Performance audit, Department of Health Services, Division of Disease Prevention

              PERFORMANCE AUDIT
DIVISION OF DISEASE PREVENTION
Report to the Arizona Legislature
By the Auditor General
May 1989
89- 2
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May 1989 Report No. 89- 2
The O f f i c e o f the Auditor General has conducted a performance a u d i t of
the Arizona Department of Health Services ( DHS), D i v i s i o n of Disease
Prevention Services i n response to a June 2, 1987, r e s o l u t i o n o f the
Joint L e g i s l a t i v e Oversight Committee. The performance audit was
conducted as a p a r t of the Sunset Review set f o r t h i n Arizona Revised
Statutes 5541- 2351 through 41- 2379.
The Arizona Department of Health Services, D i v i s i o n of Disease Prevention
Services coordinates disease prevention a c t i v i t i e s throughout the State
of Arizona. The d i v i s i o n provides very few d i r e c t services but does
assist county health departments, as we1 I as p r i v a t e p r o v i d e r s , w i t h many
disease p r e v e n t i o n f u n c t i o n s . In a d d i t i o n , the d i v i s i o n monitors
Arizona's progress i n preventing disease, compiles reports o f i n f e c t i o u s
disease throughout the State, and r e p o r t s A r i z o n a ' s disease prevention
status to the U. S. Centers for Disease Control ( CDC). This information
i s used by the CDC and Disease Prevention to evaluate the S t a t e ' s o v e r a l l
effectiveness i n addressing disease prevention.
Our audit was conducted to evaluate the e f f e c t i v e n e s s of DHS' D i v i s i o n o f
Disease Prevention Services e f f o r t s to control disease i n Arizona. Our
audit scope was l i m i t e d because we chose not to review any documents
containing names o r other i d e n t i f y i n g information of persons reported to
have s e x u a l l y t r a n s m i t t e d diseases or AIDS.
Department of Health Services Needs to Improve
Reporting of Sexually Transmitted Diseases
DHS should take a d d i t i o n a l steps to improve r e p o r t i n g of sexually
transmitted diseases ( STDs). Although underreporting of STDs i s widely
recognized, more a c t i v e f o l low- up on p o s i t i v e laboratory r e p o r t s ,
increased contacts w i t h health providers, and stronger r e p o r t i n g
regulations, may help improve STD r e p o r t i n g .
Because sexua I I y t ransm i t ted d i seases usual I y have se r i ous hea I t h
consequences, r e l i a b l e data are e s s e n t i a l to i d e n t i f y e f f o r t s needed to
i n t e r r u p t and/ or prevent t h e i r transmission and spread. Although p r i v a t e
health providers are a necessary source of t h i s data, many cases treated
i n the p r i v a t e sector go unreported. CDC estimates the underreporting o f
some STDs may be as high as 50 percent. Some reasons c i t e d for the low
r e p o r t i n g percentage include desire to maintain c o n f i d e n t i a l i t y ,
unawareness of the legal r e p o r t i n g requirements, i n s u f f i c i e n t time to
r e p o r t , and f a i l u r e t o understand the reasons f o r r e p o r t i n g .
States have adopted d i f f e r i n g s t r a t e g i e s to address the underreporting
problem. One s t r a t e g y c o n s i s t s of greater follow- up on laboratory
r e p o r t s . By law l a b o r a t o r i e s must report p o s i t i v e t e s t r e s u l t s to DHS.
However, Arizona has o n l y i n v e s t i g a t e d c e r t a i n types of STDs i d e n t i f i e d
by p o s i t i v e laboratory r e p o r t s . A r e c e n t l y developed computer system
appears capable of i d e n t i f y i n g p o s i t i v e laboratory reports that lack
corresponding physician reports so that DHS s t a f f can f o l l o w up on them.
However, the department has not f u l l y evaluated the system's impact on
workload and s t a f f i n g . For example, more than 10,000 laboratory t e s t
r e s u l t s may now be entered i n t o the system. As a r e s u l t , DHS may lack
the c a p a b i l i t y t o e f f e c t i v e l y u t i l i z e i t s new system.
Increased contact w i t h h e a l t h providers i s another s t r a t e g y . Some s t a t e s
have found that d i r e c t contact w i t h h e a l t h p r o v i d e r s , working through
med i ca l assoc i at ions, and mass mai I i ngs have helped to improve STD
r e p o r t i n g . A Colorado study found that p e r i o d i c telephone contacts could
more than double the number of cases reported.
Although DHS o f f i c i a l s a s s e r t t h a t l i m i t e d resources and other p r i o r i t i e s
p r o h i b i t them from addressing the underreporting problem, we i d e n t i f i e d
three actions t h a t can be taken to improve r e p o r t i n g w i t h a l i m i t e d
impact on resources. F i r s t , DHS should f u r t h e r t e s t i t s automated system
and develop a complete data base of laboratory reports to assess the
extent of underreporting and to i d e n t i f y physicians who are not
r e p o r t i n g . Second, DHS could emphasize the importance of STD r e p o r t i n g
i n t h e i r bimonthly b u l l e t i n which i s sent t o every provider i n the
State. F i n a l l y , DHS could contact randomly selected h e a l t h providers
throughout the State to ensure consistency i n r e p o r t i n g . A l l three of
these a c t i v i t i e s would require minimal s t a f f time and no a d d i t i o n a l
resources.
D i v i s i o n o f Disease Prevention Services Needs to Change
P l e nMeet i ng Law
The D i v i s i o n o f Disease Prevention Services has not complied w i t h
Arizona's open meeting law i n holding meetings of the Governor's Task
Force on AIDS.
Work groups of the AIDS Task Force met without providing proper n o t i c e to
the p u b l i c . Since October 1988, committee members have held numerous
working sessions without proper p u b l i c n o t i f i c a t i o n . According t o DHS
o f f i c i a l s , t h e i r f a i l u r e to comply w i t h the open meeting law was not
i n t e n t i o n a l but an a d m i n i s t r a t i v e o v e r s i g h t .
The Attorney General's Open Meeting Law Enforcement Team and DHS'
Assistant Attorney General Representative both maintain t h a t the
Governor's Task Force on AIDS and t h e i r working groups are subject to the
State open meeting law. As a r e s u l t , decisions made by the group at
those meetings may be i n v a l i d . More i m p o r t a n t l y , i t may a l s o c o n t r i b u t e
to p u b l i c d i s t r u s t o f o f f i c i a l motives and a c t i o n s .
DOUGLAS R NORTON, CPA
AUDITOR GENERAL
STATE OFARIZONA
OFFlCEOFTHt
AUI3ITOR (; ENERAI,
LINUAJ BLESSING, CPA
ULPVTY AUDITOR GENERAL
May 24, 1989
Members of the Arizona L e g i s l a t u r e
The Honorable Rose Mofford, Governor
Mr. Ted Williams, D i r e c t o r
Department of Health Services
Transmitted herewith i s a report of the Auditor General, A Performance
Audit of the Department of Health Services, D i v i s i o n of Disease
Prevention Services. This report i s i n response to a June 7, 1987,
r e s o l u t i o n of the J o i n t L e g i s l a t i v e Oversight Committee. The performance
a u d i t was conducted as a p a r t o f the Sunset Review set f o r t h i n Arizona
Revi sed Statutes 5941 - 2351 through 41 - 2379.
This i s the fourth i n a series of reports to be issued on the Department
of Health Services. The report addresses ways the department can improve
r e p o r t i n g of s e x u a l l y t r a n s m i t t e d disease from p r i v a t e p h y s i c i a n s .
Although p u b l i c h e a l t h p r o f e s s i o n a l s recognize t h a t underreporting by
p r i v a t e physicians i s a problem, the department has not e f f e c t i v e l y used
l a b o r a t o r y r e p o r t s or other i n f o r m a t i o n t o i d e n t i f y unreported cases or
t o encourage compliance w i t h Arizona's r e p o r t i n g requirements.
The a u d i t also found t h a t the department has not complied w i t h the Open
Meeting Law i n h o l d i n g meetings of the Governor's Task Force on AlDS
because i t f a i l e d t o provide n o t i c e f o r any meetings of working groups
associated w i t h the AlDS Task Force.
My s t a f f and I w i l l be pleased to discuss or c l a r i f y items i n the r e p o r t .
S i n c e r e l y ,
DRN: lmn
S t a f f : W i l l i a m Thomson
Mark Fleming
Jerome E. Mi l l e r
Kimberly S. Hildebrand
Roberta Leighton
~ ou@ hs R. Norton
Auditor General
SUWARY
The O f f i c e o f the Auditor General has conducted a performance a u d i t of
the Arizona Department of Health Services ( DHS), D i v i s i o n of Disease
Prevention Services i n response to a June 2, 1987, r e s o l u t i o n of the
J o i n t L e g i s l a t i v e Oversight Committee. The performance a u d i t was
conducted as a p a r t of the Sunset Review set f o r t h i n Arizona Revised
Statutes 9341- 2351 through 41- 2379.
The Arizona Department of Health Services, D i v i s i o n o f Disease Prevention
Services coordinates disease prevention a c t i v i t i e s throughout the State
of Arizona. The d i v i s i o n provides very few d i r e c t services but does
a s s i s t county h e a l t h departments, as well as p r i v a t e p r o v i d e r s , w i t h many
disease prevention f u n c t i o n s . I n a d d i t i o n , the d i v i s i o n monitors
Arizona's progress i n preventing disease, compiles r e p o r t s o f i n f e c t i o u s
disease throughout the State, and r e p o r t s A r i z o n a ' s disease prevention
s t a t u s to the U. S. Centers f o r Disease Control ( CDC). This i n f o r m a t i o n
i s used by the CDC and Disease Prevention t o evaluate the S t a t e ' s o v e r a l l
e f f e c t i v e n e s s i n addressing disease prevention.
