Tobacco Institute
Promoting Health Preventing Disease; Objectives for the Nation
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- 1. Us Department Health Human Ser Author
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US. DEPARTMENT OF HEALTH AND HUMAN SERVICES
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Office of the Assistant Secretary
for Health
Washington DC 20201
I am pleased to share with you Promoting Health/Preventing Disease:
Objectives for the Nation. Our national strategy for achieving further
improvements in the health of Americans was established in Healthy People,
a document that notes our accomplishments in prevention, identifies the
major health problems, and sets national goals for reducing death and
disability. This volume sets out specific and measurable objectives for
fifteen priority areas that are key to achieving our national health
aspirations. We appreciate the work of so many people to define quantifiable
objectives against which we can assess the effectiveness of our efforts.
Achievement of these objectives by 1990 is a shared responsibility, requiring
a concerted effort not only by the health community, but also by leaders
in education, industry, labor, community organizations and many others.
These challenges for the eighties demand creative approaches and by working
together we can realize our aspirations and really make a difference.
ulius B.
'Assistant Secretary fo
and Surgeon General
November, 1980
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E
EVENTI NG B I SEASE
OBJECTIVES FOR THE NATION
FALL 1980
HUMAN SERVICES
UBLIC HEALTH SERVICE
TIMN 364880
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Patricia Roberts Harris, Secretary
C HEALTH SERVICE
Julius B. Richmond, M.D., Assistant Secretary
for Health and Surgeon General
OFFICE OF DISEASE PREVENTION AND HEALTH PROMOTION
J. Michael McGinnis, M.D., Deputy Assistant Secretary
for Health
CENTER FOR DISEASE CONTROL
William H. Foege, M.D., Director
HEALTH RESOURCES ADMINISTRATION
Henry A. Foley, Ph.D., Administrator
CONTENTS
INTR{lI1UCT IOAI ANI} OVERVIESd . . . . . . . . . . . . . . . . . . . . . v
PREVENTIVE HEALTH SERVICES
HIGH BL(}(}]} PRESSURP CQNTRlL . . . . . . . . . . . . . . . . . I
' Specific Object1ve5. . . s . . a , . a . . . . . . . . . 6
FAls'IZLY PLANNING . . . a . . , . a . a . . . . . a . Il
Specific t3bjactives. . . . . . . . . . . . . . . . . . . 16
PREGNANCY AND
INFANT HEALTH . . . . . . . . . . . . . . . . . 21
Specific Objectives. . . . . . . . . . . . . ... . . . . 26
IMMUNZZAT I(3N . . . . . . a . . . . . . . . . . . . . . . . . . 3 5
Specific tlbjectzves. . . . . . . . . . . . , . . . . . 38
SEXUALLY TRANSMITTED DISEASES . . . . . . . . . . . . . , a . 45
Specific Objectives. . . . . . . . , . a . . . . . . 49
HEALTH PROTECTION
TCXIC AGENT C{3NTR4L . . . . . . . . . . . . . . . . . . . . . 55
Specific (3b,jectives. . . , . a . . . a a a . . . . . . . 64
3CCiIPAT IUNAL SAFETY AND HEALTH . . . . . . . . . . . . . . . . 71
Specific Objectives. . . . a . . . . a . a . . . . . . . 77
ACCIDENT PREVENTION AND INJURY CONTR{)L. . . . . . . . . . . . 83
SpeL3fi(..' Objectives . . . . . . . . . . . . . . . . . . . 89
FLUORIDATION AND DENTAL HEAZ.TH . . . . . . . . . . . . . 95
Specific Objectives. . . . . a , a . . . . . . . . a I(72
SURVEILLANCE AND CONTROL OF INFECTIOUS DISEASES a.....1C7
Specific Objectives . . . . . . . . . . . . . . . . . . . III
SMCKING f1NB HEALTH. . . a . . . . . . . . . . . . . . . .II7
Specific Objectives . . . . . . . . . . . . . . . . . . .122
MISUSE OF ALC(1HOL ANT3 DRUGS . . . . . . . . . . . . . . . . .3.23
Specific C1b ject3ves. . . . . . . . . . . . . a . . . . }.36
NUTRITION . . . . , a . . . . . . . . . . . a , . . a . , .143
Specific (}bjectiV28. . . a . . . . . . . . . . . . . . . }.48
PHYSICAL FITNESS AND EXERCISE . . . . . a . . 155
Specific Objectives. . . . , . . . . . . . . . . . .159
CONTROL OF STRESS AND 4FIOLENT BEHAVIOR. . , . . . . . . . . .IEr3
Spe(:iii~.' Vi}jQctjvesa . . t . . a . a . a a . . . , a .169
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . 173
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INTRODUCTION AND OVERVIEW
The Pur ose and the Process
In 1979 the first Surgeon General's Report on Health Promotion and
Disease Prevention, Healthy People, was issued. That report chronicled
a century of dramatic gains . in the health of the American people,
reviewed present preventable threats to health, and identified fifteen
priority areas in which, with appropriate actions, further gains can be
expected over the decade. The report established broad National
goals--expressed as reductions in overall death rates or days of
disability--for the improvement of the health of Americans at the five
major life stages. Specifically, the goals established were:
To continue to improve infant health, and, by 1990, to
reduce infant mortality by at least 35 percent, to fewer
than nine deaths per 1,000 live births.
s To improve child health, foster optimal childhood
development, and, by 1990, reduce deaths among children
ages one to 14 years by at least 20 percent, to fewer
than 34 per 1.0[i, 0()0.
s To improve the health and health habits of adolescents
and, young adults, and, by 1990, to reduce deaths among
people ages 15 to 24 by at least 20 percent, to fewer than
93 per 100,000.
s To improve the health of adults, and, by 1990, to reduce
deaths among people ages 25 to 64 by at least 25 percent,
to fewer than 400 per 100, 0(10.
s To improve the health and quality of life for older adults
and, by 1990, to reduce the average annual number of
days of restricted activity due to acute and chronic
conditions by 20 percent, to fewer than 30 days per year
for people aged 65 and older.
This volume, Promoting Heaith/Preventing Disease, sets out some
specific and quantifiable objectives necessary for the attainment of these
broad goals. Objectives are established for each of the 15 priority
areas identified in the Surgeon General's report: high blood pressure
control; family planning; pregnancy and infant health; immunization;
sexually transmitted diseases; toxic agent control; occupational safety
and health; accident prevention and injury control; fluoridation and
dental health; surveillance and control of inectious - diseases; smoking
and health; misuse of alcohol and drugs; nutrition; physical fitness and
exercise; and control of stress and violent behavior. A number of
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different objectives are specified for each of the 15 areas. Taken
together the targets established in Promoting Health/ Preventing Disease,
when attained, should permit the realization of the overall National goals
set down in the Surgeon General's report.
The objectives are the result of a year long effort involving more than
500 individuals and organizations from both the private and
governmental sectors. First drafts were drawn up by 167 invited
experts at a conference held in Atlanta, Georgia, on June 13 and 14,
1979, sponsored by the then Department of Health, Education, and
Weifare. The conference, organized into work groups for the 15
subject areas, was a joint effort of the Center for Disease Control and
the Health Resources Administration, coordinated by the Office of
Disease Prevention and Health Promotion of the Office of the Assistant
Secretary for Health.
An invitation for public comment on these drafts was published in the
Federal Register and the volume containing them was also circulated
widely to people and agencies concerned with the various subjects.
During the fall of 1979 the objectives and reports were revised
according to the suggestions received. In early 1980 the revised
objectives were circulated within the Department of Health and Human
Services, to other relevant Federal agencies, and to Atlanta conference
work group chairpersons to elicit further comment. Final revisions
were made in the spring of 1980.
Because the process received such a substantial contribution from the
1979 Atlanta conference, it merits special note. The conference
participants and invited observers were all knowledgeable about some
aspect of risk reducing actions that can improve the opportunities for
health. The chairpersons and members of each of the 15 work groups
were expressly selected to provide a mix of backgrounds which could
bring to the task not only technical expertise and consumer and
professional viewpoints, but also practical experience with planning and
program implementation. Thus, participants were drawn from a variety
of affiliations--providers, academic centers, State and local health
agencies, voluntary health associations, and many others.
To facilitate the discussions, each work group member received a draft
background paper, prepared by staff of an HEW office with program
responsibility in the relevant prevention activity. Other HEW activities
in setting goals and standards for prevention were taken into account
both in the background papers and in work group discussions,
particularly the National Health Planning Goals called for by Section
1501 of P.L. 93-641, presently under development by the Health
Resources Administration, and the Model Standards for Community
Preventive Health Services called for by Section 314 of P.L. 95-83,
whose development was coordinated by the Center for Disease Control.*
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While the objectives were developed under Public Health Service
sponsorship, and are consistent with Federal policies, they are far
wider in purpose and scope. They are intended to be National--not
Federal--objectives. To realize the potential for reducing the rates of
premature death and disability to the levels set forth here requires a
truly National commitment, including, but going far beyond, that of
government.
To achieve these objectives demands actions by Americans in all walks
of life, in their roles as concerned individuals, parents, and as citizens
of their Nation and of States and local communities. Sustained interest
and action is required not only by physicians and other health
professionals, but also by industry and labor, by voluntary health
associations, schools, churches, and consumer groups, by health
planners, and by legislators and public officials in health departments
and in other agencies of local and State governments and at the Federal
level.
While the diagnosis and treatment of disease are the
responsibility of health professionals and health organizations, actions
to reduce the risks of disease or injury extend far beyond health
services per se. The range of preventive activities is broad. Included
are key preventive services, such as immunization, delivered to
individuals by physicians, nurses, other health professionals, and
trained allied health workers. Also important- are standards, voluntary
agreements, laws and regulations, such as engineering standards,
safety regulations and toxic agent control, to protect people from
hazards to health in their living, travel and working envircnments. In
addition, and perhaps most important for today's health threats, there
are activities that individuals may take voluntarily to promote healthier
habits of living and activities that employers and communities may take
to encourage them.
This document is designed for the use of leadership in the wide range
of private and public sector organizations with important roles in these
various areas. At a time in the Nation's history when budgets become
ever tighter, legislators, public officials and governing boards of
industry, foundations, universities and voluntary agencies are
beginning to re-examine their traditional bases for allocating their
limited health-related resources. It is anticipated that in the years to
come policy makers will be able to use the objectives in this volume to
track the Nation's successes or failures in prevention.
*Readers who want to place disease prevention priorities in the
perspective of overall national health policy should refer to the draft
National Health Planning Goals, forthcoming from the Health Resources
Administration which address broad health status and health system
considerations. Readers who want more specifics on how to put
prevention measures to work are referred to Model Standards for
Community Preventive Heaith Services, issued in 1979 by the Center for
Disease Control.
VI i
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The Reports
Each of the reports focuscs on one of the 15 prevention areas and is
presented in a standard format allowing a review of ;
the nature and extent of the problem, including health
implications, status and trends;
s prevention/promotion measures illustrative - of approaches
in education and information, services, technology,
legislation and regulation, and economic incentives,
followed by observations on the relative strength of these
measures;
specific national objectives for:
improved health status
reduced risk factors
improved public/ professionai awareness
improved scrviceslprotection
improved surveillance/evaluation;
s the p
objectives ;
e the data necessary for tracking progress.
Discussion of the objectives is limited to some extent by the need to
distill often comprehensive and complex issues into a short outline form
as well as by limitations in the knowledge base. In some instances, for
example, it is not possible to relate the magnitude of a targeted problem
to a specific disease incidence--e.g., the prevalence of a particular
carcinogen in the environment to an identifiable level of cancer
incidence. Also, the discussions of the various intervention measures
are offered principally as checklists rather than as detailed blueprints
with appropriate sequencing carefully established, and presented. They
do not necessarily reflect Federal policy--rather they represent a
broader range of possible measures available throughout the public and
But these limitations are dictated by the character of the existing data,
as well as the necessity to tailor efforts to local conditions. Given
these considerations, the discussions provide a concise review of the
central issues relevant to each area.
With respect to the objectives themselves, certain premises are
inherent. First, the stated objectives should reflect a careful balancing
of potentials for benefits and harm to the individuals or populations
vii' TMN 364886
concerned. Second, specific actions suggested should be in line wi
professional consensus on likely efficacy of the action. Thir
continued biomedical, epidemiological and behavioral science researc
and systematic evaluation will result in improved judgments.
,
The objectives focus on interventions and supports designed primarily
for well people; to reduce their risks of becoming ill or injured at some
future date. Thus, few of the objectives deal with secondary
prevention. Objectives relating to the frequency and content of
physical examinations and other means of detecting early conditions
(such as cervical, breast and colon cancer, diabetes, vision and
hearing problems and dental caries) were deliberately excluded from
consideration, despite their obvious importance in signaling needs for
intervention.
Finally, an attempt has been made to confine objectives to what might
feasibly be attained during the coming decade, assuming neither major
breakthroughs in prevention technology, nor massive infusions of new
Federal spending. For example, the goal for infant health is to reduce
the infant mortality rate to no more than 9 deaths per 1, 000 live births.
In theory the Nation should be able to do much better. Several areas
in western Europe, and certain political jurisdictions within the United
States already have achieved rates of 5 per 1, 000. Yet, the size of the
gaps that presently exist between the risks experienced by pregnant
women in different age, ethnic and income groups of the population,
and the limited resources that now appear likely to become available to
narrow those gaps make 9 per 1,000 a more realistic objective.
Inn sum, the objectives were framed in the context of current knowledge
and the current aggregate level of public and private resources for the
15 prevention areas. While this parameter was not adhered to in every
instance, it promoted a greater measure of restraint--or realism--on the
process.
No effort has been made to establish priorities among the 15 areas, or
even among the various objectives within any given area. Given the
nature of our pluralistic society and the diversity of regional and local
needs and capabilities, both the setting of priorities and the choice of
program directions are best left to those responsible for planning,
coordinating, and implementing prevention strategies--namely State and
local health agencies, State health planning development agencies,
health system agencies, and governing boards of the wide range of
private sector organizations involved.
It is important to note that some themes can be identified which group
the activities of the 15 areas into subcategories with common elements..
"Substance abuse," for example, links the areas of smoking and health
and misuse of alcohol and drugs. Common elements in these areas
ix
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include questions of addictive properties, neurochemical action,
long-term sequelae, age-related vulnerability, effectiveness of primary
and secondary prevention measures, and ethical issues attendant to
behavior change. Each of these issues should be considered not only
on its own merit, but also for its lessons for, and commonalities with,
the other abusive behaviors. Another example is the theme of
11reproductive health." Family planning, pregnancy and infant health,
and sexually transmitted diseases are, of course, all concerned with
reproductive health, but elements are also found in the discussions of
smoking and health, misuse of alcohol and drugs, nutrition, toxic agent
control, occupational safety and health, and immunization. Approaches
to ensuring positive results of human reproductive processes compel
consideration of issues of sexual attitudes and behavior, understanding
of fertility and infertility, decisions about pregnancy, activities and
exposures during pregnancy, obstetrical services, and follow-up care of
mother and infant. All are important factors in reproduction; central
concerns of much of reproductive life. Considering the spectrum of
issues in the aggregate, rather than a series of isolated events, has
substantial merit.
Because such collective themes can be important to the implementation of
measures to address the identified objectives, program directors
designing such measures and setting priorities should search for the
common elements particularly germane to their program needs and
resources.
Crosscutting Issues
A number of issues are common to most or all of the reports: the
problem of developing objectives in the face of economic uncertainties, a
rapidly changing science base, the needs for more research and data,
unpredictable shifts in popular interests and values, trade-offs between
health and other societal interests, and ethical considerations in
attempts to influence changes in people°s customary habits. Two are
discussed below: data requirements and research needs.
Data requirements--The most salient common feature
across the 15 areas is the need for better data both to
profile current status and to track progress towards the
established objectives. Statistical analyses derived from
reliable data, continuously reported and coded according
to universally accepted definitions and conventions, are
the sine qua non for establishing the true nature of the
problems preventive measures should address, as well as
for charting trends towards achieving the objectives.
There is currently great variability in the depth and
reliability of data available among the 15 areas. While
statistical reports relevant to the problem of smoking are
x TLWN 364888
quite complete, virtually no data exist to estimate the
problem of unmanaged stress in the population, and its
association with mental illness, cardiovascular disease or
violent behavior.
In some cases, the availability of baseline data and ability
to track progress have been relatively more prominent
than overall importance to health in shaping the nature of
objectives. The paucity of data is particularly
handicapping for State and local organizations and
agencies seeking to set and track progress toward their
own local priorities and objectives for prevention. For
the most part, birth and death statistics and local
hospital discharge abstract analyses remain their only
guides. Results from the continuing National surveys,
such as the Health Interview Survey (HIS) and the Realth
and Nutrition Examination Surv ey (HANES ), while
essential for tracking change in the United States
population as a whole, are based on samples too small to
r
alysis applicable to small areas.
Surveillance systems developed to monitor the occurrence
of infectious diseases provide models for many of the
specific objectives relating to the prevention of other
types of diseases and injuries. They depend on systems
through which the occurrence of the particular condition
or action will be reported within some ascertainable limits
of accuracy and completeness. Whatever the source of
the necessary data--physicians, hospitals, highway
patrols, or insurance claim systems--important issues
concerning the quality of the data must be addressed.
Using data from surveillance systems which are not based
on probability sample designs, or which are based on
voluntary reporting, carries risks in making National
estimates for tracking objectives. The level of voluntary
reporting may differ markedly from one local area to
another and fluctuates unpredictably at different points in
time.
Scientific evaluation of the impact of risk reduction on
trends in health status or in reduction of risk factors is
difficult methodologically and collection of the data
required is expensive. To obtain valid results, test and
control populations of considerable size must be followed
over considerable periods of time, and a multiplicity of
variables must be systematically taken into account.
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We anticipate considerable improvements will be made in
our data capabilities over the next decade. New methods
now being developed will help State health planning
agencies, health systems agencies and health departments
use existing data more effectively to establish base lines
of prevention needs and opportunities. New efforts are
underway to target new subjects for National data
collection efforts. By 1990 the Nation should have a
considerably improved data collection network and
therefore be able to assess the progress with greater
reliability as well as to establish new priorities based on
new knowledge.
: Research needs--The development of realistic objectives
for risk reduction obviously must take place within the
framework of whatever scientific knowledge is currently
available. Since for most areas the state of the art is
constantly changing, developing objectives for a point in
time ten years down the road often means shooting at a
moving target. For example, when the initial section on
high blood pressure was drafted in June 1979,
uncertainty about the efficacy of intervention in cases
where blood pressure was only slightly elevated (90 to
104 mm Hg diastolic blood pressure without complications)
led the work group to caution that in such cases:
"...intervention...is not yet of clearly proven benefit."
Ten months later, based on tiae results of aNationai
study sponsored by the National Heart, Lung and Blood
Institute, the statement was revised to read: "Based on
1979 research results, intervention seems warranted in a
large proportion of this population. "
If the objectives developed are to be refined and
improved, the continuing need for basic biomedical
research in most of the 15 subject areas of prevention is
clear. Were our understanding of biological processes
sufficient to develop vaccines to protect individuals
against the most prevalent sexually transmitted diseases,
tremendous opportunities for prevention would unfold and
the task would become much easier. Similarly,
epidemiological and biomedical research to identify major
health risks from exposures to toxic agents is
fundamentally important. We need new technologies to aid
prevention in many areas--the development of acceptable,
reversible, male contraceptives, for instance. Many of
these issues have beenn addressed inn the process of
establishing National research principles, directed by the
National Institutes of Heaith.
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Additionally, behavioral research is needed to learn the
basis for such addictions as smoking, overeating, and
dependence on alcohol and drugs. Research at the
interface between biomedical and behavioral methodologies
is required to advance our knowledge of the effects of
stress on health, and of how to control them.
Social science research is needed to find more effective
ways to communicate to vulnerable and inaccessible
populations, such prevention techniques as lifestyle
change measures to reduce their percentage of low birth
weight, high risk infants. Health services research is
required to learn how to maintain adherence to health
promotion measures over long time periods, such as high
blood pressure control regimens and maintaining a balance
between energy input from food and output from exercise.
Cost effectiveness studies, too, could identify preferred
measures in some areas of prevention, despite the
difficulties already noted in defining the associated costs
and benefits that limit the applicability of such analysis to
many prevention activities.
Finally, legal and public policy research is called
many areas of prevention, so that questions of individual
and collective rights and responsibilities, and of
trade-offs between economic and health values, and of
short run versus long run benefits can be systematically
introduced into public debate.
I m pl.ementation
Implementation of the objectives for each of the 15 areas requires a
pluralistic process involving public and private participants from many
sectors and backgrounds. Health officials and health providers must be
joined by employers, labor unions, community leaders, school teachers,
communications executives, architects and engineers, and many others
in efforts to prevent disease and promote health. It is important to
emphasize that, while the Federal Government must bear responsibility
for leading, catalyzing and providing strategic support for these
activities, the effort must be collective and it must have locall roots.
Accordingly, the objectives contained in this volume must be viewed
dynamically. They. ought not to be considered rigid obligations, but as
useful National guideposts--to be altered to fit local conditions, or as
our level of understanding of the problems at hand changes. There
will be controversy. Issues often raised in connection with the
advocacy and adoption of prevention measures include: the appropriate
role of government in fostering personal behavior change; the
pv" 364891
philosophy and psychology of throwing responsibility for serious health
problems back to the victi.m ; the role of business and industrial
processes in health and disease; the preferential treatment of certain
categories of people for insurance purposes; the role of government in
regulating health protection measures.
Despite such questions, the objectives presented in Promoting
fiealthlPreventing Disease represent an important component of a
focused National prevention strategy. Substantial- gains to the health of
Americans can be attained if we have the will to apply what we know.
From the Federal perspective, work is already under way to apply the
capabilities of Federally sponsored programs to the agenda set forth.
If similar efforts are undertaken at the State and local levels to design
measures for implementing locally-based objectives, progress can be
greatly facilitated. To draw upon the last line of Healthy People, "If
the commitment is made at every level, we ought to attain the goals
established in this report, and Americans who might otherwise have
suffered disease and disability will instead be healthy people."
T.IUN 364892
HIGH BLOOD PRESSURE CONTROL
1. Nature and Extent of the Problem
High blood pressure is perhaps the most potent of the risk factors
for coronary heart disease and stroke--and contributes as well to
diseases of the kidney and eyes. Because it is asymptomatic, a
large number of people are unaware of their condition. High blood
pressure is, however, only one of several risk factors for heart
disease and stroke. Other prominent factors for heart disease
include cigarette smoking, elevated blood cholesterol levels, diabetes
and obesity. It is essential to recognize the multiple nature of these
risks and their proved or suspected interaction. Correspondingly,
both health professionals and the public need to know more about
approaches for dealing comprehensively with these multiple risk
factors and how to act on the basis of this knowledge. Control of
high blood pressure requires patients to adhere to regimens over
their lifetime. These may include various combinations of
pharmaceutical interventions and changes in diet, exercise and stress
management practices. (See Smoking and Health, Nutrition, Physical
Fitness and Exercise, and Control of Stress and Violent Behav%or. )
a. Health implications
s Heart disease, the leading cause of death in the U.S.
population, was responsible for over 700,000 deaths in 1977;
stroke led to 183,000 deaths in that year. Survivors are often
severely handicapped.
s About 60 million people have elevated blood pressures (above
140/90) and are at increased risk for death and illness.
s©f these, about 35 million people (15 percent of the U.S.
population) have high blood pressure at, or above 160/95,
which is the World Health Organization definite determination of
hypertension. These people face excess risk of death or
illness from heart attack, heart failure, stroke, and kidney
failure, and are the primary targets for control efforts.
s Much of this excess risk is attributable to mild high blood
pressure (90 to 104 mm Hg diastolic blood pressure without
complications) . Based on 1979 research results, intervention
seems warranted in a large proportion of this population.
a Other important risk groups are: persons with diastolic blood
pressure over 104 (for whom drugs have been proven
beneficial); populations having a high prevalence (e.g., blacks
and el.d.erly ); persons with limited access to, or use of,
medical care such as young men and the poor.
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Among special issues are the growing proportion of elderly in
the population, their high prevalence of high blood pressure,
uncertainty about the benefit of treating isolated systolic blood
pressure and the sometimes unpredictable side effects of drugs
used to control high blood pressure in older people.
Children present an opportunity, since precursors of high
blood pressure may be identified in them, but also present a
dilemma as the benefit of early intervention i.nn this population
is not known and a firm consensus on defining high blood
pressure in youngsters has not yet been reached. Changes in
habitual diet may prove useful in prevention.
nd tren
: Although blood pressure can be controlled, the specific cause
of 90 to 95 percent of high blood pressure is not known.
Thus, while short-term emphasis must be placed on control,
increased understanding of the causes of hypertension must be
pursued to enable prevention of high blood pressure in the
long run.
# High salt intake is associated with high blood pressure in
susceptible people; reduced salt intake is one measure for
reducing high blood pressure.
~Many successful approaches to detection and control (e.g., use
of allied health personnel, wori:site care, patient tracking
systems) are not yet widely adopted or integrated into
mainstream care.
Aithough prevalence data indicate a problem of great
magnitude, incidence data for high blood pressure and its
complications do not exist to aid improved planning of
intervention strategies for both primary and secondary
prevention.
Men are only half as likely as women to have their high blood
pressure controlled.
Rural (non-SMSA) areas and urban inner city areas have made
less progress in high blood pressure control in recent years
than have metropolitan areas.
9 Many health professionals are - inattentive to regimen adherence
kills to deal with adherence.
t School health education rarely addresses risk factor control
and lifestyle impact on health in a satisfactory way.
TVAN 364894
The proportion of the population with high blood pressure who
are aware of their condition and are successfully controlling it
appears to have doubled in the last 5 years, while the
proportion of this population who are unaware of their
condition has sharply decreased. However, the proportion who
are aware of their condition, but whose high blood pressure
remains untreated or ' uncontrolled, appears to have stayed
constant. -
PreventionJPromotion Measures
a. Potential measures
*Education and information measures include:
continuing current efforts to heighten professional and
public awareness of possibilities for blood pressure control,
with messages targeted to groups at special risk, such as
black males, the elderly and users of oral contraceptives;
informing the public that daily intake of over 5 grams total
salt (2 grams sodium) is not essential for good health and
may contribute to the development of high blood pressure in
some people;
-- developing and distributing palatable recipes for low sodium
diets ;
-- raising public awareness that overweight predisposes to
high blood pressure and weight control often assists blood
pressure control; avoidance of juvenile obesity is especially
important;
encouraging increased physical activity and understanding
that maintaining an appropriate balance between the energy
individuals expend in their daily physical activity and the
amount of energy they consume through the food they eat
determines their success in controlling weight;
increasing public awareness of the fact that stress
reduction and exercise may be useful adjuncts for some
persons to provide a healthy lifestyle and lessen the risk of
hypertension;
increasing public awareness of multiple risk factors and the
interaction of risk factors;
alerting physicians on value of monitoring the children of
hypertensives with attention to weight control and low salt
intake;
3
TIMN 364895
-- increasing professional school training in
behavioralJmotivatian skills;
-- involving specialists in behavioral medicine in teaching
programs and assisting in patient adherence to regimens;
-- encouraging introduction/inclusion of health-related content
into the curricula of public/private institutions which train
food preparationJprocessing personnel;
-- more active nutrition education in school health and lunch
programs for school children and for the elderly;
-- influencing industry to take active steps to promote high
blood pressure controllprevention among its employees and
throughout the Nation by changes in both products
(primarily reduced sodium content of processed foods) and
marketing approaches;
awareness by employers and the public of the
potential for insurance premium cost savings associated with
blood pressure control, not smoking and weight control
among individual and group policy purchasers.
s Service measures include:
-- providing blood pressure checks routinely at contact with
health providers (e, g. , physicians, dentists, nurse
practitioners) and through programs staffed by suitably
trained non-professionals (e, g . , firemen ) ;
-- providing high blood pressure detection and treatment
services at the worksite with a systematic program for
fallotiv-up;
-- giving health providers instruction in techniques to improve
patient adherence to blood pressure control regimens.
s Technologic measures include:
increasing use of systems/policy analysis methods in
program planning at all levels;
reducing fat content (caloric density) and sodium content of
snack and highly processed foods;
-- developing practical means to supply low sodium content
water to populations living in "hard" water areas.
TIMN 364896
Legislative and regulatory measures include:
promoting consumer choice through labeling of foods for
sodium and caloric content;
seeking uniform National guidelines and Federal agency
(National Institutes of Health, Department of Agriculture,
and Food and Drug Administration) policies for nutrition
(e, g. , sodium consumption, total dietary fat content);
modifying State practice acts to provide for expanded roles
of allied health professionals in the management/control of
high blood pressure.
Economic measures include:
providing free or low cost access to blood pressure checks
during intervals between physician examinations;
reducing economic barriers (e.g.,
costs) to use of allied health personnel;
providing industry with tax incentives to encourage
development of lower calorie, fat, sodium-containing
foodstuffs ;
-- reducing economic barriers to control through
reimbursement for antihypertension prescription drugs.
b. Relative strength of the measures
Education and information measures:
-- established impact; low technology implementation possible;
wide acceptance of this approach now exists; excellent
costleffective potential.
Service measures;
-- effective with potential for significant impact.
Technologic measures:
use of syst_ems analysis approach to planning to facilitate
more comprehensive/objective problem analysis resulting in.
more effective plans;
food content changes to allow greater consumer choice; may
influence a major source of calorie self-abuse, and could be
especially relevant to school children among whom adverse
eating patterns have lasting effects.
5
TIMN 364897
Legislative and regulatory measures:
-- not well evaluated as a behavioral tool, slow to achieve
resuits .
~ Economic measures:
-- difficult to achieve but usually effective when accomplished.
3. Specific Objectives for 199(3
Irrproved health status
a. By 1990, at least 60 percent of the estimated population having
definite high blood pressure (160/95) should have attained
successful long term blood pressure control, i.e., a blood
pressure at or below 140/90 for two or more years. (High
blood pressure control rates vary among communities and
States, with the range generally being from 25 to 60 percent
based on current data.)
. Reduced risk factors
*b. By 1990, the average daily sodium ingestion (as measured by
excretion) for adults should be reduced at least to the 3-6 gram
range. (In 1979, estimate's ranged between averages of 4 to 10
grams sodium. One gram salt provides approximately .4 gram
sadium. )
*c. By 1990, the prevalence of significant overweight (120 percent
of "desired" weight) among the U.S. adult population should be
decreased to 10 percent of men and 17 percent of women,
without nutritiona3l impairment. (In 1971-74, 14 percent of adult
menn and 24 percent of women were more than 120 percent of
"desired" weight. )
*NOTE: Same objectives as for Nutrition.
Increased public/professional awareness
d. By 1990, at least 50 percent of adults should be able to state
the principal risk factors for coronary heart disease and
stroke, i.e., high blood pressure, cigarette smoking, elevated
blood cholesterol levels, diabetes. (Baseline data unavai.lable. )
e. By 1990, at least 90 percent of adults should be able to state
whether their current blood pressure is normal (below 140/90)
or elevated, based on a reading taken at the most recent visit
to a medical or dental professional or other trained reader. (In
1971-74, 55 percent of people with high blood pressure greater
than 160/95 were not aware of their condition. )
5
TLMN 364898
s Improved services/protection
f. By 1990, no geopolitical area of the United States should be
without an effective public program to identify persons with
high blood pressure and to follow up on their treatment.
(Baseline data unavailable. )
g. By 1985, at least 50 percent of processed food sold in grocery
stores should be labeled to inform the consumer of sodium and
caloric content, employing understandable, standardized,
quantitative terms. (In 1979, labeling for sodium was rare; the
extent of calorie labeling was about 50 percent in the market
place.)
-- See Nutrition.
t Improved surveiliancelevaluation systems
h. By 1985, a system should be developed to determine the
incidence of high blood pressure, coronary heart disease,
congestive heart failure and hemorrhagic and occlusive strokes.
After demonstrated feasibility, by 1990 ongoing sets of these
data should be developed.
i. By 1985, a methodology should be developed to assess
categories of high blood pressure control, and a National
baseline study of this status should be completed. Five
categories are suggested: (1) Unaware; (2) Aware, not
under care; (3) Aware, under care, not controlled; (4)
Aware, under care, controlled; and (5) Aware, monitored
without therapy.
4. Principal Assumptions
The etiology of high blood pressure is multifactorial and no
research breakthrough will eliminate it as a public health problem
in the next decade.
s`I`he basic components of successful control programs will continue
to be detection, evaluation, treatment andJor changes in lifestyle,
and follow-up.
~ 4Vhile. there are still some uncertainties about the quantitative
relationship between sodium ingestion and high blood pressure, it
is important to begin moving in the direction suggested by the
data.
s While there is not yet a true consensus as to what constitutes
dangerous levels of overweight for the population as a whole, the
stated targets provide the pattern for a productive trend.
7
TV4N 364899
G4vernmentai efforts to control high blood pressure will be
continued and expanded.
Voluntary and private sector efforts to control high blood pressure
will be continued and expanded.
Health Systems Agencies will give high priority to high blood
pressure detection, treatment and control.
*Implementation of the smoking, nutrition, and physical activity
recommendations (see appropriate sections) will impact favorably on
the prevention and control of high blood pressure.
5. Data Sources
a. To National level only
s Health and Nutrition Examination Survey (HANES). Prevalence
of hypertension by demographic characteristics; blood pressure
distributions; some data on awareness and control status.
DHHS-National Center for Health Statistics (NCHS). NCHS
Vital and Health Statistics, Series 11, selected reports,
especially No. 203, and Advance Data from Vital and Health
Statistics, selected reports. Periodic National surveys,
obtaining data from physical examinations, clinical and
laboratory tests and related measurement procedures on
National probability sample of the U.S. civilian
noninstitutionalized population. Data on adults currently
available from the 1960-1962 Health Examination Survey and the
1971-1974 HANES. 1971-1975 data are expected during 1980.
1976-1980 data not yet available.
Health Interview Survey (HIS ). Interview reported data on
prevalence of hypertension by demographic characteristics,
disability days associated with high blood pressure therapy
and regimen adherence, and other related topics.
DHHS-NCHS, NCHS Vital and Health Statistics, Series 10,
selected reports, especially No. 121, and Advance Data from
Vital and Health Statistics. Continuing household interview
health survey; National probability samples of the U.S. civilian
noninstitutionalized population. Special survey on
hypertension conducted in 1974. Data on hypertension
available from the 1972 and 1978 HIS will be published in the
1979 and 1980 survey reports.
*IsIational Ambulatory Medical Care Survey (NAMCS). Patient
visits to office-based private practice physicians in the U.S.
by patient and physician characteristics, diagnosis (including
high blood pressure and its sequelae), patient's reason for the
visit and services provided. DHHS-NCHS. NCHS Vital and
8 TIMN 364900
Health Statistics, Series 13, selected reports and Advance Data
from Vital and Health Statistics. Continuing survey, since
1973; National probability sample of office-based physicians.
Hospital Discharge Survey (HDS ). Patient stays in short-term
hospitals, by patient characteristics, diagnosis (including high
blood pressure and its sequeiae), surgery and other
procedures. DHHS-NCHS. NCHS Vital and Health Statistics,
Series 13, selected reports. Continuing survey, since 1965;
data from discharge records of samples of patients in a
National probability sample of general and special short stay
hospitals.
s National Disease and Therapeutic Index (NDTI). Patient visits
to office-based private practice physicians in the I3. S. by
patient and physician characteristics, type of visit,' diagnosis
(including high blood pressure and its sequelae), whether
blood pressure was measured and actual measurement and
prescribing behavior of the physician. IMS America, Ltd.,
Ambler, Pennsylvania. Regular reports from IMS, plus
specially requested computer tabulations. Continuing survey
from a representative sample panel of physicians in private
practice. Blood pressure measurements available only since
1976.
s Nationai Prescription Audit (NPA). Drug sales (including
hypertensive drugs ), source of prescription, payment status
and prescriber type. IMS America, Ltd., Ambler,
Pennsylvania. IMS reports. Continuing audit of pharmacies
on IMS panel.
0 Physician response to high blood pressure diagnosis.
Physiaians' knowledge, attitudes and behavior toward high
blood pressure; perceived importance of high blood pressure
diagnosis and treatment practices. Surveys conducted for
DHHS-Food and Drug Administration (FDA) and the National
High Blood Pressure Education Program (NHBPBI*), National
Heart, Lung, and Blood Institute (NHLBI), National.Institutes
of Health. DHHS Publication No. (NIH) 79-1056, Diagnosis and
Management of Hypertension: A Nationwide Survey of
Physicians' Knowledge, Attitudes and Reported Behavior.
National survey 1977; follow-up surveys anticipated.
The publio's view of high blood pressure. Public knowledge,
attitudes and reported behavior towards high blood pressure.
Surveys conducted for NHBPEP-NHLBI, National Institutes of
Health. DHHS Publication No. (NIH) 77-356 (1973 survey ),
The Public and High Blood Pressure: A Survey. 1979 survey
to be published. Periodic surveys; National probability sample
of the L} . S. ad uIt pop ulation .
TIMN 364901
Hypertension Detection and Follow Up Program. State of
knowledge among persons at high risk of coronary and
vascular diseases. DHHS-NHLSI. NHLBI (NIH) Hypertension
Task Force Reports, Nos. 8 and 9. One time survey.
b, To State andlor local level
National Vital Registration System
-- Mortality. Deaths by cause, including hypertension and
hypertension-related sequelae, by age, sex and race.
DHHS-NCHS. NCHS Vital Statistics of the United States,
Vol II, and NCHS Monthly Vital Statistics Reports.
Continuing reporting from States; National full count.
(Many States issue earlier reports. )
Hospitalized illness discharge abstract systems
-- Prof essional Activities Study (PAS). Patients in short stay
hospitals; patient characteristics, diagnoses of hypertension
and hypertension-related sequelae, procedures performed,
length of stays. Commission on Professional and Hospital
Activities, Ann Arbor, Michigan. Annual reports and
tapes. Continuous reporting from 1900 CPHA member
hospitals. Not a probability sample; extent of hospital
participation varies by State.
-- Medicare hospital patient reporting system (MEDPAR).
Characteristics of Medicare patients, diagnosis, procedures
by hospitals, HSA areas. DHHS-Health Care Financing
Administration, Office of Research, Demonstration and
Statistics (C3RDS ). Periodic reports 1975, 1976, 1977.
Continuing reporting from hospital claim data, 20 percent
sample.
-- Other hospital discharge systems as locally available.
s Selected health data. DHHS-NCHS. NCHS Statistical Notes
for Health Planners. Compilations and analysis of data to
State level.
Area Resource File (AFtF).- Demographic, health facility and
manpower data at State and county level from various sources.
I]HHS-Health Resources Administration, Area Resource File: A
Manpower Planning and Research Tool, DHHS-HRA-80-4, Oct
79. One time compilation.
10
TIAIN 364902
FAMILY PLANNING
Nature and Extent of the Problem
Family planning is based on the voluntary decisions and actions of
individuals. Its purpose is to enable individuals to make their own
decisions regarding reproduction and to implement their decisions.
Family planning includes measures both to prevent unintended
fertility and to overcome unintended infertility.
a.
Health implications
Family planning is a preventive health measure which
suppurts :
-- maternal and infant health;
-- the emotional and social health of individuals and the
f amil.y.
. Pregnancies among teenagers, among women who are
unmarried, among women over the age of 34 and among high
parity women are all associated with higher than average rates
of maternal andJor infant morbidity and mortality. They are
also more likely than other pregnancies to be unintended and
unwanted.
s Compared to pregnancies carried by women in the most
favorable childbearing years, teenage pregnancies are
associated with markedly increased risks of maternal morbidity
and mortality and of premature and other low birth weight
infants who have reduced chances of surviving infancy and
high rates of serious neurological impairment.
sAdolescent motherhood is associated with greater risk of
lowered educational and occupational attainment, reduced
income and increased likelihood of welfare dependency.
s Unwanted pregnancies impose psychological and social costs
that often continue throughout the lifetimes of the mother and
the child.
b. Status and trends
s In 1978, about 545,000 babies were born to unmarried American
women, almost half of whom were teenagers.
