POLICY POSITION STATEMENTS

Table of Contents

Access to health services is a significant problem in the United States. Affordability of health services has a significant impact on access. Recent data from the U.S. Census Bureau estimates that 15% of Americans amounting to over 44 million persons do not have health insurance. Persons living in poverty or near-poverty are commonly uninsured. Some minority groups and certain vulnerable populations are disproportionately represented among the underinsured and uninsured. Low income individuals cannot afford significant out of pocket expenses.

In addition to affordability, the appropriateness and timeliness of the health services provided are important dimensions of access. The recent growth of managed care has led to greater scrutiny of these dimensions. Managed care has shown encouraging short term results in controlling health care costs. Cost containment is important to the affordability of health care. State health agencies have an interest in the balance between cost containment and the appropriateness or timeliness of services.

Other factors are important to access. The highest quality health services should be provided appropriate to the social, cultural, and economic characteristics of the consumer. Programs providing services must be staffed by providers who are trained to respond to the unique physical, emotional, spiritual, and cultural needs of each individual. Consistent with the expectations of the Americans with Disabilities Act, persons with disabilities may benefit from supportive and/or enabling services such as assistive technology, specialized transportation, and enhanced family involvement and support.

A sentinel 1988 study by the Institute of Medicine's Committee for the Study of the Future of Public Health defines the mission of public health as "the fulfillment of society's interest in assuring the conditions in which people can be healthy." Within this mission, the committee describes the three core functions of public health as assessment, policy development, and assurance. The committee further suggests that assurance functions to "make sure that necessary services are provided to reach agreed upon goals, either by encouraging private sector action, by requiring it, or by providing services directly."

In the fall of 1994, ASTHO, together with a diverse group of public health organizations and agencies, adopted the document "Public Health in America." This document also affirms the mission of public health to assure the quality and accessibility of health services and defines essential public health services as those that:

• Link people to needed personal health services and assure the provision of health care when otherwise unavailable,
• Assure a competent public health and personal health care workforce, and
• Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

These statements of mission and responsibility are unique to the discipline of public health in that their perspective encompasses the entire population. The unit of study and concern is broad and inclusive. The scientific base for public health analysis is epidemiology, a statistical discipline concerned with the incidence, distribution, and control of disease in populations. This is the fundamental paradigm for public health organizations and the professionals who comprise them. The purpose of the ASTHO Access Committee is rooted in these core functions and essential services of public health.

Access to appropriate, affordable, and timely health services for all persons within the United States is fundamental to the health of the public. These services should be provided within the context of the geographical, social, and cultural environments in which the individual resides by appropriately trained health care providers who are sensitive to the unique physical, emotional, spiritual and cultural needs of each individual.

• ASTHO advocates for access to health services for all persons within the U.S.
• Services should be appropriate, that is, provided services should be medically indicated, based on consumer wants and needs, and where possible, scientifically proven to restore health, prevent disease, or improve the quality of life.
• Vital preventive and emergency health services should be accessible to all persons. A person's inability to assure payment at the time of service provision should not delay vital preventive and emergency health services.
• Services should be provided without unnecessary delays or waiting periods that could result in adverse patient outcomes.
• Services should be appropriate within the geographic, social, and cultural environments where individuals reside, accommodating different languages, practices, and customs.
• Health care providers should be trained to recognize and respond to the unique physical, mental, emotional, spiritual, cultural, and developmental needs of each individual, accommodating persons with disabilities and differing emotional capacities, support systems, and religious beliefs.
• Health care should be provided in community-based settings as close to family and community as possible.
• Evaluation of services should be based on a combination of meeting service delivery goals, cost effectiveness, patient and provider satisfaction, and improved health outcomes.
• Evaluation of services should also be based on assessment of health needs and outcomes of diverse populations, including racial/ethnic/language minorities and persons with disabilities.

ASTHO supports the delivery of preventive and personal health services to all persons. Preventive health services are services primarily concerned with preventing disease and promoting health within an entire population. Providing immunizations, monitoring the incidence and vectors of communicable disease, and promoting healthy behaviors and lifestyles are examples of preventive health services. Personal health services are services provided in response to the specific health issues of an individual patient. Private physician consultations, inpatient hospital services, and outpatient physical therapy are examples of personal health services.

ASTHO supports evolution of health services toward those in which accountable primary care clinicians play a central role in linking people to needed personal health services and a contributing role in monitoring the health status of the patients under their care. Primary care services should be consistent with the Institute of Medicine definition, which is "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." ASTHO supports efforts to collect information to monitor access, both over time and for different populations. These data should determine if all communities are receiving affordable and appropriate care, and can assist in defining community health needs. Patient confidentiality should be reasonably maintained but should not prevent meaningful analysis. Data standards and transitions in standards should allow comparisons across sites, populations, and time periods.

Financial barriers for vital preventive and emergency health services should not prevent the provision of such services. Financial barriers are a major reason persons do not seek timely health services.

Financial resources should be available for appropriate access to preventive and personal health services.

Service providers, as well as third party payers, must be publicly accountable for the quality of care provided and the health outcomes of the populations they intend, or are required, to serve. State health agencies should be involved in these assessments and at times, be involved with regulatory activities.

Quality services can be provided within a cost containment environment. Informed and reasonable choice among a number of available and qualified providers is desirable and may enhance the quality of health services. Programs that limit consumer choice must be monitored by a combination of government and the public.

Government programs to provide health services or assist in the provision of health services are administered at local, state and federal levels. Federal partners in these programs should be responsive to state needs and priorities. Within broad policy goals, states should have programmatic flexibility to accomplish these goals. State accountability is important and our federal partners should respect varying state needs and approaches. ASTHO supports federal funding partnerships and the importance of many existing well-designed federal programs to accomplishing national health objectives.

A sufficient number of appropriately trained health professionals should be distributed to provide appropriate access to all populations within the United States. This workforce should be well-trained in the specific skills of their discipline, with opportunities for ongoing learning, and with skills required to be effective team members in our evolving health care system.

The distribution of public and personal health service providers is an issue of concern to state health agencies. The distribution of service providers is of special concern to many special populations, especially providers who are sensitive to the unique physical, emotional, spiritual and cultural needs of these special populations. Federal programs to effect the distribution of health service providers are appropriate when these programs work together with state governments to increase access to health services. ASTHO supports the primacy of state health agencies in defining state areas of health provider need. The assessment of need must recognize that certain subgroups may have different needs than the overall group.

While supporting access to health services for all, ASTHO has special concern for vulnerable populations who may have special health needs or who may be at risk for adverse health outcomes. These populations may require targeted interventions and tailored programs to achieve improvements in health status. Relevant demographic data on the populations of concern and of their health status should be collected, analyzed, and disseminated to help assure appropriate health interventions and health care assurance. Such interventions should be structured with the goal of achieving improved health status for all persons within the community.

Policy Expires: December 31, 2003
Recommended for adoption by the ASTHO Access Policy Committee on July 17, 1997
Adopted by ASTHO Executive Committee on September 2, 1997
Ratified by ASTHO Membership on September 25, 1997

Revisions and Additions adopted by the ASTHO Access Policy Committee on June 9, 2000
Revisions and Additions adopted by the ASTHO Executive Committee on June 15, 2000
Revisions and Additions Ratified by ASTHO Membership on July 20, 2000

An environment that is free from harm is the beginning of good public health. Clean air, pure water, uncontaminated food, and other aspects of a healthy environment are vital conditions for healthy people. The birth of public health, in fact, was the purification of drinking water, which halted the waterborne epidemics that not so long ago raged through the population.

Exposure to physical, chemical, biological, and radiological contaminants through air, water or other means can bring suffering, illness, disability, societal costs, or even death. Preventing such exposures must continue to be a first principle of public health policy; and public health and environmental protection agencies at all levels of government must work closely together to achieve the greatest feasible level of protection.

In the quarter century since the nation has become aware of the need for increased protection of the environment, its quality has unquestionably improved greatly. Seldom do we see the thick clouds of smoke or smog that used to choke our cities. Rivers no longer catch fire.

Much remains to be done, however. Today, pollution and its effects on health are often more subtle and long term; but still must be addressed to ensure that our environment is not a cause of disease or injury. The added dimension of intentional harm through chemical, biological, and radiological terrorism further underscores the continuing vital role that environmental health plays in improving and protecting the well being of our nation, and this policy statement is intended as a guide for improving environmental health programs.

Prevention is the first principle of public health. It applies to environmental health just as it does to immunization, health education, and the other dimensions of public health action. It is far easier to prevent illness than to cure it, and it is easier and less expensive to prevent environmental contamination than to clean it up or treat the people harmed by it.

