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HomeMy WebLinkAbout2002- November File Copy • Jefferson County Board of Health Agenda • Minutes November 21, 2002 • • JEFFERSON COUNTY BOARD OF HEALTH Thursday, November 21, 2002 2:30—4:30 PM Main Conference Room Jefferson Health and Human Services AGENDA I. Approval of Agenda II. Approval of Minutes of Meetings of October 17, 2002 III. Public Comments IV. Old Business and Informational Items 1. DTaP Vaccination Requirement Reinstated for School, Preschool, and Childcare Attendance • 2. State Funding Forecasts and Public Health System Impacts—OFM Report and National Trends V. New Business 1. Smallpox Vaccination—Pre-event Immunization of Outbreak Response Teams and Post-event Mass Vaccination Planning for Jefferson County Lisa, Tom 2. Port Townsend Public Water System Update Larry, Tom 3. Environmental Health Policy Issues—Priority Setting Larry 4. Health Dept. vs Health District—a Comparison Jean, Tom VI. Agenda Planning VII. Next Meeting: December 19, 2002, 2:30-4:30 PM Main Conference Room, JHHS • • JEFFERSON COUNTY BOARD OF HEALTH • MINUTES Thursday, October 17, 2002 Board Members: Staff Members: Dan Titterness,Member- County Commissioner District#1 Jean Baldwin,Nursing Services Director Glen Huntingford,Member-County Commissioner District#2 Larry Fay,Environmental Health Director Richard Wojt,Member- County Commissioner District#3 Thomas Locke,MD, Health Officer Geoffrey Masci, Vice Chairman-Port Townsend City Council Jill Buhler,Member-Hospital Commissioner District#2 Sheila Westerman, Chairman- Citizen at Large(Cil) Roberta Frissell,Member- Citizen at Large(County) Vice Chairman Masci called the meeting to order at 2:30 p.m. All Board and Staff members were present, with the exceptions of Chairman Westerman and Commissioner Titterness. There was a quorum. • APPROVAL OF AGENDA • Member Buhler moved to approve the .as agenda presented.p Commissioner Huntingford seconded the motion, which carried by a unanimous vote. APPROVAL OF MINUTES Commissioner Huntingford moved to approve the minutes of September 19, 2002. Commissioner Wojt seconded the motion, which carried by a unanimous vote. PUBLIC COMMENT -None OLD BUSINESS AND INFORMATIONAL ITEMS Status of Meeting Minutes for August 15, 2002: Staff distributed a legal opinion from Deputy Prosecutor David Alvarez in response to the Board's question as to whether an official meeting could be held absent a quorum. Because the August meeting was conducted without a quorum, the"discussion notes" of that gathering would stand as such. To the question whether the Board could begin a meeting •awaiting a quorum to be formed, such a meeting would not be official until a quorum is established. When a quorum is lost, the meeting can continue until such a time as a member calls for a count of the quorum, at which time if a quorum is found to be absent the meeting should end. Dr. Tom Locke said generally, meetings of Boards can continue after a quorum is lost, but they take no further action. HEALTH BOARD MINUTES - October 17, 2002 Page: 2 • NEW BUSINESS Local Health Jurisdiction Reorganization—JHHS Budget History and Forecasts: At the request of Vice Chairman Masci, Jean Baldwin and Dr. Locke briefed the Board on Staff's research into health districts. They noted that the agenda packet included cites from the Revised Code of Washington (RCW) and the Washington Administrative Code (WAC) that distinguish between a health district and health board. Dr. Locke talked about the independent legal authority of the Health Board, which is uniquely different from the tract of other departments who receive their authority by the Board of County Commissioners. While a Health District would remain the fiscal responsibility of the County, its liability would be reduced—47 employees go away, leaving the Health District and the County both with smaller, easier-to-manage governments. Ms. Baldwin talked about the challenges of being tied to County budgeting. A win-win situation for the County would be for a district to receive a finite amount from the County, City, hospital, etc., from which the Department can do the work. With many rural counties in financial crisis an ongoing, stable funding source is needed. Three funding plans are currently before the legislature. Vice Chairman Masci, reasoning that management of the Health District would then become the purview of the Board, asked if the voting requirement of needing at least two County Commissioners would still hold true? Larry Fay noted that under RCW 70.46 the resolution or ordinance establishing the district would create the membership and voting. • Referring to the listed RCWs, Commissioner Huntingford said he does not see what the County would gain from a district except for the release of liability. What types of checks and balances are there other than possibly the Health District saying that they need more money? How are we going to negotiate and what are the state guidelines? Dr. Locke noted that, due to lack of use, those guidelines were eliminated 3-4 years ago as part of regulatory reform aimed at cleaning up the WAC. The reason for repeal was that, in reality, the way that it works is through negotiations between the Health District and the County. Commissioner Huntingford noted there would still need to be a source of funding. Jean Baldwin said that with many additional cuts expected, a district would give the Department the flexibility in delivering health services as well as flexibility to make adjustments such as lending staff to Clallam County. Because the Health Department is unique within the County, it would also be easier for some who interact with the Health Depaitment—such as the Auditor, the Treasurer, etc.—if the Department were an outside contractor. Member Frissell asked what a change such as this would mean to the people who use the services? Jean Baldwin said it shouldn't impact services to clients of Environmental Health or nursing, as it is a governance and budgeting issue. Substance abuse would be different in that the Department would have to contract with the County Commissioners. Vice Chairman Masci asked about the concept of accountability. In a district scenario, a service package • would be presented to the County Commissioners? The district does not have any barriers to contracting for additional services, such as with the City, which could be individually negotiated. Who ultimately would be in charge, the Board of Health or the County Commissioners? Jean Baldwin noted the Board of Health would be in charge of the District. Larry Fay noted that the accountability to deliver public HEALTH BOARD MINUTES - October 17, 2002 Page: 3 • health service would rest directly with the Board of Health and, ultimately, with the County Commissioners because they are the ones with responsibility for ensuring public health delivery systems are in place. As far as the District negotiating a contract with the City for services peculiar to the City, this is something to be investigated. Dr. Locke noted that the Interlocal Agreement Act permits the City to contract for specific public health services with the County or any other Country or Tribe. Member Buhler asked how the Hospital District enters into the picture? Dr. Locke noted that the County's legislative authority—the County Commissioners— sets up Health Districts and defines membership of the Board. So the Commissioners would play a dual role in a district; they could be the entire Health District board or part of a larger body (e.g., the current seven member board). In any case, the budget would be developed within the department, approved by the Board of Health and thus pre- approved already, or at least pre-discussed substantially by three Health Board Members it would then go to the County Commissioners for formal adoption. Jean Baldwin said that Health Districts are not unusual in small counties. One of the other confounders that make us look different from other county departments is that while 20% of the Department's budget is the County general fund, the majority of funding comes from State and federal government and from fees. The goal of getting the Department ongoing funding is to decrease the dependence on local funding and to let the County concentrate on law and justice issues. Vice Chairman Masci noted that if there were a move to a district, the County Commissioners would have to acquiesce to it. He suggested Staff prepare a chart of the advantages and disadvantages to clearly see how the shift could be justified to the public. Commissioner Wojt asked how a district would help save the Health Department from being party to the fact that the County cannot come up with the funds to fulfill its obligations when it balanced the budget? Commissioner Huntingford said the stable funding source, if it happens, would come from the State, but the County would still be a partner. If the County has to reduce budgets, the County's funding may or may not be stable. Dr. Locke agreed that a district structure does not assure stable funding. Health Districts in Washington State are having the same problems as County Departments. The overall problem is the trend toward the downsizing of County governments. Although demand for service is increasing, revenue sources are decreasing. Public health in the State is being dismantled piece by piece and is now in extreme jeopardy. There are some areas of the State that are measurably less safe because of cutbacks in restaurant inspections and drinking water programs. Jean Baldwin noted that the State Department of Health is grappling with whether they now need to go into those Counties. MaryAnn Preece addressed the question of stable funding. A benefit of a district would be the ability to partner with other areas and look to other jurisdictions in the region for sources for financing. It might also be able to partner with Clallam for west end services in order to be more effective and efficient. There are many ways to be more fiscally sound. Jean Baldwin clarified that the Health District would not have any taxing authority. Commissioner Huntingford agreed that a chart might be helpful in comparing the advantages and HEALTH BOARD MINUTES - October 17, 2002 Page: 4 disadvantages of a district. While it sounds appealing to split off the Health Department, he is concerned • about responsibility, accountability and liability. MaryAnn Preece explained that the State Auditor would audit a district separately from Jefferson County. Other County services, such as County Attorney, would have to be negotiated. Larry Fay added that most