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Doctor, please describe the success you have had in implementing the 1990 National Academy of Sciences Report, "Injury in America," specifically, the information campaigns designed to increase the use of child safety seats, seatbelts and helmets.

Answer. The CDC injury control program is embarking on a national campaign of proven-effective interventions to reduce deaths and injuries to children in motor vehicle and bicycle crashes and a multifaceted campaign to limit unsupervised access of children to firearms. The overall approach of the campaign will be

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Develop and carry out a public information campaign
that is national in scope.

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Work with our partners in the public and private sector in implementing and evaluating the interventions.

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Determine the most effective way to implement the
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Provide information to stimulate appropriate regulatory and legislative changes.

Manage and evaluate the campaign.

Question. How will the $2 million increase requested for 1992 build on your past work in this area of child safety?

Answer. The $2 million increase will build on existing program efforts in child safety and move injury control from analysis to action. Using the foundation of intra- and extramural research findings and building on the cornerstones put in place by capacity building grants to State and local health departments, and collaborating closely with the National Highway Traffic Safety Administration, the activities supported by the increase will tie together all of the elements of injury control into a national campaign to prevent three childhood injuries--motor vehicle, unintentional shootings, and bicycle.

Staff have spoken about injury control at the National Day care provider meetingThe 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 reconmendations 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 cap.

LEAD POISONING

Question. CDC has recently released a strategic plan for the elimination of childhood lead poisoning. What needs to be done to implement that strategic plan and what, in your professional judgment, would be the dollar amounts associated with this implementation.

Answer. The strategic plan describes the first 5 years of a 20-year effort to eliminate childhood lead poisoning. This effort will require a shared commitment by the public and private sectors. The plan calls for $974 million over 5 years to carry out both program and research agendas. We have not divided this cost into public vs. private sector costs, but clearly, some costs will have to be borne by both. In addition, implementation of this plan will require efforts at all levels of government, not just the Federal government.

Implementation of the strategic plan, as well as the plans developed by the Environmental Protection Agency and the Department of Housing and Urban Development, will also require close coordination between the Federal agencies. We will continue to work with these agencies towards the goal of eliminating childhood lead poisoning

PREVENTION

Question. Dr. Roper, we now know a great deal about how to prevent or greatly reduce the risk from childhood diseases, breast and cervical cancer, heart disease, tuberculosis, lead poisoning, and injury, to name just a few. And, we also know that investing in prevention saves us millions of dollars. In spite of this, we have not incorporated prevention into the core of our health care system. Should we make prevention an integral part of any health care program?

Answer. Yes. We must build a system that will make prevention an integral part of the nation's health care. Leaders in public health and clinical medicine can work more effectively to prevent disease if they are truly partners. It does not make sense for public health to actively identify persons with high blood pressure, only to have the health care system leave a large proportion of them without proper treatment. We must increase the provision of preventive services in the delivery of health care. We also must ensure that medical education includes preventive health curricula, and we must re-examine our system of health care financing and reach a consensus that includes the financing of preventive care.

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.

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