Adventist Health-Portland 2016 Community Health Needs Assessment Executive Summary

Adventist Health-Portland Collaborating to achieve whole-person health in our communities

Adventist Health- Portland invites you to partner with us to help improve the health and wellbeing of our community. Whole-person health—optimal wellbeing in mind, body and spirit—reflects our heritage and guides our future. Adventist Health Portland is part of Adventist Health, a faith-based, nonprofit health system serving more than 75 communities in California, Hawaii, Oregon and Washington. Community has always been at the center of Adventist Health’s mission—to share God’s love by providing physical, mental and spiritual healing.

The Community Health Needs Assessment is one way we put our faith-based mission into action. Every three years, we conduct this assessment with our community. The process involves input and representation from all: community organizations, providers, educators, businesses, parents, and the often marginalized—low-income, minority, elderly and other underserved populations.

We use the Community Health Needs Assessment to achieve these goals:

 Learn about the community’s most pressing health needs

 Understand the health behaviors, risk factors and social determinants that impact our community’s health

 Identify community resources and prioritize needs

 Collaborate with community partners to develop collective strategies

Partnering with our communities for better health

While conducting the Community Health Needs Assessment we solicited feedback and input from a broad range of stakeholders. Contributors to the process included these partners:

 Healthy Columbia Willamette Collaborate

 Multnomah County Public Health Department

 Portland Adventist Community Services

ii Data Sources

The assessment drew from publically available secondary data sources, as well as from nationally recognized data sources. We collected data on key health indicators, morbidity, mortality, and various social determinants of health from the Census, Centers for Disease Control and Prevention, Community Commons, County Health Rankings and various other state and federal databases. The Healthy Columbia Willamette Collaborative includes 15 hospitals, 4 health departments and 2 Coordinated Care Organizations in the Clackamas, Multnomah and Washington counties of Oregon and in Clark County, Washington. This unique public-private partnership serves as a platform for collaboration around health improvement plans and activities that leverage collective resources to improve the health and wellbeing of our communities. Executive Summary

One of the goals of any CHNA is improving the preparation process, data gathering and addressing gaps in our previous CHNA. We believe we have addressed the short falls with this document.

We have also continued our membership with the Healthy Columbia Willamette Collaborate and we continue to use the CHNA generated by that organization as a major supplement to our own CHNA.

The following bullet points are the major findings of this report.

• Since our 2013-2016 CHNA it has been observed that the concentration of our patients, either receiving charity care and Medicaid, has increase by a substantial amount in a number the zip codes in our service area.

• Black/African Americans experienced the greatest number of disparities with the highest level of concern relative to other communities of color.

• Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems.

• The suicide rate is increasing in Oregon

• Diabetes is becoming more common in the United States. Diabetes and obesity have more than doubled among Oregon adults since 1990.

• Obesity is the number two cause of preventable death in Oregon and nationally, second only to tobacco use. Obesity prevalence among Oregon adults has risen dramatically in the past two decades.

• During 2014, heart disease was the second leading cause of death in Oregon.

• In 2014, COPD was the third leading cause of death in the U.S. and Oregon.

• 10.8% of adults and 7.8% of children in Oregon had asthma in 2011.

• Allergies are the sixth leading cause of chronic illness in the U.S.

• Up to one-third of cancer cases in the United States are related to excess weight or obesity, physical inactivity, and/or poor nutrition.

iii  Lung cancer is the leading cause of cancer mortality in both men and women in the United States.

 Breast cancer is the second leading cause of cancer death in women.

 While mental disorders are common in the United States, their burden of illness is particularly concentrated among those who experience disability due to serious mental illness (SMI).

 Alzheimer’s disease is the sixth leading cause of death in the United States and is the fifth leading cause among people aged 65 years and over.

 People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder.

 The higher percentage of people who were current illicit drug users in 2014 than in prior years appears to reflect trends in marijuana use.

 Nonmedical pain reliever use continued to be the second most common type of illicit drug.

 In 2009-2010, Oregon was one of the top ten states for rates of drug-use in several categories.

 By 2013, the number of individuals receiving treatment had increased by more than 107% compared with 2004.

 From 2010–2014, there was an approximate 2.6-fold increase in the number of reported acute hepatitis C cases from 850 to 2,194 cases, respectively.

 Chlamydia is the most common reportable illness in Oregon. More than 13,000 cases occurred in 2012.

 About 110,000 more Oregonians were poor in 2014 than in 2009 at the end of the Great Recession.

 Multnomah County child poverty prevalence is higher for all communities of color than nationally.

 Between 2014 and 2015, homelessness among individuals increased in 19 states. The largest increases were in New York (3,492 more people), California (2,391), Oregon (1,473), Washington (1,136), and Illinois (802).

iv A review of the results of the community surveys shows similar concerns. Those concerns are as follows:

Behavior/Mental Health

Access to Affordable Health Care

Life Style Concerns surrounding:

Drug and Alcohol Abuse

Health Eating Habits

Obesity

Lack of Exercise

Social Determinates of Health

Housing

Homelessness

v Prioritization process

Prioritization of the needs of our community came from the cooperation of our Hospital Collaborative group. Because of our participation in the Together We Can! collaborative and the diverse list of members, we already had good broad community input and data including important insight on our medically underserved, low income and other minority segments of our populations about what major concerns in our community rise to the top. From that list, we evaluated the severity and magnitude of top issues and the opportunity for partnership, existing resources, and mission alignment to then vote on our top three areas of focus. Top priorities identified in partnership with our communities

One of our top priority areas in our community has been identified as Chronic Disease. The high rates of Heart Disease, Diabetes, and Obesity are unacceptably high. This is especially true in our communities of color. Aiming our efforts at reducing the numbers of lifestyle-created Chronic Disease impacts not only the current good but future good of our community members.

Secondly, we see that access to Health Care and health resources continues to be an obstacle for our community as the issue is not always unavailable services, but sometimes lack of awareness of services available.

Thirdly, we have identified Behavioral Health as an increasing issue in our community. It is an issue that affects a large portion of the population. Depression, suicide and addictions are major concerns in our community.

Homelessness and housing is the most mentioned concern in terms of the Social Determinates of Health.

Adventist Health-Portland Top Priority Health Needs For 2016-2019

Prioritized Need Health Indicator

Chronic Disease Racial disparities, heart Disease and Stroke, Cancer, Diabetes

Access To Care Urgent Care, Financial Assistance

Behavioral Health Depression/Anxiety, Substance Abuse

Social Determinates Homelessness, Housing, Hunger

vi Making a difference: Results from our 2013-2016 CHNA/CHP

Adventist Health wants to ensure that our efforts are making the necessary changes in the communities we serve. In 2013 we conducted a CHNA and the identified needs were:

Chronic Illness

 Held a Women’s Health Fair with 245 attending form the community

 Held a Fair of the Heart with 250 attending

 Conducted Smoke Free Support Group with 400 attending

 Cancer Clinical Trial program

 Conducted numerous health education sessions

 Twice weekly Meals On Wheels deliveries

Access to Care

 Assisted in the Enrollment 1,642 members of the community in Medicaid

 Donated to Project Access Now for members of the community needing assistance in paying for medical insurance

 Opened our Parkrose Urgent Clinic located in high need community

 Provided rides for 148 at risk cancer patients

 Provided 321 nursing students hospital training opportunities

Mental Health

 Inpatient Subsidized Behavioral Health Unit

 Donated to the National Alliance for the Mentally ILL

vii

Table of Contents

Mission Statement 3 Adventist Health- Portland 4

Our Introduction 5 Community Executive Summary 6 Whom We Serve 8 Race and Ethnicity Information 13 Community Health Needs Survey 15 Healthy Columbia Willamette Collaborate Survey - Top Responses 17 Primary Data East Multnomah County Service Provider Summary 18 Survey Conclusions 19 Racial and Ethnic Health Disparities 20 Leading Causes of Death 25 The State of Oregon/Multnomah/ Clackamas County Health Factors 30 Preventive Clinical Services Performed 34 Influenza Vaccination 35 County Health Rankings 36 Pregnancy/Childbirth 39 Diabetes 47

Secondary Obesity 58 Data Heart Disease and Stroke 67 Chronic Obstructive Pulmonary Disease 98 Asthma/ Allergies 101 Cancer 113 Mental Health 138 Tobacco 151 Illicit Drug Use 164 Hepatitis C 189 Sexually Transmitted Diseases 205

Adventist Health-Portland Hospital Patient Data 227 Social Determinants of Health 228 Poverty 230 Hunger/ Food Access 245 Homelessness 255 Uncompensated Care 262 Hospitalization Costs 263

SUMMARY 2014 Community Needs Assessment Summary 271 Appendices Appendix A: Healthy Columbia Willamette Collaborate AMC Community 278 Survey Appendix B: East Multnomah County Service Provider Survey 286 Appendix C: Healthy Columbia Willamette Collaborate 293 Appendix D: Sexually Transmitted Diseases Supplemental Data 296 Appendix E: Community Resources 306 Appendix F: Existing Health Care Facilities and Resources 310 Appendix G: Data Sources 326 2016 CHNA Approval 333

Our Mission

The mission of Adventist Medical Center and those who serve here is to demonstrate the human expression of the healing ministry of Jesus Christ.

We who serve here are dedicated to:

 delivering health care that nurtures body, mind and spirit through our personnel, programs and services;

 encouraging healthful living practices consistent with optimal health and well-being;

 reflecting God's love by serving our patients, guests and each other with compassion, dignity and respect;

 focusing outreach and planning on improving the health of our local communities while providing emergency care for anyone with an immediate health care need;

 offering services in the most medically and financially appropriate setting;

 continually improving through technical excellence and a highly qualified professional staff;

 creating an environment of care that inspires trust and confidence and promotes safety among our patients, families, employees, volunteers and physicians;

 serving as a religious health care organization in a manner consistent with the philosophy of the Seventh-day Adventist Church.

Adventist Health- Portland

Adventist Health - Portland is a not-for-profit, faith-based organization which includes Adventist Medical Center, (AMC) a 302 bed community hospital. The hospital provides a full range of inpatient, outpatient, emergency and diagnostic services to communities in and near East Portland. AMC serves more than 900,000 residents. Our hospital is located at 10123 SE Market Street, Portland, Oregon 97216. For a listing of our medical clinics please visit their web site.

Our mission, vision and values are core to the daily operations of this organization. As a healthcare delivery system, our technology, quality and cost structures are in line with our values. The difference you will notice at Adventist Health is the culture of delivering care. Providing exceptional patient centered care through staff who are passionate about the mission of whole person care is what sets us apart from other providers. We believe that our ability to decrease anxiety and increase compliance, results in improved clinical outcomes and increased patient satisfaction. Please visit our web site for more information.

Services & Programs

Our network of services is here to serve all of our communities’ health needs. Our emphasis on wellness and whole-person care means that we don't just treat our patients after they get sick, we want to keep them healthy.

Adventist Health Medical Group Orthopedics

Arthritis and Bone Care Palliative Care

Cancer Care Pastoral Care

Cardiac Care Primary Care/ Family Medicine

Diabetes and Endocrine Care Pulmonary Medicine

Diagnostic and Imaging Services Rehabilitation

Family Birth Place Robotic-Assisted Surgery

Home Care Sleep Disorders Center

Hospitalist Service Stroke Care

Internal Medicine Surgery

JobCare Urgent Care

Laboratory Wellness Services

Mental Health Women’s Services

Nutrition Wound Healing and Hyperbaric Medicine

Introduction

On behalf of the Adventist Health-Portland (AHP), the hospital’s Community Outreach Committee under the guidance of the Community Benefit Compliance Committee and the hospital’s Administration and Board, conducted a Community Health Needs Assessment (CHNA) to distinguish the unmet medical and public health needs within the greater East Multnomah County area. The study has two objectives. One objective was to meet the state and federal requirement that the hospital conduct a comprehensive community health needs assessment every three years. The second, ultimately more important objective was to conduct a study that would provide a guide for AHP to build a consensus on the area’s health care needs and provide a basis for the implementation plan to best direct our resources to improve the health of the area’s residents.

The information for this report was collected from multiple primary and secondary sources. First, our membership with the Healthy Columbia Willamette Collaborate gave us access to the group’s in-debt analysis of the community health needs of Multnomah County. Secondly, a Community Health Expert survey was sent to public health experts within the hospital and through the community. The data also includes a review of publicly collected health and demographic statistics.

Adventist Medical Center, like other non-profit hospitals, is a tax-exempt institution and has a statutory obligation to provide community services. The State of Oregon and the Federal government require non-profit hospitals to report the value of the community services provided during the year. The government identities that collect this data have the responsibility to assure the public that all healthcare organizations claiming non-profit, tax- exempt status fulfill their fiduciary obligation by providing community benefit commensurate in value to the organization’s tax savings.

The guidelines used to determine what activities qualify as measurable community benefit, for both the state of Oregon and the Internal Revenue Department, are based on the guidelines created by the Catholic Hospital Association. Members of the AMC Community Benefit Compliance Committee served on various committees with the Oregon Association of Hospitals and Healthcare Services to develop the State’s community benefit collection and reporting process. With the passage of the Accountable Care Act, non-profit hospitals will be receiving additional scrutiny.

In creating this document, one of the greatest challenges was updating the secondary data from our previous CHNA. Data sources used at that time often were either not updated with current data or there were methodology changes for the more current data. An example would be data that was previously reported as an annual figure are now reported as a three-year average. Some data was extracted from a one-time report.

Executive Summary

One of the goals of any CHNA is improving the preparation process, data gathering and addressing gaps in our previous CHNA. We believe we have addressed the short falls with this document. We have also continued our membership with the Healthy Columbia Willamette Collaborate and we continue to use the CHNA generated by that organization as a major supplement to our own CHNA. The following bullet points are the major findings of this report.

 Since our 2013 CHNA, it has been observed that the concentration of our patients, either receiving charity care and Medicaid, has increase by a substantial amount in a number of zip codes in our service area.  Black/African Americans experienced the greatest number of disparities with the highest level of concern relative to other communities of color.  Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems.  The suicide rate is increasing in Oregon.  Diabetes is becoming more common in the United States. Diabetes and obesity have more than doubled among Oregon adults since 1990.  Obesity is the number two cause of preventable death in Oregon and nationally, second only to tobacco use. Obesity prevalence among Oregon adults has risen dramatically in the past two decades.  During 2014, heart disease was the second leading cause of death in Oregon.  In 2014, COPD was the third leading cause of death in the U.S. and Oregon.  10.8% of adults and 7.8% of children in Oregon had asthma in 2011.  Allergies are the 6th leading cause of chronic illness in the United States.  Up to one-third of cancer cases in the United States are related to excess weight or obesity, physical inactivity, and/or poor nutrition.  Lung cancer is the leading cause of cancer mortality in both men and women in the United States.  Breast cancer is the second leading cause of cancer death in women.  While mental disorders are common in the United States, their burden of illness is particularly concentrated among those who experience disability due to serious mental illness (SMI).  Alzheimer’s disease is the sixth leading cause of death in the United States and is the fifth leading cause among people aged 65 years and over.

 In 2013, suicide was the second leading cause of death among persons aged 15-24 years, the second among persons aged 25-34 years, the fourth among person aged 35- 54 years, the eighth among persons aged 55-64 years, the seventeenth among persons 65 years and older, and the tenth leading cause of death across all ages.  People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder.  The higher percentage of people who were current illicit drug users in 2014 than in prior years appears to reflect trends in marijuana use.  Nonmedical pain reliever use continued to be the second most common type of illicit drug.  In 2009-2010, Oregon was one of the top ten states for rates of drug-use in several categories.  By 2013, the number of individuals receiving drug dependent treatment had increased by more than 107% compared with 2004.  From 2010–2014, there was an approximate 2.6-fold increase in the number of reported acute hepatitis C cases from 850 to 2,194 cases, respectively.  Chlamydia is the most common reportable illness in Oregon. More than 13,000 cases occurred in 2012.  Oregon’s rate of early syphilis infections greatly increased during the last eight years. There were 0.7 cases per 100,000 people in 2007 and 10.5 cases per 100,000 people in 2014. This represents a 1500% increase. Increases continue during 2015.  About 110,000 more Oregonians were poor in 2014 than in 2009 at the end of the Great Recession.  Multnomah County child poverty prevalence is higher for all communities of color than nationally.  Between 2014 and 2015, homelessness among individuals increased in 19 states. The largest increases were in New York (3,492 more people), California (2,391), Oregon (1,473), Washington (1,136), and Illinois (802).

A review of the results of the two surveys shows similar concerns among the both. Those concerns are as follows:

 Behavior/Mental Health  Access to Affordable Health Care  Life Style Concerns surrounding: . Drug and Alcohol Abuse . Health Eating Habits . Obesity . Lack of Exercise  Social Determinates of Health . Housing . Homelessness

Whom We Serve

In conducting a community health needs assessment, a hospital has many decisions to make. One of the decisions a hospital needs to make is to determine what is the community that they serve as it applies to their needs assessment.

The Treasury Department and the IRS allow a hospital facility to take into account all of the relevant facts and circumstances in defining the community it serves. A hospital needs to make sure that it does nothing to exclude any at risk populations.

Adventist Medical Center (AMC) is a member of the Healthy Columbia Willamette Collaborate (HCWC) (see appendix C). The Needs Assessment that was developed by the HCWC is substantial and meets the Federal requirements required. The decision was made by the AMC Community Benefit Committee to supplement the work completed with the Collaborate with a Community Health Needs Assessment of a more narrowly defined area. We established our service area using our hospital’s patients declared place of residence. Our service area would direct where we would allocate our hospital resources to be used to address the community needs identified by this needs assessment.

In keeping with the spirit of recent IRS proposed regulations, AMC has determined from its hospital patient base, the zip codes where our patients live.

“Finally, if a hospital facility uses a method of defining its community that takes into account patient populations, these proposed regulations require the hospital facility to treat as patients all individuals who receive care from the hospital facility, without regard to whether (or how much) they or their insurers pay for the care received or whether they are eligible for financial assistance.” 78 FR 20523 April 2, 2013

This data set was draw from 46,819 unduplicated patients from January 2015 to June 2016. In the following table, the top 22 zip codes are listed. This represents 77.96% of the 46,819 patients. The first column list the zip codes in order of total amount of patients from most to least. For each zip code, the number of Charity Care and Medicaid patients for that zip code is listed along with the total of both. For each category, a percent of the zip codes total patient counted is listed. For example, for zip code 97236, 6.65% of the 3,803 patients from that zip code had received Charity Care and 42.83% had Medicaid. Please note that the 46,819 patients are patients that were either inpatients or outpatients that use AMC hospital facilities for health care services. AMC patients that were patients exclusively of AMC Home Health Services, AMC Hospice or Adventist Health Medical Group are not counted as part of this group.

The second table represents the top ten zip codes for AMC patients using either Charity Care or Medicaid and a column for combined total of Charity Care and Medicaid patients. For zip code 97236, 51.39% of the AMC patient count for 97233 were either Charity Care or Medicaid patients. It also had the lowest median income for those ten zip codes.

Adventist Medical Center 2016 Unique Patient Count By Zip Code

Percent of Patients Percent of Patients Percent of Total Percent Patient Average Census per Zip Code Total Patient with Patent Total with Patent Total Charity and Poverty Count Income ZipCode Count Charity per Zip Code Medicaid per Zip Code Medicaid 97236 3803 8.12% 253 6.65% 1629 42.83% 49.49% 27.3% 40,907 37,236 97233 3622 7.74% 236 6.52% 1589 43.87% 50.39% 31.8% 39,150 41,571 97266 3131 6.69% 191 6.10% 1418 45.29% 51.39% 26.5% 36,722 34,119 97230 2907 6.21% 160 5.50% 797 27.42% 32.92% 22.0% 46,237 40,997 97030 2526 5.40% 160 6.33% 392 15.52% 21.85% 20.7% 42,404 38,011 97080 2398 5.12% 105 4.38% 262 10.93% 15.30% 11.5% 63,032 40,501 97206 2023 4.32% 127 6.28% 631 31.19% 37.47% 16.3% 52,414 48,448 97220 1904 4.07% 152 7.98% 683 35.87% 43.86% 20.1% 46,908 29,730 97216 1808 3.86% 90 4.98% 529 29.26% 34.24% 22.4% 44,919 16,381 97055 1690 3.61% 57 3.37% 207 12.25% 15.62% 8.9% 60,611 17,303 97086 1258 2.69% 45 3.58% 154 12.24% 15.82% 7.6% 75,867 27,466 97060 1191 2.54% 60 5.04% 128 10.75% 15.79% 18.8% 54,943 21,739 97222 1132 2.42% 82 7.24% 174 15.37% 22.61% 13.5% 49,558 35,323 97045 1066 2.28% 45 4.22% 138 12.95% 17.17% 10.7% 63,915 52,182 97015 960 2.05% 26 2.71% 144 15.00% 17.71% 9.4% 59,986 20,190 97089 857 1.83% 22 2.57% 61 7.12% 9.68% 7.7% 84,469 12,140 97023 837 1.79% 32 3.82% 104 12.43% 16.25% 14.1% 59,229 10,570 97267 787 1.68% 40 5.08% 90 11.44% 16.52% 11.7% 58,920 31,665 97009 752 1.61% 21 2.79% 60 7.98% 10.77% 7.7% 63,227 7,476 97024 728 1.55% 47 6.46% 102 14.01% 20.47% 19.3% 51,633 10,103 97202 569 1.22% 32 5.62% 117 20.56% 26.19% 15.8% 55,606 39,901 97213 551 1.18% 35 6.35% 131 23.77% 30.13% 12.8% 58,176 30,597 Balance 10,319 22.04% Total Unique (unduplicated) patients that provided Zip Code. The Zip Codes chosen above had a minimum of 500 patients

Total patient count for those patients providing Zip Codes is 46,819. Unique patients are the unduplicated count of patients (each individual patient only counted once). Above chart includes hospital patients only. It does not include Home Health, Hospice or Clinic patients.

Adventist Medical Center 2016 Zip Code Summary

Charity Care Medicaid Charity Care/Medicaid Combined

Top Ten Zip Top Ten Percent Top Ten Percent Percent Codes for Zip Codes of Zip Codes of of Median Combined for Patent for Patent Patent Population* Household Charity and Charity Total per Medicaid Total per Total per Income* Medicaid Patients Zip Code Patients Zip Code Zip Code Patients 97236 6.65% 97236 42.83% 97266 51.39% 34,119 36,772 97233 6.52% 97233 43.87% 97233 50.39% 41,571 39,150 97266 6.10% 97266 45.29% 97236 49.49% 37,418 40,907 97230 5.50% 97230 27.42% 97220 43.86% 29,730 46,908 97030 6.33% 97220 35.87% 97206 37.47% 48,448 52,414 97080 4.38% 97206 31.19% 97216 34.24% 16,381 44,919 97206 6.28% 97216 29.26% 97230 32.92% 40,997 46,237 97220 7.98% 97030 15.52% 97213 30.13% 30,597 58,176 97216 4.98% 97080 10.93% 97202 26.19% 39,901 55,606 97055 3.37% 97055 12.25% 97222 26.61% 35,323 39,150

Census Data American FactFinder - Results *Population and Income Levels from http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml.

Prime Service Area

The above data would indicate that the prime service area for Portland Adventist Medical Center is the following areas of Multnomah and Clackamas Counties: Mid County East County The eastern most portions of Central Eastside and Southeast. Also included would be the areas of Clackamas County that border East County and Southeast Multnomah County and the Sandy region.

Patient Mapping by Zip Code

Figure 1 below is a mapping of the zip codes that represent 37,455 of the 46,819 AMC patients. 80% of the 46,819 total are located in the zip codes listed below. This represents Adventist Medical Center’s primary service area.

Primary Service Area (80% of Patients) PSA 97236 97233 97266 97230 97030 97080 97206 97220 97216 97055 97060 97086 97222 97015 97267 97089 97009 97024 97202 97213 97023 97045 97215

Race and Ethnicity Information

Race as a % of Population per Zip Code 2010-2014 American Community Survey 5-Year Estimates

Zip White Black / African American Indian/ Asian Native Hawaiian Hispanic/ Code Alone American Alaska Native Alone or other Pacific Latino Alone Alone Islander 97009 88.3% 0.1% 0.1% 0.5% 0.0% 9.1% 97015 72.0% 1.5% 1.4% 9.0% 1.5% 10.0% 97022 89.6% 0.6% 1.4% 1.7% 0.0% 6.2% 97023 88.6% 0.4% 0.9% 0.7% 0.0% 7.8% 97024 73.1% 4.3% 1.5% 3.4% 0.0% 16.5% 97027 83.7% 1.4% 0.2% 2.9% 0.0% 9.4% 97030 69.8% 2.0% 0.6% 3.4% 1.2% 18.4% 97045 87.3% 0.6% 0.6% 1.4% 0.0% 7.6% 97055 90.4% 0.3% 0.3% 0.6% 0.1% 5.9% 97060 72.2% 2.3% 0.7% 6.8% 0.5% 14.5% 97067 91.2% 0.0% 0.0% 0.0% 0.1% 8.6% 97080 80.1% 1.0% 1.1% 2.6% 0.8% 11.5% 97086 68.5% 1.6% 0.2% 14.7% 0.3% 10.2% 97089 89.0% 0.3% 0.8% 3.6% 0.0% 4.4% 97202 82.3% 2.0% 0.2% 5.5% 0.1% 6.8% 97203 60.9% 9.3% 0.9% 4.0% 2.5% 16.7% 97206 74.4% 2.5% 0.8% 9.6% 0.4% 8.4% 97209 82.6% 3.6% 0.5% 4.8% 0.1% 5.4% 97211 63.8% 18.6% 0.8% 3.1% 0.1% 7.5% 97213 79.2% 4.6% 0.7% 6.5% 1.0% 4.0% 97214 84.7% 1.4% 0.7% 3.6% 0.1% 5.4% 97215 85.8% 1.0% 0.7% 4.6% 0.0% 4.7% 97216 60.6% 5.5% 0.9% 16.2% 0.6% 11.9% 97217 70.5% 10.5% 0.1% 5.3% 0.6% 8.9% 97218 52.0% 14.3% 0.6% 5.8% 0.5% 23.3% 97220 60.2% 7.4% 0.9% 11.4% 0.5% 14.5% 97222 83.1% 1.7% 0.5% 3.0% 0.3% 8.2% 97230 60.4% 9.6% 0.5% 9.0% 1.9% 14.1% 97233 57.3% 6.5% 0.8% 8.5% 1.6% 21.8% 97236 61.8% 6.5% 0.6% 11.2% 0.6% 16.7% 97266 56.0% 5.3% 0.6% 16.2% 0.0% 18.6% 97267 84.2% 1.7% 0.6% 1.7% 0.3% 7.8% 98682 75.9% 2.1% 0.7% 5.5% 0.8% 10.8%

Data Source: American FactFinder

Zip Code Total AMC-P Community

% of Total Zip Code Language data from 2000 American Zip Code Population FactFinder QT-P16 (2010 N/A) Population Population of Zip Code 540,059 100.0% Speak only English 380,194 70.4% Speak a language other than English 76,912 14.2% Spanish or Spanish Creole 28,878 5.3% French (incl. Patois, Cajun) 1,584 0.3% French Creole 139 0.0% Italian 511 0.1% Portuguese or Portuguese Creole 112 0.0% German 2,971 0.6% Yiddish 5 0.0% Other West Germanic languages 462 0.1% Scandinavian languages 490 0.1% Greek 324 0.1% Russian 7,588 1.4% Polish 214 0.0% Serbo-Croatian 657 0.1% Other Slavic languages 3,003 0.6% Armenian 95 0.0% Persian 348 0.1% Gujarathi 197 0.0% Hindi 288 0.1% Urdu 143 0.0% Other Indic languages 491 0.1% Other Indo-European languages 3,413 0.6% Chinese 3,380 0.6% Japanese 1,642 0.3% Korean 1,742 0.3% Mon-Khmer, Cambodian 492 0.1% Miao, Hmong 605 0.1% Thai 222 0.0% Laotian 1,609 0.3% Vietnamese 8,363 1.5% Other Asian languages 1,004 0.2% Tagalog 1,752 0.3% Other Pacific Island languages 1,072 0.2% Navajo 42 0.0% Other Native North American languages 125 0.0% Hungarian 255 0.0% Arabic 744 0.1% Hebrew 50 0.0% 14 African languages 527 0.1% Other and unspecified languages 373 0.1%

Community Health Needs Surveys

The following rules and regulations gives the guidance used to determine whom in the community we need to solicit feedback.

The following is from the Federal Register / Vol. 79, No. 250 / Wednesday, December 31, 2014 /Rules and regulations

(b) Conducting a CHNA—(1) In general. To conduct a CHNA for purposes of paragraph (a) of this section, a hospital facility must complete all of the following steps: (i) Define the community it serves. (ii) Assess the health needs of that community. (iii) In assessing the health needs of the community, solicit and take into account input received from persons who represent the broad interests of that community, including those with special knowledge of or expertise in public health.

(4) Assessing community health needs. To assess the health needs of the community it serves for purposes of paragraph (b)(1)(ii) of this section, a hospital facility must identify significant health needs of the community, prioritize those health needs, and identify resources (such as organizations, facilities, and programs in the community, including those of the hospital facility) potentially available to address those health needs. For these purposes, the health needs of a community include requisites for the improvement or maintenance of health status both in the community at large and in particular parts of the community (such as particular neighborhoods or populations experiencing health disparities). These needs may include, for example, the need to address financial and other barriers to accessing care, to prevent illness, to ensure adequate nutrition, or to address social, behavioral, and environmental factors that influence health in the community. A hospital facility may determine whether a health need is significant based on all of the facts and circumstances present in the community it serves. In addition, a hospital facility may use any criteria to prioritize the significant health needs it identifies, including, but not limited to, the burden, scope, severity, or urgency of the health need; the estimated feasibility and effectiveness of possible interventions; the health disparities associated with the need; or the importance the community places on addressing the need.

(5) Persons representing the broad interests of the community—(i) In general. For purposes of paragraph (b)(1)(iii) of this section, a hospital facility must solicit and take into account input received from all of the following sources in identifying and prioritizing significant health needs and in identifying resources potentially available to address those health needs: (A) At least one state, local, tribal, or regional governmental public health department (or equivalent department or agency), or a State Office of Rural Health described in section 338J of the Public Health Service Act (42 U.S.C. 254r), with knowledge, information, or expertise relevant to the health needs of that community.

(B) Members of medically underserved, low-income, and minority populations in the community served by the hospital facility, or individuals or organizations serving or representing the interests of such populations. For purposes of this paragraph (b), medically underserved populations include populations experiencing health disparities or at risk of not receiving adequate medical care as a result of being uninsured or underinsured or due to geographic, language, financial, or other barriers.

(ii) Additional sources of input. In addition to the sources described in paragraph (b)(5)(i) of this section, a hospital facility may solicit and take into account input received from a broad range of persons located in or serving its community, including, but not limited to, health care consumers and consumer advocates, nonprofit and community-based organizations, academic experts, local government officials, local school districts, health care providers and community health centers, health insurance and managed care organizations, private businesses, and labor and workforce representatives. Two Survey Approach

In order to be compliant with above IRS regulations, AMC has chosen two different community surveys to be able to take into account the various groups that need to be represented. In order to not duplicate responses, AMC has chosen to use the Healthy Columbia Willamette (HCWC) has their main source of primary data for our service area. Use the following link to view the full HCWC CHNA: https://multco.us/healthy-columbia-willamette-collaborative/reports

A second survey (Service provider) was conducted to gather the opinions of the community from various health experts in our community.

We heard from the following groups whose opinion on community health we greatly value.  Pearl Health Center  Multnomah County Health Department  Human Solutions  Adventist Medical Center  Portland Adventist Community Services  Adventist Health Medical Group  The Healthy Columbia Willamette Collaborate

Survey details for the Healthy Columbia Willamette Collaborate survey can be found in Appendix A.

Survey details for East Multnomah County Service Provider survey can be found in Appendix B.

Surveys Summaries

Healthy Columbia Willamette Collaborate Survey - Top Responses

% of responses Safe, affordable housing 11.4% Access to physical, mental, and/or oral health care 10.5% Access to healthy, affordable food 9.6% Low crime/safe neighborhoods 8.9% Good schools 8.7%

% of responses Homeless/lack of safe, affordable housing 13.2% Unemployment/lack of living wage jobs 11.6% Mental health challenges (e.g. depression, lack of purpose or hope, anxiety, bi-polar, PTSD, eating disorders) 9.3% Hunger/lack of healthy, affordable food 8.2% Lack access to physical, mental, and/or oral health care 6.5%

Q3: In the following list, what do you think are the three most important "risky behaviors" in your community? (Those behaviors that have the greatest impact on overall community health.)

% of responses Drug use/abuse 20.3% Alcohol abuse/addiction 16.4% Poor eating habits 10.8%

East Multnomah County Service Provider Survey

The next two questions are about health problems that have the largest impact on the community as a whole. We would like for you to pick five of the most important health problems in East Multnomah County.

Answer Options Response Percent Mental health (depression, schizophrenia, anxiety, etc.) 88.2% Drugs and alcohol abuse 73.5% Overweight/obesity 60.3% Heart disease/heart attacks 32.4% Diabetes 29.4% Dental health 25.0%

Please pick the top five unhealthy behaviors that you believe are a problem in East Multnomah County. Answer Options Response Percent Drug/Substance abuse 82.4% Alcohol abuse 66.2% Smoking/tobacco use 55.9% Poor eating habits 52.9% Lack of exercise 50.0%

This question is about community-wide issues that have the largest impact on the overall quality of life in East Multnomah County. Please pick five from this list of community issues. Answer Options Response Percent Homelessness 67.6% Drug and alcohol abuse 66.2% Low income/poverty 64.7% Inadequate/unaffordable housing 52.9% Affordability of health services 38.2%

In your opinion, what would improve the quality of life for residents of East Multnomah County? (Please choose up to five.) Answer Options Response Percent More mental health services 79.4% More affordable housing options 63.2% Safe neighborhoods (less crime) 57.4% Increased job opportunities 51.5% Substance abuse treatment 42.6%

Survey Conclusions

A review of the results of the two surveys shows similar concerns among the both. Those concerns are as follows:

 Behavior/Mental Health

 Access to Affordable Health Care

 Life Style Concerns surrounding: . Drug and Alcohol Abuse . Health Eating Habits . Obesity . Lack of Exercise

 Social Determinates of Health . Housing . Homelessness

These results will be added to concerns raised by the following sections of secondary data research. The data is drawn from publicly available data. Analysis will be made based on trends in occurrences of the major areas of illness, leading causes of death and cost of medical care.

Where data by county was not really available, statewide data was used.

Racial and Ethnic Health Disparities

According to the Multnomah County Health Department Report “2014 Report Card on Racial and Ethnic Health Disparities” December 2014 (The full report can be found at http://web.multco.us/health/reports),

“In Multnomah County, all racial and ethnic groups examined in this report experienced some disparities relative to their non- Latino White counterparts. A striking number of disparities exist for Black/African Americans and American Indian/Alaska Natives. Numerous disparities also exist for Latinos and Asian/Pacific Islanders, but those communities also fared better than non-Latino Whites for some indicators.

Non-Latino Black/African American Black/African Americans experienced the greatest number of disparities with the highest level of concern relative to other communities of color. As shown in Figure 1, of the 33 indicators examined in this report, Black/African Americans experienced disparities for nine indicators that require intervention and 18 indicators that need improvement. There were only four indicators where a disparity was not detected. There were no indicators where the group fared significantly better than the non- Latino White comparison group. Black/African Americans experienced a geographic disparity for each of the physical environment indicators.”

Black/African Americans experienced the largest number of health disparities among racial/ethnic groups in Multnomah County. The report shows statistically significant disparities for 9 of the 18 health indicators for African Americans.

Health indicators requiring improvement/intervention include:  Cigarette use  Obesity  Teen birth rates  Health Insurance  Children with untreated tooth decay  First trimester prenatal care  Low birth weight babies  Infant mortality  Stroke mortality  Prostate cancer mortality  Gonorrhea  HIV incidence  Diabetes mortality  Coronary Heart Disease  All cancer

Relative to their White non-Hispanic counterparts African Americans:  continued to have significantly higher proportions of mothers who did not receive prenatal care.  in their first trimester experienced an infant mortality rate that was almost twice as high.  had a higher stroke mortality rate.  had a diabetes mortality rate more than two and a half times as high.  were almost two times as likely to die of prostate cancer though there was no disparity in other forms of cancer.  Homicide rates about six times higher.

Social and Economic indicators with improvement needed include:  Children living in poverty  Children living in single-parent households  Children not meeting third-grade reading standards  Unemployment

Asian/Pacific Islanders

Asian/Pacific Islanders experienced fewer health disparities than other racial/ethnic groups in Multnomah County. For 11 indicators, Asian/Pacific Islanders, did significantly better than non- Latino Whites. Though this group, as a whole, fared well for many indicators, it is likely that aggregation of data into this large group is masking some disparities being experienced by sub-groups of Asian/Pacific Islanders. More attention should be given to disaggregated data for this population. A supplemental report focusing on Pacific Islander health disparities is forthcoming.

Health indicators with improvement needed include:  First trimester prenatal care  Low birth weight babies  Homicide rates

Adults without health insurance was the one indicator that requires intervention level for Asian/Pacific Islanders. The percentage without health insurance is more than two times higher among non-Latino Asian/Pacific Islanders in Multnomah County than among non-Latino Whites.

Relative to their White non-Hispanic counterparts Asian/Pacific Islanders:  continued to have significantly higher proportions of mothers who did not receive prenatal care in their first trimester.  continued to have higher proportions of low birth weight births.  experienced a higher homicide rate.

Social and Economic indicators with improvement needed include:  Third-grade reading level  Post-high school education

Native Americans

There are statistically significant disparities in 5 of the 18 health indicators for Native Americans and 12 at the needs improvement level. However, for seven of the other health indicators, Native Americans did not have a sufficient number of events to calculate a rate.

Health indicators requiring intervention:  Teen births  Current cigarette smoking  Adults with no physical activity outside of work

Health indicators needing improvement include:  No first trimester prenatal care  Stroke mortality

 Infant mortality  Low birthweight  Self-reported mental health

Relative to their White non-Hispanic counterparts:  Native American had higher rates of teen births.  Native Americans continued to have significantly higher proportions of mothers who did not receive prenatal care in their first trimester.

Social and Economic indicators with improvement needed include:  Are more than twice as likely to have children living in poverty  Twice as likely to have children not meeting third-grade reading standards  Lack of post-high school education

Hispanics

There are statistically significant disparities in 6 of the 18 health indicators for Hispanics. There were also eight indicators where Latinos fared significantly better than non-Latino Whites.

Health indicators requiring intervention include:  Obesity  First trimester prenatal care  Untreated tooth decay  Teen birth rate  Lack of health insurance

Health indicators needing improvement include:  HIV incidence  Diabetes mortality rates  Overall health status

Relative to their White non-Hispanic counterparts Hispanics:  continued to have significantly higher proportions of mothers who did not receive prenatal care in their first trimester  experienced a teen birth rate that was 3.5 times higher.  Latino adults were two times more likely to lack health insurance

Social and Economic indicators with improvement needed include:  Are more than twice as likely to have children living in poverty

 Twice as likely to have children not meeting third-grade reading standards  Lack of post-high school education  Homicide rate

From the “Facing Race- 2013 Legislative Report Card on Racial Equity.

 Whites are far less likely to face poverty than communities of color in Oregon. In 2012, the poverty rate for Whites was only 15 percent, but 30 percent for Latinos, 34 percent for Native Americans and Alaska Natives, 36 percent for Native Hawaiians and Pacific Islanders and 41 percent for African Americans.

 As for public education, in Multnomah County, just 7 percent of White students do not graduate from high school compared to 30 percent of students of color.

 In Oregon’s placement of children in foster care, Native American youth are more than five times as likely to be placed into foster care; African American youth are four times as likely, and Pacific Islanders are twice as likely to white youth.

 Oregon’s population is increasingly diverse—more multiracial, multicultural and multilingual. From 1990 to 2012, Oregonians of color have increased from just 9.2 percent of the state’s population to 22.4 percent.

 Communities of color face greater obstacles to health insurance than White Oregonians generally do. The primary source of health coverage in Oregon— job-based insurance— is not accessed by people of color to the same degree given the higher unemployment and underemployment rates.

 While two out of three uninsured Oregonians in 2012 were White, Oregonians of color were significantly over-represented among the uninsured.

http://www.safetyandjustice.org/files/Facing%20Race%202013.pdf

Leading Causes of Death

From the Centers for Disease Control and Prevention site website:

Chronic Diseases: The Leading Causes of Death and Disability in the United States Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems.  As of 2012, about half of all adults—117 million people—had one or more chronic health conditions. One of four adults had two or more chronic health conditions.  Seven of the top 10 causes of death in 2010 were chronic diseases. Two of these chronic diseases—heart disease and cancer—together accounted for nearly 48% of all deaths.  Obesity is a serious health concern. During 2009–2010, more than one-third of adults, or about 78 million people, were obese (defined as body mass index [BMI] ≥30 kg/m2). Nearly one of five youths aged 2–19 years was obese (BMI ≥95th percentile).  Arthritis is the most common cause of disability. Of the 53 million adults with a doctor diagnosis of arthritis, more than 22 million say they have trouble with their usual activities because of arthritis.  Diabetes is the leading cause of kidney failure, lower-limb amputations other than those caused by injury, and new cases of blindness among adults. http://www.cdc.gov/chronicdisease/overview/index.htm

United States’ leading causes of death 2014 National Vital Statistics Reports,  Diseases of heart (heart disease)  Malignant neoplasms (cancer)  Chronic lower respiratory diseases  Accidents (unintentional injuries)  Cerebrovascular diseases (stroke)  Alzheimer’s disease  Diabetes mellitus (diabetes)  Influenza and pneumonia  Nephritis, nephrotic syndrome and nephrosis (kidney disease)  Intentional self-harm (suicide) Bold print are causes of death whose position on the list has change since 2010

United States’ leading causes of death 2010- National Vital Statistics Reports, Vol. 61, No. 4  Diseases of heart (heart disease)

 Malignant neoplasms (cancer)  Chronic lower respiratory diseases  Cerebrovascular diseases (stroke)  Accidents (unintentional injuries)  Alzheimer’s disease  Diabetes mellitus (diabetes)  Nephritis, nephrotic syndrome and nephrosis (kidney disease)  Influenza and pneumonia  Intentional self-harm (suicide) Data source: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf

Oregon’s Leading Causes of Death 2014  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Chronic lower respiratory diseases  Cerebrovascular diseases (stroke)  Accidents (unintentional injuries)  Alzheimer’s disease  Diabetes mellitus (diabetes)  Intentional self-harm (suicide)  Alcohol-induced Deaths

Oregon’s Leading Causes of Death 2011  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Chronic lower respiratory diseases  Cerebrovascular diseases (stroke)  Accidents (unintentional injuries)  Alzheimer’s disease  Diabetes mellitus (diabetes)  Alcohol-induced Deaths  Suicide

Data source: http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/11v2/Pages/chapter6.aspx

Oregon’s Leading Causes of Death 1990-2007  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Chronic lower respiratory diseases  Cerebrovascular diseases (stroke)  Accidents (unintentional injuries)  Alzheimer’s disease  Diabetes mellitus (diabetes)

 Alcohol-induced Deaths  Influenza and pneumonia Source of data: http://www.dhs.state.or.us/dhs/ph/chs/data/arpt/07v2/chp6toc.shtml

Multnomah County’s leading causes of death 2014  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Chronic lower respiratory diseases  Accidents (unintentional injuries)  Cerebrovascular diseases (stroke)  Alzheimer’s disease  Diabetes mellitus (diabetes

Multnomah County’s leading causes of death 2011  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Chronic lower respiratory diseases  Accidents (unintentional injuries)  Cerebrovascular diseases (stroke)  Alzheimer’s disease  Diabetes mellitus (diabetes) Data source: http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/11v2/Documents/Chapter%206/Table635.pdf

Multnomah County’s leading causes of death 2007  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Cerebrovascular diseases (stroke)  Accidents (unintentional injuries)  Chronic lower respiratory diseases  Diabetes mellitus (diabetes)  Alzheimer’s disease Data source: http://www.dhs.state.or.us/dhs/ph/chs/data/arpt/07v2/chapter6/table635.pdf

Clackamas County’s leading causes of death 2014  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Chronic lower respiratory diseases  Cerebrovascular diseases (stroke)  Accidents (unintentional injuries)  Alzheimer’s disease  Diabetes mellitus (diabetes)

Clackamas County’s leading causes of death 2011  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Chronic lower respiratory diseases  Cerebrovascular diseases (stroke)  Accidents (unintentional injuries)  Alzheimer’s disease  Diabetes mellitus (diabetes)

Data source: http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/11v2/Documents/Chapter%206/Table635.pdf

Clackamas County’s leading causes of death 2007  Malignant neoplasms (cancer)  Diseases of heart (heart disease)  Cerebrovascular diseases (stroke)  Accidents (unintentional injuries)  Chronic lower respiratory diseases  Alzheimer’s disease  Diabetes mellitus (diabetes) Data source: http://www.dhs.state.or.us/dhs/ph/chs/data/arpt/07v2/chapter6/table635.pdf

Leading Causes of Death Summary

Nationally-Accidents moved up to 4th, Influenza and pneumonia moved up one, Nephritis, nephrotic syndrome and nephrosis (kidney disease) and stroke moved down one.

