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Home My WebLink About10 October JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, October 18,2001 Board Members: Dan Titterness, Member - County Commissioner District # 1 Glen Huntingford, Member - County CommÙJ'ioner DÙtritt #2 Richard U7qjr. Member - County Commissioner District #3 Geoffrry MaJ'd, Member - Port Town.rend City Council Jill Buhler, Chairman - Ho.rpital Commi.rsioner District #2 Sheila U7esterman, Vice Chairman - Citizen at Lal~;e (City) Roberta Fris.rell - Citizen at Large (County) StatfMembers: Jean Baldwin, Nursing Service.r Director Larry Fcry, Environmental Health Direttor Thoma.r Locke, MD, Health O.ffìcer Chairman Buhler called the meeting to order at 2:30 p.m. All Board and Staff members were present with the exception of Vice Chair Westerman. 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 September 20,2001 with one correction noted by Member Frissell on Page 2, paragraph 5: In the last sentence, the words "of not" should be replaced with "under." Commissioner Huntingford seconded the motion, which carried by a unanimous vote. PUBLIC COMMENT Dale Wurtsmith read his letter to the Board restating his recommendation that all properties with on-site sewage systems be required to have an Evaluation of an Existing System (EES) inspection, including those systems currently monitored by PUD as well as homes sold under the PUD contract. He feels the septic tank must be inspected to determine if the system is functioning satisfactorily. Looking only at a pump chamber for an indication of failure is reactive rather than preventive. He stressed that homeowners should be allowed to choose to have their system monitored by someone other than the PUD. He also pointed out that he cannot compete with the County inspection at a cost of $100. In response to questions from the Board, Larry Fay explained the difference between an EES, an Advanced EES, and a real estate inspection. He noted a provision in the on-site sewage code which says that an EES Ís not required if monitoring is being provided by the PUD. . Member Masci expressed support for requiring an EES at the time of sale. He suggested a privatization model for on-site inspections in which the fees could be included in the property closing costs. HEALTH BOARD MINUTES - October 18, 2001 Page: 2 Chairman Buhler expressed concern about liability and potential delays to the closing. Larry Fay said price is an issue for many who would prefer to wait for the cheaper public inspection rather than use a private service. He noted that at a cost of $100 per inspection, the County is not covering its costs. Before considering ordinance or policy changes, he asked to clarify whether the main objective is to promote private sector inspections or accomplish a particular level of inspection. He then talked about the arrangement with the PUD for on-site sewage inspection, tracking and notification. He believes we should begin thinking of this relationship in terms of a utility, with the County providing permitting and regulatory (compliance) functions. He mentioned that Staff has talked about scheduling a Board of Health workshop to assess the relationship with the PUD and discuss these issues. It was the Board's feeling that all inspectors should use the same forms for reporting and tracking and that the same reporting requirements apply to the PUD and the private sector. Commissioner Huntingford expressed concern about the inspector taking on an enforcement role, checking the site and drawing on the plot plan any new buildings or additions whether or not they relate to the function of the septic system. Mr. Fay responded that the inspection form notes the number of bedrooms under which the system was originally permitted. He asked if the inspector should ignore an obvious addition to a structure if the system is currently working. He believes it may be good to clarify in a policy what factors an inspector considers. It was agreed that this could be a future agenda topic. Grace Chawes thanked the Department for the article in The Leader on how to check your mail. She asked how prepared the Health Department, hospital, and County are for a smallpox outbreak (training of doctors, nurses and staff; methods of educating/informing the public; and preparations by mental health professional to address public fears). She would like to see these topics covered in the newspapers so that the public knows what discussions and preparations are occurring. She recommended that retired health professionals be trained and utilized to assist in an emergency. Chairman Buhler talked about some of the collaborative efforts by the hospital and the County. Jean Baldwin reviewed the two main sources of information for the public: the County's new emergency management website and staff at the County Health Department. Other measures include distributing information from the CDC to healthcare and medical service providers, labs, pharmacies, law enforcement, and the general public. She noted that aside from personal contacts, they have access to state and national databases of retired physicians and nurses. The emergency management system also provides access to additional resources. OLD BUSINESS (Re)Adoption of Amendments to Ordinance No. 08-0921-00 On site Sewae:e Disposal Svstems Rules and Ree:ulations: Larry Fay explained that due to insufficient public notice of the code revisions, the revisions approved by the Board last month have been resubmitted for approval by the Board. HEALTH BOARD MINUTES - October 18, 2001 Page: 3 Member Masci moved to adopt amendments to Ordinance No. 08-0921-00 Jefferson County On- site Sewage Code as presented and approved by the Board at the last meeting. Commissioner W ojt seconded the motion, which carried. Commissioner Huntingford abstained. (Ordinance No. 06A- 1018-01) NEW BUSINESS Report from the 2001 Washine:ton State .Joint Conference on Health: Referring to budget information provided in the agenda packet from Mary Selecky, Dr. Locke said the biggest challenge is to preserve effective Public Health programs while maintaining and building up capacities to respond to public health emergencies. Currently, the State budget is $1 billion in the hole and departments are being asked to make further budget cuts. He noted that bio-terrorism was a major focus of the conference. Bio-terrorism Preparedness - National. State and Local Efforts: Dr. Locke talked about local responses, proactive and reactive strategies to address local concerns about the risk of anthrax. Targeted outreach efforts have initially focused on hospital staff and healthcare providers. The Center for Disease Control is setting the standard for public health guidelines. Of the potential risks, anthrax ranks below HIV, multi-drug resistant TB, and the West Nile virus. There is little argument on the need to gear up the infectious disease control system. While anthrax threats have averaged about 80 a year throughout the 90s, they were 100% pranks or hoaxes. He said the threat of anthrax is being monitored on a day-to-day basis. He believes the Jefferson-Peninsula Regional Emergency Planning Committee (JPREP) meeting tomorrow will be well attended. Dr. Locke then talked about the County's likely response to new agents and probable bio-terrorism scenarios. A big concern, and one that has been used in table-top exercises across the nation, is covert introduction of a contagious agent. There is a need to develop criteria for evaluating potential threats, although the biggest challenge in dealing with an actual bio-terrorist incident is building up a competent emergency workforce. It was noted that the County is equipped for passive surveillance only and will be challenged if there is a long-term bio-terrorist attack. We can build up local capacity to contain an event, but it is believed that federal resources will become available to gear up surveillance systems. There was discussion regarding the Board of Health's role during this period. Dr. Locke suggested that the Board educate itself on these issues and concerns. Depending on how events play out, it may be up to local Boards of Health to enforce state mandatory infection control procedures as well as getting tougher with surveillance. The Board expressed interest in receiving the same information being circulated to doctors. Dr. Locke agreed to include the Board in distributions of emergency and general information, including forwarding links to potentially helpful websites. Member Masci suggested that all those with a state health license be included in the distribution of information. Charles Saddler reported that at tomorrow's JPREP meeting, an action plan for a bio-terrorist type incident will be presented. He noted that the County has an all-hazard emergency operations plan with a critical incident command structure designed to be implemented for manmade or natural disasters or weapons of mass destruction. He indicated there has been much discussion about how best to HEALTH BOARD MINUTES - October 18, 2001 Page: 4 communicate with the public when conventional wisdom would indicate that the risk for this area is low. The County has updated its web site and it is considered the best tool for getting out timely and very accurate information. During discussion about how best to disseminate information, Member Frissell suggested showing data such as the comparative risk of death from influenza as opposed to anthrax. She also recommended the County begin talking with the public about steps they can take, such as getting flu shots, updating their earthquake kit, etc. There was support for adding to the website a statement such as "while there is no problem in Jefferson County, you may obtain information on bio-terrorism...." Noting that not everyone has a computer or reads the newspaper, Commissioner Huntingford suggested a newsletter be sent from the Board of County Commissioners to Jefferson County residents to let people know the issues being addressed and where to call for information. Charles Saddler said a tri-fold bulletin is being prepared. Member Masci suggested the insert be placed in the City utility bill. .Jefferson County Strategic Plan and Public Health Standards - Prioritization Exercise: Jean Baldwin and Larry Fay reviewed materials included in the agenda packet to aid in the prioritization exercise, which included the County's strategic plan, the County resolution adopting the plan, and example of the Law & Justice Committee's plan, and two matrixes. Mr. Fay then explained the matrix linking public health standards on which the State Board has been working to the County's goals and strategies. The Board then considered how best to prioritize the five most important things that need to be addressed in the area of Public Health for Jefferson County. The decision was to use as a basis for this exercise the matrix prepared of the County's goals and strategies and Washington State Department of Health's key measurement standards. The Board then prioritized the five key areas as defined by the Washington State Health Department. Following individual Board rankings, the collective priority rankings were as follows: 1. Assuring safe and healthy environment for people, 2. Protecting people from disease, 3. Prevention is best: promoting healthy living, 4. Understanding health issues, and 5. Helping people get the services they need. Member Masci moved to accept the prioritized list as above, using the strategic plan from the State. Member Frissell seconded the motion which carried by a unanimous vote. Charles Saddler noted that since the Board has chosen to use the same goals and strategies as defined by the Washington State Department of Health, this ranking shows the financial and budgetary priorities. AGENDA CALENDAR/ ADJOURN HEALTH BOARD MINUTES - October 18, 2001 Page: 5 Due to a Commissioners' conflict with the date of the next regular meeting, the Board agreed to cancel its November meeting. If by November 15, it is determined that a meeting is necessary, a tentative date of November 29,2001 at 1:30 p.m. in Commissioner's Chambers was set. 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 4:25 p.m. The next meeting will be held on Thursday, December 20,2001 at 2:30 p.m. at the Jefferson County Health and Human Services Conference Room. JEFFERSON COUNTY BOARD OF HEALTH ~~ (Excused Absence) Sheila Westerman, Vice-Chair hi ./ G~ingford, g ~- ~ RichaId w -it, - - ember /8tœdbJ;~ Roberta Frissell, Member Dan Titterness, Member Aft~idavit of Publication STATE OF WASHINGTON) SS COUNTY OF JEFFERSON) NOTICE OF PUBLIC HEARING NOTICE. IS HEREBY GIVEN that a public hearing is scheduled by the. Jefferson County Board of Health for Thursday, October 18, 20.01 at 2:30 p.m. in the Health Department Conferenc~ Room,' 615 Sheridt:\n . Avenue, Port Town- send, WA ,98368. ,. This public hearing. has been scheduled for the· Board of Health members to take.,meIlt~.J~,rªQd' figainst an Cp SCOTT WilSON, being sworn, says he is the publisher of the Port Townsend Jefferson County leader, a weekly newspaper which has been established, published in the English language and circulated continuously as a weekly newspaper in the town of Port Townsend in said County and State, and for general circulation in said county for mom than six (6) months prior to the date of the first publication of the Notice hereto attached and that the said Port Townsend Jefferson County leader was on t-he 27th day of June 1941 approved as a legal newspaper by the Superior Court of said Jefferson County and that annexed is a true copy of the ~R~=~O:ÒAR6 O¡= H'ËAl1"H Ordinance No. AMENDING ORDINANCE NO. 08-0921~OO , JEFFERSON COUNTY HEALTH ,. AND HuMAN,SERYICESDE- PARTMENT , RULES AND REGULATIONS ON~SITE SeWAGE' DIsPOSAL SYSTEMS Jeffèrson .,COUntY Ordinahce No. 08-0921-00, relating' to. . the county Health and HumanServ~ ices Departmønt and. sewage dis- posal systems, is· hereby amend- ed as' .follows: Amend: B.15.14b(3)(c) to· read: Written proof showing a minimum ofone~ year experience Linder the plrect supervision ofa Certified Instal- ler, Designer,Operation.. and Monitoring· Specialist, Pumper or other experiencea's-a.pprovedby' the Health Officer. Completion of classroom training speçific topn- site sewage¡system .. operation and maintenance as approved by the. Health Division. may be sub- stitutedfor up to sixmonth$ work experience; . Add: .8: 15,.1.10(4J(b)(v) excavate fQr, purposes Of affixing sweeping 45 degree angle lateral ends and removable end caps on mal1i.lol.ds and lateral lines', for purposes of maintenance, such as flushing, Jetting and brushing. . Add: 8.15.140(Þ)(vi) O~ otherasa,p- proved Þy the hea!th;offiçer. Amend: ..8.15.140X4){C)(iv) to read: .Alterqr replacø' any portion of t:he 'subsúrface·di.~posalcÖm- pønent"'ør pretrea.tmentcGmpo~ nent~; .. ,EXGEPT ias,.sta.ted,:ir 8.15;.1'40,(Þ) 'lvjaEdrEX~r3p:r: in tn£téã~fà,wl;(êT~';,hß¡~Þ~:'a,tso:'hþlêis ¡:¡ ,vàJ¡~.,lri~~lle:t·~G~àifiç~t~Çtnda. perrr;¡itÞas." þ~en.obt€1in:ed for such . ";W0,F~;or ,.... Amend 8.115; 15Q(6),( c).-to· fSI:\d.:. OWner$ of all on site!ßßw~ge ~Y;$tems. (con- ventional,,:alter,natfve¡and:. proprio' etary ,$Y$tem$>éiftßr ,ffl'i'etiÐg man- ufacturer~,traiQjng, ·¡,øquirement$) ma.y Qblajnoperations'anq JTPDi- toring. insPEilctions trom, a Certified fvfonitoring Speciali~ts ,in lieu of the Health Division, Licensed De- signer or, licen3ed professional enpineer for the fQllowinginspec- tion:(i)RoutineO'&M' (¡¡)The. sale or· tran:sfepöf.. a pròpërty (iii)The application fòr a þuili;:ling permit that is not classified as an expan" siÖh:"i,,":<,,' ..,.., '::'i,\-';';+:~'14-ØJT1'JOi3 ..~ :'I;~ 'f.,; ;,~' Notice of Public Hearing: RE: Jefferson County Health and Human Services Department Rules and Regulations for On-site Sewage Disposal Systems Ordinance No. 08-0921-00 as it appeared in the regular and entire issue 01 said paper itself not in a sW.Jplement thereof for a period of one JroC)NÐm(j~ weel<K. IJeginning on the~_day 01 & ending on the -Lday of October October ,20QL, ,20QL, and that said newspaper was regularly distributed to its subscribers during all of this period, That the full amount 01 $ 105. 75 has been paid in full, at the rate of $9.50 ($9.00 for legal notices re- tion. Publisher Subscribed and sworn to before me this_Lday of October:. Notary Public in and for the State of Washi gton residing at Port Hadlock o r 'J (ß) 'BDc c.. Ordinance No. 06A-1018-01 AMENDING ORDINANCE NO. 08-0921-00 JEFFERSON COUNTY HEALTH AND HUMAN SERVICES DEPARTMENT RULES AND REGULATIONS ON-SITE SEWAGE DISPOSAL SYSTEMS Jefferson County Ordinance No. 08-0921-00 , relating to the County Health and Human Services Department and sewage disposal systems, is hereby amended as follows: Amend: 8.15.140(3)(c) to read: Written proof showing a minimum of one-year experience under the direct supervision of a Certified Installer, Designer, Operation and Monitoring Specialist, Pumper or other experience as approved by the Health Officer. Completion of classroom training specific to on-site sewage system operation and maintenance as approved by the Health Division may be substituted for up to six months work experience. Add: 8.15.140(4)(b)(v) Excavate for purposes of affixing sweeping 45 degree angle lateral ends and removable end caps on manifolds and lateral lines, for purposes of maintenance, such as flushing, jetting and brushing. Add: 8.15.140(b)(vi) Or other as approved by the health officer. Amend: 8.15 .140(4)( c)( iv) to read: Alter or replace any portion of the subsurface disposal component or pretreatment components, EXCEPT as stated in 8.l5.140(b) (v) and EXCEPT in the case where he/she also holds a valid Installer's Certificate and a permit has been obtained for such work; or Amend 8.15.150(6)(c) to read: Owners of all onsite sewage systems (conventional, altem~tive and proprietary systems) may obtain operations and monitoring inspections from a Certified Monitoring Specialist (after meeting manufacturers training requirements) in lieu of the Health Division, Licensed Designer or licensed professional engineer for the following inspection: (i) Routine O&M (ii) The sale or transfer of a property (iii) The application for a building permit that is not classified as an expansion. APPROVED Oc.+c:.