Communicable Disease Prevention Skagit County

Public Health Communicable Disease Prevention Team

Funded by:

Island Hospital Skagit County Public Health Department Skagit-Island Counties Medical Society Skagit Valley Hospital United General Hospital

January 2007 Table of Contents

Preface: Bacteria, Vectors and Viruses on the Move ...... 1 Demographics of Communicable Disease ...... 2 Preventing Communicable Disease ...... 3 Reportable Communicable Diseases ...... 5 Vaccine Preventable Diseases ...... 6 Tuberculosis in Washington State and Skagit County ...... 7 Our Immune System...... 8 Sexually Transmitted Diseases ...... 10 Food and Water...... 11 Bloodborne Diseases ...... 12 HIV/ AIDS ...... 13 New and Emerging Infectious Diseases ...... 14 Conclusions ...... 16

From left to right

TB staff: STD/ family planning Admin Staff Communicable Immunization Team Sharon Kirkman clinicians Luanne Geerdes Disease Nurse Amie Tidrington, RN Magdalena Smith, LPN Alba Gutierrez, PA Maria Vivanco Maryl Skjei, RN Marjorie Reece, RN Debbie Chavarria, RN Cathy Smith, ARNP Graciela Ibarra

Report prepared by:

Sandi Paciotti, RN, BSN Communicable Disease Nursing Supervisor e-mail: [email protected]

Alex von Cube, MPH, Ph.D. Population and Health Information Manager e-mail: [email protected] Peter Browning, Director Sandi Paciotti, Nursing Supervisor A special thank-you to Jennifer Walton for editorial Howard Leibrand, Health Officer fine-tuning.

Thanks to all Hospital Infection Control Staff and our laboratories for timely reporting of communicable diseases.

Consistent with the policy objective of prevention, the Skagit County Public Health Department publishes periodic reports on demographic and health issues relevant to Skagit County residents.

Skagit County Public Health Department Skagit County Board of Health 700 South Second Street Commissioner Don Munks, District 1 Mount Vernon, WA 98273 Commissioner Kenneth A. Dahlstedt, District 2 Peter Browning, Director Commissioner Sharon Dillon, District 3 Howard L. Leibrand, MD, Health Officer PREFACE

BACTERIA, VECTORS AND VIRUSES ON THE MOVE

Our report is intended to share information which controlled. Yet, we know better. will help you protect yourself from contracting a communicable disease--a major source of illness. In fact, we increasingly find infectious disease pro- I cesses can exacerbate chronic disease. For ex- Everybody is aflutter about the dreaded bird flu. ample, hepatitis B and C can lead to chronic liver It has us making emergency plans for a disease disease. ere which we are unsure if it will come, when it will come or how virulent it will be. It has a lot of people Some diseases are veritable champion communi- scared; it has a lot of us preparing and we hope cators. Contamination can occur in various ways: some of this preparation will pay off for other dis- from human to human, environment to human, ease threats. animal to human, and from bird to human.

Unfortunately the threat from communicable disease What is Public Health’s role in communicable is not limited to bird flu. Visualize the world of disease? communicable disease as a crowded restaurant. Since 2000 alone the world population has grown 1. To trace the source and extent of a disease and by 410 million. We have moved a little closer to to track over 60 reportable diseases in coopera- each other, and are a little more prone to catch tion with the State Department of Health (pg 5). diseases due to globalism, increased trade activity and shortened travel times. 2. To conduct an epidemiological investigation, identifying and promptly treating individuals who Although the threat of bird flu cannot and should have come into contact with the bacteria, viruses not be dismissed, existing reality is that there were or other infectious agents. 3.1 million AIDS deaths in 2005 worldwide with close to 5 million persons newly infected with the 3. To prevent the further spread of a disease. In virus. Two million persons die annually of TB with special cases, this might require isolating individu- more than twice that number of new TB cases als to protect the community from being infected emerging yearly. SARS, Mad Cow and Marburg with a serious illness and/ or to educate the indi- Disease--all relatively new emerging diseases-- vidual how to prevent the spread of their disease. have given us no comfort about the prospects for communicable disease in the US. 4. Finally, the steady, quiet daily prevention ac- tivities of immunizations and education to assure Prior to the twentieth century, communicable dis- disease does not spread out of control from the eases such as diphtheria killed huge numbers of many ‘ready-made incubators’ such as child care, people in this country and throughout the world. schools, churches, hospitals and other places where The history of preventing infectious diseases with children and adults congregate, eat and otherwise vaccines goes back about one hundred years. Vac- are in close contact. Our nurses answer an end- cinations reduce fatalities by about two thirds. less stream of questions from the public, health Vaccinations of millions of sheep and cattle against care providers, child care providers--anyone con- anthrax and the inoculation of a child bitten by a cerned with preventing and treating communi- rabid dog are testimony to major improvements. cable disease.

As we continue to be vaccinated against many infectious diseases and our life expectancy increases in the US, the emergence of chronic diseases demands our attention. We begin to think infectious diseases are gradually being eliminated or well-

Untitled-1 1 2/20/2007, 1:56 PM DEMOGRAPHICS OF COMMUNICABLE DISEASE

Our “bread and butter” work in UNEQUAL RISK Skagit Population 2005 communicable disease touches by Five Year Age daily lives and responds to daily We are not equally at risk Groups by Sex needs. It is the basis for effective for communicable disease. and early response to potential Age Male Female Our immune systems are weak emergencies. as we first come into this world, I strengthen in our teens and 0-4 3,574 3,401 PREVENTION weaken again as we grow old. 5-9 3,748 3,615 10-14 4,128 3,959 ere In response to this life cycle, we 15-19 4,391 4,025 Public Health provides health immunize our babies and edu- 20-24 3,485 3,282 education through press and cate the population not to take 25-29 3,031 3,019 other media, immunization unnecessary risks. We immu- 30-34 3,191 3,137 education, limited testing and nize again as we age and become 35-39 3,533 3,460 screening (e.g. for water and sep- more prone to catch diseases 40-44 3,915 4,089 tic, hepatitis, TB, HIV), and edu- when our immune response 45-49 4,321 4,318 cation/monitoring about appro- weakens. 50-54 4,048 4,149 priate food preparation. We en- 55-59 3,480 3,595 courage healthy behaviors like Beyond this general propensity 60-64 2,794 2,832 handwashing, testing for STD, for diseases, there are many risk 65-69 2,063 2,224 and not sharing needles. groups with vectors and viruses 70-74 1,849 1,972 ever ready to attack. 75-79 1,471 1,684 We try to get the word out 80-84 1,058 1,551 to Skagit County residents We protect our children from 85+ 884 1,619 about communicable dis- disease through a series of im- ease risks and preventive measures. This is done by munizations. Based on esti- Total: 54,967 55,933 mates from the National Immu- various technological and per- nization Survey in 2003, sonal means: children’s immunization per- PUBLIC HEALTH’S ROLE ♦ Satellite broadcasts hosted centages ranged from about 70 IN COMMUNICABLE DISEASE to 95 percent. by CDC What do we do for you? ♦ Adolescent health confer- From time to time we may have From watching TV and listen- ence for all Skagit providers ♦ to revaccinate due to outbreaks. ing to the radio, one could get Vaccines for Children (VFC) Recent examples are the out- the impression that all we do is program conference for pro- breaks of mumps in Iowa or wait for the dreaded bird flu to viders ♦ whooping cough in Washington arrive, so we can ‘show our stuff’ The media ♦ State. in a disease disaster. Site visits as needed to provide education and/or Other communicable diseases We do have an active role in assistance with vaccine stor increase and ebb according to emergency preparedness, in age and handling changing health behavior, considering a range of possible changing age structure, influx emergency scenarios and in de- of migration, strain of virus, ex- termining what resources we posure to disease, and vaccina- can realistically deploy under tions. what circumstances.