of the options that would be available to a district could be done through a continued contract with the County paying the same rates as we have now. Jean Baldwin recognized there is a list of details associated with a Health District that will need further consideration and investigation (e.g., employee benefits, liability insurance, etc.). She noted that in many ways the Health Department is already very different from other departments. Vice Chairman Masci asked to better understand whether the cost of transition would be a big obstacle to a changeover? Dr. Locke recommended Staff first outline the pros and cons of a Health District for the Board's review before costing out the reconfiguration. Commissioner Wojt moved to direct Staff to gather more information on Health Districts. Member Buhler seconded the motion, which carried by a unanimous vote. National Smallpox Vaccination Plan: Dr. Locke reported that the County is in the process of developing a smallpox vaccination plan and briefed the Board on the two types of smallpox vaccinations: pre-event and post-event. There is no disagreement that post-event vaccination is essential; typically the vaccine can be effective if people are vaccinated within three to four days after exposure. There is concern, however, about the number of people that should be vaccinated before exposure. He then talked about some of the reactions to the pre-event vaccination where the risks of the vaccine are high enough that only those most at risk for the disease should be vaccinated. This has become a political issue since the White House and Health and Human Services is considering a plan to vaccinate anywhere from 1/2 to 10 million people. What is most worrisome is that people who have been vaccinated can spread the infection to those unvaccinated for a period of up to 19 days. While the population under 30 is the most vulnerable, everyone is susceptible to smallpox. He then talked about those who should not receive the vaccination, such as those with immuno-deficiencies, because of their susceptibility to complications. From a national defense standpoint, it would make strategic sense to have as many people vaccinated as possible,but the issue is the price for this coverage. He noted that any plan would be implemented at the local level by the local Health Depaitment. Vice Chairman Masci asked how quickly a local policy would need to be established? Dr. Locke said it would likely be necessary to be decided in reaction to national policy and guidelines. He believes most of the public health community would support the Advisory Committee on Immunization Practices (ACIP) recommendations, which are that vaccinations at this point should be very limited, with a focus on a plan to vaccinate quickly in response to exposure. It would be hard to justify thousands of deaths in response to a theoretical concern. Asked by Member Buhler about identifying exposure, Dr. Locke said that while people are minimally infectious until the rash appears, the clock starts ticking from the point of exposure. Jean Baldwin talked • about the difficulties of vaccine distribution. She noted staff has gone to trainings about how to get immunization going. Dr. Locke pointed out that the process of vaccinating a population is complicated by the necessity of a detailed screening process. HEALTH BOARD MINUTES - October 17, 2002 Page: 5 • Vice Chairman Masci asked if the Board could receive any information from the ACIP so they could look at who might be considered central personnel such as fire district, emergency room personnel? Mr. Fay noted that JPREP would be receiving a briefing on smallpox from Communicable Disease Coordinator Lisa McKenzie. There was additional discussion of the complications due to vaccinating first responders and the risk of complications from the vaccine. Dr. Locke noted that we live in an era where we believe the risks of vaccines should be close to zero and for this vaccine it is not very close. Newer, safer smallpox vaccines are under development, but would not be available for three to five years. Israel has an ambitious generalized vaccination program and Great Britain has embarked on a healthcare worker vaccination program. Jean Baldwin, noted that smallpox is just one of the possible agents in bio-terrorism preparedness. The Hospital and JPREP did a bio-terrorism surveillance survey last Friday. The Health Department did theirs the week prior. All survey results will be rolled up into a regional evaluation. West Nile Virus Response Planning: Dr. Locke reported that the West Nile Virus has made its appearance in the bird population of Washington State. The two human cases in Washington State were contracted in other states. The speed with which this virus has spread across the United States was greater than expected. Four of the mosquito vectors that are favorable for transmission of this virus are present in Jefferson County. Environmental Health response is doing active bird surveillance. Once it spreads into the bird population, it will start jumping into humans, but only about 1 out of 150 people get sick and of those, 50% would never fully recover and have permanent neurological injury. Commissioner Wojt asked if the symptoms in the majority of those infected are mild, how are they detected. Dr. Locke responded that this is done with antibody testing of a population. The incubation period is a fairly short 7-10 days and the most sensitive test is actually of spinal fluid, which does little good because there is currently no treatment. In the future, West Nile is something that should be vaccine preventable. Jean Baldwin noted that Environmental Health's partners in this issue are local veterinarians. Mr. Fay said that to-date, all results on the many birds tested under the County's bird surveillance have been negative. It is likely that next year Environmental Health will expand its bird surveillance activities to more active surveillance of adult and larval mosquitoes while working to identify and minimize their breeding areas. Noting that some people have already asked about the County's plan for mosquito abatement, he said the County would struggle with differing expectations within the community about environmental protection and the local risk to this disease. The response he has seen across the country has been mostly in the way of public information about minimizing exposure to mosquitoes using insect repellant and reducing breeding areas. While there are known human implications, it is not known how this will impact the bird populations. Public Health Funding Reform: A Progress Report: Dr. Locke reported that all said district reorganization would not solve the central problem currently challenging all counties and all health di districts in the State. Stable, dedicated funding for public health disappeared in the early 1970s and ever since, it has been a scramble from year to year to cobble together funding from a variety of different sources. Public Health appears increasingly ill suited to the current situation where we have a crash national program to rebuild our public health infrastructure with new problems coming all the time. We HEALTH BOARD MINUTES - October 17, 2002 Page: 6 are likely to see the roles of the uninsured and those lacking access to medical care swell as healthcare financing problems get worse, which will then cause different types of health problems. There appear to be serious discussions leading toward action going on in Washington State. Noting that the agenda packet included a resolution from the State Public Health Association describing the various issues, he said a more useful resolution from the State Medical Association recently passed was committing them to supporting our legislative proposals. And that is really where this is going to go. The Washington State Association of Counties (WSAC) and Washington Association of County Officials (WACO) have adopted as their top priority the issue of pushing the legislature to find a dedicated statewide funding source this year. There are three different funding proposals being circulated: additional property tax authority, a combination of"sin" taxes, and a utility tax. While the plan is to bring a proposal to the legislature this year, the legislature will likely try to pass it on as a referendum to the people in the next election rather than act on it. Vice Chairman Masci asked if the Board should pass a resolution for forwarding to WACO, who would be doing this lobbying. Commissioner Huntingford said that in order to speak as one voice, he recommends first getting more information from WSAC and WACO. Member Frissell suggested asking legislators for face-to-face meetings with local boards of health. Jean Baldwin noted that a forum involving Clallam, Grays Harbor, and Jefferson Counties might be a possibility. There was Board support for Staff exploring this idea. Data Steering Committee Update: Jean Baldwin reported that after the last Data Steering Committee meeting, Staff arrived at the "Blueprint for the Future of Assessment and Evaluation"with Community Health as the center. The idea is to create a web page similar in format to the diagram, where citizens can access specific data. Rather than providing links to other sites, Staff would plan to download pieces into this format. Currently, the City is considering how much they might be able to contribute to this website development project, which is now reaching $24K. She explained how the information would be presented in order to provide it in context. She recommended the focus groups, which were discussed after the last meeting, be put on hold until after a prioritization of projects. It is also likely another data steering committee meeting would be needed before focus groups are organized. A hard copy of the data should be available this fall Member Frissell suggested that the web page provide a mechanism for public feedback and ask questions. Member Buhler suggested there be a search function. AGENDA CALENDAR/ ADJOURN November Agenda Items: Health District versus Health Board, Review Summary of Upcoming Environmental Health issues, December Meeting with Legislators. Jean Baldwin noted that Staff also agreed to draft a letter from the Board of Health recommending the Health Department and Hospital offer a breast-feeding in-service. Commissioner Wojt noted that table talk at the Rotary meeting this week was that drug use is prevalent • and openly tolerated among the kids at all three district schools. Jean Baldwin noted that the local schools would be conducting a survey in October. Previous