11
TEYIN 364903
. Although fertility rates for teenagers are declining in the
United States, the rates continue to exceed those in more than
a dozen developed countries.
~ Although the birth rate for unmarried women is decreasing,
the number of births is increasing; unmarried mothers are
more likely to have begun prenatal care late in pregnancy and
to have made fewer prenatal visits than married mothers;
infants born to single mothers are more likely to have a low
birth weight.
s Ten percent of babies born to married American women
between 1973-1976 resulted from conceptions the mothers
wished had never happened. An additional 25 percent resulted
from pregnancies which the mothers wanted to have some time
in the future but which occurred too early in their lives.
~Certain subgroups of our population have disproportionately
high risks of unintended pregnancy and childbearing. These
same groups have problems of access to all health services,
including family planning. Examples include:
-- unplanned births almost twice as high in poor as compared
to nonpoor families (52 percent of births that occurred
during the previous five years were unplanned as reported
in 1976 by women with family incomes below the poverty
level, compared to 29.2 percent for women with family
incomes of 150 percent of poverty level or higher);
reports of black women in a 1973 survey that one of every
four of their births had been unintended, versus reports
by white women that only one of every 10 of their births
had been unintended;
high rates of - unintended pregnancy among teenagers,
women with language barriers and/or illegal immigration
status, women living in rural areas or on Indian
reservations and members of some religious groups.
More than a million American women have pregnancies
terminated by abortion every year. The teenage population
accounts for approximately one-third of these abortions.
a The risk of death associated with temporary methods of
contraception, sterilization and legal abortion is less than the
risk of death from childbearing, although the absolute numbers
of deaths are about equal. In 1977, aapproximately 400 women
died in childbirth, while an estimated 470 American women die
each year as a result of fertility control measures;
approximately 75 percent from use of oral contraception, 20
12 TLAN 364904
percent from sterilization operations, and the remainder from
abortions and use of IUDs.
a Many deaths associated with methods of contraception are
preventable, including those associated with:
-- smoking by women who use oral contraceptives;
-- oral contraceptives with unnecessarily high estrogen
content;
-- legal abortions performed after the first trimester of
pregnancy;
-- ille gal abortion.
:'The psychologicai and biologic bases and underlying causes of
a large proportion of infertility cases are not understood
and/or are not remediable by medical treatment. Those
treatments which are available technically are costly and are
largely inaccessible to the poor.
2. PreventionJPromotion Measures
a. Potential measures
s Education and information measures include:
providing content on human sexuality, reproduction, family
planning and parenting in the curricula of schools which
train personnel for delivery of human services (i.e.,
professional schools for social workers, clergy, nurses,
nurse practitioners, teachers, counselors, pharmacists and
physicians);
-- providing content on human sexuality, reproduction and
contraception within continuing education programs for
graduate level professionals involved in human services;
incorporating into elementary and high school educational
programs a family life curriculum which includes human
sexuality, reproduction, contraception and parenting as well
as approaches to decision-making and values clarification
--offering parents opportunities to participate in parallel
programs;
-- using a variety of approaches to inform teenagers about
prescription and nonprescription contraceptives, including
how they work, their relative effectiveness, how to use
them effectively, their availability and cost;
13
TIMN 364905
-- educating parents to provide effective and accurate sex
education to their children;
encouraging and assisting the public media to educate the
public, especially parents and young people, about the
realities and possible problems of unwanted pregnancies,
and to present teenage role. models who are not sexually
active, and others who, while sexually active, take
measures to avoid pregnancy and sexually trans
diseases;
using the public media for advertisements explaining the
use, cost and benefits of certain over-the-counter
contraceptives, such as their providing protection against
sexually transmitted diseases, being available at low cost
and requiring no physical examination;
upgrading the knowledge of family planning clinicians
regarding the relative risks and effectiveness of all family
planning methods and of lifestyle characteristics which may
place certain individuals at increased risk of complications
associated with one or more specific methods, such as
smoking by users of oral contraception;
upgrading the counseling skills of individuals who work in
health care settings which serve adolescents--taking care to
avoid coercive implications;
improving knowledge within the general public (both males
and females) of the relative safety and effectiveness of
available family planning methods;
preparing and expecting family planning counselors and
clinicians to include concern for protection of future
fertility and prevention of sexually transmitted diseases
when they counsel family planning clients regarding
selection of a family planning method;
improving knowledge and skills of family planning
educators, counselors and clinicians regarding "natural"
family planning methods which require periodic abstinence;
increasing awareness of family planning problems among
health care planners;
informing HSAs how to interpret local data relevant to
f amily planning.
14 -rtmN 36
a Service measures include:
-- making all forms of contraception accessible and acceptable
to people who find the currently available services either
inaccessible or unacceptable;
-- encouraging wider and more varied distribution of effective
nonprescription contraceptives (in medical and other
settings ) ;
-- providing opportunities for teenage boys and girls to attend
family planning educational and counseling sessions in
environments not identified specifically for family planning
and in which they do not feel pressure to make a decision
regarding use of contraception;
-- providing family planning education, counseling and
services to sexually active males as well as females;
-- reducing the waiting time required for the social,
educational and medical assessment of clients in family
planning clinics;
ensuring that family planning is part of routine perinatal
service (if a woman is breastfeeding, preference should be
given to contraceptive methods which
normal lactation) .
s Technologic measures include:
-- development of reliable, acceptable male contraceptives.
Relative strength of the measures
By 1976, 68 percent of married U.S. couples were using
contraception:
almost 80 percent of married users were employing methods
which are at least 95 percent effective in preventing
conception (male or female surgical sterilization, oral
contraception or an intrauterine device);
most of the 32 percent non-users were trying to conceive,
were pregnant, post partum, subfecund or sterile because
of surgery performed for a non-contraceptive reason;
fewer than 8 percent of married couples were not using
contraception for some other reason, including lack of
access to services.
is
EMN 364907
s Part 'of the problem of prevention of infertility is linked to
control of sexually transmitted diseases and to other known
causes. However, in a high proportion of cases, basic
knowledge for prevention and treatment is not yet available.
3. Specific Objectives for 1990
s Improved health status
oiding the personal or social burdens of unintended
pregnancy (or infertility) is an important health status
objective, though nott easily quantifiable. However, family
planning is a key component of efforts to reduce infant and
maternal mortality;
-- See Pregnancy and Infant Health.
9 Reduced risk factors*
a. By 1990, there should be virtually no unintendedd births to girls
14 years old or younger. Fulfilling this objective would
probably reduce births in this age group to near zero. (In
1978, there were less than 10,800 births in this age group.)
b. By 1991, the fertility rate for 15-year-old girls should be
reduced to 10 per 1,000. (In 1978, there were 14.2 births per
1,000 for this age gr4up. )
c. By 1990, the fertility rate for 16-year-old girls should be
reduced to 25 per 1,0(lfl. (In 1978, there were 31.8 births per
1,000 for this age group. )
d. By 1990, the fertility rate for 17-year-old girls should be
reduced to 45 per 1, 000. (In 1978, there were 52.1 births per
I, 000 for this age group. )
e. By 1990, reductions in unintended births among single American
women (15 to 44 years of age) should reduce the fertility rate
in this group to 18 per 1,000. (In 1978, there were 26.2
births , per 1,000 unmarried women 15 to 44 years of age. )
By 1990, the proportion of abortions performed in the second
trimester of pregnancy should be reduced to 6 percent (in
1976, about 111 percent of abortions were performed in the
second trimester), thereby reducing the death-to-case rate for
legal abortions in the United States to 0.5 per 100,000. . (In
1977, it was 1.4 per 100,000.)
16 TIMN 364908
9
By 1990, the availability of family planning information and
methods (education, counseling and medical services) to all
women and men should have sufficiently increased to reduce by
50 percent the disparity between Americans of different
economic levels in their ability to avoid unplanned births. (In
1976, 52 percent of births that occurred -during the previous
five years reported by evermarried women with family incomes
below the poverty level were unplanned, compared to 29.2
percent for women with family incomes of 150 percent of poverty
level or higher. )
*NQTE: Objectives a. to e. specify reductions in the fertility
rate to reduce unintended births for specific age and marital
status groups of women. Some births to women in these groups
are planned. However, unintended births account for a very
large proportion of births to women in these groups. Thus,
reductions i.n unintended births would allow the target
objectives to be met without affecting the numbers of planned
births.
s Increased public/profess%onail awareness
h. By 1990, at least 75 percent of men and women over the age of
14 should be able to describe accurately the various
contraceptive methods, including the relative safety of one
versus the others. (Baseline data unavailable.)
Improved serviceslprotection
i. By 1985, oral contraceptives containing more than 50 micrograms
of estrogen should not be used for family planning, and sales
of these preparations should have been reduced to 15 percent.
(In 1978, about 27.11 percent of preparations sold were at this
Ievei. )
1985, 100 percent of Federally funded family planning
programs should have an established routine for providing an
initial infertility assessment, either directly or through referral.
{ Baseline data unavailable. }
Principal Assumptions
a There will continue to be no policy on population growth in the
United States. Therefore, the goals and objectives of family
planning are predicated solely on individual choice, social
responsibility and concern for health.
sStable families promote the physical, emotional and sociall health of
the family members, community and society. The ability of couples
to plan the number and timing of the births of their children
supports the stability of families.
17
TIMN 364909
Religious convictions may influence society's ability to establish
fertility control policies and programs.
Federal support of family planning services will increase as
evidence grows on the ability of family planning dollars to effect
savings in dollars expended to address problems in other
publicly-financed health, social and welfare programs.
`I'he mechanisms for funding clinical family planning services will
remain the same.
s Legal, socioeconomic and bureaucratic barriers to contraception will
be removed.
s Federal support of population and family planning research will
continue.
Although the overall U.S. abortion rate may decline somewhat by
1990, the incidence of abortion among certain high risk groups will
not decrease significantly.
: There will be no major breakthroughs in contraceptive technology
available to the public during the 1980s.
s Educat.ion can result in behaviorall change.
Few adolescents younger thann age 18 are adequately prepared for
the responsibilities of parenthood.
The current trend of an increasing proportion of adolescents who
are sexually active will continue. However, many teenagers are
not ready for sexual relationships which include intercourse, and
the majority of adolescents under 18 will continue to defer sexual
activity.
s In the 1980s, industry will not invest heavily in research and
development of new contraceptive methods.
5. Data Sources
a. To National leveil only
e National Survey of Family Growth (NSFG). Proportion of
women sexually active by age, race and marital status, and a
wide range of socioeconomic characteristics; fertility experience
(pregnancy histories) of the sexually active population,
including sterility and subfecundity; planning status of each
pregnancy according to whether contraception had been used,
and whether the birth had been wanted, mistimed (wanted but
at a later date) ,or unwanted at the time of conception;
18 TIMN 364910
pregnancy outcome and survival of the newborn; family
planning services received; sources of contraceptive supplies,
including over-the-counter methods; contraceptive methods
being used, use-effectiveness of methods; switching of methods
and reasons for switching, side effects of contraception.
DHHS-NCHS. NCHS Vital and Health Statistics, Series 23,
selected reports. Interview survey of 10,000 women in
National probability sample representing American women 15-44
years of age. Surveys in 1973 and 1376 limited to women who
were or had been married, or single with offspring in the
household. In later surveys, all women 15-44 years of age will
be represented.
. The National Prescription Audit (NPA) . Distribution of
contraceptive prescriptions written by physicians, by hormonal
potency. IMS America Ltd., Ambler, Pennsylvania. Selected
reports. Continuing survey; pharmacies on IMS panel.
Naticnai Reporting System for Family Planning Services
(NRSFPS) . Visits to family planning clinics. DHHS-NCHS.
Annual reports. Continuous sample survey since June 1977;
continuous fui3l count reporting from 1972 to June 1977.
b. To State and/ar local level
s Abortion Surveillance. Number and characteristics of women
who have legally induced abortions in the United States,
abortion related morbidity and mortality. DHHS-Center for
Disease Control (CDG). Annual reports, since 1972.
Continuous reporting of abortions from centrall health agencies
in 43 States and from hospitals and/ar other facilities in the
remaining jurisdictions. Abortion related deaths reported from
the vital statistics section of State health departments,
abortion related morbidity reported from the Joint Program for
the Study of Abortion.
s National Vital Registration System
Natality. Births and birth rates by place of occurrence
and by the mother's place of residence, age, race and
parities. DHHS-NCHS. NCHS Vital and Health Statistics,
Series 21, selected reports, and Monthly Vital Statistics
Report. Continuous reporting by States; full count of
birth certificates 38 States; 50 percent sample remaining
States. State health agencies, derived from certificates of
live births to U.S. residents. Birth rates calculated on the
basis of the number of women 14-49 years of age residing
in the respective areas enumerated in census years, and
estimated for inter-census years.
19
TIMN 364911
Nature and Extent of the Problem
Assuring all infants a healthy
of their mothers are among
disease and promoting health.
start in life and enhancing the health
the highest priorities in preventing
The principal threats to infant health
are problems associated with low birth weight and birth defects
which can lead to lifelong handicapping conditions. Of particular
concern are the disparities in the health of mothers and infants that
exist between different population groups in this country. These
differences are associated with a variety of factors, including those
related to the health of the mother before and during pregnancy as
well as parental socioeconomic status and lifestyle characteristics.
Although the precise relationship between specific health services
and the health status of pregnant women and their infants is not
certain, the provision of high quality prenatal, obstetrical, and
neonatal care, and preventive services during the first year of life,
can reduce a newborn's risk of illness and death. Of particular
concern are adolescents, whose infants experience a high degree of
low birth weight and whose health problems should be addressed in a
broad context taking into consideration social and psychological
implications.
a. Health implications
sMaternai and infant mortality and morbidity records show
striking demographic variations:
an overall rate of maternal mortality of 9. 6 per 100, 000 live
births in 1978, but with a rate for blacks almost four times
that for whites;
an infant mortality rate of 13.8 per 1,000 live births in
1978, but with the infant mortality rate for black babies 92
percent higher than for whites;
infant mortality rates for individual States ranged from 10.4
to I8.7 in 1978;
infant mortality rates in 1977 for 26 major cities (with
populations greater than 500,000) ranged from 13.0 to 27.4;
22 of the 26 major cities had higher rates than the National
average of 14.1 in 1977.
s The greatest single problem associated with infant mortality is
low birth weight; nearly two-thirds of the infants who die are
low birth weight.
21
TIAV~ 364912
Maternal factors associated with a high risk of low birth weight
babies are: age (17 and under, and 35 and over), minority
status, high parity, previous unfavorable pregnancy outcome,
low education level, low socioeconomic status, inter-pregnancy
interval less than 6 months, inadequate weight gain during
pregnancy, poor nutrition, smoking, misuse of alcohol and
drugs and lack of prenatal care.
High quality early and continuous prenatal, birth and postnatal
care can decrease a newborn's risk of death or handicap from
pregnancy complications, low birth weight, maternall infection
from sexually transmitted disease and developmental problems,
both physical and psychological.
After the neonatal period the causes of infant mortality and
morbidity, many of which may be preventable, are: disorders
related to a high risk birth, infectious diseases, congenital
anomalies, accidents, lack of health care and abuse.
Status and trends
sAlthough the overall rate has been gradually improving since
1965, an excessive number of infants born in the United States
are of less than optimal birth weight for survival and good
health. This includes:
-- approximately 7 percent of all babies are of low birth
weight, that is, 2,500 grams or less; the rate is almost
twice as high for blacks; other industrialized nations
experienced substantially lower rates during the period
1970-1976; for example in Japan 5.3 percent of births were
low birth weight and in Sweden 4.1;
-- approximately another 17 percent of all newborns in the
United States in 1978 had birth weights falling between
2,501 and 3,000 grams.
Many children in the United States are born to women who
have an increased risk of having a low birth weight infant or
other health problems, particularly:
-- the 25 percent of women giving birth in 1978 who made no
prenatal visit during the first trimester and the 5 percent
who had no prenatal care during either of the first two
trimesters;
-- the pregnant teenagers (at higher risk for low birth weight
babies)' who accounted for 17 percent of the infants born in
1978;
22 TIMN 364913
-- the two-thirds of pregnant teenagers in 1976 whose
pregnancies were not intended when they occurred;
-- the births to single women (26.2 births per 1,000 single
women in 1978) for whom the data indicate special risk of
poor health outcomes for mother and infant.
2. Prevention/ Promotion Measures
a. Potential measures
s Education and information measures include:
developing, implementing and evaluating the quality and
quantity of health education curricula in schools and
communities, with emphasis on lifestyle risk factors (poor
nutrition and use of alcohol, cigarettes and drugs), as well
as family life and parenting;
developing, implementing and evaluating preventive
educational strategies and materials for use in private and
public prenatal care;
-- increasing the use of mass media to encourage more
healthful lifestyles; developing television and radio
programs that support healthful lifestyles;
-- making prospective parents at high risk of impaired fetuses
aware of genetic diagnosis and counseling services so that
those affected can make informed decisions consistent with
their personal ethical and religious values;
promoting, educating and supporting breastfeeding where
possible.
s Service measures include:
family planning services which optimize the timing of
pregnancies;
prenatal care which routinely includes education on
avoidable risks to maternal and fetal health during
pregnancy;
assuring that all populations are served by organized
medical care systems that include providers (physicians,
nurse practitioners, nurse midwives, nutritionists and
others) who are trained to deliver prenatal, postnatal and
infant care on site (requires personnel strategies and
economic and professional incentives);
23
TIMN 364914
-- developing local, easily accessible prenatal services for all,
including access to amniocentesis for high risk pregnant
women;
-- regionalizing prenatal and perinatal services so that all
women and newborns receive diagnostic and therapeutic care
appropriate to their assessed needs;
-- assuring adequate linkages, including transportation, to
regional centers for high risk expectant mothers and
newborns;
-- outreach perinatal and infant care services for currently
underserved populations, such as teenage expectant
mothers;
-- evaluating the quality of perinatal and infant care being
received and relating program activities to pregnancy and
infant health outcomes;
-- identifying and tracking infants and families with medical
congenital, psychological, social, and/or environmental
problems;
-- reducing the number of low birth weight infants by
reducing teenage and other high risk pregnancies, reducing
damaging effects from alcohol, cigarettes and other toxic
substances, improving nutrition, and assuring participation
in comprehensive pre-conceptional, inter-conceptional and
early and continuing prenatal care;
-- eliminating unnecessary radiation exposure to pregnant
women and babies;
-- assuring that all programs of primary care support and
contribute to the fulfillment of objectives related to maternal
and infant health ;
-- encouraging parent support groups, hotlines, and
counseling for parents of high risk infants and suppr~rts for
lowering stress levels in troubled parents who may have
potential for child abuse.
-- See Family Planning, Immunization, and Sexually
Transmitted Diseases.
24 TIMN 364915
Legislative and regulatory measures include:
requiring that all Federally funded programs for delivering
perinatal care assure adequate health and prenatal
education, screening for pregnancy risks and patient plans
for care during labor and delivery appropriate to
discovered risks, and for infant follow-up and care through
the first year of life;
requiring fiscal and pregnancy outcome accountability
publicly funded prenatal and perinatal programs;
reducing exposures to toxic agents that may contribute to
physical handicaps or cognitive impairment of babies.
Economic measures include:
-- reviewing all programs that finance or provide health
services for mothers and children in order to:
- assure inclusion of health promotion and preventive
services;
- optimize their effect by reducing overlaps, pockets of
neglect and contradictory objectives;
adequate public financing for outreach, early and
continuous prenatal care, deliveries, support services,
intensive care when needed and continuing care of infants;
consideration of direct Federal financing tied to uniform
standards of performance where public health departments
show potential for expanding maternal and child health
servipes to populations in need.
b. Relative strength of the measures
s The relative effectiveness of various interventions to improve
pregnancy outcome and infant health is not without
controversy. The records of many demonstration projects,
both domestic and foreign, amply confirm that dramatic
improvements can be made in the indicators of maternal and
infant heai.th. For example, the infant mortality rate for
American Indians was reduced by 74 percent between 1955-1977
and maternal mortality decreased from 2.2 times the total i).S.
rate in 1958, to below the total U.S. rate by 1975-76.
Unfortunately, studies have not generally been designed to
yield firmly defensible data on the relative contribution of
different features of different intervention programs.
However, the evidence indicates that emphasis be placed on
25
TIMN 364916
family planning which optimizes the timing of pregnancies,
early identification of pregnancy and routine involvement of all
pregnant women in prenatal care. Therefore, the following
priorities are strongly suggested :
systems of care that reach everyone with basic services,
emphasizing advantageous personal health behavior and
including outreach, education, and easy access to
community-based services without social, economic, ethnic
or time or distance barriers;
measures which prevent unwanted pregnancies and which
optimize the most favorable maternal age for childbearing,
including sex education, contraception, easy access to
pregnancy testing, genetic counseling, prenatal diagnosis
and associated counseling;
early and continuing prenatal care, particularly for those at
greatest risk--poor, poorly educated women, those near the
beginning or the end of their reproductive age, those with
previous pregnancy loss and those with recent pregnancy;
nutrition education and food supplementation as needed, as
well as parent education on importance of good infant
nutrition, preventive measures essential to avoid childhood
disease and accidents and parenting conducive to sound
emotional development;
cessation of smoking during pregnancy (which may
contribute much more to the improvement of birth weight
and to favorable pregnancy outcome than is now fully
doc umented );
regionalized programs of care with referral systems which
assure access to levels of care appropriate to special risks.
3. Specific Objectives for 1990
: Improved health status
a. By 1990, the National infant mortality rate (deaths for all
babies up to one year of age) should be reduced to no more
than 9 deaths per 1,000 live births. (In 1978, the infant
mortality rate was 13.8 per 1,000 live births. )
b. By 1990, no county and no racial or ethnic group of the
population (e.g., black, Hispanic, Indian) should have an
infant mortality rate in excess of 12 deaths per 1,000 live
births. (In 1978, the infant mortality rate for whites was 12.0
per 1,000 live births; for blacks 23.1 per 1,000 live births; for
26 TIMN 364917
American Indians 13.7 per I, 000 live births; rate for Hispanics
is not yet available separately.)
c. By 1990, the neonata3l death rate (deaths for all infants up to
28 days oid ) should be reduced to no more than 6.5 deaths per
1,000 live births. (In 1978, the neonatal death rate was 9.5
per 1,000 live births. )
d. By 1990, the perinatal death rate should be reduced to no more
than 5.5 per 1, 000. * (In 1977, the perinatal death rate was
15.4 per 1,000.)
*NOTE: The perinatal death rate is total deaths (late fetal
deaths over 28 weeks gestation plus infant deaths up to 7 days
old) expressed as a rate per 1,000 live births and late fetal
deaths.
e. By 1990, the maternal mortality rate should not exceed 5 per
100, 000 live births for any county or for any ethnic group
(e.g., black, Hispanic, American Indian). (In 1978, the
overall rate was 3. 6--the rate for blacks was 25. (l, the rate for
whites was 6. 4, the rate for American Indians was 12.1, the
rate for Hispanics is not yet available separateiy. )
f. By 1990, the incidence of neural tube defects should be
reduced to 1.0 per 1,000 live births. (In 1979, the rate was
1.7 per 1,000.)
g.
By 1990, Rhesus hemolytic disease of the newborn should be
reduced to below a rate of 1.3 per 1,000 live births. (In 1977,
the rate was 1.8 per 1,000.)
*h. By 1990, the incidence of infants born with Fetal Alcohol
Syndrome should be reduced by 25 percent. (In 1977, the rate
was 1 per 2,000 births or approximately 1,650 cases. )
*NOTE: Same objective as for Misuse of Alcohol and Drugs.
-- See Nutrition.
Reduced risk factors
i. By 1990, low birth weight babies (2,500 grams and under)
should constitute no more than 5 percent of all live births. (In
1978, the proportion was 7.0 percent of all births. )
. By 1990, no county and no racial or ethnic group of the
population (e.g., black, Hispanic, American Indian) should
have a rate of low birth weight infants (prematurely born and
small-for-age infants weighing less than 2,500 grams) that
27
TEqN 364918
exceeds 9 percent of all live births. (In 1978, the rate for
whites was about 5.9 percent, for Indians about 6.7 percent,
and for blacks about 12.9 percent; rates for Hispanics are not
yet separately available; rates for some other nations are 5
percent and less. )
k. By 1990, the majority of infants should leave hospitals in car
safety carriers. (Baseline data unavailable. )
-- See Nutrition, Family Planning, Smoking and Health, Misuse
of Alcohol and Drugs, Sexually Transmitted Diseases,
Immunizations, Occupational Safety and Health, and Toxic
Agent Control, and Accident Prevention and Injury -Gontroi.
s Increased public/ professional awareness
I. By 1990, 85 percent of women of childbearing age should be
able to choose foods wisely (state special nutritional needs of
pregnancy) and understand the hazards of smoking, alcohol,
pharmaceutical products and other drugs during pregnancy and
lactation. (Baseline data unavailabie. )
-- See Nutrition, Smoking and Health, Misuse of Alcohol and
Drugs, Sexually Transmitted Diseases, Immunizations,
Occupational Safety and Health, and Toxic Agent Control.
s Improved serviceslprotection
m. By 1990, virtually all women and infants should be served at
levels appropriate to their need by a regionalized system of
primary, secondary and tertiary care for prenatal, maternaIl and
perinatal health services. (In 1979, approximately 12 percent
of births occurred in geographic areas served. by such a
system. )
n. By 1990, the proport.ionn of women in any county or racial or
ethnic groups (e. g. , black, Hispanic, American Indian ) who
obtain no prenatal care during the first trimester of pregnancy
should not exceed 10 percent. (In 1978, 40 percent of black
mothers and 45 percent of American Indian mothers received no
prenatal care during the first trimester; percent of Hispanics is
unknQwn. )
o. By 1990, virtually all pregnant women at high risk of having a
fetus with a condition diagnosable in utero, should have access
to counseling and information on amniocentesis and prenatal
diagnasis, as well as therapy as indicated. (In 1978, about 10
percent of women 35 and over received amniocentesis. Baseline
data are unavailable for other high risk groups. )
28 TIMN 364919
P
the women or their families. )
q. By 1990, virtually all newborns should be provided neonatal
screening for metabolic disorders for which effective and
efficient tests and treatments are available (e.g., PKU and
congenital hypothyroidism). (In 1978, about 75 percent of
newborns were screened for PKU ; about 3 percent were
screened for hypothyroidism in the early 1970's, with the rate
By 1990, virtually all women who give birth should have
appropriately-attended, safe delivery, provided in ways
acceptable to them and their families. (In 1977, less than .3
percent of births were unattended by a physician or midwife.
Furthermore, of births which are attended by a physician or
midwife, an unknown share are not considered satisfactory by
now rapidly increasing. )
r. By 1990, virtually all infants should be able to participate in
primary health care that includes well child care; growth
development assessment; immunization; screening, diagnosis and
treatment for conditions requiring special services; appropriate
counseling regarding nutrition, automobile safety, and
prevention of other accidents such as poisonings. (Baseline
data unavailable.)
-- See Nutrition, Immunization, Accident Preventionn and Injury
Control.
. Improved surveillanceJevaluation systems
s. By 1990, a system should be in place for comprehensive and
longitudinal assessment of the impact of a range of prenatal
factors (e.g., exposure to radiation, ultrasound, dramatic
temperature change, or toxic agents; or maternal smoking, use
of alcohol or drugs, exercise, stress) on infant and child
physical and psychological development.
4. Principal Assumptions
sAssurances of participation in essential services will be enhanced
by various programs of outreach and by communication with client
groups to achieve styles of service that are appropriate and
acceptable to different populations, and by initiating or expanding
publicly sponsored programs of care as may be necessary for
people who are not reached by private and traditional provider
systems.
:Current efforts to ensure an adequate supply of food will be
continued and extended (WIC and food stamps) .
29
TIMN 364920
s Information will be routinely provided to pregnant women on serum
alphafetoprotein screening; screening will be provided for medical,
obstetric, psychosocial and genetic risks, and participation assured
in appropriate levels of diagnosis, support and treatment.
Prenatal care will routinely include education on avoidable i
maternal and fetal health during pregnancy, and to infant
following birth.
a Perinata}l and infant care wili include but not be
ed to:
-- nutritional education and supplementation as needed, including
preparation and support for breastfeeding (See Nutrition) ;
psychosocial supports which promote parenting behavior
conducive to parent-child attachment;
promotion of lifestyles that encourage good parental, infant and
child health practices ;
linkages that assure antenatally identified risks, risk reduction
activities and completed plans for participation in appropriate
intrapartum and continuing infant care;
provision of Rhesus immune globulin to all Rh negative women,
not previously sensitized, who have a known or presumed Rh
positive pregnancy.
s Achieving objectives that dea1l with mortality and low birth weight
presumes participation in comprehensive services that will also
work to reduce maternal and infant morbidity associated with
lifestyle and environmental risks, including:
alcohol and drug use;
smoking;
management of parental stress;
toxic substances during pregnancy and lactation;
occupational safety and health;
prevention of infant and child accidents;
See Misuse of Alcohol and Drugs, Smoking and Health, Control
of Stress and Violent Behavior, Toxic Agent Control,
Occupational Safety and Health, Accident Prevention and Injury
Control.
30 TIMN 364921
s Reduction of unwanted and unintended pregnancies will achieve
reduction of pregnancies in teenage and late childbearing years,
and will concentrate childbearing during optimum maternal ages.
Efforts to reduce unwanted pregnancies are presumed to provide
forf
education on sex, family life and reproductive health;
ready access to all forzns of family planning services;
ready access to pregnancy testing, with associated counseling
and referral;
See Family Planning.
Aii needful infants and families will participate in support services
(e.g., food supplementation, income supports, day care, minimum
housing) that are defined by Nationally enforced standards which
assure equity.
.All pregnant women will have access to regionalized systems of
maternity care which assure services appropriate to need.
Agencies receiving public funds related to health care--including
Federal, State and local units of government, private agencies,
and quasi-public agencies such as HSAs--will adopt these or more
stringent objectives, and will document their progress toward
meeting them.
5. Data Sources
a.
To National level only
. Health Interview Survey (HIS ). Smoking and drinking
prevalence among women of childbearing age. DHHS-NCHS.
NCHS Vital and Health Statistics, Series 10, selected reports,
and NCHS Advance Data from Vitall and Health Statistics,
selected reports. Continuing household interview survey;
National probability samples.
. Hospital Discharge Survey (HDS). Deliveries in hospital.
DHHS-I}IDHS. NCHS Vital and Health Statistics, Series 13,
selected reports. Continuing survey, National probability
sample short-stay hospitals.
s National Ambulatory Care Survey (NAMCS). Visits to private
physicians for prenatal care. DHHS-NCHS. NCHS Vital and
Health Statistics, Series 13, selected reports. Continuing
survey; National probability sample office-based physicians.
31
TIMN 364922
National Reporting System for Family Planning Services
(NRSFPS) . Visits to family planning clinics. DHHS-NCHS.
Annual Reports. Continuous sample survey since June 1977;
continuous full count reporting from 1972 to June 1977.
s National Natality Follow Back Survey. Selected data from
1964-66 Follow Back. NCHS Vital and Health Statistics, Series
22. Survey of mothers with legitimate live births; sample of
birth records.
s 1980 NNational Natality Survey/1980 National Fetal Mortality
Survey. Birth and fetal deaths by numerous characteristics
not available from the Vital Registration System. DHHS-NCHS.
Currently in the field. Public use data tapes will be available
from the survey. National sample survey.
National Survey of Family Growth (NSFG ). Characteristics of
women of childbearing age. DHHS-NCHS. NCHS Vital and
Health Statistics, Series 23, selected reports, and Advance
Data from Vital and Health Statistics, selected reports.
Periodic surveys at intervals of several years; National
probability sample.
. To State and/or local level
National Vital Registration System
Natality: Births by age, race, parity, marital status. Most
States also have number of prenatal visits, timing of first
prenatal visit, educational level of mother, sometimes of
father. DHHS-NCHS. NCHS Vital Statistics of the United
States. Vol. 2, and Monthly Vital Statistics Reports, Series
21. Continuous reporting by States; fuli count of birth
certificates 38 States, 50 percent sample remaining States.
(Many States issue their own earlier reports).
Mortality. Deaths (including infant and fetal deaths) by
age at death, sex, race. Some States link mortality and
natality thus making full natality data available.
DHHS-NCHS. Vital Statistics of the United States, Vol. 1,
parts A and B; and NCHS Monthly Vital Statistics Report,
by States, Series 21, selected reports. Continuous
reporting by States, all events. (Many States issue their
own earlier reports. )
# Hospitalized illness discharge abstract systems.
Professional Activities Study (PAS). Patients in short stay
hospitals; patient characteristics, deliveries, diagnoses of
congenital anomo3ies, procedures performed, length of
32
TIMN 364923
stays. Commission on Professional and Hospital Activities,
Ann Arbor, Michigan. Annual reports and tapes.
Continuous reporting from 1900 CPHA member hospitals; not
a probability sample, extent of hospital participation varies
by State.
-- Other hospital discharge systems as locally available.
-- Selected health data. DHHS-NCHS. NCHS Statistical Notes
for Health Planners. Compilations and analysis of data to
State level.
s Area Resource File (ARF). Demographic, health facility and
manpower data at State and county level from various sources.
DHHS-Health Resources Administration. Area Resource File -
A Man ower Planning and Research Tool, I?HHS HRPi-3fl-4! Oct
79. One time compilation.
33
IP4MUNIZATION
1. Nature and Extent of the Problem
Vaccines are among the safest and most effective measures for the
prevention of infectious and communicable diseases. Introduction
and widespread use of vaccines have resulted in global eradication of
smallpox and in dramatic declines in the incidence of diphtheria,
measles, mumps, pertussis (whooping cough), polio, rubella and
tetanus. Although efforts to vaccinate increasingly higher
proportions of target populations have been successful in recent
years, continued activities are required to complete the task.
Moreover, continued vigilance is required to maintain past successes
in avoiding illnesses and deaths from these diseases, since, with the
exception of smallpox, the causal agents have not been eliminated
and the risk continues. Full implementation of influenza
immunization, and new vaccines as they are developed, imposes a
continuing challenge, since the target populations (such as for a
sexually transmitted diseases vaccine) may be different from those
presently receiving vaccines.
a. Health implications
sCessation of vaccination would inevitably lead to the
recurrence of annual epidemics, for example, of measles,
rubella, diphtheria, and mumps, as well as periodic epidemics
of polio and greater incidence of tetanus.
s]3uring periodic pandemics, thousands of people may die
prematurely as a result of influenza. Between these
pandemics, excess mortality due to influenza may also be in
the thousands. Those primarily affected are the chronically ill
and the elderly.
. Pneumonia causes over 50,000 deaths annually and over half
these deaths occur among people over 65. The risk of death
from pneumonia is 2.5 times higher for those aged 65 to 74 and
10 times higher for those 75 to 84 than for the population as a
w hoie .
and trends
From the years of their initial development to the present, the
various immunizations have brought global eradication of
smallpox and sharp declines in morbidity and mortality from
other diseases:
35
TIIiIN 364925
-- diphtheria--approximateiy 160,000 cases and 10,000 deaths
or more annually in the early 1920s; 59 cases in 1979 and 4
deaths in 1978 ((most recent year for which data are
available );
cough--approximately 200,000 cases and
5,000 deaths annually in the early 1930s;
1}617 cases in 1979 and 6 deaths in 1978;
polio--21,0Q0 cases of paralytic polio in 1952 (epidemic
year); 26 cases in 1979;
__ mumps--152,000 cases in 1968; 14,225 in 1979;
-- rubeila--6Q,(}}Q cases in 1969; 11,795 in 1979;
-- measles--48Q, 000 cases in 1962; 13,597 cases in 1979.
Tvlorbidity from influenza and pneumonia is not reportable, so
trends cannot be determined.
With the dramatic reduction of vaccine-preventable diseases,
the rare adverse effects of immunization have become
increasingly visible.
An effective system for assuring that routine immunizations are
delivered to susceptible populations has not yet been
established nationwide.
immunization is required by law for first entry into school in
all 50 States and the District of Columbia.
Liability associated with vaccines, and compensation of those
injured as a result of immunization, have emerged as issues in
the effective delivery of services.
2. Prev entionl Promotion Measures
a. Potential measures
Education and information measures include:
-- providing useful immunizatio ' n information to all mothers and
new parents by hospitals, physicians and others;
-- aiming educational programs at members- of the health care
professions;
36 reyAAN 164926
-- including discussion of immunization and preventive
measures in schooI health curricula;
-- enlisting day care centers; senior citizen centers and
churches to provide immunization information to parents and
to older people;
-- using the mass media for immunization activities;
-- continuing use of volunteers.
s Service measures include:
-- adopting standardized official immunization records;
-- developing and using "tickler" and recall systems to ensure
that children return for immunizations on schedule;
-- reviewing records to identify children needing
immunizations;
-- making immunizations available without financial barriers in
all health care settings as a part of comprehensive health
services ;
-- providing information and immunization services to special
populations such as immigrants and non-English speaking
groups;
-- continuing use of volunteers.
* Legislative and regulatory measures include:
enforcing existing school immunization requirements and
extending them to include children at all grade levels in
both public and private schools, as well as in organized
preschool settings;
including coverage of immunization as a Medicare benefit not
subject to deductible provisions;
requiring carriers under any National
to reimburse for immunization services;
s
ce plan.
requiring immunization as a condition of employment (e.g.,
in health care institutions and for school age employees) ;
requiring rubella immunization as a service routinely offered
in family planning clinics, primary care clinics, hospitals
(particularly post-partum settings ) and HMOs.
37
WAN 364927
s Economic measures include:
reimbursing for immunizations under public and private
health insurance plans;
providing vaccine free to all health care providers as long
as they do not charge for it;
providing economic incentives to health care providers and
vaccine recipients.
b. Relative strength of the measures
The uniform and forceful implementation of school immuniza
requirements is one of the most effective means of improving
immunization levels currently available. Enforcement of such
requirements to the point of exclusion from school has resulted
in the highest achievable immunization levels of schoo3l children
and the lowest reported levels of diseases such as measles.
One problem with this measure is that it does not assure that
all preschool children are adequately immunized before the time
of entry to school. Other potential regulatory measures, such
as immunization requirements for employment in hospitals,
address specific problems in selected population groups and
are less effective.
Continuing education and motivation of the general public and
health- providers about the need to continue routine
immunization and the accompanying need to accept the minimal
risk of severe complications associated with some vaccines are
essential to maintain and extend prevention of these diseases.
Experience developed from the recent Childhood Immunization
Initiative has demonstrated the importance of mass media and
volunteer promotion of routine immunization to parents and
child ren .
3. Specific objectives for 1990 (or earlier)
s Improved health status
a. By 1990, reported measles incidence should be reduced to less
than 500 cases per year--all imported or within two generations
of importation. (In 1979, there were 13,597 measles cases
reported. )
b. By 1990, reported mumps incidence should be reduced to less
than 1,000 cases per year. (In 1979, there were 14,225 mumps
cases reported.)
38
TIMN 364928
c. By 1990, reported rubella incidence should be reduced to less
than 1,000 cases per year. (In 1979, there were 11,795 rubella
cases reported.)
d. By 1990, reported congenital rubella syndrome incidence should
be reduced to less than 10 cases per year. (In 1979, there
were 62 new cases of congenital rubella syndrome. )
e. By 1990, reported diphtheria
less than 50 cases per year.
diphtheria cases reported. }
9_
e should be reduced to
(In 1979, there were 59
By 1990, reported pertussis incidence should be reduced to less
than 1,000 cases per year. (In 1979, there were 1,617
pertussis cases reported. )
By 1990, reported tetanus incidence should be reduced to less
than 50 cases per year. (In 1979, there were 81 tetanus cases
reported. )
h. By 1990, reported polio incidence should be less than 10 cases
per year. (In 1979, there were 26 polio cases reported. )
s Increased public/professional awareness
By 1990, all mothers of newborns should receive instruction
prior to leaving the hospitall or after home births on
immunization schedules for their babies.
