TETANUS

Very recent surveys in some sections of the country have shown that certain segments of the rural population, the group most at risk, are immunized against tetanus to the extent of only slightly over 1 percent. This is a disease with a fatality rate of from 60 to more than 80 percent. The immunizing agent is an effective one and deaths occurring from this disease are inexcusable in an enlightened civilization.

DIPHTHERIA AND WHOOPING COUGH

Diphtheria as a public health problem should have long since ceased to exist. In the very recent past, an outbreak occurred in Iowa, and persistant local reservoirs of this disease continue to threaten many parts of the country.

An upsurge in whooping cough cases occurred during the winter of 1961-62 in Grand Rapids, Mich., one of the best immunized populations in the Nation, simply because there were pockets of unprotected people to maintain and disseminate this disease.

FUNDING

The funds requested would be available only for the purchase of vaccine for children under 5 years of age; for the cost of planning, organizing, and promoting programs; for laboratory and epidemiologic surveillance; and for developing a continuing maintenance program. All of these programs are directed primarily to the high-risk, poorly immunized preschool groups for which all types of polio, diptheria, whooping cough, and tetanus vaccines are considered safe, effective, and urgently needed.

The Vaccination Assistance Act of October 1962 authorized the appropriation of $14 million for fiscal year 1963 and $11 million for each of the 2 fiscal years 1964 and 1965. The amount of money authorized supports a program to insure immunization of approximately 30 million preschool children, including those born during that period, who will have to be immunized for the effective consummation of this program.

SUMMARY

Again, it must be emphasized that effective immunizing agents are and have been available for polio, diphtheria, whooping cough, and tetanus for a number of years; that State and local health departments are doing what they can to utilize these too; and that, in spite of this, only one-third of the preschool population are, at present, protected. It is evident that a short-term intensive program designed to assure immunization of 85 to 90 percent of the preschool children in the country is badly needed. Enabling legislation has been recently enacted. Communities have demonstrated their eagerness to protect these children.

In short, the immunization program, the objectives of which were endorsed by the American Medical Association, the Association of State and Territorial Health Officers, and the American Public Health Association, is a joint endeavor of Federal, State, and local departments of health to finance the utilization of knowledge and tools already available to protect our population from those communicable diseases that no longer need be tolerated and thus start in motion a permanent system for the future protection of all newborn and the eventual eradication of these diseases from America.

Mr. THOMAS. You have $500,000 here for administrative expense, Is that correct, Doctor?

Mr. THOMAS. I understand you have a nice building in Atlanta. Dr. GODDARD. A very nice facility, sir.

Mr. THOMAS. How many employees do you have there now? Dr. GODDARD. There is a total of 2,200 employees in the Communicable Disease Center's activities.

Mr. THOMAS. How badly do you need this money?

Dr. GODDARD. We think it is very important to have it in order that the States can begin this job.

Mr. THOMAS. You want $12.6 million. You already have had $10,062,000. Couldn't you wait for your regular bill? Wouldn't it be better to let the regular committee handle this matter?

Dr. GODDARD. No, sir.

Mr. THOMAS. Why?

Dr. GODDARD. The basic legislation authorizing this vaccination assistance program, which is 87-868, has an expiration date of June 30, 1965. This gives us a limited period of time in which to accomplish the purposes of the act.

IMMUNIZATION

Mr. THOMAS. You are going to vaccinate the children. You have a 3-year program for communicable diseases. You have whooping cough, tetanus, diphtheria, and polio. We have had these diseases for a long time and we have done a pretty good job here.

Dr. GODDARD. There has been a decreasing incidence of these diseases but at the same time in the 20 million under the school age, only 6.4 million have been adequately immunized against these diseases.

Last year we had something in the magnitude of 13,452 cases of these four diseases reported to the Communicable Disease Center. The true incidence of these diseases would probably be much higher if we had 100 percent reporting. There were something in the neighborhood of 500 deaths due to these four diseases in this country, most of them in children under 5 years of age.

JUSTIFICATION OF THE ESTIMATES

Mr. THOMAS. Mr. Reporter, put page 5 in the record and follow that with 8 and 9.

(The pages follow:)

The health of the children of our country deserves the best protection that medical science has made available. Studies show, however, that preschool children have not been effectively immunized and unnecessary illness and death continue to occur despite the fact that good vaccines are available for certain diseases that affect these children. Of 20.3 million children under 5, only 6.4 million have received the vaccinations that they need against poliomyelitis, diphtheria, tetanus, and whooping tough. In recognition of the situation, the President, in his health message in 1962 called for a nationwide vaccination program to stamp out these four diseases.

The Vaccination Assistance Act of 1962 authorizes the Public Health Service to make grants to States and, with the approval of the States, to local areas, for intensive immunization programs against polio, diphtheria, whooping cough, and tetanus. It authorizes the appropriation of $14 million for 1963 and $11 million each for 1964 and 1965. The appropriation requested will enable the Surgeon General to make grants to States and with the approval of the State health authority, to political subdivisions or instrumentalities of the State. Appropriate objects for use of these grant funds include: (1) purchase of vaccines needed to protect children under 5, and (2) salaries and expenses of additional State and local health personnel needed for planning, organization, and promotion activities in connection with intensive community vaccination programs. This includes such things as studies to detect the immunization needs of communities and the means of best meeting such needs, and costs of maintaining laboratory and field surveillance and evaluation of the programs to measure the effectiveness of coverage.