Our a u d i t was conducted t o evaluate the e f f e c t i v e n e s s of DHS' D i v i s i o n o f
Disease P r e v e n t i o n S e r v i c e s e f f o r t s t o c o n t r o l disease i n Arizona. Our
aud i t scope was l imi ted because we chose not to review any documents
containing names or other i d e n t i f y i n g i n f o r m a t i o n of persons reported t o
have s e x u a l l y t r a n s m i t t e d diseases or AIDS.
Department of Health Services Needs to Improve
Reporting of Sexual ly Transmitted Diseases ( see pages 7 through 12)
DHS should take a d d i t i o n a l steps to improve r e p o r t i n g of sexually
t r a n s m i t t e d diseases ( STDs). Although u n d e r r e p o r t i n g of STDs i s widely
recognized, more a c t i v e follow- up on p o s i t i v e l a b o r a t o r y r e p o r t s ,
increased contacts w i t h h e a l t h p r o v i d e r s , and stronger r e p o r t i n g
r e g u l a t i o n s , may help improve STD r e p o r t i n g .
Because sexually transmitted diseases u s u a l l y have serious health
consequences, r e l i a b l e data are e s s e n t i a l t o i d e n t i f y e f f o r t s needed to
i n t e r r u p t and/ or prevent t h e i r transmission and spread. Although p r i v a t e
health providers are a necessary source of t h i s data, many cases treated
i n the p r i v a t e sector go unreported. CDC estimates the underreporting of
some STDs may be as high as 50 percent. Some reasons c i t e d for the low
r e p o r t i n g percentage include desire to maintain c o n f i d e n t i a l i t y ,
unawareness of the legal r e p o r t i n g requi rements, i n s u f f i c i e n t time to
r e p o r t , and f a i l u r e to understand the reasons for r e p o r t i n g .
States have adopted d i f f e r i n g s t r a t e g i e s t o address the underreporting
problem. One s t r a t e g y c o n s i s t s of greater follow- up on laboratory
reports. By law l a b o r a t o r i e s must report p o s i t i v e t e s t r e s u l t s to DHS.
However, Arizona has only investigated c e r t a i n types of STDs i d e n t i f i e d
by p o s i t i v e l a b o r a t o r y r e p o r t s . A recently developed computer system
appears capable of i d e n t i f y i n g p o s i t i v e laboratory r e p o r t s t h a t lack
corresponding p h y s i c i a n r e p o r t s so that DHS s t a f f can f o l l o w up on them.
However, the department has not f u l l y evaluated the system's impact on
workload and s t a f f i n g . For example, more than 10,000 laboratory test
r e s u l t s may now be entered i n t o the system. As a r e s u l t , DHS may lack
the c a p a b i l i t y to e f f e c t i v e l y u t i l i z e i t s new system.
Increased contact w i t h health providers i s another s t r a t e g y . Some states
have found that d i r e c t contact w i t h h e a l t h p r o v i d e r s , working through
medical associations, and mass mailings have helped to improve STD
r e p o r t i n g . A Colorado study found that p e r i o d i c telephone contacts could
more than double the number of cases reported.
Although DHS o f f i c i a l s assert that l i m i t e d resources and other p r i o r i t i e s
p r o h i b i t them from addressing the underreporting problem, we i d e n t i f i e d
t h r e e a c t i o n s that can be taken to improve r e p o r t i n g w i t h a l i m i t e d
impact on resources. F i r s t , DHS should f u r t h e r t e s t i t s automated system
and develop a complete data base of l a b o r a t o r y r e p o r t s to assess the
extent of underreporting and t o i d e n t i f y physicians who are not
r e p o r t i n g . Second, DHS could emphasize the importance of STD r e p o r t i n g
i n t h e i r bimonthly b u l l e t i n which i s sent to every provider i n
the State. F i n a l l y , DHS could contact randomly selected health providers
throughout the S t a t e t o ensure consistency i n r e p o r t i n g . A l l three of
these a c t i v i t i e s would require minimal s t a f f time and no a d d i t i o n a l
resources.
D i v i s i o n of Disease Prevention Services Needs t o Change
Practices t o Comply w i t h Open Meeting Law ( see pages 13 through 14)
The D i v i s i o n of Disease Prevention Services has not complied w i t h
Arizona's open meeting law i n holding meetings of the Governor's Task
Force on AIDS.
Work groups of the AIDS Task Force met without providing proper n o t i c e t o
the p u b l i c . Since October 1988, committee members have held numerous
working sessions without proper p u b l i c n o t i f i c a t i o n . According to DHS
o f f i c i a l s , t h e i r f a i l u r e to comply w i t h the open meeting law was not
i n t e n t i o n a l but an a d m i n i s t r a t i v e o v e r s i g h t .
The Attorney General's Open Meeting Law Enforcement Team and DHS'
Assistant Attorney General Representative both m a i n t a i n t h a t the
Governor's Task Force on AIDS and t h e i r working groups are subject to the
State open meeting law. As a r e s u l t , decisions made by the group at
those meetings may be i n v a l i d . More importantly, i t may also c o n t r i b u t e
to public d i s t r u s t of o f f i c i a l motives and a c t i o n s .
TABLE OF CONTENTS
Page
INTRODUCTION AND BACKGROUND. . . . . . . . . . . . . . . . . . . 1
FINDING I: DEPARTMENT OF HEALTH SERVICES
NEEDS TO IMPROVE REPORTING OF
SEXUALLY TRANSMITTED DISEASES . . . . . . . . . . . . . . . . 7
Various Methods to lmprove Sexually Transmitted
Disease Reporting Are Available . . . . . . . . . . . . . . . 8
Even with Limited Resources DHS Can Take Steps
to lmprove Reporting. . . . . . . . . . . . . . . . . . . . . 10
Recomnendations . . . . . . . . . . . . . . . . . . . . . - 11
FINDING II: DIVISION OF DISEASE PREVENTION SERVICES
NEEDS TO CHANGE PRACTICES TO COMPLY
WITH OPEN MEETING LAW . . . . . . . . . . . . . . . . . . . . 13
Open Meeting Law Applies to A l l
Study Cornittee A c t i v i t i e s . . . . . . . . . . . . . . . . . . 13
Open Meeting Laws Have Been Violated. . . . . . . . . . . . . 14
Recornendation. . . . . . . . . . . . . . . . . . . . . . . . 14
OTHER PERTINENT INFORMATION. . . . . . . . . . . . . . . . . . . 15
Controlling Acquired lmnune Deficiency Syndrome
i n A r i z o n a . . . . . . . . . . . . . . . . . . . . . . . . 15
Maryvale Studies Are S t i l l Controversial. . . . . . . . . . . 17
AREAS FOR FURTHER AUDIT WORK . . . . . . . . . . . . . . . . . . 23
DEPARTMENTRESPONSE. . . . . . . . . . . . . . . . . . . . . . .
LIST OF TABLES
Page
TABLE 1 - Division of Disease Prevention Services L i s t of Federal
Grants Received for Fiscal Year 1988- 89. . . . . . . . . . 5
TABLE 2 - Division of Disease Prevention Services
Appropriated Funds- Statement of
Actual and Estimated Expenditures
Fiscal Years 1986- 87 through 1988- 89 ( unaudited) . . . . . 6
INTRODUCTION AND BACKGROUND
The O f f i c e o f the Auditor General has conducted a performance a u d i t of
the Arizona Department of Health Services, D i v i s i o n of Disease Prevention
Services i n response to a June 2, 1987, r e s o l u t i o n of the J o i n t
L e g i s l a t i v e Oversight Committee. The performance audit was conducted as
a part of the Sunset Review set f o r t h i n Arizona Revised Statutes
5541 - 2351 through 41 - 2379.
Division's Role
The D i v i s i o n of Disease Prevention Services coordinates disease
prevention e f f o r t s throughout the State of Arizona. While the d i v i s i o n
provides very few d i r e c t s e r v i c e s , i t does a s s i s t county health
departments, as well as p r i v a t e providers, w i t h many disease prevention
functions. For example, the d i v i s i o n provides expertise to the counties
regarding contagious disease s u r v e i l l a n c e . Also, Disease Prevention
provides t r a i n i n g for a l l s a n i t a r i a n s working i n the State and develops
standard inspection procedures. The d i v i s i o n provides an immunization
program for a l l school- age c h i l d r e n . Health educators from the d i v i s i o n
coordinate we1 lness seminars w i t h major State employers and the pub1 i c at
large. The d i v i s i o n also administers federal and State grants, and
contracts. These monies a s s i s t county, l o c a l , and p r i v a t e providers
conducting disease prevention a c t i v i t i e s .
In a d d i t i o n , the d i v i s i o n monitors Arizona's progress i n preventing
disease. For example, i n the area of disease s u r v e i l l a n c e , the O f f i c e of
I n f e c t i o u s Disease Services receives reports from counties, p r i v a t e
physicians, and other medical sources t o i d e n t i f y and monitor i n f e c t i o u s
disease outbreaks and problems. The numbers are compi led and sent to the
U. S. Centers for Disease Control ( CDC). Disease Prevention and CDC use
the information to track and monitor disease prevention a c t i v i t i e s and
evaluate the S t a t e ' s e f f e c t i v e n e s s i n c o n t r o l l i n g disease.
