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INCENTIVE GRANTS AND VACCINE DELIVERY Senator BUMPERS. Now there are two things in your budget here. No. 1, the President, to his credit, has asked for and obviously will receive a $40 million increase this year in this program; $20 million of the increase is in what you call incentive grants.

Dr. ROPER. Yes, sir.

Senator BUMPERS. Now also there is a $6,300,000 addition for vaccine delivery. Now how do incentive grants and vaccine delivery differ? How do those two programs work?

Dr. ROPER. The vaccine delivery line is to support Federal personnel who would deliver technical assistance; that is, advice to State and local health departments and others about how to remove barriers and improve vaccine delivery. So it is CDC sending experts out into the field.

The $20 million incentive grants are grants particularly to State health departments to give them incentives to improve their vaccination levels among young children, again these preschoolers that we have been talking about. So it is money that would go out to support their activities.

Senator BUMPERS. This is an outreach program, in effect. Is that what you are saying?

Dr. ROPER. Yes, sir; as you know, the Federal Government has for years spent a large amount of money in grants to support particularly State and local health departments. In the President's budget there is a total of $208 million which would be so spent. This $20 million is a part of that $208 million.

Senator BUMPERS. OK. In that connection, we have a lot of States who say that they just do not have the money to provide the kinds of incentives and vaccine delivery systems that they would like to have. Now would you say your incentive grant program is designed more to help those States that are already doing a good job? Do you think that is a good idea when you have other States who simply do not have the money to do a good job?

Dr. ROPER. Yes, sir; the design we have put forward to you is one that would say States that are not doing a good job now or were not doing a good job in the past but who have made an effort to help themselves and have begun to improve would be rewarded for those first steps in improvement and would be able to go on and do yet more. I guess the theory behind it is sort of the Federal Government will help those who help themselves.

I understand your concern that there are some States like yours of Arkansas and mine of Alabama that are in desperate financial shape generally, but our design here is to give a boost to those who are beginning to improve themselves.

FORMULA FOR PROVIDING FUNDS TO STATES Senator BUMPERS. Do you have a formula worked out on how you are going to do this?

Dr. ROPER. My staff is working on that, but we do not

Senator BUMPERS. I would like to have access to that as soon as you finish it, because that is really troublesome to me.

Dr. ROPER. The alternative way to formulate it, if I understand you, would be to say those who are worst off, the lowest level,

ought to get the money, and it could be done that way. I take your point.

Senator BUMPERS. As I say, I am ambivalent about it because I am reluctant to reward people who are not trying to help themselves. By the same token, we are dealing with a health problem, and that transcends normal rationales that we use around here in cases like that.

DEMONSTRATION PROJECTS FOR VACCINES Staff was telling me about Los Angeles, who said that they would not go into the demo projects unless they thought this kind of assistance was going to be continued. Are you talking about once they do it that it would be continued?

They are saying it is not worth it to do a one shot.

Dr. ROPER. What we are talking about is the need to step up total commitment, State, local and, in this case, Federal commitment to vaccine delivery. No question about that. It is not a onetime effort. There are going to be children next year who need to be immunized, too.

Senator BUMPERS. You know, you and I talked about the possibility of sort of a one-stop shopping demonstration project in the delta.

Dr. ROPER. Yes, sir.

Senator BUMPERS. Could you use this money for something like that?

Dr. ROPER. We have asked for another chunk of money on the immunization line, $8.7 million, to do demonstrations of the sort that you have described. Yes, sir; some of that money could go to support a demo like what you have suggested.

We currently have demonstrations underway in New York City, Jersey City, and Chicago, and what we would hope to use this $8.7 million for is to do other demonstrations of that sort.

IMMUNIZATION PROGRAMS Senator BUMPERS. Dr. Roper, when I first got into this, and I should say when Mrs. Bumpers first got into it, we immunized almost 300,000 children one Saturday. We did it in National Guard armories, we did it in churches, we did it in schools, we used every public facility we could find. You and I have discussed before that no matter how much money we have in this program, unless we can somehow convince the mamas and papas to bring the children in to be immunized it will never be successful.

I cannot speak for the inner city, but I can speak for the delta regions, and I can tell you that the problems are probably the same. The most common thing you hear is: No. 1, I have no transportation, I cannot get to the clinic; and No. 2, usually if it is a sin. gle head of household with a mother as the head of the household and she is holding down an 8 a.m. to 5 p.m. job or an 8:30 a.m. to 4:30 p.m, job—the clinic is closed. The clinic is open precisely during the hours she works, and there is no other availability to her.

I think back about how we did that on sort of a massive scale on a Saturday with all the volunteers, and I know that is not a

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:)

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