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Four: Immunization programs should be aimed at high-risk groups, not at the total population of the country.

Five: All State health departments should have teletype or reactive computer terminal capability in order to receive rapid communication from CDC.

Six: More teletype and postal communications should emanate from CDC, all telephonic communications should be followed by written confirmation.

Seven: CDC should develop a mechanism to obtain input from State and local health departments.

Eight: If CDC is going to use its regional offices to transmit or handle requests for information, such offices need to be better informed.

Nine: When considerable amounts of State and local resources will be required for such a program, the program should not be hailed as a Federal program.

Ten: An estimate of State and local costs should be considered in the initial decisionmaking process.

Eleven: Funds should be made available for State and local public information efforts, since these were generally more effective than the Federal efforts.

Twelve: The public should be provided at the start of a program with information on potential side effects.

Thirteen: More realistic dates for vaccine delivery should be given with recognition that delays will occur.

Fourteen: Normal distribution channels should be used for vaccine, with availability through commercial outlets, where possible.

Fifteen: Immunization schedules should be kept simple.

Sixteen: HEW should develop a national policy on informed consent with substantial planning around the issue of informed consent before the next program requires immediate action.

Seventeen: Input on form preparation should be obtained from public health professionals and lay persons.

Eighteen: HEW should develop a mechanism for involving national, State, and local medical societies in medical policymaking at an earlier stage.

Nineteen: The role of private medicine in such a program should be enhanced and encouraged.

Twenty: More publication of clinical trials data is needed in medical journals.

Almost all of these criticisms and recommendations bear on CDC's handling of this program. This is inevitable, given CDC's key role in coordinating the program and communicating with the States. The State health officers do not mean to impugn CDC. On the contrary, the Center is held in high regard as an indispensable source of aid and expertise in preventive medicine, especially in communicable disease control. It is, in fact, the Federal agency most adept at providing public health services, working through State and local health departments. Our hope is that through CDC the Federal capability to pursue all sorts of preventive medical programs on a mass scale may be refined and expanded.

If one were asked to make an overall assessment or draw conclusions from the multitude of responses from the health department heads throughout the country, the following would be the product:

First: The swine influenza immunization program of 1976-77 indicated that State health departments are not slow-moving bureaucracies. State and local health departments can rapidly launch a massive effort in response to demonstrated need.

Second: The swine influenza immunization program has enabled health departments to refine their skills in community organization, to improve relationships with the media, and to develop a cadre of health-oriented volunteers. Our fear is that the program may have harmed the credibility of health departments in some areas due to the many problems which appeared to develop unexpectedly.

If I may, I would like to add a personal note. Connecticut achieved one of the highest levels of immunization of its population in the country, almost 58 percent of the target population and more than 95 percent of the high-risk population was immunized in less than 242 months. These achievements were the direct result of the extraordinary hard work and dedication of the health professionals of the State. It was those individual efforts and the outstanding cooperation from the news media which were the cornerstone of the Connecticut's successful program.

I would like to thank you for your kind attention and will be most happy to answer any questions either at this time, or at any future date of your choosing.

Mr. ROGERS. Do you feel that we will have this type of liability problem in future immunization programs?

Dr. LLOYD. It was a major headache for us in the State of Connecticut. We constantly had to deal with problems of liability. We found, for instance, that many of the private doctors did avoid the program because of the liability. There was a lot of unnecessary expense. I would think that the Congress needs to look very seriously at some sort of no-fault situation in the future for untoward effects.

Mr. ROGERS. You mean a better system of keeping records on the persons receiving immunization. What could have been done to improve this?

Dr. LLOYD. We spend roughly 13 cents per dose for delivery. We think as much should be spent for records. The reason is that if we are going to learn from massive health programs like this, we have to have better data. We need access in the event of reaction, death, or legal complications.

Many of the points that were brought in the testimony before the committee this morning show that we need better records. Absolutely, it is going to be necessary to evaluate effectiveness in the future, so that we can do the job better.

Mr. ROGERS. What about communications being improved. I think you have a good point there.

Dr. LLOYD. We would agree that communication, and CDC also agrees, is extremely important. It was somewhat embarrassing that the press very often had answers to questions that were being asked before we did. We feel that some sort of almost instantaneous communication between the CDC and the State health departments is going to be extremely important, some sort of interactive computer or teletype system. We feel that it is going to be very important.

Since the swine flu program, other problems that we have had, whether it be with measles, and other issues that we have had to respond to have required some sort of better communication.

Mr. ROGERS. I thought that you might like to know that the American Medical Association did endorse the program, the entire program.

Dr. Lloyd, thank you for your presence. We appreciate your helpful testimony, and we will ask HEW to comment on your suggestions.

Dr. LLOYD. Thank you, sir.