A sound scientific foundation is essential for a successful public health policy. Policies should be based on reasonable and appropriate data about hazards, exposure and health risks evaluated by competent scientists from a variety of relevant disciplines. Only through the use of proper scientific discipline and methods can health risks be accurately assessed, their causes clearly identified, and effective technologies and interventions developed.

Environmental health policy should set priorities on the basis of realistic assessments of comparative environmental health risks. Preferably, these risks should be assessed on measurements of actual exposure to potentially harmful agents rather than on models of risk or exposure. In the absence of actual exposure data, however, information derived from animal studies or realistic risk models may be used. Health risk assessment should include not only direct or primary effects but also secondary, indirect, and unintended effects. The greatest cumulative risks to health, using a multimedia approach described below, should have the highest priority and the largest expenditure of time, financing, and expertise to mitigate them. Lesser risks should have a proportionately lesser share of resources. Risks should be assessed over the entire life cycle of an activity to ensure that environmental health risks are not merely transferred from one stage to another.

Environmental health policy should balance the risks and benefits of actions taken. In attempting to reduce an environmental health risk, policies and programs should account for the health or environmental benefit of the product or activity of concern.

People are exposed to hazards from all environmental media, and a complete environmental health assessment should include all exposures. Too often, however, risks are assessed on the basis of a single contaminant in a single medium, which can understate the magnitude of risk where several routes of exposure exist. For instance, the risk of a single chemical may be assessed to establish a drinking water standard, but exposure to that substance may include air and food contamination as well. Likewise, regulations that reduce contamination in one medium may inadvertently increase it in another, overstating the benefit of that regulation. For instance, water pollution control regulations that result in the creation of sludge that is then burned may reduce water contaminants at the expense of creating air contaminants.

Governments at all levels must closely coordinate their health and environmental programs. Environmental health efforts frequently cross jurisdictional and bureaucratic boundaries. State environmental and health agencies are usually separate; and close communication is essential to provide a public health perspective to environmental programs and an environmental perspective to public health programs. Such a multidisciplinary approach helps to ensure that all aspects of protecting health and the environment are considered in developing and carrying out environmental health programs.

Coordination among federal, state, and local government activities should leave maximum flexibility to address state and local conditions, priorities, and approaches to environmental public health. State and local health and environmental officials must be involved early in any planning process to ensure that their needs are addressed adequately. Nonprofit and private sector organizations should also be included to broaden the perspective of planning and implementation efforts, and to strengthen the public support for environmental health efforts.

Environmental health policies must be affordable for the nation, and must be funded sufficiently to permit them to succeed. Federal funds should be distributed among states in a long term, equitable manner based on the environmental health risks that each faces. Since protecting human health is the foundation of almost all environmental laws and regulations, federal partnership grants and other financial relationships with state environmental agencies should include funding for environmental health surveillance and evaluation to ensure that the laws' intents are being achieved.

Flexibility in resources should be ensured for their efficient and effective use. Environmental health programs should not be overly prescriptive, but should focus on results. Free market approaches should be considered to the extent that they will improve efficiency without reducing environmental health protection, or will increase the level of protection with the same amount of resources. Such approaches should ensure that the costs of environmental health are accounted for internally rather than borne by others downstream or downwind.

When making decisions about environmental health policies, health officials should seek to protect sensitive populations and ensure that risks and benefits are reasonably distributed among ethnic, racial and economic groups. Populations such as pregnant women, children, the aged, and those with compromised immune systems are especially vulnerable, and their risks should be considered as part of environmental health policies and programs. Likewise, the risks of environmental contamination should not be concentrated by race, ethnicity, or economic status.

People have the right to participate meaningfully in decisions that will affect their lives, and government has an obligation to provide people the opportunity to do so. In a democracy, government answers to the people. Public officials must provide clear and understandable information, placed in an accurate perspective, which enables people to participate meaningfully in decisions. Public participation is essential to obtain the acceptance that will allow a program to succeed.

The Clean Air Act has proven to be effective in reducing health risks, but not all people can be protected against risks of air contaminants "with an adequate margin of safety" as called for in the law. When such situations arise, the public should be informed about voluntary measures that can reduce exposure and health risk.

Our ability to assess and characterize these risks is still limited because information on actual exposure to potentially harmful substances is incomplete. ASTHO supports the continued evolution of science supporting the implementation of the Clean Air Act to improve our understanding of the health effects of air pollution.

Administratively, states should continue to have primary responsibility for carrying out the mandates of the Clean Air Act. ASTHO recognizes that EPA has a responsibility to ensure that air standards are met. Once the agency has approved an implementation plan, however, the state should have the flexibility to carry out that plan without micromanagement. EPA should instead focus on its oversight and audit responsibilities. It should not review individual state actions and decisions as long as the state operates consistently with the approved program.

ASTHO believes that the Clean Water Act's goal of "fishable, swimmable water quality" should be retained. Health officials are charged with protecting the public from exposure to biologic and physical contamination at beaches, and may have to issue public warnings or close beaches if necessary. The decision about when contamination is great enough to close beaches or to issue warnings can be difficult.

There are at present no generally accepted criteria for making such hard decisions. Each jurisdiction generally decides for itself how to manage these health risks. This situation can lead to varying decisions, depending on who is making them, when and where. Thus, ASTHO recommends that federal, state, and local health officials develop understandable and consistent guidelines to help make risk assessment and risk management decisions at beaches.

ASTHO believes that the use of fish consumption advisories should be consistent among federal and state agencies and should balance the health risks of eating fish at predicted exposure levels with the nutritional benefit of fish in the diet of groups that may have limited dietary options.

Protecting people from the health consequences of poor quality drinking water is of paramount importance to state health agencies. ASTHO believes that EPA should collaborate with other federal public agencies as well as state environmental and public health agencies to develop and administer drinking water programs that address both naturally occurring and man made contaminants.

ASTHO considers it essential that states be provided with adequate time and resources to build state capacity to accommodate any devolution of responsibility from the federal government to the states. To this end, ASTHO strongly supports a clear definition of state primacy in the drinking water program, and urges EPA to conserve its resources by eliminating duplicative activities where parallel or overlapping responsibilities exist.

ASTHO supports the use of the following four criteria in guiding EPA's drinking water program: sound science, risk-based standard setting, implementation partnerships, and source water protection.

ASTHO continues to support the fluoridation of drinking water as a means to lessen the incidence of tooth decay.

A fundamental mission of the membership of the Association of State and Territorial Health Officials is disease prevention. Food-borne illnesses are preventable diseases that pose a widespread threat to human health. An estimated 76 million cases of food-borne disease occur annually in the US and result in 325,000 hospitalizations and 5000 deaths. Economic losses likely exceed 5 billion dollars annually.

Ensuring the safety of the nation's food supply is a primary responsibility of public health agencies. Consequently, ASTHO believes that we should reduce the use of potentially harmful substances in food to the extent that such reductions do not increase risks associated with bacteria or other hazards, or significantly reduce crop productivity. ASTHO recognizes that extensive safety factors are already built into the tolerance setting process. Nevertheless, ASTHO believes that pesticide tolerances should be set at a level that poses a reasonable certainty of no harm to consumers; including children, who eat and drink more per pound of body weight than adults, and whose growing organs offer greater chances of injury as a result of their exposure. Pesticide and microbial contamination are particular concerns in products imported from countries that may not have the same health or safety standards.

ASTHO supports the EPA Administrator's authority to set pesticide tolerance limits for agricultural products in an efficient manner. ASTHO opposes, however, any attempt to limit the states' authority to set more stringent standards.

Microbial contamination remains a significant threat to the food supply. Minimizing the potential for food contamination "from farm to fork" should be a high public health priority. ASTHO supports current and planned efforts to enhance food inspection through a hazard analysis and critical control point (HACCP) program that will help to identify and remove contaminated food before it reaches consumers. ASTHO anticipates that this effort will ultimately ensure that farmers, ranchers, processors, transporters, and others in the food delivery chain employ the most up to date standards of management and manufacturing practices to prevent food contamination.

ASTHO supports the use of food irradiation as an effective barrier to the transmission of food-borne disease. Food irradiation provides an additional barrier to disease transmission that supplements, but does not supplant, clean food processing plants and proper food handling and preparation. The safety of food irradiation and irradiated foods has been systematically and comprehensively evaluated. The scientific evidence is clear that irradiated foods are safe and nutritious. Food irradiation has been endorsed by the Centers for Disease Control and Prevention, the American Medical Association, the American Veterinary Medical Association and the American Dietetic Association.

