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PREVENTION "80

Prevention '80 U.S. Department of Health and Human Services Public Health Service Office of Disease Prevention and Health Promotion DHHS (PHS) Publication No. 81-50157

Preface "The health o! the American people has never been better." Healthy People Progress toward better health for Americans has been substantial in recent years. CertainIy the data give us cause for encouragement. Dramatic declines in the incidence of certain ~nfectious diseases have been joined by impressive gains in infant survival, and, ~pecially in the la.~t decade, surprising reductions in death rates from heart disease and stroke. Our sueeesses in preventing disease and di~abilit y in this country have led to a growing sense of optimism about the potential for future gains. Moreover, development of our national preven- tion strategy to enhance the prospect of those gains has taken form over the last decade. A number of prominent milestones are notable for their contribution to the definition of priorities and objectives. • President's Committee on Health Education, I971 • Preventive Medicine Task Forces of the Fogarty Center and the American College of Preventive Medicine, 1975 • Department of Health, Education and Welfare Task Force on Disease Prevention and Health Promotion, 1978 • The Surgeon General's Report on Health Promotion and Disease Prevention, Healthy People, 1979 • Promoting Health/Preventing Disease: Objectives for the Nation, 1980 With the specification of the measurable goals and objectives for 1990 contained in Healthy People and Objectives for the Nation, our emerg- ing concepttta] "roadmap" offers a clear charge. The task is now to marshal the collective resources of public agencies arid private organizations and businesses to achieve what is possible. Though the objectives that have been identified are national guideposts--as distinct from Federal standards the Federal government has consider- able capability to contribute to their attainment. Prevention 'SO is offered as an annual report to describe the Federal prevention activities, review the major accomplishments of the past year, and establish a mechanism for tracking our progress. It is our hope that this report will also facilitate the efforts of health professionals and program managers engaged in similar activities in States and communities throughout the country. With a cooperative commitment of energy, imagination and will, the decade ahead can offer an exciting opportunity for even greater gains for the health of Americans. J. Michael McGinols, M.D. Deputy Assistant Secretary for Health and Assistant Surgeon General

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Contents Prefsce .................................................................................. v Chapter I : Prevention Highllgbt~ ............................................................ l Chapter 2: Health Statu~ Trend~ ............................................................. 7 Chapter 3: Agency Innovations .............................................................. 33 Department of Health and Human Services Public Health Service ............................................................. 34 Other DHHS Agencies Health Care Financing Administration ............................................... 69 Office of Human Development Services .............................................. 70 Other Federal Agencies ................................................................ 72 Chapter 4: Prevention Inventories ............................................................ 77 Table 1. FY 1979 and FY 1980 Resources for Prevention Activities by Agency Department of Health and Human Services ............................................... 78 Table 2. FY 1979 and FY 1980 Resources by Prevention Priority Area Department of Health and Human Servlees ............................................... 79 TabIe 3. DHHS Agencies Reporting Prevention Activities in 1980 by Priority Area ............................................. 80 Table 4. FY 1979 ~md FY 1980 prevention Inventories by Agency and Priority Area Department of Health and Human StTvices ............................................... 82 vii

Figures Figure I. LeadingCausesofDeathinlg(iOand197g .......................................... 9 Figure 2. TrendsinAge-AdjustedDeathRatesFtomSelectedCauses:sele~tedYears, 1900.1978 ..... 10 Figure 3. Major CausesoflnfantDeaths: 1950and 1978 ....................................... 11 Figure 4. PercentageofInfa.ntsofLowBirthWeight, ByRace: 1950-1978 ........................ 12 Figure 5, TrendsinRef:~>rtedlnodeneeRatesofTenSelcctedBirthDefe~'q~: 1970-1979 ............. 13 Figun~ 6. MajorCausesofehiltihoodDealhs: 1950and 197g ................................... 14 Figure 7. TrendslnAccidentalDeathRatesforChiMren, FromseIectedCau~e*: Selected Years, 1950-197g ........................................................ 15 Figure g. TrendsinReportedlncidenccRatesofChildhoodDiseases:SeleetedYears, 1950-1979 ..... [6 Figure 9. Major CausesofAdolesccnt Deaths: 1950and 197g ................................... 17 Figure 10. Trends in Death Rates for Suicide, Homicide, and Motor Vehicle Accidents Among Adolescent Males, By Color: Selected Years, 1950-1978 ........................ I g Figure 11. Trends in Death Rates for Suidde, Homicide, and Motor Vehicle Accidents Among Adolescent Females, By Color: Selected Years, I950.1978 ....................... 19 Figure 12. Cigarette Smoking Among Teenagers, By Age and Sex: 1968, 1974, and 1979 ............. 20 Figure 13. Cigarette Smoking Among Young Adults, By Race and Sex: 1965, 1976. and 197g ......... 21 Figure 14. Major Causes of Adult Deaths: 1950and 1978 ....................................... 22 Figure 15, T~nds in Death Rates for Heart Disease and Stroke Among Adult Females, By Color: Selected years, 1950.197g ........................................................ 23 Figure 16. Trends in Death Rates for Heart Disease and Stroke Among Adult Males, By Color: Selected years, 1950-1978 ................................................ 24 Figure 17. Age-Adjusted Cancer Death Rates for Males, By Site and RaCe: Selef.ted Years, 1969-1977..25 Figure 18. Age-Adjusted Cancer Death Rates for Females, By Site and Race: Selected Years, 1967-1977 ...................................................................... 26 Figure 19. Trends in Selected Alcohol-Associated Causes of Death: 1949-1978 ..................... 27 Figure 20. Trends in Apparent Per Capita Ethanol Consumption, Based on Beverage Sales: 1944-1978 ...................................................................... 28 Figure 21. Major Causes of Older Adult Deaths: 1950 and 1978 .................................. 29 Figure 22. Trends in Death Rates for Pneumonia and In nuenza Among Older Adults: Selected Years, 1950-197g ........................................................ 30 Figure 23. Trends in Re~t tiered Acdvit y Days and Bed Disability Days Among Older Adults: 31 1960.1979 ....................................................................... viii

