2010 grant county public health potpourri
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Grant-Adams County Medical Society Meeting Monday, October 11 th , 2010 Alexander L. Brzezny, MD, MPH, FAAFP Health Officer Grant County Health District (GCHD). 2010 Grant County Public Health Potpourri. State of the Public’s Health in Grant County. - PowerPoint PPT PresentationTRANSCRIPT
2010 GRANT COUNTY PUBLIC HEALTH POTPOURRI
Grant-Adams County Medical Society MeetingMonday, October 11th, 2010Alexander L. Brzezny, MD, MPH, FAAFPHealth Officer Grant County Health District (GCHD)
TOPICS AND OBJECTIVES State of the Public’s Health in
Grant County. Is our resident’s health better than 2 years
ago? H1N1 2009-2010 Pandemic in
Numbers. Who became infected and where?
2010-2011 Influenza Season. How to diagnose, what to report, what is
new? Pertussis Resurgence in the United
States. Why now, why here, and how to fight it?
GRANT COUNTY STATE OF THE PUBLIC’S HEALTH 2010
http://www.doh.wa.gov/HWS/GHS2007.shtmhttp://www.doh.wa.gov/PHIP/products/phi/indicator.htm\http://www.countyhealthrankings.org http://www.wspha.org/2010HealthChamps
Notifiable Conditions, Grant County, 2010
Chlamyd.
HCV
Salmonel.
Pertussis
Years of healthy life expected at age 20
(2009)
GRANT 46 years(66 years total)
Seattle-KING 55 yearsKITTITAS 54 years (74 years total)
CHELAN -DOUGLAS 51 years(71 years total)
Adult physical activity (2007)
GRANT 58%
SAN JUAN 74%
ADAMS 64%
Adults with diabetes (2008)
GRANT 9% (ADAMS 11%)
KITTITAS 5%Seattle-KING 6%CHELAN-DOUGLAS 7%
Low birth weight rate (per 1,000)
(2009)
GRANT 6/1,000ADAMS 6/1,000
KITTITAS 3/1,000
Teen birth rate (per 1,000)
GRANT 35 /1,000(ADAMS 57 /1,000)
Seattle-KING 10/1,000
Teens overweight
GRANT 32% ADAMS 34%
CHELAN-DOUGLAS 23%
Adult preventive cancer screening -
Colorectal
GRANT 61%
KITTITAS 70%
Adult dental care
GRANT 59%
BENTON FRANKLIN 78%
Food service safety
GRANT 92%
Counties with 100%
Reported child immunizations
GRANT 68% (ADAMS 71%)
SPOKANE 28%
Maternal cigarette smoking
GRANT 10%
SPOKANE 19%
ADAMS 2%
Adults with unmet medical
needs
GRANT 13%
OKANOGAN 19%ADAMS 22%
Teen physical activity
GRANT 50%
Seattle-KING 40%SNOHOMISH 41%YAKIMA 42%
ADAMS 54%
QUIZ QUESTION #1 (U. OF WI) Where does Grant County rank in
health factors and outcomes among WA State counties? A. Top 10% B. Top 30% C. Just about in the middle D. Bottom 30% E. Bottom 10%
Grant County Health Factors (#28 /39)
Grant County Health Factors (#28 /39)
• Health Behaviors: #30 (obesity, smoking, teen birth rate, Chlamydia rate, drinking); #1 San Juan
• Clinical Care: #31 (uninsured, DM2 screening, hospice use, primary care); #1 Sea-King
• Social and economic factors: #27 (HS graduation, income inequality, single-parent, children in poverty); #1 Whitman
• Physical environment: #7 (pollution, healthy foods access; liquor stores density); #1 Garfield
Grant Morbidity & Mortality (#28 /39)
Grant MORBIDITY and MORTALITY
• Mortality: #28 (premature death); #1-#3 Whitman, San Juan, King
• Morbidity: #27 (poor physical or mental health days (DAYS /YEAR), low birth weight, poor health (%)); #1-#3 San Juan, Douglas, Kittitas
QUIZ QUESTION #1 Where does Grant County rank in
health factors and outcomes among WA State counties? A. Top 10% B. Top 30% C. Just about in the middle D. Bottom 30% E. Bottom 10%
BAD NEWS (GRANT COUNTY) Population growth with socioeconomically
challenged in-migration Grant ranks at the bottom 30% for health
in WA Several indicators demonstrate a
persistent lack of improvement: lower life expectancy, less physical activity, higher rates of DM2, high teen overweight, lower preventative services utilization, low birth weight, and alarming teen pregnancy rate.
