HomeMy WebLinkAbout2005-January File Copy
•
Jefferson Count
Board ofileaCth
.agenda
Minutes
. '
..r
r
leAmffi L
January 20, 2005
.
JEFFERSON COUNTY BOARD OF HEALTH
Thursday, January 20, 2005
2:30—4:30 PM
Main Conference Room
Jefferson Health and Human Services
AGENDA
I. Approval of Agenda
H. Election of Chair and Vice-Chair for 2005
III. Approval of Minutes of Meetings of December 16, 2004
IV. Public Comments
V. Old Business and Informational Items
VI. New Business
• 1. 2005 Legislative Session Preview—Key Public Health Issues
2. 2005 Board of Health Workplan—Program Review, Priority Setting,
Rule Development and Emerging Issues
3. Influenza Season—Outbreak Activity,Lessons Learned from Vaccine
Shortage, Policy Implications for the Future
VII. Activity Update
1. Isolation and Quarantine Conference—February 3, 2005, Fort Worden
2. Reproductive Health Continuing Education Conference—January 20,
2005,Jefferson Healthcare Auditorium
VIII. Agenda Planning
IX. Next Scheduled Meeting: February 17, 2005
2:30—4:30 PM
Main Conference Room
Jefferson Health and Human Services
• JEFFERSON COUNTY BOARD OF HEALTH
MINUTES
Thursday, December 16, 2004
Board Members: StaffMembers:
Dan Tittemess, Chairman- County Commissioner District#1 Jean Baldwin, Health &Human Services Director
Glen Huntingeord-County Commissioner District#2 Julia Danskin,Nursing Services Director
Patrick M Rodgers- County Commissioner District#3 Thomas Locke,MD, Health Officer
Geoffrey Masci-Port Townsend City Council
Jill Buhler-Hospital Commissioner District#2 Ex-officio
Sheila Westerman- Citisen at Large(City David Sullivan, PUD #1
Roberta Frissell, Vice Chairman-Citizen at Large(County)
Chairman Tittemess called the meeting to order at 2:40 p.m. in the Health Department Conference
Room. All Board and Staff members were present with the exception of Commissioner Huntingford
and Member Buhler. There was a quorum.
APPROVAL OF AGENDA
Member Masci moved to approve the Agenda as written. The motion was seconded,which
carried by a unanimous vote.
APPROVAL OF MINUTES
Commissioner Rodgers moved to approve the minutes of November 18,2004, as corrected to
reflect Commissioner Huntingford's absence. Member Masci seconded the motion,which
carried by a unanimous vote.
PUBLIC COMMENT-None
OLD BUSINESS AND INFORMATIONAL ITEMS
Nurse Family Partnership: Julia Danskin reviewed that Secretary of the Department of Social and
Health Services(DSHS),Dennis Braddock had provided$25,000 to enable the County to
supplement and extend expiring City and County services through June 2005—half of the amount
requested. Chairman Tittemess was recognized for his special effort on this matter. He commented
that while it is important to maintain the integrity of the Commissioner's office,it is certainly okay
to step outside the protocol. Member Masci said that from talking with the City Council Monday he
• believes it might be possible to get the additional$26K to assist for the remainder of 2005,adding
his hope that the County could also contribute. Julia Danskin indicated that they do not anticipate
HEALTH BOARD MINUTES -December 16,2004 Page: 2 •
financial support from DSHS into the next biennium,but she agreed to follow up with Sheila
McNamara of DSHS.
Hepatitis C Surveillance System: Dr. Locke noted the agenda packet contained a communication
to primary care providers reminding that Hepatitis C is a notifiable condition and requesting their
assistance as the Department tries to determine the prevalence of the disease in this county. He
provided a brief history of Hepatitis C testing,which began in 1992.Noting that the number of cases
among IV drug users is growing, the burden is expected to be mostly that of old infections,which is
thought to have peaked in the U.S. in the late 1980s. Because of the cost and drawbacks of the
available treatments and cures,prevention(diagnosis and needle exchange programs)would be
extremely important in the next 10-20 years. Dr. Locke then described the differences between
Hepatitis A, B, and C. Jean Baldwin mentioned the Department provides the vaccine for Hepatitis
B,which is preventable but not curable. There is also a combination Hepatitis A/B vaccination.
Having signed up for the electronic surveillance system this month,by next month Lisa McKenzie
should be able to run electronic reports on communicable diseases.
NEW BUSINESS
Influenza Update—Vaccine Redistribution,Influenza Activity,Policy Implications: Dr. Tom
Locke talked about recent press coverage of production difficulties. Fortunately,Jefferson County
received its 12-13,000 doses and was able to share its surplus to help cover regional shortages in
Clallam and Kitsap Counties. Aventis' distribution of extra supplies to the critical shortage areas, •
while coming relatively late in the flu season,will be of substantial benefit. Although there remains
a surplus of pediatric vaccine, several jurisdictions are going to broaden their priority list as soon as
next week. Last year, 87 million people were vaccinated; this year 60 million—at best—would be
vaccinated. There continues to be a scramble to redistribute vaccine,but the real issue is how to
address shortages and production problems. There is some feeling that the vaccine should be more
widely used and possibly a requirement for school-age kids. More manufacturers would make
vaccine if they knew they would be able to sell it. Even if the government decided to nationalize the
production of the vaccine, it would take a decade to ramp up to the private sector.
Some discussion of vaccination rates among the at-risk(high priority)populations ensued. Dr.
Locke noted that those most likely to be vaccinated are those 65 and over,In contrast,the rate
among healthcare workers is 34%and it is even lower among children.He stressed that as a
communicable disease prevention tool, a vaccine must reach 80-90%of the population. Of the
approximately 10 known cases in the state,there have been no known associated deaths.
The vaccination rate among the county is currently unknown.Jean Baldwin said the pediatric flu
vaccination has only recently been available for kids and it has only been suggested recently as
disease prevention. When asked if a question about vaccination could be added to BRFSS survey,
Dr. Locke suggested focusing efforts on correcting misinformation and changing the public's
attitudes about vaccines. Providing information about the risks and benefits is an area Public Health
could influence. Jean reported having been approached by the Rotary about partnering to change
perceptions about vaccines, and solicited member input on such a potential project.Jean Baldwin •
agreed to follow up with the Rotary and report back to the Board.
HEALTH BOARD MINUTES -December 16,2004
• Page: 3
Member Westerman acknowledged that exemptions in Port Townsend are historically high,but
added that the concerns center on the dangerous components of past vaccines. People tend to make
this decision solely on the basis of their individual risk and might not realize the risk they are
presenting to those compromised members of the public when they do not immunize their children.
While vaccines are not perfect, in the bigger picture they represent the more responsible path.