Improved serviccslprotection
By 1990, at least 90 percent of all children should have
completed their basic immunization series by age 2--measles,
mumps, rubella, polio, diphtheria, pertussis and tetanus. (In
1978, completion varied from 50 to 90 percent. )
k. By 1990, at least 95 percent of children attending licensed day
care facilities, and kindergarten through 12th grade should be
fully immunized. (Based on data collected during the 1978-1979
school year, the immunization level for measles, rubella, polio
and DTP was about 90 percent for first school entrants, lower
overall. )
1. By 1990, at least 60 percent of high risk populations as defined
by the Immunization Practices Advisory Committee of the Public
Health Servic- AGIP) should be receiving annual immunization
against influenza. (In 1979, about 20 percent of high risk
populations were immunized. )
39 TININ 364929
m. By 1993, at least 60 percent of high risk populations, as
defined by the ACIP, should have received vaccination against
pneumococcal pneumonia. (Baseline data unavailable. )
By 1990, at least 50 percent of people in populations designated
as targets by the ACIP should be immunized within 5 years of
licensure of new vaccines for routine clinical use.
*NC3TE. Same objective as for Surveillance and Control of
Infectious Diseases. Potential candidates include: hepatitis A
and B; otitis media (S. pneumoniae and H. influenza)3 selected
respiratory and enteric viruses; meningitis (group B N.
meningitides, S. pneumoniae, H. influenza).
o. By 1985, the Nation should have a plan in place to mount mass
ization programs in the face of possible epidemics of
influenza or other epidemic diseases for which vaccines may
exist.
p. By 1990, no comprehensive health insurance policies should
exclude immunizations. (Baseline data unavaiiabie. )
s Improved survefliance/evaluation systems
q.
By 1990, at least 95 percent of all children through age 18
should have up-to-date official immunization records in a
uniform format using common guidelines for completion of
nization. (Baseline data unavailable.)
r. By 1990, surveillance systems should be sufficiently improved
that (1) at least 90 percent of those hospitalized, and 50
percent of those not hospitalized, with vaccine preventable
diseases of childhood are reported, and that (2) uniform case
definitions are used nationwide. (Baseline data unavail.able. }
4. Principal Assumptions
s Support for immunization activities in the private sector will remain
at least as high as in 1978-79.
s In the public sector, local, State and Federal support will maintain
immunization activities at least at current levels.
s Issues of vaccine liability and compensation of individuals damaged
by vaccine--which have occasionally hampered immunization
activities--will be resolved, or at least will not worsen.
Procedures for informing recipients of the risks and benefits of
vaccines will not become more complex and may be simplified. Any
worsening in these areas would jeopardize attainment of the
objectives.
40 TIMN 364930
Vaccines will continue to be available in the quantities needed,
a timely fashion, and with no extraordinary increase in cost.
No hitherto-unknown serious adverse reactions will appear which
will affect vaccine acceptability.
a Immunity induced by recently introduced vaccines (e, g. , measles,
mumps and rubella) will prove to be permanent. Immunity will be
induced in well over 30 percent of recipients.
~ Schools will continue active involvement and strict enforcement of
immunization requirements; no legal challenges to this approach will
be successful.
Use of multiple antigen vaccines (e. g., combined
measles-mumps-rubella) will be standard procedure.
Support for the development and testing of new and improved
vaccines will continue at least at present levels. Current
difficulties in recruiting volunteers for vaccine trials will be
resolved.
. Data Sources
a. To National level only
a National Ambulatory Medical Care Survey (NAMCS). Patient
visits to physicians by patient and physician characteristics,
diagnosis, patient's reasons for the visit and services
provided, including immunization. DHHS-National Center for
Health Statistics (NCHE ). NCHS Vital and Health Statistics,
Series 13, selected reports, and NCHS Advance Data from Vital
and Health Statistics. Continuing; National probability sample
physician's office based practices since 1973.
e Health Interview Survey (HIS ). Interview respondents reports
of illness (including childhood communicable diseases,
influenza, pneumonia), disability, use of hospital, medical,
dental, and other services, and other health-related topics.
DHHS-NCHS. NCHS Vital and Health Statistics, Series 10.
Continuing survey; household interviews, National probability
sample.
s Health and Nutrition Examination Survey (HANES).
Immunization status; serologic data. DHHS-NCHS. HANES I,
1371-2974-, HANES II, 1979. NCHS Vital and Health Statistics,
Series 10. Periodic surveys, data obtained from physical
examinations, National probabil%ty samples.
41
,VIT4
U:S. Immunization Survey ( USIS ). Percentages of individuals
immunized with DTP, TOPV, measles, rubella and mumps
vaccines by age and socioeconomic status. DHHS-Center for
Disease Control (CDC). Survey; National subsample of
households interviewed for the Current Population Survey of
the U.S. Census. United States Immunization Survey: 1979.
Continuing, annual.
Vaccine distribution systern. Distribution of vaccines by
antigen. DHHS-CDC. CDC Biologics Surveillance Report.
Quarterly. Continuing; reports from vaccine manufacturers.
sVaccines administered. Doses of vaccines administered in the
public sector. DI-iHS-CDC. CDC Memoranda to State and local
health departments. Continuing; quarterly reporting from
State and local immunization programs.
! Adverse Reaction Monitoring System (ARMS). Adverse
reactions to vaccination. DHHS-CDC. Surveillance report.
Continuous reporting from State and local immunization
programs.
a School Entry Immunization Survey. Immunization status of
children on entry to kindergarten or first grade. DHHS-CDC.
Memoranda to State' and local health departments. Annual
reporting from State and local immunization programs.
#Preschool immunization surveys. Immunization status of
preschool children. DHHS-CDC. Memoranda to State and local
health departments. Annual or as needed. Survey of day care
centers and other surveys of 2 year old children by State and
local immunization programs.
b. To State andlor local level
National Vital Registration System
-- Mortality. Deaths by cause (including diseases preventable
by immunization), age, sex and race. DHHS-NCHS. NCHS
Vital Statistics of the United States, Vol II, and NCHS
Monthly Vital Statistics Reports. Continuing reporting from
States; National full count. (Many States issue earlier
reports. )
s Hospitalized illness discharge abstract systems
-- Medicare hospital patient reporting system (MEDPAR)
Characteristics of Medicare patients, diagnoses, procedures.
DHHS-Health Care Financing Administration-Office of
Research, Demonstrations and Statistics (ORDS). Periodic
42 TIMN 364932
reports. Continuing reporting from hospital claim data; 20
percent sample.
-- Other hospital discharge systems as locally available.
s Selected health data. DHHS-NCHS. NCHS Statistical Notes
for Health Planners. Compilations and analysis of data to
State level.
s National Morbidity and Mortality Reporting System. Numbers
of 46 reportable diseases ; deaths in 3.21 13 . S. cities.
i3HHS-CDC. CDC Morbidity and Mortality Weekly Report, and
annual reports. Morbidity: continuous reporting from State
health departments on basis of physician reports.
(Completeness of reporting varies greatly, since not all cases
receive medical care and not all treated conditions are
reported. ) Mortality: continuous reporting from volunteer
panel of health departments in 121 U.S. cities, full count.
. Early and Periodic Diagnosis and Treatment (EPSDT) reporting
system. Immuni.zationn status and referral of children
screened. DHHS-Health Care Financing Administration
(HCFA) , Office of Research, Demonstration and Statistics.
Medicaid Statistics, selected reports. Continuing reporting
from State Medicaid files.
Area Resource File (ARF). Demographic, health facility and
manpower data at State and county level from various sources.
DHHS-Health Resources Administration (HRA). HRA Area
Resource File: A Manpower Planning and Research Tool.
I1HHS-HRA-$0-4, Oct 79. One time compilation.
43
TIMN 364933
SEXUALLY TRANSMITTED DISEASES
. Nature and Extent of the Problem
Sexually transmitted diseases (STDs) are infections grouped together
because they spread by transfer of infectious organisms from person
to person during sexual contact. Sexually transmitted diseases are
major public health problems because they cause enormous human
suffering, cost hundreds of millions of dollars and impose tremendous
demands on medical care faciLities. The sexually transmitted disease
problem is rooted in apathy and ignorance. Neglect is widespread,
dehumanizing and institutionalized in the public and private sectors,
including educational settings ranging from pub3ic schools to those
for the health professions. Women and children bear an inordinate
share of the sexually transmitted disease burden: sterility, ectopic
pregnancy, fetal and infant deaths, birth defects and mental
retardation. Cancer of the cervix may be linked to sexually
transmitted Herpes II virus.
Health implications
s The most serious complications caused by sexually transmitted
agents are pelvic inflammatory disease, infant pneumonia,
infant death, birth defects and mental retardation.
Pelvic inflammatory disease is the most serious complication
from gonorrhea and chlamydial infections. More than 850,000
cases are diagnosed and treated each year; the major
proportion of these are associated with past or present
sexually transmitted diseases. In 1978, it was estimated that
150,000 new cases of pelvic inflammatory disease were caused
by gonorrhea. In addition:
-- half of all women hospitalized for pelvic inflammatory disease
are less than 25 years of age; sterility due to pelvic
inflammatory disease currently affects over 50,000 women
annually and is increasing;
ectopic pregnancies occur each year resulting
in danger to the woman's life; many of these result from the
long-term effects of pelvic inflammatory disease;
-- pelvic inflammatory disease yearly accounts for over 250,000
hospitalizations and over 50,000 major surgical procedures,
many involving total removal of the reproductive organs.
s Ghiamydia causes an estimated 50,000 eye infections and 25,000
cases of pneumonia per year in infants.
45
TIMN 364934
sGenitai herpes infections are very common, with an incidence
of one-half to one million new cases annually, with several
million recurrences each year, and :
no effective treatment is currently available for this painful
condition; periodic recurrences are the rule;
herpes-complicated pregnancies often result in abortion,
stillbirth or severe neonatal infection; neonatal herpes
results in death or permanent disability in two-thirds of the
cases.
Hepatitis B is caused by a virus with many different modes of
transmission, including sexual transmission. Homosexual men
are at very high risk; nearly 60 percent attending sexually
transmitted disease clinics show evidence of past or present
Hepatitis B infection. This same population is also at high
risk of several other sexually transmitted diseases, including
amebiasis and giardiasis.
s'These and other sexually transmitted diseases have placed
great strain upon the resources of local health departments
during the 1970s.
b. Status and trends
Total costs for sexually transmitted diseases vastly exceed one
.
billion dollars annuaiiy.
s Costs for the most common reported sexually transmitted
disease, gonorrhea, were estimated to total over $770 million in
1978.
2. PreventionlPromotion Measures
a. Potential measures
a Education and information measures include:
-- education and training, including clinical experience in
schools for health professionals;
-- education and information about sexually transmitted
diseases for school children before, and during, the time
they are at highest risk;
-- preservice and continuing professional education for both
health providers and health educators to deal with sexually
transmittedd diseases in a confidential, non-judgmental
fashion;
46 TIMN 364935
improved public understanding of sexually transmitted
disease risks and confidentiality of treatment through
effective and continuous campaigns using mass media; the
measures may be directed to wide populations or targeted to
special groups such as adolescents, homosexuals, women
with pelvic inflammatory disease and other risk groups;
counseling of patients being treated for sexually transmitted
diseases regarding complications and measures to avoid
future infectich;
use of peers, who are often adjuncts to educate and counsel
adolescents about sexually transmitted diseases.
* Service measures include:
-- provision of diagnostic and treatment services for the
sexually transmitted diseases and their complications;
-- counseling infected patients and tracing and treating their
contacts;
-- screening for selected sexually transmitted disease
-- encouraging joint availability of services among related
programs such as sexually transmitted diseases, family
planning and maternal and child health.
s Techncslogic measures include:
properly used condoms as the best known measure for
persons engaging in sexual activity to avoid acquiring or
transmitting many of the sexually transmitted diseases;
vaccine for Hepatitis B (being tested for efficacy);
vaccines for gonorrhea and genital herpes (at an earlier
stage of development ).
s Legaslat%ve and regulatory measures include:
-- Health Systems Agencies (HSAs) determining the magnitude
of the sexually transmitted disease problem and establishing
objectives for inclusion in their Annual Implementation Plans
(AIPs),
-- State Health Planning and Development Agencies (SHPDA)
making certain that the State health plan addresses gaps inn
education and service delivery regarding sexually
transmitted diseases;
47
TIMN 364936
examination of health professionals' knowledge of sexually
transmitted diseases and competency in dealing with
sexually transmitted diseases by specialty boards, certifying
agencies and other regulatory boards;
establishment of a comprehensive review rating and
accreditation to evaluate and maintain the quality of STD
care and services;
-- State and local governments repealing statutes and
ordinances which inhibit the advertising, display, sale or
distribution of condoms;
-- regulations mandating information about sexually transmitted
diseases as part of school health education programs.
s Economic measures include:
-- sexually transmitted disease services, as with other
prevention-related activities, being exempted from
coinsurance or deductible provisions of health insurance;
-- prepaid health plans receiving financial incentives for
sexually transmitted disease promotionlprevention activities
including management of contacts who are not members of
the plan.
b. Relative strength of the measures
s Readily available quality clinical services without stigma form a
necessary foundation for other clinic-related prevention
activities.
s Early diagnosis and treatment of sexually transmitted diseases
among patients attending clinics, contacts and those identified
in screening programs are highly effective in preventing
transmission of the diseases and in limiting their disabling
complications.
. Persons who properly and consistently use condoms experience
lower rates of sexually transmitted diseases.
As vaccines are developed and introduced, they can be
effectively administered in the health care system.
fMass and targeted education and information measures appear
to be the only way to modify hardened public opinion and
reduce sexually transmitted disease ignorance and apathy.
48 TIMN 364937
Education and training of health professionals and health
educators is a necessary first step toward effective sexually
transmitted disease service measures.
3. Specific Objectives for 1990 (or earlier)
Improved health status
a. By 1990, reported gonorrhea incidence should be reduced to a
rate of 280 cases per 100,000 population. (In 1979, the
reported case rate was 457 per 100,000 popuiati.on. )
b. By 1990, reported incidence of gonococcal pelvic inflammatory
disease should be reduced to a rate of 60 cases per 100,000
females. (In 1978, the estimated rate was 130 cases per 100,000
females. )
c. By 1990, reported incidence of pr
should be reduced to a rate of 7 cases per 100,000 pop
per year, with a reduction in congenital syphilis to 1.5 cases
per 100,000 children under 1 year of age. (In 1979, the
reported incidence of primary and secondary syphilis was 11
cases per 100,000 population while reported congenital syphilis
was 3.7 cases per 100,000 children under 1 year of age.)
d. By 1990, the incidence of serious neonatal infection due to
sexually transmitted agents, especially herpes and chlamydia,
should be reduced to a rate of 8.5 cases of neonatal
disseminated herpes per 100,000 children under 1 year of age,
and a rate of 360 cases of chlamydial pneumonia per 100,000
children under 1 year of age. (In 1979, about 16.8 cases of
neonatal disseminated herpes per 100,000 children under 1 year
of age and about 720 cases of chlamydial pneumonia per
100,000 children under 1 year of age were estimated to have
occurred.)
e. By 1990, the incidence of nongonococcal urethritis and
chiarnydial infections should be reduced to a rate of 770 cases
per 100,000 population. (In 1979, the case rate was estimated
to be 1,140 per 100,000 popul.ation. )
s Reduced risk factors
f. By 1990, the proportion of sexually active men and women
protected by properly used condoms should increase to 25
percent of those at high risk of acquiring sexually transmitted
diseases. (In 1979, the estimated proportion was less than 10
percent. )
49
TIMN 364938
s Increased publicfprofessionai awareness
g
By 1990, every junior and senior high school student in the
United States should receive accurate, timely education about
sexually transmitted diseases. (Currently, 70 percent of school
systems provide some information about sexually transmitted
diseases, but the quality and timing of the communication varies
greatly. )
h. By 1985, at least 95 percent of health care providers seeing
suspected cases of sexually transmitted diseases should be
capable of diagnosing and treating all currently recognized
sexually transmitted diseases, including: genital herpes
diagnosis by culture, therapy (if available) and patient
education; hepatitis B diagnosis among homosexual men,
prevention through a vaccine (when proved effective) , and
patient education; and nongonococcal urethritis diagnosis,
therapy and patient education. (Baseline data unavailable. )
9 Improved services/protection
By 1990, at least 50 percent of major industries and
Governmental agencies offering screening and health promotion
programs at the worksite should be providing sexually
transmitted disease services (education and appropriate testing)
within those programs. (Baseline data unavailable. )
e Iaproved* surveillance/evaluation systems
j'
By 1985, data should be available in adequate detail (but in
statistical aggregates to preserve confidentiality) to determine
the occurrence of nongonococcal urethritis, genital herpes and
other sexually transmitted diseases inn each local area, and to
recommend approaches for preventing sexually transmitted
diseases and their complications.
k. By 1990, surveiBance systems should be sufficiently improved
that at least 25 percent of sexually transmitted diseases
diagnosed in medical facilities are reported, and that uniform
definitions are used nationwide. (Baseline data unavailable. )
4. Principal Assumptions
. Biologic changes in the sexually transmitted disease organisms are
likely but unpredictable as to their occurrence or effect, therefore
they have not been considered.
~ The size of the at-risk sexually-active population is not expected
to change substantially during the 1980s. ((Declines in younger
age groups are expected to be balanced by increases in
nonmonogamous sexual activity in all groups. )
50 T'IAIN 364939
s During the next decade, the health planning process will provide
the opportunity to influence providers to raise norms and meet
guidelines for prevention and management of sexually transmitted
diseases. HSAs will include sexually transmitted diseases among
other health status indicators, and will include sexually transmitted
disease objectives and controll measures in their plans.
. All health professional training programs will give greater emphasis
to the prevention, early diagnosis and treatment of sexually
transmitted diseases.
Medical schools will establish clinical affiliations with public and
private sexually transmitted disease facilities so that all medicall
students and physicians in training will receive supervised clinical
experience in the diagnosis and treatment of sexually transmitted
diseases.
s Support for studies of mechanisms of antibiotic resistance and for
the development of antiviral drugs and new vaccines will continue
at 1979 levels.
5. Data Sources
a. To National level only
s Annual Census of State and County Mental Hospitals. Resident
patients and new admissions to mental institutions ; costs,
diagnoses of syphilitic psychoses. DHHS-Alcohol Drug and
Mental Health Administration, National Institute of Mental
Health (NIMH). Mental Health Statistical Notes, selected
issues; special reports and tabulations furnished to the Center
for Disease Control (CDC), Venereal Disease Control Division.
Continuing; National sample surveys of patients in State and
county mental hospitals.
a National Ambulatory Medical Care Survey (NAMCS). Patient
characteristics, diagnoses of STD. DHHS-National Center for
Health Statistics (NCHS ). NCHS Vital and Health Statistics,
Series 13, selected reports, and CDC, Division of Venereal
Disease Control, special tabulation from tapes provided by
NCHS. Continuing; National probability sample, office based
physicians.
s Health and itlutrition Examination Survey (HANES). Adults,
patient characteristics, seriologic tests for syphilis, urine
cultures for gonorrhea. DHHS-NCHS. NCHS Vital and Health
Statistics, Series 11, selected reports. Periodic surveys;
National probability sample.
51
TIMN 364940
Hospital Discharge Survey (HDS ). Patient stays in short-stay
hospitals, patient characteristics, diagnoses, including
salpingitis and PID; surgery and other procedures; length of
stay. DHHS-NCHS. NCHS Vital and Health Statistics, Series
13, selected reports, and special tabulations by CDC, Venereal
Disease Control Division from tapes provided by NCHS.
Continuing survey; National probability sample of short stay
hospitals.
STD Surveillance. Nonreported as well as reported STDs.
Patient visits to VD clinics; age, race, sex, reason for
attendance, sexual preference, laboratory tests and results,
diagnoses of 14 of the sexually transmissible diseases.
DiiHS-CDC, Venereal Disease Control Division. In-house
summaries provide part of basis for Nationa.ll
incidencelprevalence estimates of STD in STD Fact Sheet, HEW
Publication No. (CDC) 8195, and other program
documentations. Continuing reporting; full count from 7 STD
clinics.
Gonorrhea Therapy Monitoring Network. Gonorrhea patients
treated with a variety of antibiotics in varying dosages; post
treatment results, minimum inhibitory concentration of
antibiotics. DHHS- CDC, Venereal Disease Control Division.
Supplement to Sexually Transmitted Diseases (Journal of the
American Venereal Disease Association) Vol. 6, No. 2, April -
June 1979. CContinuing i971-1979; discontinued 1979.
The Hepatitis B Collaborative Study. Hepatitis incidence and
prevalence among male homosexuals; sexual behavior modalities.
DHHS-CDC, Venereal Disease Control Division and Hepatitis
Laboratories Division. Results in preparation. One time study
from five clinics.
b. To State andlor local level
National Case Reporting System (NCRS ). Reported cases of
gonorrhea, syphilis by stage, chancroid, granuloma inguinale
and lymphogranuloma; age, race, sex and reporting source
(private vs. public). DHHS-CDC, Bureau of Epidemiology and
Venereal Disease Control Division. STD Fact Sheet,
Publication No. (CDC) 8195; Sexually Transrnitted Disease
(STD ) Statistical Letter. Continuing full National count of
reported cases, State and major city breakdown, additional
characteristics, e.g., marital ~status may be locally available in
some States.
Hospitalized illness from discharge abstract systems
52 TIW 3649,11
Professional Activities Study (PAS). Patient stays in
short-stay hospitals; patient characteristics, diagnoses of
salpingitis and PID. Commission on Professional and
Hospital Activities ( CPHA) , Ann Arbor, Michigan. Special
tabulations and/or tapes provided to DHHS-CDC, Venereal
Disease Control Division. Continuing reporting from
discharge records. Full count of patients discharged from
CPHA 1900 member hospitals. Not a probability sample.
Extent of hospital participation varies by State.
Other hospital discharge systems as locally available.
National Morbidity and Mortality Reporting System.
Numbers of 46 reportable diseases; deaths in 121 U. S.
cities. DHHS-CDC . CDC Morbidity and Mortality Weekly
Report, and annual reports. Morbidity: continuous
reporting from State health departments on basis of
physician reports. (Completeness of reporting varies
greatly, since not all cases receive medical care and not all
treated conditions are reported. ) . Mortality: continuous
reporting; volunteer panel of health departments in 121
LT. S. cities, full count.
s Quarterly Epidemiologic Activity Report -(CDC 9.2127).
Number of interviews by disease, contacts elicited and
examined, medical disposition. DHHS-CDC, Venereal Disease
Control Division. STD Fact Sheet, HEW Publication No.
( CDC ) 8195; Sexually Transmitted Disease (STD ) Statistical
Letter. Continuing reporting from State health departments;
full National count with project area breakdown.
aGonorrhea Culture Results of Females. Number women
screened and positive, by type of provider. DHHS-CDC,
Venereal Disease Control Division. STD Fact Sheet, HEW
Publication No. (CDC) 8195, Sexually Transmitted Disease
(STD) Statistical Letter. Continuing reporting from State
health departments; Nationa.il full count of federally sponsored
gonorrhea screening activity.
s Infectious Syphilis Epidemiologic Control Record. Early
syphilis interviews; age, race, sex of cases, contacts, time
intervals between case report and final disposition of contacts.
DHHS-CDC,, Venereal Disease Control Division. S'I'D Fact
Sheet, HEW Publication No. (CDC) 8195; Sexually Transmitted
Diseases (STD ) Statistical Letter. Continuing reporting from
State health departments ; National full count.
s R.esuits of Followup of Serologic Reactors. Reactive serologic
tests reported to health departments and results of followup.
DHHS-GDC, Venereal Disease Control Division. STD Fact
53
TIMN 364942
Sheet, HEW Publication No. (CDD) 8195; Sexually Transmitted
Disease (S`I°D ) Statistical Letter. Continuing reporting from
State health departments ; National full count.
VD Laboratory Surveillance Report. Number of tests for
syphilis performed, number positive, type of laboratory.
DHHS-CDC,Venereal Disease Control Division. STD Fact
Sheet, HEW Publication No. (CDC) 8195; Sexually Transmitted
Disease (STD) Statistical Letter. Continuing reporting from
State health departments; National full count.
a National Vital Registration System
-- Mortality. Deaths by cause (including infant deaths
attributable to sexually transmissible diseases and to
syphilis) by age, sex and race. DHHS-NCHS. NCHS Vital
Statistics of the United States, Vol II, and NCHS Monthly
Vital Statistics Reports. Continuing reporting from States;
full count. (Many States issue earlier reparts. )
54 TE1IN 364943
TOXIC AGENT CONTROL
tent of the Problem
Toxic agents include, but are not limited to, natural and synthetic
chemicals, dusts, minerals, and materials which produce acute or
chronic illness. Such agents may be carcinogenic, mutagenic or
teratogenic, and they may adversely affect the reproductive system,
nervous system, or specific organs such as the liver or kidney.
Included as a toxic agent for the purposes of this document are
radiation exposures of various types.
a. Health implications
sHealth effects attributed to toxic agents and/or radiation of
various types include:
-- acute effects including systemic poisoning;
-- chronic effects including teratogenic abnormalities and
growth impairment;
-- infertility and other reproductive abnormalities;
-- skin disorders;
-- cancer;
-- neurologic disorders;
-- behavioral abnormalities;
-- immunologic damage;
-- chronic degenerative diseases involving the lungs, joints,
vascular system, kidneys, liver and endocrine organs.
Though the extent to which toxic agents are associated with
disease is not completely known, recent empirical evidence
confirms that serious environmental health hazards exist. New
evidence unfolds regularly, revealing previously unsuspected
associations between specific environmental agents and
diseases. The detection of specific etiology is greatly
complicated because (a) many agents may contribute to the
same diseases, (b) there may be long latency periods between
exposure and disease onset, and (c) data are sometimes
unavailable or inappropriately aggregated for discovery
purposes.
55
TIMN 364944
s Iliseases associated with toxic agents may differentially affect
different age groups, present and future generations and
groups with different histories of past exposure and
predisposing conditions.
. Varying latency associated with many chronic diseases, complex
history of previous exposure and other factors mentioned
above make assessment of the magnitude of the problem
difficult. Although current disease incidence and rnortality
data are inaccurate measures, they serve as indicators of the
effectiveness of existing control and prevention efforts.
:Objective laboratory measurements of toxicity, levels of
concentrations, and human biological effects are necessary to
characterize effectiveness of control mechanisms and to define
biochemical sequelae of toxic insults to biological systems.
b. Status and Trends
tScurces of environmental health hazards presently subject to
Federal regulation include:
ai.r/w ater emissionsleffiuents ;
hazardous waste disposal;
transportation of hazardous materials;
occupational exposure;
products (food additives, pharmaceuticals, pesticides,
consumer and industrial chemicals);
radiation exposure from medical devices, consumer
products, food and the envirgnment:
The rapid advancement of post-World War II industrial
production has created substantial increases in the quantity
and kinds of substances and materials which may pose
significant health hazards.
It is estimated that of the four million chemical compounds
which have been synthesized or isolated from natural materials,
more than 55,000 are produced commercially. Approximately
1,000 new compounds are introduced annually; pesticide
formulations alone contain about 1,500 active chemical
ingredients.
56 TIMN 364945
s There may be as many as 30, 000 toxic solid waste disposal
sites in the United States.
s Over 13, t}tlt0 substances currently in commercial use have been
identified as potentially toxic to workers, with an additional
number introduced every year.
s Over 2, 000 chemicals are suspected carcinogens in laboratory
animals. Current epidemiologic evidence builds a convincing
case for the carcinogenicity 'in humans of 26 chemicals and/or
industrial processes.
9 More than 20 agents are known to be associated with birth
defects in humans; many times this number are associated with
birth defects in animals.
s Of 700 atmospheric contaminants, 47 have been identified in
animal studies as recognized carcinogens, 42 as suspected
carcinogens, 22 chemicals as promoters and 128 as mutagens.
From over 2,200 contaminants of all kinds identified in water,
765 were identified in drinking water. Of these, 12 chemical
pollutants were recognized carcinogens, 31 were suspected
carcinogens, 18 were carcinogenic promoters and 59 were
mutagens. It is not known what the additive effects of these
chemicals will be on the total cancer burden.
.As water resources become in shorter supply, more and more
surface water, used for drinking water, will be recycled or
reprocessed, continuing the recycling of pollutants unless
adequate water treatment measures are taken.
aEven if carcinogenic pesticides are no longer available for sale
by 1990, some will persist in the environment, in food supplies
and in human bodies for many years.
t Problems with toxic agents are not only attributable to
industry, but also medical and dental care (x-rays and
drugs ), agriculture (pesticides and herbicides ), Government
(biological and chemical agents); consumers (incorrect use of
consumer products which contain toxic substances) and natural
sources (fungal products).
s Low levels of ionizing radiation can produce delayed effects,
such as cancer, after a latent period of many years. Fifty
percent of the current United States population dose comes
from naturally occurring background radiation, radioactive
materials in the water, soi3l and air, and cosmic radiation; 45
percent results from diagnostic and therapeutic medical
applications. Fallout, industrial use, production of nuclear
57
TIMN 364946
power and consumer products account for the remaining 5
percent. Thus roughly half the exposure to the population at
large comes from manmade sources.
The synergistic effects of exposures to ionizing radiation and
toxic agents may greatly increase carcinogenic risks.
2. Frevention/Prgmotion Measures
a. Potential measures
Many of the m easures outlined below need to be carried out by
environmental and health regulatory and research agencies.
Mechanisms such as the Interagency Regulatory Liaison Group
(IRLG ) are essential to coordinate their activities in the areas
of:
assessing agent toxicity;
assessing the number of persons at risk from a particular
agent and estimating intensity of exposures and conditions
of exposure as they affect risk;
technology assessment and development;
economic impact analyses;
developing generic or group standards for classes of toxic
substances;
pooling limited technological resources required to control
environmental health hazards;
establishing effec
mede ( s ) of control
for each agent.
Eduea.tion and information measures include:
-- informing the public that exposure to hazardous agents is
serious, but manageable, and that government control
measures are essential;
- through prime time television announcements (including
use of equal time provisions under FCC regulations) ;
- through establishing a system to warn consumers and
workers of possible carcinogens, teratogens, or other
toxic substances so that precautionary actions to prevent
health effects may be exercised;
58 TIMN 364947
- through providing information on the control of
environmental and occupational health hazards to teachers
and students in elementary and secondary schools within
the context of comprehensive mandatory classroom health
education.
educating health professionals and directors in industry
about toxicology, epidemiology, industrial hygiene, medical
surveillance, control technology design and hazardous
substance control;
expanding sensitivity of practicing physicians, nurses and
other health professionals in the diagnosis of environmental
and occupational diseases and associated reporting
responsibilities;
educating managers of industrial firms through both their
training curricula and through continuing education
(especially those trained in chemical and mechanical
engineering, law and business administration);
staffing the regulatory agencies with well-trained
professionals, not only in the sciences, medicine and
engineering, but also in policy analysis.
* Service measures include:
-- relating diseases to toxic agent exposures and providing
appropriate medical care;
screening and diagnostic services for individuals with
suspected exposure to toxic substances, and treatment as
necessary.
. Technologic measures include:
-- timely efforts to encourage andlor upgrade:
- instrumentation and laboratory operations for
detection and mo
- laboratory standardization programs to insure validity and
interlaboratory comparability of data;
- emission and effluent control technology;
- hazardous and radioactive waste disposal technology;
59
TIMN 364948
- manufacturing process design;
- new product development and testing for deleterious
health effects.
__ Government assistance in developing control technology and
process redesign where the industrial incentives or
requirements for such development are lacking;
__ technology to control nuclear wastes and certain classes of
hazardous wastes and technology to minimize transportation
risks ;
-- technology improvements including modification of current
technology and development of new diagnostic tools to
reduce the amount of radiation required for medical and
dental diagnosis and treatment;
-- sharing of control technology information among the
regulatory agencies and joint development among agencies to
address related problems;
-- technology-forcing regulatory initiatives to encourage
process redesign and new product development.
*Leg%siative and regulatory measures include:
-- enforcement of major environmental laws controlling
hazardous substances:
- Clean Air Act;
- Clean Water Act and the , Safe Drinking Water Act;
- Resource Conservation and Recovery Act (regulating
hazardous substances disposal) ;
- Toxic Substances Control Act;
- Federal Hazardous Substances Control Act;
- Consumer Product Safety Act;
- Federal Environmental Pesticide Control Act;
- The Food, Drug, and Cosmetics Act;
- Hazardous Substances Transportation Act;
7'MN 364949
Atomic Energy Act;
National Environmental Protection Act;
Occupational Safety and Health Act;
Federal Insecticide, Fungicide, and Rodenticide Act;
Radiation and Safety Act.
-- ensuring the comprehensive application of these laws;
certain groups of chemicals and classes of substances are
now exempted from existing testing and regulatory
authorities ;
grouping of toxic agents into classes for both testing and
regulatory action under all toxic substances control laws;
continuing to place the burden of obtaining an exemption
fremm a class rule on the manufacturer since similar
compounds can have differing toxicities;
labeling hazardous ingredients in trade name products, to
address both the content of the product with respect to
potentially hazardous substances and directions for proper
use and disposal of the chemical (a prerequisite for both
effective hazard recognition and the implementation of
appropriate control measures);
disclosure of health-related data to potentially affected
including toxicological and epidemiological data, in
vitro tests, elemental analysis, molecular structure and
process or synthesis information;
establishing priorities and developing more standards for
hazardous substances in both air and water (e.g., careful
attention to ambient air standards as energy programs are
implemented );
establishing State systems for monitoring pollution from both
diesel and conventionally powered vehicles;
expediting promulgation of regulations defining categories of
hazardous materials disposal under the Resource
Conservation and Recovery Act (RCRA) and coordination of
their control;
-- identifying and detoxifying past hazardous substance
disposal sites, and prioritizing the action taken on sites to
reflect the magnitude of the public health risk;
61
TEMN 364a~~
requiring sufficient screening examination by the
manufacturer (before marketing) for the full range of health
effects for a3.3l new chemicals for which there may be
potentially serious risk to health/ environ.men.t;
withholding from introduction into commerce new chemicals
that pose a significant public health threat unless the
manufacturer can demonstrate that there are safe and
practical methods for their manufacture, intended uses and
disposal;
expedited procedures to remove from the
sumer products containing known carcinogens,
-- controlling intensive use of pesticides to achieve marginal or
questionable production increases;
implementing integrated pest management; establishing
a condition for permits to use the more hazar
pesticides;
developing and implementing improved standards for
transportation containers and inspection standards for
vehicles and routes of transportation for hazardous
substances, with particular emphasis on railroad safety;
an adequate system of records of toxic
substances being transported;
establishing centralized National occupational records of
radiation exposure of workers to include exposures to all
types and levels of radiation, including records for
part-time workers;
establishing siting criteria for industries using radioactive
materials (to preclude such events as the recent
contamination of food in a grammar schcoil cafeteria);
establishing approved routes for transportation of nuclear
fuels and nuclear wastes designed to avoid metropolitan
areas and potential watershed contamination.
Economic measures include:
-- taxation and Ieaai redress:
- effluent/emissian taxes (using effluent/emission taxes as
supplements to, and not replacements _ for, regulation to
create additional incentives for hazard abatement );
62 TIMN 364951
- favorable tax treatment of investment in pollution control;
- legal redress for harm resulting from exposure to toxic
agents.
tax policies encouraging capital investment in redesigning
process technology to emphasize process improvement over
add-on technology;
amending the limited liability principles applied to reactor
safety by the Price Anderson Act in measures that deal
with the effects of toxic substances.
b. Relative strength of the measures
. Exerting effective control in these areas by means appropriate
to each is complex. Steps are required to ensure that Federal
regulatory efforts are adequately coordinated, that they are
anticipatory rather than reactive in dealing with the problems
of a rapidly changing industriail production system and that
they are appropriately attentive to protecting the public
h ealth .
~ There are inherent and complicated inter-relationships between
regulatory and economic and technologic measures applied to
protecting the public from the hazards of exposure to toxic
ag ents .
a The most effective measures may well be technologic, but
development and application depends upon adequate regulatory
support and economic incentives.
*Industry, which is the principal target of most efforts to
reduce exposure to toxic agents, is most likely to be
responsive to economic incentives.
s Et3uca.ticnn of the public is of particular
public's seeming bias against some regulatory processes and
given the substantial counterpressures offered by conflicting
social values (e.g. energy production) and by existing
advertising efforts.
The pressures which drive the demand for increased
consumption must be reconciled with an increased demand for
protection of health ' or the environment. Resolving these
conflicting social goals has been attempted (a) by providing
legislative guidelines and directives in individual environmental
laws, (b) by g%ving extensive discretion to agency
administrators, (c) by requiring economic impact statements
through Presidential directives, and (d) by introduction of
63
TIMN 364952
Federal legislation requiring regulatory impact analysis. To
the present, the balancing of social goals and the fulfillment of
regulatory mandates have been reviewed by the courts with
unpredictable results.
3. Specific Objectives for 1990
. Improved health status
-- Improvements in the control of toxic agents can be expected
over the longer term to yield reduced rates (or slowing in the
rates of increase) for cancer, birth defects, respiratory
disease, kidney disease, nervous system disease and other
acute and chronic conditions. Because of uncertainties in the
quantification of the exposure-to-disease relationship (short and
long term ), the statement of measurable health status objectives
at this time has been limited to the two noted below.
a. By 1990, 80 percent of communities should experience a
prevalence rate of lead toxicity* of less than 50(311t10, il(3t3 among
children ages 0 to 5, especially age 0 to 1. (In 1980, the
estimated prevalence of lead toxicity* Nationally exceeds
1, t30(#11t#0, 3}Q. )
*NOTE: Lead toxicity is defined as an erythrocyte
protoporphyrin level exceeding 50 ug/dl whole blood and a
blood lead level exceeding 30 ugJdl.
b. By 1990, virtually no individual should suffer birth defects or
miscarriage as a result of exposure to a toxic chemical disposed
after implementation of the Resource Conservation and Recovery
Act. (Baseline data unavailable. )
Reduced risk factors
c. By 1990, virtually all communities should experience no more
than one day per year when air quality exceeds an individual
ambient air quality standard with respect to sulfur dioxide,
nitrous dioxide, carbon monoxide, lead, hydrocarbon and
particulate matter. (In 1979, the level was estimated to be
about 50 percent. )
d. By 1990, at least 95 percent of the population should be served
by community water systems that meet Federal and State
standards for safe drinking water. (In 1979, the level was 85
to 90 percent for the National ' Interim Primary Drinking Water
Standards.)
64 TMN 364953
e. By 1990, there should be virtually no preventable contamination
of ground water, surface water or the soil from industrial
toxins associated with wastewater management systems
established after 1980. (Baseline data unavailable, but EPA is
starting a series of programs to prevent ground water
contamination in 1980 that should show results by 1990.)
g
or rodenticides available for sale which are known to be
carcinogenic, teratogenic or mutagenic in man, unless
determined to be vital to the Naticnal interest under certain
conditions. (Baseline data unavailabie. )
y 1990, there should be no pesticides, herbicides, fungicides,
By 1990, inhalation of fumes from toxic materials during
transport of such materials should be eliminated. (Baseline
data unavailable. )
h. By 1990, the number of medically unnecessary diagnostic x-ray
examinations should be reduced by some 50 million examinations
annually. (In 1979, the number of diagnostic x-ray
examinations performed in the United States annually was 278
million, of which 83 million were estimated to be medically
unnecessary. )
* Increased pubiic/professional awareness
i. By 1990, at least 75 percent of all city council members in
urban communities should be able to report accurately whether
or not the quality of their air and water has improved or
worsened over the decade and to identify the principal
substances of concern. (Baseline data unavailable. )
1990, at least half of all adults should be able to accurately
report an accessible source of information on tGxic substances
to which they may be exposed--inciuding information on the
interactions with other factors such as smoking and medications.
