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Question. The Congress provided funding in FY 1990 and in FY 1991 to begin a breast and cervical cancer screening initiative. West Virginia received planning funds in FY 1990. What funding level will West Virginia receive in FY 1991, and what is the projected amount that the State will receive in FY 1992?

Answer. In FY 1990, the West Virginia project was approved for funding through a competitive review process. The State was awarded $400,000 in direct and financial assistance to begin preparatory activities that would enable them to establish a comprehensive breast and cervical screening program in subsequent years.

In FY 1991, West Virginia will be eligible to receive up to $2.5 million to implement the more comprehensive program, which includes actual provision of screening and follow-up services. The actual amount of the award will depend on West Virginia's request and their ability to meet the matching requirement as described in Public Law 101-354.

Given the anticipated appropriation of $50 million in FY 1992, each State funded in FY 1991 will receive increased funding to enable them to expand their screening efforts to reach additional women in a wider geographic area. West Virginia will be eligible for up to $5 million, depending on their request and ability to meet the matching requirement.

PREVENTION

Question. West Virginia is a rural State that has a myriad of health problems, including high incidence of lung cancer, diabetes, perinatal and infant mortality, and a shortage of physicians in many areas of the State. What is CDC currently doing in West Virginia in the areas of prevention/intervention and in your professional judgment, what more needs to be done?

Answer. West Virginia ranks second only to Michigan in ageadjusted chronic disease mortality. More than half of all deaths in the nation can be attributed to one of nine chronic diseases: stroke, coronary heart disease, chronic obstructive lung disease (COPD), lung cancer, breast cancer, cervical cancer, colorectal cancer and cirrhosis. In West Virginia, the pattern is similar, with 53% of the deaths due to these nine diseases. Specifically, West Virginia has been found to rank 3rd in cervical cancer rates, 4th in lung cancer rates, 6th in diabetes, 7th in coronary heart disease and 15th in stroke.

In response to these needs, the Centers for Disease Control has established two collaborative programs with the West Virginia Department of Health. First, in 1985 West Virginia was one of the early participants in the Planned Approach to Community Health (PATCH) program that now involves eight counties. In this program, local agencies and citizens are provided technical assistance to enable them to plan chronic disease prevention and health promotion programs that address leading health problems. Second, the CDC's Office of Surveillance and Analysis provides funding and technical assistance to carry out Behavioral Risk Factor Surveillance. This survey of the prevalence of major risk factors for the leading causes of mortality and morbidity helps agency planners to target the State's most serious health problems. And, third, the Division of Chronic Disease Control and Community Intervention collaborates with the West Virginia Department of Health in the delivery of a school-based program that addresses the high prevalence of cardiovascular risk factors among elementary and secondary school children.

In our professional judgement, additional efforts could be directed toward ensuring that currently existing intervention methods and materials are designed to address the special needs of the citizens of West Virginia. CDC also works with State and local agencies in the areas of AIDS/HIV, diabetes, immunization, occupational safety and health, sexually transmitted disease, and tuberculosis.

QUESTIONS SUBMITTTED BY SENATOR DALE BUMPERS

COUNSELING AND TESTING

Question. Dr. Roper, how much counseling and testing will your FY 91 appropriation support?

Answer. If trends since 1988 continue through FY 1991, CDC projects that nearly 1.9 million HIV-antibody tests will be administered at publicly funded counseling and testing sites in 1991, and approximately 72,500 will be positive.

Question. In FY 92, with the addition of early intervention services requirements but level funding requested by the President, how much less counseling and testing will be supported?

Answer. Although the CARE legislation requires grantees to expend at least 35 percent of their formula grant awards on

counseling, testing, referral and partner notification (CTRPN) related activities, they are also required to expend at least 35 percent on other early intervention services. However, grantees will have a great deal of latitude on allocating the remaining 30 percent, i.e., they may expend all or a portion of it on CTRPNrelated services or other early intervention services or a variety of optional services. If the states only allocate the required minimum 35 percent of CARE grant funds for HIV-antibody counseling and testing (C/T) in FY 1992, then an estimated 1,235,000 fewer tests would be performed compared to FY 1991. However, if all states expend all of their allowable discretionary funds (30 percent) for C/T in addition to the 35 percent minimum mandated by the CARE Act, an estimated 665,000 fewer tests will be performed.

Question. In the professional estimation of the CDC, how much additional money would be required in Title III to maintain the current level of testing and counseling AND provide early intervention services for those who need them?

Answer. If one assumes that all of the States will choose to expend only the minimum required 35% of their CARE formula grant funds on CTRPN-related services, then, in our professional judgement, it would take an additional $189.4 million above the requested $102 million to ensure that no State receives less funds in 1992 under the CARE Act for CTRPN-related activities than was received in 1991. On the other hand, if one assumes that all of the States will choose to make maximum use of their allowable 30% discretionary funding under the CARE Act for CTRPN-related services, then it would take $54.9 million above the requested $102 million to maintain CTRPN funding at 1991 levels. In either case, such funding levels would, of course, require offsetting reductions in other programs within the domestic discretionary spending cap.

