SECTION III - ACTIONS FOR HEALTH


FIFTEEN
PRIORITY ACTIVITIES

  Attaining the national goals described in Sec-
tion II will depend on the development of effective
strategies, many of which are applicable to several
life stages.

  This section  is concerned with 15 important
activities--grouped into three categories:

0   key preventive services which can be de-
  livered to individuals by health providers
  (Chapter 8);

a   measures which can be used by governmental
  and other agencies, as well as by industry,
  to protect people from harm (Chapter 9); and

e   activities which individuals and communi-
  ties can use to promote healthy lifestyles
  (Chapter 10).

  All are based on recommendations from a number
of working groups recently sponsored by the Public
Health Service and reflect the setting of priorities
from a national perspective.  It must be recognized
that in some conrnunities these priorities may need
to be modified to local health conditions.

  But developing measurable objectives within each
of these areas,  to be achieved within a reasonable
amount of time, ought to do much to provide a better
focus--and workable structure for both national and
local efforts to promote health and prevent disease.

III-1


     CHAPTER 8
PREVENTIVE HEALTH SERVICES

  People are accustomed to seeking medical care
only when they feel ill and ordinarily perceive no
need for preventive health services when they feel
well.

  But we have evidence now that certain key
services can do much to preserve health--and that
people can be attracted to using them, with striking
benefits, when they are offered.

  Not by any means has every service delivered in
the past in the name of prevention been efficient.
Routine annual checkups, although traditional, have
not been as effective in reducing health problems as
the tailoring of pertinent screening, detection,
diagnostic and treatment services to specific risks
for individuals at specific ages.

  Major progress has been made, however, toward
defining what preventive health services should be
delivered to the well population, designed for the
specific needs of different age and risk groups.
Proposed by various expert review panels, they have
been   modified as   new  procedures   have   become
available and others found to be less effective.

  While the proposals differ in some respects,
they are  notable for their similarities.   What
amounts almost to a national consensus on a core of
essential preventive services has been developing.
One list representative of the current view has been
prepared for the Institute of Medicine of the
National Academy of Sciences and is summarized in
the Background Papers to this Report.

  The five priority preventive services discussed
in this  chapter --family planning, pregnancy and
infant care,  immunizations,  sexually transmissible

8-l


diseases services, and high blood pressure control--
are typical of the range of activities, the settings
for delivery,  and the blend of public and private,
individual and organized efforts necessary for a
well-rounded prevention strategy.

  Other preventive services may also be important
and some are discussed in Section II--e.g. testing
for serum cholesterol levels or screening for cancer
in appropriate risk groups.

   The five  included here are priority services
with potential  for substantially reducing death,
disease and disability from problems affecting large
numbers of people at earlier ages.

Family Planning

  All pregnancies  should be wanted.  Any child
whose birth is planned is far more likely to get off
to a healthy start in  life and to receive the
continuing parental  love and support needed for
healthy development.

  Yet, of the more than four million pregnancies a
year in this country, one million are terminated by
legal abortion.  And of the slightly more than three
million births, an  estimated one-third are un-
planned.   It appears, then,  that half of all
pregnancies are mistimed and many are unwanted.

  A large increase  in demand for abortions has
come from women aged 15 to 19.

  From 1973 to 1977, reported legal abortions in
the United States increased by an annual average of
about 15 percent.   In 1977,  over 1,079,OOO were
reported-- and over 332,000 of these were for women
under 20.  Although they represent 21 percent of all
women of  childbearing  age,  15 to 19-year-olds
accounted for about one-third of all abortions and
only 17 percent of live births.

  But unwanted pregnancies are not limited to
unwed teenagers.  Each year,  an estimated 300,000

8-2


married women have babies they say they do not
want.  In 1977, there were 190 legal abortions for
every 1,000 live births among women who already had
given birth to one child.   The abortion rate for
women with two children was 297--and for women with
three children it was 358--for every 1,000 live
births.

  Unplanned births affect not only the health of
children but also the social well-being of mothers.
Early  child-bearing  interferes  with  educational
attainment--and,  because education is related to
occupation  and  income,  can permanently influence
social and economic status.

  The association of unwanted births with lower
socioeconomic conditions and poverty also persists.
And, clearly, having more children than desired can
have adverse health and social effects on families.

Contraceptive Efficacy and Safety

  Unplanned   and  unwanted  pregnancies   can be
prevented   with  relatively   safe   and   effective
contraceptives.

  Among the most widely used and efficient are
male and female sterilization, oral contraceptives
("the pill"), and  intrauterine devices (IUDs).
Vaginal diaphragms, condoms, and spermicides (foam
and jelly) are somewhat less effective but still
acceptable and satisfactory.

  The efficacy of contraceptives is determined by
pregnancy rates  among sexually active women cor-
rectly using a method.  (Many methods require active
effort by a woman or her partner and low efficacy
can be due to failure to use a method consistently
and well rather than to limitations inherent in the
method.)

