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Home My WebLink About07 July JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, July 19, 2001 Board Members: Dan Titterness, Member - County Commissioner District #1 Glen Huntingford, Member - Counry Commissioner DiJ'trid #2 Richard Wqjt, Member - County Commissioner District #3 Geriffrry Masd, Member - Port Townsend Ciry Coundl Jill Buhler, Chairman - Hospital Commissioner District #2 Sheila Westerman, V'ice Chairman - Citizen at Lcl1:ge (Ciry) Roberta Frissell - Citizen at Lcu:ge (Counry) Staff Members: Jean Baldwin, Nursing Services Director Larry Fqy, Environmental Health Director Thomas Locke, MD, Health qflicer Chairman Buhler called the meeting to order at 2:30 p.m. All Board and Staff members were present. Member Masci moved to approve the agenda. Commissioner Huntingford seconded the motion, which carried by a unanimous vote. APPROVAL OF MINUTES Member Masci moved to approve the minutes of June 21, 2001. Commissioner Huntingford seconded the motion, which carried by a unanimous vote. OLD BUSINESS Consumer Reports and WSMA Reports Articles on Vaccine Safety: This information was provided as a prelude to a follow-up study the Department of Health will conduct in October on school immunization exemption rates. Jefferson County has one of the highest exemption rates in the state at 8.9%. While it is believed this percentage can be improved, it is not expected to reach the statewide average of 3%. Dr. Tom Locke noted that in addition to efforts in the schools, nurses from the Health Department have provided information on a case-by-case basis. He also noted that there is currently an outbreak of pertussis (whooping cough). Member Frissell suggested that Dr. Locke rerun last year's Leader article on vaccinations before the school year begins. Commissioner Huntingford asked what recourse parents of vaccinated children have against those kids without vaccinations who are nonetheless attending school. Dr. Locke said there is no recourse. Although it is often after the fact, once an outbreak reaches the school, unvaccinated kids are sent home. He said there are states that do not have an exemption; if you are not vaccinated, you are not allowed in HEALTH BOARD MINUTES - July 19, 2001 Page: 2 school. There is no vaccine that is 100% effective. His greatest concern is that parents make the decision to sign exemptions based on misinformation. When asked about communication with home schools and how their compliance is tracked, Jean Baldwin said several contacts are made with home school parents through several groups. There is a statewide tracking system - Child Health Tracking - not funded by the legislature this year but will be funded by the Department of Health. While 50% of the records have been entered into the database, none of those records are currently available. Vice Chairman Westerman asked if there is communication with alternative care providers. Jean Baldwin said there is a lot of contact and information through events such as the recent Fact Night on pertussis. Senator Maria Cantwell Visit: The Department learned yesterday that Senator Cantwell is interested in meeting with the Board and others about health access problems. She will be at the Health Department at 4:00 on Saturday NEW BUSINESS Adult Diphtheria- Tetanus Vaccine Shortae:e - .T efferson County Response Plan: Dr. Locke reported that there will likely be a delay and shortage of flu vaccine again this year. The adolescent and adult form of diphtheria/tetanus vaccine is also in short supply nationwide. The routine vaccination, which is recommended for all adults every ten years, will be inadequate to cover the U.S. population. Only one of two suppliers remains and it has decided to prioritize available stores and distribute only to emergency rooms and county health departments (at a rate of 30 vaccinations per month). Among the four priority groups - those traveling to counties having diphtheria outbreaks, those needing to complete their three dose series, pregnant women to prevent tetanus of the newborn, and management of tetanus-prone wounds and injuries - it is the last that is the biggest challenge. Vaccinations will be sold to local practitioners at cost, with the request that they restrict use to the four priority categories. The local goal is to have minimal disruptions of care patterns while not wasting vaccine. Community Indicators Workgroup Presentation: Jean Baldwin reported that the Data Steering Committee, working with Dr. Chris Hale, has been looking at Jefferson County health indicators. This group will identify issues and provide guidance on a data decision-making mechanism. Because $25,000 of the funding for this project was provided by the City for the law and justice study, there will be deliverables due to the City in two years. With the data that has been delivered to date, Members Masci and Prissell outlined the following issues that are beginning to surface and that we should stress in our outlook: economic development/housing/poverty, seniors, law and justice, substance abuse, policy/prevention, and mental health. Member Frissell said she finds it interesting, from the data received so far, that some of the assumptions made by different agencies are not correct. While some fascinating preliminary data exists, it is still raw data. Member Masci stressed that since the data has yet to be processed it should be used cautiously. HEALTH BOARD MINUTES - July 19,2001 Page: 3 Dr. Hale talked about the unique demographics of the County. While the population has doubled in 20 years, births have remained constant. Despite the fact that the number of women in their oldest childbearing years (40s) has doubled, Jefferson County's fertility rate has not reached 2.1 since the early to mid 1990s. The County is aging rapidly not only because the total fertility rate is low, but because of an immigration of people 65 and older, with the most rapidly growing segment being 85 and older. She stressed that the 85+ group also consumes the largest share of healthcare resources. Dr. Hale then reviewed Jefferson County data compared to other area counties and to the State. Because Clallam and Jefferson have similar demographics and needs, they have agreed to share the staff resources of Hillary Whatcom for routine data analysis and updating. Regional issues that are surfacing are the rapid aging of the population and children born to older women are likely to be poor and suffer from a number of other disadvantages. She noted that this includes only civilian figures, not military data. Some 600 Jefferson County residents will complete the Behavioral Risk Factor Surveillance System (BRPSS) survey to help identify health risks of people who have been here a long-time versus those who have arrived in the past five years. She noted that because over half the births Jefferson County women are reimbursed out of the Medicaid Insurance system and many are on welfare. Jefferson County families are going to be disproportionately impacted by the implementation of welfare cuts. As this data is reviewed, the issues that remain on the table are persistent poverty, especially in families, and the large senior population. These two groups have very different demands for the use of public dollars. Substance abuse (tobacco and alcohol) and suicide data are also running above State averages. There was significant Board discussion about mental health, poverty, and employment as factors in suicide rates. Dr. Hale said while there may not be able to be much gain in the biological health indicators, there is room for improvement on quality of life issues. Because of the unique age distributions, there are rich opportunities for putting together programs that work across generations and communities. Final BRFSS data will be ready to analyze at the end of January. It was suggested that a BRPSS update be listed on the Board of Health's October agenda. Policy Discussion-Required Connection to Community Sewer Systems: Larry Fay explained that this issue was triggered by an application for a subdivision in Port Ludlow. While the lots were large enough to support a septic system, the question is whether to require a connection to sewer service when it is available. When conditions were originally placed on these plats, the clear intention was that they would be connected to the sewer when service became available, but there was no formalized condition in the approval. Clear direction will be needed if these decisions come up in the future and he asked for input from the Board. He recognized that any time you consider a lot in isolation sewer service is expensive. However, every time a septic permit is issued, it creates one more obstacle to expanding sewer lines. The question is how to provide incentives for the community to pool its resources and develop the necessary infrastructure. He indicated that minimum land area requirements say that if sewer service is available, a waiver will not be issued. There is no utility policy that encourages people to make the extensions. Chairman Buhler asked who would determine the practical distance to the sewer line under which a HEALTH BOARD MINUTES - July 19,2001 Page: 4 connection would be required? Vice Chairman Westerman questioned the County's role in what seems to be the job of the developer. "Available" service could actually be 300 feet away. She believes the Board could pick a fixed number rather than stating a range (e.g. 200-500 feet). She asked why the City's policy on this matter is not clear to the County? Commissioner Huntingford said if the line is within 100 feet but there are five-acre tracts on an elevation, he does not believe it is the intention to put them on sewer. He suggested that a countywide sewer or septic plan that the County and PUD are discussing might be an appropriate place to address this problem. Larry Pay said he is interested in initiating this discussion and its ties to planning policies. He will be reviewing any existing models or policies that at a minimum do not interfere with the desire to extend sewer lines. He questions how the County, through the utility, can get into a community process to create utility districts that allow them to access funding to finance the sewer extensions? Vice Chairman Westerman believes this is more a planning than public health issue. The utility provider appears to be willing to spend the necessary money to run the sewer lines. Commissioner Titterness said he believes the Comprehensive Plan says if sewers are available you will connect. Commissioner Wojt said that, as a Urban Growth Area, Port Ludlow needs to provide the infrastructure to deal with sewer and water. The question for the Board of Health is whether they have the sewer available to them. The community itself has to answer questions about economic accessibility. Commissioner Huntingford believes it may be a land use issue. He agreed to take the issue back to the Port Ludlow Village Council to see if they want to seek a solution through the utility provider. Member Masci said the confusion with the City is that they are discussing the idea of a sewer levy to extend the lines. If enacted, people will be required to hook up because the City already has such an ordinance. Member Prissell said it is important for the Board of Health to make a commitment to sewers whenever possible. Perhaps a developer could be expected to bring the sewer distances greater than 200 feet from the existing line and factor the cost into the lots. In response to a question, Larry Fay explained that State law says that if a property within 200 feet of sewer service has a failed septic system it is required to connect to the line. Chairman Buhler said there are other factors involved in whether it is cost effective to put in a sewer outlet, such as elevation. She would not like to see an arbitrary 200-foot limit established without having an appellate process in place. HEALTH BOARD MINUTES - July 19,2001 Page: 5 Larry Fay said any time you have existing lots, densities, and marginal soil conditions sewers are desirable. Our policies should not create a disincentive. The County is getting increased pressure from people who want permission to build on lots that fall short of septic size requirements because they cannot afford sewer extensions. Commissioner Titterness commented that while it is to some degree a disincentive to allow a septic system to go in, it is not as large a disincentive as one might think recognizing the value of a Step system. Larry Fay responded that as a utility, Port Ludlow is not interested in a Step system. He agreed to place this item on the agenda next month after there has been a chance to collect more information. He understands that the County's minimum land area policy stands. Policy Discussion - Buildine: Permit Applications with Existing On-Site Sewae:e Systems: Larry Fay introduced this item to see if this approach is acceptable to the Board. If so, he will take more specific comments with respect to the language. The goal is to find some predictability for staff and the public when processing a building permit. He believes the general policy statement being made is that if you have an existing, permitted on-site sewage system, it is highly unlikely you are going to be denied a building permit over sewage issues. Furthermore, the decisions made with respect to compliance are based on critical features in the installation of systems that protect public health. He agreed with Commissioner Titterness that generally, a system does not exist that could not be enhanced to perform up to standard. Member Westerman suggested that "public health" be replaced with "public and environmental health." Member Masci asked about the Board's action to allow independent inspectors thereby eliminating delays in environmental health inspections? He believes the realty industry and homeowners continue to be confused about this issue. He suggested that a letter be sent immediately to the Realtors explaining the process and timeline. He also suggested that a sentence be added under the General Policy Statement specifying either Environmental Health, a licensed septic system designer or a registered professional engineer. Larry Fay agreed to make this change. He will meet next week with several independent contractors interested in being licensed inspectors. The program and training criteria are being established. Starting in August, it is expected that there will be at least two people authorized to do the inspection. The uncertainty relates to what that statement in the regulations means and how extensive an evaluation is required. Commissioner Huntingford expressed his continued concern that there is little evidence of a threat to public health from systems that may not meet current code but which met the code when installed. Even though a renovation such as a new roof may not affect the septic system, it may entail an upgrade to their septic system, marking out a reserve area, and waiting ten weeks for approval. If an upgrade is unrelated to public health threat why should it be required? Member Masci said the County needs to get more information about Smart Coding. HEALTH BOARD MINUTES - July 19, 2001 Page: 6 AGENDA CALENDAR/ADJOURN 2001 AGENDA ITEMS 1. CONTINUED STABLE FUNDING TO REPLACE MVET 2. ACCESS HEALTH CARE 3. PROGRAM MEASURES (Genetic Research and Public Health Implications) 4. METHAMPHETAMINE SUMMIT 5. PERFORMANCE STANDARDS & COMMUNITY ASSESSMENT 6. TOBACCO PREVENTION AND COALITION 7. FLUORIDE 8. TRANSIT AND PUBLIC HOUSING 9. BIOTERRORISM READINESS & PLAN 10. AGING POPULATION 11. WATER 12. MATERNAL CHILD PREVENTION GOALS (0-3) The meeting adjourned at 4:35 p.m. The next meeting will be held on Thursday, August 16, 2001 at 2:30 p.m. at the Jefferson General Hospital Conference Room. J~FFERSON COUNTY BOARD OF HEALTH ( .. JYJ.htfJ ~ #B~hl;;:Chairman Z;~lu- U)~4er~~ . ard Wojt, Member /~~~ Roberta Frissell, Member Dan Titterness, Member JEFFERSON COUNTY BOARD OF HEALTH Thursday, July 19, 2001 2:30 - 4:30 PM Main Conference Room Jefferson Health and Human Services AGENDA I. Approval of Agenda II. Approval of Minutes of Meetings of June 21, 2001 III. Public Comments IV. Old Business and Informational Items 1. Consumer Reports and WSMA Reports Articles on Vaccine Safety 2. Mandatory Vaccination Exemption Survey Timeline V. New Business 1. Adult Diphtheria-Tetanus Vaccine Shortage-- Jefferson County Response Plan 2. Community Indicators Workgroup Presentation-- 3. Policy Discussion - Required Connection to Community Sewer Systems 4. Policy Discussion - Building Permit Applications \Vith Existing On-site Sewage Systems VI. Agenda Planning 1. Future Agenda Topics VII. Adjourn Next Meeting:: August 16, 2001 - 2:30 - 4:30 PM Main Conference Room Jefferson Health and Human Services Tom (5 min) Dr. Chris Hale (60 min) Larry (20 min) Larry (20 min) JEFFERSON COUNT)'" BOARD OF HEALTH MINUTES ORAf't Thursday, June 21, 2001 DRAFT Board :vl~mber:: Dan Ti::ernes:. _Hember - Count Commiwoner Dis:ri",:;::'/ Cler: Hunimgjord, Alember - Coun~l' CummiJ'Jioner DiJ:r.i'/ #:: Ri:hard [FD.!:' Member - CO/./ltD CommiJSioner Distri:t #3 Geof('rer _\Jasd, }lemher - Pori Townsend Cit)' Council Ti:~' B;;h,;r. Oair771an - Homi/a! Commissione; Dzstrict #2 5 mi/u If''esterman, Vice Ch~irman - Citizen at LArge (Cit]/ Roberta Friml! - Citizen at urge (CounC/) Staf-"vlembers: feal: BaiawllZ. _'\;trsing Jm/im' Director L:zrr.: F0' Envzronmenia/ Heat/h Direi'tor Thomas Locke. MD. Heaid? q/lZeer Chairman Buhler called the meeting to order at 2:30 p.m, All Board and Staff members were present. Commissioner Tittemess asked that an item titled Clearinghouse for /v! edicaid Billing be added under New Business. Member IVlasci moved to approve the agenda as revised. Commissioner W ojt seconded the motion, which carried by a unanimous vote. APPROVAL OF MINUTES A correction was made to the last sentence on Page 3. The word "made" should be added so that the sentence reads "Member Frissell said while this may satisfy the situation when the property is sold, what is the mechanism when payments have not been made establishing a fund for system repairs?" Commissioner Huntingford moved to approve the minutes of May 17, 2001 as corrected. Member Masci seconded the motion, which carried by a unanimous vote. OLD BUSINESS Jefferson Health Access Summit 2001: Dr. Tom Locke noted that the meeting summary for this well- attended event was provided in the agenda packet. He believes the next step will include the original workgroup polling participants to plan a follow-up summit, which would focus on specific proposals, associated costs, legal authorities, and other issues. In other words, moving from issues to solutions. Member Masci noted that a common thread among the Summit workgroup was the idea of a community clinic. He proposed that since this subject keeps surfacing, the Board of Health may want to make a statement of support or a directive to look into it. Vice-Chairman Westerman said while the subject of common elements from the summit workgroups could be a Board agenda topic, it may be premature to make a statement of support. HEALTH BOARD MINUTES - June 21. 