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CDC: Environmental Health Assessment

Explicitly tie budget requests to the accomplishment of annual and long-term goals, and present resource needs in a complete and transparent manner.

Demonstrate adequate progress in achieving all the programs long-term performance goals.

Achieve the targets for the program's annual performance measures.

Take steps to improve the program so that independent evaluations indicate that the program is effective and achieving results.

Measure: Number of laboratory quality standards maintained in certified or participating laboratories for tests such as lipids; newborn screening; those predictive of type 1 diabetes; blood lead, cadmium, and mercury; and nutritional factors

Explanation:One real constraint that has occurred since 2007 is a technical/security one: the problems resulting from prohibitions imposed by other countries shipping or receiving samples packaged in dry ice (required for shipping urine samples to preserve the integrity of the sample). Consequently, targets have been revised to reflect that reality. Therefore the targets for this measure are robust and realistic given this constraint.

Measure: Number of children under age 6 with elevated blood lead levels

Explanation:The elimination of elevated blood lead levels in children under age 6 will be determined as non-detectable by CDC's NHANES. Children aged 1--5 years have the highest prevalence of elevated blood lead levels. Elevated blood lead levels are considered more than or equal to 10 ??g/dL. The 2000 actual is 1999/2000 and the 2002 actual is 2001/2002.

Measure: Percentage increase in capacity of state health departments to anticipate and prevent the spread of illness/disease outbreaks from food, water, and air contaminants/vectors

Explanation:"The measure is under development. It would measure increased state health departments' capacity, in accordance with established benchmarks of environmental public health capacity, to anticipate and prevent the spread of illness/disease outbreaks from food, water and air contaminants/vectors. The program will first develop benchmarks to measure state capacity to prevent the spread of illness/disease outbreaks from food, water and air contaminants/ vectors. The program will annually evaluate state health departments' capacity in accordance with established benchmarks and recommend changes as needed and verify that past recommendations have been implemented and have increased capacity. The program intends to accomplish this performance measure by working with partners to create benchmarks based on the Ten Essential Environmental Public Health Services listed in NCEH's National Strategy to Revitalize Environmental Public Health Services. After the benchmarks are created, NCEH will oversee the development of an assessment tool that will be distributed to the environmental health divisions of public health departments. After the data from the surveys are collected and analyzed, recommendations for further increasing environmental public health capacity will be formulated, resulting in programmatic changes, where appropriate. The efficacy of the programmatic changes will be verified through additional assessments. The assessment responses will be compared against previous years to determine increases in capacity. "

Measure: Percentage reduction in asthma hospitalizations in states funded for partial and full implementation per 100,000 people

Explanation:The measure is focused on the 35 states that are currently funded by NCEH to implement comprehensive asthma control programs. The national baseline is 166.6 hospitalizations per 100,000 people. The 2000 age-adjusted hospitalization rate baseline for full implementation states is 146.95 with 6 of 6 states reporting and for partial implementation states is 118.76 with 16 of 19 states reporting. These states represent 59% of the U.S. Population.

Measure: Number of environmental chemicals, including nutritional indicators, that are assessed for exposure of the U.S. population

Explanation:The program can measure at least 300 chemicals or their metabolites in human blood or urine. However, not all of these are measured in specimens obtained from participants in the National Health and Nutrition Examination Survey (NHANES). The target for 2005 is not above 2004 because a new sampling of the population is completed in even-numbered years.

Measure: Number of FTE providing program support through the office of the director per $1 million in total program budget

Explanation:The measure compares the number of FTE providing leadership, administrative support, policy and other non-front line public health functions that are in the office of the director to the program's total program budget. The reduction in FTE at that level has increased the proportion of human and financial resources dedicated to front-line public health functions. The numerator is the number of FTE in the NCEH/ATSDR office of the director. The denominator is the total program budgets of NCEH and ATSDR.

Measure: Increase the proportion of those with current asthma who report they have received self -management training for asthma in populations served by CDC funded state asthma control programs.