The ~ i ; v i s i o n of Disease Prevention Services i s d i v i d e d i n t o f i v e o f f i c e s :
Risk Assessment and I n v e s t i g a t i o n s , Chronic Disease Epidemiology,
l n f e c t i o u s Disease Services, Health Promotion and Education, and a
Business O f f i c e . I n a d d i t i o n , the a s s i s t a n t d i r e c t o r of the Department
of Health Services for the D i v i s i o n of Disease Prevention Services has
f i v e employees, who perform a v a r i e t y of duties to support d i v i s i o n
a c t i v i t i e s . The d i v i s i o n has a t o t a l o f 88 State funded and 29.5
f e d e r a l l y funded p o s i t i o n s . Below i s a b r i e f d e s c r i p t i o n o f each o f f i c e .
O f f i c e o f Risk Assessment and I n v e s t i g a t i o n s - The O f f i c e of Risk
Assessment and l n v e s t i g a t i o n s evaluates environmentally r e l a t e d h e a l t h
problems facing Arizona. In the past, t h i s o f f i c e has conducted a
voluntary screening program for young c h i l d r e n to determine t h e i r blood
lead l e v e l s , The o f f i c e assisted the Department of Health Services'
D i v i s i o n of Environmental Health Services ( now the Department of
Environmental Q u a l i t y ) i n s e t t i n g standards and performing
epidemiological i n v e s t i g a t i o n s of adverse health e f f e c t s associated w i t h
d r i n k i n g water. In a d d i t i o n , the o f f i c e provides information and
conducts i n v e s t i g a t i o n s , inspections, and s u r v e i l l a n c e o f h e a l t h e f f e c t s
related to environmental contaminants. This o f f i c e has 18 employees.
Off ice o f Chronic
Defects Moni t o r i n g
col l e c t s data to
Disease Epidemiology - This o f f i c e d i r e c t s the B i r t h
Program and the Arizona Cancer R e g i s t r y . The o f f i c e
i d e n t i f y various b i r t h defect trends, h i g h - r i s k
populations, and h i g h - r i s k l o c a t i o n s . The program i s modeled a f t e r those
of C a l i f o r n i a and the CDC. The Arizona Cancer Registry receives,
processes, and analyzes data concerning cancer p a t i e n t s . The o f f i c e
c o l l e c t s the information from p a r t i c i p a t i n g h o s p i t a l s and records i t i n
the central r e g i s t r y . Physicians and h o s p i t a l s use the information to
monitor the progress o f t h e i r p a t i e n t s and to implement improved
treatment m o d a l i t i e s . The o f f i c e also p a r t i c i p a t e s i n drowning
prevention a c t i v i t i e s and analyzes drownings i n Arizona. The information
i s used to i d e n t i f y causes of drowning and may lead t o a r e d u c t i o n of
such preventable accidents. The o f f i c e has 19 employees.
O f f i c e o f l n f e c t i o u s Disease Services - The O f f i c e o f I n f e c t i o u s
Disease Services a d m i n i s t e r s a v a r i e t y of programs w i t h the purpose of
decreasing p u b l i c r i s k for diseases transmitted through unsanitary and
unhealthy c o n d i t i o n s . Risk reduction i s achieved through d e t e c t i n g ,
monitoring and diagnosing diseases, and providing treatment to prevent
f u r t h e r transmission. In a d d i t i o n , the o f f i c e uses s u r v e i l l a n c e and
i n v e s t i g a t i o n techniques to monitor a1 I i n f e c t i o u s diseases for which
special c o n t r o l s have not yet been established. Because of the wide
v a r i e t y of ways i n which diseases can be transmitted and prevented, there
are a number of specialized programs w i t h i n the o f f i c e . The programs
include AIDS, S a n i t a t i o n , Sexually Transmitted Diseases, Tuberculosis
Control, Immunization, Vector- borne and Zoonotic Diseases, and l n f e c t i o u s
Disease Epidemiology. The o f f i c e employs 56 s t a f f i n s i x d i f f e r e n t
programs.
O f f i c e o f Health Promotion and Education - The O f f i c e of Health
Promotion and Education i s responsible for statewide health ~ r o m o t i o na nd
education. The o f f i c e develops programs to inform the ' public about
health problems and actions necessary to a l l e v i a t e them. For example,
the o f f i c e has conducted programs to prevent childhood drowning ( s i m i l a r
to the drowning program offered by the O f f i c e of Chronic Disease
Epidemiology), conducted a prevalence survey o f h e a l t h r i s k behaviors of
Arizona a d u l t s , provided smokeless tobacco education m a t e r i a l s f o r j u n i o r
and senior high school students, and cosponsored a physical f i t n e s s
walking program for older a d u l t s . In a d d i t i o n , i n coordination w i t h the
AIDS section of the O f f i c e o f I n f e c t i o u s Disease Services, the O f f i c e of
Health Promotion and Education has developed an AlDS r i s k reduction
p r o j e c t . The program's a c t i v i t i e s focus on increasing the p u b l i c ' s
knowledge about AlDS and i t s prevention. The o f f i c e has 12.5 p o s i t i o n s .
Business O f f i c e - The Business O f f i c e provides a d m i n i s t r a t i v e support
for d i v i s i o n a c t i v i t i e s i n areas such as procurement, budget preparation,
and contracting. The o f f i c e i s s t a f f e d by seven FTEs.
Budget
The D i v i s i o n o f Disease Prevention Services receives operating money from
the federal government, a general fund a p p r o p r i a t i o n , and an interagency
service agreement w i t h the Arizona Department of Environmental Quality
( ADEQ). State funding was approximately $ 5.7 m i l l i o n i n f i s c a l year
1988- 89. The d i v i s i o n receives money- f ram the federal government i n the
form of grants to operate disease prevention programs statewide. Grant
monies are used by the d i v i s i o n to fund i t s a c t i v i t i e s and t o a s s i s t
county health departments and community based programs i n providing
services. In 1988- 89, the d i v i s i o n received more than $ 4.6 m i l l i o n i n
federal grant monies; the bulk of which went to the O f f i c e of l n f e c t i o u s
Disease Services. See Table 1 ( page 5) for a l i s t i n g of federal grants
the d i v i s i o n received for f i s c a l year 1988- 89. The ADEQ agreement w i l l
provide approximately $ 244,000 during 1988- 89
The d i v i s i o n ' s general fund expenditures for f i s c a l years 1986- 87 and
1987- 88, and a p p r o p r i a t i o n s f o r f i s c a l year 1988- 89 are shown i n Table 2
( see page 6).
Audit Scope
This audit was conducted to evaluate the effectiveness of the D i v i s i o n of
Disease Prevention Services e f f o r t s to control disease i n Arizona. The
audit addresses issues i n these two s p e c i f i c areas:
0 Methods the D i v i s i o n of Disease Prevention Services can use to
improve compliance w i t h requirements for r e p o r t i n g sexually
transmitted diseases.
0 The D i v i s i o n of Disease Prevention Services' adherence to the open
meeting laws.
Our audit scope was l i m i t e d because we d i d not review any documents which
contained the names ( or other i d e n t i f y i n g information) of persons
reported to have s e x u a l l y t r a n s m i t t e d diseases or AIDS. The lack of
i d e n t i f y i n g information prevented us from t e s t i n g and v e r i f y i n g the
accuracy of data reported by the d i v i s i o n . We o r i g i n a l l y planned to
compare names of i n d i v i d u a l s l i s t e d on p o s i t i v e l a b o r a t o r y r e p o r t s w i t h
the names shown i n the d i v i s i o n ' s records of s e x u a l l y t r a n s m i t t e d
disease. However, d i v i s i o n o f f i c i a l s expressed concern that i n d i v i d u a l s
might not seek treatment i f they saw our review as a breach of
c o n f i d e n t i a l i t y by the department. Therefore, we attempted to use
records withaut i d e n t i f y i n g information for our audit work but found that
such an approach did not allow us to r e l i a b l y determine the accuracy of
the d i v i s i o n ' s records.
This report also contains a section regarding AIDS and the Maryvale
Cancer Cluster e n t i t l e d Other Pertinent Information.
The section Area For Further Audit Work addresses issues we i d e n t i f i e d
during the course of the audit but were unable to research due to time
c o n s t r a i n t s .
This a u d i t was conducted i n accordance w i t h generally accepted
governmental a u d i t i n g standards.
TABLE 1
DIVISION OF DISEASE PREVENTION SERVICES LIST OF
FEDERAL GRANTS RECEIVED FOR FISCAL YEAR 1988- 89
A l DS
P r e v e n t i v e H e a l t h Block
STD
Az. Immunization P r o j e c t
AIDS Drug Reimburse. Program
Food and Drug I n s p e c t i o n s
Behavior Risk Factor
TB Cooperative Agreement
O f f ice
l n f e c t i o u s Disease/
H e a l t h Promotion
Dept. Wide A c t i v i t i e s
l n f e c t i o u s Disease
l n f e c t i o u s Disease
l n f e c t i o u s Disease
l n f e c t i o u s Disease
H e a l t h Promotion
l n f e c t i o u s Disease
T o t a l f o r A l l D i v i s i o n F e d e r a l G r a n t s
T o t a l Amount
o f Grants
( a ) A p o r t i o n o f t h i s grant i s a l l o c a t e d t o the D i v i s i o n o f State Laboratory S e r v i c e s .
Source: DHS Budget Documents, f i s c a l year 1988- 89
TABLE 2
DIVISION OF DISEASE PREVENTION SERVICES
APPROPRIATED FUNDS- STATEMENT OF
ACTUAL AND ESTIMATED EXPENDITURES
FISCAL YEARS 1986- 87 THROUGH 1988- 89
( unaud i t ed )
Expenditures:
Personal se rv i ces
Employee r e l a t e d
Professional and
o u t s i d e s e r v i c e s
Travel :
I n- state
Out- of- state
Aid to organizations
Other operating
Capital outlay
Special l i n e items
Actual
1986- 87
Actual
1987- 88
TOTAL
( a ) Expenditures of funds in t h i s category will be charged to 1 ine i terns such as aid
to organizations or personal s e r v i c e s .