  The established efficacy rates are:  virtually
100 percent for sterilization; 98 to 99 percent for
oral contraceptives;  96 to 98 percent for IUDs; 85
to 90 percent for diaphragm with contraceptive cream

8-3


or jelly; 90 percent for condoms; 85 percent for
spermicides.  Periodic abstinence (rhythm method) is
less reliable--about 80 percent dependable when used
scientifically and conscientiously.

  Actually, most people do not consistently use a
contraceptive method correctly, and efficacies may
be considerably lower than those indicated above.
Often,  incorrect use results from inadequate or
inappropriate  instructions given by professional
providers.

  Although not all long-term effects may be known
for oral contraceptives, the relative safety of the
various contraceptive methods is well established
except for certain high-risk groups.

  Among women under 30,  the risk of death asso-
ciated with the major birth control methods is eight
to 12 times lower than the risk of dying as a result
of a pregnancy-related circumstance.  After 30, risk
rises for women who use oral contraceptives and also
smoke but remains low for nonsmokers.

  In both cases, however, risk is less than that
for women who use no  method of contraception.
Adverse reactions can occur in some cases with use
of a particular method; when they do, a different
method often is more appropriate.

The Non-Users

  Although more women than ever before are users
of contraceptives, including more than 80 percent of
married women aged 15 to 44, 25 percent of sexually
active unmarried women aged 15 to 19 never use
contraceptives and about 45 percent use them only
occasionally.

  Reasons given  by teenage women for not using
contraceptives are that they can predict the time of
month when they are fertile, that they have a low
risk of pregnancy,  and that contraceptive services
are not available.

8-4


  Yet, in fact the services are widely available.
Virtually all primary care physicians provide con-
traceptives or family planning counseling.   There
are also an estimated 6,000 family planning clinics
in the country,  a six-fold increase in the last 10
years.

  What is apparently lacking is an effective out-
reach and information program to enhance practical
accessibility and timely use of the services.

  Where they are carefully designed and compre-
hensive,  community-based programs serving pregnant
teenagers have succeeded in reducing one of the
problems of greatest concern--the rate of repeat
pregnancies among adolescents.   In Delaware and
Baltimore,  for example,  programs  which provide
education,  medical and social services, and infant
day care have been reporting one-year repeat preg-
nancy rates less than half the national 25 percent
average for adolescents.  Such programs need more
study but early results are encouraging.

  Primary prevention  efforts must also be more
effective.

  Making family planning information available at
the earliest possible age is one need.   Peers now
are the most common source of information.  Unfor-
tunately this information may often be of question-
able completeness and accuracy.  In theory, parents
are the most important potential resource for better
information,  and efforts should be made to improve
both their knowledge and their ability to communi-
cate the knowledge to their children.

  Sex education courses should teach males as well
as females the importance of assuming responsibility
for practicing birth control.

  However,  only eight States and the District of
Columbia now mandate some form of sex education as
part of health education curricula, and only 39
percent  of the Nation's  school  districts offer
information on human reproduction and sexuality.

8-5


  A major focus of primary prevention efforts must
be on providing contraceptive information and ser-
vices to all sexually active teenagers in a manner
that is accessible, convenient, inexpensive and,
perhaps most importantly, is effective in comnuni-
eating with them.

  Finally, family planning involves more than the
question of "when" to have a child; for some people,
the question is "whether." There are couples at
high risk of conceiving a child with an inherited
disorder.  They may wish to consider that risk in
deciding whether or not to have children.  Alterna-
tives available to such couples include adoption,
artificial insemination,  or conception and use of
fetal diagnostic measures.

  In some cases--such as sickle cell  anemia,
Tay-Sachs disease,  and hemophilia--the  important
genetic  characteristics  can be detected before
pregnancy through analysis of blood samples (carrier
detection).   Other  genetic  disorders,   described
below,  can be detected during the prenatal period
through  amniocentesis   and  analysis of  amniotic
fluid, but detection of an abnormality may require a
decision on an abortion.

  There should be greater effort by physicians,
clinics,  other health providers--and by schools--to
make the availability of these tests and alterna-
tives more widely known.

Pregnancy and Infant Care

  The chance that an infant will be of low birth
weight  and at  increased  risk of  developmental
problems,  and perhaps death,  is heightened by lack
of early, regular, quality prenatal care, as noted
in Chapter 3.

  Although between 1969 and 1977 the proportion of
women receiving prenatal care during the first three
months of pregnancy increased from 68 to 74 percent,
too many still do not receive care until the last
three months--and the greatest risk is for the one
to two percent who receive none at all.

8-6


  From 1950 to 1977, infant mortality dropped from
30 to 14 deaths per 1,000 live births. While some
of the improvement was due to greater availability
of regionalized intensive care units for newborns,
better prenatal services have clearly played an
important role.

