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HomeMy WebLinkAbout2012- January JANUARY • MFFIJNG File Copy • Jefferson County Board of aLeaCth .agenda .v1 inutes • January 19, 2012 • . '�'e DRAFT JEFFERSON COUNTY BOARD OF HEALTH • MINUTES Thursday, December 15, 2011 - 2:30 PM—4:30 PM Public Health Conference Room, 615 Sheridan Street, Port Townsend Board Members Staff Members Phil Johnson, Vice Chair, County Commissioner District#1 Thomas Locke,MD,MPH Health Officer David Sullivan,County Commissioner,District#2 Jean Baldwin,Public Health Services Director John Austin,County Commissioner,District#3 Julia Danskin,Nursing Services Director Roberta Frissell, Citizen at large(County) Kristen Nelson, Chair,Port Townsend City Council Sheila Westerman, Citizen at large(City) Jill Buhler,Hospital Commissioner,District#2 Chair Nelson called the meeting of the Jefferson County Board of Health to order at 2:35 PM. A quorum was present. Members Present: Phil Johnson, David Sullivan, John Austin, Roberta Frissell, Kristen Nelson, Sheila Westerman,Jill Buhler Staff Present: Dr. Thomas Locke, Jean Baldwin, Veronica Shaw, Julia Danskin • APPROVAL OF AGENDA Member Austin requested that item#3 under Old Business, Information from the State, be added to the agenda. Member Austin moved to approve the agenda for the December 15,2011 BOH meeting as amended. Member Buhler seconded. The motion passed unanimously. APPROVAL OF MINUTES Member Buhler moved to approve the minutes for the November 17,2011 BOH meeting. Member Frissell seconded. The motion passed unanimously. Chair Nelson requested the person who seconds the motion be named in the minutes. PUBLIC COMMENTS None I BOH Minutes December 15,2011 DRAFT 'A OLD BUSINESS and INFORMATIONAL ITEMS 2012 Jefferson County Budget Summary Ms. Shaw reported that she met with Philip Morley, County Administrator,regarding a reduction in the 2012 Water Quality County contribution by $30,000, leaving a total contribution of $50,000. Ms. Shaw expressed concern that with the reduction in the County funds, grant dollars will not be able to be matched and current deliverables will not be met. Ms. Baldwin stressed that Water Quality is important because Water Quality grants and programs are supporting Environmental Health staff,which has helped to avoid layoffs in Environmental Health. A copy of the Recommended 2012 Jefferson County Budget was included in the agenda packet. EPA Workgroup Update Linda Atkins,Environmental Health Specialist,updated the Board on the progress of the EPA workgroup. Ms. Atkins stated that 3 bids were obtained, a choice has been made, and a contract has been signed and is going to the Board of County Commissioners for signature. An ad was placed in the December 7th Leader for workgroup participants and she expects the first meeting to be in January. Information from the State Member Austin distributed a handout on the delivery of service from the State Health Director, which shows the impact Public Health has had on Washington State. • New Business Community Health Concerns Regarding Biomass Energy Plants: Kees Kolff,MD MPH, and Wendy White,ARNP Dr. Locke briefed the Board on the regulatory structure for permitting industrial activities such as the Port Townsend Paper Corporation (PTPC). Air pollution control authority exclusively rests with federal and state agencies. Local governments, including local boards of health are excluded from air pollution permitting or enforcement activities. Local government authority is largely restricted to land use and building permit-related activities. Kees Kolff,MD MPH, of The Sierra Club,gave a presentation on health concerns regarding burning biomass at a proposed PTPC cogeneration projects. The two issues of greatest concern are emissions of dioxins and ultra-fine particulates. He presented studies and statistics on the health risks of being exposed to dioxins and ultra-fine particulates which could potentially be released into the environment from such a facility. Following the presentation there was a period of question and answers and discussion among Board members as to additional information they would like to receive on this issue. 2 BOH Minutes December 15,2011 Il DRAFT • Year End Summary of JCPH Clinic Client Reviews Ms. Baldwin included in the agenda packet a copy of all JCPH Clinic and Environmental Health client comments from 2010-2011,which as she pointed out were all positive comments. Washington State budget: Special Session Update Dr. Locke discussed a letter from Doug Porter, Director of Washington State Health Care Authority concerning the Governor's Supplemental Budget Proposals, a copy of which was included in the agenda packet. The letter discusses the $2 billion in proposed budget cuts from the current supplemental budget. These cuts will have negative impacts on the most vulnerable residents of Washington State. Ms. Baldwin discussed how she will not be able to defend the smaller programs, like AIDS prevention because of these cuts. Proposed Legislation for 2012: S-3335 On-Site Sewage Program Management Plan Funding Dr. Locke stated that Bill S-3335 is to be introduced in the regular session of the Legislature in January and would allow the local Board of Health to impose fees to cover the costs of administering the on-site sewage management plan. The bill would also allow the county treasurer to collect these assessments on behalf of the local board of health. Call for Public Hearing for JCPH Fee Updates — January 19, 2012 Board of Health • Meeting Ms. Baldwin announced the Public Hearing did not get posted in the local newspaper in time in order to hold the public hearing at the December 2011 BOH meeting. Member Austin moved to publicize the Public Hearing for JCPH fees for the January 19, 2012 Board of Health meeting. Member Westerman seconded the motion. The motion passed unanimously. ACTIVITY UPDATE None AGENDA PLANNING CALENDAR Dr. Locke asked how much information they would like to have on the biomass issue. Member Westerman requested more information on the Puget Sound Air Qualities position and a copy of the SEPA plan that was adopted. Dr. Locke stated that Eveleen Muehlethaler, Vice President for Environmental Affairs at PTPC, has offered to respond to technical questions on this issue. Member Johnson voiced that it would be useful to have a representative from ORCAA (Olympic Regional Clean Air Authority)to present the information from the report he prepared for the 111 3 BOH Minutes December 15,2011 DRAFT Stockholm Environmental Institute in Seattle and that he will invite him to speak at a BOH • meeting. The next scheduled BOH meeting will be held Thursday January 19,2012 from 2:30—4:30 PM at Jefferson County Public Health, 615 Sheridan Street, Port Townsend, WA. ADJOURNMENT Vice Chair Johnson adjourned the December BOH meeting at 4:20 p.m. JEFFERSON COUNTY BOARD OF HEALTH Kristen Nelson, Chair Phil Johnson, Vice-Chair Jill Buhler, Member John Austin, Member Roberta Frissell, Member David Sullivan, Member i Sheila Westerman, Member 4 BOH Minutes December 15,2011 • Board of Health Old Business & Informational Items .agenda Item # 1 � Peninsula Daily News Commentary: "Why Johnny's a bad kid" and Draft B03-1 Response January 19, 2012 • j:; C,_ w.1 !UU?LIh hIHUb O ~ - TiF ,G . p:_8:0 0'° , mw m , . w� x 8Cm a 2 ,9: m c ' ,V‘t_ R. mo23%9 ° wnwA �. co *2'6 c•-- )--) cp Vc'.. 5�pmRwiowmo �'mc, NP 'aww < p , N c' -•<? 4. mC- °a1n, pzN d � m +�j F. :-.1P2: -.,, . .g,..7, 25-,, g9-F. . p ap `''� E:g m8 p < .•F ?'p "_ , aa_ " p O'RYQ °> w0cp ( �;iI i. HII N .'85. 8 '*¢ Dr. WC „." . Nn ° c3,E p .'CaE g,p: r --. ?. huh F (omm °.v,' " ,4 w ?I0oiCD 1K o m m .° w o 4 } •To O rn+-�n ° o0-w'. crXp'o ter—.- w 8c. 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C _�0y y O '.4 m b ] OK 0 C+ K pb O R- w.- oR �. ro mc.mw a' w 1k0)1'. ♦ �V ,\ 4 o . rC m ° < R.er •o "•11'Ga'm .N m.� C7 -.a m ° --- ' �e, wa, o�,p c `< :y4 C y r° R'woo ,' G d+ 4i , Roo' dm 'ypa wlpNcq, 'm R ., pK .;.a<. �� ' ),* • R w „ w , m .8 ' R5'5"y o oop m p CD m o5Icp ,m8g. 0''m K & gm a5 . 0.° ` R oro • -- k American Academy of Pediatrics DEDICATED TO THE HEALTH OF ALL CHILDREN` • TECHNICAL REPORT The Lifelong Effects of Early Childhood Adversity and Toxic Stress abstract t r c Jack P.Shonkoff,MD,Andrew S.Garner,MD,PhD,and THE c i si COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND Advances in fields of inquiry as diverse as neuroscience, molecular FAMILY HEALTH,COMMITTEE ON EARLY CHILDHOOD, ADOPTION,AND DEPENDENT CARE,AND SECTION ON biology, genomics, developmental psychology, epidemiology, sociology, DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS and economics are catalyzing an important paradigm shift in our un- KEY WORDS derstanding of health and disease across the lifespan.This converging, ecobiodevelopmental framework,new morbidity,toxic stress, multidisciplinary science of human development has profound impli- social inequalities,health disparities,health promotion,disease cations for our ability to enhance the life prospects of children and to prevention,advocacy,brain development,human capital development,pediatric basic science strengthen the social and economic fabric of society.Drawing on these multiple streams of investigation,this report presents an ecobiodeve- ACE—adveroNs p g ACE—adverse childhood experiences lopmental framework that illustrates how early experiences and envi- CRH—corticotropin-releasing hormone ronmental influences can leave a lasting signature on the genetic EBD—ecobiodevelopmental predispositions that affect emerging brain architecture and long-term PFC—prefrontal cortex health.The report also examines extensive evidence of the disruptive This Academy documentof isPediatrics copyrightedandits andBoard is propertyofDirectors.of theAll American impacts of toxic stress, offering intriguing insights into causal mech- have filed conflict of interest statements with the American anisms that link early adversity to later impairments in learning, be- Academy of Pediatrics.Any conflicts have been resolved through • havior, and both physical and mental well-being. The implications of a process approved by the Board of Directors.The American Academy of Pediatrics has neither solicited nor accepted any this framework for the practice of medicine,in general,and pediatrics, commercial involvement in the development of the content of specifically, are potentially transformational. They suggest that many this publication. adult diseases should be viewed as developmental disorders that begin The guidance in this report does not indicate an exclusive early in life and that persistent health disparities associated with pov- course of treatment or serve as a standard of medical care. Variations,taking into account individual circumstances,may be erty, discrimination, or maltreatment could be reduced by the allevi- appropriate. ation of toxic stress in childhood.An ecobiodevelopmental framework also underscores the need for new thinking about the focus and bound- All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, aries of pediatric practice. It calls for pediatricians to serve as both revised,or retired at or before that time. front-line guardians of healthy child development and strategically po- sitioned, community leaders to inform new science-based strategies that build strong foundations for educational achievement, economic productivity, responsible citizenship, and lifelong health. Pediatrics 2012;129:e232—e246 INTRODUCTION Of a good beginning cometh a good end. John Heywood, Proverbs(1546) The United States, like all nations of the world, is facing a number wwwpediatrics.org/cgi/doi/10.1542/peds.2011-2663 of social and economic challenges that must be met to secure doi:10.1542/peds.20112663 a promising future.Central to this task is the need to produce a well- PEDIATRICS (ISSN Numbers:Print,0031-4005;Online,1098-4275). educated and healthy adult population that is sufficiently skilled to participate effectively in a global economy and to become responsible Copyright©2012 by the American Academy of Pediatrics stakeholders in a productive society. As concerns continue to grow 410 about the quality of public education and its capacity to prepare the nation's future workforce, increasing investments are being made in e232 FROM THE AMERICAN ACADEMY OF PEDIATRICS FROM THE AMERICAN ACADEMY OF PEDIATRICS the preschool years to promote the the 20th century,as effective vaccines, ecobiodevelopmental (EBD) framework foundations of learning. Although antibiotics, hygiene, and other public to stimulate fresh thinking about the IP debates about early childhood policy health measures confronted the in- promotion of health and prevention of focus almost entirely on educational fectious etiologies of childhood illness, disease across the lifespan.Second, it objectives, science indicates that a variety of developmental,behavioral, applies this EBD framework to better sound investments in interventions and family difficulties became known understand the complex relationships that reduce adversity are also likely to as the "new morbidities."8 By the end among adverse childhood circum- strengthen the foundations of physical of the century, mood disorders, pa- stances, toxic stress, brain architec- and mental health, which would gen- rental substance abuse, and exposure ture, and poor physical and mental erate even larger returns to all of to violence, among other conditions, health well into adulthood. Third, it society.1.2 This growing scientific un- began to receive increasing attention proposes a new role for pediatricians derstanding about the common roots in the pediatric clinical setting and to promote the development and im- of health, learning, and behavior in became known as the "newer mor- plementation of science-based strate- the early years of life presents a po- bidities"9 Most recently, increasingly gies to reduce toxic stress in early tentially transformational opportunity complex mental health concerns; the childhood as a means of preventing for the future of pediatrics. adverse effects of television viewing; or reducing many of society's most Identifying the origins of adult disease the influence of new technologies; ep- complex and enduring problems, and addressing them early in life are idemic increases in obesity; and per- which are frequently associated with critical steps toward changing our sistent economic, racial, and ethnic disparities in learning, behavior, and current health care system from a disparities in health status have been health. The magnitude of this latter "sick-care" to a "well-care" model3-5 called the "millennial morbidities."10 challenge cannot be overstated. A re- Although new discoveries in basic Advances in the biological, develop- cent technical report from the Amer- science, clinical subspecialties, and mental, and social sciences now offer ican Academy of Pediatrics reviewed high-technology medical interventions tools to write the next important 58 years of published studies and continue to advance our capacity to chapter. The overlapping and syner- characterized racial and ethnic dis- treat patients who are ill, there is gistic characteristics of the most parities in children's health to be ex- growing appreciation that a success- prevalent conditions and threats to tensive, pervasive, persistent, and, in ful well-care system must expand its child well-being—combined with the some cases, worsening.t1 Moreover, scope beyond the traditional realm of remarkable pace of new discoveries the report found only 2 studies that individualized, clinical practice to ad- in developmental neuroscience, ge- evaluated interventions designed to dress the complex social, economic, nomics, and the behavioral and social reduce disparities in children's health cultural, environmental, and devel- sciences—present an opportunity to status and health care that also corn- opmental influences that lead to confront a number of important ques- pared the minority group to a white population-based health disparities tions with fresh information and a group, and none used a randomized and unsustainable medical care ex- new perspective. What are the bi- controlled trial design. penditures.2•e'7 The science of early ological mechanisms that explain the The causal sequences of risk that childhood development has much to well-documented association between contribute to demographic differences offer in the realization of this vision, childhood adversity and adult health in educational achievement and physi- and the well-being of young children impairment? As these causal mecha- cal well-being threaten our country's and their families is emerging as a nisms are better elucidated,what can democratic ideals by undermining the promising focus for creative invest- the medical field, specifically, and so- national credo of equal opportunity. ment. ciety, more generally, do to reduce or Unhealthy communities with too many The history of pediatrics conveys a rich mitigate the effects of disruptive fast food franchises and liquor stores, narrative of empirical investigation early-life influences on the origins of yet far too few fresh food outlets and pragmatic problem solving. Its lifelong disease? When is the optimal and opportunities for physical activity, emergence as a specialized domain time for those interventions to be contribute to an unhealthy population. of clinical medicine in the late 19th implemented? Unemployment and forced mobility century was dominated by concerns This technical report addresses these disrupt the social networks that sta- • about nutrition,infectious disease,and important questions in 3 ways. First, bilize communities and families and, premature death. In the middle of it presents a scientifically grounded, thereby,lead to higher rates of violence PEDIATRICS Volume 129,Number 1,January 2012 e233 • and school dropout. The purpose of has been demonstrated to be passed this technical report is to leverage new Biology on to the next generation.18-22 This Physiological Adaptations knowledge from the biological and and Disruptions burgeoning area of research is chal- social sciences to help achieve the P lenging us to look beyond genetic positive life outcomes that could be c° The o predispositions to examine how envi- accrued to all of society if more effec- � ;' Basic Sc. c� ronmental influences and early expe tive strategies were developed to re- Science of c% F0 riences affect when, how, and to what duce the exposure of young children AL s Pediatrics 4) ,.rt , x degree different genes are actually to significant adversity. 