~QII'(. to ~ ~C() I JEFFERSON COUNTY BOARD OF HEALTH ~ Ge asci, Member £c~1Þ'~4UåL¿ Roberta Frissell, Member SEAL ATTEST: JEFFERSON COUNTY BOARD OF HEALTH Thursday, October 18, 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 September 20, 2001 III. Public Comments IV. Old Business and Informational Items 1. (Re)Adoption of Amendments to Ordinance No. 08-0921-00 On-Site Sewage Disposal Systems Rules and Regulations _ Action Item Larry (10 min) V. New Business 1. Report from the 2001 Washington State Joint Conference on Health 2. Bioterrorism Preparedness - National, State, and Local Efforts 3. Jefferson County Strategic Plan and Public Health Standards - Prioritization Exercise 4. November Meeting Scheduling VI. Agenda Planning 1. Future Agenda Topics V. Adjourn Next Meeting: Date and Time to be Determined Main Conference Room Jefferson Health and Human Services Tom (10 min) Tom/Lisa (30 min) Jean/Larry/Charles (60 min) Tom (5 min) Oct-IO-Ol IO:07A P.OI JEFFERSON COUNTY BOARD OF HEALTH f1 MINUTES II OR~ Thursday, September 20, 2001 ~4:'1' Board Membe1"s: Dan Titternus, Member' - County Commissioner DÜtn'ct # 1 Glm Huntingford, Member - COlin!} CommÙ.no"e1" DÙtrÙ't #2 Richard W'qjt, Member - County c..òmmlrsioner District #3 Geoffrry Ma.rci, MfflIbe1" - Port Townsend Ciry Corma! fi1l Buhler, Chairman - Hospital Commissioner District #2 Sheila Westerman, Vice Chairman - Citizm at LArge (Ciry) Roberta Fri.m!/ - Citizen at Lzr;ge (Cormry) StcrtfMembm: Jean Baldwin, ..'\luning S ervim Director Lmy E:¡', Environmental Health Dim'tor Thomas Locke, MD, Health Officer Chairman BuWer called the meeting to order at 2:30 p.m. All Board and Staff members were present. The agenda was amended to include Old Business item "Pl.)'D Saltwater Intrusion Monitoring Program" and New Business item "Access to Baby and Child Dentistry (ABCD)." Member Masci moved to approve the agenda as amended. Commissioner Wojt seconded the motion, which carried by a unanimous vote. APPROVAL OF MINUTES Member Masci moved to approve the minutes of August 16,2001. Commissioner Wojt seconded the motion, which carried by a unanimous vote. PUBLIC COMMENT Dale Wurtsmith expressed his concern that operations and monitoring inspections by the PUD exclude examination of the septic tank. He asked that a resolution be created requiring that all on-site septic systems have EES inspections prior to any sale of the property. He also believes people should have the right to choose who they want to monitor their alternative system. He agrees with the amendments to the On-Site Sewage Code as proposed. Chairman Buhler welcomed health services consultant Sherry Harry, RN to the meeting. Member Masci said Ms. Harry brings a lot of experience to the community through her work with First Choice Health Systems. Oct-IO-Ol IO:OBA P.02 HEALTH BOARD MINuìES - September 20, 2001 Page: '1 OLD BUSINESS 4th Annual Local Board of Health Leadership Workshop: Chairman Buhler encouraged Board members to consider attending the October 25-26 conference at SeaTac. When asked whether the topic of biological weapons will be on the agenda given the recent terrorist attacks in New York City, Dr. Tom Locke said he believes bio-terrorism will be discussed. Jean Baldwin agreed to forward information and registration materials to the Board. Letter to Senator Maria Cantwell: Chairman Buhler said the letter to Senator Cantwell reviews the issues raised during her July visit with community leaders. Public Utility District No.1 Saltwater Intrusion Monitorine Pro~am: County Administrator Charles Saddler distributed a copy of the PUD's response to the Joint Resolution between the PUD, Board of Health, and Board of County Commissioners. The resolution, discussed by the Health Board last month, would establish a program to conduct systematic groundwater monitoring to assess whether seawater intrusion may be affecting water quality. While it appears the PUD is interested in monitoring, they are concerned that addressing this issue now may delay the WRIA 17 watershed planning process, In their opinion, the severity of seawater intrusion has not yet been demonstrated. Mr. County Administrator Saddler argued that under State statute, the WRIA planning process provides the only real mechanism for addressing the issue. County Administrator Saddler will address this topic with the Board of County Commissioners, but it is not expected that the they will adopt this resolution or propose a substitute soon. Commissioner Wojt questioned whether the Water Utility Coordinating Committee might be able to put forward a recommendation on the issue? Communicable Disease Update - Pertussis. Chronic Hepatitis Reporting. 2000 .Jefferson County STD Profile: Public Health Nurse Lisa McKenzie said the report included in the agenda packet was sent to local health care providers to update them on the summer pertussis outbreak and other communicable diseases. She noted that 12 of the 14 reported measles cases in Washington State were in King County where the outbreak cost $60,000 - most of which was for 125 rash illness investigations to rule out measles. It was noted that half of the pertussis occurred in a susceptible population. Dr. Locke added that there appears to be widespread of not reporting on STDs and that it is difficult to improve the rates of reporting communicable disease. NEW BUSINESS Public Health Law 101- Rules. Policies. Waivers, and Appeals: Dr. Locke referred to his memo in the agenda packet, which was meant to remind the Board of its many options under rules that have been passed. Rule changes and appeals are intended to be considered only after policies and waivers have been employed. Oct-lO-Ol lO:OBA P.03 HEALTH BOARD MINUTES - September 20,2001 Page: 3 Onsite Sewa2e Code Rule Revision - Action Item: Dr. Locke reviewed the Board's action at the last meeting directing staff to prepare amendments to the Onsite Sewage Code to address O&M specialist qualifications and scope of practice. He noted that in addition to the language provided, Staff proposed the addition of two clauses for consideration, one of which would enable the department to respond to additional, unanticipated technical issues with policy changes rather than through continued amendment to the rule. The other would allow "other experience" to be considered on a case-by-case basis through an expedited waiver process, Staff is still trying to define appropriate qualifications for performing the latter, but he noted that the rule will be implemented primarily by monitoring the performance of O&M specialists. There were requests for clarification of the difference between approval by the "health officer" and approval by the "health division." Dr. Locke said the health officer has the power to waive regulations under the State codes where divisions or departments do not. Also, since the health officer is appointed, they may delegate the responsibility to whomever they choose. Regarding 8.15.150(6)(b), Member Masci asked why, in the absence of a local engineer, would the list of those who may perform an initial inspection not include a certified monitoring specialist or certified installer? He also asked why individuals with advanced degrees are required and why the owner of a convention a] system would even need such a technical initial inspection? Commissioner Tittemess mentioned Eric Page as a licensed professional engineer who provides the service in the County. Vice Chairman Westerman asked to understand the difference between an initial inspection and an O&M monitoring inspection? Linda Atkins explained that the reason for having a highly trained person perform initial inspections is to achieve a greater level of detaiL Because many installers install only certain systems they may have a limited understanding of all components of various systems. She also discussed the different skills and qualifications brought by someone with an advanced degree. In explaining the leve] of training and licensing, she added that PUD staff can do initial inspections if they are licensed. Dr. Locke then reviewed the Board's options which were to leave the ordinance as adopted and previously amended; adopt the amendments as presented, induding the Health Officer language; or adopt the ordinance as originally amended, striking staff's recommended additional language. It is Staff's recommendation that the Board adopt the amendments with the Health Officer language. Commissioner Titterness suggested the Board may choose to adopt the modifications as submitted, but also propose additional changes. Commissioner Titterness moved to adopt the amendments to the On-site Sewage Code as presented editing 6(c) to read "Owners of aU onsite sewage systems (conventional, alternative and proprietary systems) may obtain operations and monitoring inspections from a Certified Monitoring Specialist (after meeting manufacturers training requirements) in lieu of the Health Division, Licensed Designer or Licensed Professional Engineer for the following inspection." Oct-lO-Ol lO:09A P.04 HEALTH BOARD MINUTES - September 20. 2001 Page: 4 Member Masci seconded the motion, which earned by unanimous vote. Commissioner Huntingford wondered about the eventual need for cornpliance officers to oversee training compliance. He expressed frustration with what appear to be increasingly complex and possibly unnecessary aspects of the septic code. Linda Atkins explained the registry system which ensures training compliance and how the public can obtain referrals to trained individuals. County Administrator Saddler referred to the WAC 246.272, adopted in 1995, which is the basis for this code. Commissioner Huntingford said his difficulty is not with the intent to protect public health, but with a process so complex and confusing that some people either cannot afford to comply or simply refuse to comply. He questioned whether septic inspections tied to a building permit on an unrelated project was something the public really wanted. He suggested that the code be reviewed annually to see if it can be simplified. Several Board members spoke about the Board's extensive work in drafting the ordinance. While there was some concern that it has been difficult for the Board to track the issues surrounding the code, most felt it is a work in process and that the Board will continue to address issues as they come to their attention. Regarding the concerns expressed by Dale Wurtsmith, Vice Chairman Westerman asked whether it would be necessary for the Board to take action? Linda Atkins explained that staff is currently modifying this process with the PUD. Until September 2000, it was clear on the form that the owner was responsible for having the septic tank inspected. She noted, however, that even on systems where there has been continuous monitoring, there would be no requirement for an inspection at the time of sale. Vice Chairman Westerman expressed interest in receiving more information on what is involved in an initial inspection. Member Masci and Vice Chainnan Westerman agreed to meet with Linda Atkins and report back to the Board. There was also Board interest in having Staff present background on the organization of the O&M program at the October meeting. Joint Board Access Proiect: Dr. Locke reviewed a list that he and Vic Dirksen generated following the Joint Board meetings of possible activities to improve access. Some of these activities were: better coordination of services among providers, ensuring that people in need of services are accurately evaluated for eligibility, looking for ways to increase insurance coverage for uninsured populations, and adding insurance products. They believe a steering group other than the Health Access Summit work group could attend a single meeting to scope out short and medium-range projects that the Washington Health Foundation could fund. He envisions including representatives from the different boards as well as several individuals who would be involved in those projects that are determined to be feasible. Depending on the project, they might be service providers, health department staff or hospital staff. Oct-lO-Ol lO:09A P.05 HEALTH BOARD MINUTES - September 20, 2001 Page: 5 Dr. Locke then referred to the Menu of Critical Health Services adopted by the State, noting that this list reflects minimum standards. He suggested that in order to compare assessment data with this minimal set of critical health services and determine where gaps exist, the Board needs to first outline a process for determining how to arrive at a locally-adopted list. Discussion ensued about coordinating a follow-up summit. Several members understood from a previous meeting that the Access Group would be presenting to the Board some solid ideas for discussion at the next summit. It was suggested that the minimum standards would easily fold into the work of the Access Group. Dr. Locke supported reconstituting the Access Work Group if a follow-up summit were to be held. While the original goal of the summit was to discuss innovative ideas for healthcare financing, he doubted the achievability of such a solution and suggested that other potential options might not warrant another summit. He does not believe the Joint Board came to a resolution to pursue a local health authority model. The Health Board may have been interested in a system-wide approach, but the Hospital preferred several discrete projects to improve access. He asked if the Board wants to reach consensus with the Joint Board? Following several members of the Board expressing interest in holding a follow-up summit, Member Masci proposed convening several meetings of the Access Committee to discuss in what form and how such a presentation might be structured? He believes three to five choices could be presented to at least the leadership group assembled at the last Health Access Summit. Chairman Buhler and Vice Chairman Westerman felt there was agreement among the Joint Board that the Access Committee should meet to discuss next steps and make a recommendation to the Joint Board. Jean Baldwin mentioned that all Health Board and Hospital Commission members were interested in being notified of the Access meeting in the event they want to attend. .Jefferson County Strategic Plan: Commissioner Titterness distributed a copy of the adopted vision, mission statement and goals. He suggested the Health Board, as a gesture of support, could choose to support specific goals or the Jefferson County Strategic plan in its entirety. County Administrator Saddler explained the process by which the County Law and Justice Council created their own strategic plans, goals and objectives. He asked whether the Board of Health may want to take a similar course to develop its own goals and objectives? Commissioner Titterness suggested the Board might look at the strategies already developed by Law and Justice and use the parallel goals as the basis for the Board of Health exercise. Jean Baldwin suggested the Board of Health strategic goals integrate with the Department's goals and objectives. Vice Chairman Westerman said she is supportive of the goals and objectives process, but wants the Board to stay focused on the Health Access Summit issues and long-range goals. Oct-IO-Ol IO:IOA P.06 HEALTH BOARD MINUTES - September 20,2001 Page: 6 Member Masci moved that County Administrator Saddler and David Goldsmith facilitate a strategic planning exercise with the Board of Health. Member Frissell seconded the motion which carried by a unanimous vote. There was interest in starting the next meeting at 1 :30 for this purpose. Access to Baby and Child Dentistrv Programs (ABCD): In response to a request from Member Masci, Jean Baldwin explained that dental services for Jefferson County residents are offered infrequently via a long distance phone call to Clallam County. She agreed to forward her suggestions for improvements to the OlyCAP Board. It was noted that OlyCAP is trying to arrange a permanent base for dental services at a Brinnon facility and that oral health access are important to include in health access discussions. 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 S. 