There was Board support for a comprehensive education program. The peninsula's Parent Teacher
Associations were thought to present an opportunity for vaccination lectures by Dr. Locke. The goal
would be to target 2005 fall registration.
Public Health Emergency Preparedness and Response(aka Bioterrorism)Workplan 2005:
Jean Baldwin reviewed the contract and deliverables associated with the$25K Public Health Bio-
terrorism work plan. The County is now testing its plan—there will be a discussion between the top
Staff of both the Health Department and Jefferson HealthCare on January 20; in March there would
be a two-day public health"incident."There would also be a training at Fort Worden on February
3rd to explain the legal issues and implications of isolation and quarantine. It will be an explanation
of the legal issues and responsibilities of quarantine and will be attended by Commissioners and
other elected officials from Jefferson, Clallam and Kitsap Counties, as well as the upper level
personnel of their various law enforcement, fire,and health agencies. Dr. Locke noted that the need
for this comprehensive approach is driven by the SARS outbreak. The issue is not only finding a
place for containment but how you feed and monitor them and getting law enforcement to recognize
the statutory responsibility. Jean Baldwin noted that many programs are funded, but not fully
funded,which is the case with this program. Side benefits are collaboration with other counties. Lisa
McKenzie and the regional organizers are doing most of the work to send invitations.
Member Westerman suggested a memorandum of understanding document the effort in time and
training. There was agreement to the need to outline/document the existing authorities. Since he could
not attend, Commissioner Rodgers asked to get information from this training.
ACTIVITY UPDATE/OTHER ANNOUNCEMENTS
Environmental Health Director: Jean Baldwin reported the Department is completing a new job
description and would soon be re-advertising for this position.Given the staffing shortages in
Environmental Health, she is still considering how to cover the gap in the meantime. She would also
be seeking some outside assistance for contract review and analysis.Board of Health assistance
would be sought for reviewing applications and interviewing candidates. There was a brief
discussion about whether the County's internal standards and policies might be exceeding State
standards, although they were thought to have had positive impacts to the County.
Big Brother and Big Sister: This program is funded from a grant the Health Department wrote in
conjunction with the Office of Juvenile Justice. It funds a school mental health person,the Big
Brother and Big Sister program and a little of the work with the Community Network Prevention
Plan. Community members are being sought to serve on the Board.
HEALTH BOARD MINUTES -December 16,2004 Page: 4
•
AGENDA PLANNING/ADJOURN
The meeting was adjourned at 3:40 p.m. The next meeting will be on January 20,2005 at 2:30 p.m.
in the Conference Room of the Jefferson County Health Department.
JEFFERSON COUNTY BOARD OF HEALTH
(Excused Absence)
Dan Tittemess, Chairman Jill Buhler,Member
Roberta Frissell,Vice Chairman Sheila Westerman, Member
(Excused Absence)
Geoffrey Masci, Member Glen Huntingford, Member
Patrick M. Rodgers,Member
•
1110
Board-of 3{eaCth
Netiv Business
Agenda Item # �VI., 1
• 2005 Legislative Session
Preview
January 20, 2005
•
ELL tel -Washington
. a2 State Association of Counties
Legislative Package for 2005
Public Health and Human Services Recommended Position
2003 1 2004 1 2005
Issue/Background Position Position I Recommended
! Position
County Impacts of DSHS Budget Cuts: Significant budget I N/A Support J Support
cuts to the state Department of Social and Health Services !I j
directly impact county-administered programs in both
human services and public health and indirectly impact the
local economy and criminal justice and emergency systems.
We will continue to support efforts to:
I I I
• Minimize reductions in human services funding
across the board of DSHS programs,focusing on
those programs with a direct county impact such as I
mental health,developmental disabilities,and E
chemical dependency and/or those whose reduction { '
will impact other county systems such as criminal
justice and emergency services.
• Reduce state and local duplication,unnecessary
regulatory requirements,and fragmentation of I
service delivery systems.
• • Create new human services programs,
requirements,or enhancements only if sufficient
funding based on local fiscal note estimates is
authorized or other requirements are reduced. 1
( j 1
Closure of Fircrest School:Continue downsizing Fircrest Support Support ( Support
Residential Habilitation Center(RHC)for the ( i
developmentally disabled. Establish trust for savings to be
used in the community including county services such as
employment. _
Financing the Public Mental Health System:The federal N/A iIi Support f Support
government has determined that the state may no longer ! i
pay for services for nonmedicaid clients or nonmedicaid
services. During the 2004 session,the legislature was l
educated on the potential impact of that change and the I [
need to invest additional state only money in mental health
in 2005.
Mental Health Parity:Parity of mental health benefits with Support Support Support
physical health benefits will be re-introduced in 2005. , i
Employment and Day Programs for Persons with Support Support [ Support
Developmental Disabilities:The 2004 budget included$1.3 I
million for employment services.A request for additional
funds will be made in 2005. I J
DRAFT—For Internal Discussion Purposes Only
Page 1 of 3
S:/LSC.'Leg Pkgs120052005 LegPkgs-Hurnan Services.doc
2003 1 2004 2005
Issue/Background Position Position Recommended
Position
Chemical Dependency Residential Treatment N/A
Support
__......_.._..-...__..Support
.._._._.._..___
Reimbursement Rates:The residential rate study has been f; E
completed and DSHS will propose a rate increase in 2005.
Increase Substance Abuse Funding:For 2005,emphasize Support Support Support
treatment on demand for specific populations and renewal '1
of the CJTAP funds.
Participation of All School Districts in 0–3 Programs _ — E
for N/A Support Support
Youngsters with Developmental Disabilities/Delays: Only
about/the state's school districts access funding to support
0-3 programs.
....................................................................................................................._..........................._........................._........_......................................................................................_..............................._...,......._................._...........................................__......._
Washington Medicaid Integration Partnership:Continue Support E Support Support
efforts to delay or terminate the Washington Medicaid
Integration Partnership pilot in Snohomish County as long
as it interferes with the delivery of county human services I I
programs to vulnerable adults and children
Prohibit Smoking in Public Places:Tobacco use is the N/A I Support Support
leading cause of death and chronic disease in Washington. legislatio legislation that
Tobacco caused disease extracts a great cost to society and 1 n that prohibits
to employers in increased illness,reduced productivity,and prohibits smoking in
a large burden on the health care system. Recognition of j smoking indoor public
that lead to prohibition of smoking in office workplaces. in indoor places.
Prohibiting smoking in all indoor public places recognizes public
that second-hand smoke is a health hazard and protecting j places. •
all workers from the effects of second-hand smoke is good
public health policy. Protecting workers is a responsibility j I
of government. The industries affected have indicated that j
if a smoking ban is going to happen,they would prefer that
I {
it be a statewide ban,rather than jurisdiction by jurisdiction
because it provides a more level playing field for affected
businesses.