200J Page: 2 Dr. Locke said in planning the next summit. the work group will be looking at common issues among the Summit workgroups and the possibilities for bringing in more money or spending less monev on ~ administrative overhead. . Commissioner Huntingforc asked whether there may be a tie-in between the Hospital's search for additional revenues and the goals of the Access Committee? Chairman Buhler said that aside from looking at increasing revenue. the Hospital believes it will be important to reevaluate the many programs offered by both Jefferson General and the Department of Health to determine who can do the work most efficiently. Some trends in reimbursement may favor one entity over the other. Dr. Locke said the workgroup would be reporting back to the Board of Health in July. Legislative Update: The legislature produced a status quo budget of $22.8 billion in the two key public health areas of concern which were the 1-695 backfill money (which replaced 90% of S27 million in local health funding and added a modest fiscal growth factor for the next two years) and local capacity development funding (which was to be a down payment on the public health improvement plan). The Child Death Review received a modest appropriation of $1 million, which will help defray some local expenses in reviewing unexpected deaths. It appears there is also some funding for investigating and cleaning up clandestine methamphetamine labs. During discussion about what was not funded, County Administrator Charles Saddler commented that this budget included $600 million which came out of a one-time pension trust fund. It is projected that some agencies will run out of money before the end of the biennium. Community Indicators Workshop: Jean Baldwin reviewed the list of attendees of workgroup meetings . whose task it is to review data and how it is used, as well as identifying problems and priority areas. Topics of concern are senior issues, violence among kids, school enrollment, substance abuse, and affordable housing. The group decided that a review of health issues must include quality of life issues. She reported the County applied for a Motor Vehicle Accident grant to investigate the high incidence of motor vehicle injuries in Jefferson County. The County website incorporates data as it becomes available and includes regional data. As the BRFSS data is available, the committee will release this information to the community. Dr. Chris Hale expects to have her analysis of BRFSS complete by spring 2002. She will attend next month's Board of Health meeting. Member Masci mentioned that while the City and County agreed to co-fund BRFSS for two years, he believes a commitment to sustain this funding over a longer term will be needed as a way to support the strategic planning processes of each government. HEALTH BOARD MINUTES - June 21, 200l Page: 3 Take Chare:e Pro2ram Implementation: Jean Baldwin described this program as a family planning waiver that allows DSHS lvledical Assistance Administration to make available family planning services for cliems not currently enrolled in DSHS. but who qualify based on their income. The intent of the program is to decrease unintended pregnancies and lower the number of births. She noted that JCHHS is increasing its family planning services to both Port Hadlock and Quilcene. A June 18 memo explains that 550 out of 936 JCHHS clients could qualify for Take Charge. Although there are billing issues to work through. this program provides an unexpected source of funding. Jean Baldwin reported that she recently received a contract from DSHS for an outreach program in Port Hadlock and South County. Because these contracts are only available to nurses, there is an opening for a three-days a-week, 4-hours-a-day nurse to perform this outreach and education. Additional handouts were a Provider Newsletter and a June 15 letter from Ms. Baldwin in support of Jefferson General's hospice work. Maternal Child Health - Hear & Say: Readin2 with Toddlers Proe:ram: Jean Baldwin explained that this universal prevention program encourages parents to work on reading to promote toddler language development. The philosophy is based on the knowledge that kids who cannot read well end up performing poorly in school and that a lack of success in school can lead to other issues. The study has proven that if a parent works with the toddler, the child's reading skill will improve. This research project is funded by private donations and will be available to all two year olds, using several different methods. The client base will be chosen from volunteers using birth certificate records and the WIC program. A part of this project will be training three or four local individuals to run the program so that it will be sustainable. Aside from providing office space, there is no cost to the JCHHS for this study. In response to questions about how success will be measured, Jean Baldwin said some of the data will be available in six months. Regarding funding an ongoing program, she said the amount of funding needed will depend on the best method. This program may be able to be integrated into another program. She noted that the schools and the libraries are both involved in the planning group to get the program going. Chairman Buhler suggested this item be placed on the agenda in seven months for an update. Topics for Local Board of Health Workshop - Survev Results: Based on a survey of interests for a potential leadership development workshop. Dr. Locke reviewed the prioritized list of topics included in the agenda packet. This list will be used to plan for the workshop, which has been scheduled for all day October 25 and a half-day on October 26 at Sea Tac. He reviewed the workshop format of presentations followed by small group discussions and urged Board members to put the workshop on their calendars. Member Frissell suggested a format allowing several different presentations to occur simultaneously so Board members may choose which to attend. HEALTH BOARD MINUTES - June 21. 200] Page: 4 Jefferson Health and Human Services Director Recruitment: County Administrator Charles Saddler briefed the Board on the internal assessment of JCHHS needs and issues. Based on this feedback. the BOCC approved the appropriation of funding for the position of Health and Human Services Director. Staff has begun creating a recruitment brochure and gathering information on important traits or -....... .... - .. management skills. They expect to fill this new position by the fall 2001. In response to a question about this position's impact on the Board. Dr. Locke responded that when the expanded Board was created. the Director of HHS became the Administrative Officer of the Board. In Washington State. the role of Administrative Officer and Executive Secretary default to the Health Officer. The new director would become the Administrative Officer to the Board. This new position will not only allow the department managers to focus on the issues at hand. but assist the Board and managers' efforts on medium and long-range planning. Clearinghouse for Medicaid Billing: Commissioner Titterness asked to discuss the potential efficiency of a centralized Medicaid billing n~twork. County Administrator said this issue arose from a problem identified by Jefferson Mental Health and the Department of Mental Health, where significant staff resources were necessary to do Medicaid billing. The question is whether there can be economies of scale. Jean Baldwin said that Washington is one of the hardest states in the country in which to accomplish DSHS billings, with a major problem being reimbursement rejections. Member Masci talked about medical software, which he and other practitioners use. He believes a good way to choose a product is to get a consultant to come in and evaluate the range of software, vendors, and support. Maybe several agencies having difficulties with billing could participate in such an evaluation. Jean Baldwin said what makes the billing complicated is that public agencies are asked not only how much the service costs, but to specify the deliverables and the types of services. There was consensus that a centralized Medicaid billing network is not a topic on which the Board wants to proceed. AGENDA CALENDAR / ADJOUR.N Charles Saddler said the Board would receive email asking them to identify the five most pressing issues concerning public health so as to assist the BOCC and elected officials in Jefferson County in a strategic planning process. HEALTH BO..\RD MINl;TES - June 21. 2001 Page: 5 2001 AGENDA ITEMS 1. CONTINUED STABLE FUNDING TO REPLACE MVET ACCESS HEALTH CARE PROGRAM MEASURES (Genetic Research and Public Health Implications) ~IETILI\MPHETAMINE SUMMIT PERFORMANCE STANDARDS & COMMUNITY ASSESSMENT TOBACCO PREVENTION AND COALITION FLUORIDE TRANSIT AND PUBLIC HOUSING BIOTERRORISM READINESS & PLAN AGING POPULATION WATER MATERNAL CHILD PREVENTION GOALS (0-3) ...., ,.., ~ .' , 4. 5. 6. ~ I. 8. 9. 10. II. 12. Meeting adjourned at 4:33 p.m. The next meeting will be held on Thursday, July 19,2001 at 2:30 p.m. JEFFERSON COUNTY BOARD OF HEALTH Jill Buhler, Chairman Geoffrey Masci, Member Sheila \Vesterman, Vice-Chairman Richard Wojt, Member Glen Huntingford, Member Roberta Frissell, Member Dan Titterness, Member .' PAn 0 'of'atwo-partserles Misinformation and government foot-dragging are fanning fears. his is the season of the shots. when parents sGamble for appoint- ments to bring their kids' immuni- zations up to date in time for school openings. The annual ritual is be- LOming Jnvthing but routine for growing numbers of parents who feel thev're LOnfronting a terrible dilem- ma: Do I expose my (hild and (orn- munity to the risk of a serious disease? Or do I expose my (hild to the risk of one of those rare (atastrophic reactions to the vaccine itself-reactions that I keep read- ing about on the Internet? Even for those who don't have small (hildren or grandchildren, distrust of the vaccine program--one of America's most successful public-health initiatives-is (ause for concern, It's contributing to a severe underuse of the adult vaccines for tIu ~lI1d pneumonia and also to locai outbreaks of vac(ine-preventable diseases. A friend's doubts about vaccine safety worried Suzanne Walther of ;\lurtTeesboro, Tenn" who decided to search the Internet for information. "I just typed in the word 'vaccines' and everything that popped up was antivaccine material," says Walther, who decided as a result to postpone immuniza- tion of her infant, .\lary Catherine, She waited too long. On the eve of her hrst birthday, Mary Catherine contracted Haemopilillls inf711crIzae B (Hibl meningitis and landed in intensive care, It was the hrst case the hospital had seen in eight years; Hib meningitis has become rare since the 1987 introduction of a vaccine against it. The dis- ease had a significant chance of killing or disabling the baby; fortu- nately, she recovered. Ninety percent of pediatricians and 60 percent of familv doctors recently surveyed by University of Michigan researchers said they cared for at least one child whose par- ent refused immunization. A study in Col- orado found that unimmunized children were 22 times more likely to contract measles and 6 times more likely to contract pertussis (whooping cough) than vaccinat- ed children. "In the middle ~lfe parents who are trying to do the right thing," says Bruce Gellin, ;\1.D., a preventive-medicine specialist at Vanderbilt University and executive director of the National Network for Immunization Information, an independent source of scien- tifically verified vaccine information. JUST A TINY PINCH Dr. Peter Richel (above) ofMt. Kisco, N.Y., gives Carlie Grave her polio and DTaP (diphtheria, tetanus, pertussis) boosters. Vaccines have spared Carlie and her friends at Quality Time Nursery School, Katonah, N. Y. (left), the risk of 11 serious childhood diseases. 2001) CONSUMER REPORTS 17 A. CLOSE CHI A.nti- vaccine arguments persuaded Suzanne Walther of Alurfreesboro, Tenn., to postpone vaccination for baby Alary Catherine Iin striped romper). Just before her first birthday, the baby contracted a serious case of vaccine- preventable Hib meningitis. Luckily, she recovered fully. imf11uniz,ltiol1 decisions tod,ll. Jrc in their .20s ,md 30s. "\Ve're f'risoncrs ,)f pur own succcss," 'lhserws WilliJm SchJffner, \1.D.. chJirn1.ln PI the Dq'Jrtf11ent of Prc\'enti\.L' :Vlcdicine Jt \'aIllkrbilt L'nil'C[- sitv, "\Vhen formerl:' drcaded diseascs have been pushcd into the shadows-or eliminateJ- questions about the vaccines themselves spring up," The next decade is likeh' to bring new vaccines against HI\', genital herpes, tvpe 1 diabetes, Epstein-Barr virus, cervical can- cer, and streptococcus :\ and B, to name iust ;1 few under development. That will make oversight of the benefits and risks of vaccines more crucial. Improving the safetv record of vaccines is no small task for several reasons: ~ Since vaccines are given to healthy people, serious risks Jre unacceptable, But what's ''seri- ous"? If a vaccine prevents l.OOO deaths. are 10 vaccine-related iniuries an acceptable trade-oft? If you or your child is one of the 10, the answer is probablv no, If you are a public-health official. the answer isn't so obvious. ~ \Iost childhood vaccines en- joy almost total protection trom product-liability lawsuits, While this has kept manutJcturers in the vaccine business, it has ,llso removed one important incenti\e to improve satety be:;ond current levels, IR '01'. t: ::-% =-1 THEANSWERMAN Walther credits Dr. Bruce Gellin of Vanderbilt University, where Mary Catherine was treated, for taking her concerns seriously and finding answers to her questions. "I never felt like 1 was being blamed," Walther says. She is now an ardent supporter of childhood immunizations. The small but intluential antivaccine groups circulating the information that Walther tiJUnd are doing the nation both ,I disservice and a service. Their best-known accusations-that too mall\' \'accines "overwhelm" the immune ,I-stem and that the \1.\[R vaccine against measles, l11umf's, and rubella causes ,1Lltism-.lppe~:r gwundless, according to the btest resl.\lrch, But the noise-making has shaken up the Food ,Ind Drug :\dministration (FDA! and the (:L'nter, tll[ Disease Control ,ll1d Pre- \TI1lltln (:DC, the two agenCies most con- .:erned '".ith ':accine satetv, ()ll[ examination ()f the vaccine-safet\' rl,,'(lrd has :()UnJ that in SOllle' ,lre:1S this ,h'lke-up i, :ong overdue: .. There are significant gaps in the S\'stem t;,r mOl1it"nn;.: 'he safet\' \)f newlv introduced .. . . ,I11J "ida I,l(cine's, ~ ThL' gtl~lrdiJns of vaccine satet\' han: bL'en sIllw tll address correctable problems, such ,IS the use of mercurv as ,I preservati\.e in )ome' infant ':accines, .. The ,ldversariaJ treatment of the 150 or so .-\mericl11s ',,'ho ,lpplv each Veal' tin com- pensation t'l[ adverse errects irom \'accines has angered manv and provided recruits to the antivaccine tl)rccs. In this report, wc.lI discuss where the v.lccine-safen' wstem has t;lllen short and how it can he improved, \Ve will examine ""'.";:' the evidence behind the main arguments of the antivaccination actIvists, ,\nd we will suggest ways in which consumers can bene- ht from immunization while minimizing risks, In an upcoming rcport this bll, we'll rake a closer look ,n adult vaCCllles, THE PRICE OF SUCCESS L'nder the current scheduie, children reeer\e 23 shots ,Igainst t 1 diseases betl)re starting kindergarten, Betine the \-accines were introduced, the toll of ] 0 of these vaccine- preventable diseases-diphtheria, me~lsles, mumps, pertussis, polio, rubella German measles), tetan us, hepa ti tis E, pneulllococ- cus, and Hib--was neadv .2 rnil!ion report- ed cases of disease per veal', based on their peak veal' of incidence, Even the "mildest" vaccine-preventable disease, chicken pox. claimed 1 00 lives each vear. But the youngest Americans who C,ln remember diphtheria and whooping cough are on :Vledicare, The voungest who can remember polio and measles are in their 50s and 40s, respectively. ,vlost parents making 3 CONSUMER REPOllTS HOW VACCINES ARE TESTED \Iost vaccines come to market with Ji1 incomplete safetv record. ,\ new vaccine is tvpicallv tested on IO,OOtl to .20,000 peo~'le before the FDA approves it. That's enough to studv disease protectIOn but not enough to reliably detect rare complications. In 1998, the FDA licensed RotaShield, J vaccine to prevent an intestinal infection that was striking an average of 3.5 mil!ion babies in the L',S. a veal' and killing 20. Of the 10,054 babies vaccinated during the tests,S devel- oped a condition called intussusception, ,I life-threatening collapse of the boweL Since intussusception can also occur spontaneouslv, it wasn't mathematically dear whether or not the vaccine caused those cases. But within six months of the vaccine's introduction, after some 1.5 million babies had received it, monitoring studies found Details on vaccinations The 11 diseases prevented by childhood vaccines were bad ones, as this table demonstrates. The damage they caused far outweighed even the most trou' blesome known vaccine-related complications. This chart shows the most common complications unique to each vaccine. In addition, any vaccine can cause minor reactions such as a mild fever or pain at the injection site. And very occasionally. any vaccine (or one of its inactive ingredients) can cause an imme- diate. serious allergic reaction known as anaphylaxis. ..: :J. ~ :923 206.939 1927 1.560' 40 :926 (whole cell) 265.269 7.288 19911acellularl 1985 20.000' 71 1981 300.000' 7.694 Encephalitis (1/1,OCO cases), pneumonia (6/100 cases I. death (1 to 2/1,000 cases), seizure (6 to 7/1000 cases) Deafness (1/20.000 cases), inflamed testicles (20 to 50/100 postpubertal males) Blindness. deafness, heart defects and/or ~etaraatlon in 85 percent of children born to ;]lathers infected in eariy preGnancy MeninGitis (800 cases/year), pneumonia (17,000 New vacc:ne cases), blood pOisoninG (15,000 cases) Death (2 to 5/100 case in children), 89.6 resPiratory failure. paralYSIS. costPOIio syndrome ,Gurce: Cenrers 'or Disease Control and P'evenrion . Eslimarec "Journal 01 t.~e ."mer:can Medical ASSOCiatiOn. March 15. 2000 894.134 100 152,209 387 56,686 267 93.000' New vaCCIne 21.269 0 Chicken pox (varicella) DTaP :995 4 million' Diphtheria Tetanus Pertussis H influenzae B (childhood) Hepatitis B MMR Measles :963 Mumps 1967 Rubella :969 Pneumococcal** 2000 (childhood) Polio :955 (paralytic) that vaccinated babies had a 2 I-times higher chance of intussusception than normal within the first few weeks after their shots. [he vaccine is no longer in use. The obvious way to catch such problems before marketing is to vaccinate more test )ubiects. But the price of new vaccines is al- ready high-a single dose of the newest, a \'accine against childhood pneumococcal disease, costs S58-and testing more sub- iects would drive costs still higher. Moreover, it's hard to recruit enough volunteers even tar the modest-sized trials. "Everybody wants more babies studied, but whose babies are these going to be? Your babv or somebody else's baby?" .lsks Kathryn Edwards, M.D., a Vanderbilt University pediatrics professor who has worked on many vaccine research projects. Once J vaccine goes on the market, the N/A Encepnalitis (2/10.000 cases), bacterial skin infections. shlnqles i300000/yearJ Jeat~, 15 to 10/100 cases). muscle paralYSIS, heart faiiure Death 130/100 cases), fractured bones, pneumonia Death (2/1.000 cases), pneumonia (10/100 cases), seizures (1 to 2/100 cases) Death 12 to 3/100 cases), meninGitis. pneumonia, 93.5 blood poisoning, Inflammation of epiglottis, skin or bone infections Deam from cirrhOSiS or !iver cancer (4,000 to 88.1 55DOlvearl main way of tracking unexpected complica- tions is thwugh a federai program called the Vaccine .-\dwrse Event Reporting System I VAERS!. But this system has major draw- backs: It's voluntary i except for manufac- turers i, and reports don't necessarily mean that the ,ldverse reaction is truly associated with the vaccination. To compensate for these failings, the government also finances a smaller but more complete program, the Vaccine Safety Datalink, that uses the comprehensive records of several large managed care orga- nizations to track vaccine outcomes, Addi- tional sat'et\' research programs are under development as well. TWO SAFETY LAPSES In two recent cases, vaccine-safety agencies were slow to act on emerging problems: 59.4 Mild rash 11/20 doses) 833 ProlonGed cryinG, fever of 105 OF or hiGher Peripheral neuritis, Guillain-Barre syndrome (temporary paralysis-rare) Brain disease (Q to 10/1 million doses-whale-cell vaccine onlv) 91.5 Fever of 103 OF or higher (5 to 15/100 doses) Temporary joint pain \25/100 adult doses in women) Fever over 100.3 OF (22/100 dosesl VaCCine-induced pOlio (oral vaCCIne only-I/2A 'nlilion doses) Mercury in vaccines. Even minuscule doses of mercury can impair the cognitive development of babies and young children. Just this year, the FDA warned pregnant and nursing women and very young children to avoid certain mercury-containing fish. Yet until last year, the same agency permitted the use of .:hiidhood vaccines containing mercury in quantities that many, including Consumers Union, consider unsate. Mercury is a maior constituent of thi- merosal, a preservative that tar the past 70 years has been added to multidose vials of vaccines to inhibit bacterial growth. There has never been a scientific study of the safety of using this product in chil- dren's vaccines_ Nevertheless, its use con- tinued until 1999, when the FDA added up vaccine-related thimerosal exposure for the first time, as part of an agencywide AUGUS~ 2001 ) CONSUMER REPORTS 19 ,tudv I)f lllercurv-containing f'ruduc(:" :\t thc time, three vaccincs routlI1l,k given to ncwborns ,ll1d int~ll1ts, he[',ltitis B, !-lib, ,1Ild DTP. containcd thimeru"d. ,\n avcrage-,izl'd babv givcn \.;\ccinc, con- talIlIng thc nLlximum conccntr.ltion ,'1' thil11erlh,ll was being exposcd to 1 S- micrugrams of mercurv, more th.m tWICe what the Environmental Protcction ,\gcnc'.' deems sate for vcrv voung childrcn, bp')- mrc didn.t exceed the much kllhcr FD,\ guidelinc. which Consumers L'nlOn bc- lieves is too high, j :-ievcrthdess, the FDA and CDC .dhJ\\cd immunizations with thimerosal-containing vaccines to continue-while coop- erating with manufacturers to cre- ate thimerosal-free versions as quicklv as possible, :-iot until eark ~ POLIO FRO}.! \~\CCl.\E David Salamone, now age 11, got polio from the oral vaccine he received as a baby more than a decade after the last case of "wild" polio in the U.S. His father, John, spearheaded the successful effort to force a switch back to the safer killed-virus injectable polio vaccine. ~~'b': F1 .. : fl<. .....;~ --l ,- ; =~ - ""L =- ,., =- "m jQ]u in 2001. more than a \"ear and a haif ,uter the issue t1r,t surfaced. were ,111 childhood vaccines made without significant .ln10unts of thimerosaL Vaccine-associated polio. The 11ral polio vaccinc In use from 1960 on had an .llk1l1- tage ovcr the original kilbi-Vlrus),uk \,IC' cine, The live. weakened virus it containcd replicated and spread from person tn ,'er- son. immunIzing mam' who werc expo'cd to it even though the\' weren't vaccin,lted themseh'es. This so-called herd immul1lt\' is whv experts expect that polio will ,oon be the second disease in history, atter ,mall[oux, to be eradicated from the globe. But the oral vaccine has alittle-klh1wn downside: In about I in everv 2,4 million doses, the ingested virus mutates back into a virulent form capable of causing disl"lse, Since] 979. the onlv cases of polio in the U.S. have been caused by the oral vaccine. Yet not until 1999 did the CDe's vaccine policv-making group vote to switch belCh to :0 CONSUMER REPORTS A t hl' ; lllect.lble, inactivated \'accine that can- not C.lll,e polio, During that 20-\'ear period. there ..llTe eight to nine cases of \'accine- a'5oClat,'d paral\'tic polio each \'ear. "\\!n' did it uke 20 \ear, to make the ch,lnge"'"lVS John Salamone, a Virginia f',lrent whlbe 11.