surveys have indicated that Jefferson County has had a higher initiation of drug use and a pretty open acceptance of it, but not significantly more than HEALTH BOARD MINUTES - October 17, 2002 Page: 7 other rural districts. Clinical services employees are hearing that there continues to be a lot of methamphetamine use. She noted that the Department recently received another$100,000 grant to continue education in schools. The meeting adjourned at 4:00 p.m. The next meeting will be held on Thursday, November 21, 2002 at 2:30 p.m. at the Jefferson County Health and Human Services Conference Room. JEFFERSON COUNTY BOARD OF HEALTH (Excused) Sheila Westerman, Chairman Jill Buhler, Member Geoffrey Masci, Vice-Chairman Richard Wojt, Member Glen Huntingford, Member Roberta Frissell, Member (Excused) Dan Titterness, Member • • Board of Health Old Business Agenda Item # IV. , 1 • btaP Vaccination Requirement Reinstated November 21, 2002 • STATS yai VALI �y� boy isss • STATE OF WASHINGTON DEPARTMENT OF HEALTH Olympia, Washington 98504 ?64* RECEIVED OCT 31 2002 October 25, 2002 Jefferson County Dear Partner in Health: The purpose of this letter is to inform you that diphtheria, tetanus, and pertussis (DTaP) vaccine supplies are approaching normal levels, and, therefore, the minimum requirements for school, preschool, and childcare attendance are reinstated as of November 1, 2002. In a letter dated August 5, 2002, you were informed of action taken by the State Board of Health to extend the length of conditional school entry status per Washington Administrative Code in . order to accommodate children who had not received required immunizations. This was done in order to promote a smooth transition back to school and allow parents and providers sufficient time to bring children's immunizations up to date after vaccine supplies were determined to be adequate. As of November 1, 2002, students attending schools, preschool, and childcare programs will have 60 days to receive any vaccines necessary to bring them up-to-date with state immunization requirements. Sending a reminder to parents of children who need vaccine would be appropriate at this time. Children who have not received the required doses of vaccine upon their return from holiday break in January will be out of compliance with school and childcare requirements under Washington Administrative Code. Thank you for your efforts to ensure all children are appropriately immunized. Sincerely, *A„e/A/ ,x.C, Maxine Hayes, MD, MPH State Health Officer 110 41. 18 %ft PATTY MURRAY WASHINGTON COMMITTEES: APPROPRIATIONS BUDGET United eStates senate HEALTH,EDUCATION,LABOR AND PENSIONS VETERANS'AFFAIRS WASHINGTON,DC 20510-4704 September 24, 2002 Ms. Sheila Westerman Chair Jefferson County Board of Health 615 Sheridan St. Port Townsend, Washington 98368-2439 Dear Ms. Westerman: Thank you for contacting me with your concerns about the national shortage in vaccine supplies. It was good to hear from you. As a result of coordinated efforts by the Food and Drug Administration, the Centers for Disease Control and Prevention and vaccine manufacturers, there is currently no national shortage or delays of recommended childhood vaccines. However, as you well know, there is still a backlog of children whose immunization schedule was disrupted. In addition, the manufacture and distribution process is vulnerable. We are only one outbreak away from another crisis. • As a Senator, and a mother, I fully understand the importance of vaccinating our children against harmful diseases and developing new vaccines to treat deadly diseases such as AIDS and tuberculosis. I have been a strong supporter for increased funding to the National Institutes of Health and Centers of Disease Control and Prevention so that they might continue to research and develop vaccines for diseases such as HIV/AIDS, malaria, tuberculosis, anthrax, the West Nile Virus and even against bone loss. As a member of the Labor, Health and Human Services, and Education Appropriations Subcommittee, I have also been working with my colleagues to increase funding to the national vaccine stockpile and to provide the Food and Drug Administration(FDA) increased funding so that the regulatory review process might be expedited for new, promising vaccines. However, increased efforts are needed in order to ensure our nation benefits from an adequate, reliable supply of vaccines. As you probably know, vaccine shortages have become an all too common occurrence. Over the past several years, many factors have contributed to the decline in vaccine supplies. These factors include FDA compliance, shortages of raw materials, and a declining number of vaccine manufacturers. In order to better understand the problem, several of my colleagues and I have participated in several hearings on this issue and supported a recent study by the General Accounting Office (GAO) to determine the causes of increasing vaccine shortages and establish new ways to alleviate them. I anticipate the results of this study and am looking forward to implementing the GAO's recommendations. ETMORE AVENUE 2988 JACKSON FEDERAL BUILDING 601 WEST MAIN AVENUE 903 915 2ND AVENUE THE MARSHALL HOUSE SUI EAST YAKIMA AVENUE EVERETT,WA gg207�107 SUITE 1213 1323 OFEICER's Row SEATTLE,WA 98174-1003 SPOKANE,WA 99201-0613YAKI A, (425)259-6515 (206)553-5545 (509)624-9515 VANCOUVER,797 98661-3856 Y09) 98901-2760 (360)696-7797 453-7462(509) PRINTED ON RECYCLED PAPER e-mail:senator murray@murray.senate.gov Internet:http://murray.senate.gov Senator Kennedy (D-MA), Chairman of the Senate Health, Education, Labor and Pensions (HELP) Committee, of which I am a member, has tentatively planned committee action on • legislation aimed at addressing many of the factors that have contributed to current shortages. This legislation will be based in part on the findings and recommendations of the GAO investigation. In addition, I am proud to be a cosponsor of the Vaccines for the New Millennium Act, S.895. This important piece of legislation would amend the Internal Revenue Code of 1986 to allow an income tax credit against research related to developing vaccines to combat widespread disease and ensure that such vaccines are affordable and widely distributed. Vaccines are important in ensuring the health of our children and may be the only hope in fighting the plague of AIDS in less developed countries. Rest assured, I will continue to support efforts to increase the supply of vaccines and develop new ones. Again, thank you for contacting me with your concerns about this important issue. If I can be of further assistance, please be in touch. Sincerely, 4-7 4"a- Patty Mr ay `4^ United States Senator • PM\jmh • • Board of Health Old Business Agenda Item # IV. , 2 State Funding Forecasts • And Public Health System Impacts November 21 , 2002 • • . p �} .r }� ) tiv \r ��. CD .� �\ } 0 , O \ vbmailCU2 • 0 Almal CD C LL 1.0 O = � \§ 0 ,„»: • ® \ ��/�. 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Ef▪t En- d' ' ,-- M CI ti O c0 1` r d' O r a? 0 N O imar r' E E{3 r r I . (F)- t ^i.�... WO O N ti O V O M N Efl' X^W^, N r Eft E!3 o V"." • � � N M t0 LC) "1:3® ,s., O N M r CNI O toM .... N c3-• „r_ Efl, 6/4- L 1- RS \ E!3 Ef' C,4 N o � T- w t_ o C.) C� CI) ._ w u. ,a V) - W p :1,:ic c5 ch LL. L > L 0 CV E O 0 • L 0 �� z:).) a V/ W L .L C\9 ,`= a r V O s-- a) a) H n •— CD > t2. N0. CCS o. w # Cca C v 0 p t-- E-- (/) C.) AMNews: Oct. 28, 200...: Feds giveth but the states taketh away ... American Medical New Page 1 of 4 • amedn .corn SPECIAL. SECTION g - , 'MITI' WEEK K HEALTH&SCIENCE Public health funding: Feds giveth but the states taketh away Public health officials didn't expect budget cuts after government promises to shore up the system following the World Trade Center and anthrax attacks. By Victoria Stagg Elliott,AMNews staff. Oct. 28, 2002. Additional information Public health departments throughout the country are experiencing an infusion of federal funds for bioterrorism preparedness. But in an unexpected twist, that new money may have made it easier for some • cash-strapped state and local governments to slash their public health budgets. In many cases, the state and local cuts are completely overwhelming the benefit of the federal funds, leaving public health departments in worse shape. For example, in rural Larimer County, Colo., the Dept. of Health and Environment will gain 1.4 positions because of the new bioterrorism funds but will eliminate 15 positions because of state cuts, said Adrienne LeBailly, MD, MPH, the department's director. Her$6 million annual budget will receive $100,000 in federal money but lost $700,000 in state funding. "We're eliminating dollars for public health programs that ... will impact more lives and prevent more deaths and injuries and diseases than will ever happen from bioterrorism in our state," she said. The county will hold a referendum later this year to try to raise money to replace the lost state funds, and, if it passes, the cuts will be reversed. But for the time being, the department has just reduced the family planning and childhood immunization programs. More than 200 women will not have access to birth control. One thousand children will not be able to get immunized at the public clinic. ...\AMNews Oct. 28 2002. Public health funding Feds giveth but the states taketh away ... Amer10/21/02 AMNews: Oct. 28, 200...: Feds giveth but the states taketh away ... American Medical New Page 2 of 4 Public health systems in other areas are hurting as well. In Los Angeles County, officials already have closed 11 health centers and four school • - based clinics this year and are talking about closing two of their six public hospitals. In Illinois' DuPage County, a suburban area west of Chicago, a substance abuse program for women and an abstinence education program for the schools have been chopped. "A lot of our members are reporting that they $1.1 billion in are experiencing cuts. It reflects overall budget grants to state conditions at the state and local level, although and local health it seems anomalous in the face of increased departments federal resources directed to public health," said Patrick Libbey, executive director of the target National Assn. of County and City Health bioterrorism Officials. preparedness. It wasn't supposed to be this way. In January, the U.S. Dept. of Health and Human Services announced $1.1 billion in grants to state and local health departments for bioterrorism preparedness -- money above and beyond what was already granted for other services. President Bush's proposed 2003 budget includes $940 million for state • and local health departments to improve laboratory capacity, epidemiology, disease surveillance, training and communication infrastructure. HHS Secretary Tommy Thompson said the money would rebuild the long-neglected U.S. public health infrastructure so that it could respond to more common public health crises, such as West Nile or influenza, and that local health departments were a vital part of that system. "If we never have another bioterrorism attack, as [Thompson] often says, the silver lining of the 9/11 attacks is that we have the opportunity to build a public health infrastructure second to none," said HHS spokesman Bill Pierce. "Local health departments are critical to this." Lean times drain resources The reasons public health departments are still taking a financial hit are varied, although most are linked to the bleak economy. Tax revenues are down, and nearly every state is struggling with deficits. During lean times, the public health budget is frequently the first in line for the chopping block, but public health officials say this year is worse 411 than others. They say the promised windfall from the federal government has facilitated many states' decisions to cut their funding. ...