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residential care facilities are impaired because of exposure to alcohol while in utero. The experts also estimate that fetal Alcohol Syndrome costs the Nation over $1.6 billion for neonatal and residential care each year.

What is CDC doing to prevent Fetal Alcohol Syndrome by targeting education programs to pregnant women?

Answer: CDC is sponsoring a conference titled "Fetal Alcohol Syndrome and Other Congenital Alcohol Disorders: A National Conference on Surveillance and Prevention," to be held in Atlanta on April 1-3, 1991. One of the purposes of this conference is to promote discussion among federal, State, and local health agencies, academic and research institutions, and public and private organizations concerning methods for locating women at risk before they become pregnant, or early during pregnancy, to prevent exposure to alcohol during pregnancy.

CDC collects data using the Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based system that gathers information from new mothers about their behaviors during and around pregnancy. The PRAMS questionnaire includes questions about the use of alcohol during pregnancy and if they have received information on the effects of alcohol during pregnancy. It is designed to oversample high risk sub-populations of special interest. It therefore provides useful information about the use of alcohol during pregnancy specific to high risk subpopulations, as well as providing State-wide estimates.

CDC has a surveillance program which monitors the incidence of Fetal Alcohol Syndrome in newborn infants. We are currently working to improve this program since we strongly suspect underreporting in certain groups, specifically the white, middle class population. Good surveillance programs can be used to determine which populations should be targeted for prevention programs and are required in order to know if prevention programs are working. CDC assists States in beginning or improving their surveillance programs.

Technical assistance is provided to States and communities to develop and evaluate programs to prevent Fetal Alcohol Syndrome. Many of these programs target educational programs to pregnant women, some of them specifically for high risk populations.

CDC is working with the Indian Health Service to evaluate Fetal Alcohol Syndrome prevention programs in Alaska and will expand to include programs in other States.

TUBERCULOSIS

Question. Although tuberculosis has been a preventable disease for almost 40 years, yet, more than 1/3 of the world population harbors the bacillus that causes TB and 10 to 15 million persons in the U.s. Although the elimination of TB was part of our 1990 health objectives, TB is still prevalent and the number of cases are on the rise. In your professional judgement, is this budget sufficient to set us on the path to eradicate TB by the Year 20007

Answer. The provisional tuberculosis case count for 1990 is 25,739. This represents an increase of 9.6 percent over the final 1989 count of 23,495. In my professional judgement, A total of $40.7 million would be needed in FY 1992 to fully implement CDC's portion of the Departmental Strategic Plan for the Elimination of Tuberculosis in the United States by 2010. Such a level would, of course, require reduction of other programs within the domestic discretionary spending cap. Given full funding of elimination by 2010 can still be achieved. The longer full implementation takes, the greater the likelihood of missing the 2010 objective.

Question. What is required to fully implement the plan for eradication of this disease by the Year 2000?

Answer. A total of $40.7 million is needed in FY 1992 to fully implement CDC's portion of the Departmental Strategic Plan for the Elimination of Tuberculosis in the United States. Such a level would of course require a reduction of other programs within the domestic discretionary cap.

INFECTIOUS DISEASES

Question. Infectious disease problems such as AIDS, Lyme Disease, hepatitis, chronic fatigue syndrome, and polio have been the focus of Congress and the Administration in the past few years. However, there are a number of new and emerging diseases that are being tracked by CDC. Could you give this Subcommittee some insight into these new and emerging diseases, the hazards they pose to health, and your professional judgment as to what is required to intervene and prevent these diseases from becoming full-scale health threats?

Answer. While Congress and the Administration have been prudent in providing resources to address many of the high priority infectious disease problems facing our nation, core support for infectious disease prevention activities in general has eroded. The CDC is responsible for maintaining surveillance, and epidemiologic and laboratory expertise and resources for the prevention of over 130 infectious diseases. In this regard, several infectious diseases are emerging or reemerging, posing new threats to the public health both nationally and internationally. For example: cholera, a disease for which CDC has responsibility but has devoted few resources in recent years, is now emerging as a major threat in Peru, Ecuador, Colombia, the middle East and southern Africa; papillomatosis (papillomaviruses infection), an infection long known as the cause of genital warts, is now seen as the key in the development of cervical cancer; rabies, a disease subjected to intense control efforts throughout the world for many years, is now reemerging as a threat in the northeastern United States; dengue a disease transmitted by mosquitoes, is now emerging in its most virulent form, epidemic dengue hemorrhagic fever in the Caribbean basin just as it did in southeast Asia in the 1960s. These and other diseases not yet fully characterized pose a potential threat which can best be addressed by development of a strong surveillance base and laboratory expertise. This is the kind of responsibility which CDC has traditionally met. Strong and steady support for core infectious disease programs, with an

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 19.52 ($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 major 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 202 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

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 сар.

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.

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