Source: Arizona F i n a n c i a l Information System
Estimated
- 1- 9 88- 89
FINDING 1
DEPARTMENT OF HEALTH SERVICES NEEDS TO
IMPROVE REPORTING OF SEXUALLY TRANSMITTED DISEASES
DHS should take a d d i t i o n a l steps to improve r e p o r t i n g of sexually
t ransmi t ted diseases ( STDs) . A I though under r e p o r t i n g of STDs i s a
n a t i o n a l problem, several o p t i o n s t o improve r e p o r t i n g i n Arizona e x i s t .
Limited resources may determine the extent of DHS' a c t i o n ; however, some
e f f o r t s to improve r e p o r t i n g can be taken using e x i s t i n g resources.
Sexually transmitted diseases can have serious h e a l t h consequences,
i n c l u d i n g i n f e r t i l i t y , ectopic pregnancy, increased r i s k of cancer, and
death. Consequently, r e l i a b l e STD data are e s s e n t i a l to i d e n t i f y where
prevention and i n t e r v e n t i o n e f f o r t s are needed and t o i n t e r r u p t and/ or
prevent the transmission and spread of STDs.
Even though accurate r e p o r t i n g i s e s s e n t i a l for e f f e c t i v e s u r v e i l l a n c e
and i n t e r v e n t i o n , i t i s widely recognized that not a l l STD cases treated
i n the p r i v a t e s e c t o r a r e reported. Although Arizona s t a t u t e s , r u l e s ,
and regulations d i r e c t physicians, l a b o r a t o r i e s , and others to report
c e r t a i n STDs to local and S t a t e h e a l t h departments, v i r t u a l l y a l l
f e d e r a l , S t a t e , and local h e a l t h o f f i c i a l s contacted acknowledge that
STDs are underreported."' The Centers for Disease Control ( CDC)
estimates that the underreporting o f c e r t a i n STDs may be as high as 50
percent nationwide. Reasons for underreporting are v a r i e d . A survey of
Arizona medical association representatives found several reasons why
physicians do not report STDs. Reasons c i t e d by these representatives
for not r e p o r t i n g included: d e s i r e t o maintain c o n f i d e n t i a l i t y o f data,
( ' 1 I n 1988, cases reported by the p r i v a t e sector accounted f o r l e s s than 20 percent o f
a l l reported ST0 cases i n Arizona.
unawareness of the legal r e p o r t i n g requi rement, lack of t ime to r e p o r t ,
and f a i l u r e t o understand the reason f o r reportin$.')
Various Methods to Improve
Sexually Transmitted Disease
Reporting Are Available
DHS could take a d d i t i o n a l steps to improve p r i v a t e sector r e p o r t i n g of
STDs by implementing various methods used i n other s t a t e s . Laboratory
reports provide an important source of information t h a t can be used to
i d e n t i f y unreported STDs and m o n i t o r d o c t o r s who f a i l t o r e p o r t . In
a d d i t i o n , methods emphasizing the importance of r e p o r t i n g STDs can be
implemented.
Laboratory information not f u l l y u t i l i z e d - E f f o r t s t o i n v e s t i g a t e
p o s i t i v e l a b o r a t o r y r e p o r t i n f o r m a t i o n have been l i m i t e d i n Arizona.
Other states make extensive use of laboratory r e p o r t i n f o r m a t i o n to
i d e n t i f y new STD cases. In a d d i t i o n , p o s i t i v e laboratory reports can be
used as a t o o l to m o n i t o r p h y s i c i a n s compliance w i t h r e p o r t i n g .
L a b o r a t o r i e s a r e a valuable source of information for i d e n t i f y i n g new STD
cases. Laboratories are legal l y required to report p o s i t i v e laboratory
f i n d i n g s f o r s y p h i l i s , gonorrhea, and chlamydia to the Arizona Department
of H e a l t h . D u r i n g 1988, l a b o r a t o r i e s reported 5,394 p o s i t i v e chlamydia
t e s t s , 5,346 p o s i t i v e s y p h i l i s t e s t s , and 1,520 p o s i t i v e gonorrhea t e s t s
to DHS.") Department r e g u l a t i o n s requi re local heal t h agencies to
i n v e s t i g a t e each reported case or suspected case; t h u s , l o c a l h e a l t h
agencies need to i n v e s t i g a t e every p o s i t i v e laboratory t e s t i n order to
comply w i t h legal requirements. U n t i l r e c e n t l y , however, not a l l
( ' ) Auditor General s t a f f contacted representatives of several medi cal associations,
i n c l u d i n g the Arizona Medical Association, Maricopa County Medical Association,
Arizona Association o f American Coll ege of O b s t e t r i c s and Gynecology, Tucson and
Phoenix O b s t e t r i c s and Gynecology Societies, Arizona Chapter o f the American
College of Physicians, and t h e Arizona Urology Association.
( 2 ) An a d d i t i o n a l 3,271 p o s i t i v e gonorrhea t e s t s f o r p u b l i c sector cases were reported
di r e c t l y t o and i n v e s t i g a t e d by Mari copa County.
reported p o s i t i v e t e s t s were invest igated! ll
In A p r i l 1989, DHS implemented a computerized information system intended
to f a c i l i t a t e s t a f f review of a l l laboratory and m o r b i d i t y reports. DHS
and county health department s t a f f w i l l input reports of p o s i t i v e STD
tests submitted by l a b o r a t o r i e s and reports of STDs diagnosed by p r i v a t e
physicians ( morbidity r e p o r t s ) . The automated system w i l l allow DHS to
match laboratory and m o r b i d i t y r e p o r t s . Matching i s used i n several
states to enhance STD r e p o r t i n g . ' 2' DHS plans to use the system to
p e r i o d i c a l l y compare the laboratory and morbidity r e p o r t s t o i d e n t i f y
unreported STD cases and physicians who f a i I to report STD cases. DHS
s t a f f w i l l then follow up on unreported cases.
However, Arizona's system i s new and has not been i n use long enough to
adequately assess i t s f u l l c a p a b i l i t i e s or p o t e n t i a l problems.
S p e c i f i c a l l y , DHS has not evaluated the system's impact on s t a f f
resources and generally expects the system's increased e f f i c i e n c y to
allow e x i s t i n g s t a f f to match reports and conduct needed follow- up. For
example, i f the system had been i n use during 1988, DHS s t a f f would have
had to input r e s u l t s from an a d d i t i o n a l 12,000 laboratory t e s t s . Although
the system appears to increase the d i v i s i o n ' s a b i l i t y to track STDs, the
d i v i s i o n may s t i l l lack s t a f f . Therefore, the system's impact on the
d i v i s i o n ' s a b i l i t y t o promote compliance w i t h STD r e p o r t i n g requirements
remains unknown.
Additional e f f o r t s emphasize importance of reporting - In a d d i t i o n t o
i n v e s t i g a t i n g laboratory r e p o r t s , other states have developed a v a r i e t y
of methods for improving STD r e p o r t i n g . Those methods primari l y consist
of increased contacts w i t h health providers. DHS could also work w i t h
medical l i c e n s i n g boards to obtain t h e i r assistance i n enforcing the
report i ng requ i remen t s .
( 1 ) U n t i l A p r i l 1989, DHS p o s i t i v e l a b o r a t o r y t e s t s were turned over to the counties t o
i n v e s t i g a t e . S y p h i l i s and r e s i s t a n t gonorrhea t e s t s are followed up to various
degrees; however, chlamydia and nonresistant gonorrhea t e s t s were not u s u a l l y
pursued.
( 2) We contacted several s t a t e s t o o b t a i n i n f o r m a t i o n on how t o improve ST0 r e p o r t i n g .
Texas, Utah, Colorado, and C a l i f o r n i a were contacted because o f t h e i r p r o x i m i t y t o
Arizona. F l o r i d a was contacted because of i t s s t r i c t ST0 r e p o r t i n g requirements.
Other states have attempted to address underreporting by p e r i o d i c a l l y
contacting h e a l t h p r o v i d e r s , working through medical associations, and
mass mai I ings. Three nearby western states ( Texas, Utah, and Cal i f o r n i a )
and F l o r i d a have implemented various measures to stress the importance of
r e p o r t i n g , including v i s i t i n g or phoning targeted physician groups and
laboratories. These states consider p e r i o d i c contact w i t h providers and
laboratories c r i t i c a l to ensure consistency i n r e p o r t i n g . In f a c t , a
study conducted by independent researchers i n Colorado showed that
p e r i o d i c telephone contact more than doubled the number of gonorrhea
cases previously reported by p r i v a t e physicians. In a d d i t i o n , some
states d i s t r i b u t e information through medical a s s o c i a t i o n n e w s l e t t e r s and
mass mai I i ngs ."'
Although underreporting i s p r e v a l e n t , most s t a t e s , i n c l u d i n g Arizona, do
not penalize doctors for not r e p o r t i n g . A more e f f e c t i v e method of
enforcing STD r e p o r t i n g requirements may be for DHS to work w i t h medical
l i c e n s i n g boards. According to the Board of Medical Examiners ( BOMEX)
executive d i r e c t o r , the board could use i t s e x i s t i n g a u t h o r i t y to
d i s c i p l i n e a p h y s i c i a n who c o n s i s t e n t l y f a i l s to comply w i t h STD
r e p o r t i n g requi rements. A. R. S. 932- 1401.12( a) defines f a i lure to
comply w i t h State o r federal laws and regulations as f'unprofessional
conduct." However, BOMEX would require that DHS show that i t attempted
to inform the physician about the r e p o r t i n g requirement, and the
physician refused to comply before BOMEX could take a c t i o n . F l o r i d a
health o f f i c i a l s plan to pursue the use of such d i s c i p l i n a r y a c t i o n w i t h
the assistance of t h e i r medical board.
