Texas Public Health Journal A quarterly publication of the Texas Public Health Association (TPHA)
Volume 66, Issue 4 Fall 2014
In This Issue
President’s Message 2
Commissioner’s Comments - The Public Health Impact of Unaccompanied Children 3
Public Health Commentary: Children Refugees in San Antonio and Laredo 4
Comparison of Adverse Events Involving Infl uenza Vaccine Reported to Two Programs 5
Anabolic-Androgenic Steroid Abuse in Texas 7
Public Health Practice Commentaries Submitted by Texas Public Health Professionals 8
Age Well Live Well Texas 10
Not Their First Rodeo: Texas Researchers Battle Ebola Virus 12
Commentary on Ebola: Dr. James Swan 13
Improving Collaboration between Federally-funded Health Centers and Aging Services 14
An Overview of Tobacco-Free Policy Among Worksites in a Central Texas County 18
Public-Private Partnerships: Multidisciplinary Plans to Reduce Child and Adolescent Obesity 23
In Memorium - Dr. Ron Anderson 26
Save the Date 27
Please visit the Journal page of our website at http://www.texaspha.org for author information and instructions on submitting to our journal. Texas Public Health Association PO Box 201540, Austin, Texas 78720-1540 phone (512) 336-2520 fax (512) 336-0533 Email: [email protected] “The articles published in the Texas Public Health Journal do not necessarily refl ect the offi cial policy or opinions of the Texas Public Health Asso- ciation. Publication of an advertisement is not to be considered an endorsement or approval by the Texas Public Health Association of the product or service involved.”
Subscriptions: Texas Public Health Journal, PO Box 201540, Austin, Texas 78720-1540. Rates are $75 per year. Subscriptions are included with memberships. Membership application and fees accessible at www.texaspha.org. Please visit the journal page for guidelines on submitting to the Texas Public Health Journal. Catherine Cooksley, DrPH - Editor Terri S. Pali - Managing Editor President’s Message Editorial Board Kaye Reynolds, MPH - Co-chair James Swan, Ph.D. Carol Galeener, PhD - Co-chair Jean Brender, RN, PhD Children at the Border, Legalities, and Amol Karmarker, PhD Public Health Kimberly Fulda, DrPH TheT recent increase life and limb if a child, or adult, were deported Mathias B. Forrester, BS ini children arriving back to the country of origin. This is clearly Natalie Archer, MPH ata the U.S. border a public health as well as moral and legal is- Kathryn Cardarelli, PhD TPHA Offi cers fromf three countries sue; but the outcomes will fl ow from legal, and President ini Central America some political, points. There are many legal James H. Swan, PhD hash been described advocates standing ready to aid new arrivals in President-Elect asa a “crisis.” Wheth- making such asylum claims; but such claims Cindy Kilborn, MPH, M(ASCP) ere oorr nonott ononee thinks ooffit it as a crisis for U.S. are likely to be very hard to establish before First Vice President immigrationim and border security, there are immigration judges. The issue is that asylum Melissa Oden, DHEd, LMSW-IPR, MPH, certainlyc crisis elements from a public health is to protect victims of persecution based on CHES standpoint.st The major crisis for the children race, religion, nationality, political beliefs, or Second Vice-President anda their families involves the violence and belonging to a specifi c social group. The law Michael Hill, MPH, MPA, FACHE outrighto slavery (e.g., attempted use of chil- does not speak to gang-related persecution Immediate Past President drend as drug mules) in their countries of ori- (e.g., intimidation, coercion, violence); and Alexandra Garcia, PhD, RN, FAAN gin.g That issue is the central point of requests judges routinely denied on gang-related cas- Executive Board forfo asylum and refugee status. There are other es. This suggests that many (most?) such new Three Years publicp health issues involving the journey to claims will be rejected, submitting the new ar- Sandra H. Strickland, DrPH, RN theth U.S., and at times within the U.S.: a very rivals to deportation back to countries of ori- Rachel Wiseman, MPH dangerousd journey, fraught with threats of vio- gin – making the public health issues “their” Laura Wolfe, PhD lence,le rape, and extortionate demands, as well issues rather than “our” issues. Two Years Rita Espinoza, MPH asa natural hazards. Some of those hazards are Debbie Flaniken metm by some within the U.S., insofar as they There are, however, other legal avenues open One Year attempta undocumented immigrant routes, to many of the new arrivals. Perhaps the most- Charla Edwards, RN, BSN, MSHP mostlym through rough desert country, to avoid promising approach for a child would be to Robert L. Drummond immigrationim enforcement. However, many, if seek Special Immigrant Juvenile Status (SIJ), Terri S. Pali, Executive Director notn most, of the recent arrivals have not cho- based on abuse or neglect, including abandon- Governing Council sens means to avoid immigration enforcement, ment, by one or more parents, whether in the Three Years in fact have gladly turned themselves in with U.S. or elsewhere. Thus, for example, a child Martha Culver, RN, MSPH requestsre to have their legal status adjudicated. arriving without parents, or with a mother but Kaye Reynolds, MPH, MT (ASCP), EvenE so, such immigrants can face threats of not a father, can have a legal plea that one or Jennifer Smith, MSHP abusea and neglect, violence, rape, being vic- both parents abandoned (or even abused) the Two Years timsti of human traffi cking, and so on even after child, whether in the U.S. or the country of ori- Patricia Diana Brooks beingb temporarily settled in the U.S., whether gin. This would involve obtaining a Predicate Carol M. Davis, MSPH, CPH withw extended family or other arrangements. Order from a state judge, (often in a family Julie Herrmann Further,F aside from these major hazards, these court) that a parent has abused or neglected the One Year newn arrivals face public health issues faced by child and that the child’s best interests would Arianne Rhea U.S.U citizens and documented immigrants, es- not be served by a return to the country of Bobby D. Schmidt, MEd Christine Arcari, PhD peciallyp those who are poor: particularly those origin. Whatever the diffi culties in obtaining Section Chairs ofo access to adequate health care. So, what are such an order, they are likely less insurmount- Gloria McNeil, RN, BSN, MEd- theth legal opportunities and threats facing these able than winning an asylum case. Of course, Administration & Management newn arrivals, and how do these interact with obtaining such an order and a subsequent SJIV David Sanders, PhD-Aging and publicp health? leaves the public health issue alive of abuse Public Health and neglect of a minor, as well as other public Ambericent Cornett-Epidemiology It has been widely noted that a 2008 law man- health issues, but it would fi rmly root the is- Terry Ricks, RS-Environmental & datesd that such new arrivals be allowed to stay sues as American, in many cases Texan, public Consumer Health in the U.S. until their legal status can be ad- health challenges. Vacancy-Health Education judicated.ju Ideally, these new arrivals will be Vacancy-Public Health Nursing placedp with close-family or extended-family There are other avenues of legal recourse that Elizabeth Barney-Student Section membersm already resident in the U.S. Despite are possible but more remote. U-visas can be Parliamentarian somes political efforts to nullify such protec- obtained where an adult or child can be shown Bobby Jones, DVM, MPH, DACVPM tions,ti those protections are currently in place to be a victim of a qualifying crime in the U.S., Affi liate Representative to the untilu cases can be adjudicated, so the issue is where such violence is reported to law enforce- APHA Governing Council ono what legal bases such adjudication may ment, and where there is active cooperation Catherine Cooksley, DrPH proceed.p with prosecution of the perpetrator(s). Simi- John R. Herbold, DVM, MPH, PhD (Alternate) larly, Violence Against Women Act (VAWA) Journal Typesetting WhatW has been widely mentioned, and what cases can result in resident visas for victims Charissa Crump willw likely be the legal route taken by many, is (female or male) of domestic abuse in the U.S. requestre for asylum based on reasonable fear for at the hands of a U.S. resident or citizen family 2 TPHA Journal Volume 66, Issue 4 member. There is also a T-visa to protect those brought to the U.S. Special thanks to Meghan Abigail, immigration attorney, and board as victims of human traffi cking. Such laws were enacted with the member of Opening Doors International Services, Denton, TX. good public health aim of encouraging victims of such violence to report it, and to lessen the ability of perpetrators to threaten victims From the Editor: Our Fall, 2014 issue starts off with the Tex- with being deported if they did report. However, , these approaches as perspective on the border health topic of unaccompanied minor require that the offenses occur in the U.S. This is less likely if a new immigrants crossing U.S. borders. On other topics we include some arrival immediately surrenders to the Border Patrol upon arriving in “welcome to Fall” poison control information and several public the U.S.; but such violence, domestic or otherwise, may certainly health commentaries submitted by Texas public health profession- occur after the new arrival is temporarily settled in the country, pend- als on a variety of topics. Of course we feature our public health ing adjudication of immigration status. This suggests the need for research and practice papers that are peer-reviewed by experts. Our public health-related campaigns to detect and report cases of abuse, goal is to provide quality information our readers will fi nd informa- rape, human traffi cking, and other violence among new arrivals tem- tive and helpful as public health duties are carried out around the porarily resettled in the U.S. state. As public health practice around the state evolves and changes, the TPHJ is trying to keep up and has revised our journal information This leaves the regular public health threats faced by poor people in and author guidelines. Please visit the “Journal” page of our website the U.S. Contrary to the claims of some, new arrivals, particularly at www.texaspha.org . Our TPHJ editorial team and board want to children, are not major disease carriers (nor drug smugglers); but hear from all of you about the great work you do. We look forward to they do face many of the same health hurdles as do other lower- including your articles in future issues. Thanks for all you do! income residents of the U.S. And unsettled immigrant status raises barriers to healthcare access higher than those faced by people with settled resident status. Public health workers, as well as personal- health providers, need to respond to the health needs of these highly- vulnerable new arrivals.