4,- ,v��°o e a 4v It'.eee,, activated, thereby elucidating the ") c d� tifeCourse Qy mechanistic linkages through which °p� sciences �rr,,s-t,32 gene-environment interaction can af- A NEW FRAMEWORK FOR s'),, �0 Q PROMOTING HEALTHY fect lifelong behavior, development, DEVELOPMENT FIGURE 1 and health (see Fig 1). The basic science of pediatrics. An emerging, Additional evidence for the proposed Advances in our understanding of multidisciplinary science of development sup- framework comes from insights ac- the factors that either promote or ports an EBD framework for understanding the undermine early human development evolution of human health and disease across crued during the "Decade of the the life span. In recent decades, epidemiology, Brain" in the 1990s,when the National have set the stage for a significant developmental psychology, and longitudinal paradigm shift.12 In simple terms,the studies of early childhood interventions have Institutes of Health invested signifi process of development is now un- demonstrated significant associations (hashed cant resources into understanding red arrow) between the ecology of childhood both normal and pathologic neuronal derstood as a function of "nature and a wide range of developmental outcomes dancing with nurture over time," in and life course trajectories. Concurrently, ad- development and function. Subse- vances in the biological sciences,particularly in quent advances in developmental contrast to the longstanding but now developmental neuroscience and epigenetics, outdated debate about the influence have made parallel progress in beginning to neuroscience have begun to describe of "nature versus nurture."t3 That is elucidate the biological mechanisms (solid further, in some cases at the molec- • to say, beginning prenatal) , continu arrows) underlying Tr,pe aular and cellular levels, how an in Y tions. The convergencethese of ithese ad ivt erse ss dc ii through infancy, and extending ciplines defines a promising new basic science tegrated, functioning network with into childhood and beyond, develop of pediatrics. billions of neurons and trillions of ment is driven by an ongoing, in- connections is assembled. Because extricable interaction between biology Some of the most compelling new this network serves as the biological (as defined by genetic predisposi- evidence for this proposed framework platform for a child's emerging social- tions) and ecology (as defined by the comes from the rapidly moving field emotional, linguistic, and cognitive social andphysical environment)12,la,ls skills, developmental neuroscience is of epigenetics, which investigates the (see Fig 1). molecular biological mechanisms (such also beginning to clarify the under- Building on an ecological model that as DNA methylation and histone acet lying causal mechanisms that explain explains multiple levels of influence ylation) that affect gene expression the normative process of child de on psychological development's and a without altering DNA sequence. For velopment. In a parallel fashion, Ion- recently proposed biodevelopmental example, studies of maternal care in gitudinal studies that document the framework that offers an integrated, rats indicate that differences in the long-term consequences of childhood science-based approach to coordinated, quality of nurturing affect neural adversity indicate that alterations in early childhood policy making and function in pups and negatively affect a child's ecology can have measurable practice across sectors,77 this techni- cognition and the expression of psy- effects on his or her developmental cal report presents an EBD framework chopathology later in life. Moreover, trajectory, with lifelong consequences that draws on a recent report from rats whose mothers showed increased for educational achievement, economic the Center on the Developing Child at levels of licking and grooming during productivity, health status, and Ion- Harvard University to help physicians their first week of life also showed less gevity.23_27 and policy makers think about how exaggerated stress responses as adults The EBD framework described in this early childhood adversity can lead to compared with rats who were reared article presents a new way to think • lifelong impairments in learning, be- by mothers with a low level of licking about the underlying biological mech- havior, and both physical and mental and grooming, and the expression of anisms that explain this robust link health.1'e mother-pup interactions in the pups between early life adversities (ie,the e234 FROM THE AMERICAN ACADEMY OF PEDIATRICS 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS new morbidities of childhood) and im- underscores the need for greater un- a conceptual taxonomy comprising 3 portant adult outcomes.The innovation derstanding of how stress"gets under distinct types of stress responses (in 110 of this approach lies in its mobilization the skin," as well as the importance contrast to the actual stressors them- of dramatic scientific advances in the of determining what external and in- selves) in young children—positive, service of rethinking basic notions of ternal factors can be mobilized to tolerable,and toxic—on the basis of health promotion and disease pre- prevent that embedding process or postulated differences in their po- vention within a fully integrated, life protect against the consequences of tential to cause enduring physiologic span perspective from conception to its activation. disruptions as a result of the intensity old age.6 In this context, significant Physiologic responses to stress are and duration of the response.t7'45 A stress in the lives of young children is well defined.38-38 The most exten- positive stress response refers to viewed as a risk factor for the genesis sively studied involve activation of the a physiologic state that is brief and of health-threatening behaviors as well hypothalamic-pituitary-adrenocortical mild to moderate in magnitude. Cen- as a catalyst for physiologic respon- axis and the sympathetic-adrenomedullary tral to the notion of positive stress is ses that can lay the groundwork for system, which results in increased the availability of a caring and re- chronic, stress-related diseases later levels of stress hormones, such as sponsive adult who helps the child in life. corticotropin-releasing hormone (CRH), cope with the stressor, thereby pro- cortisol, norepinephrine, and adrena- viding a protective effect that facili- Understanding the Biology of line. These changes co-occur with tates the return of the stress response Stress a network of other mediators that systems back to baseline status. Ex- Although genetic variability clearly include elevated inflammatory cyto- amples of precipitants of a positive plays a role in stress reactivity, early kines and the response of the para- stress response in young children in- experiences and environmental influ- sympathetic nervous system, which clude dealing with frustration, getting ences can have considerable impact. counterbalances both sympathetic an immunization, and the anxiety as- Beginning as early as the prenatal pe- activation and inflammatory respon- sociated with the first day at a child riod, both animal26-30 and human31,32 ses. Whereas transient increases in care center. When buffered by an en- • studies suggest that fetal exposure to these stress hormones are protective vironment of stable and supportive maternal stress can influence later and even essential for survival, ex- relationships, positive stress respon- stress responsiveness. In animals,this cessively high levels or prolonged ses are a growth-promoting element effect has been demonstrated not exposures can be quite harmful or of normal development. As such, they only in the offspring of the studied frankly toxic,' and the dysregulation provide important opportunities to pregnancy but also in subsequent of this network of physiologic observe, learn, and practice healthy, generations. The precise biological mediators (eg, too much or too little adaptive responses to adverse expe- mechanisms that explain these find- cortisol; too much or too little in- riences. ings remain to be elucidated, but flammatory response) can lead to A tolerable stress response, in con- epigenetic modifications of DNA ap- a chronic "wear and tear" effect trast to positive stress, is associated pear likely to play a role.31'33'34 Early on multiple organ systems, including with exposure to nonnormative the brain. "41 This cumulative, stress expe- postnatal experiences with adversity riences that present a greater magni- are also thought to affect future re- induced burden on overall body func- tude of adversity or threat.Precipitants activity to stress, perhaps by altering tioning and the aggregated costs,both may include the death of a family the developing neural circuits con- physiologic and psychological, re- member, a serious illness or injury, trolling these neuroendocrine respon- quired for coping and returning to a contentious divorce, a natural di- ses.34'35 Although much research homeostatic balance, have been re- saster, or an act of terrorism. When "38,42-44 ferred to as "allostatic load. remains to be performed in this area, experienced in the context of buffer- there is a strong scientific consensus The dynamics of these stress-mediating ing protection provided by suppor- that the ecological context modulates systems are such that their over- tive adults, the risk that such the expression of one's genotype. It activation in the context of repeated or circumstances will produce excessive is as if experiences confer a "sig- chronic adversity leads to alterations activation of the stress response nature" on the genome to authorize in their regulation. systems that leads to physiologic • certain characteristics and behaviors The National Scientific Council on harm and long-term consequences and to prohibit others. This concept the Developing Child has proposed for health and learning is greatly PEDIATRICS Volume 129,Number 1,January 2012 e235 reduced. Thus, the essential char- in pediatrics remains to be written, sympathetic activity and causes neu- • acteristic that makes this form of but the outline and plot are clear. rons in the hypothalamus to release stress response tolerable is the CRH. CRH, in turn, signals the pituitary extent to which protective adult Toxic Stress and the Developing to release adrenocorticotropic hor- relationships facilitate the child's adap- Brain mone, which then stimulates the tive coping and a sense of control, adrenal glands to increase serum In addition to short-term changes in cortisol concentrations.The amygdala thereby reducing the physiologic stress yg response and promoting a return to observable behavior, toxic stress in contains large numbers of both CRH young children can lead to less out and glucocorticoid receptors, be in baseline status. g wardly visible yet permanent changes ningearlyin life, which facilitate the The third and most dangerous form of in brain structure and function.3s,4s stress response, toxic stress, can re- establishment of a positive feedback The plasticity of the fetal, infant, and loop. Significant stress in early child suit from strong, frequent, or pro early childhood brain makes it par- longed activation of the body's stresshood can trigger amygdala hypertro- ticularly sensitive to chemical influ phy and result in a hyperresponsive response systems in the absence of ences, and there is growing evidence the buffering protection of a supportive, from both animal and human studies or chronically activated physiologic stress response, along with increased stress adult relationship. The risk factors that persistently elevated levels of 4a4s studied in the Adverse Childhoodpotential for fear and anxiety. It is 23 hormones candisrupt its de- in this way that a child's environment Experiences Study include examples veloping architecture.45For example, of multiple stressors (eg, child abuse abundant glucocorticoid receptors are and early experiences get under the or neglect, parental substance abuse, found in the amygdala, hippocampus, skin. and maternal depression) that are and prefrontal cortex (PFC), and ex- Although the hippocampus can turn capable of inducing a toxic stress re- posure to stressful experiences has off elevated cortisol, chronic stress sponse.The essential characteristic of been shown to alter the size and diminishes its capacity to do so and this phenomenon is the postulated neuronal architecture of these areas can lead to impairments in memory • disruption of brain circuitry and other as well as lead to functional differ- and mood-related functions that are organ and metabolic systems dur- ences in learning, memory, and as- located in this brain region. Exposure ing sensitive developmental periods. pects of executive functioning. More to chronic stress and high levels of Such disruption may result in ana- specifically, chronic stress is associ- cortisol also inhibit neurogenesis in tomic changes and/or physiologic ated with hypertrophy and overactivity the hippocampus,which is believed to dysregulations that are the precursors in the amygdala and orbitofrontal play an important role in the encoding of later impairments in learning and cortex, whereas comparable levels of of memory and other functions. Fur- behavior as well as the roots of chronic, adversity can lead to loss of neurons thermore,toxic stress limits the ability stress-related physical and mental ill- and neural connections in the hippo- of the hippocampus to promote con- ness.The potential role of toxic stress campus and medial PFC.The functional textual learning, making it more dif- and early life adversity in the patho- consequences of these structural ficult to discriminate conditions for genesis of health disparities under- changes include more anxiety related which there may be danger versus scores the importance of effective to both hyperactivation of the amyg- safety, as is common in posttraumatic surveillance for significant risk factors dala and less top-down control as a stress disorder. Hence, altered brain in the primary health care setting.More result of PFC atrophy as well as im- architecture in response to toxic stress important, however, is the need for paired memory and mood control as in early childhood could explain, at clinical pediatrics to move beyond the a consequence of hippocampal re- least in part, the strong association level of risk factor identification and to duction.47 Thus, the developing archi- between early adverse experiences leverage advances in the biology of ad- tecture of the brain can be impaired and subsequent problems in the de- versity to contribute to the critical task in numerous ways that create a weak velopment of linguistic, cognitive, and of developing,testing, and refining new foundation for later learning, behav- social-emotional skills,all of which are and more effective strategies for re- ior, and health. inextricably intertwined in the wiring ducing toxic stress and mitigating its Along with its role in mediating fear of the developing brain 4s effects as early as possible, before and anxiety, the amygdala is also an The PFC also participates in turning • irrevocable damage is done. Stated activator of the physiologic