Explanation:Strong evidence exists in the peer reviewed literature demonstrating that asthma self-management education activities (such as those performed by the state asthma control programs) leads to subsequent reductions in the occurrence of adverse health outcomes associated with poor asthma management (e.g. asthma hospitalizations, emergency room visits, unscheduled office visits, lung function, school absenteeism, restricted activity). CDC believes this proposed PART measure provides a more accurate portrait of the performance our program is making towards reducing the burden of asthma within funded states. The NACP has increased national and state asthma surveillance and can provide regular reports beginning in late 2007 about asthma-self management education for individuals who report currently having asthma. The data source CDC will use is the Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-Back Survey.

Is the program purpose clear?

Explanation: The purpose of the National Center for Environmental Health (NCEH) at the Centers for Disease Control and Prevention (CDC) is to maintain and improve public health by promoting a healthy environment and preventing death and avoidable illness and disability caused by non-infectious, non-occupational environmental factors. Key activity areas for the program include asthma control, childhood lead poisoning prevention, national and international emergency event response, environmental public health tracking, radiation and environmental health studies, landmine survivors support, advanced laboratory biomonitoring, vessel sanitation and chemical and biological weapons disposal. NCEH was created in 1980 to plan, direct, and coordinate a national program to prevent or control environmentally related health problems.

Evidence: Evidence includes the Public Health Service Act authorizations (42 USC 301/247b-1/247b-10/317_I/399L), annual appropriations reports, Federal Register Notice Vol 45, No 200, page 67772, 10/14/80, and the NCEH mission statement and strategic plan.

Does the program address a specific and existing problem, interest, or need?

Explanation: The program addresses the specific and existing problem of human exposure to a variety of toxic substances and hazardous environmental conditions. There are multiple human health hazards in the environment that can have an impact on human health. Health problems that can be caused or worsened by environmental hazards that the program addresses in some form include asthma, lead and other heavy metal poisoning, illness from harmful algal blooms, chemical poisoning, food and waterborne illness, pesticide poisoning, infectious diseases, cancer, kidney dysfunction, carbon monoxide poisoning, lung and other chronic respiratory disease, birth defects and other adverse reproductive outcomes and disorders, immune function disorders, liver dysfunction, nuerologic diseases and neurotoxin disorders, and injuries caused by explosions and natural disasters.

Evidence: The program estimates 434,000 young children had elevated blood lead levels in 1999-2000. Twenty million Americans had asthma in 2001 and 12 million had an attack in the previous year. Over 15,000 persons with confirmed or possible non-fire-related carbon monoxide exposure were treated annually in hospital emergency departments from 2001-2003 (National Electronic Injury Surveillance System All Injury Program). An estimated 10 million U.S. adults reported physician-diagnosed chronic obstructive pulmonary disease (COPD) and according to data from CDC's National Health and Nutrition Examination Survey, 24 million have evidence of impaired lung function. According to the program, population-based data available for San Francisco suggest a rate of 1-2 cases of aspergillosis from mold per 100,000 per year. In addition to known risks, such as asbestos exposure lung cancer, many environmental exposure risk areas require further research to better determine causation of disease and harmful levels of exposure.

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The program is not redundant of the Environmental Protection Agency (EPA), the National Institutes of Health (NIH), especially the National Institute of Environmental Health Sciences (NIEHS), or the Agency for Toxic Substances and Disease Registry (ATSDR). EPA's focus is on the environment and in general it approaches environmental risks to human health through regulatory and policy making, environmental monitoring, and through modeling rather than laboratory research, and often with the assistance of NIEHS, NCEH and ATSDR. NIEHS is focused on more basic research and targeted studies, rather than surveillance and applied research, related to human health risks. ATSDR focuses specifically on toxic substances with expertise in toxicology, risk assessments, sampling, cleanup and other Superfund related activities. NCEH has a more broad focus and also has laboratory capacity.