ASTHO believes that public health education and training are essential to food safety. Consumers and food industry workers must be aware of and follow safe food handling practices to prevent foodborne illness.

ASTHO believes that all of the waste products of our society should be disposed of in a manner that poses a negligible risk to human health. Moreover, the volume of waste should be reduced throughout a product's life cycle first through source reduction, then through reuse, recycling, treatment, and finally disposal when other options are not feasible.

Waste sites should, at a minimum, be cleaned consistent with their intended future uses, especially in the rehabilitation of industrial sites. State health officers should be actively involved in site assessments and decisions; and they should be active participants in initial exposure and disease investigations, in early community education, and in reviews of site closures. Such activity should not arbitrarily be limited to National Priorities List (NPL) sites, but should include all sites where a significant potential exists for human exposure to hazardous substances and resulting adverse health effects.

A comprehensive public health assessment is not needed at all toxic waste sites to protect the public from harm. ASTHO believes that public health professionals should have the flexibility to design a more rapid and targeted response. Health assessments should be allowed to include environmental risks other than toxic waste sites that may exist in a community to present a more comprehensive view of environmental threats to public health including the psychological and social aspects of a population living near a waste site. Such an approach would be consistent with the comparative cumulative risk and multimedia concepts discussed under the General Principles of Environmental Health Policy.

Indoor environmental quality is vital to environmental health because pollutant levels indoors can exceed outdoor pollutant levels, and people spend upwards of 90 percent of their time indoors. Radon is a known human carcinogen that can accumulate to unhealthy levels in the indoor environment. EPA estimates that 7,000 to 30,000 people die of lung cancer each year because of radon exposure in their homes. Radon levels at or above an annual average of four picocuries per liter of air should be reduced through available mitigation techniques.

ASTHO believes that state health agencies should promote radon awareness, testing and mitigation, regardless of the organizational location of a state's radon program. State health agencies should also promote radon-resistant new construction, encourage radon disclosure during real estate transactions, and address inequity of action among minority populations. ASTHO encourages states to work with EPA and state radon offices to serve as a resource for radon awareness and mitigation health education materials.

Even in the absence of needed indoor air quality (IAQ) standards, government has a role in fostering practices to improve the quality of the indoor environment. ASTHO encourages businesses and individuals to ensure the proper operation, maintenance, and cleaning of heating, ventilation and air conditioning (HVAC) systems. The control of air flow, maintenance of comfortable temperatures and humidity, control of dust, and similar measures would greatly lessen real and perceived poor IAQ. In addition, simple housekeeping measures such as the timing of painting and pesticide applications, the proper storage of cleaners and chemicals, and the ventilation of structures after the installation of new carpets or wall coverings would also improve IAQ. ASTHO recommends that HVAC systems be maintained and cleaned regularly to prevent the growth of pathogens that could then be distributed throughout a structure. Homeowners and building managers should also ensure that carbon monoxide, oxides of nitrogen, and other combustion products be safely vented to the outside and not be allowed to accumulate to harmful levels in the indoor environment.

ASTHO also believes that lead based paint continues to pose an indoor health hazard, and lead dust is a major pathway of children's lead exposure. Funds should be made available for low-income families to lessen their potential exposure to lead. Funds should also be made available to state health departments to assess blood lead levels and environmental lead levels in soil, paint, dust, and other media. Likewise, exposure to environmental tobacco smoke (ETS) should be restricted to provide indoor air that is free from this substance. The public health community should promote legislation or regulation and provide information to the public to reduce the potential for ETS exposure.

The federal government should provide the resources to help state health departments to upgrade their environmental epidemiology and toxicology programs, and to ensure that states have the capacity to perform these functions. Moreover, federal funding should provide resources to help state health departments upgrade their environmental laboratories' capacities to support environmental public health programs.

In addition, EPA should devote more resources to develop health advisories for public health officials to use in preventing adverse health effects from exposure to toxic substances.

Finally, state health officers should maintain the organizational responsibility for risk assessment in environmental and occupational exposure to hazardous substances.

Disease vectors are numerous and widespread in the United States and exotic vectors and the diseases they carry have been imported into this country. The prevention of vector-borne disease involves public education, surveillance, epidemiology, and vector control. Over the past half-century, public interest in and knowledge of vector-borne diseases has declined, resulting in lessened capability to deal with them adequately.

Vector-borne diseases of increasing public health importance include Lyme disease, ehrlichiosis, and West Nile fever. Malaria and dengue are repeatedly introduced into the U.S. by infected travelers returning from endemic areas. Epidemics of mosquito-borne encephalitis occur sporadically, involving hundreds to thousands of human cases. The Asian tiger mosquito was introduced into Texas during the 1980's and spread throughout the south and north to the Great Lakes states. Hordes of mosquitoes invade communities following hurricanes and after floods. Flies emerge from large accumulations of manure at concentrated animal feeding operations and plague residents for miles around. Vector-borne diseases such as plague, Q-fever and others are potential bioterrorist threats.

The infrastructure to educate the public and professional communities and to monitor and prevent vector-borne disease must be improved and maintained in all levels of government. The federal government should provide resources to enhance the capabilities of state agencies to prevent or control vector-borne diseases. States should also devote resources to combat vector-borne diseases and develop expertise in those diseases endemic to their jurisdictions. An integrated pest management approach to vector control should be encouraged for maximum effectiveness and minimal environmental impact.

In 1997, US EPA reported to Congress that 25% of the U.S. population is served by onsite wastewater systems. Further, nearly 40% of new development uses onsite/decentralized wastewater. US EPA stated that properly managed onsite/decentralized wastewater systems are a viable alternative to public sewer systems.

However, at present many of these systems are in unmanaged environments and can become sources of disease vectors. Prior onsite/decentralized wastewater systems that met older technical standards may not be able to meet current technical standards. Therefore, more attention needs to be paid to the operation, maintenance, and monitoring of these older systems. At the same time new onsite/decentralized wastewater systems that are more technically advanced require more frequent monitoring. Current national initiatives to remedy the aforementioned problems are handicapped by a lack of research, practitioner education, public and political understanding and support, and the lack of fiscal and human resources.

There is a need for training and research related to onsite/decentralized wastewater systems, including associated regulations, and site evaluation, design, construction and management practices. Accordingly, ASTHO supports the exploration of a coordinated regional approach for onsite/decentralized wastewater systems to be developed in association with universities that could offer applicable courses, and train presenters and researchers. Such an approach would coordinate regional training for regulators, contractors and others involved in the industry and, would conduct practical research on new and emerging technologies.

Policy Expires on December 31, 2005
Executive Committee Review and Approval on June 28, 2002
Ratified by the ASTHO Membership on September, 11 2002

Approval History
Recommended for Adoption by the ASTHO Environmental Health Policy Committee on June 25, 2001
Executive Committee Review and Approval on June 23, 2001
Ratified by the ASTHO Membership on October 26, 2001 (fax ballot)*

The Comprehensive Environmental Response, Compensation and Liability Act (CERCLA), commonly called Superfund, was enacted almost two decades ago in response to public concern about human health effects resulting from exposure to chemicals from hazardous waste sites. Exposure to chemicals and the possibility of disease remain major sources of public concern at hazardous waste sites.

2.2 PUBLIC HEALTH PROVISIONS

ASTHO believes that the health provisions of CERCLA Section 104(i) should remain largely intact. They are an important foundation for the public health aspects of CERCLA in site specific public health assessments, studies, surveillance, and registries. They also support the identification of key health information and research needs in specific chemicals, and allow community education in public health.

State health agencies and the Public Health Service bring a unique and vital public health perspective to address the public's concerns about exposure to toxic substances. They bring expertise in epidemiology, and can conduct chemical exposure assessments. Often, they are skilled at other aspects of risk assessment and risk communication as well. Most importantly, they involve the community meaningfully in the assessment and decision process. State health agencies should therefore be involved significantly and early in assessing hazardous waste sites, as well as in conducting later public health, exposure, and disease studies.

State health agencies should be involved at waste sites early to discover and explain to the public the health risks from past, current, and potential future exposure to hazardous substances. While some state and federal health agencies are active and vital participants at waste sites, no formal role now exists for them. ASTHO believes that state health agencies should be a recognized part of site assessment and decision teams, and should be active participants in initial exposure and disease investigations, in early community education, and in reviews of site closures. Such activity should not be arbitrarily limited to sites designated on the National Priorities List (NPL), but should include all sites, including brownfields redevelopment, where a significant potential exists for human exposure to chemicals and resulting adverse health effects.