Oregon- Suicide moved up one on the list.

Multnomah County- Order remained the same from 2011.

Clackamas County- Order remained the same from 2011.

The State of Oregon/Multnomah/Clackamas County Health Factors

In the University of Wisconsin Population Health Institute’s report, County Health Rankings 2010 and County Health rankings 2013, a snapshot of the overall health of Oregon by county has shown the following. The summary health factors represent a weighted summary that influence the health of the county and the summary health outcomes represent how healthy a county is.

2010 Oregon Health Factors & Outcomes Ranking by County Health Factors Ranking Health Outcomes Ranking Social & Health Physical County Clinical Care Economic Sum Mortality Morbidity Summary Behaviors Environment Factors Multnomah 11 2 16 14 9 17 22 21 Clackamas 6 4 3 23 5 4 4 3 Washington 3 6 2 26 3 2 7 2

2013 Oregon Health Factors & Outcomes Ranking by County Health Factors Ranking Health Outcomes Ranking Social & Health Physical County Clinical Care Economic Sum Mortality Morbidity Summary Behaviors Environment Factors Multnomah 9 6 17 17 9 14 19 15 Clackamas 6 3 3 15 4 4 5 5 Washington 4 4 2 25 3 2 7 4 www.countyhealthrankings.org/oregon

The health factors ranking is based on four factors: health behaviors, clinical care, social and economic factors, and physical environment.

Health Behaviors include measures of smoking, diet and exercise, alcohol use and risky sex behavior.

Clinical care includes measures of access to care and quality of care.

Social and economic factors include measures of education, employment, income, family and social support, and community safety.

The physical environment includes measures of environmental quality and the built environment.

The health outcomes ranking is based on measures of mortality and morbidity.

The mortality rank represents length of life and is based on a measure of premature death; the years of potential life lost prior to age 75.

The morbidity rank is based on measures that represent health-related quality of life and birth outcomes. Four morbidity measures were combined: self-reported fair or poor health, poor physical health days, poor mental health days, and the percent of births with low birth weight.

Date Updated: September 25, 2015

Prevalence of Selected Chronic Conditions among Adults by County

Coronary Heart County Arthritis Asthma Heart Attack Disease

Multnomah 21.10% 9.90% 3.60% 3.80%

Clackamas 23.30% 9.00% 2.80% 2.80%

Oregon in Total 24.50% 10.40% 3.40% 3.60% Data form BRFSS, by County, Oregon, 2010-2013, Chronic Diseases among Oregon Adults

Prevalence of Selected Chronic Conditions among Adults by County

High Blood County Stroke Diabetes High Blood Pressure Cholesterol

Multnomah 2.60% 7.90% 26.80% 30.80%

Clackamas 2.00% 8.60% 25.20% 34.20%

Oregon in Total 2.50% 8.20% 27.70% 31.80% Data form BRFSS, by County, Oregon, 2010-2013, Chronic Diseases among Oregon Adults

Rates for both of the above tables are age-adjusted.

Age-adjusting a rate is a way to make fairer comparisons between groups with different age distributions. For example, a county having a higher percentage of elderly people may have a higher rate of death or hospitalization than a county with a younger population, merely because the elderly are more likely to die or be hospitalized. The same distortion can happen when we compare races, genders, or time periods. Age adjustment can make the different groups more comparable.

Date Updated: September 25, 2015

Preventive Clinical Services Performed

Age-adjusted Prevalence of Preventive Health Screening among Adults by County

Pap test within Current1 on Mammogram past three colorectal cancer within past Cholesterol years (women screening (50‐75 two years (women checked within County 21‐65 years years 50‐74 past five years (%) old with a cervix; old; %) years old; %) %) Multnomah:2010-2013 63.70% 81.40% 81.20% 70.10% Multnomah:2008-2011 62.30% 86.20% 84.60% 76.00% Clackamas:2010-2013 66.60% 86.10% 78.90% 74.20% Clackamas:2008-2011 64.40% 87.20% 82.50% 74.50% Oregon in Total: 2010-2013 61.10% 81.70% 75.30% 70.80%

Oregon in Total:2008-2011 61.20% 84.40% 79.70% 73.10% Age-adjusted Prevalence of Preventive Health Screening among Adults by County

Pap test within Current1 on Mammogram past three Cholesterol colorectal cancer within past years (women checked within screening (50‐75 two years County 21‐65 years past five years years (women 50‐74 old with a (%) old; %) years old; %) cervix; %) Multnomah:2010-2013 63.70% 81.40% 81.20% 70.10% Multnomah:2008-2011 62.30% 86.20% 84.60% 76.00% Clackamas:2010-2013 66.60% 86.10% 78.90% 74.20% Clackamas:2008-2011 64.40% 87.20% 82.50% 74.50% Oregon in Total: 2010-2013 61.10% 81.70% 75.30% 70.80% Oregon in Total:2008-2011 61.20% 84.40% 79.70% 73.10% Current1 on colorectal cancer screening includes: having a fecal occult blood test (FOBT) in the past year; a colonoscopy within the past 10 years; or, a sigmoidoscopy within the past five years as well as an FOBT within the past three years.

Data form BRFSS, by County, Oregon, Health screenings among Oregon adults, by county, 2008‐2011 and 2010-2013

Influenza vaccination

Oregon falls short of the Healthy People 2020 goal of 70% annual flu vaccination rates among both adults and children. Neither adult nor child targets are likely to be met in the foreseeable future. This is in part due to low rates among adolescents and non-senior adults, and persistent gender differences among adults.

About the Data: Data source is the ALERT Immunization Information System. Rates are based on the number of seasonal influenza immunizations reported to ALERT and administered between August 1st and May 1st for each influenza season.

Date Updated: August 5th, 2015

2016 County Health Rankings Multnomah Clackamas Factor Oregon County County % of adults in poor or fair health 14% 14% 11% Poor physical health days 3.8 3.8 3.6 Poor mental health days 3.9 4 3.5 Low birth weight 6.00% 6.00% 6.00%

Food Insecurity 16% 16% 13%

Limited access to healthy foods 5% 4% 3%

Preventable hospitals stays 35 35 32

Violet crime rate per 100,000 pop. 249 487 106

Adult obesity 26% 21% 26%

Frequent mental distress 11% 11% 10%

Insufficient sleep 30% 28% 26%

Data from: Health Rankings | County Health Rankings & Roadmaps

 The average numbers of days a county’s adult respondents report that their physical health was not good.  Low birth weight is the percent of live births for which the infant weighed less than 2,500 grams (approximately 5 lbs., 8 oz.).  Adult obesity- Percentage of adults that report a BMI of 30 or more  Preventable hospital stays are measured as the hospital discharge rate for ambulatory care- sensitive conditions per 1,000 Medicare enrollees.  Preventable hospital stays are measured as the hospital discharge rate for ambulatory care- sensitive conditions per 1,000 Medicare enrollees.  Access to healthy foods is measured as the percent of zip codes in a county with a healthy food outlet, defined as a grocery store or produce stand/farmers’ market. Data source: http://www.countyhealthrankings.org/oregon/multnomah/

Health risk and protective factors among adults, Oregon 2014

http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/DataReports/Documents/datatables/ORAnnualBRFSS_riskfactors.pdf Oregon Health Authority, Public Health Division, Health Promotion and Chronic Disease Prevention section. Health risk and protective factors among adults, Oregon 2014. http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/DataReports/Pages/AdultData.aspx. Created November 16, 2015. Accessed 7-24-2016.

Falls Among Older Adults in Oregon

Fatal falls The rate of fatal falls among adults age 65 years and older was 91.9 per 100,000 in 2013, an increase of 46% since 2000. Older men have a higher risk of fatal fall, compared to women within the same age group. The rate of fatal falls among people age 85 years and older is 21 times greater than for those age 65–74 years. An aging population, combined with increased life expectancy means fatal falls will likely continue to increase in the future.

Fall hospitalizations In 2013, the rate of fall hospitalization in Oregon was 964.4 per 100,000 adults age 65 and older. Women were hospitalized more often than men. There were 1,230.5 hospitalizations per 100,000 women age 65 and older in 2013, compared to 643.8 per 100,000 men age 65 and older. Hospitalization increases with age; those age 85 years and older are 7 times more likely to be hospitalized than those age 65-74 years.

http://public.health.oregon.gov/DiseasesConditions/InjuryFatalityData/Documents/Fact%20Sheets/Falls_Older_A dults_2015v02262015.pdf

Pregnancy-Childbirth

How does CDC define pregnancy-related deaths? For reporting purposes, a pregnancy-related death is defined as the death of a woman while pregnant or within 1 year of pregnancy termination—regardless of the duration or site of the pregnancy—from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

In the United States

Of the 3,404 deaths within a year of pregnancy termination that occurred during 2011-2012 and were reported to CDC, 1,329 were found to be pregnancy-related. The pregnancy-related mortality ratios were 17.8 and 15.9 deaths per 100,000 live births in 2011 and 2012, respectively.

Considerable racial disparities in pregnancy-related mortality exist. During 2011-2012, the pregnancy- related mortality ratios were—

 11.8 deaths per 100,000 live births for white women.  41.1 deaths per 100,000 live births for black women.  15.7 deaths per 100,000 live births for women of other races.

The reasons for the overall increase in pregnancy-related mortality are unclear. The use of computerized data linkages by the states, changes in the way causes of death are coded, and the addition of a pregnancy checkbox to the death certificate in many states have likely improved identification of pregnancy-related deaths over time. Whether the actual risk of a woman dying from pregnancy-related causes has increased is unclear. Many studies show that an increasing number of pregnant women in the United States have chronic health conditions such as hypertension, diabetes, and chronic heart disease. These conditions may put a pregnant woman at higher risk of pregnancy complications. Although the overall risk of dying from pregnancy complications is low, some women are at a higher risk than others. The higher pregnancy-related mortality ratios during 2009-2011 are due to an increase in infection and sepsis deaths. Many of these deaths occurred during the 2009-2010 influenza A (H1N1)pdm09 pandemic which occurred in the United States between April 2009 and June 2010. Influenza deaths accounted for 12 percent of all pregnancy-related deaths during that 15-month period. Variability in the risk of death by race, ethnicity, and age indicates that more can be done to understand and reduce pregnancy-related deaths.

Perinatal Quality

Vitamin D Studies

Vitamin D inadequacy (<50 nmol/L) is estimated to affect about 38% of U.S. reproductive-aged women and 28% of U.S. pregnant women. Among pregnant women, vitamin D deficiency varies significantly by racial and ethnic groups, ranging from 13% of non-Hispanic white women to 80% of non-Hispanic black women. Women who have low levels of vitamin D may be at higher risk for problems during pregnancy, including preterm birth, but more research is needed to clarify the relationship between pregnancy problems and vitamin D. CDC conducted a study in Michigan, North Carolina, and Washington State to examine vitamin D levels in stored blood samples of women who had a preterm birth. An additional analysis confirmed seasonal changes in levels of 25-hydroxyvitamin D (a substance used to measure vitamin D status), with peak levels in summer and the lowest levels in winter. However, there are smaller seasonal changes among black mothers. CDC also funded researchers at the University of Pittsburgh to conduct a study examining whether vitamin D deficiency and variations in vitamin D receptor genes are associated with risk of preterm birth in pregnant women.

Smoking in Pregnancy

Despite decreases in smoking prevalence over recent years, about 19% of women of reproductive age are smokers (2009 data), and about 10% of women reported smoking during pregnancy in 2011 (25 states). In addition to a variety of negative pregnancy outcomes, smoking during pregnancy is associated with 5%-8% of the cases of preterm birth. CDC is actively working to improve reproductive health outcomes through the reduction of smoking among women before, during, and after pregnancy in the United States and globally.

Teen Pregnancy

Trends in Teen Pregnancy by Age

The declines in teenage pregnancy have been much steeper for younger than for older teenagers.

 The rate for teenagers 15-17 years of age dropped more than half, from 77.1 per 1,000 in 1990 to 36.4 in 2009.  The rate for older teenagers 18-19 years of age fell as well, by 38 percent from its 1991 peak (172.1 per 1,000) to 106.3 in 2009.

 The rates in 2009 for these age groups were also lower than for any year during the 1976- 2009 period.

Source: Curtin SC, Abma JC, Ventura SJ, Henshaw SK. Pregnancy rates for U.S. women continue to drop. NCHS data brief, no. 136. Hyattsville, MD: National Center for Health Statistics. 2013.

Source: Curtin SC, Abma JC, Ventura SJ, Henshaw SK. Pregnancy rates for U.S. women continue to drop. NCHS data brief, no. 136. Hyattsville, MD: National Center for Health Statistics. 2013. Rates by Race and Hispanic Origin

Pregnancy rates dropped for teenagers in all race/Hispanic groups between 1990 and 2009. Overall, in 2009 pregnancy rates for non-Hispanic white and black teenagers aged 15-19 declined 51 percent each, with much larger declines for younger than for older teenagers in each group. The rates for Hispanic teenagers began to decline after 1992 (the peak year); the overall teen pregnancy rate for this group fell 42 percent from 1992 to 2009.

Source: Curtin SC, Abma JC, Ventura SJ, Henshaw SK. Pregnancy rates for U.S. women continue to drop. NCHS data brief, no. 136. Hyattsville, MD: National Center for Health Statistics. 2013.

Demographic characteristics of mother by race/ethnicity 2013-2015

Non-Hispanic single mention race Oregon:Demographic Total Multiple Hispanic characteristics of mother White Black AI/AN Asian NH/PI Other/Unk Race Total births 136,349 93,309 2,900 1,439 6,559 877 195 4,984 25,467 Mother's Age <15 50 17 1 1 - 1 - 4 26 15-19 7,276 3,829 223 122 44 62 8 396 2,559 20-24 27,658 17,719 692 420 464 229 33 1,295 6,695

Martial status Unmarried 48,775 29,477 1,599 910 852 446 55 2,488 12,683

Married 87,265 63,634 1,297 523 5,697 429 129 2,478 12,739 Unknown 309 198 4 6 10 2 11 18 45

Start of prenatal care 1st Trimester 105,414 74,738 1,916 949 5,183 356 131 3,708 18,028 2nd Trimester 23,466 14,190 681 358 1,026 320 42 947 5,775 3rd Trimester 5,156 2,955 214 100 259 145 13 239 1,198 No care 952 605 37 18 17 41 4 46 153

Prenatal Care Inadequate 7,723 4,548 314 175 339 221 20 367 1,667 Adequate 125,602 86,870 2,495 1,232 6,085 659 165 4,504 23,132 Unknown 3,014 1,891 91 32 135 27 10 113 668

Demographic characteristics of mother by race/ethnicity 2013-2015

Multnomah Non-Hispanic single mention race County:Demographic Total Multiple Hispanic White Black AI/AN Asian NH/PI Other/Unk characteristics of mother Race Total births 28,191 18,051 1,937 163 2,117 310 48 1,266 4,184 Mother's Age <15 9 1 - - - 1 - 1 6 15-19 1,124 396 165 9 22 20 2 96 412 20-24 4,298 2,124 502 31 204 89 8 313 1,007

Martial status Unmarried 9,346 4,575 1,216 116 420 152 14 699 2,104 Married 18,821 13,468 19 47 1,698 158 28 566 2,078 Unknown 24 8 2 - 1 - 6 1 2

Start of prenatal care 1st Trimester 21,777 14,541 1,289 106 1,607 129 33 914 3,077 2nd Trimester 4,776 2,706 459 39 372 115 10 249 806 3rd Trimester 1,179 553 135 12 117 49 4 76 230 No care 220 114 29 4 7 12 1 16 29

Prenatal Care Inadequate 1,745 848 204 21 156 74 6 113 310 Adequate 25,941 16,910 1,679 137 1,931 227 42 1,122 3,795 Unknown 505 293 54 5 30 9 - 31 79

Demographic characteristics of mother by race/ethnicity 2013-2015

Non-Hispanic single mention race Clackamas:Demographic Total Multiple Hispanic characteristics of mother White Black AI/AN Asian NH/PI Other/Unk Race Total births 12,278 9,650 102 53 565 30 12 342 1,474 Mother's Age <15 4 3 - - - - - 1 - 15-19 441 259 4 3 1 2 1 27 142 20-24 2,031 1,533 24 16 34 4 - 73 343

Martial status Unmarried 3,440 2,487 44 24 81 18 3 156 608 Married 8,828 7,154 58 29 483 12 9 186 866 Unknown 10 9 - - 1 - - - -

Start of prenatal care 1st Trimester 9,796 7,853 73 42 455 13 11 260 1,055 2nd Trimester 1,872 1,351 17 11 91 11 1 61 320 3rd Trimester 403 287 6 - 15 5 - 16 72 No care 112 90 2 - 1 1 - 2 14

Prenatal Care Inadequate 639 469 10 2 18 7 - 22 107 Adequate 11,488 9,066 88 51 542 23 12 316 1,347 Unknown 151 115 4 - 5 - - 4 20

Low birthweight infants by county of residence, Oregon resident births, 2016 Through July Low birthweight infants Low birthweight rates County of Less than 1,500- Less tham 1,500- Total births Total low All low residence 1500 2,499 1500 2,499 birthweight birthweight grams grams grams grams Oregon 25,621 1,677 239 1,438 65.5 9.3 56.1 Multnomah 5,088 352 48 304 69.2 9.4 59.8 Clackamas 2,397 137 17 120 57.2 7.1 50.1

Low birthweight infants by county of residence, Oregon resident births, 2014

Low birthweight infants Low birthweight rates County of Less than 1,500- Less tham 1,500- Total births Total low All low residence 1500 2,499 1500 2,499 birthweight birthweight grams grams grams grams Oregon 45,557 2,847 460 2,387 62.5 10.1 52.4 Multnomah 9,463 592 99 493 62.6 10.5 52.1 Clackamas 4,092 253 33 220 61.8 8.1 53.8

Low birthweight infants by county of residence, Oregon resident births, 2010

Low birthweight infants Low birthweight rates County of Less than 1,500- Less tham 1,500- Total births Total low All low residence 1500 2,499 1500 2,499 birthweight birthweight grams grams grams grams Oregon 45,596 2,873 480 2,393 63.5 10.5 52.5 Multnomah 9,610 636 105 531 66.2 10.9 55.3 Clackamas 3,869 250 48 202 64.6 12.4 52.2

Diabetes

The American Diabetes Association reports that in 2012, 9.3% (8.3% in 2010 and 7.8% in 2007) of the American population had diabetes. The Centers for Disease Control and Prevention reports that in 2012, 9.9% of the population of Oregon were diagnosed with diabetes (7.2% in 2010, 6.8% in 2007). It is estimated that 27.8% of these have undiagnosed diabetes. It was the 7th leading cause of death in 2014.

Diabetes is becoming more common in the United States. From 1980 through 2014, the number of Americans with diagnosed diabetes has increased fourfold (from 5.5 million to 22.0 million).

Number of Civilian, Noninstitutionalized Persons with Diagnosed Diabetes

25.0

20.0

15.0

10.0

% Millions in

5.0

0.0

1 2 3 4 5 6 7 8 9

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 10

Year

CDC - Number of Persons - Diagnosed Diabetes - Data & Trends - Diabetes DDT Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. Statistical analysis by the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation.

Complications of diabetes include the following: o Heart disease and stroke o High blood pressure o Blindness o Kidney disease o Nervous system disorders (Neuropathy) o Amputation

Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. Statistical analysis by the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation.

According to the Oregon Health Authority’s January 2015 Oregon Diabetes Report:

 In Oregon, adults with less than a high school education are twice as likely to have diabetes.

 Diabetes and obesity have more than doubled among Oregon adults since 1990.

 The cost of diabetes to Oregonians each year in health care costs and reduced productivity is $3 billion.

 More than a quarter of adults in Oregon are considered obese (defined as having a Body Mass Index (BMI) of 30.0 or over.

https://public.health.oregon.gov/DiseasesConditions/ChronicDisease/Diabetes/Documents/OregonDiabetesReport.pdf

Data Source: Centers for Disease Control and Prevention. National Center for Health Statistics; Division of Health Interview Statistics; Data from the National Health Interview Survey. Statistical analysis by the Centers for Disease Control and Prevention; National Center for Chronic Disease Prevention and Health Promotion - Division of Diabetes Translation.

Methods and Limitations: http://www.cdc.gov/diabetes/statistics/prev/national/methods.htm.

Oregon-Rate of New Cases of 12 Diagnosed Diabetes per 1000 Adults

8 6

2 Ppercentage 0 1 2 3 4 5 6 7 8 9 Year

Oregon- Percentage of Adults (aged 18 years or older) with 70 Diabetes and High Cholesterol 60 50 40 30

20 10

Ppercentage 0 1 2 3 4 5 6 7 8 9 10 Year

Oregon - Percentage of Adults (aged 18 years or older) with 80 Diabetes and Hypertension

Ppercentage 0 1 2 3 4 5 6 7 8 9 10

Year

Oregon - Percentage of Adults (aged 18 years or older) with Diabetes Who Are Current Smokers 25 20

15 10

Ppercentage 0

9 2 3 4 5 6 7 8

16 10 11 12 13 14 15 17 18 19 20

Year

Oregon- Percentage of Adults (aged 18 years or older) with

70 Diabetes Who Are Obese

60 50

40 30

10 Ppercentage 0

1 2 3 4 5 6 7 8 9

11 12 13 14 15 16 17 18 19 20 10

Year

Information for the above five tables is from: Centers for Disease Control and Prevention: National Diabetes Surveillance System. Available online at. : http://www.cdc.gov/diabetes/statistics. Retrieved 6/3/2016 Crude data, not age adjusted. More information can be found at www.diabetes.org., www.cdc.gov/diabetes

15 Prevalence 10

0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

Clackamas- Diabetes Multnomah- Diabetes Clackamas- Obesity Multnomah- Obesity

Age-adjusted Diagnosed Diabetes Prevalence Age-adjusted Obesity Prevalence https://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%2Fwww.cdc.gov%2Fdiabetes%2F%2Fatlas%2Fob esityrisk%2Fdmincid%2Fdata_Oregon.xls

The following is from research conducted by James P Boyle, Theodore J Thompson, Edward W Gregg, Lawrence E Barker and David F Williamson.

Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence The following is from research conducted by James P Boyle, Theodore J Thompson, Edward W Greg, Lawrence E Barker and David F Williamson.

“The authors project that annual diagnosed diabetes incidence (new cases) will increase from about 8 cases per 1,000 in 2008 to about 15 in 2050. Assuming low incidence and relatively high diabetes mortality, total diabetes prevalence (diagnosed and undiagnosed cases) is projected to increase from 14% in 2010 to 21% of the US adult population by 2050. However, if recent increases in diabetes incidence continue and diabetes mortality is relatively low, prevalence will increase to 33% by 2050. A middle-ground scenario projects a prevalence of 25% to 28% by 2050. Intervention can reduce, but not eliminate, increases in diabetes prevalence.

These projected increases are largely attributable to the aging of the US population, increasing numbers of members of higher-risk minority groups in the population, and people with diabetes living longer. Effective strategies will need to be undertaken to moderate the impact of these factors on national diabetes burden. Our analysis suggests that widespread implementation of reasonably effective preventive interventions focused on high-risk subgroups of the population can considerably reduce, but not eliminate, future increases in diabetes prevalence.” http://www.pophealthmetrics.com/content/8/1/29

According to the American Diabetes Association “You can prevent or delay the onset of type 2 diabetes through a healthy lifestyle. Change your diet, increase your level of physical activity, maintain a healthy weight...with these positive steps, you can stay healthier longer and reduce your risk of diabetes.”

In 2014, diabetes was the 7th leading cause of death in both Multnomah and Clackamas Counties. Among Oregon adults with diabetes: 1in 2 is obese 1 in 4 smokes cigarettes 2 in 3 have high blood pressure 1 in 2 has high cholesterol 1 in 4 is physically inactive

Above charts are from the Oregon Diabetes Report- https://public.health.oregon.gov/DiseasesConditions/ChronicDisease/Diabetes/Documents/OregonDiabetesReport.pd

Obesity

National

According to the report “The State of Obesity: Better Policies for a Healthier America 2015”

 Adults: More than a third of adults (34.9 percent) were obese as of 2011 to 2012.6 More than two-thirds of adults were overweight or obese (68.6 percent).  Nearly 40 percent of middle-age adults, ages 40 to 59, were obese (39.5 percent), which was more than younger adults, ages 20 to 39 (30.3 percent) or older adults, ages 60 and over (35.4 percent).  More than 6 percent of adults were severely obese (body mass index (BMI) of 40 or higher).  More women than men, ages 20 and over, have higher rates of obesity and extreme obesity (36.1 percent and 8.3 percent versus 33.5 percent and 4.4 percent).  Obesity rates were highest among Black (47.8 percent) adults, followed by Latino (42.5 percent) and White (32.6 percent) adults and lowest among Asian American (10.8 perfect) adults.  Children: Approximately 17 percent of children and teenagers (ages 2 to 19) were obese from 2011 to 2012, and 31.8 percent were either overweight or obese.  More than one-in-12 children (8.4 percent) are obese in early childhood (2- to 5-year-olds).  By ages 12 to 19, 20.5 percent of children and adolescents were obese.  More than 2 percent of young children were severely obese, 5 percent of 6-to 11-year-olds were severely obese and 6.5 percent of 12- to 19-year-olds were severely obese.  Racial and ethnic inequities persist among children also; 22.5 percent of Latino children and 20.2 percent of Black children are obese, compared to 14.1 percent of non-Latino White and 6.8 percent of Asian-American children.

RACIAL AND ETHNIC INEQUITIES AND OBESITY

Among adults:  Obesity rates are higher among Black (47.8 percent) and Latino (43 percent) adults than Whites (32.6 percent) and Asian Americans (10.8 percent).  Rates of obesity (56.6 percent) and severe obesity are highest among Black women.  Nearly 78 percent of Latino and 76.2 percent of Black adults are either overweight or obese, compared to 67.2 percent of Whites and 38.6 percent of Asian Americans.  Black women are more than twice as likely to be severely obese and Latinas are nearly 1.5 times more likely to be severely obese than White women.  A reported 54 percent of American Indian/Alaska Native adults, ages 20 to 74, are obese and 81 percent are overweight or obese, according to an Indian Health Survey data.

Among children:  Overweight and obesity rates are higher, start at earlier ages and increase faster among Black and Latino children than among White children.  More than 20 percent of Black, 22.4 percent of Latino, 14.1 percent of White and 8.6 percent of Asian American children and teenagers ages 2 to 19 are obese.  Severe obesity rates are 8.5 percent among Black, 6.6 percent among Latino and 4.8 percent among White children.  35.2 percent of Black, 38.9 percent of Latino, and 28.5 percent of White children are overweight or obese.  More than 20 percent of Black and Latina girls and 15.6 percent of White girls are obese; 19.9 percent of Black boys, 24.1 percent of Latino boys and 12.6 percent of White boys are obese.  For 2- to 5-year-olds, 11.3 percent of Blacks, 16.7 percent of Latinos and 3.5 percent of Whites are obese.  By ages 6 to 11, 23 percent of Black children are obese compared to 13.1 percent of Whites. Among American Indian/Native Alaskan children:  25 percent of 2- to 5-year-olds are obese, and 45 percent are overweight or obese;  31 percent of 6- to 11-year-olds are obese, and 49 percent are overweight or obese; and  31 percent of 12- to 19-year-olds are obese, and 51 percent are overweight or obese. http://stateofobesity.org/files/stateofobesity2015.pdf

http://www.cdc.gov/obesity/data/prevalence-maps.html

http://www.cdc.gov/obesity/data/adult.html

What was the prevalence of obesity among adults in 2011–2014?

The prevalence of obesity was 36.5% (crude estimate) among U.S. adults during 2011–2014. Overall, the prevalence of obesity among middle-aged adults aged 40–59 (40.2%) and older adults aged 60 and over (37.0%) was higher than among younger adults aged 20–39 (32.3%). No significant difference in prevalence was observed between middle-aged and older adults (Figure 1). Overall, the prevalence of obesity among women (38.3%) was higher than among men (34.3%). For adults aged 20–39 and 40–59, the prevalence of obesity was higher among women than among men, but the difference between older women and men aged 60 and over was not significant. Among both men and women, the prevalence of obesity followed a similar pattern by age. Men aged 40–59 (38.3%) had a higher prevalence of obesity than men aged 20–39 (30.3%). Women aged 40–59 (42.1%) had a higher prevalence of obesity than women aged 20–39 (34.4%). The prevalence of obesity among men and women aged 20–39 was lower than among men and women aged 60 and over, except the difference for men was not significant.

Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. 2015

The prevalence of obesity among adults by race and Hispanic origin

The prevalence of obesity was lowest among non-Hispanic Asian adults (11.7%), followed by non-Hispanic white (34.5%), Hispanic (42.5%), and non-Hispanic black (48.1%) adults. All differences were significant. The pattern among women was similar to the pattern in the overall

61 adult population. The prevalence of obesity was 11.9% in non-Hispanic Asian, 35.5% in non- Hispanic white, 45.7% in Hispanic, and 56.9% in non-Hispanic black women. The prevalence of obesity was lower in non-Hispanic Asian (11.2%) men compared with non-Hispanic white (33.6%), non-Hispanic black (37.5%), and Hispanic (39.0%) men. No difference in obesity prevalence was observed between non-Hispanic black and non-Hispanic white men, nor was there a difference between non-Hispanic black and Hispanic men (Figure 2).

The only differences by sex were found among non-Hispanic black and Hispanic adults. The prevalence of obesity among non-Hispanic black women was 56.9% compared with 37.5% in non-Hispanic black men. The prevalence of obesity was 45.7% among Hispanic women compared with 39.0% in Hispanic men.

http://www.cdc.gov/nchs/data/databriefs/db219.pdf

Oregon

According to the Oregon Public Health report “2015 State Health Improvement Plan”,

 Obesity is the number two cause of preventable death in Oregon and nationally, second only to tobacco use.

 Obesity related conditions account for 1,400 deaths in Oregon each year.

 Preventing obesity among Oregonians lowers the risk of diabetes, heart disease, stroke, cancer, high blood pressure, high cholesterol, arthritis, stress and depression.

 Each year, Oregon spends about $1.6 billion ($339 million paid by Medicaid) in medical expenses for obesity-related chronic conditions such as diabetes and heart disease.

 Annual medical costs of persons who are obese are estimated to be $1,429 higher than those who are not obese.

 Obesity prevalence among Oregon adults has risen dramatically in the past two decades, from 11.2% in 1990 to 26.8% in 2013. (27.9% in 2014).

 The obesity rate for the state of Oregon was 25.9%.

 Multnomah County was 21.4%

 Clackamas count was 25.2%.

 Obesity is less prevalent among younger (18–24) and older (75+) age groups. Obesity is most prevalent between the ages of 35 to 74.

Obesity among adults by sex, race and ethnicity, Oregon 2010–2011

Information from State Health Improvement Plan

Between 1999–2002 and 2011–2014, the prevalence of obesity was stable among children aged 6–11; increased among adolescents aged 12–19; and increased from 1999–2002 to 2003–2006 among those aged 2–5, then declined through 2011–2014.

Excess body weight in children is associated with excess morbidity during childhood and excess body weight in adulthood (13–16). Obesity among children is defined as a body mass index at or above the sex-and age-specific 95th percentile of the CDC growth charts (15,16). From 1988–1994 to 1999–2002, obesity increased among children aged 2–19. Among children aged 2–5, the prevalence of obesity increased from 1999–2002 to 2003– 2006 and then declined through 2011–2014. Among children aged 6–11, the prevalence of obesity was stable from 1999–2002 to 2011– 2014. Between 1999–2002 and 2011–2014, the prevalence of obesity among adolescents aged 12–19 increased 28%.

SOURCE: CDC/NCHS, Health, United States, 2015, Table 59.

Data from the National Health and Nutrition Examination Survey (NHANES).

In 2011–2014, among children and adolescents aged 2–19, Hispanic children and adolescents had the highest prevalence of obesity (21.9%) and non-Hispanic Asian children and adolescents had the lowest prevalence (8.6%)

http://www.cdc.gov/nchs/data/hus/hus15.pdf

Heart Disease and Stroke

According to the U.S. Department of Health and Human Services • Centers for Disease Control and Prevention • National Center for Health Statistics report “Summary Health Statistics: National Health Interview Survey, 2014”

The age-adjusted percentages (with standard errors) of selected circulatory diseases among adults aged 18 and over, by selected characteristics: United States, 2014

Coronary Summary Health Statistics: National Health All Types of Heart Hypertension Stroke Interview Survey, 2014 Heart Disease Disease

Total 10.9 (0.21) 5.5 (0.16) 24.5 (0.27) 2.4 (0.010)

Sex:

Male 12.2 (0.31) 7.3 (0.26) 25.3 (0.41) 2.5 (0.15)

Female 9.8 (0.27) 4.0 (0.17) 23.7 (0.35) 2.4 (0.13)

Race:

White 11.1 (0.24) 5.6 (0.18) 23.5 (0.30) 2.3 (0.11)

Black or African American 10.3 (0.53) 5.5 (0.41) 33.1 (0.73) 4.0 (0.34)

American Indian or Alaska Native 13.7 (2.80) 6.0 (1.44) 26.4 (3.02) 3.0 (0.84)

Asian 6.0 (0.65) 3.3 (0.47) 19.5 (0.96) 1.5 (0.34)

Hispanic or Latino 7.8 (0.47) 4.9 (0.40) 23.0 (0.64) 2.4 (0.27)

Native Hawaiian or Other Pacific Islander 19.1 (5.51) 6.9 (2.06) 36.4 (6.50) *8.6 (3.84) * Estimates are considered unreliable.

Coronary Summary Health Statistics: National Health All Types of Heart Hypertension Stroke Interview Survey, 2014 Heart Disease Disease Total Education (adults 25 or older) Less than a high school diploma 13.7 (0.61) 8.5 (0.48) 31.6 (0.81) 3.8 (0.33) High school diploma or GED 12.4 (0.52) 7.4 (0.45) 31.0 (0.64) 3.1 (0.22) Some College 12.5 (0.43) 6.0 (0.31) 29.6 (0.61) 3.4 (0.25) Bachelor's degree or higher 10.8 (0.41) 5.0 (0.27) 22.3 (0.52) 1.3 (0.14) Poverty status Poor 13.8 (0.56) 8.3 (0.44) 30.3 (0.74) 3.9 (0.31) Near poor 12.5 (0.51) 7.2 (0.43) 27.9 (0.60) 4.1 (0.29) Not Poor 10.2 (0.27) 4.8 (0.19) 23.0 (0.34) 1.8 (0.12)

"Poor" persons live in families defined as below the poverty threshold. "Near poor" persons live in families with incomes of 100% to less than 200% of the poverty threshold. "Not poor" persons live in families with incomes that are 200% of the poverty threshold or greater.

The following is from the Oregon Health Authority’s “Oregon Vital Statistics Annual Report 2014-Volume 2”:

“Heart disease Despite brief occasional breaks in the long-term downward trend in its crude death rate, heart disease was the leading cause of death in Oregon during most of the 20th century. In 2001, for the first time, more deaths (five) resulted from cancer than from heart disease. During 2014, heart disease was the second leading cause of death; 6,523 Oregonians succumbed to it, 1,339 fewer than from malignant neoplasms. The crude death rate decreased from 165.8 in 2013 to 164.6 in 2014, while the age-adjusted death rate decreased from 134.6 per 100,000 population to 131.3. By comparison, the age-adjusted death rate was 264.2 in 1990, 101.2% higher than the 2014 rate. Heart disease was listed on 6,266 death certificates as a contributing factor in decedents’ death, but not the underlying cause. The 2014 crude death rate for heart disease was 20.3% higher for males than females (180.0 versus 149.6). The 2014 age-adjusted death rate for heart disease was 69.3% higher for males than females (170.5 versus 100.7). Heart disease was the leading cause of death for Oregonians age 85 or older and one of the top-five causes among all Oregonians, except decedents less than one year of age. It was the second leading cause of death for residents aged 55– 84. The median age at death was 83 years in 2014. The relatively older ages at which Oregonians died from heart disease suppress its rank among the causes of premature death; there were 24,665 years of potential life lost, making it the third leading cause of premature death following cancer and unintentional injuries. Excluding counties with fewer than 20 deaths due to heart disease, the age-adjusted death rates for eight Oregon counties during 2012–2014 were significantly higher than the state rate (132.1): Curry (176.2), Jefferson (167.1), Malheur (167.0), Baker (159.8), Coos (151.7), Linn (148.5), Douglas (146.4) and Multnomah (140.1). Significantly lower rates were recorded for four counties: Benton (106.5), Washington (112.6), Lane (123.8) and Clackamas (125.1).

Cerebrovascular disease (Stroke) Accounting for 5.3% of all deaths, cerebrovascular disease was the fourth leading cause of mortality among Oregonians. The number of deaths attributed to cerebrovascular disease increased from 1,769 in 2013 to 1,821 in 2014. The number of deaths in which this disease was a contributing factor remained the same in 2014 as in 2013 at 1,557 deaths. For the past decade, the crude death rate for this cause has trended downward; however, between 2013 and 2014, the crude death rate increased from 45.1 per 100,000 population to 46.0 per 100,000 population. The age- adjusted death rate remained at 37.0 in 2014. “More females than males died from cerebrovascular disease, and the male crude death rate was 16.4% lower than the female rate (41.8 versus 50.0). However, the age-adjusted rate for males was 16.8% higher than the rate for females (40.3 versus 34.5)”. “Fatal cerebrovascular disease was uncommon before age 45, but it was the fifth most common cause of death among Oregon residents aged 65–74 and fourth most common cause of death among Oregonians aged 75 and older. Nearly three-fourths (73.0%) of the deaths occurred after age 74, and the median age at death decreased from 84 in the previous year to 83 years in 2014. During the three-year period 2012– 2014, two counties had an age- adjusted death rate significantly higher than the state rate (37.2): Linn (45.1) and Josephine (44.3). Two counties had a significantly lower rate: Yamhill (30.7) and Washington (31.4). The cerebrovascular disease death rate has long been higher in Oregon than in the United States as a whole. In 2013, the age-adjusted death rate was 3.0% higher than the nation’s rate and ranked 22nd among the states, including the District of Columbia.” http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/Volume2/Docume nts/2014/2014%20VITAL%20STATS%20VOL%202.pdf

High Blood Pressure Hospitalization State National Rate per 1,000 Medicare Beneficiaries, All Race Black White All-Race All-Race 65+, all gender-age-adjusted

Multnomah County 2005-2007 1.5 5.1 1.3 1.2 3.6

2008-2010 1.5 5.4 1.3 1.1 3.3

2009-2011 1.7 5.9 1.5 1.2 3.3

2011-2013 2.2 7.1 1.8 1.2 3.1

Clackamas County

2005-2007 1.0 4.4 1.0 1.2 3.6

2008-2010 1.2 1.6 1.2 1.1 3.3

2009-2011 1.4 3.1 1.4 1.2 3.3

2011-2013 1.5 7.6 1.5 1.2 3.1

Insufficient data for Hispanic reporting

American Asian High Blood Pressure Death Indian State All and National Rate per 100,000 , 35+, all Black White Hispanic and All- Race Pacific All-Race gender-age-adjusted Alaskan Race Islander Native

Multnomah County 2005-2007 221.3 397.0 217.8 146.9 173.2 148.6 203.3 207.6 2008-2010 212.2 409.7 207.2 168.3 151.5 164.8 209.9 210.2 2009-2011 209.7 352.6 209.7 153.8 190.3 144.4 209.1 211.3 2011-2013 207.9 300.9 209.2 105.3 184.5 151.7 215.9 216.9 Clackamas County 2005-2007 189.6 308.1 191.8 125.3 196.8 135.5 203.3 207.6 2008-2010 199.4 362.6 199.1 150.1 222.8 155.8 209.9 210.2 2009-2011 192.8 329.6 193.8 155.0 169.7 135.2 209.1 211.3 2011-2013 207.9 300.9 209.2 105.3 184.5 151.7 215.9 216.9

American Asian Heart Disease Death Rate Indian State All and National per 100,000 , 35+, all Black White Hispanic and All- Race Pacific All-Race gender-age-adjusted Alaskan Race Islander Native Multnomah County 2005-2007 332.0 313.8 344.0 140.3 216.8 186.7 315.7 400.3 2008-2010 282.2 349.6 288.2 213.3 185.2 169.2 278.1 358.6 2009-2011 270.0 332.0 277.6 176.4 184.3 148.1 296.6 442.8 2011-2013 273.7 320.4 283.3 127.4 196.9 149.0 259.3 332.7 Clackamas County 2005-2007 302.6 317.3 309.3 99.8 177.8 183.5 315.7 400.3 2008-2010 262.7 270.1 267.2 140.6 173.4 162.7 278.1 358.6 2009-2011 254.4 228.3 258.5 151.4 173.9 150.6 296.6 442.8 2011-2013 245.5 265.8 250.1 129.0 190.6 150.8 259.3 332.7

American Asian Stroke Death Rate per Indian State All and National 100,000, 35+, all gender-age- Black White Hispanic and All- Race Pacific All-Race adjusted Alaskan Race Islander Native Multnomah County 2005-2007 101.0 164.3 93.8 75.8 * 96.2 96.6 88.2 2008-2010 78.8 115.8 77.8 76.5 * 81.4 82.9 78.2 2009-2011 83.7 109.8 82.8 67.0 * 72.7 81.2 75.5 2011-2013 80.4 107.4 78.1 43.9 93.1 78.3 75.4 71.8 Clackamas County 2005-2007 91.9 155.4 92.9 99.5 101.5 80.3 96.6 88.2 2008-2010 81.7 114.8 81.8 61.0 * 81.7 82.9 78.2 2009-2011 77.8 99.6 78.7 41.7 * 69.7 81.2 75.5 2011-2013 71.7 96.8 72.6 45.2 90.1 75.0 75.4 71.8 * insufficient data

Source of DHDSP data: http://nccd.cdc.gov/DHDSPAtlas/detailedreports.aspx?areaIds=41051&themeSubClassId=1&filterIds=9,2,3,4,7&filt erOptions=1,1,1,1,1#report

Heart Disease:  Second leading cause of death for Oregon as well as in Multnomah and Clackamas Counties.  Sixth among chronic diseases for adults

Cerebrovascular Disease:  Fourth leading cause of death for Oregon as well as in Multnomah and Clackamas Counties.  It is the fifth leading cause of death for men  It is the third leading cause of death for women

Death Rates per 100,000, 35+, All Gender Heart Disease % Change Death Rate 2011-2013 Death Rate 2008-2010 Death Rate 2005-2007

Oregon 259.3 278.1 315.7 -17.9% Multnomah County 273.7 282.2 332.0 -17.6% Clackamas County 245.5 262.7 302.6 -18.9% United States 332.7 358.6 400.3 -16.9% Heart Failure % Change Death Rate 2011-2013 Death Rate 2008-2010 Death Rate 2005-2007

Oregon 199.4 194.2 205.6 -3.0% Multnomah County 224.9 209.5 223.0 0.9% Clackamas County 200.1 185.6 199.6 0.3% United States 160.9 166.3 180.9 -11.1% Stroke (all) % Change Death Rate 2011-2013 Death Rate 2008-2010 Death Rate 2005-2007

Oregon 75.4 82.9 96.6 -21.9% Multnomah County 80.4 78.8 101.0 -20.4% Clackamas County 71.7 81.7 91.9 -22.0% United States 71.8 78.2 88.2 -18.6% All ages, races and genders http://nccd.cdc.gov/DHDSPAtlas/Default.aspx

Heart Disease Facts

 Heart disease is the leading cause of death for both men and women. More than half of the deaths due to heart disease in 2009 were in men.  About 610,000 Americans die from heart disease each year—that’s 1 in every 4 deaths.  Coronary heart disease is the most common type of heart disease, killing more than 385,000 people annually.  Every year about 735,000 Americans have a heart attack. Of these, 525,000 are a first heart attack and 210,000 happen in people who have already had a heart attack.2  Coronary heart disease alone costs the United States $108.9 billion each year. This total includes the cost of health care services, medications, and lost productivity.  In the United States, someone has a heart attack every 34 seconds. Each minute, someone in the United States dies from a heart disease-related event.  Heart disease is the leading cause of death for people of most racial/ethnic groups in the United States, including African Americans, Hispanics, and whites. For Asian Americans or Pacific Islanders and American Indians or Alaska Natives, heart disease is second only to cancer.