  Maternity and Infant Care (MIC) Projects--part
of a  national effort to provide  assistance to
vulnerable   populations--have   consistently   been
associated  with  declines in  low birth weight
incidence and infant mortality.

  In Birmingham, Alabama, for example, after the
MIC project began in 1967, prenatal clinics avail-
able for low income pregnant women increased and the
proportion of women receiving prenatal care during
the first trimester rose from 24 percent in 1968 to
39 percent in 1978.  Although direct cause and
effect relationship  cannot be determined,  infant
mortality in this area dropped from 25 deaths per
1,000 live births in 1965 to about 14 in 1977--and
infant deaths during the first month of life went
from 19 to 10 per 1,000 live births, a 47 percent
decrease.

  In Denver, Colorado, infant mortality was 28 per
1,000 live births when the MIC project began in
1965; by 1972,  it was down to 17 and the incidence
of low birth weight also had declined.

Prenatal Care

  What are the important services needed during
pregnancy?

  They include thorough assessment of any special
risks because of family history or past personal
medical problems;  physical  examination and basic
laboratory tests; amniocentesis where indicated; and
counseling on  nutrition,  smoking,   alcohol   use,
exercise, sexual activity, and family planning
(Figure 8-A).

  Through  a prospective mother's carefully re-
corded medical experience and family history, it is

8-7


    Figure 8-A
Preventive Services for
The Pregnant Woman and Fetus

           INITIAL      SUBSEQUENT
SERVICES        VISIT-       vIsIlS*

HlSTORv

PHYSICAL
EXAtllnlATION

LABORATORY
EXAMINATIONS

CoUHSE:IYG
WITH REFERRALS
A; NECESSARY
AND DESIRED

General Medical

Family and Genetic

Previous Pwgndncies

current Pregnancy

General

Blood Pressure

Height and Weight

Fetal Development

VORL

Papanlcola" Smear

HemaglobinlHematocrit

Urinalysis for Sugar
and Protein

Rh Determlnatlon

Bloodgroup Oetermlnation
Rubella RAI Titre

A~"~OC~~t~5,*
(for women OYer 35)'

.

.

.

.           .

.

.           .

.           .

          .

.

Y"tr~t~a" Of Infant,
lncludlng Breastfeeding o

????????? ?????*?        ?

??? ??? ?o????o? ???o?? ?????
durlrg Pregnancy        .

Sexual lntercwrse
dbrlng Pregnancy        .

Signs of Abnormal Pregnancy a

.

.

.

.

.

.


possible to identify factors which may put mother
and fetus at special risk for avoidable problems.

  About 80 percent of women at high risk of having
a low birth weight infant can be identified in the
first prenatal visit,  and action can be taken to
reduce the risk.  Without such care, as noted in
Chapter 3,  an expectant mother is three times as
likely to have a low birth weight child.

  Through family history, risk can be identified
for several inherited diseases, including Down syn-
drome,  Tay-Sachs disease,  and metabolic disorders,
all discussed in Chapter 3.

  Women with histories of such problems as re-
peated miscarriages, bleeding, and premature mem-
brane rupture are at increased risk for not having a
live and healthy baby--but measures can be taken
during pregnancy to reduce the risk.

  Also needing more intensive obstetrical care are
women who have congenital reproductive tract malfor-
mations or medical problems such as diabetes, hypo-
or hyperthyroidism, heart disease or kidney disease.

  Laboratory tests are important because they can
confirm problems suggested by an expectant mother's
family or individual history.

  Women who tend to be more susceptible to toxemia
of pregnancy are  those with high blood pressure,
diabetes or kidney disease.

  Toxemia, which, when present, usually occurs
during the second half of pregnancy, is character-
ized by rapid weight gain, swelling of legs and
eyelids,  headaches,  elevated blood pressure,  and
loss of protein in the urine.  If it persists, it
can threaten the pregnant woman's  life through
complications  such as convulsions and stroke--and
lead to fetal death.


  When detected,  toxemia can be controlled by
rest,  sedatives,  antihypertensive and anticonvulsant
drugs,  and correction of chemical imbalances. In
most cases,  it subsides after pregnancy but in some
it has residual effects.

  For women 35 and over, those with a history of
multiple miscarriages, and others with certain gene-
tic indications,  amniocentesis should be offered.
In this fetal diagnostic procedure, which is used at
about the 16th week of pregnancy, a needle is in-
serted through the wall of the woman's abdomen into
the womb to withdraw a sample of amniotic fluid con-
taining cells shed by the developing fetus.  Cells
and fluid can be analyzed for chromosomal and bio-
chemical defects.

  Currently,  about 100 conditions can be reliably
detected by amniocentesis, including Down syndrome
and neural tube defects.  Neural tube defects also
can be detected during pregnancy by a blood test
and, in   some  cases,  by ultrasound examination.
Women with family histories of such genetic pro-
blems,  or of multiple birth defects or inherited
metabolic disorders, are at higher risk of having a
fetus with a defect detectable through amniocentesis.