Evidence: EPA's human health mission is to study the effects of pollution on the human body, monitor environmental quality and reduce human exposure to contaminants in the air, land, and water. NIEHS' mission is to understand environmental factors, individual susceptibility and age and their interrelation to human health and disease. There were administrative and management redundancies between ATSDR and NCEH; ATSDR and NCEH focus on environmental health, are part of HHS, share general mission and purpose of protecting the public's health, are in Atlanta and rely on some of the same staff expertise. The program is working to address any redundancies through a merger of functions at the office of the director level. The merger was announced in the Federal Register, Vol. 69, No. 1, Jan. 2, 2004.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: "There is no evidence that another approach or mechanism would be more efficient or effective to achieve the intended program purpose. The program approaches to environmental health problems are public health surveillance, applied research (including epidemiologic studies, laboratory analyses, stastical analyses, behavioral interventions, operations and systems research), communication and education, standards, guidelines, and recommendations, and training and technical assistance. "

Evidence: The program relies on direct federal staffing, especially for the laboratory, cooperative agreements with states and non-governmental organizations, and some contracts for clinical trials. The program supports cooperative agreements for states, and in some cases local and territorial governments, in environmental public health tracking, lead poisoning prevention, asthma control, and biomonitoring capacity for public health laboratories.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: The program targets state, local and tribal health departments, other federal agencies, academia and international organizations. There is no evidence of unintended subsidies or poor distribution of cooperative agreement and other funds. The program's environmental public health tracking network is designed in part to help states target environmental health resources by strengthening surveillance and integrating multiple sources of data. The program's laboratory helps CDC and other agencies such as EPA target interventions by determining exposure levels from a variety of substances and providing evidence to set appropriate exposure warning levels. The program focuses on some of the leading environmental health risks, such as childhood lead exposure and asthma, and is primarily focused on areas that have been designated by Congress over time.

Evidence: The program works to benefit the public's health primarily by advancing the science of environmental health and working through states and organizations. Organizations that the program targets as intermediary beneficiaries with direct assistance or support include EPA, NIH, the National Aeronautics and Space Administration, the National Oceanic and Atmosphere Administration, the US Geological Survey, the World Health Organization, the UN Commissioner on Refugees, the World Food Program, the National Environmental Health Association, the Association of Public Health Laboratories, the Immune Deficiency Foundation, and the Landmine Survivor Network. On a more limited basis, the program serves the public more directly through vessel sanitation activities, informational and health education materials, and publications.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The program has long-term outcome performance measures that reflect program achievements and provide information to make programmatic and resource management decisions. The measures are targeted to asthma control and lead poisoning prevention, which together make up half of the program budget. A portion of the efforts of other NCEH activities, including the environmental health lab and environmental and health outcome tracking, also relates to asthma control and lead poisoning prevention.

Evidence: The long-term outcome measures include the number of asthma hospitalizations and the number of children under age 6 with elevated blood lead levels. Elevated blood lead levels can cause learning problems, including reduced IQ, and brain and kidney damage.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program has ambitious targets and timeframes for the long-term measures.

Evidence: The asthma targets are a 10% reduction in asthma hospitalizations in partial implementation states and a 17% reduction in full implementation states by 2010. The lead target is to achieve zero levels of elevated blood lead by 2010.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The program has annual performance measures that reflect program achievements and indicate progress toward meeting the long-term performance measures.

Evidence: The annual measures include the percentage increase in capacity of state health departments to anticipate and prevent the spread of illness/disease outbreaks from food, water, and air contaminants/vectors; the number of environmental chemicals, including nutritional indicators, that are assessed for exposure of the U.S. population; the number of laboratory quality standards maintained in certified or participating laboratories for tests such as lipids; newborn screening; those predictive of type 1 diabetes; blood lead, cadmium, and mercury; and nutritional factors; and a developing efficiency measure of the percentage reduction in administrative and/or production costs.

Does the program have baselines and ambitious targets for its annual measures?

Explanation: The program has ambitious targets and timeframes for the annual measures.

Evidence: The state health departments capacity measure is under development. The target is an increase of 50% in 2007 above the 2004 baseline. The environmental chemicals assessed target is 200 in 2007. The laboratory quality standards target is 1,151 in 2007.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: The program requires grantees to link proposals and annual plans of work to broad goals, objectives and targets. The program will add the new goals and measures to the grants process. Federal Register Notices will state the appropriate goal/measure/target the grantee must achieve. Grant applications will include scoring on the grantees' ability to achieve desired results. The program will work with partners on meeting these goals, targets and measures through incentives and changes in funding levels.