Risk Factors

High blood pressure, high LDL cholesterol, and smoking are key heart disease risk factors for heart disease. About half of Americans (47%) have at least one of these three risk factors.5 Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including:  Diabetes  Overweight and obesity  Poor diet  Physical inactivity  Excessive alcohol use

Heart disease is the leading cause of death for people of most ethnicities in the United States, including African Americans, Hispanics, and whites. For American Indians or Alaska Natives and Asians or Pacific Islanders, heart disease is second only to cancer. Below are the percentages of all deaths caused by heart disease in 2008, listed by ethnicity.4

Race of Ethnic Group % of Deaths African Americans 23.8 American Indians or Alaska Natives 18.4 Asians or Pacific Islanders 22.2 Hispanics 20.8 Whites 23.8 All 23.5 Heart Disease Fact Sheet|Data & Statistics|DHDSP|CDC

Stroke Facts

 Stroke is a leading cause of death in the United States, killing nearly 130,000 Americans each year—that’s 1 of every 19 deaths.  A stroke, sometimes called a brain attack, occurs when a clot blocks the blood supply to the brain or when a blood vessel in the brain bursts.  Someone in the United States has a stroke every 40 seconds. Every four minutes, someone dies of stroke.  Every year, about 800,000 people in the United States have a stroke. About 610,000 of these are first or new strokes; 185,000 are recurrent strokes.  Stroke is an important cause of disability. Stroke reduces mobility in more than half of stroke survivors age 65 and over.  Stroke costs the nation $34.0 billion annually, including the cost of health care services, medications, and lost productivity.  You can’t control some stroke risk factors, like heredity, age, gender, and ethnicity. Some medical conditions—including high blood pressure, high cholesterol, heart disease, diabetes, overweight or obesity, and previous stroke or transient ischemic attack (TIA)—can also raise your stroke risk. Avoiding smoking and drinking too much alcohol, eating a balanced diet, and getting exercise are all choices you can make to reduce your risk.

Stroke Facts | cdc.gov

Risk Factors High blood pressure, high cholesterol, and smoking are major risk factors for stroke. About half of Americans (49%) have at least one of these three risk factors. Several other medical conditions and unhealthy lifestyle choices can increase your risk for stroke.

Medical Conditions

High blood pressure. High blood pressure, also called hypertension, can greatly increase your risk for stroke. Smoking cigarettes, eating a diet high in salt, and drinking too much alcohol can all raise your blood pressure.

High blood cholesterol. High blood cholesterol can build up fatty deposits (plaque) on blood vessel walls. The deposits can block blood flow to the brain, causing a stroke. Diet, exercise, and family history affect blood cholesterol levels.

Heart disease. Common heart disorders can increase your risk for stroke. For example, coronary artery disease (CAD) increases your risk because a fatty substance called plaque blocks the arteries that bring blood to the heart. Other heart conditions, such as heart valve defects, irregular heartbeat (including atrial fibrillation), and enlarged heart chambers, can cause blood clots that may break loose and cause a stroke.

Diabetes. Having diabetes can increase your risk of stroke and can make the outcome of strokes worse. Diabetes is a condition that causes blood to build up too much sugar instead of delivering it to body tissues. High blood sugar tends to occur with high blood pressure and high cholesterol.

Overweight and obesity. Being overweight or obese can raise total cholesterol levels, increase blood pressure, and promote the development of diabetes.

Previous stroke or transient ischemic attack (TIA). If you have already had a stroke or a TIA, also known as a "mini-stroke," there is a greater chance that you could have a stroke in the future.

Sickle cell disease. This is a blood disorder that is associated with ischemic stroke, and mainly affects African-American and Hispanic children. A stroke can happen if sickle cells get stuck in a blood vessel and clog blood flow to the brain. About 10% of children with sickle cell disease will have a stroke.

Tobacco Use

Smoking injures blood vessels and speeds up the hardening of the arteries. The carbon monoxide in cigarette smoke reduces the amount of oxygen that your blood can carry. Secondhand smoke can increase the risk of stroke for nonsmokers.

Alcohol Use

Drinking too much alcohol raises your blood pressure, which increases the risk for stroke. It also increases levels of triglycerides, a form of cholesterol, which can harden your arteries.

Physical Inactivity

Not getting enough exercise can make you gain weight, which can lead to increased blood pressure and cholesterol levels. Inactivity also is a risk factor for diabetes.

Stroke Heredity

 Family history. Having a family history of stroke increases the chance of stroke. Find out more about this type of risk at CDC's genomics and disease prevention Web site.

 Age and gender. The older you are, the more likely you are to have a stroke. For ages 65 and older, men are at greater risk than women to have a stroke.

 Race and ethnicity. Blacks, Hispanics, and American Indian/Alaska Natives have a greater chance of having a stroke than do non-Hispanic whites or Asians. See CDC's interactive maps to learn more about race and the risk for stroke.

http://www.cdc.gov/stroke/risk_factors.htm

Health Promotion and Prevention Programs

Oregon Health Authority Center for Prevention and Health Promotion 5 Year Strategic Plan 5-Year Heart Disease and Stroke Health Outcome (July 2012 – June 2017)

By June 30, 2017, the rate of heart attack hospitalization among Oregon adults ages 74 or younger will be reduced by 12 percent.

The 2010 baseline was 135 hospitalizations per 100,000 people under the age of 74 and the 2017 target is 119 hospitalizations per 100,000 people under the age of 74. Leading risk factors for heart disease and stroke include diabetes, high blood pressure, high cholesterol, obesity, tobacco use and physical inactivity. As reproduced from the Oregon Health Authority (OHA) Health Promotion and Chronic Disease Prevention 5-Year Strategic Plan (2012-2017) http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/documents/hpcdp-strategic-plan.pdf

Healthy People 2020

What Is Healthy People? Healthy People is a set of goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States.

About Healthy People | Healthy People 2020

Blood Cholesterol

The following is from the NCHS Data Brief • No. 226 • December 2015 During 2011–2014, approximately 12% of adults had high total cholesterol and nearly 19% had low HDL cholesterol. Overall and when examined by sex, non-Hispanic black adults had a lower prevalence of high total cholesterol than non-Hispanic white and Hispanic adults. Non-Hispanic black men had a lower prevalence of low HDL cholesterol than non-Hispanic white and Hispanic men; non-Hispanic black and non-Hispanic Asian women had lower prevalence of low HDL cholesterol than non-Hispanic white and Hispanic women. Declining trends between 2007–2008 and 2013–2014 were seen in the prevalence of both high total cholesterol and low HDL cholesterol among adults. These results are based on measured cholesterol only and do not take into account whether cholesterol-lowering medications were taken. Total cholesterol and HDL cholesterol are two lipid measures that clinicians may use to assess patient health. In fact, clinicians may use both of these lipid measures, in addition to systolic blood pressure, smoking, and diabetes, to calculate the risk of developing diseases associated with atherosclerosis, such as heart disease and stroke (5). Therefore, both of these lipid measures are important to clinical practices designed to reduce cardiovascular disease in the United States.

Total cholesterol is also used to monitor the health of the U.S. population. One of the Healthy People 2020 goals regarding total cholesterol is to reduce the percentage of adults with high total blood cholesterol levels to 13.5% (6). For 2011–2014, approximately 12% of adults aged 20 and over had high total cholesterol, thus meeting this goal. Adults aged 20–39 and 60 and over also achieved this goal, but adults aged 40–59 (16.0%) did not. This target was met in all sex and race and Hispanic-origin groups except for non-Hispanic white women (13.8%).

Definitions High total cholesterol: Serum total cholesterol greater than or equal to 240 mg/dL. Low HDL cholesterol: Serum HDL cholesterol less than 40 mg/dL. Healthy People 2020; Heart Disease and Stroke, Object 7: Reduce the proportion of adults with high total blood cholesterol levels, target: 13.5%

Data from the National Health and Nutrition Examination Survey

 During 2011–2014, 12.1% of adults had high total cholesterol and 18.5% had low high- density lipoprotein (HDL) cholesterol.  The prevalence of high total cholesterol was lower in non-Hispanic black men than in non-Hispanic white, non-Hispanic Asian, and Hispanic men, and lower in non-Hispanic black women than in non-Hispanic white and Hispanic women.  Low HDL cholesterol prevalence was lower in non-Hispanic black and non-Hispanic Asian men and women than in Hispanic men and women; in non-Hispanic black men and women than in non-Hispanic white men and women; and in non-Hispanic Asian women than in non- Hispanic white women.  From 2007 to 2014, the percentage of adults with high total and low HDL cholesterol declined.

Approximately 12% of adults had high total cholesterol during the 4-year period. Overall, the percentage with high total cholesterol was lowest for adults aged 20–39 and highest for adults aged 40–59: 7.5% for age group 20–39, 12.9% for 60 and over, and 16.0% for 40–59. The percentage of men with high total cholesterol was higher for those aged 40–59 (15.3%) than for those aged 20–39 (8.2%) or 60 and over (7.3%). The percentage of women with high total cholesterol was lower for those aged 20–39 (6.8%) than for those aged 40–59 (16.7%) or 60 and over (17.7%) (Figure 1).

A lower percentage of men (10.6%) than women (13.0%) had high total cholesterol. The percentage with high total cholesterol did not differ by sex for those aged 20–39 and 40–59, but was lower for men aged 60 and over (7.3%) than for women in the same age group (17.7%). Overall, the percentage of adults with high total cholesterol was lower for non-Hispanic black (8.6%) than for non-Hispanic white (12.5%) and Hispanic (13.1%) adults. The same race and Hispanic-origin patterns were seen in men (7.3%, 10.8%, and 13.5%, respectively) and in women (9.6%, 13.8%, and 12.5%, respectively). Overall and for men, the prevalence of high total cholesterol was lower in non-Hispanic black than in non-Hispanic Asian subgroups, but this difference was not seen in women. Non-Hispanic white women had higher prevalence of high total cholesterol (13.8%) than non-Hispanic white men (10.8%) (Figure 2).

More than 18% of adults aged 20 and over (27.9% of men and approximately 10.0% of women) had low HDL cholesterol over the 4-year period. Overall, the percentage of adults with low HDL cholesterol was lower among those aged 60 and over (15.3%) than among those aged 20–39 (19.5%) or 40–59 (19.8%). A lower percentage of men aged 60 and over (25.0%) than those aged 40–59 (30.2%) had low HDL cholesterol. A lower percentage of women aged 60 and over (7.2%) had low HDL cholesterol compared with those aged 20–39 (11.7%) or 40–59 (9.9%). The percentage with low HDL cholesterol was consistently lower in women than in men in each age group (Figure 3).

Overall, the prevalence of low HDL cholesterol was lower in non-Hispanic black (13.6%) and non-Hispanic Asian (15.2%) adults than in non-Hispanic white (19.1%) and Hispanic (21.1%) adults. The prevalence of low HDL cholesterol was lower in non-Hispanic black (20.7%) and non- Hispanic Asian (25.0%) men than in Hispanic (30.7%) men. A lower percentage of non-Hispanic black men had low HDL cholesterol compared with non-Hispanic white men (28.4%), but no difference was observed between non-Hispanic Asian and non-Hispanic white men. The prevalence of low HDL cholesterol was lower in non-Hispanic black (8.0%) and non-Hispanic Asian (6.7%) women than in non-Hispanic white (10.3%) or Hispanic (11.8%) women. The

84 percentage with low HDL cholesterol was consistently lower in women than in men of the same racial and ethnic group (Figure 4).

Section above is from: Total and High-density Lipoprotein Cholesterol in Adults: United States, 2011–2014

.Carroll MD, Fryar CD, Kit BK. Total and high-density lipoprotein cholesterol in adults: United States, 2011– 2014. NCHS data brief, no 226. Hyattsville, MD: National Center for Health Statistics. 2015.

NCHS Data Brief • No. 226 • December 2015

Cholesterol helps the body build new cells, insulate nerves and produce hormones. However, too much cholesterol in the blood can build up on the walls of arteries and block blood flow to vital organs such as the heart and brain, which can lead to heart disease and stroke. High cholesterol is also an indicator for diabetes, as elevated levels of cholesterol are seen in people with insulin resistance. High cholesterol is caused by excess fat — particularly trans fats — in the diet, being overweight or obese, lack of physical activity and cigarette smoking.

High cholesterol tends to affect some more than others. Age and genetic predisposition are important factors that contribute to high cholesterol. Poor nutrition, excessive intake of trans fats, lack of physical activity and cigarette smoking can also trigger high cholesterol or make treating high cholesterol more complicated. There are no symptoms of high cholesterol. Many people have never had their cholesterol checked and are unaware that they are at risk for the associated chronic diseases. Cholesterol levels can be determined with a simple blood test. Preventing high cholesterol or lowering cholesterol levels if already high can be achieved through eating a healthy diet low in trans fats, maintaining a healthy weight, exercising regularly, not cigarette smoking and treating high cholesterol through medication.

 In Oregon, 64% of adults with diabetes and 67% of adults with heart disease or stroke have high cholesterol, compared with 33% of the general population.

 Oregon adults with less than a high school education are 23% more likely to have high cholesterol and 24% less likely to have had a cholesterol screening in the past five years compared to Oregon adults with a college degree.  During the last 20 years, high cholesterol in the Oregon adult population increased by 26%, from 26% in 1990 to 33% in 2011.  More than 1.1 million adults in Oregon have high cholesterol.  The percentage of adults who have high cholesterol increased 27% during the past 20 years, from 25.8% in 1990 to 32.7% in 2011.  Fewer Oregon adults (32.7%) currently report high cholesterol compared to the overall U.S. population (34.2%). However, the prevalence of high cholesterol among adults in Oregon and the United States has been fairly similar over time.  More African American (38.3%) and American Indian/Alaska Native (38.6%) persons reported high cholesterol compared to other racial and ethnic groups (Figure 2.4.11)  The percentage of non-Latino African American persons who reported high cholesterol was 12.6% higher than non-Latino white persons (Figure 2.4.11).

Age-adjusted Prevalence of High Cholesterol Among Adults, by County, 2008-2011 Clackamas 33.1% Multnomah 32.4% Oregon 32.2%

Data source: Oregon BRFSS County Combined Dataset 2008–2011 Note: Age-adjusted estimates are adjusted to the 2000 Standard Population using three age groups (18–34, 35–54 and 55+)

Age-adjusted Prevalence of High Cholesterol Among Adults, by County, 2010-2013 Clackamas 34.2% Multnomah 30.8% Oregon 31.8%

Oregon Health Authority, Public Health Division, Health Promotion and Chronic Disease Prevention section. Health risk and protective factors among Oregon adults, by county, 2010‐2013. https://public.health.oregon.gov/DiseasesConditions/ChronicDisease/DataReports/Pages/CountyData.aspx. Created March 9, 2015. Accessed August 2016.

Abnormal Cholesterol Among Children and Adolescents in the United States, 2011–2014 Duong Nguyen, D.O.; Brian Kit, M.D., M.P.H.; and Margaret Carroll, M.S.P.H.

Approximately one out of five children and adolescents (21%) had at least one abnormal cholesterol measure (high total cholesterol, low HDL cholesterol, or high non-HDL cholesterol). Of the three cholesterol measures examined in this report, low HDL cholesterol was the most common abnormality. In general, prevalence of high total cholesterol, low HDL cholesterol, and high non-HDL cholesterol was greater in adolescents aged 16–19 compared with children aged 6–8. Children and adolescents with obesity had the highest prevalence for all cholesterol measures examined, most notably with low HDL cholesterol where prevalence was five times greater among those with obesity than for those of normal weight, similar to previous studies. Some CVD risk factors, including cholesterol, track from childhood into adulthood. To identify children with abnormal cholesterol values, clinical practice guidelines endorsed by the American Academy of Pediatrics recommend monitoring cholesterol for all children, including those aged 9–11 years. In this analysis, 7.4% of children and adolescents aged 6–19 had high total cholesterol. Continued monitoring of abnormal cholesterol levels among children and adolescents may inform public health interventions to promote long-term cardiovascular health and prevent CVD in adulthood.

 One in five youths had high total cholesterol, low high-density lipoprotein (HDL) cholesterol, or high non-HDL cholesterol.  Prevalence of low HDL cholesterol (13.4%) was greater than high non-HDL cholesterol (8.4%) or high total cholesterol (7.4%).

 Prevalence of high total cholesterol, low HDL cholesterol, and high non-HDL cholesterol was greater in adolescents than children.  Girls had higher prevalence than boys for high total cholesterol and high non- HDL cholesterol, but lower prevalence for low HDL cholesterol.  Youth with obesity had greater prevalence of high total cholesterol, low HDL cholesterol, and high non-HDL cholesterol than youth of normal weight.

The prevalence of high total cholesterol among U.S. children and adolescents was 7.4% (Figure 1). The prevalence of high total cholesterol was greater among adolescents aged 16–19 (8.9%) than children aged 6–8 (6.0%). The prevalence of high total cholesterol was lower in boys (5.9%) than in girls (8.9%). The prevalence of high total cholesterol was greater among non- Hispanic black and non-Hispanic Asian children and adolescents and lower among non-Hispanic white and Hispanic children and adolescents. The prevalence of high total cholesterol was greater in children and adolescents with obesity (11.6%) than in those of normal weight (6.3%) and in those who were overweight (6.9%).

Overall, 13.4% of all children and adolescents had low HDL cholesterol (Figure 2). There was an increasing age trend in the prevalence of low HDL cholesterol, from 7.7% for children aged 6–8 to 18.4% for adolescents aged 16–19. Boys (14.8%) had a higher prevalence of low HDL

89 cholesterol than girls (12.0%). Both non-Hispanic black (7.4%) and non-Hispanic Asian (8.2%) children and adolescents had a lower prevalence of low HDL cholesterol than non-Hispanic white (14.4%) or Hispanic (15.6%) children and adolescents. The prevalence of low HDL cholesterol increased with increased body mass index (BMI). Furthermore, the prevalence of low HDL cholesterol among children and adolescents with obesity (33.2%) was almost five times higher than for children and adolescents of normal weight (6.8%).

The overall prevalence of high non-HDL cholesterol among children and adolescents was 8.4% (Figure 3). The prevalence of high non-HDL cholesterol among adolescents aged 16–19 was higher than among children and adolescents aged 6–8, 9–11, and 12–15, and no differences were seen between children and adolescents in the other age groups. The prevalence of high non-HDL cholesterol was greater in girls (9.4%) than in boys (7.5%), but did not differ among race and Hispanic origin groups. High non-HDL cholesterol prevalence increased with increased BMI, and the prevalence among children and adolescents with obesity (16.7%) was almost three times higher than children and adolescents of normal weight (5.7%).

The above children and adolescents’ data from the NCHS Data Brief ■ No. 228 ■ December 2015

Nguyen DT, Kit BK, Carroll MD. Abnormal cholesterol among children and adolescents in the United States, 2011–2014. NCHS data brief, no 228. Hyattsville, MD: National Center for Health Statistics. 2015.

Products - Data Briefs - Number 228 - December 2015

High blood pressure (hypertension)

High blood pressure is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. Blood pressure is determined both by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure. You can have high blood pressure (hypertension) for years without any symptoms. Even without symptoms, damage to blood vessels and your heart continues and can be detected. Uncontrolled high blood pressure increases your risk of serious health problems, including heart attack and stroke. High blood pressure generally develops over many years, and it affects nearly everyone eventually. Fortunately, high blood pressure can be easily detected. And once you know you have high blood pressure, you can work with your doctor to control.

By Mayo Clinic Staff high blood pressure (hypertension) - Mayo Clinic

High Blood Pressure in the United States

 Having high blood pressure puts you at risk for heart attack and stroke, which are leading causes of death in the United States.  About 75 million American adults (32%) have high blood pressure—that’s 1 in every 3 adults.  About 1 in 3 American adults has prehypertension—blood pressure numbers that are higher than normal—but not yet in the high blood pressure range.  Only about half (54%) of people with high blood pressure have their condition under control.  High blood pressure was a primary or contributing cause of death for more than 410,000 Americans in 2014—that's more than 1,100 deaths each day.  High blood pressure costs the nation $48.6 billion each year. This total includes the cost of health care services, medications to treat high blood pressure, and missed days of work.

Risk Factors for High Blood Pressure

Having certain medical conditions can increase your chances of developing high blood pressure. These conditions include

 Prehypertension (http://www.cdc.gov/bloodpressure/conditions.htm).  Diabetes (http://www.cdc.gov/diabetes/index.html). Unhealthy behaviors can also increase your risk for high blood pressure, especially for people who have one of the medical conditions listed above. Unhealthy behaviors include

 Smoking tobacco.  Eating foods high in sodium (http://www.cdc.gov/salt) and low in potassium.  Not getting enough physical activity.  Being obese.  Drinking too much alcohol

High Blood Pressure Fact Sheet|Data & Statistics|DHDSP|CDC

Oregon 2013 Adult Hypertension rate: 31.8% 2013 Rank among states: 24/51 2010 Hypertension Cases: 749,127 2030 Projected Cases at current rate: 989,454

Oregon Data Source: Oregon State Obesity Data, Rates and Trends: The State of Obesity

High blood pressure  More than 900,000 adults in Oregon have high blood pressure.  The percentage of Oregon adults with high blood pressure increased 33% during the past 20 years, from 20.7% in 1990 to 27.6% in 2011.  Fewer Oregon adults (27.6%) report high blood pressure compared with the overall U.S. population (30.2%), which has been consistent over time.  The percentage of African American persons who report high blood pressure was nearly double that of white persons.  Diabetes also increases a person’s risk for developing high blood pressure.  Among adults with diabetes: 68% have high blood pressure; 73.2% of those with high blood pressure are taking medication for high blood pressure.  Among adults surviving a heart attack: 50% have high blood pressure; 89% of those with high blood pressure are taking medication for high blood pressure.  The proportion of adults with high blood pressure has been increasing over the last 15 years in Oregon and nationally.  Fewer Oregon adults reported high blood pressure compared with the overall U.S. population, which has been consistent over time.  From 1995 to 2011, the percentage of Oregonians with high blood pressure increased by 16.5%.  The prevalence of high blood pressure increases greatly with age. More than half of Oregonians aged 65 and older had been diagnosed with high blood pressure, compared to less than 13% of adults aged 18–44.

High blood pressure is called the “silent killer” because many people don’t realize they have it. High blood pressure often has no warning signs or symptoms. The only way to detect whether or not you have high blood pressure is to have your blood pressure measured by a doctor or health professional — it is quick and painless. Lowering blood pressure by changes in lifestyle — such as quitting cigarette smoking, exercising or taking medication — can lower the risk of heart disease and heart attack.

http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/Documents/OHA8582_AllVolumes.pdf

Healthy People 2020 objective- Reduce the proportion of adults with hypertension to 26.9%.

Prehypertension

Prehypertension is blood pressure that is slightly higher than normal. Prehypertension increases the risk that you will develop chronic, or long-lasting, high blood pressure in the future.

If your blood pressure is between 120/80 mmHg and 139/89 mmHg, you have prehypertension. Learn more about how blood pressure is measured(http://www.cdc.gov/bloodpressure/measure.htm). You can take steps to control your blood pressure(http://www.cdc.gov/bloodpressure/control.htm) and keep it in a healthy range.

Blood Pressure Levels Systolic: less than 120 mmHg Normal Diastolic: less than 80 mmHg Systolic: 120–139 mmHg At Risk (Prehypertension) Diastolic: 80–89 mmHg Systolic: 140 mmHg or higher High Diastolic: 90 mmHg or higher Conditions That Increase Risk for High Blood Pressure | cdc.gov

Chronic Obstructive Pulmonary Disease

COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants—such as air pollution, chemical fumes, or dust—also may contribute to COPD. What Is COPD? - NHLBI, NIH

COPD includes two main illnesses: chronic bronchitis and emphysema. Most people who have COPD have both of these conditions.

Chronic lower respiratory disease, primarily COPD, was the third leading cause of death in the United States in 2011. Fifteen million Americans report that they have been diagnosed with COPD. More than 50% of adults with low pulmonary function were not aware that they had COPD; therefore, the actual number may be higher. The following groups were more likely to report COPD:  People aged 65–74 years.  Non-Hispanic whites.  Women.  Individuals who were unemployed, retired, or unable to work.  Individuals with less than a high school education.  People with lower incomes.  Individuals who were divorced, widowed, or separated.  Current or former smokers.  Those with a history of asthma. CDC - COPD Home Page - Chronic Obstructive Pulmonary Disease (COPD)

Death Rates (per 100,000 U.S. Population) for Chronic 48.0 Obstructive Pulmonary Diseases, United States 46.0 44.0 42.0 40.0 38.0

Death Rateper 100,000 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year http://www.cdc.gov/nchs/data

According to the American Lung Association’s Disparities in Lung Health Series “The Rise of COPD in Women”

“Today, more than 7 million women in the United States have COPD, and millions more have symptoms but have yet to be diagnosed. Women have higher rates of COPD than men throughout most of their lifespan, although it appears that they are especially vulnerable before the age of 65. The profile of the “typical” woman with COPD is not that different from the “typical” man with the disease, and also looks a lot like the average smoker. She is most likely to be white, to reside in a southeastern or Appalachian state and to have an income below the poverty level. A small number of people have a rare inherited form of COPD called alpha-1 antitrypsin deficiency, which occurs about equally in women and men.

Women with COPD experience the disease differently than men, in ways that increase their burden. COPD is a disease that brings with it a heavy burden on patients and families. It often means years of poor health, lost productivity and costly healthcare expenses. Women with COPD have more frequent disease flare-ups, which are a sudden worsening of COPD symptoms that are often caused by a cold or other lung infection. These bouts of illness may require urgent care or emergency department visits, and sometimes hospitalization. Each flare up accelerates the progressive loss of breathing ability, eventually leading to long-term disability and death.” Copyright ©2013 by the American Lung Association. American Lung Association® and Fighting for Air® are registered trademarks. Designed by Barbieri & Green, Inc., Takoma Park, MD June

Lung Health Disparities | American Lung Association

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Asthma

Is asthma really a problem? Yes. Asthma is a serious health and economic concern in the United States. It’s expensive. •Asthma costs the United States $56 billion each year. •The average yearly cost of care for a child with asthma was $1,039 in 2009. In 2008, asthma caused: •10.5 million missed days of school •14.2 million missed days of work It’s common. In 2010: •18.7 million adults had asthma. That’s equal to 1 in 12 adults. •7 million children had asthma. That’s equal to 1 in 11 children. It’s deadly. •About 9 people die from asthma each day. •In 2009, 3,388 people died from asthma. What makes a person more likely to have asthma? Gender: •Women are more likely to have asthma than men. •In children, boys are more likely to have asthma than girls. Age:  Adults ages 18 to 24 are more likely to have asthma than older adults. Race and ethnicity: •Multi-race and black adults are more likely to have asthma than white adults. •Black children are 2 times more likely to have asthma than white children. Education level:  Adults who didn’t finish high school are more likely to have asthma than adults who graduated high school or college. Income level:  Adults with an annual household income of $75,000 or less are more likely to have asthma than adults with higher incomes. http://www.cdc.gov/asthma/

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National

National Centers for Disease Control and Prevention Adult Self-reported Asthma Prevalence Rate by State, BRFSS 2013 Table A-2a. Age-adjusted percentages (with standard errors) of selected respiratory diseases among adults aged 18 and over, by selected characteristics: United States, 2014

Ever had Still Have Hay Selected Characteristic Sinusitis Asthma Asthma fever 7.7 11.9 Total Total 12.9 (0.27) 7.4 (0.20) (0.22) (0.25) Sex 6.6 Male 10.8 (0.35) 5.1 (0.26) (0.29) 8.6 (0.33) 8.7 14.9 Female 14.8 (0.40) 9.6 (0.30) (0.31) (0.34) Race 8.0 12.2 White 12.7 (0.31) 7.3 (0.24) (0.26) (0.28) 6.0 12.1 Black 15.0 (0.69) 8.6 (0.53) (0.42) (0.59) American Indian or 8.1 10.3 Alaska Native 14.2 (2.43) 10.4 (2.11) (1.93) (1.95) 5.8 Asian 9.2 (0.79) 4.9 (0.61) (0.60) 6.6 (0.77) 5.8 Hispanic 10.4 (0.51) 5.9 (0.40) (0.47) 9.0 (0.52)

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6.9 12.2 Family Income Less than $35,000 15.0 (0.44) 9.3 (0.35) (0.31) (0.39)

Suggested citation: Blackwell DL, Lucas JW. Tables of Summary Health Statistics for U.S. Adults: 2014 National Health Interview Survey. 2015. Available from: http://www.cdc.gov/nchs/nhis/SHS/tables.htm. SOURCE: CDC/NCHS, National Health Interview Survey, 2014.

National Current Asthma* Prevalence (2014)

Characteristic** Number with Current Percent with Current Asthma (in thousands) Asthma

Total 24,009 7.7%

Child (Age <18) 6,292 8.6%

Adult (Age 18+) 17,717 7.4%

All Age Groups

0-4 years 849 4.3%

5-14 years 4,244 10.3%

15-19 years 1,912 9.1%

20-24 years 1,890 8.9%

25-34 years 3,133 7.5%

35-64 years 8,897 7.3%

65+ years 3,084 6.9%

Child Age Group

0-4 years 849 4.3%

5-11 years 3,021 10.6%

12-17 years 2,422 9.7%

Young Teens (12–14 years) 1,223 9.7%

Teenagers (15–17 years) 1,199 9.7%

Adolescents (11–21 years) 4,236 9.3%

Young Adults (22–39 years) 5,634 7.6%

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Sex

Males 9,659 6.3%

Boys (Age <18) 3,770 10.1%

Men (Age 18+) 5,889 5.1%

Females 14,350 9.0%

Girls (Age <18) 2,522 7.0%

Women (Age 18+) 11,828 9.6%

Race/Ethnicity

White NH 14,852 7.6%

Child (Age <18) 2,910 7.6%

Adult (Age 18+) 11,942 7.6%

Black NH 3,760 9.9%

Child (Age <18) 1,332 13.4%

Adult (Age 18+) 2,428 8.7%

Other NH 1,746 7.0%

Child (Age <18) 533 7.6%

Adult (Age 18+) 1,213 6.8%

Hispanic 3,651 6.7%

Child (Age <18) 1,516 8.5%

Adult (Age 18+) 2,135 5.8%

Puerto Rican† 817 16.5%

Child (Age <18) 365 23.5%

Adult (Age 18+) 452 13.3%

Mexican/Mexican American† 1,952 5.7%

Child (Age <18) 857 7.1%

Adult (Age 18+) 1,095 4.9%

Federal Poverty Threshold

Below 100% of poverty level 5,180 10.4%

100% to less than 250% of poverty level 6,746 7.6%

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250% to less than 450% of poverty level 6,237 7.6%

450% of poverty level or higher 5,846 6.3% Note: NH = Non-Hispanic *Includes persons who answered “yes” to the questions: “Have you EVER been told by a doctor or other health professional that you had asthma?” and “Do you still have asthma?” **Numbers within selected characteristics may not sum to total due to rounding †As a subset of Hispanic Source: 2014 National Health Interview Survey (NHIS) Data, (Note: Child Age Group data analyzed separately) Lower income levels may have greater exposure to asthma triggers. They also have greater percentage of smokers. In addition to the risk factors for the lower income population, the lack of medical insurance or assistance makes it difficult for those with asthma to afford the medications and care necessary to control their disease. Death rates due to asthma have consistently decreased since 1999.

______

In a 2013 report “The Burden of Asthma”, by the Oregon Asthma Program, it is stated that in 2011, 10.8% of adults and 7.8% of children in Oregon had asthma, meaning that almost 387,000 Oregonians had asthma. The burden of asthma is both economic and personal, affecting the state with direct costs (e.g., hospitalizations and emergency department visits) and indirect costs (e.g., missed school and work days and days of restricted activity) as well as reducing the quality of life for people with asthma and their families.

Asthma Risk Factors: • One in four Oregonians with asthma is a smoker (25.3%), which is a higher percentage than among people who do not have asthma (20.0%). Tobacco smoke is an asthma trigger. People with asthma should not smoke or be exposed to secondhand smoke. Those who do smoke should be offered tobacco cessation assistance such as the Oregon Tobacco Quit Line.

• Adult Oregonians with asthma report lower exposure to secondhand smoke (13.3%) than those without asthma (18.3%). However, no one with asthma should be exposed.

• Over 94% of adults (those with or without asthma) report having rules against smoking in the home. A smaller percentage of adults with asthma (87.7%) and without asthma (89.1%) have rules against smoking in the car.

• A higher percent of extremely obese people reported having asthma (20.4%) than healthy weight individuals (8.5%).

• Most Oregonians with asthma live in homes with carpeting in the bedroom (78.7% of adults and 76.2% of children) and dogs in the home (69.3% of adults and

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76.2% of children). In addition, many live in homes where there were wood burning stoves (34.3% of adults and 31.9% of children) or mold had been seen or smelled in the past 30 days (15.0% of adults and 11.3% of children). These are all important indoor asthma triggers.

Common asthma triggers include tobacco and other smoke, animals with fur or feathers, breathing cold air, pollen from trees, flowers, and plants, mold or mildew, and other sources. Direct costs associated with asthma include hospitalization and emergency visits.

More than one out of four Oregon adults with asthma smoke, and 13% of non-smoking adults with asthma report being exposed to secondhand smoke, both of which are significant triggers for asthma. Conversely, although 94% of Oregon adults with asthma say they have rules against smoking in the home, many are exposed to secondhand smoke, a major asthma trigger. ______

Prevalence of Adults with Current Asthma

12.0

10.0

8.0 Oregon 6.0 U.S.

Percentage 4.0

2.0

0.0 2008 2009 2010 2011 2012 2013 2014 Year

Data source: Oregon Behavioral Risk Factor Surveillance System, National data from Behavioral Risk Factor Surveillance System.

Asthma Severity among Adults with Current Asthma Intermittent Severity % Persistent Severity % U.S. Total 35.2 64.8 Oregon 34.6 65.4

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Percent of Adults who are Obese People with Asthma who are People without Asthma who Obese % are Obese % U.S. Total 38.8 26.8 Oregon 36.9 26.5

Obesity is a risk factor for the development of asthma

Obesity is associated significantly with the development of asthma, worsening asthma symptoms, and poor asthma control. This leads to increased medication use and hospitalizations. In 2010, the obesity rate among adults with current asthma (38.8%) was significantly higher than the rate among adults without current asthma (26.8%).

FastStats – Asthma

Decrease obesity

Obesity is the No. 2 preventable cause of death and disability among Oregonians. By reducing obesity, the burden of chronic diseases, including asthma, arthritis, cancer, diabetes, heart disease and stroke, will decrease.

Adults with Current Asthma

County Multnomah Clackamas Oregon

Year Yes No Yes No Yes No

2010-2013 9.9 90.1 8.9 91.1 10.3 89.7 2010 8.3 91.7 6.4 93.6 9.5 90.5 2009 9.2 90.8 11.0 89.0 11.1 88.9 2007 8.4 91.6 9.4 90.6 9.7 90.3 2005 9.6 90.2 12.1 87.7 10.1 89.9 2003 9.9 90.1 6.0 94.0 9.3 90.7 Asthma: Adults who have been told they currently have asthma Data source BRFSS 107

Allergies

Allergies are the 6th leading cause of chronic illness in the U.S. with an annual cost in excess of $18 billion. More than 50 million Americans suffer from allergies each year.

Allergies are an overreaction of the immune system to substances that generally do not affect other individuals. These substances, or allergens, can cause sneezing, coughing, and itching. Allergic reactions range from merely bothersome to life-threatening. Some allergies are seasonal, like hay fever. Allergies have also been associated with chronic conditions like sinusitis and asthma. Who's at Risk?

Anyone may have or develop an allergy - from a baby born with an allergy to cow's milk, to a child who gets poison ivy, to a senior citizen who develops hives after taking a new medication. Can It Be Prevented?

Allergies can generally not be prevented but allergic reactions can be. Once a person knows they are allergic to a certain substance, they can avoid contact with the allergen. Strategies for doing this include being in an air-conditioned environment during peak hay-fever season, avoiding certain foods, and eliminating dust mites and animal dander from the home. They can also control the allergy by reducing or eliminating the symptoms. Strategies include taking medication to counteract reactions or minimize symptoms and being immunized with allergy injection therapy. The Bottom Line

 The most common allergic diseases include: hay fever, asthma, conjunctivitis, hives, eczema, dermatitis and sinusitis.  Food allergies are most prevalent in young children and are frequently outgrown.  Latex allergies are a reaction to the proteins in latex rubber, a substance used in gloves, condoms and other products.  Bees, hornets, wasps, yellow jackets, and fire ants can cause insect sting allergies.  Allergies to drugs, like penicillin, can affect any tissue or organ in the body.

Anaphylaxis is the most severe allergic reaction. Symptoms include flush; tingling of the palms of the hands, soles of the feet or lips; light-headedness, and chest-tightness. If not treated, these can progress into seizures, cardiac arrhythmia, shock, and respiratory distress. Anaphylaxis can result in death. Food, latex,

insect sting, and drug allergies can all result in anaphylaxis. Allergies | Gateway to Health Communication | CDC

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Age-adjusted percentages (with standard errors) of hay fever, respiratory allergies, food allergies, and skin allergies in the past 12 months for children under age 18 years, by selected characteristics: United States, 2014 Respiratory Food Skin Selected Characteristic Hay Fever Allergies Allergies Allergies Total 8.4 (0.34) 10.1 (0.35) 5.4 (0.28) 11.7 (0.37) Sex Male 9.3 (0.50) 11.5 (0.54) 5.5 (0.40) 11.8 (0.53) Female 7.4 (0.43) 8.5 (0.46) 5.4 (0.39) 11.5 (0.52) Age 0-4 years 3.4 (0.38) 6.7 (0.57) 4.7 (0.47) 13.0 (0.73) 5-11 years 9.0 (0.54) 12.1 (0.61) 5.9 (0.50) 12.1 (0.62) 12-17 years 11.7 (0.69) 10.3 (0.59) 5.5 (0.43) 10.0 (0.59) Race White 8.4 (0.40) 10.2 (0.42) 5.1 (0.32) 10.4 (0.44)

Black or African American 7.1 (0.71) 9.8 (0.80) 6.1 (0.73) 16.5 (1.03)

American Indian or Alaska Native 10.0 (3.80) 13.7 (4.20) 4.4 (2.15) 10.2 (3.21) Asian 8.4 (1.18) 6.7 (1.00) 5.0 (0.92) 10.9 (1.32)

Hispanic or Latino 6.8 (0.61) 7.9 (0.54) 4.6 (0.42) 8.7 (0.62)

http://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2014_SHS_Table_C-2.pdf

Allergic conditions are among the most common medical conditions affecting children in the United States. An allergic condition is a hypersensitivity disorder in which the immune system reacts to substances in the environment that are normally considered harmless. Food or digestive allergies, skin allergies (such as eczema), and respiratory allergies (such as hay fever) are the most common allergies among children. Allergies can affect a child’s physical and emotional health and can interfere with daily activities, such as sleep, play, and attending school. A severe allergic reaction with rapid onset, anaphylaxis, can be life threatening. Foods represent the most common cause of anaphylaxis among children and adolescents. Early detection and appropriate interventions can help to decrease the negative impact of allergies on quality of life.