\'ear-nld son Je\'Cloped p.lr.linlc ['olio from his second dose of \)ral ':,llcine, .'It was an egregious act bv the gov- ernment." Some \',lCcine experts .1gree that the vac- cine', >.Hetl' should have been considered ,ooner, 'The decision could have been made lO I'ears earlier," savs :\eai Halsev, .\1.0.. Jirectur of the Institute t(lr Vaccine Safetv at - '. Johns Hopkll1s Universitv, Sai,lmone believes the turning point came when affected families ,1ppeared before the CDC committee that sets im- munization policv, "Until these doctors ,aw these kids in wheelchairs. thev never put !~l(('S i:)n ',vhat the!' \v\:'r~ doing," he :'hl:'). THE ANTIVACCINE ARGUMENT This is 110t the nnlv example nf hlJw -,ocal ,larenb ,md ,rnti\'accinelCtivists have pllshl'll government agencies to Improve 1',!Ccine' satetv. In 1985 Barbara Loe Fisher, a Washington, D.C.. mother whose son clevel- (lped neurological ,mJ cognitive disorders after his pertussis \-accination, wrote "A Shot in the Dark." The book was ,I well- researched histlJrv .md indictment of a \.,1(cine that even its supporters concede c.lUsl'd .1l1 unusual incidence of reactions, from fever 10 seizures, because it was made from '.I'hole, killed whooping-cough bacte- ria, Fisher went on to t(lund the National Vaccine Information Center, the mo,t prominent of the .mtivaccine groups, While Fi,;)ler's argument-that the per- tussis vaccine caused .m increase in epileptIC ,md learning-disabled chilJren-a['pear, basdess, her .!Ctlvismled to the crealior. uf.i compens.!tllln svstem tar vaccine \ictims aIll: prompted the (:DC to plan a major expan- sion of programs to studv I'accine salet\', Other arguments and suppositions 111' antivaccine .1ctivists. Fisher included, ,Ire either incorrect or misleading. Here arc the mall1 ones: Vaccines "overwhelm" the immune svs- tern and cause it to turn against itself. \'ac- cines \\Imk by stimulating the produc- tion of protective antibodies. So the idea that multiple vaccines can "overstress" the immune systems of infants seem, reasonable. It's behind the belief that the measles component of the measles- mumps-rubella .\L\IR \ vaccine has caused an epidemic of autism, In fact. vaccines tax the immune svs- tern much less than natural diseases, san Halse\', ,\ natural inrection can lead tL1 the stimulation of as many as 25 to 5U separate immune responses. "\\'hen we give something like the Hib vaccine, we're ::>;iving only two antigens:' san Halsev, "The immune system's poter.tia; :s enormous. It can respond to 10 mil- lion to 100 million antigens." Vaccines are as dangerous as the dis- eases. The 'itatistics can be misleading. In 199G, :1earlv 12,000 vaccine "adverse cvents"-estabiished or presumed. and mosth. mild-were reported to govern- ment he.lith officials. That same \'eaf, t);~ diseases themselves caused only 6,777 caseo 1)1' mnes> or iniury. But that does not mear: tn.!t v.!ccines are ,1 poor risk, ExcC['t ;"or polio, vaccine-pfevental<~ diseases .Ire still around, The Co[oraJ,-, :-itlh':y th~H ....iclCUme!lted ~ln :ncreJsed ri:)~ <- measles .!nd pertussis .!mong unvaccinated children .lls,) found that \'accine refusal pur; the communin" ,ll risk, because vaccin.:.' don't "uk.:' in evervbodv who gets them. The rese,lrchers found more measles and whooping cough among vaccinated cnd- dren in ,chods with many unvaccinated children th.!n in schools where nearlv .IiI chilJren had been vaccinated, If someone gets sick soon after getting a vaccine, the shot is to blame. This idea is at the root of the most contentious vaccine- safet\" issues; the alleged links between vaccines .lI1d autism. brain damage, and multiple ,clerosis. Some antivaccine web sites teature .lCcounts of Ii vel v toddlers who, arter recel\'in\? their \1;..llZ shot, turned into neurologICally impaired preschooiers. But ,m vaccines really to blame? To date, two expert panels. one convened by the AmerIcan .\cademY nr PediatrICS and the other 11\ the :\atlonal Academy of Sciences, ha\.e .,tudied the .\I;..!R vaccine and autism. They found that autism cases did not increase .dong the same trend lines as increases 111 the percentages or children who received the \1\IR vaccine. Both expert groups have conduded that aithough more needs to be learned about autism-and above all about the .lpparent increase in the numbers of autistic children-the M.vIR vaccine is almost certainlv not to blame. For now, the most likely explanation for the seeming link is pure coincidence. Manv childhood neurological and developmental problems hrst emerge at an age when chil- dren are getting vaccines frequently. COMPENSATING THE INJURED When the pertussIs vaccine controversy sur- faced in the C.S. in the mid-1980s, vaccine manufacturers threatened to get out of the business rather than risk ruinous lawsuits. (Today, there are only four major childhood- vaccine manufacturers in the C.S.: Glaxo SmithKline, Aventis Pasteur, Wyeth Lederle, and .vlerck & Company.) As a result, the federal Vaccine Iniury Compensation Program was created in 1988. Funded bv a small tax on every lot of vaccine, it is in essence a no-fault insurance plan against childhood-vaccine injuries. The program set up a list of conditions such as vaccine-associated polio that, based on scientific evidence, seem to be vaccine- related. Anvone with a condition on the list is entitled to compensation for "pain and suffering" and for ongoing medical expens- es. The trade-off: giving up the right to sue manufacturers and doctors. "With respect to manufacturers and phvsicians, the svstem has been an unqual- ified success," savs Peter .\[evers, a law pro- fessor who heads the vaccine-injury law clinic at George Washington University. "But it's been a much more mixed record with respect to ((Jnsumers." "It's very difficult to bring a claim under this program." \Ievers says. "The govern- ment is very aggressive. If there are any tech- nicalloopholes, they raise them. They fight everything to the bitter end." Even claimants who win compensation can run into trouble. "1 have had to fight to get my son two pairs of braces a year, to keep up with his growth," says Salamone, whose son contracted polio from the vac- cine. "Thev said one pair should be enough. Thev asked why he needed physical thera- pv I)nce a week." Vaccine-victim advocates say the pro- gram.s accumulated S 1.6 billion balance is evidence of its lack of generosity. The gov- ernment says the surplus is the result of the development of ever-safer vaccines. RECOMMENDATIONS .. Consumers should ask for the safest vac- cines. The whole-cell pertussis vaccine, childhood vaccines containing thimerosal as a preservative, and the oral polio vaccine mav still be in the distribution system. Tell your doctor not to use these vaccines. .. Be sure to let the doctor know if the child has a fever. diarrhea, or other significant medical svmptom at the time of an immu- nization appointment. The doctor may rec- ommend postponing the immunization. If this occurs, it's critical to promptly make up the missed vaccine doses. For additional information, consult the CDC's Contra- indications for Childhood Immunization document, available on the Internet at www.cde.govlniplrecsicontraindications.pdf. .. Ask the doctor which post-vaccination symptoms are normal-and which warrant medical attention. Mild fever and fussiness are common consequences of vaccine- induced immune reaction. But a high fever or seizure is out of the ordinary. .. Seek intormation from reliable sources such as the CDC (www.cdc.govlnip), the National :-.Ietwork for Immunization In- formation (www. immunizationinfo.org), the Immunization Action Coalition (www .immunize.org), and the Vaccine Education Center (www. vaccine.chop.edu). Be aware that some groups with official-sounding names, such as the National Vaccine Intor- mation Center and Parents Requesting Open Vaccine Education, are actually anti- vaccine networks. .. Policy-makers should continue-and ade- quately finance-improvements in tracking and analyzing vaccine injuries. This includes expanding state immunization registries (with proper privacy safeguards), which are are invaluable tor researching safety con- cerns. Vaccine-safety guardians need to keep faith with parents bv taking prompt action when possible problems or concerns surface. .. The Vaccine Injury Compensation Program should use some of its burgeoning surplus to become more user-friendly. And physicians and health educators must deal fully and respectfully with the vaccine-safety concerns of patients and parents. It's no longer enough to say, "Trust us, we're the experts." <!ll C - nsumer Reports New Car Buying Guide 2001 L1 ow can you find the best model in this f year's auto market? Consumer Reports New Car Buying Guide 2001 Will lead you through the chOices with reviews and recommendations based on the latest tests. 'Cnsumer .r,~ Renorts '---==-. r_.__ ...... NEW ~i\~ 3 TtJi;Jii Glm:U: 2001 I nSlde this 256-page guide, you'll find: ~ Top picks for 2001 . Guide to the latest safety features " Step-by-step guide to buying and leasing , 20-year trends in auto reliability . Price-saving strategies for buying car insurance > Auto sites on the I nternet, plus how to do your online research quickly and efficiently . Four-wheel drive 'IS. all-wheel drive. how to make your test-drive count. and more! The newCR SAFETY ASSESSMENT- Consumer Reports sums up track- test results and crash-test data to make it easy to spot which models are safer. ..- _. ,~. ~...-_.._---- On sale now wherever books and magazines are sold, or __ m~J.1 the coupon below: 1- - - - - - - - - - - - - - - - - - - -I 1 To order Consumer Reports New Car Buying I 1 Guide 2001. please send a check or money 1 : order for $9.95 plus $3.50 shipping and : handling, payable to Consumer Reports. I ProMP: 41 402107 I I 1 I I 1 1 I 1 APT. 1 1 1 1 ZIP 1 CONSUMER REPORTS I po. Box 10537. Des Maines.IA 50336-06371 1 (Please 3/low 4 weeks for delivery) 1 I NAME iPLE.-\SE PRiNn ADDRESS CITY STATE :. u'~. ; CONS\I!-iER REPORTS 21 A PUBLICATION FOR THE '.IEMBE"SJF 'HE 'NASHiNGTC~1 STATE MEDICAL ASSOCIATION MAY I JUNE 2001 www.wsma.org Safe vaccines: doubt and worry can trump facts to affect public's acceptance The debate over the safety and effectiveness of vaccines would seem to have been settled years ago. Vaccines are required for school entry in all 50 states. A number of vaccine-preventable diseases are now almost non- existent in the United States, thanks to widespread immunization. Y/ET POWERFUL STORIES FROM THE MEDIA AND the Internet can Hood the public . consciousness and fuel fear over even the most \velI-tested vaccines. \'Vhen the medical community, - both mainstream and :t!ternative practitioners - raises questions about the safety or need for certain immunizations. those inquiries intertwine with the public debate and can change public polic;:. . In 1998 1Il an article in Lancet. Dr. Andrew WakefIeld. a pediatric gastroenterologist in London. England. described 12 children with borh "pervasive developmental disorders" (9 of the children had <lUtism) and intesrinal abnormali ries. The parenrs of S of the 12 children reported that the behavioral symp- roms appeared around the time the :\'Oungsters received their measles-mumps-rubella ("-IMR) vaccine, Dr. \Xakefie!d Jnd his coauthors . After physicians in Sweden questioned the need for pertussIS vaccination in the 1970s.coverage rates dropped from 900/0 in 1974 to 12% five years later. During 1980 to 1983, the annual incidence of pertussis for Swedish children aged 0 to 4 years increased to 3,370 per 100.000 with rates of serious complications from pertussis approaching rates seen in developing countries. In Japan in 1974. two children died within 24 hours of receiving their diphtheria/tetanus/pertussis vaccines, and the minister of health and welfare responded by eliminating the vaccine. Over the next two years pertussis coverage for infants fell from 80% to 10%. In 1979 a pertussis epidemic resulted in more than 13,000 cases and 41 deaths. In 1981 the acellular pertussis vaccine was introduced and widely adopted. concluded chat they had identified a chronic enterocolitis that might be linked to autism through an immune ddlcit. but they did not go quite so far as to say they'd proven an association between the MMR immunizations and autism. The article received tremendous publicic;.' in Great Britain and the United States and quickly resulted in a drop in MMR continued on page 3 On immunizations and the uburden" on the immune system N THE UNITED STATES, WE IMMUNIZE ROUTINELY against only ten infectious agents (measles, mumps, rubella, polio, diphtheria, pertussis, tetanus, hepatitis B,and varicella) out of the multitude of common childhood infections. The primary function of the multifaceted immune system is to identify foreign substances (anti- gens). When the immune system is presented with a foreign antigen, it mounts a response involving production of antibodies (humoral immunity) and activation of specific cells whose purpose is to facilitate the elimination offoreign substances (cell-mediated immunity). The most powerful immune responses are generally produced in response to live antigens. continued on page 3 TABLE OF CONTEN"'S Newsclips . 'NSMA's health,plan report :afG avai iable for patients . A "must" conference for your group managers or administrators · Local clinic for low-income patients gets boost from teas . Locai immunization informar,::: available on the Web . Free HIV/AIDS hotline material available for your waiting rooms · Free email service for )00- seeking physicians . Help make patients aware or Tobacco Quit Line; free materials available ............ ..2 CMEs Upcoming courses ..........4 Update from Physicians Insurance Report of claim trends oy sPEcialty.............. .4 Health Care Economics Law on physician referrals and ownership interests 6 Risk Management Our culture binds us together ~ seeing what's right what's not .................8 Drug errors Tracking the patient with an unexoected reaction ......10 Classifieds .................. .. ...14 Newsmakers ................. ...16 Safe lfaccilles . . . (Ofu:nut'dFro1'1'l :f')dgt' I immunization ratt:.', in England. \X'ales ,lI1d Irdand. Rep. Dan Burton of Indiana held Congressional hearings on the link he~ween .\IMR vaccines and aurism. The public's worry that the :vIMR ':accine somehow causes ,lutism escalated [0 [he point that the Centers ror Disease (:ontroJ and the National Institutes of Health commissioned the Institute of \ledicine (lOM) last vear to studv the , , h\'pothesized connection. The 10,\1 report. released in April. concluded that there is no evidence that MMR vaccine causes autism. and it could find no "proven biological mechanisms" that would explain a relationship between \IMR vaccine and autism. It acknowl- edged that existing epidemiological tools may be unable to detect whether the \I,\IR vaccine somehow contributes to autism in a very small number of children. bur it stressed that the health bendlts of the vaccine tar outweigh anv hypothetical risk. ~. The report made the news nation- wide. prompting many parents to call pediatricians, family practitioners, school nurses and the state Department of Health Immunization program. DR. ED MARCUSE, ASSOCIATE MEDICAL director ;It Children's Hospital and Regional \fcdical Center in Seattle, has closely tollowed the controversy over the safety of the MMR vaccine as well as controversies over other vaccines. He also is on the steering committee of the ~ational ~et- \vork for Immunization Intormation. a group that disseminates scientirIcally accurate materials to parents and Others. He's not surprised that the .\IMR-autism hypothesis would attract so much attention because parents and health professionals were alreadv looking hard ror an explanatio~ to an apparent rise in autism. attention detlcit hyperacrivit;: disorder and other learning disabilities among children. But the connection between autism Dr. Ed Marcuse ~ /\l",-')(Jrt and MMR appears to be a coincidence based on timing. Autism. which is a whole spectrum of disorders, is often di,lgnosed between the ages of two and rIV<.: years. with symptoms first becom- ing apparent in the second year. Most all children receive an MMR vaccine at age two. Said Dr. Marcuse. "Anvbodv r;-ced with a devastating illness iooks' for associations. Our way of relating to the world is to employ temporal associa- tions - something happens, something else happens, In fact, that is a basis tor raking a medical history," THE WAKEFIELD HYPOTHESIS SPUN AROUND the world with breathtaking velocity, showing up in newspapers and on television. radio (and the Internet) seemingly everywhere. "In the old days, physicians and scientists would raise a hypothesis, then subsequent studies would refute or accept it." commented Dr. \farcuse. "The debate would take place within the scientific societies and more recently. in the medical journals. Today the debate takes place on talk radio and the Internet. I get my breaking [medical] news from National Public Radio. " Pediatrician David Springer, MD, who practices some homeopathy alongside conventional medicine at his office in the Wallingford District of Seattle, otten is on the receiving end of media reports of the day. "If somebody talks about whooping cough and seizures, I'll get questions," he said. He's been quizzed by parents about the detrimen- tal effects of mercury in vaccines, escala- ting reactions to shots, the advisability of ;rying to get separate vaccines for . each component of M,\fR, whether natural disease confers better immunity than a vaccine. and the connection ' between polio vaccine and AIDS. "\Vhen you're a parent. anything is bct if it potentially will harm your child," he said. "Your ears perk up when you hear about a friend of a friend who's had a shot and then six weeks later gets diagnosed with autism, "\Vhatever we know scientifically may not be the bcts parents consid'er [()r themselves." he added. "I trv to listen to their facts, and then I ~ell them .vl" r ".' _' II f) ! On immunizations. . . continued from page 3 Infants undergo constant exposure to foreign antigens from the moment they enter the world. The normal process of colonizing the oral mucosa and gas- trointestinal tract exposes the infant to thousands of different antigens during the first few months of life. An upper respira- tory viral infection exposes a child to 4-10 antigens and streptococcal pharyngitis to 25-50 antigens. In contrast, a hepatitis B vaccination exposes an infant to one antigen. It is therefore unlikely that immunization with multiple vaccinations would add an appreciable burden on the developing immune system, which is learning to recognize thousands of different antigens. ~ From:"Vaccine Safety:'(urrent Problems in Pediatrics. Vol. 31. Number 4,ApriI2001, by Heather McPhillips. MD. MPH, and Edgar K. Marcuse. MD, MPH, University of Washing- ton. Reprinted with permission. mv tacts. r don't judge them. .\Iv job is to' find out what the~" are willin~ to do, and my job changes 'depending ~on what their attitude is. " With their questions ans\vered, the vast majoriry of parents do have theIr children immunized, Dr. Springer said. But about 6-100,'0 have less than all immunizations on the recommended schedule or have none at all. "Sometime, I go only ror tetanus immunization. They ma:; be open ,0 one. but want nothing to do with .\fMR or whooping cough," he said. "A,t some visits, if vou follow academy [American .-\cade~v of Pediattics 1 sta~dards. vou can ,~ive t~ve shots cove'ring seven diseases in "one \,isi L That :s a bit overwhelming ror parents." Dr. Springer witnessed an epidemic of measles in Ne\v York City in 1970 and saw first-hand some "p~etty awful" complications. "Parents need to hear that these childhood illnesses are not benign, They wam [0 think it is a safe world out there. '. Famil:: Practitioner Jim Merrill. .\10, of Enumchw said that only a few parents have asked recently about continued OJ] ptlge /1 1";llll711IlCcilles t'OlltllllU!t(lruJ!' fltl.({,e J \\\HZ ,1nd autism. Far more vexing, he "lid, are claims bv rwo of rhe ,()I11I11Unjty'~ chiropracrors thar spinal ilLlnipu!atio!1, starred on babies "from ,lav one." can prevent disease as ,:tkcrivelv ,15 vaccines and more safely. '1n'eral v~;m ago. Dr. \Ierrill chided one chiropracror for sClring a parem ahout rhe safery of immunizations for her children. He told rhe chiropracror in ,l lerrer thar he had removed rhe ptactitioner from his list of recom- ;nended chiropractic providers, In a lerter back, rhe chiropractor wrote, " . , . the scicmific community is increas- ing/v aIJrmed at the increase in the m~;1gth of pathogens and the corre- ~p(Jl1ding decrease in the ability of vaccines and amibiotics to control rhem. . . ." (However. there is no reliable sciemific evidence that patho- gens are developing resisrance against vaccines. There is evidence that cerrain pathogens are becoming resistant to tlntibiotics.) The chiropractor :1lso implied he mighr sue Dr. Merrill for libel if Dr. \I~rrill communicared to "anvone that me. my approach or . . . my practice is h:1rmful. " Commemed Dr. .