Commissioner’s Comments The Public Health Impact of Unaccompanied Children David L. Lakey, M.D. Commissioner, Texas Department of State Health Services Earlier this year the southwestern border licly and held informational coordination calls with our public health of the United States saw dramatic in- partners across the state. creases in the numbers of unaccompanied children from Central American entering Regarding the impact on overall public health, we urged the federal the United States. Thousands of children government to involve the Centers for Disease Control and Preven- were apprehended by U.S. Customs and Border Protection, result- tion in health and medical plans for the detention centers. We also ing in an emergency situation along the Texas-Mexico border that called for full medical screenings for any children staying in deten- stretched federal resources. tion centers longer than 72 hours and for anyone released from fed- eral custody. In the midst of this high profi le and fl uid situation, we While this was largely a federal issue, local health departments dealt worked to convey accurate information to our stakeholders, lawmak- with the ripple effects of managing the infl ux of people and of re- ers, the general public and the news media about the potential pub- sources, offers of help, opinions and questions about the situation lic health impact. We explained that the children coming here were on the ground. understandably stressed and vulnerable to illness, and the potential for an outbreak – particularly in the detention centers – was real. At At the state health department, we mobilized an incident command that time, we were seeing issues in line with what we would expect structure this summer due to the volume of information and requests to see – illnesses that we are accustomed to seeing in Texas and are related to the situation. Higher numbers of children detained in more treatable. This included lice, scabies, gastrointestinal illness, respira- cramped quarters over longer periods of time demanded increased tory illness, skin conditions, allergies. There were also at least three attention to public health. Along with local health departments in the fl u cases and four tuberculosis cases reported among unaccompanied Rio Grande Valley and across the state, we closely monitored the children in Texas. situation to evaluate the impact on public health in Texas. Because the number of children crossing the border is now within One of our key actions was to visit border detention centers used Border Patrol’s capacity, we recently demobilized our formal re- to temporarily house children. We initially found major issues with sponse structure, but continue to monitor the situation. The number overcrowding. Notably, there was a lack of hand washing stations, a of children crossing the border has declined. Progress has been made lack of medical screening and a lack of adequate rest and recreation. in the detention centers. A new Border Patrol central processing fa- Our staff believed the children’s initial living conditions posed a high cility in McAllen has opened, and a visit we made to the new facility potential for infectious disease outbreak among the children and staff this summer showed improved attention to public health concerns. and were not acceptable by Texas and national public health stan- We continue to encourage the federal government to develop proce- dards. We made our concerns known, quickly providing the federal dures for family units that take public health into account. Clearly government with information about infectious disease, hygiene is- challenges remain, but progress has been made and I’m open to con- sues, and Texas communicable disease law. We recommended that tinuing the dialogue with local health departments about the public detention centers follow standards of mass care to the extent possible health impact of the situation. My thanks to our local partners for including adequate showers, water, toilets, trash receptacles, and ad- sharing information along the way and for working with us to ensure herence to hand washing protocols. We shared this information pub- health is a top consideration during a federal response. TPHA Journal Volume 66, Issue 4 3 Public Health Commentary: Children Refugees in South Texas Thomas Schlenker, MD, MPH1, Hector F. Gonzalez MD, MPH2 1San Antonio Metropolitan Health District 2City of Laredo Health Department
As early as March 2014, a few hundred Central American children, any of the other U.S. shelters. A handful of refugee children hospi- who had travelled, unaccompanied by adults, up thru Mexico and talized with severe pneumonia in California turned out to have the crossed the U.S. border, were being housed and cared for in nine, common pneumococcal variety that was easily treated with antibiot- closed-for-the-winter, summer camps in the Texas Hill Country. ics. Testimony at the 9th Annual Border Health Conference at the Baptist Child and Family Services (BCFS), a private, non-profi t U.S. Capitol in Washington, DC corroborated that the claim of ex- agency located in San Antonio, but with substantial national and otic, tropical diseases being brought into the U.S. was not factual.1 international experience in sheltering vulnerable populations, was Legal status of unaccompanied children refugees and the care they contracted by the U.S. Offi ce of Refugee Resettlement (ORR), to receive are determined by the “Traffi cking Victims Protection Reau- execute the operation, just as they had during a similar surge of refu- thorization Act” signed into law by President George W. Bush. The gees in 2012. BCFS considered the 2014 surge action an emergency goal of the act is to unite refugee children with family or other spon- response, best compared to responses for special needs populations sors in the U.S. while their cases are adjudicated. By mid July over during disasters like Hurricanes Katrina and Rita. 30,000 children had be so placed.2
Because the camps were soon to be recommissioned for summer- In Laredo and other points of entry, local authorities focused on im- time use and because the numbers of unaccompanied, border cross- migrants’ journey, initial detention and transport. Local public health ing children continued to rise dramatically, BCFS, at ORR request, provided initial screening and attention while coordinating with opened on May 18 a site for 1200 children at Lackland Air Force Base Customs and Border Protection Agents (CBP) and detention centers. in San Antonio. The physical site proved to be quite well suited: a They worked alongside CBP to assure there was no public health single large building, one of several modules used for basic training, threat and gave Homeland Security advice on precautions for the organized with boys and girls dormitories and bathrooms, a heavy migrants, UACs and for the protection of the agents. Several out- duty cafeteria, meeting and recreation rooms and a large expanse of breaks of chicken pox and scabies were contained, while vigilance green space holding air conditioned tents for classrooms and outdoor was maintained for potential outbreaks of respiratory diseases like sports fi elds, all entirely secure on a very large, urban U.S. military tuberculosis and infl uenza. Equally challenging were the thousands base. On June 13, BCFS opened a facility of similar capacity at Fort of migrants, mostly from Central America, who were released into Sill in Oklahoma. Refugee arrivals continued to surge until early local communities. Public health services from El Paso, Laredo, Hi- July (residency peaked at 2,323 on July 3rd) and then tapered off dalgo and Cameron Counties worked with other community agen- rapidly. Both Lackland and Sill shelters were closed by August 10. cies to address feeding, clothing, medical needs and surveillance for potential communicable diseases in the immigrant population as The San Antonio Metropolitan Health District, as an integral com- they waited to leave for other destinations in the U.S. where their ponent of the local emergency response network and long-time part- court hearings would take place. Many travelled to the west and east ner of BCFS, helped with initial sanitation and food safety logistics coasts, primarily Los Angeles and Maryland. The Texas/Mexico bor- for the Lackland shelter and supported BCFS health services with der public health system was initially overwhelmed and seriously immunizations, tuberculosis testing and infectious disease surveil- tested but persevered and continues to respond. lance. The bulk of the work however was performed 24/7 by BCFS excellent full time and contracted staff who provided on-site medical REFERENCES care and high quality, culture and language specifi c, social services, 1. Choate, T. July 24, 2014, “Epidemiologist says notion that immigrants education and recreation. are brining disease is a myth” http://www.timesrecordnews.com/news/local- news/epidemiologist 2. New York Times. July 15, 2014, “Where have children been placed af- For example, several hours of classroom instruction for all school ter leaving a shelter?” http://www.nytimes.com/interactive/2014/07/15/us/ age children taught by certifi ed bilingual teachers were offered daily. questions-about-the-border-kids.html Focus was on grade-specifi c English, math and civics in the expecta- tion that students would be enrolled in community schools through- out the United States when classes resumed in the Fall. Children, initially frightened and disoriented, felt, at the end of an average two to three week stay at Lackland, a sense of safety and well being that perhaps they had never experienced before. Recreation was also bi- cultural in that it included both soccer and American football played on used Astro turf donated by San Antonio’s Alamo Dome.
The medical care provided was thorough and excellent. BCFS bi- lingual nurses triaged those with true medical problems to on-site pediatricians but spent most of their time listening, talking and com- forting lonely and frightened children. Not surprisingly, most of the troubles uncovered were psychological, the result of trauma experi- enced in their violent homelands or on the road thru Mexico. The nurses believed strongly that the time spent was very therapeutic for the children, who, most of all, greatly missed their parents and hoped for reunion with families in the U.S. The exotic, tropical diseases, much hyped by the media, were nowhere in evidence at Lackland or
4 TPHA Journal Volume 66, Issue 4 The TPHJ Poison Control Column features the following two topics of interest coinciding with the beginning of the 2014-2015 school season. Comparison of Adverse Events Involving Infl uenza Vaccine Reported to Two Programs Mathias B. Forrester Texas Department of State Health Services, Austin, Texas Multiple programs may collect information on the same conditions number of patients in both the VAERS and TPCN programs were age of public health importance. Each program will have its advantages 20 years or more with the next highest number being patients age fi ve and disadvantages, depending on the type of information in which years or less. Most of the patients in both programs were female. In one is interested. the VAERS program, emergency department visits were reported in 1,408 (34.0%) of the cases. In the TPCN program, 43 (19.0%) of the Although infl uenza vaccines are produced with high levels of safety, patients were already at or en route to a healthcare facility when the adverse events (health problems or possible side effects) may occur poison center was contacted or referred to a healthcare facility by the in a portion of the individuals exposed to the vaccines. Monitoring poison center. such adverse events is important for evaluating vaccine safety. The Vaccine Adverse Event Reporting System (VAERS) is a surveillance Table 4 lists the most frequently reported symptoms or adverse clini- program sponsored by the Centers for Disease Control and Preven- cal effects in the VAERS and TPCN programs. Most of the symptoms tion (CDC) and Food and Drug Administration (FDA). VAERS col- were dermal in nature. The percentages for symptoms in TPCN were lects information on suspected adverse events that occur after the lower than roughly similar symptoms in the VAERS program. This use of vaccines licensed in the US. VAERS is a passive program; could be because some of the exposures reported to TPCN do not reports are voluntarily submitted by the individuals who receive the result in any symptoms. In these instances, the caller was most likely vaccines, their family or friends, healthcare providers, public health concerned about the exposure even in the absence of symptoms. For organizations, and others. The law requires that all personal identi- example, a patient might have been given a double-dose of the in- fi ers are kept confi dential.1 Publically available data on all vaccine fl uenza vaccine and the caller worried what the consequences might exposures reported to VAERS is available on the program’s website be. Among the TPCN cases, 85.4% were classifi ed as not serious; no (https://vaers.hhs.gov/index). effects at all were observed or expected in 19.5% of the cases. US poison centers are telephone consultation services that assist in This study illustrates that poison centers serve as an additional in- the management of potentially adverse exposures to a wide variety of formation source for adverse events involving infl uenza vaccines. substances, including vaccines. Each poison center uses an electronic Poison centers offer a much smaller dataset than VAERS. However, database to collect information on patient demographics and the cir- poison centers might be useful for validating patterns of exposures cumstances, management, and outcome on all exposure calls they reported to VAERS. Also, poison centers collect a wide variety of receive. The data fi elds and allowable fi eld options are standardized information on exposures, some of which might not be available in by the American Association of Poison Control Centers (AAPCC).2,3 the VAERS database. Since both programs collect information on Reporting exposures to poison centers usually is voluntary; as a infl uenza vaccine exposures, poison centers might want to submit result, their databases also may be considered passive surveillance the exposures they manage to VAERS. In fact, a portion of adverse programs. events involving infl uenza vaccines may already be reported to both VAERS and poison centers.5 Additionally, poison center data on in- A previous study of all human vaccine exposures reported to VAERS fl uenza exposures may used by organizations in certain situations. from Texas and to the Texas Poison Center Network (TPCN) during For example, when the H1N1 infl uenza vaccine began to be distrib- 2000-2013 found that the most commonly reported type of vaccine uted to the public, the Texas Department of State Health Services was the infl uenza vaccine, reported in over 25% of the exposures in (DSHS) wanted to monitor adverse events involving the vaccine. 