Untitled-1 2 2/20/2007, 1:56 PM PREVENTING COMMUNICABLE DISEASE shingles after having had We take our disease-free health VACCINES FOR ADULTS chicken pox as a child. It is rec- status for granted. The reality ommended for people age 60 and is, our country would be like older. many developing countries if Adults need routine immuniza- we would not have such high tions as well. Tetanus shots should be updated every 10 The Public Health Depart- immunization rates. This is ment administers approxi- one of the most fundamental years--sooner if an injury ex- I poses you to tetanus. Added this mately 7,000 doses of adult reasons we are protected from vaccine, 5,000 of which are communicable disease. year we now have pertussis (whooping cough) protection in flu shots each year. ere tetanus vaccine. VACCINES FOR C HILDREN Other vaccines may be recom- Hepatitis A & B vaccines are mended for people with certain Today’s immunization schedule now recommended for all, with work-related exposures or for has newborns getting their first no need for booster shots once people whose “immunization dose of vaccine before they the initial series is completed. memory” may be lost, after leave the hospital. Fully immu- transplants, spleen removal or nized children receive 25 doses Pneumonia vaccine is recom- chemotherapy. of vaccine by the time they en- mended as a one-time vaccine ter kindergarten. for those age 65 or older. Some Travel Vaccines people get it sooner, due to other We administer about 2,500 Childhood vaccinations include health factors and should have doses of travel vaccine DTaP, hepatitis A, hepatitis B, it repeated at age 65. yearly to protect both the trav- HIB, MMR, PCV, polio and va- elers and those here at home ricella, administered according Flu shots are offered every fall. from diseases which may be to the age of the child. The new- They are now recommended for prevalent in the countries trav- est in the childhood vaccine rep- everyone. The optimal time to elers pass through. ertoire include protection from get a flu shot in Washington is rotavirus, HPV and meningo- mid-October through mid-No- In addition, we conduct ap- coccal disease. vember. Flu shots are now more proximately 300 travel con- widely available (barring any sultations, providing individu- It’s not all over at Kindergarten, shortages) from health care pro- alized health advice and vaccine either. Colleges try to assure viders, pharmacies, etc. The recommendations. students have had their second Public Health Department typi- shot of measles and inform them cally restricts flu vaccine to high Approximately 1,800 clients about protection against risk people in the first weeks of receive travel health recom- meningococal disease. vaccine availability to assure mendations via the phone. those vulnerable to complica- “Our goal is to keep disease out In Skagit County, 43,000 tions or death from the flu can of the general population in doses of children’s vaccine be protected. Skagit County by protecting the were distributed to health individual traveler,” according care providers in 2005. Our A new vaccine, Zostavax, pre- to Amie Tidrington, immuniza- Public Health Department vents the development of tion clinic coordinator. clinic administered approximately 1,800 doses to WASHING HANDS FREQUENTLY children. IS STILL THE BEST PROTECTION AGAINST COMMUNICABLE DISEASE, ACCORDING TO THE CENTERS FOR DISEASE CONTROL

Untitled-1 3 2/20/2007, 1:56 PM OUR COUNTY

PREVENTING COMMUNICABLE DISEASE

There is some resistance to immunizations in our country as CHEAP METHOD OF P REVENTION: Handwashing today still is a well as in our county. Some WASHING HANDS major means of preventing com- have read about the occasional municable disease whether hos- but extremely rare reaction to Keeping communicable disease pital, work or home contracted. one or the other immunization under control is tough for phy- and thus feel they want to avoid sicians as well. Much of the fol- Washing your hands may seem I the risk. lowing information was taken elementary, but stay with us for a quick bacterial count: 5,000 to from an article in the New En- ere Every so often we are reminded gland Journal of Medicine in 5 million colony-forming units of how quickly we can slide 2004 in which a physician de- per square centimeter; it’s down the slope of communicable scribes how difficult it is to get crowded on your palm! The hair, disease, like recently when sev- clinicians to consistently wash axillae, and groin harbor eral states experienced active their hands. greater concentrations. On the cases of TB--which has grown hands, deep skin crevices trap quite costly to local health ju- 10 to 20 percent of the flora, risdictions. “The worst place is under the making removal difficult, even fingernails. Hence the re- with scrubbing. Another reminder of “disease cent Centers for Disease communication” occurred in Control and Prevention So we continue to preach re- Iowa in May of 2006 where they guidelines requiring hospi- peating the Medical Journal’s had over 1,800 confirmed, prob- tal personnel to keep their recommendations. To wash able and suspect cases of nails trimmed to less than a hands properly: mumps reported to the Iowa De- quarter of an inch and to re- partment of Public Health. This move artificial nails.” Remove your watch, rings, and mumps outbreak quickly other jewelry (which are notori- spread to neighboring Illinois, A Gawande, M.D. ous for trapping bacteria), Minnesota, Nebraska, Missouri, lather up for 15 to 30 seconds, and Wisconsin. Most of these rinse for 30 seconds and use a cases were reported in college- Handwashing is not exactly a disposable dry towel. In fact, use age students. new scientific discovery! the towel to turn off the faucet. Semmelweis at age 28, in 1847 Also, Washington State has ex- deduced that by not washing Now, don’t worry, most of us perienced measles outbreaks in their hands consistently or well have a hard time adhering to past years at Clark Community enough, doctors were them- such a strict regimen, but you College in Vancouver and at selves to blame for puerperal should at least know how best to Western Washington Univer- fever, the leading cause of ma- protect yourself and others. This sity in Bellingham. One ac- ternal deaths in hospitals. becomes especially critical when count of a campus-related dis- we experience some outbreak of ease explained that “college stu- The death rate from puerperal a communicable disease such as dents in general have a higher fever immediately fell from 20 methicillin-resistant staphylo- risk of sharing saliva.” percent to 1 percent - dramatic coccus aureus (MRSA) or the flu. proof of his theory. His col- leagues ‘rewarded’ him by firing him from his job -- offended over his claim they might be killing their patients.