Evidence: Evidence includes the childhood lead poisoning prevention program cooperative agreement; communications to cooperative agreement partners on setting goals, focusing activities to be consistent with NCEH's mission and supporting program evaluations;

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: The Government Accountability Office has produced three reviews on program activities in the last six years that cover the bulk of the program. The reports relate to the program's laboratory and surveillance systems and lead poisoning prevention. The program's board of scientific counselors has a comprehensive review procedure for all NCEH activities to review effectiveness and program progress. Asthma activities have not been evaluated. The HHS Office of Inspector General has not evaluated NCEH activities. One of the cooperative agreement recipients supported an independent program review of their activities under the cooperative agreement to determine strengths and focus program directions. Given the focus and timing of the GAO reports, additional independent and comprehensive evaluations of the impact of agency activities should be supported in the near future. The program further intends to encourage future evaluation from independent external sources.

Evidence: GAO documents include a report on measurement of toxic chemicals (GAO/HEHS-00-80), testimony on pesticide illness reporting systems (GAO-01-501T), a report on lead poisoning and Federal healthcare programs (GAO/HEHS-99-18). Two other reports refer to NCEH activities, but do not evaluate the impact of those efforts (GAO-04-1068T, GAO-04-703). The newly consolidated NCEH/ATSDR Board of Scientific Counselors will perform external peer reviews of ATSDR and NCEH major programs and services. Reviews are planned in 2005 for environmental health services, air pollution and respiratory health, in 2006 for biomonitoring, in 2007 for terrorism preparedness and emergency response and international emergency and refugee health, in 2008 for health studies, and in 2009 for environmental public health tracking and other laboratory based activities. Each program is to be peer reviewed once every five years.

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: The program has made significant progress in this area but has not yet reached an integrated development of the program budget and performance information that meets the standards set out for this question. Resource allocation decisions do not clearly reflect specific performance levels and the anticipated effects of funding changes on results are not clear.

Evidence: Evidence includes the annual budget submission to OMB and the Congress.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The program is taking multiple steps to address weaknesses identified in this section. The program has begun integration of the budget and performance display for annual budget justifications. The program is developing direct and indirect cost estimates for performance measures. The program is incorporating requirements in grants and cooperative agreements to encourage partners to commit to and report on long-term and annual goals and measures. The program is working to implement a new budget and performance process this fiscal year. The program conducts extensive strategic planning efforts to guide program directions, such as the development of a public health response to asthma and development of a strategy for environmental and health tracking. These efforts provide a greater level of program direction and metrics for managing the program. The program has allocated the entire budget across its performance goal areas.

Evidence: Evidence includes the FY 2006 Congressional budget justification; strategic planning documents; and the NCEH/ATSDR Strategic Planning Allocation Report.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: The program has a database that associates goals and measures to budget activities and uses this information at the end of each fiscal year to make funding decisions for the next fiscal year. The program generates internal "ProTrack" reports that contain status information on specific intervention, studies and research efforts. The program's laboratories continually pursue improvements in methods and procedures to expand the reach of assessments using finite samples, resources and equipment.

Evidence: Evidence includes the program's Project Profile [pending], ProTrack printouts, end of year performance reports from the divisions.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: Senior program managers are responsible for cost and schedule outcomes and performance results. Senior executive service managers, such as the director, have performance-based contracts. Program partners are held accountable for cost, schedule and performance results. Non-SES program managers do not yet have performance-based contracts or personnel evaluations that consider program performance. Program divisions identify discrete targets by program area. The program monitors the performance of partners through interim and annual progress reports and program evaluations. The program indicates defunding partners previously for poor performance.

Evidence: Evidence includes the grantee financial reference guide for cooperative agreements; workplans and performance plans for evaluations of the program director and other senior managers with specific performance objectives related to the long-term and annual goals of the program.

Are funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: Funds for the program are obligated in a timely manner and spent for the intended purpose. At the agency level, CDC consolidated budget execution functions in 2004 into a central office that is now charged with quality assurance and data validation for program execution. The agency approves internal reallocations that vary from spend plans; regularly reviews unliquidated obligations; and established a standard operating procedure for spending plan execution to help ensure program funds are obligated consistently with the overall objective of the program and that allotted funds are fully executed in a timely manner. CDC conducted risk assessments to determine whether specific programs were susceptible to improper payments exceeding $10 million and a 2.5 percent error rate and will estimate improper payments. At the agency level, data validation of commitments is used to help identify whether funds are committed for the allotted purpose and done correctly to track with budget and accounting systems.