Mr. ROGERS. Dr. Elsea, you may proceed. STATEMENT OF WILLIAM R. ELSEA, M.D., VICE PRESIDENT,

NATIONAL ASSOCIATION BY COUNTY HEALTH OFFICIALS (NACHO); ACCOMPANIED BY MIKE GEMMELL, LEGISLATIVE REPRESENTATIVE

Dr. ELSEA. Mr. Chairman, and members of the committee: I am Dr. William Elsea, health officer and director of the Fulton County, Ga., Health Department in Atlanta, and vice president of the National Association of County Health Officials--NACHO-on whose behalf I am appearing today. NACHO is the public health affiliate of the National Association of Counties.

I am also a member of the U.S. Public Health Service Advisory Committee on Immunization Practice which advised HEW on implementation of the national influenza immunization program. With me today is Mike Gemmell, legislative representative for both NACHO and NACO.

The purpose of my statement is to point out some of the successes and problems local government health officers faced during the implementation of the national immunization program last year.

In the interest of time, I will summarize my testimony. With your permission, I would like to have the attached survey of county agencies made a part of the record. The survey demonstrates the high level of county involvement of the national swine flu program.

Mr. ROGERS. Without objection, it will be made part of the record (see p. 392].

Dr. ELSEA. I would like to point out for the record that the National Association of County Health Officials and the National Association of Counties strongly supported the initial decision to launch the vaccination program against swine influenza. Both associations pledged their support and cooperation in carrying out the immunization program.

We did warn our county health officers about the potential problems they might face, such as problems in storage of the vaccine, lack of manpower, confusion over implied consent, public apathy, and most importantly, the lack of financial resources to get the job done.

On the last point, for example, Jefferson County, Ky., spent $140,000 of local money that was not reimbursed; Arlington County, Va., spent $16,000; Jefferson County, Ala., spent $54,000; Palm Beach County, Fla., spent $30,000, and large amounts of funds were spent in Los Angeles County, and that will be submitted on Monday.

Mr. Chairman, these do not sound like large amounts, perhaps, compared to the Federal budget, but these represent mainly local property taxes that are especially keenly felt by the local people.

In retrospect, and this does not include in general local resources, and we will go to that point in a moment, in restrospect we remain convinced that those Federal officials responsible for initiating the program acted in good faith. They made the hard decisions that circumstances required.

What concerns us now is the long range negative impact the swine flu program will have on other immunization programs conducted by county health agencies. Of the 52 million American children under 15 years of age, 20 million are not properly immunized against polio, measules, rubella, tetanus, diphtheria and whooping cough.

We have the vaccine, the public and private health care resources and the know-how to immunize these children, yet the experience with the swine flu program and the current immunization rates suggest a real danger of outbareaks of these preventable diseases.

The county health officers have strongly endorsed Secretary Califano's child disease immunization initiative. We want to be consulted during initial stages of the program. The feedback from the swine flu episode highlights the essential need to involve local health officers in program implementation.

During the swine flu program there was a definite drain on local resouces. We estimate that they probably nearly match the amounts spent on vaccine by the Federal Government. As a result, basic public health immunization programs suffered from the diversion of money, time and manpower to the national influenza program.

However, our failure to maintain proper immunization levels cannot be solely blamed on the swine flu episode. It is a result of inadequate knowledge on the part of the lay population, insufficient concern and vigilance on the part of the professional community, the fact that disease prevention has traditionally been the neglected part of Federal health care policy and, finally, the lack of Federal, State and local funds to improve the capacity of local health agencies to carry out their primary mission, that of protecting the public's health through disease

prevention activities. We concur with the Association of State and Territorial Health Officials' conclusions and recommendations just presented concerning the national influenza immunization program. Our own research found that the very nature of the emergency immunization program, including the preparation and administration of a new vaccine against a poorly understood virus, created problems that were to be expected and constituted a great majority of the complaints from the counties.

These included: Insufficient supplies of vaccine; time consuming informed consent forms; constantly changing guidelines creating numerous administrative problems, among others. But, many basic organizational problems could and should be avoided in any future mass immunization program.

More money allocated toward administration of the program, including personnel costs at the local level, better communication

and direct local agency involvement in the policymaking and implementation process were the most often cited suggestions for improvement of the national immunization program.

In summary, Mr. Chairman, the national swine flu program demonstrated that State and local health agencies have the capability to rapidly gear-up to carry out a national immunization program.

One final point needs to be made. Let it go on record, Mr. Chairman, that when the call went out to prepare for a possible influenza epidemic in the spring of 1976, county, State and city public health officials, at the expense of other public health endeavors, performed with distinction. They shouldered the burden. They faced the critical public and their local governments supported their immunization activities.

We thank you for giving us the opportunity to share our observations concerning county health agency involvement in the national influenza immunization program.

The National Association of County Health Officials' survey is attached to this testimony. This documentation will no doubt be of importance since HEW is launching a mass immunization program.

On a closing note, we wish to commend the chairman for his leadership under conditions that have been extremely volatile and mostly politically charged.

Thank you, Mr. Chairman. We will be happy to answer any questions.

[Testimony resumes on p. 397.]
Dr. Elsea's prepared statement and attachment follows:)

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