Untitled-1 4 2/20/2007, 1:56 PM REPORTABLE COMMUNICABLE DISEASES

WHY REPORT DISEASE? “NOTIFIABLE” INFECTIOUS DISEASES IN WASHINGTON STATE

Reporting of diseases goes back Acquired Immunodeficiency Leptospirosis to 1878, when Congress autho- Syndrome (AIDS) Listeriosis rized the US Marine Hospital Anthrax (bioterrorism origin) Lyme disease Service (the forerunner of the Arboroviral neuroinvasive & Lymphogranuloma venereum I Public Health Service) to collect non-neuroinvasive diseases Malaria morbidity reports regarding Botulism Measles (Rubeola & Rubella) ere cholera, smallpox, plague, and Brucellosis Meningococcal disease yellow fever from US overseas Chancroid Mumps consults. The intent was to use Chlamydia trachomatis, geni- Pertussis this information to institute tal infection Plague (bioterrorism origin) quarantine measures to pre- Cholera Psittacosis vent the introduction and Cryptosporidiosis Q fever spread of these diseases in the Cyclosporiasis Rabies, animal or human United States. Today, recom- Diphtheria Rubella mendations for additions and Enterohemorrhagic E. Coli (in- Rubella, congenital syndrome deletions of reportable diseases cluding 0157:H7) Salmonellosis are made annually by the Cen- Giardiasis Severe acute respiratory syn- ters for Disease Control and Pre- Gonorrhea drome-associated coronavirus vention (CDC). Reporting also Haemophilus influenzae, inva- (SARS-CoV) disease identifies outbreaks which may sive disease Shigellosis be happening within the state Hantavirous pulmonary syn- Smallpox (bioterrorism origin) and/ or the nation. drome Syphilis, including congenital Hemolytic uremic syndrome, Tetanus There are currently over sixty postdiarrheal (HUS) Trichinosis infectious diseases classified as Hepatitis A, acute; Tuberculosis notifiable to the CDC. Severity Hepatitis B, acute; chronic (ini- Tularemia of the disease and/ or ease of tial diagnosis only) Typhoid fever spread govern the timeframe of Hepatitis B, perinatal infection Typhus reporting. Hepatitis C, acute and chronic Vibriosis (paralytic shellfish Herpes Simplex poisoning) The purpose of notification is to Human Immunodeficiency Vi- Yellow fever obtain regular, frequent and rus (HIV) infection Yersiniosis timely information for the pre- Legionellosis vention and control of disease.

We submit such notifications More information about the re- routinely to the State Depart- spective diseases can be ac- ment of Health, which in turn cessed via the CDC website, passes them on to the National listed on the back cover of this Notifiable Diseases Surveil- report. lance System (NNDSS) which is operated by the CDC.

Untitled-1 5 2/20/2007, 1:56 PM VACCINE-PREVENTABLE DISEASES

IMMUNIZE AGAINST IMPORTS Polio still circulates in Asia and caused by the hepatitis A virus. Africa, paralyzing the world’s The virus is shed in the stool of The average life expectancy in most vulnerable children. In a infected persons. It is usually the early 1900’s was 47. Now it shrinking world, polio and other spread by close personal contact is 78. A good share of this im- vaccine-preventable diseases or by eating contaminated food provement is credited to the de- remain only a plane ride away. or drinking water containing crease in vaccine-preventable the virus. A person with hepati- I disease. Diptheria is easily spread tis A can easily pass the disease through coughing or sneezing, to others within the same house- ere We can now protect ourselves and can cause paralysis, breath- hold. Handwashing is impor- from many serious diseases. Yet ing and heart problems, and tant in preventing the spread. diseases seen 50 years ago re- death. main a threat to our society--es- Hepatitis B is an infection of pecially for our children and se- Tetanus (lockjaw) occurs when the liver. It can be passed from niors. a tetanus germ, usually found an infected mother to her new- in soil, dust or manure, enters born during childbirth and from Along with the importation of the body through a cut or punc- one person to another through goods into the US, we also im- ture wound. It can cause muscle blood or body fluids or by inti- port diseases that are no longer spasm, breathing and heart mate contact. The hepatitis B endemic in our country but can problems, and death. virus can cause liver damage, result in indigenous transmis- liver cancer and death. sion. Pertussis (whooping cough) is spread through respiratory Varicella (chickenpox) is a Measles, preventable by vacci- droplets, and can cause spasms very contagious disease causing nation, is a highly infectious, of coughing which make it hard rash and fever, spread by cough- acute viral illness which can for a child to eat, drink, or even ing and sneezing or direct con- cause severe pneumonia, diar- breathe. Pertussis can cause tact with drainage from the rhea, encephalitis, and death. lung problems, seizures, brain rash. Having had disease, could Measles has been a reportable damage and death, especially in result in the development of disease since 1912. Endemic infants less than one year of shingles when older. transmission had been elimi- age. We still document 10 to 30 nated in the US; in 2004, cases per year in Skagit Haemophilus Influenzae twenty-seven cases were im- County.And we now have a per- Type b (Hib) disease can ported by US residents with tussis vaccine booster for ages cause meningitis (inflammation multiple cases picked up while 10 to 64. of the brain and spinal cord), in- traveling abroad in China, In- fections of the joints, skin and dia, Bangladesh and Thailand. Pneumococcal disease can blood, brain damage, and death. cause bacterial meningitis It is most serious in infants un- Currently 93% of the nation’s (swelling of the brain and spinal der one year of age. children under age two are vac- cord). It can also cause serious cinated once against measles, infections of the lungs (pneumo- Reviewing this list of diseases mumps, and rubella, according nia) and the blood (bacteremia). underscores the point why im- to the CDC’s National immuni- The disease is spread from per- munizations are one of the zation Survey. More than 95% son to person through respira- greatest medical success stories of the nation’s children are fully tory droplets. in human history. vaccinated by the time they Unimmunized people risk get- enter school. Hepatitis A is a liver disease ting diseases routine vaccinations can prevent. 6