  Also very important in prenatal  care is  the
counseling of expectant mothers on potential pro-
blems for the fetus that may be caused by smoking,
alcohol use, and poor nutrition, including referral,
when necessary, to suitable social support services.

  It would be difficult to overemphasize the need
for seeing to it that nutritional requirements are
met during pregnancy.  There are increased require-
ments--especially   for  calories,   iron,  calcium,
phosphorus  and protein-- and  all the more so for
pregnant teenagers whose requirements may be further
increased by habitual poor dietary habits coupled
with the accelerated needs associated with adoles-
cent growth.

  Maternal nutritional deficits have been shown to
materially increase chances for low birth weight or
stillbirth.

8-10


  As early as 30 years ago, diet corrections--even
in the last weeks of pregnancy--for women who had
experienced famine conditions in the first trimester
were found to help offset the potential effect of
severe caloric deficiencies on the birth weight of
their babies.

  Although famine conditions do not exist in the
United States,  nutritional and socioeconomic status
are linked, and many pregnant women, even some with
incomes above poverty level, are not receiving ade-
quate diets for normal fetal development. Providing
an important adjunct to good health care are pro-
grams   such  as the Department  of Agriculture's
Special Supplemental Food Program for Women, Infants
and Children (WIC) which gives dietary supplements
and nutrition education at no cost for certain preg-
nant women, infants,  and children up to five years
of age.

  Even before they become pregnant, women need to
know about factors that may affect the health of
their future babies.  While providing information
about risks of using cigarettes, alcohol and drugs,
is an important part of prenatal care, many women
are pregnant several  weeks before knowing they
are--and it is at the very early stages that the
fetus is most vulnerable.

  Early on, too,  the fetus can be affected by
toxic chemicals and infectious agents.  Moreover,
exposure to ionizing radiation above a certain level
in the first week or two of pregnancy increases risk
of spontaneous  abortion --and subsequent exposure,
especially during weeks two through six, increases
risk of malformations and some childhood cancers,
including leukemia.

  Here,  again, we  need intensified educational
efforts by schools, health providers, and the media.

The Birth Process

  Although most women experience uncomplicated
childbirth,  about 20 percent  have some problem

8-11


during  labor,  according to  the 1972 National
Natality Survey.

  There may, for example, be hemorrhaging, sudden
worsening of toxemia, or impairment of oxygen supply
to the fetus because of its position in the uterus.

  Because these problems require prompt interven-
tion,  preventive care during pregnancy should also
focus on the birth process itself and include edu-
cation  about childbirth and preparation  of both
parents, with underscoring of the importance of se-
lecting a place for delivery in or near facilities
that can be used to respond to emergency situations.

  Recent technological  advances promise improved
capability for responding to birth process problems.
Electronic fetal monitoring, for example, has im-
proved ability to detect fetal distress and there-
fore to save the lives of many high risk infants.
While the technique, if not used properly, may lead
to needless surgical deliveries as well as maternal
infections,  it can offer significant benefits when
appropriately used to monitor high risk pregnancies.

Postnatal Care

  Once a baby is born,  prospects for good health
can be enhanced by a number of preventive services
(Figure 8-B).

  A simple blood test can be used to screen new-
borns  for PKU (phenylketonuria)   and  congenital
hypothyroidism.  With dietary manipulation for an
infant with PKU, and thyroid hormone medication for
one  with hypothyroidism, mental  retardation  and
other problems that otherwise would develop can be
avoided.

  Routine neonatal care also includes intramus-
cular administration of vitamin K to prevent the
bleeding which occasionally occurs in newborns, and
instillation of silver nitrate solution in the eyes
to prevent eye infection which might occur if the
mother has active gonorrhea.

8-12


Figure 8-B

Preventive Services for the Normal Infant

             BIP,TH      SECOND      SUBSEQUENl
SERV!CES        VISIT      VISIT]       VIS:TS*

HISTORY AND
PHYSICAL
EXAMINATION

PROCEDURES

IFMIJNIZATIONS

Length and Weight         @         e          .

Head Circumference        .

Urine Stream            .

Check for Congenital
Abnormalities           6                    .

Developmental Assessment                        .


PKU Screening Test                  .

Thyroxln T4                      .

Vitamin K                       o

Silver Nitrate
Prophylaxis            .


Diptheria                                  .

Pertussis                                  .

Tetanus                                   .

Measles'
Mumps3
Rubella3

Poliomyelitis                               .

Infant Nutrition and Feeding
Practices (especially breast-
feeding)

Parenting

Infant Hygiene

Accidental Injury Prevention (including

PARENTAL COUN-    use of automobile restraints)

SELING, WITH    Family Planning and Referral
REFERRALS AS      for Services
NECESSARY AND
DESIRED       Child Care Arrangements

          Medical Care Arrangements

Parental Smoking, Use of
Alcohol and Drugs

Parental Nutrition, Physical
Activity and Exercise

In Response to Parental
Concerns

.          .