SOME GOOD NEWS (GRANT COUNTY) Grant Co. residents enjoy open spaces,
low traffic and pollution, proximity to healthy foods and outdoor recreation.
CHILD PROFILE utilization is high. Maternal smoking rate is low and
overall smoking rate is dropping (cost?).
Grant Co. teens are more active than those in most of the state.
Access to healthcare services is good.
PUBLIC HEALTH FUNDING AND STAFFING
2009: Budget ~$2.2mln (final) Staff ~27.0+ FTE
2011 (projected) Budget ~$1.7+mln (in 1999: $1.86mln) Staff ~22.0+ FTE (in 1999: 25.6 FTE) (Grant Co. population in 2000: 74,698) (Grant Co. population in 2010: ~90,000)
GRANT PUBLIC HEALTH, 20052011
2011 1,787,310
2010 1,876,259
2009 2,107,274
2008 2,072,423
2007 1,854,956
2006 1,820,951
2005 1,932,706
050000
100000150000200000250000300000350000400000450000500000550000600000650000
Revenue Sources
Permits Fed Grants State Grants County / CityMvet & McaidFees & Other
2011 & 2010 Budgeted 2009 - 2005 Actual Revenues
Reve
nue
In D
olla
rs
20052011
DRAFT DOCUMENT, GCHD, 10/11/2010
H1N1
GRANT COUNTY AND WASHINGTON STATE 2009-2010 H1N1 PANDEMIC IN NUMBERS
http://www.doh.wa.gov/notify/other/H1N1SummRpt.pdf
QUIZ QUESTION #2 (DOH) Which County in Washington experienced
the second highest severe pan-H1N1 disease rate during 2009-2010 season? Which one the highest?
A. Whatcom County (Bellingham) B. King County (Bellevue) C. Grant County (here) D. Adams County (near here) E. Pend Oreille County (Newport)
20
2009-2010 INFLUENZA A H1N1 VIRUS
A/Mexico/4108/2009 (H1N1)
neuraminidasetype of nuclear material
hemagglutinin
virus type geographicorigin
strain number
year isolated virus subtype
AvianInfluenza viruses
Pandemic H1N1 2009 Pedigree, 1979-2009Eurasian Swine
A/H1N1(1979-present)
Human “seasonal”A/H3N2
(1968-present)
North American SwineA/H1N1
(1918-present)
“Triple reassortant”Swine A/H1N2(1998-present)
2009 HumanA/H1N1
(2009-??)?