\1errill, "All the people who don't get vaccinated end up looking pretty healthv down the road. But it's nor the chiropractic protecting them. Thev assume it is, but it's the herd immunitv effecr." Although he belie'es that he has ''stemmed the tide" of misinformation coming from rh:1t chiropractor, he still worries about parents who either wai t to get their children immunized or forgo immunizations altogether. THE STATE DEPARTMENT OF HEALTH REPORTS that .lbout ()-% of children newly entering school in the 1999-2000 school year had all their required immunizations. Of those not immunized (about 30,000 children), 9100 were exempted for "philosophical or personal" reasons, 4.5% for medical reasons and 'L 50b for religious reasons. Even though rhe exemptio~ rate is low, Pat DeHarr~ .l state epidemiologist, rhinks rhar it might be inHared, If the parent can't find KoS114 R(pqrt, the immunization record, it's possible that school officials suggest that rhe parent sign an exemption reporr, If the school has neither an immunization record nor an exemprion from a parent, the schou I is considered out of compli- ance and docs not receive certain state funding. Although it's hard to get at a true exemption rate, rhe latesr 3% is much rhe same as ir has been the last five years. However, the rates do vary by countv. In Ferrv Count\', 10% of schooi-age children are 'not immunized, JdTersun (8.9%), Skamania (8,3%), San Juan (8.20!rJ) and Stevens (7,1%) counties are well :1bove the average, roo, as are Island (6.5%) and Whatcom (5.2%), In some of these counties, said Norma Holliday, public health nurse consul rant with rhe state immunization program, "people have a different philosophy. They don't believe in immunizarion. Thev're free thinkers," Exemption rates above 5% are cause for concern, said Dr. ;\IIarcuse, "Measles can go into a school where 5% are susceptible and can pick rhem off They'll ger sick; it's highly communi- cable." A subsuntial minority of parents does not have a good grasp of how immunizations work, Dr. Marcuse added. He helped design a survey of parents conducted in April and May 1999 for the National Network for Immunization Information Steering Committee and published in Pediatrics (Do Parents Understand Immuniza- tions? A National Telephone Survey, by Bruce G. Gdlin, ;\lID et aI., Vol. 106, No. 5, November 2000. Pages 1097- 1102). Among the respondents, 25% believed rhar their child's immune wsrem could become weakened as a result uf roo many immunizations; 23% believed rhat children get more immunizations than are good for them, Dr. \XTakefIdd, in rhe Lancet article that created such a stir, proposed rhar components of rhe MMR vaccine be given separately lest the child's immune svstem be overwhelmed, A bill intro- duced in the Louisiana legislature last year (0 give MMR components sepa- rately failed by only rwo votes, "Yet, AI d r / f {{ !l (' .: () lJ i there's not a shred of evidence that the immune system can be overwhelmed h\ childhood' immunizations," said Dr. . Marcuse. THE ANTI-VACCINATION FORCES ARE GmlNG more sophisticated in purveying their views. The president of the official- sounding National Vaccine Intormatiun Center has rwo children who, she <;a:,', have been injured by vaccines: she managed to get featured in the New York Times Magazine on May 6. In rhe article, she commented on the "ever increasing number of vaccines. . . . If you give [biologically susceptible children] 37 doses of 11 different vaccines, including MMR, you could be creating :1 larger and larger group of genetic:1lly susceprible children, tipping them into neuroimmune dysfunction." (However, scientists have nor tound medical or biological evidence ::0 support this rheory, nor have the:; even found a disorder labeled "neuroimmune dysfunction. ") Dozens more vaccines are under development, and controversies over their etfIcacy and safety are certain to erupt as they become available. "Con- sumerism is on the rise," said Dr. ;\Ibrcuse. "People have questions abour rheir food. their air, their warer, their TV. rheir dental fIllings, Wh\' should vaccines be anv different?" \XTirh bver ,md fewer parents having direct experienc:: with diseases like polio or measles, it is imperative that physi- cians t:1lk to parents and parients about immunizarion and its role in protecting both individuals' health and rhe public health. Dr, .\!arcuse argues. "For \'Jccinc, the dan uf 'if vou build ir. rhe\' will .. . come' .lre pretty much over," he said. "Plwsicians and nurses must work deriveh- ro sustain the public's contldcncc: in vaccines. These issues are roo impor- tant ro leave ro the infectious disease gurus ;md public health officials." D,: , 'v[,zrcwe recommends thilt p/~l'si(i,liU we the W~'b site IJttp:i/www.idsocieryolg' NiViiilillks.htlll as Ii source o{accurate immulliZlitioll informtltion. 'Please fee! free to ,'op} and tlistribute this tf/S,ki Reporto' ,lrtic!e to patients. ~ CASTLE HILL CENTER' 615 SHERIDAN . PORT TOWNSEND, WA 98368 July 5, 200 I Re: Jefferson County Health Care Providers Tom Locke, MD, MPH, Jefferson County Health Officer 0!9 Response Plan for Tetanus-Diphtheria Vaccine Shortage To: From: As most health care practitioners are now aware, there is a nationwide shortage of adult- type Tetanus-Diphtheria vaccine caused by the abrupt discontinuation of manufacturing by the Wyeth-Lederle Corporation. Aventis Pasteur is now the sole manufacturer of this vaccine for the U.S. market and is committed to expanding capacity to fully meet national need. This process will not be completed until 2002. In the meantime, A ventis Pasteur is restricting sales ofTd to hospitals and health departments only. During this period of relative shortage, the ACIP (Advisory Committee for Immunization Practices) has revised its recommendation for Td use. Priority uses are: 1) Travel to countries with a high risk of diphtheria exposure, 2) Management of tetanus-prone wounds and injuries, 3) Lack of a primary (3 dose) tetanus-diphtheria vaccine series, and 4) Pregnant women whose last Td dose was> ten years ago (to prevent neonatal tetanus via transplacental passive immunization). A detailed listing of ACIP tetanus prevention guidelines is available at: hap:! /www.cdc.gov/mmwr/previe\v/mmwrhtml/0004l645.htm Routine immunization of individuals whose last Td was> 10 years ago should be deferred until 2002 when vaccine supplies are expected to be adequate. Jefferson Health and Human Services (JCHHS) offers a wide range of immunizations during regular hours of operation and will continue to provide Td immunization to clients meeting the ACIP priority criteria. JCHHS will also make Td available to Jefferson County health care providers who agree to restrict its use to the priority groups listed above. Clinics or individual practitioners who are unable to purchase Td through normal supply channels may contact JCHHS at 385-9400 to arrange for at-cost purchase ofTd vaccine. Due to our very limited supply, we will only be able to supply one 10-dose vial at a time. We ask that providers fully use each vial before placing additional orders to assure maximum distribution of limited vaccine supplies. HEALTH DEPARTMENT 360/385-9400 ENVIRONMENTAL HEALTH 360/385-9444 DEVELOPMENTAL DISABiliTIES 360/385-9400 ALCOHOUDRUG ABUSE CENTER 360/385-9435 FAX 360/385-9401 Population Growth, Clallam, Jefferson & Kitsap Counties, 1981-83 through 1998-2000. Period 1981-83 1982-84 1983-85 1984-86 1985-87 1986-88 1987 -89 1988-90 1989-91 1990-92 1991-93 1992-94 1993-95 1994-96 1995-97 1996-98 1997-99 1998-2000 Cfallam County 0.3% 2.1% 0.8% 0.6% 0.6% 3.0% 4.7% 3.8% 5.9% 6.3% 5.0% 4.2% 3.6% 4.0% 4.4% 2.6% 0.8% -3.3% Jefferson County 1.1% 2.7% 5.6% 4.8% 3.7% 4.4% 6.2% 5.3% 9.8% 11.7% 8.8% 8.0% 6.8% 5.8% 3.8% 4.7% 6.5% 7.0% Kitsap County 3.4% 4.3% 4.8% 2.4% 2.0% 7.1% 6.5% 5.8% 7.3% 8.4% 6.9% 3.7% 5.0% 5.4% 4.0% 1.9% 0.1% 1.3% Population growth, Clallam, Jefferson, and Kitsap Counties, 1981-83 through 1998-2000. 14.0% - 12.0% - Source: Intercensal projections and estimates generated by the Washington State Office Of Financial Management, September 2000. 10.0% - 8.0% - 6.0% - 2.0% -:- 0.0% C") "'-1' In <0 ,.... IX) en 0 .... N C"'l "'-1' In <0 ,.... co CCI IX) co IX) IX) IX) IX) en en en en en en en en en . . . ~ . . . cO . . . I . ~ .;, ..c -2.0% ;;; N C"'l In <0 ,.... en 0 .... N C"'l IX) IX) IX) IX) IX) IX) co co en en en en en en en CI) en en en en en en en en en en en en en en en .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ~ -4.0% - .... -6.0% - . -+- Clallam County ___ Jefferson County -.- Kitsap County 5/30/01 DRAFT Median Age of Clallam, Jefferson, and Kitsap Counties, 1980-99. Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 ClaJ/am County 31.7 32.2 32.9 33.7 34.5 35.2 35.9 36.6 37.3 37.8 38.4 38.8 39.1 39.6 40.2 40.8 41.2 41.5 41.9 42.3 Jefferson County 35.0 35.5 36.3 37.3 37.9 38.5 39.0 39.6 40.2 40.6 41.0 40.9 40.8 40.8 40.9 41.1 41.4 41.7 42.1 42.4 Kitsap County 29.3 29.5 29.7 30.1 30.4 30.6 30.9 31.2 31.4 31.5 31.7 31.8 31.8 31.9 32.1 32.2 32.5 32.7 33.0 33.2 Median Age of Clallam, Jefferson, and Kitsap Counties, 1980-1999. Source: Intercensal projections and estimates generated by the Washington State Office of Financial Management. September 2000. 45.0 '" 40.0 - 35.0 . . . -- . . . . . . . . . 25.0 ~ 20.0- 15.0- 10.0 5.0 0.0 - 0 .... N M ~ Il'l to r-- co (l) 0 .... N M ~ Il'l to r-- co (l) co co co co co co co co co co (l) (l) (l) en (l) (l) (l) en (l) en (l) (l) en (l) en (l) en en en (l) (l) (l) (l) en en (l) (l) en en en .... .... ,.. .... .... ,.. .... .... ,.. .... .... .... .... .... .... ,.. .... .... .... .... ___ Clallam County --.- Jefferson County --- Kitsap County! 5/30/01 DRAFT Percent Population Age 65+, ClaJlam, Jefferson, and Kitsap Counties, 1980, 1990-2000. Year 1980 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Cla/lam County 14.2% 20.3% 20.3% 20.4% 20.5% 20.6% 20.6% 20.4% 20.2% 20.5% 20.9% 22.2% Jefferson County 15.8% 20.3% 20.1% 20.1% 19.8% 19.6% 19.6% 19.7% 19.6% 19.7% 20.0% 21.0% Kitsap County 9.9% 10.6% 10.6% 10.4% 10.5% 10.6% 10.5% 10.5% 10.5% 10.7% 10.9% 11.1% Population Age 65+, Clallam, Jefferson, and Kitsap Counties, 1980 and 1990-2000. Source: 1980,1990, and 2000 - U.S. Census. 1991-1999 - Intercensal projections generated by the Washington State Office of Financial Management, September 2000. 25.0% ~ 20.0% - 15.0%- 10.0% ..------ 5.0% - . . . . . . .. ..... en en ..... N en en ..... . . 0.0% - o co en ..... o en en ..... M en en ..... ~ en en ..... ,..., en en ..... co en en ..... en en en ..... It) en en ..... c.o en en ..... __ Clallam County .........- Jefferson County -- Kitsap County 5/30/01 DRAFT Racial and ethnic composition of Clallam, Jefferson, and Kitsap Counties, US Census, 2000 White African-American Native American Asian Native Hawaiian/Other Pacific Islander Other racial designation Two or more races Hispanic* Clallam County 87.4% 0.8% 4.8% 1.1% 0.2% 0.1% 2.1% 3.4% Jefferson County 91.0% 0.4% 2.2% 1.2% 0.1% 0.3% 2.7% 2.1% Kitsap County 82.2% 2.8% 1.5% 4.3% 0.7% 0.3% 4.0% 4.1% *Hispanic persons may be of any race and are not included in any specific racial group. Racial and Ethnic Composition, Clallam, Jefferson, and Kitsap Counties, 2000 Source: u.s. Census, 2000 NOTE: Data are final. 100% - 90% ~ 0% ,.----. 80% - 70% ~ i 60% 1- i . Clallam County 0 Jefferson County 0 Kitsap County ((" ~~ q.'lf v" .~ 'l; Cj f,.q, ~'lJ ~ ~ ,'~'lf ~ 'l;~ ((,x:- i<:>~ ~'l; *Hispanic persons may be of any race and are not included in speCific racial group. 50% - 40% - 30%- 20% .- 10% - .~((, ~ 'l;~ i..,v tf''lJ .~((, 'l;'<> ~ ~ ~'lf "'" 'l;~ i..,v ~'lJ ~ 'lj ~,v "" r--: * '~v "b-~ .":J~ ~ .o~ 'l;O<:> ~ ~O] 0.((, "~ 'l;v f,.' ~'lJ o ((,":J ,,'l; Cj ~((, ~o ~~ o ~o ~ 5/30/01 DRAFT Civilian unemployment rate, Clallam, Jefferson, and Kitsap Counties, 1980-2000. Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Clallam County 13.6% 17.9% 19.1% 14.4% 12.3% 10.1% 9.7% 9.6% 8.2% 8.5% 6.9% 7.7% 8.8% 10.0% 10.1% 8.5% 9.7% 7.9% 7.9% 7.2% 7.9% Jefferson County 9.3% 11.6% 10.0% 10.0% 9.5% 8.9% 8.3% 7.9% 5.9% 5.8% 4.9% 6.5% 8.9% 8.3% 8.5% 7.3% 8.3% 6.8% 6.7% 5.8% 5.7% Kitsap County 6.1% 7.7% 8.7% 7.7% 6.9% 5.9% 6.3% 6.0% 5.4% 5.3% 4.0% 4.9% 6.0% 6.8% 6.0% 6.7% 6.8% 5.5% 52% 5.0% 5.6% 25.0% - 20.0% - , 15.0% - 10.0% - Civilian unemployment rates, Clallam, Jefferson, and Kitsap Counties, 1980-2000. Source: Washington State Department of Labor and Industry, April 2001. -+--- Clallam County ___ Jefferson County -It- Kitsap County 5.0% - 0.0% - 0 .... N M ~ It) CJ:) r-- CICl en 0 .... N M ~ It) CJ:) r-- CICl en 0 CICl CICl 00 00 00 CICl 00 00 CICl 00 en en en en en en en C) C) en 0 en en en en en en en en en en en en en en en en C) C) C) en 0 .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... N 5/30/01 DRAFT Median household income, Clallam, Jefferson, and Kitsap Counties, 1989.2000. Year 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Clallam County $25,434 $27,149 $27,212 $27,282 $27,433 $27,486 $28,128 $28,887 $30,700 $31,443 $31 ,162 $32,268 Jefferson County $25,197 $27,350 $28,207 $28,569 $28,821 $29,122 $29,002 $30,028 $31,749 $32,664 $33,446 $34,662 Kitsap County $32,043 $36,636 $37,670 $38,185 $38,223 $38,908 $38,813 $39,808 $41,524 $42,484 $44,036 $45,401 $60,000 - Median household income, Clallam, Jefferson, and Kitsap Counties, 1989.2000. Source: Washington State Department of Labor and Industry, April 2001 $50,000 - : _ Clallam County [J Jefferson County ill Kitsap County $40,000 - ~ r~ ~ ~ j ~ ~ ~ ~ ~I $30,000 ~I ,:~ ~ ~ - ~ r~ ~ i ~ ~ $20,000 - ~ iI. ~ I $10,000 - ~ ~ ~ $0 ~ en c .... N M ~ It) co ,.... co en c co en en en en en en en en en en c en en en en en en en en en cn en c .... .... .... .... .... .... .... .... .... .... .... N 5/30/01 DRAFT Median house price, Clallam, Jefferson, and Kitsap Counties, 1995.2000. Year 1995 1996 1997 1998 1999 2000 Clallam County $102,000 $110,100 $112,300 $118,000 $120,000 $11/,800 Jefferson County $127,300 $142,100 $135,000 $136,300 $155,900 $174,700 Kitsap County $124,600 $127,700 $131,200 $145,600 $143,100 $148,500 Median house prices, Clallam, Jefferson, and Kitsap Counties, 1995-2000. Source: Washington State Center for Real Estate Research, Washington State University, December 2000. $200,000 - . Clallam County 0 Jefferson County ~ Kitsap County $175,000 $75,000 $150,000 ~ $125,000 ~ $100,000 - $50,000 $25,000 $0 It) en en ..- <0 en en ..- l'-- en en ..- DO en en ..- en en en ..- c c C N 5/30/01 DRAFT Population Growth in Jefferson County and Washington State, 1981-83 through 1998-2000. Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Population Jefferson County 15,965 16,736 17.017 16,925 17.480 17,873 18,317 18.533 19,131 19,673 20.406 21,600 22,500 23,500 24,300 25,099 25.700 26,300 26,500 26.600 25.953 WA State 4,132,156 4.229,278 4.276,549 4,307.247 4,354,067 4.415,785 4.462,212 4,527,098 4,616,886 4,728,077 4,866,692 5,000,400 5,116,700 5,240,900 5,334,400 5,429,900 5,516,800 5,608,100 5,685,300 5,757,400 5,894,121 Period 1981-83 1982-84 1983-85 1984-86 1985-87 1986-88 1987 -89 1988-90 1989-91 1990-92 1991-93 1992-94 1993-95 1994-96 1995-97 1996-98 1997 -99 1998-2000 % Growth Jefferson County 1.1% 2.7% 5.6% 4.8% 3.7% 4.4% 6.2% 6.7% 9.8% 10.3% 8.8% 8.0% 6.8% 5.8% 4.8% 3.1% 1.1% -2.1% Washington State 1.8% 1.8% 2.5% 2.5% 2.5% 3.5% 4.4% 5.4% 5.8% 5.1% 4.8% 4.3% 3.6% 3.4% 3.3% 3.1% 2.7% 3.7% Population growth in Jefferson County and Washington State, 1981-83 through 1998-2000. Source: Washington State Office of Financlai Management Intercensal estimates, 1980-90. 'N ashington State data are finai intercensal counts adjusted to the 2000 census. Jefferson County data-projections 1991- 1999, census 2000. NOTE: Jefferson County data are provisionai-OFM projections exceeded actual 2000 count Adjusted 1991-99 .-:umbers will be lower than those shown here. 12.0% - 10.0%- 8.0% - 6.0%- 4.0% - 2.0% 0.0% ~ JJ') co r-- 00 en 0 .... N M ~ JJ') co r-- 00 00 00 00 00 00 00 en en Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l . . ..t . . r-:. . en . . N . . .;, J, -2.0% ~ M U'l co 00 0 .... M ~ 00 00 00 00 00 00 00 Cl'l Cl'l Cl'l Cl'l 0> Cl'l Cl'l CD Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l Cl'l 0> Cl'l .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... -4.0% - 00 Cl'l Cl'l .... 5/30/01 DRAFT sources of population growth Components of Population Growth, Jefferson County, 1981-2000 Number of % growth from Year Observed Births Deaths Expected migrants Year Migration Natural Increase 1980 15,965 225 154 1980 1981 16,736 236 142 16,036 700 1981 90.8% 9.2% 1982 17,017 237 168 16,830 187 1982 66.5% 33.5% 1983 16,925 204 168 17,086 -161 1983 175.0% -75.0% 1984 1 7,480 224 164 16,961 519 1984 93.5% 6.5% 1985 17,873 223 148 17,540 333 1985 84.7% 15.3% 1986 18,317 197 186 17,948 369 1986 83.1% 16.9% 1987 18,533 218 174 18,328 205 1987 94.9% 5.1% 1988 19,131 230 197 18,577 554 1988 92.6% 7.4% 1989 19,673 199 221 19,164 509 1989 93.9% 6.1% 1990 20,406 216 209 19,651 755 1990 103.0% -3.0% 1991 21 ,600 247 195 20,413 1,187 1991 99.4 % 0.6% 1992 22,500 233 203 21,652 848 1992 94.2% 5.8% 1993 23,500 236 232 22,530 970 1993 97.0% 3.0% 1994 24,300 212 254 23,504 796 1994 99.5% 0.5% 1995 25,099 216 241 24,258 841 1995 105.3% -5.3% 1996 25,700 199 267 25,074 626 1996 104.2% -4.2% 1997 26,300 214 255 25,632 668 1997 111.3% -11.3% 1998 26,500 207 282 26,259 241 1998 120.5% -20.5% 1999 26,600 220 283 26,425 175 1999 175.0% -75.0% 2000 25,953 26,537 -584 2000 90.3% 9.7% - ...._.n___._._____ _.,,---._--- --~-_._~--_._,~_...__._-~-----_.._- ._----.-,-,.._---_..------- -. -,---- -- .,-----...---- Migration and Natural Increase as Sources of Population Growth, Jefferson County, 1981-2000 Source: Washington State Office of Financial Management Intercensal estimates, 1980-90, projections 1991-1999. census 2000. NOTE: Data are provisional-OFM projections exceeded actual 2000 count. Adjusted 1991-99 numbers will be lower than those shown here. 200.0% 180.0% 160.0% 140.0% 120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% ""' N M co co co en en en ""' .... ""' Natural Increase v ~ ~ ~ co en 0 .... N M V ~ ~ ~ co en 0 co co co co co co en en en en en en en en en en 0 en en en en en en en en en en en en en en en en 0 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ N 5/30/01 DRAFT Age Composition, Jefferson County, 1980 Age Group Males Females Age Group Males Females 0-4 538 533 0-4 -3.4%) 3.3% 5-9 534 505 5-9 -3.3% 3.2% 1 0-14 525 593 1 0-14 -3.3% 3.7% 15-19 579 542 15-19 -3.6% 3.4% 20-24 480 501 20-24 -3.0% 3.1% 25-29 632 662 25-29 -4.0% 4.1% 30-34 704 659 30-34 -4.4 % 4.1% 35-39 517 475 35-39 -3.2% 3.0% 40-44 413 331 40-44 -2.6% 2.1% 45-49 354 380 45-49 -2.2% 2.4% 50-54 397 433 50-54 -2.5% 2.7% 55-59 512 564 55-59 -3.2% 3.5% 60-64 540 544 60-64 -3.4% 3.4% 65-69 522 482 65-69 -3.3% 3.0% 70-74 357 371 70-74 -2.2% 2.3% 75-79 184 196 75-79 -1.2% 1.2% 80-84 87 129 80-84 -0.5% 0.8% 85 + 73 117 85 + -0.5% 0.7% Age Composition, Jefferson County, 1980. Source: 1980 census. NOTE: data are final. 85 + 80-84 75-79 70-74 65-69 Males 60-64 55-59 Co ::l 50-54 0 r.. 45-49 e,:) I1l 40-44 Cl <( 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 -6% -4% -2% 0% 2% Percent of Total Population (15,965) Females I I 4% 6% 5/30/01 DRAFT Age Composition, Jefferson County, 1990 Age Group Males Females Age Group Males Females 0-4 570 596 0-4 -2.8% 2.9% 5-9 719 682 5-9 -3.5% 3.3% 10-14 682 611 1 0- 14 -3.3% 3.0% 15-19 557 501 15-19 -2.7% 2.5% 20-24 412 353 20-24 -2.0% 1.7% 25-29 518 476 25-29 -2.5% 2.3% 30-34 757 734 30-34 -3.7% 3.6% 35-39 866 924 35-39 -4.2% 4.5% 40-44 899 840 40-44 -4.4% 4.1% 45-49 647 585 45-49 -3.2% 2.9% 50-54 485 492 50-54 -2.4% 2.4% 55-59 493 547 55-59 -2.4% 2.7% 60-64 637 686 60-64 -3.1% 3.4% 65-69 741 772 65-69 -3.6% 3.8% 70-74 605 599 70-74 -3.0% 2.9% 75-79 358 394 75-79 -1.8% 1.9% 80-84 171 223 80-84 -0.8% 1.1% 85 + 92 182 85 + -0.5% 0.9% Age Composition, Jefferson County, 1990. Source: 1990 census. NOTE: Data are final T 85 + 80-84 75-79 70-74 65-69 ?Jl~s 55.59 Q, 50.54 :::l 0 ... 45-49 t!) Q) 40-44 ~ 35-39 30-34 25.29 20-24 15-19 10.14 5.9 0-4 -6% -4% -2% 0% Percent of Total Population (20,406) 2% Females 4% 6% 5/30/01 DRAFT Age Composition, Jefferson County, 1999 Projected Population Age Group Males Females Age Group Males Females 0-4 739 703 0-4 -2.6% 2.4% 5-9 842 853 5-9 -2.9% 3.0% 1 0- 14 925 875 1 0-14 -3.2% 3.0% 15-19 869 747 15-19 -3.0% 2.6% 20-24 574 555 20-24 -2.0% 1.9% 25-29 695 636 25-29 -2.4% 2.2% 30-34 720 648 30-34 -2.5% 2.2% 35-39 939 922 35-39 -3.3% 3.2% 40-44 1,083 1,108 40-44 -3.8% 3.8% 45-49 1,108 1,041 45-49 -3.8% 3.6% 50-54 934 868 50-54 -3.2% 3.0% 55-59 837 805 55-59 -2.9% 2.8% 60-64 679 724 60-64 -2.4% 2.5% 65-69 694 756 65-69 -2.4% 2.6% 70-74 669 753 70-74 -2.3% 2.6% 75-79 550 626 75-79 -1.9% 2.2% 80-84 290 367 80-84 -1.0% 1.3% 85 + 163 302 85 + -0.6% 1.0% Age Composition, Jefferson County, 1999 (projected) Source: Washington State Office oi FinanCial Management. September 2000, 2000 precensus projections NOTE: Data are provisional-CFM prOjections exceeded actual 2000 count. Adjusted 1991-99 numbers will be lower than those shown here. 85 + 80-84 75.79 70-74 65-69 60-64 55.59 g. 50-54 o l5 45-49 Q) 40-44 ~ 35.39 30.34 25.29 20.24 15.19 10.14 5.9 0-4 Males Females -6% -4% -2% 0% 2% 4% 6% Percent of Total Population (28,801) -5/30/01-DRAFT------..--~--.- Median Age of Jefferson County and Washington State, 1980-99. Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County 35.0 35.5 36.3 37.3 37.9 38.5 39.0 39.6 40.2 40.6 41.0 40.9 40.8 40.8 40.9 41.1 41.4 41.7 42.1 42.4 Washington State 29.8 30.0 30.4 30.9 31.2 31.6 32.0 32.3 32.6 32.8 33.0 33.2 33.4 33.6 33.9 34.2 34.5 34.8 35.2 35.4 Index 1.17 1.18 1.20 1.21 1.22 1.22 1.22 1.23 1.23 1.24 1.24 1.23 1.22 1.22 1.21 1.20 1.20 1.20 1.20 1.20 Median Age, Jefferson County and Washington State, 1980-1999. Source: Washington State Office of Financial Management, Intercensal projections and estimates, September 2000. NOTE: Washington State 1980-2000 data are final; Jefferson County 1980-90 data are final but 1991-1999 data are provisional 45.0 - Jefferson County : : : : : 4O.0~ · · · · · ... 