4 both the VAERS (n=4,138) and TPCN (n=226) databases. Table 1 As part of that effort, the DSHS and TPCN created a system where shows the annual number of infl uenza vaccine cases. In both pro- the former would be notifi ed of all H1N1 infl uenza vaccine adverse grams, the annual number of infl uenza vaccine exposures tended events reported to the latter.6 The system was considered useful. Sub- to increase during the time period. Moreover, the number of TPCN sequently, the system was expanded to include the reporting of all cases experienced a sudden surge in the number of cases in 2009 (an human vaccine exposures received by TPCN to DSHS. increase of 253% over the number reported the previous year). The number of VAERS cases likewise surged in 2009-2010 (an increase REFERENCES of 151%). This 2009 surge could be related to the occurrence of the 1. Zhou W, Pool V, Iskander JK, English Bullard R, Ball R, Wise RP, Haber infl uenza A H1N1 pandemic that year. A vaccine for that infl uenza P, Pless RP, Mootrey G, Ellenberg SS, Braun MM, Chen RT. 2003. Surveil- strain was quickly developed and made available to the public. As a lance for safety after immunization: Vaccine Adverse Event Reporting Sys- tem (VAERS) United States, 1991 2001. MMWR Surveill Summ 52:1 24. result of heightened concerns over the new vaccine, the public and 2. Mowry JB, Spyker DA, Cantilena LR, Bailey JE, Ford M. 2012 Annual Re- healthcare providers might have been more likely to report potential- port of the American Association of Poison Control Centers' National Poison ly adverse H1N1 infl uenza vaccine exposures to VAERS and TPCN. Data System (NPDS): 30th Annual Report. Clin Toxicol (Phila) 2013;51:949 1229. When the distribution of cases by month was examined (Table 2), 3. American Association of Poison Control Centers National Poison Data season trends were observed for both programs. The greatest pro- System (NPDS)(C) Reference Manual Part 2 System Information Manual. portion of cases were reported during September-December, with American Association of Poison Control Centers; Alexandria, Virginia; 2007. October showing the highest rate. The US infl uenza season can start 4. Forrester MB, Villarreal CL. Comparison of vaccine exposures reported to as early as October and end as late as May. In anticipation of this, two programs. Clin Toxicol (Phila) 2014;52:744. the infl uenza vaccine may begin to be administered a month or more 5. Forrester MB. Feasibility of matching Vaccine Adverse Event Reporting prior to the expected start of the infl uenza season. System and poison center records. J Registry Manage 2013;40:93 97. 6. Forrester MB, Aragon T, Samples Ruiz M, Borys DJ. Poison center report- When the patient demographics were examined (Table 3), the highest ing of H1N1 vaccine exposures to a state department of health. Clin Toxicol (Phila) 2010;48:640. TPHA Journal Volume 66, Issue 4 5 Table 1. Annual number of influenza vaccine exposures reported to the Vaccine Adverse Event Reporting System (VAERS) and Texas Poison Center Network (TPCN) from Texas during 2000-2013
Year VAERS TPCN
2000 77 4 2001 95 10 2002 81 9 2003 122 11 2004 99 8 2005 152 14 2006 180 11 2007 245 15 2008 277 15 2009 696 53 2010 733 21 2011 471 18 2012 423 21 2013 487 16 Total 4,138 226
Table 2. Monthly number of influenza vaccine exposures reported to the Vaccine Adverse Event Reporting System (VAERS) and Texas Poison Center Network (TPCN) from Texas during 2000-2013
Month VAERS TPCN Number % Number % January 327 7.9 16 7.1 February 205 5.0 7 3.1 March 115 2.8 1 0.4 April 75 1.8 4 1.8 May 66 1.6 1 0.4 June 70 1.7 1 0.4 July 51 1.2 1 0.4 August 153 3.7 2 0.9 September 410 9.9 28 12.4 October 1,153 27.9 82 36.3 November 930 22.5 54 23.9 December 583 14.1 29 12.8 Total 4,138 226
Table 3. Influenza vaccine exposures reported to the Vaccine Adverse Event Reporting System (VAERS) and Texas Poison Center Network (TPCN) from Texas during 2000-2013 by patient demographics
Patient demographic VAERS TPCN Number % Number % Patient age (years) 0-5 557 13.5 47 20.8 6-12 380 9.2 21 9.3 13-19 231 5.6 14 6.2 20+ 2,841 68.7 134 59.3 Unknown 129 3.1 10 4.4
Patient gender Male 1,305 31.5 91 40.3 Female 2,748 66.4 124 54.9 Unknown 85 2.1 11 4.9 Total 4,138 226
Table 4. Influenza vaccine exposures reported to the Vaccine Adverse Event Reporting System (VAERS) and Texas Poison Center Network (TPCN) from Texas during 2000-2013 by most common symptoms (adverse clinical effects)
VAERS TPCN Symptom Number % Symptom Number % Pyrexia 677 16.4 Dermal edema 20 8.8 Pain 557 13.5 Dermal erythema/flushed 19 8.4 Injection site erythema 489 11.8 Dermal irritation/pain 19 8.4 Injection site pain 412 10.0 Dermal rash 16 7.1 Erythema 398 9.6 Fever/hyperthermia 15 6.6 Headache 357 8.6 Neurological headache 15 6.6 Dizziness 348 8.4 Dermal hives/welts 9 4.0 Injection site swelling 334 8.1 Dermal puncture/wound/sting 9 4.0 Pain in extremity 315 7.6 Gastrointestinal nausea 9 4.0 Pruritus 303 7.3 Dermal pruritus 8 3.5
Total 4,138 Total 226
An exposure might involve more than one symptom.
6 TPHA Journal Volume 66, Issue 4 Anabolic-Androgenic Steroid Abuse in Texas Mathias B. Forrester Texas Department of State Health Services, Austin, Texas
Anabolic-androgenic steroids, commonly known as anabolic ste- one route.) Seventy-three percent of the exposures occurred at the roids, are a family of hormones that include the natural male hor- patient’s own residence, 17.6% public area, 1.4% another residence, mone testosterone in addition to others that are synthetic such as 1.4% school, and 6.8% unknown. stanozolol, danazol, fl uoxymesterone, methyltestosterone, oxandro- lone, and oxymethalone. These hormones have anabolic (“muscle The site of management of these exposures indicated that 47.3% building”) and androgenic (“masculinizing”) effects, resulting in were managed on site (not healthcare facility), 35.1% already at or increased muscle strength and athletic performance, at times beyond en route to a healthcare facility when the poison center was contact- what could be attained naturally. In recent years there has been con- ed, 13.5% referred to a healthcare facility by the poison center, and siderable media attention regarding abuse of anabolic steroids and 4.1% unspecifi ed other or unknown site. The distribution by medical other performance enhancing drugs (PEDs) among elite professional outcome was 25.7% no effect, 12.2% minor effect, 4.1% moderate athletes.1 However, the majority of anabolic steroid abusers are not effect, 1.4% not followed-judged as nontoxic, 17.6% not followed- competitive athletes but individuals whose goal is to be more mus- minimal effects possible, 28.4% unable to follow-potentially toxic, cular.1,2 Such individuals often take more than one anabolic steroid and 10.8% unrelated effect. Thus, 36.4% of the exposures were at a time (an activity known as “stacking”), and the dose they take known or suspected to be serious. frequently is many times the natural amount of testosterone produced normally by males.1 The most commonly reported adverse clinical effects were tachycar- dia (14.9%), chest pain (9.5%), agitation (8.1%), vomiting (5.4%), In addition, in recent years, testosterone has increasingly been pro- abdominal pain (4.1%), nausea (4.1%), and dizziness (4.1%). The moted for the treatment of “Low T” or low testosterone in men. After clinical effects reported in two (2.7%) cases each were hypertension, men reach 30 years in age, their testosterone levels decline approxi- erythema, fever, unspecifi ed pain, ataxia, and headache. The clinical mately 1% each year. As a result, older men may experience a de- effects reported in one (1.4%) case each were edema, dermal irrita- crease in muscle mass and strength as well as depression, lethargy, tion, low aspartate aminotransferase - alanine aminotransferase ratio, reduced sex drive, and sexual dysfunction. U.S. sales of testosterone bleeding, electrolyte abnormality, drowsiness, and muscle rigidity. have more than doubled since 2008 to $1.6 billion in 2012, and are projected to reach $5 billion by 2017.3 Thus, men may abuse tes- In conclusion, relatively few instances of anabolic steroid abuse were tosterone, and possibly other anabolic steroids, to reverse perceived reported to Texas poison centers each year. Although testosterone symptoms of Low T. sales are increasing, there was no corresponding increase in anabolic steroid abuse. The majority of patients were male and half were 26 Long-term use of anabolic steroids may result in a wide variety of years or younger. The most common routes of exposure were injec- adverse outcomes such as cardiovascular effects (hypertension, car- tion and ingestion. Although the preponderance of exposures oc- diomyopathy, atherosclerosis, coagulation abnormalities, arrhyth- curred at the patient’s own residence, the next most common locale mia), suppression of testicular function, gynecomastia, genitourinary was a public area. The majority of exposures did not result in serious effects (impotence, priapism, azoospermia, prostate enlargement and outcomes, and the reported clinical effects were generally consis- cancer), hepatic dysfunction, neurological problems (psychosis, ag- tent with the literature. This pattern of exposures was similar to that gression, violent behavior, depression), dermal effects (acne, edema, found in a previous study that examined anabolic steroid abuse expo- pruritis, hirsutism), nausea, and vomiting.1,4,5 Adverse effects report- sures involving moderate and major outcomes reported to all poison ed with acute overdose of anabolic steroids include leukopenia or centers nationwide during 2003-2012.4 neutropenia, hirsutism, gynecomastia, jaundice, hypertension, and depression.5 REFERENCES 1. Kanayama G, Hudson JI, Pope HG. 2008. Long-term psychiatric and medi- During 2000-2013, 74 instances of intentional abuse or misuse of cal consequences of anabolic-androgenic steroid abuse: a looming public anabolic steroids were reported to Texas poison centers. The number health concern? Drug Alcohol Depend 98:1-12. 2. Pope HG, Wood R, Rogol A, Nyberg F, Bowers L, Bhasin S. 2014. Ad- of agents used per case varied with one anabolic steroid reported in verse health consequences of performance-enhancing drugs: An Endocrine 69 cases, two anabolic steroids in four cases, and three anabolic ste- Society Scientifi c Statement. Endocr Rev er20131058. roids in one case. The specifi c substances among these 80 anabolic 3. Briggs B. October 24, 2013. Men seek testosterone quick fi x, with risks. steroids were testosterone (40.5%), nandrolone (9.5%), stanozolol NBC News. Available at http://www.nbcnews.com/health/mens health/men (6.8%), fl uoxymesterone (4.1%), oxymethalone (4.1%), methandro- seek testosterone quick fi x risks f3236114. Accessed March 5, 2014. stenolone (2.7%), methyltestosterone (2.7%), trenbolone (2.7%), an- 4. Scholzen S, Borys D, McGraw J. 2013. Abuse and misuse of anabolic ste- drostenedione (1.4%), boldenone (1.4%), mesterolone (1.4%), meth- roids. Clin Toxicol (Phila) 51:682. andriol (1.4%), methenolone (1.4%), oxandrolone (1.4%), zeranol 5. Leikin JB, Paloucek, editors. 1998. Poisoning & Toxicology Compendium with Symptoms Index. Lexi-Comp Inc; Cleveland, Ohio: 552-553. (1.4%), and unknown anabolic steroid (25.7%). There was no clear annual or seasonal trend in the exposures. The age distribution of cases showed 18.9% who were younger than 20 years and 81.1% older than 20 years. Of the 61 cases where the patient age in exact years was known, the mean age was 26 years (range 14-53 years). The gender distribution was 95.9% male and 4.1% female.