Evidence: Evidence includes operating procedures of the budget execution branch at CDC, sample data validation reports, the budget execution standard operating procedures, agency procedures for development and submission of annual spending plans, budget execution spending plans and obligation reports for NCHS, CDC's February 2005 submission for risk assessments under the Improper Payments Information Act. The spending plans are to be used to certify and monitor the status of funds at the program and agency level.

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The program's efficiency measure is the ratio of administrative support at the office of the director level compared to the total program budget. The program is reviewing options for a more encompassing efficiency measure for adoption during this assessment cycle. Examples of a more comprehensive efficiency measure include total NCEH FTE or administrative FTE versus total program budget and total salaries and expenses costs for NCEH versus the total NCEH budget. The program does have other procedures in place to achieve efficiencies and cost effectiveness in program execution. Most notably, the program merged administrative functions with ATSDR to improve efficiency and reduce redundancy. This merger has the potential to improve efficiency in program oversight and execution.

Evidence: Evidence includes the annual budget submission to OMB and the Congress; the Federal Register, Vol. 69, No. 1, Jan. 2, 2004 announcing the merger with ATSDR.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The program solicits input and guidance from partners and external stakeholders in developing strategic plans and program reviews. The program's laboratory conducts measurements for other Federal agencies, including programs within CDC, most notably ATSDR, health statistics and chronic disease, the National Institute for Environmental Health Sciences at NIH, and EPA. The program collaborates with the Department of Defense on chemical weapons elimination.

Evidence: Evidence includes GAO/HEHS-00-80, recommendation reports to the Department of Defense on chemical weapons elimination. The program is collaborating with the National Institute for Environmental Health Sciences at NIH on environmental solutions to childhood obesity.

Does the program use strong financial management practices?

Explanation: CDC recently underwent a major effort to bring on the new Unified Financial Management System that is intended to reconcile any remaining weaknesses in this area. The system and CDC's associated process changes are to provide more real time data, streamlined processes, absolute funds control, and improved monitoring. UFMS automated funds control has enabled tracking of commitments, including aged balances, to provide better management information; improved financial planning using commitment data; produced tracking of current data on obligations to date, commitments and balances to provide information on spending actions, trends, plans, and the resulting impact on remaining funds availability; and provided historical data on all commitments, undelivered orders, payables, and payment transactions. Continued success will require positive documentation from independent auditors that indicates the new system has resolved weaknesses. Prior Performance and Accountability Reports noted continued weaknesses with CDC's financial systems, including a material weakness.

Evidence: Evidence includes error reports and other preliminary financial controls data from CDC's initial experience with fully implementing the Unified Financial Management System. CDC also automated reimbursable billings, enhanced year end closing transactions, implemented a new indirect cost methodology, and addressed staff needs. A December 2003 report by the OIG noted the agency had not implemented a system to allocate indirect costs until FY 2003, but found the new system to be a significant improvement for equity and accuracy. The OIG recommends CDC periodically review indirect costing methods. CDC has received five consecutive unqualified opinions. CDC issued 64 duplicate or erroneous payments in FY 2002, or 0.042 percent of all payments and has a 97 percent compliance rate for prompt payments. In November 2000, GAO (GAO-01-40) reported the agency's financial management capacity systems and procedures were insufficiently developed to address the agency's mission and budget growth.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: The program is addressing many of the identified weaknesses in this section. The program is working to develop an efficiency measure. The program has not taken steps to make performance information more widely available to the public. The agency has taken numerous steps to improve the financial management system and oversight of resources. CDC is among the first operating divisions in HHS to implement the Unified Financial Management System. The conversion was a large and ambitious effort that required considerable work in advance of the conversion. The agency is extending the incorporation of performance measures into employee evaluations and work contracts. The agency is also putting considerable effort into setting priorities and reorganizing operations through the Future's Initiative, including to improve CDC's business practices.