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Among children aged 0–17 years, the prevalence of food allergies increased from 3.4% in 1997– 1999 to 5.1% in 2009–2011. The prevalence of skin allergies increased from 7.4% in 1997–1999 to 12.5% in 2009–2011. There was no significant trend in respiratory allergies from 1997–1999 to 2009–2011, yet respiratory allergy remained the most common type of allergy among children throughout this period (17.0% in 2009–2011). Skin allergy prevalence was also higher than food allergy prevalence for each period from 1997–2011 (Figure 1).

Hispanic children had lower rates of all three types of allergies compared with children of other race or ethnicities. Non-Hispanic black children were more likely to have skin allergies and less likely to have respiratory allergies compared with non-Hispanic white children.

Hispanic children had a lower prevalence of food allergy (3.6%), skin allergy (10.1%), and respiratory allergy (13.0%) compared with non-Hispanic white and non-Hispanic black children. Non-Hispanic black children had a higher percentage of reported skin allergy (17.4%) compared with non-Hispanic white children (12.0%) and a lower percentage of respiratory allergy (15.6%) compared with non-Hispanic white children (19.1%) (Figure 3).

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Among children under age 18 years in the United States, the prevalence of food and skin allergies increased from 1997–1999 to 2009–2011. The prevalence of respiratory allergy, which is the most prevalent type of allergy among children, did not change during this period. There was no significant difference in food allergy prevalence between age groups. However, skin allergy decreased with the increase of age, and respiratory allergy increased with the increase of age. The prevalence of allergies varies by race and ethnicity, with Hispanic children having the lowest prevalence of food, skin, and respiratory allergies compared with non-Hispanic white and non- Hispanic black children. Non-Hispanic black children were more likely to have skin allergies and less likely to have respiratory allergies compared with non-Hispanic white children. The prevalence of allergies differed by poverty status. Food allergy and respiratory allergy increased with the increase of income level, but there was no difference in the prevalence of skin allergy by poverty status. http://www.cdc.gov/nchs/data/databriefs/db121.pdf

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Cancer

According to the “Annual Report to the Nation on the Status of Cancer, 1975-2012, the overall cancer death rates in the U.S. decreased from 2003-2012. CDC - Annual Report to the Nation on the Status of Cancer, 1975–2012

Overall cancer death rates decreased during 2003-2012 by:  An average of 1.8 percent per year for men  An average of 1.4 percent per year for women  An average of 2 percent per year for people ages 0 to 19.

“Trends in mortality (cancer death rates) are the gold standard for evidence of progress against cancer. Below are 10-year mortality trends for the most common cancers for men and women. These trends show that liver cancer is one of the few common cancers with increasing death rates and that its death rate is increasing the fastest among all common cancers.”

“In addition to reporting rates and trends for the most common cancers, this year’s report also includes a special section on liver cancer. Among both men and women, liver cancer deaths are on the rise in the United States, increasing at the highest rate of all common cancers during the period 2003-2012.”

” A major risk factor for liver cancer is hepatitis C virus (HCV) infection. The incidence of new HCV infections was highest in the 1960s through 1980s, before the virus was discovered and preventive measures could be taken. Although risk of liver cancer for all people increases up to age 85, liver cancer incidence rates were higher among people born during 1945-1965 than among those born in other periods because of higher rates of HCV infection in the 1945-1965 birth cohort. Among persons born during 1945-1965, rates of hepatitis C infection were highest among non-Hispanic whites, non-Hispanic blacks, and Hispanics.”

“The incidence rate of liver cancer in the U.S. is higher in men than in women.”

During 2008-2012, among both men and women, liver cancer incidence rates were highest among non-Hispanic American Indian/Alaska Natives, followed by non-Hispanic Asian/Pacific Islanders and then by Hispanics. The dominant liver cancer-related virus among Asian/Pacific Islanders is Hepatitis B virus (HBV), and infection with HBV is more common among Asians than among other racial groups, especially Asians who were born outside the United States.

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Statistics at a Glance: The Burden of Cancer in the United States

 In 2016, an estimated 1,685,210 new cases of cancer will be diagnosed in the United States and 595,690 people will die from the disease.

 The most common cancers in 2016 are projected to be breast cancer, lung and bronchus cancer, prostate cancer, colon and rectum cancer, bladder cancer, melanoma of the skin, non-Hodgkin lymphoma, thyroid cancer, kidney and renal pelvis cancer, leukemia, endometrial cancer, and pancreatic cancer.

 The number of new cases of cancer (cancer incidence) is 454.8 per 100,000 men and women per year (based on 2008-2012 cases).

 The number of cancer deaths (cancer mortality) is 171.2 per 100,000 men and women per year (based on 2008-2012 deaths).

 Cancer mortality is higher among men than women (207.9 per 100,000 men and 145.4 per 100,000 women). It is highest in African American men (261.5 per 100,000) and lowest in Asian/Pacific Islander women (91.2 per 100,000). (Based on 2008-2012 deaths.)

 The number of people living beyond a cancer diagnosis reached nearly 14.5 million in 2014 and is expected to rise to almost 19 million by 2024.

 Approximately 39.6 percent of men and women will be diagnosed with cancer at some point during their lifetimes (based on 2010-2012 data).

 In 2014, an estimated 15,780 children and adolescents ages 0 to 19 were diagnosed with cancer and 1,960 died of the disease.

 National expenditures for cancer care in the United States totaled nearly $125 billion in 2010 and could reach $156 billion in 2020.

Cancer Statistics - National Cancer Institute

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New Cancer Case (Incidence) Rates Oregon 2012 Male and Female

Cancer Type 2012 2009 2007 2005 2003 2001

Prostate 87.2 131.1 147.4 145.8 144.2 172.4

Female Breast 125.3 132.9 131.8 130.1 129.4 147.1

Lung and Bronchus 55.9 63.7 64.5 69.8 68.7 72.1

Colon and Rectum 40.4 40.4 40.8 46.4 49.1 49.1

Melanomas of the Skin 24.8 24.7 24.8 26.7 21.7 24.1

Corpus and Uterus, NOS 28.0 28.0 24.2 23.2 23.5 23.7

Urinary Bladder 21.6 21.0 22.7 24.0 22.4 24.6

Non-Hodgkin Lymphoma 17.4 18.5 18.0 21.3 20.9 20.0 Suggested Web citation: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2015. Available at: www.cdc.gov/uscs.

New Cancer Case (Incidence) Rates Oregon/United States 2012 Male and Female

Percentage Change Cancer 2007 2009 2012 2007-2012 Type Oregon U.S. Oregon U.S. Oregon U.S. Oregon U.S. Prostate 147.4 163.6 131.1 142.2 87.2 105.3 -40.8% -35.6% Female Breast 131.8 123.0 132.9 125.0 125.3 122.2 -4.9% -0.7% Lung and Bronchus 64.5 67.8 63.7 65.9 55.9 60.4 -13.3% -10.9% Colon and Rectum 41.8 46.9 41.0 43.5 35.2 38.9 -15.8% -17.1% Melanomas of the Skin 25.0 19.5 24.7 20.1 24.8 19.9 -0.8% 2.1% Corpus and Uterus, NOS 24.2 24.3 28.0 25.3 28.0 25.7 15.7% 5.8% Urinary Bladder 22.7 21.5 21.0 21.2 21.6 20.2 -4.8% -6.0% Non-Hodgkin Lymphoma 18.0 19.7 18.5 19.7 17.4 18.5 -3.3% -6.1% Kidney and Renal Pelvis 14.4 16.0 15.0 16.2 14.4 15.9 0.0% -0.6% Ovary 12.9 12.6 12.8 12.2 12.0 11.3 -7.0% -10.3% Thyroid 11.1 11.8 10.9 13.5 12.8 14.3 15.3% 21.2% Rates are per 100,000 persons and are age-adjusted to the 2000 U.S. standard population (19 age groups — Census P25-1130). See USCS for 95% confidence intervals for rates. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2015. Available at: www.cdc.gov/uscs.

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2012 Cancer Rates per 100,000

Thyroid Ovary Kidney and Renal Pelvis Non-Hodgkin Lymphoma Urinary Bladder Corpus and Uterus, NOS Melanomas of the Skin Colon and Rectum Lung and Bronchus Female Breast Prostate

0 20 40 60 80 100 120 140

U.S. Oregon

Oregon Cancer Rates per 100,000

Non-Hodgkin Lymphoma Urinary Bladder Corpus and Uterus, NOS Melanomas of the Skin Colon and Rectum Lung and Bronchus Female Breast Prostate

0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0

2003 2005 2007 2009 2012

Source data: CDC United States Cancer Statistics (USCS) Data-2009 Top Ten Cancers

U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2015. Available at: www.cdc.gov/uscs.

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Age-Adjusted Incidence Rate cases per 100,000 2008-2012

Multnomah Cancer U.S. Oregon Clackamas County County All Cancer 453.8 447.6 459.5 447.3 Breast (Female) 123.0 128.4 137.8 141.3 Prostate 131.7 122.8 113.3 120.4 Colon & Rectum 41.9 38.3 40.7 36.2 Lung & Bronchus 63.7 61.0 65.3 55.5 Created by statecancerprofiles.cancer.gov on 05/18/2016 12:23 pm. Data for the United States does not include data from Nevada. State Cancer Profiles > > Table

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Cancer Trends Progress Report

The Cancer Trends Progress Report summarizes our nation’s progress against cancer in relation to Healthy People 2020 targets determined by the Department of Health and Human Services. Data were gathered from the National Cancer Institute, the Centers for Disease Control and Prevention, other Federal agencies, professional groups, and cancer researchers. The report, available online only, is updated annually.

Report Highlights

Making Progress The nation is making progress toward major cancer-related targets for Healthy People 2020, a comprehensive set of 10-year health objectives sponsored by the U.S. Department of Health and Human Services. Prevention

 Adult cigarette smoking prevalence has been slowly declining since 1991, while smoking prevalence among adolescents has declined since the late 1990s.  Substantial decreases in secondhand smoke exposure have been realized since the beginning of the 1990s for all subgroups and across a variety of measures. This includes biological measures, as well as workplace policies, rules about smoking in the home, and, more recently, through state and local smoke-free indoor air legislation.  More adults are focusing on physical fitness, which has the potential to reduce both cancer- and non-cancer-related morbidity. Studies have shown that the percentage of adults who are meeting federal guidelines for aerobic and muscle-strengthening activity has risen consistently since the late 1990s.  Adult sun protective behaviors (e.g., using sunscreen, wearing protective clothing, seeking shade) have risen slightly since 2005, though young adults, especially young men, show much lower levels of this behavior.  Teen indoor tanning has decreased since 2005, and has decreased significantly among female high school students since 2009. Many states have enacted policies to control the indoor tanning industry, and some are restricting minors’ access to indoor tanning facilities. Still, more than one in five young women have engaged in indoor tanning within the past 12 months.

Diagnosis

 Estimates of cancer incidence for 2010 show that Healthy People 2020 targets were reached in 15 states for reduced colorectal cancer incidence, and in 24 states for reduced cervical cancer incidence.  Overall breast cancer incidence rates have remained relatively stable since 2004, and improvements in breast cancer treatment and early detection have helped lower death rates substantially since 1990.  Colorectal cancer incidence rates have decreased steadily, with slight exceptions, since the mid - 1980s, and declines have accelerated in recent years. These declines have largely been attributed to increased colorectal cancer screening, which not only reduces incidence rates, but also increases the likelihood of survival.

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Life after Cancer

 The majority of cancer survivors (64 percent) were diagnosed 5 or more years ago, and 15 percent were diagnosed 20 or more years ago.

End of Life

 The rate of death from cancer continues to decline among both men and women, among all major racial and ethnic groups, and for the most common types of cancer, including lung, colon, breast, and prostate cancers.  The death rate from all cancers combined continues to decline, as it has since the early 1990s.  Length of cancer survival has increased for all cancers combined. The 5-year relative survival rate for all cancers diagnosed between 2003 and 2009 is 68.0 percent, up from 66.7 percent in 2003. Improvement in survival must continue to meet the Healthy People 2020 objective for 5-year survival of 72.8 percent.

Areas of Concern The nation is losing ground in other important areas that demand attention. Prevention

 While smoking initiation rates have declined among adolescents aged 12–17 years, initiation rates among those aged 18–25 years have risen.  While the percentage of smokers attempting to quit smoking each year has recently risen and is now at 55 percent, successful quitting percentages have been low and recently have shown only slight improvement. In addition, Hispanics and non-Hispanic African Americans and those with low socioeconomic status are significantly less likely to receive cessation services.  Although progress has been made in reducing exposure to secondhand smoke among all populations, children living below the poverty level and Black, non-Hispanic children were more likely than their peers to be living in homes where someone smoked regularly.  Up to one-third of cancer cases in the United States are related to excess weight or obesity, physical inactivity, and/or poor nutrition, and thus could be prevented.  Alcohol consumption, which can increase the risk of some cancers, has risen slightly since the mid- 1990s. More progress is needed to reach Healthy People 2020 targets for cancer screening tests that can identify breast, cervical, and colorectal cancer in early stages. In 2010, the breast cancer screening rate was 72.4 percent (below the Healthy People 2020 target of 81.1 percent); cervical cancer screening was 83.0 percent (below the target of 93.0 percent); and colorectal cancer screening was 58.6 percent (below the target of 70.5 percent).  Not enough children in the U.S. are being properly vaccinated against the cancer causing human papillomavirus, or HPV. Although most cervical cancers could be prevented through HPV vaccination and effective screening, only 33 percent of girls aged 13–17 years received the recommended three- dose HPV vaccine series in 2012.

Diagnosis

 Unexplained cancer-related health disparities remain among population subgroups. For example, the incidence of late-stage breast cancer is highest among Black women, who are less likely than White women to be diagnosed with local-stage breast cancer and generally have lower survival rates than White women within each stage.  The incidence of some cancers, including kidney, thyroid, pancreas, liver, uterus, melanoma of the skin, myeloma (cancer of plasma cells), and non-Hodgkin lymphoma, is rising.

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 Lung cancer incidence rates in women continue to rise but not as rapidly as was seen from about 1975 to 1990.

Life after Cancer

 Even for patients with health insurance, out-of-pocket costs for cancer care often pose a significant financial burden. As the U.S. population ages and newer technologies and treatments become available, national expenditures for cancer continue to rise, potentially exceeding overall medic al care expenditures combined.

http://progressreport.cancer.gov/

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Lung Cancer

“Lung cancer is the leading cause of cancer mortality in both men and women in the United States. An estimated 224,210 new cases are expected to be diagnosed in 2014, accounting for almost 14 percent of all cancer diagnoses.32 It has been shown that rises and declines in lung cancer incidence and mortality rates parallel past trends of cigarette smoking. It has been estimated that active smoking is responsible for close to 90 percent of lung cancer cases; radon causes 10 percent, occupational exposures to carcinogens account for approximately 9 to 15 percent and outdoor air pollution 1 to 2 percent. Because of the interactions between exposures, the combined attributable risk for lung cancer can exceed 100 percent.33 Five‐year survival rates are low compared to other common cancers at 16.8 percent.

Smoking‐Attributable Lung Cancer Deaths The most important cause of lung cancer in the United States is cigarette smoking. It is estimated that 80 percent of lung cancer deaths in women and 90 percent in men, respectively, are caused by smoking. Compared to non‐smokers, men who smoke are 23 times more likely to develop lung cancer, while women are 13 times more likely. The risk increases with the duration of smoking and amount smoked per day.28 Between 2005 and 2009, an average of 130,659 Americans (74,300 males and 56,359 females) died of smoking‐attributable lung cancer annually.” Above from the American Lung Association’s “Trends in Lung Cancer Morbidity and Mortality’ November 2014 copyright

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For additional information on Lung Cancer in African Americans, please see The American Lung Association’s report: “Too Many Cases, Too Many Deaths”

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Radon

What is Radon? Radon is a naturally occurring radioactive gas that is colorless, odorless, and tasteless. It is formed by the natural breakdown of uranium in rock, soil and water.

Radon gas moves up through the soil and can be drawn into our homes by slight pressure differences. Once inside, radon can become trapped and build up to unsafe levels.

The U.S. Surgeon General warns that radon is the second leading cause of lung cancer after cigarette smoking and the number one cause of lung cancer in non-smokers. The U.S. Environmental Protection Agency estimates that radon causes around 20,000 deaths from lung These estimates were prepared by Portland State University, Department of Geology. As we continue to analyze data and more people test their home for radon, we will update these resources.

This data provided is for informational purposes only. It is compiled by the Oregon Public Health Division from long-term radon tests (more than 90 days), conducted primarily by homeowners.

Indoor radon concentrations are influenced by weather, season, geology, type of construction and heating, ventilation and air conditioning systems. Therefore in general, this data should not be used to substitute for radon tests in homes. The Public Health Division recommends testing all residences, specifically the living areas, on a long-term basis, to evaluate the annual average concentration. When the annual average concentration in a living area of a home exceeds 4 pCi/liter, it is recommended that measures be taken to lower the concentration to below the 4 pCi/liter level.

Additional information on testing, measurement services or mitigation contractors can be obtained from the Oregon Public Health Division, Radon Information Line (971) 673-0440cancer annually in the United States. http://public.health.oregon.gov/HealthyEnvironments/RadiationProtection/RadonGas/Pages/index.aspx

Radon Risk in Oregon

Indoor Radon Risk Levels

The Oregon Public Health Division recommends that ALL residences be tested for radon regardless of the risk level assigned to the home’s geographic location. You can easily test your home by following these steps recommended by EPA. If your radon levels are above 4 pCi/liter, the Public Health Division and the Environmental Protection Agency (EPA) recommend that further action be taken to lower the concentration below that level.

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The data presented in the links below was compiled by the Oregon Public Health Division. It contains long- term radon tests (more than 90 days) and short-term radon tests (2-90 days) that have been conducted primarily by homeowners. Indoor radon levels can be influenced by weather, season, geology, type of construction and heating, ventilation and air conditioning systems. Because of this, radon levels may not be consistent among a group of homes, even those next door to each other. *if your zip code has no risk level assigned, you may be eligible for a free test kit, call or email us today!

To understand how the radon risk scores (green/yellow/red rankings) were determined; please review the last page of Table of Radon Risk Levels in Oregon by Zip Code (pdf). Indoor radon concentrations are influenced by weather, season, geology, and type of construction as well as heating, ventilation and air conditioning systems. The maps and table provided here should not be used to substitute for radon testing of an individual home. The only way to know if you have high radon levels in your home is to test YOUR home.

The following Oregon counties have Radon Mitigation Code Requirements for new construction: Baker, Clackamas, Hood River, Multnomah, Polk, Washington, and Yamhill counties.

The data used to make this map comes from long- and short-term radon test results. These results are submitted to the Oregon Radon Program by test kit manufacturers.

The level of radon risk for each zip code is based on the maximum result, the average of all results and the percent of locations within the zip code with a result of 4 pCi/L or greater.

What do the colors mean? The color is a general indication of risk from indoor radon. Red is the highest level of risk. Green is the lowest. Yellow is in between.

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Breast Cancer

This section is from http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer- key-statistics What are the key statistics about breast cancer?

Breast cancer is the most common cancer among American women, except for skin cancers. About 1 in 8 (12%) women in the US will develop invasive breast cancer during their lifetime.

Current year estimates for breast cancer

The American Cancer Society's estimates for breast cancer in the United States for 2016 are:

 About 246,660 new cases of invasive breast cancer will be diagnosed in women.

 About 61,000 new cases of carcinoma in situ (CIS) will be diagnosed (CIS is non-invasive and is the earliest form of breast cancer).

 About 40,450 women will die from breast cancer.

Trends in breast cancer incidence

After increasing for more than 20 years, breast cancer incidence rates in women began decreasing in 2000, and dropped by about 7% from 2002 to 2003. This large decrease was thought to be because fewer women used hormone therapy after menopause after the results of the Women's Health Initiative were published in 2002. This study linked using hormone therapy to an increased risk of breast cancer and heart diseases.

In recent years, incidence rates have been stable in white women, but have increased slightly in African American women.

Trends in breast cancer deaths

Breast cancer is the second leading cause of cancer death in women. (Only lung cancer kills more women each year.) The chance that a woman will die from breast cancer is about 1 in 36 (about 3%).

Death rates from breast cancer have been dropping since about 1989, with larger decreases in women younger than 50. These decreases are believed to be the result of finding breast cancer earlier through screening and increased awareness, as well as better treatments.

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Breast cancer survivors

At this time, there are more than 2.8 million breast cancer survivors in the United States. (This includes women still being treated and those who have completed treatment.) Survival rates are discussed in “Breast cancer survival rates by stage.”

Visit the American Cancer Society’s Cancer Statistics Center for more key statistics.

Last Medical Review: 09/25/2014 Last Revised: 05/04/2016

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Incidence Trends

From 2002 to 2011 in the United States, the incidence rate of breast cancer—

 Remained level among women.  Remained level among white women.  Increased significantly by 0.7% per year among black women.  Remained level among Hispanic women.  Remained level among American Indian/Alaska Native women.  Increased significantly by 0.8% per year among Asian/Pacific Islander women

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Mortality Trends

From 2002 to 2011 in the United States, the death rate from breast cancer—

 Decreased significantly by 1.9% per year among women.  Decreased significantly by 2.0% per year among white women.  Decreased significantly by 1.5% per year among black women.  Decreased significantly by 1.5% per year among Hispanic women.  Decreased significantly by 2.8% per year among American Indian/Alaska Native women.  Decreased significantly by 1.6% per year among Asian/Pacific Islander women.

Data source: Kohler, BA, Sherman RL, Howlader N, Jemal, A, Ryerson AB, Henry KA, Boscoe, FP, Cronin KA, Lake A, Noone, A-M, Henley, SJ, Eheman, CR, Anderson, RN, Penberthy, L. Annual report to the nation on the status of cancer, 1975–2011, featuring incidence of breast cancer subtypes by race/ethnicity, poverty, and state. Journal of the National Cancer Institute 2015;107(6):djv048.

Note: Hispanic origin is not mutually exclusive from race categories (white, black, Asian/Pacific Islander, American Indian/Alaska Native).

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Content source: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention

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Page last reviewed: August 20, 2015

Page last updated: August 20, 2015

Content source: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention

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Prostate

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Mental Health

Any Mental Illness (AMI) Among U.S. Adults

 Mental illnesses are common in the United States.  The data presented here are from the National Survey on Drug Use and Health (NSDUH), which defines any mental illness (AMI) as: o A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders); o Diagnosable currently or within the past year; and, o Of sufficient duration to meet diagnostic criteria specified within the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).  AMI can range in impact from no or mild impairment to significantly disabling impairment, such as in individuals with serious mental illness (SMI), defined as individuals with a mental disorder with serious functional impairment which substantially interferes with or limits one or more major life activities.  As noted, these estimates of AMI do not include substance use disorders, such as drug- or alcohol-related disorders. For statistics and other information about drug- and alcohol-related disorders, please visit the statistics pages of the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the Substance Abuse and Mental Health Services Administration (SAMHSA).  In 2014, there were an estimated 43.6 million adults aged 18 or older in the United States with AMI in the past year. This number represented 18.1% of all U.S. adults.

NIMH » Any Mental Illness (AMI) Among U.S. Adults

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Serious Mental Illness (SMI) Among U.S. Adults

 While mental disorders are common in the United States, their burden of illness is particularly concentrated among those who experience disability due to serious mental illness (SMI).  The data presented here are from the National Survey on Drug Use and Health (NSDUH), which defines SMI as: o A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders); o Diagnosable currently or within the past year; o Of sufficient duration to meet diagnostic criteria specified within the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); and, o Resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.  In 2014, there were an estimated 9.8 million adults aged 18 or older in the United States with SMI. This number represented 4.1% of all U.S. adults.

NIMH » Serious Mental Illness (SMI) Among U.S. Adults

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The National Alliance on Mental Illness (NAMI) reports in their Mental Illness Facts and Numbers brief the following:

Prevalence of Mental Illness

 Approximately 1 in 5 adults in the U.S.—43.8 million, or 18.5%—experiences mental illness in a given year.  Approximately 1 in 25 adults in the U.S.—10 million, or 4.2%—experiences a serious mental illness in a given year that substantially interferes with or limits one or more major life activities.  Approximately 1 in 5 youth aged 13–18 (21.4%) experiences a severe mental disorder at some point during their life. For children aged 8–15, the estimate is 13%.  1.1% of adults in the U.S. live with schizophrenia.  2.6% of adults in the U.S. live with bipolar disorder.  6.9% of adults in the U.S.—16 million—had at least one major depressive episode in the past year.  18.1% of adults in the U.S. experienced an anxiety disorder such as posttraumatic stress disorder, obsessive-compulsive disorder and specific phobias.  Among the 20.2 million adults in the U.S. who experienced a substance use disorder, 50.5%—10.2 million adults—had a co-occurring mental illness.

Social Stats

 An estimated 26% of homeless adults staying in shelters live with serious mental illness and an estimated 46% live with severe mental illness and/or substance use disorders.  Approximately 20% of state prisoners and 21% of local jail prisoners have “a recent history” of a mental health condition.  70% of youth in juvenile justice systems have at least one mental health condition and at least 20% live with a serious mental illness.  Only 41% of adults in the U.S. with a mental health condition received mental health services in the past year. Among adults with a serious mental illness, 62.9% received mental health services in the past year.  Just over half (50.6%) of children aged 8-15 received mental health services in the previous year.  African Americans and Hispanic Americans used mental health services at about one- half the rate of Caucasian Americans in the past year and Asian Americans at about one- third the rate.  Half of all chronic mental illness begins by age 14; three-quarters by age 24. Despite effective treatment, there are long delays—sometimes decades—between the first appearance of symptoms and when people get help.

-NAMI: National Alliance on Mental Illness | Mental Health By the Numbers

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It is reported in the BRFSS and Trends Data that 20.1% of adults in the U.S. are limited in any activities because of physical, mental, or emotional problems in 2012. The percentage was 20.6 in 2008. Oregon adults reported 26.4% in 2012 as compared to 23.9% in 2008.

Oregon Adults (18 years or older) Had no poor mental health in past 30 days

Weighted Percentage Area 2010- 2006- 2004- 2002- 2013 2009 2007 2005 Oregon 59.8 66.4 63.8 61.5 Multnomah County 57.0 61.9 60.0 59.4 Clackamas County 60.2 68.1 66.0 63.5

Source: Oregon Behavioral Risk Factor Surveillance System Age adjusted

Major Depression among Oregon Residents

http://public.health.oregon.gov/BirthDeathCertificates/Surveys/AdultBehaviorRisk/brfssresults/Documents/2013/ChronicHealthCond13.pdf

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http://public.health.oregon.gov/BirthDeathCertificates/Surveys/AdultBehaviorRisk/brfssresults/Documents/2013/ChronicHealthCond13.pdf

Alzheimer’s

Data from the National Vital Statistics System

• The age-adjusted death rate from Alzheimer’s disease increased by 39 percent from 2000 through 2010 in the United States.

• Alzheimer’s disease is the sixth leading cause of death in the United States and is the fifth leading cause among people aged 65 years and over. People aged 85 years and over have a 5.4 times greater risk of dying from Alzheimer’s disease than people aged 75–84 years.

• The risk of dying from Alzheimer’s disease is 26 percent higher among the non- Hispanic white population than among the non-Hispanic black population, whereas the Hispanic population has a 30 percent lower risk than the non-Hispanic white population.

• In 2010, among all states and the District of Columbia, 31 states showed death rates from Alzheimer’s disease that were above the national rate (25.1). http://www.cdc.gov/nchs/data/databriefs/db116.pdf

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http://www.cdc.gov/nchs/data/series/sr_03/sr03_038.pdf

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Suicide

Suicide is a significant problem in the United States:

• 41,149 people killed themselves in 2013.

• Over 494,169 people with self-inflicted injuries were treated in U.S. emergency departments in 2013.

• Suicides result in an estimated $44.6 billion in combined medical and work loss costs.1

These numbers underestimate this problem. Many people who have suicidal thoughts or make suicide attempts never seek services.

Suicide, by definition, is fatal and is a problem throughout the life span. In 2013, suicide was the second leading cause of death among persons aged 15-24 years, the second among persons aged 25-34 years, the fourth among person aged 35-54 years, the eighth among persons aged 55-64 years, the seventeenth among persons 65 years and older, and the tenth leading cause of death across all ages.

There is no single cause of suicide. Several factors can increase a person’s risk for attempting or dying by suicide. However, having these risk factors does not always mean that suicide will occur.

Risk factors for suicide include:

• Previous suicide attempt(s)

• History of depression or other mental illness

• Alcohol or drug abuse

• Family history of suicide or violence

• Physical illness

• Feeling alone

Suicide affects everyone, but some groups are at higher risk than others. Men are about four times more likely than women to die from suicide. However, women are more likely to express

144 suicidal thoughts and to make nonfatal attempts than men. The prevalence of suicidal thoughts, suicide planning, and suicide attempts is significantly higher among young adults aged 18-29 years than it is among adults aged ≥30 years.3 Other groups with higher rates of suicidal behavior include American Indian and Alaska Natives, rural populations, and active or retired military personnel.

Note: This is only some information about risk. To learn more, go to http://www.cdc.gov/violenceprevention/suicide.html. http://www.cdc.gov/violenceprevention/pdf/suicide_factsheet-a.pdf

• Suicide was the tenth leading cause of death for all ages in 2013.

• There were 41,149 suicides in 2013 in the United States—a rate of 12.6 per 100,000 is equal to 113 suicides each day or one every 13 minutes.

• Based on data about suicides in 16 National Violent Death Reporting System states in 2010, 33.4% of suicide decedents tested positive for alcohol, 23.8% for antidepressants, and 20.0% for opiates, including heroin and prescription pain killers.

• Suicide results in an estimated $51 billion in combined medical and work loss costs.

• Among students in grades 9-12 in the U.S. during 2013

17.0% of students seriously considered attempting suicide in the previous 12 months (22.4% of females and 11.6% of males).

13.6% of students made a plan about how they would attempt suicide in the previous 12 months (16.9% of females and 10.3% of males). 8.0% of students attempted suicide one or more times in the previous 12 months (10.6% of females and 5.4% of males).

2.7% of students made a suicide attempt that resulted in an injury, poisoning, or an overdose that required medical attention (3.6% of females and 1.8% of males).

• Males take their own lives at nearly four times the rate of females and represent 77.9% of all suicides.

• Females are more likely than males to have suicidal thoughts.

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• Suicide is the seventh leading cause of death for males and the fourteenth leading cause for females.

• Firearms are the most commonly used method of suicide among males (56.9%).

• Poisoning is the most common method of suicide for females (34.8%).

Racial and Ethnic Disparities

• Suicide is the eighth leading cause of death among American Indians/Alaska Natives across all ages.

• Among American Indians/Alaska Natives aged 10 to 34 years, suicide is the second leading cause of death.

• The suicide rate among American Indian/Alaska Native adolescents and young adults ages 15 to 34 (19.5 per 100,000) is 1.5 times higher than the national average for that age group (12.9 per 100,000).

• The percentages of adults aged 18 or older having suicidal thoughts in the previous 12 months were 2.9% among blacks, 3.3% among Asians, 3.6% among Hispanics, 4.1% among whites, 4.6% among Native Hawaiians /Other Pacific Islanders, 4.8% among American Indians/Alaska Natives, and 7.9% among adults reporting two or more races.

• Among Hispanic students in grades 9-12, the prevalence of having seriously considered attempting suicide (18.9%), having made a plan about how they would attempt suicide (15.7%), having attempted suicide (11.3%), and having made a suicide attempt that resulted in an injury, poisoning, or overdose that required medical attention (4.1%) was consistently higher than white and black students.

• Among adults aged 18-22 years, similar percentages of full-time college students and other adults in this age group had suicidal thoughts (8.0 and 8.7%, respectively) or made suicide plans (2.4 and 3.1%).

• Full-time college students aged 18-22 years were less likely to attempt suicide (0.9 vs. 1.9%) or receive medical attention as a result of a suicide attempt in the previous 12 months (0.3 vs. 0.7%). http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf

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In 2012–2013, young adult males aged 18–24 were more likely than young adult females to commit suicide. This relationship was found for the five race and ethnicity groups studied (non- Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander [API], and American Indian or Alaska Native [AIAN]). The suicide rate was highest in the AIAN population for both males and females (34.3 and 9.9 deaths per 100,000 population, respectively). AIAN males were more than twice as likely to commit suicide as most other gender and racial and ethnic subgroups. Suicide rates for AIAN young adults are likely to be underestimated; a previous study found that deaths overall for the AIAN population were underreported by 30%.

Based on combined data from 2009 through 2013 for non-Hispanic black and non-Hispanic white young adults who committed suicide, firearms were the most common method used,

147 followed by suffocation. For Hispanic, API, and AIAN young adults who committed suicide, suffocation was the most common method used, followed by firearms. Poisoning and falls were more common methods among API young adults who committed suicide (12.6% and 8.1% of suicide deaths, respectively) than among other race and ethnicity groups.

Products - Health E Stats - Racial and Gender Disparities in Suicide Among Young Adults Aged 18–24: United States, 2009–2013

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Products - Health E Stats - Racial and Gender Disparities in Suicide Among Young Adults Aged 18–24: United States, 2009–2013

Research shows that risk factors for suicide include:

 depression and other mental disorders, or a substance-abuse disorder (often in combination with other mental disorders). More than 90 percent of people who die by suicide have these risk factors.  prior suicide attempt  family history of mental disorder or substance abuse  family history of suicide  family violence, including physical or sexual abuse  firearms in the home, the method used in more than half of suicides  incarceration  exposure to the suicidal behavior of others, such as family members, peers, or media figures. http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml

In an Oregonian Article “Suicides surge in U.S., state” written by Associated Press writer Mike Stone, it is stated that suicides by middle aged Americans have increased sharply and even more so in Oregon. “The federal Centers for Disease Control and Prevention reports Oregonians

149 saw a 49.3 percent increase in suicides among men and women aged 35-64 from 1999-2010, compared with 28 percent nationally.

A 2012 report on suicide trends and risk factors for the Oregon Health Authority found that the state’s overall suicide was 41 percent higher than the national rate, …”

Oregon Deaths from Suicide by Age

Suicides All Ages <15 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Year Total M F M F M F M F M F M F M F M F M F M F 2014 781 614 167 5 2 70 20 86 23 97 25 104 35 112 33 68 17 39 9 33 3 2011 639 508 131 5 3 55 9 85 18 98 28 83 41 78 17 52 10 35 4 17 1 2008 581 458 123 2 0 52 11 61 15 69 34 112 35 82 19 37 6 24 2 19 1 2005 559 443 116 3 0 54 4 58 14 67 22 97 44 58 17 46 3 43 8 17 4

http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/Volume2/Documents/2014/table606.pdf

The following is taken from the Portland Police Bureau’s report:

Behavioral Health Unit: An Analysis of Completed Suicides: April 2011 through June 2013

 There was a total of 202 completed suicides, between April 2011 through June 2013; with a rate of 34.4 per 100,000, over that time period. This was nearly three times the 2010 national rate of 12.4 per 100,000.

 There was an average 7.5 completed suicides per month.

 The average days between completed suicides was 3.9 days; with the longest time between completed suicides being 23 days.

 The average age of those who completed suicide was 44.8 years of age; with the oldest person that completed suicide being 89 years of age and the youngest being 10 years of age.

 Males represented 83.7% (N=169) of the completed suicides; females represented 16.3% (N=33).

 Caucasians represented 87.6% (N=177) all completed suicides. African-American/Blacks and Asians each represented 4.5% (N=9) of the total completed suicides. Hispanics represented 3.5% (N=7), of the total completed suicides.

 Completed suicides were evenly distributed throughout PPB’s three precincts. Central Precinct had the highest number of completed suicides (N=74; 36.6% of total); followed by North Precinct (N=64; 31.7% of total), then East Precinct (N=63; 31.2% of total).

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http://ftpcontent.worldnow.com/kptv/KPTV/story_pdfs/suicide_analysis.pdf

Many of the factors that increase the risk for substance abuse, such as traumatic experiences, also increase the risk for suicidal thoughts and behaviors, and substance abuse, like mental health problems, is linked with a several-fold increase in suicide risk. http://www.whitehouse.gov/blog/2013/09/10/substance-abuse-prevention-suicide-prevention

Tobacco

According to the CDC, more than 480,000 deaths each year are caused by cigarette smoking. Tobacco use and smoking do damage to nearly every organ in the human body, often leading to lung cancer, respiratory disorders, heart disease, stroke, and other illnesses.

In 2014, an estimated 66.9 million Americans aged 12 or older were current users of a tobacco product (25.2%). Young adults aged 18 to 25 had the highest rate of current use of a tobacco product (35%), followed by adults aged 26 or older (25.8%), and by youths aged 12 to 17 (7%). In 2014, the prevalence of current use of a tobacco product was 37.8% for American Indians or Alaska Natives, 27.6% for whites, 26.6% for blacks, 30.6% for Native Hawaiians or other Pacific Islanders, 18.8% for Hispanics, and 10.2% for Asians.

Smoking Prevalence is Much Higher Among People with a Mental Illness

Nationally, nearly 1 in 5 adults (or 45.7 million adults) have some form of mental illness, and 36% of these people smoke cigarettes. In comparison, 21% of adults without mental illness smoke cigarettes. (Mental illness is defined here as diagnosable mental, behavioral, or emotional conditions and does not include developmental and substance use disorders.)

There are other troubling statistics from the report:

 31% of all cigarettes are smoked by adults with mental illness.  40% of men and 34% of women with mental illness smoke.  48% of people with mental illness who live below the poverty level smoke, compared with 33% of those with mental illness who live above the poverty level.

You can read more about smoking prevalence among people with mental illness in the Vital Signs Report.

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What Contributes to Higher Smoking Prevalence in this Population?

While many mental health providers and facilities have made progress in reducing smoking in their facilities and among their patients, others are just now beginning to address tobacco use. Because they are more focused on treating the mental illness of their patients, some providers and facilities may not consider smoking to be a problem, or ignore it.

Smoking can cause unique issues for people with mental illness. Nicotine has mood-altering effects that put people with mental illness at higher risk for cigarette use and nicotine addiction. However, recent research has shown that adult smokers with mental illness—like other smokers—want to quit, can quit, and benefit from proven stop-smoking treatments. These treatments need to be made available to people with mental illness and tailored as needed to address the unique issues this population faces.

What Can Be Done to Reduce Smoking Among People with Mental Illness?

Mental Health Professionals:

 Find out if patients smoke. Sometimes patients aren’t asked whether they smoke when beginning mental health treatment.  If they do smoke, offer to help patients quit by providing proven quitting treatments, including referring them to the toll-free 1-800-QUIT-NOW quitline, the Web site www.smokefree.gov , or other resources.  Make quitting tobacco part of an approach to mental health treatment and overall wellness. Mental health professionals should be especially aware of the behavior changes that may occur when withdrawing from nicotine, and should make sure that their patients are aware of them. Medicines used to treat mental illness may need to be monitored and adjusted for people with mental illness who are trying to quit tobacco use.

Mental Health Facilities:

 Include tobacco cessation treatments as part of an overall mental health treatment strategy.  Make mental health facilities and campuses completely tobacco-free (no use of any tobacco product by anyone anywhere inside or outside at any time).  Call attention to and stop practices that encourage tobacco use (e.g., providing cigarettes to patients, allowing smoking as a reward, selling tobacco products on site, and allowing staff to smoke with patients).

http://www.cdc.gov/features/vitalsigns/smokingandmentalillness/

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Co-occurring Disorders

People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity. In many cases, people receive treatment for one disorder while the other disorder remains untreated. This may occur because both mental and substance use disorders can have biological, psychological, and social components. Other reasons may be inadequate provider training or screening, an overlap of symptoms, or that other health issues need to be addressed first. In any case, the consequences of undiagnosed, untreated, or undertreated co-occurring disorders can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.

Many people in the criminal justice system have co-occurring disorders. Providing integrated treatment to address mental and substance use disorders can lead to positive outcomes such as reduced substance use and arrests. Failure to effectively screen and assess inmates with co- occurring disorders is a major concern in the criminal justice system.

Co-occurring disorders are common among people experiencing homelessness. This population often has a variety of issues that require services beyond behavioral health treatment, such as life skills development, employment assistance, and housing.

While treating people experiencing homeless who are suffering from co-occurring disorders through integrated care is important to recovery, few have access to it. People experiencing homelessness may be isolated or have little to no access to health and behavioral health services, and therefore their health issues may go undiagnosed or untreated. This can lead to chronic homelessness and further deterioration in physical and behavioral health, as well as social and economic functioning.

Co-occurring disorders, such as post-traumatic stress disorder (PTSD) and substance use, is prevalent among veterans and the military community. According to the Veterans Affairs Department (VA), approximately one-third of veterans seeking treatment for substance use disorders also met the criteria for PTSD. Veterans and service members benefit from integrated care for mental and substance use disorders. However, some veterans may not seek medical treatment for one of many reasons, including a fear of being treated differently. http://www.samhsa.gov/disorders/co-occurring

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The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General

The century-long epidemic of cigarette smoking has caused an enormous, avoidable public health catastrophe in the United States.

 Since the first Surgeon General’s report on smoking and health was published 50 years ago, more than 20 million Americans have died because of smoking.  If current rates continue, 5.6 million Americans younger than 18 years of age who are alive today are projected to die prematurely from smoking-related disease.  Most of the 20 million smoking-related deaths since 1964 have been adults with a history of smoking; however, 2.5 million of those deaths have been among nonsmokers who died from diseases caused by exposure to secondhand smoke.  More than 100,000 babies have died in the last 50 years from Sudden Infant Death Syndrome, complications from prematurity, complications from low birth weight, and other pregnancy problems resulting from parental smoking.  The tobacco epidemic was initiated and has been sustained by the tobacco industry, which deliberately misled the public about the risks of smoking cigarettes.

Despite significant progress since the first Surgeon General’s report, issued 50 years ago, smoking remains the single largest cause of preventable disease and death in the United States.

 Smoking rates among adults and teens are less than half what they were in 1964; however, 42 million American adults and about 3 million middle and high school students continue to smoke.  Nearly half a million Americans die prematurely from smoking each year.  More than 16 million Americans suffer from a disease caused by smoking.  On average, compared to people who have never smoked, smokers suffer more health problems and disability due to their smoking and ultimately lose more than a decade of life.  The estimated economic costs attributable to smoking and exposure to tobacco smoke continue to increase and now approach $300 billion annually,

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with direct medical costs of at least $130 billion and productivity losses of more than $150 billion a year.

The scientific evidence is incontrovertible: inhaling tobacco smoke, particularly from cigarettes, is deadly. Since the first Surgeon General’s Report in 1964, evidence has linked smoking to diseases of nearly all organs of the body.