Chapter 1: Prevention Highlights Recent years have ~eet~ impre~slve gains for the health of Amerlcans--gains largely accomplished through the prevention of disease and disability. In I979, the Surgeon General released Health~ People: The Surgeon Generel's Report On Health Promotion and Disease Prevention, which chronicled the important changes in the health status of Americans since the turn of the century and outlined national goals for the future. Even in the short time since the release of the Surgeon General's Report. prominent advances have been made toward those goals. Prevention "80 summarizes some major developments now under way in prevention and reviews the Federal contributions to achievement of our prevention objectives. This first chapter presents five particularly important achievements receiving special recognition within the last year that exernplify the potential for further advances: the eradication of smallpox, enhanced childhood immunization, the decline in infant morality, the decline in heart disease and stroke mortality, and the hypertension detection and folIow-up program.

Prevention Highlights Smallpox Eradication The conquest of smallpox, officially declared in May IPgO by (he Assembly of the World Health Organization, was one of the most important achievcrnent~ in the history of puhiic health. Irx Ociohrr of 1977. the last documented epldemlc case of smallpox OCcurred in Marka. Somalia. ending a scourge that historicaffy has been a leading cause of unnecessary death. The United States was a major contributor to the woridwlde effort directed by the World Health Organization, having provided nearly a fourth of the WHO and bilateral aid budget, as well ~.~ the services of el~idemiologicai consultants, largely from the U,S. Public Health Servicc'~ Center for Disease Control. Smallpox is the first disease ever eliminated through a carefully designed and implemented program. Early Asian writings indicate that smallpox was long prevalent in the more densely populated parts of Asia, and it probably reached Europe around the sixth century. E~timat~ vary as to the early death rate, but references taken from documents about epidemics of the 17th and lgth centuries suggest that the death rate among those who con- reacted smallpox was between 20 and 50 percent. From the ]3th through the Igtb centuries, civilized man explored the new world, and as im- proved transpOrtatiot~ and the need for commerce ended the isolation of many remote areas, smallpox epidemics followed and led to the dec~matlon of entire popaiat~on~. By Ih¢ middle 1700s, smallpox in the United States was believed to account for 10 percent of all deaths, and was ihr leading catlse of in f~nt death. Clues to control of the disease emerged over centuries. As early as 2.500 years ago, peac¢i- tioners in China and India found that varlola- lion--development of a light ease of smallpox through deli'0erate ~noculation with material from smallpox pustules or ~¢abs---<oaid confer imrnnnl- ty to the disease. The death rate o[ 1 or 2 percent from variolal~on was far less ~han the expected death rate from the natural disea.~e. In I978, the English country physician Edw,~rd Jenner documented the fact that srn~dlpox im- munity; could he obtained through inoeul~ion with the much milder cowpox. His prediction that this practice would result in "the annihilation of smallpox" marked the bo~Jrming of a finest that succeeded 179 year~ later. In spite of the growing wide-scale use of smallpox vaccination in the lg00s and early 1903s, the disease remained endemic throughout the woeld during much of this century. Tho~c who were riot immune ran a high risk of being stricken sometime during their lifetimes. Following World War [I. the concept of worldwide eradication gained new suppor tees as smallpox was ~ucct:ss ful- ly edmina~ed f[om North America, Europe, and a number of other countries willing and able to vac- cinate the re*crvoirg of nonimmune indlvidua]$ in population centers, and to prohiblt travelers from crossing their borders without evidence of smallpox vaccination. In I949, the last ittdigenous ca.~e of smallpox in the United States occurred in tbc Rio Grande Valley in Te:~as. To strengthen the global program, in 1959 the World Health Assembly passed a resolution directed at smallpox eradication, and the World Health Organization, UNICEF. and other organ- izations offered heIe to those eovntri~ w~li~ng to uIlder take mass vacclnations. However, it was [lot until 1905 that the commitment to worldwide Pra(i~¢a~ion of smalfaox was angrl~ettted with budget and bilateral a.ssignmenls sufficient to make feasible the gaal of eradication by 1976. In 1967 the disease was still considered endemic in 33 count~ics, and eases attributed to travel through