Even with Limited Resources DHS
Can Take Steps to Improve Reporting
DHS recognizes the importance of accurate STD r e p o r t i n g , but health
o f f i c i a l s assert that l i m i t e d resources and other p r i o r i t i e s p r o h i b i t
them from taking c o r r e c t i v e a c t i o n . However, at least two actions can be
taken to improve r e p o r t i n g w i t h l i m i t e d impact on resources.
( 1 ) I n C a l i f o r n i a , physicians can r e c e i v e c o n t i n u i n g education c r e d i t ( CPEs) f o r
attending biannual meetings of the STD Control Association. Their June 1989
meeting w i l l address STD r e p o r t i n g requirements due t o recent changes i n the law.
( 2 ) DHS has previous1 y worked w i t h BOMEX on a case i n v o l v i n g a physician who f a i l e d to
r e p o r t hepati ti s cases.
10
F i r s t , DHS could make greater use of mass mai l i n g s directed to
health- care providers emphasizing the importance of r e p o r t i n g . For
example, DHS publishes a bimonthly b u l l e t i n which i s sent to many
providers i n the State. ' However, the b u l l e t i n has not addressed
sexually transmitted disease r e p o r t i n g requirements since January 1987.
Although one medical a s s o c i a t i o n r e p r e s e n t a t i v e p r a i s e d DHS for keeping
them abreast of new STD diagnosis and treatment regimens, representatives
of other medical o r g a n i z a t i o n s i n d i c a t e d l i t t l e e f f o r t i s directed toward
educating doctors on the importance of r e p o r t i n g . DHS' Prevention
B u l l e t i n provides a way to emphasize r e p o r t i n g requirements w i t h l i t t l e
or no impact on current resources. Further, DHS might also be able to
place information i n newsletters and b u l l e t i n s published by other
organizations such as BOMEX and the medical associations.
Second, DHS could attempt to p e r i o d i c a l l y contact randomly selected
health providers throughout the State to ensure consistency i n
r e p o r t i n g . Contracting i n d i v i d u a l s responsible for STD r e p o r t i n g at
providers' o f f i c e s would allow DHS to review requirements and procedures
used to report STDs. Such contact i s e s p e c i a l l y important to ensure
consistency when there i s s t a f f turnover i n these o f f i c e s . DHS o f f i c i a l s
c l a i m t h a t p e r i o d i c contact w i t h physicians and laboratories i s not
emphasized at the State program level i n Arizona due to lack of s t a f f .
However, at least one county program i n Arizona contacts targeted
c l i n i c a l s e t t i n g s q u a r t e r l y using three i n v e s t i g a t o r s who also have other
r e s p o n s i b i l i t i e s . DHS may be able to contact randomly selected providers
on a l i m i t e d basis w i t h i t s e x i s t i n g STD s t a f f . For example, even a few
periodic telephone contacts would provide DHS w i t h an i n d i c a t i o n of
compl iance w i t h the r e p o r t i n g law.
RECOWENDAT I ONS
1. DHS should review the operation and effectiveness of the recently
developed STD r e p o r t i n g system to determine i f current s t a f f w i l l be
adequate to handle the a d d i t i o n a l data entry workload and to f o l l o w
up on unreported cases.
( 1 ) The a s s i s t a n t d i r e c t o r i n d i c a t e s t h a t a l l physicians l i c e n s e d by the Board o f
Medical Examiners are on the m a i l i n g l i s t f o r the b u l l e t i n , but t h a t osteopathic
physicians a r e n o t included.
11
2. DHS should improve p r i v a t e sector STD r e p o r t i n g by:
e P e r i o d i c a l l y c o n t a c t i n g randomly selected providers by telephone
to ensure t h a t t h e i r s t a f f c o n s i s t e n t l y report STD cases.
e Publishing a d d i t i o n a l a r t i c l e s i n the DHS Prevention B u l l e t i n
addressing the importance of STD r e p o r t i n g .
e E s t a b l i s h i n g g u i d e l i n e s to deal w i t h providers who c o n s i s t e n t l y
f a i l to report STDs as required by law. The g u i d e l i n e s should
require department s t a f f to document attempts to o b t a i n
physician compliance w i t h r e p o r t i n g requirements and provide for
f i l i n g complaints w i t h the Board of Medical Examiners i n cases
where physicians do not comply.
FINDING II
DIVISION OF DISEASE PREVENTION SERVICES NEEDS TO CHANGE
PRACTICES TO COMPLY WITH OPEN MEETING LAW
The D i v i s i o n o f Disease P r e v e n t i o n S e r v i c e s has not complied w i t h
Arizona's open meeting law i n holding meetings of the Governor's Task
Force on AIDS. Although the open meeting law a p p l i e s t o a l l a c t i v i t i e s
of the AlDS Task Force, the d i v i s i o n d i d not provide proper n o t i c e of
meetings and agendas as required by law.
The AlDS Task Force was created to address major issues regarding the
AlDS epidemic i n Arizona. The D i v i s i o n of Disease P r e v e n t i o n S e r v i c e s
provides s t a f f assistance to the committee and i s responsible f o r
ensuring that the Task Force complies w i t h State laws governing committee
meetings.
Open Meeting Law Applies t o A l l
Study Comni t t e e Act i v i t i e s
Arizona's open meeting law applies t o a l l meetings o f the Governor's Task
Force on AIDS. A. R. S. 038- 431 e t seq. i d e n t i f i e s e n t i t i e s t h a t a r e
subject to the S t a t e ' s open meeting law which requires committees to post
n o t i c e of o f f i c i a l meetings, e s t a b l i s h agendas, and keep minutes
a v a i l a b l e f o r pub1 i c i n s p e c t i o n . T h i s act applies t o a l l p u b l i c bodies.
The Attorney General has provided a d d i t i o n a l guidance t o agencies f o r
compliance w i t h the law and has s p e c i f i c a l l y i d e n t i f i e d advisory
committees created by the DHS d i r e c t o r as b e i n g r e q u i r e d t o
comply. ") The Attorney General's O f f i c e Open Meeting Law Enforcement
Team ( OMLET) and DHS' A s s i s t a n t A t t o r n e y General Representative both
maintain that the Governor's Task Force on AlDS i s subject t o the State
open meeting law. According to the lawyers, working groups and
interagency meetings must also comply w i t h the law.
' A. R. S. 536- 109 E. a l l o w s t h e DHS d i r e c t o r t o e s t a b l i s h any s p e c i a l c o u n c i l s as
required by State o r federal law, r u l e s , or r e g u l a t i o n s , o r determined t o be
essential t o the pub1 i c ' s i n t e r e s t . The Attorney General I s Handbook s p e c i f i c a l l y
includes DHS advisory commi ttees and c i t i z e n advisory groups appointed by the
Governor as among those requi red t o comply w i t h the open meeting 1 aw.
13
Open Meeting Laws
Have Been Violated
Study sessions of the AlDS Task Force committee met without providing
proper notice to the p u b l i c . The p u b l i c has never been n o t i f i e d or i n
attendance at the Governor's AlDS Task Force working sessions. Since
October 1988 members of the f o u r planning committees of the Governor's
Task Force on AlDS have held numerous working sessions. Although the
decisions made and topics discussed were l a t e r presented at a pub1 i c
meeting, these study sessions s t i l l must comply w i t h the S t a t e ' s open
meeting law.
According to department o f f i c i a l s i t ' s f a i l u r e t o comply w i t h the open
meeting law was an a d m i n i s t r a t i v e o v e r s i g h t . They also maintain that the
p u b l i c was never o f f i c i a l l y excluded from the sessions and that the
p u b l i c was represented at many of the meetings.
F a i l u r e t o comply w i t h the open meeting law may c o n t r i b u t e to p u b l i c
d i s t r u s t o f o f f i c i a l motives and actions regarding such a serious issue
as AIDS.
DHS should e s t a b l i s h procedures to ensure that a l l meetings of the AlDS
Task Force, including subcommittees and other working groups, f u l l y
comply w i t h A. R. S. 538- 431 ef seq. and A. R. S. 936- 109 E .
OTHER PERTINENT INFORMATION
During the course of our audit we developed information on ( 1) e f f o r t s to
control the spread of Acquired Immune Deficiency Syndrome ( AIDS) and ( 2)
problems involving the study of the suspected cancer c l u s t e r i n the
Maryvale area of Phoenix.
C o n t r o l l i n g Acquired lmnune Deficiency Syndrome
i n Arizona
The D i v i s i o n o f Disease Prevention Services has primary r e s p o n s i b i l i t y
for much of Arizona's e f f o r t to control the spread of AIDS. The
incidence of AlDS has s t e a d i l y increased i n Arizona and the Governor has
appointed a task force to make recommendations for developing a
comprehensive statewide p o l i c y for dealing w i t h the AlDS epidemic. In
the interim the d i v i s i o n i s implementing a number of programs to address
s p e c i f i c aspects of the AlDS problem.
AIDS i n Arizona - Since s u r v e i l lance began i n 1982, the number of AIDS
and AlDS Related Complex ( ARC) cases diagnosed annual l y has i ncreased
each year i n Arizona and nationwide. The U. S. Centers for Disease
Control ( CDC) s t a t i s t i c s show that 74,447 persons i n the United States
were diagnosed w i t h AlDS between January 1, 1981 and September 26, 1988.