 In the United States, smoking causes 87 percent of lung cancer deaths, 32 percent of coronary heart disease deaths, and 79 percent of all cases of chronic obstructive pulmonary disease (COPD).  One out of three cancer deaths is caused by smoking.  This report concludes that smoking causes colorectal and liver cancer and increases the failure rate of treatment for all cancers.  The report also concludes that smoking causes diabetes mellitus, rheumatoid arthritis and immune system weakness, increased risk for tuberculosis disease and death, ectopic (tubal) pregnancy and impaired fertility, cleft lip and cleft palates in babies of women who smoke during early pregnancy, erectile dysfunction, and age-related macular degeneration.  Secondhand smoke exposure is now known to cause strokes in nonsmokers.  This report finds that in addition to causing multiple serious diseases, cigarette smoking diminishes overall health status, impairs immune function, and reduces quality of life.

Smokers today have a greater risk of developing lung cancer than did smokers in 1964.

 Even though today’s smokers smoke fewer cigarettes than those 50 years ago, they are at higher risk of developing lung cancer.  Changes in the design and composition of cigarettes since the 1950s have increased the risk of adenocarcinoma of the lung, the most common type of lung cancer.  Evidence suggests that ventilated filters may have contributed to higher risks of lung cancer by enabling smokers to inhale more vigorously, thereby drawing carcinogens contained in cigarette smoke more deeply into lung tissue.

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 At least 70 of the chemicals in cigarette smoke are known carcinogens. Levels of some of these chemicals have increased as manufacturing processes have changed.

For the first time, women are as likely to die as men from many diseases caused by smoking.

 Women’s disease risks from smoking have risen sharply over the last 50 years and are now equal to men’s for lung cancer, COPD, and cardiovascular diseases. The number of women dying from COPD now exceeds the number of men.  Evidence also suggests that women are more susceptible to develop severe COPD at younger ages.  Between 1959 and 2010, lung cancer risks for smokers rose dramatically. Among female smokers, risk increased 10-fold. Among male smokers, risk doubled.

The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General | SurgeonGeneral.gov

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State Tobacco Activities Tracking and Evaluation (STATE) System: State Highlights | OSH | CDC

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Current cigarette smoking among Oregon adults has decreased over recent years. Since 2010, smoking prevalence among Oregon adults has decreased 14%.

However, cigarette smoking continues to be a significant risk factor among Oregon adults. Approximately 519,100 Oregonians smoke cigarettes. When smokeless tobacco is included, this number increases to approximately 604,600 adult tobacco users in Oregon.

The burden of tobacco use falls hardest on lower-income Oregonians and certain racial and ethnic groups, who use tobacco at higher rates and suffer the harshest consequences in terms of chronic disease burden. Tobacco use prevalence among adults is nearly twice as high among African Americans and American Indian/Alaskan Natives than among the general population (33.3%, 35.3% and 17.8%, respectively).

Rates of tobacco use are almost twice as high among adults of low socioeconomic status than among the general population (33.7%, 17.8%). Cigarette smoking prevalence among Oregon adults with less than a high school education is four times higher than among those who have graduated from college. Tobacco prevalence is also higher among Oregon adults enrolled in Medicaid; 29.3% of Oregon adults enrolled in Medicaid smoke cigarettes. https://public.health.oregon.gov/About/Documents/ship/oregon-state-health-improvement-plan.pdf

The following Citation is from the “State of Tobacco Control 2016” American Lung Association

Tobacco use remains the leading cause of preventable death and disease in the United States. To address this enormous toll, the American Lung Association and its partners have committed to three bold goals: 1. Reduce rates of smoking and tobacco use to less than 10% for all communities by 2024; 2. Protect all Americans from secondhand smoke by 2019; and 3. Ultimately eliminate the death and disease caused by tobacco use.

The American Lung Association in Oregon recognizes that these bold goals will only be met in Oregon if the following three actions are taken by our elected officials: 1. Increase funding for tobacco prevention and control efforts; 2. Increase tobacco taxes; and 3. Raise the legal sales age for tobacco products to 21.

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Prior to the 2015 legislative session, Oregon was one of very few states remaining to allow the sale of electronic smoking devices to persons under age 18. During the 2015 legislative session, Rep. Kathleen Taylor introduced House Bill 2546 to address this problem. The American Lung Association in Oregon and its partners stood strong with legislative champions and the legislation was approved in both houses of the legislature and signed into law. In addition to prohibiting sales of electronic smoking devices and accessories to minors, the legislation also includes electronic smoking devices in Oregon's Indoor Clean Air Act.

Maintaining tobacco prevention funding is a perennial objective for Oregon's tobacco prevention coalition. In the 2013-2015 biennium, a little over $4 million had been allocated to Oregon's tobacco prevention and cessation program from the tobacco Master Settlement Agreement (MSA), in addition to funding from tobacco tax revenue the program has received for many years. Joining together with other advocates, the Lung Association was able to secure that same $4 million from the tobacco MSA for the 2015 to 2017 biennium to maintain current funding levels for the state program for the next two years.

The American Lung Association in Oregon will continue to seek opportunities to increase its tobacco taxes, maintain and increase tobacco control program funding and raise the legal sales age for tobacco products to 21 years old.

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State Highlights | American Lung Association

To get involved with the American Lung Association, please contact: American Lung Association in Oregon 7420 SW Bridgeport Rd., Suite 200 Tigard, OR 97224 503-924-4094 www.lung.org/oregon

Youth use of e-cigarettes has increased dramatically

Current use of e-cigarettes (i.e., in the last month) among Oregon eleventh-graders has almost tripled recently: from 1.8% in 2011 to 5.2% in 2013, even as cigarette smoking appears to decline. This mimics national trends of current e-cigarette use among high school students overall (1.5% in 2011 to 2.8% in 2012). • Among Multnomah County high school students in 2012: • 10.1% have ever used an e-cigarette, similar to high school students nationally (10.0%). • 3.9% currently use e-cigarettes, not significantly different than high school students nationally (2.8%).

Youth are very aware of e-cigarettes and many perceive them as less harmful than regular cigarettes

 In Multnomah County, more than half (55.1%) of the high school students perceived e- cigarettes as less harmful than regular cigarettes (CPPW YRBS 2012).

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E-cigarette use may lead to regular cigarette use Indirect evidence both locally and nationally suggests that e-cigarette use may lead to use of regular cigarettes: • In Multnomah County in 2013, among eighth- and eleventh-graders who do not currently smoke: those who currently use e-cigarettes are nearly three times as likely to intend to smoke regular cigarettes (49%) than those who do not use e-cigarettes (17%) (p<.01). • Similar patterns are seen nationally among middle and high school students who do not currently smoke: those students who had ever used e-cigarettes were twice as likely to intend to smoke (44%) than students who had never used e-cigarettes (22%) (2011-2013).

Many youth who currently use e-cigarettes also use regular cigarettes

• In Multnomah County, current smoking is much more common among high school students who currently use e-cigarettes (47%) than among high school students who do not currently use e-cigarettes (5%) (2012). Multnomah County Vital Signs A data report on emerging public health policy issues-Vol.1, No.1, November 2014 Vol. 1, No. 1 November 2014Vol. 1, No. 1 November 2 https://multco.us/file/37128/download

Oregon State Facts

In an Oregonian article, “Oregon is No. 1 at selling kids tobacco”, 12.5% of Oregon 11th graders surveyed used tobacco in the previous 30 days. Oregon is one of only 13 states that does not require tobacco retailers to get a special license, which ensure tobacco sellers get special scrutiny. If violations are discovered the sales clerk is fined and not the store, with no stiffer penalties for repeat violations. In Washington, state offenders can lose a tobacco license permanently. Article published September 3, 2013. Current tobacco use and related topics among Oregon adults by County, 2010-2013 Use unadjusted to estimate the overall burden of disease; use age‐adjusted to compare among counties. Attempted to quit Tobacco Use (%) cigarette smoking Exposed to secondhand Smoking is never County during precious year (%) smoke indoors (%) allowed in home (%) Age- Age- Age- Age- Unadjusted adjusted Unadjusted adjusted Unadjusted adjusted Unadjusted adjusted Oregon 76.5 76.3 57.4 56.5 19.5 20.2 90.8 90.9 Multnomah 74.5 74.5 56.8 55.1 19.0 18.8 90.7 90.7 Clackamas 80.8 80.6 64.5 64.3 15.9 16.8 93.7 94.1

Oregon Health Authority, Public Health Division, Health Promotion and Chronic Disease Prevention section. Current tobacco use and related topics among Oregon adults, by county, 2010‐2013. https://public.health.oregon.gov/DiseasesConditions/ChronicDisease/DataReports/Pages/CountyData.aspx. Created March 9, 2015. Accessed 6-17-16.

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The health and economic burden of tobacco by county

Adult Medical Productivity Youth Adult cigarette Tobacco Tobacco costs loss County Population population smokers illness deaths (Millions) (Millions) Oregon 865,612 3,053,408 519,079 139,268 71,126 1.4 Billion 1.1 Billion Multnomah 151,482 605,048 114,354 22,936 1,174 223.9 187.5 Clackamas 88,342 297,738 51,211 11,634 595 118.7 95.1

Sources: Portland State University Population Research Center 2014; Oregon Behavioral Risk Factor Surveillance System 2013; CDC Smoking-Attributable Morbidity and Mortality Cost calculator 2013

Cigarette smoking during pregnancy by County over time 70 60 50 40 United States

30 Oregon Percent 20 Multnomah 10 Clackamas 0 1996-1999 2000-2003 2004-2007 2008-2012 Years

Data sources: Oregon Birth Certificate Statistical File, accessed via Oregon Public Health Assessment Tool (OPHAT) http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/countyfacts/data_table_pregnancy.pdf

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Illicit Drug Use

“In 2014, 27.0 million people aged 12 or older used an illicit drug in the past 30 days, which corresponds to about 1 in 10 Americans (10.2 percent). This percentage in 2014 was higher than those in every year from 2002 through 2013. The illicit drug use estimate for 2014 continues to be driven primarily by marijuana use and the nonmedical use of prescription pain relievers, with 22.2 million current marijuana users aged 12 or older (i.e., users in the past 30 days) and 4.3 million people aged 12 or older who reported current nonmedical use of prescription pain relievers.

The higher percentage of people who were current illicit drug users in 2014 than in prior years appears to reflect trends in marijuana use. The percentage of people aged 12 or older in 2014 who were current marijuana users (8.4 percent) also was greater than the percentages in 2002 to 2013. In addition, the estimate of current marijuana use was greater in 2014 than the estimates in 2002 to 2009 for young adults aged 18 to 25 and in 2002 to 2013 for adults aged 26 or older.

Although nonmedical pain reliever use continued to be the second most common type of illicit drug use in 2014, the percentage of people aged 12 or older in 2014 who were current nonmedical users of pain relievers (1.6 percent) was lower than the percentages in most years from 2002 to 2012, but it was similar to the percentage in 2013. Percentages for current nonmedical use of pain relievers also were lower in 2014 than in 2002 to 2011 for adolescents aged 12 to 17 and in 2002 to 2012 for young adults aged 18 to 25.

The use of many types of other illicit drugs has not increased in recent years. However, the percentage of people aged 12 or older in 2014 who were current heroin users was higher than the percentages in most years from 2002 to 2013”.

The estimated 27.0 million people aged 12 or older who were current illicit drug users in 2014 represent 10.2 percent of the population aged 12 or older (Figure 2). Stated another way, 1 in 10 individuals aged 12 or older in the United States used illicit drugs in the past month. The percentage of people aged 12 or older who were current illicit drug users in 2014 was higher than the percentages from 2002 to 2013. The rise in illicit drug use among those aged 12 or older since 2002 may reflect an increase in illicit drug use by adults aged 26 or older and, to a lesser extent, increases in illicit drug use among young adults aged 18 to 25 relative to the years before 2009.

Aged 12 to 17 Slightly more than 2.3 million adolescents aged 12 to 17 in 2014 were current users of illicit drugs, which represents 9.4 percent of adolescents (Figure 2). The 2014 percentage was lower than the percentages from 2002 to 2004 and was similar to the percentages between 2005 and 2013. In 2002, for example, 11.6 percent of adolescents used an illicit drug in the past month.

Aged 18 to 25 More than 1 in 5 young adults aged 18 to 25 (22.0 percent) were current users of illicit drugs in 2014 (Figure 2). This percentage corresponds to about 7.7 million young adults in

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2014 who were current users of illicit drugs. The percentage of young adults who were current illicit drug users was stable between 2009 and 2014. However, the 2014 estimate was higher than the estimates from 2002 through 2008.

Aged 26 or Older In 2014, 8.3 percent of adults aged 26 or older were current users of illicit drugs (Figure 2), or about 17.0 million adults in this age group. The percentage of adults aged 26 or older who were current illicit drug users in 2014 was higher than the percentages from 2002 to 2013.

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Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/ data/ http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

Oregon At-a-Glance:

• In 2009-2010, Oregon was one of the top ten states for rates of drug-use in several categories, including: o Past-month illicit drug use among persons age 12 or older; o Past-month illicit drug use among young adults age 18-25; o Past-month marijuana use among persons age 12 or older; o Past-month marijuana use among young adults age 18-25; o Past-month illicit use of drugs other than marijuana among persons age 12 or older; o Past-month illicit use of drugs other than marijuana among young adults age 18-25; o Past-year cocaine use among persons age 12-17; o Past-year non-medical use of pain relievers among persons age 12 or older; o Past-year non-medical use of pain relievers among young adults age 18-25; o Illicit drug dependence among persons age 12 or older; o Illicit drug dependence among young adults age 18-25. Source: National Survey on Drug Use and Health (NSDUH), 2009-2010.

• Approximately 12.63 percent of Oregon residents reported past-month use of illicit drugs; the national average was 8.82 percent.

• In 2009, the rate of drug-induced deaths in Oregon exceeded the national average.

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Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: Oregon, 2014. HHS Publication No. SMA–15–4895OR. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. http://store.samhsa.gov/shin/content//SMA15-4895/BHBarometer-OR.pdf

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Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings

Illicit Drug Use

• In 2013, an estimated 24.6 million Americans aged 12 or older were current (past month) illicit drug users. This represents 9.4 percent of the population aged 12 or older. Marijuana was the most commonly used illicit drug, with 19.8 million current users aged 12 or older (7.5 percent). There were 6.5 million nonmedical users of prescription-type drugs (2.5 percent), including 4.5 million nonmedical users of prescription pain relievers (1.7 percent). There were 1.5 million current cocaine users aged 12 or older, or 0.6 percent of the population. An estimated 1.3 million individuals aged 12 or older in 2013 (0.5 percent) used hallucinogens in the past month. An estimated 496,000 individuals aged 12 or older were current inhalant users, which represents 0.2 percent of the population. There were about 289,000 current heroin users aged 12 or older, or 0.1 percent of the population.

• In 2013, there were 2.2 million adolescents aged 12 to 17 who were current illicit drug users. This represents 8.8 percent of adolescents. In 2013, 7.1 percent of adolescents were current users of marijuana, 2.2 percent were current nonmedical users of prescription-type drugs (including 1.7 percent who were current nonmedical users of pain relievers), 0.6 percent were current users of hallucinogens, 0.5 percent were current users of inhalants, 0.2 percent were current users of cocaine, and 0.1 percent were current users of heroin.

• There were 22.4 million adults aged 18 or older who currently used illicit drugs in 2013. This represents 9.4 percent of adults. In 2013, 7.6 percent of adults were current users of marijuana, 2.5 percent were current nonmedical users of prescription-type drugs (including 1.7 percent who were current nonmedical users of pain relievers), 0.5 percent were current users of hallucinogens, 0.6 percent were current users of cocaine, 0.2 percent were current users of inhalants and 0.1 percent were current users of heroin.

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Illicit Drug Use in Past Month among Persons Aged 12 or Older by State: Percentages, Annual Averages Based on 2006 and 2007 NSDUHs

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (September 4, 2014). The NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings. Rockville, MD

Source data: http://oas.samhsa.gov/2k7State/Oregon.htm

Figure 1a. Illicit Drug Use in the Past Month among Individuals Aged 12 or Older, by State: Percentages, Annual Averages Based on 2013 and 2014 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2013 and 2014.

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Figure 1b. Illicit Drug Use in the Past Month among Youths Aged 12 to 17, by State: Percentages, Annual Averages Based on 2013 and 2014 NSDUHs

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Opiate Misuse

According to the Multnomah County Health Department’s December 2015 report “Opiate Trends- Multnomah County, 2004-2014,”

• Deaths from opiate overdose occurred more than twice a week in 2014 (109 deaths). While unacceptably high, this figure is a substantial improvement from three deaths per week in 2011 (156 deaths). • The decrease in opiate deaths reflects a decrease in heroin-related deaths, which have dropped by more than 30% since 2011. • Prescription opiate deaths have not decreased. In 2014, half of all fatal overdoses were associated with prescription opiates. • Deaths represent only a fraction of the overdoses occurring. Ambulances responded to opiate overdoses in Multnomah County more than a dozen times per week (632 times in 2014). • The expanded availability of naloxone, a drug that reverses opiate overdose, has had a significant effect on overdose outcomes. More than 1,000 lay people in Multnomah County were trained to reverse overdoses using naloxone in 2014 and they reported more than 450 overdose reversals.

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• Opiates are the most rapidly growing reason for substance misuse treatment in Multnomah County and in Oregon.

Heroin Deaths Over the six-year period, a larger number of deaths included heroin as a cause than prescription opiates. A smaller subset of deaths involved both heroin and prescription opiates. The total number of deaths involving any opiate has fluctuated, but has dropped for three consecutive years since 2011. Statistically, in 2014 there were significantly fewer opiate-related deaths compared to 2011 and to the median number of deaths from the previous five years. This suggests this decrease is significant and not likely to be explained by chance alone.

Prescription Opiate Deaths Prescription-opiate related deaths have fluctuated slightly over the past six years but without any clear trend. In 2014, the number of deaths associated with prescription opiates equaled those of heroin deaths.

Sex: Two-thirds of opiate-related deaths occurred among men between 2009 and 2014.

Race: From 2009 to 2014, there was minimal fluctuation in the proportion of opiate-related deaths accounted for by different racial and ethnic groups in Multnomah County. In all years, white residents accounted for over 88% of deaths.

Age: The median age of individuals whose deaths involved prescription opiates was on average higher (range: 43-51 years) than those whose deaths involved heroin (range: 35-44 years).

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Heroin-related Deaths by Age

In 2009, more heroin-related deaths occurred among 35-54 year olds compared to those under 35 or over 55 years. Since 2012, heroin-related deaths have been dropping among those 35-54. In 2010 and 2011, heroin-related deaths rose among those under 35 years before dropping again in 2013. There was then a small increase in deaths in this age group in 2014.

Deaths among adults over 55 account for the smallest proportion of heroin-related deaths in the county.

Death rates associated with any opiate types (prescription, heroin, or both) have been consistently higher in Multnomah County compared to the rest of the state. In 2011, opiate death rates peaked for both heroin and prescription opiates.

Trends in Multnomah County Between 2004 and 2009, opiate treatment admissions across all addictions services described in the Methods section remained stable but then increased between 2010 and 2013. Overall, there were 19% more admissions in 2013 than in 2004. The majority of treatment admissions during the reporting period were for heroin, but there was a greater proportional increase in the number of clients admitted for prescription opiate treatment.

The number of individuals receiving outpatient and residential treatment remained stable until 2008, but then increased by more than 10% each year through 2012. By 2013, the number of individuals receiving treatment had increased by more than 107% compared with 2004. In 2013, nearly 1,000 individuals received treatment for heroin use, a 46% increase compared to 2004. For prescription opiate treatment there was a 73% increase in the same period from 75 individuals to 280.

From 2004 through 2008, Multnomah County residents made up 58-61% of the state’s heroin admissions each year but gradually dropped to 43% in 2013. At the same time, Oregonians from other counties surpassed Multnomah County residents for heroin treatment admissions for the first time in 2012, making up 57% of total admissions by 2013. The same trend occurred for prescription opiates. In 2004, Multnomah County residents represented 29% of the state’s admissions for prescription opiates but only 19% in 2013 (not shown). At the same time, residents of other counties increased from 71% to 81% of those admissions. Overall, 54% of the state’s opiate admissions (heroin and prescription opiates combined) in 2004 were among Multnomah County residents, compared to only 36% by 2013.

The above information is from the Multnomah County Health Department’s December 2015 report “Opiate Trends- Multnomah County, 2004-2014”

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Heroin Use Disorder About 586,000 people aged 12 or older in 2014 had a heroin use disorder, which represents 0.2 percent of the people aged 12 or older (Figure 38). Although the percentage of people aged 12 or older in 2014 who were current heroin users was higher than the percentages in most years between 2002 and 2013 (Figure 12), the percentage of people aged 12 or older with a heroin use disorder remained steady from 2011 to 2014. However, the percentage in 2014 was higher than the percentages in 2002 to 2010 (0.1 percent in each year).

Aged 12 to 17 An estimated 0.1 percent of adolescents aged 12 to 17 in 2014 had a heroin use disorder in the past year (Figure 38), which corresponds to about 18,000 adolescents. The percentage of adolescents with a heroin use disorder remained stable from 2002 to 2014.

Aged 18 to 25 Approximately 168,000 young adults aged 18 to 25 in 2014 had a heroin use disorder in the past year, which represents 0.5 percent of young adults (Figure 38). The percentage of young adults with a heroin use disorder in 2014 was greater than the percentages in 2002 to 2009, but it was similar to the percentages in 2010 to 2013.

Aged 26 or Older In 2014, approximately 400,000 adults aged 26 or older had a heroin use disorder in the past year, which represents 0.2 percent of adults aged 26 or older (Figure 38). Between 2002 and 2014, 0.1 to 0.2 percent of adults aged 26 or older had a heroin use disorder in the past year.

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Figure 8b. Nonmedical Use of Pain Relievers in the Past Year among Youths Aged 12 to 17, by State: Percentages, Annual Averages Based on 2013 and 2014 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2013 and 2014.

Figure 6b. Illicit Drug Use Other Than Marijuana in the Past Month among Youths Aged 12 to 17, by State: Percentages, Annual Averages Based on 2013 and 2014 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2013 and 2014. Figure 8c. Nonmedical Use of

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Pain Relievers in the Past Year among Adults Aged 18 to 25, by State: Percentages, Annual Averages Based on 2013 and 2014 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2013 and 2014.

Figure 8d. Nonmedical Use of Pain Relievers in the Past Year among Adults Aged 26 or Older, by State: Percentages, Annual Averages Based on 2013 and 2014 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2013 and 2014

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Marijuana

An estimated 22.2 million Americans aged 12 or older in 2014 were current users of marijuana. This number of past month marijuana users corresponds to 8.4 percent of the population aged 12 or older. The percentage of people aged 12 or older who were current marijuana users in 2014 was higher than the percentages from 2002 to 2013. This rise in marijuana use among those aged 12 or older may reflect the increase in marijuana use by adults aged 26 or older and, to a lesser extent, increases in marijuana use among young adults aged 18 to 25 compared with the percentages of young adults who reported marijuana use in 2002 to 2009.

Aged 12 to 17 In 2014, 7.4 percent of adolescents aged 12 to 17 were current users of marijuana. This means that approximately 1.8 million adolescents used marijuana in the past month. The percentage of adolescents in 2014 who were current marijuana users was similar to the percentages in most years between 2003 and 2013.

Aged 18 to 25 An estimated 6.8 million young adults aged 18 to 25 in 2014 were current users of marijuana. This number corresponds to about 1 in 5 young adults (19.6 percent) who used marijuana in the past month. The percentage of young adults who were current marijuana users in 2014 was stable compared with the percentages between 2010 and 2013. However, the 2014 estimate was higher than the estimates from 2002 through 2009.

Aged 26 or Older In 2014, 6.6 percent of adults aged 26 or older were current users of marijuana, which represents about 13.5 million adults in this age group. The percentage of adults aged 26 or older who were current marijuana users in 2014 was higher than the percentages from 2002 to 2013.

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Source:http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

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National Trends from Office of National Drug Control Policy: (Fact Sheet 2010)

 There has been a 103% increase in the potency of seized marijuana from 1998-2008.

 Rates of marijuana used among 8th, 10th and 12th graders are higher than rates from any other illicit drug.

 Rates of marijuana use among young adults have risen by 105 from 2008 to 2009.

 In 2008, nearly 68 percent of primary treatment admissions for youth between the ages of 12 and 17 were for marijuana.

 Fewer youth today see marijuana as “great risk” in using.

 In 1991, approximately 80 percent of 8th, 10th and 12th graders perceived there to be a “great risk” in using marijuana regularly. In 2009, those rates dropped to about 70% of 8th graders, 60% of 10th graders, and 55% of 12th graders. The main active chemical in marijuana is delta-9-tetrahydrocannabinol (THC). Investigations have shown that THC changes the way in which sensory information gets into the hippocampus. It has been shown that THC suppresses neurons in the information-processing system of the hippocampus. It has also been shown that learned behaviors also deteriorate. Continuing to smoke marijuana can lead to abnormal functioning of lung tissue injured or destroyed by marijuana smoke. Marijuana users inhale more deeply and hold the smoke in the lungs. The amount of tar inhaled by marijuana smokers and the level of carbon monoxide absorbed are three to five times greater than among tobacco smokers.

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Illicit Drug Use in Past Month and Illicit Drug Use Other Than Marijuana in Past Month in Oregon among Persons Aged 12 or Older, by Substate Region: Percentages, Annual Averages Based on 2010-2012 NSDUHs

Illicit Drug Use Other Illicit Drug Use in Marijuana Use in the Cocaine Use in the Than Marijuana in Past Month Past Year Past Year State/Substate Past Month Region 95% 95% 95% 95% Estimate Estimate Estimate Estimate Prediction Prediction Prediction Prediction Interval Interval Interval Interval (11.75- (3.42- (14.97- (1.47- Oregon 13.3 4.21 16.66 1.93 15.03) 5.19) 18.50) 2.54) Region 1 (15.96- (3.84- (20.02- (2.27- 19.41 5.29 23.65 3.25 (Multnomah) 23.40) 7.25) 27.71) 4.63) (9.72- (2.58- (11.41- (1.08- Region 2 12.07 3.54 13.79 1.56 14.90) 4.84) 16.57) 2.26) (10.48- (3.40- (14.77- (1.21- Region 3 12.49 4.41 17.17 1.70 14.82) 5.70) 19.86) 2.39) (8.83- (2.58- (11.22- (1.03- Region 4 11.27 3.70 13.97 1.55 14.28) 5.27) 17.26) 2.32) (7.61- (2.73- (10.24- (1.01- Region 5 (Central) 10.31 3.94 13.2 1.53 13.79) 5.66) 16.84) 2.30) (7.23- (2.58- (8.86- (1.02- Region 6 (Eastern) 10.16 3.80 12.19 1.59 14.09) 5.56) 16.55) 2.46)

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2010-2012.

Region 1 -Multnomah Region 2- Clackamas, Washington Region 3- Benton, Clatsop, Columbia, Lane, Lincoln, Linn, Marion, Polk, Tillamook, Yamhill Region 4- Coos, Curry, Douglas, Jackson, Josephine, Klamath Region 5- Crook, Deschutes, Jefferson Region 6- Baker, Gilliam, Grant, Harney, Hood River, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, Wheeler

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Figure 6c. Illicit Drug Use Other Than Marijuana in the Past Month among Adults Aged 18 to 25, by State: Percentages, Annual Averages Based on 2013 and 2014 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2013 and 2014.

Figure 6d. Illicit Drug Use Other Than Marijuana in the Past Month among Adults Aged 26 or Older, by State: Percentages, Annual Averages Based on 2013 and 2014 NSDUHs

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2013 and 2014

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Hepatitis C HCV is transmitted primarily through percutaneous (parenteral) exposure that can result from injection-drug use, needle stick injuries, and inadequate infection control in health-care settings. Much less often, HCV transmission occurs among HIV-positive persons, especially MSM, as a result of sexual contact with an HCV-infected partner (30, 31), among persons who receive tattoos in unregulated settings (31), and among infants born to HCV-infected mothers (32). After adjustment for populations not sampled in the NHANES household surveys, such as incarcerated and homeless populations, an estimated 3.5 million persons are living with HCV infection in the United States. After receiving reports of cases of acute hepatitis C ranging from 781-877 during the years 2006–2010, reported cases of acute HCV infection increased more than 2.5 times from 2010– 2014. Cases of acute HCV infection rose annually, from 850 in 2010 to 1,232 in 2011, 1,778 in 2012, 2,138 in 2013, and 2,194 in 2014. The increase from 2010–2014 is thought to reflect both true increases in incidence and, to a lesser extent, improved case ascertainment. Based on new epidemiologic studies, at least 4.6 million persons are HCV-antibody positive and approximately 3.5 million are currently infected with HCV (13). New cases of HCV infection are predominately among young persons who are white, live in non-urban areas (particularly in Eastern and Midwestern states), have a history of injection-drug use, and previously used opioid agonists such as oxycodone (14). Improved case ascertainment by Florida, Massachusetts, and New York, which were funded by CDC to conduct enhanced surveillance, partially explains the increased incidence of acute HCV infection in these states. In other locations where the number of cases has increased markedly (e.g., Kentucky, Tennessee, Virginia, and West Virginia), increases have occurred without any federal support for investigation or follow-up, reflecting overall increases in incidence (15, 16). After adjusting for under-ascertainment and underreporting (2), an estimated 30,500 new HCV infections occurred in 2014. Mortality among HCV-infected persons—primarily adults aged 55–64 years—is increasing. For the first time in the United States in 2007, the number of HCV-related deaths (n=15,106) exceeded the number of HIV/AIDS-related deaths (n=12,734) and has since continued to increase. The number of HCV-related deaths rose to 19,659 in 2014 and more than one-half of deaths occurred among persons aged 55-64 years. A key public health challenge is to increase the proportion of persons tested, and of those who are currently infected, increase the proportion referred for care and treatment. To address this challenge the USPSTF joined with CDC in 2013 to recommend one-time testing for HCV infection among adults born during 1945– 1965.

189

What is the incidence of HCV infection in the United States? In 2014, a total of 2,194 cases of acute hepatitis C were reported to CDC from 40 states. The overall incidence rate for 2014 was 0.7 cases per 100,000 population, an increase from 2010– 2012. After adjusting for under-ascertainment and under-reporting, an estimated 30,500 acute hepatitis C cases occurred in 2014.

What is the prevalence of chronic HCV infection in the United States? An estimated 2.7-3.9 million people in the United States have chronic hepatitis C.

Who is at risk for HCV infection? The following persons are at known to be at increased risk for HCV infection:

 Current or former injection drug users, including those who injected only once many years ago  Recipients of clotting factor concentrates made before 1987, when more advanced methods for manufacturing those products were developed  Recipients of blood transfusions or solid organ transplants before July 1992, when better testing of blood donors became available  Chronic hemodialysis patients  Persons with known exposures to HCV, such as o health care workers after needlesticks involving HCV-positive blood o recipients of blood or organs from a donor who tested HCV-positive  Persons with HIV infection  Children born to HCV-positive mothers

What is the prevalence of HCV infection among injection drug users (IDUs)?

The most recent surveys of active IDUs indicate that approximately one third of young (aged 18– 30 years) IDUs are HCV-infected. Older and former IDUs typically have a much higher prevalence (approximately 70%–90%) of HCV infection, reflecting the increased risk of continued injection drug use. The high HCV prevalence among former IDUs is largely attributable to needle sharing during the 1970s and 1980s, before the risks of bloodborne viruses were widely known and before educational initiatives were implemented.

190

Is cocaine use associated with HCV transmission? There are very limited epidemiologic data to suggest an additional risk from non-injection (snorted or smoked) cocaine use, but this risk is difficult to differentiate from associated injection drug use and sex with HCV-infected partners. Content source: Division of Viral Hepatitis and National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention HCV FAQs for Health Professionals | Division of Viral Hepatitis | CDC

 Acute hepatitis C cases declined from 2000 through 2005, and remained stable from 2005 until 2010.  From 2010–2014, there was an approximate 2.6-fold increase in the number of reported acute hepatitis C cases from 850 to 2,194 cases, respectively.

191

 From 2000–2002, incidence rates for acute hepatitis C decreased among all age groups, except for persons aged 0–19 years; rates remained fairly constant among all age groups from 2002–2010.  From 2010 to 2014, the rate of acute hepatitis C increased among persons aged 20–29, 30–39 and ≥60 years.  The largest increases were among persons aged 20–29 years (from 0.75 cases per 100,000 population in 2010 to 2.20 cases per 100,000 population in 2014) and persons aged 30–39 years (from 0.60 cases per 100,000 population in 2010 to 1.66 cases per 100,000 population in 2014).  In 2014, among all age groups, persons aged 20–29 years had the highest rate (2.20 cases per 100,000 population) and persons aged 0–19 and ≥60 years had the lowest rate (0.12 cases per 100,000 population) of acute hepatitis C.

Approximately 90% of U.S. deaths from viral hepatitis are caused by infection with hepatitis C virus (HCV). In 2013, for the first time, deaths associated with HCV infection surpassed the total number of deaths from 60 other nationally notifiable infectious diseases (1). In 2014, the HCV-related incidence rate and mortality rate among American Indian/Alaska Native (AI/AN) populations were approximately twofold greater than the comparable rates for the general population. Hepatitis Awareness Month and Testing Day — May 2016. MMWR Morb Mortal Wkly Rep 2016;65:461. DOI: http://dx.doi.org/10.15585/mmwr.mm6518a1

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 Rates of acute hepatitis C decreased among males and females from 2000–2003 and remained fairly constant from 2004–2010.  From 2010–2014, rates of acute hepatitis C increased among males and females; in 2014, rates among males and females were 0.8 and 0.7 cases per 100,000 population, respectively  From 2002–2010, the incidence rate of acute hepatitis C for American Indians/Alaska Natives remained high relative to other racial/ethnic groups. Incidence rates have since increased for all racial/ethnic populations.  From 2010–2014, acute hepatitis C rates increased among all racial/ethnic groups except among Asian and Pacific Islanders.  In 2014, rates of acute hepatitis C among American Indians/Alaska Natives; Asians/Pacific Islanders; Black, non-Hispanic; White, non-Hispanic; and Hispanics were 1.32, 0.07, 0.19, 0.84, and 0.25 cases per 100,000 population, respectively.

193

 In 2014, a total of 34 states notified CDC of 162,863 case-reports of past or present hepatitis C.  Thirteen states (Florida, Illinois, Maryland, Massachusetts, Michigan, Missouri, New Jersey, New York State, Ohio, Oregon, Pennsylvania, Virginia, and West Virginia) accounted for 76.4% of the past/present hepatitis C case-reports submitted through NNDSS in 2014.  Of the three types of viral hepatitis (hepatitis A, B, and C), hepatitis C accounted for the greatest number of deaths and the highest mortality rate, at 5.0 deaths/100,000 population in 2014.  The overall hepatitis C-related mortality rate increased from 4.7 deaths/100,000 population in 2010 to 5.0 deaths/100,000 population in 2014.  From 2010–2014, the age group with the highest hepatitis C-related mortality rate was persons aged 55–64 years (25.0 deaths/100,000 population in 2014). This group accounted for 50.9% of hepatitis C-related deaths in 2014.  In 2014, the racial/ethnic group with the highest hepatitis C-related mortality rate was among American Indians/Alaska Natives (11.2 deaths/100,000 population).  From 2010–2014, the hepatitis C-related mortality rate among American Indians/Alaska Natives increased by 13%.  In 2014, the hepatitis C-related mortality rate for males was approximately 2.6 times the rate for females.

194

From the May 2015 Oregon Health Authority Report: Viral Hepatitis in Oregon In 2005, positive laboratory test results of HCV (referred to as “chronic” infections, likely representing persons who acquired HCV sometime in the past) became reportable in Oregon. Between 2009 and 2013, Acute and Communicable Disease Prevention received 25,437 reports of persons with positive laboratory HCV tests, with an average annual number of 5,087. Compared to acute cases of HCV, persons with positive laboratory reports were more likely to be male (61%) and over age 40 (79%). AI/ANs and blacks and African Americans had the highest rates of HCV laboratory reports in this time; their rates (127.7 cases /100,000 and 124.4 cases/100,000) were both more than twice the rate seen in whites during the same time (57.5 cases/100,000). The lowest rates were found among Hispanics (20.8 cases/100,000). Neither the OHA nor local health departments typically have resources to investigate persons reported with positive laboratory tests for HCV. However, a study conducted in Lane, Marion and Multnomah counties in 2011–2012 found that 77% of persons with positive laboratory reports who received follow-up investigation reported injection drug use.

195

Rates of acute infection with HCV (for which no vaccine is available) between 2009 and 2013 were stable over the same period. HCV infections were most common in younger adults; nearly half of the cases were in persons less than 30 years of age. Injection drug use was the predominant route of transmission, accounting for 64% of interviewed cases. The average rate of acute HCV in Oregon was 50% higher than the national rate in 2007– 2011. The highest rates were in AI/ANs (2.1 cases/100,000), who had rates three times higher than whites (0.6 cases/100,000) and blacks and African Americans (0.6 cases/100,000) in Oregon.

The volume of laboratory reports of positive HCV tests is more than 10 times higher than for chronic HBV, averaging 5,087 reports per year in the last five years. The majority of cases are male (61%) and over the age of 40 (79%); both AI/ANs and blacks and African Americans had rates of positive HCV laboratory reports that were twice as high as in whites. Like acute cases, the majority of persons interviewed reported injection drug use at some point in their lives. ______HCV testing is recommended for those who:  Currently inject drugs;  Ever injected drugs, including those who injected once or a few times many years ago;  Have certain medical conditions, including persons: ≫ Who received clotting factor concentrates produced before 1987; ≫ Who were ever on long-term hemodialysis; ≫ With persistently abnormal alanine aminotransferase levels (ALT); ≫ Who have HIV infection.  Were prior recipients of transfusions or organ transplants, including persons who: ≫ Were notified that they received blood from a donor who later tested positive for HCV infection; ≫ Received a transfusion of blood, blood components or an organ transplant before July 1992. HCV testing based on a recognized exposure is recommended for:  Health care, emergency medical and public safety workers after needle sticks, sharps or mucosal exposures to HCV-positive blood;  Children born to HCV-positive women.  Added in 2012: one-time testing of persons born between 1945 and 1965 (without ascertainment of risk factors).

______

 Rates of acute HCV cases in Oregon were 50% higher than the national rate during 2007–2011.  Injection drug use accounted for the majority of new HCV infections in Oregon.  Rates of acute HCV in Oregon were four times higher in AI/ANs than in any other racial group.

196

Table 9. Incidence of acute hepatitis C by county, Oregon, 2009–2013 Source: Orpheus hepatitis C surveillance and American Community Survey, June 2014 Acute hepatitis C counts and rates per 100,000 residents 2010 2011 2012 2013 2014

No. Rate* No. Rate* No. Rate* No. Rate* No. Rate* Oregon

19 0.5 20 0.5 37 0.9 14 0.4 15 0.4

Clackamas 2 1 1 0 3 1 5 1 14 1 3 0 5 1 12 2 0 0 21 1 Multnomah

*Rate per 100,000 population. Source: CDC, National Notifiable Diseases Surveillance System. (Oregon)

 More than 5,000 persons with positive HCV tests are reported each year in Oregon.  Rates of chronic HCV infection are twice as high in AI/ANs and in blacks and African Americans compared to whites.

197

Table 10. Incidence of chronic hepatitis C by county, Oregon, 2009–2013 Source: Orpheus hepatitis C surveillance and American Community Survey, June 2014 Chronic hepatitis C counts and rates per 100,000 residents

2010 2011 2012 2013 2014 No. Rate* No. Rate* No. Rate* No. Rate* No. Rate*

283 75 315 83 281 74 327 85 1554 82 Clackamas

1469 199 1430 193 1266 139 938 124 6463 174 Multnomah

198

199

 In Oregon, from 2008 to 2012, 70% of HCV hospitalizations occurred in persons aged 50–64, and the average charges per hospitalization were $26,961.  Most hospitalizations (62%) were in persons whose insurance payer was either Medicare or Medicaid.  Half of liver transplants performed at OHSU in the past five years were due to HCV.

200

 Between 2009 and 2013, the highest mortality rates from HCV occurred in two groups: AI/ANs and blacks and African Americans. Both were roughly twice the rate of whites.  The mortality rate in Oregon from HCV was nearly twice the national average in 2011.

 The majority of Oregon HBV chronic cases occur in persons born outside of the United States and were likely acquired at birth or in childhood.  In 2009–2013, 59% of Oregon’s chronic HBV cases occurred in Asians and PIs.  Chronic HBV is more common in Asian and PI women than in women of other races.  Nearly two-thirds (63%) of Oregon’s liver cancer cases associated with HBV infection were among Asians and PIs.  Asians and PIs accounted for a quarter of deaths from HBV infection between 2008 and 2012.  Rates of acute HBV among blacks and African Americans in Oregon from 2009–2013 did not differ from other racial or ethnic groups. However, chronic HBV was more than 20 times higher in blacks and African Americans than in whites.  The majority of cases of chronic HBV among blacks and African Americans in Oregon are among persons born in Africa (78%).  Cases of chronic HBV and liver cancer associated with HBV are more common in blacks and African Americans than in whites in Oregon.

201

 Chronic HCV infection is more common in blacks and African Americans than in whites in Oregon.  Among blacks and African Americans, 64% of chronic HCV cases occur in men and 67% in persons aged 40–59.  Liver cancer and deaths from HCV are nearly twice as common in blacks and African  Americans compared to whites.

 Rates of acute HCV in Oregon are more than three times higher in AI/ANs than any other racial group.  The highest rates of chronic HCV in Oregon are seen in AI/ANs and blacks and African Americans.  Hospital discharge data from the Indian Health Service (IHS) found a three-fold increase in HCV-related hospitalizations between 1995 and 2007.  In Oregon, AI/ANs are twice as likely to die from HCV as whites.

202

203

http://public.health.oregon.gov/DiseasesConditions/HIVSTDViralHepatitis/AdultViralHepatitis/Documents/Viral_Hepatitis_Epi_Profile.pdf

204

Sexually Transmitted Disease

A number of individual risk behaviors (such as higher numbers of lifetime sex partners), as well as environmental, social and cultural factors (such as higher prevalence of STDs or difficulty accessing quality health care) contribute to disparities in the sexual health of gay and bisexual men. For example, gay and bisexual men with lower economic status may have trouble accessing and affording quality healthcare, making it difficult to receive STD testing and other prevention services. Additionally, complex issues like homophobia and stigma can also make it difficult for gay and bisexual men to find culturally-sensitive and appropriate care and treatment. http://www.cdc.gov/std/stats14/std-trends-508.pdf Surveillance data shows both the numbers and rates of reported cases of chlamydia and gonorrhea continues to be highest among young people aged 15-24. Both young men and young women are heavily affected by STDs — but young women face the most serious long-term health consequences. It is estimated that undiagnosed STDs cause more than 20,000 women to become infertile each year. The 2014 data also show that youth are still at the highest risk of acquiring an STD, especially chlamydia and gonorrhea. Despite being a relatively small portion of the sexually active population, young people between the ages of 15 and 24 accounted for the highest rates of chlamydia and gonorrhea in 2014 and almost two thirds of all reported cases. Additionally, previous estimates suggest that young people in this age group acquire half of the estimated 20 million new STDs diagnosed each year.