stress off the cortisol response and has simply,the next chapter of innovation response. Its stimulation activates an important role in the top-down e236 FROM THE AMERICAN ACADEMY OF PEDIATRICS FROM THE AMERICAN ACADEMY OF PEDIATRICS regulation of autonomic balance (ie, appreciated by decision makers sensitive developmental periods (eg, sympathetic versus parasympathetic across the political spectrum. Not- from first trimester rubella or pre 4111 - effects), as well as in the develop- withstanding this growing awareness, natal alcohol exposure) can create ment of executive functions, such as however, discussions about early structural and functional disruptions decision-making, working memory, brain development in policy-making that lead to a wide range of physical behavioral self-regulation, and mood circles have focused almost entirely and mental illnesses later in adult life.1•6 and impulse control. The PFC is also on issues concerned with school A selective overview of this extensive known to suppress amygdala activity, readiness as a prerequisite for later scientific literature is provided below. allowing for more adaptive responses academic achievement and the de- The association between ACE and un- to potentially threatening or stress- velopment of a skilled adult work- healthy adult lifestyles has been well ful experiences; however, exposure to force. Within this same context, the documented. Adolescents with a his- stress and elevated cortisol results in health dimension of early childhood tory of multiple risk factors are more dramatic changes in the connectivity policy has focused largely on the tra- likely to initiate drinking alcohol at within the PFC, which may limit its ditional components of primary pedi- a younger age and are more likely to ability to inhibit amygdala activity and, atric care, such as immunizations, use alcohol as a means of coping with thereby, impair adaptive responses to early identification of sensory im- stress than for social reasons 54 The stress. Because the hippocampus and pairments and developmental delays, adoption of unhealthy lifestyles as a PFC both play a significant role in and the prompt diagnosis and treat- coping mechanism might also explain modulating the amygdala's initiation ment of medical problems. That said, why higher ACE exposures are asso- of the stress response, toxic stress— as advances in the biomedical sciences ciated with tobacco use, illicit drug induced changes in architecture and have generated growing evidence abuse,obesity,and promiscuity,5556 as connectivity within and between these linking biological disruptions associ- well as why the risk of pathologic important areas might account ated with adverse childhood experi- gambling is increased in adults who for the variability seen in stress- ences (ACE)to greater risk for a variety were maltreated as children.57 Ado- responsiveness5° This can then result of chronic diseases well into the adult Iescents and adults who manifest in some children appearing to be both years, the need to reconceptualize higher rates of risk-taking behaviors more reactive to even mildly adverse the health dimension of early child- are also more likely to have trouble experiences and less capable of,3effss hood policy has become increasingly maintaining supportive social net- tively coping with future stress. clear.1•6 Stated simply, the time has works and are at higher risk of school come to expand the public's un- failure, gang membership, unemploy- Toxic Stress and the Early derstanding of brain development ment, poverty, homelessness, violent Childhood Roots of Lifelong and shine a bright light on its re- crime, incarceration, and becoming Impairments in Physical and lation to the early childhood roots single parents. Furthermore, adults Mental Health of adult disease and to examine the in this high-risk group who become As described in the previous section, compelling implications of this grow- parents themselves are less likely to stress-induced changes in the archi ing knowledge base for the future of be able to provide the kind of stable tecture of different regions of the pediatric practice. and supportive relationships that are developing brain (eg, amygdala, hip- The potential consequences of toxic needed to protect their children from pocampus, and PFC) can have poten- stress in early childhood for the the damages of toxic stress. This in- tially permanent effects on a range of pathogenesis of adult disease are tergenerational cycle of significant important functions, such as regulat- considerable. At the behavioral level, adversity, with its predictable repeti ing stress physiology, learning new there is extensive evidence of a strong tion of limited educational achieve skills, and developing the capacity link between early adversity and a ment and poor health, is mediated, at to make healthy adaptations to future wide range of health-threatening be- least in part,by the social inequalities adversity.52•53 As the scientific evi- haviors.At the biological level,there is and disrupted social networks that dence for these associations has be- growing documentation of the extent contribute to fragile families and come better known and has been to which both the cumulative burden parenting difficulties.'58, 9 disseminated more widely, its impli- of stress over time (eg, from chronic The adoption of unhealthy lifestyles 4110cations for early childhood policy and maltreatment) and the timing of and associated exacerbation of so- programs have become increasingly specific environmental insults during cioeconomic inequalities are potent PEDIATRICS Volume 129,Number 1,January 2012 e237 risk factors for poor health. Up to 40% of toxic stress and its consequences stress in early childhood plays an • of early deaths have been estimated for all of society. The multiple dimen- important causal role in the inter- to be the result of behavioral or life- sions of these costs extend from dif- generational transmission of dispa- style patterns,3 and 1 interpretation of ferential levels of civic participation rities in educational achievement and the ACE study data is that toxic stress and their impacts on the quality of health outcomes. Second, it under- in childhood is associated with the community life to the health and skills scores the need for the entire medical adoption of unhealthy lifestyles as a of the nation's workforce and its community to focus more attention on coping mechanism.60 An additional 25% ability to participate successfully in the roots of adult diseases that orig- to 30% of early deaths are thought to a global economy. In the realm of inate during the prenatal and early be attributable to either inadequacies learning and behavior, economists childhood periods and to rethink in medical care3 or socioeconomic cir- argue for early and sustained invest- the concept of preventive health care cumstances, many of which are known ments in early care and education within a system that currently perpetu- to contribute to health care—related programs, particularly for children ates a scientifically untenable wall be- disparities.67-67 whose parents have limited education tween pediatrics and internal medicine. Beyond its strong association with and low income, on the basis of per- later risk-taking and generally un- suasive evidence from cost-benefit THE NEED FOR A NEW PEDIATRIC healthy lifestyles, it is critically im- analyses that reveal the costs of in- PARADIGM TO PROMOTE HEALTH portant to underscore the extent to carceration and diminished economic AND PREVENT DISEASE which toxic stress in early childhood productivity associated with educa- has also been shown to cause physi- tional failure.82-66 In view of the rela In his 1966 Aldrich Award address, ologic disruptions that persist into tively scarce attention to health Dr Julius Richmond identified child adulthood and lead to frank disease, outcomes in these long-term follow-up developme8 t as the basic science of even in the absence of later health- studies,the full return on investments pediatrics. It is now time to expand the boundaries of that science by in- threatening behaviors. For example, that reduce toxic stress in early corporating more than 4 decades of • the biological manifestations of toxic childhood is likely to be much higher. transformational research in neurosci- stress can include alterations in im- Health care expenditures that are ence, molecular biology, andenomics, mune function68 and measurable in- paying for the consequences of un- along with parallel advances the be- creases in inflammatory markers,69-72 healthy lifestyles (eg, obesity,tobacco, havioral and social sciences (see Fig 1). which are known to be associated alcohol, and substance abuse) are This newly augmented, interdisciplinary, with poor health outcomes as diverse enormous, and the costs of chronic basic science of pediatrics offers a as cardiovascular disease,69,70 73 viral diseases that may have their origins promising framework for a deeper hepatitis,74 liver cancer,75 asthma,76 early in life include many conditions understanding of the biology and chronic obstructive pulmonary dis- that consume a substantial percent- ecology of the developmental process. ease,77 autoimmune diseases,78 poor age of current state and federal More importantly, it presents a com- dental health,72 and depression.79-61 budgets. The potential savings in pelling opportunity to leverage these Thus, toxic stress in early childhood health care costs from even small, rapidly advancing frontiers of knowl- not only is a risk factor for later risky marginal reductions in the prevalence edge to formulate more effective strat- behavior but also can be a direct of cardiovascular disease, hyperten- egies to enhance lifelong outcomes in source of biological injury or disrup- sion, diabetes, and depression are, learning, behavior, and health. tion that may have lifelong conse- therefore, likely to dwarf the consid- The time has come for a coordinated quences independent of whatever erable economic productivity and effort among basic scientists, pediat- circumstances might follow later in criminal justice benefits that have ric subspecialists, and primary care life. In such cases,toxic stress can be been well documented for effective clinicians to develop more effective viewed as the precipitant of a physio- early childhood interventions. strategies for addressing the origins of logic memory or biological signature In summary, the EBD approach to social class, racial, and ethnic dis- that confers lifelong risk well beyond childhood adversity discussed in this parities in health and development. its time of origin.36,42-44 report has 2 compelling implications To this end, a unified, science-based Over and above its toll on individuals, for a full, life span perspective on approach to early childhood policy • it is also important to address the health promotion and disease pre- and practice across multiple sectors enormous social and economic costs vention. First, it postulates that toxic (including primary health care, early e238 FROM THE AMERICAN ACADEMY OF PEDIATRICS FROM THE AMERICAN ACADEMY OF PEDIATRICS care and education,and child welfare, improving coordination among exist- effective ways to improve the health of • among many others) could provide ing services. With this goal in mind, the nations First, current health pro- a compelling framework for a new era science tells us that interventions that motion and disease prevention poli- in community-based investment in strengthen the capacities of families cies focused largely on adults would which coordinated efforts are driven and communities to protect young be more effective if evidence-based by a shared knowledge base rather children from the disruptive effects investments were also made to than distracted by a diversity of tradi- of toxic stress are likely to promote strengthen the foundations of health tions,approaches,and funding streams. healthier brain development and en- in the prenatal and early childhood Recognizing both the critical value and hanced physical and mental well- periods. Second, significant reductions clear limitations of what can be ac- being. The EBD approach proposed in in chronic disease could be achieved complished within the constraints of this article is adapted from a science- across the life course by decreasing an office visit, 21st century pediatrics based framework created by the the number and severity of adverse is well positioned to serve as the pri- Center on the Developing Child at experiences that threaten the well- mary engine for a broader approach Harvard University to advance early being of young children and by to health promotion and disease pre- childhood policies and programs that strengthening the protective relation- vention that is guided by cutting-edge support this vision (see Fig 2).1 Its ships that help mitigate the harmful science and expanded in scope be- rationale, essential elements,and im effects of toxic stress. The multiple yond individualized health care.as,ss plications for pediatric practice are domains that affect the biology of The pediatric medical home of the summarized below. health and development—including future could offer more than the early the foundations of healthy devel- identification of concerns and timely Broadening the Framework for opment, caregiver and community referral to available programs, as Early Childhood Policy and capacities, and public and private sec- enhanced collaboration between pedia- Practice for policies and programs—provide tricians and community-based agen- Advances across the biological, be- a rich array of targeted opportunities cies could be viewed as a vehicle havioral, and social sciences support for the introduction of innovative • for testing promising new interven- 2 clear and powerful messages for interventions, beginning in the earli- tion strategies rather than simply leaders who are searching for more est years of life.1 An Ecobiodevelopmental Framework for Early Childhood Policies and Programs Policy and Program Caregiver and Foundations of Biology of Health Outcomes In levers for innovation Community Capacities Healthy Development and Development Lifelong Well-Being Primary iicaith Care (err! •,.• Stabk..Responsive llraith•Relaied Public Health folic and Commitment Behaviors Relationships Child Care and Early Education Financial.Psychological.and Gene. y Physreiosical Educational Chit Welfare Institutional Resources Sate.supportive Fnatr3nmrnt td3}tatu t 4�+ Achievement Environments hatraasnn I?iAruption, and Economic intervention Skills and 14nowled c Productivity Family Economic Stability APpropriatr .. Nutrition Community Development Physical and Embedded During Mental Health Private Sector Actions Sensitive Periods • h_ Ecology Biology Health and Development FIGURE 2 • An ecobiodevelopmental framework for early childhood policies and programs.This was adapted from ref 1.See text for details. PEDIATRICS Volume 129,Number 1,January 2012 e239 The biology of health and develop- and commitment; (2) financial, psycho- values and bodies of knowledge and • ment explains how experiences and logical, social, and institutional resour- the effects of their services are mod- environmental influences get under ces; and (3) skills and knowledge. est. With these caveats in mind, the skin and interact with genetic Public and private sector policies pediatricians are strategically situated predispositions, which then result in and programs can strengthen the to mobilize the science of early child- various combinations of physiologic foundations of health through their hood development and its underly- adaptation and disruption that affect ability to enhance the capacities of ing neurobiology to stimulate fresh lifelong outcomes in learning, behavior, caregivers and communities in the thinking about both the scope of pri- and both physical and mental well- multiple settings in which children mary health care and its relation to being. These findings call for us to grow up. Relevant policies include other programs serving young chil- augment adult-focused approaches to both legislative and administrative dren and their families. Indeed, every health promotion and disease preven- actions that affect systems respon- system that touches the lives of chit- tion by addressing the early childhood sible for primary health care, public dren—as well as mothers before and origins of lifelong illness and disability. health,child care and early education, during pregnancy—offers an oppor- The foundations of healthy devel- child welfare, early intervention,family tunity to leverage this rapidly growing opment refers to 3 domains that es- economic stability (including employ- knowledge base to strengthen the tablish a context within which the ment support for parents and cash foundations and capacities that make early roots of physical and mental assistance), community