These s t a t i s t i c s include reported cases of AlDS only; they do not include
reported cases of ARC or human immunodeficiency v i r u s ( HIV), the
r e t r o v i r u s that causes AIDS. The AlDS Section of the Arizona D i v i s i o n of
Disease Prevention Services has documented 664 cases of AIDS, 245 ARC
cases, and 1,591 cases of asymptomatic HIV reactions between July of 1981
and December 1988. AlDS cases have been reported i n 12 of the 15 Arizona
counties. The D i v i s i o n of Disease Prevention Services estimates that an
a d d i t i o n a l 1,300 cases of AlDS w i l l be diagnosed i n Arizona by 1992.
The Governor's Task Force on AlDS - In October 1988 the Governor
appointed a task force to develop a s t r a t e g y f o r dealing w i t h AlDS i n
Arizona. The 35- member task force includes l e g i s l a t o r s and
representatives from v a r i o u s o r g a n i z a t i o n s and p u b l i c h e a l t h agencies.
DHS' D i v i s i o n o f Disease Prevention Services s t a f f a s s i s t s the task force
i n a technical advisory c a p a c i t y . Committees have been used i n a number
of states to a s s i s t i n developing a coordinated approach to the h e a l t h
and social problems r e s u l t i n g from AIDS. The Arizona committee's mandate
i s t o : ( 1) evaluate current State laws and p o l i c i e s as they r e l a t e to
the disease; ( 2) i d e n t i f y needs t h a t should be met t o b e t t e r deal w i t h
the disease; ( 3) encourage p u b l i c and p r i v a t e cooperation to meet these
needs; and ( 4) develop a comprehensive State s t r a t e g i c plan w i t h proposed
p u b l i c p o l i c i e s for the S t a t e .
The task force has organized i t s e l f i n t o four d i f f e r e n t issue groups:
finance and cost of care, prevention and education, legal and p o l i c y
issues, and p a t i e n t care and s e r v i c e s . According to the task force
coordinator, the task force w i l l be able to judge i t s progress and any
possible problems a f t e r an i n t e r i m review t h a t could be completed as
e a r l y as mid- March. The task force plans to produce an i n t e r i m report i n
June and a f i n a l report i n October 1989. A f t e r completing i t s r e p o r t ,
the task force w i l l lobby f o r and a s s i s t w i t h implementation of
recommendations. The task force w i l l disband at the end of the 1990
l e g i s l a t i v e session.
D i v i s i o n a c t i v i t i e s dealing w i t h AlDS - In the absence of a statewide
s t r a t e g y , the D i v i s i o n of Disease Prevention Services has worked to meet
the growing needs created by t h e outbreak. Since 1982, the d i v i s i o n has
been and continues to be involved i n a v a r i e t y of programs and studies to
combat AIDS, p r i m a r i l y through i t s AlDS Section of the O f f i c e o f
I n f e c t i o u s Disease Services and the O f f i c e o f Health Promotion and
Education.
The AlDS Section i s involved i n several a c t i v i t i e s . The section has
created and maintains a database of reported cases. Since 1985 AlDS and
ARC have been among the diseases that must be reported to county h e a l t h
departments, which in t u r n report to the AlDS Section. The AlDS Section
has also received funding from CDC t o p a r t i c i p a t e i n a nationwide study
t h a t includes the Phoenix/ Maricopa County area and i s designed to
estimate the level of HIV i n f e c t i o n i n s p e c i f i c population groups. The
section i s also administering a f e d e r a l grant for the purchase and
d i s t r i b u t i o n of AZT, a drug proven e f f e c t i v e i n prolonging the l i v e s of
AlDS p a t i e n t s .
The O f f i c e o f Health Promotion and Education and the AlDS Section are
both working on the AlDS Prevention Project funded by CDC. The p r o j e c t
i s designed t o p r o v i d e health education, r i s k reduction programs,
counseling, and t e s t i n g . The grant funds are divided between the O f f i c e
of Health Promotion and Education and the AlDS Section. The AlDS Section
uses these funds to contract w i t h county health departments for free
counseling and t e s t i n g services. Free counseling and t e s t i n g s i t e s have
been set up i n n i n e c o u n t i e s : Cochise, Coconino, La Paz, Maricopa, Pima,
P i n a l , Santa Cruz, Yavapai, and Yuma. The O f f i c e o f Health Promotion and
Education has used i t s grant funds to design and contract for Knowledge,
A t t i t u d e , and Behaviors ( KAB) studies which a s s i s t i n d i r e c t i n g
educational e f f o r t s . The o f f i c e has also funded and taken part i n media
campaigns, established working r e l a t i o n s h i p s w i t h h i g h - r i s k communities
such as the gay community, and conducted educational workshops.
Maryvale Studies Are
S t i l l Controversial
Department of Health Services studies have found elevated death rates
from leukemia and other cancers and b i r t h defects i n west and east
central Phoenix. No causal r e l a t i o n s h i p has been i d e n t i f i e d t o date.
Studies by the department and other e n t i t i e s w i l l f u r t h e r i n v e s t i g a t e
possible causal r e l a t i o n s h i p s . However, some groups question the
responsiveness of DHS to c i t i zen concerns i n the Maryvale i n v e s t i g a t i o n s
and the v a l i d i t y and r e l i a b i l i t y of the studies themselves.
Central Phoenix cancer rates - I n 1982, a DHS study of childhood
leukemia m o r t a l i t y found a h i g h incidence of cancer m o r t a l i t y i n some
west Phoenix census t r a c t s from 1970 through 1981. A 1987 study of b i r t h
defects i n Maricopa and Pima counties also i n d i c a t e d elevated r a t e s
w i t h i n one of the census t r a c t s . As a r e s u l t , there was strong p u b l i c
concern about the f i n d i n g s of these studies and possible l i n k s w i t h
environmental f a c t o r s . DHS has attempted to address these concerns by:
( 1) i n i t i a t i n g a countywide m o r t a l i t y study, and ( 2) d i r e c t i n g outside
groups i n envi ronmental assessments to invest i gate poss i b le causes of
health problems i n the general area of the suspected cancer c l u s t e r .
The m o r t a l i t y study investigated deaths i n a l l geographic areas by cause
of death and age from 1966 through 1986 using Arizona v i t a l s t a t i s t i c
records. East central Phoenix has exhibited elevated m o r t a l i t y rates
from t o t a l cancer i n middle- aged a d u l t s ( 45- 64 years) from 1970 through
1986. The study supports e a r l i e r f i n d i n g s t h a t i n d i c a t e d a childhood
leukemia c l u s t e r e x i s t s i n west central Phoenix. Also, i t suggests that
increased cancer r i s k may e x i s t f o r a d u l t s as w e l l . East central Phoenix
also exhibited elevated m o r t a l i t y rates from b i r t h defects and
cardiovascu Iar disease. A previous study i ni t iated i n 1983 and re leased
i n 1987 i d e n t i f i e d elevated rates of b i r t h defects i n the same general
area of the west central Phoenix leukemia c l u s t e r .
However, these studies were not designed to determine what caused the
conditions observed. A series of subsequent studies explored possible
environmental causes by t e s t i n g the west Phoenix water supply,
groundwater, a i r q u a l i t y , and outdoor r a d i a t i o n . Below are the r e s u l t s
of the s t u d i e s .
a Water Quality Testing - I n June 1987, the c i t y of Phoenix began a
period of monthly sampling of the west central Phoenix water supply.
Normally, sampling i s conducted on a q u a r t e r l y b a s i s . Water samples
taken before June 1987 and those taken i n the monthly samples met a l l
e x i s t i n g q u a l i t y standards. The c i t y resumed q u a r t e r l y sampling.
r The Arizona Department of Environmental Quality ( ADEQ), the Arizona
Department of Water Resources ( ADWR), and the Salt River Project
( SRP) conducted t e s t i n g of the groundwater and i r r i g a t i o n water i n
west central Phoenix. The data confirmed the existence of i n d u s t r i a l
solvents i n the water. Some samples from the Roosevelt I r r i g a t i o n
D i s t r i c t canals c o n t a i n t r a c e s of i n d u s t r i a l solvents. No pesticides
were detected by any of these t e s t s .
A l l but two schools i n the west central Phoenix area use SRP canal
water f o r f l o o d i r r i g a t i o n . Although some i n d u s t r i e s are allowed to
discharge i n t o SRP canals, water sampling to date has not indicated
p o l l u t i o n from t o x i c substances.
r Air Quality Monitoring - ADEQ conducted a i r q u a l i t y t e s t s between
December of 1987 and March 1988. Average p o l l u t a n t levels were
highest i n east and west central Phoenix. A r i s k assessment
p r e d i c t s that short- term exposure poses no health r i s k and estimates
that the maximum excess cancer r i s k that could r e s u l t would be 1.5
excess cancer cases per year w i t h i n the e n t i r e metropolitan area.
o Other Environmental Tests - The Arizona Radiation Regulatory Agency
completed tests of ambient outdoor r a d i a t i o n i n west central Phoenix
and found normal levels of background r a d i a t i o n . Additional
measurements inside 17 west Phoenix schools also found normal
readings. In a d d i t i o n , ADEQ i s c u r r e n t l y working on a s o i l sampling
program to i d e n t i f y p e s t i c i d e contaminated surface s o i l .