STDs on the Rise Press Release | 2015 | Newsroom | NCHHSTP | CDC

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http://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/DiseaseSurveillanceData/ST D/Pages/index.aspx Chlamydia

Chlamydia trachomatis (i.e., chlamydia) is primarily a sexually transmitted bacterial infection. The majority of infections lack visible symptoms that are not recognized for months. Symptoms commonly include painful urination, vaginal discharge and pelvic pain, among others. Untreated chlamydia can cause pelvic inflammatory disease (PID) and infertility or tubal pregnancy in women. If detected, chlamydia can be treated successfully with antibiotics; this prevents long-term health consequences and sex partners from getting chlamydia. Unlike gonorrhea, chlamydia is not resistant to antibiotics.

 Chlamydia is the most common reportable illness in Oregon. More than 13,000 cases occurred in 2012.  Rates of chlamydia are highest among: • Women; • Men and women aged 15–24; and • Blacks and African Americans.

 Chlamydia can be treated with antibiotics.

206

 Physicians and other health care providers can help stop its spread by prescribing antibiotics for sex partners of people with chlamydia. They can do this even if they have not examined the partner. This is called expedited partner therapy (EPT).  Increased screening and improved laboratory tests have likely caused an increase in reported cases since 2003.  U.S. medical care costs to treat chlamydia and its complications exceed $700 million each year.

207

Data source for graphics: Oregon Public Health Division statewide mandatory reporting of chlamydia cases: http://public.health.oregon.gov/DiseasesConditions/ CommunicableDisease/DiseaseSurveillanceData/STD/ Pages/index.aspx.

208

554

499

341

970

516

115

317

388

544

ra te

2,720

1,610

2,051

1,246

1,904

1,101

3,441

2,132

2,847

1,558

2,599

1,543

2013

572

444

117

562

379

148

195

100

115

689

2,666

3,239

1,997

2,378

3,110

3,801

ca se s

647

541

415

717

173

446

439

628

ra te

2,951

1,769

1,972

1,228

2,146

1,256

3,999

1,465

2,657

2,306

1,327

2,774

1,670

2012

668

427

127

554

461

172

243

795

2,892

3,560

2,251

2,712

3,319

4,114

ca se s

669

551

384

785

103

446

444

648

ra te

3,004

1,808

2,097

1,290

1,984

1,161

4,817

1,482

3,048

1,779

1,085

2,846

1,716

†,¶

2011

701

442

127

569

431

207

279

828

3,001

3,702

2,108

2,539

3,443

4,271

ca se s

2013

—

588

570

379

771

116

442

338

585

ra te

2,585

1,565

2,075

1,287

1,929

1,134

5,179

2,146

3,573

1,812

1,049

2,500

1,518

2010

634

428

129

557

435

221

103

324

763

2,666

3,300

2,103

2,538

3,094

3,857

ca se s

562

556

371

171

631

439

561

2,504

1,514

2,386

1,398

1,944

1,133

5,823

3,392

4,593

1,086

2,827

1,576

2,487

1,496

ra te

2009

610

421

115

536

431

238

142

380

725

2,615

3,225

2,127

2,558

3,036

3,761

ca se s

19 yearsa given19 for race ethnicity or

–

509

743

368

597

284

441

758

545

ra te

2,109

1,293

2,557

1,572

1,731

1,028

6,757

3,058

4,855

2,648

1,658

2,170

1,333

2008

565

426

147

573

434

263

126

389

712

2,245

2,810

1,917

2,351

2,671

3,383

ca se s

yearreport:of

Ratesareexpressed ascases population agedper100,000 15

NCHSbridged-race estimates (sincewereavailable).usedyetNCHS were2013 not estimates as 2013 2012 a proxy for for

†

*Source: Orpheus, January 2, 2014; totals may differ from sectiontotalssection mayfrom to differ duemissing to data race) (particular 2014; for January Orpheus,*Source: 2,

female

male

Not Hispa nic (ma y be a ny ra ce )

female

male

Hispa nic (ma y be a ny ra ce )

female

male

White

female

male

Africa n Ame rica n/Bla ck

female

male

Asia n or Pa cific Isla nde r

female

male

Ame rica n India n/Ala ska Na tive

female

male Total chlamydia (ages 15-19) Chlamydia cases among persons aged 15–19 years, by race, ethnicity and sex, Oregon, 2008

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Gonorrhea

Gonorrhea is primarily a sexually transmitted bacterial infection that affects the genital tract, rectum, mouth and throat of men and women. Women are more likely to become infected with gonorrhea after exposure. However, women are less likely than men to develop symptoms after infection and before they are tested.

Gonorrhea can cause serious complications. These include pelvic inflammatory disease that sometimes leads to infertility or tubal pregnancy in women. Infections that spread can cause very rare cases of arthritis and blisters on the skin in either sex, but such infections are very rare. Untreated gonorrhea during pregnancy can cause premature delivery. Sometimes it can be hard to see the difference between symptoms caused by gonorrhea and those caused by chlamydial infection. Gonorrheal and chlamydial infections commonly occur at the same time.

 A total of 1,469 cases of gonorrhea were reported in Oregon during 2012.  Gonorrhea rates ranged from 25 to 45 cases per 100,000 Oregon residents per year during 2002–2012. These rates were well below the overall U.S. rates.  Overall reported rates of gonorrhea are higher in men than in women.  The highest rates occur among men and women in their 20s. Rates remain higher for men starting at age 20.  At least 42% of men with reported cases of gonorrhea report having had sex with other men.  Although cephalosporin is the preferred antibiotic treatment for gonorrhea, its effectiveness appears to be declining. This might become a major problem because no clear alternatives exist for treating gonorrhea.

210

Oregon STD Statistics Oregon Public Health Division statewide mandatory reporting of syphilis cases: http://public.health. oregon.gov/DiseasesConditions/CommunicableDisease/DiseaseSurveillanceData/Pages/annrep.aspx

211

326

330

328

ra te

2013

157

111

181

ca se s

109

698

268

470

114

100

ra te

2012

107

166

107

120

189

ca se s

144

350

797

133

ra te

1,303

2011

144

200

113

161

229

ca se s

†,¶

124

500

739

112

ra te

1,008

2010

128

185

139

200

ca se s

134

104

108

881

955

149

130

ra te

1,027

2009

140

222

101

137

159

246

19 yearsa given19 for race ethnicity or

ca se s

–

132

138

899

752

824

133

ra te

2008

141

209

108

137

164

239

ca se s

Ye a r

Ratesareexpressed ascases population agedper100,000 15

NCHSbridged-race estimates (sincewereavailable).usedyetNCHS were2013 not estimates as 2013 2012 a proxy for for

†

*Source: Orpheus, January 2, 2014; totals may differ from sectiontotalssection mayfrom to differ duemissing to data race) (particular 2014; for January Orpheus,*Source: 2,

female

male

Not Hispa nic (ma y be a ny ra ce )

female

male

Hispa nic (ma y be a ny ra ce )

female

male

White

female

male

Africa n Ame rica n/Bla ck

female

male

Asia n or Pa cific Isla nde r

female

male

Ame rica n India n/Ala ska Na tive

female

male T ota l gonorrhe a (a ge s 15-19) Gonorrhea cases among persons aged 15–19 years, by race, ethnicity and sex, Oregon, 2008–2013 sex,Oregon, and ethnicity race, by years, 15–19 aged persons among cases Gonorrhea

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Syphilis

Stages of syphilis Syphilis is a sexually transmitted bacterial infection. Oregon state law requires health providers and laboratories to report syphilis cases to the local health department. People with syphilis often go through long periods when they have no symptoms

Primary syphilis — Usually consists of a single sore that lasts one to five weeks. Syphilis is most infectious during this period. It can be transmitted by direct contact, most often during sex. Blood tests for syphilis are often not positive until three weeks or more after exposure. Sometimes the sore goes unnoticed. •Secondary syphilis — Secondary syphilis does not follow in every case. When present, it appears about four weeks after the sore disappears. It includes rashes of the skin, mouth and genitals and swollen lymph nodes. Symptoms last one to six weeks and then disappear, even without treatment. People with secondary syphilis are infectious. • Latent syphilis — There are no symptoms during this stage. Latent syphilis may go undetected for a lifetime or be followed in a few years by late (tertiary) syphilis. Blood tests are positive throughout latent infection. • Late (tertiary) syphilis — This stage occurs in 30% to 40% of untreated people with primary syphilis. Late syphilis can cause disabilities such as dementia, balance and sensory problems. • Congenital syphilis — This is when a fetus acquires syphilis in the womb or during delivery. Congenital syphilis is rare because most pregnant women are tested for syphilis. It may cause miscarriage, stillbirth or neonatal death. It can also cause the child to be chronically disabled. • Neurologic complications — Neurologic complications can occur at any stage of syphilis including meningitis or ocular disease in primary and secondary and early latent syphilis, or dementia and peripheral nerve damage in late stages of syphilis. ‘Neurosyphilis’ is not considered a stage of syphilis.

 Oregon’s rate of early syphilis infections greatly increased during the last eight years. There were 0.7 cases per 100,000 people in 2007 and 10.5 cases per 100,000 people in 2014. This represents a 1500% increase. Increases continue during 2015.  During 2014, people with HIV accounted for 42% of Oregon’s new early syphilis cases.  In the last decade, at least 64% of Oregon’s early syphilis cases have occurred in men who have sex with men.

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Early syphilis cases by county of residence, 2014 Multnomah County, 223 cases (29.1 per 100,000) Washington County, 54 cases (9.7 per 100,000) Clackamas County, 16 cases (4.1 per 100,000) Lane County, 23 cases (6.5 per 100,000) Marion County, 31 cases (9.6 per 100,000) Remaining 31 counties, total of 69 cases

http://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/DiseaseSurveillanceData/STD/Docume nts/9984-STD-Syphilis-Final.pdf

214

Troubling rise in syphilis infections among men, particularly gay and bisexual men Gay and Bisexual Men Face Highest – and Rising – Number of Syphilis Infections Trend data show rates of syphilis are increasing at an alarming rate (15.1 percent in 2014). While rates have increased among both men and women, men account for more than 90 percent of all primary and secondary syphilis cases. Men who have sex with men (MSM)* account for 83 percent of male cases where the sex of the sex partner is known. Primary and secondary syphilis are the most infectious stages of the disease, and if not adequately treated, can lead to long-term infection which can cause visual impairment and stroke. Syphilis infection can also place a person at increased risk for acquiring or transmitting HIV infection. Available surveillance data indicate that an average of half of MSM who have syphilis are also infected with HIV.

http://www.cdc.gov/std/stats14/std-trends-508.pdf

215

During 2014, 41% of syphilis infections occurred among people who already had HIV infection.

For additional resources and information see: http://public.health.oregon.gov/DiseasesConditions/ HIVSTDViralHepatitis/SexuallyTransmittedDisease/ Pages/index.aspx

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HIV/AIDS The following is from the “Epidemiologic profile of HIV/AIDS in Oregon” Report The rate of new HIV/AIDS infections by year of earliest reported diagnosis reached a high of 19 cases per 100,000 Oregon residents, a total of 542 cases, in 1991. The following year, however, saw the beginning of a decline. By 1997 the rate dropped to 9 cases per 100,000, and continued to decline steadily to a level of 7 cases per 100,000 in 2012. Oregon’s decline in new diagnoses during the 1990s reflected similar trends throughout the United States. These declines probably resulted from a combination of factors, including earlier diagnosis, behavior changes, reduction in infection from a pregnant woman to her baby, and reduced infectiousness of HIV-infected people taking antiretroviral therapy. In Oregon, men are more likely to be infected than women. From 2008 through 2012, diagnosis rates in Oregon were 7 times higher among men relative to women (12.1 vs. 1.6 per 100,000). Men who have had sex with men (MSM) accounted for 72% of all male cases. Roughly half of female HIV cases were infected by sexual activity with a man, and injection drug use (IDU) accounted for 18% of female cases. Recently, new diagnoses have increased relatively among younger age groups. During 2008–2012, rates of new diagnoses among males aged 20–24 years remained elevated (22.4 per 100,000) compared to the diagnosis rate prior to 2005 (13.1 per 100,000). Relative increases among younger people might reflect an increased rate of new infections among younger people or earlier diagnosis. Blacks/African Americans and Hispanics continue to be more likely than whites to become infected. During 2008–2012, diagnosis rates were 3.8 times as high among blacks/African Americans and 1.6 times as high among Hispanics compared to whites.

From 1981 through the end of 2012, 9,307 Oregon residents diagnosed with HIV infection were reported to the Oregon Public Health Division. Forty percent had died by the end of 2012, leaving 5,581 people living with HIV/ AIDS (PLWH/A). As of 2012, Multnomah County was home to 19% of the state’s population, but 55% of PLWH/A were diagnosed in Multnomah County. People diagnosed in the Portland metropolitan area and living by the end of 2012 were more likely to be male and MSM than PLWH/A in the remainder of the state, where female cases and infection from IDU — although still a distinct minority — were slightly more common. Other counties that were home to 50 or more PLWH/A at the time of their diagnosis included Clackamas, Deschutes, Douglas, Jackson, Josephine, Lane, Linn, Marion, Yamhill and Washington. Many of these people have moved to other counties since diagnosis, some having been diagnosed more than two decades ago. Consequently, county of residence at diagnosis can be an inaccurate way to estimate the number of current residents with HIV/AIDS by county.

As of December 31, 2012: • 9,307 Oregonians were diagnosed with HIV. • 3,726 Oregonians with HIV have died. • 5,581 Oregonians were living with HIV. • During the last 15 years, approximately 274 Oregonians were diagnosed with HIV each year.

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• Over the past decade, an average of 84 persons with HIV died each year. • Diagnosis rates for HIV have increased among 20–24 year olds since 2006. • Fifty-five percent of people living with HIV in Oregon resided in Multnomah County when they were diagnosed.

Half (641/1,271) of those diagnosed with HIV during 2008–2012 were Multnomah County residents. Statewide, men were about seven times (12.1 vs. 1.6 per 100,000) more likely than women to be diagnosed with HIV. The average age at diagnosis was 37.7 for males and 36.5 for females (Figure 2).

New diagnosis rates were 3.8 times higher among blacks and African Americans than whites (22.1 vs. 5.8 per 100,000).* The rate of new diagnoses for Hispanics was 1.6 times higher than for white non-Hispanics (9.6 vs. 5.8 per 100,000); other races/ethnicities accounted for roughly 4% of all diagnoses.

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During 2008–2012, 48% (48/92) of black and African American men with recently diagnosed infection acknowledged having had sex with other men. But, black and African American men with recently diagnosed HIV infection were proportionally less likely than white men to report sex with other men. Relatively few men in either racial group were assigned to the “presumed heterosexual” category (Table 1).

Twenty-six black and African American women were diagnosed with HIV during 2008–2012, with high-risk heterosexual exposure, the most common transmission category (Table 1). Only one African American woman (4% of 26) acknowledged injection drug use alone among the possible transmission categories (vs. 19/92= 21% of white women and 4/20= 20% of Hispanic women). Eight (31% of 26) of the African American women were assigned to the “presumed

219 heterosexual female” category, a slightly higher proportion than the 23 (25% of 92) white women.

HIV and mortality facts at a glance: • During 2012, the annual number of deaths among people with HIV declined (from 338 deaths during 1994 to 75 cases during 2012). • Overall cumulative probability of surviving 10 years after diagnosis was 88% among Oregonians newly diagnosed with HIV infection during 2003–2012. • Cumulative probability of surviving 10 years after diagnosis is highest among blacks/African Americans (97%) relative to all other races. • Cumulative probability of surviving 10 years after diagnosis was lower for: » American Indians or Alaska Natives relative to white non-Hispanics; » People aged >36 years at diagnosis relative to younger age groups; » People with CD4 counts <50 cells/mm3 at diagnosis relative to those with higher CD4 counts at diagnosis; » People who acquired HIV via injection drug use (IDU) relative to survival among people with other modes of transmission. • During 2008–2012, HIV disease remained the leading underlying cause of death (48%) among people with HIV who died. Cancer (16% of deaths) was the second most common underlying cause listed.

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HIV diagnoses by county of residence at diagnosis, Oregon, 1981–2012 Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 Clackamas 0 0 0 1 8 9 21 7 18 20 29 Multnomah 1 5 7 31 143 131 221 224 306 347 359

Year 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Clackamas 25 28 16 21 23 20 9 10 20 19 12 Multnomah 340 275 266 230 202 154 154 143 140 145 143

Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Clackamas 20 15 20 20 17 12 27 25 18 22 512 Multnomah 164 150 159 149 112 150 119 111 120 141 5342

Epidemiologic resources: Oregon Health Authority, HIV/AIDS epidemiology: https://public.health.oregon.gov/DiseasesConditions/ CommunicableDisease/DiseaseSurveillanceData/ HIVData/Pages/index.aspx Centers for Disease Control and Prevention: www.cdc.gov/hiv

Source of above chart: HIV Data and Analysis

The following HIV/AIDS data tables and summaries were prepared by the HIV/STD/TB Program of the Oregon Health Authority. The Epidemiologic Profile is published annually and is a comprehensive review of HIV/AIDS in Oregon. More recent and preliminary data is prepared quarterly. http://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/DiseaseSurveillanceData/HIVDat a/Pages/epiprofile.aspx

For additional Multnomah County information: HIV Care Services FY 2014 Annual Report Multnomah County Health Department September 2015

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Genital Herpes

Genital herpes is an STD caused by two types of viruses. The viruses are called herpes simplex type 1 and herpes simplex type 2.

Genital herpes is common in the United States. In the United States, about one out of every six people aged 14 to 49 years have genital herpes.

You can get herpes by having vaginal, anal, or oral sex with someone who has the disease.

Fluids found in a herpes sore carry the virus, and contact with those fluids can cause infection. You can also get herpes from an infected sex partner who does not have a visible sore or who may not know he or she is infected because the virus can be released through your skin and spread the infection to your sex partner(s).

Genital Herpes — Initial Visits to Physicians’ Offices, United States, 1966–2013

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See Appendix D: Sexually Transmitted Disease for Supplemental Data

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Adventist Health-Portland: Hospital Patient Data

Hospital Patients per ICD‐9 and ICD‐10 Codes

July 2015‐February 2016

Rank Total Per ICD Code ICD Description

1 4858 Hyperlipidemia 2 3612 Primary Hypertension 3 3540 Diabetes 4 1551 Other Specified Hypothyroidism 5 1125 Urinary Tract infection 6 979 Unspecified Chest pain 7 882 Rheumatoid arthritis, unspecified 8 708 Other malaise and fatigue 9 649 Dysuria 10 589 Unspecified Vitamin D Deficiency

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Social Determinants of Health

“Human health status is typically thought to be the result of interactions between an individual’s physiology and the person’s health-related choices i.e. whether or not she chooses to smoke, exercise, eat healthy foods etc. More recently there has been a growing recognition that health is the result of the interplay between factors affecting a person’s life long before the health behaviors or physiological problems that immediately precede illness.” “A large body of literature on the determinants of health indicates that of all factors that affect health including genetics, individual choice, and the environment, social determinants can have some of the most significant and far-reaching effects on human wellbeing. Along with a growing awareness of the importance of social determinants of health and the non-traditional policies needed to achieve better health for all, we continue to recognize that individual health-related choices also play a role in determining health outcomes.” Quotes from “Social Determinants of Health in Multnomah County” Executive Summary December 2010 Multnomah County Health Department, Health Assessment and Evaluation

There are many influences on how a family or individual makes their nutritional choices. They can be affected by financial resources, availability of transportation, education levels, and location of affordable sources of food. These same influences, along with social conditions, can determine other lifestyle choices such as regular exercise.

The Multnomah County Health Department’s report “Transportation and Health” discusses how the transportation planning affects a person’s health through the availability of clean air to breath, opportunity for physical activity and employment, and the access to healthcare. 75% of the commuters in Multnomah County drive to work as compared to 86% nationally. 19% of the residents used active transportation to work (10% nationally). Active transportation includes walking, bicycling, and public transportation. The motor vehicle-related mortality rate is the same as the national rate (15.2 per 100,000 population). The county compared well to other cities in walking ability and biking. It also compared well in per capita carbon footprint from transportation and residential energy use. This use decreased between the years 2000 and 2005.

The “Transportation and Health” report also discusses the effect of vehicle emissions on people’s health. It states that the top three hazardous air pollutants with adverse health effects and cancer risk in the Portland area are diesel, benzene, and formaldehyde. The higher concentrations and elevated cancer risks align with major traffic corridors. Another adverse health risk caused in part by transportation is noise exposure. This includes noise from road traffic, rail traffic, and air traffic.

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Section on next page is from: http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39 Examples of social determinants include:

 Availability of resources to meet daily needs (e.g., safe housing and local food markets)  Access to educational, economic, and job opportunities  Access to health care services  Quality of education and job training  Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities  Transportation options  Public safety  Social support  Social norms and attitudes (e.g., discrimination, racism, and distrust of government)  Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)  Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)  Residential segregation  Language/Literacy  Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)  Culture

Examples of physical determinants include:

 Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)  Built environment, such as buildings, sidewalks, bike lanes, and roads  Worksites, schools, and recreational settings  Housing and community design  Exposure to toxic substances and other physical hazards

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 Physical barriers, especially for people with disabilities  Aesthetic elements (e.g., good lighting, trees, and benches)

Poverty

Poverty rates are important indicators of community well-being and are used by government agencies and organizations to allocate need-based resources.

The following is from: Income and Poverty in the United States: 2014 Current Population Reports U.S. Department of Commerce Economics and Statistics Administration U.S. CENSUS BUREAU census.gov

Household Income Median household income was $53,657 in 2014, not statistically different from the 2013 median in real terms, 6.5 percent lower than the 2007 (the year before the most recent recession) median ($57,357), and 7.2 percent lower than the median household income peak ($57,843) that occurred in 1999.

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For family households, married-couple households had the highest median income in 2014 ($81,025), followed by households maintained by men with no wife present ($53,684). Those maintained by women with no husband present had the lowest median ($36,151).

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Community Commons.org

According to The Oregon Center for Public Policy:

 In 2014, 16.6 percent of Oregonians – 1 in every 6 people – lived below the federal poverty level.

 Though down from its 2011 peak of 17.5 percent, the poverty rate in 2014 remained higher than during the period of the Great Recession.

 About 110,000 more Oregonians were poor in 2014 than in 2009 at the end of the Great Recession.  More than one in five children in Oregon live in a household without the resources needed to grow up happy and healthy.

 In 2014, 21.1 percent of Oregon children lived in poverty.

 Poverty can seriously harm a child’s physical, mental and social development, making it harder for the child to become a productive adult

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Income inequality

Source of above: Oregon Center for Public Policy | www.ocpp.org

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How does Multnomah County compare to the United States? Multnomah County child poverty prevalence is higher for all communities of color than nationally, based on data from 2006–2010 (U.S. Census Bureau, 2011). The local prevalence for Black/African Americans is 50.5% compared to 35.4% nationally. The local prevalence for Asian/Pacific Islanders is 18.0% compared to 12.2% nationally. The local prevalence for American Indian/Alaska Natives is 37.5% compared to 33.7% nationally. And the local prevalence for Latinos is 35.2% compared to 29.2% nationally. The prevalence of poverty among non-Latino White children is higher locally (13.2%) than nationally (11.3%).

2014 Report Card on Racial and Ethnic Disparities December 2014 Multnomah County Health Department

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Federal and state safety net programs lift an estimated 640,000 Oregonians above the poverty line each year, reducing the poverty rate from 29.2 percent (before counting government benefits and taxes) to 12.5 percent. Many are children: the safety net lifts roughly 160,000 Oregon children above the poverty line, reducing the child poverty rate from 29.1 percent to 10.9 percent.

Impact of Largest Programs

Social Security lifts more Oregonians above the poverty line each year than any other program. “Means-tested programs,” which tie eligibility to a person’s income — such as SNAP (formerly food stamps) and the Earned Income Tax Credit — also reduce poverty considerably, especially among the non-elderly. In Oregon:  Social Security lifts an estimated 370,000 people — most of them elderly — above the poverty line and cuts the elderly poverty rate from 54.7 percent to 11.4 percent.  SNAP lifts an estimated 120,000 people above the poverty line, and it makes many others less poor. Altogether, SNAP assists an average of 780,000 people a month, including about 270,000 children.  Two working family tax credits, the Earned Income Tax Credit and Child Tax Credit, lift an estimated 130,000 people out of poverty. Altogether, roughly 880,000 people — including 490,000 children — receive the Earned Income Tax Credit or low-income part of the Child Tax Credit.  Supplemental Security Income, which provides critical aid to elderly and severely disabled people with very low incomes, lifts an estimated 38,000 people above the poverty line.  Housing assistance lifts an estimated 43,000 people above the poverty line. In total, federal rental assistance helps 110,000 people keep a roof over their heads; many other families eligible for assistance don't receive it due to funding limitations. Safety net programs not only reduce immediate deprivation but also have long-term benefits for children, a growing body of research indicates. The findings suggest, for instance, that SNAP and the Earned Income Tax Credit help reduce infant mortality and low birthweight, and improve children’s reading and math test scores, high school completion, college entry, and expected future earnings. The findings also indicate that housing assistance that helps low- income families move to safe, low-poverty neighborhoods with better schools can enhance their children’s long-term prospects. Center on Budget and Policy Priorities: http://www.cbpp.org/sites/default/files/atoms/files/7-22-16pov-factsheets-or.pdf

"The above material was created by the Center on Budget and Policy Priorities (www.cbpp.org).”

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The following data is from the Kaiser Family Foundation’s WWW.statehealthfacts.org

Distribution of Total Population by Federal Poverty Level 2014

Oregon # Oregon % U.S. # U.S. % Under 100% 577,200 15% 47,021,300 15% 100-199% 685,800 17% 58,690,600 19% 200-399% 1,103,000 28% 92,283,700 29% 400%+ 1,596,400 40% 118,172,300 37% Total 3,962,300 100% 316,167,900 100%

Distribution of Total Population by Federal Poverty Level | The Henry J. Kaiser Family

Foundation

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2016 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA Poverty Persons in family/household guideline For families/households with more than 8 persons, add $4,160 for each additional person. 1 $11,880 2 16,020 3 20,160 4 24,300 5 28,440 6 32,580 7 36,730 8 40,890

Health Insurance Coverage of Total Population 2014

Oregon # Oregon % U.S. # U.S. % Employer 1,840,400 46% 154,347,500 49% Individual 290,300 7% 19,313,000 6% Medicaid 825,400 21% 61,650,400 19% Medicare 635,700 16 41,896,500 13% Other Public 59700 2 5,985,000 2% Uninsured 310,800 8% 32,967,500 10% Total 3,963,300 100% 316,159,900 100%

Health Insurance Coverage of the Total Population | The Henry J. Kaiser Family

Foundation

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http://www2.census.gov/programs-surveys/demo/visualizations/p60/252/figure4.pdf

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Oregon Department of Human Services Districts Map Feb. 2016

Statewide Supplemental Nutrition Assistance Program Activity

FY 09-10 FY 10-11 FY 11-12 FY 12-13 FY 13-14 FY 14-15

Mean Mean Mean Mean Mean Mean Statewi 353,70 401,19 433,74 443,81 440,45 435,06 de 9 8 6 6 0 1 % 13.43 8.11% 2.32% -0.76% -1.22% Change % District 43,549 58,723 66,568 72,175 73,774 71,440 2 % 34.84 13.36 8.42% 2.22% -3.16% Change % % District 10,868 15,796 18,900 20,772 20,614 19,921 15 % 45.34 19.65 9.90% -0.76% -3.36% Change % % Data source: http://www.oregon.gov/DHS/ASSISTANCE/Pages/data-pa.aspx

FY 11-12 FY 12-13 FY 13-14 FY 14-15 FY 15-16 FY 10-11 Mean Mean Mean Mean Mean Mean 77,372 91,760 96,834 91,475 77,674 63,813 16.78% 18.60% 5.53% -5.53% -19.79% -30.24% 8,181 8,833 8,893 8,463 7,226 11.72% 7.97% 0.68% -4.84% -18.75% 3,748 4,709 4,997 4,348 3,543 8.67% 25.64% 6.12% -12.99% -29.10% Data: www.oregon.gov/DHS

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Data source: http://www.oregon.gov/DHS/ASSISTANCE/Branch%20District%20Data/Oregon%20Self-Sufficiency%20at%20a%20Glance%20- %20June%202016.pdf June 2016 TANF- Temporary Assistance to Needy Families Program

Tax Facts That Matter: 2016 Edition OCPP- Oregon Center for Public Policy June 15, 2016

Who pays more taxes, low- or high-income households? The income group in Oregon that pays the highest share of their income to state and local taxes: Lowest income households.

The income group in Oregon that pays the lowest share of their income to state and local taxes: The wealthiest 1 percent of households.

Have taxes increased as a share of Oregonians’ income? Oregon state and local general revenue as a share of income in 1991: 15.7 percent. Oregon state and local general revenue as a share of income in 2013: 15.7 percent.

How much do working poor Oregonians pay in income taxes? 2014 federal poverty threshold for a family of four with two children: $24,008. State income tax paid in Oregon by a family of four living at the poverty line in 2014: $130.

Of the 42 states with income taxes, the number that taxed the income of a family of four living at the poverty line in 2014: 14.

Oregon’s rank in taxing the income of a family of four living at the poverty line in 2014: 9th highest.

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Hunger

From the Oregon Food Bank Network:

Record numbers seek emergency food  For the fourth year in a row, the OFB statewide network of regional food banks distributed more than 1 million emergency food boxes.  Since the beginning of the Great Recession in 2008, food box distribution has increased 41 percent.  The OFB Network of regional food banks now distributes about 350,000 more food boxes annually than it did before the recession.  270,000 people per month ate meals from emergency food boxes. A typical emergency food box provides a three- to five-day supply of groceries. Most food pantries serve a specific geographic area and limit the number of times a family can receive help. On average, families access emergency food boxes four times per year.  In an average month, 92,000 children eat meals from emergency food boxes.  3.9-million emergency meals were served at soup kitchens and shelters.  And more than 105,000 people received food through other programs in the OFB Network.  Long-term unemployment is forcing more people to seek emergency food. 27 percent of respondents said long-term unemployment was a major reason they sought emergency food. That compares to 22 percent in 2008 at the beginning of the recession.

 Most adult emergency food recipients are looking for work, working, retired or disabled.

 34 percent of those receiving emergency food are children.

OFB Network Stats | Oregon Food Bank

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Report prepared by Community Commons, August 14, 2016.

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Food Security Among Hispanic Adults in the United States, 2011-2014 by Matthew Rabbitt, Michael D. Smith, and Alisha Coleman-Jensen Economic Information Bulletin No. (EIB-153) 42 pp, May 2016

 In 2014, 14.0 percent of all U.S. households were food-insecure and 5.6 percent suffered very low food security. Food insecurity was about twice as prevalent among Hispanic households (22.4 percent) as among non-Hispanic White households (10.5 percent) but less prevalent than among non-Hispanic Black households (26.1 percent). The prevalence of very low food security—when the food intake of some household members is reduced and normal eating patterns disrupted at times during the year due to limited resources—followed a similar pattern: 6.9 percent for Hispanic households versus 4.5 percent for White households and 10.4 percent for Black households.

 Trends in food insecurity from 2000 to 2014 among Hispanic households appear to be closely related to trends in the U.S. labor market.

 Food insecurity for U.S. Hispanic adults living in food-insecure households during 2011- 2014 differs by Hispanic origin, immigration status, household composition, and metropolitan status, but differs little by State of residence.  Food insecurity was less prevalent among Hispanic adults identifying themselves as originating from Cuba (12.1 percent) versus those from Mexico, Central and South America, or Puerto Rico (20.8, 20.7, and 25.3 percent, respectively).  Food insecurity was less prevalent among Hispanic adults who are U.S. citizens (18.9 percent) than among noncitizens (24.4 percent).

 The food insecurity of Hispanic adults declined with the length of time they lived in the United States. This reflects the higher naturalization rate of those who have lived in the United States longer.  The prevalence of food insecurity was higher for Hispanic adults living in households headed by single women with children (30.7 percent) and with incomes below the Federal poverty line (37.3 percent) than for all Hispanic adults (20.6 percent). Prevalence rates were lower for Hispanic adults living in households with no children (18.1 percent), households with elderly members (18.1 percent), and households with incomes above 185 percent of the Federal poverty line (9.4 percent).  Food insecurity was more prevalent among Hispanic adults living in households in principal cities (21.3 percent) than for those in suburban and other outlying parts of metropolitan areas (18.8 percent).  The prevalence of food insecurity among Hispanic adults differs little across States and groups of States.

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Household Food Security in the United States in 2014, ERR-194 Economic Research Service/USDA

Whom Does SNAP Reach? In Fiscal Year 2015, it reached:  780,000 Oregon residents, or 19% of the state population (1 in 5)  45,767,000 participants in the United States, or 14% of the total population (1 in 7)

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Many Oregon households struggle to put food on the table. The most recent data show:  16.1% of households were “food insecure,” or struggled to afford a nutritionally adequate diet.  Median income was 8.2% below the 2007 level, after adjusting for inflation.  16.6% of the population lived below the poverty line.  21.1% of children lived below the poverty line.  8.8% of elderly lived below the poverty line.

SNAP reaches needy populations: 100% of eligible individuals participated in SNAP in Oregon in 2013, and 100% of eligible workers participated. SNAP kept 119,000 people out of poverty in Oregon, including 54,000 children, per year between 2009 and 2012, on average. (These figures adjust for households’ underreporting of benefits)

"This material was created by the Center on Budget and Policy Priorities (www.cbpp.org).”

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Food Access

“Healthy food retailers—grocery stores; farmers’ markets; cooperatives; mobile markets; and other vendors of fresh, affordable, nutritious food—are critical components of healthy, thriving communities. As the country inches its way out of the Great Recession and seeks to grow a more sustainable and equitable economy, ensuring that healthy food is accessible to all is crucial. Without access to healthy foods, a nutritious diet and good health are out of reach. And without grocery stores and other fresh food retailers, communities are also missing the commercial vitality that makes neighborhoods livable and helps local economies thrive.

Moreover, the challenge of access to healthy food has been a persistent one for communities of color. Beginning in the 1960s and 1970s, white, middle-class and working-class families left urban centers for homes in the suburbs, and supermarket chains went with them, leaving many innercity neighborhoods with few or no full-service markets—often for decades. Limited access to healthy food also plagues many rural communities and small towns, where population losses and economic changes have diminished food retail options. Even in agricultural centers where fruits and vegetables are being grown, residents may not have a retail outlet nearby. Many of the communities that lack healthy food retailers are also oversaturated with fast-food restaurants, liquor stores, and other sources of inexpensive, processed food with little to no nutritional value. For decades, community activists have organized around the lack of access to healthy foods as an economic, health, and social justice issue.”

 Accessing healthy food is a challenge for many families, particularly those living in low income neighborhoods, communities of color, and rural areas.

 Predominantly African American neighborhoods and low-income neighborhoods had the smallest increase in food store availability and the greatest reduction in the number of available grocery stores.

 Lack of transportation to grocery stores presents a serious problem for many people. About 2.1 million households do not own a vehicle and live more than one mile from the nearest supermarket. While this figure has been improving (down from 2.4 million households in 2006), the lowest vehicle ownership occurs among low-income people, further exacerbating the challenges to accessing healthy food in low-income communities.

 Convenience stores located in close proximity to middle and high schools represent an important—yet predominantly unhealthy— source of food for youth, and can have a substantial impact on diets regardless of the quality of food provided in schools.

 Living closer to healthy food retail is associated with better eating habits and decreased risk for obesity and diet-related diseases.

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Access to Healthy Food and Why It Matters- Policy Link and The Food Trust http://www.policylink.org/sites/default/files/GROCERYGAP_FINAL_NOV2013.pdf

Low-income census tracks where a significant number or share of the residents are more 1 mile (urban) or more than 10 miles (rural) form a supermarket. USDA ERS - Go to the Atlas

Journal of the Academy of Nutrition and Dietetics: Experts Weigh in on SNAP Problems and Solutions “A recent study by members of the SNAP to Health Project Team was published in the Journal of the Academy of Nutrition and Dietetics (JAND). Experts from advocacy, government, industry and research organizations were interviewed about the challenges SNAP participants face eating nutritiously with SNAP benefits. Respondents also gave their opinions about improvements that could be made to the program to help overcome these challenges. After interviewing the experts, several key barriers to eating nutritiously with SNAP benefits emerged. These included the high cost of nutrient-rich foods, inadequate SNAP benefit amounts, as well as environmental factors associated with poverty. Unfortunately, foods with greater nutritional value tend to be more expensive. Combined with the fact that many experts agreed recipients are not receiving a sufficient amount of benefits, it’s easy to see why “SNAP participants might purchase nutrient-poor foods and beverages instead of purchasing fruits and

252 vegetables to stretch their budget.” Taking into consideration environmental factors associated with poverty like poor access to transportation, few local retailers that carry produce and healthy foods, and neighborhood violence that can make walking to retailers unsafe, it is evident that there are many barriers for SNAP recipients who want to eat nutritiously.” SNAP to Health-http://www.snaptohealth.org/journal-of-the-academy-of-nutrition-and-dietetics-experts-weigh-in- on-snap-problems-and-solutions/

Distance to store, food prices, and obesity in urban food deserts. Ghosh-Dastidar B1, Cohen D2, Hunter G3, Zenk SN4, Huang C5, Beckman R2, Dubowitz T3. Background Lack of access to healthy foods may explain why residents of low-income neighborhoods and African Americans in the U.S. have high rates of obesity. The findings on where people shop and how that may influence health are mixed. However, multiple policy initiatives are underway to increase access in communities that currently lack healthy options. Few studies have simultaneously measured obesity, distance, and prices of the store used for primary food shopping.

Purpose To examine the relationship among distance to store, food prices, and obesity.

Methods The Pittsburgh Hill/Homewood Research on Eating, Shopping, and Health study conducted baseline interviews with 1,372 households between May and December 2011 in two low- income, majority African American neighborhoods without a supermarket. Audits of 16 stores where participants reported doing their major food shopping were conducted. Data were analyzed between February 2012 and February 2013.

Results Distance to store and prices were positively associated with obesity (p<0.05). When distance to store and food prices were jointly modeled, only prices remained significant (p<0.01), with higher prices predicting a lower likelihood of obesity. Although low- and high-price stores did not differ in availability, they significantly differed in their display and marketing of junk foods relative to healthy foods. Conclusions Placing supermarkets in food deserts to improve access may not be as important as simultaneously offering better prices for healthy foods relative to junk foods, actively marketing healthy foods, and enabling consumers to resist the influence of junk food marketing Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved

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Report prepared by Community Commons, August 14, 2016. Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity: 2011

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Homelessness

Key findings from: The 2015 Annual Homeless Assessment Report (AHAR) to Congress NOVEMBER 2015

All Homeless People  In January 2015, 564,708 people were homeless on a given night. Most (69 percent) were staying in residential programs for homeless people, and 31 percent were found in unsheltered locations.  Nearly one-quarter of all homeless people were children, under the age of 18 (23 percent or 127,787). Nine percent (or 52,973) were between the ages of 18 and 24, and 68 percent (or 383,948) were 25 years or older.  Homelessness declined by 2 percent (or 11,742 people) between 2014 and 2015 and by 11 percent (or 82,550) since 2007. Homelessness by Household Type  In January 2015, 358,422 people experienced homelessness as individuals (64 percent of all homeless people).  There were 206,286 homeless people in families with children on a single night in January 2015, accounting for 36 percent of all homeless people.  Homelessness among individuals declined by less than 1 percent (or 1,767) between 2014 and 2015, and by 13 percent (or 54,278) between 2007 and 2015.  Homelessness among people in families with children declined by 5 percent (or 9,975) between 2014 and 2015, and by 12 percent (or 28,272) between 2007 and 2015. Homelessness among Subpopulations  In January 2015, 83,170 individuals and 13,105 people in families with children were chronically homeless.  Chronic homelessness among individuals declined by 1 percent (or 819) over the past year, and by 31 percent (or 36,643) between 2007 and 2015.  In January 2015, 47,725 veterans were homeless on a single night. Fewer than 10 percent (4,338) were women.  Between 2014 and 2015, homelessness among veterans declined by 4 percent (or 1,964). Homelessness among veterans declined by 35 percent (or 25,642) between 2009 and 2015.  There were 36,907 unaccompanied youth on a single night in 2015. Most (87 percent or 32,240) were youth between the ages of 18 and 24, and 13 percent (or 4,667) were children under the age of 18.

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On a Single Night in January 2015  358,422 individuals were homeless in the United States, representing 63 percent of all people experiencing homelessness.  Fifty-seven percent of homeless individuals (205,616 people) were in emergency shelters, transitional housing programs, or safe havens.  Forty-three percent of homeless individuals (152,806 people) were staying in unsheltered locations such as under bridges, in cars, or in abandoned buildings. People experiencing homelessness as individuals were much more likely to be unsheltered than people experiencing homelessness as part of a family with children (10%).

Demographic Characteristics  Nine of every 10 homeless individuals are over 24 years of age in 2015. Ten percent are between the ages of 18 and 24, and 1 percent are children under 18 years of age. This distribution varies little by shelter status.  Most homeless individuals are men (72% or 257,061 people).  Women make up a much smaller portion of the homeless individual population (28%) than the proportion of all homeless people (40%).  About 17 percent of homeless individuals are Hispanic or Latino. A somewhat higher percentage of unsheltered individuals are Hispanic or Latino (20%) compared to sheltered individuals (14%).  Most homeless individuals are either white (54%) or African American (36%).  Compared to all homeless individuals, a higher percentage of African Americans are in the sheltered homeless population (41%), while a higher percentage of whites are in the unsheltered individual homeless population (57%).

Between 2014 and 2015, homelessness among individuals increased in 19 states. The largest increases were in New York (3,492 more people), California (2,391), Oregon (1,473), Washington (1,136), and Illinois (802).

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States with the greatest reductions in the number of homeless people in families with children between 2007 and 2015 were: Texas (6,069 fewer homeless people in families with children), Florida (5,454), California (5,452), New Jersey (4,433), and Oregon (3,954). In percentage terms, the largest decline was in Kentucky (67%).

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EXHIBIT 3.11: CoCs with the Highest and Lowest Rates of Unsheltered Homeless People in Families with Children By CoC Category, 2015

Oregon BoS had the largest number of unaccompanied youth in its category, with 751 unaccompanied people under the age of 25.

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Uncompensated Care

Oregon Hospitals Uncompensated Care

Year Charity Care Bad Debt Total Uncompensated Care

Portland Metro Hospitals Uncompensated Care

Year Charity Care Bad Debt Total Uncompensated Care

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Adventist Health Charity Care and Medicaid Shortfalls 25,000,000

20,000,000

15,000,000 Medicaid Charity Care 10,000,000 Total

5,000,000

- 2010 2011 2012 2013 2014

State Wide Charity Care and Medicaid Shortfalls 900,000,000

800,000,000

700,000,000

600,000,000

500,000,000 Medicaid

400,000,000 Charity Care Total 300,000,000

200,000,000

100,000,000

- 2010 2011 2012 2013 2014

Data from Oregon Association of Hospitals and Health Systems

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Hospitalization Costs

Health Care Expenditures per Capita by State of Residence | The Henry J. Kaiser Family Foundation

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How much does the U.S. spend to treat different diseases?

