorbing playground surfaces may be a possible intervention to reduce both injury frequency and severity. Injury Control program studies have also shown that as the number of playground hazards increase, so did the likelihood that a playground-related injury occurred. The program is currently evaluating an educational intervention to correct playground hazards at day care centers. The findings of these studies have already been used to rewrite regulations for day care centers in some jurisdictions.

Division staff have done injury control training of day care workers and day care regulators. They have consulted with licensing agencies on regulations. Staff have spoken about injury control at the National Day care provider meeting. The Program has also provided technical consultation for the model standards in day care centers being put together by the American Public Health Association and the American Academy of Pediatrics under a grant from Maternal and Child Health.

As a special project, CDC is evaluating the extent to which current recommendations to prevent injuries and decrease transmission of infectious diseases are in place in daycare centers. The project will evaluate the extent to which recommendations have been adopted and enforced by State and local regulatory agencies and by daycare centers as reflected in their policies and practices.

CDC is currently spending $ 1 million on the child day care activities discussed above. In our professional judgement, for CDC to begin to move forward more quickly in preventing infectious diseases and injuries in child day care settings, approximately $2,000,000 would be required the first year, after other program reductions were taken within the domestic discretionary spending cap.

CHILDREN'S INJURIES

Question. Doctor, I understand from recent reports that more than 30,000 children suffer permanent disabilities from injuries each year, at a total cost to our health system of over $7.5 billion dollars.

CDC has documented that childhood death rates in the U.S. are considerably higher than any other industrialized country. This is specifically true in the area of childhood fatalities from motor vehicles.

Doctor, please describe the success you have had in implementing the 1990 National Academy of Sciences Report, "In jury in America," specifically, the information campaigns designed to increase the use of child safety seats, seatbelts and helmets. .:

Answer. The CDC injury control program is embarking on a national campaign of proven-effective interventions to reduce deaths and injuries to children in motor vehicle and bicycle crashes and a multifaceted campaign to limit unsupervised access of children to firearms. The overall approach of the campaign will be to:

Develop and carry out a public information campaign
that is national in scope.

Work with our partners in the public and private sector in implementing and evaluating the interventions.

Determine the most effective way to implement the
interventions.

Provide information to stimulate appropriate regulatory and legislative changes.

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Question. How will the $2 million increase requested for 1992 build on your past work in this area of child safety?

Answer. The $2 million increase will build on existing program efforts in child safety and move in jury control from analysis to action. Using the foundation of intra- and extramural research findings and building on the cornerstones put in place by capacity building grants to State and local health departments, and collaborating closely with the National Highway Traffic Safety Administration, the activities supported by the increase will tie together all of the elements of injury control into a national campaign to prevent three childhood injuries--motor vehicle, unintentional shootings, and bicycle

Staff have spoken about injury control at the National Day care provider meeting. The Program has also provided technical consultation for the model standards in day care centers being put together by the American Public Health Association and the American Academy of Pediatrics under a grant from Maternal and Child Health.

As a special project, CDC is evaluating the extent to which current recommendations to prevent injuries and decrease transmission of infectious diseases are in place in daycare centers. The project will evaluate the extent to which recommendations have been adopted and enforced by State and local regulatory agencies and by daycare centers as reflected in their policies and practices.

CDC is currently spending $1 million on the child day care activities discussed above. In our professional judgement, for CDC to begin to move forward more quickly in preventing infectious diseases and injuries in child day care settings, approximately

$2,000,000 would be required the first year, after other program reductions were taken within the domestic discretionary spending cap.

LEAD POISONING

Question. CDC has recently released a strategic plan for the elimination of childhood lead poisoning. What needs to be done to implement that strategic plan and what, in your professional judgment, would be the dollar amounts associated with this implementation.

Answer. The strategic plan describes the first 5 years of a 20-year effort to eliminate childhood lead poisoning. This effort will require a shared commitment by the public and private sectors. The plan calls for $974 million over 5 years to carry out both program and research agendas. We have not divided this cost into public vs. private sector costs, but clearly, some costs will have to be borne by both. In addition, implementation of this plan will require efforts at all levels of government, not just the Federal government.

Implementation of the strategic plan, as well as the plans developed by the Environmental Protection Agency and the Department of Housing and Urban Development, will also require close coordination between the Federal agencies. We will continue to work with these agencies towards the goal of eliminating childhood lead poisoning.

PREVENTION

Question. Dr. Roper, we now know a great deal about how to prevent or greatly reduce the risk from childhood diseases, breast and cervical cancer, heart disease, tuberculosis, lead poisoning, and injury, to name just a few. And, we also know that investing in prevention saves us millions of dollars. In spite of this, we have not incorporated prevention into the core of our health care system. Should we make prevention an integral part of any health care program?

Answer. Yes. We must build a system that will make prevention an integral part of the nation's health care. Leaders in public health and clinical medicine can work more effectively to prevent disease if they are truly partners. It does not make sense for public health to actively identify persons with high blood pressure, only to have the health care system leave a large proportion of them without proper treatment. We must increase the provision of preventive services in the delivery of health care. We also must ensure that medical education includes preventive health curricula, and we must re-examine our system of health care financing and reach a consensus that includes the financing of preventive care.

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