Human “seasonal”A/H1N1
(1977-present)
PANDEMIC H1N1 INFLUENZA VIRUS - TIMELINE
April 15 – first U.S. case confirmed by CDC (CA)
April 26 – U.S. Government declares a “public health emergency”
May – CDC provides prototype vaccine virus to manufacturers
June 11 – WHO raises pandemic level to 6 June 19 – H1N1 reported in all 50 states October 6 – first H1N1 vaccine doses
admin’d April 2010 – first confirmed H1N1 death in
Grant
Extrapolation ’08‘09 season
WASHINGTON LABORATORY SURVEILLANCE, 2009-2010
First WaveSecond Wave
NUMBER OF SEVERE H1N1 CASES (WA) (N=1667)
First Wave
Second Wave
?Third Wave
NUMBER OF SEVERE H1N1 (BY WA REGION)
NUMBER AND RATE OF H1N1 (1ST WAVE)
NUMBER AND RATE OF SEVERE 2009 H1N1 BY AGE GROUP, APRIL–AUGUST 2009 (N=188)
8.9
NUMBER AND RATE OF CRITICAL H1N1 BY AGE, APRIL–AUGUST 2009 (N=63); (2ND WAVE)
0.9 0.9
NUMBER AND RATE OF SEVERE FLU A BY AGE, SEPT 2009–APRIL 2010 (N=1479), (2ND WAVE)
NUMBER AND RATE OF CRITICAL INFLUENZA A BY AGE, SEPT 09–APRIL 10 (N=360); (2ND WAVE)
8.2
NUMBER AND RATE OF FATAL FLU A BY AGE GROUP, SEPT 09–APRIL 10 (N=81); (2ND WAVE)
2.32.2
0.2
1.2
NUMBER OF FATAL 2009 H1N1 BY COUNTY, APRIL–AUGUST 2009 (N=17)
NUMBER OF FATAL INFLUENZA A BY COUNTY, SEPTEMBER 2009–APRIL 2010 (N=81)
RATE OF SEVERE 2009 H1N1 BY WA COUNTY, APRIL–AUGUST 2009 (N=188)
RATE OF SEVERE INFLUENZA A BY WA COUNTY, SEPTEMBER 2009–APRIL 2010 (N=1479)
QUIZ QUESTION #2 Which County in Washington experienced the
second highest severe pan-H1N1 disease rate during 2009-2010 season? A. Whatcom County (Bellingham) B. King County (Bellevue) C. Grant County (here) D. Adams County (near here) 2nd
highest E. Pend Oreille County (Newport)
highest
SUMMARY OF THE 2009-2010 H1N1 (I.) Two distinct pandemic waves. Grant County: 1 fatality, 31 severe cases. Grant County severe disease rate: 36 /100,000 WA State: at minimum confirmed 1,650
hospitalizations and deaths in WA were due to this novel influenza virus (4,459 CDC estimate).
Severe disease rate greater in E. Washington (especially 2nd Wave).
Pre-school children: highest hospitalization rate. 5-24 y.o. age group had highest attack rate.
SUMMARY OF THE 2009-2010 H1N1 (II.) Pregnant 8-11x more likely to be
hospitalized and 3-4x more likely to be admitted to an ICU.
Fatal and critical cases treated later than those with less severe disease.
Most hospitalized and fatal cases had an ACIP-recognized high risk medical condition (asthma, chronic lung disease, and diabetes).
Overall, H1N1 less severe than anticipated.
SUMMARY OF THE 2009-2010 H1N1 (III.) 1.4 influenza deaths per 100,000. 24.7 severe influenza cases per 100,000. 5% of severe cases died in the 1st Wave
compared to 9% deaths among the severe cases in the 2nd Wave.
GRANT COUNTY HEALTH DISTRICT Cost: $360,000 (or $4.50 per resident) 70 volunteers augmenting 28 staff (100 individuals) 8,920 vaccines given in 8 weeks (11% population) WSPHA recognized GCHD for “exemplary public
service”.
Estimates of child and adult state-specific seasonal influenza vaccination coverage, 2009-2010
MMWR April 30, 2010 / 59(16);477-484
NUMBER OF PERSONS REPORTING SEASONAL FLU VACCINE (2008-2010); BRFSS
MMWR April 30, 2010 / 59(16);477-484
PRACTICE-CHANGING KNOWLEDGE 20% influenza cases are ASYMPTOMATIC. Surgical face masks decrease transmission. Early treatment improves outcomes. Pregnancy is a major risk factor for influenza. You can get fooled (infected) TWICE with the
same virus during the same season /pandemic.
Emergency declaration proved useful in increasing the number of “public health workers.”