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 4:32 p.m. The next meeting will be held on Thursday, October 18, 2001 at 2:30 p.m. at the Jefferson County Health and Human Services Conference Room. JEFFERSON COUNTY BOARD OF HEALTH Jill Buhler, Chairman Geoffrey Masci, Member Sheila Westerman, Vice-Chairman Richard Wojt, Member Glen Huntingford, Member Roberta Frissell, Member Dan Tittemess, Member Publish one (1) time: October 3, 2001 Bill to Jefferson County Health & Human Services 615 Sheridan Avenue Port Townsend, W A 98368 NOTICE OF PUBLIC HEARING NOTICE IS HEREBY GIVEN that a public hearing is scheduled by the Jefferson County Board of Health for Thursday, October 18, 2001 at 2:30 p.m. in the Health Department Conference Room, 615 Sheridan Avenue, Port Townsend, W A 98368. This public hearing has been scheduled for the Board of Health members to take comments for and against an ordinance amending Jefferson County Health and Human Services Department Rules and Regulations for On-site Sewage Disposal Systems Ordinance No. 08-0921-00 as provided below. JEFFERSON COUNTY BOARD OF HEALTH Ordinance No. AMENDING ORDINANCE NO. 08-0921-00 JEFFERSON COUNTY HEALTH AND HUMAN SERVICES DEPARTMENT RULES AND REGULATIONS ON-SITE SEWAGE DISPOSAL SYSTEMS Jefferson County Ordinance No. 08-0921-00 , relating to the County Health and Human Services Department and sewage disposal systems, is hereby amended as follows: Amend: 8.15.140(3)(c) to read: Written proof showing a minimum of one-year experience under the direct supervision of a Certified Installer, Designer, Operation and Monitoring Specialist, Pumper or other experience as approved by the Health Officer. Completion of classroom training specific to on-site sewage system operation and maintenance as' approved by the Health Division may be substituted for up to six months work experience. Add: 8.15.140(4)(b)(v) Excavate for purposes of affixing sweeping 45 degree angle lateral ends and removable end caps on manifolds and lateral lines, for purposes of maintenance, such as flushing, jetting and brushing. Add: 8.15.140(b)(vi) Or other as approved by the health officer. Amend: 8.15.140(4)(c)(iv) to read: Alter or replace any portion of the subsurface disposal component or pretreatment components, EXCEPT as stated in 8.15.140(b) (v) and EXCEPT in the case where he/she also holds a valid Installer's Certificate and a permit has been obtained for such work; or Amend 8.15.150(6)(c) to read: Owners of all onsite sewage systems (conventional, alternative and proprietary systems after meeting manufacturers training requirements) may obtain operations and monitoring inspections from a Certified Monitoring Specialists in lieu of the Health Division, Licensed Designer or licensed professional engineer for the following inspection: (i) Routine O&M (ii) The sale or transfer of a property (iii)The application for a building permit that is not classified as an expansion. APPROVED JEFFERSON COUNTY BOARD OF HEALTH Overview of 2001-03 Budget and Revenue Conditions - 10/02/01 The size of the potential shortfalls, imbedded problems in the 2001-03 budget, and expected longer-term fiscal constraints in the 2003-05 and 2005-07 biennia all combine to create a complex and fragile fiscal climate. Uncertainty in the budget and revenue picture demands a disciplined approach including "holding" approval of capital budget allotments, potentially "holding" second year operating allotments, re-examining cut options, and limiting agency requests for additional resources and legislation. The September 2001 revenue forecast: · Released on Sept. 18. Lowered expected general fund revenue by $101 million compared with the June forecast. · Does not reflect economic and revenue impact of 9/11 attacks or 9/18 Boeing employment reduction announcements. The November 2001 revenue forecast is due on Nov. 16: · Once completed, it is expected to reflect the impact of the more recent economic and employment news on expected revenue. · A wide range of revenue impacts is possible depending on whether the Boeing employment change is taken in isolation (down $200m), or is accompanied by some variant of a general economic slowdown (down $800m). · Economists have recently shifted from arguing over whether or not there would be a recession to debating how deep one will be and how long it will last. Many currently are saying they believe a recession would be short with a recovery starting in late 2002. After the September revenue forecast: · The 2001-03 operating budget now contains $761 million more in state general fund spending than the revenue forecast for the 2001-03 period. · Additional federal revenue for health and long-term care programs, along with general fund reserves and a variety of other fund transfers, has to fill the $761 million gap. This leaves only $66 million in the unrestricted balance, and another $390 million in the emergency reserve. · For a variety of reasons, there is an additional shortfall of nearly $300 million for 2001-03. Another $35 million in state revenue will be lost if Initiative 747 passes and $24 million will be lost to Initiative 773. ,-<-= ~~~ To: Jefferson County Health Care Providers From: Tom Locke, MD, MPH, Jefferson County Health Officer RE: Bioterrorism The Problem: The September 11 th terrorist attacks on New York and Washington, D.C. have heightened public awareness on the threat of biologic agents as potential weapons of war. Although the United States formally abandoned development of offensive biological warfare agents in 1969 (and destroyed existing stocks in the early 1970's), there is compelling evidence that large stockpiles of "weaponized" biologic agents were produced by Soviet Union until the early 1990's. Countries that support state-sponsored terrorism have likewise developed the capability of manufacturing some of these agents. U.S. concerns about preparedness for a bioterrorist attack began to intensify following the Gulf War when it was learned that Iraq had developed weaponized forms of anthrax and botulinum toxin. In 1998 the Public Health Threats and Emergencies Act (commonly known as the "Frist- Kennedy Bill") was introduced in Congress. It was passed in December of 2000 but awaits implementing appropriations. The purpose of the Act is to bolster the long-neglected public health infrastructure necessary to detect and effectively respond to major biologic public health threats, either deliberate (in the case of a bioterrorist attack) or natural (as with an influenza pandemic or antibiotic-resistant bacteria outbreak). Efforts to fully implement this Act will likely accelerate as part of America's new war on terrorism. Prompt recognition that a biologic attack has occurred is key to limitation of human casualties. For many agents, it is possible that early signs of widespread infection would be confused with other, more common, causes of illness. Surveillance for disease outbreaks can take two forms: passive and active. The best example of a passive surveillance system is our current "notifiable conditions" system of reportable disease. Over 50 different diseases and conditions (e.g. HIV, TB, Measles) are reportable to public health authorities when diagnosed. Under such a system, public health jurisdictions are in a "passive" mode, awaiting information to react to. Active surveillance involves special efforts to identify cases meeting certain clinical criteria (e.g. rash illnesses during a Measles outbreak). Both methods of surveillance have a role to play in monitoring for infectious disease emergencies. Biological threats for civilian populations fall into 3 categories: bacterial agents, viruses, and biological· toxins. 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 Bacterial Agents: The microbial pathogens responsible for Anthrax, Brucellosis, Cholera, Glanders, Plague, Tularemia, and Q Fever are all candidates for use in biological warfare. Anthrax, Plague and Tularemia are considered the most likely agents to be used by bioterrorists given their potential for airborne transmissions and high case fatality rates if untreated. All are responsive to antibiotic therapy and vaccines have been developed for all agents except for Brucellosis and Glanders. None of the vaccines that have been developed are available for general public use. Ominously, scientists in the former Soviet Union have been reported to have carried out extensive research on antibiotic and vaccine resistant strains of anthrax, plague and tularemia. Viruses: Smallpox, Venezuelan Equine Encephalitis, and the causative agents of the various Viral Hemorrhagic Fevers are the leading candidates for weaponized viral agents. Smallpox is of greatest concern as a potential agent of mass infection. Naturally occurring smallpox was eradicated worldwide in the late 1970's. Routine U.S. vaccination ceased in 1972 and worldwide efforts stopped in the early 1980's. The military ceased routine vaccination of personnel in 1989. Average duration of immunity after vaccination is ten years. Most of the world's population is now considered susceptible to smallpox infection. Case fatality rates for smallpox average 30%. The CDC maintains a stockpile of approximately 7 million doses of smallpox vaccine. The vaccine has been in storage for over 2 decades and there is concern about its stability. In 2000, the CDC contracted for production of an additional 40 million doses of smallpox vaccine with first production batches expected in 2002. Venezuelan Equine Encephalitis is endemic to South and Central America where it is spread by several mosquito vectors. It was weaponized by the U.S. Biological Warfare Program in the 50's and 60's and other countries are thought to have done likewise. An investigational vaccine is available. Viral Hemorrhagic Fevers are a large family of viral pathogens ranging from Ebola virus to Yellow Fever. Only Yellow Fever has an effective vaccine available. Intravenous ribavirin is thought to be beneficial for several types of hemorrhagic fever. Biological Toxins: Botulinum, Staphylococcal Enterotoxin B, Ricin, and T-2 Mycotoxins are candidates for biologically derived toxic weapons, Botulinum toxin is, gram for gram, the most neurotoxic agent known to man. It is relatively easy to produce and hs a high lethality. For those who survive initial exposure, prolonged disability is the rule. A heptavalent antitoxin is available. Staph Enterotoxin B is a common cause of food poisoning. In its concentrated form, it can be lethal. Ricin is a toxic protein derived from castor beans. It is highly toxic if inhaled. T -2 Mycotoxins are produced in a variety of fungi and are absorbed through the skin, digestive and respiratory epithelium. Health Care Provider CME and Reference Sources: An excellent resource for health care providers has been developed by Johns Hopkins University School of Medicine and Public Health's Center for Civilian Biodefense Studies. Their web site can be reached at httµ://www.hopkins-biodefense.org/index.html. Concise "agent fact sheets" are available for the 5 most likely bioterrorist agents: Anthrax, Botulinum Toxin, Plague, Smallpox and Tularemia. JAMA Consensus Statements for each of these agents have also been developed and are accessible on the Hopkins website. 2 A more comprehensive reference is the U.S. Army Medical Research Institute of Infectious Disease's "Medical Management of Biological Casualties". The third edition of this manual was published in July of 1998. At the annual meeting of the Washington State Medical Association on September 23,2001, a resolution was passed by the House of Delegates calling for physician participation in biologic, toxic and radiologic disaster preparedness activities and promoting the development and distribution of appropriate CME materials. Summary: The events of September 11, 2001 have shocked the nation into an awareness of an organized international terrorist network whose apparent goal is to maximize human casualties. The potential use of biologic agents for this purpose has long been recognized. As the United States prepares for a long and uncertain war against world terrorism, the possibility of additional domestic attacks is very real. Just as police and fire fighters were the first line of defense against the bombing of the world Trade Center and Pentagon, health care providers will likely be on the front lines of a biologic attack, should it occur. Bioterrorism experts note that marine ports are a very attractive target for the importation of biologic agents. Clallam and Jefferson Counties have several commercial ports and smaller marinas. Professional education and ongoing disease surveillance should be the two highest priorities for health care providers. Unusual disease occurrences or increased numbers of illnesses should be promptly reported to local and/or state health officials. The Centers for Disease Control maintains a 24-hou emergency number of (770) 488-7100 and an e-mail contact address of healthalert@cdc.gov. The emergency number for the Washington Department of Health's Communicable Disease EPI / Public Health Lab is (toll free) (877) 539-4244. I can be reached after-hours by cell phone at (360) 808-3333. 3 ¡'OCW:::'Udy.LUIU. U..:I. IH-n~pd.l~U 1"01' UlUlcrronsm rage 1 01 L ~-.. ~""'~.J ór. ~r1.!'Þ." Un)}w,,,,,,,', newsdav .com/news/nali onworld/nati on/nv -usbi02223 79246sep22 .stor\' AMERICA'S ORDEAL u.s. III-Prepared For Bioterrorism Critics say measures to deal with an attack are 'woefully inadequate' By Laurie Garrett STAFF WRITER September 22, 200 I A day after President George W. Bush told Congress he'll create a cabinet-level position to protect the nation against terrorism, experts in biological weapons said they're concerned that the classic law enforcement structure this position will oversee will not be effective in battling a bioterrorist attack. The critics, many of whom are top-level biologists, say neither the Republican administration nor its predecessor properly understood the unique nature of biological weapons. Therefore, they said, Ttleasures now in place to deal with such an attack are woefully inadequate. "No one is in charge. They don't have anybody expert in biosciences and public health, as far as the eye can see in this administration," said Dr. Tara O'Toole, deputy director of the Center for Civilian Biodefense Studies at the Johns Hopkins Schools of Medicine of Public Health in Baltimore. Meanwhile, fonner Sen. Sam Nunn, speaking on CBS Tuesday night, said he believes the U.S. capacity to pre-empt or respond to a bioterrorist attack is in a shambles, all but nonexistent. Nunn, who heads the Nuclear Threat Initiative in Washingto~ D.C., is widely considered the best- briefed political leader in the United States on matters of intelligence and terrorism. He warned during that appearance that "the likelihood of a biological incident happening in the next few years far outweighs that of a missile" attack. Jerome Hauer, who created New York City's emergency preparedness and response syste~ is an adviser on bioterrorism to Health and Human Services Secretary Tommy Thompson. Friday, Hauer told Newsday that in the wake of the events of Sept. 11, there is a new sense of urgency in Washington on the bioterrorism issue. He said there is intelligence infonnation that terrorist Osama "bin Laden wants to acquire these agents, and we know he has links to Saddam. And Saddam Hussein has them," Hauer said. Friday, in testimony before the Senate Committee on Governmental Affairs, David Walker, who heads e General Accounting Office, echoed Hauer's remarks, noting, "the spread of infectious disease is a ~rowing concern." Newsday.com: U.S. Ill-Prepared For Bioterrorism Page 2 of2 "Whether a disease outbreak is intentional or naturally occurring, the public health response to determine its causes and contain its spread is the same," Walker said. "Because a bioterrorist event could look like a natural outbreak, bioterrorism preparedness rests in large part on public health preparedness." Citing New York City's battles with the West Nile Virus, Walker said even the best municipal health department in the nation had been unable to control the outbreak of a mosquito-borne disease, and outlined several public health shortfalls, at all levels of government, he said render America acutely vulnerable to a biological attack: Surveillance systems for monitoring disease trends and outbreaks are antiquated, even nonexistent in some regions, Walker said, and none is keyed to watching for the sorts of trends most likely to be related to a terrorist event. In many jurisdictions, health departments don't even have modern computers for use in tracking diseases. Few public health laboratories in America can correctly and rapidly diagnose such things as anthrax, smallpox, tularemia or Ebola. Despite outbreak drills conducted in many cities, most physicians cannot recognize the sorts of symptoms typical of bioweapons, and hospitals are ill-equipped to handle the expected burden of patients, hysteria and necessary quarantine. Concerns about biological weapons were heightened for some last week when the Atlanta-based Centers for Disease Control and Prevention, home to such·deadly viruses as smallpox and Ebola, was evacuated within hours of the attacks on the Pentagon and W orId Trade Center last week, according to government sources. CDC director Dr. Jeffrey Koplan and his senior staff were hastily removed from their offices and taken to a private Atlanta airfield, where they were placed in a military transport. While Koplan and his staff waited, the rest of the complex was evacuated. However, Hauer said Friday that "CDC security has been reviewed on an ongoing basis." Hauer, who works three days a week for Kroll Associates in New York, said he'll be scrutinizing that security, as well as security of the Plwn Island animal disease facility near Long Island in coming days. In the new command structure, dozens of federal agencies will answer to Pennsylvania Gov. Tom Ridge. The bulk of the $20 billion allocated for terrorism threat reduction and response will then go to law enforcement. Of $500 million requested for development of local public health infrastructures, $124omillion was approved. Copyright © 2001, Newsday. Inc. r'i~w~uay .çom: tlaUlll1g tlloterror rage 1 or '+ 1't.- .. · "... !tW.-I... .. " .r 1..!f Þ III Uj1://\V\\''\\'.newsdav .com/news/nationworId/nationlnv-usbioO I 23935460ctO I.story Battling Bioterror Government's readiness is challenged as fear escalates By Laurie Garrett STAFF WRITER October 1,2001 With public anxiety about bioterrorism on the rise, gas mask sales soaring and talk shows rife with alarming claims, the head of the federal department of Health and Human Services, Tommy Thompson, yesterday said America is prepared to deal with any kind of biological attack. But public health experts throughout the nation say yesterday's comments, made on the CBS show "60 Minutes," don't reflect a 2-week-Iong gag order that's kept them from getting specific information about preparedness from such agencies as the Centers for Disease Control and Prevention in Atlanta, leading to confusion and concern. "I've had people caIling me. They can't get through to the CDC, because the CDC isn't allowed to talk to nybody. They can't get through to HHS. And they're just terrified," said Dr. James Curran, dean of the ",-oIlins School of Public Health at Emory University in Atlanta. "I think it's stupid," he said. "I think the CDC ought to be responding." Dr. Steven Wolinsky, chief of infectious diseases for Northwestern University Medical School in Chicago, agrees. He said that as soon as he saw the videotape of the jets slamming into the World Trade Center, he decided to set up a meeting with leading infectious-disease doctors in the Chicago area to make sure they were ready. "But we are meeting the same difficulties [as other health professionals] because we don't know who to deal with" on the federal level, Wolinsky said. No government authority has explicitly said that members of the suspected terrorist network believed to be responsible for the Sept. 11 attacks have plans for a biological assault inside the United States. But the issue moved strongly into the public consciousness last week following announcements by Attorney General John Ashcroft. Last Monday, Ashcroft said there were indications suspected terrorists had looked into renting crop dusters. One day later, he said suspected terrorists had obtained licenses for trucks that can carry large tanldoads of dangerous materials. By Wednesday, doctors and phannacists from Montauk to Honolulu were reporting runs on the -·,ltibiotic ciprofloxicin, the preferred prophylaxis for anthrax infection. Gas mask sales were vigorous .tionwide, and by the end of the week most Internet distributors reported they were sold out. Newsday.com: Battling Bioterror Page 2 of 4 " Finally, on Saturday, Newsweek added an exclamation mark to the activity with the release of a poll saying that almost half of Americans are "not too confident" that government in this country is prepared to handle an attack with biochemical weapons. And just over eight in lOin the poll, which surveyed 1,000 adults, thought the use of such weapons is at least "somewhat likely." Despite