\AMNews Oct. 28 2002. Public health funding Feds giveth but the states taketh away ... Amer10/21/02 AMNews: Oct. 28, 200...: Feds giveth but the states taketh away ... American Medical New Page 3 of 4 In addition to budget cuts, an increased A weak demand for services is taking a toll on health economy is departments. The weak economy has created a draining state greater need for services as people lose health public health insurance along with their jobs. budgets. "We've done some really good things with the money for bioterrorism preparedness. We've updated our public health lab and bought vaccines," said John Wallace, director of intergovernmental relations at the Los Angeles County Dept. of Health Services. "But at the same time, we have an overwhelming number of uninsured who need to access our system on a daily basis, and there's just no funding stream to support indigent care in this country." The L.A. County health department is looking at an $800 million deficit over the next three years and has an annual budget of$3 billion. It received more than$28 million for bioterrorism response. Public health officials also say the money granted for bioterrorism does not quite cover what they are expected to do with it, and this is creating another strain on the system. "We have bioterrorism activities all the time, but I'm contributing several • times more in staff time than I'm getting in return," said Leland Lewis, executive director of the DuPage County Health Dept. "At my level, I'm not seeing a lot of money. I do see some, but I would've hoped that there would have been more." His department received $300,000 for bioterrorism response from the federal government. He blames his department's struggles on rising costs and a$38 million budget that hasn't increased in years. Despite tough times, officials say they'll cope. They're raising fees and trying to squeeze a little bit more out of what they've got. Public health has traditionally been underfunded, and they're used to working this way. But they warn that the system will not be able to respond to bioterrorism if this continues. "I try to run a pretty lean group here, because I want the taxpayer to feel comfortable that every dollar they're sending us is being used wisely," Lewis said. "We'll get through this. The economy will turn around, and some of the funding we've lost will be restored. But it's a strange time to be cutting funding ... when we're asked to do so much more." And public health officials say this is not what they expected to happen after Sept. 11, 2001, and the ensuing anthrax attacks. "It would have been nice to have the bioterrorism money to enhance the ...\AMNews Oct. 28 2002. Public health funding Feds giveth but the states taketh away ... Amer l 0/21/02 AMNews: Oct. 28, 200...: Feds giveth but the states taketh away ... American Medical New Page 4 of 4 services that we used to have," Dr. LeBailly said. "At this point, I feel like we've been hurt more. I certainly wasn't expecting to have a weaker public health infrastructure than we had before 9/11." • Back to top. _ ADDITIONAL INFORMATION: Federal funding snapshot Amounts that some states and cities have received from the Health and Human Services Dept. for bioterrorism preparedness in 2002: California: $70,779,150 Texas: $59,749,890 New York state: $33,917,260 Michigan: $31,225,867 Illinois: $30,140,755 Los Angeles: $28,250,343 New York City: $26,181,040 Arizona: $18,659,807 Colorado: $16,492,100 Chicago: $12,819,246 Delaware: $7,298,076 Wyoming: $6,540,590 Source: Dept. of Health and Human Services Backto top......_._...................................................... ........_._.............._............................................._.._ ..... Weblink HHS announcement of bioterrorism preparedness grants to states (http://www.hhs.govinews/press/2002pres/20020 1 3 1 b.html) NACCHO, the National Assn. of County and City Health Officials (http://www.naccho.org/) Back to top._____...____.----.__._-- Copyright 2002 American Medical Association.All rights reserved. • ...\AMNews Oct. 28 2002. Public health funding Feds giveth but the states taketh away ... Amer 10/21/02 • Board of Health New Business Agenda Item # V. , 1 � Smallpox Vaccination November 21, 2002 • • 4 Nations Thought To Possess Smallpox Iraq, N. Korea Named, Two Officials Say By Barton Gellman Washington Post Staff Writer Tuesday,November 5,2002;Page A01 A Bush administration intelligence review has concluded that four nations --including Iraq and North Korea--possess covert stocks of the smallpox pathogen, according to two officials who received classified briefings. Records and operations manuals captured this year in Afghanistan and elsewhere, they said, also disclosed that Osama bin Laden devoted money and personnel to pursue smallpox, among other biological weapons. These assessments, though unrelated, have helped drive the U.S. government to the brink of a mass vaccination campaign that would be among the costliest steps, financially and politically, in a year-long effort to safeguard the U.S. homeland. Public health authorities in and out of government project that the vaccine itself; widely administered, could kill more Americans -- 300 is a common estimate, and some are higher-- than any terrorist attack save that of Sept. 11, 2001. It has been left to President Bush to resolve a deadlock among his advisers. Vice President Cheney is said by participants in the debate to be pressing for rapid, universal inoculation, while Health and Human Services Secretary Tommy G. Thompson prefers a voluntary program that would wait at least two years for an improved vaccine. In public, the White House has described its smallpox concerns in only hypothetical terms, and until now the gravity of its assessment has not been known. Bush administration officials did not share their evidence with a panel of outside scientists established to advise them on smallpox. Some officials said the reticence results from unwillingness to compromise intelligence sources. Others cited fear of provoking public demands for action the government is not yet prepared to take. Washington's anxiety about smallpox, and limited intelligence-sharing with friendly governments, have prompted urgent requests from allies in the Middle East -- including Jordan and Kuwait-- for assistance in obtaining vaccine before the outbreak of war with Iraq. The National Security Council's Deputies Committee, a panel of officials just below Cabinet rank, met last Tuesday to weigh the allies'requests. Smallpox, which spreads by respiration and kills roughly one in three of those infected, took hundreds of millions of lives during a recorded history dating to Pharaonic Egypt. The last case was in 1978, and the disease was declared eradicated on May 8, 1980. All but two countries reported by Dec. 9, 1983, that they no longer possessed the virus, but the World Health Organization had no means to verify those reports. Seed cultures are now held officially in only two heavily guarded laboratories, one in Atlanta and the other in Koltsovo, Siberia. The United States renounced germ warfare in 1969 and has undertaken no known offensive program since. An authoritative official said there is "no reason" to believe bin Laden succeeded in obtaining the smallpox pathogen. Bin Laden's efforts are significant chiefly because U.S. policymakers believe he would use it. "Al Qaeda is interested in acquiring biological weapons, to include smallpox," according to a classified intelligence summary prepared for senior officials debating options on the scope of a preventive vaccination campaign. Officials who read the homeland security briefing said bin Laden's organization spent money on the effort, but gave higher priority to other biological and chemical agents. The "top five list" for al Qaeda, one official said, included anthrax, the nerve agent ricin, and botulinum toxin. The U.S. government has known since the early 1990s about Soviet-era smallpox weapons, and collected circumstantial evidence of programs elsewhere. But substantial new reporting has circulated in recent months. "This is not an issue where once every two years we put out an intelligence estimate," one official said. "There's an ongoing requirement to assess the threat. I see reports on this every other week." The CIA now assesses that four nations -- Iraq,North Korea,Russia and, to the surprise of some specialists, France -- have undeclared samples of the smallpox virus. The agency's Weapons Intelligence, Nonproliferation and Arms Control Center (WINPAC) described a sliding scale of confidence in those assessments in a briefing prepared last spring. The briefing circulated among senior homeland security,public health and national security officials. Though the quality of its information varied from "very high" to "medium," one official said the report covered only nations for which "we have good evidence." WINPAC placed Russia in the top category, saying that contrary to diplomatic assurances, Russia retains covert stocks of the virus. The Soviet Union produced smallpox by the ton -- a laborious endeavor, since the standard method is to grow cultures in the lining of chicken eggs. Ken Alibek, who was second in command of"black biology" at Biopreparat before he defected in 1992, said in an interview that he supervised production of the virus in liquid form, suitable