To address this problem, CDC is focusing its funding priority to support syphilis prevention and control activities in the 35 highest morbidity-reporting counties in the Nation. Further, STD programs must develop better techniques to reach women who do not receive adequate prenatal care. For example, ensuring syphilis screening in the first and third trimesters and at delivery, improving communications with hospitals that deliver high numbers of at-risk women, and developing effective coalitions with National, regional, and community-based organizations in high-risk areas are techniques that will help in the prevention and control of not only syphilis and congenital syphilis, but also most of the other STDs.

CURRENT HIV/AIDS TRENDS

Question. Since its recognition in 1981, HIV infection and AIDS have emerged as the nation's most pressing public health problem, with more than 160,000 cases of AIDS reported to date. What are the current trends in the HIV epidemic?

Answer. CDC and the PHS currently estimate that 1 million persons are infected with HIV nationwide.

Reported cases continue to increase with more than 43,000 cases reported in 1990, a 23 percent increase over the number reported in 1989.

A leveling trend has been noted among reported cases of men who have sex with men, with proportionately higher increases reported among injecting drug users and individuals who have been exposed through heterosexual contact.

Reported AIDS cases in women account for an increasing proportion of all AIDS cases in the United States. In 1990, 11.5 percent of all reported adult cases were in women. Reported cases among women increased by 34 percent in 1990 over 1989 as compared to a 22 percent increase among men.

HIV disproportionately affects blacks and Hispanics. In 1990, the rate per 100,000 population for blacks was 53.8 compared to 42.0 for Hispanics and 14.0 for non-Hispanic whites.

More than 100,000 deaths have been reported among individuals diagnosed with AIDS and HIV was the third leading cause of death among men 25-44 years of age in 1988 (the most recent year for which data for ranking deaths is available). In 1989, it was estimated to be second, after unintentional injuries. Among women 25-44 years of age, HIV ranked eighth in 1988 among causes of death and in 1991, based on current trends, HIV is likely to be among the 5 leading causes of death.

HIV IN HEALTH-CARE SETTINGS

Question. Recently there has been increasing concern among health-care workers about their risk of acquiring HIV infection on the job. Now you have reported that three patients got AIDS from a

dentist. What is CDC doing to prevent the transmission of HIV infection in health-care settings?

Answer. In order to assess and reduce the risk of HIV transmission in health-care settings, CDC conducts a variety of surveillance projects, epidemiologic risk-assessment, laboratory investigations, and prevention, control, and evaluation activities. Major areas of current focus include surveillance of health care workers with AIDS; assessment of the nature, frequency, and preventability of blood contact among health care workers and patients; assessment of the risk of HIV transmission due to these exposures; evaluation of preventive measures, including work practices and control technology; and recently, assessment of the risk of HIV transmission to patients during invasive procedures.

Question. What is your position on HIV testing of health care workers with practice restriction for those who test positive?

Answer. CDC's evaluation of the possible need for changes in the current recommendations for prevention of HIV transmission during invasive procedures has been a continuing process, with input solicited from expert consultants and from the public. CDC convened such a meeting in late February, 1991, to review the risks of HIV and hepatitis B virus transmission to patients during certain invasive procedures. If revisions to the guidelines are deemed necessary, a draft of revised recommendations will be circulated for public comment prior to their being issued.

HIV/AIDS AMONG ADOLESCENTS

Question. Although a relatively small proportion of AIDS cases occur in adolescents, because of the long incubation period of the disease, most young people who become infected do not develop AIDS until they are in their 20s. How is CDC assessing HIV risk and HIV infection in adolescents and what are you finding?

Answer. As part of our serologic surveillance program, CDC monitors HIV infection prevalence levels and trends in a variety of groups including those groups that represent young adults. The second component in assessing HIV risk in adolescents is behavioral surveillance research. Through the Youth Risk Behavior Surveillance System, CDC helps States and cities regularly monitor the prevalence of health-risk behaviors among high school students.

In virtually all the adolescent groups assessed, HIV infection increases progressively with year of age from the midteens up well into the late 20s. This indicates that adult type risks begin in the early teens, as does HIV infection, and continue throughout the adolescent and young adult period. Over the past 3 years, HIV prevalence in young female Job Corps students has significantly increased and now exceeds that in male Job Corps students. CDC is undertaking a collaborative study with the Job Corps to evaluate the risks most responsible for this HIV infection. We are concerned about heterosexual and drug-related HIV transmission in poor, and especially minority, youth, as well as out-of-school youth in homeless and run-away situations.

CDC'S CARE ACT IMPLEMENTATION

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.

DIABETES

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.

EMS

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.

DATA COLLECTION/ASSESSMENT

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.

EPIDEMIC INTELLIGENCE SERVICE (EIS)

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?

CDC

Answer. CDC's major effort to meet the need for well-trained epidemiologists is the Epidemic Intelligence Service Program. CDC is trying 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. 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.

PREVENTION CENTERS

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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