A comprehensive public health assessment is not needed at all sites to protect the public from harm, but is required under the existing law. ASTHO believes that public health professionals should have the flexibility to design a more rapid and targeted response. Site reviews and updates would often be adequate alternatives. Moreover, health assessments should be allowed to include environmental risks other than waste sites that may be present in a community to present a more comprehensive view of environmental threats to public health. The Agency for Toxic Substance and Disease Registry (ATSDR) should have the flexibility to carry out all site related public health activities.

Site assessments should consider the needs of sensitive populations and ensure that the risks and benefits of remediation are reasonably distributed among ethnic, racial and economic groups. Populations such as children, the aged, and those with compromised immune systems are especially vulnerable. Moreover, site assessments should consider the psychological aspects of a population living near a waste site as well as the physical effects of exposure to potentially toxic substances.

ATSDR assesses health effects of hazardous waste sites, frequently through cooperative agreements with states. These efforts are not required to be integrated into the site assessment process, however, and public health assessments often seem to have little or no effect on the outcome of feasibility studies or remediation decisions. Clearly, the role of ATSDR and other public health agencies involved in health assessment and site decision processes need to be strengthened; and the results of their efforts should be required to be integrated into decisions to help simplify, accelerate, and improve the remediation process, and to ensure that it is both efficient and protective of public health.

Federal funding should exist to provide adequate funding to state health agencies who must rely heavily federal resources to perform their roles as part of protecting public health at waste sites. In particular, ASTHO believes that adequate funding should be provided for environmental health surveillance and evaluation at waste sites to help ensure the long-term health of nearby residents.

Policy Expires on December 31, 2005
Executive Committee Review and Approval on June 28, 2002
Ratified by the ASTHO Membership on September, 11 2002

Approval History
Recommended for Adoption by the ASTHO Environmental Health Policy Committee on May 23, 2000
Executive Committee Review and Approval on June 15, 2000
Ratified by the ASTHO Membership on July 20, 2000

The ultimate goal of public health is to ensure healthy people in healthy communities by promoting physical and mental health and preventing disease, injury and disability. Improving the health of the public is achieved only through a partnership of federal, state and local agencies along with the private sector, community-based organizations, and individuals. Essential public health functions include monitoring the health status of the entire population; identifying, investigating, and diagnosing health problems; informing, educating and empowering individuals about health issues; fostering community partnerships; developing policies and plans to improve public health; enforcing laws and regulations; improving access to health services; assuring a trained health professional workforce; evaluating the effectiveness of services; and conducting research.

The Association of State and Territorial Health Officials (ASTHO), representing the public health agencies of the states and territories, has developed a set of principles that frame ASTHO's policy position should consolidation of federal public health grants occur. The principles address five broad areas: concept, flexibility, funding, administration, and accountability. These principles reflect the states' need for flexibility, desire for equity in formula development and application, and need for active participation in the development of a rational and reasonable set of outcome measures.

Federal grant consolidation proposals should be evaluated on their overall potential for improving the nation's public health delivery system. This evaluation should take into account the proposal's likelihood to improve the nation's health status and maintain responsiveness to emergent public health issues. If grants are consolidated only similar programs should be combined, preferably those that already have established working relationships. Due to the unique natures of public health and social welfare programs, ASTHO strongly encourages policymakers to maintain the distinction between the two.

Public health threats are not always predictable instances. Outbreaks of diseases and natural disasters strain limited public health resources. In order to address these unexpected public health crises, state health agencies should be allowed to transfer funds among public health programs. For accountability purposes, the agency should justify the need for the transfer by documenting the comparative urgency of new demands versus existing programs and assuring that state outcome objectives will continue to be met at the state and local levels. If multiple public health block grants are established, states should have the option to use previous years' carryover funds from any of the health block grants to address priority health needs as determined by the state.

The cost-effectiveness of many public health programs is well documented. It has also been demonstrated that cuts in public health funding result in increased morbidity in this nation. A sustained investment in public health is essential to ensure that we are prepared to meet the health needs of the nation into the 21st century. Funding formulas should be based on a combination of three criteria: population, poverty and health status. Legislative authorization for consolidated grants should run for a standard five-year period with authorized funding levels established at the outset for the duration of the grant.

Only programs that are active in all states should be considered for immediate consolidation. Redistributing funds that are currently granted to only some states will disrupt programs and jeopardize services. A transition period for states to plan for these losses or increases in resources is needed. Research and demonstration programs that have insufficient funding to reach all states should be excluded from consolidations until the authorization period for these programs end. At the end of their program authorization, if the grant contains recurring dollars, that amount should be added to the appropriate consolidated grant's funding.

Formulas for consolidated grants should not be designed to reduce funding to states. Improvements in performance cannot be expected if funds decline relative to the need for public health services. No formula change should impose disproportionate funding reductions on individual states.

Federal grant consolidation proposals should incorporate state input into the development of application and reporting processes. A multi?year state plan that can be amended annually is preferred. The state public health agency should be designated as the administrator of public health grants, unless otherwise designated by the governor. The application process for federal consolidated grants should be tailored to promote administrative efficiency, facilitate the attainment of outcome objectives, and assure adequate accountability.

The need for standardized data collection and report generation should be addressed in grant negotiations between the states and HHS. However, not all states operate data collection and report generation activities at the same level of efficiency and sophistication. Therefore, to meet standardized, automated data collection and grant report goals and, at the same time, increase the capacity of the states, it is necessary to include processes to develop and maintain reporting activities that are an equal component of the grant award requirements. The negotiated outcomes should also contain suitable development time periods plus sufficient funding to enable the states to complete the transition to standardized, automated report formats.

Policy Expires on December 31, 2005
Executive Committee Review and Approval on July 12, 2002
Ratified by the ASTHO Membership on September 11, 2002

Approval History
Recommended for Adoption by the ASTHO Management Committee on May 21, 2001
Executive Committee Review and Approval on July 23, 2001
Ratified by the ASTHO Membership on October 26, 2001 (fax ballot)*

Immunization is a vital public health tool and one of the most effective means of public health promotion and disease prevention. Few measures in public health can compare with the cost benefit ratios of vaccines.

Prior to the institution of routine immunizations, vaccine-preventable diseases were a major cause of morbidity and mortality in children. Widespread vaccination of children has resulted in dramatic decreases in vaccine-preventable disease in the United States. In recent years, most of the diseases for which childhood vaccines are routinely administered have become increasingly rare in the United States.

ASTHO strongly supports efforts to achieve and maintain high levels of immunization coverage rates among children and adults. Federal, state, and local resources should be used cooperatively with private resources to assure that the entire population, children, and adults, are appropriately immunized.

Policies for vaccine requirements, including school and daycare entry laws, are made almost exclusively at the state level. States consider vaccines on an individual basis, and employ a rigorous decision-making process. Many states call together groups of experts to guide policy formation, and all state health departments work closely with state legislatures and some with state boards of health to enact policies which serve to protect the public's health.

States also seek specific immunization guidance from experts on the national level. The Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) all provide guidance and advice on the use of vaccines. Vaccine recommendations are made through a careful, deliberative process, which includes expert testimony, scientific data, and public input. While vaccine manufacturers play a role in this process, advisory committees must operate under conflict of interest laws.

ASTHO supports this approach and believes that vaccination implementation authority must be maintained at the state level. We are confident in the integrity of this process, and continue to support careful state consideration of recommendations put forward by the ACIP, AAP and AAFP.

ASTHO believes that states must continue to have the primary responsibility for vaccine accountability in publicly funded vaccine programs. State health officials support the development of national guidelines on vaccine accountability and believe that state input into these guidelines is critical. Flexibility at the state level is essential to prevent waste and discourage fraud. A careful balance between requiring reports and maintaining provider participation is needed. States have extensive experience with vaccine management and are in the best position to work with providers.

ASTHO supports prompt reporting and thorough investigation of suspected cases of vaccine-preventable disease to allow rapid institution of effective control measures to limit the spread of such disease. ASTHO recognizes that continued development and support for national and state surveillance systems is essential to successful immunization and disease prevention strategies. Efficient immunization and disease surveillance provides important information for disease control activities, policymaking, and successful immunization delivery strategies. As disease incidence falls, collecting and reporting complete and accurate information becomes increasingly important. This same surveillance allows on-going review of vaccine efficacy.

ASTHO supports continued study of vaccine safety issues and the continued development of safety improvements in vaccines and vaccine delivery techniques. We further recommend that the federal government publish, distribute, and regularly update vaccine information forms (such as the Vaccine Information Statements currently produced by Department of Health and Human Services) explaining the risks and benefits of individual vaccines and the availability of compensation for vaccine-related injuries. Active surveillance of vaccine-related injuries through the Vaccine Adverse Effects Reporting System (VAERS) and the Vaccine Safety Datalink (VSD) is an important part of the support system to encourage high utilization of vaccines. ASTHO recommends sufficient funding and resources be allocated to support the activities of the VAERS and VSD.

