CLINICAL TRIAL PLANNING GRANTS TO GUIDE AND IMPROVE TIMING, INTENSITY,
DURATION AND OUTCOMES OF PEDIATRIC CRITICAL CARE AND REHABILITATION
THERAPEUTIC INTERVENTIONS IN CHILDHOOD CARDIOPULMONARY ARREST
RELEASE DATE: July 26, 2002
RFA: HD-02-026
National Institute of Child Health and Human Development (NICHD)
(http://www.nichd.nih.gov)
LETTER OF INTENT RECEIPT DATE: October 31, 2002
APPLICATION RECEIPT DATE: November 25, 2002
THIS RFA CONTAINS THE FOLLOWING INFORMATION
o Purpose of this RFA
o Research Objectives
o Mechanism of Support
o Funds Available
o Eligible Institutions
o Individuals Eligible to Become Principal Investigators
o Where to Send Inquiries
o Letter of Intent
o Submitting an Application
o Peer Review Process
o Review Criteria
o Receipt and Review Schedule
o Award Criteria
o Required Federal Citations
PURPOSE OF THIS RFA
The purpose of the Clinical Trial Planning Grant is to provide support for
the initial development and organization of an effective research team and
the elements essential for conducting successful clinical trials. The
National Center for Medical Rehabilitation Research (NCMRR) of the National
Institute of Child Health and Human Development (NICHD) wishes to use its
program in pediatric critical care and rehabilitation research (PCCR) to
support clinical trials focused on evaluating the timing, intensity, duration
and outcomes of pediatric critical care and rehabilitation interventions for
childhood cardiopulmonary arrest.
RESEARCH OBJECTIVES
Background
Outcomes after childhood cardiopulmonary arrest remain suboptimal, despite
attempts to standardize rapid intervention and advanced pediatric life
support. Neurodevelopmental devastation after restoration of cardiopulmonary
function is too common. The effects on the family unit of caring for
children after such an occurrence are well known to every pediatric
intensivist, rehabilitation specialist and general pediatrician. Both
profound neurodevelopmental change and persistent vegetative state are
common, enduring, and expensive in terms of financial and social costs to the
larger community, as well as to the family.
In the United States, 16,000 children are estimated to die of unexpected
cardiopulmonary arrest (CPA) each year. Remarkably, overall incidence in
children (survivors and non-survivors) remains somewhat difficult to assess,
although one recent prospective study found an overall annual incidence of
19.7/100,000 children. Although the data set created by the current
literature remains somewhat ambiguous, the current figures assigned to
survival to hospital discharge among children arriving at the hospital in
both cardiac and pulmonary arrest is reported as two to eight percent. Of
survivors of combined cardiac and respiratory arrest, neurological
devastation is likely in a high proportion of children: some studies find
poor functional outcomes in virtually all such survivors. One study of
children discharged from the hospital in a persistent vegetative state showed
that death or only minimal awareness was the uniform outcome in subsequent
years, and substantial costs (greater than $90,000 per year per patient) were
sustained.
The prognosis is better for children who experience a respiratory arrest
alone. A collective review of available studies shows that there is a 75
percent survival to discharge rate among children arriving at the hospital
apneic but with a palpable pulse. The same study showed a much higher
percentage of children with a good neurologic outcome, as compared to those
with both cardiac and pulmonary arrest. In-hospital cardiopulmonary arrest
is also known to carry a better prognosis, but there is considerable
variability in reported outcomes. As the initiation and withdrawal of
resuscitation, critical care and rehabilitative strategies in childhood
cardiopulmonary arrest take place in the context of tragedy, decision making
is exceptionally difficult, and the lack of substantial data and uniformity
of practice standards adds to the agony for patients, families and
practitioners.
The challenge for the health care system is to develop and universally adopt
guidelines to avoid futile resuscitation and to improve the outcomes in
survivors. The emerging discipline of pediatric rehabilitation is providing
interventions for some special needs children that may be beneficial in
promoting improvements in functional areas such as cognition, mobility,
performance of self-care, community and school integration, and
family/caregiver education and support. Important questions, however, remain
regarding the effectiveness of individual treatment strategies, as well as
the organization and intensity of pediatric rehabilitation services that
realistically can be offered.