35.0 . Washington State . . . . . . . . . . . 30.0 . . .. . 25.0 ~ 20.0 - 15.0 - 10.0 - 5.0 - 0.0 0 .... N M ~ Lrl to ,... ClC en 0 .,... N M ~ Lrl to ,... ClC en ClC ClC ClC ClC ClC ClC ClC ClC ClC ClC en en en en en en en en en en en en en en en en en en en en en en en en en Q) en en en en .,... .,... .... .,... .,... .... .... .,... .... .,... .,... .,... .... .... .,... .... .... .,... .,... .,... 5/30/01 DRAFT Population age 65+, Jefferson County & Washington State, 1980 and 1990-2000 Year 1980 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Jefferson County 15.8% 20.3% 20.1% 20.1% 19.8% 19.6% 19.6% 19.7% 19.6% 19.7% 20.0% 21.0% Washington State 10.4% 11.7% 11.6% 11.6% 11.4% 11.4% 11.4% 11.3% 11.2% 11.1% 11.1% 11.1% Population Age 65+, Jefferson County and Washington State, 1980 and 1990-2000. Source: Washington State Office of Financial Management. May 2001. NOTE: Washington State data are final; Jefferson County 1980 and 1990 data are final but 1991-1999 are provisional and subject to change. 25.0% ~ 20.0% / . . Jefferson County --A . . . . . . 15.0% 10.0% ~ Washington State . . . . . . . . . 5.0% - 0.0% . o co lj) ~ o lj) lj) .... .... lj) lj) .... N lj) lj) ~ ~ lj) lj) ~ co lj) lj) .... I"- lj) lj) ~ co lj) lj) .... lj) lj) lj) .... M lj) lj) .... It) lj) lj) .... 5/30/01 DRAFT Racial and ethnic composition of Jefferson County and Washington State, US Census, 2000 White African-American Native American Asian Native Hawaiian/Other Pacific Islander Other racial designation Two or more races Hispanic* Jefferson County 91.0% 0.4% 2.2% 1.2% 0.1% 0.3% 2.7% 2.1% Washington State 78.9% 3.1% 1.4% 5.3% 0.4% 0.2% 3.0% 7.5% *Hispanic persons may be of any race and are not included in any specific racial group. Racial and Ethnic Composition, Jefferson County and Washington State, 2000 Source: us Census, 2000. NOTE: All data are final. . Jefferson County 0 Washington State 3.1% 2.2"1. 1.4% 0.4% African-American Native American 5.3% 1.2% I I Asian *Hispanic persons may be of any race and are not included in any specific racial 0.1% 0.4% Native Hawaiian/Other Pacific Islander ~070l-0RA-FT Civilian unemployment rate in Jefferson County and Washington State, 1980-2000. Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Jefferson County 9.3% 11.6% 10.0% 10.0% 9.5% 8.9% 8.3% 7.9% 5.9% 5.8% 4.9% 6.5% 8.9% 8.3% 8.5% 7.3% 8.3% 6.8% 6.7% 5.8% 5.7% Washington State 7.9% 9.5% 12.1% 11.2% 9.5% 8.1% 8.2% 7.6% 6.2% 6.2% 4.9% 6.4% 7.6% 7.6% 6.4% 6.4% 6.5% 4.8% 4.8% 4.7% 5.2% 14.0% - 12.0% -,- 10.0% ~ 8.0% 6.0% - 4.0%- Civilian unemployment rates, Jefferson County and Washington State, 1980-2000. Source: Washington State Department of Labor and Industry, April 2001. Washington State 2.0% '- 0.0% .,---- 0 ..... N M '<t It) CO ,.... co Q') 0 ..... N M '<t It) co ,.... co Q') 0 co co co co co co co co co co Q') Q') Q') Q') Q') Q') Q') Q') Q') Q') 0 Q') Q') Q') Q') Q') Q') Q') CD Q') Q') Q') Q') Q') Q') Q') Q') Q') Q') Q') Q') 0 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... N 5/30/01 DRAFT Poverty Status by age in Washington State and Jefferson County, 1989, 1993,1995, and 1997. Jefferson County Washington State All persons, 1989 12.6% 11.0% <18 years old, 1989 23.7% 16.7% 5-17 years old, 1989 20.5% 14.9% All persons, 1993 12.3% 12.0% < 18 years old, 1993 19.8% 17.3% 5-17 years old, 1993 17.9% 15.0% All persons, 1995 11.4% 10.8% < 18 years old. 1995 18.1% 15.1% 5-17 years old, 1995 16.3% 12.8% All persons. 1997 11.4% 10.2% <18 years old. 1997 18.2% 15.2% 5-17 years old. 1997 17.8% 13.7% Poverty by age, Jefferson County and Washington State, 1989, 1993, 1995, and 1997. Source: us Bureau of the Census, Small Area Income and Poverty Estimates Program, November 2000. 20.0%- 18.0% ~ -; 16.0% - - c- - 14.0%- - - 12.0% -+- 8.0% I-"' 10.0% 6.0% I 4.0% ~ 2.0% -:-- 0.0% -~ ~ - L-~ L.J L ---'--- M M M II') II') II') t- t- t- O) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) Q') 0) 0) .... .... .... .... .... .... .... .... .... vi "C 'ti vi 'ti 'ti vi "C "C c:: '0 '0 c:: '0 '0 c:: '0 '0 0 0 0 Ul Ul Ul Ul Ul Ul Ul Ul Ul .... .... .... .... .... .... .... .... .... Q) ('lJ ('lJ Q) ('lJ ('lJ Q) ('lJ ('lJ 0.. Q) Q) 0.. Q) Q) 0.. Q) Q) >. >. >. >. >. >. et co t- et co t- et co t- .... .... .... .... .... .... V . V . V . II') II') II') . Jefferson County OWashington State i ,-.-.- I Cl) co Cl) .... vi c:: o Ul .... Q) 0.. 0) 0) co co 0) 0) .... .... 'ti "C '0 '0 Ul Ul .... .... ('lJ ('lJ Q) Q) >. >. 00 t- .... .... V . II') et 5/30/01 DRAFT'-- Median household income, Jefferson County and Washington State, 1989-2000. Year Jefferson County Washington State Index 1989 $25,197 $31 , 183 0.81 1990 $27,350 $33,461 0.82 1991 $28,207 $34,374 0.82 1992 $28,569 $35,880 0.80 1993 $28,821 $36,519 0.79 1994 $29,122 $37,674 0.77 1995 $29,002 $38,707 0.75 1996 $30,028 $40,808 0.74 1997 $31,749 $43,460 0.73 1998 $32,664 $46,080 0.71 1999 $33,446 $48,289 0.69 2000 $34,662 $50,152 0.69 Median Household Income, Jefferson County and Washington State, 1989-2000. Source: Estimates and forecasts prepared by Washington State Office of Financial Management, September 2000 $60,000 - $50,000 - n I I I I I I I i $40,000 - n I I I ~ $30,000 - n I I I I n i i ~ I ! I n I ! I I i ! I $20,000 . $10,000 ! I $0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 r I I I I ! I I ' i I I I I ! i I i I I I I I I I I 5/30101 DRAFT Median house sales prices, Jefferson County and Washington State, 1989.99. Year Jefferson County Washington State Index 1995 $127,300 $136,600 0.93 1996 $142,100 $142,200 1.00 1997 $135,000 $150,000 0.90 1998 $136,300 $160,700 0.85 1999 $155,900 $166,600 0.94 2000 $174,700 $176,900 0.99 $200,000 - $180,000 - $160,000 - $140,000 $120,000 - $100,000 - $80,000 - $60,000 - $40,000 - $20,000 - $0 1995 Median House Sales Prices, Jefferson County and Washington State, 1995-2000. Source: Wasington State Center for Real Estate Research, Washington State University, December 2000 1996 1997 1998 1999 2000 . Jefferson County DWashington State 5/30/01 DRAFT Housing Affordability Index, Jefferson County and Washington State, 1989-2000. Year 1995 1996 1997 1998 1999 2000 Jefferson County 118.2 87.9 84.3 97.4 103.2 78.1 Washington State 109.2 121.5 109.3 120.8 126.1 108.4 100.0 ~ ; I I More Affordable I 80.0 ~ Less Affordable 140.0 ~ 120.0 60.0 40.0 20.0 0.0 Housing Affordability Index, Jefferson County and Washington State, 1995-2000. Source: Washington Center for Real Estate Research, Washington State University, Octoberr 2000 Jefferson County 1995 1996 1997 1998 1999 2000 5/30/01 DRAFT Jefferson County Board of Health Agenda Item Infor.mation / Description Regular Business For Month of: July, 2001 Description - a brief description of the agenda item: please include project, road, contract, grant, etc. number if one is available for the Commissioner Index Discussion concerning policy options for sewer extensions within sewer service areas Issue - a short outline of the issue: strategy or objective issue supports; (law/policy/regulations) : including policy issue falls within; key reference areas This is a policy issue intended to clarify when the health department may require connection to public sewers. The attached document is offered to initiate the discussion. Opportunity Analysis - what is the type of action Board is being asked to take: discussion/decision - if decision - what is the range of possible solutions considered by the department in preparing its recommendation The board is being asked to review the attached document and offer policy direction from which staff will initiate, if appropriate, specific policy language for further board review. Specific Departmental Recommendation - why was the action recommended and what would be the impact of not taking the action: what specific action is necessary by the BOCC approval - adoption - deny - remand back to department None at this time. Review Process - if this issue was sent back for further review by the board, please indicate additional reviews undertaken. If the review is simply good business policy - indicate what reviews have taken place Risk Management Legal/Prosecuting Attorney Fiscal/Budget Department Head Public Service Director Board Management Team Other Impacted Departments - please list Work Plan including What, Who, When and How has been completed YES (please provide copy) not?) (check one) NO (why Subject: Required connection to public sewers Issue: The recently adopted Jefferson County Onsite Sewage Ordinance requires connection to public sewers when sewer service is available. An onsite sewage system may be permitted only when sewer service is not available. The ordinance does not provide specify how to determine if sewer service is available. Current Guidance: Indirectly guidance is provided in several areas; . WAC 246-272 requires connection to sewer when sewer service is available within 200 feet of the residence, the existing onsite sewage system is failing, the sewer utility will provide the service and the health officer requires it. The state regulation does not address new systems and new construction. . Various utilities have policies concerning required connection. Port Townsend policy has undergone changes in recent years with connection required when service is available with in 200 to 500 feet of the property line. (I am not sure about the current standard) Additionally, the city requires connection of existing septic systems when sewer service becomes available. . Port Ludlow policy is to allow sewer connection within the boundaries of the master planned resort at the expense of the property owner. In other words sewer service is available, but at a cost. Additionally, covenants establish requirements to connect to sewer when sewer is available for both new construction and existing buildings. The covenants do not specify how to determine availability. . Health and Human Services Policy Statement97-02, "Minimum Land Area Requirements", prohibits waivers from minimum land area requirements as established in WAC 246-272 when sewer service is available in a timely and reasonable matter. Discussion: Environmental Health frequently receives applications for onsite sewage system permits for properties located within areas generally served by sewers (Port Townsend and Port Ludlow) but where specific lots may not be conveniently located for connection. Typically the septic permit application has been submitted because the cost of extending sewer service greatly exceeds the cost of the individual septic system when only the lot in question is bearing the cost of the extension. When all the lots that may benefit from the extension are factored in, community sewers are often less expensive or cost competitive with onsite sewage. Practice has been to defer to the utility and proceed with the septic application only if the utility indicates an unwillingness to extend service as determined by the utility policies and the site will otherwise support a septic system irrespective of whether the lot density will support septics over the long run. The problem with this approach is that the expediency and immediacy of the individual application takes precedent over the long-term interests of the community at large. When costs for sewering are considered only with respect to a specific property the cost of installing a septic system will almost always be much less than extending a sewer line. When each development proposal is reviewed in isolation there will almost always be a short term interest is using onsite systems. However, each time a septic system is installed a barrier is created to the eventual extension of sewers. The owner of a lot with a septic system, especially one who has incurred the expense of an alternative system, is much more likely to be resistant to paying for future sewer service than the owner of an undeveloped lot. (assuming there are expectations of building in the future). And as the number of lots that will be sewered goes down, the cost per connection goes up creating an additional barrier. The basic problem then would appear to be how to motivate a community to work together or at least assure that when septic permits are issued they are issued at sustainable densities. To some extent this has occurred through the adoption of the county land area policy. Additionally, Port Townsend has adopted an ordinance limited septic installation to land areas of at least one acre. ( I believe this is mainly intended to keep septic density low enough that potential infill will drive eventual sewer extension.) Although the county land area policy has functioned reasonably well there has been increasing pressure by individuals to allow septics in Port Ludlow in particular even though lots sizes do not meet the policy requirements. Policv Options: . The staff preferred option would be a kind of carrot and stick approach initiated by a clear policy statement from the BOH that sewer service is the first priority within sewer service areas and septics are the exception. (RCW70.l18.050 provides that local boards of health may adopt more restrictive standards than those contained in 70.ll8 or rules adopted by the state.) This then would be followed up by the provision of technical assistance and guidance, possibly through public works or the PlJD in the county, to assist the communities with the processes necessary to establish local utility or improvement districts leading towards financing the improvements. . A second option would be to continue as we have but reaffirm the limitations with respect to land area as specified in the adopted policy. . Irrespective of the above, Staff would recommend a clear statement with respect to subdivision within sewer service areas requiring extension of sewers into the new plats as a condition of approval Jefferson County Board of Health Agenda Item Infor.mation / Description Regular Business For Month of: July, 2001 Description - a brief description of the agenda item: please include project, road, contract, grant, etc. number if one is available for the Commissioner Index Draft policy regarding new construction using existing onsite sewage systmes. Issue - a short outline of the issue: strategy or objective issue supports; (law/policy/regulations) : including policy issue falls within; key reference areas RCW 70.118 authorizes local boards of health to adopt regulations more restrictive that those adopted by the state board of health or as established in 70.118. The law specifically authorizes local boards ability to establish restrictions on expansions on residences when the board finds it necessary to do so in order to protect the public health and water quality standards. Section 8.15.060 of the Jefferson County Onsite Sewage Code states that any new or replacement structure may be connected to an existing onsite sewage system only when the system has the hydraulic capacity, sufficient horizontal and vertical separation and adequate reserve area. The draft policy statement addresses how existing onsite sewage systems will be evaluated in order to determine whether the intent outlined in 8.15.060 is met. Opportunity Analysis - what is the type of action Board is being asked to take: discussion/decision - if decision - what is the range of possible solutions considered by the department in preparing its recommendation The Board is being asked to review and comment on the draft policy. It is anticipated that board recommended revisions will be incorporated into a next draft for further review Specific Departmental Recommendation - why was would be the impact of not taking the action: by the BOH approval - adoption - deny - remand the action recommended and what what specific action is necessary back to department Staff does not have a specific recommendation with respect to the draft policy at this time. Review Process - if this issue was sent back for further review by the board, please indicate additional reviews undertaken. If the review is simply good business policy - indicate what reviews have taken place Risk Management Legal/Prosecuting Attorney Fiscal/Budget Department Head Public Service Director Board Management Team Other Impacted Departments - please list Work Plan including What, Who, When and How has been completed YES (please provide copy) not? ) (check one) NO (why REVISED CODE OF WASHINGTON Page I of I RCW 70.118.050 Adoption of more restrictive standards. If the legislative authority of a county or city finds that more restrictive standards than those contained in *section 2 of this act or those adopted by the state board of health for systems allowed under *section 2 of this act or limitations on expansion of a residence are necessary to ensure protection of the public health, attainment of state water quality standards, and the protection of shellfish and other public resources, the legislative authority may adopt ordinances or resolutions setting standards as they may find necessary for implementing their findings. The legislative authority may identify the geographic areas where it is necessary to implement the more restrictive standards. In addition, the legislative authority may adopt standards for the design, construction, maintenance, and monitoring of sewage disposal systems. [1939 c 349 5 3.] NOTES: *Reviser's note: "Section 2 of this act" did not become law. See effective date note following. Effective date -- 1989 c 349: "(1) Except as provided in subsection (2) of this section, this act shall take effect November 1, 1989. (2) *Section 2 of this act shall not take effect if the state board of health adopts standards for the replacement and repair of existing on-site sewage disposal systems located on property adjacent to marine waters by October 31, 1989." [1989 c 349 ~ 4.] *Reviser's note: Section 2 of this act did not take effect. See chap-:::?L23J - 9_6~ 'i'JAC. http://search.leg.wa.go,,o/wslrcwIRC\V%20%2070%2...IRCW%20%2070%20.l18%20.050.ht 7/11/01 U) An owner falls to complete required 0 & M inspections. comply with the 0 & M schedule In TABLE 1 and/or submit the reports to the PUD. (k) An owner fails to comply with conditions of the on-site sewage permit. 8.15060 ADEQUATE SEWAGE DISPOSAL REQUIRED (1) Every residence. place of business, or other building or place where people congregate. reside or are employed shall be connected to an approved public sewer. If no public sewer is available. the building sewer shall be connected to an on-site sewage system approved by the Health Officer. Said sewage disposal system shall be built or rebuilt. constructed and maintained in such manner as to meet the requirements as prescnbed by the Health Officer in accordance with minimum requirements and ~tandards of WAC 246-272 and this code. Such system may include the use of waterless toilet devices In conjunction with an approved graywater system or other proprietary devices approved by Washington State Department of Health. (2) Any uniUfacility with the potential to generate waste water by virtue of being equipped with a toilet, sink. shower or other plumbing fixture that is in a water service area or has a well on site, shall be connected to an approved public sewer or shall be connected to an on-site sewage system approved by the Health Officer. (3) Any new or replacement residence or any expansion. as that term is defined in Section 8.15.050(7) of this Code. may be connected to a pre-existing on-site sewage system only when the pre-existing system has hydraulic capacity, sufficient vertical and horizontal separation. an adequate reserve area and satisfies all other requirements to be in compliance with current code. 8. ~ 5.070 NO DISCHARGE TO WATER OR GROUND SURFACE Effluent from anyon-site sewage disposal system shall not be discharged directly or indirectly to surface water or upon the surface of the ground. except where expressly permitted by the Health Division or by the Washington State Department of Ecology. 