.          .

.          .


.          .


.          @

.          .

.          I


e          .


.          .


.          .

'Second visit should occur within 10 days or before leaving the hospltal
,::a~: health visits the rest of first year or enough to provide immunira-
3Should be administered at 18 months of age

a- 13


  Prevention of Rh (rhesus) sensitization is a
major advance.  The sensitization can occur when a
mother has Rh negative blood and the fetus' type is
Rh positive.  It can be prevented by administering a
blood protein-- Rh  immune globulin--to the mother
after the birth of an Rh positive baby or after an
abortion or miscarriage.  If the immune globulin is
not administered, the mother may develop antibodies
to the baby's red blood cells and the antibodies,
during a subsequent pregnancy with an Rh positive
fetus,  may destroy the  infant's red blood cells,
producing   anemia,   brain   damage,   spontaneous
abortion, or death.

  Since introduction of Rh immune globulin in
1968, the estimated incidence of erythroblastosis
fetalis (the disease caused by Rh incompatability)
has dropped from about 4.1 cases per 1,000 births in
1970 to about 1.6 per 1,000 in 1977.

  Despite its relative lack of public attention,
the disease is still  a significant preventable
problem which affected 233 infants in 1976, 10 times
the number born with congenital rubella syndrome
that year.  Yet, appropriate postnatal intervention
could do away almost entirely with the disease.

ing Bl;;;stvf";ding.  Emotional and physical nurtur-
           to an infant's health and breast
feeding provides a way of enhancing both.

  Until this century, breast feeding was the prin-
cipal source of nutrition for infants during the
first six months of life, the period of most rapid
growth.   In the 1940s about two-thirds of infants
were being breast-fed but by the late 1960s and
early 197Os,  the proportion was down to about 15
percent.  Recently,  the trend has reversed; a 1976
survey found more than half of all mothers breast
feeding.

  Human breast milk provides nutritionally com-
plete,  convenient,  prewarmed food for infants.
Breast feeding also increases mother-infant contact,

8-14


confers some protection from infectious diseases by
transferring antibodies from mother to child, and
helps women who have gained excessive weight during
pregnancy to lose it.

  Moreover,  breast fed infants rarely are obese
and virtually never develop iron deficiency anemia,
the most common nutritional problem of American
infants.  If the nursing mother is healthy and well
fed, -fluoride and possibly vitamin D may be the only
supplements needed by the baby.   After about four
months, a source of iron may also have to be added
to the diet.

  Commercial  formulas   are   available  and  when
prepared according to directions provide adequate
nutrition but,  in contrast to breast feeding, they
are not regarded as the optimal food source.

  Solid foods.  Solid foods should be introduced
with care--generally not until the baby is at least
three months old.   No adverse effects occur when
solid food--and cow's milk--introduction is delayed
until much later in infancy.

  On the other hand,  when fed too early, solid
food may predispose an infant to food allergies,
overeating, and choking.

  In choosing  solid foods,  mothers should use
nutritional value rather than taste as the primary
guideline.  An infant does not need sweetened or
salted food and commercial baby foods should not be
supplemented with extra sugar or salt.

  New foods should be introduced one at a time,
with each continued for a week before another is
introduced.  This helps identify and avoid food
intolerances or allergies.  Commonly,  rice cereals
are used first, followed by fruits and vegetables,
and finally by meat.  To determine the proper diet
for an infant,  parents would do well to consult a
pediatrician,   dietitian, or    other    health
professional.

8-15


Immunizations

  Because of vaccines, diseases that once ranked
among the leading causes of death, particularly for
children,   now   are  regarded  with less concern.
Figure 8-C shows the change in incidence due to
immunization.

  But while substantially reduced as threats in
most cases--and eliminated in the case of smallpox--
these diseases still can be quite dangerous. Recent
epidemics of measles and pertussis, and occasional
outbreaks of diphtheria and polio, indicate that,
short of  complete  eradication,  reduction in a
disease's incidence is temporary and immunization
must be continually emphasized.

Childhood Immunization

  Each of the seven major childhood infectious
diseases which can be prevented by imnunization--
measles, mumps, rubella, polio, diphtheria, pertus-
sis,  and tetanus--can  cause permanent disability
and, in some cases, death.

  The provision of protection against these prob-
lems has become a national priority.  When polio
vaccination became possible in the 1950s the Federal
government moved to provide funds to State and local
health departments for large-scale immunization cam-
paigns.  Similar campaigns were begun when measles
and rubella vaccines were introduced.  The combined
Federal,  State and local efforts were notably
successful (Figure 8-C).