for delivery on intercontinental missiles. U.S. officials said they generally accept his account. Iraq and France are assessed to have smallpox with high, but not very high, confidence. U.S. officials said the French program is believed to be defensive in nature, and some of them expressed consternation that its inclusion in the WINPAC report was disclosed to a reporter. It could not be learned whether the Bush administration has objected to, or sought information about, the French program. France is one of five members of the U.N. Security Council with a veto, and it is the linchpin of U.S. diplomatic efforts to establish a legal basis for war with Iraq. Jacques Drucker,who stepped down recently as director of France's National Public • Health Surveillance Center, said his country favors research with live smallpox that is • forbidden under present conventions. France recently opened one of the world's only Biological Containment Level 4 facilities. Drucker said the Jean Merieux Laboratory in Lyon works with viruses that "could be used for bioterrorist purposes," and mentioned hemorrhagic fevers such as ebola, Marburg and lassa. The lab is "equipped for smallpox," he said, but "I would suspect that if there was variola virus left in France it would be on the military laboratory research facilities." Some of the evidence on Iraq emerged from unpublished discoveries of the U.N. Special Commission (UNSCOM), which searched for prohibited weapons after the Persian Gulf War. In 1995, David Kelly, a British inspector, led a team to the maintenance shop of the State Establishment for Medical Appliances on the edge of Baghdad. There he found a freeze drier labeled "smallpox." Two years later, on Oct. 7, 1997,inspector Diane Seaman seized a document on the grounds of the Al Rasheed Military Hospital describing vaccines currently in use for Iraqi troops. Third on the list was smallpox. Confronted with other evidence on pox research, Iraq's chief bioweaponeer, Hazem Ali, told UNSCOM inspectors that he had considered camelpox as a weapon because Iraqis, unlike Americans, spent enough time near camels to be immune. Richard Spertzel, UNSCOM's chief biological inspector, said that explanation was laughable. "Only one person ever died of camelpox," Spertzel said in an interview. Ali was "much too good a scientist to believe the story." On Jan. 14, 1991, the Defense Intelligence Agency said an Iraqi agent described, in • medically accurate terms, military smallpox casualties he said he saw in 1985 or 1986. Two weeks later, the Armed Forces Medical Intelligence Center reported that eight of 69 Iraqi prisoners of war whose blood was tested showed current immunity to smallpox, which had not occurred naturally in Iraq for 20 years. The same prisoners had been inoculated for anthrax, a well-established Iraqi bioweapon. More recently, according to the WINPAC report, a former Soviet scientist told U.S. officials that his country "transferred [smallpox] technology in the early 1990s to Iraq." Northern Iraq suffered one of the last known smallpox epidemics in 1971-72. The WINPAC report assessed that Iraq "retained samples from the 1971 outbreak." The last country on WINPAC's list is North Korea, which the authors wrote "has a longstanding and active biological weapons program." Though assessing that Pyongyang has the smallpox pathogen, WINPAC said its evidence was of"medium" quality. On March 5, 1993, the Russian Foreign Intelligence Service reported that "North Korea is performing applied military-biological research" with "pathogens for malignant anthrax, cholera, bubonic plague and smallpox." Gordon Oehler, then head of WINPAC, told Congress that the Russian report was "not a bad summary." Much more recently, sources said, the United States has obtained reports of ongoing pox research and manufacture of vaccine. • "I've spent a lot of time trying to understand the biological weapons threat," one policymaker said in an interview, "and I have concluded on a very personal basis that there is a small chance that we will have definitive evidence, smoking gun evidence, for countries like North Korea, very closed societies." Confidence about the smallpox evidence varies somewhat among the 14 U.S. intelligence agencies and departments. "The assessment is, they have it," said one official, speaking as he held his own office's written summaries of evidence on North Korea and Iraq. "We don't say 70 percent certainty. We assess that they have it." Officials who agreed that the evidence is not decisive said few differences exist in the ultimate judgment of national security and homeland defense officials. One person who has access to the compartmented intelligence on smallpox offered to "bet my next year's salary" that the four countries named in WINPAC's report have live seed cultures. Bush administration officials with central roles in smallpox policy said the government- commissioned Advisory Committee on Immunization Practices was unequipped for its ostensible role of balancing the risks of vaccination against the risks of a smallpox attack. The committee recommended against a broad vaccination campaign, but many members said they would change their views if they knew a rogue nation possessed the virus. • "They give the scientific assessment of what the risks of vaccination are," a senior administration official said. "They do not have the same amount of information that is circulated around this issue here." Those who disclosed the intelligence assessments described above, speaking on condition of anonymity, were not authorized by the White House to do so. Those assigned to speak for the administration's views, who also declined to be identified, would not discuss intelligence reports. They hewed to their public position, as one of them put it, that "there is a concern with regard to North Korea and Iraq that they may have smallpox." U.S. allies' smallpox fears come in part from U.S. reports and -- especially in Jordan -- from independent intelligence on the Iraqi threat. In an interview, Kuwaiti ambassador Salem Abdullah Jaber Sabah acknowledged that his government asked for vaccine last summer"in readiness for any eventuality." Two U.S. officials called the requests unlikely to be granted. The scarcity of vaccine, and likely repercussions in domestic and coalition politics, permit Bush to do no more, they said, than offer assurances of help if Iraq's neighbors suffer an outbreak. Cheney, who confronted biological threats as defense secretary years ago, was energized about smallpox by a videotape and briefing shortly after Sept. 11, 2001. In a war game called Dark Winter, former senator Sam Nunn played a president who failed to contain a • • fictional smallpox outbreak that began in Oklahoma City. It spread in less than two weeks to 25 states and 15 countries overseas, inflicting "massive civilian casualties." "It's a dramatic briefing," Cheney's chief of staff, I. Lewis Libby, recalled, "but we were well on this road already." Libby said Cheney favors "a forward-leaning position on protecting Americans from this threat," but declined to describe his advice to the president. At Health and Human Services, officials said, Thompson has been influenced by doubts at the Centers for Disease Control and Prevention. "If you look at the vice president's office, they're thinking strategic, not public health," said one debate participant. He cited the swine flu debacle of 1976, when President Gerald Ford had to abandon plans for universal inoculation after people starting dying of the vaccine and others developed Guillain-Barre syndrome, a rare and occasionally fatal paralysis. "If something bad happens, the public is not going to be blaming Dick Cheney, they're going to be blaming Tommy Thompson. And the fact is they're going to be blaming the president. That's why the political people are weighing in, and that's why the decision is still sitting on his desk." Staff researcher Lucy Shackelford contributed to this report. © 2002 The Washington Post Company C' I C'------�-- -r�-`-1---nnnn n 10TH cL---11-__ �r---=---`=--- n------ I _1_4_____ /77.__1_4_ 1 !1_ Tl_�_ 1 _1•C RUPP- ritidk CDC Home Search Health fiapits A-E Public Health Emeigency Preparedness&Response SAFER•HEk THiER•PEOPLE^' Home 1 Search I Contact Us Smallpox Home > In-Depth Information &Resources > Vaccination > ce Summary of October 2002 ACIP Smallpox Vaccination ccination u.s.oer „...., nt Recommendations and Humans Servc»s (Updated October 21, 2002) Agents & Threats CDC asked the ACIP to provide guidance on eight smallpox vaccination implementation issues Biological (Listing) Now joint ACIP-HICPAC recommendations will be forwarded to CDC and DHHS for review and ►Smallpox consideration ►Smallpox Basics Note: see also the June 2002 Draft Supplemental Recommendations of the ACIP on the Use of ►In-Depth Info & Smallpox (Vaccinia) Vaccine Resources ►Diagnosis/ On this page: Evaluation ►Exposure • Background Management • Opportunity to Establish Smallpox Health Care Teams Images • ACIP Recommendations: Summary of the Eight Issues ►Infection Control 1. Smallpox Health Care Teams ►Lab Testing 2. Smallpox Vaccination Site Care Preparation& 3. Administrative Leave for Vaccinated Health Care Workers Planning ►Reference 4. Screening for Atopic Dermatitis as a__.Contraindication for Vaccination Materials 5. Screening for Pregnancy as a Contraindication for Vaccination Surveillance& 6. Screening for HIV Infection as a Contraindication for Vaccination Investigation 7. Simultaneous Administration of Smallpox Vaccine with Other Vaccines ►Training 8. Vaccination of Smallpox Vaccinators Vaccination kalcal (Listing2 ►Rilpprogical Emergencies Background Site Topics In June 2001, the Advisory Committee on Immunization Practices (ACIP) made Preparation & recommendations for the use of smallpox (vaccinia) vaccine to protect persons who work Planning with orthopoxviruses, to prepare for a possible bioterrorism attack, and to respond to an Emergency attack involving smallpox. This recommendation was followed in June 2002 with draft Response ►Lab Information supplemental recommendations that extended the ACIP's smallpox vaccination recommendation to include people designated to respond or care for a suspected or 'Surveillance confirmed case of smallpox. Specifically, the ACIP recommended voluntary vaccination of ►News & Media people serving on what subsequently have been designated as Relations q y ►Training ►Resources/Links 1. "Smallpox Public Health Response Teams" and ►Lab&Health 2. "Smallpox Health Care Teams" Professionals FAQ The June 2002 draft supplemental smallpox vaccine recommendations also clarified and En Espanol expanded the primary strategy for control and containment of smallpox in the event of an ►Pagina Principal outbreak. de Terrorismo Biologic() In September, the Centers for Disease Control and Prevention (CDC) asked the ACIP to Public Inquiries provide additional guidance on eight smallpox vaccination implementation issues, including English (888) 246- the scope and composition of the Smallpox Health Care Teams. The eight issues were: 2675 Espanol (888) 246- 2857 1. types of healthcare workers that should be included in Smallpox Health Care Teams; TTY 6) 874-2646 2. care of the smallpox vaccination site; ESam 11pm 3. need for administrative leave for vaccinated healthcare workers; Sat-Sun 10am-8pm 4. screening for atopic dermatitis as a contraindication for vaccination; EST 5. screening.