Similarly, innovative strategies to improve outcomes in the acute setting and
minimize organ damage are needed. Hypothermia, institution of extracorporeal
life support systems, and development of new therapies for the prevention and
treatment of hypoxic-ischemic encephalopathy are a few of the newer
therapeutic avenues under discussion in the literature. The roles of
excitotoxic amino acids, proteolytic enzymes, free radicals, nitric oxide and
leukocyte biology are not precisely understood. The importance of
reperfusion injury after anoxic-ischemic encephalopathy is emerging in the
critical care literature. As injury and cellular repair mechanisms,
especially neuronal apoptosis and necrosis and neuronal stem cell biology,
are better understood, potential avenues for therapeutic interventions are
developed. Such therapeutic strategies may be of different value in immature
vs. mature animals and humans.
The increasing presence of comorbidities in childhood cardiopulmonary arrest
parallels the increased numbers of children with special needs in our
communities. The increasing numbers of children with impaired pulmonary
function, immunologic disability, post-surgical cardiac conduction and
functional limitations, and impaired cognition and mobility, impose
additional complexity. In planning for clinical research addressing
improvement for childhood victims of cardiopulmonary arrest, investigators
should take into account the differences in appropriate strategies for
special needs children, and how comorbidities may influence therapeutic
outcome.
Treatments delivered by rehabilitation specialists can dramatically increase
the quality of life and functional independence for individuals following
devastating illnesses. There is presently inadequate evidence in the
pediatric and rehabilitation literature to substantiate the use of
rehabilitation treatment as effective for minimizing disability in survivors
of cardiopulmonary arrest. These factors underscore the need to determine
efficacious rehabilitation strategies for these disorders. Such evidence is
urgently needed as the population of childhood cardiopulmonary arrest
survivors increases. Central to rehabilitation is the primary goal of
functional independence and return to pre-injury or pre-surgical status.
Where such goals are unrealistic, or adequate data to support realistic goal-
setting is lacking, the choice, timing, intensity and duration of therapeutic
interventions must be subjective, and the influence of socioeconomic
disparities maximal. Although these issues underlie medical rehabilitation
practice, few studies have demonstrated the most appropriate treatment course
to help guide clinical practice in cohorts of cardiopulmonary arrest
survivors.
Similarly, there is a lack of adequate evidence to demonstrate which
components in the resuscitation continuum are most critical in preventing
neurological devastation in childhood arrests. It might be hypothesized that
oxygenation must be restored to pre-arrest levels, but is this to be
prioritized over restoration of circulation or metabolic manipulation
(hypothermia, substrate)? Is enhanced oxygen delivery of benefit in the
child in cardiopulmonary arrest? Some studies suggest that increased oxygen
concentration in the injured brain may exacerbate reperfusion injury via
oxygen radical formation and lipid peroxidation. In a few animal models,
neurologic outcome was less favorable in subjects resuscitated with higher
inspired oxygen concentrations. Inadequate data exist regarding the timing,
intensity, and duration of resuscitation treatment interventions and outcomes
after childhood cardiopulmonary arrest.
For the community of clinical rehabilitation practitioners, the techniques
and therapies to maximize functional ability in cohorts of childhood
cardiopulmonary arrest survivors have not been demonstrated empirically.
Additionally, the data substantiating the time frame of rehabilitation
interventions to maximize outcome is vital to planning for such services.
Due, in part, to the diversity of the needs and goals of the post-arrest
population, there is little agreement among professionals as to treatment
strategies, the efficacy of rehabilitation, or desired or achievable
outcomes. What is the sequence by which different areas of function recover
following arrest, and how can this information be used to design/guide
intervention? Should rehabilitation begin in the pediatric intensive care
unit (PICU)? If so, which interventions can or should be implemented in the
intensive care unit? If rehabilitation intervention is initiated in the PICU
immediately after resuscitation, is outcome enhanced? Is there an optimum
time for aggressive intervention? Is twice-a-day physical therapy more
effective than once-a-day therapy? Is there a point in time when one or the
other is more effective?