(Baseline data nnava%Lable. )
k. By 1990, at least half of all people aged 15 years and older
should be able to identify the major categories of environmentall
threats to health and note some of the health consequences of
those threats. (Baseline data unavailable.)
1. By 1990, at' least 70 percent of all primary care physicians
should be able to identify the principal health consequences of
exposure to each of the major categories of environmental
threats to health. (Baseline data unavs.ilable. )
65
TLMN 364954
s Irnprov
se
es/protection
m . By 1990, at least 90 percent of all children identified with lead
toxicity in the 0 to 5 age group (especially those age 0 to 1)
should have been brought under medical and environmental
management. (Baseline data unavailable. Approximately 34,000
children ages S to 5 with lead toxicity are reported annually
from Federally supported programs, and an estimated one
percent of the U.S. population ages I to 5 have lead toxicity.)
n. By 1990, the Toxic Substances Control Act and the Resource
Conservation and Recovery Act should be fully implemented to
protect the U.S. population against hazards resulting from
production, use, and disposal of toxic chemicals. (Baseline
data unavailabie. )
o. By 1990, individuals purchasing a potentially toxic product sold
commercially or used industrially should be protected by clear
labeling as to cont;nt, as to direction for proper use and
disposal, and as to factors that may make that individual
especially susceptible (health status, age, sex, medications,
genetic traits) . (Baseline data unavailable. )
p. By 1990, every individual should have access to an acute care
facility with the capability to provide, or make appropriate
referrals for screening, diagnosis and treatment of suspected
exposure to toxic agents. (Baseline data unavailable. )
q. By 1990, oevery individual residing in an area of a population
density greater than 20 per square mile, or an area of
particularly high risk, should be protected by an early warning
system designed to detect the most serious environmental
hazards posing imminent threats to health. (Baseline data
unavaiiable. )
r. By 1990, every populated area of the country should be able to
be reached within 6 hours by an emergency response team in
the event of exposure to an environmental hazard posing acute
threats to healthh from a toxic agent, chemical and/or radiation.
( Basoiine data unavailable.)
Improved surveillance/evaluation systems
s. By 1990, a broad scale surveillance and monitoring system
should have been planned to discern and measure known
environmental hazards of a continuing nature as well as those
resulting from isolated incidents. Such activities should be
continuously carried out at both Federal and State levels.
955
66
t. By 1990, a central clearinghouse for observations of
agent/disease relationships and host susceptibility factors
should be fully operational, as well as a Nafienall environmental
data registry to collect and catalogue information on
concentrations of hazardous agents in air, food and water.
4. Principal Assumptions
s ControI and prevention measures will continue to be developed
within a framework reflecting Federal regulatory efforts developed
during the 1970s.
~ Consumers and workers will have ready access to central
information sources (like Poison Control Centers) describing major
substances or products known to be toxic, their known
interactions with life style behaviors such as smoking and
medications, insofar as these are known, and recommended actions
to be taken.
The capability to trace the generation, transport, disposal and
ultimate fate of various agents through the various environments
relevant to public health will continue to be enhanced.
s Permissible exposure levels and individual harmful levels will
reflect real-world multiple exposures, the history of previous
exposure, individual susceptibilities and the effects of aging, and
will accommodate qualitative and quantitative differences in the
health consequences of toxic substances exposures in the prenatal
and perinatal periods.
s A substance-by-substance regulatory approach alone will not be
able to solve a large proportion of public health problems traceable
to toxic agents.
s In designing a regulatory strategy, potential health problems
arising from technology wiii be anticipated.
Schaols for the health professions and continuing educatian-
programs will have evaluated their curricula so that by 1990 health
professionals will be receiving training in toxicology and in the
health consequences of environmental exposure to toxic agents.
An integrated health education curriculum in most public school
systems will include information on toxic substances, their
relationship to the environment and the studenfs' role in protecting
their health.
*Contrei technology will have been developed for dealing with the
major known texic agents.
67 TININ 364956
*Programs wil3l be operating to replace pesticides that show high
acute toxicity and/or carcinogenic or teratogenic effects by safer
substances or approaches (such as integrated pest management).
They will be targeted in each year to the 10 percent most
hazardous materials in use.
s'I'ransportation of toxic and radioactive materials wili be fully
regulated.
. State systems of mobile source monitoring for both diesel and
conventionally power vehicles will be fully operational.
s The National water quality goals for 1984 of fishable and swimable
water will have been met and maintained.
s Performance standards in hospital and ambulatory/patient care
situations involving exposure to toxic agents will be operational.
#Suffioient penalties will be attached to toxic agent pollution to
provide strong econoruc
s Ind.ustrial investment for reducing exposure to toxic agents will
receive favorable tax treatment.
s A strict liability system for industrial waste disposal will be
operational.
. By 1985, a plan will have been developed to protect humans from
the consequences of toxic agents in existing sites of toxic solid
waste disposal. (Approximately 30,000 solid waste disposal sites
may be involved. Proposed "Superfund" willl be used to clean up
the. worst sites. )
5. Data Sources
a.
To National level only
Nationwide Evaluation of X-ray Trends (NEXT ). . X-ray
examination dosemetry, distribution of exposure levels by type
of examination, type of facility and type of equipment.
DHHS-Food and Drug Administration (FDA). Periodic reports.
Continuing reporting from participating State radiation control
programs.
~r Breast Exposure: Nationwide Trends (BENT). Mammography
dosemetry, distribution of radiation exposure levels of x-ray
equipment used in mammography. DHHS-FDA. Periodic
reports. Continuous reporting from participating State
radiation control programs.
68
TIMN 3649-57
s Dental Exposure Normalization Technique (DENT ). Data on
dental x-ray exposure, distribution of radiation exposure
levels of dental x-ray equipment used in dental facilities.
DHHS-FDA. Periodic and annual reports. Continuous
reporting from participating State radiation control programs.
. Birth Defects Monitoring Program. Birth defects diagnosed at
birth, by major types. DHHS-CDC. CDC quarterly report,
Congenital Malformations Surveillance Report. Continuing
hospitall discharge abstracts from
hospital members of the Professional Activities study (PAS) ,
Commission on Professional Hospital Activities. (Not a random
sample of hospitals}.
sNational Occupational Hazard Survey. Inventory of work
hazards. DHHS-CDC, National Institute for Occupational
Safety and Health (NIOSH). National Occupational Hazard
Survey Reports, Vol 1-4, 1974-1.979. Survey wil.l be updated
1980-82. Data obtained from on-site inspections of 800
industrial facilities, 1972-79.
# Health and Nutrition Examination Survey (HANES). Levels of
various toxic agents in blood obtained from laboratory tests.
DHHS, NCHS. HANES II, 1979. Reports will appear in NCHS
Vital and Health Statistics, Series 10.
Toxic Effects. Listing of che
N
OSH
effects have been reported. DHtiS-CDC, NIOSH.
Reports of Toxic Effects of Chemical Substances.
Annual
reports derived from findings reported in journall literature.
b. To State and/or local level
Early and Periodic Diagnosis and Treatment (EPSDT) reporting
system. Lead poisoning detected among children screened,
and referral. DHHS-Health Care Financing Administration
(HCFA), Office of Research, Demonstrations and Statistics
(ORDS ). Medicaid Statistics, selected reports. Continuous
reporting from State Medicaid offices.
Lead based paint poisoning prevention. Number children
screened for lead toxicity, number positive, number brought
under envircnmenta3l and medical management in participating
areas. DCD Laboratory Quarterly Report, Surveillance of
Childhood Lead Poisoning, United States. DHiIS-GDC.
Quarterly report. Continuous reporting from states.
*Survezllance, Epidemiology and End Result Program (SEER).
Cancer incidence, morbidity and survival. DHHS-National
Institutes of Heaith, National Cancer Institute. Periodic
reports from cancer registries, selected geographic areas.
69
TIAIN 364958
~ National Aerometric Bank (NADB ). Measurements on the five
pollutants for which National Ambient Air Quality standards
have been set. Environmental Protection Agency (EPA).
National Air Quality, Monitoring and Emissions Trends De ort,
1977, and continuing reports. Research Triangle Park, N.C.
Continuing reporting, quarterly, from 3,400 pollution control
agencies.
MN 364959
70
OCCUPATIONAL SAFETY AND HEALTH
1. Nature and Extent of the Problem
Occupational ilinesses and injuries are of human origin, and thus
preventable. With approximately 100 million workers in this country,
occupational hazards can pose a serious threat to heaith. Work
conditions can yield daily exposure to such risks as : toxic
chemicals, asbestos, ccsa7l dust, cotton fiber, ionizing radiation,
physical hazards, excessive noise, as well as stress and routinized
trivial tasks. A broad range of health problems may be associated
with such exposures, including cancers, lung and heart diseases,
birth defects, sensory deficits, injuries and psychological problems.
Steps important to protecting the health of workers include not only
education of workers about potential hazards, but engineering
modifications to control hazards, regulatory efforts to promote
worker safety, and additional research to identify the full range of
occupational safety and health problems.
It must be recagnizedd that there are limitations to the ability of
regulatory agencies to contribute to the achievement of these
objectives. The Occupational Safety and Health Administration and
the Mine Safety and Health Administration are responsible for setting
and enforcing standards to control work place hazards, but the
enabling legislation for both of these agencies holds employers
responsible for a healthful and safe work environment. Meeting
these objectives will require a concerted National effort involving a
commitment from not only regulatory agencies, but also employers
and employee organizations.
a.
Health implications
a Occupational illness
-- occupational exposure to toxic chemicals and physical
hazards such as dust from asbestos, silica, grain and
cotton; fumes from chemicaIs-, noise; ionizing radiation;
sunlight and vibration can produce conditions such as lung
disease, cancers, sensory loss, skin disorders,
degenerative diseases in a number of vital organ systerms,
birth defects or genetic changes. These toxic effects may
be acute or chronic;
occupational exposures to some agents can also increase the
frequency of stillbirths, spontaneous abortions, reduced
fertility and sterility;
71
TIMN 364960
brought on by jcb-roIated diseases, the National
for Occupational Safety and Health (NIOSH) estimates that
each year 100,000 Americans die from occupational illnesses;
nearly 400,000 new cases of occupational diseases are
recognized annually; although these estimates made
NIOSH for the May 1972 Presidentts Report on Occupational
Safety and Health are controversial, no better estimates are
available from the presently inadequate reporting of
occupationai disease;
-- skin diseases are the largest group of occupational illness
(43 percent in 1976), followed by repeated trauma (14
percent );
-- about 15 percent of coal miners exhibit some chest x-ray
evidence of coal workers' pneumoconiosis and black lung
disease may be responsible for 4,000 deaths each year;
-- recent studies suggest that occupations associated with
handling wood and wood products have increased risk of
certain cancers;
an estimated 1.6 million present and former asbestos
workers have increased risk of death from asbestos-related
diseases such as lung cancer, mesothelioma and asbestosis;
the lung cancer rate among coke oven workers is about 10
times the National average;
an estimated 2 million workers have been exposed to
benzene and 2 to 3 million to vinyl chloride, chemicals
thought to cause cancer;
job-related stress, ergonomic issues, and poor job designn
also contribute to illness and injury (in both service and
manufacturing sectors) to an undetermined degree.
See Misuse of Alcohol and Drugs and Control of Stress and
Violent Behavior.
Occupational injury
-- in 1978, work accidents resulted in 4,590 deaths;
-- in 1977, more than 2.3 million workers experienced disabling
injuries (80,000 of which were permanently disabling);
72
-- the injuries span a wide spectrum including: electrical
shocks, falls, crushes, motor vehicle accidents, burns and
eye injuries;
-- workers in mining 3 agriculture (including forestry and
fishing) and construction are six, three and three times,
re§pectiveiy, more likely to die from a work-related injury
than other private sector workers;
-- slips and falls are often due to lack of good housekeep
at the job site ;
poor architectural design such as incorrect placing of
stairs, wrong height of stair lifts, improper lighting and
ventilation, and improper engineering of equipment can
contribute to or cause illness and injuries.
b. Status and trends
a Occupational illness
toxic effects have been reported for nearly 45,000 to 50,000
chemicals which are thought to appear in the
workplace--over 2,000 of which are suspected human
carcinogens in laboratory animals;
one survey has indicated - that 9 out of 10 Am
industrial workers may not be adequately protected from
exposure to at least 1 of the 163 most common hazardous
industrial chemicals;
approximately 21 million American workers are exposed to
substances regulated by the Occupational Safety and Health
Administraticn.
9 Occupational injury
direct and indirect costs of occupational accidents are
estimated at $20.7 billion per year;
each year about one worker in nine in private industry
experiences an occupational injury;
-- in 1978, there were, on average, 9.2 injuries and illnesses
and 62.1 lost workdays per 100 full-time workers;
Worker's Compensation payments
.
up 14 percent from 1975 and were three times the level of
1966;
73
-- between 1976 and 1977, the number of work-related injuries
increased from 5.0 million to 5.3 million, the number of
workdays lost increased from 32.5 million to 35.2 million,
the average days lost per injury decreased from 17 days to
16 days, and the number of fatalities increased for
companies with 11 or more employees from 3,940 to 4,760;
these data show aggregate trends, however, they do not
reflect the relative severity of different injuries.
2. Prevention/ Promotion Measures
a. Potential measures
s Education and information measures include:
reviewing, recommending, initiating and publicizing
ocoupationall health and safety standards, procedures,
controls, and practices necessary for assessing, monitoring,
controlling, and eliminating on-the jab health and safety
hazards, including environmental health requirements s
initiating, as a management responsibility
workers and their representatives, experin ental
and
innovative educational programs regarding exposures to and
control of occupational health and safety hazards;
initiating and expanding methods designed to motivate labor
and management responsibility for the development and
maintenance of a safe and healthful work and community
environment ;
developing awareness of the potential interactions between
occupational health hazards and lifestyle habits and
behavior and their effects on heaith ;
developing worker awareness through labeling, electronic
and print media, vocational training programs, health care
providers, campaigns aimed at high-risk worker groups
( e. g., asbestos workers, newly employed and elderly
workers) and organized labor programs;
developing professional occupational health and safety
personnel including occupational health physicians and
nurses, industrial hygienists, toxicologists and
epidemiologists and including occupational health education
in the curricula of medical and nursing schools and
continuing education;
74
developing awareness inn other groups that either interact
with workers or the workplace, including engineers,
managers, teachers, social workers and health ca.re
workers;
developing public awareness of occupational disease and
injuries and their high cost to the Nation;
labeling in simple language to inform workers, employers,
health professionals and the public of the hazards, the
associated risks and symptoms as appropriate;
-- including occupational health as part of the comprehensive
health education curricula in high schools and vocational
s choois.
s Service measures
clude:
well-designed corporate occupational health programs that
include preventive and treatment services directed at
nonoccupational as well as occupational health;
consultation services of Governmental agencies to assist
businesses to identify problems and to establish suitable
programs to eliminate or control thesn ;
encouraging small businesses to form cooperative groups to
seek occupational health expertise;
developing a personal health service delivery system in
which the diagnosis and treatment of occupational illnesses
and injuries will be coordinated and integrated with all
other health services provided the worker and his family;
upgrading capabilities of State and local health departments
to participate in occupational health and safety services,
including monitoring, surveillance and consultation to , small
businesses.
Technologic measures inciude:
mproved architecturail and
o prevent injuries;
worksite
-- control technology to protect workers, including
development of safe substitutes for toxic substances, design
of process units that eliminate worker exposure, design of
safe maintenance procedures and design of jobs to eliminate
harmful physical and mental stress;
75
TYMN 364964
-- measurement technology to enable quick, accurate and
economical assessment of hazard levels in the workplace by
workers, employers or health professionals.
s Legislative and regulatory measures include:
fully implementing the C3SHAIMSHA and other laws related
to workers} health as well as the product control provision
of the Toxic Substances Control Act and the Consumer
Product Safety Act;
recommending, initiating and evaluatin
ed
to improve and expand occupational health and safety
legislation, paying particular attention to possibilities of
standardizing benefits through a national system of work
compensation;
-- developing criteria documents
(NIOSH);
recommending
s
-- promulgating new health standards on hazardous substances
(flSHA);
annual inspections by industrial hygienist compliance
officers;
conducting mandated andustrywide studies and Health
Hazard Evaluations for carcinagenicity, , reproductive
effects, and other hazards that could lead to Emergency
Temporary Standards;
changing Warker's Compensation Laws to provide stronger
economic pressures on employers to reduce hazardous
conditions at the worksite.
s Econo
include:
Mies and negative publicity for poorly controlled health and
safety conditions;
tax deductions and other economic incentives for capital
investment in control technology or occupational health
programs.
b. Relative strength nf- the measures
sGiven the broad nature and scope of occupational safety and
health problems, the relative strength of the measures varies
with the problem at hand, with the nature and adequacy of
enforcement effort and social and political support and with
76 ['IMN 364965
research capacity. Most occupational health problems require
the simultaneous or consecutive application of several types of
measures as a total strategy to comprehensive hazard
eradication. For example, eradication of the asbestos hazardd
might be achieved by:
banning all nonessential uses of asbestos;
substitution of other effective materials found to be
nonhazardous;
research to determine physiologic effects of human exposure
to the asbestos fiber;
worker information to minimize exposure that may still occur
during demoiition and repair work;
rigid enforcement of asbestos standards while use remains
necessary;
professional education for physicians to assure proper
medical help for exposed individuals.
: This type of eradication program focuses public attentio:
the problem and goes beyond establishing a standard
permissible exposure levels.
3. Specific Objectives for 1990
Improved health status
a. By 1990, workplace accident deaths for firms or employers with
11 or more employees should be reduced to less than 3,750 per
year. (In 1978, there were 4,170 work-related fatalities for
firms or employers with 11 or more employees. )
b. By 1990, the rate of work-related disabling injuries should be
reduced to 8.3 cases per 100 full time workers. (In 1978,
there were approximately 9.2 cases per 100 workers. )
c. By 1990, Ilost workdays due to injuries should be reduced to 55
per 100 workers annually. (In 1978, approximately 62.1 days
per 100 workers were Iost. )
d. By 1990, the incidence of compensable occupational dermatitis
should be reduced to about 60,000 cases. (In 1976, there were
approximately 70,000 cases involving cornpensation. )
77
TIMN 364966
e. By 1990, among workers newly exposed after 1985, there should
be virtually no new cases of f4ur preventable occupational
diseases--asbestosis, byssinosis, silicosis and coal worker's
pneumoconiosis. (In 1979; there were an estimated 5,000 cases
of asbestosis; in 1977, an estimated 84,000 cases of byssinosis
were expected in active workers; in 1979, an estimated 60,000
cases of silicosis were expected among active workers in mining,
foundries, stone, clay and glass products and abrasive
blasting; in 1974, there were an estimated 19,400 cases of coal
workers pneumocQniosis. )
f. By 1990, the prevalence of occupational noise-induced hearing
loss should be reduced to 415,000 cases. (In 1975, there were
an estimated 462,000 cases of work-related hearing lass. )
9-
By 1990, occupational heavy metal poisoning (lead, arsenic,
zinc) should be virtually eliminated. (Baseline data
unavailable. )
s Reduced risk factors
h. By 1985, 50 percent of all firms with more than 500 employees
should have an approved plan of hazard control for all new
processes, new equipment and new installations. (Baseline data
unavailable. )
i. By 1990, aall firms with more than 500 employees should have an
approved plan of hazard control for all new processes, new
equipment and new installations. (Baseline data unavailable. )
& Improved pubiic/ professional awareness
j. By 1990, at least 25 percent of workers should be able, prior
to employmelit, to state the nature of their occupational health
and safety risks and their potential consequences, prior to
employment, as well as be informed of changes in these risks
while employed. (In 1979, an estimated 5 percent of workers
were fully informed. )
k. By 1985, workers should be routinely informed of lifestyle
behaviors and health factors that interact with factors in the
work environment to increase risks of occupational illness and
injuries. (Baseline data unavailable.)
all workers should receive routine notification in a
timely manner of all health examinations or personal exposure
measurements taken on work environments directly related to
them. (Baseline data unavailable.)
78 rMN 364967
m. By 1990, all managers of industrial firms should be fully
informed about the importance of and methods for controlling
human exposure to the important toxic agents in their work
environments. (Baseline data unavailable. ) .
n. By 1990, at least 70 percent of primary health care providers
shculdd routinely elicit occupational health exposures as part of
patient history, and should know how to interpret the
information to patients in an understandable manner. (Baseline
data unavailable. )
o. By 1990, at least 70 percent of all graduate engineers should be
ski}.ied in the design of plants and processes that incorporate
occupational safety and health control technologies. (Baseline
data unavaiiabie. )
Improved services/pratection
p. By 1990, generic standards and other f4rms of technology
transfer should be established, where possible, for standardized
employer attention to such major common problems as: chronic
lung hazards, neurological hazards, carcinogenic hazards,
mutagenic hazards, teratogenic hazards and medical monitoring
requirements.
q. By 1990, the number of health hazard evaluations being
performed annually should increase tenfold; the number of
industrywide studies being performed annually should increase
threefold. (In 1979, NIOSH performed approximately 150 health
hazard evaluations; 50 industrywide studies were perfcrmed. )
s Improved surveillance/evaluation
1985, an ongoing occupational health hazard/illness/injury
coding system, survey and surveillance capability should be
developed, including identification of work-place hazards and
related health effects, including cancer, coronary heart disease
and reproductive effects. This system should include adequate
measurements of the severity of work-related disabling injuries.
s. By 1985, at least one question about lifetime work history and
known exposures to hazardous substances should be added to
all appropriate existing health data reporting systems, e,
g.,
cancer registries, hospital discharge abstracts and death
certificates.
t. By 1985, a program should be developed to: 1) follow up
individual findings from health hazard and health evaluations,
reports from unions and management and other existing
surveillance sources of clinical and epidemiological data; and 2)
79
TIMN 364968
use the findings #o determine the etiology, natural history and
mechanisms of suspected occupational disease and injury.
Prin cipal As s umptions
s Gontrol technology will have been developed in the public and
to reduce many major workplace hazards.
A regulation program will have been developed for pre-evaluation
and approval of hazard control plans for all new processes, new
equipment and new installations.
Greater use will be made of relevant State and local Government
agencies, as well as those academic units which can address
occupational safety and health problems.
Comprehensive school health education curricula will incorporate
concepts of occupational ilIness. and injury including the role of
lifestyle and personal habits (such as smoking and alcohol
consumption) and the level of hazard for the individual with
occupational exposures (e.g., asbestos and smoking, vinyl chloride
and excessive drinking).
Growi,ng awareness of the importance of preventing occupational
disease and injuries will facilitate legislative incentive to support
the recommendations.
~ Coordinated State and local implementation systems for recognition
and prevention of occupational health and safety hazards will have
been developed.
aQuality control in the delivery of occupational health and safety
services will be improved.
s Workers in the public sector wiill be extended the same protection
as those in the private sector.
Data Sources
a. To National level only
National Occupational Hazard Survey. Inventory of work
hazards. DHHS-Center for Disease Control (CI?C), National
Institute for Occupational Safety and Health (NIC3SH ). CDC
National Occupational Hazard Survey Reports, Vol 1-4,
1974-1979. Survey to be updated 1980-1982. Data obtained
from on-site inspections of 800 industrial facilities 1972-79.
80 VMN 364969
Health hazard evaluation and industrywide studies. Morbidity,
mortality and environmental studies. DHRS-CDC, NIOSH.
Selected NIOSH Technical Reports. Continuous reporting.
sOccupational injury and illness. Job related injury and illness
rates. Bureau of Labor Statistics. Annual reports, Chartbook
on Occupational Injuries and Illnesses (summary tables).
Continuous reporting; National sample.
s Surveillance, Epidemiology and End Result Program (SEER).
Cancer incidence, morbidity and survival. DHHS-National
Institutes of Health, National Cancer Institute. Periodic
reports. Continuous reporting from State and regiona]l cancer
registries.
~ Mine injuries. Injuries per hours worked. Department of
Labor-Mine Safety and Health Administration. Quarterly
reports. Mine Injuries and Work Time. Continuing reporting
from workplace.
b. To State and/or local level
s State Worker#s Compensation Systems. Occupational illness and
injuries. Data collected by official State agencies. Sometimes
analyzed in form to permit incidence estimates.
81
TIMN 364970
ACCIDENT PREVENTION AND INJURY CONTROL
Nature and Extent of the Problem
The principal causes of disability and death from injury are those
associated with motor vehicles, falls, drownings, burns, poisoning
and gunshot wounds. Most such deaths and injuries occur while
driving, in the home or at work; many are also associated with
recreation and sports. See Pregnancy and Infant Health, Toxic
Agent Control, Occupational Safety and Health, Smoking and Health,
Misuse of Alcohol and Drugs.
Health implications
. Unintentional injuries are the leading cause of death for people
between I and 38 years of age, and a leading cause of
disabiiity.
.
population. For example,
accidental death rate was 3.1
races.
s According to
population is
year.
# 10,700 children under 15 years of age died from accidental
injuries in 1978:
-- for children between 5 and 15, motor vehicle fatalities
accounted for 52 percent of all accidental deaths;
-- the overall death rates from accidents for children under 15
fell from 26.6 per 100,000 in 1968 to 21.1 per 1tf0,0(1(0 in
1978, a decrease of 20.7 percent.
-- the most common fatal accidents to children at home were
from fires (36 percent ) and suffocation (25 percent).
b. Status and trends
sMotor vehicle accidents account for the largest number of
trauma deaths and injuries:
-- there were approximately 52,400 deaths from motor vehicle
accidents in 1978, a rate of 24.0 per 100,000 population,
which represents an increase from the low of 21.5 deaths
per 100,000 in 1975;
83
t
death rates than the overall
1973-75 the American Indian
es the U.S. death rate for all
4naa Health Survey, 30 percent of the
TIMN 364971
-- of these motor vehicle accident deaths, over 9,000 were
pedestrians, a 2 percent increase from 1977;
-- there were approximately 2 million disabling
motor vehicle accidents in 1978;
-- the motor vehicle fatality rate for children under 15
decreased from 10.4 per 100,000 children in 1968 to 9.1 per
100,000 in 1978, a decrease of 12.5 percent;
-- for 15 to 24 year olds, the motor vehicle fatality rate has
clim bed from 39.2 per 100,000 in 1975 to 46.1 in 1978;
__ at least 45 percent of all fatall motor vehicle accidents are
alcohol related; in single vehicle accidents, 65 percent of
drivers are legally drunk (i.e. blood alcohol concentrations
of over .10 percent).
9 Falls
there were 13,690 deaths from falls in 1978 and over 11
million injuries;
the mortality rate from falls was 6.3 per~ 100,000 in 1978,
and has been declining in recent years;
-- over fifty percent of fatal falls occur
-- fifty-seven percent of fatal falls involve persons 75 or
older;
-- older people who survive falls are more apt to experience
fractures than are younger people;
-- impairment by alcohol is a major contributor to falls.
s Drownings
-- in 1978, there were 6,900 deaths from drownings, a number
which has remained fairly constant over the past 15 years
despite increasing participation in water-related activities;
-- approximately 1 in 6 drownings (over 1,000) involve boating
mishaps;
-- a substantial proportion of drownings occur in unattended
bodies of water.
84
TIMN 364972
. Burns
-- there were 6,300 deaths from fires and burn injuries in
1978, a rate of 2.9 per 100,000 persons;
-- there are an estimated 60,000 hospital admissions for burn
injuries per year, with the average length of hospital stay
being 15 days ;
-- age specific rates
the elderly;
-- most fire deaths
one-third of fatal
burn injuries, are
for burn deaths are high in children and
are caused by residential fires 3 about
house fires, and a substantial number of
related to cigarette smoking;
-- the largest number of burn injuries requiring hospitalization
are caused by scalds;
-- both alcohol and smoking are significant factors in
fire-related deaths.
Gunshot wounds are second only to motor vehicle crashes in
causing death from traumatic injury:
-- in 1977, there were 31,000 deaths from gunshot wounds;
-- approximately 2,000 of these were accidental; 12,900 were
homicides; 16,000 were suicides;
-- in 1978, the death rate for non-whites from gunshot wounds
(including accidents, suicides and homicides) was 21.3 per
100,000 population; compared to a rate of 3.6 per 100,000
for whites. For black males 15 to 24, gunshot wounds are
the leading cause of death.
-- Firearm deaths are strongly associated with alcohol misuse.
s Poisonings
-- an estimated 400,000 children under age 5 are accidentally
poisoned each year, one-fourth of whom will be retreated
for poisoning.
85 TIMN 364973
2. I'revention/ Promotion Measures
a.
Education and information measures include:
integrating safety education into the kindergarten through
12th grade school curriculum, with special attention to
highway safety (and misuse of alcohol), poisoning, water
safety and burns;
educating parents and health professionals about the
importance of crash-tested child restraints and seat belts
and their proper use in motor vehicles;
educating parents and child caretakers about general safety
for children, including pre-school traffic safety;
water safety and swimming education programs;
educating the elderly
reduce risks of falls;
educating architects, building contractors and related
professionals, including health professionals, on fire safety;
safety education and first-aid training for health
professionals and the public;
educating the public on safe handling of firearms as part of
general accident prevention programs;
educating the general public, legislators and other
decisionmakers on the extent of the firearm injury problem;
self-protection training programs for shopkeepers, taxi
drivers and others working in jobs at high risk of armed
robbery.
-- See Misuse of Alcohol and Drugs.
. Technologic measures include:
-- improved automobile crashworthiness;
-- improved highway design facilitating prevention of
automobile crashes;
ators on highways;
86
TIMN 364974
-- bikepath development ;
-- improved design criteria for homes to prevent injury from
f G11ss
design of s
increased use of flame retardant materials for clothes and
furnishings ;
introduction of self-extinguishing matches and cigarettes
into generall use;
provem6nt of trigger safety lock designs;
use of non-lethal (wax) bullets for target guns;
improved safety design of toys, gymnasium equipment,
other play equipment for schools and playgrounds;
continued safety packaging of medications to prevent
poisoning;
efficient emergency medical services.
res include :
mandatory automatic restraint systems in cars;
mandatory infant and child carrier use in cars;
standards for crashworthiness and crash avoidance;
motorcycle helmet laws;
improved enfarcement of laws related to speeding, driving
while under the influence and seat belt use;
strengthened building and housing codes;
floor-covering standards to protect against falls;
standards for personal flotation devices;
safety standards for public swimming pools;
mandatory use of smoke-detectors;
87
TIMN 364975
ndatory non-scald settings for hot
-- uniform laws to license and control the purchase and
possession of handguns.
asures include:
-- reduced insurance premium rates fer_drivers who do not
drink or are otherwise at very low risk;
__ reduced insurance rates on home insurance for special
protective measures against falls or fires;
-- reduced insurance rates for recreational facilities such as
chiidren~s camps and parks, which have implemented
effective safety measures.
Relative strength of the measures
Safety education is a time-honored and widely used prevention
measure in injury control. The National Safety Council, the
American Red Cross, and a large number of accident
prevention projects at all levels of Government depend on
education as the mainstay of their programs. Although there
is widespread support for all kinds of educational efforts in
this field, evaluation of educational programs which use rates
of morbidity and mortality as outcome measures have not
demonstrated significant effects in reducing injury rates.
However, a majority of safety professionals express strong
confidence in training and education as a powerful tool for
building skills, increasing awareness and creating a climate for
change.
Technologic strategies have accounted for signifieant
reductions in morbidity and mortality from injury and
poisoning. Motor vehicle design changes to improve occupant
protection have been demonstrated to reduce the probability of
death or serious injury in the event of a collision. Industry
has achieved remarkable reductions in injury rates through
in prcvements in machinery design. Childproof containers for
medications have dramatically reduced accidental poisoning.
The effectiveness of technologic strategies depends on both the
relationship of the design to injury causation and the rate of
adoption of the change.
Regulatory measures such as building eedes, fire codes and
safety standards for materials and machinery are widely
accepted as effective countermeasures. Regulatory measures
have variable effectiveness depending on compliance rates,
enforcement and the relationship of the measure itself to injury
causation.
88 11MN 364916
~'i'he effectiveness of economic incentives for the prevention of
injury is only beginning to be explored outside the industrial
setting. It has been suggested that low insurance rates for
drivers who have not been involved in crashes or who have no
violations on their record may provide incentives for more
careful driving, but the strategy has not been evaluated.
Product liability suits have created incentives for
manufacturers to design and market safer products and to
recall defective ones. Adjustment of insurance premiums for
summer camps has been used to provide incentives for hazard
removal and has been associated with reductions in injury
rates.
Specific Objectives for 1990
Improved health status
a. By 1.q~O, the motor vehicle fatality rate should be reduced to no
greater than 18 per 100,000 population. (In 1978, it was 24.0
per 100,000 popu3.ation. )
b. By 1990, the motor vehicle fatality rate for children under 15
should be reduced to no greater than 5.5 per 100,000 children.
(In 1978, it was 9.2 per 100,000 children under 15.)
c. By 1990, the home accident fatality rate for children under 15
should be no greater than 5.0 per 100,000 children. (In 1978,
it was 6.1 per 100,000 children under 15.)
d. By 1990, the mortality rate from falls should be reduced to no
more than 2 per 100,000 persons. (In 1978, it was 6.3 per
100,000.)
e. By 1990, the mortality rate from drowning should be reduced to
no more than 3.0 per 100,000 persons. (In 1978, it was 3.2
per 10{l, (100. )
9-
h.
By 1990, the number of tap water scald injuries requiring
hospital care should be reduced to no more than 2,000 per
year. (In 1978, it was 4,0'(30 per year.)
By 1990, residential fire deaths should be reduced to no more,
than 4,500 per year. (In 1978, it was 5,400 per year.)
By 1990, the number of accidental fatalities from firearms
should be held to no more than 1,700. (In 1978, there were
1,$QQ.)
89 TIMN 364977
See Misuse of Alcohol and Drugs.
s Reduced risk factors
By 1990, the proportion of automobiles containing automatic
restraint protection should be greater than 75 percent. (In
1979, the proportion was 11 percent. )
By 1990, all birthing centers physicians and hospitals should
ensure that at least 50 percent of newborns return home in a
certified child passenger carrier. (Baseline data unavailable).
k. By 1990, at least 110 million funct
smoke alarm systems
should be installed in residential units. (In 1979, there were
approximately 30 million systems. )
Increased public/professional awareness
1. By 1930, the proportion
who can identify appropriate measures to address the three
major risks for serious injury to their children (i.e., motor
vehicle accidents, burns, poisonings) should be greater than 80
percent. (Baseline data unavailable. )
m. By 1990, virtually all primary health care providers should
advise patients about the importance of safety belts and should
include instruction about use of child restraints to prevent
injuries from motor vehicle accidents as part of their routine
interaction with parents. (In 1979, the proportion of
pediatricians who reported that they advised on car safety
measures was approximately 20 percent. )
s Improved services/protection
n. By 1990, at least 75 percent of communities with a
over 10,000 should have the capability for ambulane
and transport within 20 minutes of a call.
approximately 20 percent had this apabiiity. }
o. By 1990, vvirtually aill injured persons
to region
spinal cDr
population lived in areas served by regionalized trauma
centers.)
p. By 1990, at least 90 percent of the population should be living
in areas with access to regionalized or metropolitan area poison
control centers that provide information on the clinical
management of toxic substance exposures in the home or work
environments. (In 1979, about 30 percent of the population
lived in such areas.)
90
TIMN 364978
s Improved surveillancelevaluation systems
q. By 1990, at least 75 percent of the states will have developed a
detailed plan for the uniform reporting of injuries.
4. Principal Assumptions
s Children:
-- improvements will occur in design and use of child restraint
systems;
will occur in use of automatic restraints ;
-- trends in product safety regulation for the protection of
children will continue.
t Motor Vehicies :
-- highway safety and vehicle safety will continue to be improved;
-- thirty-five percent use of safety belts and child restraints;
-- the 55 MPH speed limit will be vigorously enforced;
-- more State laws will be passed to reduce alcohol-re
crashes, and more stringent enforcement of existing laws
occur;
-- See Misuse of Alcohol and Drugs.
s FalIs :
;n will be effected in new and existing dwelling
s, lighting) ;
-- alcohol abuse prevention arad treatment programs will be
increasingly available.
91
` TIMN 364979
-- swimming pool design will improve, including modifications to
access;
-- Iicensingfcertification of boat operators will grow.
. Burns :
-- there
consumpti
a continued decline in per capita cigarette
ements in building codes
occur;
enforcement will
-- self-extinguishing matches and cigarettes will become available.
a
s Gunshot wounds
-- there wiil be an increase in State laws concerning licensing of
purchase and possession of handguns;
-- fewer people will purchase handguns;
-- improvements in design and increase in use of gun safety
devices.
5. Data Sources
a National Electronic Injury Surveillance System (NEISS).
Traumatic consumer product related injuries. Consumer
Product Safety Commission (CPSC). NEISS Data Highlights
and News from CPSC, selected reports. Continuous daily
injury reporting and detailed accident investigations of selected
high priority cases, National sample of 74 hospital emergency
rooms. Reporting initiated in 1972, revised in 1978.
Occupational injury and illness. Job related injury and illness
rates. Department of Labor, Bureau of Labor Statistics.
Compiled from continuous monthly and selected reports, from
Chartbook on Occupational Injuries and Illnesses tables.
Fatal Accident Reporting System (FARS). Describes detail of
fatal highway accidents. Department of Transportation (I}QT) ,
ighway Traffic Safety Administration. Fatal Accident
Reporting System Annual Report. Continuous reporting.
92 TMN 364980
e Health Interview Survey (HIS
members of households experie
Sickness an
the interviev+r. DHHS-National Center
two wee
Health
(NCHS). NCHS Vital and Health Statistics,
Continuous household interview survey; Nationa.i s
ng
prior to
Statistics
s 10.
: Boating accidents. Compilation of boating accident and
registration statistics. DOT-H. S. Coast Guard. Boating
Statistics (COMDTINST M1S754.1, Old GG-357). Fulll count
and selected activities reperted, annually from recreational boat
numbering and casualty reporting systems.
sSurveillanee and studies of accidents. Causes and prevention
of vehicular aceidents Tother studies. Accident Analysis and
Prevention - An International Journal. Pergamon Press, Ltd.
Continuous quarterly reports.
Surveiiiance and studies of accidents. Selected study reports,
various topics. Metropolitan Life Insurance Company.
Statistical Bulletin. Survey and full count data. Continuous
quarterly publication.
s Hospital Discharge Survey (HDS). Trauma, burn
discharged from short stay hospitals. DHHS-NGHS.
Vital and Health Statistics, Series 13, selected
Continuous; National probability sample.
b. To State and/or local level
# National Vital Registration System
-- Mortality. Deaths by cause (in
sex and race. DHHS-NCHS. NCHS Vital Statistics of the
United States, Vol II, and NCHS Monthly Vital Statistics
Reports. Continuing reporting from States; National, full
count. (Many States issue earlier reports. )
~ Accident reports. Numbers and rates of accidents by type.
National Safety Council. Accident Facts, an annual report of
surveys, full count data, and extrapolations of data, including
selected summary reports; and Journal of Safety Research,
selected accident study reports, published quarterly. Data
from State, . Federai, local governments and private industry
and organizations.
Motor vehicle accidents
-- Reports from State Motor Vehicle departments.
93 TLMN 364981
-- Epicieaiologic survey data on traffic accidents and
conditions. When, where and how traffic accidents occur.