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How health spending patterns vary by demographics in the U.S. Gary Claxton, Rabah Kamal, Cynthia Cox, Nolan Sroczynski Kaiser Family Foundation-Updated with 2013 Medical Expenditure Panel Survey data on August 18, 2016 In a given year, a small portion of the population is responsible for a very large percentage of total health spending. We tend to focus on averages when discussing health spending, but individuals’ health status – and thus their need to access and utilize health services – varies from year to year and over the course of their lifetimes. In fact, very few people have spending around the average. Our updated chart collection explores the variation in health spending across the population through an analysis of the 2013 Medical Expenditure Panel Survey (MEPS) data. We show that just 1% of the population – those with the highest spending — accounted for 21% of health spending and that just 5% of the population was responsible for almost half of all spending. On the other side of the spectrum, the lowest spending half of the U.S. population accounted for just 3% of total health spending in 2013. Out-of-pocket spending was about as concentrated as overall spending, with 1% of the population accounting for one fifth of total out-of-pocket health spending.

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HOW HEALTH SPENDING PATTERNS VARY BY DEMOGRAPHICS IN THE U.S. ABOVE INFORMATION IS FROM: PETERSON-KAISER HEALTH SYSTEM TRACKER MEASURING THE PERFORMANCE OF THE U.S. HEALTH SYSTEM

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Most expensive conditions treated in U.S. hospitals, 2013 Table 1 presents the most expensive conditions treated in U.S. hospitals among all payers in 2013.

Table 1. The 20 most expensive conditions treated in U.S. hospitals, all payers, 2013

Aggregate Number of CCS principal diagnosis National Hospital Rank hospital costs, hospital stays, category costs, % stays, % $ millions thousands

1 Septicemia 23,663 6.2 1,297 3.6

2 Osteoarthritis 16,520 4.3 1,023 2.9

3 Liveborn 13,287 3.5 3,765 10.6

Complication of device, 4 12,431 3.3 632 1.8 implant or graft

Acute myocardial 5 12,092 3.2 602 1.7 infarction

6 Congestive heart failure 10,218 2.7 882 2.5

Spondylosis, intervertebral disc 7 10,198 2.7 555 1.6 disorders, other back problems

8 Pneumonia 9,501 2.5 961 2.7

9 Coronary atherosclerosis 9,003 2.4 458 1.3

Acute cerebrovascular 10 8,840 2.3 585 1.6 disease

11 Cardiac dysrhythmias 7,178 1.9 710 2.0

Respiratory failure, 12 insufficiency, arrest 7,077 1.9 387 1.1 (adult)

Complications of surgical 13 procedures or medical 6,079 1.6 465 1.3 care

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Rehabilitation care, fitting 14 of prostheses, and 5,373 1.4 390 1.1 adjustment of devices

15 Mood disorders 5,246 1.4 836 2.3

Chronic obstructive 16 pulmonary disease and 5,182 1.4 645 1.8 bronchiectasis

17 Heart valve disorders 5,151 1.4 123 0.3

Diabetes mellitus with 18 5,142 1.3 531 1.5 complications

Fracture of neck of femur 19 4,861 1.3 303 0.9 (hip)

20 Biliary tract disease 4,722 1.2 405 1.1

Total for top 20 conditions 181,762 47.7 15,554 43.7

Total for all stays 381,439 100.0 35,598 100.0

Abbreviation: CCS, Clinical Classifications Software Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), National Inpatient Sample (NIS), 2013

 The 5 most expensive conditions accounted for 20.5 percent of aggregate hospital costs; the 20 most expensive conditions accounted for nearly half (47.7 percent) of aggregate hospital costs.

Septicemia was the most expensive condition treated, accounting for $23.7 billion, or 6.2 percent of the aggregate costs for all hospitalizations. Other high-cost hospitalizations were for osteoarthritis ($16.5 billion, or 4.3 percent), liveborn (newborn) infants ($13.3 billion, or 3.5 percent), complication of device, implant or graft ($12.4 billion, or 3.3 percent), and acute myocardial infarction ($12.1 billion, or 3.2 percent).

Hospital stays with principal diagnoses of complications of device, implant or graft and complications of surgical procedures or medical care accounted for 5 percent of aggregate hospital costs.

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 The 20 most expensive conditions accounted for 43.7 percent of all hospital stays.

Liveborn infants accounted for 10.6 percent of all hospital stays. Septicemia was the second most common reason for hospitalization, accounting for 3.6 percent of stays, followed by osteoarthritis (2.9 percent), pneumonia (2.7 percent), congestive heart failure (2.5 percent), and mood disorders (2.3 percent).

 In 2013, Medicare accounted for the largest proportion of aggregate hospital costs (46 percent).

Patients with primary Medicare coverage accounted for 46 percent of the $381.4 billion in aggregate hospital costs in 2013. Private insurance was the second most common payer, accounting for 28 percent of total costs, followed by Medicaid with 17 percent of costs. Stays of uninsured patients represented 5 percent of total hospital costs. Government payers (Medicare and Medicaid) accounted for 63 percent of all hospital costs.

Patients covered by Medicare accounted for a larger proportion of aggregate hospital costs (46 percent) than of hospital stays (39 percent). In contrast, patients covered by Medicaid accounted for only 17 percent of hospital costs but 21 percent of hospital stays.

Torio C (AHRQ), Moore B (Truven Health Analytics). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013. HCUP Statistical Brief #204. May 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.pdf.

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2017-2019 Community Health Needs Assessment Summary

Service Area data: In 2013, our service area zip code patient data showed our top three zip codes for combined charity care and Medicaid patients were 41.1, 39.73 and 39.55 percent. In 2016, our data shows the top three were 51.39, 50.39 and 49.49 percent. Racial and Ethnic Health Disparities

Black/African Americans experienced the greatest number of disparities with the highest level of concern relative to other communities of color. Statistically significant disparities for 9 of the 18 health indicators for African Americans.

Native Americans have statistically significant disparities in 5 of the 18 health indicators for Native Americans and 12 at the needs improvement level. However, for seven of the other health indicators, Native Americans did not have a sufficient number of events to calculate a rate.

Hispanics have statistically significant disparities in 6 of the 18 health indicators. There were also eight indicators where Latinos fared significantly better than non-Latino Whites. Leading Causes of Death

Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems.

Nationally-Accidents moved up to 4th, Influenza and pneumonia moved up one, Nephritis, nephrotic syndrome and nephrosis (kidney disease) and stroke moved down one.

Oregon- Suicide moved up one on the list.

Multnomah County- Order remained the same from 2011.

Clackamas County- Order remained the same from 2011.

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Diabetes

Diabetes is becoming more common in the United States. From 1980 through 2014, the number of Americans with diagnosed diabetes has increased fourfold (from 5.5 million to 22.0 million).

Diabetes and obesity have more than doubled among Oregon adults since 1990.

In 2014, diabetes was the 7th leading cause of death in both Multnomah and Clackamas Counties.

Obesity

Obesity is the number two cause of preventable death in Oregon and nationally, second only to tobacco use.

Obesity prevalence among Oregon adults has risen dramatically in the past two decades, from 11.2% in 1990 to 26.8% in 2013. (27.9% in 2014).

The obesity rate for the state of Oregon was 25.9%. Multnomah County was 21.4%, Clackamas count was 25.2%.

Heart Disease and Stroke

During 2014, heart disease was the second leading cause of death in Oregon.

Accounting for 5.3% of all deaths, cerebrovascular disease was the fourth leading cause of mortality among Oregonians.

The cerebrovascular disease death rate has long been higher in Oregon than in the United States as a whole.

Fourth leading cause of death for Oregon as well as in Multnomah and Clackamas Counties.

It is the fifth leading cause of death for men

It is the third leading cause of death for women

During 2011–2014, approximately 12% of adults had high total cholesterol and nearly 19% had low HDL cholesterol.

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Chronic Obstructive Pulmonary Disease

In 2014, COPD was the third leading cause of death in the U.S. and Oregon.

More than 50% of adults with low pulmonary function were not aware that they had COPD.

In 2013, 6.7 of Oregonians said they have been told they have COPD.

Asthma

10.8% of adults and 7.8% of children in Oregon had asthma in 2011.

Adults ages 18 to 24 are more likely to have asthma than older adults are.

Women are more likely to have asthma than men are.

In children, boys are more likely to have asthma than girls are.

Allergies

Allergies are the 6th leading cause of chronic illness in the U.S. with an annual cost in excess of $18 billion.

The most common allergic diseases include: hay fever, asthma, conjunctivitis, hives, eczema, dermatitis and sinusitis.

Allergic conditions are among the most common medical conditions affecting children in the United States

Cancer

Up to one-third of cancer cases in the United States are related to excess weight or obesity, physical inactivity, and/or poor nutrition, and thus could be prevented.

The incidence of some cancers, including kidney, thyroid, pancreas, liver, uterus, melanoma of the skin, myeloma (cancer of plasma cells), and non-Hodgkin lymphoma, is rising.

Lung cancer is the leading cause of cancer mortality in both men and women in the United States. Five‐year survival rates are low compared to other common cancers at 16.8 percent.

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Breast cancer is the most common cancer among American women, except for skin cancers.

Breast cancer is the second leading cause of cancer death in women. (Only lung cancer kills more women each year.)

Mental Health

In 2014, there were an estimated 43.6 million adults aged 18 or older in the United States with AMI in the past year. This number represented 18.1% of all U.S. adults.

While mental disorders are common in the United States, their burden of illness is particularly concentrated among those who experience disability due to serious mental illness (SMI).

Approximately 1 in 5 adults in the U.S.—43.8 million, or 18.5%—experiences mental illness in a given year.

Among the 20.2 million adults in the U.S. who experienced a substance use disorder, 50.5%— 10.2 million adults—had a co-occurring mental illness.

Alzheimer’s disease is the sixth leading cause of death in the United States and is the fifth leading cause among people aged 65 years and over.

In 2013, suicide was the second leading cause of death among persons aged 15-24 years, the second among persons aged 25-34 years, the fourth among person aged 35-54 years, the eighth among persons aged 55-64 years, the seventeenth among persons 65 years and older, and the tenth leading cause of death across all ages.

Tobacco

Nationally, nearly 1 in 5 adults (or 45.7 million adults) have some form of mental illness, and 36% of these people smoke cigarettes.

People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder.

Illicit Drug Use

The higher percentage of people who were current illicit drug users in 2014 than in prior years appears to reflect trends in marijuana use.

Nonmedical pain reliever use continued to be the second most common type of illicit drug.

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The estimated 27.0 million people aged 12 or older who were current illicit drug users in 2014 represent 10.2 percent of the population aged 12 or older.

In 2009-2010, Oregon was one of the top ten states for rates of drug-use in several categories.

Multnomah County, 2004-2014- Deaths from opiate overdose occurred more than twice a week in 2014 (109 deaths).

Prescription opiate deaths have not decreased. In 2014, half of all fatal overdoses were associated with prescription opiates.

Opiates are the most rapidly growing reason for substance misuse treatment in Multnomah County and in Oregon.

By 2013, the number of individuals receiving treatment had increased by more than 107% compared with 2004.

Mortality among HCV-infected persons—primarily adults aged 55–64 years—is increasing. For the first time in the United States, in 2007 the number of HCV-related deaths (n=15,106) exceeded the number of HIV/AIDS-related deaths (n=12,734) and has since continued to increase.

From 2010–2014, there was an approximate 2.6-fold increase in the number of reported acute hepatitis C cases from 850 to 2,194 cases, respectively

Thirteen states (Florida, Illinois, Maryland, Massachusetts, Michigan, Missouri, New Jersey, New York State, Ohio, Oregon, Pennsylvania, Virginia, and West Virginia) accounted for 76.4% of the past/present hepatitis C case-reports submitted through NNDSS in 2014.

The overall hepatitis C-related mortality rate increased from 4.7 deaths/100,000 population in 2010 to 5.0 deaths/100,000 population in 2014.

Sexually Transmitted Disease

The 2014 data also show that youth are still at the highest risk of acquiring an STD, especially chlamydia and gonorrhea. Despite being a relatively small portion of the sexually active population, young people between the ages of 15 and 24 accounted for the highest rates of chlamydia and gonorrhea in 2014 and almost two thirds of all reported cases. Additionally, previous estimates suggest that young people in this age group acquire half of the estimated 20 million new STDs diagnosed each year.

Chlamydia is the most common reportable illness in Oregon. More than 13,000 cases occurred in 2012.

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Oregon’s rate of early syphilis infections greatly increased during the last eight years. There were 0.7 cases per 100,000 people in 2007 and 10.5 cases per 100,000 people in 2014. This represents a 1500% increase. Increases continue during 2015.

Trend data show rates of syphilis are increasing at an alarming rate (15.1 percent in 2014). While rates have increased among both men and women, men account for more than 90 percent of all primary and secondary syphilis cases.

Half (641/1,271) of those diagnosed with HIV during 2008–2012 were Multnomah County residents.

During 2012, the annual number of deaths among people with HIV declined (from 338 deaths during 1994 to 75 cases during 2012).

Social Determinants of Health

In 2014, 16.6 percent of Oregonians – 1 in every 6 people – lived below the federal poverty level.

About 110,000 more Oregonians were poor in 2014 than in 2009 at the end of the Great Recession.

In 2014, 21.1 percent of Oregon children lived in poverty.

Multnomah County child poverty prevalence is higher for all communities of color than nationally.

For the fourth year in a row, the OFB statewide network of regional food banks distributed more than 1 million emergency food boxes.

Since the beginning of the Great Recession in 2008, food box distribution has increased 41 percent.

In an average month, 92,000 children eat meals from emergency food boxes.

Many Oregon households struggle to put food on the table. The most recent data show:

 16.1% of households were “food insecure,” or struggled to afford a nutritionally adequate diet.  Median income was 8.2% below the 2007 level, after adjusting for inflation.  16.6% of the population lived below the poverty line.  21.1% of children lived below the poverty line.  8.8% of elderly lived below the poverty line.

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Predominantly African American neighborhoods and low-income neighborhoods had the smallest increase in food store availability and the greatest reduction in the number of available grocery stores.

Survey Conclusions

A review of the results of the two surveys shows similar concerns among the both. Those concerns are as follows:

 Behavior/Mental Health

 Access to Affordable Health Care

 Life Style Concerns surrounding: . Drug and Alcohol Abuse . Health Eating Habits . Obesity . Lack of Exercise

 Social Determinates of Health . Housing . Homelessness

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Appendix A

Healthy Columbia Willamette Collaborate Survey Portland Adventist Medical Center Demographics of survey respondents living within service center of Portland Adventist Medical Center Results shown by language in which survey was taken

Age English Spanish Vietnamese Russian Chinese Total n = 829 Under 18 9 0 0 0 0 9 1.1% 19-25 64 0 0 0 0 64 7.7% 26-39 272 9 0 0 0 281 33.9% 40-54 218 10 1 3 1 233 28.1% 55-64 146 2 0 1 0 149 18.0% 65-79 87 0 0 0 0 87 10.5% 80 and older 6 0 0 0 0 6 0.7% Prefer not to answer 9 1 0 0 0 10 Blank 12 0 0 0 0 12 Total 823 22 1 4 1 851 829

Gender English Spanish Vietnamese Russian Chinese Total n = 806 Female 503 16 1 3 1 524 65.0% Male 268 5 0 1 0 274 34.0% Gender non-conforming 3 0 0 0 0 3 0.4% Transgender 3 0 0 0 0 3 0.4% Male, Female 1 0 0 0 0 1 0.1% Transgender, Gender non- conforming 1 0 0 0 0 1 0.1% Prefer not to answer 23 0 0 0 0 23 blank 21 1 0 0 0 22 Total 823 22 1 4 1 851 806 0 Total non-normative gender 8 1 0 0 0 9 1.1%

Sexual Orientation English Spanish Vietnamese Russian Chinese Total n = 807 Heterosexual 643 14 1 4 0 662 82.0% Gay or lesbian 46 0 0 0 0 46 5.7% Bisexual 27 1 0 0 0 28 3.5% Queer 8 0 0 0 0 8 1.0% Questioning or unsure 2 0 0 0 0 2 0.2% Another sexual orientation 3 0 0 0 0 3 0.4%

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Write-in identity or multiple (all are non-normative) 58 0 0 0 0 58 7.2% Write-in with no identity named (can't determine) 25 0 0 0 0 25 Prefer not to answer 7 3 0 0 1 11 Blank 4 4 0 0 0 8 Total 823 22 1 4 1 851 807

Total minority sexual orientations 144 1 0 0 0 145 18.0%

Hispanic Ethnicity English Spanish Vietnamese Russian Chinese Total n = 734 Hispanic 62 22 0 3 0 87 11.9% Non-Hispanic 645 0 1 0 1 647 88.1% Blank 116 0 0 1 0 117 Total 823 22 1 4 1 851 734

Race English Spanish Vietnamese Russian Chinese Total n = 725 African American/Black 44 0 0 0 0 44 6.1% African 3 0 0 0 0 3 0.4% Arab American/Middle Eastern 1 0 0 0 0 1 0.1% Asian American/Asian 22 0 1 0 1 24 3.3% European American/White/Caucasian 528 0 0 3 0 531 73.2% Native American/American Indian/Alaska Native 26 0 0 0 0 26 3.6% Multiracial 80 4 0 0 0 84 11.6% Other 9 3 0 0 0 12 1.7% Prefer not to answer 54 10 0 1 0 65 Blank 56 5 0 0 0 61 Total 823 22 1 4 1 851 725

Location of Childhood English Spanish Vietnamese Russian Chinese Total n = 813 Inside the United States 765 5 0 0 0 770 94.7% Outside the United States 22 16 1 3 1 43 5.3% Prefer not to answer 9 0 0 0 0 9 Blank 27 1 0 1 0 29 Total 823 22 1 4 1 851 813

Language English Spanish Vietnamese Russian Chinese Total n = 825 English 762 1 0 0 0 763 92.5%

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Spanish or Spanish Creole 15 21 0 0 0 36 4.4% Other than English or Spanish 20 0 1 4 1 26 3.2% Prefer not to answer 6 0 0 0 0 6 Blank 20 0 0 0 0 20 Total 823 22 1 4 1 851 825

Veteran Status English Spanish Vietnamese Russian Chinese Total n = 806 Veteran 58 0 0 0 0 58 7.2% Not a veteran 721 22 1 3 1 748 92.8% Prefer not to answer 18 0 0 0 0 18 Blank 26 0 0 1 0 27 Total 823 22 1 4 1 851 806

Disability Status English Spanish Vietnamese Russian Chinese Total n = 809 Has a disability 176 1 0 0 0 177 21.9% Does not have a disability 606 20 1 4 1 632 78.1% Prefer not to answer 25 0 0 0 0 25 Blank 16 1 0 0 0 17 Total 823 22 1 4 1 851 809

Educational Attainment for Ages 25 and Older English Spanish Vietnamese Russian Chinese Total n = 741 Less than high school 20 7 0 0 0 27 3.6% High school diploma or GED 193 7 0 1 0 201 27.1% AA degree 5 0 0 0 0 5 0.7% Some college 27 1 0 0 0 28 3.8% College degree or higher 471 4 1 3 1 480 64.8% Other (can't determine) 1 0 0 0 0 1 Prefer not answer 16 2 0 0 0 18 Blank 17 1 0 0 0 18 Total 750 22 1 4 1 778 741

Ratio of Income to Poverty Level English Spanish Vietnamese Russian Chinese Total n = 696 At or below 200% FPL 235 11 0 2 0 248 35.6% Over 200% FPL 442 2 1 2 1 448 64.4% Can't determine 146 9 0 0 0 155 Total 823 22 1 4 1 851 696

Health Insurance English Spanish Vietnamese Russian Chinese Total n = 802 Pay cash (no insurance) 28 8 0 0 0 36 4.5%

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Private health insurance 452 8 0 3 1 464 57.9% Medicaid 176 3 0 1 0 180 22.4% Medicare 98 0 0 0 0 98 12.2% Veterans' Administration 9 0 0 0 0 9 1.1% Indian Health Services 6 0 0 0 0 6 0.7% Medicare/Medicaid 2 0 0 0 0 2 0.2% Other public 7 0 0 0 0 7 0.9% can't determine 1 0 0 0 0 1 Prefer not to answer 18 2 0 0 0 20 blank 26 1 1 0 0 28 Total 823 22 1 4 1 851 802

Q1: QUALITY OF LIFE: In the following list, what do you think are the five most important characteristics of a "Healthy Community"? (Those factors that most improve the quality of life in a community.) n = 4,112 English Spanish Vietnamese Russian Chinese Total % of responses Safe, affordable housing 462 5 0 1 0 468 11.4% Access to physical, mental, and/or oral health care 416 12 0 2 1 431 10.5% Access to healthy, affordable food 374 17 0 2 0 393 9.6% Low crime/safe neighborhoods 357 7 1 1 1 367 8.9% Good schools 345 10 1 1 1 358 8.7% Good jobs to reach a healthy economy 285 5 0 1 0 291 7.1% Clean environment 210 7 1 1 0 219 5.3% Parks and recreation 189 5 0 0 0 194 4.7% Healthy behaviors and lifestyles 177 4 1 2 0 184 4.5% Supportive and happy family life 172 8 0 2 0 182 4.4% Welcoming of diverse communities/people 163 1 0 2 1 167 4.1% Safe, nearby transportation 141 5 0 0 0 146 3.6%

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Good place to raise children 133 5 0 1 0 139 3.4% Good job training opportunities 113 1 0 1 0 115 2.8% Participating and giving back to the community 108 3 0 0 0 111 2.7% Religious or spiritual values 93 4 1 3 0 101 2.5% Physical accommodations for people with disabilities 88 1 0 0 0 89 2.2% Low level of child abuse 66 1 0 0 0 67 1.6% Low deaths and disease rates 43 4 0 0 0 47 1.1% Good daycare and preschools 36 2 0 0 0 38 0.9% Arts and cultural events 4 0 0 0 1 5 0.1%

Q2: ISSUES AFFECTING COMMUNITY HEALTH: In the following list, what do you think are the five most important "issues" that need to be addressed to make your community healthy? (Those topics that have the greatest impact on overall community health) n = 3,996 English Spanish Vietnamese Russian Chinese Total % of responses Homeless/lack of safe, affordable housing 519 7 0 0 0 526 13.2% Unemployment/lack of living wage jobs 451 10 1 2 0 464 11.6% Mental health challenges (e.g. depression, lack of purpose or hope, anxiety, bi-polar, PTSD, eating disorders) 365 7 0 1 0 373 9.3% Hunger/lack of healthy, affordable food 319 9 0 1 0 329 8.2% Lack access to physical, mental, and/or oral health care 249 6 0 3 0 258 6.5% Gang activity/violence 194 7 1 0 1 203 5.1% Poor schools 193 1 1 2 0 197 4.9%

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Being overweight/obesity 177 11 0 3 0 191 4.8% Domestic violence, child abuse/neglect 171 7 0 1 1 180 4.5% Racism/discrimination 160 9 0 0 1 170 4.3% Unsafe streets (limited crosswalks, bike lanes, lighting, etc.) 158 5 0 0 1 164 4.1% Lack of needed job skills or training 145 2 0 0 0 147 3.7% Lack of community involvement 120 5 0 1 0 126 3.2% Dirty environment 84 2 1 1 0 88 2.2% disabilities (physical, mental) and limited mobility 80 0 0 1 0 81 2.0% Lack access to safe, nearby transportation 73 1 0 0 0 74 1.9% Bullying/verbal abuse 67 5 0 0 0 72 1.8% Lack of safe and accessible parks/recreation 63 4 1 1 0 69 1.7% Firearm-related injuries 55 2 0 0 1 58 1.5% Aging problems (e.g. memory loss, hearing/vision loss) 56 1 0 0 0 57 1.4% Lack of good daycare and preschools 44 1 0 1 0 46 1.2% Lack of physical accommodations for people with disabilities 44 2 0 0 0 46 1.2% Few arts and cultural events 32 1 0 0 0 33 0.8% Asthma/respiratory/lu ng disease 23 1 0 0 0 24 0.6% HIV/AIDS 18 2 0 0 0 20 0.5% 3996

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Q3: In the following list, what do you think are the three most important "risky behaviors" in your community? (Those behaviors that have the greatest impact on overall community health.) n = 2,426 English Spanish Vietnamese Russian Chinese Total % of responses Drug use/abuse 477 10 1 4 1 493 20.3% Alcohol abuse/addiction 386 10 0 2 0 398 16.4% Poor eating habits 249 12 0 0 0 261 10.8% Social isolation/loneliness 230 3 1 1 0 235 9.7% Lack of exercise 195 11 0 1 0 207 8.5% Dropping out of school 197 3 0 0 0 200 8.2% Unsafe driving (e.g., not using seat belts/child safety seats, distracted driving) 156 4 0 1 1 162 6.7% Tobacco use 120 7 1 1 1 130 5.4% Risky sexual behavior/unsafe sex 120 2 0 2 0 124 5.1% Not getting "shots" to prevent disease (immunizations) 89 1 0 0 0 90 3.7% Not using birth control 79 2 0 0 0 81 3.3% Self-harm (e.g. cutting, suicide attempts) 45 0 0 0 0 45 1.9% 2426

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Q4: How healthy would you rate your community as a whole? n = 851 English Spanish Vietnamese Russian Chinese Total % of responses Very healthy 21 0 0 0 0 21 2.5% Healthy 217 6 1 0 0 224 26.3% Somewhat unhealthy 431 13 0 4 0 448 52.6% Unhealthy 118 3 0 0 1 122 14.3% Very unhealthy 36 0 0 0 0 36 4.2% 851

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Appendix B

2016 East Multnomah County Service Provider Survey

Please tell us how much you agree with the following statements about our community.

Strongly Strongly Rating Response Answer Options Agree Disagree Agree Disagree Average Count There is a high-quality healthcare system in our 37 26 5 0 1.53 68 community. Our community is a good 13 34 20 1 2.13 68 place to raise children. Our community is a good 11 33 22 2 2.22 68 place to grow old. There is plenty of economic opportunity in our 8 24 33 3 2.46 68 community. Our community is a safe 4 34 26 4 2.44 68 place to live. There is plenty of help for individuals and families in 4 33 28 3 2.44 68 need in our community. answered question 68 skipped question 0

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When you imagine a strong, vibrant and healthy community what are the most important features you think of? (Please choose five.) Re sp o nse Re sp o nse Answer Options Pe rce nt Co unt Healthier food options (schools, community) 27.9% 19 Drug, cancer-causing agents and alcohol free 23.5% 16 Safe environment 67.6% 46 Access to nature/parks 22.1% 15 Walkable and bike friendly communities 14.7% 10 Senior services 10.3% 7 Senior housing 4.4% 3 Affordable housing 50.0% 34 Mental health services 39.7% 27 Convenient transportation 8.8% 6 Diverse populations 10.3% 7 Good childcare 7.4% 5 Clean environment 26.5% 18 Livable wages 45.6% 31 Strong faith community 19.1% 13 Healthy relationships 7.4% 5 Music and the arts 4.4% 3 Economic opportunities 36.8% 25 Good schools 35.3% 24 Health care services 38.2% 26 Other (please specify) 2 answered question 68 skipped question 0

287

The next two questions are about health problems that have the largest impact on the community as a whole. We would like for you to pick five of Re sp o nse Re sp o nse Answer Options Pe rce nt Co unt Aging problems (Alzheimer's, dementia, hearing or 17.6% 12 Asthma 2.9% 2 Birth Defects 0.0% 0 Dental health 25.0% 17 Autism 0.0% 0 Cancer screening (example: breast, cervical, colon, 11.8% 8 Cancer care 5.9% 4 Diabetes 29.4% 20 Gun-related injuries 16.2% 11 Sexual assault/Rape 16.2% 11 Infant death 0.0% 0 Motor vehicle accidents 14.7% 10 Infectious/Contagious diseases (TB, hepatitis, STDs, 5.9% 4 Overwork/burnout 16.2% 11 Arthritis 1.5% 1 High blood pressure 11.8% 8 Mental health (depression, schizophrenia, anxiety, 88.2% 60 Neurological disorders (Multiple Sclerosis, Muscular 0.0% 0 Other injuries (drowning, choking, home or work 2.9% 2 Environmental exposure to toxins that may cause 22.1% 15 Overweight/obesity 60.3% 41 Lung disease (emphysema, etc.) 4.4% 3 Sexually transmitted diseases (STDs) 10.3% 7 Suicide 5.9% 4 Homicide 11.8% 8 HIV/AIDS 0.0% 0 Heart disease/heart attacks 32.4% 22 Stroke 5.9% 4 Drugs and alcohol abuse 73.5% 50 Teenage pregnancy 4.4% 3 Other (please specify) 2.9% 2 answered question 68 skipped question 0

288

Please pick the top five unhealthy behaviors that you believe are a problem in East Multnomah County. Response Response Answer Options Percent Count Alcohol abuse 66.2% 45 Drug/Substance abuse 82.4% 56 Having unsafe sex 7.4% 5 Lack of exercise 50.0% 34 Not getting immunizations ("shots") to prevent 7.4% 5 disease Not using seat belts/ child safety seats 0.0% 0 Smoking/tobacco use 55.9% 38 Not going to the dentist for preventive check- 17.6% 12 ups/care Not going to the doctor for regular check-ups and 42.6% 29 health screenings, including cancer screenings Not getting prenatal care 8.8% 6 Poor eating habits 52.9% 36 Reckless/drunk driving 17.6% 12 Suicide 5.9% 4 Gambling 5.9% 4 Insufficient sleep/rest 20.6% 14 Overwork 16.2% 11 Violent behavior 36.8% 25 Other (please specify) 5.9% 4 answered question 68 skipped question 0

289

This question is about community-wide issues that have the largest impact on the overall quality of life in East Multnomah County. Please pick five from this list of community issues. Response Response Answer Options Percent Count Animal control issues 0.0% 0 Availability of child care 5.9% 4 Affordability of health services 38.2% 26 Availability of healthy food choices 19.1% 13 Bullying in schools 7.4% 5 Bioterrorism 1.5% 1 Dropping out of school 10.3% 7 Homelessness 67.6% 46 Inadequate/unaffordable housing 52.9% 36 Lack of/inadequate health insurance 14.7% 10 Lack of culturally appropriate health services 2.9% 2 Drug and alcohol abuse 66.2% 45 Lack of health care providers 2.9% 2 Lack of recreational facilities (parks, trails, 1.5% 1 community centers, etc.) Difficulty accessing urgent care center/hospital 2.9% 2 Availability of healthy family activities 7.4% 5 Availability of positive teen activities 7.4% 5 Neglect and abuse (specify type) 5.9% 4 Child abuse 2.9% 2 Domestic violence 10.3% 7 Elder Abuse 1.5% 1 Rape/sexual assault 2.9% 2 Gangs 25.0% 17 Pollution (air, water, land) 5.9% 4 Low income/poverty 64.7% 44 Lack of transportation options 0.0% 0 Unsafe, un-maintained roads 4.4% 3 Unemployment 27.9% 19 Lack of spirituality 13.2% 9 Poor family life 22.1% 15 Other (please specify) 4.4% 3 answered question 68 skipped question 0

290

In your opinion, what would improve the quality of life for residents of East Multnomah County? (Please choose up to five.) Response Response Answer Options Percent Count Improve educational opportunities for children 14.7% 10 Improve educational opportunities for adults 19.1% 13 Improve support for children and families 25.0% 17 Improve housing for seniors 5.9% 4 More affordable housing options 63.2% 43 Free or low-cost recreational opportunities 20.6% 14 Safe neighborhoods (less crime) 57.4% 39 More resources for New Americans 7.4% 5 More access to primary healthcare providers 19.1% 13 More access to dental healthcare providers 8.8% 6 More access to alternative healthcare providers 2.9% 2 More community gathering points 4.4% 3 Enhanced public transportation 1.5% 1 More mental health services 79.4% 54 Substance abuse treatment 42.6% 29 Increased job opportunities 51.5% 35 Better end of life care 2.9% 2 Healthier fast foods 26.5% 18 More incentives for healthy behaviors 20.6% 14 More creative/artistic outlets 5.9% 4 Assistance with financial concerns such as bills 17.6% 12 Other (please specify) 2.9% 2 answered question 68 skipped question 0

291

What ethnic populations do you primarily serve?

Response Response Answer Options Percent Count Black (African American) 26.8% 15 African (ie: Somoli, Eritrean) 19.6% 11 White (Non-Hispanic) 94.6% 53 Native American 7.1% 4 Hispanic 51.8% 29 Asian/Pacific Islander 32.1% 18 Eastern European 42.9% 24 New American (please specify below) 7.1% 4 Other (please specify) 11 answered question 56 skipped question 12

292

Appendix C

HEALTHY COLUMBIA WILLAMETTE COLLABORATIVE CHNA Executive Summary

Healthy Columbia Willamette Collaborative The Healthy Columbia Willamette Collaborative (HCWC) is a unique public-private partnership that includes 15 hospitals, four health departments, and two coordinated care organizations (managed Medicaid organizations) in Clackamas, Multnomah, and Washington counties of Oregon, and in Clark County, Washington. This report documents the community health needs of HCWC’s four-county region and each of the counties. The community health needs, referred to in this report as priority health issues, were identified through a comprehensive study of population, hospital, Medicaid, and community data.

2016 Community Health Needs Assessment Data Sources

Health Status Assessment 1) Population data about health-related behaviors, morbidity, and mortality.

2) Medicaid data from local Coordinated Care Organizations (CCOs) about the most frequent conditions for which individuals on Medicaid sought care in the tri-county region in Oregon (Clark County Medicaid data were not available for this report).

3) Hospital data for uninsured people who were seen in the emergency department with a condition that should have been managed in primary or ambulatory care.

Community Themes and Strengths 1) Online survey about quality of life, issues affecting community health, and risky health behaviors.

2) Listening sessions with an array of communities in the four-county region to identify community members’ vision for a healthy community, needs in the community, and existing strengths.

3) An inventory of recent community engagement projects in the four-county region that assess communities’ health needs.

Key Findings Regional demographics Approximately 2.2 million people lived in the four-county region in 2014, having increased 15.5% from 2000 to 2010. Although the racial and ethnic population is predominantly White, non-Hispanic/Latino (74.1%), the demographics of the region continue to diversify. The foreign-born population increased 16.0% from 2005- 2014, while the Hispanic/Latino population increased 69.8% in the region from 2000 to 2010.

293

Social determinants of health and equity Factors such as income, housing, and education impact communities’ health in the region. The number of individuals living in poverty in the region ranged from 9.2–18.8% (depending on the county), while the number of children (18 years or younger) living in poverty ranged from 11.2–24.1%. Nearly one fifth of households in the region received SNAP (food assistance) benefits in the past 12 months. Housing affordability and high rates of homelessness affected communities across the four-county region.

Through listening sessions, an online survey, and an inventory of recent community engagement projects, HCWC identified upstream factors, such as access to food, health care, transportation, and safe, affordable housing, as important needs in our community. Community members specified culturally and linguistically appropriate services and support for people with behavioral health challenges as needed improvements to health care and public health systems. Communities across the four-county region also advocated for policies, systems, and environments that support healthy behaviors and identified racism, discrimination, and stigma as problems that contribute to poor health in the region.

Health behaviors Population health data from state surveys show that risky health behaviors, such as binge drinking, cigarette smoking, lack of exercise, and not eating enough healthy foods, are prevalent in the region. For teenagers, specifically, the assessment identified alcohol, marijuana, and vaping/e-cigarette use as common behaviors. Access to health care and preventive services were identified as priority health issues—specifically lack of a usual source of care among adults and lack of flu shots and pneumonia vaccines for adults 65 and older.

Diagnosed health conditions for low-income residents An analysis of Medicaid claims data from CCOs in Oregon showed that for youth, asthma, attention deficit disorder, and post-traumatic stress disorder were the most commonly diagnosed chronic conditions. For adults on Medicaid in the tri-county region, depression, diabetes, and hypertension were the most common diagnoses. People with Medicaid, whose incomes are below 139% of the Federal Poverty Level, represent nearly 20% of the population in the tri-county Oregon region.

Emergency department admissions for uninsured residents Utilization data from local hospitals were analyzed for people who were uninsured or “self-pay,” and were admitted to the Emergency Department for a condition that could have been treated in a primary care setting. The most common conditions for adults within this population were diabetes, hypertension, and kidney/urinary infections. For youth, the top diagnosed conditions were asthma and severe ear, nose, and throat infections.

Morbidity and mortality Epidemiologists from the four county health departments prioritized 104 health indicators using the following criteria: existence of a disparity by race/ethnicity or sex, comparison with the state, trend over time, severity, and magnitude. Data came from a variety of sources, including vital statistics, disease and injury morbidity data, cancer registries, and adult and student surveys. In addition to the health behaviors described above, the following morbidity and mortality indicators rose to the top as orga health issues.