these concerns, attempts by the media - and even most health professionals - to get specific information from the CDC have been fended off since the Sept. 11 attacks. Sources have told Newsday that Thompson has given orders that his office is the only place that can release information. But calls to Thompson's office during this time have not been returned. Yesterday, on "60 Minutes," Thompson said: "We've got to make sure that people understand that they're safe. And that we're prepared to take care of any contingency, any consequence that develops from any kind of bioterrorism attack." He said eight staging areas around America are each stocked with 50 tons of medical supplies - including vaccines, antibiotics, gas masks and ventilators - that can be moved within hours to the site of a bioterrorist event. The secretary also said that 7,000 medical personnel are ready to respond. Yet public health experts point out that those steps - placing drugs in stockpiles and putting physicians on alert - are merely standard operating procedure under guidelines for emergency response drawn up during the Clinton years. Missing, they say, is detailed, logistical information that can guide their efforts locally. "It's really bad," said Margaret Hamburg, now head of the Nuclear Threat Initiative in Washington, D.C., and a former assistant secretary ofHHS and New York City health commissioner. "This is when they need to provide leadership, a visual presence ... the voice of the surgeon general comforting people. " One issue that may be affecting that presence, sources in government say, is the amount of time now being taken by top health officials to cement a role within the anti-terrorism hierarchy. Dr. Scott Lillibridge, a bioterrorism expert for the CDC, was named as Thompson's special assistant for bioterrorism preparedness in July. He was supposed to begin Oct. 1, but the Sept.. 11 attack moved up that timetable. He says he's just now beginning to assess the role HHS should play in the newly created Office of Homeland Defense, headed by Pennsylvania Gov. Tom Ridge. President George W. Bush announced the creation of the Office of Homeland Defense just 12 days ago. Since then, Congress has allocated $40 billion to rescue and recovery efforts for the three sites affected by the terrorist actions, as well as the new preparedness effort. Barely had the president finished his address when a power scramble began within the federal government, sources say, with several agencies competing for power and funds. Thompson, Lillibridge and other HHS officials have been preoccupied with their role in that debate. "It's unlike anything I've seen in any major departmental activity." Lillibridge told Newsday. Before Sept. 11, the relative roles of both HHS and combating bioterrorism in Washington 1'o(\;W;:'U<1.Y .\"VIII. D<1lll1llg D1UlellUr nlgc: J U1 "t counterterrorism pecking order were substantially lower than that of the Departments of Justice and Defense with bioterrorism considered "an interesting, worrisome theory," according to Sen. Richard Durbin (D-IIl.). ' Now, though, "nothing can be dismissed," Durbin told Newsday. "There's a great deal of concern ITom Washington, on down to the grassroots." The fact that the terrorists were on suicide missions, coupled with their deliberate targeting of civilians "was obviously very sobering," Hamburg said. "It removed hopes that terrorists might have a threshold beyond which they wouldn't go in terms of causing damage and disease." So the argument within government now, experts say, is who should hold the primary responsibility for heading off such an event and dealing with it once it occurs. Should it be law enforcement or the military, who have long experience with other terrorist weapons? Or should it be public health officials? "I sure hope that we understand we're not going to deal with bioterrorism with the military," answers Dr. D. A. Henderson, who heads up the Center for Civilian Biodefense at the Johns Hopkins School of Public Health. He argues that any bioterrorism event should fIrst be dealt with as an epidemic, and that health officials should have the fInal word on any decisions taken early on. Dr. Christopher Davis, chief scientist for the Arlington, Va.-based Veridian Systems, Inc., agrees. When a large number of people get influenza, "by and large the police aren't involved. The military aren't involved. So the answer is we build a system we can actually use on a day-to-day basis to protect ourselves from emerging diseases," both naturally arising, and deliberately released. After all, Davis insists, the ultimate police and military goals of fInding the culprit are unlikely ever to e achieved in a bioterrorist assault. America must "raise the bar" to battle bioterrorism, he says, oolstering the public health infrastructure so signifIcantly that terrorists see little chance that certain diseases would kill tens of thousands of people. This won't be easy, other experts note. For more than three decades, public health at all levels has suffered budget cuts, lost valuable personnel, and seen its legal and political clout diminished. Why? "As Americans we haven't had an epidemic to point to and say, 'See that? That's what we're facing,'" Wolinsky explained. One key to the public debate will be an honest assessment of just how real the threat of bioterrorism is, experts suggest. Are international terrorists capable of using diseases as weapons? Is it part of their schemes? What sorts of microbes might they use, and how would they use them? Those questions now form the basis of vigorous argument among the rougWy two hundred bona fIde bioterrorism experts in the world today. Henderson, who led the successful fIght to eradicate naturally arising smallpox, argues, "We know Iraq has a terribly sophisticated operation - there's no question about that. We've got the Russians out there. After Sept. 11, I've had some very serious additional concerns. I think what changes the equation is you've got educated people, long-term planning, timing, coordination - all of these things suggest that you've got potential at a level not seen before." "ut Jessica Stern, a terrorism expert at Harvard, says Sept. 11 demonstrates more than anything else, ..he lethal capacity of low-tech weapons. If I were in government I would be thinking of low-tech Newsday.com: Battling Bioterror Page 4 of 4 bioweapons and low-tech chemicals. " Ronald Atlas, president-elect of the American Society of Microbiology, concurs. "All you have to do is infect some of your people with smallpox, send them out and you've got an epidemic," he argues "If you've got 40 or 50 people who are out there, committing suicide, you've got an epidemic," Atlas told Newsday. "I don't have to get anthrax from a laboratory, I can just go to [Africa], to an elephant outbreak and get it from the carcasses. "We can increase security," he said, "but all sorts of things are out there in nature." As for more exotic agents, genus that have been genetically modified into superbugs, Davis says terrorists need not know anything, even the difference between a bacteria and a virus. They just need enough cash to buy killer microbes from unscrupulous scientists who until recently worked for the massive Soviet biological weapons program. In January 1991, Davis was part of a small British-American inspection team that was the first group of Western scientists allowed inside the Biopreparat laboratories. What he saw - about 52 death laboratories and test sites employing about 60,000 scientists and technicians - left Britain's Davis a changed man. "The world is full of hazards," he says. The Associated Press contributed to this story. CopyrÏght © 2001, Newsdav. Inc. l'Icwsuay.cum: UAV: U.;'). l~Oll,eaoy rage 1 01 ,¿ ~-.. ·,,,·~.l.ir. 't'1.!fÞ.II : tIp:l /",,,"\n\'. newsday .com/news/nati onworld/nati on/ny -usbio0223 9523 90ct02. story AMERICA'S ORDEAL GAO: U.S. Not Ready Says response to bioterrorism fragmented, underfunded By Laurie Garrett STAFF WRITER October 2,2001 The federal capacity to prepare for and respond to a bioterrorism attack "is fragmented," lacks accountability and suffers from duplication and inconsistencies, the General Accounting Office told Congress yesterday. The report is the third critical assessment released by the GAO on this subject since Sept. 11. It describes a government that lacks a clear line of authority over the planning process. The GAO found that at least seven executive branch departments have bioterrorism programs. But so xtensive is the fragmentation among these programs, the report said, that no two departments even "hare a common list of the pathogens most likely to be used as biological weapons. . "Fragmentation has also hindered unity of effort," the GAO wrote, leading to competition between agencies on issues concerning funding and control. The GAO report said it was difficult to determine how much is now spent on anti-bioterrorism activities because few agencies have line items within their budget specifically earmarked for such activities. But it estimated slightly more than $156 million was spent in 2001. The lion's share of that money, or $110 million, was spent by the Department of Health and Human Services, nearly half of which went to the Centers for Disease Control and Prevention, the report said. Among the smallest budget allocations were those aimed at protecting America's food and livestock from biological contamination. The U.S. Department of Agricultural spent just $200,000 on such efforts, the FDA spent $2.1 million. This comes at a time when some bioterrorism experts argue that non- human pathogens-including foot- and-mouth disease-could be used by terrorists to devastate the U.S. economy without posing a health risk to the terrorists themselves. Purdue University's Agricultural Extension Program, for instance, recently noted that a release of the foot- and-mouth disease virus into the U.S. livestock industry would cost the economy $24 billion a 'ear, every year until it is eradicated. Newsday.com: GAO: U.S. Not Ready Page 20f2 The GAD also suggested that federal problems with coordination may be sifting down to the states. The report said different U.S. agencies conduct local training programs that provide cities and states with different advice and protocols. The result is that even cities that have had several training exercises "are still not adequately prepared to respond to a bioterrorist attack." The New York region's response to the emergence of the West Nile Virus in 1999 is offered in the GAD report as evidence of problems faced by local communities in diagnosing and asses- sing epidemics. "Because of the limited capacîty at the New York laboratories, the CDC laboratory handled the bulk of the testing" for West Nile, according to the report. But that meant "the CDC laboratory would have been unable to respond to another outbreak, had one occurred at the same time." In addition, the GAD noted that most American hospitals have been reducing costs in the past decade by decreasing staff size and the number of patient beds they maintain. As a result, the report said, many regions found they had insufficient surge capacity to handle the 1999 flu season. A serious epidemic could well outstrip hospital capacities in most of the country, the GAD said. Finally, the GAD report described a tangled web of congressional and presidential laws and directives relevant to bioterrorism passed since 1989. While some of the laws and directives give authority during an outbreak to the FBI and to the Federal Emergency Management Administration, the report argues that any response should be guided by public- health authorities. Copyright © 2001, Newsday, Inc. Training for Public Health Emergencies Ed1.11~ation and tn. ~ng remain the primary means for developing a respon- sive and competent workforce. However, new training strategies. . . must be developed. 1- ~ioterrorism prepar~dness exercise demonstrates the need for Interagency collaboratIOn. Practical Training Needed This scenario was used in a bioterrorism tabletop exercise developed by the Northwest Center for Public Health Practice. Iris both fact and fiction. Many of the elements actually occurred in previously reported communicable disease outbreaks. The Center combined them to make up a fictional story of a bioterrorist threat in a local community. Fact or fiction, the story raises interesting policy questions: Who is responsible for managing this problem? What are the communication channels? How and when is information disseminated? Who responds to the news media? Should the economic conference be canceled? A local community responding to public health emergencies needs to have the answers to these and many other policy questions. , An agency's ability to respond to new and emerging issues, such as bioterrorism, depends on the level of knowledge, skills, and abilities of its workers. Education and training remain the primary means for developing a responsive and competent workforce. However, because the public health workforce needs information that is useful, practical, and can be easily assimilated into ptactice, new training strategies, including distance learning, case study exercises, mentoring, networking, and on-site practicums must be developed to augment traditional classroom teaching. This tabletop exercise is an example of a practical training approach that can be used to prepare local communities for a large-scale communicable disease or bioterrorism event. The Bioterrorism Tabletop Exercise In the summer of 2000, the Washington State Department of Health asked the North- west Center for Public Health Practice, a program of the University ofWashingron School of Public Health and Community Carl S. Osaki People have been enjoying a quiet, unevendùl summer in a county of about 150,000 people. But during the first week of August, unusual events begin to happen. Health care providers in the county begin to see increasing numbers of people with gastrointestinal symptoms. On Friday evening health care providers become alarmed when 30 patients, all exhibiting similar symptoms, flock to area hospitals or medical clinics. Hospital authorities, realizing something unusual is happening, contact the local health department. Health authorities suspect a possible food-borne disease outbreak. The outbreak continues to grow over the weekend, and local public health authorities search for a common soutce of contamination. Then, terrorists call the mayor of the largest city in the county and claim responsibility for rhe outbreak. The terrorists threaten to continue making people sick until a major economic conference scheduled in two weeks is canceled. Over the weekend, people from adjoining counties also appear to be affected by the disease outbteak. By Sunday, the source of the outbreak remains unknown, but appears to be associated with a number of restautants and specialty grocery stores in two counties. The news media ate notified. Restaurant and grocery store business plummets in the affected counties. Health Department ånd county phone lines are jammed on Monday morning. The news media request further information, particularly about what the public should do and how law enforcement and public health officials will respond. By Monday afternoon, at the peak of the outbreak, more than 400 cases have been reported. An elderly woman who ate a meal at one of the restaurants dies, and family members thteaten to bring legal action against the agency responsible for her death. Two weeks later, the outbreak seems to have abated, except for a number of secondary cases. No more is heard from the terrorisrs. 18 Northwest Public Health . Spring/Summer 2001 Medicine, (0 develop a training module for local public health personnel and their emergency coumerparts co develop skills and knowledge needed to prepare for and respond to a large- scale communicable disease or bimerrorism even!. The Health Alert Necwork and the Bioterrorism Preparedness and Response Program at the Centers for Disease Control and Prevention funded the project. The Northwest Center designed a four-hour tabletop exercise simulating the policy problems inplicit in responding to a large-scale bioterrorism event. The exercise was aimed at helping participants identifY policy questions that need to be considered in preparation for such an emergency, The lack of established and published policies and training for these kinds of events is a recognized problem. A survey conducted by the National Association of County and City Health Officials in March 1999. found that only 23% oflocal health departments had an emergency response plan that included bioterrorism. Three pilot tests of this training exercise have been conducted in rural as well as urban communities, and participants have included a mix of staff from the local community health departments, emergency management, law enforcement agencies, emergency medical services, hospitals, and boards of health. The exercise contained a scenario with a progression of 22 separate incidents similar to the scenario above. After each incident was described, the participants discussed how they would respond and what policies, if any, were already in place to support their responses. These discussions led participants to decide whether local policies were present, docu- mented, understood, communicated, and followed. Participants also identified new policies their agencies should develop in order to respond effectively to the incident. An instructor from the Northwest Center for Public Health Practice facilitated the exercise using a PowerPoint presentation and three "storyboards" that provided the context or setting for the incidents as the exercise unfolded. The storyboards enabled the participants ro progress without having to make their own assumptions about events, such as time or place within the scenario, Prepared to Prepare At the end of the exercise participants assessed the practicality and usefulness of the exercise. They indicated rhat the excrcisc had successfully: · Identified measures that can be pcrformed at the localleve\ · Promoted interagency collaboration and coordination · Recognized the roles of a variety of local public officials · Illustrated the need for intense teamwork and commumcatlon · Identified the gaps in local preparedness · Identified additional resource or capacity needs · Identified additional training needs Each pilot community also held follow-up meetings to discuss the policy gaps identified through the exercise. (See box on page 20 for some