development lifelong healthy development possible. well-being are nourished. These in- (including zoning regulations that in- Toward this end, explicit investments clude (1) a stable and responsive fluence the availability of open spaces in the early reduction of significant environment of relationships, which and sources of nutritious food), hous- adversity are particularly likely to provides young children with consis- ing, and environmental protection, generate positive returns. tent, nurturing, and protective inter- among others. It is also important to The possibilities and limitations of actions with adults to enhance their underscore the role that the private well-child care within a multidimen- learning and help them develop sector can play in strengthening the sional health system have been the adaptive capacities that promote well- capacities of families to raise healthy focus of a spirited and enduring dis- regulated stress-response systems; and competent children, particularly cussion within the pediatric corn- (2) safe and supportive physical, through supportive workplace policies munity.88,90,91 Over more than half chemical, and built environments, (such as paid parental leave, support a century,this dialogue has focused which provide physical and emotional for breastfeeding, and flexible work on the need for family-centered, spaces that are free from toxins and hours to attend school activities and community-based, culturally compe- fear, allow active exploration without medical visits). tent care for children with develop- significant risk of harm, and offer mental disabilities, behavior problems, support for families raising young Defining a Distinctive Niche for and chronic health impairments, as children; and (3) sound and appropri- Pediatrics Among Multiple Early well as the need for a broader con- ate nutrition, which includes health- Childhood Disciplines textual approach to the challenges of promoting food intake and eating and Services providing more effective interventions habits, beginning with the future moth- Notwithstanding the important goal for children living under conditions of er's preconception nutritional status. of ensuring a medical home for all poverty,with or without the additional Caregiver and community capaci- children, extensive evidence on the complications of parental mental ill- ties to promote health and prevent social determinants of health indicates ness, substance abuse, and exposure disease and disability refers to the that the reduction of disparities in to violence.10 As the debate has con- ability of family members, early child- physical and mental well-being will tinued, the gap between the call for hood program staff,and the social cap- depend on more than access to high- comprehensive services and the re- ital provided through neighborhoods, quality medical care alone. Moreover, alities of day-to-day practice has re- voluntary associations,and the parents' as noted previously, experience tells mained exceedingly difficult to reduce. workplaces to play a major supportive us that continuing calls for enhanced Basic recommendations for routine role in strengthening the foundations coordination of effort across service developmental screening and refer- • of child health. These capacities can systems are unlikely to be sufficient if rals to appropriate community-based be grouped into 3 categories: (1) time the systems are guided by different services have been particularly difficult e240 FROM THE AMERICAN ACADEMY OF PEDIATRICS FROM THE AMERICAN ACADEMY OF PEDIATRICS to implement.92 The obstacles to prog- and disease prevention for children the child welfare system to the early ress in this area have been formidable experiencing significant adversity will intervention system for children with 411 at both ends of the process—beginning require more than advocacy for in- developmental delays or disabilities; with the logistical and financial chal- creased funding.It will require a deep subsequent federal reauthorizations lenges of conducting routine develop- investment in the development, test- of the Keeping Children and Families mental screening in a busy office ing, continuous improvement, and Safe Act and the Individuals with Dis- setting and extending to significant broad replication of innovative models abilities Education Act (Part C) both limitations in access to evidence- of cross-disciplinary policy and pro- included requirements for establish- based services for children and grammatic interventions that are guided ing such linkages.The implementation families who are identified as having by scientific knowledge and led by of these federal requirements, how- problems that require intervention. practitioners in the medical, educa- ever, has moved slowly. Despite long-standing calls for an ex- tional, and social services worlds who The growing availability of evidence- plicit, community-focused approach to are truly ready to work together (and based interventions that have been primary care, a recent national study to train the next generation of prac- shown to improve outcomes for chil- of89 titioners) in new wa s 88. The sheer pediatric practices identified per- Y � dren in the child welfare system94 sistent difficulties in achieving effec- number and complexity of under- underscores the compelling need to tive linkages with community-based addressed threats to child health that transform "child protection" from its resources as a major challenge 92 A are associated with toxic stress traditional concern with physical parallel survey of parents also noted demands bold, creative leadership safety and custody to a broader focus the limited communication that ex- and the selection of strategic priori- on the emotional,social,and cognitive ists between pediatric practices and ties for focused attention. To this end, costs of maltreatment.The Centers for community-based services, such as science suggests that 2 areas are Disease Control and Prevention has Supplemental Nutrition Program for particularly ripe for fresh thinking: taken an important step forward by Women, Infants, and Children; child the child welfare system and the promoting the prevention of child care providers; and schools 93 Per- treatment of maternal depression. maltreatment as a public health con- • haps most important, both groups For more than a century,child welfare cern 95,98 The pediatric community agreed that pediatricians cannot be services have focused on physical could play a powerful role in leading expected to meet all of a child's needs. safety, reduction of repeated injury, the call for implementation of the This challenge is further complicated and child custody. Within this context, new requirement for linking child by the marked variability in quality the role of the pediatrician is focused welfare to early intervention programs, among community-based services that largely on the identification of sus- as well as bringing a strong, science- are available—ranging from evidence- pected maltreatment and the docu- based perspective to the collaborative based interventions that clearly im- mentation and treatment of physical development and implementation of prove child outcomes to programs that injuries. Advances in our understand- more effective intervention models. appear to have only marginal effects ing of the impact of toxic stress on The widespread absence of attention or no measurable impacts. Thus, al- lifelong health now underscore the to the mother-child relationship in though chronic difficulty in securing need for a broader pediatric approach the treatment of depression in women access to indicated services is an to meet the needs of children who have with young children is another striking important problem facing most prac- been abused or neglected. In some example of the gap between science ticing pediatricians, the limited evi- cases, this could be provided within and practice that could be reduced by dence of effectiveness for many of the a medical home by skilled clinicians targeted pediatric advocacy.97 Exten- options that are available (particu- with expertise in early childhood sive research has demonstrated the larly in rural areas and many states mental health. In reality, however,the extent to which maternal depression in which public investment in such magnitude of needs in this area gen- compromises the contingent reciproc- services is more limited) presents a erally exceeds the capacity of most ity between a mother and her young serious problem that must be acknowl- primary care practice settings. A re- child that is essential for healthy cog- edged and afforded greater attention. port from the Institute of Medicine and nitive, linguistic, social, and emotional At this point in time, the design and National Research Councilt5 stated development.98 Despite that well- successful implementation of more that these needs could be addressed documented observation, the treat • - effective models of health promotion through regularized referrals from ment of depression in women with PEDIATRICS Volume 129,Number 1,January 2012 e241 • young children is typically viewed as promising new directions for the pe- No other profession brings a compara- • an adult mental health service and diatric community beyond general calls ble level of scientific expertise, profes- rarely includes an explicit focus on for comprehensive, family-centered, sional stature, and public trust—and the mother-child relationship. This se- community-based services. Although nothing short of transformational rious omission illustrates a lack of the practical constraints of office-based thinking beyond the hospital and of- understanding of the consequences practice make it unlikely that many fice settings is likely to create the for the developing brain of a young primary care clinicians will ever play magnitude of breakthroughs in health child when the required "serve and a lead role in the treatment of children promotion that are needed to match return"reciprocity of the mother-child affected by maltreatment or maternal the dramatic advances that are cur- relationship is disrupted or incon- depression, pediatricians are still the rently emerging in the treatment of sistent. Consequently, and not sur- best positioned among all the pro- disease. This new direction must be prisingly, abundant clinical research fessionals who care for young children part of the new frontier in pediatrics indicates that the successful treat- to provide the public voice and scientific —a frontier that brings cutting-edge ment of a mother's depression does leadership needed to catalyze the de- scientific thinking to the multidimen- not generally translate into compara- velopment and implementation of more sional world of early childhood policy ble recovery in her young child unless effective strategies to reduce adver- and practice for children who face there is an explicit therapeutic focus sities that can lead to lifelong disparities significant adversity. Moving that fron on their dyadic relationship 98 Pedia- in learning, behavior, and health. tier forward will benefit considerably tricians are the natural authorities to A great deal has been said about how from pediatric leadership that pro- shed light on this current deficiency in the universality of pediatric primary vides an intellectual and operational mental health service delivery. Advo- care makes it an ideal platform for bridge connecting the basic sciences sating for payment mechanisms that coordinating the services needed by of neurobiology, molecular genetics, require (or provide incentives for) the vulnerable, young children and their and developmental psychology to the coordination of child and parent med- families. In this respect, the medical broad and diverse landscape of health, • ical services (eg, through automatic home is strategically positioned to education, and human services. coverage for the parent-child dyad play 2 important roles. The first is to linked to reimbursement for the treat- ensure that needs are identified,state- SUMMARY ment of maternal depression) offers 1 of-the-art management is provided as A vital and productive society with a promising strategy that American indicated, and credible evaluation is prosperous and sustainable future is Academy of Pediatrics state chapters conducted to assess the effects of the built on a foundation of healthy child could pursue. As noted previously, services that are being delivered. The development. Health in the earliest although some medical homes may second and, ultimately, more trans- years—beginning with the future have the expertise to provide this formational role is to mobilize the en- mother's well-being before she be- kind of integrative treatment, most tire pediatric community (including comes pregnant—lays the ground- pediatricians rely on the availability both clinical specialists and basic work for a lifetime of the physical and of other professionals with special- scientists) to drive the design and mental vitality that is necessary for ized skills who are often difficult to testing of much-needed, new, science- a strong workforce and responsible find. Whether such services are pro- based interventions to reduce the participation in community life. When vided within or connected to the sources and consequences of signifi- developing biological systems are medical home, it is clear that stan- cant adversity in the lives of young strengthened by positive early expe- dard pediatric practice must move children.99 To this end,a powerful new riences, children are more likely to beyond screening for maternal de- role awaits a new breed of pedia- thrive and grow up to be healthy, pression and invest greater energy in tricians who are prepared to build on contributing adults. Sound health in securing the provision of appropriate the best of existing community-based early childhood provides a foundation and effective treatment that meets services and to work closely with for the construction of sturdy brain the needs of both mothers and their creative leaders from a range of dis- architecture and the achievement of young children. ciplines and sectors to inform inno- a broad range of skills and learning The targeted messages conveyed in vative approaches to health promotion capacities. Together these constitute • these 2 examples are illustrative of and disease prevention that generate the building blocks for a vital and the kinds of specific actions that offer greater effects than existing efforts. sustainable society that invests in its e242 FROM THE AMERICAN ACADEMY OF PEDIATRICS FROM THE AMERICAN ACADEMY OF PEDIATRICS human capital and values the lives of shaped by the interactive effects 7. An EBD framework, grounded in an its children. of both genetic predisposition and integrated basic science, provides • Advances in neuroscience, molecular environmental influence, and how a clear theory of change to help biology,and genomics have converged its developing circuitry affects a leaders in policy and practice craft on 3 compelling conclusions: (1) early lifetime of learning, behavior, and new solutions to the challenges of experiences are built into our bodies; health, advances in the biological societal disparities in health,learn- (2) significant adversity can produce sciences underscore the founda- ing, and behavior (see Fig 2). physiologic disruptions or biological tional importance of the early 8. Pediatrics provides a powerful yet memories that undermine the devel- years and support an EBD frame- underused platform for translating opment of the body's stress response work for understanding the evolu- scientific advances into innovative systems and affect the developing tion of human health and disease early childhood policies, and prac- brain,cardiovascular system, immune across the life span. ticing pediatricians are ideally po- system, and metabolic regulatory con- 3. The biology of early childhood ad- sitioned to participate "on the trols; and (3) these physiologic dis- versity reveals the important role ground" in the design, testing, ruptions can persist far into adulthood of toxic stress in disrupting devel- and refinement of new models of and lead to lifelong impairments in oping brain architecture and ad- disease prevention, health promo- both physical and mental health. This versely affecting the concurrent tion, and developmental enhance- technical report presents a frame- development of other organ sys- ment beginning in the earliest work for integrating recent advances tems and regulatory functions. years of life. in our understanding of human de- 4. Toxic stress can lead to potentially velopment with a rich and growing permanent changes in learning body of evidence regarding the dis- (linguistic, cognitive, and social- LEAD AUTHORS ruptive effects of childhood adversity emotional skills), behavior (adap- Jack P.Shonkoff,MD and toxic stress. The EBD framework tive versus maladaptive