__for.oreqnancy__asa_..contraindication for smallpox vaccination; Centers for 6. screening for HIV infection as a contraindication for smallpox vaccination; Disease Control and Prevention 7. simultaneous administration of smallpox vaccines with other vaccines; and rn^ " -11 _ 1 C 1600 Clifton Rd. 8. vaccination of smallpox vaccinators. Atlanta, GA 30333 USA (404) 639-3311 The ACIP's recommendations reflect consultation with CDC's Hospital Infection Control FIRSGOV T Practices Advisory Committee (HICPAC) and DHHS's National Vaccine Advisory Committee .o,mrsaft*. a..;..M (NVAC). The ACIP recommendations are being forwarded to HICPAC for their review and • consideration on October 22 and 23, 2002. The Healthcare Infection Control Practices Advisory Committee provides advice and guidance to CDC and DHHS regarding infection control practices and strategies for surveillance, prevention, and control of health care- associated infections (e.g., nosocomial infections), antimicrobial resistance and related events in settings where healthcare is provided (e.g., hospitals, long-term care facilities, and home health agencies). In the coming weeks, the joint ACIP-HICPAC recommendations will be forwarded to CDC and DHHS for their review and consideration. Opportunity to Establish Smallpox Health Care Teams The June 2002 Draft Supplemental Smallpox Recommendations recommended that states should designate initial smallpox isolation care facilities (type C facilities) and these facilities, in turn, should pre-designate individuals who would care for smallpox patients for vaccination. However, further discussions with state health officials and hospital administrators identified problems with this approach. It was problematic to designate type C hospitals since suspected smallpox patients are likely to present at the hospitals and health care facilities which are their usual source of care, and not only at designated hospitals. Therefore, health and bio-terrorism officials indicated it was preferable to offer all acute care hospitals the opportunity to establish Smallpox Health Care Teams. ACIP Recommendations: Summary of the Eight Issues (October 17, 2002) 1. Smallpox Health Care Teams • The ACIP recommends that in the first stages of a pre-event smallpox vaccination each acute care hospital identify a group of healthcare workers who would va ciin ed and trained to provide in-room medical care for the first few smallpox patients requiring hospital admission and to evaluate and manage patients who present to the Emergency Department with suspected smallpox. For the first 7-10 days after patients with smallpox have been identified, this team would be hospital-based and provide care 24 hours a day, using 8-12 hour shifts. Non-essential workers would be restricted from entering into the rooms of patients with smallpox. The ACIP recommends that Smallpox Health Care Teams include: 1. Emergency Room Staff, including both physicians and nurses 2. Intensive Care Unit staff, including physicians, nurses, and in hospitals that care for infants and children, this encompass pediatricians, pediatric intensivists, and pediatric emergency room physicians and nurses 3. General Medical Unit staff, including physicians, internists, pediatricians, obstetricians, and family physicians in institutions where these individuals are the essential providers of primary medical care 4. Medical house staff (i.e., selected medical, pediatric, obstetric, and family physicians) 5. Medical subspecialists, including infectious disease specialists [this may also involve the creation of Regional teams of subspecialists (e.g., local medical consultants with smallpox experience, dermatologists, ophthalmologists, pathologists, surgeons, anesthesiologists in facilities where intensivists are not trained in anesthesia) to deliver consultative services • 6. Infection control professionals (ICPs) 7. Respiratory therapists 8. Radiology technicians 9. Security personnel 10. Housekeeping staff (e.g., those staff involved in maintaining the health care _ Pnvirnnment and rierreacin-n the rick of fomite trancmiccinnl. -ii.---- i - /vr--- ITT.-1_ n_ Tl--- -1•G Overall, each Smallpox Health Care Team might include about 15 emergency room doctors and nurses, 15 intensive care unit doctors and nurses, and a total of 10-15 personnel from the other areas. It is anticipated that the size and composition of a smallpox medical care team will vary according to the individual institutions and their patient populations. Each S hospital should have enough teams to ensure continuity of care. Smallpox vaccination would be voluntary. Clinical laboratory workers are not included in the initial phase of pre-event smallpox vaccination because the quantity of virus likely to be in clinical specimens of blood and body fluids is low. Consistent adherence to standard precautions and ASM/CDC protocols will prevent exposure to virus in clinical specimens. Although it is not recommended that emergency medical technicians (EMTs), as a group, be vaccinated in this first phase, individual hospitals may identify and include hospital-based EMTs (i.e., personnel who would be dispatched to transport patients with suspected smallpox) on their Smallpox Health Care Teams. 2. Smallpox Vaccination Site Care Following smallpox vaccination, the ACIP recommends that health-care workers involved in direct patient care should keep their vaccination sites covered with gauze or a similar absorbent material in order to absorb exudates that would develop. This dressing should, in turn, be covered with a semi-permeable dressing to provide a barrier to vaccinia virus. Use of a semi-permeable dressing alone could cause 1) maceration of the vaccination site and 2) increased prolonged irritation and itching at the site, thereby increasing touching, scratching and contamination of the hands. Products combining an absorbent base with an overlying semi-permeable layer can be used to cover the vaccination site. The vaccination site should be covered during direct patient care until the scab separates. • Vaccinia is generally transmitted by direct person-to-person and close contact (within 6 feet), and infection control precautions should be taken to reduce this likelihood. The most critical measure in preventing inadvertent implantation and contact transmission from the vaccinia vaccination site is thorough hand-hygiene after changing the bandage or after any other contact with the vaccination site. Hospitals should include a site-care component to their smallpox vaccination programs in which designated, vaccinated staff would assess dressings for all vaccinated health-care workers daily (whether involved in direct patient care or in other duties), determine if dressings needed changing, and then change the dressing if indicated. This designated staff would assess the vaccination site for local reactions and for vaccine take. They should also use the opportunity to reinforce messages to vaccinees about the need for meticulous hand-hygiene. Transmission of vaccinia is also a concern in other settings when close personal contact with children or other persons is likely—for example, parenting of infants and young children. In these situations, the vaccination site should be covered with gauze or a similar absorbent material, and a shirt or other clothing should be worn, and careful attention to hand hygiene (hand washing) practiced. 3. Administrative Leave for Vaccinated Health Care Workers With respect to administrative leave for health care workers, the ACIP does not believe that health care workers need to be placed on leave because they received a smallpox vaccination. Administrative leave is not required routinely for newly vaccinated healthcare workers unless they are physically unable to work due to systemic signs and symptoms of illness, extensive skin lesions which cannot be adequately covered, or if they do not adhere to the recommended infection control precautions. It is important to realize that the very • close contact required for transmission of vaccinia to household contacts is unlikely to occur in the healthcare setting. However, it is also recommended that vaccination of Smallpox Health Care Team members be phased in, starting with a small number of hospitals. Within a single institution, it would be prudent to designate a small proportion, e.g. 20-30% of the candidate healthcare worRers,-51--to'e-ni=1- fili6 Tsr"vac8narioh to-atiow Tsutvtio-ns'tb gairir6xr5e`ndr2e in Tact-^ -r vaccination management. The ACIP recognizes that the incidence of adverse events following vaccination of previously vaccinated persons is substantially less than in primary vaccinees, and therefore recommends that when feasible, previously vaccinated health care workers be included in this stage 1 vaccination program. It is also advisable to stagger vaccination of healthcare workers within an individual patient care unit by three weeks in order to minimize . the number of vaccinated individuals who would be on sick leave concurrently in association with systemic effects of the vaccine, which usually occur at days 8-10 after inoculation. 