conclusions ftom the follow-up meetings.) Next Steps Public health rat catchers attaching collection identification tags to their morning catch, San Francisco, c. 1907. In the pilot exercises, the presenters received positive feedback about the value and need for such training. Also through the pilot exercises, the Northwest Center identified a number of future training needs, including basic epidemiol- ogy, dealing with the news media, effective communication across and among agencies, and writing clear policies. The pilot exercise also identified local strengths, particularly the ability to work in teams and make rapid decisions and the desire to assist colleagues and other agencies with resource or capacity needs related to emergency preparedness. The ability of local health officials to quickly recognize a possible bioterrorism or communi- cable disease event depends, in large part, on the diagnostic capabilities of healthcare providers and clinical laboratories and their ability to communicate this information rapidly to public health officials. By the end of rhe exercise, Northwest Public Health . Spring/Summer 2001 19 participalHs rccognizcd how importanr it is [0 work with thc mcdical community to cnsurc thc prcsence of good rcporting, rccognition, and surveillance of unusual disease cvcnrs in the community. Public health agencies need [0 address rapidly changing public health issues and require pracric.'1I. value-addcd training modules for dcveloping a competent and responsive workforce. The positive response to this tabletop cxercise demonstrates that this type of creative, inreresting, hands-on learning activity should be considered an important addition to workforce training mcthods. The Northwest Center and thc Washington State Department of Health will conrinue to use this excrcisc and its outcomes to enhance our rcgion's preparation for public health cmergencies. CI&Ø Author Carl S, Osaki, R.S., MSP.H" is former chief of Environmental Health, Public Health-Searde and King County. He is also a member of the Washington State Board of Health and clinical associate ptofessor in the Department of Environmental Health, UWSPHCM. For more information about the bioterrorism tabletop exercise, call Julie Wicklund, Washington Department of Health, at 206-361-2881, or e-mail her at julie.wicklund@doh,wa,gov, Some Conclusions from the Bioterrorism Exercise · Local policy makers (boards of health, county commissioners) may have an active interest in understanding and helping to define the public health emergency response policies. · Local county emergency responders are very interested and willing to learn about their role in a large-scale communicable disease or bioterrorism events. . Local health departments are good at responding to public health emergencies, but they lack written or documented policies. · Each county had its own unique politics, personalities, and command structure. A policy for one county may not necessarily be appropriate or relevant for others. · Local agencies, other than public health agencies, generally have written policies regarding emergency response, but these policies may not address or include public health èmergencies. · Existing communication policies are typically related to internal agency or county operations, and policies for communi~ting formally across county lines or with state or federal offiCials are generàlly limited. Informal communication often leads to confu- sion, misunderstandings of decisions and authority, and misinformation about where to go for technical. ass¡;;tance or advice. · Emcrgency response policies are not al\VfŸ.s well communicated among all thc agencies involved. .'.' . ., . Those outside of the health departmen~Ìypically do not have a basic understanding of public health roles and responsibilities, . .., . Commµnication is strained when publicli.èaIth officials assume that emergency responders understan~ basic public he#thtenninology, particularly terms associated with diseases or symptoms. .. . '..,. . · A self-reported assessment of a localh,eaithdepartment'sabiIity to respond to a biorerrorism event may ~ot be corisiÚe~t with its aCruaI0r observed performance. 20 Nc>rthwesr Public Health . Spring/Summer 200 I .,..,..~_....... Viewpoint: The Public Health Threats and Emergencies Act aøDI3 .-4;tWJ14I ..._~~~..i:.:-~-!-~~"ID. ~ Addressing Public Health Preparedness Mary Se/ecky One of the most imporranr issues facing me as Secretaty of Health for Washington State is assessing the level of "preparedness" of our public healrh system. fue we ready, in rhe evenr of an emergency? fue we organized, prepared, and equipped to respond to an evenr that threatens the health of our residenrs? A terrorist was apprehended at our,border in 1999, carrying bomb-malcing materials. Would we have been ready ifhe had instead slipped through the border with a biological weapon? Our responsibility to be prepared, every minute of every day, was brought home dramatically on February 28, at 10:45 A.M., when the Nisqually earrhquake hit. Throughout the aftermath, my ever- present thought was: This could have been so much worse in terms of injuries, deaths, and damage to key systems, such as our drinlcing water supplies. I thought of all our health departments, hospitals, first responders, and laboratories. Would we have been ready? One tool to address that concern is a piece of landmark legislarion that recognizes that many communities are not prepared to respond effectively to threars to the public's health, including new and resurgent infectious disease, the emergence of pathogens resistanr to anribiotics, the potential for terrorist attack with biological weapons, and natural disasters. The Public Health Threats and Emergencies Act was signed into law by President Bill Clinton, November 13.2000. Commonly referred to as "Frist-Kennedy," in recognition of its key sponsors Senator Wtlliam Fristand Senator Edward Kennedy, the act passed with strong bipartisan supporr. As Senator Frist explained, "Our nation faces alarming risks from a number of potential public health threars.... It is vital that we take steps to address current inadequacies and ensure that our public health infrastructure is prepared to meet the challenge of any public health crisis." To protect our health into the 21" century, the country must build a reliable, strong infrastructure for public health, including: · A public health workforce that is well trained and ready to respond to biological and environmental threars · Information systems and technology to guarantee rapid detection and transmission of critical data . Health depanmenrs, laboratories, and health facilities that are fully prepared and have the Our responsibility to be prepared, every minute of every day, was brought home dramatically on !Jruary 28, at 10:45 A.M, when the Nisqually earthquake hit. resources needed to protect our health at all times As a first step, the Public Health Threats and Emergencies Act authorized funds for four specific areas: public health capacity ($99 million), antimicrobial resistance ($40 million), bioterrorism ($215 million), and CDC facilities/ laboratories ($180 million). These funds were not appropriated in the budget, but could be provided in the federal budget in future years. I am especially excited by the potential of the public health capacity provisions of the act. For the first time, our nation could underrake a systematic analysis of where we have gaps in our ability to respond to public health threats and then, armed with that knowledge, begin to fill those gaps. This is an effective and sensible process that is tailored to unique state and local needs. · The assessment section authorizes $45 million for granrs to state and local agencies to assess and inventory specific needs in public health infrastructure. This work would also help us identify the performance standards we need to measure our level of preparedness. · The improvement section authorizes $50 million to address demonstrated needs in areas such as developing electronic information networks, training public health personnel, enhancing local and state laboratory capacity, and developing detailed, coordinated emergency response plans for such evenrs as bioterrorism, natural disasters, and significant outbreaks of communicable disease. I look forward to worlcing to support the intent of this act with our partners in ASTHO, NACCHO, CDC, and HRSA to improve our ability to respond, across a system with 3,000 local health depanmenrs, 50 states, and many federal agencies. I like the way this was described in CDC's reporr to Congress: "Evny health department .fùlly prepared; every community better protected. » Public health protection is a high priority issue among the general public. I know that my col- leagues throughout federal, state, and local government, and among health care providers and health facility administrators, all share my concern about our responsibility for public health prepared- ness. ....., Author Mary C Selecky is secretary of health for the Washington Scare Department of Healrh. 12 Northwesr Public Health . Spring/Summer 2001 I ( Health Advisory to Health Care Providers - Precautionary Increase in Level of Suspicion for a Biological Attack, October 2, 2001 Please take this opportunity to review your protocols and preparedness for recognitIOn, clinical managernent and infection control procedures for agents likely to be used in a bioterrorism attack. The biological agents most likely to be used in such an attack are dispersed by air and are described below. At this time we have no indication that our region is at increased risk for such an event. This advisory is strictly precautionary. Jefferson County Health and Human Services is requesting that Health Care Providers maintain a high index of suspicion for clinical syndromes compatible with a potential biological weapons attack. Please contact Jefferson County Health and Human Services immediately if you suspect a case of the diseases listed (prior to laboratory confirmation), or an increase in compatible syndromes. :\Ionday - Friday, 9:00 - 4:30 call 385-9400 or fax 385-9401. After hours contact numbers: Tom Locke, M.D.. Health OtTicer (360) 808-3333. or Jean Baldwin, ARt~'P. Nursing Director, 531-1736, Thank you very rnuch for your support. Potential Bioterrorism Agents Agent Bacillus allthracis Disease Inhalation Anthrax Yersillia pestis Pneumomc Plague Coxiella bumetii Francisella tularensis Q Fever : Tularemia Variola Virus Smallpox Various Hemorrhagic Fevers Clostridium horulilllllll : toxin Inhalation Botulism Syndromes and Clinical Findings Fever. malaise, cough and mild chest discornfort progresses to severe respiratory distress with dyspnea. diaphoresis, stridor, cyanosis and shock. ! X-ray shows mediastinal widening. High fever, chil1s, headache, fol1owed by cough (otten with hemoptysis) ;Jrogressing rapidly to dyspnea. stridor. cyanosIs and death. GI symptoms are also often present. Fever. cough and pleuritIc chest pain. Fever. headache, malaise, substernal discomfort. prostration, weight loss and non-productive cough. Begins acutely with malaise, fever, rigors, \'omiting, headache and backache. Two to three day:, Liter macular lesions :.lppear which qUIckly progress to papular and then pustular lesions. The lesions develop synchronously and are more abundant on the extremitIes which helps diftèrentiate it tì'om rash due to vancel1a. Fever. flushing of the face and chest. petechiae. bleeding, edema. hypotension and shock and may include malaise. myalgias. headache, vomiting and diarrhea. Begins with cranial ner've palsies including ptosis. blurred vision. diplopia. dry mouth and throat. dysphoma, dysphagia and is fol1owed by symmetncal descending tlaccid paralysis, I ( Health Advisory to Health Care Providers - Precautionary Increase in Level of Suspicion for a Biological Attack, October 2, 2001 Please take this opportunity to review your protocols and preparedness for recogmtion. clinical management and infection control procedures for agents likely to be used in a bioterrorism attack. The biological agents most likely to be used in such an attack are dispersed by air and are described below'. At this time we have no indication that our region is at increased risk for such an event. This advisory is strictly precautionary. Jefferson County Health and Human Services is requesting that Health Care Providers maintain a high index of suspicion for clinical syndromes compatible with a potential biological weapons attack. Please contact Jefferson County Health and Human Services immediately if you suspect a case of the dIseases listed (prior to laboratory confirmation), or an increase in compatible syndromö, :\1onday - Friday. 9:00- 4:30 call 385-9400 or fax 385-9401. After hours contact numbers: Tom Locke, M.D" Health Officer (360) 808-3333, or Jean Baldwin. ARNP, Nursing Director, 531-1 ì36. Thank you very much for your support. Potential Bioterrorism Agents ClostridiulIl bOtzl/imllll toxin Inhalation Botulism Syndromes and Clinical Findings Fever, malaise. cough and mild chest discomfort progresses to severe respiratory distress with dyspnea. diaphoresis. stridor. cyanosis and shock. X-ray shows mediastinal widening. High fever. chills. headache, followed by cough (otten with hemoptysis) progressing rapidly to dyspnea, stridor, cyanosis :md death. GI symptoms are also often present. Fever. cough and pleuritic chest pam, Fever, headache, malaise. substernal discomfort. prostration. weight loss and non-productive cough. Begins acutely with malaise, fe\-er. rigors. vomiting. headache and backache, Two to three Jays later macular lesions appear which quickly progress to papular and then pustular lesions, The lesions develop synchronously and are more aoundant on the cxtn:mltlèS \vhlch helps differentiate it from rash due to varicella. Fever, t1ushing of the face and chest, petechiae, bleeding, edema. hypotension and shock and may mclude mahme, myalgia:,. headache, vomiting and diarrhea, Begins \vith cranial nene palsies 1I1C I uding ptosis. blurred vision. diplopia. dry mouth and throat, dysphoma, dysphagia and is followed by symmetrical descending :1accid paralysis, Agent Bacillus ullthracis Disease [nha1ation Anthrax Y¿rsillia pestis Pneumomc Plagu~ Coxiella burnetii Francisella flIlarensis Q Fe\u Tularemia Variola Virus Smallpox Various Hemorrhagic Fevers Clues that l\tIay Signal a Biologic or Chemical Attack I. Large numbers of ill persons with a similar disease or syndrome. 2. An increase in unexplained diseases or deaths. 3. Unusual illness in a population (i.e., renal disease in a large population may suggest exposure to a toxic agent such as mercury). 4. Higher morbidity and mortality in association with a common disease or syndrome or failure of such patients to respond to usual therapy. ). Single case of disease caused by an uncommon agent (i.e., Burkholderia mallei, smallpox, viral hemorrhagic fever, pulmonary anthrax). 6. Several unusual or unexplained diseases coexisting in the same patient without any other explanation. 7. Disease with an unusual geographic or seasonal distribution (i.e., tularemia in a nonendemic area, inf1uenza in the summer). 8. Illness that is unusual (or atypical) for a given population or age group (i.e., outbreak of chicken pox-like rash in adults). 9. Unusual disease presentation (i.e., pulmonary instead of cutaneous anthrax). I O. UnusuaL atypical, genetically engineered, or antiquated strain of an agent or antibiotic resistance pattern. II.Stable endemic disease with an unexplained increase in incidence (i.e., tularemia. relapsing fever). 12. Atypical disease transmission through aerosols, food, or water, which suggests deliberate sabotage. 13. Many ill persons who seek treatment at about the same time. 'iri rJJJJ L pdate: Public Health Message R~garding Florida Anthrax Case C¡:NTCHS '-OR DISEAS€'i: CONTHOL-'\NO PHE'IE~1IQN October Î. 200 I .;> The ongoing investigation of anthrax in Florida has detected evidence that the bacterium that causes anthrax. (Bactilis alllhraCIS) may be present in the building where the patient who died of anthrax worked, .;J fJ. (/lIthracis was identitied in one nasal sample from another \vorker in the building, \V'hich suggests exposure, No other workers are known to have illness consistent with ant hrax s One of many samples collected from the workplace environment contains R. a11lhracis. Final results on thç other environmental samples \vill not be avaí1ab]e for severai days. In !he meantime. public health officials, in cooperation with the company. have secured the building. ;; The current risk of anthrax among employees and ',/isitors to the building is extremely ;o\.'v However. as a preventi\'e measure, public health officials have begun to contact personnel vvho worked in the building since AUhTUst I. 2001, to provide antibiotics, .-\ntibiotic treatment before symptoms occur ',vill prevent anthrax, The incubation period from exposure to onset of illness with anthrax is usuaily l- 7 days. but may be as long as ÖO days, - S':mptoms of inhalationai anthrax include tè\er. muscle aches. .1:11.1 ~atiguè :hat rapidly progress to severe systemic illness, Workers who develop such symptoms will be advised to seek immediate medical attention for further evaluation s Anthrax is NOT contagious from one person to another Family members and contacts of persons \vho work in or ,"'isited the building are not at risk and antibiotic therapy is not rècommended Ic;r them Other members of the communi tv are not :H risk Pubiic health ortìcials, together with the FBI. are continuing the investigation, .; .::.,,:C iìì0rê :.nroïnlil¡~ún r~gafding 111i:J pubiic i1èa~tn ~Ì\':;.iG¡~ .n [:~":<i·~\."ù. j~'~:çr .~, c";1... ~\1onday, October 8. cal! ¡ gOO 342-355ï .$ \tedia: Florida contact 561 ìI2-6400: COc, pager 404318-2380, In the Matter of Adopting a set of Core Values, Vision Statement, Mission Statement, and Goals for Jefferson Count\' Sta~e of Washington COUilty Jefferson , , J ~ J } } RESOLCTION NO. ~Jl WHEREAS, the elected leadership of Jefferson County have determined that they will address the issues facing this community through the use of strategic planning; and, Vf/HEREAS, through the adoption of Resolution 38-01 reasons and methodology for the development of a strategic plan were established for Jefferson County; and, WHEREAS, the leadership of this County has collectively developed a set of Core Values that reflect those of the organization and it's leadership; and, VlHEREAS, the leadership of this County has collectively crafted Vision and Mission statements that will guide the organization, and WHEREAS, the leadership of this County, with assistance from numerous members of various Citizen Advisory Boards and with comments from hundreds of local citizens has crafted a set of 8 goals which will constitute the foundation of our strategic plan, and v..l-IERE...