GRANT COUNTY 2010-2011 INFLUENZA SEASON
http://www.phac-aspc.gc.ca/fluwatch/index-eng.phphttp://www.who.int/csr/disease/influenza/influenzanetwork/en/index.html
http://gamapserver.who.int/maplibrary/
QUIZ QUESTION #3 (WHO) So where is the avian H5N1 influenza
now??? A. Mutated into the pandemic H1N1 B. Affecting only birds C. Doing well and infecting humans D. Doing well and infecting humans in
China only E. Already in Washington
SO WHAT HAPPENED TO THE H5N1?
QUIZ QUESTION #3 So where is the “avian” H5N1 influenza
now??? A. Mutated into the pandemic H1N1 B. Affecting only birds C. Doing well and infecting
humans D. Doing well and infecting humans in
China only E. Already in Washington
H1N1, SEASONAL FLU, WHERE ARE THEY? Pandemic influenza A(H1N1) 2009 virus:
Widespread activity in India and New Zealand. Regional outbreaks in Australia, Bangladesh,
Cambodia, Costa Rica, Cuba, Honduras, Laos, Malaysia, Panama, Peru, Singapore and Thailand.
Seasonal flu (non-pandemic H1N1, H3N2, and influenza B): Sporadic H1 was reported only in China and Pakistan. Regional outbreak of H3 in China Local outbreaks of H3 in Mexico and South Africa Regional and local outbreaks of influenza B:
Argentina, China, El Salvador, Australia, France - New Caledonia, South Africa.
US: sporadic activity of H3N2 and influenza B
ILI=INFLUENZA-LIKE ILLNESS
Influenza-like illness (ILI): Fever>100F (37.8C) AND
Cough AND/OR Sore Throat
Many other symptoms Absence of other obviously known cause
ILI VS. SARI (SEVERE RESP. DISTRESS SY)
Causes two respiratory disease syndromes ILI (upper respiratory tract)
Fever (100F) plus cough or sore throat Lots of other symptoms
Severe acute respiratory illness (SARI) ILI + progressive SOB/ tachypnea/ hypoxia
Lower lung involvement ILI or SARI not specific to influenza virus
infections (parainfluenza, coronaviruses [SARS], adenovirus, HMP virus, rhinovirus, RSV)
LABORATORY CRITERIA FOR DIAGNOSIS Influenza virus in respiratory cell culture; RT-PCR testing of respiratory specimens; Immunofluorescent antibody staining (direct or
indirect); Rapid influenza diagnostic testing; Immunohistochemical (IHC) staining for influenza
viral antigens in respiratory tract (autopsy); Four-fold rise in influenza hemagglutination
inhibition (HI) antibody titer in paired acute and convalescent sera.
WHAT IS THE BEST TEST? WELL, THAT DEPENDS…
Viru
s co
ncen
trat
ion
Days from infection
0 4 5 6 7 8 91 2 3
Symptoms onset Detection thresholds
rtPCR
Virus cell culture
Direct fluorescentantibody assays (DFA)
Antigen detect (“RDT /RIT”)
INFLUENZA CONTROL: FOUR NUMBERS + 2 6 (feet of separation) 100 (Fahrenheit) 7 (days of exclusion) 24 (hours w/o fever) Influenza vaccine Surgical face mask+handwashing
INFLUENZA HIGH-RISK INDIVIDUALS Pregnant women, People with asthma and other lung disease, Diabetics, Morbidly obese person, People with blood disorders (sickle cell, etc.) People with compromised immune systems, People with heart disease, stroke or similar, Those with neuromuscular diseases (CP,
etc.), Hemodialysis patients (and other ESRD), Infants, elderly, nursing home residents, Individuals with a recent illness.
2010-2011 INFLUENZA VACCINE 11 trivalent vaccines: A/California/7/2009
(H1N1), A/Perth/16/2009 (H3N2), and B/Brisbane/60/2008
Annual influenza vaccination is recommended for every person in the United States 6 months of age and older (“almost universal”)
MMWR 2010;59 (early release)
SEASONAL INFLUENZA VACCINE IN PREGNANCY
In 2000-2003 a total of 2 million influenza vaccines administered to pregnant women: 20 VAERS reports received (9 injection site reactions; 8 systemic reactions; 3 unrelated miscarriages).