4. Screening for Atopic Dermatitis as a Contraindication for Vaccination Atopic dermatitis, irrespective of disease severity or activity, is a risk factor for developing eczema vaccinatum following smallpox vaccination in either vaccinees or in their close contacts. The majority of providers do not routinely make the distinction between eczema and atopic dermatitis, particularly when describing chronic exfoliative skin conditions in infants and young children. Due to the increased risk for eczema vaccinatum, smallpox (vaccinia) vaccine should not be administered to persons with a history of eczema or atopic dermatitis, irrespective of disease severity or activity. Additionally, persons with household contacts that have a history of eczema or atopic dermatitis, irrespective of disease severity or activity, are not eligible for smallpox (vaccinia) vaccination because of the increased risk that their household contacts may develop eczema vaccinatum. Persons with other acute, chronic, or exfoliative conditions (e.g., burns, impetigo, varicella zoster, herpes, severe acne, or psoriasis) are at higher risk for inadvertent inoculation and should not be vaccinated until the condition resolves. The literature also reports that persons with Darier's disease can develop eczema vaccinatum and therefore should not be vaccinated. To assist providers in identifying persons that should defer smallpox (vaccinia) vaccination, the ACIP offers the following two screening questions: 1) Have you, or a member of your • household ever been diagnosed with eczema or atopic dermatitis—if you answered "yes," you may NOT receive the smallpox (vaccinia) vaccine due to the risk that you or your household contact might develop a severe and potentially life-threatening illness called eczema vaccinatum; and 2) Eczema/atopic dermatitis usually is an itchy red, scaly rash that lasts more than 2 weeks and often comes and goes. If you or a member of your household have ever had a rash like this—you should NOT receive the smallpox (vaccinia) vaccine at this time unless you and a healthcare provider are sure that this rash is not atopic dermatitis or eczema. In cases where the dermatological risk factor or diagnosis is uncertain, some organizations, such as the military or CDC, may elect to develop more precise screening tools. These secondary screening tools should weigh the individual's risk of developing an adverse event with the requirement of occupational readiness through safe smallpox vaccination to ensure national security. 5. Screening for Pregnancy as a Contraindication for Vaccination Fetal vaccinia is a very rare, but serious, complication of smallpox vaccination during pregnancy or shortly before conception. Therefore, vaccinia vaccine should not be administered in a pre-event setting to pregnant women or to women who are trying to become pregnant. Before vaccination, women of child-bearing age should be asked if they are pregnant or intend to become pregnant in the next 4 weeks; women who respond positively should not be vaccinated. In addition, the potential risk to the fetus should be explained and women who are vaccinated counseled not to become pregnant during the 4 weeks after vaccination. Routine pregnancy testing of women of child-bearing age is not recommended. To further reduce the risk of inadvertently vaccinating a woman who is pregnant, at the time of pre-screening, women of child-bearing age should be educated about fetal vaccinia, and abstinence or contraception to reduce the risk of pregnancy before or within four weeks after vaccination. Any woman who thinks she could be pregnant or who wants additional assurance that she is not pregnant should perform a urine pregnancy test with a "first morning" void urine on the day scheduled for vaccination. Such tests could be made available at the pre-screening and vaccination sites to avoid cost or access barriers to rT`r C,"-_-it"'--.. I Cy-' --- --- -r^-`-�----'lnnl A /'STT ( --`11.--'_ `�-------`---- T------- testing. If a pregnant woman is inadvertently vaccinated or if she becomes pregnant within 4 weeks after vaccinia vaccination, she should be counseled regarding the basis of concern for the fetus. However, vaccination during pregnancy should not ordinarily be a reason to terminate • pregnancy. To expand understanding of the risk of fetal vaccinia and to document whether adverse pregnancy outcome may be associated with vaccination, a pregnancy registry should be maintained and any adverse outcomes carefully investigated. 6. Screening for HIV Infection as a Contraindication for Vaccination Persons with HIV infection or AIDS are at increased risk of progressive vaccinia (vaccinia necrosum) following vaccinia vaccination. Therefore, vaccinia vaccine should not be administered to persons with HIV infection or AIDS. Before vaccination, potential vaccinees should be educated about the risk of severe vaccinial complications among persons with HIV infection or other immunosuppressive conditions; persons who think they may have one of these conditions should not be vaccinated. The ACIP does not recommend mandatory HIV testing prior to smallpox vaccination, but recommends that HIV testing should be readily available to all persons considering smallpox vaccination. HIV testing is recommended for persons who have any history of a risk factor for HIV infection and who are not sure of their HIV infection status. Because known risk factors cannot be identified for some persons with HIV infection, anyone who is concerned that they could have HIV infection also should be tested. HIV testing should be available in a confidential or, where permitted by law, anonymous setting with results communicated to the potential vaccinee before the planned date of vaccination. Persons with a positive test result should be told not to present to the vaccination site for immunization. Information about local testing options should be provided to all potential vaccinees, including sites where testing is performed at no cost. • 7. Simultaneous Administration of Smallpox Vaccine with Other Vaccines Vaccinia vaccine may be administered simultaneously with any inactivated vaccine, such as influenza vaccine, to encourage appropriate receipt of all indicated vaccines, e.g., in populations such as health care workers. With the exception of varicella vaccine, vaccinia vaccine may be administered simultaneously with other live virus vaccines. To avoid confusion in ascertaining which vaccine may have caused post-vaccination skin lesions or other adverse events, and facilitate managing such events, varicella vaccine and vaccinia vaccine should only be administered >4 weeks apart. 8. Vaccination of Smallpox Vaccinators In order to minimize the clinical impact of inadvertent inoculation, should it occur, ACIP recommends that persons who will be handling and administering smallpox vaccine in the proposed pre-event smallpox vaccination program be vaccinated. Vaccination of this group will also contribute to preparedness for smallpox response, should a smallpox release occur, with development of a cadre of vaccinated, experienced vaccinators who could immediately be deployed for outbreak response. Home 'Search' Contact Us To�of Page CDC Home I CDC Search I Health Topics A-Z In general, all information presented in these pages and all items available for download are for public use. However, you may encounter some pages that require a login password and ID. If this is the case,you may assume that information • presented and items available for download therein are for your authorized access only and not for redistribution by you unless you are otherwise informed. This page last reviewed November 4, 2002 Privacy Policy I Accessibility • Considerations for Selecting a Smallpox Vaccination Clinic (5 November 2002) Physical Characteristics: • Adequate space for large crowds, under cover and out of the weather. Space enough to contain long lines inside, and able to accommodate the target population with "room to spare." • Ideally, a facility with separate rooms, or room dividers, to accommodate various clinic functions (Reception/greeting, triage/assessment, education, registration, vaccination, post vaccination, administration, and medical emergencies). • Heat and air conditioning to maintain temperatures at controlled room temperatures, which is defined as 68-77 degrees F (20 to 25 degrees C), with brief deviations between 59-86 degrees F (15 to 30 degrees C). • Cold storage (refrigerator) for vaccines at appropriate temperatures. • Adequate restrooms (fixed or portable), water, and electricity. • Readily accessible copier, telephone, and fax. • A loading and storage area for large amounts of supplies. • Proper sanitation and storage capacity for large amounts of biohazardous waste. • Ample parking at or near the site, and accessible to public transportation • Space for landing a helicopter(only if possible). • • Accommodation available for special needs (e.g. wheelchairs). • Security— a site that is secure or can be made so by law enforcement personnel. Other Considerations: • Multiple small sites vs. a few large sites. • Easy public access • Operating hours • Familiar to the public • Commercial & Public options: ❖ Public: • Existing clinics • Schools • Community recreation centers • Firehouses • Armories • Poling places • Colleges and universities • Gymnasiums/fitness centers Commercial: • Existing clinics, hospitals, and pharmacies. • Malls • • Theaters • Gymnasiums/fitness centers Vaccination Clinic Staffing Table (As of 5 November 2002) 4110 Qualification Areas of work 1 2 3 4 5 6 100 200 300 400 500 600 Emergency Manager Incident Commander 1 1 1 1 1 1 Logistic Specialist Logistics Chief/Logistics Staff 1 1 2 2 3 3 Human Resources, Personnel Manager/Officer Human Resource Coordinator 1 1 1 1 1 1 Medical Records Coordinator, Database Coordinator,Clinic Flow Admin/CSR Specialist Lead Monitor, Greeters, Special Needs Leader,Education Function 17 29 41 53 65 77 Leader,Registration Function Leader,Registrars DSHS Certified Interpreter Special Needs Interpreters 20 * * * * * * Data Entry Specialist Data Entry Staff 2 3 4 5 6 7 Information Tech IT/Comm. Support 1 1 2 2 3 3 *Licensed Medical Operations Chief,Triage Function Professional Leader,Vaccination Function Leader 3 3 3 3 3 3 Sick Assessment, Medical • MD,DO,ARNP,PA Counselor, Post Vaccination 4* 8* 12* 16* 20* 24* Educator Q Health Screener,Educator, • Nurses(RN,LPN) Question Desk Educator,Post 8* 16* 24* 32* 40* 48* • Vaccination Educator ©` • Licensed to administer vaccine Vaccination Assistants, Vaccinator 6 12 18 24 30 36 EMT/Paramedic Health Screener0,Medical Aid 4* 6* 8* 10* 14* 16* Health Educator Post Vaccination Educator® 2* 4* 6* 8* 10* 12* First Aid/CPR certified Sick Assessment Assistant 1 1 1 1 1 1 Qualified Counselor(e.g., clergy,crisis or school Mental Health Staff 2 3 4 5 6 7 counselor) Communicable disease Investigator Epidemiologic Contact Staff 1 1 2 2 3 3 Support Personnel Forms Collectors,Clinic Flow Monitors, 6 12 16 20 24 28 Law Enforcement Officer Security Chief, Security staff, Supply Forms Routers, 6 11 15 20 25 30 * See note below that corresponds with note number in"Areas of Work"column. 0 Health Screener can be Nurses,EMTs,or Paramedics. 