-4.S, the leadership of this County, has recommended the adoption of the attached Exhibit "A" that contains the Core Values, Vision Stateme~t, Mission Statement, and Goals. lv'on:. THEREFORE, BE IT RESOL lED, that the Board of Jefferson County Commissioners that the attached Exhibit A is hereby adopted and ask that all County Departments acknowledge and are guided by the concepts and principles embodied herein. Aj'f'ROi.W/;ND~OPTED this ;< 7 ~day of /Ju.rf 2001. " ~ I .). ., 1 JEFFERSON COCNTY / : ~; · r~ . . BO.A.RD OF CQMMISS \ . I ~ ,; ATTEST: '... . 'ej' Yo-?A1.If.j)£ ~~- Lorna Delaney, CM~ Clerk of :he Board SEAL: '. .. RS Dan Ti tterncs~, M!!1µembeJi If / , 2 J~ \ </~ /~/ft . / 'ìljcha~ojt, Me r v Strategic Management Objective #1: Seek new sources of revenue and create internal revenues by improving the eft'ectiveness and ef1iciency of agencies within the law and justice block. 1.1 Full\' utilize aU local option taxing authority for law and justice related needs, specifically adopt the .01 of IS: sales tax for Juvenile and Adult Corrections. 1.2 Continue to seek full funding from the Washington State Legislature through formal professional associations and meeting between local legislators and the law and justice council. 1.3 Prioritize activities to assure available resources are channeled to critical service areas. Review each program area to assure the resources expended are effective in addressing a critical need. Establish performance measurement system that monitors program cost-effectiveness for each program area. 1.-+ Review program areas across departmental lines to eliminate duplication or to shift responsibilities among agencies to eliminate or reduce duplication and to take advantage of economies of scale. 1.5 Develop a system for the exchange of data between agencies to keep all parties informed and to reduce waste or duplication of efforts. Strategic Management Objective #2: Develop short term facilities plan to address growing demand for adequate facilities while long range solution is being developed. 2.1 Assess and report to the Board of Commissioners on the existing utilization of courtroom, courthouse, detention. law enforcement and incarceration facilities to determine if low-cost alternatives exist. 2.2 Explore with Jefferson General Hospital and/or Jefferson Mental Health the provision of a Detox/Mental Health holding facility. 2.3 Explore with the Washington State Department of Social and Health Services, Division of Alcohol and Substance Abuse (DASA) additional funding for involuntary and inpatient treatment. Strategic Management Objective #3: Review current and emerging needs of the community to determine adequacy of programs provided. 3.1 Establish a Substance Abuse Task Force to review "existing programs, assess impact on criminal justice system and identify program needs and/or opportunities, and report þack to Law and Justice Committee by end of 2001. 3.2 Establish formal process to review alternatives to incarceration. 3.3 Utilize the Behavior Risk Factor Surveillance System (BRFSS) to develop a profile of emerging law and justice issues, and then match this assessment against existing program areas and identify where programs need adjusting or where no program currently exists. Strategic IVIanagement Objective #4: Inform the community on Law and Justice Issues. -1-.1 Continue the community outreach committee. Utilize specific issues or incidents to raise the public's 3.1,\"arcness on Law and Justice issues. 4.2 Include question(s) about Law and Justice/Public Safety issues as part of the upcoming community feedbacK questionnaire. Strategic Management Objective #5: Reduce the County's exposure to liability. 5.1 Review each program area for exposure to liability. Where operating policy exists insure steps are taken within agencies to train employee on policies. Where no policies exist or policies are inadequate or out dated, have department review, develop, and update as necessary. Core Values Integrity Pro fessional ism Accountability Resourcefulness Innovation Responsiveness Err,pov\erment Service C. tizen Ir.volvement Value people. heritage & natural resources Icfkr:-,pf1 l cHIJ\t: CI111111W,o-IPIl .Jetlersl)] ("HH1I: ('()Ilrlhllll"l' ! ~C() .kt't'':''I>I1 Sri'':':! r, () 110\ ¡ =20 Port: P" 1:,,'1)(1. W..\ ()HìMi Ph, .~h()_'X~_'¡ I 00 :-;()()-X~! ·2(,ìX F;h ~()Il- 'S,-I)~g2 .It:!111occri C(),.ldlc'('Il,W;\.I.h VISION STATElVíENT: We envision Jefferson Countv as a balanced, sustainable " community with economic opportunities for income potential that allows personal independence. \Vhere post secondary educational opp0l1unities exist and are tied to the local economy. W"here the community recognizes that a certain level of planned growth and development is healthy and necessary to maintain our quality of life. Where the enjoyment of a rural lifestyle is protected without the expectation of urban services. Where the community is engaged with its elected leadership to accept responsibility for contributing to the solution of community problems. MISSION STATE1\IIE.NT: Jefferson Countv Government is committed to effective " public policy, superior public service, courteous public contact, judicious exercise of authority, and stewardship of public resources, to meet the needs and concerns of our citizens. GOAloS · Create a sustainable and balanced economic base focused on family wage jobs and geographically distributed. Promote educational opportunities to support post secondary schooling, lifelong learning, and workforce training. Improve the balance between the cost of housing and earned income. Sustainable utilization of natural resources that preserve our county's physical beauty and delicate ecosystems. A healthy and safe citizenry. Adequate public tàcilities for work and play. AtIordable government. Actively engage citizens as community assets. · · · · · · · WW~=~n~~~=~~=~>=>~W~n=n =~nn~=~=n=n ~ ~ f5 ~ ~ W Š ~ ~. g fi ~ ~ o'Q' Œ Fi fi ~ S ~ ê. Š fi ~ fi~šš~fing~~= PJ ..... 'd ([) W Er ([) 0 ~ "'O::s þ" "'0 8 W ..... ....' 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(') -- 00 0' (') > ;:r- 0 ~ > g 0 ;:r-::1. > x ~ c; crQ -: ~ ::!;::;. -: ,--<::;. ::;. -: "d t:j '--< ~ -: oo__~-: 00 ~ ~~rÞr~ orÞ--:3 ()qrÞ 3 00 ¡t>j ~ -J '"d~ ::2()q ~ _.()q ~ ~ ~ ~ C/)~ ~ 00 ::::I ~ ~'- ;:r- ~ (J ::j .¡:.. 5. èjj' ~ ~ ~ N ~~9:- (t) 0 II (t) '-<: "9.. ~ (ì) ..::;, 00 t:j -, ~ ()q ~ ()q n (D' '""i 0 00 ~ 0 !!. ::! ¡t>j n ...... 0 õ' s ~ ~ ~ ~ ~ ~ ...J tTJ-< ::::. a 00 ...... 0 00 ¡t>j (ij ¡t>j ::! P. C/) ::; ~ ~ p) ~ ~ ...... ~ re. ~ 00 -- to 0 n n '-"' ¡:.¡ ::! P. ~ ~ ~ (': ~ '< >- ~ ~ ¡t>j 00 ¡t>j 00 v (t) ::::t1 ::: ~ ~ ~ (t) p. ü '< ~ ¡:.¡ 00 2: - ...J ()q .- ::2 ...J ~ C/) ~ ~ ~ ~ .- ¡:.¡ .- ~ v (t) '"C ¡t>j '""i ...... :3 (t) ::! ...... 0 ......., ~ ~ ;r:: ~ ~ ...... ;:r- ~ ~ ~ ~ ~ Assuring a Safe, Healthy Environment for People Standards for Environmental Health Standard I Environmental health education is a planned component of public health programs. Local measures: CD Information is available about environmental health educational program' through brochures. flyer¡, newsletter¡, websites or other m~chanisms. ® There are documented processes for involving community member¡ and stakeholder¡ in addressing environmental health issues, including education and the provision of technical assiHancf. Q) A plan for environmental heahh education exists and in dudes goals, objectives and learning outcomes, @ The environmental health education plan identifies performance mmures for education programs, There is an evaluation process for health education offerings that is used to revise curricula, ® Ilaff member¡ conduCling environmental health education have appropriate skill, and training, State measures: o Informalion is provided to the public about the availability of state level environmental health educational programs through contact information on brochures, flyers, newsletters, website, and other mechanisms. @ There are documented procems for involving slakeholders in addressing environmental health issues induding education and the provision of technical assistance. @ A plan for environmental health education exists, with goals, objectives and learning outcomes. There is an evaluation process for health educalion offerings that is used to revise curricula, 9 Environmental health education services are provided in conlormance with the statewide plan, fi) The environmental health education plan identifies performance measures for education programs that are monitored and analyzed on a routine basis. @ Itaff members conducting environmental health education have appropriate heahh education skills and training as evidenced by job descriptions, resumes or training documentation. Standard 2 Services are available throughout the state to respond to environmental events or natural disasters that threaten the public's health. Local measures: CD Inlormation is provided 10 the ""blic on how to report environlTH'ntal health threats or public health emergencies, 24 hours a day; this includes a phone oumber, ® Appropriale stakeholders are engaged in developing emergency response plans, Following an emergency response to an environmental heahh problem or natural disaster, stakeholders are convened to review how tbe situation was handled. and this debriefing is documented with a written summary 01 findings and recommendations. <ID Procedures are in place to monitor access to services and to evafuate the effwiveness of emergency response plans, Findings and recommendations for emergency response policies are induded in repom to the BOH, @ Thore is a plao that describes lH roles and responsibililies for environmental events or natural disasters that threaten the health of the people, There is a dear link between this plan and other local elTH'rgency response plans, ® Key staff members are trained in risk (ommunÎcatiol1 and in use of the LHJ emergency response pfan, State measures: o Information is provided to the public on how to report environmental health threatt or public health emergencies. 24 hours a day; this includes a phone numher, @ (onsultation and technical assistance are provided to lHJs and other agencies on emergency preparedness, as documented by case write-ups or logs, Following an emergency response to an environmental heafth probfem or natural disaster. lHJs and other agencies are coovened to review how the situation was handled, This debriefing is documented with a wrillen summary of findings and recommendations, @ Written procedures are maintained and disseminated for how to obtain consultation and technical assistance regarding emergency preparedness, Procedures are in place to monitor access to services and to evaluate the effectiveness of emergency response plans, Policies are revised based on event debriefing findiogs and recommendations. o There is a plan that describes DOH ioternal roles and responsibilities for environmental eventt or natural disasters that threaten the health of the people, There is a dear link between this plan and other state and f<¡cal emergency response plans, o DOH program staff are trained in risk communication and the DOH emergency response plan, as evidenced by training documentation. Standard 3 Both environmental health risks and environmental health illnesses are tracked, recorded and reported. Local measures: (j) EnvilOul1lenlal u~altl data is. ava¡lable rOf (Ummullity groups and other local agencies to review, ® A surveillance system is in place 10 record and report key indicators of environmental health risks and related illnesses, Information is tracked over time to monitor trends. A system is in place to assure that data is shared routinely with local, state and regional agencies, ® A quality improvement plan includes consideration of environmental heahh information and trends, findings from public input, evaluation of health education offerings and information from compliance activity, State measures: o (oordination is pro.ided in development of data standards for environmenlal health indicato~, Inlormation based on the surveillance system is developed and provided to lHJs aod other state stakeholders, @ A statewide surveillance system is in place to receive, record and report key indicators for environmental health risks and related illnesses, Resultt are tracked and trended over time and reported regularly, A system is in place to assure that data is transferred routinely to local, state and regional agencies, @ A quality improvement plan includes consideration of analysis of environmental health information and trends, findings from debriefings, evaluation of health education offerings and informatioo from compliance activity, Standard 4 Compliance with public health regulations is sought through enfarcement actions. Local measures: CD Written policies, local ordinances. laws and administrative codes are o<Cessible to the public. ® (om?liance procedures are written for all areas of environmentaf health activity, The procedures specify the documentarion requirements associated with enforcement action, Documentatioo demonstrates that environlTH'ntal health work conform! with policies, local ordinances and state statutes, ® There is a documented process for periodic review of enforcement actions. @ An environmental health tracking system enables documentation of the initial repor~ investigation, findings. enforcemeot and subsequent reporting to other agencies as required, ® Environmental health staff memhers are trained on compliance procedures, as evideoced by tr~ning documentation, State measures: o Written policies, local ordinances, laws and administrative codes are accessible to the public. @ Information about best practices in environmental health compliance aClivity is gathered and disseminated, including form templates, time frames, interagency coordination steps, hearing procedures, citation issuance and documentation requirements. t!) Compliance procedures are written for all areas of environmental health activity carried out by DOH, Documentation demonstrates Ihal environmental health work conforms with policies, local ordinaom and itate statutes. o There is a documented process for periodic review 01 enforcement actions. o An environmental health tracking system enables documentation, of the initial report, investigation. findings, enforcement and subsequent reporting to olher .gencies as required, @ Environmental health staff member¡ are trained on compliance procedures, as evidenced by training documentation, Prevention is Best: Promoting Healthy Living Standards for Prevention and Community Health Promotion ;tandard I 'o/ides are adopted that support prevention ,riorities and that reflect consideration of dent;fìcally-based public health literature. _ocal measures: [) Prevention and health promotion priorities are selected with involvement from the 80H, comlTlllnity groups and other organization, interested in the public's health, ID Prevention and health promotion priori tie, are adopted by the 80H, based on as,essment inlormation. local issues. funding "ailability, program evaluation and experience in ,ervice delivery, induding information on best practice, or scientific finding', :ID Prevention and health promotion priorities are reflected in the goals, objectives and performance measures of the lHJ's annual plan, Data from program evaluation and key indicators is used to develop strategies, State measures: o Repom aboot new or emerging issues that contribute to health policy choice¡ are routine~ developed and disseminated, Reporu indude information about best practices in prevenlion and health promotion programs, @ (onsultation and lechnical assi'lance is "ailable to assist lHs in proposing and developing prevention and health promotion policies and initiatives. Written pro<edures arf maintained and shared, describing how to obtain consultation artd assistance regarding development, delivery or evaluation of prevention and health promotion initiatives. @) Priorities are set for prevention and health promotion services. and a Hatewide illlplementation plall Îs devt'lopl'd with goals. objective¡ and performance measures, o The stalewide plan i, evalualed and revised regularly, incorporating information from health assessment data and program evaluation. Standard 2 Active involvement of community members is sought in addressing prevention priorities. Local measures: (1) The lH provides leadership in involving community members in considering assessment informiltion to set prevention priorities. @:I A broad range 01 community partnen takes part in planning and implementing prevention and health promotion efforu to address selected priorities for prevention and health promotion, ® Staff members have training in community I11<Ibilizalion methods as evidenced by training documentation, State measures: o The DOH provides leadership in involving stakeholders in considering assessment information to set prevention and health promotion priorities. @ A broad range of partners takes part in planning and implementing prevention and health promotion efforu to address selected priorities for prevention and health promotion, @) Information about community mobilization efforu for prevention priorities is collected and shared with LHJs and other stakeholders, o The statewide plan for prevention and health promotion identifies efforu to link public and private partnerships into a network of prevention services. 13 DOH staff members have training in community mobilization methods as evidenced by training documentation, Standard 3 Access to high quality prevention services for individuals, families, and communities is encouraged and enhanced by disseminating information about available services and by engaging in and supporting collaborative partnerships. Prevention services may be focused on reaching individuals, families and communities, Examples of prevention services include chronic disease prevention, home visiting by public heatrh nurses, immunization programs, effarts to reduce unintentional injuries and vioience, including sexual assault Local measures: (!) Summary information is available to the public describing prevenlive services available in the community, This may be produced by a partner organization or the lHJ, and it may be produced in a paper or web-based format. ® lo(al prevention services are evaluated and a gap analysis that compares exisring community prevention services to projected need for services is performed periodically and integrated into the priority setting process, @ Re..lu of prevention program evaluation and analy,is of service gaps are reported to local slake holders and to peers in other communities. ® Staff have training in program evaluation melhods as evidenced by training documentation, ® A quality improvement plan incorporates program evaluation findings, evaluation of Œmmunity f.