State traffic authorities and DOT-Federal Highway
Administration. Selected reports and annual summaries.
s State burn registries, where established.
Hospitalized ilIness discharge abstract systems.
-- Professional Activities Study (PAS). Patients in short stay
hospitals; patient characteristics, diagnoses of trauma and
burns, procedures performed, length of stays. Commission
on Professional and Hospital Activities, Ann Arbor,
Michigan. Annual reports and tapes. Continuous reporting
from 1900 CPHA member hospitals; not a probability sample,
extent of hospital participation varies by State.
Medicare Hospital Patient Reporting System (MEDPAR).
Characteristics of Medicare patients, diagnoses, procedures.
DHIiS-Heaith Care Financing Administration, t3ffice of
Research, Demonstration and Statistics (ORDS). Periodic
reports. Continuing reporting from hospital claim data; 20
percent sample.
-- Other hospital discharge systems as locally available.
*Selected health data. DHHS-NCHS. NCHS Statistical Notes
for Health Planners. Compilations and analysis of data to
State level.
~ Area Resource File (AAF). Demographic, health facility and
manpower data at State and county level from various sources.
DIiHS-fiealth Resources Administration. Area resource File:
A Manpower Planning and Research Tool. DHHS-HRA-80-4,
Oct 79. One time compilation.
94
TIMN 364982
FLUORIDATION AND DENTAL HEALTH
1. Nature and Extent of the Problem
Dental diseases probably ounstitu.te, in the aggregate, the most
prevalent health problem in the Nation. The two most prevalent oral
diseases are dentall caries (tooth decay) and periodontal disease
(diseases of the gums and other tissues supporting the teeth ). If
not controlled, each of these diseases progresses to an advanced
stage that is difficult and, therefore, expensive to treat. If left
untreated, or if treatment is delayed too long, dental caries and
periodontal disease result in tooth loss. However, based on current
knowledge, both of these diseases can be prevented in most persons.
Fluoridation--particularly of community water supplies--is the most
effective measure to reduce the incidence of the largest problem,
dental caries, with the capability of preventing 65 percent of denta7l
caries and 50 percent of children!s dental bills. Fluoridation is,
therefore, the major focus f of this section, but other measures
important to dental health are also disoussed.
a. Health Implications
~ Dentall caries is localized, progressive destruction of the tooth
initiated by acid demineralization of the outer tooth surface.
Caries results from a complex interaction among three factors:
tooth susceptibility, bacteria in plaque and dietary
environment,
a Periodontall disease is an insidious inflammatory disease which
affects the gums and the alveolar bone supporting the teeth.
There are several type of periodontal disease. The initial and
most common type is gingivitis or inflammation of the gums. If
untreated, this condition usually develops into periodontitis,
the chronic destructive stage of the disease. In the advanced
stages, the bone supporting the teeth is destroyed, the teeth
loosen and eventually are lost.
a Research findings indicate that certain oral bacteria--associated
with plaque and calculus accumulations on teeth--are the prime
cause of periodontal disease. Several other elements (factors)
that may be associated with the development of the disease
include: poor nutrition, malocclusion, grinding of the teeth,
the loss of teeth which causes those remaining to drift out of
position and hormonal imbalances.
95
rMN 364983
b.
Status and Trends
Dental caries affects 98 percent of the LI.S. population,
creating a dental disease problem of massive proportions.
s By 17 years of age, 94 percent of children have experienced
caries in their permanent teeth. On average, 17 year-olds
have had about nine permanent teeth affected.
s Low income children have
decayed teeth than high income children.
s Forty-seven percent of children under age 12 have never been
to a dentist.
About 31 million adults aged 18 to 74 years have lost all of
their upper or lower natural teeth. This includes about 19
million adults who have lost all their teeth.
. Periodontal disease is the second most prevalent oral disease.
More than 65 million persons have periodontal disease,
including nearly 12 million children and more than 53 million
S.
s The proportion of persons with periodontal disease increases
significantly with age:
-- almost one-third af children aged 12 to 17 years have
gingivitis ;
-- among those persons 65 to 74 years of age with some
natural teeth still present, two-thirds have periodontal
disease, half of whom have the disease in its destructive
stage.
Data from the initial and 1971-74 National Center for Health
Statistics (NCHS) health examination survey suggest
periodontal disease is decreasing in prevalence.
Injuries to the teeth and mouth also constitute a
dental problem.
t'reventi.onJPromotien Measures
Dental disease prevention covers aa spectrum of many activities--the
fluoridation of community and school water supplies, dental health
education, fluoride supplements and rinses, individual improvement
of oral hygiene and dietary practices and routine professional
check-ups. Included in this spectrum are procedures to modify the
behavior patterns of individuals regarding measures such as diet
change, tooth brushing and flossing.
96
TIMN 364984
a. Potential measures
Measures to prevent dental caries may be directed at one of the
three principal contributing factors: tooth suscepiibility,
bacteria in plaque and dietary environment. Reduction of
bacterial agents is accomplished through a proper personal oral
hygiene regimen and regular prophylaxes given by a dental
professional. For a proper dietary environment, highly
cariogenic foods and snacks, particularly those containing
refined sugars, should be avoided but, if such foods are
consumed, the teeth ought to be thoroughly brushed immediately
afterwards. The caries susceptibility of teeth is significantly
reduced through the proper use of fluorides. For persons not
ingesting sufficient fluoride as it occurs naturally in their
drinking water, fluoride measures are needed. The ingestion of
fluorides from birth is most effective and may be accomplished
through either fluoridation of drinking water supplies or the use
of dietary fluoride supplements. Fluoridation of water supplies
is the most practical measure. As a less effective alternative,
topical _ fluarides may be applied either by the individual or a
d enial professional. The benefits and safety of fluorides in
preventing dental caries are well documented as the result of
almost five decades of research and over 30 years of experience.
Although the technology of fluoridation as an effective
prevention measure for dental caries is well established, a
considerable gap persists between knowledge and application.
To implement near universal fluoridation in the United States
requires an array of interacting strategies.
The prevention of periodontal disease requires proper oral
hygeine to minimize plaque deposits on the teeth. Calculus, a
hard crust-like material formed at and below the gum margin by
deposition of calcium and phosphate from saliva in neglected
plaque, must also be removed. As periodontal pockets are
formed, bacteria and food particles may lodge in the pockets
resulting in more inflammation and setting up a vicious cycle in
the disease process. Plaque can be removed by the individual
by thoraugh brushing and flossing of the teeth on a daily basis.
Calculus, however, cannot be removed by simple brushing, but
requires scaling of the teeth regularly by a dentist or dental
hygienist.
Education and information measures include:
-- public educational efforts to promote fluoridation of
community and school water systems as well as other caries
and periodontal disease preventive measures at National,
State and local levels--using electronic and print media,
school health curricula, health organizations and lay
groups ;
97
TIMN 364985
-- informing
and involving key groups and
professionals, community decision makers,
ations, water works associations, and lay
groups and organizations in the prevention of dentall
disease;
-- using
oth fluoridation and improved
preventive periodontal measures;
-- developing local advocacy groups to encourage the adoption
and retention of fluoridation through the appropriate
political process.
Service measures
-- fluori
tetns*:
community water fluoridation: most community water
supplies contain less than optimum concentrations of
naturally-occnrring fluoride and need to be fluoridated.
Among communities of 1,000 or more population, about
8,670 water systems serving about 5,860 communities have
not yet been fluoridated ; approximately 32 percent of the
U.S. population (67 million persons) were served by these
fluoride-deficient water systems in 1975; another 17
percent were not served by community water systems at
all; thus, approximately 51 percent of the population was
served by public water systems providing an adjusted
optimal fluoride level and an additional 8 percent of the
population used naturally fluoridated drinking water at
- optimum or higher fluoride level.
school water fluoridation: elementary and secondary
schools on independent water systems (i. e. , schcrois not
served by community water systems) that are located in
fluoride-deficient areas need to be fluoridated ; school
water fluoridation can reduce the incidence of dental
decay by up to 40 percent # and could serve an additional
2.2 million school children.
*NOTE: Optimum fluoride concentration: For community
water fluoridation, the recommended optimum fluoride
concentration is determined by the mean maximum daily
temperature over a five-year period--in the United
States, the optimum fluoride concentration for community
water fluoridation ranges between 0.7 and 1.2 parts of
fluoride per one million parts of water (ppm); for
separate school water fluoridation, the recommended
fluoride concentration is 4.5 times the optimum fluoride
concentration recommended for community water
fluoridation in the same geographic area.
98
TIMTIN 364986
--School-based caries and periodontal disease Prevent
services; a fulll range
can be made readily
elementary and secondary
in day-care centers, Head S
opriate preventive services
to children enrolled in
s and to younger children
art programs and preprimary
programs, including as appropriate:
- self-applied fluoride measures through dietary fluoride
supplements, usually taken in tablet form, or fluoride
mouthrinses;
- educational and informational measures as a component of
general health education ;
- school andd community activities to limit the accessibility of
highly cariogenic foods and snacks to children;
- school-based educational and hygienic periodontal disease
preventive services.
. Technology measures include:
efforts to ensure that the fluoride concentrations of water
distributed from fluoridated water systems are maintained at
optimum levels at all times (unless the fluoride
concentration is maintained at the optimum level, the
reduction of dental caries is markedly decreased):
continuous operation of fluoridation equipment;
proper and timely monitoring and surveillance of
fluoridated water systeFns ;
training and continuing education for waterworks
personnel and engineers and for school personnel
responsible for operation of school fluoridation equipment;
use of modern technology in fluoridation system
s urv eillance;
- improved
for fluoridation eQuiDment, and
testing and engineering procedures;
- ensuring an adequate supply of needed types of fluoride
compounds.
99
TIMN 364987
a Legislative and regulatory measures include:
-- developing model State laws and regulations for fluoridation
and fluoridation monitoring and surveillance systems;
=- clarifying specific provisions of Federal and State safe
drinking water laws and regulations which potentially delay
the implementation of fluoridation.
s EcOMmic measures
-- financial and technical assistance to support expansion of
community and school water fluoridation;
ion of fluoridation equipment, where appropriate, in
g of new or improved water systems by the U.S.
Department of Housing and Urban Development, the
Economic Development Administration and the Farmers Home
}
reducing premiums for dental insurance for families with
children who live in fluoridated communities;
reducing HMO capitation charges for dental coverage for
families with children who live in fluoridated communities.
s.
s Measures which in combination ensure that children receive the
full benefits of fluoride, infrequently consume highly
earfogen%c foods and follow a proper personal oral hygiene
regimen have a synergistic effect on preventing dental caries
and reducing the need for and cost of ehildren.'s dental care.
These measures do not alter the need for regular visits to the
dentist and the prompt treatment of caries that does develop.
FIuor%datian of community water supplies is estimated to yield
$5£l in savings from reduced treatment for each dollar
invested.
The fluoridation of community water systems is the most
effective, least costly public health measure for preventing
dental caries. Benefits that accrue in children include:
-- teeth that are more resistant to caries;
-- as much as two thirds less caries in children who drink
fluoridated water from birth ;
100 TIMN 364988
-- as many as six times more caries-free teenagers in
ridated communities as in nonfluoridated communities;
-- fewer extractions of primary and permanent teeth;
er and less complex and, therefore, less costly
restorative services (chiidren~s dentall treatment costs in
fluoridated communities can be one half the costs in
nonfluoridated comrnunities) .
sAdults consuming fluoridated water throughouit life can expect
fewer caries-related treatment needs and less loss of teeth due
to caries.
s Substantial, though in most instances, less beneficial results
can be realized from other fluoride measures (the percentage
reductions of these measures are not arithmetically additive):
dietary fluoride supplements in recommended dosages:
- if provided in school programs result in caries reductions
in permanent teeth ranging from 25 to 35 percent after
two or more years of fluoride ingestion.
a weekly fluoride rinse regimen, utilizing a{l.2 percent
neutral sodium fluoride solution, can reduce caries incidence
by about 25 percent;
a
fluoride dentifrice (toothpaste) can reduce caries
20 percent;
lied fluorides cann reduce caries incidence
rcent.
. Regular oral examinations serve to identify caries at an early
stage so that treatment can be prompt and unnecessary further
destruction and potential loss of the teeth prevented.
sBoth fluoridation and school-based programs ensure
children of all socioeconomic levels receive caries preventive
services.
Since the United States began using community fluoridation in
1945, there have always been barriers to attaining goals of
near universal fluoridation, including community inaction,
financial limitations on communities, improper systems
surveillance, and the powerful antifluoridationist lobby. Also,
some fluoridated systems are maintained below the recommended
optimum level.
101 TVqN 364989
sVigoraus promotional efforts to prevent periodontal disease can
also be effective. Particularly important in this regard are
efforts to encourage the public--especially school children--to
practice good oral hygiene on a daily basis and to make
regular visits to the dentist.
~i.fic Obiectives for 1990
Improved
ealth status
a. By 1990, the proportion of nine-year-old children who have
experienced dental caries in their permanent teeth should be
decreased to 60 percent. (In 1971-74, it was 71 percent.)
b. By 1990, the prevalence of gingivitis in children 6 to 17 years
should be decreased to 18 percent. (In 1971-74, the prevalence
was about 23 percent.)
c. By 1990, iin adults the prevalence of gingivitis and destructive
periodontal disease should be decreased to 20 percent and 211
percent, respectively. (In 1971-74, for_adults aged 18 to 74
years, 25 percent had gingivitis and 23 percent had destructive
periodontall disease. )
. Reduced risk factors
d. By 1990, no public elementary or secondary school (and no
medical facility), should offer highly cariogenic foods or snacks
in vending machines or in school breakfast or lunch programs.
e. By 1990, virtually aI3l students in secondary schools and
colleges who participate in organized contact sports should
routinely wear proper mouth guards. (Baseline data
unavaiiabie. )
* Increased pubiic/professionall awareness
f. By 1990, at least 95 percent of school children and their
parents should be able to identify the principal risk factors
related to dentall diseases and be aware of the importance of
fluoridation and other measures in controlling these diseases.
(Baseline data unavailable. )
g. By 1990, at least 75 percent of adults should be aware of the
necessity for both thorough personal oral hygiene and regular
professional care in the prevention and control of periodontal
disease. (In 1972, conly 52 percent knew of the need for
personal oral hygiene and only 28 percent were aware of the
need for dental checkups. )
102 TIMN 364990
a Improved services/protect%on
h. By 1990, aat least 95 percent of the population on community
water systems should be receiving the benefits of optimally
fluoridated water. (In 1975, it was 60 percent.)
By 1990, at least 50 percent of school children living
fluoride-deficient areas that do not have community water
systems shouldd be served by an optimally fluoridated school
water supply. (In 1977, it was about 6 percent.)
By 1990, at least 65 percent of school children should be
proficient in personal oral hygiene practices and should be
receiving other needed preventive dental services in addition to
fluoridation. (Baseline data unavai.iable. )
s Improved surveillance/evaluation systems
k. By 1990, a comprehensive and integrated system should be in
place for periodic determination of the arail hea3.thh status, dental
treatment needs and utilization of dental services (including
reason for and costs of dental visits) of the U.S. population.
By 1985, systems should be in place for determining coverage
of all major dental public health preventive measures and
activities to reduce consumption of highly cariogenic foods.
4. Principal Assumptions
~ Even though community water fluoridation is the most effective
public health measure for preventing dental caries, this measure
alone cannot do the job. Significant progress will not be made in
reducing the national dental caries rate in children and increasing
the proportion of children who are caries free until such time as
all three major approaches to caries prevention--proper personal
oral hygiene, diet low in highly cariogenic foods and fluoride
protection--are followed in combination, as needed, by the majority
of children in this country.
sSupport for fluoridation assistance programs will grow to a Iev
meet the program's major objective--near universal fluoridation.
t]rganized dentistry#s support for dental caries and periodontal
disease prevention measures will increase at the National, State
and local levels.
s State and local health and education agencies, the Health Systems
Agencies, the State Health Planning and Development Agencies and
the Statewide Health Coordinating Councils will increase their
concern for and expand their activities to support fluoridation,
103 TIMN 364991
school-based preven
health promotion.
periudontall
to have the strong endorsement of
major National organization with health competence.
The cost/benefit ratio of community water fluoridation w
to be more favorable than for any other known pu
measure implemented for the preventionn of dental caries.
s The percent of the total I3.S. population on comm
supplies will not change appreciably between 1980
(approximately 82 percent in 1979).
5. Data Sources
and
a. To National level only
. The Health and Nutrition Examination Survey (HANES).
Prevalence of dental caries, periodontal disease,
edentulousness and related information in U. S. population.
DHHS-National Center for Health Statistics (NCHS). NCHS
Vital and Health Statistics, Series 11, selected reports.
Periodic survey, nationa3l sample. Note: dental data collected
in HANES I(I971-74), not in HANES II (1J76-8(I}.
State legislation on fluoridation. New or proposed State
legislation affeoting fluoridation of water supplies.
DHHS-Center for Disease Control (GDC). CDC analysis
compiled from Commerce Clearing House, Inc. information.
Gontinuing.
Effects of fluoridation on dental practice and dentall humann
resource requirements. American Dental Association Bureau of
Economic and Behavioral Research. Periodic reports.
Continuing; national surveys of practicing dentists.
b. To State and/or local level
Fluoridation census. Fluoridation status of community water
supplies, adjusted and natural; population served, dates
fluoridation initiated, other related information. DHHS-CDC.
CDC 1975. To be conducted annually beginning in 1980. Data
to be aggregated at National and State levels.
s National Dental Caries Prevalence Survey. Dental cqries andd
periodontal disease among school children, grades K-12,
related to fluoride content of drinking water for the school and
place of residence of the children in the study.
DHHS-National Institute of Dental Research. Report
104
forthcoming. Survey, 1980. Additional surveys planned at 3
year intervals.
s Early and Periodic Diagnosis and Treatment (EPSDT) reporting
system. Oral health status and referrall of children screened.
DHHS-Heaith Care Financing Administration (HDFA) , Office of
Research, Demonstration and Statistics. Medicaid Statistics,
selected reports. Continuous reporting from State Medicaid
offices.
s Selected health data. DHHS-NCHS. NCHS Statistical Notes
for Health Planners. Compilations and analysis of NCHS data
to State level.
e Area Resource File (ARF). Demographic, health facility and
manpower data at State and county level from various sources.
DHHS-Health Resources Administration. Area Resource File:
A Manpower Planning and Research Tool, DHHS-HE.A-80-4, Oct
79. One time compilation.
105
TLUN 364993
SURVEILLANCE AND CONTROL OF INFECTIOUS DISEASES
1. Nature and Extent of the Problem
Current surveillance and classification systems do not accurately
reflect the importance of infectious diseases on the health and
well-being of the nation. Only one category of infectious diseases
(influenza and pneumonia) is ranked among the top 10 causes of
death according to the National Center for Health Statistics (NCHS).
However, were infectious diseases to be grouped in a manner similar
to the cardiovascular diseases and cancer, 123,000 deaths would have
been attributable to infectious diseases in 1976, surpassed only by
cardiovascular diseases (719,000), cancers (387,000), and stroke
(182, 000). However, even this figure is an underestimate of the
total impact. When it is adjusted for the probable sensitivity of the
surveillance systems used, over 300,000 deaths may be attributable
to infectious diseases each year. Particularly underestimated are the
incidences of the common infectious diseases of the respiratory,
gastro-intestinal and genitourinary tracts.
a. Health implications
s Over 2 million nosQGomi.al infections (acquired in patient-care
institutions) occur each year, and 60,000 to 80,000 persons die
as a direct or indirect result of such infections. An estimated
20 percent of these infections are preventable withh current
control technologies.
s Each year, an estimated 2,400,000 cases of pneumonia occur,
with pneumococcal pneumonia alone affecting 400,000 persons at
a cost of $325 million.
s An annual average of 57,000 deaths attributable to pneumonia
and influenza has been reported over the last 10 years.
In 1977, there were 30,145 reported cases of tuber
2,968 associated deaths.
s Each year, an estimated 1,200,000 cases of salmonellosis occur,
with an estimated direct cost of $774 million.
sAnnuafly, an estimated 200,000 cases of shigellosis Occur, with
an estimated direct cost of $130 million.
sAimost three quarters of food-borne diseases originate in food
service establishments (65 percent) or food processing plants
(4 percent).
107
TENIN 364994
Each year an estimated 200,000 infections of hepatitis B virus
occur, a third of which result in jaundice. Approximately 200
people die due to acute infection, 280 from liver cancer and
3,500 from cirrhosis caused by hepatitis B virus. The cost of
acute disease is estimated to be $70 million.
An estimated 60, 000 acute cases of hepatitis A and 60, 000
cases of non A/non B hepatitis occur each year costing
approximately $120 million.
Each year, ari estimated 18,000 cases of bacte
are reported, with 2,500 associated deaths and an estimat
direct cost of $58 million.
In 1975, an epidemic year, an estimated 544,000 infections of
St. Louis Encephalitis occurred in the United States.
A 1977 epidemic of dengue in Puerto Rico resulted in an
estimated 1,740,000 cases. Dengue outbreaks continue in the
Carribbean area and in Mexico increasing the potential for the
introduction of dengue into the continental United States.
Infectious diseases including malaria, hepatitis and diarrheal
diseases of viral, bacteriall or parasitic origin, remain serious
health hazards of international travel.
Status and trends
s There are between 190 and 250 million acute respiratory
illnesses per year in the United States, resulting in a minimum
of 400 million days in bed, 125 million days lost from work and
125 millicnn days lost from school.
Acute gastroenteritis is the
accounting in one survey for
pediatricians' offices.
common illness,
of all visits to
Infccticus diseases result in approximately 27 million patient
days of acute hospita3l care each year (10 percent of the
patient days in acute care hospitals) at an estimated direct
cost of nearly $6 billion.
Infectious diseases, such as tuberculosis, continue
prevalent in poverty areas and areas with high immigration
rates.
Antibictics and antimicrobials, the most commonly prescribed
category of medication, account for ama}cr portion of
prescription drug costs.
1 08
TIMN 364995
R plasmine mediated multiple-resistant organisms, which appear
to be increasing among pathogens of man, threaten to blunt
the effectiveness of previous therapeutic regimens.
Z . Prevention/Promotion Measures
a. Potential measures
s Edu
ion measures include:
-- better understanding and practice of basic hygienic
measures, such as handwashing and proper handling of
food;
creation of an atmosphere conducive to greater public
participation in health practice ( e. g. , more local demand for
hygienic practices in food service establishments and for
immunization availability);
school health, and public and professional education to
improve individual awareness of, and responsibility for,
disease prevention practices such as handwashing, and
obtaining immunization for one;s self and one's children;
educational approaches that take into account socioeconomic
and ethnic differences that may influence both spread of
disease and receptivity to change.
Service measures include:
-- operation of surveillance networks including
dependable laboratory information to ensure ea
of infectious diseases and their causes;
assistance in analysis of surveillance data to assess the
extent -and impact of infectious diseases, to evaluate the
costs and benefits of public health efforts and to define
important areas for research;
operation of communications technology to facilitate national
dissemination of data within
ting systems;
dissemination of information to States and localities
concerning threatening infectious disease agents and new
prevention and control methods;
provision of epidemiologic investigation and control services
to facilitate response to infectious disease problems within
medical care facilities as well as in the community.
109 7'IMN 364996
s Technologic measures include:
-- better design of medical devices and implants for safety and
ease of sterilization or disinfection;
r treatment systems;
ulatory measures relating to food precessing,
e and waste disposal;
-- development and testing of new vaccines;
-- development of new diagnostic tests for disease diagnosis
and control;
-- improved vector control and vector surveillance technology;
-- improved design of health-care facilities to facilitate
infection control practices ( e. g., readily accessible sinks
for handwashing between visits to patients).
b. Relative strength of the measures
Surveillance, including epidemiologic investigations, is the
basic and essential element of disease control. Historically,
surveillance has provided the basis for understanding the
major infectious diseases of man. It will remain essential to
the future of infectious disease control. Improved surveillance
systems will allow detection of new reservoirs of infection,
definition of populations at risk, understanding of patterns of
disease spread, and the evaluation of control measures.
Surveillance systems will serve an increasingly important role
in program evaluation (e.g., cost-benefit analyses) and the
identification of new areas for intervention.
sAithough health education measures lack rigorous evaluation,
they have contributed substantially to curbing disease
transrrtission. Further progress in preventing infectious
diseases can be expected from public education measures in
areas such as vaccine acceptance, proper use of antibiotics
andd the understanding of personal hygiene.
s The history of successf uI intervention
and waterborne diseases anticipates the development of new
technologies for the control of infectious diseases and the
application of new environmental control measures to large
populations. In the hospital setting, the Study on the
Efficacy of Nosocomial Infection Control (SENIC) is a model for
evaluating environmental measures related to infectious disease
problems of public health importance.
110 TIMN 364997
3. Specific Objectives for 1990
s Improved health status
a. By 1990, the annual estimated incidence of hepatitis B should
be reduced to 20 per 100,000 population. (In 1978, it was
estimated to be 45 per 100,000 population. )
b. By 1990, the annual reported incidence of tuberculosis should
be reduced to 8 per I(lti, 0f1{I population. (In 1978, it was 13.1
per 100,000 population.)
c. By 1990, the annual estimated incidence of pneumococcal
pneumonia should be reduced to 115 per 100,000 population.
(In 1978, it was estimated to be 182 per 100,000 population.)
d. By 1990, the annual reported incidence of bacterial meningitis
should be reduced to 6 per 100,000 population. (In 1978, it
was estimated to be 8.2 per 100,000 population. )
e. By 1990, the (risk factor-specific) incidence of nosocomial
infection in acute care hospitals should be reduced by 20
percent of what otherwise would pertain in the absence of
hospital control programs. (In 1979, it was estimated that 5
percent of all hospital patients suffered nosocomial infections
and the overall rate of hospital acquired infections appears to
be increasing, although less so in hospitals with good infection
control programs. ) A similar percentage of reduction should be
seen in long-term care and residential care facilities. (Baseline
d ata. unav aiLabie . )
Improved servicesJprotccti.on
f. By 1990, 95 percent of licensed patient carc facilities should be
applying the recommended practices for controlling nosocomial
infections. (Baseline data unavailablc. )
9
By 1990, ssurveillance and control systems should be capable of
responding to and containing : (1) newly recognized diseases
and unexpected epidemics of public health significance; and (2)
infections introduced from foreign countries.
as targets by the Immunization Practices Advisory Committee of
the Public Health Service should be immunized within 5 years of
licensure of new vaccines for routine clinical use.
By 1990, at 'Ieast 50 percent of people in populations de
*NOTE: Same objective as for immunization. Potential
candidates include: hepatitis A and B; otitis media (S.
pneumoniae and H. influenza); selected respiratory and enteric
ill
TIMN 364998
viruses; meningitis (group B N. meningitides, S. pneumoniae,
H. influenza) . i
s Improved surveiIlance/evaluation systems
By 1990, data reporting systems in all States should be able to
monitor trends of common infectious agents not now subject to
traditional public health surveillance (respiratory illnesses,
gastrointestinal illnesses, otitis media) and to measure the
impact of these agents on health care cost and productivity at
the local and State levels, and by extension at the National
level.
By 1990, the extent of epidemics of respiratory and enteric
viral illnesses should be predicted within 2 weeks after they
appear, through community-wide ssn.t.inell surveRlance systems.
k. By 1990, all State health departments should be linked by a
computer system to Federal health agencies for routine
collection, analysis and dissemination of surveillance data, rapid
communication of messages, and epidemic aid investigations.
1. By 1990, Ilaboratories throughout the country should be linked
for monitoring infectious agents and antibiotic resistance
patterns and for disseminating information.
4. Principal Assumptions
~ Despite anticipated changes in antibiotic resistance patterns, there
will be no dramatic changes in the projected svolutionn of infectious
disease patterns before 1990--although disease agents willl be newly
recognized and epidemiologic patterns defined.
sContinuing change in the age structure of the U.S. population
with increasing numbers of persons over 65 and a concomitant
increase in the number and size of residential facilities for the
elderly w%lll be accompanied by a rise in the incidence of infectious
disease.
research efforts to understand the natural history of
infectious diseases will be maintained, and improved tools for
prevention, diagnosis and therapy will be developed.
.With the increased use of computer technology, there will be
improvements in surveillance, communications and data analysis.
a There will be better dissemination of current technologies ~
control disease, and new technologies will be developed
hepatitis B vaccine).
112 TVqN 364999
There will be an increasing proportion of institutionalized patients
with more serious iIlness who are subjected to a greater number of
interventions and who are more prone to nnsocomiall infections.
There ' wiIl be an increased emphasis on the prevention and control
of nosocomial infections, particularly in residential health-care
faciii.ties.
Current Federal technical assistance and advisory services inn
epidemiology and program management will be maintained at the
State and local level.
There willl be an improved use of diagnostic and therapeutic
measures such as drugs for the treatment of viral diseases.
There will be a continued overuse of antibiotic therapy as well as
an increase in the development of antibiotic-resistant strains of
bacteria such as the penicillin-resistant gonococcus.
3-3ecauso of increased internationall travel, the
opportunities for international spread of diseases.
5. Data Sources
a.
To National level only
National Hospital Discharge Survey (HDS) and National
Ambulatory Medical Care Survey (NAMCS). Utilization of
health manpower and facilities providing care for infectious
diseases, ambulatory care, hospital care. DHHS-National
Center for Health Statistics (NGHS). Vital and Health
Statistics, Series 13. Continuing surveys; National probability
s ampies .
Health Interview Survey (HIS). Interview reports on
infectious disease disability, use of hospital, medical, and
other services, and other health-related topics. DHHS-NCHS.
NCHS Vital and Health Statistics, Series 10. Continuing
survey; National probability sample.
Health Examination Survey and the Health and Nutrition
Examination Survey (HANES). Nutrition risk factors for
infectious disease, and medical sequelae from infectious disease
(e.g., rheumatic fever). DHHS-NCHS. NCHS Vital and
Health Statistics, Series 11. Periodic surveys; National
probability samples.
Investigation of epidemics. DHHS-Center for Disease Control
( GDG ). Continuous activity by CDC in response to epidemics
of infectious disease activity throughout the U.S. Data
periodically made available in reports and publications.
113 TIlVIN 365000
sStudy on the Efficacy of Nosocomial Infection Control (SENIC).
Hospital infection control activities and occurrence of hospital
acquired infection. DHiIS-DDC, Bureau of Epidemiology,
Bacterial Diseases Division (I3E-BDD). The Journal of
Epidemiology, 111: 468-653 May 1980. Special issue on SENIC.
One time study, stratified sample of U.S. hospitals.
National Nosocomial Infections Study. Nosocomial infections.
DHHS-GDG, i3E-BDI). National Nosocomial Infections Study
Report 80-8257. Continuous reporting from hospitals
voluntarily cooperating with volunteer panel of 80 short stay
hospitals.
* National Vital Registration System
-- Mortality. Deaths by cause (including infectious diseases),
by age, sex and race. DHHS-NGHS, NCHS Vital Statistics
of the United States, Vol II, and NCHS Monthly Vital
Statistics Reports. Continuing reporting from States;
National full count. Many States issue earlier reports. }
9 Hospitalized illness discharge abstract systems.
-- Professional Activities Study (PAS). Patients in short stay
hospitals; patient characteristics, diagnoses of infectious
diseases, procedures performed, length of stays.
Commission on Professional and Hospital Activities, Ann
Arbor, Michigan. Annual reports and tapes. Continuous
reporting from 1900 GCPHA member hospitals; not a
probability sample, extent of hospital participation varies by
State.
Medicare hospital patient reporting system (MEDPAR).
Characteristics of Medicare patients, diagnosis, procedures.
DHHS-Health Care Financing Administration, Office of
Research, Demonstration and Statistics (DRDS). Periodic
reports. Continuing reporting from hospital claim data; 20
percent sample.
-- Other hospital discharge systems as locally available.
National Morbidity and Mortality Reporting System. Numbers
of 46 reportable diseases; deaths in 121 U.S. cities.
DHHS-CDC. CDC Morbidity and Mortality Weekly Report, and
annual reports. Morbiiity : continuous reporting from State
health departments on basis of physician reports.
(Completeness of reporting varies greatly, since not all cases
receive medicail care and not all treated conditions are
114
TIAIN 365001
reported. ) Mortality: continuous reporting; volunteer panel
of health departments in 121 U.S. cities, full count.
s Natianal surveillance data. Detailed data on cases of 33
communicable diseases. Surveillance Reports. DHHS-CDC, BE
and Bureau of State Ser~iees. Gentin.uous reporting from
States.
Third party payers and large group practices can sometimes
provide data on diagnosis, cost and demographic features of
defined patients and populations. Data are collected on a
continuous basis but are not consistently analyzed or
distri.buted.
sState disease surveillance systems. Report of notifiable
diseases required by State law (as many as 100 in some
States);analyzed and periodically published by each of the
States.
s Special periodic Statewide studies to monitor disease activity or
to evaluate the effectiveness of disease control programs
available at State health departments.
Statewide accounting procedures to document public health
activities available through the National Public Health
Reporting System of the Association of State and Ter
Health Officers as well as individual State health departments.
s Investigation of epidemics. Continuous activity by Federal,
State and local health departments in response to epidemic
infectious disease activity. Data periodically made available by
responsible health authorities.
115
TIIIN 365002
SMOKING AND HEALTH
1. Natur
an
xtent of the Problem
Smoking, the single most important preventable cause of death and
disease, is associated with heart and blood vessel diseases, chronic
bronchitis and emphysema, cancers of the lung, larynx, pharnyx,
oral cavity, esophagus, pancreas, and bladder, and with other
problems such as respiratory infections and stomach ulcers. Though
the share of the population who smoke has declined for the country
as a whole, the declines have not been as great among adolescents
and there have even been increases in the rates for 17 and 18
year-old women. To reduce the prevalence of smoking in this
country, a variety of approaches are needed to discourage young
people from starting to smoke, to increase the number of smokers
who quit, and to assist those who continue to smoke to do so, to the
extent possible, in less hazardous ways. Particular attention should
be given to high risk groups such as pregnant women, children and
adolescents who initiate smoking at a young age, and workers who
are exposed to occupational hazards that are exacerbated by
cigarette smoking.
a. Health implications
. Cigarette smoking is responsible for approximately 320,000
deaths annually in the United States.
s Lung cancer is the leading cause of cancer death among men;
if present trends continue, by 1983 it wilIl become the leading
cause of cancer death among women.
and bladder; and chronic bronchitis and emphysema.
~ Cigarette smoking during pregnancy is associated with
retarded fetal growth, an increased risk for spontaneous
abortion and prenatal death, as well as slight impairment of
Cigarette smoking is a causal factor for: coronary heart
disease and arteriosclerotic peripheral vascular disease;
cancers of the lung, larynx, oral cavity, esophagus, pancreas
growth and development during early childhood.
s Cigarette smoking acts synergistically with oral contraceptives
to enhance the probabality of coronary and cerebrovascuLar
disease; with alcohol to increase the risk of cancer of the
larynx, oral cavity and esophagus; with asbestos and other
occupationally encountered substances to increase the likelihood
of cancer of the lung; and with other risk factors to enhance
cardiovascular risk.
117
s Involuntary or passive inhalation of cigarette smoke can
precipitate or exacerbate symptoms of existing disease states
such as asthma, cardiovascular and respiratory diseases.
Pneumonia and bronchitis are more common among infants
whose parents smoke.
Smoking is a major contributor to death and injury from fires,
burns and other accidents. Twenty-nine percent of fatal
house fires and a substantial number of burn injuries are
smoking related.
s'Ten years after quitting c%gar+
lung cancer and other sm
auDroach those of nonsmokers.
g-
. Status and trends
Adult per capita consumption of
temporarily in 1953, 1954, 1964, and 19
periods of increased national publicity
smoking. The rate of decline has accelerate
rds of
The percentage of adult men who regularly smoke declined
from 53 percent to 38 percent between 1955 and 1978.
The percentage of adult women who regularly smoke increased
from 25 percent to 33 percent between 1955 and 1965,
decreasing to 30 percent by 1978.
s The percentage of all adults who smoke regularly was about 33
percent in 1978, the lowest point in over 30 years. Smoking
cigarettes is significantly less prevalent in higher educated
groups. The decline since 1966 involves all socioeconomic
groups but cigarette smoking rates among blacks still exceed
those among whites. Most of the decrease seen in smoking
prevalence among adults is explained by smoking cessation
rather than by a lower rate of initiation.
*Teenage smoking has declined since 1974, except for young
women aged 17 to 18. Rates for women aged 17 to 24 have
risen and now exceed those of men in this age group.
n jPromotion Measures
Potential measures
Education and information measures inciude:
death rates for
uses of death
decreased
iding with
118 TIMN 36.5004
general educational campaigns using broadcast and other
mass media, coordinated with Government, business and
nonprofit voluntary efforts, focusing on such subjects. as
specific health consequences, self-initiated cessation, less
hazardous ways of smoking, the immediate benefits of
cessation and the effects of passive smoking on infants and
on people with pre-existing heart and lung conditions;
specific educational campaigns directed: to women, focusing
on the speciail health consequences of cigarette smoking for
pregnant women (and fetus) or for women using oral
contraceptives; to youth and to people in lower
socioeconomic groups, focusing on immediate consequences
and how to deal with social pressures to smoke; to workers
exposed to toxic agents and to others at special risk to
health, focusing on the synergistic and additive effects of
smoking for those exposed to occupational hazards; and to
those with other risk factors, such as high blood pressure;
special smoking education programs reaching high risk
groups;
youth smoking prevention programs, especially in grades 7
through 10, focused on the psychosocial factors which
promote smoking, which will impart knowledge and skills
necessary to help resist social influences (e.g., using
nonsmoking peer models);
media programs focused on self-initiated cessation, referring
people to materials appropriate to their special risks and
dealing with common relapse situations;
advising consumers to consider carbon monoxide as well as
levels of "tar" and nicotine;
warning consumers that changing to
yields of tar and nicotine may increase smoking hazards
accompanied by smoking more cigarettes, inhaling more
deeply or starting smoking earlier inn life;
cautioning consumers that even the lowest-yield cigarettes
present health hazards much greater than those encountered
by nonsmokers, and that the most effective way to reduce
the hazards of smoking is not to start or to quit.
Service measures include:
-- formal and self-help smoking cessation programs made more
available within the health care system, occupational
settings T union facilities and places convenient to the
general public;
119
TIMN 365005
-- coordination and exchange of programs
between Gcvernment, business; commercial and nonprofit
agencies 3
nded direct counseling and
care providers;
-- specialized service programs for women, for pregnant
women, for occupational and other high risk groups and
other smokers in particular need of assistance in stopping
smoking--to be carried on through community, church,
social and health organizations and at the work place.
* TechnoIog ic measur
-- continuing engineering and research on the development of
less hazardous ways of smoking including the development
of cigarettes with lower yields of incriminated ingredients
and the development of methods to assess the relative risks
of cigarettes with lower yields.
s Legislativs and regulatory measures include:
continuing the ban on TV and radio advertising and the
requirement of a health warning on all cigarette packages;
continuing the FTC requirement of a health warning
adv ertising ;
strengthening the visibi
warning Iabel ; requiring
placed upon the package;
.t of the present
nicotine yields be
improving enforcement of laws prohibiting sales to minors;
and local laws and regulations which
establish nonsmoking areas in public places and work areas;
examining potential new areas of regulation, such as:
increased disease-specific information in advertisements;
deglamorizing the visual and printed components of
advertising; requiring greater visibility of warnings;
banning distribution of cigarette samples to minors.