responses Andrew S.Garner, MD,PhD that guides this report suggests that to future adversity),and physiology COMMITTEE ON PSYCHOSOCIAL • many adult diseases are, in fact, de- (a hyperresponsive or chronically ASPECTS OF CHILD AND FAMILY velopmental disorders that begin early activated stress response) and can HEALTH, 2010-2011 in life. This framework indicates that cause physiologic disruptions that Benjamin S.Siegel, MD,Chairperson the future of pediatrics lies in its result in higher levels of stress- Mary I. Dobbins,MD unique leadership position as a credi- related chronic diseases and in- Marian F. Earls, MD Andrew S. Garner, MD,PhD ble and respected voice on behalf of crease the prevalence of unhealthy Laura McGuinn, MD children, which provides a powerful lifestyles that lead to widening John Pascoe,MD, MPH platform for translating scientific ad- health disparities. David L.Wood, MD • vances into more effective strategies 5. The lifelong costs of childhood . and creative interventions to reduce LIAISONS the early childhood adversities that toxic stress are enormous,as man- Robert T. Brown, PhD — Society of Pediatric ifested in adverse impacts on learn- Psychology lead to lifelong impairments in learn- ing, behavior, and health, and Terry Carmichael, MSW—National Association ing, behavior, and health. of Social Workers effective early childhood interven- Mary Jo Kupst, PhD — Society of Pediatric tions provide critical opportunities Psychology CONCLUSIONS • to prevent these undesirable out- D.Richard Martini,MD—American Academy of 1. Advances in a broad range of comes and generate large eco- Child and Adolescent Psychiatry Mary Sheppard, Ms, RN, PNP, BC interdisciplinary fields, including nomic returns for all of society. National Association of Pediatric Nurse Practitioners developmental neuroscience,molec- 6. The consequences of significant ad- ular biology, genomics, epigenetics, versity early in life prompt an ur- CONSULTANT developmental psychology, epidemi- gent call for innovative strategies George J.Cohen,MD ology, and economics, are converg- to reduce toxic stress within the ing on an integrated, basic science context of a coordinated system of CONSULTANT AND LEAD AUTHOR of pediatrics (see Fig 1). policies and services guided by an Jack P.Shonkoff, MD 2. Rooted in a deepening understand- integrated science of early child- STAFF • ing of how brain architecture is hood and early brain development. Karen S.Smith PEDIATRICS Volume 129,Number 1,January 2012 e243 COMMITTEE ON EARLY CHILDHOOD, STAFF Carolyn Bridgemohan, MD 41, ADOPTION, AND DEPENDENT CARE, Mary Crane, PhD,LSW Jill Fussell, MD 2010-2011 Edward Goldson,MD Pamela C. High,MD,Chairperson SECTION ON DEVELOPMENTAL AND Laura J.McGuinn,MD Elaine Donoghue, MD BEHAVIORAL PEDIATRICS EXECUTIVE Carol Weitzman, MD Jill J. Fussell, MD COMMITTEE, 2010-2011 Lynn Mowbray Wegner, MD, Immediate Past Mary Margaret Gleason,MD Michelle M.Macias,MD,Chairperson Chairperson Paula K.Jaudes,MD Veronnie F.Jones,MD STAFF David M. Rubin, MD Linda B. Paul, MPH Elaine E.Schulte, MD, MPH REFERENCES 1. Center on the Developing Child at Harvard 11. Flores G, ; Committee On Pediatric Re- 21. Meaney MJ, Szyf M. Environmental pro- University. The foundations of lifelong search. Technical report-racial and eth- gramming of stress responses through DNA health are built in early childhood. Avail- nic disparities in the health and health methylation: life at the interface between able at: www.developingchild.harvard.edu. care of children. Pediatrics. 2010;125(4). a dynamic environment and a fixed genome. Accessed March 8,2011 Available at: www.pediatrics.org/cgi/con- Dialogues Clin Neurosci.2005;7(2):103-123 2. Knudsen El, Heckman JJ, Cameron JL, tent/full/125/4/e979 22. Szyf M,McGowan P,Meaney MJ.The social Shonkoff JP. 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J Pediatr.2007;151(suppl 5):511-516 982-983 0 e246 FROM THE AMERICAN ACADEMY OF PEDIATRICS JEFFERSON COUNTY PUBLIC HEALTH ' rrctti, 615 Sheridan Street • Port Townsend •Washington • 98368 IPwww.jeffersoncountypublichealth.org Editor, Peninsula Daily News The Jefferson County Board of Health applauds the Peninsula Daily News for publishing Nicholas Kristoff's op-ed, "Why Johnny's a bad kid" on 1/10/12. A growing body of scientific research supports the finding that the "toxic stress"that results from early childhood exposure to abuse and neglect, substance abuse, poverty and violence has devastating lifelong ramifications. Kristoff writes about the American Academy of Pediatrics' (AAP)recent report on the lifelong effects of early childhood adversity. The AAP policy report calls for the implementation of science-based strategies to alleviate toxic stress and its negative impact on children's healthy development, learning, behaviors, and future health. Mr. Kristoff specifically names Nurse-Family Partnership, an evidence-based nurse home visiting program, as a successful early intervention program that supports young mothers and their babies to a healthy start in life by improving prenatal health, school readiness and maternal economic self sufficiency. Jefferson County Public Health has been providing Nurse-Family Partnership services to families in Jefferson County for the past 12 years. This and other family health programs offered through Jefferson County Public Health have contributed to the health of Jefferson County infants as evidenced by our • substantially lower rates of infant mortality, low birth weight babies, and premature deliveries as compared to statewide rates. The Jefferson County Board of Health supports the AAP's call for community involvement to support young children and their families and sustain the important gains we have achieved over the past 12 years. [Name] Chair, Jefferson County Board of Health • COMMUNITY HEALTH ENVIRONMENTAL HEALTH DEVELOPMENTAL DISABILITIES PUBLIC HEALTH WATER QUALITY MAIN: (360) 385-9400 /SEVERE'S WORKING FOR ik SAFER AND MAIN: (360) 385-9444 FAX: (360) 385-9401 HEALTHIER COMMUNITY FAX: (360) 379-4487 • Board of CeaCth Netiv Business .agenda Item # 171., 1 Public fearing: • Jefferson County Public .9Cealth Fee 1lpdates for 2012 January 19, 2012 • • , STATE OF WASHINGTON 0 JEFFERSON COUNTY BOARD OF HEALTH AN ORDINANCE TO AMEND Ordinance No. FEE SCHEDULE FOR JEFFERSON COUNTY PUBLIC HEALTH Section 1 —Effective Date Section 2 —Fees Section 3—Severability Section 4—Prior fee schedule repealed WHEREAS, the purpose of this ordinance is to set the fee schedule for Jefferson County Public Health, WHEREAS, adoption of this Ordinance will further the public policy memorialized in Chapter 246-215 WAC as well as other chapters of the WAC and RCW, WHEREAS, this Ordinance promotes the health, safety and welfare of the citizens of Jefferson County, and WHEREAS, this Ordinance is proposed and may be enacted pursuant to the general police power granted to efferson County and its Board of Health by the State Constitution, ii NOW, THEREFORE, BE IT ORDAINED by the Jefferson County Board of Health as follows: Section 1 —Effective Date That this Ordinance (and its Attachment) shall be effective as of February 2, 2012. Section 2—Fees That the schedule for Jefferson County Public Health fees for the year 2012 for permits, licenses, and services is hereby set by the Jefferson County Board of Health as listed in Attachment A to the proposed Ordinance. Any text listed on Attachment "A", specifically text within the column entitled "Additional Fees and Other Information" is deemed regulatory rather than advisory and as such has the full force and effect of local law. Section 3 —Severability A determination that any text, fee or fees adopted as part of this Ordinance is unlawful or illegal shall not cause any other text, fee or fees adopted as part of this Ordinance not affected by that determination to be repealed, revised, or reduced. Section 4—Prior Fee Schedules Repealed •ny prior fee schedule previously adopted by this Board that contains or reflects fee amounts that are less than those adopted herein is hereby repealed and replaced by this Ordinance. • AN ORDINANCE AMENDING 2012 FEE SCHEDULE FOR JEFFERSON COUNTY PUBLIC HEALTH ADOPTED day of 2012. JEFFERSON COUNTY BOARD OF HEALTH Kristen Nelson, Chair Phil Johnson,Vice-Chair John Austin, Member David Sullivan, Member . Roberta Frissell,Member ,_ Sheila Westerman, Member Jill Buhler, Meniber •qr JEFFERSON COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH DIVISION ENVIRONMENTAL HEALTH 2011 FEES 2012 Additional Fees and Other Information Proposed (CPIW ENERAI= ,„ alth Officer Administrative Hearing 287.00 298.00 dministrative Hearing Appeal 287.00 298.00 Technical Assistance/Plan Review-Minimum 65.00 65.0065.00 65.00 Technical Assistance/Plan Review-Per Hour 49.00 51.00 Filing Fee ,x ONSITE'SEWAGE DISPOSAL .. ,, s .s Sewage Disposal Permits 520.00 540.00 Valid for 3 years New Conventional New Alternative 620.00 644.00 Valid for 3 years - New septic tank and/or pump chamber only 247.00 257.00 Issued in conjunction with an existing sewage disposal - New Community or>1000 G.P.D.(base fee) 520.00 540.00 Plus$85 per connection-valid for 3 yrs New Commercial>1000 G.P.D. Conventional 620.00 644.00 Valid for 3 years 663.00_ 689.00 Valid for 3 years Alternative 115.00 119.00 Applies to existing installed sewage disposal system Repair/Upgrade/Modification/Desynate Reserve Area 387.00 403.00 Expansion 115.00 119.00 Applies to pending or active but not installed Redesign 144.00 149.00 Reinspection Evaluation of Existing System/Monitoring Inspection 287.00 298.00 Septic system only Septic system plus water sample 298.00 310.00 Retest/Reinspection 100.00 104.00 On Site Sewage OnSite-Site Plan Advanced Approval Determination(SPAAD) 287.00 298.00 Septic Permit with SPAAD(conventional) 280.00 291.00 Septic Permit with SPAAD(alternative) 388.00 403.00 Subdivision Review Base Fee 372.00 386.00 Plus$76.00 Per Lot Boundary line adjustment review fee 146.00 152.00 Plus$76.00 Per Lot=. Pre application meeting fee 146.00 152.00 Planned rural residential development review fee 146.00 152.00 -- D• ensi exem.tion review fee 73.00 76.00- Density exemption review fee requiring field work 146.00 -152.00 Other 72.00 179.00 - W• aiverNariance Application 1 172.00 79.0 WaiverNariance Hearing • Wet season evaluation 387.00 403.00;, Revised building application review fee146 00 152.00 New building application review fee: 73.00 76.00 Residential 146.00 152 00 Commercial • General environmental health review fee• _ 73.00 ' 76.00 Licenses Installer,Pumper,Operator(maintenance person) 387.00 403.00 Retest 158.00 164.00 Annual Renewal 273.00 283.00 Delinquent Renewal after January 31 387.00_ 403.00 FOOD"SERVICE,ESTABLISHMENT,FEES.PERMIT,;FEES(Annual Permit):r 7(,. i.,-V,;;,., .',,:' r;,`,4-,,.1.4),, ,,,,,:,;(4,;,-, .K 'ra. ',.5.k.,, ` Restaurants/Take-Out(Based on menu complexity&seating-menu changes may change category) 0-25 seats(Limited Menu) 174.00 181.00 No cooling or reheating 0-25 seats(Complex Menu) 310.00 322.00 Cooling and reheating allowed 26-50 seats 310.00 322.00 51-100 seats 372.00_ 387.00 101-150 seats 422.00 438.00 With Lounge,add 136.00 142.00 Separate lounge area Bakery Business 136.00 141.00 B&B 174.00 181.00 Caterer w/commissary or catering-only kitchen 310.00 322.00 w/restaurant,additional fee for catering 174.00 181.00 Concession/Commercial Kitchen/Church 136.00 141.00 Espresso Stand 136.00 141.00 Grocery 1-3 checkouts 174.00 181.00 May serve pre-packaged baked goods >3 checkouts 422.00 438.00 Meat/Fish Market310.00 322.00 Mobile Unit _ Limited Menu 174,00 181.00 No cooling or reheating Complex Menu 310.00 322.00 Cooling&reheating allowed School Cafeteria - Central Kitchen 310.00 322.00 410 Warming Kitchen 174,00 181.00 Tavern w/food(see Restaurants) Annual Permit Issued after September 1 50%of fee 50%of fee 50%of Annual Permit Fee 1 of 2 11/10/2011 12:48 PM ENVIRONMENTAL HEALTH 2011 FEES 2012 Additional Fees and Other Information 4 Proposed (CPIW 3.9%) Temporary Permits Single Events Limited Menu Initial Application(First Event) 98.00 102.00 Not to exceed 21 days at your location • Additional Events(Same Menu) 15.00 16.00 Not to exceed 21 days at your location Additional Events(Different Menu) 98.00 102.00 Not to exceed 21 days at your location Complex Menu Initial Application(First Event) 130.00 135.00 Not to exceed 21 days at your location Additional Events(Same Menu) 15.00 16.00 Not to exceed 21 days at your location Additional Events(Different Menu) 130.00 135.00 Not to exceed 21 days at your location Organized Recurring Events(e.g.Farmers Markets) _ Limited Menu Initial Application(First Event) 98.00 _ 102.00 Not'to exceed 3 days a week Additional Events(Same Menu) 15.00 16.0 Not to exceed 3 days a week Additional Events(Different Menu) - 98.00 102.00 Not to exceed3 days a week Complex Menu _ \ Initial Application_(First Event) 130.00 \135.00 Not to exceed S,days a week Additional Events(Same Menu) '15.00 '1l16.00 Not to exceed 3 days a week Additional Events(Different Menu) 130Q0 135.00 Not to exceed 3 days a week Late Fee for Temporary Permits +SQ10 of fee` +50%of fee 1 Additional(Paid wh' n application is submitted less than 7 ., -4- , days prior to the event) Other Food Fees _, Waiver 1 li ; 37 00 "� 39 00 Plan Review Pre-opening inspection �` 1 , 65.00 65.00 Per Hour Minimum \; \ 65.00 65.00 Per Hour ,\ \ ,, >65.00 65.00 Reinspection First Inspection \ ! ' 87.00 90.00 Each inspection after first ', I ' 149.00 155.00 Reopening Fee _ 65.00 65.00 Per Hour Food Handler Card 1-° 10.00 10.00 Reissue Unexpired Food Handler Card 10.00 10.00 Manager's Course 211.00 219.00 SOLID-WASTEO"1v a r is^a" „ ,, , - *p ''' k. Landfills requiring environmental monitoring 508.00 528.00 Inert Landfills 322.00 335.00 Biosolid Utilization 446.00 464.00 Other Solid Waste Facility Permits 322.00 335.00 Drop Boxes 149.00 155.00 • New Facility Application 409.00 425.00 Plan Review 65.00 65.00 Per Hour WATE ,�,��� �y�P��7� r'��'Ua�7,. .. '',7,-',?.i.',,i ' „FAO.S .,J".�� ,�to,,-:5.:';,:.*,,,',-',;- M s n, alas Inspection of well construction,decommission& Application Fee 149.00 155.00 reconstruction Determination of Adequate Water Supply 62.00 64.00 Building Permit Process Well Inspection&Water Sample for Loan 130.00 NEW FEE TO CAPTURE COSTS OF SERVICE Well Site Inspection-Proposed public water supply 298.00 309.00 L'NTNG`ENVIRONMENTS:(AnnriaFPermlt).g4 ,5 „+ u, ; a 3,.; ll `sou,,., Vr ,w ,',,,4n „ . Pool 273.00 283.00 Spa 273.00_ 283.00 Pool/Spa Combined 372.00 _ 387.00 Plan Review 65.00 65.00 Per Hour Indoor%Air(Tobacco)x K r`l,rti,g'H ! ,s lk/ "'J" "OVW.. € . .t.`: ",,5..., s r.,a ,P,3 Compliance Enforcement 65.00 65.00:IPer Hour Reinspection 73.00 76.00 Rebuttal Application 146.00 152.00 Note: 2012 Fees have been adjusted per Ordinance 12-1209-96,Section 4-Annual Fee Indexing:Fixed amount fees established by this ordinance shall be adjusted annually on the first business day of January (Adjusted Date)by the amount of the increase in the Consumer Price Index(CPIW). The CPIW is the Consumer Price Index-US City Average for All Urban Wage Earners and Clerical Workers,published by the Bureau of Labor Statistics for the United States Department of Labor. The annual fee adjustment shall be calculated as follows: each fee in effect immediately prior to the Adjustment Date will be increased by the percentage increase in the CPIW as reported for the month of September preceding the Adjustment Date. Increases will be rounded to the nearest dollar. A fee shall not be reduced by reason of such calculation. However,fee increases in accordance with this calculation shall not exceed 5 percent per year. i 2 of 2 11/10/2011 12:48 PM • Board of 3-feaCth Wow Business .agenda Item # 171., 2 Biomass Energy Plants Continued • Department of Ecology Perspective January 19, 2012 • • JEFFERSON COUNTY BOARD OF HEALTH January 19,2012 2:30—4:30 PM Basement Conference Room Jefferson County Courthouse AGENDA I. Approval of Agenda H. Election of Board Chair and Vice Chair for 2012 III. Approval of Minutes of Meetings of December 15, 2011 IV. Public Comments V. Old Business and Informational Items 1. Peninsula Daily News Commentary: "Why Johnny's a bad kid" and Draft • Board of Health Response Letter 2. 