~obmzation effma. use of emerging literature and best practices and delivery 01 ptevention and health promo lion services, State measures: o The DOH supporls best use of available resources for prevention services through leadership, collaboration and (ommunication with partners, Information about prevention and heallh promotion evaluation retults is collected and ,hared sJatewide, @ Prevention program!, provided directly or by contrac~ are evaluated against performance measures and incorporate amssment information. In addition, a gap analysis that compares existing prevention services to projected need for services is performed periodically and integrated into the priority setting process, @) DOH staff members have training in program evaluation methods as evidenced by training documentation, o A quality improvement plan incorporates program evaluation fmdings, evaluation of community mobilization efforu, use of emerging literature and best practices and delivery of prevention and health promotion services, Standard 4 Prevention, early intervention and outreach services are provided directly or through contracts. Heatrh promotion activities may be focused on !he entire state or community or on groups within the community, ExamPles of heatrh promotion octivities include educational efforts aimed at increasing physical activity. reduction in tobacco use, improved dietory choices, Local measures: (!) Prevention priorities adopted by the 80H are the basis for establishing and delivering prevention, early intervention and outreach services. ® Earfy intervention, outreach and health education materials address the diverse local populations and languages of the intended audience, Information about how to select appropriate r,,.terials i, available to and used by staff, ® Prevention programs collect and use information from outreach, screening. referrals, case management and follow-up for program improvement. Prevention program" provided directly or by contract, are evaluated against performance measures and incorporate assessment information. The type and number of prevention services are induded in program performance measures. ® Staff providing prevention. early intervention or outreach services have appropriate skills and training as evidenced by job descriptions. resumes or training documentation, State measures: o (onsultation and technical assistance on program implementation and evaluation of prevention services is provided for lHs, There is a sy'tem to inform lHj, and other stakeholders about prevention funding opportunities, @ Outreach and other prevention interventions are reviewed for compliance with science. professional standards, and ,tate and federal requirements, (onsideration of profmional requirements and competencies for effective prevention staff is included, @) Prevention services have performance measures that are tracked and analyzed, and recommendations are made for program improvements. o Statewide templates for documentation and data collection m provided for lHJs and other contractors to support performance measurement. 13 DOH staff members have training in prevention, early intervention or outreach services as evidenced by training documentation, Standard 5 Health promotion activities are provided directly or through contracts. Local measures: (!) Healih promotion aclivities are provided directly by lHJs or by contraclors and are intended to reach the entire population or at-ri,k populalions in the community, (:£' rrocedi..i'rl!s des,:ribe an overall system to organÎlf, develop, diwibute, evaluate and update health promotion material" Technital ",i,tance is provided to communily organizations, including 'train the trainer' methods, ® Health promotion efforts have goals, objectives and performance measures, The number and type of health promotion activities are tracked and reported, including information on content, target audience. number of atJendees, There is an evaluation procell lor healih promotion efforts that i, used 10 improve programs or revise curricula. (1) Stall member¡ have training in health promotion method, as evidenced by training documentation, State measures: o Health promotion activities are provided directly by DOH or by contractors and are intended to reach the entire population or at-risk populations in the community, @ literalure reviews of health prol11<ltion effectivenm are conducted and disseminated, (on,ultation and technical assistance on health promotion implementation and evaluation is provided for lHJs, There is a system to inform lHJs and other stakeholders about health promotion funding opportunities. @) Health promotion activities are reviewed for compliance with science. professional standards, and state and federal require menU, Health promotion materials that are appropriate for statewide use and for key cultural or linguistic groups are made available to lHs and other stakeholders through a system that organizes. develops, distributes, evaluates and updates the materials. 6 Health promotion activities have goals, objectives and performance measures that are tracked and analyzed, and recommendations are made for program improvements, The number and type of health promotion activities are tracked and reported, induding information on conten~ target audience. number of attendees, There is an evaluation process for health promotion efforts that is used to improve programs or revise curricula. 13 DOH staff members have training in health promotion methods as evidenced by training documentation. Protecting People from Disease Standards for Communicable Disease and Other Health Risks Standard I A surveillance and reporting system ;s main- tained to identify emerging health threats. Local measures: Ij) Information is prO'lided on how to contact the lH to report a public h..lth concern 24 hours per day, law enforcement has current local and state H-h",r emergency contact lim, ® Health care providers and labs know which diseases require reporting. have timeframes, and have H-hour local contact information, There is a process for identifying new providers in the community and engaging them in the reponing process, ® The local BOH receives an annuaf report. one .Iement of which summarizes communicable disease surveillance ¡ctivity. @ Written protocols are mainlained for receiving and managing informalion on notifiable conditions, The protocofs indude role- specific steps to take when receiVing information as well as guidance on providing informalion to the public. Iþ} Communicable disease kty indic3.ton and implicatiom for invest- igation, intervention or education efforts are evaluated annual~. @ A communicabfe disease tracking syslem is used which documents the initial report, investigation. findings and subsequent reporting to state and federal agencies. ("j) Staff members receive training on communicable disease reporting. as evidenced by Incal prolocols, State measures: o Information is provided to the public on how to con tan Ihe DOH 10 report a public h..lth concern 24 liours per day, law ('nfomment has cumnt state 14·hour emergency contaH listt @ Consultation and technÎcal mÎstarlce are provided to tHIs on surveillance and reponing, as dOlUmented by case summaries or repoTtl, laboratories and health care providm, including new licensees, are provided with information on disease reporting requirements. limeframes. and a )4-ho", DOH point 01 contact. @) Written procedures are maintained and disseminated for how to obtain slate or federal consultation and technical assistance for lflJs, Assistance includ,s surv,illance, reporting. disease inlervention management during oulbreaks or public heahh ,mergencies and ""uracy and darity of public heahh messag's, o Annual goals and objectives for communicable disease are a part 01 the DOH planning process. Key indicators and implications lor investigation. inlervention or ,ducation effortl are documented, o A statewide database for reportable conditions is maintained; surveil/ance dala are summarized and disseminated to lHs at leasl annual~_ Uniform data slandards and case definilions are updated and publi,hed at least annually, (II Itaff members receive training on communicable disease reporting. as evidenced by protocols, Standard 2 Response plans delineate roles and responsibilities in the event of communicable disease outbreaks and other health risks that threaten the health of people. Local measures: CD Phone numbers for weekday and after-hours emergency contacts are available to DOH and appropriate local agencies, such as schools and public safety, ® A primary contact person or designated phone line for the lH is dearly identifi,d in communicalions to health providers and approprial' public safety officials for reporting purposes, ® Written policies or procedures d,lineate specific roles and respo",ibilil~s witllin agency di~sions lor local response and case investigations 01 disease outbreaks and other h,alth risks, State measures: o Phone numbers for after,hours contaCU for al/ local and slale public health jurisdiClions are updated and disseminaled statewide at Imt annually, @ Written policies or procedures delineate specific roles and responsibiiiries for state response to disease outbreaks Dr public health emergencies. There is a formal description of the roles ilnd relationshîp between communicable disease, environmental health and program administration, Variations from overall process are identified in disease-sp"ific protocols, @) Written procedures describe how expanded lab capacity is made readi~ availabl, when needed for outbreak response. and there is a current list of labs having the capacity to analyze specimens. o DOH staff members receive training on the policies and procedures regarding roles and responsibililies for re'ponse to public health threats. as evidenced by protocols, Standard 3 Communicable disease investigation and control procedures are in place and actions documented. Local measures: Ij) lists of private and public sources for referral to lreatment are accessible to lH staff, ® Information is given to local providers tlirough public health alerts and newsletters aboul managing reportable condilio"" ® Communicable disease protocols require that investigations begin within I worlcing day, unless a disease-specific protocol defines an ahernate time fram., Disease-specific protocols identi~ information about the disease, case investigation steps, reporting requiremenls, contact and clinical management (including referral to care), use of emergency biologics and Ihe process lor exercising legaf autliority for disease conlrol (induding non- voluntary isolation), Documentalion demonstrates staff member actio", are in compliance with prolocols and state statutes, (f) An annual evaluation of a sample of communicable disease investigations is done to monitor timeliness and compliance with disease-specific protocols. 1,[; lH¡ idenli~ key performance measures for communicable disease investigation and enforcement actions. ® Itaff members (OnduCling disease investigations have appropriate ,kills and training as evidenced in job descriplions and resumes, State measures: o (onsultation and staff time are provided 10 lHJs for local support of disease intervention management during outbreaks or public health emergencies, as documented by case write-ups, Recent research findings relating to the most effective population-based methods of disease prevention and conlrol are provided to lHs, labs are provided written prolocols for Ihe handling, storage. and lransporlation of specimens, @ DOH leads statewide development and use of a standardized set IJf written protocols for communicable disease investigation and control, induding tem~ates for documenlalion, Disease-specific protocols identify information about tile disease. case investigation steps. reporting requirements. contact and clinical management (including referral to care). use of emergency biologics and the process for exercising legal authority for disease (Onlrol (induding non-voluntary isolalion), Documentation demonstrates slaff member actio", are in compliance with protocols and state statutes_ @) An annual evaluation of a sample of state cDmmunicable disease investigations and comultations is done to monitor timeliness and compliance with disease-specific protocols, o DOH identifies key perfonnance measures for communicable disease investigations and consultation. ~ Ilaff members conducting disease invesligations have appropriate skills and training as evidenced in job descriptions and resumes, Standard 4 Urgent public health messages are communicated quickly and clearly and actions are documented. Local measures: Ij) Information is pro~ded Ihrough public health alerts to key Slakeholders and press releases to the media, ® A current contact list of media and provideß is maintained and updated at least annually, This list is in the communicable disease manual and at other a>propriate departmental locations, ® Roles are identifi,d for working with the news media, Policies identify the timeframes for communications and the expectations for all staff regarding information sharing and response to I=nr ,,"''''¡tin",,' inl'nrrn,...,.i....n ,....n+",.+ +J..A nA..... _.& LI...._'...&.. _. I~Ln\ "~L "net questions, as well as the sleps for crearing and distributing clear and accurate public health alerts and media releases, @ ltaff who have lead roles in communicating urgent messages have been trained in risk communication. State measures: o A communication system is mainlained for rapid dissemination of urgent public heallh messages to the media and other state and national contacts, @ A communication system is maintained for rapid dissemination of urgent public health messages to lHs. other agencies and health providers, (onsultation is provided to lHs to assure Ihe accuracy and darily of public healih information associated with an outbreak or public health emergency, as documented by case write-ups, Itate-issued anno,"cements are shared with lll¡ in a limely manner, @) Roles are identified for working with the news media, Writt,n policies identi~ the timeframes for communications and the expectations for all staff regarding information sharing and response 10 questions, as well as the steps for creating and distributing dear and accurale public health alem and media releases, o (ommunication issues identified in outbreak response evaluations are addressed in writing with future goals and objectives in the communicable disease quality improvement plan, ~ Ilall members with lead roles in communicating urgenl messages have been trained in risk communication, Standard 5 Communicable disease and other health risk responses are routinely evaluated for opportunities for improving public health system response. Local measur~s: <j) An evaluation for each significanl outbreak response documents whal worked well and what process improvements are recommended for the future, feedback is solicited from appropriate entities. sucli as hospitals and providers, Meeting\ are convened to assess how Ihe outbreak was handled, identily issues and recommend changes in response procedures. @ Findings and policy recommendations for effective response efforls are included in reports to the BOil, ® local protocols are revised based on local review findings and model materials disseminaled by DOH. @ Issues identified in outbreak evaluations are addressed in future goals and objectives for communicable disease programs, ® Itaff training in communicable disease and other health risk issues is dGCumented. ® A debriefing process for review of response to public health threau or disease outbreaks is induded in the quality improvemenl plan and includes consideration 01 surveillance. staff roles. investigalion procedures and communication, State measures: o Timely inlormation about best practices in disease control is gathered and disseminated, Coordination is provided for a state and local debriefing to evaluate extraordinary disease events that required a multi-agency response; a written summary of evaluation findings and recommendations is disseminated slatewide, @ Model plans, protocols and evaluation templales for response to disease outbreaks or public health emergencies are developed and disseminated to lHJs, @) Model materials are revised based on evaluation findings. including review of nulbreaks, o Response issues identified in outbreak evaluations are addressed in fulure goals and objecrives for communicable disease programs, ~ Itaff members are trained in surveillance. oUlbreak response and communicable disease control and are provid,d wilh standardized tools, (II A debriefing process for review of response to public health threats or disease nulbreaks is included in Ih, qualily improvement plan and indudes consideration of surveillance. staff roles, investigation procedures and communication. --. . ... .. Understanding Health Issues Standards for Public Health Assessment Standard I Public health assessment skills and tools are in place in all public heahh jurisdictions, and their level is continuously maintained and enhanced. Local measures: CD (urrenl inlonnalion on healih ilSue¡ affecting Ihe community i, readily accwible, including 'tandardized quantitative and qualitalive dala, (2) There i, a wriuen procedure dmribing how and where to obtain technical assistance on assessment issues. @ Goals and objectiv" are established for as",sment aclivili" as a part of LHI planning, and naff or ouuide mistance is identified 10 perlorm the work, (1) Information on health ilSu" affecling the community i, updaled regularly and includes information on communicable disease. environmenl~ heallh and healih slatus, Data heing tracked have standard d,finilions, and standardized qualitalive or quantilative mealures are used, (ompuler hardware and \Oliware i, available to support word procelSing, spread,heeu with basic analy,is capabilities, databam and Internet access. I,~) Slaff who perform assessment