Untitled-1 6 2/20/2007, 1:56 PM TUBERCULOSIS IN WASHINGTON STATE AND SKAGIT COUNTY

100,000 persons marking the Patient Two: Treated six TB DEFINED end of a continued decrease in months. Tuberculosis (TB) is a slow rates since 2001. Of 39 counties, growing bacterial infection 23 had at least one new case of - Isolation, room and food which most often grows and TB. There were ten counties $8,500 multiplies in the lungs, and can with five or more cases of TB. - Home Visiting $2,320 be spread in the air to others by Among these the five highest - Medication $1,200 I coughing, sneezing, talking, county-specific incidence rates - Medical Procedures singing. When ill with TB a per- were King (7.0), Yakima (5.6), $ 700 ere son develops a nagging cough Skagit (5.4), Snohomish (3.6), which gradually worsens, along and Pierce (3.5). $12,720 with night sweats, weight loss, increased fatigue, chest pain, Local health departments incur Patient Three: Client with shortness of breath and even substantial costs for patients multidrug-resistant TB (MDR) coughing up blood. TB can also requiring intensive treatment isolated at home. Treatment for move out of the lung through over an extended time. MDR disease is prolonged. A the lymph and the blood system patient with MDR TB is ex- and can spread to other parts of pected to treat from 18 to 24 the body. A person is infectious TB CASE HISTORIES months. to others only when it is in the Prevention of TB once a person lungs. becomes infected saves dollars. Treatment cost for four months Active TB cases are very expen- only: Worldwide, TB killed 1.6 million sive to treat. Circumstances dif- people in 2005. TB in our coun- fer slightly from case to case. To Medication $3,260 try is largely a ‘foreign import’ illustrate the point, Skagit Medical Procedures $2,000 (70%), brought primarily by im- County during the past calen- Home visits $2,320 migrants from Asia, Africa, dar year had six infectious $7,580 Latin America, and Eastern cases, four of which were foreign- Europe. The remainder in the born. Following are approxi- The expense of treating an ac- US is largely found in homeless mate cost breakdowns (Staff tive case strains the Public people. time, contact tracing and test- Health Department budget and ing, history, State Department emphasizes the need for preven- Sometimes even when persons of Health requirements, etc. are tive treatment. are treated in their country of not accounted for): origin, they do not complete or Unless we vigorously pursue they deviate from the treatment Patient One: Treated for eight each case, we increase the like- regimen and can become multi- months: lihood of spreading TB in our drug resistant. community. Federal funding - Isolation, room and food decreased in our state, leading There were 14,874 cases of TB $5,000 to potentially significant impli- reported in the US in 2003. The - Medication $2,800 cations for our ability to provide TB rate has gone down nation- - Home Visiting $1,160 the best possible care to patients ally as well as within our state. - Medical Procedures with active TB. The develop- $ 600 ment of a national strategic plan In 2005, Washington State re- to address TB control is impor- ported 256 new cases of tuber- $9,560 tant to focus program priorities. culosis for a rate of 4.0 per

Untitled-1 7 2/20/2007, 1:56 PM OUR IMMUNE SYSTEM

Our immune system is amazing! It defends The immune system is against attacks on our bodies and is amazingly complex. It can rec- remarkably effective - most of the time. ognize and remember millions of different enemies -- and It could make military strategists turn green wipe out each one of them! with envy. Our body is a battle zone. In fact, it is a miracle we do not die within the first week of I life.

Our army of cells manages to recognize its ere enemies: bacteria, parasites, viruses, tumor cells. These army cell types are housed in various organs and lymph nodes of the body. They work in concert emitting chemical signals, destroying Herpes virus microorganisms, causing symptoms of allergy, The human body provides swallowing and digesting microbes. Some slay Once immune cells receive an ideal environment for tiny, on contact and some directly attack cancerous the alarm, they undergo infection-causing organisms cells - in all cases setting in motion certain tactical changes and begin to such as bacteria, viruses, domino effects. produce powerful chemicals. parasites and fungi. These substances allow the cells to regulate their own Immunity occurs or is acquired in different ways, growth and behavior, enlist active natural (contact with disease), active their fellows, and direct new artificial (immunization), passive natural recruits to trouble spots. (transplacental, i.e. mother to child).

For example, one organ through which immunity occurs - the spleen - can be visualized Schistosome parasite as a filter. It is made up of B cells, T cells, macrophages, dentritic cells, natural killer cells and red blood cells.

The lymph nodes function as an immunologic filter for the bodily fluid known as lymph. They promote the production of antibodies through B cells and T cells in response to foreign substances, proteins, viruses, bacteria and tumor cells.

We live in a physical world where contacts have become closer and diseases can spread faster. The scientific ability to fully disentangle the Bacteria mysteries of the immune system remain a fungus: Streptococci challenge in a research environment. It is penicillin mold changing rapidly and with “invaders” that have a remarkable ability to mutate.

Information summarized from “Understanding the Immune System; How it Works”. U.S. Department of Health & Human Services, National Institutes of Health, 2003

Untitled-1 8 2/20/2007, 1:56 PM OUR IMMUNE SYSTEM Keeping the Immune System Strong: Al- though immunity naturally declines with age, there is much we can do to preserve this awe- some arsenal of disease-fighting cells.