Public Health Funding:WSAC should pursue additional Support Modified i N/A
funding for public health. j in 2004—
{ see
below
Public Health Funding: WSAC should pursue additional N/A Support Modified for
funding for local public health to respond to emerging and 1 2005–see below
re-emerging public health threats. WSAC should continue
efforts to educate the public about the work of the
governmental public health system __...._._.----._..._.............._._._._._w ____.—_.._._..__...__._._. ._..__..__.__-._.--- _.... .._---._._...__...__.__...
Public Health Funding: WSAC supports continued state N/A N/A Support
funding for public health. WSAC further supports efforts to
secure an adequate,predictable,long-term funding source
E
for.public health-....._.._......_._..._._....._._................._._..........._ _.__.._.. .._....._....... ._........_.._..........._..__._._....._......_............._..................
Restrict Youth Access to Tobacco Support Support Support
•
DRAFT—For Internal Discussion Purposes Only Page 2 of 3
S;ILSC/Leg Pkgs/2005/2005 LegPkgs-Human Services.doc
2003 �2004 2005
IssueBackground I Position j Position Recommended
Position
Nutrition and Fitness: WSAC supports legislation that N/A
promotes children's access to better nutrition and nutrition Support Support
education and fitness and fitness education. WSAC further
supports working with the federal government to draw
attention to federal responsibility and ability to enhance 1
children's access to good nutrition and nutrition education
and fitness and fitness education.
•
•
DRAFT—For Internal Discussion Purposes Only
Page 3 of 3
S:1LSC/Leg Pkgs/2005/2005 LegPkgs-Human Seivices.cioc
znr.4
a
• 4
H4;Itr5
STATE OF WASHINGTON
WASHINGTON STATE BOARD OF HEALTH
1 102 SE Quince Street •PO Box 47990
Olympia, Washington 98504-7990
December 15,2004
TO: Washington State Board of Health Members
FROM: Craig McLaughlin,Board Staff
RE: PREVIEW OF 2005 LEGISLATIVE SESSION
Background and Summary
The purpose of this agenda item is to provide a very preliminary briefing to the Board about the
upcoming legislative session,a full or"long"session that will convene January 10. It is intended to
provide some context for the next agenda item, an initial review and discussion of a document that
would provide a policy framework for legislative relations during session. The Board will be asked
to approve a version of that"sense of the Board"document in January. Staff from the Board and the
Department of Health(DOH)will update the Board on legislative issues throughout the session,and
Board staff will maintain a Web page about bills on which the Board has taken a position.
I have asked Chris Townley,acting director of the DOH Office of Policy,Legislation and
Consistent Relations to join me for this presentation.
This discussion section of document lists issues related to public health and the Board's authority
that are likely to spawn discussion and legislation during the upcoming session. Information
changes quickly before and during session; this document represents the best information available
to Board staff as of December 9. The content of this memo is,of necessity,highly speculative.
Much is still up in the air about this session. In particular,while Dino Rossi is governor-elect,his
lead is only 42 votes and a hand recount is underway. Results of the recount are not likely to be
available before Dec. 23 and court action could follow. Also,Governor Locke's budget is not due
out until next week(the deadline is Dec. 20,although parts of it are likely to be available before
then). We do know that this will be another difficult budget year.The projected shortfall for the
biennium the difference between projected revenue and the projected costs of continuing to
provide the same level of service given anticipated caseload increases—is$1.6 billion.We also
know that the Democrats have a slight majority in both houses of the Legislature. There are six new
members of the Senate, four of whom were previously in the House.There are 19 new members in
the House.Moreover,there are several fresh faces in leadership positions in both houses.For
example, Senator Karen Kaiser will chair the Senate Health&Long-Term Care committee,rather
than Senator Pat Thibaudeau,past chair and the senior Democrat.
Recommended Board Action
110 None.
Washington State Board of Health Members
December 15,2004 •
Page 2 of 5
Discussion
DOH request legislation: Ms.Townley can discuss request legislation and decision packages
proposed by DOH,but there are two items of particular note for the Board's work.
■ DOH has proposed agency request legislation that would amend a law passed in 2003 that
requires DOH to develop a state plan for the management and prevention of hepatitis C. The
plan was delivered to the Legislature in January 2004. The legislation, SSB 5039, said only
federal or private money could be used to develop and implement the plan before 2007. The
DOH request legislation is so DOH potentially could receive state dollars to help implement
the plan before 2007.The Board has already implemented one recommendation of this plan
by adding hepatitis C to the list of conditions that laboratories must report. The Office of
Financial Management has not authorized the proposed legislation.
• The DOH budget request includes a$1.2 million decision package around small on-site
sewage systems(SOSS)that anticipates Board adoption of a new SOSS rule that would
require a written county plans for operation and maintenance.The department is requesting
additional funding to local health jurisdictions(LHJs) serving the 14 marine counties and to
provide to provide technical assistance to all LHJs on rule implementation. The proposal is
an outgrowth of the Priorities of Government(POG)discussion around SOSS. Although it is
not specifically mentioned in the decision package,the POG group envisioned a meeting or
conference,possibly sponsored by the Board,to bring together local planners and public
health officials to discussion possible solutions to OSS problems. It is not known whether .
this will be included in the Governor's budget.
• DOH has proposed,and OFM has approved agency request legislation that would authorize
DOH to use the"specialty clinic fee"created in 1999 to provide critical health services to
children diagnosed with the five new disorders that the Board added to the newborn
screening rule in 2003.RCW 70.83.020 specifies the disorders the fee can be used for and
lists only the disorders that were on the screening panel in 1999.
Public health funding: For the past few years,public health has stressed the need for stable and
secure funding. State funding for public health is down 10 percent over 10 years and county
contributions are dwindling rapidly. Preliminary estimates from the Public Health Improvement
Partnership(PHIP) are that something on the order of an additional$400 million would be needed
for the public health system to achieve 95 percent compliance with the PHIP standards.That would
be an increase of roughly two-thirds over current spending. Given the projected budget shortfall, it
is unlikely that the Legislature would address the gap in a significant way this session. However,
public health and its allies in the Public Health Roundtable(convened by the Washington State
Public Health Association)will be educating lawmakers on the system's funding needs.There may
be efforts to provide some interim relief—the Washington State Association of Counties is
considering a proposal to add about$10 million—and there may be a call of an legislative study,
perhaps by the Joint Audit and Review Committee,to verify the PHIP findings.
Environmental health: There are several environmental health issues that the Legislature is likely
to take up.
• There are expected to be several bills on the regulation of onsite septic systems.The POG
process looked at this issue extensively but at this time no Governor request legislation is
11110
anticipated. Legislation may be introduced by builders,homeowners,or environmental
groups, some of which could seek to either limit or expand the Board's authority.The
Washington State Board of Health Members
December 15,2004
Page 3 of 5
building industry, for example,might seek legislation allowing septic systems on smaller
lots.The environmental community has made OSS one of its top legislative priorities and is
likely to proposed legislation that would incorporate elements of the draft rule into statute
and would strengthen the shellfish protection district statute to require funding under certain
circumstances. There also may be legislation to help fund repairs to onsite systems near
marine shorelines,perhaps through a revolving low-interest loan fund.