Evidence: CDC implemented UFMS in April of 2005. The system is intended to correct the agency's prior weaknesses in financial management. The FY 2003 PAR cites improvements in preparing financial statements. The agency submitted financial statements to the Department ahead of schedule. The Director, Deputy Director, Associate Director for Planning, Budget and Legislation, and the Associate Director for Management and Operations meet regularly to review the status of performance goals, program operations, and other issues to ensure deficiencies are identified and issues are addressed in a timely basis.

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: Applications for cooperative agreements are competitively awarded based on clear criteria. Awards are made based on merit and eligibility. There are few one-year, non-competitive earmarks. The agency establishes an independent review group to evaluate each application against specified criteria. Grantees are typically state and local governments (including territories) and political subdivisions of states such as state universities, colleges and research institutions.

Evidence: Evidence includes grant review procedures from the agency and Federal Register notices of the availability of funds. Approximately 73% of NCEH's budget is distributed through contracts, grants, cooperative agreements and interagency agreements.

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: Technical Project Officers monitor performance and work with grantees to take corrective action as needed. As noted above, technical reviewers provide detailed feedback to agency grantees in performance evaluations that specify recommended actions and areas of needed improvement.

Evidence: Evidence includes examples of interim progress reports and final reports for the childhood lead poisoning prevention program that include impact data and detailed descriptions of program objectives, activities and expenditures; non-competing continuation applications; trip reports from CDC to awardees that describe findings and recommendations; an independent review for one cooperative agreement recipient that was requested by the program and supported by the recipient to refine their strategic approach and improve monitoring and evaluation;

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The agency collects grantee performance information but does not make the information available to the public. Performance information is aggregated at a high level and made public on the agency's website through the GPRA performance reports. The program does provide educational materials, surveillance and laboratory data, and health studies to the public on the internet. Performance information is made available on programs such as laboratory certification and chemical demilitarization.

Evidence: Evidence includes the agency web site (www.cdc.gov) and the 2002 GPRA performance report. Laboratory certification information is also available on the program web site and chemical demilitarization information is available on the Department of the Army's site (Laboratory Certification: www.cdc.gov/labstandards/pdf/crmln/Web_TCCert_US_Report.pdf, www.cdc.gov/labstandards/pdf/crmln/Web_TCCert_International_Report.pdf; Chemical Demilitarization: www.cma.army.mil; Laboratory Quality Standards: www.cdc.gov/labstandards/crmln.htm, www.cdc.gov/labstandards/nsqap.htm).

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: A Small Extent indicates progress on one of the two outcome measures. The program has contributed to significant declines in elevated blood lead levels among the target population of children aged 1-5 years. The program does not yet have data beyond a baseline year to indicate progress on the new long-term outcome measure for reduced hospitalizations from asthma.

Evidence: Evidence includes surveillance data from CDC's National Health and Nutrition Examination Surveys (NHANES) that found the prevalence of elevated blood lead levels declined from 1991--1994 to 1999--2002 by 68% overall and by 64% for children aged 1--5 years. This reduction follows a an even greater reduction from 1976--1980 to 1991--1994 from 77.8% to 4.4% for children aged 1--5 years. According to CDC, the decline in blood lead levels is the result of "coordinated, intensive efforts at the national, state, and local levels beginning with efforts to remove lead from gasoline, food cans, and residential paint products." (CDC MMWR, May 27, 2005 / 54(20);513-516). The 2000 age-adjusted hospitalization rate baseline for full implementation states is 146.95 with 6 of 6 states reporting and for partial implementation states is 118.76 with 16 of 19 states reporting.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The Small Extent indicates progress on one of the annual performance measures. The program does not yet have data on the measure of the capacity of state health departments. The program has made considerable progress in assessing exposure of the US population to multiple environmental chemicals. The program has achieved this progress while using finite samples through continuous improvements in measurement methods and techniques. The program has excelled at ensuring lab quality standards over the years. However, the number of laboratory quality standards maintained in certified or participating laboratories for a variety of tests has varied. In 2004, the program discontinued the quality assurance program for blood lead levels known as the Blood Lead Laboratory Reference System (BLLRS), and relaunched as the Lead and Multielement Proficiency (LAMP) program to improve the overall quality of laboratory measurements for lead, multiple species of mercury, cadmium and numerous other analytes. With the required re-tooling, the number of laboratories certified in FY 2004 (866) was lower than for FY 2003 (1039).