ASTHO recognizes the public health benefits of measuring all immunization rates and basing health policy decisions and immunization goals on the most comprehensive data available. The National Immunization Survey (NIS) is the most cost-effective tool currently available for measuring state-by-state immunization rates, and needs continued federal funding. As statewide registries emerge throughout the nations, comparable data can be generated from state systems. The data from the NIS needs to be released in a timely fashion.

While childhood immunization rates seem to be at an all-time high, about one million children under age two still have not received all of their immunizations. Federal support for childhood immunization administration comes through multiple funding sources:

• technical assistance and grants to states and local health agencies for planning, developing and conducting childhood immunization programs through section 317 of the Public Health Service Act;
• funding for vaccine purchase and delivery infrastructure, including registries and links to other health and welfare programs through section 317;
• the Childhood Immunization Initiative funded through section 317 to increase coordination among government, business, and volunteer organizations;
• Vaccines for Children program, separately funded, to improve children's immunization coverage by reducing the cost of vaccine.

ASTHO supports the full funding of section 317 programs with flexibility for state immunization efforts. Ongoing reauthorization for section 317 and adequate funding in both vaccine purchase and infrastructure support are essential to immunization efforts in the states.

Currently, only some children may receive VFC-purchased vaccines in their medical homes. Underinsured children must go to a federally qualified health center or rural health clinic. This undermines the promotion of one medical home for these children. It also undermines the public health clinics' responsibilities to provide immunizations. Missed opportunities for immunizations result when children must be referred from one site to another. ASTHO recommends that vaccines be provided in all settings where children regularly receive care. We urge the removal of the exclusion of settings for underinsured children and children enrolled in state Children's Health Insurance Program (CHIP) plans. ASTHO encourages the use of the VFC program to deliver new vaccines to all eligible children without delay. ASTHO views the VFC program as a vital component of the nation's immunization efforts and would support continuation or expansion of the program.

ASTHO supports the linkage of state-based immunization efforts with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program) based on state and local development of linkages. ASTHO will work collaboratively with the Centers for Disease Control and Prevention (CDC), U.S. Department of Agriculture (USDA), the National Association of WIC Directors (NAWD), the American Academy of Pediatrics (AAP), and the Association of Immunization Managers (AIM) to improve immunization rates by encouraging immunization programs to work in partnership with WIC programs to implement innovative linkage strategies and expand nutritional services.

ASTHO recognizes the many demands on the WIC Program, and realizes that competing demands can drain WIC resources and staff. ASTHO strongly supports the WIC Program and believes that WIC should be compensated as fully as possible for all the services it provides.

ASTHO recognizes the critical importance of providing both high quality nutritional services and appropriate childhood immunization services to all children, particularly those served by the WIC program. Such services clearly fall within WIC's directive to "serve as an adjunct to good health care during critical times of growth and development…to improve the health status of these persons [WIC Clients]." (7 CFR, Section 256) The WIC program is extraordinarily well positioned to ensure that families avail themselves of both of these important health services. State health officials believe that immunization assessment and referral activities are vital to the health and well-being of WIC children, and help to further enhance good health care. WIC-related activities must be provided within the full context of public health responsibilities.

WIC Programs are administered through the health department (or comparable agency) in each state. State health officials and WIC directors are positioned to seize a unique opportunity to support the development of healthy children through critical nutrition and disease prevention services. Additionally, state health departments should work to ensure that all programs for which they have responsibility reach the desired outcome of healthy people, and particularly healthy children.

ASTHO supports the National Vaccine Injury Compensation Program and requests that any changes in the program or the Vaccine Injury Table be made in consultation with the states. A flat vaccine excise tax at a reasonable rate can adequately fund the compensation program while reducing the cost burden on vaccine purchasers. Increases in the excise tax cannot be retroactive. Returned vaccines should be credited at the original excise tax amount.

ASTHO supports continued development of immunization registries and tracking systems which have the potential to be linked. With the Council for State and Territorial Epidemiologists, ASTHO recommends that the CDC National Immunization Program take a lead role in establishing standards for data exchange and a method for unique patient identification, working with state and local agencies to develop population-based registries and coordinating with other federal agencies. CDC should support evaluation and research activities. Immunization registries offer the best source of accurate, real-time data on immunization levels and enhanced linkage between immunization programs and other health and welfare programs (federal, state, and local) and private sector partners.

While most states allow religious exemptions from childhood immunization requirements, and all medical exemptions, only a minority of states (15 in 1998) allow philosophic or personal exemptions. Children exempted from vaccination requirements are more likely to develop vaccine-preventable disease, and when increased numbers of exempted children mix with nonexemptors, the risk of incidence of preventable disease increases in the nonexemptors as well. (Salmon, DA, et al. Health Consequences of Religious and Philosophical Exemptions from Immunization Laws. JAMA. 1999;282:47-53.)

ASTHO believes that wider adoption of these exemptions is inconsistent with good public health policy and is contrary to efforts to improve childhood immunization coverage. We support the right of states to pursue appropriate policies and legislation. We urge states considering philosophic exemptions to consider the public health impact of such exemptions and make the criteria for exemption as strict as possible if such exemptions are adopted.

The use of combined vaccines, or the simultaneous administration of multiple vaccines, can help increase vaccine coverage while reducing health provider visits. Combined vaccines increase the acceptability of immunizations. ASTHO supports the continued development of combined vaccines, but recognizes concerns related to their integration into the routine immunization schedule. To enhance the public health benefit of combination vaccines, ASTHO recommends automatic vaccine delivery systems which include product information for the provider, standardized "antigen packages" for combination vaccines, and immunization registry systems which follow the child regardless of provider.

Adolescent immunization remains an important opportunity for prevention as yet unrealized in most states. Many vaccine-preventable diseases continue to occur in adolescents and young adults. More measles cases now occur in adolescents than young children. Over 70% of new Hepatitis B cases each year occur in adolescents and young adults. ASTHO endorses the Advisory Committee on Immunization Practices (ACIP) recommendation for a routine early-adolescent visit at age 11-12, to provide an opportunity to assure adequate vaccination against Hepatitis B, varicella, measles, mumps, rubella, tetanus and diphtheria, as well as other health care and prevention services. We encourage innovative approaches to reaching adolescents such as school-based immunization services.

ASTHO firmly believes that adolescent immunization efforts deserve national attention and priority. In the interest of focusing attention on the immunization needs of adolescents and garnering support for adequate resources to respond to those needs, ASTHO endorses the national adolescent goals proposed by the Centers for Disease Control and Prevention (CDC), while remaining very concerned about the lack of dedicated resources to reach such goals. We wish to make clear that in endorsing these separate goals for adolescents, ASTHO in no way diminishes its support for early childhood immunization efforts. We cannot afford to divert resources or intensity of effort from children to adolescents. Rather, we must continue our aggressive childhood immunization campaign while expanding to meet the critical needs of adolescents.

ASTHO urges Congress to restore previously cut funding to the Section 317 immunization infrastructure program, and to respond to the proposed national adolescent immunization goals with additional funding to support the delivery of vaccines to adolescents. It is only through the collective efforts of all partners involved and adequate resources from the federal level that we will be able to meet the goal of vaccinating adolescents while maintaining 90% levels for childhood vaccines.

National Coverage goals for 13-year-olds or 8th graders:

Vaccine	2000	2002
MMR-2	90%	90%
Hepatitis B	65%	90%
Td	65%	90%
Varicella (among susceptibles)	65%	90%
3-2-1-1 (3 doses of hepatitis B, 2 doses of MMR, 1 dose of Td, 1 dose of varicella)	65%	90%

ASTHO strongly believes that childhood immunization must remain an integral part of Early and Periodic Screening, Diagnosis and Treatment, a mandatory service, regardless of any other changes in Medicaid. Medicaid managed care plans are accountable for immunization in accordance with standards for all enrollees. We recommend that state contracts include accountability and quality standards as recommended by CDC for routine immunizations. We encourage inclusion of public health officials in Medicaid managed care contract development processes.

ASTHO strongly encourages policies and programs which enhance the availability of immunizations to all children. ASTHO believes that it is critical that all children, including those covered in private insurance plans, have access to immunizations as free from barriers as possible. ASTHO encourages all health insurance plans to provide complete coverage for preventive care, including well-child and well-baby care as well as immunizations. This preventive care should be exempt from deductibles, co-payments, and co-insurance. In addition, ASTHO recommends that managed care plans be held accountable for meeting immunization standards as recommended by the CDC.