8.15.080 ON-SITE SEWAGE SYSTEM PERMIT (1) No person shall install or cause to be installed a new on-site sewage system, nor perform any alteration. extensions, relocation or connection to an existing on-site sewage system without a valid permit issued by the Health Officer. (2) When applying for a permit to install an on-site sewage system. a detailed to scale construction plan of the proposed system and site is required and shall include all items identified in WAC 246-272-11001 (2)(a). Each application shall contain the information required in WAC 246-272-09001 as a minimum. (3) The minimum land area required for approval of an OSS permit shall be determined by either Method 1 or Method 2 as established in WAC 246-272. (4) Permits are transferable with property ownership. (5) Any sewage disposal permit issued under this section shall be valid for a period of three (3) years from the date of issuance. (a) The permit may remain valid if the property for which the permit has been issued also has an active building permit for a structure that will be connected to the on-site sewage system. JEFFERSON COUNTY HEALTH AND HUMAN SERVICES ENVIRONMENTAL HEALTH DIVISION POLICY STATEMENT PROGRAM - On-site Sewage Disposal SUBJECT - Review of Building Permit Applications Effective this date the following procedure shall be adopted concerning review of building permit applications on properties where there is an existing onsite sewage system. PURPOSE Applications for building permits for properties served by on-site sewage systems shall be approved only when the on-site sewage system has adequate hydraulic and treatment capacity to accommodate the proposed construction and an adequate repair area is available. APPLICABILITY This policy applies to building permit applications for new structures that contain plumbing; alterations or remodels to existing structures that contain plumbing; and structures not containing plumbing when the placement of that structure may interfere with the performance of an existing onsite system or the ability to replace the existing system. GENERAL POLICY STATEMENT It is the policy of the Jefferson County Board of Health that all existing onsite sewage systems will be evaluated to determine whether the system has been installed with adequate vertical and horizontal separation, sufficient hydraulic capacity and reserve area to support the proposed development without compromising the public health or water quality standards before approval of building permits for new or replacement structures. Whenever feasible, the evaluation will be based on information obtained from permit records. However, when permit records provide insufficient information, field evaluation may be required. Determinations will balance the expectations and commitments implicit in the permit record with the degree to which use of a permitted system may compromise the public health. In all cases public health protection is the highest priority. It is further policy of the Board that properties that have an installed onsite sewage system that was properly permitted by Jefferson County will not be Draft Policy Review of Building Permit Applications page I of 2 denied a building permit based solely on the adequacy of the system. However, the Board reserves the right to require that the system be upgraded in order to meet the public health and water quality protection standards. The exception to this policy is the case where use of an onsite sewage system would violate state laws. SPECIFIC STANDARDS . Existing systems with more than 1 foot of vertical separation, adequate hydraulic capacity, horizontal separation and sufficient reserve area will be considered to be in compliance but will be placed on an annual inspection frequency. . Existing systems with more than one foot but less than two feet of vertical separation that do not meet horizontal separation to wells or surface water will be required to install pretreatment unit capable of meeting treatment standard 2. . Existing systems on marine shorelines will be required to meet standards specified in Table VI of the State Onsite Sewage System Regulations. . Existing systems on lots where there is not sufficient reserve area, but otherwise meet the vertical and horizontal separation requirements and have sufficient hydraulic capacity will be required to install pretreatment units capable of meeting treatment standard 2. EFFECTIVE DATE This policy shall become effective on the date of adoption and remain in effect until amended or repealed by action of the Jefferson County Board of Health. Health Officer Date Chairman of the Board of Health Date Draft Policy Review of Building Permit Applications page 2 of 2 Jefferson County Health and Human Services JUNE ~ JULY 2001 NEWS ARTICLES These issues and more are brought to you every month as a collection of ne'vvs stories regarding Jefferson County Health and Human Services and its program for the public: 1. "People First of Jefferson County plans a workshop..." P.T. LEADER. June l4. 2001 '1 "Adopt a cat this month" - P.T. LEADER. June 20. 200l 3. ""Iental health groups seek referee" - Peninsula Daily Ne'vvs. June 21. 2001 4. "Tri-Area wells protected'?" (2 pages) - P.T. LEADER. June 27. 200l 5. "Following the S206 billion trail from court to county" - Peninsula Daily News. July 1. 2001 6. '''Stemming tobacco use on Peninsula"- Peninsula Daily News. July 2. 2001 7. "Whooping cough treated" - P.T. LEADER. July 3. 2001 8. "County's teen pregnancy rate drops a third" - P.T. LEADER. July 3. 200l THURSDAY, JUNE 14 People First of Jefferson County plans a workshop on self-detennination. 9- 3:30 p.m. at the WSU Jefferson County Extension Office, 201 W. Patison, Port Hadlock. For information. call Tami Lydic, 385-6878 or 385-9400. Adopt a cat this month National-Adopt-A-Cat month is here. June is the designated month in which people are encouraged to adopt a cat from the local shelter. Members of the Jefferson County's Paws-N-Claws 4-H Cat Club visited the Jefferson County Animal Services pet shelter last month and were given a tour of / 1.1: LEA()~R... b-ZO -0/ the facility by the shelter's edu- cational specialist Brian Muck. , 4-H'ers participating included Tara Styan, Robin VanDyke, Nadine Chouinard, Rachel Ander- son, Sarah Rudolph, Callum Styan, Morgan Osmer and Mikayla Osmer. They took turns holding different cats that were up for adoption. (1) (1) J.. ~ (1) J.. ~ (1) (1) tn tn Q. ~ o J.. 'OJJ .c ..... - CO (1) .c - CO ..... 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'-" U ,.., '. r .-J..) c:: CJ ,... - '0 I '-- 1"\ .-..S ~ ;::2. ~ Leader.com * Visitor Info Website: Olympic-Peninsula.com June 27, 2001 VoL 112 No. 26 Tri-Area wells protected? City, county, PUD wrestle over aquifer protection By Barney Burke Leader Staff Writer A continuing debate over the level of roundwater protection offered by efferson County's Uniform Develop- ent Code (UDC) has put a damper on lans to complete the Tri-Area water ystem swap. The swap would have the City of Port ownsend selling its Tri-Area water sys- m to the Public Utility District (PUD), and the PUD selling its Glen Cove sys- tem to the city. But on Monday night, the Port Townsend City Council voted to sustain, until further study is done, its appeal of the county's UDC in order to ensure that protections against saltwater intrusion and possible groundwater contamination from asphalt batch plants were sufficient. That 6-0 vote caught county officials by surprise. They had expected the coun- cil to follow a city staff recommendation that the current protections are adequate and that the appeal should be dropped. But after public testimony and discussion, the council instead voted to continue the appeal for at least another 60 days. Monday night, the council heard from the public and a representative of Shine Community Action Council and the Olympic Environmental Council. (OEC), groups with their own appeals pending on the same groundwater See WATER, PageA 13 1 I I lder ~ Water: Dispute , Continued from Page A 1 1 protection issues raised by a sec- tIon of the UDC. When the Board of County CommIssioners learned Tuesday , mornmg of the delay, the board canceled an informational work- shop scheduled for Wednesday that could have facilitated a pos- sible settlement between the county and Shine/OEe. So in stepped the Public Util- ity District (PUD). The PUD an- nounced later Tuesday that it would sponsor the mfonnational workshop instead, and it INill occur today, June 27, at 1 :30 p.m. at the Pon Townsend Community Cen- ter J.t Tyler and Lawrence streets. County officIals also said they would suspend negotiations with the CIty and with Shme/OEC, cit- mg concerns that the two appeals have become "'intermmgled" in a way that is detrimental to the county's ability to negotiate. "We're getting lied to about who 'Nas negotiating in good faith," said David Alvarez, Jefferson County civil deputy prosecutmg attorney. Until the intentions of all parties mvolved are clarified, there will be no fur- ther negotIatIons. he explained. A June 26 e-mail from Dave Christensen, the county's natural resource diVision manager, said the county was canceling the meetmg "because it appears that the CIty and the GEC/Shine have been workmg in concen on their CDC appeals without our knowl- edge. Jefferson County IS sus- pending negotiations wllh OEC/ Shine and the City of Pon Townsend until we have assured ourselves that we know who we are negotiating wIth and what we ' are negotiating about." County Commissioner Dan Titterness expressed a different reason to cancel the workshop. Apparently he had helped to set up the sessIOn and was hoping a hydrogeologist from Island County could attend to share his expenise. Earl,. Tuesdav morn- Ing, Titterness learned this scien- "We're getting lied to about who vvas negotiating in good faith." David Alvarez civil deputy prosecuting attorney Jefferson County l.,. "~~ my first ~eaction was, J ihere 's~n6 'sense in having a meet- 'lng. 'Th~"n,'~ W'~reartre"'dimore of what has gone on since, we said, 'Time to halt this thing,'" According to Titterness, his colleague Glen Huntingford atso indicated that he was not interested in proceeding with the meeting. Colette Kost~lec, the engi- neering consultant who is help- ing Shine and the OEC negotiate with the county, helped resusci- tate the meeting under the spon- sorship of the PUD. She said the commitment from the Island County hydrogeologist had al- ways been tentative. Of the county's reaction, Kostelec said, ''I'm looking to the county for the basis of their accu- sation, because they haven't given us any evidence to substantiate [it)." All she did, she said, was at- tend Monday's City Council meet- ing and encourage the council not to withdraw its appeal but to get educated on the subject by attend- ing the Wednesday workshop, City appeal The city had tiled an appeal of the county's UDC in Decem- ber 2000, citing concerns about whether the county's revamped development regulations would compromise the protection of well water from asphalt batch plants and saltwater intrusion. But June 25, City Manager David -- ". Timmons and city attorney John Watts told the council that, fol- lowing meetings with county staff, they were satisfied that the protections are adequate. Quite a few city residents didn't have the same comfort level on the issue, nor did the council. Kostelec suggested that the councIl might as well take more time, since the two groups she rep- resents have asked for more tIme. Among the other speakers at the council meeting was PUD Commissioner Wayne King of Gardiner, who said the three- member PUD board unanimously supported the city's appeal. A key factor in the PUD 's per- spective is the proposed water system swap, in which the PUD IS slated to buy the city's Tri-Area water system, fed by two wells lTI the POrl Hadlock area. Asphalt batch plants, if allowed there, could contaminate those wells, some officials fear. King pointed out that protect- ing those two wells is a point that Timmons specifically made in a Feb. 21 letter to the county. ''I'm really troubled with this deal," King said. He also suggested that studies on the salt'....~lter intrusion problem were not being taken into account by the county. But in a staff repon, Timmons pOinted out that asphalt batch plJ.nts are only allowed In the heavy industnal zone (the Port Townsend Paper Corp.'s proper- ties) and in commercial forest lands. The report also says that the county's view is that batch plants were not prohibited in sus- c-epti'bYe- aqu'Je-r re'c.hargeareasl previously, and the newnIles-of-' fer added protection by requiring conditional use permits. The city staff repon also states that the county is '.';illing to act as a '"repository" of data on salt- water intrusion, and says that the county's proposal "appears suf- ficient" The next morning, Timmons left a voice mail message for County Administrator Charles Saddler informing him that the City Council acted lTI response to threalened litigaHon from the PUD. King had made a passing comment to the council about the possibility of legal action if the city entered into ,m agreement with the county, which he felt could affect Larry Fay, county director \ environmental health, thinks th: introduces a whole new player: the mix. "The PUD never aD pealed the UDC when it had th opportunity," he said. If the county can't reach a agreement with the city or WI[ Kostelec's two groups, the Wes: em Washington Growth Mal1J.gc' ment Hearings Board will dec:c: the matter. With Kostelec's arc peal extension already in plac~ that won't happen until J.t Ie a, the end of September. Leader staff writer She.. Teslermnn contributed to thLS :;lOr ~ c . .,....j o ~ V . .,....j > .. ca .. c G) E E o u 00 s: [,J z - CJ ~ ~~ ---- ~ ~ 00 I ~ z [,J 0... )'f'" . 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"It was frightening." Jefferson County Health and Human Services now has six confirmed cases of pertussis, or ',l, hooping cough, reported since J Jne 1:: Pertussis can be life- threatenIng In Infants under the age of 1 because they have such small alrv..'ays The symptoms are much less severe in teens and adults. Luckliy, none of the SIX V\ctlms were under I, but fiv~ of them ''''ere under 7. "It's rare to have so many cases under the age of 7," said Dr Tom Locke of Jefferson County Public Health. "It's a sig- nIficant outbreak." Immunity from the pertussis vaccmatlon can wear off in chil. dren over 7 "PertUSSIS IS probably more ~ommon than we realize, but the people who might have con- tracted It aren't tested very of- te". ,aid Locke. Loc,.;e said hIS agency's mis- ,ion IS 1O protect children under Jg=: To do that, he strongly rec- ommends that parents who have not immUnIzed thelf children for penu,sls do so now .It) a challenging recommen- -laliOn :n Jefferson County, be- .~~se ,t has one of the higher ~.ites J1 parents exempting their .nOldren tram vaCCination," said l.-0CKc \I,.1en Jefferson County chil- eren enter kJndergarten, between "It's rare to have so many cases under the age of 7. It's a significant outbreak." Dr. Tom Locke Jefferson County Public Health 8 and 9 percent of the students are not fully vaccinated. That rate is one of the highest for all Wash- ington state counties. Locke said that of all the vac- cinations, parents particularly have avoided pertussis. The older version, which used whole cells of pertussis, had relatively severe side effects of high fevers and local reactions. But Locke stressed that the new version, without whole cells, has much fewer side effects. According to Lisa McKenzie, a public health nurse and coor. dinator for the health department's contagious dis- eases, the pharmaceutical indus- try is developing a booster for children over 7. Unfortunately, there is no published indication of when the booster will be ready for sale. Pertussis IS only moderately contagious. Unlike measles, which can be spread by just breathing the same air as a con- tagious person, pertussis requires contact with respiratory secre- tions from a person's mouth or nose. "So it's usually spread be- tween close friends or family members," said Locke. Treatment requires quick ac- tion. Antibiotics are only effec- tive in the first two to three days, a period when many people haven't figured out they might have the disease. After that three- day period, a toxin secreted by the Bordetella pertussis bacteria damages the lining of the airways and lungs, causing coughing. Antibiotics can eradicate the . causative bacteria, explained Locke, but can't repair the damage to the mucous lIning. Antibiotics are most useful 111 protecting close family members from the infection and decreas- ing the amount of time an actiVe pertussis case is contagious. "If people know they have been exposed, they should be tested, and I strongly urge par- ents to make sure their children are immunized," said Locke. He believes the county will see additional cases before the number of cases of pertussIS drops to a lower, more acceptable level. 'l1S/01 Port Townsend &; Jefferson County Leader County's teen pregnancy rate drops a third By Janet Huck Metzger started with five peer Leader Staff Writer educators in 1990. This year she has 25 students in Port Townsend Teen pregnancy, a social chal- High Schoo1. Two months ago lenge for Jefferson County in the she started a similar program at early 1990s, has dropped nearly Chimacum High School. a third. Quilcene High School has staned About 10 years ago, the its own peer education program county's teen pregnancy rate per this year. thousand hovered around 50, Although the program focuses sometimes rising as high as 66 on abstinence, Metzger said the per thousand. Those numbers peer educators don't abandon were well above the national tar- sexually active teens. Instead get figure of 45 per thousand. they give them information about Now Jefferson County boasts harm reduction for such concerns a fIgure of only 33 pregnancies as pregnancy, sexually transmit- /' per thousand for teenage girls. ted diseases and AIDS. "Whatever was done, changed Sexually active teens can get behavior," declared University of information and treatment at Washington epidemiologist Dr. local family clinics. Washing- Christiane Hale in January as she ton state law allows county presented her analysis on health health department family plan- and economic risk factors for the ning clinics to offer confiden- Jefferson County Health and tial consulting, testing and Human Services Department, referrals to teenagers. The What has been done was a Jefferson County health depart- successful combination of edu- ment offers clinics in different cation, information and ser- parts of the county at different vices. The health department times of the week, so the ser- offers everything from absti- vices are broadly available. nence programs to family plan- Teens can also receive emer- ning. "It's a woven quilt of gencycontraception.Ifteenstake offerings," said Jean Baldwin, the the emergency contraception health department's community within 72 hours. they can prevent health director. pregnancy. "For a rural county, we have "They don't have to get a good comprehensive [sex] edu- pregnant if they made a mis- cation program that starts with take," explained Metzger. "It the basics and moves on to pre- isn't abortion, though. It won't vention," saId Hilary Metzger, stop a pregnancy that has be- health department health educa- gun. But conception is a pro- tor and public health nurse. cess that takes days." Metzger began a peer educa- Metzger also credits the fami- tion program II years ago in lies, the communities and which she trained a core group present-day society, which is of teenagers who then reached more open in talking about these out to their peers. Though the issues honestly, as contributing to program is focused on absti- the drop in pregnancy rates. /s nence, the peer educators offer "Families are a bigger piece s their fellow students real-life in- ...,~:W at)'i..Pf 'p~.Wograms," saip formation about healthy relation.-' Metzger.' .' ' ships and self-esteem as well as The economy is too. "In times condoms. It appears to be an ef- of economic prosperity, teenage fective program. pregnancy traditionally goes "It would be wonderful if the down because young women see '. teens would stop their unhealthy more opportunities to become an aCtlvities immediately," said adult," Metzger explained. l' Metzger. "But it takes awhile for "I don't want us patting our- :d it to become cool to abstain from selves on the back prematurely," ry drugs, alcohol and sexual activ- she cautioned. "If the economy ilc ity. But once you find you are not goes down, we could see a rise alone, it's easier to abstain." in teen pregnancy again." to Figure 6. Poverty among all persons, Clallam, Jefferson, and Kitsap Counties, 1989, 1993, 1995, and 1997 Year 1989 1993 1995 1997 Clallam County 12.5% 13.2% 12.1% 12.3% Jefferson County 12.6% 12.3% 11.4% 11.4% Kitsap County 8.6% 9.5% 8.8% 8.9% Figure 6. Poverty among all persons, Clallam, Jefferson, and Kitsap Counties, 1989-2000. Source: us Bureau of the Census. Small .Area Income and Poverty Estimates Program. November:ceo. 20.0% 18.0% 16.0% 14.0% 12.5% 12.6% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 1989 7/19/01 DRAFT . Clallam County 121 Jefferson County 0 Kitsap County 13.2% 1993 -_._---,._---_._~--~.."._..._..__.--_.._..-----_._---~ 12.1% 1995 12.3% 8.9% 1991 Figure 7. Poverty children age <18, Clallam, Jefferson, and Kitsap Counties, 1989, 1993, 1995, and 1997 Year 1989 1993 1995 1997 Clallam County 17.4% 19.6% 17.6% 19.4% Jefferson County 23.7% 19.8% 18.1% 18.2% Kitsap County 13.2% 13.9% 12.3% 12.6% Figure 7. Poverty among children age <18, Clallam, Jefferson, and Kitsap Counties, 1989, 1993, 1995, and 1997. Source: us Bureau of the Census. Small Area Income and Poverty Estimates Program. November 2COJ. 30.0% 28.0% 26.0% 24.0% 23.7% 22.0% 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 1989 . Clallam County 21 Jefferson County 0 Kitsap County 7/19/01 DRAFT 19.6% 19.8% 1993 12.3% 1995 19.4% 12.6% 1997 Figure 8. Poverty among children age 5-17 in families, Clallam, Jefferson, and Kitsap Counties, 1989,1993,1995, and 1997 Year 1989 1993 1995 1997 Clallam County 14.8% 16.7% 14.8% 17.5% Jefferson County 20.5% 17.9% 16.3% 17.8% Kitsap County 11.4% 11.7% 10.4% 11.6% Figure 8. Poverty among children age 5-17 living in families, Clallam, Jefferson, and Kitsap Counties, 1989, 1993, 1995, and 1997. Source IJS Bureau of the Census. Smail Area Income and Poverty Estimates Program. November 2CCQ. 30.0% 28.0% 26.0% 24.0% 22.0% 20.5% 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 0.0% 4.0% 2.0% 0.0% 1989 ~.-_._._._.._-"-_..~---_.- .." . Clallam County ~ Jefferson County 0 Kitsap County -..... .--- ..--.--.-----..-....-.