Evidence: The program can measure at least 300 chemicals or their metabolites in human blood or urine. A subset of these chemicals and metabolites are measured in specimens obtained from participants in the National Health and Nutrition Examination Survey (NHANES). The program has expanded its capacity to measure chemicals and their metabolites in the US population through NHANES from 27 to 148 chemicals in three years.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: The large extent is based on efficiency gains realized through an administrative consolidation with ATSDR, subsequent reductions in staffing levels at the office of the director level and limited other savings data. The numerator is the number of FTE in the NCEH/ATSDR office of the director. The denominator is the total program budgets of NCEH and ATSDR. The program is reviewing options for a more encompassing efficiency measure for adoption during this assessment cycle. Examples of a more comprehensive efficiency measure include total NCEH FTE or administrative FTE versus total program budget and total salaries and expenses costs for NCEH versus the total NCEH budget. The program has taken other steps to improve efficiencies, including an administrative consolidation with ATSDR described previously. The program is also reviewing an addition to the efficiency measure that captures a list of smaller cost savings (e.g., document production, administrative costs). The program and agency have achieved other savings.

Evidence: The number of FTE at the office of the director for NCEH/ATSDR declined per $1 million in total program budgets from 0.86 FTE in FY 2003 to 0.67 in FY 2005. During this time, the number of FTE declined at a greater rate than the combined program budgets. The program reduced the number of FTE in the office of the director for NCEH and ATSDR from 197 in FY 2003 to 149 in FY 2005 and a total cost in the office of the director from $32.9 million to $28.3 million. The decline is primarily attributable to retirements and not filling these and additional vacancies. Many remaining FTE allotments were shifted to program activities in the divisions. The program also reduced the cost of the NCEH/ATSDR Board of Scientific Counselors from $225,275 in FY 2004 to $194,000 in FY 2005. At the agency level, CDC has conducted or is conducting A-76 studies for library services, office automation, animal care, laboratory glassware and laundry services, printing, and material management services and is beginning to realize savings in IT administrative staffing levels and total costs.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: There are no other federal programs that share the role of the program and the program's activities cannot be compared directly with other federal, state or private entities. The processes that the program undertakes in select areas, such as laboratory research and surveillance, and select activities may be comparable.

Evidence: While other federal, state, local and international entities conduct similar research and program activities, there is insufficient evidence to draw a full comparison between the activities carried out by CDC's environmental health program and other related programs.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: A Small Extent is given because GAO has released few reports related to the activities of the program that in general highlight accomplishments and progress toward addressing weaknesses. The May 2000 GAO review on a long-term strategy for toxic chemicals found measurements covered fewer chemicals at the time with population samples too small to focus on at-risk populations and recommended a long-term intergovernmental strategy. The report noted that the program focused on compounds known or suspected to cause cancer and has added chemicals as the program grew in size and as the program continuously added new chemical testing methods. States use the program's exposure results for a variety of purposes, including studies and investigations of releases, and many states rely heavily on the program for assistance in this area. In a separate report (GAO/RCED-00-40), GAO noted the program has worked for years on pesticide illness reporting, but that significant gaps exist in both surveillance and research in this area.

Evidence: GAO documents include a report on measurement of toxic chemicals (GAO/HEHS-00-80), testimony on pesticide illness reporting systems (GAO-01-501T), a report on lead poisoning and Federal healthcare programs (GAO/HEHS-99-18). Two other reports refer to NCEH activities, but do not evaluate the impact of those efforts (GAO-04-1068T, GAO-04-703). As noted previously, for the future the newly consolidated NCEH/ATSDR Board of Scientific Counselors will perform external peer reviews of ATSDR and NCEH major programs and services. Independent researchers have cited the leadership and utility of CDC's lipid standardization for measurement in the US and globally (see, e.g., Clinical Chemistry 43: 1306-1310, 1997).