0 Special Needs Interpreters requirements will vary with the local demographics. 0 Post Vaccination Educators can be MDs, RNs, LPNs, ARNPs, PA' s, or Health Educators Numerical columns refer to the number of vaccination stations and the desired throughput per hour. One vaccination station = one table, one vial of vaccine, two nurses, and one line on each side of the table. 0 r Board of Health New Business Agenda Item # V., 3 • Environmental Health Policy Issues November 21, 2002 • Wil_.. - .' Jefferson County Health eT'Human Services T JI11444 615 SHERIDAN • PORT TOWNSEND,WA 98368 • FAX 360-385-9401 TO: Jefferson County Board of Health FROM: Larry Fay Environmental Health Director DATE: November 12, 2002 RE: EH Policy Issues/Agenda Calendar Environmental Health has a number of policy matters that need to be brought forward for Board consideration over the upcoming months. The purpose of this memo is to provide brief background information and begin discussion of priority and agenda planning. The issues following are presented in no particular order. • Civil Penalties—Uniform Enforcement Procedures • In August the Board saw a draft of the uniform procedures. At this time David Goldsmith is moving this document forward with the goal of creating a standard procedure for all departments under his authority. Therefore, this probably does not warrant Board of Health attention unless the Board feels the need to establish Health Department specific procedures. • Alternative Water Supplies As discussed in September, there is a need to make some key decisions regarding use and standards for alternative water supplies. Between our existing policy for rainwater catchments (modeled on the San Juan policies) and consideration for hauling water and desalination there are good starting points. However, use of alternative water supplies have not been broadly approved across the state. Key decisions for the Board are whether to continue to approve alternative water supplies and if so, under what conditions and with what limitations. • Update of Solid Waste Regulations Department of Ecology is poised to finally adopt WAC 173-350, replacing 173- 304, "Minimum Functional Standards for Solid Waste Facilities". DOE adoption necessitates an update of our rule. Key issues include scope and breadth of our rule (we could simply adopt by reference) and whether to create special standards for biomedical wastes. (The state rule is silent of biomedical wastes). We have one year from the date of the DOE regulation to update ours. • COMMUNITY ENVIRONMENTAL NATURAL DEVELOPMENTAL SUBSTANCE ABUSE HEALTH HEALTH RESOURCES DISABILITIES &PREVENTION 360/385-9400 360/385-9444 360/385-9444 360/385-9400 360/385-9400 • BOH Procedural Rules • Dr. Locke and I discussed this very briefly with the Board earlier this year. Essentially, this rule would establish a standard procedure for actions and hearings with the Health Officer and/or Board. This is envisioned as being a framework for administrative procedure for all Environmental Health ordinances and as such is probably a priority. • Methamphetamine Lab Rules While environmental health involvement with clandestine meth labs has been fairly limited we anticipate an increase in lab response and clean up activities over the next couple of years. State regulations establish response requirements and clean up standards. The state rules do not provide for penalties for violating property postings or failure to clean up contaminated property in a timely manner. • Various Standard Operating Policies Several policies are due for update. By our policies these updates are all reviewed and approved by the Board. These include: o Wet season evaluations o Subdivision procedures (with emphasis on boundary line adjustments) o Environmental health review of building permit applications o Two party wells Key issue: Does the Board want to retain its rule in approving operational policy • or should this be left to management and the Health Officer? Board of Health New Business Agenda Item # V. , 4 Health Dept. vs • Health District A Comparison November 21, 2002 e erso 1 , , � .jf.� n County Health ea'Hum�zn Services • • l J I 1vsk615 SHERIDAN • PORT TOWNSEND WA 98368 • FAX 360-385-9401 November 14, 2002 To: Jefferson County Board of Health From: Tom Locke, MD, MPH, Jefferson County Health Officer Re: The Future of Public Health in Jefferson County: Local Health Jurisdiction Organizational Structure The U.S. health care systems has two distinct components—a medical care system (personal health care) and a public health system (population-based health care). Both are in crisis. The imbalance in funding is remarkable—over 96% of health care dollars go into medical care services, approximately 1% support the public health system. The remainder are used to fund research efforts (primarily involving medical care). The system that finances medical care is predicted to "meltdown"in the next 2-3 years that will affect the economic viability of hospitals,physician practices, and the availability of affordable insurance. No broad-based political consensus exists on what should replace • it. Disparities in access to basic medical care services are a significant factor adversely impacting community health status. A progressive breakdown in the health care financing system will likely worsen these disparities. Funding for essential public health services has steadily declined in most areas of the U.S. over the past quarter century. This decline is largely due to competing funding priorities (education and criminal justice) and the belief that a massive investment in high technology medical care would make public health largely unnecessary. In Washington, state support of public health has generally declined while local support has remained stable or even increased. As Washington faces a worsening economic crisis, these gains are likely to be precipitously reversed with health departments experiencing significant layoffs of core staff and discontinuation of key program services in the next 2 years. In the post-9/11 era, Congress and the public have discovered the lack of preparedness of the nation's weakened public health system to deal with an expanding range of threats. While new federal funding has been appropriated to encourage intensive bioterrorism preparedness planning, its system-wide effects will likely be offset by state and local funding cuts. As with the medical care financing system, the public health funding system has failed to assure an adequate basic level of public health protection. Failures of public health systems have greater potential impacts on community health status than the breakdown of medical care systems. Washington State has a highly decentralized public health system—most of the . responsibility and expertise in public health protection resides at the local health jurisdiction level. Most rural counties in this state have health departments within local government. A few have banded together into multi-county districts (NE Tri Counties, COMMUNITY ENVIRONMENTAL NATURAL DEVELOPMENTAL SUBSTANCE ABUSE HEALTH HEALTH RESOURCES DISABILITIES &PREVENTION 360/385-9400 360/385-9444 360/385-9444 360/385-9400 360/385-9400 • Chelan-Douglas, Benton-Franklin) Others have been organized as single county health districts (Yakima, Spokane, Snohomish, Kitsap) or City-County health districts(Seattle- King, Tacoma-Pierce). All are facing financial crises. After 4 years of deep cuts in state budgets (which largely spared public health programs), the Washington State legislature is poised to cut an additional $2.6 billion from the biennial budget. Few are expecting public health funding to be spared in the next round of cuts. Coupled with major cuts in DSHS program funding, these recession-driven budget reductions could virtually shut down county health departments in many areas of the state. Many public health experts believe the future of public health lies in community-based partnerships, regional cooperative efforts, and a dedicated statewide funding source. Intensive efforts are underway in each of these areas. A fundamental question for local public health policy makers is which local health jurisdiction organizational structure is best prepared to navigate the impending crisis in public health funding—the county health department model or the single/multi-county health district model. As summarized in the attached table, the county health department model is the "default" configuration under Washington state law. Jefferson County has already deviated from this model by exercising its option to expand the membership of the local Board of Health. Formation of a Health District would be an additional exercise in county legislative authority and would allow additional customization of the governance, accountability, liability, and internal processes of the local health jurisdiction. Whether this is a change that would help assure that public health has a future in Jefferson County is a policy decision worthy of considerable thought and discussion. •• • County Health Department County Health District Cost/Benefit Legal Basis Established by RCW Established by County Greater local Legislative Authority control of public health governance model Revenue Source Federal, State, County Federal, State, County, Additional (+ user fees) City (+user fees) funding from City BOH/BOCC Roles BOCC—budget, fees BOH–budget, fees, Simplified employee performance policy, employee Governance BOH—policy, rules, performance, rules, appeals, fees appeals Legal Responsibility County District Reduced County Liability Budget Process County Budget by BOH adopts budget, Transfer of BOCC, BOH in county/city funding responsibility III Advisory Role based on mandates + (Reduced contracts County Workload) Program County oversight of BOH oversight of Consolidated Management Departmental Departmental responsibility Directors, BOH Directors and Health for program Oversight of Health Officer/Delegees management Officer/Delegees Other Services Assigned by BOCC Specific contracts No new costs (Animal Services, within County between County or identified DD, Substance Government State and District Abuse, etc.) Risk Pool WA Counties Risk WA Health Districts Probable Pool Risk Pool additional cost Benefits/Pensions No Change No Change No new costs Public BOCC-Elected BOH-Elected Consolidation Accountability Officials (City/County) + of public BOH-Elected BOCC-appointed accountability (City/County) + members (unless in BOH BOCC-appointed changed in ordinance) members • Board of Health Media Report • November 21, 2002 •