DHS i s continuing i t s study by i n v e s t i g a t i n g the incidence of childhood
cancer between 1965 and 1986 i n the west Phoenix area. The incidence
study of childhood cancers d i f f e r s from the m o r t a l i t y study. The
incidence study counts newly diagnosed cases of a disease rather than
f a t a l i t i e s a t t r i b u t e d to the disease. A progress report on t h i s study i s
compiled p e r i o d i c a l l y . Completion i s projected for l a t e summer 1989.
I f the childhood cancer incidence study i n d i c a t e s a s i g n i f i c a n t l y higher
incidence rate, DHS w i l l proceed w i t h a Case Control Study. The Case
Control Study i s i n design development now and w i l l not be undertaken
u n t i l r e s u l t s from the incidence study are i n . The Case Control Study
w i l l be designed to i n v e s t i g a t e i n d e t a i l the physical environments of
each diagnosed case. Environmental t e s t s outside and inside the home, as
well as l i f e - s t y l e and medical information, w i l l be documented i n order
to e s t a b l i s h possible p a t t e r n s . DHS o f f i c i a l s feel that the Case Control
Study w i l l be of l i m i t e d b e n e f i t should the incidence study f a i l to
support the existence of an elevated incidence r a t e . However, at least
two members of the CDC review panel support the undertaking of the Case
Control Study regardless o f incidence study f i n d i n g s . According to
review panel members, the case control may reveal something the incidence
study cannot.
Citizen distrust - Although representatives of west v a l l e y groups and
DHS claim that most area residents are s a t i s f i e d w i t h the progress and
d i r e c t i o n of the study, some c i t i z e n groups and e n v i r o n m e n t a l i s t s f e e l
that DHS has not adequately responded to c i t i z e n concerns about p o t e n t i a l
cancer dangers. Perceptions that DHS i s unresponsive have led to
d i s t r u s t o f DHS.
A number of groups appear s a t i s f i e d w i t h the studies and r e s u l t s to
date. The C i t i z e n s L i a i s o n Representative ( a u n i v e r s i t y s c i e n t i s t )
i n d i c a t e d t h a t the studies are proceeding s a t i s f a c t o r i l y and that
cooperation has been generally good among the agencies involved. He
represents the West Valley C i t i z e n s Group, a c o a l i t i o n of several groups
of area residents, which he i n d i c a t e s i s generally s a t i s f i e d w i t h current
e f f o r t s .
However, others feel DHS has discouraged t h e i r input by making the
process unnecessarily d i f f i c u l t . For example, the department i s only
allowing family members to report known cases i n i t s incidence study.
Members of the pub1 i c wonder why they cannot report cases they are aware
of and then allow DHS t o f o l l o w up. Also, some c i t i z e n s thought the
D i v i s i o n of Disease Prevention Services was unresponsive t o complaints.
I n d i v i d u a l s f e l t i t e i t h e r took DHS much too long to take a c t i o n , or the
a c t i o n taken was not r e a d i l y a v a i l a b l e f o r p u b l i c review. I n a d d i t i o n ,
c i t i zen group representatives f e i t that they shou Id have been made aware
of and been present at interagency meetings. F i n a l l y , DHS i s f a u l t e d for
i t s slowness i n completing the i n v e s t i g a t i o n .
Members of d i s s a t i s f i e d c i t i z e n s ' groups ( Mothers of Maryvale [ MOM] and
Toxic Waste I n v e s t i g a t i v e Group [ TWIG]) we contacted expressed
f r u s t r a t i o n from t h e i r dealings w i t h State o f f i c i a l s and e x h i b i t a
general d i s t r u s t of the State. An example of t h i s d i s t r u s t occurred when
an auditor contacted one i n d i v i d u a l to discuss her concerns about the
problems w i t h the s t u d i e s . The person was brought to our a t t e n t i o n as
someone who had s p e c i f i c information regarding problems and inaccuracies
w i t h the ADEQ r e p o r t s . Once contacted the i n d i v i d u a l claimed she was
unavailable due to other o b l i g a t i o n s . A f t e r approximately an hour, the
i n d i v i d u a l contacted the auditor and i n d i c a t e d t h a t she d i d have the
information and could meet w i t h an a u d i t o r , but had l i e d before because
of her d i s t r u s t of State o f f i c i a l s . In a d d i t i o n , the woman c i t e d her
d i s t r u s t for DHS o f f i c i a l s as the reason she no longer p a r t i c i p a t e s i n or
attends Maryvale meetings. Further, others claim that the poor c i t i z e n
response i n r e t u r n i n g i n f o r m a t i o n on childhood cancer cases for the
incidence study i s a r e s u l t of t h i s d i s t r u s t ! ' )
Specific c r i t i c i s m s of Maryvale studies - S p e c i f i c c i t i z e n complaints
about the Maryvale studies f a u l t the l i m i t e d scope of the studies. For
example, the incidence study looks only at childhood cancer diagnosed
between b i r t h and age 19, and does not include a d u l t s . However, the DHS
m o r t a l i t y study f i n d i n g s i n d i c a t e that c h i l d r e n are not the only group
w i t h elevated m o r t a l i t y rates from cancer. For example, a west c e n t r a l
Phoenix group r e p r e s e n t a t i v e b e l i e v e s t h a t adult leukemia rates are
elevated too. C i t i z e n s a l s o c i t e a v a r i e t y of other health problems that
DHS i s not i n v e s t i g a t i n g . These include: lupus i n a d u l t s and c h i l d r e n ,
mononucleosis i n c h i l d r e n under eight years of age ( an unusual
occurrence), l i v e r disease i n c h i l d r e n , miscarriages, and b i r t h defects.
Some c i t i z e n s also question several studies done by ADEQ. One dispute
concerns d i f f e r i n g estimates of benzene levels i n the a i r shown by two
ADEQ analyses. The f i r s t analysis showed high benzene concentrations
while a subsequent t e s t found a i r q u a l i t y to be acceptable. Independent
analyses of the r e s u l t s of the f i r s t study raised questions about i t s
accuracy. The c i t i z e n s r e j e c t the second ADEQ r e s u l t s because they feel
i t was designed to produce a best- case r e s u l t ; samples were taken at
d i f f e r e n t times of the year.
The ADEQ s o i l sample survey i s also under a t t a c k . An expert from the
C i t i z e n ' s Clearinghouse for Hazardous Waste says that the proposed
sampling plan i s inadequate because ADEQ plans to c o l l e c t samples from
only the top s i x inches o f soi I . According to t h i s expert, deeper
DHS i s attempting t o i d e n t i f y cancer cases by r e q u e s t i n g t h e p u b l i c t o respond t o
questionnaires. The comments from the questionnaires wi 11 play an important p a r t
i n the incidence study. A1 though p u b l i c i t y has been widespread, o n l y t h r e e
questionnaires have been returned to the department. The c i t i z e n s contacted
be1 ieve DHS i s r e c e i v i n g such a low response r a t e because people do not be1 ieve
anything constructive w i l l be done w i t h the i n f o r m a t i o n .
samples are needed t o e s t a b l i s h an accurate " s o i l horizon." A s o i l
horizon i d e n t i f i e s p e s t i c i d e , h e r b i c i d e , and fumigant use over time. The
expert noted that because cancers generally develop over a long term,
t h i s h i s t o r i c a l p i c t u r e of exposure may be necessary.
AREAS FOR FURTHER AUDl T WORK
During the course of our audit of the D i v i s i o n of Disease Prevention
Services we i d e n t i f i e d p o t e n t i a l issues that we were unable to pursue due
to time c o n s t r a i n t s .
a I s the d i v i s i o n meeting i t s established goals and objectives?
The D i v i s i o n o f Disease Prevention Services has established goals and
objectives i n order to evaluate i n d i v i d u a l o f f i c e performance. However,
the d i v i s i o n s ' a b i l i t y to evaluate actual versus planned performance
appears to vary among programs. For example, the immunization program
has established many q u a n t i f i a b l e processes to monitor performance, while
the r i s k assessment o f f i c e has no q u a n t i f i a b l e i n d i c a t o r s . Also, the
main concern of the chronic disease o f f i c e has been development of the
Cancer and B i r t h Defects R e g i s t r y . Therefore, an o f f i c i a l claims that
they have not had the time to develop s t r a t e g i e s regarding other goals
and o b j e c t i v e s . The STD program has e s t a b l i s h e d g o a l s , but the data
needed to measure progress toward those goals and objectives i s
questionable. Further audit work i s needed to determine the d i v i s i o n ' s
progress toward meeting i t s goals and o b j e c t i v e s .
a Are a l l current D i v i s i o n of Disease Prevention Services a c t i v i t i e s
necessary?
The D i v i s i o n of Disease Prevention Services i s responsible for c e r t a i n
licensing a c t i v i t i e s that may be unnecessary or could be performed by
other State agencies. For example, the d i v i s i o n i s responsible for
inspection of f o s t e r homes, c h i l d r e n ' s camps, and bedding manufacturers.
In the past, the d i v i s i o n has proposed l e g i s l a t i o n to t r a n s f e r these
duties to other State agencies or to the counties. However, the
department d i d not include them i n i t s current l e g i s l a t i v e packages.
Further a u d i t work i s needed to determine i f c e r t a i n a c t i v i t i e s should
remain the d i v i s i o n ' s r e s p o n s i b i l i t y .
a Are DHS' D i v i s i o n of Disease Prevention Services s a l a r i e s competitive
to r e c r u i t and maintain a p p r o p r i a t e s t a f f ?
According to D i v i s i o n o f Disease Prevention Services o f f i c i a l s , low
s a l a r i e s and inaccurate p o s i t i o n c l a s s i f i c a t i o n s l i m i t t h e i r a b i l i t y to
r e c r u i t and maintain needed professional s t a f f . These p o s i t i o n s are
Health Educators, Medical Records Technicians, B i o s t a t i s t i c i a n s ,
Epidemiologist, and S a n i t a r i a n s .