We cannot always tell what causes breakdowns of the immune system resulting in disease. The immune system and its many components are not always I easily understood. Immune system breakdown may be the result of an emerging disease, stress, or simply A dog’s tongue is a wash rag excessive demands on our body. ere and toilet paper at the same time. Wash your face and If not managed well stress can kill you! hands after Fifi licks you! Chronic stress has been linked to high blood pressure, faster heart rate and breathing, tense muscles and migraine headaches. It is also strongly suspected there is a link between stress and cancer. When you have chronic stress your body produces too much cortisol The key to a healthy im- and adrenalin, two major stress hormones which, if In abnormal mune system is its remarkable elevated over time, can lower your immunity to dis- situations, the im- ability to distinguish between ease. mune system can the body’s own cells - self - and mistake self for non- foreign cells - nonself. Maintaining a healthy immune system can self and launch an help ward off both infectious and chronic dis- attack against the often create the need for further eases such as heart disease, liver disease and cancer. body’s own cells or tis- medcations to counter side ef- sues. The result is Scientistsfects. Priceshave learned for the much 50 medi- about the immune called an autoim- system cinesand continue most often to study prescribed how the to body launches mune disease. Some attacks seniorsto destroy rose invading on average microbes, more infected cells, forms of arthritis and tumorsthan while three ignoring times the healthy inflation tissues. New tech- hepatitis and diabetes nologiesrate for betweenidentifying January individual 2002 and immune cells are are autoimmune dis- now letting scientists quickly determine which targets eases. In other cases, January 2003. Those without are triggering an immune response. the immune system insurance pay on average 72% responds to a seem- It ismore clear for some their of the prescriptions old strategies are the best ingly harmless for- preventionthan against the federal compromising government, our immune system. eign substance such When immune defenders as ragweed pollen. encounter cells or organisms which can negotiate lower We can boost the system through: The result is allergy, carrying markers that say “for- rates. The Congressional Budget Of- and this kind of anti- eign”, they quickly launch an fice estimates that total spending for ♦ Vaccinations gen is called an aller- attack. Anything triggering prescription drugs for Medicare benefi- ♦ Proper diet gen. this immune response is called ciaries will triple to nearly $228 billion ♦ betweenIntake the years of vitamins2001 and 2011. an antigen (i.e. a virus or tis- ♦ One of Goodthe most hygiene hotly contested (handwashing) issues sues or cells from another per- ♦ facing CongressSufficient right nowSleep is Medicare son). This explains why tissue ♦ prescriptionPhysical drug coverage. activity transplants may be rejected. Medicare: Medicare has been around since 1965. At that time the av- er- age life expectancy in the U.S. was about 10 years less than it is today. 9

Untitled-1 9 2/20/2007, 1:56 PM SEXUALLY TRANSMITTED DISEASES

Since sex is not a new invention, sexu- CHLAMYDIA Syphilis, a genital ulcer and ally transmitted diseases (STDs) have SKAGIT COUNTY been with us throughout history. systemic disease, is spread by Syphilis reached epidemic proportions 2001-2005 direct contact with lesions or by as far back as 1495 among French sol- perinatal transmission. The Year Cases Rate diers waging war in Naples and spread first two of three stages are in- rapidly from there. Like many other 2001 201 193.1 fectious. Untreated tertiary diseases, countries blamed it as for- 2002 229 217.9 syphilis may cause damage to I eign imports. The French called it the 2003 270 253.0 the central nervous system, “English disease”, the Italians called 2004 327 330.6 it the “Spanish disease”, the Russians heart or other organs. Syphilis 2005 294 265.1 ere called it the “Polish disease” and the facilitates HIV transmission. Arabs called it the “Disease of the Gonorrhea has symptoms Christians”. A long list of famous and Skagit County only has infamous people throughout history similar to chlamydia, when/if symptoms appear. It too, can about 1 case a year, but are speculated to have contracted nearby counties are seeing in- syphilis including Howard Hughes, Al lead to serious and permanent creases in syphilis in men who Capone, Adolf Hitler, Joseph Stalin, health problems. Gonorrhea in- have sex with other men. The Meriwether Lewis, Columbus, Henry creased from 13 (rate: 12.5) seriousness of the disease calls VIII and Pope Alexander VI. to 32 (rate: 28.9) cases in for vigilance and protective Skagit County between 2001 measures on the part of both Chlamydia is the most com- and 2005 and peaked among partners. monly reported communicable 15 through 19 year olds. disease in the US, as well as in our state and county. The prevention and control of STDs are Herpes Simplex is a based on five strategies: viral infection charac- • Education and counseling of persons at Screening of young women is terized by localized pri- risk on ways to avoid STDs through changes especially important. Most cases mary lesions - with a in sexual behaviors are reported in women ages 15 - tendency to reoccur. • Identification of asymptomatic infected 25 who are about four to five Sexually-transmitted persons and of symptomatic persons unlikely to seek diagnostic and treatment services times more likely than men to infections usually occur be carriers of the disease. • Effective diagnosis and treatment of in- in the genital tract fected persons (genital herpes). Herpes • Evaluation, treatment, and counseling Up to 70 percent of women with lesions around the of sex partners of persons who are infected chlamydia infection show no mouth are less likely to with an STD symptoms. Symptoms include be sexually-transmit- • Pre-exposure vaccination of persons at abnormal discharge from the risk for vaccine-preventable complications of ted, but both strains of an STD urethra or vagina and pain dur- the virus can appear in ing urination. Untreated • Patient delivered partner therapy to pre- either area. vent re-infection chlamydia can lead to pelvic in- flammatory disease, infertility The number of persons Human Papillomavirus and ectopic pregnancy. When newly diagnosed with her- (HPV) is a major risk factor for treatment is rendered it is im- pes in Skagit County has cervical cancer. More than 6 mil- portant to include sexual part- gradually increased from 27 lion people in the US become ners to avoid re-infection. in 2001 to 65 in 2005. This in- infected with HPV every year, crease is likely due to better and nearly 10,000 women are Prevention of STD begins with changing the sexual behaviors screening in teen clinics and diagnosed with cervical cancer. which place persons at risk for in- generally better diagnostics. A vaccine is now available to fection. protect against 4 strains of HPV.

Untitled-1 10 2/20/2007, 1:56 PM FOOD AND WATER it increased risks of contamina- to disease-free food and water. FOOD AND WATER AS DISEASE tion. Food inspections are nec- There are approximately SOURCES essarily limited due to volume, 20,000 on-site septic systems demand for low prices, and the in our county, and new sys- Contaminated drinking water, impracticality of inspecting all tems going in every year. This improper preparation of food, perishable foods. According to creates a lot of potential for dam- improper solid or human waste the Centers for Disease Control age to the environment and to I disposal can all contribute to (CDC), the food supply in the our health. Waterborne ill- disease. Environmental health US is remarkably safe and im- nesses come from agents such as staff work closely with our com- proving. Nevertheless, food can viruses, bacteria and parasites ere municable disease that contaminate rec- nurses to prevent the Food Permits Issued by Year and Type reational or drinking spread of disease from water. food or water sources. Permits 2000 2006 Environmental Health After eating contami- Food Service Establishments 893 914 staff have responsibili- nated food, people can Food Booths 209 278 ties for safe recreational develop anything from a Food Workers’ Cards 6,236 8,427 shellfish beds. We in- short, mild illness, often vestigate shellfish- mistakenly referred to as “food become contaminated with a va- borne diseases and issue warn- poisoning,” to life-threatening riety of germs as the recent e- ings and advisories in coordina- disease. CDC estimates that coli outbreak from spinach in tion with the Washington State each year 76 million Americans California shows. Almost two Department of Health. get sick, more than 300,000 are hundred people in 26 states got hospitalized, and 5,000 people sick, half of them had to be hos- BACTERIOLOGICAL LABORATORY die from foodborne illnesses. pitalized and one died. We have a small water testing If we see a cluster of disease Our food safety program works laboratory on site to test for bac- caused by a single food source, to assure our restaurants, su- teria in your water. In 2005 we we kick into ‘detective mode’ to permarkets, fair booths and the processed almost 4,000 drinking determine the origin of the ill- ‘homecook’ understand the water samples! Some of these ness. Then we take measures to simple measures which should samples are taken from public prevent any more people from be taken to prepare food safely. drinking water systems (one becoming infected. For instance, Cleanliness and proper tem- source serving multiple homes) a food worker with Hepatitis A perature control keep food and some from individual wells would be excluded from working safe. (one source with food until he/she is no serving longer infectious, and those ex- A food handler’s card is a pre- one home). posed would be given immune requisite for those working in If bacteria globulin to prevent illness. We restaurants and other food es- are found can now also prevent Hepatitis tablishments. Thirty minutes of in the A with vaccine. training and testing are re- drinking quired to ensure a basic under- water, we As consumers, we make increas- standing of safe food handling provide ingly higher demands - for to prevent the spread of disease. safe drink- fruits and vegetables out of sea- ing water son which are imported from all Sewage systems and waste con- advice. over the world. This brings with trol are important prerequisites 11