The reported route of the exposure was 54.1% injection, 50.0% in- gestion, 5.4% inhalation, 4.1% dermal, and 5.4% unspecifi ed other or unknown. (A given exposure might have occurred by more than
TPHA Journal Volume 66, Issue 4 7 Public Health Practice Commentaries Submitted by Texas Public Health Professionals Rising Anti-Vaccination Attitudes in the United States: A Plea for Paternalism Corinne McLeod University of Texas Health Science Center at San Antonio Please send comments to: [email protected] I. Introduction seeming discrepancy. When researchers in Michigan compared local In February of 1998, Dr. Andrew Wakefi eld published his infamous geographic clusters of nonmedical vaccination exemptions with re- article in The Lancet linking autism with the MMR vaccine, causing ported cases of pertussis, a signifi cant overlap was observed6. A simi- a public outcry against all childhood vaccinations. Despite the fact lar study in California found similar geographic clusters in 39 areas.7 that Wakefi eld’s study was considerably fl awed with a subject pool Geographic clusters of non-medical vaccine exemptions can have of just 12 children in Britain, only eight of which were diagnosed extremely high rates of exemption, reaching up to 24% in Orchard with autism1, a subsequent drop in vaccination rates among chil- Prairie and 17% Vashon Island in Washington, even if state-wide lev- dren in the United States and Britain ensued. Years later, evidence els of vaccinations are within recommended standards8. Given that emerged that Wakefi eld had falsifi ed his data linking the vaccine with most childhood diseases need rates of 85% or higher for herd immu- developmental disorders and subsequently lost his license to practice nity to be effective9, this can present serious problems for infants or medicine in England.2 Nonetheless, the damage was done: many be- others who cannot be vaccinated for medical reasons. gan to avoid vaccinating their children for fear of causing autism. In addition, these geographic clusters can affect more than just a Sixteen years later, we are still seeing the aftermath of this paper in single community. Large scale outbreaks in vaccine-preventable ill- the surge in cases of preventable and potentially deadly diseases, like ness can also often be traced back to an epicenter such as these non- measles and pertussis. In 2013, there were 159 cases of measles in vaccinating communities, as seen in 2013 with a Texas megachurch the United States, almost three times the typical yearly number of being linked with 20 cases of measles3. With illnesses that are so measles cases in the US, and only 26% of these cases were imported infectious and with such harmful potential, it doesn’t take much for from other countries.3 This same year, epidemic levels of pertussis vaccine-preventable illness to spread outside these communities and infection were seen in Texas.4 The myth that vaccines are unsafe pre- affect others. vails and continues to harm the health of citizens across the US and Britain alike. This is particularly evident with regards to the health III. Why the Anti-Vaccine Movement is Harmful of children, who are, unsurprisingly, most affected by diseases that Unfortunately, the anti-vaccination movement is nothing new in the are targeted by childhood vaccinations. These diseases, including United States and actually has a history going back more than a cen- polio, measles, mumps, rubella, and pertussis, were common causes tury. In 1905, the Supreme Court ruled on Jacobsen v. Massachusetts, of childhood disfi gurement, disability, and death before the age of a landmark case in public health that upheld the authority of states to vaccinations. In the decline of vaccination use, these diseases could enforce mandatory vaccination laws despite objections from individ- 10 once again become threats to human health and welfare in the United uals by imposing penalties for vaccine refusal. This was later up- States. For this reason, all physicians should be concerned about this held by the 1922 Zucht v. King ruling, which involved the exclusion rise in anti-vaccination sentiment as it has the potential to harm the of a child in Texas from public schooling because of her refusal of most vulnerable of our patients: children. mandatory vaccinations. Zucht v. King affi rmed the Jacobsen v. Mas- sachusetts ruling that states have the right to enforce vaccinations Anti-vaccine advocates tend to frame the issue as one of personal such as is “required for the protection of the public health,” namely choice and argue that people have the right to make the decisions other children that might be in school with unvaccinated children11 they think best for their family based on their personal values. This In response, the Anti-Vaccination League of America (AVLA) was argument may hold water when talking about the personal choices founded “to promote universal acceptance of the principle that health of mature adults, but what about the case when the decision is being is nature’s greatest safeguard against disease and that therefore no made by a parent as a proxy for a child? Does a parent have the right State has the right to demand of anyone the impairment of his or her to expose their child to potentially fatal diseases when it’s possible to health.”12 Similar to the modern vaccine refusal advocates, the AVLA prevent them? This paper explores the legal and ethical ramifi cations preyed upon the fears of Americans by publishing titles like, “Hor- of the anti-vaccination movement and argues that parents do not rors of Vaccination Exposed and Illustrated”13 and “Vaccination: A have the right to refuse vaccinations for their children against life- Curse and a Menace to Civil Liberty,” asserting unscientifi c claims threatening and highly transmissible diseases, assuming that these that vaccinations were unsafe and unhealthy, as well a threat to the vaccinations are not contraindicated. Furthermore, physicians have a personal freedoms of the American people. Eventually the AVLA and moral duty to ensure that these children get the preventative care that other similarly-minded organizations died out in the United States, they need and have the ability to be some of the strongest advocates most likely due to the overwhelming benefi ts of vaccines that were for children’s health in clinical and legal arenas. This means not only seen in the early and mid-20th century: massive reductions in rates making recommendations during clinic hours and in the media but of deadly childhood diseases, such as smallpox, diphtheria, polio, actively working with the legal processes to ensure that our country’s measles, mumps, rubella, and pertussis. children are protected. Unfortunately, vaccine effectiveness has become its own worst en- II. Why the Outbreaks are Happening emy. As a result, we now have what could be termed a modern-day Although there have been unusual outbreaks of childhood diseases AVLA in the form of anti-vaccine advocates like Jenny McCarthy over the past several years, rates of childhood vaccination have re- and Jim Carrey, who claim that childhood vaccinations cause autism, mained more or less the same on average in the United States.5 Even asthma, and other idiopathic disorders. These claims, of course, are looking at the level of individual states doesn’t yield many answers. contradicted by a mountain of scientifi c research showing that vac- As such, it seems diffi cult to pin the blame for recent outbreaks on cines are safe and effective, as well as numerous statements by or- the anti-vaccine movement. However, upon closer examination of ganizations like the CDC, the WHO, and the American Academy of populations at a local level, it becomes clearer as to the cause of this Pediatricians endorsing childhood vaccination.14-16 Anti-vaccination 8 TPHA Journal Volume 66, Issue 4 advocates will claim any number of horrifying side effects of vac- well as other legal pathways to ensure vaccination despite possible cinations such as autism, often citing the National Vaccine Injury parental objections. Compensation Program as evidence that there are many people who are seriously injured by vaccinations every year. However, there have V. Rebuttal to Objections: Why Vaccination is About More Than only been 3,645 substantiated claims in the 25 years of the program’s Autonomy existence – about 146 people a year, most of which are anaphylaxis Many will object that comparing blood transfusions and vaccinations or encephalitis upon administration of the vaccine, not long-term de- is unfair. Unlike vaccinations, transfusions are emergency life-saving velopmental disorders.17 Given that almost 2 billion vaccines were procedures. Furthermore, transfusions are less risky than vaccina- administered between 2006 and 2012, this comes out to be about a tions. 0.00005% chance of having a life-threatening reaction. But just as with refusal of blood transfusions, even non-emergent Despite some rare and experimentally proven side effects, there is no ones, refusal of vaccination carries the risk of disability and death. real scientifi c controversy about the benefi ts of childhood vaccina- Measles remains one of the leading causes of childhood mortality tions and, truthfully, there wasn’t any such controversy at the begin- in the world.23 1 in every 200 cases of polio results in irreversible ning of the 20th century either. Studies have shown time and time paralysis, particularly in cases of children under 5 years of age.24 1 or again that children benefi t tremendously from vaccinations against 2 out of every 200 cases of pertussis in infants leads to death.25 These diseases like measles, mumps, and rubella and that the rise in dis- are not inconsequential risks just as the risks of blood transfusion eases like autism is likely to be a diagnostic artifact.18 In short, the refusal are not inconsequential, especially given the high numbers anti-vaccination movement hasn’t changed their arguments or their of foreign immigrants to the US and citizens who travel outside of data in over a century but science has moved on without it. it. As for adverse reactions, while it is true that rarely there can be severe reactions to vaccinations, this is also true for blood transfu- IV. Why Vaccination Advocacy is Ethical and Legal sions, which carry the risk of allergic reaction, graft vs. host disease, Although many primary care providers are actively counseling pa- autoimmune hemolytic reaction, blood-borne infection, and others. tients, some going as far as “fi ring” patients for non-compliance with Objection to vaccination simply because it poses some risk is not a vaccinations, others are vocally outspoken against vaccinations and valid argument, for as a country, we have previously mandated risky have even gone so far as to create clinics specifi cally for those who procedures in children if the scientifi c consensus demonstrates that don’t wish to vaccinate their children. Previously, these vaccine-de- such benefi ts outweigh the risks. Scientifi c evidence has suggested nying doctors were the most outspoken but there has recently been exactly this. As such, medical professionals need to be advocating a surge of pro-vaccine articles in the mainstream media. However, for these children legally to protect their health and safety, even if analysis of legal requirements of vaccines has shown that this isn’t it is contrary to the religious or philosophical beliefs of the parents. enough: when a state makes it easy for parents to fi le for personal belief exemptions, the number of vaccinated children in that state Even if we accept a parent’s right to make life-threatening medical goes down and the amount of vaccine-preventable illness goes up.19, decisions for their child, we still cannot countenance that same par- 20 Given the overwhelming scientifi c evidence in favor of vaccines, ent’s ability to make medical decisions about other children. Suppose why aren’t doctors taking more of a stand against the anti-vaccina- that the unvaccinated child becomes ill but not life-threateningly so tion movement in the legal arena, particularly in the case of children? and attends school while still infectious. Not only do they pose a The usual reasons cited are patient autonomy, one of the cornerstones threat to immunocompromised children or other children who are of modern medical ethics, and the desire to avoid paternalism. We unable to receive vaccinations, they are also a threat to those who are certainly have a healthy respect for patients’ decisions in medicine, vaccinated by providing medium in which the pathogen can repli- even if we happen to disagree with them, as in the cases of Jehovah’s cate. Due to their high replication rate within an actively contagious Witnesses, who are allowed to refuse blood and blood products even person, the pathogen is subject to antigenic drift, i.e. a mutation in in life-threatening conditions. But even the respect for autonomy has the pathogen due to replication error, and this can potentially lead its limits. Doctors regularly challenge medical decisions made by to a new strain of the illness that is not responsive to the vaccine. Jehovah’s Witnesses on behalf of their minor children, particularly Viruses in particular are much more susceptible to antigenic drift, as when parents want to deny their children life-saving treatment. Usu- can be seen with the emerging strains of infl uenza and HIV, which ally paternalism is frowned upon as a practice in medicine, as it pre- is concerning given that the majority of diseases inoculated against vents patients from making decisions about their own care based on in childhood are viral. In short, by allowing unvaccinated children to their personal value system. However, in cases involving the health become reservoirs for these illnesses, we are putting all the children and welfare of children, we agree that paternalism is sometimes justi- they come in contact with at risk of being exposed to a new form of fi ed. the pathogen. In fact, there is a long history of medical and legal precedent for inter- VI. Conclusion vention in parental medical practices, dating back to 1944, when the Many healthcare professionals will argue that it isn’t worth pursuing Supreme Court ruling on Prince v. Massachusetts stated that “parents a small number of cases involving parental refusal of vaccinations; may be free to become martyrs themselves. But it does not follow that we’ll only create bad feeling between providers and patients; and they are free, in identical circumstances, to make martyrs of their that herd immunity will protect these children as well as pregnant children before they have reached the age of full and legal discretion women, the immunocompromised, and others that are at risk from when they can make that choice for themselves.”21 In the aftermath these diseases. Yet with the rising trend in anti-vaccination propa- of Prince v. Massachusetts, numerous court cases have echoed this ganda, as well as the rapidly increasing cases of preventable illness sentiment, concluding that “the child’s interests and those of the state like measles and pertussis, it is clear that it’s more than just a few outweigh parental rights to refuse medical treatment, parental rights isolated cases of parents who are refusing to vaccinate. Not only are do not give parents life and death authority over their children, [and] these parents putting their own children at risk but they are also put- parents do not have an absolute right to refuse medical treatment ting the children of others at risk as well. As such, it is clear that as for their children based on their religious beliefs.”22 Knowing this, it physicians, we have a moral duty to advocate for these children to the is certainly legal and ethical for physicians to advocate for schools’ best of our abilities both in clinic and in courts. In a developed na- enforcement of exclusionary policies for non-vaccinated children as tion in the twenty-fi rst century, no one, children especially, should be TPHA Journal Volume 66, Issue 4 9 dying of vaccine-preventable illness. Physicians are remaining too Salmon, Daniel A., Halsey, Neal A., Omer, Saad B. "Nonmedical Vaccine quiet on this issue; medical societies’ endorsement of vaccination Exemptions and Pertussis in California." 2010. Pediatrics. 2013-0878; pub- is not enough. As a profession, we need to be proactive about this lished ahead of printSeptember 30, 2013. practice by introducing bills that make it more diffi cult to get non- 8. "Autism-vaccine fear confounds scientifi c community." KIRO 7 Staff. KIRO 7. 19 Oct. 2013.