• Last session, Senator Jacobsen introduced legislation to require testing of school drinking
water for lead and other contaminants. The bill did not pass but interest in the issue has only
grown in the interim. More comprehensive legislation may be introduced this session.
• The Board regulates the disposal of dead animals under its general authorities related to
sanitation and deceased remains. The Department of Agriculture also regulates the disposal
of deceased farm animals. The Board's rules and Agriculture's rule are not consistent and
concerns were raised after the discovery of a case of"mad cow"in the state a year ago. Last
session,the Legislature requested a report from Agriculture. There may be an effort to
consolidate authority to write rules in this area,most likely with Agriculture.
• The Board has held several discussions on persistent bioaccumulative toxins (PBTs)and
has supported the Department of Ecology's previous efforts to obtain legislative support for
its PBT program. The Board specifically supported Ecology's and DOH's Mercury Action
Plan.Ecology and DOH, at the request of the Governor,have been developing an action
plan for polybrominated diphenyl ether(PBDE),a flame retardant. There is certain to be
• legislation to ban two forms of PBDE,penta-BDE and octo-BDE,but there has been
discussions about whether to ban deca-BDE as well. Its toxicity to humans is not as well
understood. The legislation could come from the Governor or from environmental groups.
Communicable disease: The most likely area where we would see communicable disease
legislation would be around HIV/AIDS. There could also be legislation or budget proposals related
to hepatitis C in addition to the DOH decision package(see above). Vaccine policy may also come
up.
• The successful Thurston County prosecution of a man who knowingly exposed several
women to the HIV virus has received extensive publicity. This may encourage legislation
that affects the Board's rules around"behaviors endangering"and"behaviors presenting
imminent danger to public health."The HIV Collaborative,which the Board co-convened
with DOH, is looking at options so it could respond to any proposed legislation.
• The members of the HIV Collaborative may propose legislation that would allow a health
officer to order that a person or his or her remains be tested for HIV or other bloodborne
infections when a"Good Samaritan"is exposed to bodily fluids at the scene of an accident.
Currently,this is only offered to people exposed during the course of employment(e.g.,
paramedics).
• Several are several vaccine policy issues the Legislature may take up.Legislation may be
introduced to ban state purchase of vaccines containing thimerosal,a preservative that
contains ethylmercury. Thimerosal is not currently used in licensed vaccines regularly
recommended for school-age children(though it may appear in trace amounts). It is used in
. some influenza vaccines. Such legislation was introduce last year but not pursued. Other
jurisdictions have since banned thimerosal. The House Health Care Committee has also
expressed an interest in raising the state's low immunization rate. One way to do this would
Washington State Board of Health Members
December 15,2004
Page 4 of 5
be to make it less easy for parents to exempt their children from school-entry requirements.
There also could be efforts aimed at requiring school and child care children to be
immunized against varicella(chickenpox),to cover or require combination vaccines, and
even to revisit the state's universal distribution policy.
Physical activity and nutrition: Last session saw several bills related to physical activity and
nutrition in school. The one that passed, SB 5436,required the Washington State School Director's
Association to take the lead in developing a model policy.The Board participated in this process.
By August,districts must adopt their own policies.There are likely to be efforts to build on SB
5436 this session, as well as other efforts to address the obesity epidemic.
• There may be efforts to establish specific minimum standards for the district physical
activity and nutrition policies required by SB 5436.
• A bill introduced last year by Senator Rosa Franklin would have required that physical
activity issues be considered when doing land use planning,including community
development and transportation planning.It would have given the Board broad authority to
write rules around physical activity and nutrition. Senator Franklin is expected to
reintroduce a form of that bill.
• DOH,Action for Health Kids,the American Heart Association of Washington, and the
Washington Cancer Society have convened a leadership group on nutrition and physical
activity. The group will attempt to prioritizing possible long-term interventions,but it is also
exploring whether the participants might be able to reach consensus on legislative priorities
for this session. I am representing the Board on this group.
Access to care: Governor Locke has stated that perhaps 40,000 low-income adults could lose
coverage under the Basic Health Plan unless the state enacts a tax increase. This has heightened
concerns about access to care.
• Budget legislation will determine levels of coverage under state-run insurance programs,
namely Medical Assistance(including SCHIP) and Basic Health. Locke may suggest cuts
that reduce the number of Basic Health enrollees to 60,000 down from 135,000 two years
ago.
• The budget legislation will determine not only who gets coverage but how much coverage
they receive and under what terms.The 2003-05 budget required premium shares and
copayments for some enrollees,and required re-certification every six months. The
Governor temporarily suspended some of these requirements. Some 47,000 children in
Washington have dropped of the insurance since April 2003. Advocates say this is largely
due to administrative barriers.There will be attempts to restore 12-month certification,
simplify income verification procedures,and make it easier for children to retain coverage
when family income fluctuates.
• Last year,the Legislature removed many mandated benefits,including benefits for proven
public health interventions,from laws governing small business insurance. There may be
other attempts to roll back mandated benefits.
• Rep.Eileen Cody has said she will reintroduce"play or pay" legislation that would require
•
that employers with 50 or more employees either provide health insurance or pay money
into Basic Health.
Washington State Board of Health Members
December 15,2004
Page 5 of 5
• In recent years, the Board has written letters of support for mental health parity legislation
that sought to extend insurance to cover mental illness.Each year it has come closer to
passage. There appears to be growing interest this year. There is also growing recognition
that the mental health infrastructure—particularly the"safety net"—is in crisis. The
Legislature has formed a Joint Legislative and Executive Task Force on Mental Health
Services and Financing.
• We expect continued legislative efforts to address problems with access to dental care,
especially for children.
School health: School health has been an area of strong legislative interest in recent years and there
may be legislation again this year.
• See above for a discussion of physical activity and nutrition in schools
• The American Lung Association of Washington is expected to introduce"asthma friendly
schools"legislation that would,among other things, include provisions related to school
indoor air quality. It would require that school employees receive in-service training for on
symptoms, treatment and monitoring of students with asthma, and would mandate that
school districts to adopt policies on asthma rescue procedures and asthma prevention. The
group also is considering legislation that would require the state to develop an asthma plan.
• There may be legislative efforts to address Washington's poor school retention rate. There
is a strong correlation between lifelong health and the level of education attained.
Health disparities: Last session the Legislature established a Joint Select Committee on Health
Disparities, which must issue a report by December 2005. The POG process also examined health
disparities.At this time, we are not aware of any health disparities legislation that is likely to be
introduced for this session.