0 & M Update 3. Introduction of New Environmental Health Director VI. New Business 1. Public Hearing: Jefferson County Public Health Fee Updates for 2012 2. Biomass Energy Plants Continued: Department of Ecology Perspective 3. Influenza Season Update 4. Washington State Legislature Update 5. Washington State Public Health Improvement Partnership and Agenda for Change Update 6. Jefferson County's Drug Take-Back Program 2011 Report VI. Agenda Planning V. Adjourn Next Meeting: February 16, 2012 2:30 PM—4:30 PM • TOWNSEND January 11, 2012 Dr. Thomas Locke Jefferson County Medical Officer Jefferson County Public Health 615 Sheridan Street Port Townsend, WA 98368 Dear Dr. Locke- Thank you for your inquiry. I have attached the PTPC NOC Order No. 7850 which serves as the • technical and regulatory basis for the Cogeneration project. It shows the project will reduce existing particulate emissions, including the PM2_5component,from Power Boiler 10 (PB10) by over 70 percent. As you can see under the Findings, Item 11 on page 4 of the Notice of Construction permit, "PB10 particulate (PM) will not increase as a result of the project."This finding is based on the data analysis and modeling done by Trinity Consultants in a 5-month study period prior to submitting a formal Notice of Construction Application to the Department of Ecology in May 2010.The baseline emissions for this study were based on 24 consecutive months of Method 5 stack testing done on the subject boiler. Currently, PB10 has pollution control equipment in place including multiclone separators and a Turbotac wet scrubber to meet the present Title V requirements for particulate matter(PM). The project modeling assumes that all of the particulate currently emitted is from the PM25 fraction, which is a conservative but reasonable assumption based on the existing control equipment. Since the NOC permit imposes a new reduced limit on PB10,the reduction in emissions will come from the PM2.5 fraction. Again from Finding 11, "Projected actual PM emissions from PB10 after project completion are 27.2 T/yr compared to baseline emissions of 103.1 T/yr." The emission factor for the boiler has been 0.1#/mmBTU. It becomes 0.020 #/mmBTU under the new limit. Furthermore,the Cogen Project overall has a net decrease in particulate emissions. PB 10 will be equipped with a new dry single chamber electrostatic precipitator located downstream from the multiclones for ash removal from the boiler flue gas. The precipitator • will contain 3 mechanical and 3 electrical fields in the direction of the gas flow and the electrical fields will be powered by 3 separate transformer-rectifiers. A 99.7% efficiency of removal is • expected. The precipitator will be located on the west side of the recovery boiler building close to the exhaust gas exit from the No. 10 Power Boiler. This is only one piece of the new pollution control equipment that will be added to P810 as part of the cogeneration project. In addition, a new selective non-catalytic reduction system (SNCR) will be installed to control nitrogen oxides (NOx), and the existing scrubber will be modified to increase sulfur dioxide (SO2) removal. The addition of these pieces of equipment plus the work on the boiler itself will result in PB10 running at decreased emissions for total particulate, NOR, SO2, hydrogen sulfide(H2S), and total reduced sulfur compounds(TRS). [See attached PTPC NOC Order No. 7850, Findings 11-15, pp 4-5.1 Carbon monoxide (CO2) and volatile organic compounds (VOC) are expected to increase slightly but are below the threshold to trigger further review. I have attached for your review a literature search done for me by Steve Stratton of the National Council of Air and Stream Improvement (NCASI). It cites various peer-reviewed articles around the issue of collection efficiencies. Also attached is a graph taken from the EPA reference on ESPs. If you have any further questions on the project or the mill in general, please don't hesitate to contact me. Sincerely- Eveleen Muehlethaler Vice President—Environmental Affairs Port Townsend Paper Corporation 100 Mill Road Port Townsend, WA 98368 Cc: Roger Loney—PTPC Attachments e uehlethaler, Eveleen T. —, , .,. From: Tom Locke <tlocke@co jefferson.wa.us> Sent: Wednesday,January 04,2012 5:11 PM To: Muehlethaler, Eveleen T. Subject: Board of Health Questions re: PTPC cogeneration project Ms.Eveleen Muehlethaler Vice President, Environmental Affairs Port Townsend Paper Corporation 100 Paper Mill Hill Road Port Townsend, WA 98368 Dear Ms. Muehlethaler: As you know,the Jefferson County Board of Health heard a presentation on"Community Health Concerns Regarding Biomass Energy Plants"at their December 15th meeting. The presentation focused on concerns about particulate matter that would be generated by the increased use of biomass as a fuel source,particularly 40 articles in the<2.5 micron particle size range(i.e. ultrafine particles). The Board had many questions and took position in favor or opposed to biomass related energy generation. One technical question that did arise that I thought you might be able to respond to is the type of electrostatic precipitation/filtration that PTPC is proposing to use in their cogeneration project and how efficient this process is removing particulate matter in various size ranges. A fundamental question the Board would like addressed is whether the cogeneration project with produce a net increase or decrease in airborne particulate matter. Nationally,opponents argue that there will be a net increase due to the increased consumption of biomass. Proponents argue that use of newer, more efficient particulate removal systems on existing emissions as well as new biomass-related emissions will significantly reduce the total particulate emissions. The Board would appreciate it if you have any technical information that addresses these issues that are specific to the PTPC proposal. The Board's next meeting is on Thursday,January 19. We usually like to send things out a week in advance and would appreciate hearing from you by January 12. Thanks very much for your attention to this request. Sincerely, Tom Locke,MD,MPH Jefferson County Health Officer • 1 !joy 1.14 • ,t ON -••"' er, - p•d C..) `K.) i:!'. • o 1j......im ;* .'• 0 *0 1"46 • ra - Ch, #-• L Yr 0 .....,- ro cp.- .— . : g .7,:,.,. -' — Zezrf-ItggleigAtitil4v 6) ., --:::...,,:r.r,V,“'5•1'-'ilt •-tV t) V14.44.:AVig-A,.,;,: • J i g 0 .1 .., * 1 ,.., .. 11) .0 4,.., .1 7', ••= ,_.,,, tiff 1 1-11 o — , 0 -1 A. '• o ..., , 5., B to 6 -4, .s., ivi 1 .• 04 1.44. ) '•#: a R I r) T, 1 ;:v • 1 . 4 , „60-4 . ii„ _ to . !To . vizi eti, co ..... 0 I.... .4) 0 ..... „..., 44. 0 • • • A Brief Review of the Literature on Removal of Fine Particles by Electrostatic Precipitation by Steve Stratton,NCASI A number of researchers have examined the effectiveness of electrostatic precipitation(ESP) technology for removing particles in the size range of about 0.03 to about 2 µm. This work is largely driven by the concern regarding the potential for this so-called ultrafine particulate (UFP) matter to have adverse health effects. ESP technology dates back to 1910 and has been an important air pollution control means for cleaning of flue gases from utility and industrial boilers and furnaces for decades. ESPs consist of a means to electrically charge particles in a gas stream and a means of collecting the charged particles and removing them from the unit. The typical arrangement is a series of parallel collecting plates with electrode wires located between the plates. A voltage is applied to the system, ionizing the gas molecules,which in turn ionize the particles in the gas stream. The particles then migrate to the plates,where they accumulate until being removed,typically by mechanically rapping the plates,which causes the collected dust to fall into a bin. ESPs have been built for applications ranging from 100 to 4,000,000 ft3/minute, are capable of removal efficiencies greater than 99%,and are used to remove particles from 0.05 to 200 µm(Wark and Warner 1976). McCain et al.(1975)reported on results of field measurements of particulates in the range of 0.03 to 5 µm of five industrial coal-fired boilers and one aluminum reduction pot line,all equipped with ESPs. Three different measurement devices were used to conduct the evaluations, • including cascade impactors to obtain size distributions on a mass basis over a range of about 0.3 to 5 gm; optical single particle counters to obtain particle concentrations on a number basis over a size range of about 0.3 to 2 gm; and diffusional sizing to obtain information on a number concentration basis over the size range from 0.01 to 0.2 µm. Their data showed that particulate removal efficiencies varied over the entire measurement range from>99%to a low of about 78% for one of the boilers. Typically,removal efficiencies were highest for particles above 1 and below 0.1 µm,with higher particle penetration between 0.1 to 1 µm. Other researchers have observed a similar"penetration window" in which removal efficiencies are lower. Strand et al. (2002)reported on performance of an ESP for removing particulates from a small (6 MW)biomass-fired boiler used for district heating. The boiler is a moving grate type, firing moist forest residue. ESP collection efficiencies for particles over the range of about 0.02 to 6 µm averaged 96%on a particle number basis. However, a penetration window was observed over the range from 0.2 to 0.8 gm. The lowest observed removal efficiency in this range was about 40%. On a mass basis,removal efficiencies averaged 88.3%overall, and were 82.6%to 86.7%in the smaller size range(<0.8 gm)and 92.5%to 95.6%for larger particles(0.8 to 6 µm), depending on the measurement device used. Ylatalo and Huatanen(1998)studied the performance of a full-scale ESP on a pulverized coal- fired boiler with a fuel capacity rating of 315 MW. Particle mass and number concentrations were measured upstream and downstream of the ESP,under varying firing loadings and ESP operating conditions. Particles were measured from a size of about 0.015 µm to about 8 µm. Consistent with other researchers,a penetration window was observed for all firing and ESP • operating conditions in the range of about 0.08 gm to about 2 µm. In this range,the particle penetration was on the order of 5%to 12%, equivalent to a removal efficiency of 88%to 95%. The degree of penetration was shown to vary with firing rate,coal grind and ESP operation. They concluded that even a well-performing ESP would allow about 4%of the particles in the penetration window size range to pass through. Overall removal efficiencies were not reported, but appear to be greater than 95%for all cases studied. Li et al. (2009)measured fine and ultrafme particulate matter removal performance of an ESP on a160 kW pulverized coal-fired pilot scale combustor. The ESP is a single-wire tubular design operated at 40—60 kV with a corona current of approximately 4 mA. Particles were measured by an electrical low-pressure impactor(ELPI),which measures particles in the range of 0.03 to 10 gm, and a scanning mobility particle sizer(SMPS),which measures particles in the range of 0.01 to 0.422 µm. Based on the SMPS measurements,particle penetration was greatest for particles smaller than about 0.04 gm and ranged from about 5%to as high as perhaps 50%for the smallest particles that could be precisely measured(0.032 gm). ELPI measurements showed somewhat higher penetrations over the range from 0.1 to 0.4 gm where the two methods overlapped, ranging from about 1 to 5%. Other researchers have conducted laboratory studies to better understand ESP removal of fine aerosols. For example,Huang and Chen(2002)studied particle size distributions of aerosols generated by atomizing sucrose and their removal by a lab-scale ESPs. They showed that particle penetration through the ESP was a function of airflow rate,applied voltage, and ESP configuration. Zhuang et al. (2000)studied UFP behavior in a lab-scale tubular ESP using NaCI and Al2O3 particles generated by atomization followed by diffusion drying. Collection efficiencies were shown to be a function of air velocity through the ESP and were consistent over • a range of about 0.05 gm to about 0.5 gm. • References Cited Huang, S.-H., and Chen, C.-C. 2002. Ultrafine aerosol penetration through electrostatic precipitators. Environmental Science and Technology 36:4625-4632. Li, Y., Suriyawong, A.,Daukoru,M., Zhuang, Y.,and Biswas,P. 2009. Measurement and capture of fine and ultrafine particles from a pilot-scale pulverized coal combustor with an electrostatic precipitator. Journal of the Air& Waste Management Association 59:553-559. McCain, J.D., Gooch, J.P., and Smith,W.B. 1975. Results of field measurements of industrial particulate sources and electrostatic precipitator performance. Journal of the Air Pollution Control Association 25(2):117-121. Strand,M., Pagels, J., Szpila,A., Gudmundsson, A., Swietlicki, E., Bohgard,M., and Sanati, M. 2002. Fly ash penetration through electrostatic precipitator and flue gas condenser in a 6 MW biomass fired boiler. Energy& Fuels 16:1499-1506. Ylatalo, S.I., and Hautanen,J. 1998. Electrostatic precipitator penetration function for pulverized coal combustion. Aerosol Science and Technology 29(1):17-30. Wark, K.,and Warner, C.F. 1976. Air Pollution, Its Origin and Control. Harper&Row. New York. P. 213. Zhuang, Y., Kim, Y.J., Lee, T.G., and Biswas,P. 2000. Experimental and theoretical studies of • ultra-fine particle behavior in electrostatic precipitators. Journal of Electrostatics 48:245-260. Other References Chang,M.-C.O., Chow, J.C.,Watson, J.G., Hopke, P.K., Yi, S.-M., and England, G.C. 2004. Measurement of ultrafine particle size distributions from coal-, oil-, and gas-fired stationary combustion sources. Journal of the Air& Waste Management Association 54:1494-1505. Linak, W.P.,Miller, C.A.,and Wendt, J.O.L. 2000. Comparison of particle size distributions and elemental partitioning from the combustion of pulverized coal and residual fuel oil. Journal of the Air& Waste Management Association 50:1532-1544. Suriyawong,A., Hogan, C.J. Jr.,Jiang,J., and Biswas, P. 2008. Charged fraction and electrostatic collection of ultrafine and submicrometer particles formed during 02—0O2 coal combustion. Fuel 87:673-682. • Board of 3-fealt( Netiv Business .agenda Item # 'VI., 3 • Influenza Season 1.lpdate January 19, 2012 CDC - Seasonal Influenza(Flu) - Situation Update: Summary of Weekly FluView Page 1 of 2 Centers for Disease Control and Prevention CDC 24,7 S z u g Lives.Protecting People=.ring Money through Prevention • Situation Update: Summary of Weekly FluView Key Flu Indicators U.S. Situation While influenza activity in the United States remains relatively Update low for the week ending December 31,there are early indications in FluView(/flu/weekly/)that flu season may be Percentage of Visits for getting underway.This includes three regions of the country Influenza-like Illness(ILI) reporting elevated levels of influenza-like illness (ILI) and more states and territories reporting greater geographical spread of influenza. Below is a summary of the most recent key indicators: = • Visits to doctors(/flu/weekly/index.htm#OISmap)for ;,,,,',Fs" .,�,"s.,-,,,,, influenza-like illness (ILI)remained below the national baseline this week,but three of the 10 U.S. regions (/flu/weekly/index.htm#OISmap) (Regions 1, 5 and 1o)reported ILI activity at or above Pneumonia and Influenza region-specific baseline levels (an increase from no regions Mortality for 122 Cities last week).These three regions are the Northeast,the P m ;a Mti Midwest and the Northwest. for 122 U S Gees • No states reported widespread influenza activity (/flu/weekly/index.htm#ISTE) . Regional influenza activity l �� y rt, ,rr J. was reported by one state (the same number as last week). Four states(an increase from two states last week) --. reported local influenza activity. Forty states (an increase ° • from 37 states last week) and Guam reported sporadic (/flu/weekly/index.htm#MS) influenza activity. Five states (a decrease from in states last Influenza-Associated Pediatric week),the District of Columbia and the U.S.Virgin Islands Mortality reported no influenza activity. Puerto Rico did not report. N�n,w,a u,na.nsaa..o ,«a aaa . oeame py Weak M Death:200&09 seas o present • The proportion of deaths(/flu/weekly/index.htm#MS) o attributed to pneumonia and influenza(P&I)based on the i: Ill 122 Cities Mortality Reporting System decreased slightly 1 . from last week,but remained within the level expected for this time of year. au • No influenza-associated pediatric deaths -- i (/flu/weekly/index.htm#MS2)were reported this week. (/flu/weekly/index.htm#MSZ) • Nationally,the percentage of specimens testing positive for Geographic Spread of influenza in the United States was 2.9% a decrease from In last week(4.3%).This decrease could be explained by a reduction in testing during the holiday season. v • Though few viruses(/flu/weekly/index.htm#whomap)have been available for testing so far this season,isolates tested #; '-....�.' remain susceptible to the antiviral drugs(/flu/antivirals/) e ` ow oseltamivir and zanamivir. � FluView(/flu/weekly/fluactivitysurv.htm)is available -and past (/flu/weekly/index.htm#ISTE) issues are archived- on the CDC website. Influenza Positive Tests Reported to CDC 0 t,tt„.//www-cdc_gov/flu/weekly/summary.htm 1/11/2012 ,a 4.- 4.----v4----1 r tD 1 . a E C „,c ti) ---.44..... ei R Q r c cfq ti}rte r:..:-...:-.7,.0 r ` - N 1, CCD T } G vF: �,� _ R b` �D ;ti ,� CD y �r '` R CD 41*V. �� r� C h+71 A' 1'`V.n; �S"011 `•:., d v...