Yet vigilance in maintaining immunization levels
has waned and large numbers of children are not
adequately immunized.  In 1976, more than a third of
all children under age 15 were not properly pro-
tected--and the following year rubella cases in-
creased by 63 percent, measles cases by 39 percent,
and whooping cough cases by 115 percent.

  In response to the low immunization levels and
disease increases,  the President in 1977 began a

8-16


               FIGURE 8-C
REPORTED CASES OF MEASLES AND POLIOMYELITIS:
       UNITED STATES, 1991-1979

800.000 r

         MEASLES
4

300,000 -



200.000 -


100,cQo -

1950      1955      1960      1965      1970      1975      1960

   60.000                     POLIOMYELITIS


E   50,000
Lo               lnrroductlon of Polio Vaccine

1950      1955      1960      1965      1970      1975      1960

8-17


major   Childhood   Immunization   Initiative.   That
Initiative reflects recognition of the need for a
coordinated, broadly-based national effort to attain
and sustain adequate immunization protection.

  With the combination of safe, effective vac-
cines,  public and private programs, and a reliable
disease   surveillance   and   outbreak   containment
system,  infectious diseases can be controlled. In
fact,  complete  elimination of measles is  within
reach and has been set as a national goal.

  Although universal childhood immunization could
eliminate a vast amount of suffering and permanent
damage,  barriers exist.   Public interest must be
maintained and parents must ensure that children are
protected.  The effort must be broad, involving not
only public and private  health sectors but also
education,  social  services,  and other fields. A
recommended schedule is shown in Figure 8-D.

  To help parents, health departments and schools
should maintain outreach programs  and educational
efforts as well as programs making health services
available on a continuing basis.

  The poor are of particular concern since survey
data indicate they consistently have lower immuniza-
tion levels and higher disease incidence.  Medicaid
experience has shown that even where payment for
preventive services is provided, there is no assur-
ance that the services will be used.

  On the other hand, neighborhood health centers,
children and youth centers, and Health Maintenance
Organizations have demonstrated that where services
are provided in an organized setting, responsive to
the needs of the population served, and coupled with
outreach and follow-up efforts, preventive services
may be used appropriately by all income groups.

Other Vaccines

  Influenza virus  strains  change periodically,
necessitating  production   and  testing of    new

8-18


FIGURE 8-D

SCHEDULE FOR CHILDHOOD IMMUNIZATION

Diphtheria
Pertussis
Tetanus    Polio    Measles   Rubella  Mumps

Age'
2 months                0          a

4 months                0          0

6 months                D      o (optional)
15 months:                                  o         ?        ?

18 months                o          o
4-6 years               0          a
14-16years3              D

'Immunizations beginning in early infancy are the recommended practice.
They can be provided in later years, however, according to a schedule
recommended by a family physician.
2Measles, rubella, and mumps vaccines can be given in a combined
form, at about 15 months of age, with a single injection.
3Children should receive a sixth tetanus-diphtheria injection (booster)
at age 14-16 years, and every 10 years thereafter.

Source:  Parents' Guide to Childhood Ionization, USDHEW Center
     for Disease Control

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vaccines,  often on short notice, yet vaccines for
many strains have been successfully developed. An
individual using the appropriate vaccine prior to
the influenza season is 70 to 90 percent less likely
to contract the disease.   Annual vaccination is
recommended for individuals determined to be at risk
because of being over  age 65 or with a chronic
disease, especially chronic obstructive lung disease.

  Vaccines against certain types of meningococcal
meningitis are licensed and usable in case of epide-
mics.  Research is under way to develop vaccines
against other causes of bacterial meningitis, hepa-
titis,  and several viral respiratory diseases of
infants and young children but it will be several
more years before these become generally available.

  A vaccine with potential for reducing pneumococ-
cal pneumonia by 60 to 65 percent is now available--
and important because some types of pneumococci are
becoming resistant to antibiotics.  Use at present
is limited to people facing greatest danger from
pneumonia:  many of the elderly, people with chronic
debilitating diseases  or sickle cell anemia,  and
those with inadequate spleen function.   It has not
been licensed for use in children under age two.
Because the risk of dying from pneumococcal disease,
acquired as a complication of influenza or other-
wise,  increases with age,  vaccination value also
increases with age.

Sexually Transmissible Diseases Services

  In 1977,  some 10 million cases of sexually
transmissible   diseases   occurred in   the  United
States, 86 percent of them in 15 to 29 year olds.
The diseases present significant health problems.

  No vaccine  is currently available to combat
these infections but intensive efforts are under way
to develop a vaccine against gonorrhea, the most
common of the more serious diseases.

  "Venereal disease" no longer is an adequate term
since it has been traditionally limited to syphilis,

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gonorrhea, lymphogranuloma venereum, chancroid, and
granuloma inguinale. Now, however, with other dis-
eases known to be transmitted during sexual contact,
such as two types of hepatitis, a more appropriate
term is "sexually transmissible diseases."