Tort reform: Medical malpractice reform will continue to be a major issue before the Legislature.
Last year,the Washington State Medical Association's proposed a$250,000 cap on non-economic
damages. The Governor has proposed an alternative that focused on patient safety initiatives. Only
part of the Governor's package passed.Initiative to the Legislature are being sponsored this year by
both by the trial bar(Initiative 336)and by physicians(I-330).
Tobacco:There will be continued efforts to extend the Clean Indoor Air Act ban on indoor
smoking in public places. There are also likely to be efforts to reduce youth access to tobacco.
Sex education: Last session,legislators asked DOH and the Office of Superintendent of Public
Instruction(OSPI)to develop program guidelines for sex education in the schools. Legislation
might be introduced that would incorporate these guidelines into statute.
I I r
c0 n, L IV (n D) o cog
v Com cn o - r gu
CD
- 0 C) �. 0 13 �I g l m
0 � > 7N � v <
�, co CI. 5' c CD m
F 6 (/�,�Fri " v c cDQ.0-
0
p o D m m D Q, ( W m `c
o = (n cn N' `.
v 7 (11mI nO
Cl)0N 3 (D co (D CC �
c IG7 N x Q CI1On
O `< NIhoO v —1 D vI
0
.te O I Cl) , n_ � ,
1 co.
D
(D c4CD
0r m H co up
< c_ c_ _, C
(5' DDQcn m C v, m - 0 '� DJ
CL
cu ppC "co c<D (D �. c o �1
0 co co - K O p c0 7
°'' CD
7 7 m o CD E -, CD
DO CD M o -� a C- m v, o' �; v
con) gm em o , RI
0
v, q Q C cD a D 3 a a .
l
o co cn
v
0
c.0 = C fl) � 1 Cl)o. n __
oc < COo I
mD CflC � Nsu
✓ Q
• v D Q 0
O oQ _
c0 ° m
- m Q x
0 0
C S C 0 CD CD "
o En n - D. Z >1 �i cD
n' N -, • n- cD C D 1 1 CD .�
n v
nmi o o a in Eu
a c 0 I C v a •
(D SD
0 `G (D O (1) 7 .--.-I A) a 0a o a , m
c o 1
CO 3 � vnoo- v • x lCo
5' ° C (0 0 3 0 c0 I cc, 1
(0 ... ti CD -0 R , '. m
n a) ET 0 an
a" m a nT
m
cN (0 > C (a
`� o m I =
0 Demo 0 3• 3 �
000 ,2. --, .o o N o 0 ' M O• 0 0 73 C p N 0 7- „ 7' -V7,,
13c0 .
33 m -• o m Cagmror, 4 —%
CD N `� D cn `< y (Q a — On i (0I 4
7 Q Q. O- 7 0 N cD• O 7 O In
n�ivm3a) � 0 mv � � * (Dmvm5-a ,-.11) ' I CD
n °• O 3 a W o- -_+ham _ °' z—— -. co- ° o ' �D
D -• o _ -a' - C
v 0
• Er 5" a ooCo gx. 3• 0m -0 ° CD N
� -, � G7 3aSt 0)w (D � a0_ .,. v a rt
-a o 0. o v -0o ° x 3 0 0 0 ° 3 a < .-f
c0 0 = � �• �m co m mo = o Q O
v cOn 7 v _, < D �' 0Oi a y N N -0 O N coi, 0 N 0
3 oa 0 ° -h v m c co
cD m
x Q cD v, Q c' m m 4.73 (D O n, m 3 0
(C, • cn 5 - fn w a o a' n' a n, o' c�D m C
� � 3 �FIT = -0 nm CD (713, oI CO a.
a
m * 3coi4. a' co 7., a3c°ivsc o oI N
'. = v o' er - a a- ° j O 7' N * I i
m m m r 3 QUI cD o 3 0- m 5 m 1
a coim ° (n < 3 3macm < 1 1
• m 3 cn. n, 0 -la) (n � 0 a n, coo c n
�" c- CDcun vv 3I m O
w m a (Di °
a'
°
= -
g g = m 0
(D 0 3 -a
j M (D n i!1
CD v v Cl)
D N m o 3
I 0 CD m n C S'0
ID v �< C
0- o
, N o
0 0 Z Z w co0
1\..) 3 o
5 coco
(CD n
N N
(D a)
o a I N
41. N
a1 i CN
0E1) 0 > ti) 5 cQ 5• N --I c m 0 O A',•) N a C 7 7 ( (D 9,•cQ O (D 0 0 0
X D-0 a o a) (D 71. 0 o: v '0 m (n CD .p cc, v o_ o" o m 3 0 . C zt �, Op
v n CD C v, (D in nrc,
C • O a 0+ 3 (O/1 a (p 0 (D
= -p' v COili al m C 0 6 -h n v N (D -6, (7 O lD O X
Da (n • o m 3 0 3 -o -,, m o - 0 ii'• Q cn m — 6 3 cD D 3 * -o
5 m CD
D co v rn (.1
'm m o m a 3. 3 w CO co m ° cQ Q
o v wv r- a " N0_ °—' m y -1 -, .. v o Q� O oo
N 7' N n' 0 W o 3 • ° o v o N 5 N O� O N N 7 •< n
3 y 3 C o w o _h Qwarn up �'• 3 "a = _• �. (aD r' 0 C
5 �' C° -, m m cn c cn co (b CD 7' 3 -� Q cn• -, 5- N
v 01 r« (D X n N 7 -,, 7 fl1 'O O a (n N
• Ul a N -, O (D (D C --n O 3 (O
(D v fl1 5 n o_ o Q 3 co p O n CD 12)
�F (D `< 0. o
CD Q C Q a 5 7 fp Oo O N 00 7 (D n o fD O Z (D CO
cn O < (IDC-r` 69 O (D 7 7 (s.- 3 3 V' =. -., O -a -
• •� N v (Q C)) O "O N CO o a (n r+ O co o (n (D
` cu
< w a Eu so o `< N A 00 N O O (D N v (� O a
3 cv << m o '
70 Un (10 = O a' .77CLOm m mu
m CCDD a * v CD 5- n m 5 a " m o
ID o W N o_ (D O r a co Eon a = 3 n 3 D vO D (D (D . 3 'B CON OOCm
O A Qr • a -D O�'in (n X ovO cs �vm
(O N _'6 (3D cn N o v (D (D O o' (D 7 c toIV N X (Q < Q cQ O
•(n C r4 .p•,. O < m n N • N 'p an. K (D 5 7 O (fl 0 7 (3D
a N cQ) o Csi) C� Cl) 3 v ca o v * o m o
m = - o = o = N I .-s:
o m 3
o 3 u) cn
-„ u)
C o o m D o ° o m m _� (Dm (D
5 c) v 5- 3 -� 0 7 0 0
m o eJv m (Do . (D3 o r 0 0 C c)
,� 3 � o o -0 m ' mac
U) 0' (D (D Q N C N cn I 0 fn CO - 0
. - N -1. N W n C I Q C C
o v o ( O a
0 cn a o gs m
a o m-
c !n c a(nno n 0 , 5 77.'