these area~ had been reported in I 1 other nations, By I970 only 21 countries reported cases, and 16 did so in I971. The sinai[pox eradication program was maitl- faceted. Techniques of mass vaccination programs were improved, and costs d~creased with the development of the jet injector gun and the bifur cated needle. Production and quality control for vaccine production were also greatly improved. Ultimately, a highly developed surveillance/ local conlainment program provided the measure of success. Workers systematically searched for cases and moved rapldly into any area in which a case was detected, sealing off the spread to other areas, isolating the patients, and finding and vac. cinatlng contacts. By 1974 the fight to er adieate smallpox was near success, with Pakistan's last case reported in 1974, NepaPs in April 1975, India's in May 1975, and the last in Bangladesh in October 1975. Ethiopia'~ last reported case occurred in 1976, and the last cases in Kenya and Somalia were reported in I977. A laboratory accident in England in 1978 pro duced the last verified case of smallpox. The Global Commission for the Certification of Smallpox Eradication required that a two-year period Pass without any naturally transmitted cases before the disease could be considered to have been eliminated. That period ended in Oc- lohor 1979, and the smallpox virus is now housed only in selected laboratories. Childhood Immunization Ociuber 1979 also marked the successful com- pletion of the two and a half year National Childhood Immunization Initiative. This effort was begun in 1977, when surveys revealed that over a third of school-aged children were inade- quately immunized against the major vaccine preventable diseases. A goal was established to raise the immunization levels to over 90 percent by the fall of 1979, and program activities were tailored to meet that goal. Today, of the million children in kindergarten through eighth grade, 91 percent are adequately immunized. Of those newly entering school in the fail of 1979, 94 percent had been immunized against measles, 93 percent again.st rubella, 87 percent against mumps, 93 percent against polio, and 94 percent against diphtheria, pertussls, and tetanus. Cases of these diseases have also declined in number. In fact, remarkable progress has been made since the 1950s in the reduction of vaccine- preventable diseases throughout the United States. Only 30 years ago the childhood dls~ produced extensive mortality and residual disability in this country. The 1955 Poliomyelitis Vaccine Assist- ance Act. later expanded by the Vaccine Assist ance Act of 1962, supported extensive growth in State-levai programs to provide all children with immunizations against the major childhood vacclne-preventable diseases. As more vaccines were developed and depinyed, the fist of diseases to be combated expanded, and the number of reported eases fell. However, as the disease in- cidence fell. efforts to immunize all children did not receive the priority warranted, and levels of immunity to many of these diseases among children crested and. in some cases, fell. The nationwide Immunization Initiative an- nounced in April 1977 was developed to ensure that the Nation's children would be immunized against seven vaccine-preventable diseases: poiiomyeiitis, diphtheria, pertussis (whooping cough}, tetanus, memsles, mumps, and rubella. Particular attention was paid to tht; gap in im mualzation levels between affluent communities and Iow-lncome areas, and in the differences be- tween levels in school-aged children and preschoolers. AS part of the effort to achieve the goal e;tab- lisbed, the Department of Health and Human Ser- vices increased grant support to health depart- ments for immunization activities, strengthened the emphasis on improved immunization levels for users of grant-supported primary care facilities serving low-income populations, and launched a national outreach and education effort to en- courage immunization. Organized professional groups making substantial contributions to this ef- fort included the Amerlean Academy of Pediat- rics. the American Medical Association, Ihe Na- tional Medical Association, the National League for Nursing, and the American Hospital Associa- tion. Local chapters of volunteer groups such as the National Council of Negro Women, the General Federation of Women's Clubs, the Parent-Teacher Association. and the American Red Cross contributed significantly at the com- munity level. Business and labor organizations participated in both publicizing and implementing the objectives of the campaign. A particularly important feature was the vigorous enforcement by school systems of school entry immunization laws, with expanded require- ments to include immunizations for more dis~. For example, the number of States requiring im- munization against mumps increased from two in 1977 to 18 in 1979, and five States enacted school entry immunization laws for the f~rst time during the same period. Today at[ 50 States have school entry statutes to help ensure that all youngsters are ~ .......................... As a consequence of these successful efforts, the Public Health Service has reaffirmed its commit- ments to maintain immunization levels among all children, to elimlnate measles as an endemic 3