The relationship between the choice, timing, intensity and duration of
treatment and subsequent follow up is an issue that pervades all pediatric
critical care and rehabilitation practice. The importance and timeliness of
this topic was highlighted at the NICHD Patient Learning During Medical
Rehabilitation Conference (1998), the NICHD Neonatal Follow-up Conference
(June, 2002), and the NICHD Pediatric Critical Care Research Planning
Conference (May, 2002). The purpose of this initiative is to encourage
studies that evaluate models of providing pediatric critical care and
rehabilitation that consider choice, timing, intensity and duration of
treatment. In addition, current practice has evolved in response to
reimbursement guidelines, rather than clinical evidence. This RFA builds on
the recommendations of these workshops, and encourages clinical research
studies that will establish optimal delivery schedules and the kinds and
amounts of pediatric critical care and rehabilitation services for patients
in different diagnosis groups or categories.
Research Scope
Current constraints on clinical researchers make the complex and time-
consuming process of planning Phase III clinical trials problematic,
especially in the fields of pediatric critical care and rehabilitation where
there is not a well-established clinical research infrastructure. These
planning grants will provide a mechanism for early peer review of the
rationale and design of the potential clinical trial, and provide successful
applicants resources to assist them in the development of detailed clinical
trial study plans and collaborations. It is hoped that these Planning Grants
will help to facilitate the development of clinical trial projects in the
NCMRR pediatric critical care and rehabilitation research (PCCR) program.
The range of activities that may be supported by this Clinical Trial
Planning Grant includes:
1. Development of a detailed experimental design, including: translation of
the clinical question into a statistical hypothesis; determination of the
sample size and duration of the trial; selection of endpoint(s) and data
to be collected; creation of inclusion/exclusion criteria.
2. Development of specific protocols, including: patient selection and
informed consent procedures; randomization and masking procedures; data
collection techniques; treatment administration and dose/quantity
measurements; follow-up and quality control procedures.
3. Development of detailed plans for patient recruitment and retention,
including women and minority individuals, and plans for recruitment outreach.
4. Identification of other personnel necessary to perform the proposed
research, including statisticians, data managers, and study coordinators.
5. Identification of the physical resources necessary to perform the
proposed research, including clinical space and equipment that is
accessible to subjects and researchers with disabilities.
6. Selection of specific methods of data analysis.
7. Evaluation of models of the pediatric critical care and rehabilitation
treatment processes, including: involvement of various professional
disciplines, team approaches and treatment settings, coordination of health
care systems and resources.
MECHANISM OF SUPPORT
This RFA will use the NIH Exploratory/Developmental Research Grant (R21)
award mechanism. As an applicant you will be solely responsible for
planning, directing, and executing the proposed project. This RFA is a one-
time solicitation. The anticipated award date is July 1, 2003.
This RFA uses just-in-time concepts. It also uses the modular budgeting
format (see https://grants.nih.gov/grants/funding/modular/modular.htm).
Specifically, if you are submitting an application with direct costs in each
year of $250,000 or less, use the modular format.
FUNDS AVAILABLE
The NICHD intends to commit approximately $1 million in total costs [Direct
plus Facilities and Administrative (F & A) costs] in FY 2003 to fund four to
six new grants in response to this RFA. An applicant may request a project
period of up to two years and a budget for direct costs of up to $100,000 per
year. Because the nature and scope of the proposed research will vary from
application to application, it is anticipated that the size and duration of
each award will also vary. Although the financial plans of the NICHD provide
support for this program, awards pursuant to this RFA are contingent upon the
availability of funds and the receipt of a sufficient number of meritorious
applications.
ELIGIBLE INSTITUTIONS
You may submit an application if your institution has any of the following
characteristics:
o For-profit or non-profit organizations
o Public or private institutions, such as universities, colleges, hospitals,
and laboratories
o Units of State and local governments
o Eligible agencies of the Federal government
o Domestic or foreign
o Faith-based organizations
INDIVIDUALS ELIGIBLE TO BECOME PRINCIPAL INVESTIGATORS
Any individual with the skills, knowledge, and resources necessary to carry
out the proposed research is invited to work with their institution to
develop an application for support. Individuals from underrepresented racial
and ethnic groups as well as individuals with disabilities are always
encouraged to apply for NIH programs.
WHERE TO SEND INQUIRIES
We encourage inquiries concerning this RFA and welcome the opportunity to
answer questions from potential applicants. Inquiries may fall into three
issues.
o Direct your questions about scientific/research issues to:
Carol E. Nicholson, M.D., M.S.