DHS maintains problems e x i s t because these p o s i t i o n s cal l f o r i n d i v i d u a l s
w i t h a high degree of technical expertise and extensive experience.
However, department o f f i c i a l s c l a i m t h a t the State personnel system often
lacks a s p e c i f i c c l a s s i f i c a t i o n for these p o s i t i o n s . As a r e s u l t , the
p o s i t i o n s are placed i n e x i s t i n g c l a s s i f i c a t i o n s for which salary levels
are not commensurate w i t h the d u t i e s , r e s p o n s i b i l i t i e s , and education
required by the D i v i s i o n of Disease Prevention Services. Further audit
work i s needed to evaluate Disease Prevention Services i n a b i l i t y to
r e c r u i t , h i r e , and r e t a i n c e r t a i n professional p o s i t i o n s .
a Does the O f f i c e of Risk Assessment and I n v e s t i g a t i o n s adequately
monitor complaints?
The O f f i c e of Risk Assessment and l n v e s t i g a t i o n s i s responsible for
i n v e s t i g a t i n g environmental complaints from the p u b l i c . For example,
c i t i z e n s w i t h evidence of improper p e s t i c i d e use may contact the o f f i c e
w i t h a complaint. According to the manager, h i s o f f i c e d i r e c t s the
complaints from the p u b l i c t o the v a r i o u s S t a t e or local e n t i t i e s
responsible f o r r e g u l a t i n g the p a r t i c u l a r a c t i v i t y . However, a cursory
review found l i m i t e d documentation i d e n t i f y i n g complaints and the f i n a l
r e s u l t s . The o f f i c e has no idea what happens w i t h the complaint unless
there i s f u r t h e r contact from the p u b l i c regarding the same complaint.
I n a d d i t i o n , members of the p u b l i c have complained to our o f f i c e about
Risk Assessments' lack of follow- up. Further a u d i t work i s needed to
determine whether the O f f i c e of Risk Assessment and I n v e s t i g a t i o n s
adequately monitors complaints.
ARIZONA DEPARTMENT OF HEALTH SERVICES
Office of the Director
ROSE MOFFORD. GOVERNOR
TED WILLIAMS. DIRECTOR May 17, 1989
Mr. Douglas R. Norton, CPA
Auditor General
2700 North Central Avenue
Suite 700
Phoenix, AZ 85004
Dear Mr. Norton:
The Department and the Division of Disease Prevention have reviewed the
preliminary report draft of your agency's performance audit of the
division. Attached i s the Department's final written response, as
requested.
Sincerely, .
Ted Williams
Director
TW: SJE: ajr
Attachment
cc: Steven J. Englender, M. D., M. P. H.
The Department of Health Services is An Equal Opportunity Affirmative Action Employer.
r)
State Health Building 1740 West Adams Street Phoenix, Arizona 85007
Final Written Response
Draft Sunset Performance Review
Division of Disease Prevention
Finding I - Department of Health Services Needs to Improve Reporting of Sexually
Transmitted Diseases
The Department agrees that sexually transmitted diseases ( STD) are underreported
and has already undertaken actions to improve reporting. The performance review fails
t o acknowledge the Department's efforts to expand and enhance STD reporting in 1987,
including the expansion of the list of required positive laboratory reports from syphilis
only to syphilis, gonorrhea and chlamydia. Only recently has the redesigned computer
data base come on line that allows matching of provider reports to laboratory reports.
Laboratory based reporting will be used as a means to enhance overall STD reporting as
well as a method of assessing the level of underreporting in the private sector. The
Department appreciates the report's recognition that additional staff may be necessary
to optimally operate this enhanced information system.
As the report indicates, the Department is aware of and has utilized the authority
of the Board of Medical Examiners to help induce physicians to report communicable
diseases. The Department, in conjunction with local health departments, will establish
clearer guidelines to deal with physicians who do not comply with communicable disease
reporting requirements, including STD.
Communication is an essential ingredient to the practice of public health.
Although the Department, in conjunction with local STD control programs, has
undertaken many provider educationai efforts, greater emphasis will be given to
reporting requirements.
The Department feels that limited staff resources may be better expended a t
correcting known problems with provider underreporting, as documented by disparities in
laboratory- provider reporting, than in random calls to Arizona's physicians to discuss
reporting requirements. Such activities must take a lower priority than known STD
morbidity and efforts to bring contacts to discovered cases to examination and
treatment. However, if time allows, the suggested system of random telephone calls to
selected providers will be pursued.
Finding I1 - The Division of Disease Prevention Services Needs to Change Practices to
Comply with Open Meeting Laws
The Department regrets that some work group sessions of the Governor's Task
Force on AIDS were not posted as required by A. R. S. § 38- 431 e t seq. As the
performance review indicates, this was an oversight. Procedures at both the Division of
Disease Prevention and the Public Information Office have been reviewed and are being
revised t o assure public meetings are appropriately noticed.
Other Pertinent Information
Controlling Acquired Immunodeficiency Syndrome in Arizona
The Department appreciates the efforts by the Auditor General to summarize AIDS
activities. However, the performance review fails to recognize that the Department
promulgated and published a statewide HIV risk reduction and disease prevention plan in
July 1987. Progress reports on activities directed by this plan have been made annually.
Maryvale Studies Are Still Controversial
Citizen Distrust
The Department's e f f o r t s t o investigate the increase in childhood leukemia
mortality in West Central Phoenix have been designed t o b e both thorough and
scientifically sound. The need for quality in study design, data collection, analysis and
interpretation has taken precedence, when appropriate, over the competing need for
rapid resolution of the problem. Finding credible answers, i f possible, has been a guiding
principle in Department activities. For these reasons, studies are being conducted by a
number of agencies under the guidance and review of both expert consultants appointed
by the Centers for Disease Control and the citizen- liaison appointed by the Governor.
That this process has failed to satisfy everyone is hardly a surprise; that most have
a c c e p t e d t h e efforts by so many to achieve this undertaking is evidence that the process
is working reasonably well.
The protocol by ~ l'hichc ancer cases are found and the reason for verification of the
process using family or self- reported cases has been approved by the CDC peer panel and
has been explained repeatedly t o t h e public. The citizen- liaison has not found fault with
the process and is participating in the report collection. Investigation of cases reported
by other than family members could be construed as an invasion of privacy. Interested
citizens aware of cases among friends and neighbors are encouraged t o contact those
individuals t o report directly. The slowness in completing these studies is dictated by the
scientific thoroughness required and meets t h e expectations of t h e CDC peer panel based
on t h e i r experiences in similar studies conducted elsewhere.
Specific Criticisms of Maryvale Studies
In embarking on the health studies in Maricopa County, the Department clearly
anticipated that the first phase would be to confirm and extend the observations of
childhood leukemia mortality, then to ascertain childhood cancer incidence, and finally,
if appropriate, conduct a case- control study to seek risk factors associated with the
development of childhood leukemia. It was recognized that other studies may be
necessary to elucidate unexpected findings in any of these studies. Few of rhe other
unsubstantiated health problems were raised as concerns at the initial public meeting in
June 1987. Many are of interest to the Department. Birth defects are being monitored
through the now established birth defects registry. The methodologies for successful
retrospective studies of miscarriages have not yet been developed. Prospective studies
of this problem are currently beyond the scope of division activities. The mortality study
did not find a significant elevation in adult leukemia. The cancer registry is designed to
d e t e c t elevated incidences of all causes of cancer. The relationship of lupus
erythematosis and other auto- immune diseases to environmental factors is of public
health interest, but reliable n~ ethodologies to ascertain an association are not yet
available. While in this country the peak incidence of Epstein Barr virus ( EBV) infections
is in the second decade of life, the occurrence in childhood is not uncornmon. This
disease in young children is often asymptomatic. Detection of antibodies to EBV by
cornmon office based laboratory tests is unusual. We are unaware of any linkage to
environmental factors for EBV.
While citizens have questioned studies done by ADEQ as well as other agencies, the
relevance of this in an audit of this division is unclear. It is inappropriate to include
t h e s e comments in this report.
Areas for Further Audit Work
o Is the division meeting its established goals and objectives
Given the diversity of responsibilities in the division, it is to be expected the ability
to evaluate progress toward meeting goals and objectives of different offices may
vary considerably. It is relatively easy to quantify immunization program
performance as it relates to delivering vaccine to a target population, yet
surveillance and control activities may not be so easily evaluated. Some of the
responsibilities of the Office of Risk Assessment involving environmental
investigations are well defined and can be readily evaluated but studies of adverse
health effects may vary widely, be less predictable, and be difficult to evaluate in
terms of goals and objectives. The Office of Chronic Disease Epidemiology
currently has as its highest priority establishment of the registries and response to
Cancer and Birth Defects. The interest and need for expansion into other chronic
disease activities is clearly recognized, but the resources are not currently
available. The progress of the STD program in meeting its goals and objectives has
been satisfactory, as judged by the Centers for Disease Control, which provides the
majority of funding for this program's activities.
o Are current Disease Prevention Services necessary
The Department agrees with the question raised. However, the report does not
recognize agency initiatives this year to rnodify activities through SB 1304
concerning foster homes and child welfare agencies, SB 1312 regarding chidren's
camps, and HB 2014 that would have eliminated the bedding program.
o Are salaries competitive to recruit and maintain staff
The Department would welcome further audit in this area to recommend solutions
t o this long standing dilemma.
o Does the office of Risk Assessment and Investigation adequately monitor
complaints
This is a valid concern and efforts will be made to establish a system to follow- up
complaints referred to appropriate agencies.