The Children's Health Insurance Program (CHIP) is a federal grant program which supports state efforts to provide health insurance for uninsured children. ASTHO believes that CHIP should work in combination with the Section 317 grant program and the Vaccines for Children (VFC) program to enhance the ability of states to ensure that at-risk children are immunized. As an insurance program, CHIP ensures coverage for vaccinations. Full funding of the Section 317 grant program is still needed to maintain population-wide immunization functions -- such as assessment, education, surveillance, and outbreak control. ASTHO also supports continued VFC eligibility for children enrolled in all types of CHIP plans.

Adult immunization is an important public health opportunity. Each year, 45,000 adults die from influenza, pneumococcal infections, and hepatitis B -- all vaccine-preventable diseases. Federal Medicare policies and insurance benefits are important factors in adult immunizations.

ASTHO supports efforts and strategies to increase adult immunization levels, such as; improving provider and public awareness, increasing the capacity of the health care delivery system to deliver vaccine to adults effectively, expanding financial mechanisms to support vaccines for adults, monitoring and improving immunization of adults, and increasing support for research on adult immunization issues. ASTHO recommends that health care providers determine immunization status of adult patients, offer immunizations and maintain complete immunization records. We recommend use of annual recall systems for adults at high risk of influenza and the inclusion of immunization needs in discharge planning. We also urge states to consider pre-enrollment immunization requirements for college and universities.

ASTHO recommends federal support for an adult immunization infrastructure, without compromising support for childhood immunization. Allowing the use of section 317 funds for adult immunization infrastructure is a beginning, but requires increased funding levels to the states. Increasing adult immunizations also depends upon Medicare support, including local health department participation, publicity on Medicare Part B coverage of influenza and pneumococcal vaccines, and simplified billing. Federal policy through Medicare and Medicaid can assist hospitals, nursing homes and other health care providers in providing immunizations to staff and patients and promoting adult immunization in the workplace. Surveillance also is a critical element in enhancing adult immunization.

ASTHO supports vigorous efforts to fully immunize health care workers and public safety workers to reduce the risk of contracting and transmitting vaccine-preventable diseases. States are encouraged to adopt policies and programs to achieve this objective.

Policy Expires: December 31, 2003

Approval History
Recommended for Adoption by the ASTHO Infectious Disease Policy Committee on June 12, 2000
ASTHO Executive Committee Review and Approval: June 15, 2000
Revisions and Additions Ratified by ASTHO Membership on July 20, 2000

Infectious diseases are human illnesses caused by microorganisms or their poisonous byproducts. Emerging infectious diseases are those that have appeared in a population within the past two decades or threaten to increase in the near future. Our nation's vulnerability to emerging infections was dramatically demonstrated in 1993. A once obscure intestinal parasite, Cryptosporidium, caused the largest waterborne disease outbreak ever recognized in the US. As a result of this outbreak, approximately 44,000 persons visited health care facilities and an estimated 4,400 persons were hospitalized. A 1993 outbreak of disease affecting multiple states was found to be caused by the E. coli 0157:H7 which resulted in more than 600 cases of infection, including 56 cases of acute kidney failure and four deaths in children. Many factors were associated with the occurrence of these outbreaks; however, a lack of proper diagnosis and reporting likely contributed to the morbidity, mortality, and economic costs. Infectious diseases are emerging on several fronts: reoccurrence or emergence.

Infectious diseases of bygone eras (malaria, gonorrhea) are also making a comeback. Reemergence of infectious disease may occur because of widespread use and misuse of antimicrobial drugs and breakdowns in public health measures for previously controlled infections. Foodborne illness also poses threats to public health. Millions of Americans are stricken by illness caused by the food they consume. The threats are numerous and varied including E. coli 0157:H7 in meat and apple juice, hepatitis A virus in strawberries, and cyclospora in raspberries. The US public health system has been challenged by newly identified pathogens and syndromes since the early 1970's such as Lyme disease, Legionnaires' disease, toxic shock syndrome, AIDS, hepatitis C, and hantavirus pulmonary syndrome. Most recently, public health has witnessed the appearance of new and unforeseen disease threats that infect humans- a virulent strain of avian influenza and West Nile virus. At the same time, the US is also poised to eliminate or diminish the occurrence of certain infectious diseases such as tuberculosis and syphilis.

In recent years, another threat has emerged - the possibility of a biological terrorist event in the United States. The United States must be aware of and prepared for the possibility of such an event. Fortunately, enhancement of the public health infrastructure is the best defense against any disease outbreak including a terrorist attack.

Diseases that arise in other parts of the world are repeatedly introduced into the United States, where they may threaten our national health and security. Infectious microbes can easily travel across borders with their human or animal hosts.

ASTHO believes public health professionals have a fundamental responsibility with regard to the prevention, investigation and response and recovery of infectious diseases by ensuring that all relevant infectious diseases are reported and that proper procedures are in place to promptly respond and appropriately control spread. State health departments collect disease surveillance information on certain communicable diseases for the purposes of determining disease impact, assessing trends in disease occurrence, characterizing affected populations, prioritizing disease control efforts, and evaluating disease prevention strategies. An epidemiologic investigation in Washington State in 1993, led to the prompt recall of 25,00 hamburgers contaminated with E. coli O157, saving millions of dollars as well as preventing human suffering and disease. However, due to limitations in diagnostic testing and resources, many important health threats go unreported. One such example is hepatitis C which is a major cause of liver disease in the United States.

State and local public health officials rely on health-care providers, laboratories, and other public health personnel to report the occurrence of notifiable diseases to state and local health departments. These data allow trends to be accurately monitored, and unusual occurrences of diseases to be detected, and the effectiveness of intervention activities to be evaluated.

States which give up their state health department laboratories and contract the work out to other parties do so at the peril of their residents and the nation as those parties often have other priorities (e.g., commercial, service, or academic work and research unrelated to the key health department functions of surveillance.) Although some collaborations appear to be working well for now, this trend is disturbing and should be arrested and reversed. ASTHO should use the issue of emerging infectious diseases as an opportunity to strongly advocate for reestablishing the critical importance of the state lab as the minimal unit of lab surveillance excellence.

Surveillance is the single most important tool for identifying infectious diseases that are emerging, causing serious health problems, or diminishing in prevalence. Moreover, surveillance is important for measuring the morbidity, mortality, and cost of infections. The quality of the nation's health care system and the effectiveness of health regulations such as microbial safety of food and water can only be adequately assessed if effective surveillance systems are in place. Effective surveillance provides a basis for evaluating the outcome of both public and personal medical care programs. Surveillance can also assure the most efficacious and cost-effective approaches to preventive as well as curative health care. Finally enhanced surveillance - which includes complete accurate and timely reporting of positive diagnostics tests and regular data analyses - is critical for disease eliminations.

Effective preparation for emerging infectious diseases also requires strong foundations in professional expertise, laboratory support, and research capacity. These foundations support the infrastructure needed to address the ongoing, but often changing, threats from emerging infections. Such a system requires trained personnel within the states and local communities and timely communications among state and local health departments, public and private laboratories, health care providers, and the Centers for Disease Control and Prevention.

The success of any surveillance system is also dependent on the willingness of physicians to report cases on infectious disease. Feedback to reporting physicians is an integral part of any surveillance system. The role and purpose of surveillance should be stressed from the start of medical training.

This is also important for a covert attack using a biologic or chemical agent. The appearance of an unusual disease or increased incidence of an ordinary disease in a normally healthy population would probably first be recognized through basic public health surveillance at the state and local level. A 1984 terrorist attack in Oregon, involving salmonella poisoning was detected when local public health authorities, carrying out their basic public health surveillance, identified the threat and its course. Identifying a single outbreak or series of unusual disease occurrences or deaths may be the first clue that a cluster of disease may be related to the intentional release of a biological agent.

Infectious disease surveillance reporting in the United States relies upon a national reportable disease system. The lead authority for disease reporting rests with the states, which determine the diseases or conditions to be reported by all physicians, laboratories and others, to state and local public health authorities. ASTHO does not support directives for disease reporting that are established through federal statute. Congress should respect and acknowledge that disease surveillance authority rests with the states. In turn, states voluntarily report more than 40 types of infectious diseases to the Centers for Disease Control and Prevention. Surveillance includes not only the reporting and investigation by states but also the submission of clinical specimens when needed, for testing at local, state, or federal public health laboratories. This network constitutes the foundation for guiding communicable disease prevention and control activities.