- 7/19/01 DRAFT 17.9% 1993 16.3% 1995 17.5% 17.8% 11.6% 1997 Figure 9. Median household income, Clallam, Jefferson, and Kitsap Counties, 1989-2000. Year 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Clallam County $25,434 $27.149 $27,212 $27.282 $27,433 $27,486 $28,128 $28.887 $30,700 $31 ,443 $31 ,162 $32.268 Jefferson County $25.197 $27,350 $28.207 $28,569 $28.821 $29,122 $29.002 $30.028 $31,749 $32,664 $33.446 $34,662 Kitsap County $32,043 $36,636 $37,670 $38,185 $38.223 $38,908 $38,813 $39.808 $41.524 $42,484 $44,036 $45,401 Figure 9. Median household income, Clallam, Jefferson, and Kitsap Counties, 1989-2000. Source: Washington State Department of Labor and Industry, April 2CX)1 $60,000 - _~ Clal~~~_~C?unty - ~~.!fer:~~_~_o~n~_~_~itsap County $50,000 - $40,000 $30,000 - ~ $20,000 - $10,000 . . . . . . ~ . ~ ---_._._,---------_._--_._-~--------- ._----_.._--_._~ Q) 0 -- N M ~ It) (Q I"- co Q) 0 co Q) Q) Q) Q) Q) Q) Q) Q) Q) Q) 0 Q) Q) Q) Q) Q) Q) Q) Q) Q) Q) Q) 0 -- -- -- ... -- -- -- -- -- -- -- N 7/19/01 DRAFT $0 _.__________________.__._____.____ __.m___.____..__________._____ - ---.- ._' .__._...____._..._..._.....__.__...u..___... ._.__~._._______ Figure 10. Median house price, ClalIam, Jefferson, and Kitsap Counties, 1995-2000. Year 1995 1996 1997 1998 1999 2000 Clallam County $102,000 $110,100 $112,300 $118,000 $120,000 $117,800 Jefferson County $127,300 $142,100 $135,000 $136,300 $155,900 $174,700 Kitsap County $124,600 $127,700 $131,200 $145,600 $143.100 $148,500 ---.-------------- Figure 10. Median house sales prices, Clallam, Jefferson, and Kitsap Counties, 1995-2000. Source: Washington State Center for Real Estate Research. Washington State University, December 2CXXl $200,000 - . -+- Clallam County - Jefferson County -r- Kitsap County $125,000 - $115,000 $150,000- $100,000 - .------. ..------- . . . $15,000 . $50,000 - $25,000 - $0 100 tn tn ~ CD tn tn "'" ,... tn tn "'" co tn tn "'" tn tn tn "'" Q Q Q N 7/19/01 DRAFT Calculation of TFR, 1980-99 Calculation of Total Fertility Rate, Jefferson County, 1980-1999 1980 Age group Female Pop Births ASFR 1 5-19 542 20 0.03690 20-24 501 75 0.14970 25-29 662 79 O. 11 934 30-34 659 39 0.05918 35-39 475 9 0.01895 40-44 331 3 0.00906 GFR 3,170 225 71.0 TFR 2.0 1981 Age group Female Pop Births ASFR 15-19 540 26 0.04815 20-24 506 71 0.14032 25-29 678 75 0.11062 30-34 715 58 0.08112 35-39 520 6 0.01154 40-44 366 0 0.00000 GFR 3,325 236 71.0 TFR 2.0 1982 Age group Female Pop Births ASFR 15-19 526 23 0.04373 20-24 488 69 0.14139 25-29 664 78 0.11747 30-34 710 44 0.06197 35-39 580 21 0.03621 40-44 395 2 0.00506 GFR 3,363 237 70.5 TFR 2.0 1983 Age group Female Pop Births ASFR 1 5-19 499 23 0.04609 20-24 457 59 0.12910 25-29 620 73 0.11774 30-34 694 41 0.05908 35-39 617 7 0.01135 40-44 429 1 0.00233 GFR 3,316 204 61.5 TFR 1.8 1984 Age group Female Pop Births ASFR 1 5-19 500 30 0.06000 20-24 449 66 0.14699 25-29 605 57 0.09421 30-34 711 51 0.07173 Page 1 Calculation of TFR. 1980-99 35-39 670 15 0.02239 40-44 482 5 0.01037 GFR 3,417 224 65.6 TFR 2.0 1985 Age group Female Pop Births ASFR 1 5-19 504 19 0.03770 20-24 431 53 0.12297 25-29 584 75 0.12842 30-34 719 53 0.07371 35-39 722 20 0.02770 40-44 528 3 0.00568 GFR 3,488 223 63.9 TFR 2.0 1986 Age group Female Pop Births ASFR 1 5-19 517 19 0.03675 20-24 409 48 0.11736 25-29 563 68 0.12078 30-34 724 46 0.06354 35-39 783 13 0.01660 40-44 572 3 0.00524 GFR 3.568 197 55.2 TFR 1.8 1987 Age group Female Pop Births ASFR 1 5-19 513 20 0.03899 20-24 386 56 0.14508 25-29 532 63 0.11842 30-34 722 54 0.07479 35-39 798 23 0.02882 40-44 641 2 0.00312 GFR 3.592 218 60.7 TFR 2.0 1988 Age group Female Pop Births ASFR 1 5-19 517 20 0.03868 20-24 371 54 0.14555 25-29 516 69 0.13372 30-34 728 53 0.07280 I 35-39 838 32 0.03819 40-44 712 2 0.00281 GFR 3.682 230 62.5 TFR 2.2 1989 Age group Female Pop Births ASFR 15-19 510 21 0.04118 Page 2 Calculation of TFR, 1980-99 20-24 360 53 0.14722 25-29 498 44 0.08835 30-34 732 47 0.06421 35-39 883 27 0.03058 40-44 774 7 0.00904 GFR 3,757 199 53.0 TFR 1.9 1990 Age group Female Pop Births ASFR 1 5-19 501 23 0.04591 20-24 353 45 0.12748 25-29 476 68 0.14286 30-34 734 44 0.05995 35-39 924 34 0.03680 40-44 840 2 0.00238 GFR 3,828 216 56.4 TFR 2.1 1991 Age group Female Pop Births ASFR 15-19 514 29 0.05642 20-24 379 53 0.13984 25-29 489 58 0.11861 30-34 789 57 0.07224 35-39 995 38 0.03819 40-44 938 12 0.01279 GFR 4,104 247 60.2 TFR 2.2 1992 Age group Female Pop Births ASFR 15-19 531 26 0.04896 20-24 387 66 0.17054 25-29 493 67 0.13590 30-34 810 43 0.05309 35-39 1,052 26 0.02471 40-44 964 5 0.00519 GFR 4,237 233 55.0 TFR 2.2 1993 Age group Female Pop Births ASFR 15-19 557 37 0.06643 20-24 396 65 0.16414 25-29 494 47 0.09514 30-34 838 51 0.06086 35-39 1,097 31 0.02826 40-44 1,013 5 0.00494 GFR 4,395 236 53.7 TFR 2.1 Page 3 Calculation of TFR. 1980-99 1994 Age group Female Pop Births ASFR 1 5-19 585 30 0.05128 20-24 395 66 0.16709 25-29 492 57 0.11585 30-34 854 51 0.05972 35-39 1,133 15 0.01324 40-44 1,061 5 0.00471 GFR 4,520 224 49.6 TFR 2.1 1995 Age group Female Pop Births ASFR 15-19 656 24 0.03659 20-24 542 59 0.10886 25-29 661 53 0.08018 30-34 739 43 0.05819 35-39 919 27 0.02938 40-44 1,019 9 0.00883 GFR 4,536 215 47.4 TFR 1.6 1996 Age group Female Pop Births ASFR 1 5-19 691 23 0.03329 20-24 530 47 0.08869 25-29 673 58 0.08625 30-34 718 33 0.04598 35-39 940 30 0.03190 40-44 1,052 8 0.00760 GFR 4,604 199 43.2 TFR 1.5 1997 Age group Female Pop Births ASFR 15-19 718 38 0.05294 20-24 538 51 0.09479 25-29 673 57 0.08465 30-34 706 33 0.04672 35-39 945 24 0.02539 40-44 1,096 11 0.01004 GFR 4,677 214 45.8 TFR 1.6 1998 Age group Female Pop Births ASFR 15-19 737 26 0.03529 20-24 544 43 0.07907 25-29 661 52 0.07872 30-34 674 52 0.07711 35-39 937 33 0.03524 40-44 1,105 1 0.00091 Page 4 Calculation of TFR, 1980-99 GFR 4,657 207 44.5 TFR 1.5 1999 Age group Female Pop Births ASFR 1 5-19 747 25 0.03347 20-24 555 61 0.10991 25-29 636 55 0.08648 30-34 648 46 0.07099 35-39 922 23 0.02495 40-44 1,108 10 0.00903 GFR 4,616 220 47.7 TFR 1.7 Page 5 Annual births, 1980-99 Figure 1. Annual birth rates, Jefferson County and Washington State, 1980-1999 Jefferson County Washington State Birth Rates Year Births Population Births Population Year Jefferson County Washington State 1980 225 15,965 67,469 4,132,156 1980 14.1 16.3 1981 236 16,736 69,489 4,229,278 1981 14.1 16.4 1982 237 17,017 69,294 4,276,549 1982 13.9 16.2 1983 204 16,925 68,448 4,307,247 1983 12.1 15.9 1984 224 17,480 68,467 4,354,067 1984 12.8 15.7 1985 223 17,873 69,847 4,415,785 1985 12.5 15.8 1986 197 18,317 69,881 4,462,212 1986 10.8 15.7 1987 218 18,533 69,497 4,527,098 1987 11.8 15.4 1988 230 19,131 71,670 4,616,886 1988 12.0 15.5 1989 199 19,673 73,863 4,728,077 1989 10.1 15.6 1990 216 20,146 77,795 4,866,692 1990 10.7 16.0 1991 247 21,600 78.159 5,000,400 1991 11.4 15.6 1992 233 22,500 77,561 5,116,700 1992 10.4 15.2 1993 236 23,500 76,868 5,240,900 1993 10.0 14.7 1994 224 24,299 75,121 5,334,400 1994 9.2 14.1 1995 215 25,099 74,939 5,428,569 1995 8.6 13.8 1996 199 25,699 77,616 5,516,805 1996 7.7 14.1 1997 214 26,057 79,640 5,606,800 1997 8.2 14.2 1998 207 26,910 78,141 5,685,300 1998 7.7 13.7 1999 220 27,738 79,577 5,757,400 1999 7.9 13.8 Figure 1. Annual Birth Rates, Jefferson County and Washington State, 1980-1999 Source: Births - annual vital statistics reports, Washington State Center for Health Statistics. Population- 1980 & 1990, US Census; 1981-89, Office of Financial Management intercensal estimates; 1991-99 - OFM intercensal projections. Rates for 1980-1990 are final; all others are provisional and subject to change. 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 9;,\:;' fb~ fbll.- fb":J fb~ fb~ fbro 9;,'\ fb~ 9;,OJ ~\:;, ~~ ~ll.- ~":J ~~ ~~ ~ro ~'\ ~~ ~OJ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 7/19/01 DRAFT Total Fertility Rates, 1980-99 Figure 2. Total Fertility Rates, Jefferson County and Washington State 1980-1999 Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County 2.0 2.0 2.0 1.8 2.0 2.0 1.8 2.0 2.2 1.9 2.1 2.2 2.2 2.1 2.1 1.6 1.5 1.6 1.5 1.7 Washington State 1.8 1.8 1.8 1.8 1.8 1.9 1.9 1.9 1.9 2.0 2.1 2.1 2.0 2.0 2.0 2.0 2.0 2.0 2.1 2.1 Figure 2. Total Fertility Rates, Jefferson County and Washington State, 1980-1999 Source: Births - annual vital statistics reports. Washington State Center for Health Statistics. Population- 1980 & 1990. US Census; 1981-89, Office of Financial Management intercensal estimates: 1991-99 - OFM intercensal projections. Rates for 1980-1990 are final: all others are provisional and may change. 2.5 :f It) .... (l) ~ 2.0 c: ca E o 3 ... 1.5 (l) c. 1Il ..c: 1:: iXi (l) ~ ~ ::i (l) CI ca ... (l) < 1.0 i I 0.5 J 0.0 I I ~~~~~~~~~~~~~~~~~~~~ "ClS "ClS ,,0:; ,,0:; "ClS "ClS "ClS "ClS "ClS "ClS "OS "OS "OS "OS "OS "OS "OS "OS "OS "OS 7/19/01 DRAFT teen pregnancy rates Figure 3. Pregnancy Components, 15-17 year olds, Jeffeson County, 1980-82 through 1997-99 Events Rates Year Births Abortions Pregnancies Population Period Birth Abortion Pregnancy 1980 3 7 10 365 1980-82 12.1 9.3 21.4 1981 5 1 6 362 1981-83 17.3 6.7 24.0 1982 5 2 7 349 1982-84 22.5 8.8 31.3 1983 8 4 12 332 1983-85 25.4 12.7 38.2 1984 10 3 13 340 1984-86 21.8 11.4 33.2 1985 8 6 14 350 1985-87 15.9 11.2 27.1 1986 5 3 8 364 1986-88 13.1 10.3 23.4 1987 4 3 7 356 1987 -89 16.3 11.5 27.9 1988 5 5 10 350 1988-90 21.6 15.7 37.3 1989 8 4 12 334 1989-91 29.3 14.7 44.0 1990 9 7 16 335 1990-92 35.8 12.3 48.1 1991 13 4 17 354 1991-93 36.6 10.7 47.4 1992 16 2 18 372 1992-94 32.2 10.2 42.4 1993 12 6 18 393 1993-95 25.9 11.0 36.9 1994 10 4 14 414 1994-96 19.0 10.9 29.9 1995 11 4 15 465 1995-97 18.4 13.0 31.4 1996 5 7 12 492 1996-98 17.1 16.5 33.6 1997 11 8 19 509 1997 -99 20.7 16.9 37.6 1998 10 10 20 517 1999 11 8 19 517 Figure 3. Birth, Abortion, and Pregnancy Rates, Jefferson County, Women Age 15-17, 1980-82 through 1997-99 Source: Births and abortions - annual vital statistics reports. Washington State Center for Health Statistics. Population -1980 & 1990, US Census; 1981-89, Office of Financial Management intercensal estimates; 1991- 99 - OFM intercensal projections. Rates for 1980-1990 are final; all others are provisional and may change. ~ 60.0 .n .... CD Jf 50.0 c: CD S 40.0 == 'E ~ 30.0 t CD 0:: g 20.0 o .... ... 8. 10.0 CIl 'E Q) &i 0.0 Abortion rate II) ~ ..... 00 O'l 0 ..... ('1.1 CO') -.:t II) ~ ..... 00 00 00 00 00 00 O'l O'l O'l O'l O'l O'l O'l O'l O'l I I I I I . I I I I I I I . CO') -.:t II) ~ ..... 00 O'l 0 ..... ('1.1 CO') -.:t II) ~ 00 00 00 00 00 00 00 O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l ..... ..... ..... ..... ..... ..... ..... ..... ..... .... ..... .... .... .... ('1.1 CO') -.:t 00 00 00 . I I o ..... ('1.1 00 00 00 O'l O'l O'l .... ..... .... 7/19/01 DRAFT Figure 4. Pregnancies per 1,000 females ages 15-17, Jefferson County & Washington State, 1980-82 through 1997-99. Period 1980-82 1981-83 1982-84 1983-85 1984-86 1985-87 1986-88 1987 -89 1988-90 1989-91 1990-92 1991-93 1992-94 1993-95 1994-96 1995-97 1996-98 1997 -99 Jefferson County 21.4 24.0 31.3 38.2 33.2 27.1 23.4 27.9 37.3 44.0 48.1 47.4 42.4 36.9 29.9 31.4 33.6 37.6 Washington State 62.3 58.9 56.4 55.0 55.0 55.1 57.6 58.1 60.5 59.2 58.3 58.5 56.4 53.6 50.2 47.6 45.2 42.3 Healthy People 2010 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 ,.... 70.0 T :;; ! ..... I f/l 60.0 I Q) C) <( f/l 50.0 ~ co E ~ 40.0 o o q, 30 0 ..... . I- Q) C. f/l 20.0 Q) 'u lij 10.0 c: C) Q) l- e. 0.0 C"') co I ..... co 0) ... Figure 4. Pregnancies per 1,000 females age 15-17, Jefferson County and Washington State, 1980-82 through 1997-99. Source: Births and abortions - annual vital statistics reports. Washington State Center for Health Statistics. Population - 1980 & 1990, US Census; 1981-89. Office of Financial Management intercensal estimates; 1991-99- OFM intercensal projections. Rates for 1980-1990 are final; all others are provisional and may change. State and National Target I I I I -.r It) co ,.... co 0) 0 ... ('II C"') -.r It) co ,.... co 0) co co co co co co 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) I I I ,;, I I I . I I I I I I I I ('II M -.r co ,.... co 0) 0 ... ('II M -.r It) co ,.... co co co co co co co co 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) ... ... ..... ..... ..... ..... ... ... ..... ..... ... ..... ..... ... ... ... 7/19/01 % births to mothers <18 Figure 5. Births to Mothers Age <18 as a Percent of All Births, Jefferson County and Washington State, 1980-82 through 1997-99 Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County All Births 225 236 237 204 224 223 197 218 230 199 216 247 233 236 224 216 199 214 207 220 Mother <18 4 5 5 8 10 8 5 5 5 9 10 13 17 13 10 12 5 11 10 11 Period 1980-82 1981-83 1982-84 1983-85 1984-86 1985-87 1986-88 1987 -89 1988-90 1989-91 1990-92 1991-93 1992-94 1993-95 1994-96 1995-97 1996-98 1997-99 Washington State 3.8% 3.6% 3.4% 3.4% 3.5% 3.6% 3.6% 3.6% 3.6% 3.6% 3.8% 4.0% 4.1% 4.2% 4.1% 4.1% 3.9% 3.9% Jefferson County 2.0% 2.7% 3.5% 4.0% 3.6% 2.8% 2.3% 2.9% 3.7% 4.8% 5.7% 6.0% 5.8% 5.2% 4.2% 4.5% 4.2% 5.0% Figure 5. Births to Mothers Age <18 As a Percent of All Births, Jefferson County and Washington State, 1980-82 through 1997-99 Source: Annual vital statistics reports. Washington State Center for Health Statistics. All rates are final. 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% N M "l:t In to r-- co en 0 ~ N M o:r co co co co co co co co en en en en en I I I I . I I I I . I I . 0 ~ N M "l:t In to r-- co en 0 ~ N co co co co co co co co co co en en en en en en en en en en en en en en en en ~ ~ ~ ~ ~ T'" ~ ~ ~ ~ ~ ~ ~ In to r-- co en en en en en en I I . I I M "l:t it) to r-- en en en en en en en en en en IIIf""" IIIf""" 't"- IIIf""" .... 7/19/01 DRAFT non-smoking Figure 6. Non-smoking* Mothers, Jefferson County and Washington State, 1984-1999 Year 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County All 218 219 195 213 227 190 206 235 232 234 211 213 194 211 200 214 Non-smokers 160 154 133 146 168 161 174 192 171 166 161 165 160 167 158 185 Year 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County 73.4% 70.3% 68.2% 68.5% 74.0% 84.7% 84.5% 81.7% 73.7% 70.9% 76.3% 77.5% 82.5% 79.1% 79.0% 86.4% *Based on birth certificates reporting maternal smoking. Washington State 77.1% 74.4% 74.7% 74.9% 75.0% 78.2% 80.0% 80.6% 79.9% 82.0% 82.9% 83.8% 84.0% 85.4% 85.4% 85.8% Figure 6. Non-smoking Mothers, Jefferson County and Washington State, 1984-1999 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% + 0.0% -I I 'It It) CD ..... co 0) 0 co co co co co co 0) 0) 0) 0) 0) 0) 0) 0) .... .... .... .... .... .... .... Washington State I .... N C") 'It It) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) .,... "t""" "t""" .,... .,... I ! CD ..... 0) 0) 0) 0) .... .... I co 0) 0) 0) 0) 0) .... .... 7/19/01 DRAFT 1 st trimester care Figure 7. Percent of Pregnant Women Beginning Prenatal Care in the First Trimester Jefferson County and Washington State, 1980-1999 Jefferson County Year All 1 st trimester Year Jefferson County Washington State 1980 224 184 1980 82.1% 79.5% 1981 232 186 1981 80.2% 79.1% 1982 235 193 1982 82.1% 77.7% 1983 199 138 1983 69.3% 77.7% 1984 221 169 1984 76.5% 78.2% 1985 219 175 1985 79.9% 77.9% 1986 196 150 1986 76.5% 77.5% 1987 216 176 1987 81.5% 77.2% 1988 227 180 1988 79.3% 77.1% 1989 192 146 1989 76.0% 77.0% 1990 212 172 1990 81.1% 77.6% 1991 240 200 1991 83.3% 79.0% 1992 228 200 1992 87.7% 79.9% 1993 227 191 1993 84.1% 80.8% 1994 201 175 1994 87.1% 82.6% 1995 213 188 1995 88.3% 82.6% 1996 195 170 1996 87.2% 83.3% 1997 207 183 1997 88.4% 83.3% 1998 201 175 1998 87.1% 83.0% 1999 212 171 1999 80.7% 82.8% Figure 7. First-trimester Prenatal Care, Jefferson County and Washington State, 1980-1999 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 100.0% 90.0% 80.0% 70.0% 60.0% I I I I I i i i : I I I I I I ~ ~ ~ ~ ~ ~ * ~ ~ * m m ~ * ~ * ~ g ~ m I ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ I ! Jefferson County Washington State 50.0% I 40.0% L 30.0% 20.0% 10.0% 0.0% 7/19/01 DRAFT late or no prenatal care Percent of Pregnant Women With Third Trimester or No Prenatal Care, Figure 8. Jefferson County and Washington State. 1980-84 through 19954-99 Period 1980-84 1981-85 1982-86 1983-87 1984-88 1985-89 1986-90 1987-91 1988-92 1989-93 1990-94 1991-95 1992-96 1993-97 1994-98 1995-99 Jefferson County All 1,109 1,103 1,067 1,049 1,077 1,048 1,041 1,085 1,094 1,092 1,101 1,112 1,066 1,045 1,019 1,018 3rd trimester/none 58 56 51 44 35 27 32 26 25 27 24 16 20 22 23 27 Period 1980-84 1981-85 1982-86 1983-87 1984-88 1985-89 1986-90 1987-91 1988-92 1989-93 1990-94 1991-95 1992-96 1993-97 1994-98 1995-99 Jefferson County 5.2% 5.1% 4.8% 4.2% 3.2% 2.6% 3.1% 2.4% 2.3% 2.5% 2.2% 1.4% 1.9% 2.1% 2.3% 2.7% Washington State 4.3% 4.5% 4.7% 4.8% 4.8% 4.9% 4.9% 4.7% 4.5% 4.3% 3.9% 3.8% 3.7% 3.7% 3.7% 3.3% Figure 8. Late or No Prenatal Care, Jefferson County and Washington State, 1980-84 through 1995-99 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 6.0% 5.0% 4.0% 3.0% 2.0% . ton State 1.0% 0.0% "l:t In (Q "'" co en 0 .... N C""l "l:t In (Q "'" co en co co co co co co en en en en en en en en en (l) I I I . I I I I I I I I . I I I 0 .... N C""l "l:t In (Q "'" co en 0 .... N C""l "l:t It) co co co co co co co co co co en en en en en (l) en en en en en en en en en en en en en en en (l) .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... 7/19/01 DRAFT unmarried mothers Figure 9. Percent of Births to Unmarried Mothers, Jefferson County and Washington State, 1980-1999 Jefferson County Year AII* Unmarried Percent Year Jefferson County Washington State 1980 225 44 19.6% 1980 19.6% 13.6% 1981 235 31 13.2% 1981 13.2% 14.5% 1982 235 37 15.7% 1982 15.7% 14.4% 1983 204 36 17.6% 1983 17.6% 15.8% 1984 223 40 17.9% 1984 17.9% 16.9% 1985 222 31 14.0% 1985 14.0% 18.5% 1986 197 44 22.3% 1986 22.3% 19.8% 1987 217 52 24.0% 1987 24.0% 20.8% 1988 230 43 18.7% 1988 18.7% 22.3% 1989 198 66 33.3% 1989 33.3% 23.5% 1990 214 59 27.6% 1990 27.6% 23.8% 1991 247 84 34.0% 1991 34.0% 25.0% 1992 230 75 32.6% 1992 32.6% 25.3% 1993 234 82 35.0% 1993 35.0% 26.6% 1994 211 61 28.9% 1994 28.9% 26.0% 1995 216 66 30.6% 1995 30.6% 26.7% 1996 198 50 25.3% 1996 25.3% 27.2% 1997 213 68 31.9% 1997 31.9% 27.2% 1998 206 79 38.3% 1998 38.3% 27.9% 1999 216 64 29.6% 1999 29.6% 28.0% --------------- *AII mothers for whom marital status was given. Figure 9. Births to Unmarried Mothers, Jefferson County and Washington State, 1980-1999 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% fO""'" fO"" fOfl.. fO":J ~ fO~ fOro fO'\ fO'b fOOj ~......, ~"" ~fl.. ~":J ~~ R>~ R>ro R>'\ R>'b R>Oj ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 7/19/01 DRAFT Figure 10. Maternal Education <High School Completion*, Jefferson County and Washington State, 1992-1999 Jefferson County Year All Births 1992 223 1993 228 1994 202 1995 210 1996 191 1997 201 1998 202 1999 205 < High School 42 35 40 34 22 43 23 29 Year 1992 1993 1994 1995 1996 1997 1998 1999 *Based on births for which education was known. Jefferson County 18.8% 15.4% 19.8% 16.2% 11.5% 21.4% 11.4% 14.1% Washington State 17.5% 18.4% 18.6% 18.8% 18.3% 18.1% 18.1% 17.8% Figure 10. Maternal Education < High School, Jefferson County and Washington State, 1992-1999 Source: Annual vital statistics reports. Washington State Center for Health Statistics. All rates are final. 25.0% ...- 19.8% 18.8% - 18.8% 18.4% 1B.6% ~ r-- 18.3% B.1% 18.1% - - 17.8% .5% - - - - r-- 16.2 0 15.4 . - - 14.1 0 - 11.5 0 11.4 0 r-- - I I I I I 20.0% 15.0% 10.0% 5.0% 0.0% 1992 7/19/01 DRAFT 1993 1994 1995 21.4% 1996 1997 i o Jefferson County DWashington State I I I I I I I I II 1998 1999 Medicaid Figure 11. Medicaid-paid delivery*, Jefferson County and Washington State, 1992-1999 Jefferson County Year All Births Medicaid 1992 228 113 1993 224 120 1994 204 92 1995 210 113 1996 195 95 1997 201 104 1998 195 103 1999 211 115 Year 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County 49.6% 53.6% 45.1% 53.8% 48.7% 51.7% 52.8% 54.5% *Based on births for which payment source was known. Washington State 30.9% 34.3% 34.1% 32.2% 33.4% 32.3% 31.3% 32.5% Figure 11. Medicaid-paid Delivery, Jefferson County and Washington State, 1992-1999 100.0% Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. I I I I I I I i 53.6% 53.8% 54.5% I 51.7% 52.8% - I 49.6% r-- .-- ,..- 48.7% r-- - 45.1% r-- - :0.9% :~.3% : .1% ~b.2% ,~.4% ,12.3% : .5% f-- f-- ~ .3% i-- 10- 10- f-- f-- - . 1992 1993 1994 1995 1996 1997 1998 1999 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% II I o Jefferson County DWashington State I 7/19/01 DRAFT First Steps Figure 12. Participants in First Steps Program*, Jefferson County and Washington State, 1992-99 Jefferson County Year All Births Participants 1992 233 76 1993 236 101 1994 214 81 1995 216 96 1996 199 108 1997 214 75 1998 207 72 1999 220 34 Year 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County 32.6% 42.8% 37.9% 44.4 % 54.3% 35.0% 34.8% 15.5% Washington State 11.5% 14.9% 15.7% 15.6% 15.9% 14.1% 12.4% 9.2% *Based on births for which program participation was known. Figure 12. Participation in First Steps Program at Child's Birth, Jefferson County and Washington State, 1992-1999 Source: Annual vital statistics reports. Washington State Center for Health Statistics. All rates are final. l I I i I I I o Jefferson County DWashington State I I 54.3% - I 44.4% I 42.8% I ~ r-- I 37.9% 32.6% - 35.0% 34.8% I - - j - i 5.7% 5.9% I 4.9% 5.6% 15.5% I 4.1% I 1.5% - ,...- - ,...- 2.4% - I - ,...- ,...- 9.2%1 In, 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1992 1993 1994 1995 1996 1997 1998 1999 7/19/01 DRAFT wic Figure 13. Participants in WIC Program*, Jefferson County and Washington State, 1992-99 Jefferson County Year All Births Participants 1992 233 115 1993 236 125 1994 212 104 1995 216 130 1996 1 99 1 08 1997 214 117 1998 207 99 1999 220 53 Year 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County 49.4% 53.0% 49.1% 60.2% 54.3% 54.7% 47.8% 24.1% Washington State 27.7% 32.2% 32.5% 33.6% 36.7% 36.2% 36.0% 28.1% *Based on births for which program participation was known. Figure 13. Participation in Women, Infant, Children (WIC) Feeding Program, Jefferson County and Washington State, 1992-1999 100.0% Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. I I 60.2% I ,..