TWN 365006
s Economic measures include:
-- tax policies vis-a-vis cigarettes;
-- increasing the price of cigarettes on military bases to the
local off-base prices;
-- income tax deduction policy for the cost of smoking
cessation programs;
encouraging employers to provide bonuses and other
incentives to workers who quit;
"no smcki.ngi; policies for workplaces where smoking on the
job presents particular hazards;
encouraging insurance companies to examine feasibility of
offering preferential life andlor health insurance premiums
to nonsmokers and of paying for smoking cessation
programs offered to group insurance subscribers.
b. Relative strength of the measures
. EdUca
strate
Educat
to chil
information, fiscal and regulatory measures are key
in
a
National smoking prevention program.
ity in such programs, especially related
needed to define
needs.
regnant women. Additional research is
types of education which best meet public
aThe major gains may come through the identification of
effective peer education strategies for children and youth.
aCounseling by physicians and health professionals on smoking
would facilitate the decline in smoking if incorporated into
routine clinical practice.
a Legislative, regulatory and
taxation), consistently and
economic
the educational efforts, but are less
enacted.
ssf ully
a If cigarettes with lower tar and nicotine should prove to be
less hazardous for some smoking-related diseases (as current
evidence snggests) , the substitution of lower level cigarettes
for those with higher levels may prove a valuable aid in
reducing disease though less desirable than not smoking at all.
measures Linclucting
snouia ennance
121 TMN 365007
Specific Objectives for 1990
# Improved health status
-- Reductions in smoking can be expected to yield reduced rates
of coronary heart disease, chronic lung disease, prematurity in
newborns, smoking related fire deaths and fewer occupational
illnesses from exposure to substances with which ci
smoking acts synergistically. Over the longer term, reductions
inn cancer rates (especially lung and bladder) can
expected. Because of uncertainties in short-term quantification
of the exposure-to-disease relationship, measurable health
status objectives are not stated.
s Reduced risk factors
a. By 1990, the proportion of adults who smoke should be reduced
to below 25 percent. (In 1979, the proportion of the U.S.
population which smoked was 33 percent. )
b. By 1990, the proportion of women who smoke during pregnancy
should be no greater than one half the proportion of women
overall who smoke. (Baseline data unavailable.) -
c. By 1990, the proportion of children and youth aged 12 to 18
years old who smoke should be reduced -to below 6 percent.
(In 1979, the proportion of 12 to 18 year olds who smoked was
11.7 percent.)
d. By 1990,
fthe sales-weighted average tar yield of cigarettes
below 10 mg. The other components of
smoke known to cause disease should also be reduced
proportionately. (In 1978, the sales-weighted average yield was
16.1 Mg.)
. Increased public/professional awareness
e. By 1990, the share of the adult population aware that smoking
is one of the major risk factors for heart disease should be
increased to at least 85 percent. (In 1975, the share was 53
percent.)
t least 90 percent of the adult population should be
aware that smoking is a major cause of lung cancer, as well as
multiple other cancers including laryngeal, esophageal, bladder
and other types. (Baseline data unavailable. )
g. By 1990, at least 85 percent of the adult population should be
aware of the special risk of developing and worsening chronic
obstructive lung disease, including bronchitis and emphysema,
among smokers. (Baseline data un.avai3.able. )
122 TININ 365008
1990, at least 85 percent of women should be aware of the
health risks for women who smoke, including the effect
s of pregnancy and the excess risk of cardiovascular
disease with oral contraceptive use. (Baseline data
unavailabie. )
1990, at least 65 percent of 12 year olds should be
identify smoking cigarettes with increased risk of serious
disease of the heart and lungs. (Baseline data unavailable. )
Improv e I d services/ pretection
~. By 1990, at least 35 percent of all workers should be offered
employerJemployee sponsoredd or supported smoking cessation
programs either at the worksite or in the community. (In 1979,
15 percent of U.S. business firms had programs to encourage
or assist their employees in smoking cessation. )
k. By 1985, tar, nicotine and carbon monoxide yields should be
prominently displayed on each cigarette package and promotional
material. (Carbon monoxide levels are not currently required. )
By 1985, the present cigarette warning should be strengthened
to increase its visibility and impact, and to give the consumer
additional needed information on the specific multiple health
risks of smoking. Special consideration should be given to
rotational warnings and to identification of special vulnerable
grgups.
m. By 1990, laws should exist in all 50 States and all jurisdictions
prohibiting smoking in enclosed public places, and establishing
separate smoking areas at work and in dining establishments.
(In 1978, 31 States had some form of smoking restriction laws.)
n. By 1990, major health and life insurers should be offering
differential insurance premiums to smokers and nonsmokers.
(In 1979, approximately 30 major companies were offering
differential premiums. )
Improved surveillance/evaluation
o. By 1985, .insurance companies should have collected, reviewed,
and made public their actuarial experience on the differential
life experience and hospital utilization by specific cause among
smokers and nonsmokers, by sex.
p. By 1990, econtinuing epidemiological research should have
delineated the unanswered research questions regarding low
yield cigarettes, and preliminary partial answers to these should
have been generated by research efforts.
123
q. In addition to bioraedica.ll hazardd surveillance, continuing
examination of the changing tobacco product, and the socioIcgic
phenomena resulting from those changes should have been
accomplished.
4. Principal Assumptions
a Pcl%cy, planning and programs to reduce smoking will continue to
be high priorities of government, voluntary agencies and industry.
s Educational programs to reduce smoking in youth, women,
pregnant women, high risk occupations and populations and lower
socio-economic groups will become more intensive.
There will be a gradual increase in the availability and use of
smoking cessation service programs.
Smoking education will be
lifestyle promotion programs.
integrated into
s The social acceptability of smoking will continue to decrease.
s There will be a continued decline in smoking among upper
socioeconomic
s, spreading to lower socioeconomic classes.
s Regulaticns against smoking in public places will increase,
providing incentives and social supports to reduce smoking.
s The decline in sales-weighted average tar content of cigarettes will
continue.
s Engineering measures will help reduce the yields by cigarettes of
hazardous particulants and the gaseous ingredients of smoke.
. There will be no dramatic change i
Data Sources
a. To National level only
tax policy cn cigarettes.
s Knowledge, attitudes and practices in
Demographic data, attitudes, information and beliefs about
te use, and smoking practices among people 21 years of
age or older, and changes between 1964 and 1970. DHEW
National Clearinghouse for Smoking and Health (now/Office on
Smoking and Health) Reports: Use of Tobacco:
Attitudes, Knowledge and Beliefs 1964-1966; and Adult Use of
'I`abacca-1170/Adult Use of Tobacco, 1975. LLongitudinal study
of panel first interviewed 1964; ffollow up interviews in 1966
and 1970: cone time survey (new sample), 1975.
124
TIMN 365010
Teenage smoking. Demographic data, attitudes, beliefs and
knowledge concerning smoking among adolescents in the United
States. Office on Smoking and Health (formerly National
Clearinghouse for Smoking and Health) 1968-1974; National
Institute of Education 1979. Teenage Smoking: National
Patterns of Cigarette Smoking, Ages 12 through 18. Published
in 1968, 1970, 1972 and 1974. (In 1979 title was changed to:
Teenage Smcking : Immediate and Long Term Patterns.
Surveys of adolescents ages 12-18 respondent sample of
general U.S. population.
Smoking behavior and attitudes of health prcfessicnals. Office
on Smoking and Health (formerly National Clearinghouse for
Smoking and Health ). Smoking Behavior and Attitudes:
Physicians, Dentists, Nurses, and Pharmacists, 1975. One
time survey.
a Health Interview Survey (HIS ); Smoking Supplement. Smoking
prevalence among adults collected as part of the He
Interview Survey. DHHS-Naticnal Center for Health Statis
(NCHS) . NCHS Advance Data from Vital and Health Statistics
and Surgeon General reports on smoking, usually annual.
1980 SSurgeon General's report entitled Health Consequences for
Women: A Report of the Surgeon General. Continuing
survey; National probability sample. Smoking supplements
periodic since 1978.
s Health and Nutrition Examination Survey (HANES). Clinical
and biochemical data on examinees collected, could be analyzed
according to their smoking characteristics. DHHS-NCHS.
NCHS Vital and Health Statistics, Series 11. Periodic survey;
National probability sample.
9 Cigarette and cigar production and imports. Number of
cigarettes (large and small) and cigars, by size and class,
shipped from factory or imported each month by manufacturer.
Department of Treasury-Bureau of Alcohol, Tobacco and
Firearms. Monthly statistical release, Cigarettes and Cigars.
Continuing; reports from manufacturers, importers.
Tobacco crops. Average yield, stock, supply, domestic use,
price and crop value. Department of Agriculture, Agricultural
Marketing Service. Annual Report on Tobacco Statistics.
Continuing.
s"Tar" and nicotine content. Results of "tar" and
yield measurements of cigarettes by brand. Federal Trade
Commission, annual report. "Tar" and Nicotine Content of the
Smoke of 176 Varieties of Cigarettes. Continuing analysis and
reports.
125
TIMN 365011
s Cigarette marketing and regulatory issues. Annual review of
current issues in labeling and advertising, advertising themes
and costs, regulatory activity, legislative recommendations,
types of cigarettes marketed. Some trend data. Federal
Trade Commission. Annual Report to Congress Pursuant to
the Public Health Cigarette Smoking A.ct. Continuing.
b. To State and/or local level
National Vital Registration System
-- Mortality. Deaths by cause (including smoking related
diseases), by age, sex and race. DHHS-NCHS. NCHS
Vital Statistics of the United States, Vol II, and NCHS
Monthly Vital Statistics Reports. Continuing reporting from
States, National full count. (Many States issue earlier
repcrts. )
Hospitalized illness discharge abstract systems.
-- Professional Activities Study (PAS ). Patients in short stay
hospitals; patient characteristics, diagnoses of
and other smoking related diseases, procedures performed,
length of stays. Commission on Professional and Hospital
Activities, Ann Arbor, Michigan. Annual reports and
tapes. Continuous reporting from 1900 CPHA member
hospitals; not a probability sample, extent of hospital
participation varies by state.
-- Medicare Hospital Patient Reporting System (IdfEI3PAR).
Characteristics of Medicare patients, diagnoses, procedures.
DHHS-Health Care Financing Administration, Office of
Research, Demonstration and Statistics (ORDS ). Periodic
reports. Continuing reporting from hospital claim data; 20
percent sample.
-- t)thcn hospital discharge systems as locally available.
s Cigarette sales. Number of cigarette packages taxed for each
month in each State, and comparison to one year previously.
Tobacco Tax Council, 5407 Patterson Avenue, Richmond,
Virginia: Monthly State Cigarette Tax Report. Continuing.
. Area Resource File (ARF). Demographic, health facility and
manpower data at State and County level from various sources.
DHHS-Health Resources Administration. Area Resource File:
A Manpower Planning and Research 'Pocl. DHHS-HRA-80-4,
Oct 79. One time compilation.
126
TIMN 365012
sSelected health data. DHHS-NCHS. NCHS Statistical Notes
for Health Planners. Compilations and analysis of data to
State level.
127 TIMN 365013
MISUSE OF ALCOHOL AND DRUGS
1. Nature and Extent of the Problem
A major objective of drug and alcohol preventionn policy is to reduce
the adverse social and health consequences associated with the
misuse of these substances, especially among adolescents, young
adults, pregnant women and the elderly.
Alcohol and other drug problems have pervasive effects: biological,
psychological and social consequences for the abuser; psychological
and social effects on family members and others; increased risk of
injury and death to self, family members and others (especially by
accidents, fires or violence); and derivative social and economic
consequences for society at large. Destructive drug and alcohol use
shares many similarities with tobacco use and may respond to some of
the same prevention strategies (see Smoking and Health) .
Per capita alcohol consumption and use of other drugs for
non-medical purposes decreases with older age groups, but the use
of drugs for medical purposes, both over-the-counter and
prescription drugs, increases.* Since the aging process is
accompanied by physiologic changes that alter the body's response to
both food and drugs, practices of self-medica.ti.on, over-prescribing
and the concurrent use of two or more drugs can create serious
health problems for the elderly. Concurrent misuse' of alcohol and
drugs consumed for either non-medical or medical purposes increases
risks to health and complicates the delivery and financing of
preventive and treatment measures from both private and public
sources.
*NOTE: For purposes of this report, the term "use of other drugs"
refers to self-reported use of licit or illicit drugs for non-medical or
self-defined purposes. It does not include inappropriate use of
drugs consumed for medical purposes, nor the use of alcohol or
tobacco. These are discussed separately.
Health Implications
ALCOHOL
s In 1975, an estimated 36,000 deaths from cirrhosis, alcoholism
or alcoholic psychosis could be directly attributed to alcohol
use.
In 1975, an additional 51,000 fatalities could be indirectly
attributed to alcohol use.
129
TIMN 36.5014
9 Alcohol has been identified as a risk factor for cancers of the
oral cavity, esophagus and liver.
9 In 1977, about 45 percent of all motor vehicle fatalities
involved drivers with blood alcohol levels of .10 percent or
more, a rate of 11.5 per 100,000 population.
s In 1975, the costs of alcohol problems were estimated to be $43
billion in lost production, health and medical services,
accidents, crime and other social consequences.
s The Fetal Alcohol Syndrome is estimated to cause some 1,400 to
2,000 birth defects annually.
OTHER DRUGS
s The vast majority of users of "other drugs" are marijuana
users, but the category is not limited to this group.
t The social cost of drug abuse, including law enforcement, has
been estimated to be at least $10 billion per year, a figure
which may be an underestimate considering the difficulties of
measuring the aggregate health and social consequences of
those behaviors.
s Between May 1976 and April 1977, there were an estimated
7,000 to 8,000 deaths and an estimated 275,000 to 300,000
medical emergencies related to misuse of drugs.
s An undetermined portion of deaths and medicall emergencies
relate to drug use for suicide and attempted suicide (see
Control of Stress and Violent Behavior) and may be very
difficult to prevent.
s Barbiturates were the class of drugs mentioned most frequently
by medical examiners in connection with drug-related deaths
reported to the Drug Abuse Warning Network between May
1977 and April 1978 (20 percent of drugs mentioned).
. Tranquilizers were the class
frequently by emergency rooms
percent of drugs mentioned).
e The proportion of barbiturate and tranquilizer misuse that is
deliberate and the proportion that is acciders.tall is not known.
130
DRUGS USED FOR MEDICAL PURPOSES
Use of high estrogen content oral contraceptives by women
smokers increases risks of coronary and cerebrovascular
disease.
-- See Family Planning
s People over 65 years of age, 11percent of the population, use
more drugs and for longer periods of time than any other age
group, accounting for 30 percent of all medicines consume
The risk of adverse drug reactions in elderly patients
almost twice that in patients between 30 and 40 years of age.
. Between. 70 and 80 percent of reactions are predictable and
preventable.
Between 0.3 and 1.0 percent of the na
hgspitall admissions each year are due to
reactions.
s Improper use of drugs ferces curtailment of normal activities,
or contributes to such curtailment, in an unknown proportion
of the disabled population.
Status and trends
ALCOHOL
An estimated 10 percent of the adult population 18 years and
over are frequent heavy drinkers (5 or more drinks per
occasion at least once per week).
9 Most problems indirectly attributable to alcohol (homicides,
car crashes) have the highest rates among young adult males
ages 18 to 24 years.
sNaticnal surveys indicate no changes in peak quantity
consumed by teenagers 12 to 17 (five or more beers at a time)
or in regularity of their drinking, between 1974 and 1978.
sAlcoholism mortality rates (2 per 100,000) and alcoholic
psychosis rates U per 3.i1(l, (l(I(I) show little overall increase
between 1950 and 1975.
s Based on survey reports and tax-pa.i.dd withdrawals, per capita
consumption of absolute alcohol did not change significantly
during the years 1971 tto 1976. More recent data indicate that
per capita consumption began to increase again after 1976,
131 TJAVV 365016
from 2.7 gallons to 2.82 gallons of absolute alcohol per capita
978. Whether the increase will continue is not yet known.
OTHER DRUGS
a A dramatic decline in level of heroin-related medical problem
indicators was seen from 1976 to 1977, suggesting a decline in
heroin use.
9 The proportion of adolescents (12 to 17 years oId ) reporting
current use of marijuana has been rising continuously for the
last decade and has increased significantly from 6 percent in
1971 to 16 percent in 1977.
~ The proportion of young adults (18 to 25 years old) reporting
that they had ever used marijuana rose from 39 percent in
1971 to 60 percent in 1977.
9 It has been estimated that there are approximately 2,500,000
persons (roughly 2 percent of the population age 18 and over)
having serious drug problems.
a Epidemiological evidence suggests that the use of alcohol,
tobacco and marijuana by adolescents is associated.
DRUGS USED FOR MEDICAL PURPOSES
s Barbiturate-related mortality accounted for less than 1,300
deaths in 1976.
Potential measures
# Education and information measures include:
-- general public information campaigns, and programs
targeted to children and youth and to specific at-risk
populations, with specific messages to facilitate problem
recognition or reinforce desired behavior;
-- programs targeted at a wide array of service professions
concerning the recognition of, and responses to, alcohol
and other drug problems;
-- information on medicine labels on drug/drug, drug/food and
drug/alcohol interactions, with practical guidance on
avoiding clinically significant interactions;
132 TIwJN 365017
and community-based health education programs,
eer leaders and models;
-- special educatienn programs emphasizing effective
risk-management skills and alternatives to drug and alcohol
use;
-- education of physicians, nursing home staff and patients
about hazards surrounding the misuse of tranquilizers,
hypnotics and other classes of prescription and
nonprescription drugs 3
-- easily understandable information available to
taking drugs for medical purposes.
s Service measures include:
-- programs which offer generall seciall support (youth centers,
recreation programs) and thereby provide alternatives to
drug and alcohol use;
-- outreach and early intervention services at the worksite and
in community settings for persons whose behavior indicates
that they are at-risk for the development of alcohol or
other drug problems;
-- anticipatory guidance, identification of children at high risk
of alcoholism;
-- a broad range of treatment services in employee assistance
programs, in generall health care delivery settings and in
specialized alcohol and drug facilities;
-- counseling by pharmacists to older people taking drugs for
medical purposes;
ance of computerized drug profiles;
otlines and drug information centers people can use to
learn about drug effects and interactions.
Technologic measures
-- product safety changes which reduce the risk of inj
death in places associated with use of aleehell a
drugs (e.g., airbags in motor vehicles and improve
fireprnofing in residences);
133 TMN 365018
-- modifications to alcoholic beverages themselves (e.g.,
reduction of alcaholl contsnt, reduction or elimination of
nLtrOsailllnE:s);
-- efforts by community institutions to modify social settings
and contexts to reduce the risk associated with intoxication
and to alter social reaction to some types of drinking or
drug-using behavior.
Legislative and regulatory measures include:
-- regulating the conditions of availability of alcoholic
beverages (e.g., zoning regulations regarding hours of
sale, numbers of outlets and numbers of licenses) ;
-- enforcing minimum drinking age laws and employing legal
disincentives to discourage the dispensing of alcohol to
obviously intoxicated persons;
-- enforcing laws prohibiting driving while intoxicated b
alcohol or drugs and initiating stronger legal disincentives;
-- controlling advertising of alcoholic beverages;
-- enforcing laws related to production, distribution and use
of -"other drugs#' that are proscribed except for medical and
scientific purposes; special law enforcement agencies are
responsible for enforcing such prohibitions and violations
are punishable by criminal sanctions;
-- regulation of conditions under which these substances are
available for authorized uses, such as measures relating to
scheduling of "controlied substances" and limitations on
prescriptions;
-- periodic reexamination Of sanctions to ensure
correspondence to the degree of severity of the health and
social problems associated with the overuse of each
particular substance or drug #
-- patient labeling for certain prescription drugs (estrogens,
progest%ns) i
-- drug information for patients in nursing homes and in other
long-term care facilities.
TIMN 365019
134
o Economic measures include:
-- excise taxes on alcoholic beverages and other means of
affecting the price of alcohol;
-- tax incentives or disincentives to control levels of
advertising expenditures for alcoholic beverages.
Relative strength of the measures
s Systematic evaluation of the effects of education and early
intervention programs targeted at children and youth and
populations at special risk is at an early stage.
Regulatory measures have been the Nation's primary tool of
drug abuse prevention during most of the 20th century.
There is much debate about the overall cost-benefit assessment
of the current prohibitions. From a more limited perspective,
however, some recent trends tend to support claims that
regulatory approaches have had an impact on the extent of
drug use.
s Heroin addiction in this country has been declining in recent
years, coincident with reduced supplies on the illegal market
and the extensive availability of treatment services. Late in
1979, however, the supply and incidence of heroin use
increased in several Eastern cities. Also, barbiturate-related
mortality has been declining steadily as a result of increased
legal controls, greater physician awareness of the most
efficacious uses of these drugs, and improved public awareness
of the hazards associated with the use of barbiturates in
combination with other depressants.
s Mass media campaigns that have focused public attention upon
alcohol use and abuse may have contributed to a period of
relative stability in alcohol consumption during the seventies
(although economic conditions were also a likely significant
factor). Alcohol problems, as noted by several indicators
(cirrhosis mortality rate decline, survey data on alcohol
consumption among youth and adults), appear also to have
leveled off during this period of apparent stability. While
direct causal attribution is not possible, the creation of a
National alcoholism treatment network and early intervention
services in the workplace probably played a role in the
stabiIization of cirrhosis deaths.
sAlcoholio beverage regulation has not traditionally been focused
on public health considerations, but data concerning the impact
of regulatory initiatives on tobacco smoking may be
transferable to the alcohol area. Research here and in other
135 TIMN 365020
countries suggests that the availability of aicohv7l may affect
the level and type of alcohol problems, particularly physical
health problems consequent to long-term excessive drinking.
Consumption, in turn, has been linked fairly conclusively to
the relative price of alcohol, and less conclusively to such
factors as the legal purchase age, number and dispersion of
retail on-premise and off-premise outlets, and hours of sale.
Also "Dram Shop" laws can offer powerful incentives for
alcoholic beverage licensees to try to reduce the likelihood of
ication among their patrons.
e In general, alcohol and drug education programs can increase
information levels and modify attitudes. Their effect on
drinking or drug-using behavior has not yet been
demonstrated conclusively, although recent studies have
yielded encouraging preliminary findings.
Specific Objectives for 1990
s Improved health status
a. By 1990, fatalities from motor vehicle accidents involving
drivers with blood alcohol levels of .10 percent or more should
be reduced to less than 9.5 per 100,000 population per year.
(In 1977, there were 11.5 per 100,000 population.)
b. By 1990, fatalities from other (non-motor vehicle) accidents,
indirectly attributable to alcohol use (e.g., falls, fires,
drownings, ski-mobile, aircraft) should be reduced to 5 per
100,000 population per year. (In 1975, there were 7 per
100,000 population. )
c. By 1990, the cirrhosis mortality rate should be reducedd to 12
per 100,000 per year. (In 1978, the rate was 13.8 per 100,000
per year.)
By 1990, the incidence of infants born with the Fetal Alcohol
Syndrome should be reduced by 25 percent. (In 1977, the rate
was 1 per 2,000 births, or approximately 1,650 cases. )
*NOTE: Same objective as for Pregnancy and Infant Health.
e. By 1990, other drug related mortality should be reduced to 2
per 100,000 per year. (In 1978, the rate was about 2.8 per
1(l0, 0tl0. }
By 1990, adverse reactions from medical drug use that are
sufficiently severe to require hospital admission should be
reduced to 25 percent fewer such admissions per year. (In
1979, estimates range from approximately 105,000 to 350,000
admissions per year. )
136 TMN 365021
Redu
g. By 1990, per capita consumption of alcohol should not exceed
current levels. (In 1978, aabout 2.82 gallons of absolute alcohol
were consumed per year per person age 14 years and over. }
h. By 1990, the proportion of adolescents 12 to 17 years old who
are not using alcohol or other drugs should not fall below 1977
levels. (In 1977, the non-user proportions were: 46 percent
for alcohol; for other drugs, ranging from 89 percent for
marijuana to 99.9 percent for heroin.*)
*NOTE: A person is defined as not using alcohol or other
drugs if he or she has never used the substance or if the last
use of the substance was more than one month earlier.
By 1990, the proportion of adolescents 14 to 17 years oldd who
report acute drinking-related problems during the past year
should be reduced to below 17 percent.* (In 1978, it was
estimated to be 19 percent based on 1974 survey data.)
*NOTE: Acute drinking-related problems have been defined as
problems such as episodes of drunkenness, driving while
intoxicated, or drinking-related problems with school
authorities.
, the proportion of problem drinkers among 'aII adults
aged 18 and aver should be reduced to 8 percent. (In 1979, it
was about 10 percent. )
k. By 1990, the proportion of young adults 18-25 years old
reporting frequent use of other drugs should not exceed 1977
levels. (In 1977, it was less than one percent for drugs other
than marijuana and 19 percent for marijuana.*)
*NOTE: "Frequent use of other drugs" means the non-medical
use of any specific drug on 5 or more days during the previous
month.
By 1990, the proportion of adolescents 12-17 years o3.d
reporting frequent use of other drugs should not exceed 1977
levels. (In 1977, it was less than 1 percent for drugs other
than marijuana and 9 percent for marijuana. )
137
TV"N 365022
* Increased public/profe
m. By 1990, the proportion of women of childbearing age aware of
risks associated with pregnancy and drinking, in particular,
the Fetal Alcohol Syndrome, should be greater than 90 percent.
(In 1979, it was 73 percent. )
n. By 1990, the proportion of adults who are aware of the added
risk of head and neck cancers for people with excessive alcohol
consumption should exceed 75 percent. (Baseline data
unsv ailable. )
o. By 1990, 80 percent
they perceive great
cigarette smoking, m
intoxication. (in 19
perceived "great rask"
cigarettes smoked daily,
72 percent with regular
school seniors should state that
associated with frequent regular
use, barbiturate use or alcohol
63 percent of high school seniors
associated with 1or 2 packs of
cent with regular marijuana use,
arbiturate use, and only 35 percent
with having 5 or more drinks per occasion once or twice each
weskend. )
p. By 1990, pharm
counsel patients on t
priority by the FDA,
for pediatric and
drinking alcoholic
drugs. (Baseline
s Improved s
ection
prescriptions
problems of
q. By 1990, the proportion of workers in major firms whose
employers provide a substance abuse prevention and referral
program (employee assistance) should be greater than 70
percent. (In 1976, 50 percent of a sample of the Fortune 500
firms offered some type of related employee assistance. )
r. By 1990, standard medical and pharmaceutica1l practice should
include drug profiles on 90 percent of adults covered under the
Medicare program, and on 75 percent of other patients with
acute and chronic illnesses being cared for in all private and
organized medical settings. (Baseline data unavailable. )
s Improved surveillance/evaluati
s. By 1990, a comprehensive data capability s
to monitor and evaluate the status and
alcohol and drugs on: health status; mo
accidental injuries in addition to those from motor vehicles;
interpersonal aggression and violence; sexual assault; vandalism
prescriptions should routinely
~ drugs designated as high
138
and property damage; pregnancy outcomes; and emotional and
physical development of infants and children.
4. .Principai Assumptions
a The Federal emphasis on research and technicall assistance will
continue, with primary reliance on State and local ~c~vernrr~sr~ts and
the voluntary sector for delivery of alcohol and drug abuse
prevention services.
sResources and services devoted by State and local governments,
and voluntary groups, for drug and alcohol prevention programs
and services will expand.
Federai funding for research and evaluation in drug and alcohol
prevention will modestly increase, with special attention to the
priority areas reflected in the proposed objectives.
a Federal information initiatives will continue to sensitize the public
to the adverse social and health consequences of heavy or frequent
use of alcohol and other drugs.
sStrnng and varied initiatives bothh public and private, will seek to
minimize use of tobacco, alcohol and other drugs by chilcirenn and
aioLesGants--i.ncluding coordinated efforts with alcohol producers,
distributors, retailers and State alcohol control commissions.
~ The allocation of resources by alcohol producers, distributors and
retailers to the marketing, promotion and distribution of alcoholic
beverages will probably increase.
s No dramatic shift in tax or regulatory policies toward avail
and consumption of alcoholic beverages will occur,
consumption trends require reconsideration.
a There will be no dramatic or permanent shift in the availability of
controlled substances outside legitimate medical and scientific
channels.
s The trend will continue toward modification of the criminal law and
its less punitive administration in cases involving arrests for
personall possession of marijuana and other drugs.
To National Iev el only
a Health Interview Survey (HIS). Accidental injuries, disability,
use of hospital, medical and other services, and other
health-related topics. DHHS-National Center for Health
TEWN 365024
Statistics (NCHS). NCHS Vital and Health Statistics, Series
10, selected reports, and Advance Data, selected reports.
Continuing household interview survey; National probability
samples.
Health Examination Survey (HES) and the Health and Nutrition
Examination Survey (HANES). Alcohol and drug related
conditions. DHHS-NCHS. Vital and Health Statistics, Series
11, selected reports. Periodic surveys; National probability
samples; data obtained from physician's examinations.
National Hospital Discharge Survey (HDS ). Utiiization of
hospital services related to misuse of alcohol and drugs.
DHHS-NCHS. NCHS Vital and Health Statistics, Series 13.
Continuing; National probability sample, short stay hospitals.
National Ambulatory Medical Care Survey (NAMCS). Alcohol
and drug related patient-physician encounters. DHHS-NCHS.
NCHS Vital and Health Statistics, Series 13. Continuing
survey; National probability sample, office based physicians.
The lifestyle and values of youth. Non-medical use of
substances in 12 categories including marijuana, barbiturates,
cocaine, prescription drugs, alcohol, cigarettes. DHHS-NIDA.
Drugs in the Class of (survey year date), Behaviors,
Attitudes and Recent National Trends, series Number 20.
Annual surveys since 1975 of high school seniors in a National
sample of public and private schools.
The National Survey on Drug Abuse. Estimates of the levels
of illicit and legal drug use in the United States:
marijuana-hashish, cocaine, hallucinogens, heroin and other
opiates; summary of data on use of inhalants, alcohol,
cigarettes and the non-medical use of psychotherapeutic drugs
legally prescribed. DHHS-NIDA. Highlights from the National
Survey on Drug Abuse, 1977. Continuing survey since 1971;
NNational sarnpie.
s}3rug Abuse Warning Network (DAWN). Drug abuse
encountered in emergency rooms and medical examination
offices. DHHS-NIDA and the Drug Enforcement
Administration. Quarterly reports of provisional data, Series
G, NIDA. Continuing survey in 26 standard metropolitan
statistical areas.
s IsTatienal Prescription Audit (NPA). Drug sales, including
barbiturates, tranquilizers; source of prescription; payment
status, provider type. IMS America, Ltd. , Ambler,
Pennsylvania. IMS reports. Continuing audit of pharmacies
on IMS panel.
140
s Third Special Report to the L7. S. Congress on Alcohol and
1978. Subsequent reports will be available
every three years.
b. To State and/or local level
nal Vital Registration System
-- Mortality. Deaths by cause (including alcohol and drug
related), by age, sex and race. DHHS-NCHS. NCHS Vital
Statistics of the United States, Vol II, and NCHS Monthly
Vital Statistics Reports. Continuing reporting from States;
National full count. (Many States issue earlier reports. )
a Hospitalized illness discharge abstract systems.
-- Professional Activities Study (PAS). Patients in short stay
hospitals; patient characteristics, alcohol and drug related
diagnoses, procedures performed, length of stays.
Commission on Prefessionall and Hospital Activities, Ann
Arbor, Michigan. Annual reports and tapes. Continuous
reporting from 1900 CPHA member hospitals; not a
probability sample, extent of hospital participation varies by
S tate .
Medicare hospital patient reporting system (MEDPAR).
Characteristics of Medicare patients, diagnosis, procedures.
DHHS-Health Care Financing Administration, Office of
Research, Demonstration and Statistics (C}RL}S ) . Periodic
reports. Continuing reporting from hospital claim data; 20
percent sample.
Other hospital discharge systems as locally available.
s Area Resource File (ARF). Demographic, health facility and
manpower data at State and county Ievell from various sources.
DHHS-Health Resources Admirfistration. Area Resource File:
A Manpower Planning and Research Tool, DHHS-HRA-80-4, Oct
79. One time compilation.
s Annual Census of State and County Mental Hospitals. Resident
patients and new admissions to mental institutions; costs,
diagnoses of alcohol psychoses. DHHS-ADAMHA, National
Institute of Mental Health (NIMH ). Mental Health Statistical
Notes, selected issues 3 special reports and tabulations
furnished to the Center for Disease Control. Continuing
reporting; National full count of patients in
mental hospitals.
141
TIMN 365026
NtITR ITIC}N
1, Nature and Extent of the Problem
Issues related to nutrition and food consumption involve complex
interactions among social, cuIturs]., economic and physiological
factors. Adequate intakes of sources of energy and of essential
nutrients are necessary for satisfactory rates of growth and
development, physica3l activity, reproduction, lactation, recovery
from illness and injury and maintenance of health through the life
cycle. Deficits of essential nutrients or energy sources can lead to
sewerall specific diseases or disabilities and increased susceptibility to
others. Excessive or inappropriate consumption of some nutrients
may contribute to adverse conditions, such as obesity, or may
increase the risk for certain diseases (e, g., heart disease,
adult-onset diabetes, high blood pressure, dental caries and possibly
some types of cancer). Such chronic diseases are clearly of complex
etiology, with substantial variation in individual susceptibility to the
factors involved. While the role of nutrients in these diseases is not
definitively established, epidemiologic and laboratory studies offer
-
important insights which may help people
ina food choices so
as to enhance their prospects of maintaining health. See High Blood
Pressure, Physical Fitness and Exercise, and Fluoridation and Dental
Health.
a. Health implications
s Obesity increases the risk for adult-onset diabetes and high
blood pressure, both of which are associated with
cardiovascular disease. Obesity also increases risk of
gallbladder disease, degenerative joint diseases, and some
types of cancer (e.g. endometrial cancer). (Obesity is
defined in this discussion as significant overweight, i.e. 120
percent or more of "ideal" we%ght, )
s Frequent consumption of highly cariogenic foods (those
containing fermentable, orally-retentive carbohydrates),
especially between meals, can nullify some of the caries
preventive benefits of adequate fluoride intake and/or can
cause rampant caries in children with a fluoride deficiency.
*Inadequate nutrition may be one factor associated with poor
pregnancy outcome, including some fraction of low birth weight
infants, and suboptimum menta}l and physical development.
Fsxcessive sodium :
pressure in suscep
associated with high blood
143
TIMN 365027
s Total dietary fat, saturated fat and cholesterol may influence
risk factors for heart disease,
more foods high in fiber may reduce the symptoms of
constipation, diverticulosis and some types of "irritable
in some individuals.
Dietary fat has been associated epidemiologically with some
cancers, but better understanding of the strength of the
relationship must await the outcome of ongoing studies.
Breast fed infants appear to enjoy significant health
advantages when compared with infants fed with breast milk
substitutes, in particular, the immunologic characteristics of
breast milk may increase resistance to infections and perhaps
certain allergies.
s Poor nutrition may enhance susceptibility or impair host
response to infections.
. See Misuse of Alcohol and Drugs and Pregnancy and Infant
Health.
Over the 10 years from 1963 to 1973, mean body weight of
American men and American women, ages 18 to 74, increased
by an average of six pounds and three pounds, respectively.
Height did not play an appreciable role in accounting for the
increase.
s Iron and folic acid deficiencies are particularly common among
pregnant or lactating women.
*Average blood cholesterol levels in the United States among
men of all age groups declined slightly between surveys
conducted in 1960-62 and 1971-74; among women, blood
cholesterol levels declined as much as 7 percent in the age
group 55 to 64, and 6 percent in the age group 65 to 74.
s Some subsets of the population are more prone to obesity than
others:
4 percent of men and 24
ion for obesity (120
-- of men who are not poor, about 12 percent of blacks and 13
percent of whites ages 45 to 64 are obese;
144
-- of men who are poor, only 4 percent of blacks and 5
percent of whites ages 45 to 64 are obese;
-- of women who are not poor, 40 percent of blacks and 29
percent of whites ages 45 to 64 are obese;
-- of women who are poor, 49 percent of blacks and 26
percent of whites ages 45 to 64 are obese.
Prevalence of breast feeding declined from 65 percent in the
late 1940s to 26 percent in 1369. In the past decade,
prevalence of breastfeeding has increased to 45 percent of
newborns, at least initially. In contrast to the past, however,
women of, lower socioeconomic status are now less likely to
breast feed than women of higher socioeconomic status.
Prevontion/ Promotion Measures
a. Potential measures
s Eduoation and information measures include:
-- increasing awareness of ideal weight ranges and safe weight
reduction and weight control strategies based on energy
balance concepts;
-- increasing awareness of the science base regarding
relationships between diet and heart disease, high blood
pressure, certain cancers, diabetes, dental caries and other
conditions;
providing information and behavioral skills to select and
prepare more healthful diets;
developing more effective means of communi
information to people in different age and ethnic
groups;
providing nutrition information and education about healthy
food choices in the home (via the rredia), in schools, at the
worksite, by and to health care providers, at the point of
purchase, as a part of government food service programs
(such as Project Head Start, sohoo3l lunch and. WIC
Programs) and by appropriate advertising;
providing appropriate information on the advantages and
techniques of breastfeeding and when appropriate,
alternatives, particularly for low
145 TIMN 365029
Service measures
-- nutritious breakfast and lunch programs for school children
andd meals for senior citizens;
-- food stamps for low income populations;
__ food supplements for low income women, infants and
children at risk for nutritional problems;
-- nutritious food offered in business and institutional
settings;
-- counseling related to dietary practices routinely offered to
high risk individuals through the health care system,
schools and workplaces;
-- psychosocial support groups focused on weight control and
weight maintenance;
-- counseling regarding the merits of breastfeeding and
appropriate techniques.
Technologic measures include:
-- ensuring nutritional quality and content of manufactured
foodstuffs, from production through consumption;
-- changing livestock practices to produce leaner meat;
__ fortifying certain foodstuffs;
_- developing and making readily available new products lower
fat, saturated fat, cholesterol, sodium and sugars;
-- positioning products in supermarkets so that key
information on caloric, cholesterol, sodium and sugar
contents of products is readily apparent.
Lsgislativs and regulatory measures include:
-- promulgation of guidelines to maintain or improve the
nutritional quality of the food supply;
requiring nutrition labeling on foods about which nutrition
claims are made or to which nutrients are added, including
information on calories, fat, carbohydrate, protein,
cholesterol, sugars, sodium and other nutrients of public
health concern;
146 TDAN 365030
providing explicit discretionary authority to regulate
fortification of foods when it is of pubIic health
significance;
regulation of food vending practices in schools and health
facilities to reduce or eliminate highly cariogenic foods and
snacks;
-- grading standards to give greater emphasis to lower fat
products ;
regulating televised advertisements which promote cariogenic
and non-nutritious foods and snacks and which are directed
at young children.
Economic measures include;
-- studying possibilities for adjusting insurance premiums, in
relation to relative risk, for corporations offering employee
health promotion programs with a nutrition component;
-- government food purchasing support practi
-- assessing feasibility and cost benefits of reimbur
third party payers of counseling services which
appropriate standards;
y
meet
reducing or eliminating local sales taxes on staple foods.
b. Relative strength of the measures
Service programs are likely to be effective in improving the
nutritional status of pregnant women and children and,
perhaps in reducing the incidence of low birth weight infants.
Certain segments of the public have responded to educational
and informational messages about fats and cholesterol by
reducing their intakes. On the other hand, some recent
messages have ' been mixed and contradictory, leaving the
public confused. The I3HHSIUSI3A dietary guidelines provide
a simple set of practical recommendations.
sTechnologic measures hold real promise, particularly if
governmental policies could be generated in support of such
measures and if resultant products are acceptable to
consumers.
With the exception of food sanitation, regulation and economic
incentives have not been employed and are, therefore, of
uncertain potential.
147 TEqN 365031
Education and counseling programs regarding breastfeeding
have been successful in increasing the prevalence of
breastfeeding among middle and upper income women. It is
reasonable to expect similar results from programs targeting
low income women.