Community immunization grants—increase requested, $12,100,000

For the first year of the immunization campaign, under the proposed supplemental, $12.1 million will be requested for grant support. Grants from these moneys can be made in 1963 and 1964 primarily for the purchase of vaccine. This would provide for some 88 million doses (29 million doses of DPT and 59 million doses of polio vaccine) or enough to immunize about one-half of the preschool population, plus newborn babies. A portion of the grant funds will go to help support the promotional, organization, surveillance, and laboratory costs involved in the immunization campaigns. While the nature of the needs will vary in each locality, the overall requirements will support approximately 70 community immunization program teams involving physicians, nurses, and community organization specialists and about 40 laboratory support units. These represent the nucleus type of activities needed for the development of compre hensive programs throughout the States. However, since the nature of the problem and need varies widely from area to area, overall distribution of grant

support between vaccine and the various elements of supporting costs authorized will differ in accordance with the program as it develops in the States. The Federal support in this instance is stimulatory and supplemental to the development of State and community intensive immunization programs and is therefore aimed at fulfilling the need which will permit these immunization programs to go forward most effectively and rapidly.

Research, training, and technical services—increase requested, $500,000

Centralized leadership is of the highest priority if the community immunization campaign against polio, diphtheria, whooping cough, and tetanus is to obtain its goal. Funds for this activity under the proposed supplemental ($500,000 and 58 positions) will be used for furnishing the leadership necessary to coordinate the national approach to the elimination of these diseases.

During 1963, it is planned to initiate research into simplified laboratory techniques so that local communities can conduct serologic surveys. Behavioral studies will be conducted to develop methods of reaching the hard core of nonresponders to immunization programs. Immunization of 80 percent of preschool age children in all socioeconomic levels is essential and intensive work in certain groups will be necessary.

Other program services, such as maintaining records, training field personnel in the use of jet-injector guns, teaching the techniques of conducting surveys, and other related services are included as part of the supporting functions. Specially trained personnel must be sent into the field to help organize State and local immunization programs.

The requested increase of $500,000 will provide $303,000 for staff and related costs and $197,000 for contractual services (of which $135,000 will be used for contracts with universities and State and local health departments). The staff will be organized in the following manner:

Contracts will be used for studies to determine the effectiveness of the program and to evaluate record systems and new methods of obtaining data for use in followup and evaluation at the community level. Accurate information will be

needed for such aspects of the program as

1. Determining levels of vaccination.

2. Identifying specific unvaccinated pockets in the population.
3. Reaching the newborn.

4. Providing the basis for followup activities.

5. Evaluating the effectiveness and progress of the campaigns.

In summary, the requested increase of $500,000 and 58 positions will provide the resources with which the Communicable Disease Center will be able to provide the leadership, coordination, and technical assistance needed in this nationwide immunization campaign.

EMPLOYMENT

Mr. THOMAS. I call the committee's attention to pages 8 and 9, and the factual information set out thereon. On the last page, it says the $500,000 will provide 58 positions. How many positions do you have in this category, 950 already?

Dr. GODDARD. None at all in the vaccination assistance program. This is a new activity.

Mr. THOMAS. But how many do you have at the laboratory already? Mr. HAMBLETON. We have 994 in this appropriation, sir.

Mr. THOMAS. Do you have more than that by transfer?

Mr. HAMBLETON. The 2,000 Dr. Goddard was referring to included. the other appropriations for tuberculosis and venereal diseases.

IMMUNIZATION

Mr. THOMAS. By the time this bill is signed, you will have about 2 months left in the fiscal year. We don't want to slow you down. We think this is a very vital program.

Listen to this, gentlemen:

Of the 20.3 million children under 5 years of age, only 6.4 million have received vaccination that they need against all 4 of these diseases.

Well, certainly, most of the children received innoculation against maybe one or two of those four diseases?

Dr. GODDARD. Part of them may have had one shot of a series of three that were needed. My memory tells me that about a third of those children have received no immunization of any type whatsoever.

FEDERAL, STATE, AND LOCAL CONTRIBUTIONS

Mr. THOMAS. Break down the costs. Are we going to pay all the bill or is this going to be on a matching basis with the States and counties?

Dr. GODDARD. This will be a program in which the cost of the vaccine will be borne by the Federal Government. The funds provided would also enable the State and local governments involved to employ individuals for the promotion and conduct of programs but would not pay the salaries of those involved in the actual administration

Mr. THOMAS. Break it down without the details. Just give us a good overall view of the contribution between Federal Government, the States, and the local communities.

Dr. GODDARD. There is no matching formula involved.

Mr. THOMAS. You furnish the vaccine; the local communities are going to furnish certain help. Overall, what does it amount to, 80-20 on the part of the Government?

Dr. SENCER. It will probably come close to 50 percent from the Federal Government.

Mr. THOMAS. It is more than that, isn't it?

Dr. SENCER. No, I don't think so, sir, because the provisions of the bill provide for immunization not only of preschool children but to improve the immunization of all people susceptible to these communicable diseases.

Mr. THOMAS. You are dealing with the children right here and that is all.

Dr. SENCER. That is not quite true. The vaccine

IMMUNIZATION OF ADULTS

Mr. THOMAS. How much of your supplemental will you spend for adults? You have 20 million children under 5 years of age. Dr. SENCER. That is correct for the vaccine. However, people whom the States can hire will be used to conduct immunization programs for school-age children, for young adults, in addition and the States will then have to furnish