- i 53.0% 54.3% 54.7% I 49.4% -, 49.1% - ,..- - ,..- 47.8% ...-- 36.7% 3 .2% 3p.O% 3~.2"10 ~ .5% 3 .6% - - I-- 2 .7% I-- - - 28.1% - 24.1 :;- - 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1992 1993 1994 1995 1996 1997 1998 1999 I o Jefferson County DWashington State i 7/19/01 DRAFT welfare Participants in AFDC or TANF*, Figure 14. Jefferson County and Washington State, 1992-1998 Jefferson County Year All Births Participants 1992 233 33 1993 236 20 1994 212 19 1995 216 34 1996 199 24 1997 214 29 1998 207 20 1999 207 20 Year 1992 1993 1994 1995 1996 1997 1998 1999 Jefferson County 14.2% 8.5% 9.0% 15.7% 12.1% 13.6% 9.7% 15.5% Washington State 5.7% 7.5% 7.0% 8.0% 9.1% 7.9% 6.1% *Based on births for which program participation was known. Figure 14. Participation in Welfare System, Jefferson County and Washington State, 1992-1998 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. I I 15.7% I 14.2% ......- 13.6% ~ 12.1% r-- I r-- 9.7% I ~~.5% 9.0% .1% - .0% .0% f-- .9% - .7% - - I-- - .1% I-- - 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 1992 1993 1994 1995 1996 1997 1998 I o Jefferson County DWashington State I 7/19/01 DRAFT Ibw by smoking Figure 16. Low Birthweight by Maternal Smoking, Jefferson County, 1984-88 through 1995-99 Period 1984-88 1985-89 1986-90 1987 -91 1988-92 1989-93 1990-94 1991-95 1992-96 1993-97 1994-98 1995-99 Smoker 7.4% 8.2% 7.6% 8.3% 6.3% 6.5% 6.7% 7.0% 8.7% 10.9% 10.3% 9.9% Non-smoker 3.7% 3.9% 4.4% 3.9% 3.5% 3.2% 3.3% 3.5% 4.2% 5.0% 4.7% 4.0% Figure 16. Low Birthweight by Maternal Smoking, Jefferson County, 1984-88 through 1995-99 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 12.0% 1 E 10.0% t l!! C) o o It) cj 8.0% Cl c: :E Cl 'ijj 3: 6.0% c: ... o aI III 'E Jl! ..5 4.0% - o 'E Ql U ... ~ 2.0% 0.0% co O'l 0 .... ('II M ~ It) (l) I"- co O'l co co O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l I I I I I I I I I I I I ~ It) (l) I"- co O'l 0 .... ('II M ~ It) co co co co co co O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l O'l .... .... .... .... .... .... .... .... .... .... .... .... 7/19/01 DRAFT Figure 1. Annual birth rates, Clallam, Jefferson & Kitsap Counties, 1980.1999. Year Clallam County Jefferson County Kitsap County 1980 17.3 14.1 17.5 1981 15.8 14.1 17.3 1982 15.0 13.9 17.1 1983 15.2 12.1 18.0 1984 15.9 12.8 16.7 1985 14.3 12.5 16.6 1986 13.5 10.8 16.7 1987 14.5 11.8 16.3 1988 12.9 12.0 15.9 1989 13.1 10.1 16.8 1990 13.4 10.7 18.0 1991 12.6 11.4 18.0 1992 11 .1 10.4 17.4 1993 11.2 10.0 14.8 1994 9.6 9.2 15.6 1995 10.4 8.6 15.0 1996 9.8 7.7 14.5 1997 9.7 8.2 14.2 1998 10.3 7.7 13.1 1999 9.2 7.9 12.6 Figure 1. Annual birth rate per 1,000 population, Clallam, Jefferson, and Kitsap Counties, 1980-1999. Source: Births - annual vital statistics reports, Washington State Center for Health Statistics. Population - 1980 & 1990, US Census; 1981-89, Office of Financial Management intercensal estimates; 1991-99 - OFM intercensal projections. Rates for 1980-1990 are final; all others are provisional and subject to change. 20.0 T 16.0 8.0 6.0 -L 14.0 12.0 10.0 4.0 T I 2.0 .1- I I 0.0 : c ..... co co en en ..... ..... C'ol M co co en en ..... ..... o:t co C'l .... It) co en ..... CD I"- co co C'l C'l .... ..... co C'l co co C'l C'l .... ..... c .... C'l C'l C'l C'l .... ..... I I C'ol M C'l C'l C'l en ..... ..... '<:t It) en en C'l C'l ..... ..... I CD I"- C'l C'l C'l C'l .... ..... I co C'l C'l C'l C'l C'l .... .... i -+- Clallam County -Jefferson County --.- Kitsap County I 7/19/01 DRAFT Figure 2. Total fertility rates, ClaHam, Jefferson, & Kitsap Counties, 1980-1999. Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 C/allam County 2.2 2.0 2.0 2.3 2.1 2.1 2.1 2.3 2.1 2.2 2.4 2.3 2.0 2.1 1.8 2.0 1.9 2.0 2.1 1.9 Jefferson County 2.0 2.0 2.0 1.8 2.0 2.0 1.8 2.0 2.2 1.9 2.1 2.2 2.2 2.1 2.1 1.6 1.5 1.6 1.5 1.7 Kitsap County 2.1 2.1 2.1 2.2 2.1 2.1 2.1 2.1 2.1 2.3 2.5 2.4 2.4 2.1 2.2 2.2 2.1 2.1 2.0 1.9 Replacement Fertility 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 Figure 2. Total Fertility Rate, Clallam, Jefferson, and Kitsap Counties, 1980-1999. Source: Births - annual vital statistics reports, Washington State Center for Health Statistics. Population - 1980 & 1990, US Census; 1981-89, Office of Financial Management intercensal estimates; 1991-99. OFM intercensal projections. Rates for 1980-1990 are final; all others are provisional and subject to change. 3.0 T I 2.5 I ~ It) T"' ~ 2.0 lU C Q) E ~ 1.5 iil .t::. 1: :c t 1.0 T ~ I 0.5 ~ i I I I 0.0 , o ~ N M co co co co 0) 0) 0) 0) ~ ~ ~ ~ I '<t It) (0 "'" co co co co 0) 0) 0) 0) ... ~ ~ ... Iii co 0) 0 ~ co co 0) 0) 0) 0) 0) 0) ... ... ... ... N M '<t 0) 0) 0) 0) 0) 0) ~ ~ ~ (0 0) 0) ~ i "'" 0) 0) ~ co 0) 0) 0) 0) 0) ~ ~ . Clallam County .a. Kitsap County It) 0) 0) ~ Jefferson County Replacement Fertility 7/19/01 DRAFT Figure 3. Pregnancies per 1,000 females ages 15-17 ,Clallam, Jefferson, and Kitsap Counties, 1980-82 through 1997-99. Period 1980-82 1981-83 1982-84 1983-85 1984-86 1985-87 1986-88 1987 -89 1988-90 1989-91 1990-92 1991-93 1992-94 1993-95 1994-96 1995-97 1996-98 1997 -99 Clallam County 47.0 39.0 37.3 36.7 38.9 44.5 45.6 52.4 57.4 64.3 62.8 52.4 42.3 39.2 38.8 38.7 40.4 38.9 Jefferson County 21.4 24.0 31.3 38.2 33.2 27.1 23.4 27.9 37.3 44.0 48.1 47.4 42.4 36.9 29.9 31.4 33.6 37.6 Kitsap County 58.7 50.9 45.7 45.3 47.6 49.6 52.1 52.6 54.5 54.0 54.7 53.9 53.2 47.9 43.3 40.0 37.6 35.4 2010 Target-US 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 45.0 ~ 70.0 I It) ... ~ 60.0 Cl <( ~ 50.0 co E Lf 40.0 , o I ~ 30.0 t C1l 0- f/) 20.0 C1l "u ; 10.0 c: Cl C1l Q: 0.0 i ("') CIO I ... CIO 0) ... Figure 3. Pregnancies per 1,000 females ages 15-17, Clallam, Jefferson, and Kitsap Counties, 1980-82 through 1997-99. Source: Births and abortions - annual vital statistics reports. Washington State Center for Health Statistics. Population - 1980 & 1990. US Census: 1981-89. Office of Financial Management intercensal estimates; 1991-99- OFM intercensal projections. Rates for 1980-1990 are final; all others are provisional and may change. I I I I I -=r It) CD ..... CIO 0) 0 ... N ("') -=r It) CD ..... CIO 0) CIO CIO CIO CIO CIO CIO 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) I I I I I I I I I I I I I I I I N ("') -=r It) CD ..... CIO 0) 0 ... N ("') -=r It) CD ..... CIO CIO CIO CIO CIO CIO CIO CIO 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... . Clallam County Jefferson County ... Kitsap County - - - 2010 Target-US I 7/19/01 DRAFT % births to mothers <18 Figure 4. Births to Mothers Age <18 as a Percent of All Births, Clallam, Jefferson, and Kitsap* counties, 1980-82 through 1997-99 Period 1980-82 1981-83 1982-84 1983-85 1984-86 1985-87 1 986-88 1987 -89 1988-90 1989-91 1990-92 1991-93 1992-94 1993-95 1994-96 1995-97 1996-98 1997 -99 Clallam County 4.0% 3.5% 3.3% 3.3% 3.3% 4.2% 4.1% 4.5% 4.7% 5.6% 6.1% 5.6% 4.6% 4.6% 4.9% 4.8% 5.0% 4.4% * civilian births only Jefferson County 2.0% 2.7% 3.5% 4.0% 3.6% 2.8% 2.3% 2.9% 3.7% 4.8% 5.7% 6.0% 5.8% 5.2% 4.2% 4.5% 4.2% 5.0% Kitsap County* 3.4% 2.9% 2.8% 2.8% 3.1% 3.2% 3.4% 3.3% 3.3% 3.1% 3.8% 3.4% 3.8% 3.7% 3.6% 3.5% 3.4% 3.2% 2010 Target - US 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% Figure 4. Births to Mothers Age <18 As a Percent of All Births, Clallam, Jefferson, and Kitsap* Counties, 1980-82 through 1997-99 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% N M "It L/') r,g ,... co 0) 0 ..... N M "It L/') r,g ,... co 0) co co co co co co co co 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) I I I I I I I I I I I I I I I I I I 0 ..... N M "It L/') r,g ,... co 0) 0 ..... N M ~ L/') r,g ,... co co co co co co co co co co 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .civilian births only. 7/19/01 DRAFT . Clallam County .\ Kitsap County* Jefferson County 2010 Target - US non-smoking Figure 5. Non-smoking Mothers as a Percent of All Births, Clallam, Jefferson, and Kitsap* counties, 1984-1999 Year 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Cla/lam County 72.9% 66.7% 64.7% 70.0% 70.7% 73.6% 74.6% 75.9% 75.2% 74.0% 72.5% 69.4% 67.5% 69.5% 72.2% 74.3% * civilian births only Jefferson County 73.4% 70.3% 68.2% 68.5% 74.0% 84.7% 84.5% 81.7% 73.7% 70.9% 76.3% 77.5% 82.5% 79.1% 79.0% 86.4% Kitsap County* 76.7% 76.0% 73.7% 72.1% 71.5% 70.4% 72.1% 74.5% 76.5% 77.4% 76.7% 77.2% 77.5% 77.5% 80.1% 82.6% 2010 Target - US 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% Figure 5. Non-smoking Mothers, Clallam, Jefferson, and Kitsap* Counties, 1984-1999 Source: Annual vital statistics reports. Washington State Center for Health Statistics. All rates are final. 100.0% 90.00/0 - - - - - - - - - - - - - - - - - - - - - - - - . - - - . Clallam County Jefferson County ~ Kitsap County* 2010 Target - US II) tc ,... 00 0) 0 .... C'\l M '<t II) tc ,... 00 0) 00 00 00 00 00 0) 0') 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0) 0') 0) 0) 0') 0) 0) 0) 0) 0) .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% '<t 00 0') .... *civilian births only. 7/19/01 DRAFT 1 st trimester care Figure 6. First trimester prenatal care, Clallam, Jefferson, and Kitsap* counties, 1980-1999 Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Clallam County 79.0% 82.1% 82.2% 81.0% 84.9% 82.2% 82.6% 84.2% 81.6% 82.1% 80.9% 79.8% 84.6% 88.3% 86.4% 80.7% 81.6% 82.9% 83.1% 82.0% ~ civilian births only Jefferson County 82.1% 80.2% 82.1% 69.3% 76.5% 79.9% 76.5% 81.5% 79.3% 76.0% 81.1% 83.3% 87.7% 84.1% 87.1% 88.3% 87.2% 88.4% 87.1% 80.7% Kitsap County* 79.5% 79.3% 78.6% 77.6% 77.8% 76.3% 74.1% 71.5% 71.7% 72.7% 71.4% 77.0% 77.7% 77.6% 80.0% 80.5% 82.6% 82.2% 79.6% 78.5% 2010 Target - US 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% Figure 6. First-trimester Prenatal Care, Clallam, Jefferson, and Kitsap* Counties, 1980-1999 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% . Clallam County ~ Kitsap County* Jefferson County 2010 Target - US 20.0% 10.0% 0.0% 0 ..... C'Il CO) '<t In (0 r-.. co O'l 0 ..... C'Il CO) '<t In (0 r-.. co O'l co co co co co co co co co CIO O'l O'l O'l O'l en en O'l O'l O'l O'l en O'l en O'l O'l O'l O'l O'l en O'l O'l O'l en O'l en O'l en O'l en en ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 'civilian births only. 7/19/01 DRAFT late or no prenatal care Figure 7. Late (3rd trimester) or no prenatal care, Clallam, Jefferson, and Kitsap* counties and Washington State, 1980-84 through 1995-99 Period 1980-84 1981-85 1982-86 1983-87 1984-88 1985-89 1986-90 1987-91 1988-92 1989-93 1990-94 1991-95 1992-96 1993-97 1994-98 1995-99 Clallam County 3.0% 2.9% 2.9% 3.1% 2.7% 2.7% 2.4% 2.5% 2.0% 2.0% 1.9% 2.0% 2.0% 2.2% 2.4% 2.4% * civilian births only Jefferson County 5.2% 5.1% 4.8% 4.2% 3.2% 2.6% 3.1% 2.4% 2.3% 2.5% 2.2% 1.4% 1.9% 2.1% 2.3% 2.7% Kitsap County* 4.1% 4.3% 4.8% 4.9% 5.0% 5.3% 5.4% 4.7% 4.4% 4.2% 3.8% 3.1% 3.0% 2.9% 2.9% 3.1% Washington State 4.3% 4.5% 4.7% 4.8% 4.8% 4.9% 4.9% 4.7% 4.5% 4.3% 3.9% 3.8% 3.7% 3.7% 3.7% 3.3% Figure 7. Late or No Prenatal Care, Clallam, Jefferson, and Kitsap* Counties and Washington State, 1980-85 through 1995-99 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% "<l" I() 00 00 I I 0 ..... 00 00 en en ..... ..... CD r-.. 00 en 0 ..... N CO') "<l" I() CD r-.. 00 en 00 00 00 CII? en en en en en en en en en en I I I I I I I I I I I I I N CO') "<l" I() CD r-.. 00 en 0 ..... N CO') "<l" I() 00 00 00 00 00 00 00 00 en en en en en en en en en en en en en en en en en en en en ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... -+- Clallam County -Jefferson County --.- Kitsap County* -*-Washington State .civilian births only. 7/19/01 DRAFT unmarried mothers Figure 8. Unmarried mothers, Clallam, Jefferson, and Kitsap. counties and Washington State, 1980-1999 Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Clal/am County 13.3% 14.3% 18.6% 17.7% 17.7% 20.7% 21.5% 21.0% 27.4% 31.5% 29.8% 30.0% 29.3% 30.2% 28.2% 36.3% 33.8% 35.0% 36.5% 29.7% . civilian births only Jefferson County 19.6% 13.2% 15.7% 17.6% 17.9% 14.0% 22.3% 24.0% 18.7% 33.3% 27.6% 34.0% 32.6% 35.0% 28.9% 30.6% 25.3% 31.9% 38.3% 29.6% Kitsap County. 14.7% 13.5% 12.9% 13.8% 15.2% 19.1% 19.2% 21.5% 25.5% 25.4% 26.1% 27.4% 29.5% 28.5% 28.3% 28.1% 28.7% 30.5% 30.9% 33.0% Washington State 13.6% 14.5% 14.4% 15.8% 16.9% 18.5% 19.8% 20.8% 22.3% 23.5% 23.8% 25.0% 25.3% 26.6% 26.0% 26.7% 27.2% 27.2% 27.9% 28.0% Figure 8. Unmarried Mothers, Clallam, Jefferson, and Kitsap* Counties and Washington State, 1980-1999 50.0% Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 40.0% 30.0% 20.0% 10.0% -+- Clallam County -.- Kitsap County. -Jefferson County -*-Washington State 0.0% 0 ..... N M '<t In CD r-- co 0') 0 ..... N M '<t In c.o r-- co 0') co co co co co co co co co co 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') 0') ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .civilian births only. 7/19/01 DRAFT maternal education Figure 9. Maternal education <high school completion, Clallam, Jefferson, and Kitsap* counties and Washington State, 1992.1999 Year 1992 1993 1994 1995 1996 1997 1998 1999 Clallam County 19.2% 19.8% 19.3% 23.9% 22.6% 19.5% 22.9% 15.7% * civilian births only Jefferson County 18.8% 15.4% 19.8% 16.2% 11.5% 21.4% 11.4% 14.1% Kitsap County* 16.4% 14.7% 14.2% 16.4% 15.5% 16.4% 16.3% 15.5% Washington State 17.5% 18.4% 18.6% 18.8% 18.3% 18.1% 18.1% 17.8% Figure 9. Maternal Education Less than High School, Clallam, Jefferson, and Kitsap* Counties and Washington State, 1992-1999 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% N 0) 0) ..... *civilian births only. . Clallam County o Kitsap County* M 0) 0) ..... oq- 0) 0) ..... IZIJefferson County DWashington State It) 0) 0) ..... CD 0) 0) ..... I"'- 0) 0) ..... co 0) 0) ..... 0) 0) 0) ..... 7/19/01 DRAFT Medicaid-paid birth Figure 10. Medicaid-paid delivery, Clallam, Jefferson, and Kitsap* counties and Washington State, 1992-1999 Year 1992 1993 1994 1995 1996 1997 1998 1999 Clallam County 40.7% 50.4 % 52.0% 56.3% 44.0% 46.1% 50.1% 51.0% * civilian births only Jefferson County 49.6% 53.6% 45.1% 53.8% 48.7% 51.7% 52.8% 54.5% Kitsap County* 27.5% 35.4% 32.2% 34.1% 37.7% 36.6% 38.1% 44.4% Washington State 30.9% 34.3% 34.1% 32.2% 33.4% 32.3% 31.3% 32.5% Figure 10. Medicaid-paid Births, Clallam, Jefferson, and Kitsap* Counties and Washington State, 1992-1999 Source: Annual vital statistics reports. Washington State Center for Health Statistics. All rates are final. 100.0% , . Clallam County 21 Jefferson County I o Kitsap County* OWashington State I I i i I ~ ~ ~ '} '} B [;il ,I ,I ~ ~ ~ f- ~ '/ ~ I ~ ~ '/ ~ ,I '/ ~ 1.1 ~ ,I '/ ) I 1.1 ~ j ~ ,I ) ~ j ~ ) j ,I ) ~ j ) ~ ) ~ ) ) ~ ,I " ~ II ,I ~ ~ ~ ~ ~ ~ ) ~ ~ ~ ~ ) 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% C'ol en en .... *civilian births only. M 0'1 0'1 .... -.:r en en .... L() en en .... (0 en en .... .... 0'1 en .... co en 0'1 .... en en en .... 7/19/01 DRAFT WIC participation Figure 11. Participation in Women, Infant, Children (WIC) Feeding Program, Clallam, Jefferson, and Kitsap* counties and Washington State, 1992-1999 Year 1992 1993 1994 1995 1996 1997 1998 1999 Clallam County 31.3% 37.8% 37.9% 42.9% 45.6% 44.0% 46.0% 28.4% Jefferson County 32.6% 42.8% 37.9% 44.4 % 54.3% 35.0% 34.8% 15.5% * civilian births only Kitsap County* 35.8% 39.1% 38.0% 35.9% 35.3% 34.2% 32.9% 34.1% Washington State 27.7% 32.2% 32.5% 33.6% 36.7% 36.2% 36.0% 28.1% Figure 11. WIC Participation, Clallam, Jefferson, and Kitsap* Counties and Washington State, 1992-1999 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 100.0% I I . Clallam County I2IJefferson County I o Kitsap County* DWashington State I i I I 1/ '/ I ,I ~ ,I II- ~ I 01 01 tt - r- I r- ~ 01 I ~ 01 ~ ~ ~ I- ~ ~ ~ ~ ~ ~ ~ 01 ~ ~ ~ I ~ ~ ~ 01 ~ 01 ~ ~ .I It It' It " ~ ~ .I CI 1.01' It' It , , 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% N en en .... M en en ..... '<t en en ..... .civilian births only. 7/19/01 DRAFT It) en en ..... <0 en en .... "- en en .... co en en .... en en en .... First Steps participation Figure 12. Participation in First Steps Program, Clallam, Jefferson, and Kitsap* counties and Washington State, 1992-1999 Year 1992 1993 1994 1995 1996 1997 1998 1999 Clal/am County 14.4% 23.2% 27.9% 28.2% 25.6% 20.6% 25.0% 11.8% Jefferson County 32.6% 42.8% 37.9% 44.4 % 54.3% 35.0% 34.8% 15.5% * civilian births only Kitsap County* 19.9% 21.3% 20.7% 20.3% 23.7% 20.2% 21.6% 19.1% Washington State 11.5% 14.9% 15.7% 15.6% 15.9% 14.1% 12.4% 9.2% Figure 12. First Steps Participation, Clallam, Jefferson, and Kitsap* Counties and Washington State, 1992-1999 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 100.0% I I . Clallam County lZIJefferson County I i I I o Kitsap County* DWashington State I I I I i '} ; " "} ; " "j ~ " "} ; ; ~ ~ ; ~ ; ~ I- " I; f't- r- I I ~ I ~ ; ~ ~ I ',I ~ ~ ~ ~ ~ rr " ~ ; "; " 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% C'\l 0) 0) ..... (Y) 0) 0) ..... 'l:t 0) 0) ..... *civilian births only. 7/19/01 DRAFT 10 0) 0) ..... CD 0) 0) ..... .... 0) 0) ..... co 0) 0) ..... 0) 0) 0) ..... welfare participation Figure 13. Participation in AFDC or TANF programs, Clallam, Jefferson, and Kitsap* counties and Washington State, 1992-1999 Year 1992 1993 1994 1995 1996 1997 1998 1999 Clallam County 4.7% 5.4% 5.5% 5.9% 6.3% 5.4% 6.0% 2.4% * civilian births only Jefferson County 14.2% 8.5% 9.0% 15.7% 12.1% 13.6% 9.7% 15.5% Kitsap County* 8.1% 9.0% 8.9% 12.0% 13.9% 12.6% 10.1% 7.0% Washington State 5.7% 7.5% 7.0% 8.0% 9.1% 7.9% 6.1% 3.3% Figure 13. Participation in AFDC or TANF (welfare), Clallam, Jefferson, and Kitsap* Counties and Washington State, 1992-1999 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 7/19/01 DRAFT 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% . Clallam County o Kitsap County* l2IJefferson County i i DWashington State I I 10.0% 0.0% N 0) 0) ..... 'civilian births only. CO') 0) 0) ..... 'I:l' 0) 0) ..... It) 0) 0) ..... co 0) 0) ..... .... 0) 0) ..... co 0) 0) ..... 0) 0) 0) ..... low birthweight rates Figure 14. Low birthweight rate, Clallam, Jefferson, and Kitsap* counties and Washington State 1980-84 through 1995-99 Period 1980-84 1981-85 1 982 -86 1983-87 1984-88 1985-89 1986-90 1987-91 1988-92 1989-93 1990-94 1991-95 1992-96 1993-97 1994-98 1995-99 Clallam County 4.8% 4.8% 4.7% 4.9% 4.7% 4.6% 4.4% 4.9% 4.4% 4.3% 4.2% 4.5% 4.2% 4.3% 4.8% 4.9% * civilian births only Jefferson County 4.7% 4.7% 4.0% 4.3% 4.8% 5.3% 5.6% 5.7% 4.9% 4.6% 4.8% 4.9% 5.6% 6.7% 6.4% 5.5% Kitsap County* 5.2% 5.1% 5.1% 5.0% 4.8% 4.9% 4.9% 5.1% 5.2% 5.3% 5.3% 5.3% 5.4% 5.6% 5.7% 6.0% Washington State 5.1% 5.2% 5.2% 5.2% 5.2% 5.3% 5.3% 5.3% 5.3% 5.3% 5.2% 5.3% 5.4% 5.5% 5.6% 5.6% Figure 14. Low Birthweight Rates, Clallam, Jefferson, and Kitsap* Counties and Washington State, 1980-84 through 1995-99 , Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 8.0% -, 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% -+-- Clallam County . -1fr- Kitsap County* -Jefferson County I --*- Washington State I 1.0% 0.0% "l:t It) to ,.... co en 0 ..- ('If M "l:t It) to ,.... co en co co co co co co en en en en en en en en en en I I N I I I I I I I I I I I I . 0 ..- M "l:t It) to ,.... co en 0 ..- ('If M "l:t It) co co co co co co co co co co en en en en en en en en en en en en en en en en en en en en en en ..- ..- ..- ..- ..- ..- ..- ..- ..- ..- ..- ..- ..- ..- ..- ..- *civilian births only. 7/19/01 DRAFT Ibw & maternal smoking Figure 15. Low birthweight rate and maternal smoking, Clallam, Jefferson, and Kitsap* counties, 1984-89 through 1995-99 Period 1984-88 1985-89 1986-90 1987-91 1988-92 1989-93 1990-94 1991-95 1992-96 1993-97 1994-98 1995-99 Cla/Jam County 5.9% 6.1% 5.5% 6.5% 5.5% 5.5% 4.8% 5.0% 4.4% 4.9% 5.5% 5.6% * civilian births only Jefferson County 7.4% 8.2% 7.6% 8.3% 6.3% 6.5% 6.7% 7.0% 8.7% 10.9% 10.3% 9.9% Kitsap County* 7.6% 7.6% 7.4% 7.7% 8.1% 8.1% 8.1% 7.9% 8.5% 8.9% 9.2% 9.6% i I I i I I I Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. I 12.0% -, I I 10.0% -I i Figure 15. Low Birthweight Rates and Maternal Smoking, Clallam, Jefferson, and Kitsap* Counties, 1984-88 through 1995-99 8.0% 6.0% 4.0% 2.0% i -+- Clallam County -Jefferson County -.- Kitsap County* I 0.0% co 0') 0 ..... N (") -.:t It') CD r-- co 0') co co 0) 0) 0') 0) 0') 0') 0) 0') 0') 0') , , I , I , , I I I I , -.:t It') CD r-- co 0') 0 ..... N (") -.:t It') co co co co co co 0') 0') 0) 0) 0') 0') 0') 0') 0) 0) 0) 0') 0) 0') 0') 0) 0') 0') ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .civilian births only. 7/19/01 DRAFT Ibw & maternal nonsmoking Figure 16. Low birthweight rate and maternal non-smoking, Clallam, Jefferson, and Kitsap* counties, 1984-88 through 1995-99 Period 1984-88 1985-89 1986-90 1987-91 1988-92 1 989-93 1 990-94 1991-95 1992-96 1993-97 1994-98 1995-99 Clallam County 3.7% 3.3% 3.3% 3.6% 3.5% 3.3% 3.4% 3.8% 3.8% 3.8% 4.3% 4.5% * civilian births only Jefferson County 3.7% 3.9% 4.4% 3.9% 3.5% 3.2% 3.3% 3.5% 4.2% 5.0% 4.7% 4.0% Kitsap County* 3.6% 3.4% 3.3% 3.4% 3.6% 3.8% 4.1% 4.2% 4.2% 4.2% 4.3% 4.6% Figure 16. Low Birthweight Rates and Maternal Non-smoking, Clallam, Jefferson, and Kitsap* Counties, 1980-84 through 1995-99 Source: Annual vital statistics reports, Washington State Center for Health Statistics. All rates are final. 12.0% l 10.0% I 8.0% 1 6.0% 1 4.0% 1 ,-+- Clallam County -Jefferson County -.- Kitsap County* I -~I -r:~~< 2.0% 0.0% co 0') 0 ..... N (") -.:t It') CD r-- co 0') co co 0) 0') 0') 0) 0') 0) 0') 0) 0') 0') I , I r-:. , I , , I I I I -.:t It') CD co 0') 0 ..... N (") -.:t It') co co co co co co 0') 0) 0) 0') 0') 0') 0) 0') 0) 0') 0') 0') 0') 0) 0) 0') 0') 0') ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... .civilian births only. 7/19/01 DRAFT