Untitled-1 11 2/20/2007, 1:56 PM BLOODBORNE DISEASE “blood to blood” contact. It can less likely transferred through BLOODBORNE PATHOGENS lead to more serious conditions sex with a person infected with Bloodborne pathogens are mi- such as cirrhosis and liver can- HCV, co-habitation with some- croorganisms such as viruses or cer over time. body and sharing tooth brushes, bacteria carried in the blood and razors that might have his/her can cause disease in people. We have a vaccine to prevent blood on them--all are possible There are many different infection with Hepatitis B. sources of exposure to HCV. I bloodborne pathogens including There is no “cure” or specific malaria, syphilis, and brucello- treatment for HBV, but there is sis, Hepatitis B (HBV), Hepati- treatment to decrease the car- According to the CDC: Al- ere tis C, Human Immunodefi- rier state. Many people who con- though biologically possible ciency Virus (HIV) and viral tract the disease will develop when poor infection control Hemorrhagic Fever (includes antibodies. Only 10-15% of practices are used, there is no Ebola and Marburg). In this re- people with Hepatitis B become evidence the hepatitis C virus port we are focusing on Hepati- carriers and can pass it to oth- has been spread through tattoo- tis B and C and HIV. ers through blood contact. It is ing. Presently there is no over- important to note, however, that sight on proper sterilization and there are different kinds of hepa- cleaning of equipment between HEPATITIS B (HBV) titis, so infection with HBV will clients. not stop someone from getting The symptoms for HBV are de- another type. ceiving. They mimic a mild flu, NEEDLE EXCHANGE with a sense of fatigue, loss of The Hepatitis B virus is durable appetite and possible nausea. This is a program allowing in- and can survive up to seven jection drug users to exchange As the disease progresses the days in dried blood. This means dirty needles for clean needles. urine may turn brown, the skin that the virus is of concern to This harm reduction program and eyes yellow. Frequently employees such as housekeep- reduces the spread of HIV and peple who are infected with ers, laundry personnel and oth- Hepatitis B & C. The program HBV will not show symptoms for ers who come in contact with also facilitates referring people some time. It can take 3-6 blood or potentially infectious into drug treatment programs. months for symptoms to develop materials. Additionally, we offer condoms after exposure. Loss of appetite in an effort to reduce indiscrimi- and stomach pain may occur in HEPATITIS C (HCV) nate spread of disease. Repeat- the first three months. edly, addicts who have success- Hepatitis C is a liver disease fully gone through drug treat- caused by the Hepatitis C virus. In the United States, approxi- ment tell us the encouragement HCV is spread by contact with mately 300,000 people are in- of our needle exchange staff was the blood of an infected person. fected with HBV each year. Of the reason they entered into There is no vaccine for the pre- these cases, a small percentage treatment. vention of HCV infection. Blood are fatal. tests can be done to determine In 2005, we exchanged if you have been infected with “Hepatitis” means “inflamma- 100,000 needles. Needle ex- HCV. tion of the liver,” and, as its change is available every Tues- name implies, Hepatitis B is a day afternoon between 1-4 at our HCV is spread primarily by di- virus that infects the liver. main office and the first rect contact with human blood. While there are several differ- Wednesday of each month from Drug injection, kidney dialysis ent types of hepatitis, HBVis 2-4:30 p.m. at the County (shared supplies, equipment transmitted primarily through Upriver Services Office. that had someone else’s blood on them), accidental needle sticks, 12

Untitled-1 12 2/20/2007, 1:56 PM HIV/ AIDS

HIV People Living with HIV/AIDS MODES OF TRANSMISSION (adults and children) 2005 HIV (Human Immunodefi- Selected Countries Myths still abound about how ciency Virus) is a retrovirus this terrible disease is spread, so Country # of Persons causing HIV infection and here is a brief refresher course: AIDS (Acquired Immunodefi- India 5,700,000 I ciency Syndrome) disease in South Africa 5,500,000 Blood: Before 1985, blood was humans. This pathogen is Nigeria 2,900,000 not tested for HIV antibodies transmitted from person to per- Mozambigue 1,800,000 prior to transfusion, so HIV was ere Zimbabwe 1,700,000 son through unprotected sexual commonly transmitted. How- Tanzania 1,400,000 ever, the current transmission contact, sharing of injection Kenya 1,300,000 rate is estimated to be less than equipment and transfusion/ United States 1,200,000 transplantation with infected Zambia 1,100,000 1 infection per 500,000 dona- blood or tissue or from mother Uganda 1,000,000 tions. This rare case of HIV to baby at time of delivery.. transmission from a transfusion can happen if a newly infected HIV/AIDS IN THE US person donates blood in the AIDS “window” period prior to their Since 1999 the number of per- HIV test turning positive. Shar- sons living with AIDS in the US AIDS is the advanced stage of ing needles or occupational has steadily increased from HIV-disease and is character- needle sticks remain an impor- 311,205 to 405,926 in 2003. The ized by severe suppression of tant means of HIV transmis- increase is most likely due to Elizabethimmune response. Persons with sion. AIDS have increased suscepti- more effective medications. Al- bility to opportunistic infec- most 5,000 new cases of HIV/ AIDS, in addition to the 9 mil- Sexual Transmission: can tions, degradation of major or- occur through anal and vaginal lion cases of STD, occurred in 15- gan systems and eventual sex. The presence of another 24 year olds annually. death. STD makes HIV infection 2 to 4 times more likely. There have Like many other communicable SKAGIT COUNTY been no documented cases of diseases, contracting HIV de- transmission of HIV through pends heavily on our unhealthy oral sex. behavior. According to the State De- partment of Health, 90 HIV/ AIDS cases have been re- Mother to Child Transmis- GLOBAL DATA ported for Skagit County sion: We rarely see babies born since data collection began. with HIV in the US due to rou- These data are approximate be- tine prenatal testing and anti- Worldwide the number infected cause these numbers include retroviral medications HIV- with HIV/AIDS was over 40 mil- both dead and presumed living. positive mothers can take while lion in 2005, including 2.3 mil- People ONLY get reported when pregnant. Babies born to HIV- lion children under the age of under a physician’s care. Many positive mothers are tested at 15. In 2005 alone, a total of 3.1 people who are HIV-positive birth and then again when they may not be in care, so they are milion people died of HIV/AIDS- have developed their own im- not reported. related causes. mune system, at 18 months.