disease in the United States by 1982, and to im prove the reporting of childhood diseases for bet- ter tracking of the incidence of outbreaks. Decline in Infant Mortality In 1979, the in fanr mortality rate ia this country continued to decline and reached the lowest point ever achieved, 13 deaths per 1,000 llve births. This achieveme~l is Mrgdy the result of advances in perinatal and neonatal medicine, improvements in the delivery of caye to ~othcrs and infants, and improved techniques for early identification and treatment of those pregnant women and infants who are at high risk. The decline in infant mortality since 1900 has been dramatic--more than it sevenfold dccfine from the 1900 leval of 100 deaths I)cr 1,000 live births. During the past 10 years, the rate has decreased from 19.2 in 1968 1o 12.0 in 1978 for whites and from 36.2 to 23.1 for blacks. Ahhough these are significant improvements for both groups, there r~snaln large differences among subgroups of the population and among geographic areas. It is important to note that total infant mortali- ty represents the combination of early infant deaths (neonatal) and those occurring after the first month of life and before the first birthday (postneonatal). Problems and intervention strategies differ between these two components, and iroproeetaents have occurred for both. Neonatal deaths--those occurring in the first 28 days after blrth--!argely represent orenabal and perinatal circumstances and events. Consequently, family planning, prenatal care with risk assess- ment and management, and newborn intensive care constitute the most important measures con- tributing to the reductions of neonatal deaths. Since the causes of postneonatal deaths reflect aspects of the infants' environments, important preventive measures include parenting in~truedon for new parents, illness sul'velifallee, and ap- propriate use of pediatric services. Neonatal mortality accounts fo~ more than two thirds of infant deathsl a substantial portion of the gains made during the past 20 years can be at- Cfibuted to developments in rtcona~ology and the establishment of regionalized networks for perinata] =ate. Care of blgb-risk preguant women and intensive care of newborns, particularly for low birth weight infants, have imeroved slgnifl- tautly. Improved prengtal nutrition, control of certain diseases like rubella that may affect the fetus if contracted by the mother during pregnan- cy, and reduced substance abuse during pregnancy (smoking, alcohol, and certain drugs) may also contribute to reductions in infant death rates. If the currently successful trends in reducing neonatal deaths continue through the 1980s, future improven~ents in infant health may depend on our ability to prevent postneonatal problems. A number of Federal efforts have contributed to the progress made in reducing infant deaths. The Maternal and Child Health Program, which dates back to pas~ge of the Social Security Act in 1935, provides grants to States for maternal and infant services. The States operate oomprehensive programs ~naludiag crippled children's sefvi~q and special projects in family planning, maternity and infant care, Jntensfae care, sch~oJ health, and dental heaith. The Improved pregmtncy Outcome initiative and Improved Child Health projects are further efforts initiated through the State grallt program to improve the health of pregnant women and children. Other aedvltiaB include a recently authorized program to fund comprehensive services and preeentlon projects to deft with adolescent pregnancies, special nutrition I~rograms ad- ministered by the Department of Agriculture for pregnant women and infants, the direct reim- bursement for medical care provided tinder Medicaid for eligible low-income women, and the comprehensive soalal services covered untiar q?itie XX. Through the National Institute of Child Health and Human Deve/ogment (NICHD), a multidlsclplinary research effort addresses the ear- ly Jdentlficatfan and reduction of risk factors associated with infant mortality. The combination of these efforts with participa- tion of Stare and local agencies has been tt signifi- cant factor in the impressive improvements of re- cent years and can be exlx'eted to yield further gains in infant health in the 1980s. Decline in Heart Disease and Stroke Mortality In the decade from 1968 to 1978, age-adjusted death rates for heart disease lieclined by 22.7 per- cent, and stroke deaths declined by 36.5 percent. indeed, heart disease and stroke death rates have dropped dramatically Mince 1950. Although heart disease continues to be the leading cause of death and stroke the third leading cause, there have been substantial gains in the fight to prevent these chronic and disabling diseases. These trends bear important witness to the fact that certain elements of chronic discuses need not always be inevitable consequences of the aging process. Between 1950 and 1970, the age.adjusted death talc for all heart dlse~-.~--inc!uding cong~tlve heart failure, rbeumatlc and hypertension-related heart dlsease--fog 18 percent, or an average of one percent every year. From 1970 to 1978, the rate declined another 18 percent, or approximately 2.5 percent each year. Far stroke, the 1950 to