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IMMUNIZATION INCENTIVE GRANTS

Question. The FY 1992 budget requests $20 million for Immunization Incentive Grants that will reward those States that improve immunization levels of children under 24 months of age. 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. Won't these incentive grants help those who are least in need of this type of assistance, while penalizing those states that are already hard-pressed in trying to provide immunizations?

Answer. Support for the immunization of our Nation's children has been a shared responsibility of Federal, State, and local governments and the private sector. The increase in immunization incentive grants proposed for 1992 will be used to reward immunization grantees which have demonstrated during the previous year the greatest proportional increase in vaccine usage in children less than 2 years of age or the greatest proportional increase in immunization levels at age 2. These funds will reward those locations which have been most innovative in developing new effective interventions or have been most successful in removing policy barriers to increase vaccine coverage in children less than 2 years of age. Many of these activities can be accomplished with existing resources and would actually benefit those States by rewarding them for becoming more efficient.

Question. Shouldn't we be helping those States that really need help to improve their immunization infrastructure?

Answer. We believe these incentive grants will actually allow those who need help most to compete successfully for these funds. Those grantees which have the lowest coverage have the greatest opportunity for improvement. One of the most effective aspects of this approach is that it rewards accomplishments, not the promise of accomplishments. With these incentive grants, States will have the option to expand their immunization activities, including the improvement of their infrastructures.

OCCUPATIONAL SAFETY AND HEALTH

Question. The FY 1992 budget requests no cost-of-living increases for occupational safety and health the assumption being that the National Institute of Occupational Safety and Health will absorb the increases in pay and health benefits. Given that fact, this budget represents a cut for occupational safety and health and certainly a reduction in commitment. Did CDC request an increase in funding for NIOSH?

Answer. The only non-facilities increase for NIOSH requested of the Public Health Service was for operating and personnel cost increases. No program increases were requested for FY 1992.

Question. In your professional judgement, what more needs to be done and what funding levels are required to address the new occupational safety and health problems that are emerging as a

result of new technologies and to maintain current levels of research in occupational safety and health?

Answer. The infrastructure of NIOSH is in need of additional support. NIOSH has received increases in recent years in needed areas, but these increases have not been available to support the core programs of NIOSH. The research grants program has had to absorb a number of years of inflation which is very high with respect to research costs. The amount of discretionary research dollars in the intramural research program has also lost ground to increases in personnel and facility costs, and inflation in the costs of equipment, supplies, services and travel. At the same time, NIOSH has also had fewer real dollars to train an adequate supply of occupational safety and health professionals. To restore the resources lost in recent years to inflation and to address emerging occupational safety and health problems. I would recommend, following reductions in other programs within the domestic discretionary cap, that the program be supplemented in FY . 1992 with a total of $20 million in new funds: $5 million each for the research and training grants programs and $10 million for its intramural research programs.

Although this is my professional judgement, I did not request these resources this year within the Administration's process to formulate the 1992 budget, and thus, there was never the opportunity to weigh these increases against other competing priorities within CDC or other parts of the President's budget request.

DISABILITY PREVENTION

Question. There are an estimated 35 million Americans with a disability with an estimated cost of about $120 billion per year. What would be the cost associated with the development of a disability prevention program that would be national in scope?

Answer. If an average of $380,000 would be needed for a mature State project (realizing that considerable cost sharing will be required and considered in program services increasing this support level), then a total of $21 million would be required. If States were to develop programs in other targeted disability groups beyond those currently being emphasized, then additional costs per State would accrue, boosting the average per State to $480,000, or $27 million. However, no such increases are being sought within the priorities of our 1992 budget request. Any such increases would require reductions in other programs within the domestic discretionary spending cap.

HEAD INJURY

Question. Head injuries will cost the Nation well over $25 billion in direct health and rehabilitative costs alone. Yet, we have no significant program to prevent head injuries. What is the current status of the implementation plan for the Federal Interagency Head Injury Task Force? Why doesn't your proposed Fiscal Year 1992 budget include any request to implement such a plan? How much would be necessary?

Answer. The implementation plan for the recommendations from the Federal Interagency Head Injury Task Force is being reviewed in the Office of the Assistant Secretary for Health. When a plan of action is agreed to by the Administration, the need for resources can be determined.

POLIO ERADICATION

Question. Funding was provided in FY 1991 to CDC to participate in the World Health Organization goal of eliminating polio from the world by the year 2000. How feasible is this goal?

Answer. Through widespread use of inactivated poliovirus vaccine and subsequently oral poliovirus vaccine (OPV), paralysis caused by indigenous wild-type polioviruses has been eliminated in the United States. No such cases have been reported in this country since 1979. Similar success has yet to be achieved in the developing world, where an estimated 180,000-200,000 cases of paralytic poliomyelitis occur each year. In view of the dramatic progress of the Expanded Programme on Immunization (EPI) in providing immunizations to children worldwide, and the preliminary success of the poliomyelitis eradication initiative in the Western Hemisphere, the World Health Organization (WHO) set a goal to eradicate the disease throughout the world by the year 2000. We believe this goal can be achieved with considerable technical, laboratory, and programmatic assistance to WHO, its Regional Offices, and its member countries by CDC.

Question. What resources are required by CDC in FY 1992?

Answer. Support for this project has been tremendous. Rotary International has already raised almost $300 million to provide vaccine. Many countries, including Great Britain, France, Japan, and Italy, are also supporting WHO in its effort to eliminate polio from the world. We believe the $3.123 million of support requested in the President's FY 1992 budget when extended through the year 2000, will be adequate to help WHO reach the goal.