CPI 1 <
• No
n0 - COa o-•
* o 0C
5 ma u�• C0mQI I D m M
oD QC ° C'< 0mm D
E. O Co 5 c_ -I N u)) (D , coii) N 14 o 5
v -� o v 5- 7 ao' w 1 — o �G
.* 0 co cn
CD 3 0 = NOm _ (D = Na) v
-0 3 o in' O O 5 N o �I 3 n a
• C cn O a O O �• (D
g. a C (D i Cu Og (D N CO 7 C -O+,
(D `G (D C (Q O C li
(D a • O
'' (D C 7 U7 (n n
_7; a) U) (D (D N U N Q * o C 6 3
N 3 Oco
.
Cr tD 91 • O (D 0 CD O� 1 M- (D U C
O o 0 ' `" N C 6 1 I I 5II 7 00
7 -0 ' 3 O (n = I (D ..-s
(D (D n I I
(D
av � cn C 3 CD
7 , CO
_I I
Q- rn o - 3 0 0 -. 0 H
C) D -i K
D 3 3 a) act 3 �. ai Q cn 3 Z Q 0 < m
vc 0m0cCD 0 5' m0 ° m
C) °: in m m m �' v v 3
e ,.-,- z O.
�' co •o ..< -n
m m m -n Q Q y is n
3 v D �, 31 �'
cn �? X l om m m3
0 o" rn v, 0
O - `<. 0 0 U, I m
O m 5 c oQ s`< v 73 �I m - v, °' 1 m
0) a. co �' o' n' 0 n' n' C) v CD
c
v a o c , N.
5 5. m ca o C
2 —
CD
Al
EA = Q Q Eft &3
cO � vQ Qt o Nco � 0_ m o m 0 = > 0 0 0 0- g )• 0 Q � � m ( m
• w = = co o 0, w � w v c c mQ Z 4. 9• Q � , Q3 Q<< 81a ..,0 .6<
o00 Eft bap) O coA � 03 -, 0D = 'n0 " m -, 3 . v Om N
N O W O O m N m 0 cQ p� �• ,,="'
m C 0 cn 7
CD 3 ino Oo 0= 0 3 _ m0 oQv o• m Qv -o = Q cn' Qo"
CD• ED 1
N m 3 N 3 ca `� o o N R. •fn cn 0 3 a) -- 0 O-g , ..) . s c a) m-s< <— -,* R'-'-• n,
0) CO m m v 0 cn • w 3 o v X- 5• '- '- m EA (n' -0 0 N m c v
. m • 0 = •Oa 3 O Q o n < c o 0) Efl ZZ
w m co m m
c) o a o) � E (0m = Dca O fD u, 0 -� wn•cl K0 a
cn cn " c m v 3 v cn 0) v 0 N N c q w N pD 0 v f 1 N
n n n 0 m �- •cn o a' E» eL _� 3 0' c i co Q
u) N N 0 _ () 'T7 - O 0 O ID
0 0 m (n. W = Efl 0 Q 0 �" O m �' m Q 0)
c 0 � � co oa 3 .Nkna) 0 :rt � oi Cl)v �
m 9• C 0 0 U' m - C) 13 b) o 0 -9 Z
CO m v n� awn' 3 � c3 � ) • - 0 o C l � 3 2 C
o m m cn
= o' vU) U) � om � cu _3
CD. co cu I "ii,-) v = 5"- 3 cm„ m A o ..0 m o m 0
O O m -i (D i' te m (D 0 0 ni m' - N v
3 3 o U �. o �� -�, v0i m ^> o 0 � 3
. f N 3 0 C O W -+I 7- m
N o Q 0 c-, I Q cD (3p N (D ' 69 0
o .-, n> m = 3Q v-a0
0-cn 0 Sa `< 3 Qom c N �' � O
`G
°' �, v Q p m 3 Zr). =
Q N Q i •.G
coO
(Q O a) = (n 3 W' 0 cR°. O m m I g D o o CD U)
n
_^ _ -„
o a u0 ED mi _ m g_ . (0 3 3 -o v I I �' cmn 3 cQ
Efl 0 c cv m `- m' o v,' m CO << o' 3
CO < N O m 0 "0 u) I 0 n 7 m
� m -: QCD rn o mI m v Qo
o cru o _—• . m 0 a) m o � I • o n v ai
cQ m 0 v m
• o K ('. c-,ahnc. = -ha O 0) CL
3
m n) m ma) O 0 m c v0—,
D- a. cn poo cn u) p n a Icn
m j m m
m Q 3 M m m •< 0 v v ' v <" N x
o Q = Qm m CD 0 5' z R. a) m o
'- H n a = -, 3 C) n
_0 0 w N , N o -9 2.)
I (0 a m Q
0cr)5 m Q c)- 0. I -hl � CD0 �
� vNO3 a o0 > I I SI ( K�
0 w O n cin 0 I - c I I N 1 v 6 o.