Current US efforts to detect, contain, and prevent emerging infectious diseases are in jeopardy. Moreover, the deterioration of the public health infrastructure for the control of diseases such as tuberculosis led to a resurgence of TB in the United States. US efforts to maintain surveillance systems for diminishing diseases are often jeopardized and must be maintained. Diminishing diseases may require enhanced surveillance that includes not only detection of cases and follow-up, but analysis of cases to determine risk factors so that effective interventions to disrupt transmission can be developed. Lack of surveillance and limited availability of diagnostic tests is interfering with public health's ability to prevent and control outbreaks. Funding for communicable disease surveillance is largely confined to diseases for which public health crises have already developed; TB, HIV/AIDS, sexually transmitted diseases and selected vaccine-preventable diseases. Likewise, the ability of state public health laboratories to support the surveillance, diagnosis, and control of other infectious diseases has diminished.

Efforts must be undertaken to improve the public health infrastructure at the local, state, and federal levels. Efforts must also be made to assure that critical public health infrastructures necessary for the control of certain diminishing diseases are also not allowed to deteriorate. In addition to strengthening domestic surveillance, it is necessary to establish effective global surveillance as international travel and commerce increase. The ability to detect what is new or reemerging depends on the capacity to identify and track the routine as well as the unusual. Surveillance with appropriate laboratory support is critical to an effective defense against these diseases. These are the most important tools for deterring infectious diseases, which are emerging, causing serious public health problems, or receding.

Many serious infectious diseases are largely or completely preventable. Simple principles of food and water safety, safer sex practices, appropriate use of antibiotics, and immunization could prevent millions of deaths and illnesses from infectious diseases each year.

Extensive abuse of antibiotics - through both overprescription and patient misuse --- has spawned a rapid evolution of tougher, drug-resistant strains of bacteria that threaten to render infectious diseases untreatable. Almost every known bacterial strain is resistant to at least one antibiotic, and some strains are resistant to multiple drugs. An estimated 50 percent of all current antibiotic use is unnecessary. Antibiotics, although effective against only bacterial infections, have been frequently misused as a treatment for viruses. Physicians must educate their patients about the differences between viruses and bacteria explain that antibiotics can in some cases be harmful rather than helpful. Doctors must resist the pressure to inappropriately prescribe antibiotics.

Public health professionals play a critical role in educating the public about how to prevent infectious diseases through education campaigns about immunizations, food safety, avoiding areas of insect infestation and staying alert to disease threats when traveling. State and local health departments play an important role in these prevention efforts through education of hospital personnel on recognition and treatment, education of communities, statewide education projects, and other efforts.

With regard to the prevention of infectious disease ASTHO recommends:

• Rebuilding the US public health infrastructure to protect Americans against infectious diseases, including those that are the result of biological terrorism or imported into the United States from other countries. This includes strengthening domestic surveillance, screening, response activities, and shoring up states' emergency preparedness efforts.
• Maintaining control of diminishing infectious disease (i.e. syphilis, tuberculosis, and measles) while adapting to a declining incidence of disease.
• Helping to mobilize support for disease elimination and supporting advocacy efforts in that regard.
• Developing better tests for the diagnosis of certain infectious diseases and for the identification of individuals at greatest risk of developing the disease (pertains to TB, HCV, and HPV).
• Supporting an active community of epidemiologists, clinical investigators, and experimental scientists ready and able to seek new solutions for new disease threats.
• Developing and implementing a national strategy to ensure that physicians (as well as hospitals, managed care organizations, and laboratories) are aware of their reporting responsibilities and that reporting is done conscientiously.
• Providing accurate and timely health information to private citizens and health providers, both in the United States and abroad, when a disease outbreak occurs.
• Educating the public about this over use of antibiotics. Such an effort should stress that antibiotics should be used only for bacterial infections and not for viruses, the cause of colds and the flu. Consumers should also be urged to complete the full course of prescribed antibiotics so that the strongest bacteria will not be left to multiply.
• Expressing concern about the non-therapeutic use of antimicrobials in food-producing animals. ASTHO supports the Food and Drug Administration's (FDA) effort to subject this practice to a high level of scrutiny to determine the adverse health effects on human beings. Federal policies and regulations that are developed on this issue should have a sound scientific foundation and should be accompanied by clear educational efforts.
• Strengthening prevention efforts - such as vaccinations and education - to change unsafe human behaviors and other public health measures to address the problem of new and re-emerging infections.
• Strengthening the ability of laboratories to test for viral and bacterial sensitivities.
• Strengthening the national notifiable disease system. Local health departments must be made stronger and more flexible, so that disease reporting can be modified to include new illnesses as they arise. State, local, and federal public health offices must work in partnership to achieve these goals.
• Strengthening the health alert network - a communications network at the state and local level to support the exchange of key information over the Internet.
• Strengthening workforce development activities and assuring organizational capacity to respond to biological terrorism and other urgent needs caused by health threats.
• Creating a national electronic system for nucleatic acid fingerprinting comparison. Such a system could link states to allow for the rapid sharing of information and to quickly determine whether outbreaks in different states have a common source.
• Developing new research methods such as technologies for prevention and control of pathogens such as new methods of decontamination of meat, poultry, seafood, fresh produce, and eggs.
• Furthering food safety education by fully informing food preparers and handlers at each point of the food chain to become more fully informed of the risks and related safe-handling practices.
• Assessing and applying innovative tools, such as computer and communications technology to facilitate collection, analysis, and dissemination of infectious disease surveillance information.
• Enhancing communication of public health information about emerging diseases to ensure prompt implementation of prevention strategies. This includes developing additional means to deliver public health information to inform health professionals about emerging infections and antimicrobial drug resistance.
• Upgrading and modifying state and local health departments computer and communications technologies.
• Supporting the Centers for Disease Control and Prevention's efforts to ensure states and local health departments capacity through cooperative agreements that provide adequate financial and technical assistance, including training to health departments.
• Screening newly arrived immigrants for certain infectious diseases such as tuberculosis.

REFERENCES

Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States, Centers for Disease Control and Prevention, 1994.

Food Safety From Farm to Table, A Report to the President, May 1997.

Infectious Disease - A Global Health Threat, Report of the National Science and Technology Council, Committee on International Science, Engineering, and Technology, Working Group on Emerging and Re-Emerging Infectious Diseases, September 1995.

Emerging Infectious Diseases Reduce the Risk, American Association for World Health.

Osterholm, Michael; Birkhead, Guthrie; Meriwether, Rebecca. Impediments to Public Health Surveillance in the 1990s: The Lack of Resources and the Need for Priorities.

Bekelman, Ruth L; Bryan Ralph T; Osterholm, Michael T; LeDuc James W.; Hughes James M
Infectious Disease Surveillance: A Crumbling Foundation: Resistance to Antibiotics.

Policy Expires: December 31, 2003
Recommended for Adoption by the ASTHO Infectious Disease Committee on June 12, 2000
ASTHO Executive Committee Review and Approval: June 15, 2000
Revisions and Additions Ratified by ASTHO Membership on July 20, 2000

Infection with the human immunodeficiency virus (HIV) and the subsequent development of acquired immunodeficiency syndrome (AIDS) persists as the major global public health epidemic in the twenty-first century. According to the Centers for Disease Control and Prevention (CDC), more than 711,344 cases of AIDS have been reported in the United States since the AIDS epidemic began in 1981. CDC estimates that between 40,000 and 60,000 Americans become newly infected with HIV each year. Of the 650,000 to 900,000 Americans currently living with HIV, CDC estimates that roughly one in three do not know they are infected. As of June 2000, AIDS is the second leading cause of death among men and women between the ages of 25 and 44.

There is currently no cure for AIDS, but the disease is easily preventable. Today, HIV prevention and education efforts are making real inroads and new drug therapies are providing vast improvement in the treatment of HIV and AIDS, demonstrated by a marked decline in AIDS deaths. Also, new treatment guidelines released by the US Department of Health and Human Services HHS) have provided health professionals with much needed guidance to help standardize care of individuals with HIV/AIDS. Nevertheless, the drug therapies do not constitute a cure, nor do they work for everyone and their long-term efficacy is unknown.

The earliest AIDS cases clustered among a few clear-cut populations, notably men who have sex with men, injecting drug users (IDUs) and recipients of blood transfusions, particularly hemophiliacs. As the epidemic in the United States has expanded, the demographics have changed. CDC reports that the populations most affected currently are young gay and bisexual men, heterosexual men and women, and injection drug users and their sex partners. Cultural barriers, which do not acknowledge homosexuality r and bisexuality, are contributing barriers for prevention and control efforts.