Age Well Live Well Texas Holly Riley1, James H. Swan, PhD2 1Age Well Live Well Program Manager, Texas Department of Aging and Disability Services and 2President, Texas Public Health Association, Professor of Applied Gerontology, University of North Texas Please send comments to: to [email protected] Americans are living longer than ever before. A study by the Na- awareness of aging issues and available resources, and by staying so- tional Institute on Aging1 found that people are living longer, in less cially engaged and connected with others.5 Even low-levels and fre- poverty and often experience lower rates of disability than previous- quencies of behaviors such as physical activity can greatly improve ly recorded. Life expectancy nearly doubled during the 20th century health,6-9 including greater longevity.10 This is especially critical with with a 10-fold increase in the number of Americans age 65 or older. the large numbers of Baby Boomers aging into senior-citizen status.11 Today, there are approximately 35 million Americans age 65 or older, and this number is expected to double in the next 25 years.2 To help Texans prepare in these key areas, the Texas Department of Aging and Disability Services (DADS) developed the Age Well Live The aging of Texas’ population is one of the most important demo- Well program. Through regional Age Well Live Well collaboratives, graphic trends affecting our state. Over the next twenty years, the 65 DADS and local organizations work together to provide Texans with and older population is projected to grow 184 percent. The “boom” information and programs to help meet the challenges of aging. of the older adult population, coupled with long life expectancy, means that Texans of all ages need to engage in regular healthy habits Age Well Live Well focuses on: now, to ensure their future is healthy1. This is certainly an issue for •Improving the physical health of older adults, people with disabili- public health, involving community health issues as well as healthy- ties, their families, and the community; lifestyle issues. •Providing opportunities for residents to stay engaged in the com- munity through volunteer activities; and A person’s ability to “age well” is heavily infl uenced by his/her en- gagement in healthy habits, particularly clusters of healthy habits,3-4 10 TPHA Journal Volume 66, Issue 4 •Creating awareness of aging issues and resources offered through •Abilene: Alesha Willis email [email protected] Age Well Live Well collaboratives and the aging and disability net- •Austin: Holly Riley email [email protected] work. •Dallas: James Shackelford email [email protected] •Denton: Marty Mascari email [email protected] Age Well Live Well collaboratives provide their residents with infor- •Houston: Beverly Brownlow email Beverly.Brownlow@hous- mation about the programs and resources to help them live and age tontx.gov well. These collaboratives also work to develop locally supported •Fort Bend: Nicole Volek email [email protected] Age Well Live Well programs that are free or low cost for the partici- •Fort Worth: Alexandra Cisneros email Alexandra.cisneros@unit- pants. Some of these programs and resources include: edwaytarrant.org •Texercise, a health promotions program of DADS, that educates •San Antonio: Kimberly Meyers email fi tnesskinektions@gmail. people about the importance of adopting healthy habits and moti- com vates them to engage in healthy behaviors. www.Texercise.com •Volunteer You’ll be Amazed, a volunteer campaign of DADS, For more information about Age Well Live Well, go to: www. that educates Texans about the value volunteers provide for the AgeWellLiveWell.org. aging and disability population and access to volunteer opportuni- ties. www.dads.state.tx.us/volunteer/volunteering/index.html REFERENCES 1. Wan He, Manisha Sengupta, Victoria A. Velkoff, and Kimberly A. DeBar- •DADS Resource Sheet provides contact information on some of ros. 2005. 65+ in the United States: 2005. U.S. Department of Health and the most popular federal and state programs for older adults and Human Services, National Institutes of Health, National Institute on Aging people with disabilities. www.dads.state.tx.us/volunteer/partners/ and the U.S. Department of Commerce, Economics and Statistics Administra- resourcesheet.pdf tion, U.S. Census Bureau. 2. Ortman, Jennifer M., Victoria A. Velkoff, Howard Hogan. 2014. An Aging Regardless of age, Age Well Live Well encourages implementing el- Nation: The Older Population in the United States. Current Population Re- ements into lifestyles to ensure long, happy, healthy lives. First, it ports: Population Estimates and Projections, P25-1140, U.S. Census Bureau, encourages healthy eating and engaging in regular physical activity Washington, DC. May. – as through Texercise. It suggests Volunteering with something that 3. Cohen-Mansfi eld, Jiska, Yogev Kivity. 2011. The relationships among has meaning to oneself. And it helps learning about the programs health behaviors in older persons. Journal of Aging and Health 23(5): 822- and services available to adults, young and old. But AWLW also ad- 42. 4. Pruchno, Rachel, Maureen Wilson-Genderson. 2012. Adherence to clus- dresses community health issues, particularly by creating community ters of health behaviors and successful aging. Journal of Aging and Health partnerships and encouraging the creation of programmatic initia- 24(8): 1279-97. tives in local communities. 5. Seeman, Teresa E. 1996. Social ties and health: the benefi ts of social integration. Annals of Epidemiology 6(5): 442-51. Age Well Live Well Denton has been active for over three years.. It’s 6. Centers for Disease Control and Prevention. N.d. How much physical aims are to: encourage healthy lifestyle activities, build awareness activity do older adults need? Physical Activity for Everyone: Older Adults: of available resources, and create change through volunteerism and http://www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html. community engagement activities. AWLWD has sponsored or par- 7. Depp, C.A., D.V. Jeste. 2006. Defi nitions and predictors of successful ticipated in a variety of activities: aging:a comprehensive review of larger quantitative studies. American Jour- 1. The Denton Mayor’s Challenge to 100 businesses to work with nal of Geriatric Psychiatry 14: 6-20. AWLWD and sponsor healthy living activity programs for 8. U.S. Department of Health and Human Services (USDHHS). 2008. 2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Govern- their employees. ment Printing Offi ce. 2. The Denton Mayor’s Mile, in fall 2013, with the second to 9. Vogel, T., P.H. Brechat, P.M. Leprêtre, G. Kaltenbach, M. Berthel, J. Lon- come in fall 2014 –sponsored and organized by AWLWD, in sdorfer. 2009. Health benefi ts of physical activity in older patients: a review. conjunction with the Mayor. International Journal of Clinical Practice 63(2):303-320. 3. Undertook community forums seeking input from citizens on 10. Wen, Chi Pang, Jackson Pui Man Wai, Min Kuang Tsai, Yi Chen Yang, meeting healthy-living challenges. Ting Yuan David Cheng, Meng-Chih Lee, Hui Ting Chan, Chwen Keng Tsao, 4. Developed partnership with a variety of organizations, includ- Shan Pou Tsai, Xifeng Wu. 2011. Minimum amount of physical activity for ing two university systems (University of North Texas and reduced mortality and extended life expectancy: a prospective cohort study. The Lancet 378(9798): 1244-1253. Texas Woman’s University), the North Central Texas Area 11. Swan, J.H., R. Friis, K. Turner. 2008. Getting tougher for the fourth Agency on Aging, local Parks and Recreation, Serve Denton quarter: boomers and physical activity. Journal of Aging & Physical Activity (a faith-based organization), and others. 16(3): 261-79. 5. Developed partnership with other organizations focused on healthy living – e.g., cosponsoring Senior Fitness Tests with local senior-fi tness organization and award-winning senior gym, Seniors in Motion. 6. Sponsored Christmas Cards for Seniors, which in 2013 sent out 3500 volunteer-made Christmas cards to meals-on-wheels recipients in Denton County, with plans in place for the 2014 initiative. 7. Seeks to partner with the Denton County Health Department, and has begun to do so particularly through the DCHD’s Healthy Communities Coalition.
Statewide, Age Well Live Well collaboratives have been developed in Abilene, Austin, Dallas, Houston, Fort Bend, Fort Worth and San Antonio, in addition to Denton; and collaboratives in additional Tex- as localities are under development. To learn more about programs and activities in those areas contact: TPHA Journal Volume 66, Issue 4 11 Not Their First Rodeo: Texas Researchers Battle Ebola Virus Carol A. Galeener, PhD University of Texas Health Science Center School of Public Health in Houston, Texas Please send comments to: [email protected] We thought we had them all on the run. Peter Piot, the Belgian in- fectious disease expert who is credited as a co-discoverer of the We cannot expect that diseases such as these will remain within their Ebola virus, recounts in his 2004 autobiography, No Time to Lose: countries of origin. Migration among the nations of West Africa is A Life in Pursuit of Deadly Viruses1, being counseled in the early believed to have contributed to the spread of the current outbreak. 1970‘s against going into the fi eld of infectious disease – there were Even in the United States, the CDC reports that sixty-eight patients supposedly no more challenges left. And then the Ebola virus crept were tested for Ebola in the fi rst three weeks of August, 2014.8 While out of central African forests in 1976 killing some 90% of those in- the testing has not thus far identifi ed any U.S. cases, the challenges fected, followed by the emergence of the AIDS pandemic in the early dealing with the outbreak “on the ground” in nations with consid- 1980’s. The scientifi c community took notice that the victory lap erably less resources will be considerable. In Liberia, a poverty- over infectious disease was wildly premature. stricken section of Monrovia, the capital, was rocked by rioters who attacked and looted a clinic where those exposed to Ebola were being The battle continues today with more than 1100 people having quarantined. The material looted had been in contact with potential died in the 2014 Ebola virus outbreak. The epicenter has moved patients and the quarantined themselves fl ed, fueling concerns about into western Africa, with outbreaks reported by the CDC in Guinea, spread of the disease. The entire slum area, West Point, was subse- Liberia, Nigeria, and Sierra Leone. Around the world, virologists, quently placed under quarantine and civil clashes broke out.9 specialists in zoonotic diseases and pharmaceutical microbiologists are all responding to the challenge. Texas researchers have likewise If the natural course of disease and civil disruption and unrest were been called upon to help respond to the outbreak, bringing to bear not enough to cause concern, viral hemorrhagic agents are consid- a long history of Ebola research and involvement, and backed by ered by the CDC to belong to the category of highest risk of being facilities that are second to none. used as bioterrorism agents: they can be easily transmitted person to person; they result high mortality and have the potential for social Texas hosts two of the “baker’s dozen” Biosafety Level 4 labora- disruption; they require special preparedness measures.10 Surveil- tories (BSL– 4) in the United States, labs that are among the most lance and emergency preparedness require that the broad community technologically advanced and most secure in the world.2 One is at the of public health workers remain aware of the state of the art, and state University of Texas Medical Branch’s Galveston National Labs and of the threat. the other at the Texas Biomedical Research Institute in San Antonio. BSL - 4 labs house the most virulent infectious disease agents on the REFERENCES planet, the kinds of agents that haunt people’s nightmares and inspire 1. Piot, P. (2004). No Time to Lose: A Life in Pursuit of Deadly Viruses. W. B-grade sci-fi fi lms. Yet in these labs the researchers calmly don W. Norton & Co., New York. 2. Centers for Disease Control and Prevention, “Biosafety in Microbiologi- suits that would seem appropriate for astronauts on a space walk and cal and Biomedical Laboratories,” Section IV -- Laboratory Biosafety Level routinely go about their business of fi nding the vaccines, treatments, Criteria, Retrieved from the World Wide Web, August 21, 2014: http://www. and tests that will be needed to conquer Ebola, its near cousin Mar- cdc.gov/biosafety/publications/bmbl5/bmbl5_sect_iv.pdf burg, and whatever else may emerge. 