. Specific Objectives for 1990
*Improved health status
-- Improvements in nutrition may yield reduced rates of infant
mortality, cardiovascular disease, dental caries and possibly
some cancers. Certain quantified health status objectives are
specified in the sections on High Blood Pressure Control,
Pregnancy and Infant Health, and Fluoridation and Dental
Health. Others are noted beIow. Still others (particularly
those related to heart disease and cancer) are not stated, due
to uncertainties in quantifying the exposure-to-disease
relationship.
a. By 1990, the proportion of pregnant women with iron deficiency
anemia (as estimated by hemoglobin concentrations early in
pregnancy) should be reduced to 3.5 percent. (In 1978, the
proportion w as 7.7 pero ent .)
b. By 1990, growth retardation of infants and children caused by
inadequate diets should have been eliminated in the United
States as a public health problem. (In 1972-73, it was
estimated that 10 to 15 percent of infants and children among
migratory workers and certain poor rural populations suffered
growth retardation due to diet inadaquacies. }
s Reduce
of significant overweight (120 percent
weight) among the U.S. adult population should be
10 percent of men and 17 percent of women,
impairment. (In 1971-74, 14 percent of adult
men and 24 percent of women were more than 120 percent of
"desirad" waight. )
*NOTE: Same objective as for High Blood Pressure Control.
d. By 1990, 50 percent of the overweight population should have
adopted weight loss regimens, combining an appropriate balance
of diet and physical activity. (Baseline data unavailable.)
e. By 1990, the mean serum cholesterol level in the adult
population aged 18 to 74 should be at or below 200 mg/dl. (In
1971-74, for male and female adults aged 18 to 74, the mean
148 TIAIN 365,,
serum cnatesterot ievei was zzu rng/cu. ror a smsuer
sample in 1972-75, mean blood plasma cholesterol
about 211 rng/dl for males aged 40 to 59 and about 210 mg/dl
for females aged 40 to 59.)
f. By 1990, the mean serum cholesterol level in children aged 1 to
14 should be at or below 150 mgldl. (In 1971-74, for children
aged 1I to 17, the mean serum cholesterol level was 176 mgldl.
For a smaller population sample in 1972-75, the mean blood
plasma cholesterol level for children aged 10 to 14 was about
160 mgJdI. )
the average daily sodium ingestion (as measured by
ults should be reduced at least to the 3 to 6
gram range. (In 1979, estimates ranged between averages of 4
and 10 grams sodium. NOTE: One gram salt provides
approximately .4 grams sod%um. )
*NOTE: Same objective as for High Blood Pressure Control.
h. By 1990, the proportion of women who breastfeed their babies
at hospital . discharge should be increased to 75 percent and 35
percent at six months of age. (In 1978, the proportion was 45
percent at hospital discharge and 21 percent at 6months of
age.)
s Increased public/professio
By 1990, the proportion of the population which is able to
identif y the principal dietary factors known or strongly
suspected to be related to disease, should exceed 75 percent
for each of the following diseases: heart disease, high blood
pressure, dental caries and cancer. (Baseline data largely
unavailable. About 12 percent of adults are aware of the
relationship between high blood pressure and sodium intake. )
By 1990, 70 percent of adults should be able to identify the
major foods which are: low in fat cantent, low in sodium
content, high in calories, good sources of fiber. (Baseline data
unavaZ ilable.)
k. By 1990, 90 percent of adults should understand that to lose
weight people must either consume foods that contain fewer
calories or increase physical activity--or both. (Baseline data
unavailable. )
TEMN 365033
149
Improved services/protection
1. By 1990, the labels of all packaged foods should contain useful
calorie and nutrient information to enable consumers to select
diets that promote and protect good health. Similar information
should be displayed where nonpackaged foods are obtained or
purchased.
m. By 1990, sodium levels in processed food should be reduced by
20 percent from present levels. (Baseline data unavai3.abie. )
n. By 1985, the proportion of employee and school cafeteria
managers who are aware of, and actively promoting,
USDA/DHHS Dietary Guidelines should be greater than 50
percent.
nutrition as a core content area in school health educa
required comprehensive school health education at
and . secondary levels. f In 1979, only 10 States
o. By 1990, all States should include nutrition educa
p. By 1990, virtually all routine health contacts with health
professionals should include some element of nutrition education
and nutrition counseling. (Baseline data unavailable.)
t Improved surve37.lance/evaluation system
q. Before 1990, a comprehensive National nutrition status
monitoring system should have the capability for detecting
nutritional problems in special population groups, as well as for
obtaining baseline data for decisions on National nutrition
policies.
4. Principal Assumptions
Bfforts to promote the DHHS/USDA Dietary Guidelines for
Americans will involve wide public and private sector participation
and support.
sGovernmental efforts in nutrition education will be continued and
isnprov ed .
. Public and private efforts to make the population aware o
science base with respect to diet and chronic disease wi
expanded, including those areas for which controversy exists.
~Current research efforts to improve the science base with respect
to diet and disease will continue to grow, with improved
dissemination of information.
150
a Research to identify effective measures of nutrition education will
be productive.
Gurrent efforts to develop sNational nutrition monitoring and
surveillance system will be maintained.
sPrograms to promote economic and physical access to high quality
foods will be continued and improved.
~ Cooperation between Government and the private health care sector
will increase on nutrition related issues.
Major food processors and distributors will incorporate nutrition
principles and concepts into their food and marketing strategies
and messages.
s Public and private sector efforts to maintain the wholesomeness of
the food supply will continue.
e Better methods to monitor the pc,puiat.ion's knowledge and
understanding of nutrition will be developed.
s IVutrition messages aired over television and radio will continue,
and will be more explicit as to healthful diets.
a Cvmprehensive school health education, including nutrition
education, will become a more integral part of the K-12 curriculum.
Health professionals will play a larger role in the provision of
nutrition information.
s A set of principles of human nutrition will be defined and used as
a basis for public policy decisions.
sHea3th and Nutrition Examination Survey (HANES). Height,
weight, skinfold thickness; serum cholesterol values and breast
feeding. DHHS-National Center for Health Statistics (NCHS).
HANES 1, 1971-1974; HANES iI, 1979. NCHS Vital and Health
Statistics, Series 11. Periodic surveys ; data obtained from
physical examinations, National probability sample.
sHeslth Interview Survey (HIS ). Food practices, food habits,
based on data collected in a continuing nationwide survey
through personal household interviews. IIHHS-NCHS. Vital
and Health Statistics, Series 10. Continuing survey;
household intervi$w3 National probability sample.
151 TININ 365035
Prevalence of dyslipidemias i
rol levels in hypercholesterolemic men
5-59 years. DHHS-National Heart, Lung,
Continuous reporting from 10
Hypertenszon Detection and Follow Up Program. Nutrition
related risk factors among persons at high risk of coronary
and vascular diseases. I)HHS-NHLBI. NHLBI- (NIH)
Hypertension Task Force Reports, Numbers 8 and 9. One time
survey.
e Multiple Risk Factor Intervention Tria
whether nutrition and other risk reduc
men 35-54 years of age who are above average ris
from coronary disease, can yield significant reduction
mortality from coronary heart disease. DHHS-NHLBI. Reports
due 1983.
s Marketing Research Survey. Prevalence and trends of
breastfeeding at one week of age. Marketing Research
Department, Ross Laboratory, Columbus, Ohio. Reported in
Pediatrics, November 1979. Continuing survey; representative
sample of short stay hospitals; recall response of mothers after
six months.
seholds.
Report. USDA-Consumer and Food Economics Institute, Human
Nutrition Center (IHNG). Collected nationally about every 10
years since 1935. National survey
s National Survey of Family Growth (NSFG). Prevalence of
breastfeeding. DHHS-NCHS, Vital and Health Statistics,
Series 23, selected reports. Interview survey of 10,000 women
in National probability sample representing American women
15-44 years of age.
*Nutrient Composition Data. Tabular analysis of nutrient
composition of specific food products. USDA-Consumer and
Food Economics Institute. Agriculture Handbook Number 8:
Composition of Foods -- Raw, Processed and Prepared.
Continuous reporting.
s Food Labeling. Use of nutrition Iabeling ; nutrition ;ontent ;
impact of numerous regulatory actions related to nutrition
labeling. DHHS-Food and Drug Administration (FDA) .
Continuing surveys.
TLWN 365036
152
Consumer Price Index (GPI ). Price changes across Nation for
a fixed market basket of footis and services. Department of
Labor-Bureau of Labor Statistics (BLS). Monthly CPI
Reports. Continuing survey; Nationall sample.
Nutrition surveillance report. Selected indices of nutritional
status from ten selected States, health department clinics, WIC
screening, and Head Start Programs. CDC Nutrition
illance Reports. DHHS-Center for Disease Control
inia from selected sources.
National Menu Census. Tabulation of about 460 food items sold
away from home as to "good," "slow," or "never sell,"
including demographic data. Institutians Magazine. Chicago,
Illinois. Reporting annually in April 1st issue of Institutions.
Continuing survey; National sample of eating establishmsnts.
Nutritional Status Monitoring System (NSMS). Comprehensive
National nutrition status monitoring system to be developed and
implemented jointly by DHHS and USDA. A coordinated system
drawing on health and other vitall statistics from DHHS, and
food use and consumptinnn data from USDA and DHH.S.
DHHS-Office of the Assistant Secretary for Health WASH ),
Nutrition Coordinating Office.
To State andlor local Ievel
National Vital Registration System
-- Mortality. Deaths by cause (including fetal and infant
mortality), by age, sex and race. DHHS-NCHS. NCHS
Vital Statistics of the United States, Vol II, and NCHS
Monthly Vital Statistics Reports. Continuing reporting from
States; National full count. (Many States issue earlier
reports.)
-- Natality. Births and birth rates by place of occurrence
and by the mother's place of residence, age, race and
parities. I3HHS-NCHS. NGHS Vital and Health Statistics,
Series 21, selected reports, and Monthly Vital Statistics
Repnrt. Birth data obtained from certificates of live births
U.S. residents filed throughout the United States. Birth
rates calculated on the basis of the number of women 14-49
years of age residing in the respective areas enumerated in
census years, and estimated for inter-census years.
*National. Morbidity and Mortality Reporting S ystsm. Numbers
of 46 reportable diseases (including foodborne outbreaks)
deaths in 121 U.S. cities. DHHS-CDC. CDG Morbidity and
Mortality Weekly Report, and annual reports. Morbidity:
TIMN 365037
153
continuous reporting from State health depar
physician reports. (Completeness of reportin
since not all cases receive medical care an
conditions are reported. ) Mortality: co
volunteer pane1l of health departments in 121
count.
s on basis of
aY I
reated
s reporting ;
.S. cities, full
s Selected health data. DHHS-NCHS. NCHS Statistical Notes
for Health Planners. Compilations and analysis of data to
State level.
~Area Resource File (ARF). I3emographic, health facility and
manpower data at State and county level from various sources.
DHHS-Iiealth Resources Administration. Area Resource File:
A Manpower Planning and Research Tool, DHHS-RRA-8II-4, Oct
79. One time compilation.
154
PHYSICAL FITNESS AND EXERCISE
Nature and Extent of the Problem
The health benefits associated with regular physical fitness and
exercise have not yet been fully defined. Based on what is now
known it appears that substantial physical and emotional benefits,
direct and indirect, are possible. Yet most Americans do not engage
appropriate physical activity, either during recreation or in the
course of their work. For the purposes of this discussion,
"appropriate physical activity" refers to exercise which i
large muscle groups in dynamic movement for periods of 20 minutes
or longer, three or more days per week, and which is performed at
an intensity requiring 60 percent or greater of an individual's
cardiorespiratory capacity. Exercise to improve flexibility and
muscular strength may reduce the frequency of musculoskeletal
problems and is an important supplement to cardiovascular
conditioning activities.
a. Health implications
:Most people feeil better when they exercise.
s Physical inactivity can result in decreased physical working
capacity at all ages, with concomitant decreases in physiologic
function and health status.
~ Physical
developin
associated with an increased risk of
obesity and its disease correlates.
a Physical inactivity is associated with increased risk of coronary
heart disease.
Apprapriate physical activity may be a valuable tool in
therapeutic regimens for control and amelioration (rehabilitation)
of obesity, coronary heart disease, hypertension, diabetes,
musculoskeletal problems, respiratory diseases, stress and
depression/anxiety. Such physica}l activity, however, is still
not routinely prescribed for the treatment of these conditions.
b. Status and trends
Though physical fitness and exercise activities have increased
in recent years--and over 50 percent of adults reported regular
exercise in popular opinion polls--generous estimates place the
proportion of regularly exercising adults ages 18 to 65 at
something over 35 percent.
155
TIMN 365039
approximately 5 percent of all
age 20, and 10 percent of men aged 20 to
s About 36 percent of adults ages 65 and older were estimated
in 1975 to take regular walks.
sOnly about a third of children and adolescents ages 10 to 17
are estimated to participate in daily school physical education
programs, and the share is declining.
* Many high school programs focus on comp
involve a relatively small proportion of students.
* Though grewing, the awareness of the health benefits of
regular exercise
Only a sma3.3l proportion (about 2.5 percent) of companies and
institutions with greater than 500 employees offer fitness
programs for their workers.
sCertain groups demonstrate disproportionately low rates of
participation in appropriate physical activity, including girls
and women, older people, physically and mentally
handicapped people of all ages, inner city and rural
residents, people of low socioeconomic status and residents
of institutions.
Z . Preventien/ Promotien Measures
Potential measures
Education and information measures inelutie:
and radio public se
provide information on appropriate physical activity and its
benefits ;
providing information in school and college-based programs;
-- providing information in health care delivery systems,
including incorporation of queries about exercise habits into
the routine clinical history;
encouraging health care providers, especially in HNiOs,
community health centers and other organized settings, to
prescribe appropriate exercise in weight loss regimens as a
complementary treatment modality in the management of
several chronic diseases, and to give patients 65 years and
older and the handicapped more detailed information on
156
together with warnings about
adopting an exercise component by community service
agencies (such as the American Red Gross, the American
Heart Associat%on);
-- assuring that all programs and materials related to diet and
weight loss have an active exercise component;
-- tailoring education programs
characteristics of specific populatio
needs and
to the
sures include:
-- providing physical fitness and exercise programs to school
children, and ensuring that those proorams emphasize
activities for all childrenn rather than just competitive sports
for relatively few;
-- providing physical fitness and exercise programs
coIIe -ges i
-- providing worksite-based fitness programs which are linked
to other health enhancement components (e.g., smoking
cessation, nutrition improvement) and which have an active
outreach effort;
-- incorporating exercise and fitness protocols as regular
clinical tools of health providers.
a Technologic measures include:
-- increasing the availability of
promoting the development of new
private and corporate entities (e.g.,
paths, parks, pccls) ;
facilities and
by public,
ails, bike
-- upgrading existing facilities, especially in inner city
neighborhoods, and involving the population to be served at
all levels of planning.
Leeislative and resiulatorv measures include:
city council support for bicycle and walking paths for use
in trips to work and school;
developing and operating local, State and National park
facilities which can be used for physical fitness activities in
urban areas;
157
TIMN 365041
e number of school-mandated physical education
programs that focus on health-related physical fitness ;
-- establishing State and local councils on health promotion and
physical fitness;
allowing expenditure of funds for fitness-related activities
under Federally funded programs guided by Federal
regulations.
-- tax
fitness
tives for the private sector to offer physical
-- encouraging
company tin
of facilities;
for employees #
s to permit employees to exercise on
giving employees flexible time for use
-- offering health and life insurance policies with reduced
premiums for those who participate in regular vigorous
physical activity.
Relative strength of the measures
s Programs which are most likely to be successful in recruiting
new participants to appropriate physical activity include those
which offer services and facilities to individuals, and economic
incentives to groups and individuals.
9 On the other hand, programs which can more easily be
implemented include those related to the provision of public
information . and education and improving the linkages with
other health promotion efforts.
The effectiveness
limitation in knowle
measures is handicapped by the
respect to:
-- the relation between exercise and physical and emotional
h ealth ;
-- the optimum types of exercises for various groups of people
with special needs;
-- the appropriate way to measure levels of physical fitness
for various age groups.
158
TEWN 365042
. Specific Objectives for 1990
# Improveti health status
-- Increased levels of physical fitness may contribute to reduced
heart and lung disease rates, possibly reduced injuries among
the elderly, and, more broadly, an
well-being which may reinforce positive
other areas. Currently, however,
status objectives for physical fitness
developed.
Reduced risk factors
enhanced s
health behavio
t%fiable hea
ise
of
a. By 1990, the proportion of children and adolescents ages 10 to
17 participating regularly in appropriate physical activities,
particularly cardiorespiratory fitness programs which can be
carried into adulthood, should be greater than 90 percent.
(Baseline data unavailab
b. By 1990, the proportion of children and adolescents ages 10 to
17 participating in daily school physical education programs
should be greater than 60 percent. (In 1974-75, the share was
33 percent.)
c. By 1990, the proportion of adults 18 to 65 participating
regularly in vigorous physical exercise should be greater than
60 percent. (In 1978, the proportion who regularly exercise
was estimated at over 35 percent. )
d. By 1990, 50 percent of adults 65 years and older should be
engaging in appropriate physical activity, e.g., regular
walking, swimming or other aerobic activity. (In 1975, about
36 percent took regular walks. )
s Incrss.sed public/professional awareness
e. By 1990, the proportion of adults who can accurately identify
the variety and duration of exercise thought to promote most
effectively cardiovascular fitness should be greater than 70
percent. (Baseline data unavai.l.able. )
By 1990, the proportion of primary care physicians who include
a careful exercise history as part of their initial examination of
new patients should be greater than 50 percent. (Baseline data
unauailable. )
159
Improved services/protection
g. By 1990, tthe proportionn of employees of companies and
institutions with more than 500 employees cffering
cmplcycr-sponscrcd fitness programs should be greater than 25
percent. (In 1979, about 2.5 percent of companies had formally
organized fitness programs. )
s Improved surveillance/ cval.uation systems
h. By 1990, a methodology for systematically assessing the physical
fitness of children should be established, with at least 70
percent of childrenn and adolescents ages 10 to 17 participating
uch an assessment.
i. By 1990, data should be available with which to evaluate the
short and long-term health effects of participation in programs
of appropriate physical activ%ty.
.
j. By 1990, data should be available to evaluate the effects of
participation in programs of phys
and health care costs.
job performance
k. By 1990, data should be available for regular monitoring of
National trends and patterns of participation in physical
activity, including participation in public recreation programs in
communit
a Increased physical activity by the American public will re
overal3l improvements in health.
sPerscnal commitment to enhance health will become a prarr,
factor promoting increased participation in exercise activities i
United States.
sVoluntary agencies, private corporations and government will
expand their commitment to physi
Private industry and rel
physical fitness, which w
pr cducts .
Environmental, cultural and
attitudes toward, and participa
will support activities promoting
o promote increased sales of their
al differences influence
gular exercise.
+. Inner city residents will continue to have fewer adequate facilities
and appropriate activity programs.
160
TIMN 36-5044
s Special attention will be required to make gains in participation
among lower socioecon
There will be a reversal of the trend in reductions of school-based
programs aimed at promoting physical fitness. However, these
programs will not necessarily be founded in the traditional ph.ysica3l
education mold.
* New school-base
beyond compe
embrace activities wh.i.chh expand
s The increasing costs associated with health
policy to emphasize measures such as phys
health.
a
a Reduced levels of physical fitness in the work force may re
absenteeism from acute illness and, accordingly,
sed productivity. Thus, employers have incentives for
hysical fitness programs to their employees.
5. Data Sources
a.
self-reported change over previous year. Survey for General
Mills, conducted by Yankaiovich, Skelly and White. Family
Health in an Era of Stress. General Mills, Inc., 9200 Wayaata
Boulevard, Minneapolis, Minnesota, 1979. One time survey 3
National probability sample.
Extent of regular exercise. (Non-work related only. ) Survey
for Pacific Mutual Life Insurance Company, conducted by Louis
Harris and Associates. Health Maintenance, 1978. Pacific
Mutual Life Insurance, Newport Beach, California.
Public attitudes regarding physical fitness. Attitudes,
knowledge and behavior regarding physical fitness and
exercise. Survey for Great Waters of France, conducted by
Louis Harris and Associates, Inc. The Perrier Study; Fitness
in America, 1979. One time survey; representative sample and
special sample of runners.
parti.cipationn inn exercise reported in household survey,
s Extent of regular exericse. (Non-work related only.)
Advance Data from Vital and Health Statistics,
Continuing survey; National probability sample.
job related physical activity; regular participation in exercise.
DHHS-National Center for Health Statistics (NCHS )= NCHS
Vital and Health Statistics, Series 10, selected reports, and
To National level only
9 Health Interview Survey (HIS). Extent of regular exe
161
,yMN 365045
nd/or local level
s Exercise programs in schools, Student enrollment in physical
fitness activities; program content and scheduling. Councils
on Physical Fitness, selected States only.
s Student physical fitness levels. Councils on Physical Fitness,
selected States only.
162 TEMN 365046
CONTROL OF STRESS AND VIOLENT BEHAVIOR
Nature and Extent of the Problem
Some stress may be beneficial. On the other hand, stressful
conditions can result in substantial dysfunction. Public perception
of the role of stress as a contributor to major illness and diminished
quality of life has focused considerable attention upon the need to
provide practical and ethical means of favorably influencing this
pervasive condition of 20th century life. As used here, the term
stress refers to those pressures and tensions (whether behaviorally,
biologically, economically or environmentally induced) which, unless
suitably managed, can lead to psychological or physiological
maladaptations manifested in phenomena such as fatigue, headache,
obesity, absenteeism, illness, accident-proneness or violence.
Because the socioeconomic impact of contemporary psychosocial stress
and its biologic devastation is probably enormous, comprehensive
public health programs aimed at stress management are of high
priority. However, it would be unwise to mount extensive programs
on the basis of beliefs rather than evidence. The major
responsibility and challenge for a stress management strategy is to
find means to identify individuals or groups especially vulnerable to
stress, to provide health professionals and the public with whatever
accurate information exists on stress identification and management
and, when the answers are not known, to formulate the questions
that will offer the best chance for obtaining rational answers.
Violent behsvior- -in its many forms--exacts a huge toll on America;s
physical and mentall health. Suicide and homicide lead to thousands
of premature deaths annually. Assault, including rape and child and
spouse abuse cause much injury and emotional suffering. Numerous
factors underlie these violent forms of behavior. Heath programs
alone cannot deal with these factors. Many major aspects of American
social structure are involved--the family, the community, the system
of stratification, the educational system and the econonlie structure.
Much remains unknown regarding means of reducing mortality
associated with violent behavior. Even in the absence of such
information important steps can be taken.
a. Health impicatiens
~ Evidence linking psychosocial and behavioral factors to major
health disorders seems persuasive enough to justify the
conclusion that stress is importantly involved. However, there
is a clear need to study and evaluate the interaction of
psychological, environmental and biological factors in
laboratory, clinical, industrial and school settings.
163
TIAIN 365047
a There is much evidence that many causes of stress (situ
external demands, challenging life events) have clearly
measurable physiologic and psychological effects.
s Usually, however, reactions or responses to stress are
short-term; homeostasis is restored through various coping
mechanisms without damage to the organism.
sMuch remains to be elucidated about the variability of peop
vulnerability to stress, including their developmentall histories,
their psychological defenses and coping capabilities. While
most people face I%fs#s stresses with appropriate resistances, a
ority do not. For these highly susceptible groups and
iduals, stress intervention programs would be desirable.
*Whsther stress becomes a problem for any given i
depends on a combination of factors, unique to that person,
that may bolster resistance andJor resilience. Also, any
.individualss perception of stress and reaction to it may vary
with time, circumstance and environmental factors.
in the population appear to be particularly
vulnerable to stress overload (adolescents, the elderly, the
unemployed, workers in certain occupations, people who
experience major disruptions in their lives such as death of a
spouse or 'job change).
:Strass may function as a precipitator of dysfuncti
as a predisposing factor or as a sustaining factor in chronic
conditions, or as a precipitator of violent
.
sEvidsnce on the disease effects of stress is strongest for
depression, coronary heart disease, peptic ulcer, asthma and
diahetas.
Evidsnca is also available regarding the relationship of stress
to mental health problems, substance abuse, accidents, lower
back pain, terminal renal failure, skin rashes, tuberculosis,
multiple sclerosis, cancer and childhood streptococcal
Znf*.rVt1AJ1Z..7 i
~Unmanagad stress plays a major role in suicides and homicides
which are leading causes of death among youth in the 15 to 24
age group.
Stress is also related to family violence, including child abuse.
aA possible major mechanism for the relationship of stressful life
events on certain disease states is through suppression of the
normal immune response of the organism. However, precise
164
TIMN 365048
knowledge of the mechanisms relating stress to psychological
and physicall dysfunction is not clearly identified.
Status and trends
s In one recent National survey, 82 percent of those polled
indicated that they "need less stress in their lives."
# In 1978 there were 5,100 deaths from suicide among people
ages 15 to 24.
s In recent years suicide has ranked as the ninth leading cause
of death for all age groups. It ranks as the second leading
cause of death among youths 15 to 24. Increasingly it is also
an important cause of death among the aged.
s It is estimated that 200,000 to 4millian cases of child abuse
occur each year and that 2,000 children die each year in
circumstances suggesting abuse or neglect.
sHundreds of thousands of cases of violent (but non-fatal)
assault occur each year. These include instances of spouse
abuse and rape.
s The death rate from homicide among black males ages 15 to 24
increased from 46.4 per 100,000 population in 1960 to 72.5 in
1978.
s Min.ority groups have a greater risk of death from homicide
than whites. An estimated 60 to 80 percent of homicides occur
as the result of personal disagreements and conflicts.
Firearms were used in 63 percent of murders occurring in
1977, with handguns used in half.
s There are few (if any ) definitive measures identified of the
prevalence of harmful stress.
s There is increasing public awareness that stress may be
harmful.
s The public has limited accurate knowledge and information
about what can be done to control (reduce) stress. This leads
to simpl.istic perceptions and techniques which may be harmfull
andlor impede successful long-term
2. Prev entionl Pro[notion Measures
Programs of any nature directed at stress management must first
relate to the individual perception, motivation, evaluation and
response to the stress. A sense of well-being and good stress
165
TINW 365049
management usually accompany some combination of the following life
job satisfaction; people who provide affection and
sense of belonging to a social
group; time for self; physical fitness; adequate sleep; and freedom
frum disease.
Certain approaches seem prudent for the management of stress:
-- individually focused efforts (exercise, relaxation tec
adequate sleep, general T'self-carelt, improved psycho
mechanisms);
-- social group focused efforts (mutual aid, self-help support
groups);
-- societally or institutionally focused efforts to change
unsatisfactory environmental conditions such as overcrowded
housing, pollution, stressful working conditions; to modify social
norms or values such as in relation to smoking and drinking ; and
to inform the public regarding the role of stress.
A
major
ive for
s Education and information measures include:
and self-mastery.
behavior, while occurring in all strata of
society, exacts a far greater toll among minority and other
deprived groups in the United States. Thus many
measures which would improve the economic and social position of
these groups might well be accc3MIpanied by a reduction in rates of
homicide.
a. Potential measures
-- increasing the public's awareness, through planned
campaigns utilizing the appropriate media, that stress can
be an antecedent of illness and that stress management can
be an important component of health;
fields of medicine and
stress diagnosis an
-- developing
and thus to provide the will to
t,
-- helping parents recognize and deal
ities of health
166
training secondary, elementary and preschool teachers to
include discussictnn of stress recognition and management in
school health curricula;
training of police in handling calls involving domestic and
interpersonal disputes which would potentially lead to
violent behavior;
-- public education, especially for high risk groups, on steps
to take to reduce risks of rape;
training all "helping" professionals regarding
indicate high risk for suicide;
-- helping the public be aware of indicators of possible
suicide.
-- See Pregnancy and Infant Health.
9 Service measures include:
-- hotlines for people under acute stress (suicide, child abuse
prsvenfion );
stress management programs in work places;
stress management programs targeted fo- adolescents,
parents and the elderly;
stress appraisal analysis (self-administered or performed by
a legitimate objective outside source);
professional and social support systems to assist in
resolution of stressful life events, including self-help
groups such as Reach for Recovery, bereavemenft groups,
single parent groups;
-- information and counseling with regard to individually
appropriate leisure and stress-reducing activities including
exercise;
-- a variety of self-help relaxation and biofaedback
techniques, which can be individualized in concert with a
diversity of lifestyles and work requirements;
-- psycho-physiologic tests to aid in assisting employees who
are having difficulty adjusting to their work and to their
co-workers;
167
,rIMN 365051
support services for inevitable or necessary life change
events--especially in relation to death, separation, job
changes and geographic relocation;
domestic crisis teams to defuse domestic disputes;
targeting the above measures to high risk populations and
individuals with low coping abilities;
-- evaluating
-- special
ntion efforts ;
for suicide prevention and child abuse;
for persons who have attempted suicide;
mutual-aid groups for child abusing parents;
shelters for abused wives (and husbands);
training all health (and other human services--
educational) personnel to be alert to evidence
abuse.
Technologic measures include:
c
-- actions by employers, labor and government to reduce
stress-creating work environments t
-- reducing stressful aspects of the environment such as noise
pollution and overcrowding;
s Legislative and regulatory measures inciude:
ate employment opportunities for youth ;
to limit the availability of handguns, to
iaes
suicides that occur
stressfui periods ;
-- strengthening mandatory child abuse reporting laws.
sThe relative strength of potential stress intervention efforts
(measures) is not yet known.
Stress reduction and management often require behavioral
changes, but most physicians and other health professionals
are not trained in assisting their patients to modif y their
lifestw3.es or behavior.
168 TIMN 365052
measures call for extensive
attitudes and complex cultural
reappraisals at all levels, public and private. These cannot be
expected to take place quic
sAt a minimum, vigorous efforts at early detection and
assistance will be necessary at common sites where this is
possible--i.e. schools and worksite.
s Little is known about the relative strength of potential efforts
to reduce rates of violent behavior. There is some evidence
that suicide prevention and rape prevention efforts do have an
impact--at least with certain populations.
3. Specific Objectives for 1990
*Improved health status
a. By 1390, the death rate from homicide among black males aged
15 to 24 should be reduced to below 60 per 100, 000. (In 1978,
the homicide rate for this group was 72.5 per 100,000.)
b. By 1990, iinjuries and deaths to children inflicted by abusing
parents should be reduced by at least 25 percent. (Reliable
baseline data unavailable--estimates vary from Zi3}, {i{l0 to 4
million cases of child abuse occurring each year in this
country. )
c. By 1990, the rate of suicide among people 15 to 24 should be
below 11 per 100,000. (In 1978, the suicide rate for this age
group was 12.4 per 100,000).
Reduced risk factors
-- Certain risk factors for stress are well-identified.
been addressed in the sections on Family Planning
pregnancies), Occupational Safety and Health, Misuse o
and Drugs, and Physical Fitness and Exercise. Other risk
factors for stress such as those imbedded in family history and
hanges, are not easily controlled or quantified and
ified as measurable objectives.
d. By 1990, the number of handguns in priv
s
have declined by 25 percent. (In 1978, the tcatall number of
handguns in private ownership was estimated to be 30 to 40
millzon. )
169
TIMN 365053
a Increased publie/profe
e. By 1990, the proportion of the population over the age of 15
which can identify an appropriate community agency to assist in
coping with a stressful situation should be greater than 50
percent. (Baseline data unavaiIabie. )
f. By 1990, the proportion of young people aged 15 to 24 who can
identify an accessible suicide prevention "hatline" should be
greater than 60 percent. (Baseline data unavailable. )
g. By 1990, the proportion of the primary care physicians who
take a carefuI history related to personal stress and
psychological coping skills should be greater than 60 percent.
(Baseline data unavaiiable. )
Improved services/protection
h. By 1990, to reduce the gap
number of persons reached by mutual suppor
groups should double from 1378 baseline figures. (In
estimates ranged from 2.5 to 5 million, depending on
definition of such graups. )
By 1990, stress identification and -controI should become integral
components of the continuum of health services offered by
organized health programs. (Baseline data unavaiiable. )
, By 1990, of the 500 largest U.S. firms, the proportion offering
work-based stress reduction programs should be greater than
30 percent. (Baseline data urravaiiable. )
Improved survefll.ance/ evaluation systems
k.$y 1985, suru eys should show what percentage of the U.S.
population perceives stress as adversely affecting their health,
and what proportion of these are trying to use appropriate
stress control techniques.
By 1985, a methodology should have been developed to rate the
-major categories of occupation in terms of their environmental
stress Ioad s.
m. By 1990, the existing knowledge base through scientific inquiry
about stress effects and stress management should be greatly
enlarged.
n. By 1990, the reliability of data on the incidence and prevalence
of child abuse and other forms of family violence should be
greatly increased.
170
TIMN 365054
S
sMuch of stress and stress-related illness is the result of
fundamental socioeconomic status over which the health system has
limited control.
Further research will establish the relationship of stress to illness.
Ressarch will identify and demonstrate effective stress-control
measures.
~ The role of physical fitness and nutrition in successfully managing
stress will be better understood.
s Vsrious health care systems will be wiDing to assist patients in
making the changes in their lifestyles that may be necessary to
reduce stress and to improve coping with stress.
s Health professionals, health organizations, industry and labor will
devote increased attention to understanding the relation of stress
to illness and to violent behavior, as well as to better methods of
stress reduction and management.
~ Medical and nursing schools will offer instruction targeted at
understanding the pathophysiology of stress and its management;
training of other health professionals will also include stress
education, as wit.ll continuing education programs for all health
professionals.
s Hotlines and community support groups will prove effective in
aiding individual efforts to cope with personal crises.
Actions at the individual and community levels will foster measures
to reduce the availability of handguns.
Actions will be taken at the Federal, State, and local levels to
increase the employment opportunities for youth.
a.
a National Vital Registration System--Mortality. Deaths by cause
(including homicides and suicides), by age, race, and sex.
DHHS-NCHS. NCHS Vital Statistics of the United States,
Volume II, and NCHS Monthly Vital Statistics Reports.
Continuing reporting from States; full National count. (Many
States issue earlier reports ).
171
TIAIN 365055
sPublic attitudes regarding stress. Perceptions of how
problems of everyday life relate to health and mental health.
Survey for General Mills, conducted by Yankelovich, Skelly
and White, Inc. Family Health in an Era of Stress. General
Mills, Irsc.,9200 Wayzata Bnulevard, Minneapolis, Minnesota.
One time survey; Nationall probability sample.
To State andlor local level
No data sources unless questions on State or local household
interview surveys.
172
M[N 365056
ACKNQWLEDGEMENF5
Preparation of this document was a joint effcrt of the Center for
Disease Control and the Health Resources Administration, coordinated by
the Office of Disease Prevention and Health Promotion. Contributions
were made by a wide variety of agencies and individuals, listed below.
Special acknowledgement should be given to the staff work of Katharine
G. Bauer and Martha Katz of the Office of Disease Prevention and Health
Promotion; Julia M. Fuller, James W. Stratton and Dennis Tolsma of the
Center for Disease Control; Laurel Carson Shannon and Cheryl Polansky
of the Health Resources Administration; and Ronald W. Wilson of the
National Center for Health Statistics.
PAR.T ZG IPAfi iNG AGENC IES
Public Health Service (HHS)
Alcohol, Drug Abuse, and Mental Health Administration
Gerald L. Klerman,
.I}.. Administrator
Center for Disease Control
William H. Foege, M.D., Director
Food and Drug Administration
Jere Goyan, Ph.D., Commissioner
Health Resources Administration
Henry A. Foley, Ph.D., Administrator
Health Services Administration
George I. Lythcott, M.D., Administrator
National Institutes of Health
Donald S. Fredrickson, M.D., Director
Office of Adolescent Pregnancy Programs
Lula Mae Nix, Ed.D., Director
4f fice of Dental Affairs
John G. Greene, D.M.D., Chief Dental Officer
Office of Disease Prevention and Health Promotion
J. Michael McGinnis, M.D., Deputy Assistant Secretary for Health
Office of Environmental Affairs
James F. Dickson, ZZI, M.II., Senior Advisor
173
Office of Health Maintenance Organizations
Howard Viet, Director
Office of Health Planning and Evaluation
Suzanne Stoiber, Deputy Assistant Secretary for Health
Office of Health Research, Statistics, and Technology
Ruth S. Hanft, Deputy Assistant Secretary for Health
National Center for HeaLth Services Research
Gerald Rosenthal, Ph.D., Director
National Center for Health Statistics
Dorothy P. Rice, Director
Office of Intergovernmental Affairs
Alonzo S. Yerby, M.D., Deputy Assistant Secretary for Health
Clf fice of International Health
John H. Bryant, M.D., Deputy Assistant Secretary for Health
Office of Population Affairs
Ernest Peterson, Acting Deputy Assistant Secretary for Health
Office of Public Affairs
Mort Lebow, Directcsr *
Office on Smoking and Health
John M. Pinney, Director
Health Care Financing Administration (HHS )
Howard Newman, Administrator
Office of Human Developuent Services (HHS)
Cesar A. Perales, Assistant Secretary for Human Development
Services
Social Security Administration (HHS)
William J. Driver, Commissioner
of 4riculture
Carol Tucker Forema.n., Assistant Secretary for Food and Consumer
Services
174
TIAW 36.50.58
Consumer Product Safety Commission
Susan B. King, Chairman
Department of Defense
John H. Moxley, III, M.D., Assistant Secretary for Health Affairs
Department of Education
Floretta D. McKenzie, Acting Deputy Assistant Secretary,
Office of School Improvement
Environmental Protection Agency
Douglas M. Costle, Administrator
Federal Trade Commission
Hichae3. Pertschuk, Chairman
Department of Housing and Urban Development
Father Geno Baroni, Assistant Secretary for Neighborhoods,
Voluntary Associations and Consumer Protection
Department of the Interior
Margaret G. Maguire, Deputy Director, Heritage, Conservation,
and Recreation Service
Department of Labor
Eula Bingham, Ph.D., Assistant Secretary for Occupational Safety
and Health
Department of Transportation
Joan Claybrook, Administrator, National Highway Traffic Safety
Asiministration
Department of the Treasury
Richard J. Davis, Assistant Secretary for Enforcement and
Operations
TIMN 365059
175
CONTRIBUTORS AND REVIEWERS
The following individuals participated in va
the document. Chairpersons and Recorders o]
Atlanta Conference are noted with an asterisk.
stages of the development of
15 Work Groups of the 1979
Herbert K. Abrams, M.D., M.P.H.
Health Sciences Center
The University of Arizona
Michael Adams, M.D.
Office of Program Planning and
Evaluation
Center for Disease Control
Chung-Hae Ahn
Office of International Health
Office of the Assistant Secretary for
E.H. Ahrens, .ir., M.D.
The Rockefeller University
Allen, M.D.
Department of Public Health
State of Tennessee
Archie F. Allen
Domestic Operations C3f f ice
ACTION
*Myron Allukian, D.D.S., M.P.H.
Bureau of Community Dental Programs
City of Boston
Ronald Altman, M.D.
New Jersey Department of Health
George R. Anderson, M.D.
Bureau of State Health Planning and
Resource Development
Texas Department of Health
Linda Andreasen
Division of Health
Nevada Department of Human Resources
177
*Nicholas A. Ashford, Ph.D., J.D.
Center for Policy Alternatives
Massachusetts Institute of Technology
Dean A. Austin, Ph.D.
Lincoln Public Schools
Lincoln,
Karen J. Axnick, R.N.
Department of Infection Control
Stanford University Hospital
Matilda A. Babbitz
School of Public Health
University of South Carolina
John Bagrosky
Office on Smoking "ani Health
Office of the Assistant Secretary for
Health
Lillian Bajda
Depar tment of Health
Statee of New Jersey
Ned E. Baker, M.P.H.