a) m
40 J N c7 -co �' <' fn I QI ? v , _
-N o 0 0 N v cn 0 m
a cn 3 a
o Cco0O O o .-ma , 51 - re
0 0 ai < o s n CD n ml I ' o n m m
CD 0 I I I c
v 13-1 poo v :z -. o o , � a 3
n0'i <_ = m co E. O co I I I �' o"
,-.. am m v • 1 ! 10 r. m v
- 0
m `0 __ cmi S 3 I aS —
Q. I 0 C)
0
I
-o I
= ngCr1CT 2 -. 2Cr
2
-r1 D n nom ) 7
3
v D) .m c v s m
(4.3m omQv _ (D mo m m m O m m m
nQ vm E o6m v
• Wamm m v m o mcn = -
o 0 2 cn o w ED
Q. o o_ CCU) 0 • ai � m
3 W �a m m 0 ,"0 Z K c o -,CO Co o -63 Co
o cn <
o C z C CU N N •O• 5 -" 0 N 0 .< 0 o 0
O CD Qm = ,< n) o 0 CD Coco Cl) om
N o m m K R m O -0 m 0o n D o D
0) �I 0e. < � � � Do D-I Q � 0-
rn 3 I- o _ CL=� C _ c
o F �' CD °i a E. I< m to m cn Io in
C Im < CCDI
(D _� N _
m ' c=" „' oI'<
:. o `<
-En o rnZNZ Z Z
N.) - W (D ' � O AO NO O0 0
W A
W Oo N N - .A ) ED co ED N n O
0 - ? 0o o `< 7 C-0 - W-0 7,1-1:3 —
rl C) 0 o_ v (n-p N"0 O-o co-0 v
O 0 0 O C , (D C O O O O 3 0)
O O O O O O�. O�• O�• O�- O
o O v N O N O
Cn U' (n m = �� CD nm Q2Q2
en
a) iii cn gi
(7N c- rn (D -n a) rncn "nV)
0 O
Q �° 3 'n O n) o_ -- o_ -- o_ n. �
(- • . O n
CD N O r 2 �_ tmn v tmn N N N
m o- v (Di 0 D >
13
c c o 0
co
mrt c c
c) _ _
Co ' I N =D 21 I
Cl) > -1 -1 'v
0 C A. 0i -•- 2 -I -10
O 0 I C - -
0 - �i �
c0 - CD) CD) > D
O ) o n
O 0 o o
c I c o 0
O m c C
0 m
I , 1
Q N o_ "'• (n O (n 0 (D -I a-.O -o o --1
O 0 " n 0 2 a) (D O F 5.N N, 0 Q O m m fcn N CQ (D (D o ca cD m
v 3 v o 0 0- < -. z C (). -, c _. v. c 6' co o_ m- 2
--„ _o - •�� ovnm � ho � c. mcOcncDv ou) 3 coI
5. n) O -0 `< 0 ° cn �+ 3 2 ,..,._ o 1 00 O (n m m _. (D 7 (D NEll co
v m 3 m o v� m �,- v o ' Qpm o o-73 � mco ED i 535n- 01
I
v
m * ° o• 0 0 0 v 3 C iD o m m w• - 2. ° v CT ,. o cn i
o n- ccn v 3 m SD. o- a N QcnO 0CC - v 0 0 0 W o
0 vci) o c m m w an c 0) m(n -a v -o -LI 0 m cD m m (t o
a) (.0 5 c2 <Ei: n o m 0 co 3 -4 m o . (n o m 0it; 0 '' * o_ R
a, m m 0- v ri w - o = 6 * D Q m m a C.cQ < n
cn _• 3 o c� -m0 -I �. m < 5- o D'< o (o < Co v � W
ci) a 2. D) N r- < 0) m v c n 7 = O -s 0) _`�. 0
3 3 6 C c- m -0 o c-n 3 5• Q -W CT o 0 3 CO �' in
D O 0 0 h. (n 17).cZ. o m < (n m- 0 m o Q- •
v m •
v3, 00 �'B co mov, v Qc 3vm g03: =-Coo j
c 0 .� D) v7 n �' a c 0t 9 C0. cr m- Q * Y 0
o m ? n _. * �' I mmv mvcn0 m 3 1 0
v 5. o c `< (n 3 0 of i• 3 ' _
Q ci v = 7- 0• T.' O 0 N 0 a) , c Co (D
`< vog o 30
cD v c
- 0
li
-0 M
rnTI I
CD v 0 o
i
=QI 0 < 03 ' 0 0 o D- '-� CD p 5- o S o I 0c f N o O (A,- wj=' m u o A-10 v o -; oD o .. 0 V0 r- 0 -, C -ic o c , QIli Cl03
v Q
n (DCT D
H
rN U D CQ = o 0 c
o � n
C7 cn -.• MO a) FD- ` 13 to-
94 D 0
CD = = - (D CDO C0 a) Q. 0 * >
ar o v n > -pN tFp'.-a m o ona° 3 <0) m c cl. c D nCDm '
OO p 0 —
CD O (D m o= = C�
�� II I a.
69 fn � rncfl 63
0) W A. 1\3 Ca -a. (.71 -
CD oa 0 ) O (O O O N . t
03 O CD- - V CO 01 COO O "'
CDcri
O OCD O O O -1 GJ 0
CDO
10 CD ' CD 0 0 CD O OCD CD
O ' 0 l i^ 1 coO CD
0 3 O) (i) Q) ' ' i
(D N N v -CI _� 0
)
CD CD (DD CD N Q v CD 11
Cn
C7) in' X --I m fic
-
v (D O
'm CL Q 3 D) I 1 Y.
Q Q vi 1 ap
p ' i ! I I Q
O o n
13 < ;
CU
co
co
pID(D C)
n o
O O
C
m
(3
IC)
i Q
la 1CDCL I
NNI
• (li132- rt .� p I _
o70NOo3in «cD ') N gm ( (ti 0fitES mmm m m m � � - avis
3 m a, c < �' m o m 0 (n co *. v c a) 3 a CD CD cu CD m m °) s 0 m �. n
D N Q O S O N 0 O o �. (v o (QD 9j O CD 3 Q CC') 0 `< (li v (li (v CO fl)0 CSD ID Co o'
5 � 0CL 3 � (s� 0_COD" m - 3 0505000 � 10 � -0 -0 � o ( mD0v
cQ 3 �G O O si) -. " p r. v N O 'p (A cp 7 Q v N v a) CD CD ti CD _„
p 3 0 3 Ill O • v Q m -s -1 -, v m - 3 o c
0 s a) Q (D o o (D Q o Q Cu n 0 j O o O o N v, u) — r a
m . O 0 m Qm v v =*. v m -o Q - I o- cn
o o 3 °-,a) cn Fir
ta) c v - y) o 0 m o o -, < o Q 0 0 0 0 0 O N 0 (D -0 0 5.
v 0 v �• 5- Q c 3 0 5t -sv 3- (nn) o o CD O (D (D CD CD I CD rn m c N ° -61 °) (v
— 3 Q 1131 m 0 0 0 CI n0) cc v m CD m a m ili 3 m o 0 0 0 o c o a
co m 0 . D D CD C' Q m o 0 3 �) O Q a 3 Q 3 0 0 N. v_) �. v a)
Fco 73 2 � c o it,„.—
m �i a) 3 v
) - m -10) O0 >-DOC') cD0 0CQcDa5' wcn T3 ococo1 ca c0 0NQ � 5• c
O CD C —sl) c .< Z` 0 v c D 0 0 CD .(D I CD (D (D t
(D �, c fD 0 :D a)) 0- j- (n Q Q CO (0 (D I (D �. co Q �.