3. Moore, C. (August 7, 2014). BioNews Texas. “UTMB Experts Battling Ebola In Labs And On The Front Lines.” Retrieved from the World Wide Ebola and Marburg belong to the fi lovirus family, co-discovered by Web, August 21, 2014: http://bionews-tx.com/news/2014/08/07/utmb-ex- Dr. Frederick A. Murphy of Galveston’s National Labs. As an ad- perts-battling-ebola-in-labs-and-on-the-front-lines/ ditional example of depth of expertise, Galveston National Labs’ Dr. 4. Mylar, B. (July 31, 2014). KSAT, “SA's Texas Biomedical Research In- Thomas Geisbert has more than a quarter century of experience re- stitute looks for cure to Ebola.” Retrieved from the World Wide Web, August searching Ebola and is working toward vaccines and broad spectrum 21, 2014: http://www.ksat.com/content/pns/ksat/news/2014/07/31/local-ebo- therapeutics to treat fi loviruses.3 Dr. Jean Patterson’s lab at the Tex- la.html 5. Texas Biomedical Research Institute: Texas Biomed Staff Biographies. as Biomedical Research Institute has been working on fi loviruses for Retrieved from the World Wide Web, August 21, 2014: http://www.txbiomed. over a decade and in collaboration with other institutions has helped org/departments/virology/virology-staff-bio?u=33 develop three Ebola vaccines which are still in process of evaluation. 6. UT Health Science Center Faculty. Retrieved from the World Wide Web, Dr. Patterson is also chair of the Department of Microbiology and August 21, 2014: http://uthscsa.edu/micro-immunology/faculty/jlp/jlp.asp Immunology at the UT Health Science Center San Antonio School 7. Hensley, K. (August 5, 2014). Galveston Daily News, “UTMB scientist of Medicine.4-6 is headed into the Ebola hot zone.” Retrieved from the World Wide Web, August 21, 2014: http://www.utmb.edu/newsroom/article9735.aspx BSL – 4 labs are designed and operated ever in mind of the awe- 8. Ludwig, D. (August 20, 2014). The Wire, “CDC Counts 68 Ebola Scares inspiring responsibility their charge implies. Dr. Thomas Ksiazek is in United States.” Retrieved from World Wide Web, August 21, 2014: http:// responsible for high containment lab operations at the UTMB facil- www.thewire.com/national/2014/08/cdc-counts-68-ebola-scares-in-united- ity. His resume includes having served as Director of the CDC’s states/378850/ 9. Anonymous. (August 19, 2014). LA Times, “Liberia Imposes Ebola quar- Special Pathogens Unit. Trained as a veterinarian and epidemiolo- antine and curfew in Monrovia slum.” Retrieved from the World Wide Web, gist, his specialty lies in understanding how disease passes between August 21, 2014: http://www.latimes.com/world/africa/la-fg-africa-ebola- animals that serve as the viral reservoir and humans, and passes be- liberia-curfew-20140819-story.html tween humans. In his long career he has been involved in contain- 10. Centers for Disease Control and Prevention, “Emergency Agents and ment efforts of ten other outbreaks of Ebola or Marburg alone. At Response: Bioterrorism Agents/ Diseases.” Retrieved from the World Wide times he has responded to three major infectious disease outbreaks Web, August 21, 2014: http://www.bt.cdc.gov/agent/agentlist-category.asp in a single year. Dr. Ksiazek has been tapped to head up the team of CDC experts requested by the government of Sierra Leone to assist in containment of the current outbreak, which is particularly severe in that country.7 12 TPHA Journal Volume 66, Issue 4 Commentary on Ebola: James Swan, PhD
What do we have to fear from Ebola? The Ebola virus suddenly So, what do we have to fear? Ebola is a deadly disease that has jumped into the news, with this year’s hard-to-control outbreak in killed many. But its means of transmission is known. With proper western Africa. As of early October, there had been over 3,000 protocols, its spread can be prevented.6 Even when the protocols deaths in Guinea, Liberia, and Sierra Leone.1 The news strongly hit fail, the public health system has considerable resilience to control it. the U.S. media when U.S. missionaries contracted the disease and And ultimately, control of the disease must be accomplished in West were treated in a specially-prepared hospital wing in the U.S. More Africa, not just because of the human tragedy there but because it’s recently a case appeared here in Texas, in Dallas, with treatment in in American self-interest so as to keep more cases from coming here. a hospital that had quietly prepared itself for such an event. Perhaps We should not be complacent, but neither should we be overly fear- fewer Americans noted that an outbreak in Lagos, Nigeria (a city of ful. With adequate public health funding we can protect the U.S. and over 20 million population) was successfully controlled, based on the world populations from disease outbreaks such as Ebola. existence of facilities and trained personnel that had been dedicated to the care for other diseases, but which were quickly adapted to the UPDATE: On October 8th the Dallas Ebola patient, Thomas Eric response to Ebola. There are common threads in these stories of suc- Duncan, became the fi rst patient in the US to die from the disease. cessful response: adequate treatment facilities and laboratories, well- We offer our condolences to his family. trained personnel, some advance planning for response to infectious disease, and, most importantly, basic public health practices. UPDATE: On October 12th, it was announced that Nina Pham, a nurse at Presbyterian Hospital Dallas who had treated Ebola patient In the Dallas case and the Nigerian outbreak, an important factor in Thomas Eric Duncan, was herself diagnosed with Ebola. Ms. Pham successful response was the basic public health, particularly contact is the fi rst known case of Ebola being contracted in the U.S. She was tracing, including new technology that aids in performing it.2 The wearing protective gear while treating Mr. Duncan; but offi cials have cases differed. In the Dallas case, the original infected individual noted that wearing the gear does not by itself prevent contracting the showed no symptoms (so was not contagious) on the fl ight to Dallas. disease – a major issue being the avoidance of contamination while He came into contact with relatively few people, and, when symp- taking off the gear. toms appears, he went to the emergency room at a hospital that in theory was equipped both to diagnose the illness and to maintain REFERENCES infection controls. However, he was not diagnosed at that point. In 1. Centers for Disease Control and Prevention (CDC). 2014a. 2014 Eb- consequence, he came into contact with additional people, including ola outbreak in West Africa. Atlanta: Centers for Disease Control and school children. When symptoms worsened, he returned to the ER, Preven¬tion, updated daily. Accessed October 2, 2014: http://www.cdc.gov/ vhf/ebola/outbreaks/2014-west-africa/index.html. was diagnosed, isolated, and had treatment initiated. Contact trac- 2. Centers for Disease Control and Prevention (CDC). 2014b. CDC Dis- ing was done, identifi ed those who might have been infected, and ease Detectives Using New Software Tool in Ebola Hemorrhagic Fever Out- precautions taken to follow those contacts. Failure to follow proto- break. Centers for Disease Control and Prevention, press release, April 29. cols, or their lack in some health facilities, will likely create future Accessed October 2, 2014: http://www.cdc.gov/media/releases/2014/p0429- concern about control of Ebola3; but to date, control appears to have new-soft¬ware.html. been effective. 3. Gawande, A. 2014. The Ebola epidemic is stoppable. The New York- er, October 3: http://www.newyorker.com/news/daily-comment/ebola- In the Nigerian case, the individual had been under observation as epidem¬ic-stoppable. 4. Holmes GP, McCormick JB, Trock SC, Lewis SM, Hall PA, Perez-Oronoz possibly infected in another country, did show symptoms (so was GI, McDonnnell MK, Paulissen GP, Schonberger LB, Fisher-Hoch SP. 1990. contagious) on the fl ight to Lagos, and did infect other contacts in Lassa fever in the United States: Investigation of a case and new guidelines Lagos. In that case, others were infected, including a health worker for management. New England Journal of Medicine 323(16): 1120--3. and died as a result. And in fact, the disease was spread to another 5. Morbidity and Mortality Weekly Report (MMWR). 2004. Imported Lassa Nigerian city. However, contact tracing led to the identifi cation and Fever --- New Jersey, 2004. Morbidity and Mortality Weekly Report 53(38): isolation of contacts; and the response was timely enough to stop the 894-7. spread of the disease. That success depended on the existence of ad- 6. Morbidity and Mortality Weekly Report (MMWR). 2009. Imported case equate laboratories to diagnose Ebola, facilities and programs to re- of Marburg Hemorrhagic Fever --- Colorado, 2008. Morbidity and Mortality Weekly Report 58(49): 1377-81. spond to infectious disease (e.g., polio), adequately-trained medical and public health personnel, and rapid training of additional needed personnel. This, as in the U.S., depended upon the existence of ad- equate resources (lacking in the countries most affected by the out- break), but it was public health that made the difference. Although experiences with human Ebola infection inside the U.S. is new, ex- periences with other hemorrhagic diseases is not. For example, a case of Lassa fever in suburban Chicago in 1989 led to the death of the infected individual but no infection of others, including eleven individuals who had been considered high or moderate risk.4 An- other case was diagnosed in Trenton, NJ, in 20045, again resulting only in the death of the infected individual, but no further spread. A case of Marburg Hemorrhagic Fever was diagnosed in Colorado in 2008, leading to no deaths and no spread. Of course, each hemor- rhagic disease is different, and Ebola may be more virulent. How- ever, these cases do suggest that an outbreak is unlikely in the U.S. or other countries with adequate health facilities and public health infrastructure.