Program Director, Pediatric Critical Care and Rehabilitation Research
National Center for Medical Rehabilitation Research
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 2A03 MSC 7510
Bethesda, MD 20892-7510
Telephone: (301) 435-6843
Email: nicholca@mail.nih.gov
o Direct your questions about peer review issues to:
Robert H. Stretch, Ph.D.
Director, Division of Scientific Review
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 5B01, MSC 7510
Bethesda, MD 20892-7510
Telephone: (301) 496-1485
FAX: (301) 402-4104
Email: STRETCH@NIH.GOV
o Direct your questions about financial or grants management matters to:
Christopher Myers
Grants Management Branch
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 8A14H, MSC 7510
Bethesda, MD 20892-7510
Telephone: (301) 435-6996
FAX: (301) 480-4783
Email: cm143g@nih.gov
LETTER OF INTENT
Prospective applicants are asked to submit a letter of intent that includes
the following information:
o Descriptive title of the proposed research
o Name, address, and telephone number of the Principal Investigator
o Names of other key personnel
o Participating institutions
o Number and title of this RFA
Although a letter of intent is not required, is not binding, and does not
enter into the review of a subsequent application, the information that it
contains allows NICHD staff to estimate the potential review workload and
plan the review.
The letter of intent is to be sent by the date listed at the beginning of
this document. The letter of intent should be sent to:
Carol E. Nicholson, M.D., M.S.
Program Director, Pediatric Critical Care and Rehabilitation Research
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 2A03 MSC 7510
Bethesda, MD 20892-7510
Telephone: (301) 435-6843
Email: nicholca@mail.nih.gov
SUBMITTING AN APPLICATION
Applications must be prepared using the PHS 398 research grant application
instructions and forms (rev. 5/2001). The PHS 398 is available at
https://grants.nih.gov/grants/funding/phs398/phs398.html in an interactive
format. For further assistance contact GrantsInfo, Telephone (301) 710-0267,
Email: GrantsInfo@nih.gov.
SPECIFIC INSTRUCTIONS FOR MODULAR GRANT APPLICATIONS: Applications
requesting up to $250,000 per year in direct costs must be submitted in a
modular grant format. The modular grant format simplifies the preparation of
the budget in these applications by limiting the level of budgetary detail.
Applicants request direct costs in $25,000 modules. Section C of the
research grant application instructions for the PHS 398 (rev. 5/2001) at
https://grants.nih.gov/grants/funding/phs398/phs398.html includes step-by-step
guidance for preparing modular grants. Additional information on modular
grants is available at
https://grants.nih.gov/grants/funding/modular/modular.htm.
USING THE RFA LABEL: The RFA label available in the PHS 398 (rev. 5/2001)
application form must be affixed to the bottom of the face page of the
application. Type the RFA number on the label. Failure to use this label
could result in delayed processing of the application such that it may not
reach the review committee in time for review. In addition, the RFA title
and number must be typed on line 2 of the face page of the application form
and the YES box must be marked. The RFA label is also available at:
https://grants.nih.gov/grants/funding/phs398/label-bk.pdf.
SENDING AN APPLICATION TO THE NIH: Submit a signed, typewritten original of
the application, including the Checklist, and three signed photocopies, in
one package to:
Center for Scientific Review
National Institutes of Health
6701 Rockledge Drive, Room 1040, MSC 7710
Bethesda, MD 20892-7710
Bethesda, MD 20817 (for express/courier service)
At the time of submission, two additional copies of the application must be
sent to:
Robert H. Stretch, Ph.D.
Director, Division of Scientific Review
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 5B01, MSC 7510
Bethesda, MD 20892-7510
Rockville, MD 20852 (for express/courier service)
APPLICATION PROCESSING: Applications must be received by the application
receipt date listed in the heading of this RFA. If an application is
received after that date, it will be returned to the applicant without
review.
The Center for Scientific Review (CSR) will not accept any application in
response to this RFA that is essentially the same as one currently pending
initial review, unless the applicant withdraws the pending application. The
CSR will not accept any application that is essentially the same as one
already reviewed. This does not preclude the submission of substantial
revisions of applications already reviewed, but such applications must
include an Introduction addressing the previous critique.