Untitled-1 13 2/20/2007, 1:56 PM NEW AND EMERGING INFECTIOUS DISEASES

and the third leading cause of used to be most often acquired INFECTIOUS DISEASES ARE HERE death in the United States. in the hospital. In recent years, TO STAY Some of these infectious dis- MRSA has become community eases are re-emerging while oth- acquired, primarily through the It’s not just the movies that get ers are newly emerging in our drug population in and out of reinvented... Only a decade ago country. our jails. it was perfectly accepted in public health to speak about how we I EMERGING DISEASES Many of the emerging diseases have moved from the era of in- are transmitted by animals. fectious disease to chronic dis- We are facing a litany of emer- Mad Cow Disease is a rare, de- ere ease. Today we talk more about gent diseases, unique in that generative, fatal brain disorder. emerging and re-emerging in- they are a danger to all people The British government be- fectious disease. regardless of age, gender, came aware of this disease in lifestyle, ethnic background or cows in 1986. The connection to Increasingly effective public economic status. They are put- humans though, did not become health measures, broadened use ting an increasing strain on pub- apparent until ten years later, of a growing number of vac- lic health. It is our task to pre- when people began dying of cines, and the judicious applica- vent diseases and to prepare for Creutzfeldt-Jakob disease, tion of powerful and ever more diseases whose course we only which is a human version of sophisticated antimicrobial have limited knowledge about mad cow disease. To date in En- drugs have helped stem the toll and can be costly. SARS, West gland, there have been 117 of infectious diseases. Smallpox Nile, hantavirus, monkey pox, deaths. The disease can lie dor- and polio are only two examples. avian flu are a few examples. mant from five to 40 years, and For a while it looked like we had there is no known cure. There a smooth transition from the era Globalization has contributed is currently one case in the US, of infectious diseases to the to greater awareness of world- a 22 year old woman in Florida newly emerging era of chronic wide diseases, but it also who was born and lived in En- diseases. Not so. Ever increas- brought diseases - formerly not gland until the age of 13. It is ing life expectancies and so mobile to this country. The not transmitted between hu- lifestyle issues in industrialized potential terrorism threat has mans. nations emphasized the chronic placed greater prevention re- diseases to the point of neglect- sponsibilities on public health Lyme Disease was identified in ing infectious diseases. departments - largely without as transmitted through a tick appropriate funding to do this. and now is the most common There are other reasons for the vectorborne disease in the US. rise of infectious diseases in in- The following describes some of It became reportable in Wash- dustrialized nations, for ex- the emerging diseases of con- ington State in 1987. It is a bac- ample, globalism. More specifi- cern: teria transmitted from a tick cally, world population growth when it feeds on humans and and increased contact between Methicillin-resistant S. isn’t removed before 36-48 people. As recently as 1970 aureus (MRSA) an emerging hours, starts with a telltale rash, there were 3.7 billion people in cause of skin and soft tissue dis- then can lead to chronic arthri- the world. In 2005 that count ease. So-called “staph bacteria” tis, heart irregularities and neu- was 6.4 billion. And everyone is live on the skin and in the nose rological problems. An average as close as a 24 hour plane ride! - usually without causing harm. of 12,000 cases are reported an- However, some strains are par- nually in the US. It can be Infectious diseases are the lead- ticularly virulent - and imper- treated successfully with antibi- ing cause of death worldwide vious to standard antibiotics. It otics if found early. A vaccine 14

Untitled-1 14 2/20/2007, 1:56 PM EMERGING DISEASES

was developed in 1998, but has surfaced in Hong Kong in 2003 far. CDC has now embargoed all since been discontinued due to and has been traced to the Civet .sale, movement or transfer of adverse side effects. cat which Chinese eat as a deli- these animals in the US and cacy. stopped importation of these Avian Influenza: This disease animals. Through 2005, 81 first surfaced in Hong Kong in SARS spreads easily like a cold people have been ill in nine 2003 and since then in a vari- through droplet secretions and states. People who have recently I ety of countries. It is a type of is most virulent. Worldwide received smallpox vaccine may flu virus common to chickens, there have been 8,442 cases re- be protected from this disease. ere ducks, pigs and horses. Up to ported with 812 deaths. There is no evidence of human this point transfer to humans to human transmission. occurred only through direct Monkey Pox: Endemic in contact with infected animals. Ghana and Gambia, this dis- RE-EMERGING TB These are deadly flu viruses to ease was imported via rodents which humans have no immu- (rope and tree squirrels, rats nity and which could potentially and striped mice) from Africa. It More unsettling to public health develop into a pandemic. If they was first identified in Wisconsin than newly emerging diseases develop the ability to transfer in 2003. The transmittal to hu- are those returning with a ven- from human to human, quick mans occurred through direct geance like TB. It is perhaps the and determined action will be contact with a prairie dog which most typical of our increasingly required to contain the disease was bitten by a Gambian rat. global world, a disease that was at the source. People develop blister-like largely confined to developing rashes similar to smallpox. One countries but with increased mi- West Nile Virus (WNV): This to ten percent of the cases could gration and travel is constantly disease is spread via birds bit- die, as opposed to smallpox re-introduced to our country ten by mosquitoes who in turn where 30% of the cases die. (and our County) because there bite humans transmitting the There have been no deaths so are inadequate checks at our disease to us. Bird migration borders and ineffective routes describe the gradual New TB Cases and Deaths 2005 or no treatment in their spread throughout the country. Selected Countries own countries. WNV was first reported in the US in 1999 when allegedly a Country New Cases Deaths Sixty-seven percent of rare bird imported into the US TB cases in Washing- from Israel was brought to the India 1,788,043 352,085 ton State in 2005 were New York Zoo. In 2005 there China 1,334,066 236,377 in the foreign-born. We were 4,500 cases diagnosed with Indonesia 627,047 143,178 are not only seeing infection in 39 States. It has Nigeria 362,819 105,311 multi-drug resistance been found in surrounding Bangladesh 360,747 83,533 (MDR), which is resis- counties in birds, horses and Pakistan 278,392 66,503 tance to the first-line humans who have traveled to Ethiopia 251,685 56,146 TB drugs, but are now other states. One was acquired South Africa 241,537 32,794 seeing extensive drug this summer in Washington Philippines 236,537 38,872 resistance (XDR) which State. Kenya 195,207 42,660 means resistance to the Mexico 34,409 not avail. first and second-line Severe Acute Respiratory Canada 1,745 not avail. drugs used to kill TB. Syndrome (SARS): This U.S. 14,093 not avail. Skagit County has had highly contagious viral illness one MDR and zero XDR cases. 15