TPHA Journal Volume 66, Issue 4 13 Improving Collaboration between Federally-funded Health Centers and Aging Services Jennifer Jurado Severance, Ph.D.1,Princess D. Jackson, Ph.D.2 1Program Manager, Senior Citizen Services of Greater Tarrant County, Inc.; Adjunct Faculty, Department of Applied Geron- tology, University of North Texas 2Regional Administrator, Health Resources and Services Administration, Offi ce of Regional Operations, Dallas Regional Division ABSTRACT (5) Health centers services are provided through multiple deliv- Background: Federally-funded health centers that harness the rein- ery sites located in medically underserved and health profession- forcing nature of collaborative efforts with aging services can better al shortage areas. prepare for the needs of rapidly increasing numbers of vulnerable (6) Health centers provide services regardless of a person’s abil- older adults. Methods: We surveyed 44 key informants at 31 health ity to pay. centers across Texas to evaluate partnerships with seven types of or- ganizations serving older adults. Findings were analyzed to deter- Despite these outstanding attributes, health center use by older adults mine the level of collaboration with aging services and barriers to averages 7% and has fl uctuated around this level for fi fteen years 12 collaboration and serving older adults. Results: Health centers col- amidst rapid growth in minority and low-income older populations. laborated with at least one aging service through more informal than As the older population increases, health centers can gain a leading formal partnerships. Respondents indicated major barriers to pro- role in healthcare delivery for the elderly through a working integra- viding services to older adults, including inadequate transportation, tion with aging services. inadequate reimbursement from third party payer sources, and lim- Health centers secure resources for patients requiring complex and ited funding. Also, respondents indicated employees with multiple costly treatment.13-14 Aging service organizations also confront the responsibilities were unable to develop collaborative relationships burden of chronic disease management for older populations, and with aging services. Conclusion: Findings indicate that although col- offer health centers with an opportunity to coordinate efforts, par- laboration occurs, fi nancial incentives and a shared focus on under- ticularly in addressing the needs of vulnerable elderly lacking access served older adults can enhance commitments across public health to primary care services. Although previous studies have explored and aging sectors. 15 collaboration of aging and public health sectors at the state level , INTRODUCTION the role of aging services in the public health delivery system model Although older adults age 65 years and over comprised 13% of the to older adults at the community level remains unclear. We address total population, they account for over one-third of hospital inpatient this need by identifying the types and levels of collaboration exist- days of care and a disproportionate number of physician offi ce visits ing between health centers and aging services in Texas, health center and pharmacy purchases.1 Health care spending per capita is four characteristics that may affect service collaboration between sectors, times higher for older adults than for persons under age 65, a gap and barriers to service delivery for older adults at health centers. that will increase as more baby boomers retire and healthcare costs METHODOLOGY 2 continue to escalate. Furthermore, older adults, particularly those The study design and survey instrument were developed with the who are minorities or foreign-born, are more likely to have multiple contribution of HRSA’s Dallas Regional Division and the primary chronic conditions and functional limitations requiring long-term investigator, and approved by the University of North Texas’s Insti- 3-6 intervention. Primary care practices of health promotion, disease tutional Review Board. Between July and August 2008, 44 person- prevention and disease management for older populations are gain- nel were surveyed at 31 health centers in Texas. Personnel included ing the attention of the healthcare community as research continues executive directors, medical directors and social workers involved to support these trends. with patient referrals to external agencies and were key informants Health centers are key contributors to improving access to primary about their health center. Written consent was provided by all survey health care services. Administered by the Health Resources Services participants. Administration (HRSA), Bureau of Primary Health Care (BPHC) Survey respondents rated perceived barriers to providing services to under Section 330 of the Public Health Service Act, health centers older adults and to collaborating with aging services on a three-point provide quality services and their achievements are well documented response scale from “major barrier” to “not a barrier”. Executive di- in their ability to address health disparities, particularly for uninsured rectors were asked to indicate a level of collaboration with seven 7-9 and minority populations. health Health centers demonstrate high categories of aging services, including senior centers, Area Agencies scores in several domains of primary care, including “ongoing care, on Aging (AAA), home health agencies, the American Association coordination of service, comprehensiveness, and community orienta- of Retired Persons (AARP), the Alzheimer’s Association, long term 10 tion.” care providers, and Shepherd’s Center faith-based volunteer organi- Signifi cant features of health centers contribute to their potential for zations. Formal levels were evidenced by a recognized agreement in improving senior health. place between the organizations to signify a greater commitment be- (1) Health centers provide comprehensive primary care, includ- tween organizations. Informal levels were identifi ed by the absence ing translation, transportation, care management and preventive of this formality and signaled a lower level of commitment between services, to serve patients across the lifespan.11 organizations. (2) Health centers focus on health disparities related to chronic Data was analyzed in SPSS through a standard frequency analysis on diseases, such as diabetes or asthma, which disproportionately categorical responses for levels of collaboration, perceived barriers affect older adults. to collaboration, and perceived barriers to service provision for older (3) Health centers use a multi-disciplinary approach with health adults. professionals who refl ect diversity of the community served. (4) Health centers take a community-oriented approach involv- RESULTS ing local leadership, responsive health planning, and community Table 1 summarizes the levels of collaboration with agencies serv- health workers. ing older adults as indicated by 13 executive directors responding to 14 TPHA Journal Volume 66, Issue 4 the survey. Respondents reported more informal than formal partner- portation (46%) and lack of program funding (43%) were perceived ships within each agency category. Informal partnerships occurred as major barriers. Inadequate insurance was seen as a “major bar- most frequently with senior centers (69%), home health agencies rier” (46%) and “somewhat a barrier” (46%) by an equal number of (69%), and long term care providers (69%). Formal partnerships oc- respondents. Over half of respondents observed attributes of older curred primarily with Area Agencies on Aging (15%), senior centers adults as “somewhat a barrier”, including older adults’ perceived lack (8%) and the Alzheimer’s Association (8%). Respondents indicated of need (61%), frailty and mobility issues (59%), lack of awareness the unavailability of agencies within the health center’s service area, (55%), lack of caregiver support (55%) and literacy (52%). Figure 2 with Shepherd’s Centers (54%) being the most frequently absent provides barriers to collaborating with aging services. A third of the agency. respondents (34%) viewed the state’s low priority of aging and em- ployees with multiple responsibilities as major barriers to collabora- All 44 respondents indicated their perceptions of barriers to provid- tion. Over half of respondents indicated a lack of interest at the health ing services to older adults. As seen in Figure 1, inadequate trans- center (55%) and in the community (52%) as “somewhat a barrier.”
Table 1: Comparison of Health Centers’ (N=13) Level of Collaboration with Agencies Serving Older Adults
Informal Formal Agency not Agency serving older adults collaboration collaboration Available No Response f % f % f % f % Senior Center 9 69% 1 8% 1 8% 2 15% Home Health Agency 9 69% 0 0% 1 8% 3 23% Long Term Care Provider 9 69% 0 0% 1 8% 3 23% Area Agency on Aging (AAA) / Councils on Aging (COA) 7 54% 2 15% 1 8% 3 23% Alzheimer’s Association 4 31% 1 8% 4 31% 4 31% AARP 4 31% 0 0% 6 46% 3 23% Shepherd’s Center 2 15% 0 0% 7 54% 4 31%
Figure 1 : Key Informants' (N=44) Perceived Barriers to Providing Services for Older Adults
Lack of funding
Lack of board support
Staff's educational limits
Inadequate transportation
Location
Inadequate physical access
Procedural inconvenience Barriers Older adults' lack of awareness
Older adults' perceived lack of need
Perceptions about FQHC
Literacy of older adults Major barrier Language of older adults Somewhat a barrier Inadequate insurance Not a barrier Frailty and mobility Don't know Lack of caregiver support No answer Absence of need
0% 50% 100% Percent
TPHA Journal Volume 66, Issue 4 15 Figure 2: Key Informants' (N=44) Perceived Barriers to Collaborating with Aging Services
Aging is low priority in state
Lack of community interest
Lack of designated staff
Major barrier
Barriers Lack of interest
Somewhat a barrier Lack of organizational trust Not a barrier
Organizational cultural differences Don't know
No answer Overloaded staff
0% 50% 100% Percent DISCUSSION collaborate with aging services. An overburdened staff that cannot A health center’s commitment to serving older adults can be observed absorb the added responsibility of establishing and maintaining part- through partnership strategies with different types of aging services. nerships can undermine the potential of sharing resources. A lack of The fi ndings suggest that collaboration between health centers and interest within the organization and in the community may under- aging services in Texas occurs more frequently through informal score perceptions of scare resources both in funding and infrastruc- than formal partnerships as illustrated in Table 1. Informal partner- ture that discourage collaboration in an environment of competing ships with aging services identifi ed in this study may demonstrate populations and community needs. necessary impartiality of referrals and support a patient’s personal choice for providers such as home health agencies and long term Because the study included responses from multiple staff from dif- care services, rather than refl ect diminished commitments to serving ferent disciplines, it is possible that responses were biased towards older adults. Formal commitments were more likely to occur with a respondent’s position of control and responsibility within the or- aging services having directives to serve vulnerable populations. ganization. Key informants provided perspectives on the practical Local government agencies and senior centers funded by the Older aspects of caring for older adults in health center settings. However, American Act, and the Alzheimer’s Association provided opportuni- more in-depth statistical analysis can identify the extent that indi- ties for formal partnerships with health centers. The perception that vidual-level responses represent organizational-level. Finally, gen- agencies serving older adults are unavailable would signal gaps in eralizing these results beyond Texas may not be practical, thereby services, although further questions are needed about the agency’s enforcing the need for regionalized and community-level studies of physical absence from the area or the respondent’s lack of awareness health center activity. about existing services. CONCLUSION Concerns about establishing programs to serve older adults include Identifying and overcoming barriers and improving current levels of barriers related to resources and perceptions about older adults. In- collaboration are critical steps in preparing health centers for the fu- adequate fi nancial resources of the health center and inadequate in- ture needs of the aging populations. In an environment of consumer- surance coverage of older adults were perceived as major barriers to directed care, coordination between agencies and across sectors is 16 providing services to older adults. With the complexity of care that essential. Moreover, community-based organizations must dem- older adults with comorbid conditions require, and with stretched onstrate cohesive and well-organized partnerships to effi ciently op- budgets and staffi ng on which health centers operate, low reimburse- erate in the current environment. Addressing barriers to formal part- ment is a signifi cant and complicated barrier to health center collabo- nerships can improve effective collaboration, and thereby enhance rations and service delivery for older adults. Inadequate provision of patient care and maximize resources. At the local level, enhancing transportation was also identifi ed as problematic to offering services competencies of key staff in geriatrics and hiring practices that con- to older adults. For community-dwelling older adults no longer able sider previous education and experience with gerontology enrich to drive or access public transportation, the absence of transporta- health center services for older adults. At a policy level, encouraging tion limits access to health centers. Impediments to serving older collaboration across public health and aging sectors should include adults were related to perceived negative attributes of older patients, fi nancial provisions to support partnership efforts between organi- such as physical frailty, low literacy and lack of awareness. Provider zations. Regulatory standards that direct organizations towards the education to improve communication and outreach with older adults needs of underserved older adults encourage partnerships and stra- may address these perceptions and overcome ageism. tegic efforts for both sectors. Research on identifying health center barriers to aging services and on models of proven partnerships at re- Also, fi ndings revealed several internal barriers for health centers to gional and community levels will also improve collaborative efforts. 16 TPHA Journal Volume 66, Issue 4 ACKNOWLEDGEMENTS ington, DC; Congressional Research Services; March 13, 2007. Publication We thank the Health Resources and Services Administration, Dallas RS22619. Regional Division for their guidance, support and access; communi- 8. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ ty health centers in Texas for their participation in the survey; faculty knowledge, attributes, and practices regarding infl uenza and pneumococcal vaccinations for elderly and other high-risk patients. Arch of Intern Med. at the University of North Texas Department of Applied Gerontology 2001;161:2702-2708. and Health Science Center School of Public Health for direction in 9. Ostbye T, Yarnall KSH, Krause KM, Pollack KI, Gradison M, Michener developing the survey instrument; Senior Citizen Services of Greater JL. Is there time for management of patients with chronic diseases in primary Tarrant County for its support for the fi nal manuscript. care? Ann of Fam Med. 2005;3:209-214. 10. Politzer RM, Yoon J, Shi L, Hughes RG, Regan J, Gaston MH. Inequality REFERENCES in America: The contribution of health centers in reducing and eliminating 1. Adams, WL, McIlvain, HE, Lacy, NI, et al. Primary care for elderly peo- disparities in access to care. Med Care Res and Rev. 2001; 58:234-248. ple: Why do doctors fi nd it so hard? Gerontologist. 2002:42:835-842. 11. Ross, H. Minorities more likely to rely on Medicare. Closing the Gap. 2. Asch, SM, Kerr, EA, Keesey, J, et al. Who is at greatest risk for receiving May 2000:8-9. poor-quality health care? N Eng J of Med. March 16, 2006; 254:1147-1157. 12. Bureau of Primary Health Care. Uniform Data System. Bethesda, MD: 3. Bailey, BE, Langespi, MM. Experts with experience: Community and mi- Bureau of Primary Health Care; 2010. grant health centers highlighting a decade of service. Bureau of Primary Care 13. Baxter C, Levin R, Legaspi MM, Bailey BE, Brown CL. Community website. Available at: http://bphc.hresa.gov/chc/chcmain.asp. Accessed April health center-led networks: Cooperating to compete, J of Healthcare Man- 4, 2005. agement. 2002: 376-390. 4. Bureau of Primary Health Care. Uniform Data System. Bethesda, MD: 14. Mays, GP. Public Health Administration. Gaithersburg, MD: Aspen Pub- Bureau of Primary Health Care; 2007. lishers, Inc.; 2001;63-116 5. Cheng, T. Primary loss: A doctor-patient mourns a once-key health care 15. National Association of State and Territorial Chronic Disease Program bond. Washington Post. July 6, 2004;p. F01., 1998 to 2000. J of Gen Intern Coordinators & National Association of State Units on Aging. The Aging Med. 2004;19: 991-998. States Project: Promoting opportunities for collaboration between the public 6. Hatch SL. Conceptualizing and identifying cumulative adversity and health and aging services networks. 2003. protective resources: Implications for understanding health inequalities. J. 16. Harley, DA., Donnell C, Rainey, J. Interagency collaboration: Reinforcing Gerontol B Psychol Sci Soc Sci. 2005;60B: 130-134. professional bridges to serve aging populations with multiple service needs. 7. Jensen J. Health care spending and the aging of the population. Wash- J of Rehabil, 2003;69:32-37.