� � mO � S O W o � v m m m �cCD I 3 <CD CDm v
0 a) *• (D o v =-) v .0 _1 Qv a� o (D c0 (D m I 3 s Qm y
oa�o� m� oCD am3oo � a my ga
0-a) 0cn � 0 �
0 m in' n0i v c m 3 a ° a m m �x-,• N cQ < 0
• .--,-o'm3 o = �,• . * s3 m Q o 2 sv , off I I I — cn rn3 CD 6-.
rn 0 3 m 3 m c l ° � CD O o h; < CD m (.1)
D I 0 5' CD a 0 (li
v ° * v � � in rn m l N o j ! 1. 0 �� v
v c l
CD I , _ _
0 0 a I m I o j Q
CD
0 0 I_ I I j (D (n
I
x -im Km K0 C)
y r C7 O (D o C sv ° O. m
Q � V'. o = < QX• Q n7i B 7
Cy a 7 7 (D �. v °.9.,mc C
G virO7'i 01
n'
00 7 v ; °' I 0 �. 74.o � m mi
�_ p D aai o a aa)i
to < sv
1 O v ,� a co O (D Q B.
rn 0 (� m N m 0 0 D
.A. (D -0 � N O� CD a) .-�
O
7 6
- 0) a. C co
3 - m
0) D {fl coo N CO N 01
(31 C) Oj W N _a O O c) op 00
p p CO —' -Co O
OC
O --4O b
0 0 \) c) -co f p c) O
p p O O1 p of C)
C) CD OI
O
O C) 1 0 001 3 0
r cr.) 0 3 7- ml Cl)
° v 3 m CD cn CD
DJ m CD 0) N.
W 0)I 0-
o c 7 1 Cl
X 1 Q la; a
(0 O I
o 0 7- I
7 O CD
7
EDL (-I
> 2I
o o o i
CD D °7
(.0e D_,..
CD n
Cn i
O v 93
C0 '
0)
m
0
C
0)
o c o o W O D <O N --. o D N o Q = c v v C°' rn ° O C' o o m m Q m 8 g
— CD CD CO OQCD • 7- = to— O - v (D 6 ,--'- m < o' 7- CD (n v -, = rn m 3
o� m -. � 3a �' 3 �(74 o -, pcn �n �. oN �. CD , = vv, oa) ° <5. 3_ =
7 cQ' N CD ° �, 0�, (n vii ; (n O ap O a) n v 7 v
I .6 to < CD C) < N (D cn m 7 O O C v— O (n 7 7 Q- 'C (0 �. 7 Sv O
mov3 � ° = O <`c_ < a) voo � 3 � -0o CD . 5cnoc-, ,_ 00fa03i 53fl -,
< -s 7 (D O O -. (D CD ,..,. 7 , r (D 6 Do N (Q Q < (D (D CD q, C D-
< zs a. 3 o cQ < 2 O m m � ° ^ 0- o 2. g v 6 v o v' 3 cu
° 6 o C' -z (D v CD a (D m :
I
cn1 -ni £ o -Do CI, ' I
C/) C n `cc) 0- < cD m v 3 m o cCn 7n o o o
D 0 0 0 v co 7 (n (CD -, 3 c ° o
o X5 m o oCO bi .13 co' 5' ° 0
O co
c0 -' co D �' 0) CD 30 0. `G C <' cC
7 = ° CO 7 m o ~' 3 `� c-D = o
N 0 o 0) ° a 7 0 v -'
D 7 7 t7 r 7 (0 0) 0) 7 0 O0 CD
1 i . v 2. CD 7 0 0
rn i c_n v v 3 * 0. o `�
0_ I m
m v v 7• m DI <
j �� w = N c0 N N
I N. co I >
m1 I 73 m I o
v 1 °) o
I 7 v 0 � ;
Z'a 2 o o CD
� cDm ° ° g -' � �' on'i mwX �cQ � G� cn D H
.
ov,' -, ° xo < 3 0 • = ::i...0
o (DC o o cn 7 Q: — w O N w 0 3 p v
,_. cfl � = o o' = o c0 � — v 7 .-•. N `< �•�< 3 . o' ° Q v, 7• v _. m m If
0 c• D N -• Q0 o 0 o � Q � o m co c0 A _=v ID m ID -ca i.,, ('. o' a) og
...r 0 O 0 St (D :2 — �' g o W 0_ 1'7 a) al O — 0 0 0) .-* 0)o -n Er 7 7 0 7
� 3' c•m f7 D 3 * c 3 v < 27 A--� 3 m _Q 3 o -io�'o � v vim, mc7i ° � ° v
o c m n) o (? v mcQ7 0 — mem 0 o 0 0 3 0. 0. 3rri � 9 7- _, m m
a � O o D
0 Ccn D o N o a, Q 3 5' S' * --0 7 m 3 ? t0 0 ( o °c 3 • 0 m 0 o
n � v �' < a v m3 o m� 5 m 5. 3 m' o m� 0 cco _ o _ ° co a
-n ca o 7. 0 1° 8 c Q c0 7 0;cc) c s 0 cD co- 3 11 3 0_ N 3 Q c 7 v v l
-I - van m 3 m „ vm vmv c0 _,c z- Sc0 rn -.-< o _« rvmv c 3v
IrtTI c0 0 `G N o 3 7 N 7 N co c7j 0 co 0. 7 N co rn o R 0 00 :•v CO 3 c
O • a) -ti 3 CD _� to 0 �< v •N' 7 o CD
n 13; • O o u) 0 -0 - 5
0 (D 7 v ffl N. N =. v • = c * cn . co 7 N O O c)-
a;
N "' co cD a) 0. 7 0 0_ --u 0 o cn m- 0 < 0 ,., 7 .-* < = w
c0 ma 2N m v mN0. o v 7 W -0 mg m - co CO v3 =• -
v v c0 0' o v m o 3 -, 0.cn 0. -a -0 9) 7 0 ca m c o
c0 cD a O 7 N a, (Do r4• 7 = t/,- 3. 2 O N p.O io 0 O 0 co 69 O CD . 0 C
° c v . c0 c'no � 7 n) vo 7 0 � 7 . o cDnin '< CD
7
FA
CO N 7 7 0 Cn 0 CD c O O — y N E c (,) n 0) — N , — -0
N O -, 7. O N N .7* " O c� 7 I 0 0. 7 c 0 0 g 3- c
3 u, o < , — ti 7. c 0 CD co Cn �p ° Q- I? c_i) I ° CO CO
7- ,.* o - v ° c -O Q < fn u) Vj N 7 o N
con
0 0 a) g m m m v n m m = .a o o c `� 0. o ao
v M. c-n o . m e 0. N * 5 c
7 7' N 7
0_ c0 7 7 -a Q
0
7
c N v 0 v a D O m
Q� N N 0. 0 i7 N.
c m ' a-I 13o m �
�� 13 � � 3 a)1 • co
-, SR 0) 0 CD ; al0 ; j
v
.0 0 0)o 5 cif CI n I 5 O I 7
c. c n o' cn
v, a -0 n 7 --ss 0 I
= m c i
o' o v,' 0 o Q
I 7 7 — . _
ID n) O - °
3 3 m o Pr
o
o N
I v CD I I `~. 3
m
�, ' I Qo 0 7
° g I 3 a)•
Q � i I I NI I c
• I
< cQ I m e m 1 ~•I
0. 7
C m CD `< 7
o 7.
_CD co ,
I