SEXUALLY TRANSMITTED DISEASES

Question. An increase of $4,580,000 has been requested for sexually transmitted diseases (STD's). STD's are on the increase, and there are a number of STD's that are proving drug resistant. What plan of action is CDC undertaking to reduce STD's and what more should be done?

Answer. In 1990, an estimated 52,600 cases of primary and secondary syphilis were reported, reflecting an increase of 14.6 percent over the 48,861 cases reported in 1989. This represents the fifth consecutive year of increases for syphilis and is the highest number of cases reported since 1949. While not all STD's are increasing (e.g., gonorrhea decreased by 4.5 percent in 1990; this was the 6th consecutive year of decreases), it is apparent that genital ulcer disease continues as a significant challenge for this Nation. Similarly, congenital syphilis has increased substantially.

To address this problem, CDC is focusing its funding priority to support syphilis prevention and control activities in the 35 highest morbidity-reporting counties in the Nation. Further, STD programs must develop better techniques to reach women who do not receive adequate prenatal care. For example, ensuring syphilis screening in the first and third trimesters and at delivery, improving communications with hospitals that deliver high numbers of at-risk women, and developing effective coalitions with National, regional, and community-based organizations in high-risk areas are techniques that will help in the prevention and control of not only syphilis and congenital syphilis, but also most of the other STDs.

CURRENT HIV/AIDS TRENDS

Question. Since its recognition in 1981, HIV infection and AIDS have emerged as the nation's most pressing public health problem, with more than 160,000 cases of AIDS reported to date. What are the current trends in the HIV epidemic?

Answer. CDC and the PHS currently estimate that 1 million persons are infected with HIV nationwide.

Reported cases continue to increase with more than 43,000 cases reported in 1990, a 23 percent increase over the number reported in 1989.

A leveling trend has been noted among reported cases of men who have sex with men, with proportionately higher increases reported among injecting drug users and individuals who have been exposed through heterosexual contact.

Reported AIDS cases in women account for an increasing proportion of all AIDS cases in the United States. In 1990, 11.5 percent of all reported adult cases were in women. Reported cases among women increased by 34 percent in 1990 over 1989 as compared to a 22 percent increase among men.

HIV disproportionately affects blacks and Hispanics. In 1990, the rate per 100,000 population for blacks was 53.8 compared to 42.0 for Hispanics and 14.0 for non-Hispanic whites.

More than 100,000 deaths have been reported among individuals diagnosed with AIDS and HIV was the third leading cause of death among men 25-44 years of age in 1988 (the most recent year for which data for ranking deaths is available). In 1989, it was estimated to be second, after unintentional injuries. Among women 25-44 years of age, HIV ranked eighth in 1988 among causes of death and in 1991, based on current trends, HIV is likely to be among the 5 leading causes of death.

HIV IN HEALTH-CARE SETTINGS

Question. Recently there has been increasing concern among health-care workers about their risk of acquiring HIV infection on the job. Now you have reported that three patients got AIDS from a dentist. What is CDC doing to prevent the transmission of HIV infection in health-care settings?

Answer. In order to assess and reduce the risk of HIV transmission in health-care settings, CDC conducts a variety of surveillance projects, epidemiologic risk-assessment, laboratory investigations, and prevention, control, and evaluation activities. Major areas of current focus include surveillance of health care workers with AIDS; assessment of the nature, frequency, and preventability of blood contact among health care workers and patients; assessment of the risk of HIV transmission due to these exposures; evaluation of preventive measures, including work practices and control technology; and recently, assessment of the risk of HIV transmission to patients during invasive procedures.

Question. What is your position on HIV testing of health care workers with practice restriction for those who test positive?

Answer. CDC's evaluation of the possible need for changes in the current recommendations for prevention of HIV transmission during invasive procedures has been a continuing process, with input solicited from expert consultants and from the public. CDC convened such a meeting in late February, 1991, to review the risks of HIV and hepatitis B virus transmission to patients during certain invasive procedures. If revisions to the guidelines are deemed necessary, a draft of revised recommendations will be circulated for public comment prior to their being issued.

HIV/AIDS AMONG ADOLESCENTS

Question. Although a relatively small proportion of AIDS cases occur in adolescents, because of the long incubation period of the disease, most young people who become infected do not develop AIDS until they are in their 20s. How is CDC assessing HIV risk and HIV infection in adolescents and what are you finding?

Answer. As part of our serologic surveillance program, CDC monitors HIV infection prevalence levels and trends in a variety of groups including those groups that represent young adults. The second component in assessing HIV risk in adolescents is behavioral surveillance research. Through the Youth Risk Behavior Surveillance System, CDC helps States and cities regularly monitor the prevalence of health-risk behaviors among high school students.

In virtually all the adolescent groups assessed, HIV infection increases progressively with year of age from the midteens up well into the late 20s. This indicates that adult type risks begin in the early teens, as does HIV infection, and continue throughout the adolescent and young adult period. Over the past 3 years, HIV prevalence in young female Job Corps students has significantly increased and now exceeds that in male Job Corps students. CDC is undertaking a collaborative study with the Job Corps to evaluate the risks most responsible for this HIV infection. We are concerned about heterosexual and drug-related HIV transmission in poor, and especially minority, youth, as well as out-of-school youth in homeless and run-away situations.

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