activities have documented lraining and experience in 'pidemiology. ,,,earch, and data analysis, Au"dance at trainings and peer exchange opportunili" 10 expand available amssment expertise is docuITK!nted. State measures: o (onsultalion and technical alSi!lance are provided to LH]s and Slale programs on healih data coll",ion and analysi,. as documented by logs or reports. Coordination is provided jrl the development and use of data standards. including definitions and descriptions. @ Written procedures are mainrained and disseminated for how to obtain conrultation and technical a\listance for LH)s or state programs regarding health data collection and analysi,. and program evaluation. @) Goals and objecti", are established for assmment activities as a par! of DOH planning, and 'esources are identified 10 perlorm th, work, o Inlormallon on health ilSues alfecting th, state i, updated regularly and indudes information on communicable diseasl!, environm,nrll health and data about health status, Data being lracked have standard definitions. and standardized qualitllive or quantitative measures are used. (omputer hardware and software is availlble 10 suppor! word promsing, spreadsheets, complex analy,i, caPlbiliti". database, and Internet "ms, o Itaff I11fmbm who perlorm mmment activities have documenled training and experien" in epidemiology, relearch. and dala analysis, Ilatewide training and pm exchange opportunities are coordinated and documenled, Standard 2 Information about environmental threats and community health status is collected, analyzed and disseminated at intervals appropriate for the community. Local measures: CD AmlSmenl data is provided to community group' and representatives of tM broader community for review and identification of emerging issues that may require investigation. © The Board of Health recei", infonnation on local health indicalor! at leasl annnally, ® AmlSment procedure, dmrihe how populalion level inveSligations ar!! carried out for documented or emerging health i!Sues and problem!, ® Am!Sment invenigatioß! of changing or em'rging health i!Sues are part 01 the LHJ's annual goals and objective!, ® A core set of health 'talUS indicalOr!, which may indude sefected local indicatOr!, i, uled as the basi, for continuoUl monitoring of the health !tatus of the community, A IUmillance system using monitoring data is maintained to signal changes in priority he;¡¡!th issues. State measures: o fteporu are provid,d to LH]s and other groups, The reporls provide health inlonnation analysi, and indud, key health indicator, tracked over tim" @ A core set of health stalus indicator! i, u,ed as the basis for conlinuous mnniloring 01 the health 'talUS of Ihe stale. and result' are published al s¡hedul,d intervals, A sumillance system u,ing monitoring data is maintained to ,ignal changes in priority health ilSue!, @) W,iuen procedures dmribe how populalion level invesligations ,< are carri.d oul in cooperalion wilh LH]s in respoß!e to known or .merging health ilSues, Th. procedure, indude expect.d time frames for response, o In"'ligalion, 01 changing or emerging health issues are part of the annual goal! and ob~ctive! estahli,hed by DOH, Standard 3 Public health program resuhs are evaluated to document effectiveness. Local measures: CD The annual report to the BOH indudes progre!S toward, program goal,. © There is a wriuen procedure for using appropriate dala to "aluale program ,ffectivenm, Programs, wh'lher provid,d directly or contracl.d. have wriuen goal" objectiv" and performance measures, and are based on relevant researcR. ® Program performance measures are monitored, the data is analyzed. and regular reporls document Ihe progrm lowards goals, ® LH) program slaff have training in m.thods 10 evaluale perkmliUlŒ ;¡gains: goals and ;;mss prJg~anl el;eCtl'¡~f'Q:~. "') (hanges in activiti" Ihal are based on analysi, of key indica lor data or performance mea1urement data are 1ummarized a1 a part of quality improvement activitie1. State measures: o (onsultalion and technical assistance are provid,d to LHJs and slat. programs on progTlm evaluation, " docum.nt.d by case write-ups or log1. @ Program, administered by the DOH have wriuen goal" objectives and p,rlormance measur", and are based on rel"anl r"earch, There is a wriuen prolocol lor u,ing appropriate data 10 evaluate program .ffeeli"nm, @) Program perlormance measUre! are mnnilored, the data is analyzed. and regular repom document the progrm towards goals, o Itate and LH) slaff m.mbers have he.. trained on program evaluation" evidenced by documentation of slaff training, o (hang" in acliviti" that are based on analys~ of k.y indicalor data or performance measurement data are summarized as a part of quality improvement activiti", Standard 4 Health policy decisions are guided by health assessment information, with involvement of representative community members. Local measures: <D There is documentation of community involvement in the proce1s of revi.wing health data and recommending action such as further inmtigation, new program effort or policy direction, ® The annual report to the BOH summarizes asmsment dala. induding environmental heallh, and the recomtntnd,d aclion! for health policy decisions as evidenced through program. hudge~ and grant applicatioO!, ® There i, a wriuen prolocol for developing recommendation! for action using health as",sment infonnation to guide health policy deci,ioO!, ® Key indicator data and related recommendations are uled in evaluating goal, and objective!, For additional information contact the Dept. of Health at (360) 236-4085 State measures: o There i, documentation 01 stak.holder involvement in DOH health as",sment and policy development. @ There is a written protocol for using health assmment information to guide health policy decisioO!, @) Itale health as,mment data i, linked to heallh policy decisions. " evidenced through I.gislative requem. budg.t decisioO!, program' or grants, ~. Sta:~dard 5 Health, data is handled so that confidentiality is protected and health information systems are secure. Local measures: CD (ommunity members and stakeholders thaI rec.ive dala have demonslrat.d agreement 10 comply with confidentiality policies and practice!, as appropriate, © There are w,itten polici" regarding confidenlialilY, Written polici", induding data ,haring agreements, govern the Ule, ,haring and IraO!ler of data within the LHI and with parlner agenci", Written protocols describe th. m'lhods for ""uring protection of data (passwords, firewalls, backup 'y'l,ms) and dala systems, ® All program dala are ,ubmitted 10 local, stat., regional and f.deral agencies in a confidenlial and mure manner, ® Employ", are trained regarding confidentiality, induding Ihole who handl. palient informalion and dinical record" " well as thOle handling data, \§! All employ'" and BOH members, as appropriate. have signed confider.ti:\lity statements. State measures: o Itak,holders that receive data have d,mon!lrat.d agreemenl to comply wilh confidentiality polici" and praclim, " approprial', @ Ther. are written policies, induding data sharing agreements. regarding confid.nlialilY Ihal govern Ihe use, ,haring and transfer of data within the DOH and among Ih, DOH, LH]s and partner agencies, Wriuen protocols describe the m'lhods for "suring protection of data (passwords, firewall" backup syst,ms) and data systems, @) Air program data are submiued 10 local, state, regional and lederal agencies in a confidential and mure manner. o Employ", are trained regarding confidenliality. induding thole who handl. Pltient information and clinical record" " w,1I as thole handling data, o All .mploy", have sign.d confidenliality agreemenu, Standardr;: fn,. p..hlir ""ø.~'+'" ;... tAf_......l____ ~.._.._ Helping People Get the Services They Need Standards for Access to Critical Health Services Standard I Information is collected and made available at both the state and lacal level to describe the local health system, including existing resources for public health protection, health care providers, facilities and support services. Local measures: CD Up-to-d.t. inlorm.tion on loc.1 critical heallh services is ",il.bl. lor u" in building partnmhips with community groups .nd't.k.holdm, ® lH st.ff and contractors haY! a mour" list of local providers 01 critical ",.lIh smices for u" in m.king di.nt referrals, ® Th. li,t of critical hullh mvi"s is US!d .Iong with .,,!!Sment information to d.t!rmi.. whm d.tail.d documentation of local cap.city is n..d.d, State measures: o A list of critical hullh "rvices is establish.d and . core set of st.t!wid. ace!!S measures !!t.bli,hed, Inrorm.tion is collect!d on the core S!t of """ mmures, .n.lyz.d .nd reported to Ihe lHs .nd other agencies, @ Infnrm.tion is provided to lHs and oth.r agencies abm .vail.bility of li"n"d hullh care providers, I"ilities and support ,,,,ices, Standard 2 Available information is used to analyze trends which, over time, affect access to critical health services. Local measures: (J) Ðata tracking and r~porring sysrems Ißclude key measurts of ""ss, P"iodic surveys ar. conducted regarding the .vail.bility of critical hullh "rvi"s and barrim 10 .mss, @ G.ps in ace!!! to crilic.1 heallh "rvices .re idenlified using p.riodic ..rv.y d.t. and other ""ssment information, ® The BOH receives summary informalion regarding access to critical health "rvi"s at le"l annually, State measures: o Consultation is provided to communiti.s to help gather and an.lyze inlormation abOUI barriers to acc!!Sing crirical hullh services. @ Writt.n pro"dures ar. m.intained and disseminated for how to obtain consultation and technical assist.n" for lHJs and other agencies in gathering and analyzing information regarding barriers to access, @ Gaps in access to critical health servi"s .re identified using periodic survey data and other assessment information, o Periodic studies regarding workforce needs and the effect on critical health "rvices are conducled, incorporated into the gap analysis and disseminated 10 lHJs and olher ag.ncies. Standard 3 PIons to reduce specifìc gaps in access to criticol health services are developed and implemented through collaborotive efforts. Local measures: (!) Community groups and stakeholders. induding healÚ1 care providers. are conven.d to address access 10 critical h"lIh servi"s, "I goals and take action, based on information about local resour"s and lrend" This pro"" may be led by the lH or it may be part of a "parate community pro"" sponsored by mulliple partners. including tho lHJ, ® Coordination of critical health mvi" delivery .mong health providers is reßWed in the local planning processes .nd in the implementation of acms initiatives. @ì Where specific initiatives are selected 10 improve access, there is .naly,is or local data and established goals, objwi", and prrtoffi1ance measures. State measures: o Inrormation about access barriers affecting groups within the ,tate is shared with other state agencies that pay for or support critical health ,ervices, @ Slate-initiated contracts and program evaluations include performance measures that demonstrate coordination of critical health services delivery .mong health providers, @) Prolocols are dmloped for implementation by state agencies. lHs and othtr local providers to maximize enrollment and particip.tion in available insurance coveragt, o Whm specific initiatives are selecttd to improve access, Ú1m is analysis of local data and establishtd goals, objectives and performan" measures, Standard 4 Quality measures that address the capacity, process for delivery and outcomes of critical health services are established, monitored and reported. Local measures: (!) Clinical services provided directly by Ihe lHJ or by contract have a writttn quality imprnvemtnt plan including sptcific quality-based perform.nce or outcome measures, Perform,nce measures are tracked and reported, ® Staff members are trained in quality improvement methods as evidenced by training document.tion, State measures: o Inrormation about best practices in delivtry 01 critical he.llh services is gathmd and disseminated, Summary inrormarion regarding dtlivery system changes is provided to lHJs and other agencies. @ Training on quality improvemtnt methods is ",ilabl. and is incorporated into grant and program requirements, @ Regulalory programs and clinica¡ services adminislered by DOH haY! a written quality improvemtnt plan induding specific quality-bastd performance or outcome measurt', Menu of Critical Health Services This menu identifìes health services and health condition or risks for which appropriate services - screening, education and counseling, or intervention - ore needed. General access to health services Ongoing primary care Emergency medical services and care Consultative specialcy care Home care services Long-term care Health risk behaviors Tobacco use Dietary behaviors Physical activity and fitness Injury and violence prevention (bike safety. motor vehicle safecy, firearm safecy. poison prevention, abuse prevention) Responsible sexual behavior Communicable and infectious diseases Immunizations for vaccine preventable diseases HIV/AIDS Tuberculosis Other communicable diseases Pregnancy and maternal, infant, and child health and development Family planning Prenatal care Women. Infants and Children (WIC) services Well child care Behavioral health and mental health services Substance abuse prevention and treatment Depression Suicide/crisis intervention Other serious mental illness For ndditional information contact the Debt. of Health at (3601 236-4085 Cancer services Cancer-specific screening (i.e" breast, cervical, colorectal) and surveillance Specific cancer treatment Chronic conditions and disease management Diabetes Asthma Hypertension Cardiovascular disease Respiratory diseases (other than asthma) Arthritis, osteoporosis, chronic back conditions Renal disease Oral health Dental care services Water fluoridation Standards for Public Health in Washinø-ton State Jefferson County Health and Human Services SEPTEMBER ~ OCTOBER 2001 NEWS ARTICLES These issues and more are brought to you every month as a collection of news stories regarding Jefferson County Health and Human Services and its program for the public: 1. "PT woman honored for advocacy" - P.T. LEADER, September 19,2001 2. "Not everyone must get shots" - Opinion Forum, P.T. LEADER. September 26.2001 See Editor's Note. 3. "Welcoming us" - Opinion Forum. P.T. LEADER, October 3.2001 4. "Bioterrorism experts meet on Peninsula" - Peninsula Daily News, October 10,2001 ) PT woman honored for advocacy Tarni Lydic of Port Townsend was honored Sept. 8 at a luncheon at Sea-Tac Marriott for her com- mitment and active participation in People First, an advocacy group for the developmentally disabled. Lydic is a lifelong resident of Port Townsend. As a learning and Pr: L~A-QeR- ~ - {~ -ð I disabled adult she has become a voice in the community for those who are unable to speak for themselves, according to Harvey Putterman, communíty access worker for Creating Connec- tions. She has been a self-advo- cate for approximately six years and is currently on the Jefferson County Developmental Disabil- ity Board. Lydic's primary reason for her extensive involvement is to give back to the community what it has graciously given her, Putterman said. Not everyone must get shots Editor, Leader: I need to take issue with your brief article regarding vaccinations in the Sept. 5 issue of the Leader, The article stated that vaccinations are "required" before a child may enter school. This is simply not true. In Washing- ton state parents have the right to choose whether or not their child gets vacci- nated. For any number of good reasons - such as an adverse reaction to a vac- cine in a family member - a parent may choose to forego vaccination, to selec- tively choose which vaccines to get, or to wait until a child is older and has a more mature immune system. If this is your choice, you fill out an exemption with the school agreeing to keep your child home in the event of an outbreak. This is the law. Here is the problem with printing propaganda as fact: Many people are bullied into doing what they don't want to do because they believe they have no choice in the matter. SANDRA TALLARICO Port Townsend (Editor's Note: The press release from the Jefferson County Health De- partment published Sept. 5 included the following statements: "Several immuni- zations are required before children are allowed to attend school. Immunization exemptions are all-owed for medical, personal or religious reasons." ) ~; ~ -::;-~t'L í)J~ 1~'D-n I -,. l-c-:-A-- t: r L 1-;2..0-01 Welcoming us Universalist Fellowship and the local medical co~munity. Editor, Leader: We would also like to thank the fol- We would like to thank the com- lowing for their acts of kindness and munity for their response following support after reading the article about the article of Sept. 19 in the Leader our family: Skookum, Dal's Trea- about our family. sures, the many people involved with When we fIrst moved up here from Head Start, and the many anonymous Portland, Ore., we were concerned donot;'s of cash and services. about how we would be accepted _ an ; We are proud to caÌ1 Port Townsend' AIDS-affected family in a small rural ",,~ome! , . " community. But, Port Townsend has A final note: We àre not alone in been outstanding in its support and the struggle against AIDS in this' friendship. ' '. - county. Other families and individu- We would like to give speci~l' . â1s' are affected by AIDS and need thanks to the following people, who acts of kindness and support as' especially welcomed us to the com- well. If you wish to help, please send' munity: Denis Langlois and the "do~ations to.;_Jefferson AIDS Ser- Jefferson County Health Department, vices, P.O. Box 1686, Port Townsend, Mark Gordon, Al Hernandez, Peter WA 98~68. Freyer, Janet Huck, Jefferson AIDS·We thank you one and all! Services, the Rev. Craig Moto, the THE MONTEITH FAMILY members of the Quimper UnitarÜui't"'-" ",T'" ":.pórt Townsend PT L8A02fC ! ó -- 3.-- 0 I f: I ¡ f;, '. .. I t · , rn . a¡ . "'" rn a¡ '0:>; Q/) a¡ "'" I-< Q/)' I.. "0 ..!<:..!<:""o 0 a¡ a¡:::: 6.. :¡¡ a¡...:.. ~ rñ .3 I-< ().- "0 I.. oj ¡;:: ~..c: ~ "'" oj C.o .- a¡ c "0 0 a¡ rn () a¡ C -' .D ..c:.- 0 ..c: ..c:.-. 0 ,_ a¡ a¡ .';;: oj.o ~ ~ _ a¡ ~ ~ "" <..::. a¡ .¡:: ~ ::3 oj a¡ -' ..!<: "'" -' oj ,.. 61..rnà)o. 0 a¡-'~ ,-~"O'6~ o.-o.....;;;¡~a¡c -Q/) 1.."0 0. >,,..6-e "0 a¡ -' ~ a¡ !:: ..... .0 2 "0" a¡ a ., -::3 0 '-J 0. 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