Health Planning Association of
Northwest Ohio
Susan Sorem Baker
Of f ice of Health Planning and
Evaluation
Office of the Assistant Secretary for
Health
Wendy Baldwin, Ph.D.
National Institute of Child Health and
Human Development
National Institutes of Health
Linda Balog
Schoo1l of Public Health
University of South Carolina
TIMN 365060
Albert Balows, Ph.D.
Bureau of Laboratories
Center for Disease Control
Diane Barhyte
Association
Kathryn E. Barnard, R.N. s Ph.D.
University of Washington
Seattle, Washington
Carolyn Barnes
Bureau of Training
Center for Disease Control
*He len B. I3arnes, M. D.
Department of Obstetrics and Gynecology
University of Mississippi Medical Center
*Patricia Z. Barry, Dr.P.H.
Department of Health Administration
University of North Carolina
James R. IiealI, Ph.D.
Department of Labor
Lynn Beasley
Palmetto-Lowcountry Health Systems
Agency, Inc.
Summerville, South Carolina
Dan E. Beauchamp, Ph.D.
School of Public Health
University of North Caroiina
Ruth A.
Center for Health Promotion
American Hospital Association
Selina Bendix, Ph.D.
Department of City Planning
City and County of San Francisco
Ira Bernstein
College of Medicine
tJniversitv of Vermont
Donald A. Berreth
Office of Information
Center for Disease Control
178
Pay R. Biles, Ph.D.
Department of Health and Safety
Education
Kent State University
*Iianry Blackburn, M.D.
School of Public Health
University of Minnesota
Chris Bladen
Office of the Assistant Secretary for
Planning and Evaluation
Department of Health and Human Services
*Howard T. Blane
University of Pittsburgh
Ronald G. Blankenbaker, M.D.
Indiana State Board of Health
Nick Biask.ovich, Jr., Ph.D.
National Institute for Occupational
Safety and Health
Genter for Disease Control
*t3iliiam .. Blockstein, Ph.D.
University of Wisconsin
Joseph H. Blount
Bureau of State Services
Center for Disease Control
*[dilliam B. Bock, D.D.S.
Bureau of State Services
Center for Disease Control
F. James Boehm, M.P.ti.
Depar tment of Human
Resources
State of North Carolina
*Sue Bogner, Ph.D.
'Heaith Services Administration
Department of Health and Human Services
Frank P. Bolden
D.C. Public Schools
Washington, District of Columbia
TIMN 365061
*Richard J. Bonnie, L. L. B.
School of Law
University of Virginia
Joyce Borgmeyer, R.D.
Iowa State I?epartraent of Health
Gilbert J. Botvin, Ph.D.
American Health Foundation
Susan Boucher
Division of Cancer Prevention
Baltimore City Health Department
Frank Bowyer, D.D.S.
American Dental Association
Philip S. Brachman, M.D.
Bureau of Epidemiology
Center for Disease Control
Robert C. Bradbury, Ph.D.
Central Massachusetts Health Systems
Agency
Shrewsbury, Massachusetts
Windell R. Bradford
Bureau of State Services
Center for Disease Control
Allen G. Brailey, Jr., M.D.
Per sonnel I7epar tment
Burlington Northern
*Elaine Bratic
National Cancer Institute
National Institutes of Health
Tameron E. Brink, R.D., M.P.H.
Division of Health
Nevada Department of Human Resources
Seiko Baba Brodbeck
American Public Health Association
Washington, District of Columbia
Edward M. Brooks
Office of Toxic Substances
Environmental Protection Agency
179
Wayne G. Brown
Bureau of Training
Center for Disease Control
Audrey K. Brown, M.D.
I}owns tate Medical Center
Brooklyn, New York
Sara Brown, Ph.D.
Select Panell on the Promotion of Child
Health
Helen B. Brown, Ph.D.
Cleveland Clinic
Cleveland, Ohio
Richard Bryan
Indian Health Service
Health Services Administration
Dawn Bryan
American Heart Association
Dallas, Texas
Rlswor th R. Buskirk, Ph. i1.
Laboratory for Human Performance
Research
Pennsylvania State University
Earl B. Byrne, M.D.
Bryn Mawr, Pennsylvania
Harry P. Cain, II, Ph. D.
American Health Planning Association
Antonio Calarco
Butte County Department of Health
Chico, California
C. Wayne Callaway, M.D.
Nutrition Coordinating Committee
Public Health Service
Joseph Cameron
National Highway Traffic Safety
Commission
Department of Transportation
TININ 365062
Miriam M. Campbell, M.P.H.
Health Education Consultant
Orono, Maine
Richard Carleton, M.D.
The Memorial Hospital
Pawtucket, Rhode Island
Paula L. Carney
Food and Nutrition Service
U.S. Department of Agriculture
Charlotte Catz, M.D.
National Institute of Child Health and
Human Development
National Institutes of Health
Dewey Cederblade
American Social Health Association
Don B. Chaffin, Ph.D.
Industrial and Operation Engineering
Daniel Chatfield
Ohio Department of Health
*James Chin, M, I}.
California Department of Health
Services
William B. Cissell, Ph.D.
School of Public and Allied Health
East Tennessee State Univesity
Ray A. Ciszek, Ed.D.
American Alliance for Health, Physical
Education, and Recreation
James W. Clark, Jr.
American Optometric Association
Washington, District of Columbia
Linda Clemmings
American Public Health Association
Carl F. Coffelt, M.D.
County Health Department
Los Angeles, California
Dennis L. Colacino, Ph.D.
PepsiCo, Incorporated
Valerie Coleman
Heritage Conservation and Recreation
Service
U.S. Department of the Interior
Durward R. Collier, D.D.S., M.P.H.
Department ~if Public Health
State of Tennessee
Gere Collosky
Blue Cross and Blue Shield
Chicago, Illinois
Bonnie A. Connors
American ColLege of Obstetricians and
Gyuecologi s ts
C. Carson Conrad
The President `s Council on Physical
Fitness and Sports
James P. Cooney, Jr., Ph.D.
Office of the Center Director
National Center for Health Statistics
John A.D. Cooper, M.D.
Association of American Medical Colleges
Claire M. Coppage } R. N. , M. P. H.
Bureau of Training
Center for Disease Control
Robert D. Corwin, M.D.
American Heart Association
Audrey Cross
Office of the Sec
U.S. Department o
Jeffrey F. Cross
National Environmental Health
Association and Ferris State College
*James W. Curran, M.D.
Bureau of State Services
Center for Disease Control
TIMN 365063
Russell W. Currier, D.V.M.
Division of Disease Prevention
Iowa Department of Health
Irvin M. Cushner, M.D.
Office of the Assistant Secretary for
Health
David A. Damn.ann
ACTIt}N
Suzanne Dandoy, M. D. , M. P.Ii.
Arizona Department of Health Services
Helen Darling
National Academy of Sciences
Robert M. Daugherty, Jr., M.D.
Subcommittee on Smoking
American Heart Association
Ann Davis, R. N. ,$. S. N.
Overlook Hospital
Summit, New Jersey
Runyan Deere, Ph.D.
Cooperative Extension Service
University of Arkansas
John B. DeHoff, M.D., M.P.Ii.
Health Department
City of Baltimore
Sarah L. Diamond
Bureau of Health Education
Center for Disease Control
Gene Dickey
Food and Nutrition Service
i. S. Department of Agriculture
Ernest M. Dixon, M.D.
Celanese Corporation
*Ronald D. Dabbin
National Institute for Occupational
Safety and Health
Center for Disease Control
181
Jane Dolkart, J.D.
Division of Advertising Practices
Federal Trade Commission
Charles L. Donahue, Jr.
Center for Health Planning
Boston University
Susan E. Donald
Bureau of Training
Center for Disease Control
Deborah Drudge, Esq.
Healthy America
Washington, District of Columbia
James 21. Dunning, lJ.I1.S., M.P.H.
Massachusetts Citizens ` Committee for
Dental Health
Robert L. DuPont, M.D.
Institute for Behavior and Health, Inc.
Merlin K. Duval, M. D.
National Center for Health Education
Lucy Eddinger
Office of AcloIescent Pregnancy Programs
Office of the Assistant Secretary for
Health
Robert Edelman, M.D.
National Institute of Allergy and
Infectious Diseases
National Institutes of Health
Mary Egan, R.D., M.S., M.P.H.
Program Office for Maternal and. Child
Health
Health Services Administration
*Robert S. Eliot, M.D.
Garciiovascular Center
The University
Center
Effie 0. Ellis, M.D.
American Medical Association and
National Foundation March of Dimes
TP4N 365064
Mary Enig
Department of Chemistry
University of Maryland
James H. Erickson, M.I}., M. P. ii.
Bureau of Medical Services
Health Services Administration
Caswell Evans, D.D.S.
Seattle-King County Department of Public
Health
Beth Ewy
Division of Cancer Prevention
Baltimore
Ivan J. Fahs, Ph.D.
Rural Sociolog
Rochester, Minnesota
Robert C. Faine, I3.11. S.
Bureau of State Services
Center for Disease Control
Henry A. Falk, M.D.
Bureau of Epidemiology
Center for Disease Control
Gerald Feck
Burn Injury Control Program
New York State Department of Health
Charles E. Feigley, M.D.
School of Public Health
University of South Carolina
Yehudi M. Felman, M.D.
Bureau of Venereal Disease Control
City of New York Department of Health
Barry Felrice
National Highway Traffic Safety
Administration
Department of Transportation
Joe Fenwick, D.D.S.
Health Planning Association of Northwest
Ohio
182
Bernice Ferguson, R. N. , M. P. H.
Depar tment of Health
State of New Jersey
Harry L. Ferguson, M.D., Ph.D.
Science and Education Administration
Extension
t3. S. Department of Agriculture
Conrad P. Ferrara
Bureau of Training
Center fcar Disease Control
Claudia E. Finney, X.T. (ASCP)
Saint Elizabeth's Hospital
Washington, DC
John R. Fleming
School of Allied Health
Ferris State College
Gordon Flint
Bureau of Health Education
Center for Disease Control
Dee Flynn
Bureau of Alcohol, Tobacco, and
Firearms
Department of the Treasury
Peter Fraleigh
Health Planning Association of Northwest
Ohio
Herman M. Frankel, M.D.
Health Services Research Center
Kaiser Foundation Hospitals
Todd M. Frazier
National Institute for Occupational
Safety and Health
Center for Disease Control
Jack Friel
Bureau of Epidemiology
Center for Disease Control
Wendy Frosh, M. S.
Union Hospital
Lynn, Massachusetts
TIMN 365065
Lois W. Gage, Ph.D.
Medical School
The University of Michigan
George Galasso, Ph.D.
National Institute of Arthritis and
Metabolic Diseases
National Institutes of Health
Judy Gartin, R.D.
Georgia State University
Atlanta, Georgia
Kristine M. Gebbie
Health-Division
State of Oregon
Stephen D. Gelineau, APR
Union Hospital
Lynn, Massachusetts
Elizabeth C. Giblin
University of Washington
Dottie Gillon, R.N., F.P.N.P.
Division of Health
Nevada Department of Human Resources
Charles Gish, D.D.S.
Indiana State Board of Health
Virginia M. Gladney, R. D. , M. P. H.
Department of Health Services
County of Los Angeles
David Glasser, M.D., M.P.H.
Bureau of Disease Control
Baltimore, Maryland
Edwin M. Gold, M.D.
Women and Irfants Hospital
Providence, Rhode Island
Willis B. Goldbeck
Washington Business Group on Health
Frank Goldsmith, M.P.H.
New York State School of Industrial
and Labor Relations
Cornell University
Jan Richard Goldsmith, D.M.D.
U.S. Public Health Service
Region II
el Goodwin, Ph.D.
Mine Safety and Health Administration
Department of Labor
Janice Gordon
Food and Beverages Trades Department
AFL CIO
Millicent Gorham
Office of the Honorable Louis Stokes
Representative, Ohio
Deanne F. Gottfried, M.D.
Northern California Cancer Program
Palo Alto, California
Stanley N. Graven, M.D.
Department of Pediatrics and OB-GYN
University of South Dakota
Gareth M. Green, M.D.
Department of Environmental Health
Sciences
Johns Hopkins University
Lawrence W. Green, Ph.D.
flff ice of Health Information, Health
Promotion and Physical Fitness and
Sports Medicine
Office of the Assistant Secretary for
Health
Kenneth Greenspan, M.D.
College of Physicians and Surgeons
Columbia University
Joel R. Greenspan, M.D.
Bureau of Epidemiology
Center for Disease Control
Roy Griffin
Texas Area V Health Systems Agency, Inc.
Irving, Texas
~oj-N 365066
Billy G. Griggs
Bureau
Center for Disease Control
Stephen Grossman, J.D.
V.A. Scholars Program
Washington, DC
Susan R. Guarnieri
Baltimore City Health Department
Dale Hahn
Blue Cross and Blue Shie
Chicago, Illinois
Thomas J. Halpin, M.D., MPH
Bureau of Preventive Medicine
Ohio Department of Health
Lee Hand, M.D.
VA Medical Center
Decatur, Georgia
Jean H. Hankin, Dr.P.H.
School of Public Health
Department of Public Health Services
University of Hawaii at Manoa
Dea Hanson, R.D.
Georgia State University
Atlanta, Georgia
A. E. Harper
College of Agricultural and Life
Sciences
University of Wisconsin-Madison
Alfred E. Harper, Ph.D.
Department of Biochemistry
University of Wisconsin-Madison
Robert L. Harrington, M.D.
Permanente Medical Group
San Jose, California
Jeffrey E. Harris, M.D., Ph.D.
Department of Economics
Massachusetts Institute of Technology
Mi chael ,T . Har t f or d
School of Nu
Georgetown
L. Howard Hartley, M.D.
Committee on Exercise
American Heart Association
William L. Haskell, Ph.D.
School of Medicine
Stanford University
Dale Hattis, Ph.D.
Massachusetts Institute of
Technology
Patricia Hausman, M.S.
Center for Science in the Public
Interest
Stephen W. Havas, M.D.
National Heart, Lung, and Blood
Institute
National Institutes of Health
Victor M. Hawthorne, M.D.
School of Public Health
University of Michigan
Maxine Hayes, M.D.
Hi.nds-Rankin Urban Health Innovation
Project
Brandon, Massachusetts
*Clark W. Heath, .Tr., M.D.
Bureau of Epidemiology
Center for Disease Control
Mark Regsted
Science and Education Administration
U. S. Department of Agriculture
Herman A. Hein, M.D.
Iowa Perinatal Program
The University of Iowa Hospitals and
Clinics
Victor Herbert, M.D., J.D.
SUNY Downstate Medical Center and
Bronx VP. Medical Center
184
M. Ward Hinds, M.D., M.P.H.
Cancer Center of Hawaii
of Hawaii at Manoa
*Alan R. Fiinmant M.D.
Bureau of State Services
Center for Disease Control
Robert S. Hoekwald, M.D.
American Occupational Medical
Association
Chicago, Illinois
Hap Hodd
Office of the Assistant Secretary for
Management and. Budget
Department of Health and Human Services
Barbara Holloway
Bureau of Epidemiology
Center for Disease Control
Debbie Holman, R. N.
Outpatient Clinic
Center for Disease Control
Priscilla B. Holman
Bureau.of Health Education
Center for Disease Control
King K. Holmes, M.D., Ph.D.
U.S. Public Health Service Hospital
- Seattle and University of Washington
Frank M. Hoot
Environmental Health
Baltimore, Maryland
Joann Horai, Ph.D.
American Psychological Association
Thomas J. Horne
Bureau of State Services
Center for Disease Control
Arthur H. Hoyte, M.D.
Department of Health Affairs
Washington, District of Columbia
185
Susan Hubbard, R. D.
Georgia State University
Atlanta, Georgia
Sara M. Hunt, Ph.D., R.D.
Georgia State University
Atlanta, Georgia
*Robert Hutchings
Of f ice on Smoking and Health
Department of Health and Human Services
James N. Hyde, M.P.H.
Division of Preventive.Medicine
Massachusetts Department of Public
Health
Robert Isman, D.D.S., :
Dental Health Services
Multomah County Oregon
Jack Jackson
Bureau of State Services
Center for Disease Control
George J. Jackson, Ph.D.
Division of Nutrition
Food and Drug Administration
Andrew B. James, M. S. , Dr. P. H.
Department of Public Health
City of Houston
Ronnie S. Jenkins
Georgia Department of Human Resources
Robert E. Johnson, M.D.
Bureau of State Services
Center for Disease Control
Lloyd D, Johnston, Ph.D.
Institute for Social Research
The University of Michigan
Steven Jonas, M.D.
School of Medicine
State University of New York at
Stoney Brook
TIMN 365068
Stephen B. Jones (Retired
Missouri Department of
Services
State of Missouri
Barbara L. Kahn
Department of Human Resources
State of North Carolina
John T. Kalberer, Jr., Ph.D.
National Institutes of Health
Department of Health and Human Services
Norman M. Kaplan, M.D.
The University of Texas Health Science
Center at Dallas
Snehendu B. Kar, Dr. P. H.
Center for Health Sciences
University of California, Los Angeles
Stanislav V. Kasi, Ph.D.
School of Medicine
Yale University
Judith Katz
National Foundation March of Dimes
Abraham J. Kiuvar, M.D.
Denver Department of Health and
Hospitals
Mark Keeney
Department of Chemistry
University of Maryland
James A. Keith
School of Public Health
University of South Carolina
Bruce C. Kelley, Ph.D.
Department of Health
Providence, RI
Douglas Kellogg, Ph.D.
Bureau of Laboratories
Center for Disease Control
186
Lorin E. Kerr, M.D.
Department of Occupational Health
United Mine Workers of America
Samuel Kessel, M.il.
Office of the Assistant Secretary for
Health
Public Health Service
Anne Kiefhaber, B. S. N.
Washington Business Group on Health
Major John E. Killeen
Office of the Assistant Secretary of
Defense (Health Affairs)
Department o
e
James R. Kimmey, M. D.
Midwest Center for Health Planning
Madison, Wisconsin
Stephen H. King, M.D.
Division of Health Sciences
PHS Regional Office (Atlanta)
George M. Kingman
National Institute of Environmental
Health Sciences
National Institutes of Health
Robert J. Kingon
Bureau of State Services
Center for Disease Control
Janie Ann Kinney, J.D.
Bluzn and Nash
Washington, District of Columbia
Ardine Kirchhofer
Georgia State University
Atlanta, Georgia
John Kirscht, Ph.D.
School of Public Health
University of Michigan
Lawrence A. Klapow, Ph.D.
State Water Resources Control Board
State of California
TEAN 365069
Stuart A. Kleit, M.D.
National Kidney Foundation
John J. Rlu.mb
Department of Education
State of California
Ruth N. Kn.alimuelier, R.N., M.P.H.
School of Nursing
Yale University
Sam Knox
American Social Health Association
Dieter Koch-Weser, M.D.
Harvard Medical School
Ross L. Koeser
U.S. Consumer Product Safety Commission
Roz Kohn
Baltimore City Health Department
Lloyd J. Kolbe, Ph.D.
National Center for Health Education
Gretchen Kolsrud, Ph.D.
Office of Technology Assessment
U.S. Congress
John 11. Korn
Bureau of Health Education
Center for Disease Control
Paul ilo3.1 n, P2 . 33 .
Johns-Manville Corporation
Mary Grace Kovar
National Center for Health Statistics
Georgetown University
David P. Kraf t, M.D.
University Mental Health Service
University of Massachusetts
Dorine G. Kramer, M.D.
Bureau of Health Education
Center for Disease Control
187
Helen Krause, M. P. H.
District V Health Department
Twin Fal
Kathleen Kreiss, M.D.
Bureau of Epidemiology
Center for Disease Control
Lawrence J. Krone, Ph.D., R.S.
Na t ional Environmental Health
Association
W. Stanley Kruger
U. S. flf f ice of Education
Saul Krugman, M.D.
Department of Pediatrics
New York I3niversi ty Medical Center
F. A. Kummerow
College of Agriculture
University of Illinois at
Urbana-Champaign
Robert E. Lamb, D.D.S.
Council on Dental Health and Health
Planning
American Dente.l' Asscciaticn
Louis C. LaMotte, Sc.D.
Bureau of Laboratories
Center for Disease Control
J. Michael Lane, M.D.
Bureau of Smallpox Eradication
Center for Disease Control
Herbert G. Langford, M.D.
The University of Mississippi Medical
Center
Laurent P. LaRoche, M.D.
Glestern Electric Company
.Iudi th H. LaRosa, R. N. ,M.N. Ed.
National Heart, Lung, and Blood
Institute
National Institutes of Health
TIAIN 365070
Dolores Lemon
Joint Commission on Accreditation
of Hospitals
John D. Lenton, M.D.
VA Medical Center
Decatur, Georgia
Carl Leukefelci, Ph.D.
Division of Resource Development
National Institute on Drug Abuse
Cora S. Leukhart
Bureau of State Services
Center for Disease Control
Gilbert A. Leveille
Department of Food Science and Human
Nutrition
Michigan State University
Richard A. I evin.son, ti. D.
Veterans Administration
Richard Light, M.D.
Indian Health Service
Health Services Administration
Marc B. Lipton, Ph.D., M.P.A.
Mental Health and Addictions
City of Baltimore Health Department
*Frank S. Lisella, Ph.D.
Bureau of State Services
Center for Disease Control
J. William Lloyd, Sc.D.
Occupational Safety and Health
Administration
Department of Labor
Keith R. Long, Ph.D.
College of Medicine
University of Iowa
Katherine S. Lord
Office of Information
Center for Disease Control
Cliff E. Lundberg
Natiana
e
Red Cross
Karen M. Lynch
South Carolina Department of Health and
Environmental Control
John C. MacQueen, M.D.
Department o
University of Iowa
George F. Mallison, M.P.H.
Bureau of Epidemiology
Center for Disease Control
Arnold M. Malmon
Milwaukee Blood Pressure Program
Milwaukee, Wisconsin
Robert B. Mancke
Bureau of Health Education and
Znf orma tiuo.
City of Baltimore Health Department
Edgar K. Marcuse, M.D.
Children's Orthopedic Hospital and
Medical Center/Seattle
Louise Markley
American Public Health Association
Russell (Bud) Mason
Indian Health Service
Health Services Administration
James 0. Mason, M.D., Dr. P.H.
Utah State Department of Health
Kathleen A. ivleBurney, R.D., M.P.H.
Department of Human Resources
State of Nevada
Jermyn F. McCahan, M.D.
Department of Environmental Public
and Occupational Health
American Medical Association
188
David B. McCallum, Ph.D.
South Carolina Department of Health
and Environmental Control
John J. McCarthy, Jr., M.D.
National Family Planning Federation
of America
Roger McCIaiu
Indiana State Board of Health
Indianapolis, Indiana
William M. McCormack, M.D.
Massachusetts State Laboratory
Institute
William J. McCurry
Division of Preventive Health Services
Public Health Service Region IX
Peggy McManus
Health Resources Admin
Philip R.B. McMaster, M.D.
Bureau of Laboratories
Center for Disease Control
Simon A. McNeeley
Bureau of Elementary and Secondary
Education
il. S. Off ice of Education
Donald McNellis, M.D.
Bureau of Community Health Services
Health Services Administration
Kristen W. McNutt, Ph.D.
National Nutrition Consortium, Inc.
Robert Mecklenburg, 37. I}. S.
Indian Health Service
Health Services Administration
Antonio S. Medina, M.D., M. P.H.
School of Public Health
University of California, Berkeley
189
Marie C. Meglen, M.S., C.N.M.
Department of Health and Environmental
Control
State of South Carolina
Harold R. Metcalf
Drug Enforcement Administration
Department of Justice
Anna Cay Milfeit
Health Systems Agency
Pittsburgh, Pennsylvania
Nancy Milio, Ph.D.
School of Nursing
The University of North Carolina at
Chapel Hill
Program Development Department
Blue Cross & Blue Shield
Associations
*C. Arden Miller, M. il.
School of Public Health
University of North Carolina
Anita Mills
Office of Dental Affairs
Office of the Assistant Secretary for
Health
Lloyd Milistein, Ph.D.
Food and Drug Administration
Jane Mitcham
School of Public Health
University of South Carolina
Debby Moore
Region IV - ACTIC3AI
*Lenora Moragne, Ph.D.
Department of Health and Human Sevices
Douglas H. Morgan, M. P. A.
Department of Health and Welfare
City of Newark
TEqN 365072
Gary E. Morigeau
Indian Health Service
Health Services Administration
Naomi M. Morris, M.D.
University of Health Sciences
The Chicago Medical School
Robert F. Murphy
Sierra Club (New England)
Clayton R. Myers, Ph.D.
Nationa
New York, New York
Kitty Naing, M.D.
Bureau of Community Health Services
Health Services Administration
Rose Navarro
American Public Health Association
Washington, District of Columbia
Larry Needham, Ph.D.
Bureau of Laboratories
Center f or Disease Control
Jane W. Neese, Ph.D.
Bureau of Laboratories
Center for Disease Control
Mark Nelson, M.D.
Bureau of Epidemiology
Center for Disease Control
Elaine Nemoto
American Public Health Association
Washington, District of Columbia
*Robert 0. Nesheim, Ph.D.
The Quaker Oats Company
Stephen R. Newman, Ed.D.
Charlotte Drug Education Center
Charlotte, North Carolina
Ervin E. Nichols, M.D., FACOG
The American College of (3bs tetric#.a.ns
and Gynecologists
Washington, District of Columbia
Patricia K. Nicol, M.D.
Department for Human Resources
Commonwealth of Kentucky
Elena 0. Nightingale, M.D., Ph.D.
Institute of Medicine
National Academy of Sciences
Joel L. Ni tzkin, M. D.
Monroe County Department of Health
Rochester, New York
Arthur Norr
National Center for Toxicological
Research
Food and Drug Administration
Cynthia Northrop, R.IY., M. S. , J.D.
Community Health Nursing
University of Maryland
Helen H. , Nowlis, Ph.D.
Office of School Health
U.S. Office of Education
Patricia O'Gorma.n
National Institute on Alcohol Abuse
and Alcoholism
Alcohol, Drug Abuse, and Mental Health
Administration
Go ci f r ay Oa kle y, M. U.
Bureau of Epidemiology
Center for Disease Control
Robert E. Olson, M.D.
School of Medicine
St. Louis University Medical Center
Gilbert S. Omenn, M.D.
Office of Management and Budget
Executive Office of the President
Edward 0. Oswald
School of Public Health
University of South Carolina
190 TIMN 365073
Elizabeth Owen
Heritage, Conservation, and Recreation
Service
Department of the Interior
Fran Owen, M. P. H.
South Carolina Department of Health and
Environmental Control
George M. Owen, M.D.
School of Public Health
University of Michigan
Richard L. Parker, D. V.M. ,11. P. ii.
Bureau of Epidemiology
South Carolina Department of Health and
Environmental Control
Russ Pate
School of Public Health
University of South Carolina
Linwood J. Pearson, M.D.
Department of Health
Commonwealth of Pennsylvania
A.M. Pearson
Nutrition
Michigan State University
Terry-F. Pechacek, Ph.D.
School of Public Health
University of Minnesota
Barbara Perman
Yale University
*Thomas F. A. Plaut, Ph.D.
Natio.nal Institute of Mental Health
National Institutes of Health
Richard N. Podell
Overlook Family Practice Association
Overlook Hospital (Summit, NJ)
Michael R. Pollard
Office of Policy Planning and Evaluation
Federal Trade Commission
191
octc,
Department of Healt
California State University
Iawrence E. Posey
Bureau of Health Education
Center for Disease Control
E. Char3ton Prather, M.D.
Department of Health and
Rehabilitative Services
State of Florida
Richard A. Prescott
Health Systems Agency of South Central
Connecticut
Shirley S. Preston
American Cancer Society
James H. Price, Ph.D., M.P.H., FASHA
Department of Health and Safety
Education
Kent State University
Jeanne M. Priester
U.S. Department of Agriculture
Milton Puziss, Ph.'P.
National Institute of Allergy and
Infectious Diseases
National Institutes of Health
David L. Rabin, M. B. , M. F.H.
Georgetown University School of
Medicine
Washington, II~strict of Columbia
David E. Raley
Directorate of Aerospace Safety
Department of Defense
John Rankin, M.D.
School of Medicine
University of Wisconsin
Gil Itatclif, f, Jr., M.D.
West Virginia Gommit~ee for Perinatal
Health
TIN[N 365074
H. Dickinson Ra thbun.
Christian Science Committee on
Publication of The First Church of
Christ, Scientist, in Boston,
Massachusetts
Elizabeth B. Rawlins
Simmons College
Wi Iliam. E. Rawls, M. D.
Department of Pathology
McMas ters [Tniversi ty
Jack Recht
National Safety Council
James Q. Regnier
Blue Cross and Blue Shield of Minnesota
*Robert L. Retka
National Institute on Drug Abuse
Department of Health and Human Services
Gladys H. Reynolds, Ph.D.
Bureau of State Services
Center for Disease Control
Y.B. Rhee
U.S. Public Health Service,
Anne M. Rhome, hi.P.H., R.N.
American Nursest Association
Houston. Texas
Gina Ries, R.D.
Iowa State Department of Health
Elizabeth W. Riggs, R.N., CNM
Georgia Department of Human Resources
Atlanta, Georgia
Adonna A. Riley
Commission on Health and Welfare
National PTA
I3awi d Rimland, M. D.
V.A. Medical Center
Decatur, Georgia
192
William P. Ringo, Ph.D.
Birmingham Regional Iiqalth Systems
Agency
Birmingham, Alabama
Hania W. Ris, M.D.
Department of Pediatrics
University of Wisconsin
School
Sherrill W. Ritter, Jr.
Office of Human Development Services
Department of Health and Human Services
Hilda H. Robbins
Mental Health Association
Arlington, Virginia
Frances T. Roberts
Office of Child Day Care
State of Connecticut
Susan Roberts, R. D.
Iowa State Department of Health
H. Clay Roberts
Educational Service District #121
Seattle, Washington
Jack Robertson
Office of Dental Affairs
Public Health Service
Donald H. Robinson, M.D
South Carolina Departme
Environmental Control
Edward Roccella, Ph.D.
National Heart, Lung, and Blood
Institute
National Institutes of Health
Roger W. Rochat, M.D.
Bureau of Epidemiology
Center for Disease Control
Ava Rodgers, Ph.D.
Science and Education Administration -
Extension
U. S. Department of Agriculture
TIMN 365075
Maria L. Rodriguez
Guadalupe Family Health Clinic
Toledo, Ohio
Milton I. Roemer
School of Public Hea
University of California
Vincent C. Rogers,
Bureau of Dental Ca
William N. Rom., M.D., MPH
College of Medicine
University of Utah
s
geles
P. Rooks
(3f fice of Population Affairs
Office of the Assistant Secretary of
Health
William L. Roper, M.D.
Jefferson County Health Department
Birmingham, Alabama
Patricia F. Roseleigh, R.D., M.S.
Indian Health Service
Health Services Administration
Gerald Rosenthal, Ph.D.
National Center for Health Services
Research
John Roskis, Pharm. D.
Mercer University Southern
Atlanta, Georgia
Ronald K. St. John, M.D.
Bureau of State Services
Center for Disease Control
James H. Sammons,
American Medical Association
Chicago, Illinois
Joseph Sampugna
Department of Chemistry
University of Maryland
Anthony V. Sardinas, M.A., M.P.H.
Office of Public Health
State of Connecti.cut
Roger Sargent
School of Public Health
University of South Carolina
John W. Scanlon, M.D.
Columbia Hospital for Women
Washington, District of Columbia
William Schaf fuer, M.D.
Departments of Medicine and
Preventive Medicine
Vanderhil t Universi ty Hasgi taI
Renee Schick
Capital Systems Group
Rackville, Maryland
Roger Schmidt
American Lung Association
Stephen C. Schoenbaum, M.D.
Peter Bent Brigham Hospital
Boston, Massachusetts
Sheldon Rovin, D.D.S., M.S.
V.A. Scholars Program
Washington, District of Columbia
George Rubin, M.D.
Bureau of Epidemiology
Center for Disease Control
David D. Rutstein, M.D.
Countway Library
Boston, Massachusetts
James A. Schoenberger, M.D.
Rush-Presbyterian-St. Luke's Medical
Center
Chicago, Illinois
Marc Schuckit
Veterans Administration Hospital
San Diego, California
193
Myron G. Schuitz, M.D.
Bureau of Epidemiology
Center for Disease Control
Catherine Schutt, R. N. , M. S.
Union Hospital
Lynn, Massachusetts
Barbara Scott, R. D. ,
Division of Health
Nevada Department of Human Resources
Robert H. Selwitz, D.D.S., M.P.H.
Region III
Degartment of Health and Human Services
John C. Sessler,
Office of Health
Evaluation
Public Health Service
Iris R. Shannon, R. N. , ht. S.
American Public Health Association
Alvin P. Shapiro, M.#3.
Department of Medicine
University of Pittsburgh School of
Medicine
Marion Sheehan
Metropolitan Life
Susan B. Shelton
Bureau of Tra
Center for Disease Control
Cecil Sheps, M.D.
Health Services Research Center
University of North Carolina
Edward Shmunes
School of Public Health
University of South Carolina
Clyde R. Shorey, Jr.
The National Foundation March of Dimes
Naseeb L. Shory, D.H.S.
Bureau of Dental Health
Alabama Department of Public Health
194
Carole J. Sieverson
Metropolitan Health Board
St. Paul, Minrtesota
Artemis P. Simopoulos, M.D.
Nutrition Coordinating Committee
National Znstitutes of Health
Slesin, Ph. i3.
al Resource Defense Council
John Scott Small
National Institute of Dental Researc
National Institutes of Health
Jessie M, Smallwood
Heaith Systems Agency, Inc.
New Orleans, Louisiana
Johnnie W. Smith
South tmarolina Department of Health and
Envirtinmentai Ccuttol
*W. McPate Smith, M.D.
Department of Medicine
University of California at San
Francisco
Roy G. Smith, M.D.
School of Public Health
University of Hawaii at Manoa
s M. Sontag, Ph. i3.
aaLxcsnai c~ancer xnsrirure
National Institutes of Health
Harrison C. Spencer, M.D.
Bureau of Tropical Diseases
Center for Disease Control
Dick Spruyt,
Division of Health Services
North Ga
Resources
Harry Staffileno, Jr., D.D.S.
The American Academy of Periodontology
TLWN 365077
Rose Stamler
The Medical School
Northwestern University
Charles S. (Jack) Stanley
Bureau of Training
Center for Disease Control
Fredrick J. Stare, M.D.
School of Public Health
Harvard t3nivers ity
William B. Stason, M.D.
School of Public Health
Ha rva rd I3n 3.ve r s i ty
Chedwah .i. Stein 3 M. S. , R. D.
Nutrition Unit
Oregon State Health Division
Jeanne M. Stellman, Ph.D.
Women's Occupational Health Resource
Center
American Health Foundation
Pauline G. Stitt, M.D.
School of Public Health
University of Hawaii at Manoa
T. Wayne Stott
National Family Planning and
Reproductive Health Association
Angela Strickland
American Public Health Association
David F. Striffler, D.D.S.
School of Public Health
University of Michigan
Phyllis E. Stubbs, M.D.
Baltimore City Health Department
A. T. Sturdivant
Atlanta Area Office
Consumer Product Safety Commission
Mary E. Sullivan
Bureau of Health Education
Center for Disease Control
-195
Jim Summers
Metairie, Louisiana
John David Suomi, I3.D. S.
t}f fice of Dental Af f airs
Office of the Assistant Secretary for
Health
Juris M. Svarcbergs, DMD, MPH
Henry ,I. Austin Health Center
Trenton, New Jersey
*Glen Swengros
President's Council on Physical Fitness
and Sports
Donald A. Swetter, M.D.
Indian Health Service
Health Services Administration
C. Barr Taylor, M.D.
Department of Psychiatry and Behavior
Science
Stanford Medical Center
L. David Taylor
Office of the Secretary
Department of Health and Human Services
Andy Tepper-Itasmussen
Oklahoma Health Systems Agency, Inc.
Stephen Teret, J.D.
School of Hygiene and Public Health
Johns Hopkins University
*Stephen Thacker, M.D.
Bureauu of Epidemiology
Center for Disease Control
Caroline B. Thomas, M.D.
School of Medicine
Johns Hopkins Univers ity
Flora L. Thong
Department of Health
State of Hawaii
TVqN 365078
Hugh H. Ti
North Caro
Services
Marian Tompson
La Leche League International
Carl W. Tyler, Jr., M.D.
Bureau of Epidemiology
Center for Disease Control
Louise B. Tyrer, M.D.
Planned Parenthood Federation of
America, Inc.
John E. Vanderveen, Ph.D.
Division of Nutrition
Food and Drug Administration
Betty Vanta, R.D.
Georgia State University
Atlanta, Georgia
James D. Vargo, M. F3.
VA Medical Center
Decatur, Georgia
*Tom M. Vernon, M.D.
Colorado Department of Health
Murray Vincent
School of Public Health
University of South Carolina
John R. Viren, Ph.D.
{3f f ice of Health and Environmental
Research
Department of Energy
Frank J. Vocci, Ph.D.
Drug Abuse Staff
Food and Drug Administration
Thomas M. Vogt, M. D. , M. P. H.
Kaiser Foundation Hospitals
Portland, Oregon
196
Jane Voicheck, Ph. D.
Science and Education Administration -
Extension
t3. S. Department of Agriculture
Haiwatha B. Walker, Ph.D.
School of Public and Allied Health
East Tennessee State University
Lawrence M. Wallack, M.S.
School of Public Health
University of California
Julian A. Waller, M.D.
Department of Epidemiology and
Environmental Health
University of Vermont Medical School
Elli Walters
Environmental Policy Institute
Virginia U Wang, Ph. i3.
School of Hygiene and Public Health
Johns Hopkins University
*Graham Ward
National Heart, Lung and Blood Institute
National Institutes of Health
Beverly G. Ware, Dr. P.K.
Ford Motor Company
Kenneth E. Warner, Ph.D.
School of Public Health
University of Michigan
*David H. Wegman, M. D.
School of Public Health
Harvard University
John H. Weisburger, Ph.D.
American Health Foundation
Naylor Dana Institute for Disease
Prevention
Jerrold L. Wheaton, M.D.
Riverside County Health Department
Riverside, California
Patricia F. Whitmore, M.S.W.
Department of Mental Health/Mental
Retardation
State of Tennessee
Paul J. Wiesner, M.D.
Bureau of State Services
Center for Disease Control
K.D. Wiggers
Iowa State University of Science and
Technology
Health
Jean C. Wilford
Bureau of Training
Center for Disease Control
Jane Williams
Environmental Policy Institute
*Jack Wilmore, Ph.D.
Department of Physical Education and
Athletics
University of Arizona
Ronald W. Wilson
Division of Analysis
National Center for Health Statistics
John J. Witte, M.D.
Bureau of Health Education
Center for Disease Control
Ilene Wolcott, Ma. Ed.
Women and Health Round Table
Washington, District of Columbia
Frederick S. Wolf, M.D.
Alabama Department of Public Health
Joan M. Wolle
Health Education Center
Maryland Department of Health and Mental
Hygiene
197
George J. Wolnez, C.S.P., P.E.
Sanderson Safety Supply
Portland, Oregon
Sidney Wolverton
Division of Prevention
Alcohol, Drug Abuse, and Mental Health
Administration
Catherine Woteki, Ph.D.
Office of Technology Assessment
I3. S. Congress
William L. Yarber, HSU
Department of Health Education
Purdue University
Eleanor A. Young, Ph. D.
Department of Medicine
University of Texas Health Science
Center
Steven Zifferblatt, Ph.D.
National Heart, Lung, and Blood
Institute
National Institutes of Health
# tI.S. GOVERNMENT PRiNT1NG tTFNCE: t93i1 0- 33t-599
TLWN 365080
