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were unvaccinated.

Although inner-city, minority, and preschool children are often described as hard-to-reach, many of them are in regular contact with public assistance programs. Recent investigations of several inner-city measles outbreaks indicate that, depending on the site, 40-91 percent of unvaccinated preschool cases were enrolled in one or more public assistance programs. Programs such as WIC or AFDC typically see enrolled families frequently (every 1 to 2 months) and offer additional opportunities to vaccinate high-risk children.

One chief goal of this program is to link/coordinate immunization with other public assistance programs. An Intergovernmental Committee on Immunizations has been formed. Through this group, which includes the various agencies of the Departments of Agriculture, Health and Human Services, and Housing and Urban Development that are involved in vaccine delivery or serving high-risk populations, selective pilot studies will be conducted to investigate and evaluate the effectiveness of a variety of approaches for improving immunization coverage of infants and young children served by low-income assistance programs. Through this committee, we will also ensure that the immunization status of WIC and AFDC clients is assessed and that on-site vaccination or referral for vaccination is established.

Question. CDC has reported that many children do not receive immunizations at the appropriate age because of barriers to immunization services. What are those barriers and what actions do you plan to take to eliminate those barriers?

Answer. While investigating outbreaks of measles, a number of policy and resource barriers to immunization of preschool-aged children have been identified. The policy barriers include: immunization availability by appointment only, requirements for physical examination prior to immunization, need for physician referral in order to be vaccinated, and requirements for enrollment in well-baby clinics in order to be immunized. State and local resource barriers include: insufficient clinic personnel, inadequate clinic hours, and too few clinic locations. These barriers are disincentives to obtaining age-appropriate immunizations and must be addressed in each public health agency where they occur in order to attain immunization levels of 90 percent in preschool-aged children.

CDC is requesting $6.3 million and 26 FTEs to conduct indepth program reviews of State and local immunization activities. Through these reviews, area-specific barriers will be identified and CDC will assist State and local health officials in developing action plans to remove or reduce those barriers. In a limited number of locations, demonstration projects will be conducted to evaluate the effectiveness of those efforts in increasing vaccine coverage.

Question. Haemophilus influenzae type b is the most common cause of meningitis and the major cause of invasive bacterial meningitis in children under 5 years of age. The ability to use Hib vaccines in infants less than 15 months of age creates the potential to prevent 12,000 to 18,000 deaths annually. How much

funding is required to meet 100 percent of the public sector's need?

Based

Answer. Based on a new contract which was awarded March 13, 1991, the $36 million requested in the 1992 President's budget for Hib vaccine will purchase 6,979 million doses of vaccine or approximately 87 percent of the public sector's annual need. on this new contract price, and on revised estimates of the number of new births per year, it is estimated that an additional $5.3 million would be required to meet 100 percent of the public sector's need in 1992, following reductions in other programs under the domestic discretionary spending cap. However, CDC does not currently purchase 100 percent of the public sector need of any childhood vaccine.

Question. Although there is an effective vaccine for

hepatitis B, the number of cases which occur each year is higher than before the vaccine became available in 1982. What is being done to curb transmission of hepatitis B to children, and specifically, how are we addressing high risk infants?

Answer. The President's budget for 1992 includes $13,766,000 in grant funds, which includes an increase of $1,845,000, to continue and expand the public sector screening and immunization program initiated in 1990 to reduce perinatal transmission of hepatitis B. This funding level will support 95 percent of the public sector's need for the screeing of pregnant women for hepatitis B and the immunization of approximately 17,800 infants born to infected carrier mothers.

Question. What would it take to implement universal immunization of children?

Answer. We believe that it would take 3- to 5- years to fully implement a program for universal immunizations of infants against hepatitis B. If such a program were to begin in 1992, to become fully operational we estimate that an additional $55-$60 million per year in grant funds would be needed by 1996-1997. This estimate includes a projected price reduction of about 30 percent in the cost of vaccine or a savings of about $10 million. These grant funds would be in addition to the current funding support for the perinatal grant program. The first phase of reaching approximately 20 percent of infants in the public sector is estimated to require an additional $15.0 million in grant funds, after reductions were taken for other programs within the domestic discretionary cap. However, the CDC budget proposal for FY 1992 does not request any such additional funds for universal immunization of children against hepatitis B. Other prevention activities, such as removing immunization barriers, control of congenital syphilis, prevention block grant enhancements, screening breast and cervical cancer and childhood lead poisoning, health surveys, infant mortality surveillance and investigations, are regarded by CDC as higher priorities than universal hepatitis B immunization of children, as the 1992 budget request indicates.

TROPICAL DISEASES

Question. What is CDC doing to prevent tropical infectious diseases and reduce the threat of newly emerging diseases?

Answer. CDC is deeply concerned with the striking increase in tropical infectious diseases and recognizes that this problem will continue to grow. CDC is utilizing its traditional public health strength in laboratory and epidemiologic science to develop cost effective approaches most likely to have greatest impact. These include carrying out surveillance to identify disease transmission, risk factors, cases and epidemics; developing and improving diagnostic tests; carrying out epidemiologic studies; evaluating interventions, prevention and control strategies; developing and evaluating new vaccines and promoting health through training and education. Some specific examples include: studies to determine control factors which contribute to and prevent transmission of cholera and shiga dysentery; evaluation of new prophylaxis regimens for prevention of drug-resistant malaria and expansion of our network for providing public information on malaria prevention; efforts on development of a dengue vaccine through collaborative relationships with the U. S. Army Medical Research and Development Command and University of Puerto Rico. are continuing to build our surveillance systems and technical and epidemiologic expertise in order to be ready to identify and respond to new disease problems as they emerge. The complexity of the infectious organisms involved in tropical disease and their propensity to mutate with changing virulence means that we must be able to respond rapidly and effectively to protect our populations.