Untitled-1 15 2/20/2007, 1:56 PM CONCLUSIONS

Communicable Disease has Along with global imports of Public Health’s role is to prevent an easy time in an increas- products, we are also “import- disease, provide surveillance, ingly mobile world with a ing” more people and unfortu- statistical information and steadily growing popula- nately along with them, fre- early detection of disease, and tion. quently more germs and vi- disseminate education and ruses adding up to more dis- treatment to prevent the spread Visualize a restaurant with a eases. This is the story of our of disease. I seating capacity of 40 suddenly report - and why early detection, adding tables and chairs to seat investigation, education and There are some basic principles 120 in the same space. It is plau- ere treatment are so important. all of us can follow: sible if someone sneezes in such crowded space, your chances of We tried to explain how we con- • Get immunizations when they catching the next table’s cold tract communicable diseases are recommended, for example, increases. Are we exaggerating? and how we prevent them. Be- flu vaccines Let the numbers speak for cause they use the machinery of themselves. their host cells to reproduce, vi- • Practice good handwashing. ruses are difficult to kill. The Useful as they are, your hands most effective medical ap- are also the most efficient dis- Word Population proaches to viral disease, thus tributors of germs and viruses - actual and projected far, are vaccination to provide to your own body. (in billions) protection from infection, and 1950 2.5 drugs that treat the symptoms • Minimize stress (get enough 1960 3.0 of viral infections. Effective an- sleep, find healthy supports, pet 1970 3.7 tibiotic use is important. Always your cat or dog) 1980 4.4 take medications as prescribed 1990 5.2 by your doctor to prevent the • Limit or don’t use alcohol 2000 6.0 development of antibiotic resis- 2010 6.8 tance. • Eat regular meals with a 2020 7.5 variety of healthy foods 2030 8.2 Our society is approaching a 2040 8.7 major aging surge with the • Control your weight 2050 9.2 baby boomers - born between 1946 and 1964 - entering retire- • Do not smoke ment age in growing numbers. The percentage of persons 65 • Be physically active In 1950 we faced a world and over will rise nationally from with a mere two and half currently 13 percent to 18.5 per- The Boy Scout motto “Be Pre- billion people in it. Today cent by 2025. This is accompa- pared“, says it best. This is what we have four billion more nied by rising health care needs, we’ve tried to emphasize people in the same space and personal, social and eco- throughout the report. Prevent with a vastly expanded nomic costs. As we age, our im- what you can and prepare transportation net and a mune system weakens and we for what you can ‘t prevent. global economy. Small won- may become more prone to any der then, we are facing new communicable diseases we are communicable diseases and exposed to. This gives rise to the re-emerging diseases. key question, how can we protect ourselves from such exposure?

Untitled-1 16 2/20/2007, 1:56 PM WHERE HAVE YOUR HANDS BEEN TODAY?

Where else have your hands been today? ...... Go wash them!

Stinkey at the Court

Support bacteria. They There were times in history when washing yourself was are the only culture considered unhealthy. King Louis VIX instructed his court not some people have... to wash for a whole month. Instead of soap they dusted themselves with powder and sprayed perfume.

Tuberculosis Death Rate from this disease per 100,000 population: 2006 0.2 1967 3.5 1915 140.1 What Every Child Knows... When doctors in Paris as recently as a century ago called for washing yourself at least once a month they were ridiculed; every child knew that washing yourself was most unhealthy...

The Silent Disease A strong body odor was considered healthy. This opinion was Chlamydia is one of the most widespread bacterial sexually taken over from the Middle Ages when a “dirt crust” on the transmitted infections (STI) in the US. Chlamydia bacteria live body was thought to be protection against communicable in vaginal fluid and in semen. About 70 percent of chlamydial disease. People washed rarely and were worried that the “plague- infections have no symptoms, thereby naming it the “silent” contaminated air” would infiltrate the body’s pores. disease.

Occult Infection Medical terminology for a “hidden” infection, that is, one which presents no symptoms.

What’s the Difference between Soil and Dirt? Dirt is what you find under your fingernails. Soil is what you find under your feet. Think of soil as a thin living skin that covers the land; it goes down into the ground just a short way. Even the most fertile topsoil is only a foot or so deep. For more details and current schedule, see: www.cdc.gov/nip/recs/child-schedule.htm#Printable

COMMUNICABLE DISEASE RESOURCES & INFORMATION

Centers for Disease Control & Prevention ...... www.cdc.gov Coughing Etiquette ...... www.coughsafe.com/media.html Washington State Department of Health--Notifiable Conditions ...... www.doh.wa.gov/notify

EMERGENCY PREPAREDNESS

WA State Department of Health ...... www.doh.wa.gov/phepr American Red Cross--Mount Baker Chapter (Skagit County) ...... www.skagitredcross.org (360-733-3290) American Red Cross--Anacortes Chapter ...... www.anacortessanjuan.redcross.org (360-293-2911) Skagit County Department of Emergency Management ...... www.skagitcounty.net/emergencymanagement Federal Emergency Management Agency ...... www.fema.gov

IMMUNIZATION RESOURCES & INFORMATION Skagit County Public Health Department ...... 336-9477 Skagit County Flu Hotline ...... 419-3315 CHILD Profile...... www.childprofile.org WA State Department of Health ...... www.doh.wa.gov/cfh/immunize Immunization Call Center ...... 1-800-CDC-INFO (1-800 232-4636) Traveler’s Health ...... www.cdc.gov/travel