PEER REVIEW PROCESS
Upon receipt, applications will be reviewed for completeness by the CSR and
responsiveness by the NICHD. Incomplete and/or nonresponsive applications
will be returned to the applicant without further consideration.
Applications that are complete and responsive to the RFA will be evaluated
for scientific and technical merit by an appropriate peer review group
convened by the NICHD in accordance with the review criteria stated below.
As part of the initial merit review, all applications will:
o Receive a written critique
o Undergo a process in which only those applications deemed to have the
highest scientific merit, generally the top half of the applications under
review, will be discussed and assigned a priority score
o Receive a second level review by the National Advisory Child Health and
Human Development Council.
REVIEW CRITERIA
The goals of NIH-supported research are to advance our understanding of
biological systems, improve the control of disease, and enhance health. In
the written comments, reviewers will be asked to discuss the following
aspects of your application in order to judge the likelihood that the
proposed research will have a substantial impact on the pursuit of the goals
discussed in this request for applications (RFA).
o Scientific and clinical significance of the proposed clinical
intervention, including analysis of the need and potential impact on health
care, comparison with competitive therapies, and relevance of the proposed
clinical trial to outcomes desired by the target patient population;
o Basis or grounding of the project in the relevant literature, including
biological mechanisms and supporting clinical data;
o Qualifications and research experience of the Principal Investigator and,
for multi-center trials, a core of potential center investigators, and a
clear statement of the leadership and proposed organization and committee
structures of the clinical trial;
o The potential of the proposed planning activity to lead to a full-scale
clinical trial, including: (a) adequacy of collaborative linkages, (b)
likelihood of successfully recruiting research participants, (c) the
likelihood of sustaining participant cooperation throughout the trial, and
(d) the capability to standardize data collection and follow-
up procedures.
ADDITIONAL REVIEW CRITERIA: In addition to the above criteria, your
application will also be reviewed with respect to the following:
o PROTECTIONS: The adequacy of the proposed protection for humans, animals,
or the environment, to the extent they may be adversely affected by the
project proposed in the application.
o INCLUSION: The adequacy of plans to include subjects from both genders,
all racial and ethnic groups (and subgroups), and children as appropriate for
the scientific goals of the research. Plans for the recruitment and
retention of subjects will also be evaluated. (See Inclusion Criteria
included in the section on Federal Citations, below)
o BUDGET: The reasonableness of the proposed budget and the requested period
of support in relation to the proposed research.
RECEIPT AND REVIEW SCHEDULE
Letter of Intent Receipt Date: October 31, 2002
Application Receipt Date: November 25, 2002
Peer Review Date: February/March 2003
Council Review: June 2003
Earliest Anticipated Start Date: July 1, 2003
AWARD CRITERIA
Criteria that will be used to make award decisions include:
o Scientific merit (as determined by peer review)
o Availability of funds
o Programmatic priorities.
REQUIRED FEDERAL CITATIONS
MONITORING PLAN AND DATA SAFETY AND MONITORING BOARD: Research components
involving Phase I and II clinical trials must include provisions for
assessment of patient eligibility and status, rigorous data management,
quality assurance, and auditing procedures. In addition, it is NIH policy
that all clinical trials require data and safety monitoring, with the method
and degree of monitoring being commensurate with the risks (NIH Policy for
Data Safety and Monitoring, NIH Guide for Grants and Contracts, June 12,
1998: https://grants.nih.gov/grants/guide/notice-files/not98-084.html).
INCLUSION OF WOMEN AND MINORITIES IN CLINICAL RESEARCH: It is the policy of
the NIH that women and members of minority groups and their sub-populations
must be included in all NIH-supported clinical research projects unless a
clear and compelling justification is provided indicating that inclusion is
inappropriate with respect to the health of the subjects or the purpose of
the research. This policy results from the NIH Revitalization Act of 1993
(Section 492B of Public Law 103-43).
All investigators proposing clinical research should read the AMENDMENT "NIH
Guidelines for Inclusion of Women and Minorities as Subjects in Clinical
Research - Amended, October, 2001," published in the NIH Guide for Grants and
Contracts on October 9, 2001
(https://grants.nih.gov/grants/guide/notice-files/NOT-OD-02-001.html); a complete
copy of the updated Guidelines is available at
https://grants.nih.gov/grants/funding/women_min/guidelines_amended_10_2001.htm.