  The most comnon of those identified to date
include:

0   trichomoniasis--3 million cases annually;


0   gonorrhea--2.5 million cases;


0   non-gonococcal  urethritis (NGU)--caused by
  organisms  such as  chlamydia  and  myco-
  plasma--2.5 million cases;

    0   genital herpes-- 300,000 cases; and


   0   syphilis--25,000 new cases a year.

  While most of the diseases may cause burning,
itching,  and discharge,  often they occur without
symptoms  and persons who have frequent sexual
contact with different partners should be examined
periodically.

  Several of the diseases can lead to serious
complications.

  In young women, for instance, pelvic inflam-
matory disease from extensive gonorrhea1 infection
or abscess in the Delvic cavity and reDroductive
organs is t he leading cause of infertility and
sterility.   Gonorrhea also is a cause of acute
arthritis in young adults.

  Genital  herpes--which is  manifested by very
painful lesi ons  similar to cold sores or fever
blisters--can cause severe neurological damage in an
infant infected while passing through the birth
canal.  Such infection occurs in about 50 percent of
infants delivered vaginally by infected mothers--and
active lesions in a pregnant woman are an indication
for a Cesarean section.

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  Although unchecked syphilis can have serious
consequences,  the availability of penicillin and an
organized control effort have almost eliminated it
in the general population.  Certain groups, how-
ever-- including homosexuals, migrant workers, and
the poor--remain at high risk.   The life of an
infant with congenital syphilis is threatened when
appropriate treatment is not provided.

  For trichomoniasis,  long-term consequences   are
not yet known, but no severe complications have been
detected thus far.  The consequences of infection by
chlarnydia,  one agent of non-gonococcal urethritis,
have recently been discovered to be eye infection
and pneumonia in infants, and pelvic inflarrmatory
disease in women.

  Substantial   difficulties   hinder   control of
sexually transmissible diseases.  Feelings of guilt
or shame can make it difficult for some patients to
seek proper care.  Professional and paraprofessional
training related to the diseases has never been a
priority in  curriculum development.   Some health
professionals find it difficult to provide care in a
straightforward, nonjudgmental manner.  In addition,
these diseases may receive less attention because
they are most prevalent in groups without signifi-
cant political influence--the young minority groups,
inner city dwellers, and homosexuals.

Nevertheless, there have been successes.

  After World War II, again in the mid-1960s, and
once more in the mid-70s, renewed efforts success-
fully reduced the incidence of syphilis. Gonorrhea,
which had quadrupled in incidence between 1960 and
1975, began to plateau  in 1975 after a national
gonorrhea control program was initiated with Federal
funding in 1972.

  One striking example of progress is found in a
pilot program started in 1969 in Memphis, Tennessee,
to control gonorrhea and resulting pelvic inflam-
matory disease.  It focused on increasing public
awareness and education about gonorrhea, expanding

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and extending the hours of clinic facilities, and
increasing  gonorrhea  screening,  casefinding  and
counseling.

  By 1976, results were apparent:  hospitalization
rates for pelvic inflammatory disease were down by
50 percent from 1971--with the reductions most
dramatic in hospitals serving predominantly young,
poor women,  the population  mainly served by the
national gonorrhea control program.

  As the Memphis program indicates, the essential
elements  for  controlling  sexually  transmissible
diseases include education of the public, particu-
larly adolescents,  to understand early signs of
disease and the kind of sexual behavior which in-
creases risk;  encouraging males with multiple part-
ners to use condoms;  screening high risk groups;
treatment with appropriate antibiotics of all found
infected;  and identification and treatment of sexual
contacts.

  There is clear evidence that most important in
attracting those who need the services are both the
quality of the services and the attitudes with which
they are delivered.

  While existing programs are interrupting the
transmission of syphilis and slowing the transmis-
sion of gonorrhea,  many vulnerable groups are not
yet being served.  To approach them effectively will
require not only the efforts of sexually transmis-
sible disease clinics and investigators  but also
those of family planning clinics, private physi-
cians, schools and employers.

High Blood Pressure Control

  Controlling   elevated   blood   pressure,   which
affects one in six Americans, is an essential if we
are to reduce the 500,000 strokes and 1,250,OOO
heart attacks which occur annually.

  Hypertension often begins early in life and
becomes progressively more severe with age.   It is

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one of the most important risk factors for coronary
heart disease--and, for stroke, the most important.

  Blood pressure elevation is more frequent, up to
age 55,  in men than women, but the reverse is true
after 55.  Blacks are twice as likely as whites to
have it and it is more frequent in people with lower
incomes and lower education levels.

  In only about 10 percent of people with hyper-
tension is there a known cause such as kidney
disease or toxemia of pregnancy which sometimes may
be followed by permanent blood pressure elevation.
Excessive salt in the diet and stress are factors
not yet completely understood; they may contribute
to the development in some cases of what is called
"essential"  hypertension in the 90 percent of pa-
tients in whom the disease is present without any
known organic cause.  Recent evidence indicates that
the hypothalamic region of the brain plays a role in
the development of essential hypertension but more
research is needed to clarify the role.