-...,....,..4174}- T� Q rt al �' '' m 4 .„....rx.,..„ in O -tz Q E rt'O .c Q co ., .... 1nili cuff) w 151 110 ... 4 v, i VU ,,,,,, # ID -:MC Udo JO i.1 I P aIlik- T m tD tD DJ 30 C Nikliklipb... to .... 12, IP' ill' Iv :a er Ns ni5 XI r in Z Z YO nG C o n Cm O NID O 001 A tap r) 0 tD 0 n C 0 3 0 •'''» e ms \ OF/ im Q' O C t� ., titin,.. I\ Board of 3-fealth Wow Business .agenda Item #17I., .5 ANA State Public 3-CeaCth r Improvement Partnership and Agenda for Change 1144-ate January 19, 2012 • AGENDA FOR CHANGE UPDATE The three Agenda for Change subgroups have been hard at work drafting • priorities and specific actions to most effectively improve the public's health. Those subgroups and their work are as follows: Communicable Disease and Other Health Threats Subgroup E gam. The goal of this group is to provide guidance on best or standard practices around communicable disease threats. Its work is organized NE\^/c around the following questions: ,I r V 0 Immunizations - What are some best practices for assessing community immunizations practices? o Capacity for communicable disease surveillance and response - What is our need to evaluate and streamline our communicable disease and surveillance and response system? AGENDA FOR CHANG o Informatics - Is it time to plan for an updated and integrated communicable disease and data collection system? An Updat:,, Healthy Communities and Environments Subgroup w, .. .s.; The goal of this group is to provide guidance by focusing on policy and ACTIVITIES & SERVIC* system efforts that foster healthy communities. Its work is organized New Data and Toolkit „ ,n, around the following strategic areas: o Tobacco-free living o Healthy eating INDICATORS 0 Healthy and safe physical environments o Healthy starts New Data en. E a 1.' • Public Health Partnering with the Health Care System Subgroup The goal of this group is to identify ways public health can improve + access to care and preventive services by partnering more effectively with the healthcare system. Its work is organized around the question: Updat ' How shall public health partner more strategically with the health care Center for Excellenc>> system of the future to: o Collect and share community health data to increase knowledge of health issues prevalent in the community o Compile data on community-wide or region-wide health care capacity o Publish community needs assessments: partner with hospitals and other provider groups to develop community health needs assessments o Monitor healthcare access issues o Share information and educate on effective practices; examples include efforts to create regional consortia and efforts to develop clinically integrated health systems o Create ongoing networks among providers, public health and hospitals to deliberate about problems and possible solutions The Agenda for Change Workgroup will reconvene for its next meeting in early 2012 to review the subgroups' work and progress and begin looking OCT-DEC 20 at cross-cutting themes, gaps and funding. For more detailed information on the Agenda for Change efforts,visit www.doh.wa.gov/phip/workgroup/a4c/a4c/a4c.htm JLORKcORASAFEANDLI G HEALTHIER WASII L"., John Wiesman,Administrator Gregg Grunenfelder Clark County Public Health DOH/Deputy Secretary ACTIVITIES & SERVICES , , INDICATORS STANDARDS Abkir The Public Health Activities The 2011 Public Health Currently the Public Health 0 and Services Inventory ' Indicators Update is almost Standards Workgroup is on a workgroup has developed complete. The final round of brief between cycles hiatus. various tools for displaying ', updated indicators will be In the new year, the workgroup inventory results. available in early 2012. will focus on: Here is a list of some helpful • Guiding the implementation Public Health Activities & indicator resources: of the 2011 system wide Services Inventory Database Local Public Health recommendations https://fortress.wa.gov/ Indicators website Restructuring the future doh/phip/PHIP/ www.doh.wa.gov/phip/ standards review process to products/phi/overview.htm align with the Public Health • 2010 Public Health Accreditation Board National Activities & Services • To view highlights from the Inventory Results Report most recent updates, visit Standards www.doh.wa. ov hi The Centers for Excellence will (coming in early 201 2) g /p p/ products/phi/doc/tools/ support local and tribal agencies 2010 Public Health , r highlights.pdf choosing to seek voluntary Activities & Services national accreditation. Inventory Highlights • For examples of how local www.doh.wa.gov/phip/ health agencies are using For more information on the work the data, visit doc/phos/l Oinv/ of the Public Health Standards www.doh.wa.gov/phip/ highlights.pdf Workgroup, visit catalog/topic/phi.htm www.doh.wa.gov/phip/initiati - One-page template phs.htm summing up how public For more information on the health affects the health Public Health Indicators, visit For more information on the of your county www.doh.wa.gov/phip/ Centers for Excellence, visit www.doh.wa.gov/phip/ initiative/phi.htmwww.doh.wa.gov/PHIP/ doc/phas/l Oinv/ perfmgtcenters/index.htm example.pdf • Other examples of how public health activities & services data is used can be found under Toolkit PHIP WEBSITE at www.doh.wa.gov/ phip/catalog/topic/ The Department of Health is currently working on transitioning to a phas.htm new website. As a result of this, beginning immediately through the end of March, there will be little to no updates posted to the PHIP website. For more information on the In addition, in April, the PHIP website will take on a new identity to Public Health Activities & better align with the Department of Health's web standards. We plan Services efforts, visit on communicating with the Partnership and its workgroups as well as www.doh.wa.gov/phip/ all external communications exclusively via e-mail during this period. initiative/phas.htm We appreciate your patience and understanding during this time of transition! www.doh.wa.gov/phip PUBLIC HEALTH IMPROVEMENT PARTNERSHIP AGENDA FOR C _ NGF , O KG UPI P December 2011 evFRV E The Agenda for Change (A4C) workgroup is one of the four currently active workgroups under the Public Health Improvement Partnership (PHIP). The A4C workgroup will build on the discussions and work of the Reshaping Governmental Public Health Workgroup (February—December 2010) which included a review of health data, public health system assessment, forces of change and identification of themes and the final product, An Agenda for Change. The workgroup will move the Agenda for Change from a fairly broad description of what the governmental public health system should focus on in the future into a more specific set of priorities and a small set of specific action items that should be pursued immediately in order to most effectively improve the health of the public. These priorities and actions can guide the directions we set as a public health system in the next 2 to 5 years. • The workgroup is co-chaired by John Wiesman from Clark County Public Health and Gregg Grunenfelder from the Department of Health (DOH). The A4C web page (www.doh.wa.gov/phip) includes a roster of members, workgroup charter, work plan and all meeting and reference materials. WORKGROUP ROLE Guide the process Continually scan the environment and identify issues relevant to this process Oversee the work of three or more subgroups, each with a clear charge Review output of the subgroups and determine what to carry forward and integrate into the statewide action plan Identify common themes, overarching or key issues and gaps in the work Address any overarching or cross-cutting issues, including workforce, business practices and financing Integrate all these elements into an action plan for the governmental public health system The workgroup met twice during 2011 and will meet next in February 2012. • December 2011 Agenda for Change Workgroup Update 1 s WORKGROUP TIMELINE 2011 2012 PHIP Agend pea u group'"or. m Status Update Status Update Interim Report Input Process & Iterative Revisions Workgroup Address Overarching Issues Publish • 2012 PHIP Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 lo 2011, 3rd Quarter: Status Update A session was held at the Joint Conference on Health in October to provide an update on work and an opportunity for participants to provide input.The purpose of this written update is to further share information and continue to invite input. AGENDA FOR CHANGE (A4C) SUBGROUPS The Agenda for Change identifies three areas on which to focus the efforts of the governmental public health system in order to most effectively improve the health of the public (the what). In 2011, three subgroups were formed based on these focus areas and charged with identifying priorities and specific actions in each area to guide the governmental public health over the next 2-5 years. The subgroup members will provide content expertise on the topic area including associated data and epidemiology, evidence-based interventions, public health practice and measurement. They are considering their topic area broadly and in relationship to all aspects of the Agenda for Change, including the ways in which the public health system needs to change (the how),the guiding principles, and criteria for policy, program and funding choices. • December 2011 Agenda for Change Workgroup Update 2 The subgroups are: • Communicable disease and other health threats Healthy communities and environments Partnering with the Healthcare System Each subgroup is taking a slightly different tack—depending on what makes sense for the topics. Membership is also dependent on the topic. Communicable Disease and Other Health Threats Subgroup Co-Chairs: Scott Lindquist (Kitsap Health District) and Jennifer Tebaldi (DOH) Members: from the governmental public health system The subgroup will identify goals and strategies to give the public health system the `biggest bang for its buck' and may provide guidance on best or standard practices around communicable disease threats. The subgroup will also look at systems and technology to accomplish this work over the next two to five years. The subgroup met twice between September and October 2011. It has organized its work around the following focus areas: Immunizations - What are some best practices for assessing community immunization coverage? • • Capacity for Communicable Disease Surveillance and Response - What is our need to evaluate and streamline our communicable disease and surveillance and response system? o Prioritize our work o Standardize our work o Leverage our work • Informatics - Is it time to plan for an updated and integrated communicable disease and data collection system? The subgroup is currently working to develop specific language for the objectives and strategies for the three focus areas selected above. Next steps include: developing a draft guidance document for prioritizing notifiable conditions investigations.The challenging budget climate is reducing local health jurisdiction capacity to perform this work now and prioritizing notifiable disease investigations will help us focus our work in a meaningful way. • December 2011 Agenda for Change Workgroup Update 3 Healthy Communities and Environments Subgroup Co-Chairs: Dennis Worsham (Public Health —Seattle-King County) and Allene Mares (DOH) Members: from the governmental public health and community organizations The purpose of the subgroup is to develop an action agenda focusing on policy and system efforts that foster healthy communities. The subgroup met twice in 2011 and has agreed on four strategic areas: Tobacco-free living Healthy eating Healthy and safe physical environments Healthy starts Over the next few months the subgroup will flesh out strategies under each of these areas that not only support and maintain existing efforts, but also address how we will do our work differently in terms of workforce development, business practices, and funding structures. Next steps include: conduct key informant interviews with stakeholders to gather input on strategies and define criteria for prioritizing strategies. Public Health Partnering with the Healthcare System Subgrouz • Co-Chairs: Joan Brewster (Grays Harbor Health and Human Services) and Karen Jensen (DOH) Members: from the governmental public health, healthcare and the mental health system This subgroup's charge is to identify ways public health can improve access to care and preventive services. While many of the problems related to access to care are beyond the scope of this workgroup,they do provide important context to address the question: low shall public health partner more strategically with the neclurt care system of the futur, The workgroup met twice between September and November 2011. ACCESS TO CARE CHALLENGES No Care LACK OF CAPACITY Shortages(supply) Workforce and recruitment issues Available resources mismatched to needs • Too many people at once(additional 400K+Medicaid enrollees by 2014)? Confusion NAVIGATING SYSTEM FOR RIGHT CARE/RIGHT TIME • Fragmented services People don't know what is available,or how to use Languages and literacy Vulnerable population challenges No Money PAYMENT/FINANCING AS BARRIERS • People can't pay(even co-pays for some) • Reimbursement rates are too low,restricts access or providers drop out ▪ Public budget inadequate to meet demand December 2011 Agenda for Change Workgroup Update 4 Next steps include: development of more specific objectives and strategies in the coming months based on emerging themes around the question /Vhat shall Public Health do'<' Collect and share community health data to increase knowledge of health issues prevalent in the community Compile data on community: wide or region-wide health care capacity Publish community needs assessments: partner with hospitals and other provider groups to develop community health needs assessments Monitor healthcare access issues Share information and educate on effective practices; examples include efforts to create regional consortia and efforts to develop clinically integrated health systems Create ongoing networks among providers, public health and hospitals to deliberate about problems and possible solutions WHAT'S NEXT: 2O2 The Agenda for Change Workgroup will reconvene in early 201 2 to review the work and progress of the subgroups and begin looking at cross-cutting themes, gaps and funding. Relative to funding, the workgroup will be looking at the legally mandated responsibilities for federal, state, and local government entities, and coordinating with the Washington State Association of Local Public Health Officials (WSALPHO),the Washington State Association of Counties (WSAC), and the Washington • State Public Health Association (WSPHA) on this topic. The Agenda for Change Workgroup will release an interim report in Spring 2012. The report will be version 1 of the plan to move the Agenda for Change from a fairly broad description of what the governmental public health system should focus on in the future into a more specific set of priorities. At the same time a process to assure that governmental public health leaders and key partners are aware of the report and have opportunities to provide input through a variety of channels will be implemented. In December 2012, the bi-annual Public Health Improvement Partnership (PHIP) Report will incorporate information from the three other PHIP workgroups along with the final priorities of the A4C. This report will guide and be the major focus of the State Public Health Improvement Plan. Please feel free to contact any A4C co-chairs, staff or participants with questions, ideas and input. Contact: hip@doh.wa.gov More information: www.doh.wa.gov/phip/workgroup/a4c/a4c/a4c.htm PUBLIC HEALTH • ALWAYS WORKING FOR A SAFER HEALTHIER WASHINGTt December 2011 Agenda for Change Workgroup Update 5 Board-of CeaCt( Netiv Business .agenda Item f}17I., 6 • , Iefferson County 's Drug make-Back Program 2011 Report January 19, 2012 • DRUG TAKE-BACK PROGRAM 2011 • FOR JEFFERSON COUNTY ANNUAL REPORT JANUARY 12, 2012 The Port Townsend Police Department and the Jefferson County Sheriff's Office participated in a drug take-back program. Both the PTPD and the JCSO have secure drop-off boxes at their locations. They also participated in a National Drug Take-Back Day in April and October. The chart below indicates the totals by month and the combined total for both law enforcement departments. PT JC COMBINED MONTH POLICE SHERIFF TOTAL JANUARY 12# 7oz _ 0 12# 7oz FEBRUARY 5# 4oz 29# 12oz 35# MARCH 10# 14 oz _ 10# 8oz 21# 6oz APRIL 7# 9oz 9# 8oz 17# 1oz • MAY 6# 6# 12# JUNE 6# 8oz 10# 16# 8oz JULY 5# 13oz 9# 14# 13oz AUGUST 5# 12oz 5# 8oz 11# 4oz SEPTEMBER 11# 12oz 4# 7oz 16# 3oz OCTOBER 6# 6oz 32# 8oz 38# 14oz NOVEMBER 2# 5oz 62# 64# 5oz DECEMBER 7# 2oz 25# 32# 2oz TOTALS 87# 12oz 204# 3oz 291# 15oz S JCSO DRUG TAKE- BACK PROGRAM SSafely and legally dispose of your unwanted and expired medications. a Jefferson County q Miir ier r 4 Sheriff's Office , - '0'4 1•0 ,. ..".'"