The amended policy incorporates: the use of an NIH definition of clinical
research; updated racial and ethnic categories in compliance with the new OMB
standards; clarification of language governing NIH-defined Phase III clinical
trials consistent with the new PHS Form 398; and updated roles and
responsibilities of NIH staff and the extramural community. The policy
continues to require for all NIH-defined Phase III clinical trials that: a)
all applications or proposals and/or protocols must provide a description of
plans to conduct analyses, as appropriate, to address differences by
sex/gender and/or racial/ethnic groups, including subgroups if applicable;
and b) investigators must report annual accrual and progress in conducting
analyses, as appropriate, by sex/gender and/or racial/ethnic group
differences.
INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN SUBJECTS:
The NIH maintains a policy that children (i.e., individuals under the age of
21) must be included in all human subjects research, conducted or supported
by the NIH, unless there are scientific and ethical reasons not to include
them. This policy applies to all initial (Type 1) applications submitted for
receipt dates after October 1, 1998.
All investigators proposing research involving human subjects should read the
"NIH Policy and Guidelines" on the inclusion of children as participants in
research involving human subjects that is available at
https://grants.nih.gov/grants/funding/children/children.htm.
REQUIRED EDUCATION ON THE PROTECTION OF HUMAN SUBJECT PARTICIPANTS: NIH
policy requires education on the protection of human subject participants for
all investigators submitting NIH proposals for research involving human
subjects. You will find this policy announcement in the NIH Guide for Grants
and Contracts Announcement, dated June 5, 2000, at
https://grants.nih.gov/grants/guide/notice-files/NOT-OD-00-039.html.
PUBLIC ACCESS TO RESEARCH DATA THROUGH THE FREEDOM OF INFORMATION ACT: The
Office of Management and Budget (OMB) Circular A-110 has been revised to
provide public access to research data through the Freedom of Information Act
(FOIA) under some circumstances. Data that are (1) first produced in a
project that is supported in whole or in part with Federal funds and (2)
cited publicly and officially by a Federal agency in support of an action
that has the force and effect of law (i.e., a regulation) may be accessed
through FOIA. It is important for applicants to understand the basic scope
of this amendment. NIH has provided guidance at
https://grants.nih.gov/grants/policy/a110/a110_guidance_dec1999.htm.
Applicants may wish to place data collected under this RFA in a public
archive, which can provide protections for the data and manage the
distribution for an indefinite period of time. If so, the application should
include a description of the archiving plan in the study design and include
information about this in the budget justification section of the
application. In addition, applicants should think about how to structure
informed consent statements and other human subjects procedures given the
potential for wider use of data collected under this award.
URLs IN NIH GRANT APPLICATIONS OR APPENDICES: All applications and proposals
for NIH funding must be self-contained within specified page limitations.
Unless otherwise specified in an NIH solicitation, Internet addresses (URLs)
should not be used to provide information necessary to the review because
reviewers are under no obligation to view the Internet sites. Furthermore,
we caution reviewers that their anonymity may be compromised when they
directly access an Internet site.
HEALTHY PEOPLE 2010: The Public Health Service (PHS) is committed to
achieving the health promotion and disease prevention objectives of "Healthy
People 2010," a PHS-led national activity for setting priority areas. This
RFA is related to one or more of the priority areas. Potential applicants
may obtain a copy of "Healthy People 2010" at
http://www.health.gov/healthypeople.
AUTHORITY AND REGULATIONS: This program is described in the Catalog of
Federal Domestic Assistance No. 93.929, and is not subject to the
intergovernmental review requirements of Executive Order 12372 or Health
Systems Agency review. Awards are made under authorization of Sections 301
and 405 of the Public Health Service Act as amended (42 USC 241 and 284) and
administered under NIH grants policies described at
https://grants.nih.gov/grants/policy/policy.htm and under Federal Regulations
42 CFR 52 and 45 CFR Parts 74 and 92.
The PHS strongly encourages all grant recipients to provide a smoke-free
workplace and discourage the use of all tobacco products. In addition,
Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in
certain facilities (or in some cases, any portion of a facility) in which
regular or routine education, library, day care, health care, or early
childhood development services are provided to children. This is consistent
with the PHS mission to protect and advance the physical and mental health of
the American people.