QUESTIONS SUBMITTTED BY SENATOR HARRY REID

CHILDHOOD LEAD POISONING

Question. In his February 21, 1991, testimony before the Toxic Substances Subcommittee that I chair, Assistant Secretary for Health Mason stated that "we have the tools to eliminate childhood lead poisoning in the next 20 years" and that "we do not need new technology to complete this task." I agree--the government and people have the willingness, especially the financial willingness, to do so.

While the Administration's budget proposal represents a major increase over current budgeted expenditures, isn't it inadequate to meet the goals of the Strategic Plan?

Answer. Implementation of this plan is going to require a combined effort among all levels of government and the private sector. The CDC budget requests $14.9 million in FY 1992 for support of State and local childhood lead poisoning prevention programs. This is an increase of $7.1 million (+92%) over 1991 appropriations. We believe these funds, in addition to the funds being requested for lead abatement activities by the Department of

Housing and Urban Development, are a significant step in attacking this problem.

Question. How much of the $974 million will be needed for the first year of the Strategic Plan? Why has the Administration not sought the full amount of such first year funding?

Answer. The first year of the Strategic Plan calls for $111 million. This represents a shared commitment by the private and public sectors, not an entirely public sector effort.

Question. How much of the $974 million will be needed for each of the other four years of the Strategic Plan? What level of federal funding does the Administration intend to seek for the second through fifth years of the Strategic Plan?

Answer The following are the combined National costs in millions of dollars of the first 5-years of the Strategic Plan which represents Federal and non-Federal costs.

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Question. How will the shortfall between the amounts of Federal funding sought in the budget and the amounts recommended in the Strategic Plan be funded?

Answer. This Plan is a strategic plan, not an implementation plan. Strategies will be developed to increase State and local government and private sector support for the necessary actions to eliminate childhood lead poisoning.

Question. The Strategic Plan identifies reducing exposure to environmental lead from water, food, air, soil and the work place as one of the four major program elements in the effort to eliminate childhood lead poisoning, but it provides few specific recommendations for federal action in this area. Furthermore, it does not include any funding recommendations for this major program element. Why is this portion of the strategy so limited in its recommendations? Why is funding for this element not addressed in the Strategic Plan?

Answer. The strategic Plan addresses primarily lead-based paint because of the higher priority as a source of lead for children with the highest blood lead levels and who are, thus, more likely to suffer from lead poisoning. Furthermore, efforts to reduce lead exposure to environmental lead in water and air are already well underway at the Environmental Protection Agency. The Food and Drug Administration is continuing to increase its regulation of sources of lead contamination of food. Worker issues are being addressed by NIOSH and OSHA, using existing funding. Soil remediation is addressed in the plan, mainly as a research question. We do not yet have enough information to embark on a national campaign to abate U.S. soils; we estimate it will take at least another 5 years to develop the information necessary to determine which soils constitute a hazard to children and at what

levels, and to determine the cost-effectiveness of alternative soil abatement methods.

Question. It has been estimated that there are some three to four million children in the United States with blood lead levels high enough to adversely affect intelligence and behavior, of whom an estimated 250,000 children meet the current definition of lead poisoning. It has also been estimated that about 13.6 million children under age 7 live in homes with lead-based paint, of whom 2 million live in deteriorated housing with peeling lead paint or other high risk of lead exposure.

How many of these lead poisoned and adversely affected children would be identified by screening programs funded at the levels recommended for five years in the Strategic Plan? would be identified at the level of funding called for in the Administration's FY 1992 budget?

How many

Answer. The Strategic Plan calls for $25 million for childhood lead poisoning prevention programs for the first three years, $35 million for the fourth year, and $45 million for the fifth year.

This would allow screening of around 3 million children in addition to the approximately 1 million children receiving lead screening services under other existing Federal, State, and local programs. About 1-3% of these additional children would be expected to have lead poisoning using the definition in the 1985 CDC statement on Preventing Lead Poisoning in Young Children. CDC is expected to revise that level downward in the near future; the number of children identified as lead poisoned would increase around 10-fold.

In Fiscal Year 1992, at a funding level of $15 million, an estimated 276,000 children will be screened through the CDC categorical grants for lead poisoning prevention. Between 3,000 and 9,000 will probably meet the current definition for lead poisoning

Question. How many lead-painted housing units would be abated at levels of funding recommended in the five-year Strategic Plan? How many under the Administration's FY 1992 budget?

Answer. The costs of abatement vary greatly according to the size and kind of housing unit, the region of the country, and other factors. For this plan, we assumed that an average abatement costs around $6,500. The plan states that within 3 years, resources should be made available to perform 20,000 to 30,000 more abatements annually than are currently being performed. The resources suggested in the plan would be enough to abate the home 8 of all lead-poisoned children currently being identified by childhood lead poisoning prevention programs that have no other source of funding for abatement. (As the amount of screening increases, the estimate of additional units to be abated annually will also need to be adjusted.) These resources would also make it possible to have demonstration projects and to abate units in the second priority group, homes that have a large potential for poisoning children. The unit cost of abatement is likely to decrease over the next several years as new abatement methods are

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