°. Ii 79 Elkins Road, Port Hadlock uor Ran Y ilk A AI 360-385-383110 Office Hours: Monday-Friday 8:30 am-4:00 pm The following items are now being collected for disposal: • Prescription medications . Inhalers III • Over-the-counter medications • Unopened EpiPens • Vitamins **Please Note: Pills do not have be in original containers-Loose pills accepted** Present your items to the staff person at the front counter. Staff members are not allowed to touch any of the items brought in for disposal. The following items are UNACCEPTABLE: • Liquids • Bloody/Infectious Waste • Empty containers • Personal Care Products • Needles/Syringes • Hydrogen Peroxide/Other • Thermometers Chemicals • . IV Bags • Aerosol Cans �i Opened EpiPens **If you are presenting any items that are ineligible for disposal, a staff member wil, give you a handout directing you to otherresources for safe disposal.** April 14,21 1 Please call 360-385-3831 if you ha , ny questions. PTPD DRUG TAKE- BACK PROGRAM Safely and legally dispose of your unwanted and expired medications. 40 IIII\ 41111111M111111111111111/ It Port Townsend -vitt/ ,, ,,., Police Department ,- `- , * a „., 1925 Blaine Street, Port Townsend I. , r r 360-385-2322 F.,. . ., . _ ,• Office Hours: Monday-Friday41, libp . 0 8:00 am-5:00 pm ''` The following items are now being collected for disposal: . Prescription medications . Inhalers • Over-the-counter medications • Unopened EpiPens • • Vitamins **Please Note: Items Must be in Original Containers** Present your items to the staff person at the front counter. Loose pills will not be accepted. Staff members are not allowed to touch any of the items brought in for disposal. The following items are UNACCEPTABLE: • Liquids • Bloody/Infectious Waste • Empty containers • Personal Care Products • Needles/Syringes • Hydrogen Peroxide/Other Chemicals • Thermometers • Aerosol Cans • IV Bags 410 Opened EpiPens **If you are presenting any items that are ineligible for disposal, a staff member wil, give you a handout directing you to other resources for safe disposal.** April 14, 2. 1 Please call 360-385-2322 if you have any questions. r Board of.9CeaCth _Media Report i January 19, 2012 r • • Jefferson County Public Health December 2011/January 2012 NEWS ARTICLES 1. "Passion over profit," Port Townsend Leader, December 14th, 2011. 2. "Thank You to Jefferson County EnviroStars and Green Businesses!", Port Townsend Leader, December 21st, 2011. 3. "Reduce your junk mail," City of Port Townsend Newsletter, January 2012. 4. "Preserve open space," City of Port Townsend Newsletter, January 2012. 5. "Septic education grant received," Peninsula Daily News, January 6th, 2012. 6. "Why Johnny's a bad kid," Peninsula Daily News, January 10th, 2012. • • • • ', .4 'i, ,` ,„ 4'r a'.„ sI•w 7.t-y , j:tJ,T PassIon r 3r r r t Kir w 34, 5; "° � ' .. . 1 f k 1 .�4 a,�*e f s� t , f'r > 4 t �i' t +�x7fa4, k� + r. f S 4 � ski# � }; f �; grk,,4,4-''',tSI over .1; S p ..i1:1 k ..^;.,k,i,$'i NN4,4,k i , istr profit - ,, s „ „,„kg. , _,,,,,,,i, F- .,'\' - ,-10 kt. n 1.'",;,.7:-.-.1'.'.,7,1::- a atn;�.' ° a • ., ..,, :,. ., .,,,,,,,„/,.....,._,,,,...,rez c � a •. .1,-.‘f: tPgf f t,Tt. ..,Yt ,rry ClF b� p / 3 '”anty r4't"'F # : Ff J.R 1 `� New businesses sprout = J S F �� - ' ' - t<r . r.^' " {u i-k i < in midst of recession �- ...17.. a ,_ '. t y fh; '..g,.;.,',,P,1""=' a < By Lauren Sateedo of the Leader ••Q'�, 43, r 4... Ac, I.. ' r v ..1-•••,4't =` - "Whenyou helpthe world,you helpthe corn. `+ 1^r� # #• » qf":„;;;.••;:,‘ munity too,"said Pama O'Toole,owner of PT ` / R nth f ' Iry § Pearl,a new store in downtown Port Townsend m" �t ° f+ to. ',/1'I t s 4 f•i"�"•; that specializes in fair trade,organic and racy ' ,r i f t-45-;;;.N.-;,.;..:c1!)-i; `wy : ••:".'.i'''. „c -r ... /; +� '-‘,-;',,!'-':$7,:z.,...;,;',',.".4.`'...„,'�e cled clothing for women and babies. 1 z; tM d PT Pearl is one of the many new businesses :::,:-F:',.,..4 f r.• 1 `” t' ,'''.,,,t,,,' ,}. in Jefferson County that are fighting the eco- .e, t nomic decline and breathing life into our local , t economy. 1.:,.-:.,,--;,/,:-“i:,r ` "1 want this shop to represent something A good happening in our community and in the • world,"O'Toole said. x O'Toole opened PT Pearl with her niece %.1,- , _ r° - Tara Welk as her business partner,in early r•fl ?� November. / "This used to be the Sea Hag,a secondhand -af �' �, ,'�. store,"said O'Toole."The owner Vicki was going f a f ry . C: at •: out of business and so she offered this to me at v'" t 1 �y +� Z. a marvelous price.She walks on water in my FL7.'-'.- a•� .". eyes." •-•.,:i, ..•,,i, v) ,3a ° ` , i Between buying the space and opening, O'Toole and Welk had only three weeks to reno- t , - vete and acquire inventory. .4.3'4,..s„, 'i "It was kind of a rush;O'Toole said."Even �,,, :. ¢ • : . • '` • in these economic times,we are filling a niche � i that doesn't exist anywhere else in town." �ep�t� "Our town,our communitywants to buy i { 13 z ;;''1?)` a` KM.1 he 01 locally,"she said. Gina Landon,owner of Sweet P.T.candy shop downtown,shows off some of the delicious goodies to be PT Pearl offers everything from hemp cloth- found at her store,which opened last month.Photo by Nicholas Johnson See PASSION,Page 11♦ . ,- .- / 2// 4/ • PM Townsend&Jefferson County Le- -r Passiew business owners appreciate stronc local support �Cominued from page 1 \ :�;. -,....",,. • P ,, f § +` .....,,,,;,:i,,,„-...,...„., mg made in Bellingham, • t 3 r, { w ", g q�x eil' tx 4`, 43 • - utility belts made in Port z -_-[.,.,.,....7y,-.,.v.,:-R.A..a42. ` «n a 4 1,.. • ,,,� ,,..� 7 Townsend out of recycled a•1 'x,.-a' ,, r.,,' i Sr• . ..4. skirts from Guatemala. x 1 • ` t t`' o f "Jake we do in life.we � � ,� x^F ' �: ��-'dd-� "r,.+� �' � go ahead and do the best we In 1�1171..::1 } - )y'. ry S 4: r. S$, :.tom :ia'� 'Y}tK ,y � r `.. Tr'yXcan with the tools at hand;' q• ,. fi O'Toole said."That's what i � 0 . e t we're doing., _ t , *,,,,?-.-",r,,:' ,'''''."., l ciA� w t.:� i - , a ,x ti �!� :s �wt� METRO BAGELS:ONE YEAR _ ` ,, F a :. tt ^" „ l: "There was a lot of z, � , � � $ r S1 demand for a good,high- 4 t {� f �f 1 � quality traditional-style4 4 `.7 i� ` bagel baked fresh daily," x r *� . g said Metro Bagels co-owner •� ` ..' ? ,r g '...?'....c,,,.1 i Mike Garling,Metro Bagels '!` `'tt 2 ; opened on Jan.22,2011.It x `.E-CT jt has been well received and K r fir; .�: �f is looking to expand. xf , - "We are putting in some i' .Sara Hayes and Vanessa Herold have been successful since they opened their new Fusion Spa and Wellness in seating and indoor dining;' " said Garling,who expects , August They look fo ward to future expansion.Photos by Lauren Salcedo the project fewto be completed "It was scaryin that trip to the Galapagos, Despite their quick suc- in the next months. ;' but I'll go see Vanessa and cess,opening a small busi- Like PT Pearl,Metro s 3 the beginning. Sara and feel like I did,"she Hess wasnt easy. Bagels was built to fill a We had to be joked' It was scary in the begin- .. Al f Taking care of"self"is Hing.We had toa be really ded- local need.Garling and i , co-owner Jeff Dale,whor really dedicated." becoming more important in icated,"said Hayes."We spent troubled times. a lot of our own money and are longtime friends,were jl "Pen le arc focusing on time on renovating the space. talking one day when the ``7°'� z Sara Hayes p 4. „ iy 1.', .- a,r y health and wellness and But then we were rewarded idea of opening a bagel co-owner,Fusion Spa and really taking care of them- with this overwhelming shop was brought hanging t , r " • Wellness "We were ghtup.out, ' {3 selves,"Hayes said.Both positive response." y pm women agreed that local sup- trying to figure out what 1 .",,,�" g Landon credits Port port has helped their start-up to do to support our fami- :14",k1A 'Townsend's ability to draw business. lies,"Garling said."Jeffin: visitors who want to "The other Uptown busi- had been baking bagels for f=z °` ;support local businesses reuses have sent people our a fundraiser at our kids' .as a way for her store to way.They have been really school,and we thought, ...,,,q4:4.,'''''' survive."People come from 'How about a bagel shop?'" ,,,al'k helpful,said Herold. r ; Port Angeles,Se to b and - Garling and Dale began t� $a even Bainbridge to buy a by taking their business to ° 7,1-";:..•,._ T .- local and support local the area farmers'markets j ` 9businesses."she said. to see if there was any '1 ....`:".'1,,,I,1,0„:,.1.„.1.''..:.„112.::.1.1.::',„* Landon caters to Port demand.And there cer- mq ,,,, , �" = • Townsend style by selling fainly was. % mostly Pacific Northwest Garling credits their .114' t° - 1- :.. products at her store.She when he talks a also makes homemade about their success this year. x 4 fudge,which is great dur- aboutteamt "Jeff has agraphic w, i ,; ing the holiday season. arts and marketing back- ground,plus his bak- "" UPTOWN GIRLS OPEN SPA ing skills.And I have a .,r, nr Vanessa Herold and background in running Pama O'Toole displays a recycled art utility belt(designed by local Port Sara Hayes opened businesses,"Garling said. Townsend resident Natalia Robinson)on sale at her store,PT Pearl,which Fusion Spa and Wellness "That's the key to our suc- opened in November. on Lawrence Street in cess.Things are going r ' l Uptown Port Townsend well.We love this location , Jez.' in August and despite the and business is growing." 1, ,'; economic decline,their Like O'Toole,the own- t ' business is booming. ers.of Metro Bagels know ra sa sr si,V+ ;� ;,, p "It's going really well. that this is an area where ;..,:',,.7'.',.. i�, , People are excited about local support is essential. 0 4:7:7-W?: v" - the space."said Hayes. 'It's really the locals ,- It., A OS/ i t '"°W0 c'"0 "All of our former clients ' ck Garling said.who are supporting Bagels :' ?g`tt'' sl r 4 x •i , L stuFusion hSpa is said in supports locals by dont- \4 NI l 4< x� pp 5�5 * { the space where Izadora's ing excess bagels to local , t i Iy Salon and Spa was previ- food banks and using a X- ct akr,' y ", `' «"k` '. ously located;Izadora's Washington state coffee ,,, ,, w t�'-' moved to Washington Street roaster for their espresso. , K ° s l "` downtown.The holidays are Mike Garlingtor,co-owner of Metro Bagels In our is shown helping their success as well. CANDY FOR CHRISTMAS with the se logo.Metro Bagels opened onPoUpperTownsend,Sims Way almost "Gift certificate sales are On Nov.1,Sweet P.T. a year ago,and has been so successful that the owners are thinking through the roof because of owner Gina Landon opened about expanding. Christmas,"said Herold. the doors of her candy shop Sweet P.T.shares s ace Despite the economic downtown. owner of the Upstage,to P "Once you've owned create his new restaurant, with Seams to Last,a recession,people are finding your own business,you Necesito Burrito,opening locally owned children's time for themselves,which are kind of addicted," soon in the space below clothing store. should help a blossoming spa . Landon joked.Sweet P.T. Wynwoods Gallery&Bead "It's scary to see what's business. Studio. going to happen this year," 1 feel like people are is Landon's second local "I had a candy shop in the admitted Landon,with die- treating themselves rather business.Her first(the deli,so I kept it and moved it ruption likely from the city's than traveling,"said Herold. Victorian Square Deli) over here,"she said. 2012 sidewalk tunnel project. They'll say,`I cant afford was sold to Mark Cole. rheawelc ®it'' To Jefferson County EnviroStars and Green Businesses! • These businesses work to reduce waste,recycle and conduct business in an environmentally conscientious manner:' 0 0 0 0 0 Five Stars Auto Works Jefferson Transit Satch Works Taku Marine Zen Care Mowing Circle&Square Printery Auto Repair SOS Printing Port Hadlock Auto Care Communications Port Ludlow PT Rigging Marina Dentistry Marina Uptown Northwest Dental Clinic 0000 Four Stairs g 00 Dockside Pleasant Point Hudson Marketech/J&5 ENVIRos7AHS Cleaners Harbor Marina Marina Fabrication ma�ageha=ard hazardous SOS Printing Port Townsend The Car Wash All City Boat Haven Goldstar Marine Autobody Annapurna Center Quilcene Schools Charles Kanieski,(PA for Self Healing Silverwater Café Auto Works Wild Sage World Teas, Wholistic Skin Tonics&Herbs Blue Heron Middle School Therapy Center Wandering Wardrobe Circle and Square Computer.Fix p Abracadabra The Food Coop Naturally Green Cleaning Brion Toss Yacht Riggers Lehani's Printery Communications Monroe St.Clinic PT Computers 3" Pane d'Amore Saint Paul's Episcopal Church 4*; Matthew Berberich b III Gardening Service SOS Printing Ravenstone Tiles Jefferson Countys Public Health . 4. PUBLIC HEALTH ETH For additional information on becoming an EnviroStars or Green Business please HEA.rrnEJUTER�u contact Pinky Feria Mingo atJefferson County Public Health 360-385-9444. • /`D G.a c.., /c-r,/,2/' /� Reduce your junk mail" fitu More than 4 million tons of junk mail is discarded (unread or unopened) each year. (source: EPA) Reduce the junk in your mailbox: • www.dmachoice.org: The Direct Marketing Association's free Mail Preference Service helps remove your name from members' mail- ing lists. • www.directmail.com: Fee service sponsored by a direct marketing company. Click on "National Do Not Mail List" from left column. • www.optpoutprescreen.com: Free service of Joint venture of three credit bureaus stops prescreened credit and insurance solicitations. Find more links and tips to reduce junk mail at www.jeffersoncountypublichealth.org, click on Solid Waste, and continue to Green Living. • Preserve open space. Support farms and forests. JeffCo Conservation Futures application period begins January 11. For info call Tami 379-4498. / _/ i , . . . pSe tic educationgrant received • Clallam County County videothat will that we produced were Department link and the replace the original Septics really good,high-quality vid- Environmental Health Ser- takes video 101 video that was produced eos. vices page. by Island County. "So the Department of Commissioner Mike to next level "They did that on a very Health actually got funding Doherty congratulated tight budget," Clallam to update the Septics 101, Health and Human Services ROB OLLIKAINEN County Environmental and they called us." staff for winning the corn- BrHealth Director Andy Bras- petitive grant. PNINSULA DAILY NEWS tad said. `Septics 201' Commissioner Jim PORT ANGELES — "It's been online for a McEntire, who was sworn number of years." The county,which agreed into office last week after Clallam County has won a to take on the project,is re- com competitive grant to update In early 2010, Clallam p serving as a Port of Port its Septics 101 video to teach County received a grant paring to unveil It You self Se-- Angeles commissioner, said people how to inspect and from the state Department tic System Inspection pro- the Septics 101 class he of Ecology to develop a pilot Y Pe attended was "very enlight- maintain their own septic training curriculum for do- gram. ening and valuable." systems. it-yourself septic system The online 101 course is "I had lived in a house in County commissioners inspections. a prerequisite for Septics Virginia years prior with a Tuesday approved a "The first step was just: 201. septic system, and I finally renewed $817,412 contract 'This is what a septic system "So we're now redoing found out after I moved here with the state Department is,"'Brastad said. the Septics 101 video to what I was doing wrong of Health that includes a "We brought it to a level make it more professional then," McEntire told Bras- $75,000 grant for the Envi- of 'This is how to inspect and in line with our Septics tad. ronmental Health Division your own septic system.' Inspection 201 videos,"Bras- "So,well done." to update the instructional "That's a pilot project tad said. video available at www. that's ongoing that we'll The original 30-minute Reporter Rob 011ikainen can be clallam.net. wrap up this year. Septics 101 video can be reached at 360-417-3537 or at rob. Other counties will be "But we've got a lot of found by clicking the Health o ll i k a i n e n@ p e n i n s u l a d a i l y able to use the Clallam feedback that the videos and Human Services news.com. • II . / A) 4/ // .., • Q 0 Ead 1 oY • : ,m "'i.;. _0 3 ate' ca +, -,0 o G ro m m E o o 5 tl o•C .. • {(y 1 f'I .0-• o) 'hc�3d nuI1I; 1ii: HIIU11 - , DIU m l 3 •vf",m ppyA.E :V.G0 • Io > "� o A 2 8 -.p .,4 ...../..-_,,A...), ,s 8 ,1'0'..31,---g' ,23 .5'..4 --6t yq� cma'_� G�� 0 QL °6 d • c7 G o 0 '.".7w.:::, // 7 �/) .0- a ma cEo ) m m .0 0 C "ti "Y �` ,.c Q .o'0 v [ cd F'GrnYomy y GGU(� cY C� h2-.• Q�A' \ .i V. ! 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'•• 0 E> yr we'd k .r 7, i ` .. 1. 44, R l .• *ou are invited to afternoontea-,--'- - _ ,,. „,,.. ...1... ....._.... at Jefferson County Public Healt . d Pacific fic Room _. = Ls. aY, Ja uary 26th 4 6*�pm •