2 studies (N=2,252): no adverse events. Influenza more severe in pregnancy. ACIP: Seasonal Inactivated Influenza
Vaccine (TIV) INDICATED in pregnancy (not LAIV).
IMMEDIATELY REPORTABLE TO GCHD IN 2010-11
(Pediatric) influenza deaths are currently reportable in Washington (death resulting directly or indirectly from a disease clinically compatible and laboratory-proven as influenza).
Suspected and laboratory-confirmed infections with a novel influenza including avian influenza A (H5N1) virus (excluding 2009 H1N1).
Unexplained critical illnesses and deaths in persons <50 years old
Laboratory-confirmed influenza hospitalizations are not legally reportable statewide, HOWEVER, CDC requested.
GRANT COUNTY AND NATION’S HEALTH RESURGENCE OF PERTUSSIS IN UNITED STATES
http://www.cdc.gov/vaccines/vpd-vac/pertussis/default.htmhttp://www.cdph.ca.gov/programs/immunize/Documents/PertussisReport10-6-2010.pdf
http://www.who.int/vaccines-documents/DocsPDF-IBI-e/mod4_e.pdf
QUIZ QUESTION #4 (USMLE) The 3-year-old sister of an infant boy is diagnosed with
pertussis by nasopharyngeal swab. The mother gives a history of being immunized as a child. Which one is correct.
A. Mother has no risk of acquiring the disease because of her immunization status.B. Hyperimmune globulin is effective in protecting the infant.C. Erythromycin should be prescribed to the infant.D. The risk to the infant depends on the immunity of the mother E. The 3-year-old sister should be immediately immunized with an additional dose of pertussis vaccine.
QUIZ QUESTION #4 The 3-year-old sister of an infant boy is diagnosed with
pertussis by nasopharyngeal swab. The mother gives a history of being immunized as a child. Which one is correct.
A. Mother has no risk of acquiring the disease because of her immunization status.B. Hyperimmune globulin is effective in protecting the infant.C. Erythromycin should be prescribed to the infant.D. The risk to the infant depends on the immunity of the mother E. The 3-year-old sister should be immediately immunized with an additional dose of pertussis vaccine.
PERTUSSIS IN GRANT COUNTY 2010 TOTAL CASES: 9 ONE FATALITY (2 week old)
eight (8) laboratory proven cases, one (1) epidemiologically-linked, age 2 w.o.– 60’s y.o.
First case: 8/23/2010; Last case: 9/23/2010 Total suspects: 19 (all culture or PCR or both
NEG) Total contacts: 222 (185 case contacts: of those
58 HEALTHCARE WORKERS, 37 suspect contacts)
CLOSE CONTACTS PEP rate: 100% TOTAL COST: $24,835; staff hours:480 (9/30)
Incidence increasing since the 1990s Cyclical: peaks every 2-5 years as numbers of
susceptible people increase enough to allow sustained transmission; last peak year 2005 with 25,616 U.S. cases, a 45 year high
Adults are vulnerable to pertussis 27% of reported cases are among adults Pertussis immunity wanes 5 to 10 years after DTaP* series
(immunity from disease wanes in 15 years) ONLY 25% of cough illness lasting >2 weeks is pertussis
First pertussis vaccines (Tdap)† for adolescents and adults licensed in 2005; uptake suboptimal
*Diphtheria and tetanus toxoids and acellular pertussis vaccine†Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine
PERTUSSIS: MOST POORLY CONTROLLED VACCINE-PREVENTABLE DISEASE
SYMPTOMS OF INFANT PERTUSSIS Initially infant looks deceptively well:
coryza, no fever, mild cough Leukocytosis with lymphocytosis Apneic episodes Seizures Respiratory distress Pneumonia Adenovirus or RSV co-infection can
confuse picture
“TYPICAL” SYMPTOMS OF PERTUSSIS Three-stage bacterial illness (catarrhal,
paroxysmal and convalescent) that lasts 4-12 weeks
“Typical” symptoms paroxysmal cough lack of fever no systemic illness coryza; no pharyngitis post-tussive vomiting post-tussive whoop absolute lymphocytosis
Adults with pertussis often report feeling as if they’re choking on something, sweating episodes
Adults transmit pertussis to infants Among 264 known source-cases:
Almost 50% were parents, most often mothers 51% were adults >19 years of age
Bisgard KM, et al. Infant pertussis: who was the source? Pediatr Infect Dis J 2004; 23(11):985-989. Wendelboe AM, et al. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J 2007; 26(4):293-299.