294

Morbidity (Disease)*  Asthma  Cancer, 9 types (see population data section of full report for specific types)  Chlamydia  Depression  Hypertension  High Cholesterol  Obesity/overweight

*Issues are listed in alphabetical order. Mortality (Death)*  Alcohol-induced  Alzheimer’s disease  Breast cancer  Diabetes  Drug-induced  Heart disease  Leukemia and lymphoma  Non-transport accidents (e.g. poisonings, falls)  Suicide

295

Appendix D

Sexually Transmitted Disease Supplemental Data

296

5.3

1.7

2.6

33.4

44.1

387.7

413.8

247.4

592.8

143.3

346.8

115.6

405.1

526.7

251.7

390.9

1,045.2

2,137.5

1,559.1

Rate

Incidence Incidence

per100,000

.1%

.0%

.2%

.7%

.0%

.1%

3.9%

1.9%

1.2%

3.8%

87.0%

13.0%

35.2%

57.1%

13.9%

17.8%

37.4%

25.0%

68.1%

31.9%

100.0%

2014

Percent

603

285

296

182

581

106

2,002

5,412

8,767

2,139

2,734

5,739

3,835

4,895

13,361

10,458

15,363

Cases

1.0

5.8

23.7

94.5

42.4

358.0

398.3

261.2

688.2

145.3

324.5

327.8

956.9

502.5

220.1

362.9

2,043.7

1,546.1

Rate

Incidence Incidence

per100,000

.0%

.2%

.9%

.7%

.0%

4.9%

2.0%

1.9%

3.3%

86.5%

13.5%

26.2%

64.9%

12.1%

17.6%

38.5%

26.7%

70.0%

30.0%

100.0%

2013

Percent

700

289

277

129

475

102

1,927

3,741

9,257

1,731

2,503

5,487

3,803

9,978

4,280

12,337

14,264

Cases

5.1

1.3

19.8

70.1

46.8

338.5

401.3

251.9

709.3

153.6

315.6

269.5

786.5

479.8

209.5

346.1

1,992.5

1,663.4

Rate

Incidence Incidence

per100,000

.0%

.2%

.8%

.0%

5.2%

2.2%

2.0%

2.6%

86.0%

14.1%

24.9%

65.8%

10.4%

15.3%

39.4%

30.5%

70.1%

30.0%

100.0%

Year

2012

Percent

705

296

266

109

355

113

1,897

3,354

8,876

1,401

2,058

5,313

4,113

9,454

4,043

11,600

13,497

Cases

2.1

3.2

2.1

14.0

80.0

50.3

348.2

395.7

230.9

836.0

163.1

322.6

261.0

775.2

487.3

217.6

353.9

2,065.8

1,717.1

Rate

Incidence Incidence

per100,000

.0%

.1%

.6%

.9%

.0%

5.9%

2.2%

2.0%

3.0%

9.8%

86.6%

13.4%

30.8%

59.1%

15.0%

39.4%

31.2%

69.6%

30.4%

100.0%

2011

Percent

812

303

268

408

122

1,830

4,217

8,087

1,340

2,047

5,394

4,269

9,523

4,164

11,857

13,687

Cases

1.6

3.9

2.1

13.5

62.8

43.7

309.0

416.3

231.4

919.7

150.2

320.9

266.5

737.4

441.6

199.1

321.6

1,824.5

1,522.5

Rate

Incidence Incidence

per100,000

.0%

.1%

.6%

.9%

.0%

7.1%

2.2%

2.1%

2.6%

84.7%

15.3%

23.4%

65.3%

11.0%

15.8%

37.6%

31.3%

69.4%

30.7%

100.0%

2010

Percent

873

270

263

321

106

1,883

2,882

8,053

1,361

1,953

4,640

3,857

8,558

3,782

10,458

12,341

Cases

Trait

(all reports) (all

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race

Agegroup Sex 297

County

2010 Through2014 4 2010 Quarter

Oregon Chlamydia Cases, Proportional MorbidityCases, Chlamydia Oregon and Incidence by County

1.8

n/a

15.6

92.1

547.7

566.7

395.1

222.6

699.3

167.5

317.6

103.2

228.3

540.8

664.3

428.5

1,176.0

2,618.4

2,341.4

Rate

Incidence Incidence

per100,000

.0%

.3%

.9%

8.0%

8.6%

2.6%

1.1%

2.4%

5.9%

92.0%

54.0%

33.8%

17.5%

19.4%

31.8%

21.7%

61.3%

38.7%

100.0%

2014

Percent

336

361

107

102

249

736

812

912

4,196

3,860

2,266

1,417

1,334

2,573

1,623

Cases

3.5

n/a

15.6

71.8

79.7

513.4

517.3

482.1

234.6

896.9

183.1

225.9

170.5

426.2

648.5

374.3

1,107.9

2,642.0

2,410.7

Rate

Incidence Incidence

per100,000

.8%

.1%

.3%

.8%

.1%

3.0%

1.8%

4.7%

89.6%

10.4%

46.5%

38.0%

11.8%

14.8%

19.5%

34.2%

23.9%

63.9%

36.1%

100.0%

2013

Percent

410

463

117

186

580

765

939

3,933

3,523

1,828

1,493

1,346

2,512

1,418

Cases

1.8

8.2

4.3

n/a

47.3

95.8

450.0

456.2

399.3

204.4

929.8

179.8

184.7

130.9

346.7

827.3

564.4

332.9

2,319.6

2,359.7

Rate

Incidence Incidence

per100,000

.8%

.1%

.0%

.2%

.1%

9.7%

3.3%

1.4%

4.1%

1.1%

90.3%

44.2%

37.8%

14.0%

13.5%

16.8%

35.3%

27.4%

63.4%

36.6%

100.0%

Year

2012

Percent

332

478

112

141

462

574

934

3,415

3,083

1,509

1,290

1,207

2,166

1,249

Cases

7.2

n/a

13.0

45.3

533.5

547.9

415.5

219.2

187.7

467.8

180.2

374.2

969.7

124.1

688.9

374.4

1,119.6

2,673.2

2,829.7

Rate

Incidence Incidence

per100,000

.0%

.2%

.1%

.0%

8.5%

2.8%

1.6%

1.1%

4.8%

1.2%

91.5%

47.1%

34.2%

14.3%

12.2%

17.0%

35.1%

28.3%

65.3%

34.7%

100.0%

2011

Percent

339

569

113

190

486

677

3,991

3,652

1,878

1,366

1,401

1,130

2,606

1,385

Cases

4.3

n/a

11.3

10.8

27.3

94.4

446.9

452.7

399.5

195.8

169.2

322.3

105.9

366.9

858.1

570.8

320.1

1,229.4

2,081.5

2,287.3

Rate

Incidence Incidence

per100,000

.2%

.8%

.1%

.0%

9.7%

3.0%

1.4%

3.3%

1.1%

90.3%

40.4%

36.5%

18.8%

14.1%

18.1%

33.5%

28.5%

64.6%

35.4%

100.0%

2010

Percent

321

618

109

465

597

940

3,295

2,974

1,330

1,203

1,105

2,127

1,167

Cases

(all reports)

Trait

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race

Agegroup Sex

298

County

2010 Through2014 4 2010 Quarter

Oregon Chlamydia Cases, Proportional MorbidityCases, Chlamydia Oregon and Incidence by County

4.1

n/a

83.7

24.8

79.0

23.1

271.0

276.5

208.6

114.9

543.1

159.7

337.6

845.1

367.4

171.0

1,706.7

1,009.0

Rate

Incidence Incidence

per100,000

.8%

.1%

.2%

.6%

.1%

6.3%

2.9%

1.5%

1.4%

4.0%

93.7%

55.7%

39.2%

14.9%

17.3%

36.6%

24.9%

68.8%

31.1%

100.0%

2014

Percent

986

586

412

157

182

385

262

724

327

1,052

Cases

6.1

n/a

83.7

23.2

71.4

19.3

229.2

230.5

214.9

153.9

271.5

159.7

260.2

826.5

828.0

317.2

138.6

1,400.8

Rate

Incidence Incidence

per100,000

.9%

.3%

.6%

7.6%

1.7%

1.8%

1.6%

4.3%

92.4%

33.6%

62.0%

13.6%

20.0%

35.5%

24.2%

70.2%

29.8%

100.0%

2013

Percent

890

822

299

552

121

178

316

215

625

265

Cases

n/a

13.2

44.5

22.7

238.8

236.7

262.6

160.8

417.2

103.3

182.1

181.7

674.7

999.8

326.6

148.2

1,823.1

Rate

Incidence Incidence

per100,000

.0%

.9%

.7%

8.8%

2.4%

2.1%

1.0%

2.6%

9.1%

91.2%

32.2%

62.3%

15.5%

43.2%

28.1%

69.4%

30.6%

100.0%

Year

2012

Percent

916

835

295

571

142

396

257

636

280

Cases

9.9

n/a

45.7

18.7

256.5

259.1

226.0

173.8

586.3

151.8

226.4

205.9

670.7

364.2

145.1

2,020.1

1,092.2

Rate

Incidence Incidence

per100,000

.0%

.6%

.5%

7.0%

3.0%

2.8%

1.1%

2.6%

9.6%

93.0%

30.3%

62.8%

14.5%

43.4%

28.9%

72.2%

27.8%

100.0%

2011

Percent

974

906

295

612

141

423

281

703

271

Cases

4.7

n/a

20.0

57.9

14.9

250.7

244.3

327.3

172.3

480.8

156.4

186.3

208.2

520.3

346.1

152.1

1,769.2

1,301.1

Rate

Incidence Incidence

per100,000

.2%

.4%

2.4%

2.9%

1.0%

1.3%

3.4%

89.8%

10.2%

30.0%

63.8%

10.1%

11.5%

37.4%

35.8%

70.2%

29.8%

100.0%

2010

Percent

945

849

283

603

109

353

338

663

282

Cases

(all reports)

Trait

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race

Agegroup Sex 299

County

2010 Through2014 4 2010 Quarter

Oregon Chlamydia Cases, Proportional MorbidityCases, Chlamydia Oregon and Incidence by County

4.9

2.9

58.4

59.7

49.2

43.7

16.6

73.8

21.5

44.2

85.0

39.0

78.0

169.1

119.1

204.2

205.2

100,000

Rateper

Incidence

.0%

.3%

.0%

.1%

7.5%

1.4%

2.8%

1.0%

5.1%

9.7%

9.1%

89.6%

10.4%

20.8%

67.5%

27.4%

23.3%

24.0%

33.8%

66.1%

100.0%

2014

Percent

238

478

172

117

222

629

534

551

209

775

2,294

2,056

1,548

1,517

Cases

2.8

2.9

44.6

45.3

39.3

35.7

20.6

30.5

16.7

38.2

78.8

74.4

28.9

60.5

195.6

154.1

165.4

100,000

Rateper

Incidence

.0%

.1%

.7%

.4%

.1%

.0%

2.3%

1.5%

5.2%

89.2%

10.9%

12.6%

72.2%

11.4%

11.0%

23.8%

23.0%

25.4%

10.5%

32.8%

67.2%

100.0%

2013

Percent

190

220

199

192

416

403

444

183

574

1,751

1,561

1,265

1,177

Cases

2.4

2.5

37.7

38.7

30.5

28.6

15.6

46.3

12.4

36.5

67.1

76.4

27.0

48.6

191.2

118.1

131.6

100,000

Rateper

Incidence

.0%

.1%

.8%

.4%

.0%

9.8%

2.0%

2.7%

4.6%

90.2%

13.7%

68.7%

12.9%

12.6%

23.8%

21.0%

23.9%

12.9%

36.2%

63.8%

100.0%

Year

2012

Percent

144

201

190

185

349

309

351

189

532

937

1,469

1,325

1,009

Cases

2.8

4.1

38.5

39.2

33.7

26.2

14.0

18.1

11.8

31.4

55.7

92.1

30.9

46.3

336.7

113.6

162.8

100,000

Rateper

Incidence

.0%

.1%

.8%

.7%

.1%

1.7%

1.0%

4.4%

89.5%

10.5%

13.8%

61.5%

22.0%

10.7%

19.2%

20.1%

28.5%

15.4%

40.5%

59.5%

100.0%

2011

Percent

156

205

917

327

160

286

300

425

229

603

887

1,490

1,334

Cases

8.3

4.2

28.1

28.9

22.3

19.8

11.0

21.1

39.4

84.2

78.9

24.7

31.6

224.4

125.0

100,000

Rateper

Incidence

.8%

.0%

.3%

.2%

.0%

9.4%

1.4%

2.1%

90.6%

14.1%

63.9%

19.8%

10.0%

18.7%

20.7%

29.5%

18.6%

44.3%

55.7%

100.0%

2010

Percent

977

101

152

689

213

108

201

223

318

200

478

600

1,078

Cases

Trait

(all reports)

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race Agegroup Sex 300

County

2010 Through2014 4 2010 Quarter

Oregon Gonorrhea Cases, Proportional Gonorrhea Oregon MorbidityCases, and Incidence by County

Source: Orpheus data exported 01/02/2015. Data are provisional and subject to change. to subject and provisional are Data 01/02/2015. exported data Orpheus Source: STATE

4.9

2.9

58.4

59.7

49.2

43.7

16.6

73.8

21.5

44.2

85.0

39.0

78.0

169.1

119.1

204.2

205.2

100,000

Rateper

Incidence

.0%

.3%

.0%

.1%

7.5%

1.4%

2.8%

1.0%

5.1%

9.7%

9.1%

89.6%

10.4%

20.8%

67.5%

27.4%

23.3%

24.0%

33.8%

66.1%

100.0%

2014

Percent

238

478

172

117

222

629

534

551

209

775

2,294

2,056

1,548

1,517

Cases

2.8

2.9

44.6

45.3

39.3

35.7

20.6

30.5

16.7

38.2

78.8

74.4

28.9

60.5

195.6

154.1

165.4

100,000

Rateper

Incidence

.0%

.1%

.7%

.4%

.1%

.0%

2.3%

1.5%

5.2%

89.2%

10.9%

12.6%

72.2%

11.4%

11.0%

23.8%

23.0%

25.4%

10.5%

32.8%

67.2%

100.0%

2013

Percent

190

220

199

192

416

403

444

183

574

1,751

1,561

1,265

1,177

Cases

2.4

2.5

37.7

38.7

30.5

28.6

15.6

46.3

12.4

36.5

67.1

76.4

27.0

48.6

191.2

118.1

131.6

100,000

Rateper

Incidence

.0%

.1%

.8%

.4%

.0%

9.8%

2.0%

2.7%

4.6%

90.2%

13.7%

68.7%

12.9%

12.6%

23.8%

21.0%

23.9%

12.9%

36.2%

63.8%

100.0%

Year

2012

Percent

144

201

190

185

349

309

351

189

532

937

1,469

1,325

1,009

Cases

2.8

4.1

38.5

39.2

33.7

26.2

14.0

18.1

11.8

31.4

55.7

92.1

30.9

46.3

336.7

113.6

162.8

100,000

Rateper

Incidence

.0%

.1%

.8%

.7%

.1%

1.7%

1.0%

4.4%

89.5%

10.5%

13.8%

61.5%

22.0%

10.7%

19.2%

20.1%

28.5%

15.4%

40.5%

59.5%

100.0%

2011

Percent

156

205

917

327

160

286

300

425

229

603

887

1,490

1,334

Cases

8.3

4.2

28.1

28.9

22.3

19.8

11.0

21.1

39.4

84.2

78.9

24.7

31.6

224.4

125.0

100,000

Rateper

Incidence

.8%

.0%

.3%

.2%

.0%

9.4%

1.4%

2.1%

90.6%

14.1%

63.9%

19.8%

10.0%

18.7%

20.7%

29.5%

18.6%

44.3%

55.7%

100.0%

2010

Percent

977

101

152

689

213

108

201

223

318

200

478

600

1,078

Cases

Trait

(all reports)

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race Agegroup Sex 301

County

2010 Through2014 4 2010 Quarter

Oregon Gonorrhea Cases, Proportional Gonorrhea Oregon MorbidityCases, and Incidence by County

8.3

n/a

26.0

27.2

12.6

18.7

72.4

10.5

20.0

18.8

43.0

97.5

50.1

19.3

32.4

141.9

100,000

Rateper

Incidence

.0%

4.0%

2.0%

1.0%

5.0%

9.9%

1.0%

96.0%

26.7%

66.3%

19.8%

20.8%

31.7%

12.9%

37.6%

61.4%

100.0%

2014

Percent

101

Cases

1.7

n/a

24.7

23.8

34.8

19.5

90.5

15.7

20.7

43.0

88.7

46.2

16.7

32.9

148.6

100,000

Rateper

Incidence

.0%

5.2%

3.1%

1.0%

88.5%

11.5%

18.8%

72.9%

11.5%

20.8%

33.3%

20.8%

12.5%

34.4%

65.6%

100.0%

2013

Percent

Cases

5.4

2.1

6.6

n/a

26.6

26.9

22.7

20.8

40.5

27.8

56.9

31.1

20.5

32.8

208.6

114.0

110.5

100,000

Rateper

Incidence

.0%

6.9%

1.0%

2.0%

1.0%

3.9%

7.8%

93.1%

13.7%

72.6%

10.8%

14.7%

25.5%

23.5%

39.2%

60.8%

100.0%

Year

2012

Percent

102

Cases

8.3

n/a

24.5

22.9

43.2

21.0

41.2

14.6

53.1

90.4

58.3

20.2

28.9

141.5

105.1

100,000

Rateper

Incidence

.0%

7.5%

2.2%

5.4%

8.6%

86.0%

14.0%

10.8%

79.6%

25.8%

20.4%

23.7%

16.1%

41.9%

58.1%

100.0%

2011

Percent

Cases

5.8

n/a

18.0

17.6

23.9

14.9

20.7

16.3

32.9

85.9

75.2

42.3

15.7

20.5

104.5

100,000

Rateper

Incidence

.0%

7.4%

1.5%

89.7%

10.3%

13.2%

76.5%

13.2%

22.1%

26.5%

22.1%

16.2%

44.1%

55.9%

100.0%

2010

Percent

Cases

(all reports)

Trait

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race

Agegroup Sex

302

County

2010 Through2014 4 2010 Quarter

Oregon Gonorrhea Cases, Proportional Gonorrhea Oregon MorbidityCases, and Incidence by County

9.9

8.8

6.5

5.9

1.0

4.1

5.3

1.7

10.3

13.2

21.6

11.6

16.3

22.7

19.9

19.0

Rate

Incidence Incidence

per100,000

.0%

5.5%

3.2%

1.2%

1.0%

4.7%

3.2%

8.4%

84.2%

15.8%

12.9%

77.2%

15.6%

20.3%

29.7%

12.9%

12.6%

91.6%

100.0%

2014

Percent

404

340

312

120

370

Cases

9.4

4.5

5.9

2.6

7.7

10.3

17.0

23.6

11.9

22.7

18.4

23.7

13.0

20.0

Rate

Incidence Incidence

per100,000

.0%

.3%

.0%

8.6%

5.9%

2.2%

1.2%

3.0%

8.6%

4.7%

4.0%

79.8%

20.3%

82.0%

16.1%

28.2%

24.0%

15.3%

96.1%

100.0%

2013

Percent

405

323

332

114

389

Cases

8.0

7.6

7.2

4.7

3.6

3.5

8.7

1.6

10.4

24.1

16.4

17.5

14.5

10.9

15.7

Rate

Incidence Incidence

per100,000

.0%

.6%

.0%

7.4%

7.7%

2.9%

1.0%

5.1%

9.3%

1.3%

2.9%

84.2%

15.8%

81.0%

15.4%

26.7%

29.3%

12.2%

97.1%

100.0%

Year

2012

Percent

311

262

252

302

Cases

4.4

4.1

7.2

2.7

2.4

1.2

4.2

8.4

9.7

6.5

1.2

8.8

10.2

Rate

Incidence Incidence

per100,000

.0%

.6%

6.5%

4.1%

2.9%

1.2%

2.9%

1.8%

88.8%

11.2%

85.3%

13.5%

25.3%

29.4%

15.9%

10.0%

99.4%

100.0%

2011

Percent

170

151

145

169

Cases

2.8

2.7

3.3

2.6

4.2

1.7

1.2

1.8

5.9

6.1

6.0

5.5

1.2

5.6

Rate

Incidence Incidence

per100,000

.9%

.0%

.9%

.0%

.9%

8.3%

3.7%

2.8%

9.3%

2.8%

86.1%

13.9%

84.3%

27.8%

28.7%

14.8%

13.0%

99.1%

100.0%

2010

Percent

108

107

Cases

Trait

(all reports)

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race

Agegroup Sex

303

County

2010 Through2014 4 2010 Quarter

Oregon Early Syphilis Cases, ProportionalSyphilis Early Oregon MorbidityCases, and Incidence by County

5.3

5.1

2.1

n/a

28.0

34.1

26.4

31.0

14.1

18.2

40.5

47.7

46.3

43.4

31.4

56.0

28.7

Rate

Incidence Incidence

per100,000

.9%

.0%

.9%

.0%

7.3%

4.1%

1.4%

6.4%

7.3%

3.6%

86.8%

13.2%

11.4%

76.4%

18.2%

23.6%

28.6%

13.6%

96.4%

100.0%

2014

Percent

191

168

212

220

Cases

9.4

1.8

n/a

29.2

47.0

29.9

31.0

35.3

11.7

40.5

67.8

42.6

49.2

31.4

18.0

62.3

31.2

Rate

Incidence Incidence

per100,000

.4%

.0%

9.2%

6.7%

2.5%

2.1%

3.8%

6.7%

2.9%

1.3%

83.3%

16.7%

79.5%

16.7%

31.0%

24.3%

14.2%

98.7%

100.0%

2013

Percent

199

190

236

239

Cases

8.0

3.6

7.6

1.3

n/a

26.3

37.3

26.8

37.0

14.2

16.3

28.2

54.8

50.3

33.1

28.8

54.4

27.5

Rate

Incidence Incidence

per100,000

.0%

6.7%

9.1%

2.4%

1.0%

5.7%

7.2%

1.4%

2.4%

85.2%

14.8%

80.9%

13.4%

28.2%

32.1%

11.0%

97.6%

100.0%

Year

2012

Percent

178

169

204

209

Cases

8.6

3.3

1.9

2.9

2.5

n/a

16.5

16.0

13.8

14.4

20.1

27.5

26.9

31.5

13.4

31.6

15.6

Rate

Incidence Incidence

per100,000

.0%

.9%

.0%

6.0%

5.1%

6.0%

1.7%

6.0%

94.0%

85.5%

17.1%

24.8%

29.9%

18.8%

100.0%

2011

Percent

110

100

117

Cases

8.4

9.1

4.0

1.7

7.2

1.5

5.1

n/a

8.7

11.2

22.4

16.6

10.1

13.2

17.6

Rate

Incidence Incidence

per100,000

.0%

6.3%

3.1%

1.6%

7.8%

85.9%

14.1%

87.5%

35.9%

32.8%

10.9%

100.0%

2010

Percent

Cases

(all reports) (all

Trait

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race

Agegroup Sex

304

County

2010 Through2014 4 2010 Quarter

Oregon Early Syphilis Cases, ProportionalSyphilis Early Oregon MorbidityCases, and Incidence by County

2.0

9.5

2.2

2.0

3.3

7.5

4.3

4.6

4.7

n/a

2.6

20.0

Rate

Incidence Incidence

per100,000

.0%

70.0%

30.0%

10.0%

80.0%

10.0%

20.0%

40.0%

20.0%

10.0%

90.0%

100.0%

2014

Percent

Cases

5.6

5.9

8.3

4.3

4.4

3.9

1.5

n/a

6.2

12.6

18.1

10.5

22.6

13.9

11.0

Rate

Incidence Incidence

per100,000

.0%

4.2%

8.3%

4.2%

83.3%

16.7%

87.5%

20.8%

50.0%

12.5%

87.5%

100.0%

2013

Percent

Cases

8.2

6.5

7.9

4.2

4.6

n/a

8.1

37.9

18.2

11.1

17.5

14.3

15.9

Rate

Incidence Incidence

per100,000

.0%

6.5%

3.2%

6.5%

9.7%

3.2%

93.6%

90.3%

35.5%

19.4%

25.8%

96.8%

100.0%

Year

2012

Percent

Cases

1.7

3.3

2.0

2.8

1.7

5.5

2.2

4.8

3.2

n/a

1.8

Rate

Incidence Incidence

per100,000

.0%

85.7%

14.3%

42.9%

14.3%

85.7%

100.0%

2011

Percent

Cases

3.7

3.4

5.8

5.0

5.4

8.8

9.5

5.0

6.5

n/a

3.4

Rate

Incidence Incidence

per100,000

.0%

7.7%

92.3%

23.1%

30.8%

15.4%

92.3%

100.0%

2010

Percent

Cases

(all reports) (all

Trait

Non-Hispanic

Hispanic

Missing

White

Black

Asian

Am.Ind./AK Native

Missing

70+ 70+ yrs

60-69 yrs 60-69

50-59 yrs 50-59

40-49 yrs 40-49

30-39 yrs 30-39

25-29 yrs 25-29

20-24 yrs 20-24

15-19 yrs 15-19

10-14 yrs 10-14

5-9 yrs 5-9

0-4 yrs 0-4

Missing

Female

Male

Grouping

Total

Ethnicity

Race

Agegroup Sex

305

County

2010 Through2014 4 2010 Quarter

Oregon Early Syphilis Cases, ProportionalSyphilis Early Oregon MorbidityCases, and Incidence by County

Abbreviations: . = no data, n/a = not applicable, * = very small population, omitted to protect confidentiality protect to omitted population, small very = * applicable, not = n/a data, no . = Abbreviations: Source: Orpheus data exported 01/02/2015. Data are provisional and subject to change. to subject and provisional are Data 01/02/2015. exported data Orpheus Source: CLACKAMAS Appendix E Community Resources Portland Adventist Community Services 11020 NE Halsey Street Portland, Or 97220 503-252-8500 WWW.portlandacs.org Volunteers needed. PACS is a private, not-for-profit service organization that addresses the needs of low-income families and individuals. In 2009, PACS programs served 288,681 people. PACS services include: - Family Health Center - Client Choice Grocery Warehouse - Thrift Ministry - Needs Assessment and Referral to other agencies if necessary

Multnomah County Health and Human Services 501 SE Hawthorne Blvd. Portland, OR 97214 503-823-4000 Information center 1221 SW 4th Ave. Portland, OR 97204 503+823-4000 http://web.multco.us/health-human-services

Clackamas County Social Services 2051 Kaen Road Oregon City, OR 97045 503-655-8640 http://www.co.clackamas.or.us/socialservices/

Multnomah County Aging and Disability 421 SW Oak Street, Suite 510 Portland, OR 97204 503-988-3620 http://web.multco.us/ads

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Washington County Department of Disability, Aging, and Veterans services 133 SE 2nd Avenue Hillsboro, OR 97123 503-640-3489 http://www.co.washington.or.us/HHS/DAVS/

Compassion Connect P.O. Box 808 Fairview, OR 97024 http://www.compassionconnect.com/

Volunteers needed. Compassion Connect was formed with the belief that the Church is to be a transformational presence in the community, daily reflecting the Kingdom of God by addressing the needs of the whole person. We believe that there is more that unites us as Christians than divides us, and that by working together as church communities our witness and impact is magnified. Compassion Connect serves as an umbrella organization for these local church collaboratives by providing experience, inspiration, and guidance as churches work to build relationships of grace with their neighbors Health, Housing, Helps We have experienced three models of collaborative service that have worked very well in the Portland Metro area. Health - Free Medical/Dental Clinic and Social Service Fair. Housing - Apartment Complex Initiative. Helps - Churches working with schools, law enforcement, and others

Catholic Charities 2740 SE Powell Boulevard, #5 Portland, Oregon 97202 503- 231-4866 http://www.catholiccharitiesoregon.org/

Volunteers needed. Catholic Charities brings hope, resources and advocacy to the poor and most vulnerable among us regardless of faith, race, marital status or condition in life. Our activities are based upon the fundamental belief in the dignity and sanctity of human life and the principles of Catholic Social Teaching. We serve as the professional social service arm of the Archdiocese of Portland.

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Snow Cap Community Charities 17805 SE Stark Street Portland, OR 97024 503-674-8785 http://www.snowcap.org/

Volunteers needed. SnowCap Community Charities is a philanthropic organization created to provide food, clothing, advocacy and other services to the poor.

The Oregon Food Bank 7900 NE 33rd Drive Portland, OR 97211 503-282-0555 http://www.oregonfoodbank.org/

Volunteers needed.

We work with a cooperative network of regional food banks, partner agencies and programs to distribute emergency food to hungry families. In addition, we are working to fight hunger's root causes through public policy, outreach and education

Central City Concern 232 NW 6th Ave. Portland, OR 97209 503-294-1681 http://www.centralcityconcern.org

Central City Concern (CCC) is a 501(c)(3) nonprofit agency serving single adults and families in the Portland metro area who are impacted by homelessness, poverty and addictions. Founded in 1979, the agency has developed a comprehensive continuum of affordable housing options integrated with direct social services including healthcare, recovery and employment. CCC currently has a staff of 500, an annual operating budget of $38 million and serves more than 13,000 individuals annually.

American Lung Association in Oregon 7420 SW Bridgeport Rd., Suite 200 Tigard, OR 97224 (503) 924-4094 www.lungusa.org/oregon

Volunteers needed

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Portland Rescue Mission 503-Mission (647-7466) http://www.portlandrescuemission.org/

The Wallace Medical Concern Rockwood Building 124 NE 181st Ave, Suite 103 Portland, OR 489-1760 http://wallacemedical.org/

Iron Tribe “IRON TRIBE is a Community Organization of Ex-Cons in Recovery. We are men and women who have been incarcerated and are now engaged in a program of living that is based upon recovery, peer support and building community. Our mission is to provide peer support and guidance for the releasing ex-con and people in recovery, as they navigate successful integration into our community. IRON TRIBE encompasses all nations, tribes, ethnicities, lineages and religious preferences. We celebrate the diversity that is contained within each individual, moving beyond simple tolerance to understanding that each individual is unique, encouraging each member in a safe, positive, and nurturing environment. Together we are collectively known as: IRON TRIBE.” From Iron Tribe web site. http://www.irontribenetwork.org/

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Appendix F

Existing Health Care Facilities and Resources

Health-related Associations Oregon Alliance for Senior Health Services

Oregon Ambulatory Surgical Center Association

Oregon Association for Home Care

Oregon Association of Hospitals and Health Systems

Oregon Health Care Association

Oregon Hospice Association

Oregon Medical Association

Oregon Nurses Association

Community Health Coalitions

The Oregon Medical Association works closely with the following coalitions in its community health advocacy efforts.

Alliance for Community Traffic Safety

The Mission of ACTS Oregon is to reduce fatalities, injuries and the severity of injuries resulting from vehicle crashes throughout Oregon. Its vision is to motivate individuals and communities throughout

Oregon to solve their traffic safety problems by providing resources, technical training and education.

Health Reform Collaborative

The Oregon Health Reform Collaborative is a group of over 25 organizations committed to creating solutions to Oregon's health care crisis. Representing providers, insurers, underserved populations,

310 businesses, consumers, and faith-based communities, these groups together work on behalf of thousands of Oregonians.

Healthy Kids Learn Better

Healthy Kids Learn Better is a statewide effort to help local schools and communities form partnerships and reduce physical, social and emotional barriers to learning.

Human Services Coalition of Oregon

The Human Services Coalition of Oregon is comprised of organizations and individuals whose purpose is to educate and advocate in the Oregon Legislature for vulnerable Oregonians.

Immunization Policy Advisory Team

The DHS Immunization Policy Advisory Team, as experts in immunization and/or policy fields, will advise the Immunization Program of the Oregon Department of Human Services on the development, prioritization and implementation of immunization policy issues.

Oregon Adult Immunization Coalition

The Oregon Adult Immunization Coalition, a statewide network of health and community partners, will promote prevention and control of vaccine-preventable disease through immunization of adults in Oregon and Southwest Washington.

Oregon Alliance for Drug Endangered Children

A Drug Endangered Children program is a multi-agency approach to assist and protect children whose lives, health, and safety are jeopardized by drug manufacture, drug dealing, or drug abuse in the family home. DEC is designed to provide a comprehensive response by coordinating the efforts of law enforcement, child protective services, prosecutors, and health professionals.

Oregon Alliance Working for Antibiotic Resistance Education

Oregon AWARE encourages the appropriate use of antibiotics and aims to reduce the problem of antibiotic-resistant bacteria in Oregon.

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Oregon Asthma Program

The OAP is working to make sure that all Oregonians with asthma get quality medical care, and have the right information and skills to manage their disease.

Oregon Environmental Council

The OEC's mission is to bring Oregonians together for a healthy environment.

Oregon Health Care Volunteer Registry

The intent of the OHCV is to create a pool of volunteers who are potentially available to respond to national, state, and local disasters.

Oregon Nutrition Policy Alliance

The ONPA's mission is to increase awareness about the impact of nutrition on the health of Oregonians and to promote policy that creates a healthy, active Oregon.

Oregon Partnership for Cancer Control

The Partnership is a group of individuals and organizations with a commitment to reducing the burden of cancer in our state by enhancing cancer prevention activities, increasing equity in access to care, promoting research and awareness of cancer issues, and maximizing the quality of life for those affected by cancer.

Oregon Partnership to Immunize Children

OPIC facilitates the collaboration of public and private partners to protect Oregon's children against vaccine-preventable diseases.

Physical Education for All Kids

PEAK's mission is to promote quality physical education for all Oregon children. http://www.theoma.org/media/public-health-fact-sheets/community-health-coalitions

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Human Services Coalition of Oregon http://oregonhsco.com/ (unverified for 2016)

The Human Services Coalition of Oregon is comprised of organizations and individuals whose purpose is to educate and advocate in the Oregon Legislature for vulnerable Oregonians.

Immunization Policy Advisory Team

The DHS Immunization Policy Advisory Team, as experts in immunization and/or policy fields, will advise the Immunization

Program of the Oregon Department of Human Services on the development, prioritization and implementation of immunization policy issues.

Oregon Adult Immunization Coalition

Oregon Alliance for Drug Endangered Children

Oregon Alliance Working for Antibiotic Resistance Education

Oregon AWARE encourages the appropriate use of antibiotics and aims to reduce the problem of antibiotic-resistant bacteria in Oregon.

Oregon Asthma Program

The OAP is working to make sure that all Oregonians with asthma get quality medical care, and have the right information and skills to manage their disease.

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Oregon Environmental Council

The OEC's mission is to bring Oregonians together for a healthy environment.

Oregon Health Care Volunteer Registry

The intent of the OHCV is to create a pool of volunteers who are potentially available to respond to national, state, and local disasters.

Oregon Nutrition Policy Alliance

The ONPA's mission is to increase awareness about the impact of nutrition on the health of Oregonians and to promote policy that creates a healthy, active Oregon.

Oregon Partnership for Cancer Control

Oregon Partnership to Immunize Children

OPIC facilitates the collaboration of public and private partners to protect Oregon's children against vaccine-preventable diseases.

Physical Education for All Kids

PEAK's mission is to promote quality physical education for all Oregon children.

NORTHWEST PORTLAND

• Cornell Urgent Care is a resource for uninsured or underinsured patients suffering from non-life threatening injuries or illness.

• Legacy Clinic Good Samaritan: Please visit the Legacy Clinic page to get contact information for this clinic.

• Legacy Clinic Northwest: Please visit the Legacy Clinic page to get contact information for this clinic.

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• NCNM Pettygrove Classical Chinese Medicine Clinic: Pettygrove Classical Chinese Medicine Clinic offers a full- spectrum of Oriental medicine therapies, including acupuncture. The Chinese medicine formulary provides herbal medicines. Sliding scale discounts are available to patients below FPL, proof of FPL may be required. Please inquire.

• NCNM at Chinese Consolidated Benevolent Association Native Asian Community Support Center.

• NCNM at PCC Capitol Formerly known as Homestreet, serves Hillsboro, Aloha and surrounding neighborhoods such as Washington County.

• ZoomCare is a resource for affordable primary care, urgent care, lab test and same-day medical procedures.

NORTHEAST PORTLAND

• Legacy Clinic Northeast: Please visit the Legacy Clinic page to get contact information for this clinic.

• PACS Familty Health Center: Primary care and general medicine. All laboratory, radiology and emergency services are facilitated by Adventist Medical Center, Portland.

• NCNM at PCC Workforce Clinic: This Clinic services minority women and children, community members and dislocated workers training to re-enter the workforce.

• NCNM at In-Act Clinic: Located in Downtown Portland providing services for court mandated offenders with drug and/or alcohol addictions. Community members welcome.

• NCNM at Hooper Detox: Short term inpatient care for adults and teens with alcohol and drug addiction.

• East County Community Clinic Operates out of Multnomah County Health Clinic facility, provides for migrant farm workers, Latinos and the general community.

• Providence Clinics: Please visit the Providence Clinic page to get contact information for the NE Portland clinics.

• Planned Parenthood

• Working Class Acupuncture Traditional Chinese medicine and Western medicine. Sliding scale fees.

SOUTHWEST PORTLAND

• Legacy Clinic Bridgeport: Please visit the Legacy Clinic page to get contact information for this clinic.

• Legacy Clinic Lake Oswego: Please visit the Legacy Clinic page to get contact information for this clinic.

• NCNM Natural Health Center on First Ave: Natural Health Center focuses on all facets of naturopathic medicine. Providing primary care for acute and chronic disease. The clinic includes a comprehensive natural medicine pharmacy as well as a licensed, full-service laboratory. Sliding scale discounts are available to patients below FPL, proof of FPL may be required.

• NCNM at PCC Sylvania Clinic: Only community health center on campus. Provides services to staff, students, community members in the neighborhood.

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• NCNM at In-Act Clinic Court mandated persons for addiction and recovery, but open to the community.

• Men’s Wellness Center: The Men’s Wellness Center, part of the Cascade AIDS Project, offers free rapid HIV testing as well as a variety of other health services for men.

• Ninety Nine West Urgent Care & Health is a resource for uninsured or under-insured patients suffering from non-life threatening injuries or illness.

• OHSU Community Health Centers provide low-cost primary and urgent care for uninsured patients.

• Providence Clinics Please visit the Providence Clinics page to get contact information for the SW

Portland clinic.

• Southwest Community Health Center A safety-net clinic providing basic, high quality health care services to low income, uninsured and underinsured residents of SW Portland.

• Shriner’s Hospital for Children Acceptance, for children up to age 18, is based solely on a child’s medical needs. Income or insurance status is not an issue for a child’s acceptance as a patient.

• Good News Community Health Center Good News provides care for uninsured patients.

• OHSU Richmond Clinic A teaching clinic of OHSU primarily serving SE Portland.

• Rosewood Family Health Center Comprehensive medical care in SE Portland.

• NCNM at Asian Health and Service Center Part of NCNM focuses on Chinese Classical Medicine.

• NCNM at Immune Enhancement Program Immune Compromised.

• Providence Clinics: Please visit the Providence Clinics page to get contact information for the SE Portland clinic.

• Balanced Life Health Care Provides free women’s health & family planning services to eligible patients.

• Low Cost Primary Care: Primary health care, including mental health care, for $60 a visit. Please call (503)231- 2994 for more information or to schedule an appointment.

• Planned Parenthood

• Oregon College of Oriental Medicine Traditional Chinese medicine. Sliding scale fees.

GRESHAM

• Gresham Urgent Care: Treatment of non-life-threatening injury and illness. No appointment necessary.

• Legacy Clinic Mount Hood: Please visit the Legacy Clinic page to get contact information for this clinic.

• Providence Clinics: Please visit the Providence Clinic page for contact information for the Gresham clinics.

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• Wallace Medical Concern General Medicine. Basic urgent medical care and specialty podiatry and dermatology care at clinics located in Gresham and Downtown Portland.

• Planned Parenthood

SW WASHINGTON

• Free Clinic of SW Washington The Free Clinic of SW Washington serves uninsured, low-income Washington residents who do not have health insurance or state medical assistance.

• Legacy Clinic Salmon Creek: Please visit the Legacy Clinic page to get contact information for this clinic.

• New Heights Clinic provides primary care for uninsured and state insured individuals and follows clients until they receive their own coverage.

• Sea Mar Community Health Centers offer primary care and basic dental care on a sliding fee scale.

• Clinica de Salud Familiar Primary care services

• Planned Parenthood

CLACKAMAS

• Providence Sunnyside Family Medicine, Obstetrics & Internal Medicine.

• Willamette Falls Immediate Care is a resource for urgent medical needs.

• Oregon City Health Clinic

• Planned Parenthood

Clinics in Multnomah County

These private, primary care clinics offer low-cost or sliding fee payment options for uninsured clients.

Clinics

• Balanced Life Health Care

• Good News Community Health Center

• Dr. Michael Horowitz

• Salvia Medica

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Mental Health Resources

From NAMI 2015 Mental Health Resource Guide http://namimultnomah.org/wp-content/uploads/2015/04/nami-resource-guide-2015.pdf

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Please go to NAMImultnomah.org for additional Addiction/Substance Abuse Programs in their Resource Guide

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Appendix G

Data Sources

Agency for Healthcare Research and Quality http://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital- Conditions.pdf.

American Cancer Society 1-800-227-2345 http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-key-statistics

American Diabetes Association 1701 North Beauregard Street Alexandria, VA 22311 800-DIABETES http://www.diabetes.org/

American Factfinder U.S. Census Bureau http://www.census.gov/

American Community Survey http://www.census.gov/acs/www/

American Heart Association 7272 Greenville Ave. Dallas, TX 75231 1-800-AHA-USA1 www.heart.org.

American Lung Association 1301 Pennsylvania Ave. NW, Suite 800, Washington, DC 20004 202-785-3355 http://www.lungusa.org/ Freedom From Smoking Program: http://www.ffsonline.org “Too Many Cases, Too Many Deaths”

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American Lung Association in Oregon 7420 SW Bridgeport Rd., Suite 200 Tigard, OR 97224 (503) 924-4094 www.lungusa.org/oregon State Highlights | American Lung Association

Quitline: Contact Information: 1-800-QUIT-NOW; http://www.oregonquitline.org/

BioMed Central Floor 6, 236 Gray's Inn Road London WC1X 8HB United Kingdom http://www.pophealthmetrics.com/content/8/1/29

Center on Budget and Policy Priorities http://www.cbpp.org/sites/default/files/atoms/files/7-22-16pov-factsheets-or.pdf

Centers for Disease Control and Prevention 1600 Clifton Road, Atlanta, GA 90333 800-232-4636 http://www.cdc.gov/chronicdisease/overview/index.htm http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf http://www.cdc.gov/diabetes/statistics

Community Commons Community Commons | Data, tools, and stories to improve communities and inspire change.

Healthy Columbia Willamette Collaborate https://multco.us/healthy-columbia-willamette-collaborative/reports

HealthyPeople.com A Federal Government Web site managed by the U.S. Department of Health and Human Services 200 Independence Avenue, S.W., Washington, DC 20201 • © 2014 About Healthy People | Healthy People 2020 https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of- health?topicid=39

The Henry J. Kaiser Family Foundation

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Washington, D.C. Office/Public Affairs Center 1330 G Street, NW Washington, DC 20005 202- 347-5270 http://www.kff.org/ http://www.statehealthfacts.org/

Mayo Clinic 200 First St. SW Rochester, MN 55905 High blood pressure (hypertension) - Mayo Clinic

Multnomah County Health Department https://multco.us/file/37128/download

2014 Report Card on Racial and Ethnic Disparities December 2014 https://multco.us/file/37530/download

Multnomah County Health Department’s December 2015 report “Opiate Trends- Multnomah County, 2004-2014” https://multco.us/file/46229/download- HIV Care Services Annual Report 2014 Report Card on Racial and Ethnic Disparities December 2014

National Alliance on Mental Illness 3803 N. Fairfax Dr., Ste. 100 Arlington, VA 22203 800-950-9264 http://www.nami.org/

NAMI Multnomah 524 NE 52nd Ave Portland, OR 97213 503-228-5692 [email protected] www.nami.org/multnomah NAMI: National Alliance on Mental Illness | Mental Health By the Numbers

Local Resources available at the following link: http://www.nami.org/MSTemplate.cfm?Section=Resource_Guide&Site=NAMI_Of_Multnomah _County&Template=/ContentManagement/ContentDisplay.cfm&ContentID=110240

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National Cancer Institute U.S. Department of Health and Human Services National Institutes of Health Cancer Statistics - National Cancer Institute

National Center for Health Statistics CDC - NCHS - National Center for Health Statistics

National Center for Chronic Disease Prevention and Health Promotion Behavioral Risk Factor Surveillance System (BRFSS) BRFSS, by County, Oregon, 2010-2013, Chronic Diseases among Oregon Adults BRFSS, by County, Oregon, Health screenings among Oregon adults, by county, 2008‐2011 and 2010-2013 NCHS Data Brief • No. 226 • December 2015 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention(https://www.cdc.gov/nchhstp/) STDs on the Rise Press Release | 2015 | Newsroom | NCHHSTP | CDC

National Institute of Mental Health NIMH » Any Mental Illness (AMI) Among U.S. Adults

National Survey of Children’s Health http://www.nschdata.org/Content/Default.aspx

National Health and Nutrition Examination Survey http://www.cdc.gov/nchs/nhanes.htm Multnomah County Health Department 426 SW Stark Street Portland, OR 97204 503-988-3674 http://web.multco.us/health

Office of Applied Studies Substance Abuse and Mental Health Services Administration (SAMHSA) http://www.oas.samhsa.gov/ Co-occurring Disorders | SAMHSA SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2010-2012.

Office of National Drug Control Policy 800-666-3332 http://www.whitehousedrugpolicy.gov/

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Oregon Association of Hospitals and Health Systems 4000 Kruse Way Place, Building 2, Suite 100 Lake Oswego, OR 97035 503-636-2204 http://www.oahhs.org

Oregon Center for Public Policy 204 North First, Suite C Silverton, OR 97381 503-873-1201 www.ocpp.org

Oregon Department of Human Services In the Oregon Temporary Assistance For Needy Families (TANF) Flash Figures report- December 2010.

Oregon Food Bank 7900 N.E. 33rd Drive Portland, OR 97238-5370 503-282-0555 http://www.oregonfoodbank.org/ OFB Network Stats | Oregon Food Bank

Oregon Health Authority Public Health Division 500 Summer Street, NE, E-20 Salem, OR 97301-1097 503-947-2340 http://www.oregon.gov/OHA/ http://www.dhs.state.or.us/dhs/ph/chs/data/arpt/07v2/chp6toc.shtml http://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/11v2/Doc uments/Chapter%206/Table635.pdf http://public.health.oregon.gov/DiseasesConditions/ChronicDisease/DataReports/Documents/ datatables/ORAnnualBRFSS_riskfactors.pdf State Health Improvement Plan Oregon STD Statistics

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The Oregonian 1320 SW Broadway Portland, OR 97201 503-221-8327 http://www.oregonlive.com/oregonian/

Policy Link Access to Healthy Food and Why It Matters- Policy Link and The Food Trust http://www.policylink.org/sites/default/files/GROCERYGAP_FINAL_NOV2013.pdf

Portland Adventist Community Services 11020 NE Halsey Street Portland, Or 97220 503-252-8500 http://www.portlandacs.org/about.shtml

1111 SW 2nd Ave Portland, OR 97204 www.portlandpolice.com http://ftpcontent.worldnow.com/kptv/KPTV/story_pdfs/suicide_analysis.pdf

The Robert Wood Johnson Foundation www.rwjf.org Health Rankings | County Health Rankings & Roadmaps http://stateofobesity.org/files/stateofobesity2015.pdf

County Health Rankings- Mobilizing Action Toward Community Health Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. www.countyhealthrankings.org/oregon State of Oregon- Geospatial Data, Maps & Applications Oregon ArcGIS Online

Surgeon General The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General | SurgeonGeneral.gov

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Trust for America’s Health 17300 M Street, NW, Suite 900 Washington, DC 20036 202-223-9871 University of Wisconsin Population Health Institute http://uwphi.pophealth.wisc.edu/

U.S. Census Bureau http://www.census.gov/

American Community Survey http://www.census.gov/acs/www/

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics http://www.cdc.gov/nchs/data/databriefs/db226.pdf Products - Data Briefs - Number 228 - December 2015

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2016 CHNA approval

This community health needs assessment was adopted on October 18, 2016 by the Adventist Health System/West Board of Directors. The final report was made widely available on December 31, 2016.

CHNA/CHP contact:

Peter Morgan, MBA Community & Government Affairs Coordinator Adventist Medical Center-Portland 10123 SE Market Street Portland, OR 97141

Request a copy, provide comments or view electronic copies of current and previous community health needs assessments: https://www.adventisthealth.org/pages/about- us/community-health-needs-assessments.aspx

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