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Question. How does CDC plan to implement the Comprehensive AIDS Resources Emergency (CARE) Act and what is the potential impact of CARE on current prevention programs?

Answer. In FY 1992, it is anticipated that CDC will award approximately $102 million for early intervention services under the CARE Act. CDC is currently drafting a proposed notice of the availability of funds to support state formula grants in FY 1992 for early intervention services cited in Section 2641 of the Public Health Service Act as amended by the CARE Act of 1990. The availability of funds is scheduled to be announced in the Federal Register prior to July, 1991. The application submission deadline will be October 1 and funds will be awarded prior to January 1, 1992.

As CDC implements the formula funding provisions of the CARE Act, every effort will be made to ensure that each state receives no less than 85 percent of what it received for HIV counseling, testing, referral, and partner notification (CTRPN) in FY 1990. Based upon currently available data, it is estimated that 40 states, two territories and Washington, D.C. will receive fewer dollars for early intervention services in FY 1992 than they received for CTRPN in FY 1990 or 1991.

Since the CARE Act requires funding recipients to expand existing testing services to include tests to determine the extent of immune deficiency and to provide information on appropriate therapeutic measures, and to expend at least 35 percent of their funds on other diagnostic and clinical services and therapeutic measures, Federal support for current CTRPN services may have to be drastically reduced. As a result, states may be required to reduce or eliminate HIV counseling and testing sites with subsequent staff reductions or increase their own level of expenditures for these services.

Under the CARE Act, the six directly-funded city health departments (Chicago, Houston, Los Angeles, New York City, Philadelphia and San Francisco) will continue to receive an amount equal to that which they received in FY 1990 for CTRPN. However, the city health departments will also be required to provide the additional testing services, as well as the other clinical and diagnostic services and therapeutic measures, cited in the legislation.


Question. Diabetes remains one of the leading causes of death and disabling complications. What is CDC doing to deal with this trend?

Answer. As you know, CDC has been designated to take the lead within the Federal Government for translating the most promising results of diabetes research into widespread clinical and public health practice. We have begun by strengthening diabetes surveillance nationally and at the State level, and by undertaking some important epidemiologic projects, to develop a better understanding of the nature and extent of the diabetes problem. We are also continuing to work closely with 27 State and Territorial health departments to carry out State-based programs to reduce the burden of diabetes and its complications. We estimate that CDC spends over $7 million a year on these diabetes activities.


Question. Recently a contaminant in a dietary supplement appears to have caused in excess of 1,500 people to become ill with a very rare disease commonly referred to as EMS. CDC responded and identified the cause of this rare ailment. How much did this response cost and what activities were not undertaken as a result, of addressing the EMS emergency situation?

Answer. The Centers for Disease Control (CDC) estimates that the dollar cost to date for its continuing investigation of Eosinophilia-Myalgia Syndrome to be $800,000.00 all of which came from CDC core funds. These costs include salary and travel costs, laboratory supplies and materials, and costs for other related support needs.

These investigations also include allocating CDC's epidemiologic, laboratory, and management resources away from ongoing but lower priority prevention efforts. As a result, many important, but lower priority planned or ongoing projects were delayed because of the reassignments of personnel and reallocation of funds to purchase laboratory materials. For example, during the course of the EMS investigations, CDC has not been able to undertake systematic epidemiologic and laboratory studies of other toxicants such as dioxin and mercury.

Question. How can we address this situation to ensure that CDC does have funding available to respond to problems like EMS, or to respond in cases of natural disasters here and abroad?

Answer. That is hard to answer because of the uncertainty of when during a year the disaster will occur, how extensive is the problem, and how long will the problem last. All these variables affect the cost of the disaster.


Question. In the Institute of Medicine's report, The Future of Public Health, assessment is one of the three core functions of public health. Assessing what is going on will become increasingly important over the next decade as public health agencies attempt to monitor progress toward achieving the national health objectives set out in Healthy People 2000.

What plans does CDC have to improve the capabilities of State and local health departments to assess progress in preventing disease and improving health?

Answer. CDC plans to use the Preventive Health and Health Services block grant as the vehicle for assisting States in following progress toward the Year 2000 Objectives. CDC will be

working closely with other PHS agencies and representatives of State and local health departments to develop a comprehensive assessment plan. The plan will include four essential elements: 1) developing new health data systems to track priorities; 2) making health data rapidly available to States; 3) building State and local capacities to use the direct programs; and 4) evaluating the impact of programs.

The proposed increase for assessment supports each of these elements, with special reference to building the capacity of State and local health departments. It also allows DHHS to actively advance the establishment of uniform National data set recommended by the IOM and the PHS Plan to Strengthen Public Health.


Question. CDC has been very successful in sending out young scientists to investigate serious public health problems all over the U.S. and the world. These disease detectives have been instrumental in protecting the country from polio, legionnaire's disease, toxic shock syndrome, etc. It is my understanding that while we have about 4,600 of these specialists in the Epidemic Intelligence Service (EIS), this actually is less than half of what is required. How is CDC addressing this shortage and is there a need to increase the number of individuals participating in the EIS Program? In your professional judgment, what would CDC require in FY 1992 to address this critical need?