  Although hypertension cannot be cured--except in
the relatively few  cases where a surgically or
otherwise curable cause may be involved--effective
treatments to control it are available.   In most
cases, medica*ion is needed for a lifetime.

  One problem is that because high blood pressure
does not usually produce symptoms, many people do
not take required medications, even when they are
supposedly under medical care, because of failure to
understand the significance of hypertension and its
control.  Some stop taking medication because they
experience adverse reactions, as can occur with many
medications.  Yet very often an adjustment of dosage
or use of an alternative drug more suitable for the
individual can minimize or eliminate undesirable
effects.

  It is unfortunately true, too, that some physi-
cians are not attentive enough to close control of
high blood pressure for their patients.

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  Exactly how high an individual's pressure should
be before treatment begins is not yet settled.   But
it is clearly beneficial when diastolic pressure--
the second pressure reading, taken between beats of
the heart--exceeds 105.  Although research conti-
nues,  it is generally believed that there are also
benefits from treatment when diastolic pressure is
above 95--especially when other risk  factors for
cardiovascular disease,  such as a family history of
the disease, excessive smoking, and elevated choles-
terol levels are also present.

  The risk of long-term use of antihypertensive
medication in young people is unknown but thought to
be low and certainly less than the risk of untreated
hypertension.   In some elderly people with only
mildly elevated pressure,  possible side effects may
outweigh benefits of treatment.

  Measures other than drugs that may be useful in
preventing or treating hypertension are being inves-
tigated.  Weight loss and dietary salt restriction
lessen need for medication in some people and permit
use of smaller doses for others.   Exercise and
relaxation therapy (biofeedback) can be helpful in
some circumstances and are under study.

  Because hypertension is a "silent" disease, a
National High Blood Pressure Education Program was
initiated in 1972 by the Department  of Health,
Education and Welfare.  Targeted especially to high
risk groups,  it seeks to alert people to the high
frequency and significance of blood pressure eleva-
tion and the importance of periodic blood pressure
examinations.

  And since 1972,  as a result of education and
screening efforts by government, voluntary health
agencies,  comnunity leaders, medical societies, and
health care providers, the proportion of people with
hypertension who know they have it has increased
from 50 percent to more than 70 percent.

  Moreover,  between 1972 and 1974, nationwide
surveys indicate that the proportion of those with

8-25


hypertension   who   received   effective   treatment
doubled from 15 percent to 30 percent, and more
recent State and community studies indicate that the
trend is continuing.

  For example,  studies in New York (Westchester
County, 1975), Illinois (Chicago, 1977), and Mary-
land (1978) have found, respectively, 43 percent, 59
percent,  and 71 percent of the hypertensive popu-
lation under proper care.

  A longitudinal survey of a predominantly black
area in Baltimore found that hypertensive patients
whose pressure  was controlled increased from 17
percent to 60 percent between 1971 and 1978.

The effects?

  From 1972 to 1976, the age-adjusted death rate
for all cardiovascular diseases declined by about 15
percent and stroke mortality fell by 25 percent.
These improvements are almost surely due in part to
better high blood pressure control.

  A program in Milwaukee is one example of many
successful commmunity hypertension control efforts
which have produced these gains.  Initiated in 1974,
the Milwaukee effort involved many community re-
sources,  including the health department, a medical
school,  voluntary organizations, an insurance com-
pany, the local media, industrial firms, and others.
An important element in the program was development
of a well-designed p'tient  tracking system for
thorough follow-up after connnunity screening of
nearly 200,000 persons.

  And in Milwaukee,  heart attack deaths in 1977
were 17 percent less than the average annual rate
for 1971 to 1973.  Stroke deaths dropped 38 percent
in the four years of program operation.

  Use of the worksite for hypertension control
programs is especially rewarding.  The occupational
setting affords unique access to working people who
may be not only at higher risk for cardiovascular

8-26


disease but who are also less likely to follow
through with appropriate treatment for hypertension.

  As one example,  a collaborative union/employer
program providing hypertensive services at worksites
for store workers in New York City has been success-
ful in increasing, from 14 percent in 1973 to about
80 percent currently,  the proportion of hyperten-
sives  whose blood pressure is  under  effective
control.

  The strategy for hypertension control entails
using   resources  and services from a variety of
sectors.  And it also entails dealing with the kinds
of individual motivation,  lifestyle changes, and
long-term intervention which are needed to address
today's major health problems.  But the results can
be dramatic.

*********

  This chapter has urged greater use of family
planning services,  improved care for pregnant women
and newborn children,  immunization for vaccine-pre-
ventable diseases, control of sexually transmissible
diseases, and better high blood pressure control.

  Each of these measures can improve the quality
of life for many people and each is achievable with
our current state of knowledge.

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