PERTUSSIS TRANSMISSION TO INFANTS
PERTUSSIS RESURGENCE SINCE THE 1990S Genetic changes in B. pertussis; greater
virulence? Variable vaccine efficacy (acellular pertussis
vaccines licensed in 1991 for 4th/5th doses; entire series in 1996)
Waning of vaccine-induced immunity and lack of natural booster events
General availability of better laboratory tests Greater awareness of pertussis by clinicians
http://www.doh.wa.gov/PHIP/products/phi/indicator.htm
PERTUSSIS IN CALIFORNIA 1950-2010
PERTUSSIS INCIDENCE BY AGE -- CALIFORNIA, 2010
0
5
10
15
20
25
30
<1 1-6 7-9 10-18 19-64 65+age group
case
s pe
r 10
0,00
0
PERTUSSIS COMPLICATIONS BY AGE*
*Cases reported to CDC 1997-2000 (N=28,187)
0
10
20
30
40
50
60
<1 1-4 5-14 15-24 >25Age group (years)
Rat
e pe
r 100
,000
pop
ulat
ion
PERTUSSIS INCIDENCE BY AGE GROUP (EXCLUDING INFANTS), CALIFORNIA 2005-10-- CALIFORNIA, 2005-2010
0
2
4
6
8
10
12
14
16
2005 2006 2007 2008 2009 2010year
case
s pe
r 10
0,00
0
1-6
7-10
11-18
19-64
65+
All ages
STANDARD TDAP/DTAP RECOMMENDATIONS
DTap for children at 2, 4, 6, & 15‐18 monthswith a booster at 4‐6 years Tdap for adolescents at 11‐17 years Tdap for adults 18‐64 years Tdap for all household contacts &
caregivers ofinfants; especially post‐partum mothers
Tdap should replace one dose of Td
Promote the use of Tdap - particularly in those who have contact with infants Postpartum Tdap policies (standing orders for Tdap
postpartum); encourage ED use of Tdap instead of Td Tdap for grandparents, daycares, caregivers, HCW’s! Work with payers re: Tdap reimbursement
Clinician education Tdap recommendations Pertussis signs and symptoms: if you’re testing,
TREAT Exclude immediately; once antibiotic started for
a minimum of 5 days (7days in HCW’s)!Public education
Vaccination/cocooning Limitation of visits Pertussis signs and symptoms Keep ill people away from infants
PERTUSSIS MITIGATION
ALTERNATIVE MITIGATION VIA VACCINATION (NOT ACIP /CDC)
Tdap workplace requirement:L&D, PEDI, daycares Off-label Tdap use:
>65 years old (very likely to be approved by ACIP late October 2010)
<10 years old (7-9 y.o.; possibly to be endorsed by ACIP with VFC annotation)
Use in pregnancy (not a contraindication, but category C; little to no risk with inactivated vaccine; important in local outbreaks or when working with children /adolescents)
DTaP changes Starting as early as 6 weeks of age, and accelerate Adding another shot at 6 y.o. (not just 4-6 range)
PERTUSSIS: WHO SHOULD BE TESTED? Patients of any age with cough >2
weeks. Patients with respiratory illness of
any duration who are contacts to a pertussis or to persons with prolonged cough illness.
Infants <12 months old with any respiratory symptoms of any duration, even those immunized against pertussis or test positive for RSV.