Answer. CDC's major effort to meet the need for well-trained epidemiologists is the Epidemic Intelligence Service Program. CDC is tryirg to make the composition of the EIS reflect the Nation's demographic and diverse needs. The latest group of outstanding public health professionals CDC has accepted to join the EIS this year total 75 persons and includes 56 physicians and 19 persons trained in other disciplines, such as nursing and veterinary medicine; 50% are women, and 27% of the total are minorities. CDC was able to accept only 75 outstanding public health professionals to join the EIS this year. Over 50 additional highly qualified applicants had to be turned away. Additional resources will enable CDC to train these and other health professionals to meet the Nation's need for epidemiologists. As CDC expands into other areas of health promotion and disease and injury prevention, the EIS Officers will continue to play a critical role in State and local health department assignments as shifting priorities of field assignments include new prevention initiatives in chronic disease, environmental and occupational health and injury control. Currently, the demand for epidemiologists in the States far exceeds the supply. In our professional judgement, at least $1,000,000 is needed in order to recruit, train, assign, and support 13 additional EIS Officers, which would require reductions of other programs within the domestic discretionary spending cap.


Question. A decrease of $418,000 has been proposed for Prevention Centers, which would return funding to $3,949,000, the

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same level provided in FY 1990. Please provide a breakout of how funding in FY 1991 will be spent.

Answer. CDC currently provides financial and technical assistance to seven Prevention Centers--Columbia University, University of Arizona, University of Hawaii, University of Illinois at Chicago, University of North Carolina, University of Texas Health Science Center at Houston, and University of Washington. Financial assistance varies by Center depending on the number of approved projects and stage of Center development, with newly established centers funded at slightly reduced levels compared to more mature centers.

The funding appropriated for FY 1991 will allow each center to maintain current activities, plus support a meeting of Prevention Center staff to share their project results. We also expect to add an additional project in one of the existing Centers.

Question. What impact will this have on the 7 centers now in existence?

Answer. In FY 1992, CDC will continue to provide both financial and technical support to existing Centers at the approximate level of FY 1990. Productive prevention research and demonstration activities will continue at all Centers. However, if one assumes that only Federal monies are used, this level of funding may necessitate somewhat of a decrease in current activities, given costs associated with inflation. We believe the States and universities will obviously support such efforts.

Question. What is the cost of establishing a new center?

Answer. Financial assistance has requested ranged from $400,000 to $750,000 to begin activities as new Centers have been established.


Question. The FY 1992 budget requests $50 million for the Breast and cervical Cancer Mortality Prevention Act. How many State grants for comprehensive screening programs will be awarded in FY 1991 and how many will be awarded in FY 1992?

Answer. In FY 1991, the Centers for Disease Control (CDC) anticipates funding seven to nine States for the implementation of comprehensive breast and cervical cancer early detection and control programs. Awards to States in FY 1991 are expected to range from $2.5 to $4.0 million, and will enable States to initiate screening and follow-up activities in selected populations on a statewide basis. With a $50 million appropriation in FY 1992, CDC would increase support to States funded in FY 1991 to allow them to reach a greater number of women in need and would also enable us to add one or two additional States to the program.

Question. Would it make good prevention sense to expand this program to all 50 States?

Answer. Yes, it would make good prevention sense to expand this program to all states. Indeed, the level proposed in the FY 92 budget is a good start in that direction. It is clear that in every state substantial numbers of women are not getting screened for breast and cervical cancer. For many, financial barriers are important. For others, lack of knowledge on the part of the woman or her health care provider may contribute to not being screened. It is important to point out that mortality from breast cancer alone would be reduced by 10-15,000 deaths per year (over a 30 percent reduction) if all women over 40 years of age received a regular mammogram.

It should also be noted that Medicare coverage has been recently expanded to provide for mammography and pap smear screenings for women 65 and older; it is estimated that about 6 million women will be served by this coverage. In addition to expanded Federal efforts, the number of States mandating that public and private health insurers include coverage for breast cancer screenings has increased to at least 33 States.

Question. When will you have data on outcomes of this screening initiative?

Answer. CDC will routinely obtain information from funded States on the number of women who receive screening and follow up services from this program. In order to evaluate the impact of this effort in detecting cancers at earlier stages of development, and ultimately in reducing mortality, States will have to establish surveillance systems that will permit this type of monitoring. CDC will provide assistance to States in the development and implementation of surveillance systems that can monitor the impact of the program over time. Shifts to earlier stage of diagnosis of these cancers, through widespread utilization of these proven screening tests, should lead to mortality changes in time.

Question. Cervical cancer claims about 8,000 lives per year. What effort is CDC undertaking in the area of human papillomavirus, which has been discussed as a cause of cervical cancer?

Answer. Cervical cancer epidemiology shows that the disease behaves as a sexually transmitted disease. This fact has been known for many years. However, since there are numerous factors which contribute to the development of cervical cancer, identification of the sexually transmitted, infectious agent or agents associated with cervical cancer has been difficult. Recent work from numerous laboratories around the world have build a strong case for the human papillomaviruses as the infectious agent involved in cervical cancer. The Center for Infectious Diseases is studying the human papillomaviruses. The work on the human papillomaviruses in the CID focuses on the following areas:

Epidemiology and natural history of HPV infections and disease. This work centers around epidemiologic studies of human papillomavirus and disease in selected populations including HIV infected women, women from areas of high cancer

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