Racial and ethnic minorities are also disproportionately affected by the AIDS epidemic. Recent statistics show that racial and ethnic minorities comprise some 70 percent of all new HIV infections, with the majority of infections occurring in African Americans and Hispanics. This disproportionate impact of HIV/AIDS on racial and ethnic minorities is even more dramatic among women. In 1997, 69 percent of women infected with HIV and 60 percent of women with newly reported with AIDS were African American. In 1997, 7 percent of women infected with HIV and 20 percent of the newly reported AIDS cases were Hispanic.

Pending a cure or a vaccine, education and prevention are critically important factors in altering the course of the HIV epidemic. Even with successful drug treatments or vaccines, prevention strategies will continue to be a key component of HIV containment.

There is clear evidence that prevention is possible and that changes in attitudes and behavior can occur as a result of carefully tailored, targeted, and credible prevention efforts. However, in order to encourage behavior change, prevention messages must be transmitted in a language and manner that can be understood by the persons to whom the messages are directed and the target audience must embrace the prevention messages. Those who design and implement prevention programs must be able to use unvarnished language and communications that are meaningful and acceptable to the particular community or group being addressed. ASTHO opposes restrictions on the use of federal funds for certain kinds of education and prevention programs, such as sexually explicit materials that may be developed for certain audiences.

Prevention efforts require a sustained commitment. These efforts require long-term funding support for multiple interventions as opposed to investments in a single solution. Prevention programs must be accountable and evaluation should consider both short-term and long-term consequences. Progress and results must be measurable, and training and support must be provided to those administering the programs.

Substance abuse use plays a variety of roles in HIV transmission. Drugs can have a disinhibiting effect of individuals that impairs judgements and leads to greater risk taking in sexual behavior. (Recent research suggests that adolescents may be prone to riskier behaviors while under the influence of drugs.) In areas of high HIV seroprevalance, injection drug use poses an extremely grave risk to injection drug users and to their sex partners and/or children. Since the onset of the epidemic, more than one-third of all AIDS cases in the US have been related to injection drug use.

Beyond the risk of impaired judgement related to drug use, injection drug use poses a severe threat of HIV transmission and other blood borne pathogens whenever syringes and drug paraphernalia are shared.

Substance abusers, such as heroin or cocaine addicts and in particular injection drug users, are at increased risk for HIV/AIDS as well as other infectious diseases (hepatitis, tuberculosis, sexually transmitted diseases). For these individuals and the community at large, drug addiction treatment is disease prevention. Optimal treatment services can also present opportunities for HIV counseling, screening, testing and additional services.

Effective modes of HIV prevention among IDUs and substance abusers at risk for HIV should include a multifaceted approach in order to maximize prevention opportunities. This approach can include:

• increased provision of substance abuse treatment and provision of primary care, mental health, and other services,
• HIV counseling and testing services, partner counseling and referral services and prevention case management,
• access to sterile syringes through syringe exchange programs and/or repeal or modification of laws and regulations that restrict the sale of syringes to IDUs,
• services within the criminal justice system as inmates have disproportionately high rates of HIV infection, STDs and hepatitis,
• HIV prevention and education provided to IDUs through special outreach efforts,
• primary drug prevention to prevent the first use of alcohol, marijuana, inhalants and other drugs among youth in order to reduce the risk that they will go on to use injection drugs, and possibly become infected with HIV, and
• strategies to prevent sexual transmission of HIV and other STDs as IDUs are an important source of sexual transmission of HIV and hepatitis B and high-risk drug use and sex behaviors are often linked.

It is important to recognize the interrelationship between HIV/AIDS and other sexually transmitted diseases STDs). Recognizing that other STDs like gonorrhea, syphilis and chlamydia make a person 2-5 times as likely to both transmit and acquire HIV makes it clear that the HIV epidemic cannot be adequately addressed without also combating the epidemic of other STDs. ASTHO recommends that states undertake HIV prevention counseling for clients attending STD clinics or clients who have a recent history of STDs.

Persons with HIV infection are also at higher risk for tuberculosis (TB) infection than the general population. This is in part because TB transmission occurs most frequently in crowded environments such as correctional facilities, hospitals, and shelters where HIV-infected individuals and individuals with active TB make up a growing percentage of the population.

ASTHO supports better funded TB control programs that encourage collaboration between HIV and TB services, and increased research for better prevention and treatment for individuals co-infected with HIV and TB.

Community prevention planning is one of the key innovations in HIV prevention programming. State and territorial health departments implement a planning process through which they collaborate with communities to identify unmet needs and establish priorities for HIV/AIDS prevention programming. With federal support for prevention efforts, this planning process gives states the flexibility to design and implement targeted prevention programs at the state and local levels that meet state and locally determined needs and are consistent with the ability of states to develop prevention strategies. ASTHO encourages that community planning efforts make special efforts to meet the often unaddressed needs of disenfranchised populations.

ASTHO strongly supports the HIV prevention community planning process. Some of the key principles that apply include:

• recognition of the state public health agency as the determinative authority in planning and coordinating prevention health services, and assessing state capacity for community-based prevention planning as an important factor in coordinating services for people with HIV/AIDS,
• state and local health agencies must have the determinative authority on final plans for HIV program policy and resource allocation,
• adequate flexibility and new resources for states to develop and maintain a community-based HIV prevention process,
• CDC should support and provide funding to state/local health departments in the development of HIV prevention evaluation plans and activities,
• ASTHO opposes any mandate that states direct a specified amount of HIV prevention funds to testing or other individualized prevention programs, and
• ASTHO opposes any restrictions on prevention initiatives that reduce state and local flexibility.
  

Community-based organizations (CBOs) play a critical role in providing front-line services to people with AIDS. Such organizations often have an effective, grassroots system designed to reach high risk populations with targeted messages and structured programs to address their unique needs.

ASTHO, while supporting the important role that CBOs play in the provision of HIV/AIDS services, believes that HIV prevention and control efforts can best be served through the pass through of federal HIV prevention and control funds through state health departments. State health departments fund many CBOs within their jurisdictions and thus can leverage limited resources more efficiently when they know of the resources coming into their states. Moreover, the direct funding of CBOs may not reinforce the prevention priorities established by community planning groups. Finally, state health agencies may actually be in a better position than federal agencies to provide the type of technical assistance and oversight that may be needed in these types of fiscal arrangements. ASTHO believes that health departments should provide considerable technical assistance and capacity building to community planning groups and providers of prevention services in their jurisdictions, including local health departments and CBOs.

CDC recommends that state health departments support the provision of high quality HIV prevention counseling, reinforced by repeated meetings, to educate individuals going through the HIV testing process.

Counseling provides critical opportunities to promote understanding of transmission, assess risks, offer information on risk reduction strategies and help clients commit to specific risk reduction steps, particularly if test results are negative. For those testing positive, such interactions also provide a forum for individuals to learn about the clinical care necessary to delay disease progression and to receive needed services or referrals for services.

HIV prevention counseling and education are important components of the national education and prevention effort. Counseling, testing and referral services should be an integral part of the HIV testing effort. State health agencies also rely on counseling sessions to offer voluntary partner counseling and referral services, prevention case management, and prevention and control of STDs and opportunistic infections. Federal laws should not supersede state laws and preferences with respect to issues surrounding counseling, testing, referral, or reporting. In this regard, ASTHO believes that decisions about the role of publicly funded anonymous testing are best made by public health officials and community planning groups in each jurisdiction, not Congress.

Young people face a range of developmental issues that place them at unique risk of HIV infection. Adolescence is a period of self-discovery and exploration and the period during which many youths have their first sexual encounters. Yet, lack of experience and information, feelings of invulnerability and limited control over their lives can render youths highly vulnerable to the risk of HIV. Adolescents may be at heightened risk for HIV infection through sexual activity or through sexual activity that occurs in conjunction with substances such as alcohol and other drugs. Therefore adolescents need clear, realistic prevention messages about the risks of HIV transmission associated with unprotected intercourse and sexual activity in conjunction with substance abuse.

Abstinence is the most efficacious means of preventing HIV transmission, but it is neither more effectively preventive than a number of sexual activities which do not involve exchange of body fluids nor is it alone sufficient as an HIV prevention strategy.

HIV is only one aspect of the risks posed to the sexual health of adolescents. HIV prevention for adolescents should be integrated with STD and pregnancy prevention messages and those messages should include the positive personal and societal advantages of delaying sexual activity. However, for those adolescents who chose to be sexually active, instruction on the importance of correct and consistent use of latex condoms is important. Prevention education activities should encompass the entire spectrum of activity that enables individuals to make informed and educated choices about their health and lifestyles. (Refer to the ASTHO position statement on the role of state health agencies in HIV prevention in the schools and comprehensive school health programs, P-1.)