We

LABORATORY TESTS

Question. Considerable concern has been expressed over the accuracy of laboratory tests. To address these concerns, the Congress passed the Clinical Laboratory Amendments of 1988 (CLIA). It is anticipated that approximately 300,000 laboratories will be subject to CLIA. What role does CDC play in the implementation of

CLIA.

Answer. Through a Memorandum of Understanding, CCC provides technical and scientific support to Health Care Financing Administration to develop and implement CLIA '88.

CDC is specifically responsible for assisting HCFA in the development of final regulations for the complexity model including the technical advisory committee, proficiency testing and cytology aspects of the Amendments. These CDC tasks comprise developing the final rule for CLIA including the reading, coding, and tabulating comments concerning the above aspects and identifying the major issues and regulatory alternatives. In collaboration with FDA, CDC will develop a scientifically supportable set of alternatives and assist HCFA to draft regulatory text.

CDC also provides ongoing technical and scientific support to HCFA for the development of standards, resolution of technical issues, review of proficiency testing provider programs and accrediting organization standards for equivalency, and for the

development and delivery of training interventions identified through the implementation of CLIA.

Question. The practice of public health can often be improved by increasing the knowledge and skills possessed by the public health workforce. What is CDC doing to reach public health workers in need of essential training?

Answer. In 1988, The Institute of Medicine Report, The Future of Public Health, indicated numerous weaknesses within the infrastructure of public health in this country and outlined a series of recommendations for strengthening this infrastructure. One of those recommendations stated that public health training should place greater emphasis on managerial and leadership skills such as the ability to communicate important agency values to employees and enlist their commitment; to sense and deal with important changes in the environment; to plan, mobilize, and use resources effectively; and to relate the operation of the agency to its larger community role. Thus, CDC is currently examining a variety of options to assist high level public health officials in strengthening their management and leadership skills.

CDC is utilizing a variety of modern training and communications techniques to increase the accessibility and efficiency of its training activities. Examples include computerbased electronic bulletin boards for exchange of health information and self study training packages to reach larger, more diverse and geographically disperse audiences.

In 1989, training was implemented at the regional and local level through the establishment of the National Laboratory Training Network which not only delivers training, but also serves as an important resource for information about laboratory training activities and materials which are available nationally and locally to laboratory professionals. CDC developed the National Laboratory Training Network (NLTN) to strengthen the skills, particularly HIV antibody testing, of laboratory workers throughout the country. The NLTN has been a success in reaching a wide variety of laboratory workers in the public and private sectors. CDC is examining its potential as a model for developing a broader public health training network designed to meet the need for improved management and health practice skills of health workers at all levels.

NATIONAL HEALTH INTERVIEW SURVEY

Question. The National Health Interview Survey is a major source of data on the health of the American people, including data on the Year 2000 Health objectives. What is the status of this survey in the FY 1992 request?

Answer. The request contains sufficient resources to fully fund the 1992 National Health Interview Survey (NHIS) ($10.7 million to direct survey costs). Data collection will continue at the full sample size of 50,000 households. In addition to items included in

each year's questionnaire, the 1992 NHIS will focus on adolescent risk behaviors and other areas relative to the Year 2000

Objectives; cancer epidemiology and control, AIDS/HIV knowledge and attitudes, and detailed data on income and program participation for policy research.

AUTOMATION AND TECHNOLOGY

Question. Your request for FY 1992 includes funding for efforts to improve the timeliness and quality of health statistics, and access to those statistics. What kinds of activities will be supported by these funds?

Answer. The President's request recognizes that investment in improving our ability to measure our nation's health needs, and to target and measure the effectiveness of public health programs is particularly critical. All public health programs included in the President's budget, as well as medical research and entitlement programs, rely on timely, high quality data.

The increase in the request of $3,535,000 for automation and technology development will provide the following benefits:

Increased timeliness, with considerably shorter lag time between data collection and release of published reports and electronic data to the public.

Increased productivity through improved analytic
output, improved access to data by public and

Government researchers, and improved responsiveness in
answering public inquiries.

Improved quality of data, by reducing the number of
manual steps that introduce human error.

Examples of activities that will be undertaken under the request include expanding the use of laptop computers in home interviews; developing automated coding and data processing systems to speed production of vital statistics; and expanding access to data through increased use of electronic data dissemination products, such as compact disk (CD-ROM) and other PC-oriented tools.

INFRASTRUCTURE

Question. The Institute of Medicine Report on the Public Health System stated that if State and local health agencies are to fulfill their mission of providing quality health services, they would need improvements. Dr. Roper, one of your agenda items for CDC includes rebuilding infrastructures. First, would you explain what needs to be done at the State and local health agency level. Second, please explain what needs to be done at CDC to rebuild it's infrastructure to support State and local health agencies.

Answer. Efforts to strengthen the public health infrastructure need to focus on approaches designed to enhance the capacity of state and local health agencies to carry out the core

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