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TPHA Journal Volume 66, Issue 4 17 An Overview of Tobacco-Free Policy Among Worksites in a Central Texas County Kahler Stone, MPH1, Jake Pry, MPH2, Hammad Akram, MPH1 1Epidemiologist, Nursing Division, Waco-McLennan County Public Health District, Waco, TX 2Epidemiologist, Sacramento County Department of Health and Human Services, Disease Control and Epidemiology Unit, Sacramento, CA ABSTRACT been implemented is signifi cant. There is evidence that comprehen- The State of Texas is not smoke-free, leaving Texas municipalities sive smoke-free policy in the worksite decreases smoke exposure20. and worksites to decide their smoke-free ordinances and policies. The majority of worksites in McLennan County are not regulated Population and Methods by comprehensive municipal smoke-free ordinances. Large employ- McLennan County, Texas has a reported population of 234,906 ac- ers (N=118) in McLennan County were sent a survey electronically, cording to the 2010 US Census and the majority of the municipalities by mail, and/or by phone interview to assess worksite policies and are not regulated by comprehensive smoke-free ordinances. Seeking measures to protect against smoke and smokeless tobacco exposures. to understand the potential risk of smoking exposure and evaluate The survey was distributed and the resulting data was analyzed and the broader tobacco-free policy landscape in a Central Texas County, reported. A response rate of 64% (n=75) was achieved across work- a survey was conducted to evaluate the tobacco-free policy among sites. Fifty-eight (77.3%) worksites reported having a tobacco use worksites in McLennan County. The Waco-McLennan County Pub- policy with 14 (24.1%) reporting a comprehensive tobacco-free cam- lic Health District (WMCPHD), seeking to assess public health pus policy. Among industries with more than 4 worksites surveyed, risk associated with tobacco in the worksite, took initiative to bet- education (84.6%), healthcare (87.5%) and non-profi t (85.7%) had ter describe the level of protection large worksites offered their em- the highest percentage of existing tobacco-free policy. A minority, ployees/customers. The Texas Smoke-Free Ordinance Database and 13 (22.4%) worksites, reported that their tobacco-free policy is not data provided by WMCPHD Environmental Health Department was enforced. A total of 56 (74.6%) worksites reported not offering used to describe the smoking ordinances in municipalities through- tobacco cessation support to their employees. This survey led to a out McLennan County. With varying smoke-free ordinance protec- better understanding of the tobacco and secondhand smoke protec- tion throughout McLennan County, large worksites were surveyed tion among large employers in McLennan County. Ultimately, with to document the overall tobacco protection levels in the workforce, a 100% tobacco-free campus being the highest level of protection, including smoke protection. 61 (81.3%) of large employers surveyed in McLennan County have The WMCPHD implemented a short, 10 question survey to describe the ability to reduce the risk of exposure to tobacco and secondhand the tobacco protection levels at large worksites in McLennan County. smoke through complete tobacco protection policy integration. Collaboration between WMCPHD, the Smoke-Free Waco Coalition BACKGROUND and Texas Department of State Health Services tobacco control ex- An association between smoking tobacco and cancer of the lung and perts ensured the survey would be valuable across different tobacco larynx, head and neck, bladder, esophagus, pancreas, stomach and initiatives. To meet the criteria for inclusion, the worksite had to em- kidney exists1,2. Additionally, a relationship between cigarette smok- ploy at least 50 individuals as listed by the Greater Waco Chamber of 21 ing and chronic conditions such as coronary heart disease, chronic Commerce as of May 2013 . The survey was distributed electroni- obstructive pulmonary disease, aortic aneurysm and atherosclerotic cally, by mail and by phone to key personnel at large worksites in peripheral vascular disease has been established3-5. A meta-analysis McLennan County. In order to capture more than smoke protection of 55 studies supports the existence of a causal relationship between from existing policies, tobacco-free terminology was used to cover passive smoking and lung cancer6. Exposure to secondhand smoke all forms of tobacco use. Tobacco-free, which includes smoke and increases the risk of fatal and non-fatal coronary heart disease in non- smokeless tobacco, is considered to be comprehensive, which is why smokers7-9, an increase in chronic bronchitis symptoms10,11 and devel- this term was used in the survey. The survey was addressed to the opment of atherosclerosis, which increases the risk of heart disease12. wellness coordinator or human resources representative of the busi- ness, agency or organization. Long-term use of smokeless tobacco has been associated with a greater risk of myocardial infarction13. Children living with smoke- Initially, a Uniform Resource Locator (URL)/link to the survey was less tobacco users may be exposed secondhand to nicotine and oth- sent via electronic mail (email) to all worksites for which email con- er constituents of tobacco via contact with contaminated dust and tact information was available (n=51) on May 6, 2013. A third party household surfaces14. It is for these reasons, that a tobacco-free en- survey tool, SurveyMonkey© was used for all emailed surveys. A vironment has been identifi ed as lower risk compared to a strictly four-week window for email survey response was allowed. During smoke-free environment. The Centers for Disease Control and Pre- the fi rst week of June 2013, the survey was mailed via United Stated vention (CDC) estimates that nearly 41,000 Americans die annually Postal Service (USPS) for follow up among those worksites that did from disease attributable to secondhand smoke exposure15. Exposure not respond electronically and to those who did not have a listed to secondhand smoke has shown to have an immediate adverse im- email address (n=106). The fi rst week of July 2013, phone interviews pact on the cardiovascular system, which increases risk for heart at- were conducted with worksites (n=58) that had not responded ei- tack and stroke16, 17. ther electronically nor via the mailed survey. Pearson’s Chi Square test was used to assess signifi cant differences between data collec- There are 36 states in the United States that have implemented tion methods. Overall, 75 of 118 (64%) of employers responded to some form of statewide smoke-free law18. The State of Texas is not the survey electronically, by mail or by phone interviews to assess among them. Smoke-free, as it is used in this study, is as defi ned by worksite policy and protection levels regarding tobacco use (Table the Texas Department of State Health Services Texas Smoke-Free 2). Multiple worksites were given more than one way to respond to Ordinance Database19. Each Texas municipality has the liberty to the survey. The administration and collection of the survey spanned determine their smoke-free ordinances and policies. This study has 11 weeks. The data was analyzed with StataCorp LP STATA SE 13 particular interest in tobacco-free policy regarding the worksite. The (College Station, TX). This project did not undergo review by an potential for decreased chronic exposure on a daily basis for fi rst or internal review board but was approved by the Waco-McLennan secondhand smoke where smoke-free or tobacco-free policy has not County Public Health District. 18 TPHA Journal Volume 66, Issue 4 RESULTS The worksites surveyed represented 17 different types of industry ac- A population breakdown for McLennan County and the associated cording to the Greater Waco Chamber of Commerce21. The industries nested populations is illustrated in Figure 1. McLennan County has of construction (6), education (13), healthcare (8), manufacturing an estimated 104,749 (44.6%) employed individuals with an unem- (15), non-profi t (7) and utilities (5) had the highest frequencies for ployment rate of 4.6%22. The worksite tobacco tool was distributed worksites surveyed (Table 3). Education (84.6%), healthcare (87.5%) to different types of industry of varying size. The survey response and non-profi t (85.7%) had the highest percentage of worksites re- from 75 large worksites represents an employed population of ap- porting an existing tobacco-free policy. Industries with more than proximately 25,943. Among worksites surveyed, 20,330 employees 4 worksites responding, construction (66.7%) and utilities (60.0%) are under some sort of tobacco-free policy with the remaining 5,613 had the lowest percentage of tobacco-free policies. The education, employed at worksites without any tobacco-free policy. healthcare and manufacturing industries are the largest employers who responded to the survey. McLennan County is comprised of 22 incorporated and 2 unincorpo- rated municipalities. There are 10 municipalities reporting smoke- Fifty-eight (77.3%) worksites reported an existing tobacco-free free ordinances, 2 of these are considered comprehensive smoke-free policy. Table 4 shows 39 (52.0%) worksites indicated they permit (Table 1). The two municipalities offering comprehensive smoke tobacco use in designated areas only, while 14 (18.7%) worksites free ordinances make up a total population of 11,016 (4.7%). The reported they did not allow tobacco on the premises. Several work- other eight municipalities make up the majority of the population sites indicated having a tobacco-free facility that permitted tobac- (169,369 / 72.1%) serving the community with weak or mixed level co use in designated outdoor areas, such as smoking zones. As the smoke-free ordinances. Residents living in unincorporated areas or strength/comprehensive-nature of the tobacco-free policy increases, municipalities without a smoke-free ordinance make up 23.2% of the the likelihood of an employer having the policy decreased. Worksites McLennan County population. reporting some level of tobacco-free policy included the following
Table 1: Smoke-Free Ordinances in McLennan County, using the Texas Smoke-Free Ordinance Database Protection Level Municipal Private Bars (Not in Bars in Percent County Municipality Worksite Worksite Restaurant Restaurant) Restaurants Pop. Pop. Bellmead 2 1 2 1 1 9,901 4.21% Beverly Hills 2 2 2 2 2 1,995 0.85% Hallsburg§ 5 5 5 5 5 507 0.22% Hewitt 3 3 3 1 3 13,549 5.77% Lacy Lakeview 5 1 1 1 1 6,489 2.76% Moody 3 1 3 1 1 1,371 0.58% Robinson 5 5 5 5 5 10,509 4.47% Waco 2 2 4 4 4 124,805 53.13% West 2 1 1 1 1 2,807 1.19% Woodway 5 5 5 1 5 8,452 3.60% All other * * * * * 54,521 23.21% Note: 5=100% Smoke Free; 4=Moderate; 3=Mixed; 2=Limited; 1=No Coverage *All cities who have no existing smoking ordinance and unincorporated areas §Reported by the Waco-McLennan County Public Health District
TPHA Journal Volume 66, Issue 4 19 TABLE 2. Survey response rates from worksite contacts by multiple methods. E-Mail Mail Phone Total Sample (n= 51) (n=106) (n=58) (N=118)* Response No. (%) No. (%) No. (%) No. (%) Yes 12 (24) 48 (45) 15 (26) 75 (64) No 39 (76) 58 (55) 43 (74) 43 (36) * The total number of worksites surveyed, some worksites were surveyed through multiple methods
TABLE 3. McLennan County worksite survey responses by industry Number of Worksites (N=75) Number of Employees at Worksites (N=71) * Count (%) within Count (%) within (%) of all Type of with industry with Total with industry with surveyed Total count (%) Total Industry policy policy surveyed policy policy with policy employees employees Total 58 75 20330 25943
Aerospace 1 100.0% 1 102 100.0% 0.5% 102 0.4% Construction 4 66.7% 6 842 74.6% 4.1% 1129 4.4% Education 11 84.6% 13 5975 66.9% 29.4% 8930 34.4% Financial 2 100.0% 2 170 100.0% 0.8% 170 0.7% Healthcare 7 87.5% 8 5504 93.0% 27.1% 5920 22.8% Insurance 1 100.0% 1 117 100.0% 0.6% 117 0.5% Local Governme1 100.0% 1 1506 100.0% 7.4% 1506 5.8% Logistics 3 75.0% 4 803 89.5% 3.9% 897 3.5% Management 1 100.0% 1 230 100.0% 1.1% 230 0.9% Manufacturing 12 80.0% 15 2935 77.6% 14.4% 3783 14.6% Media 0 0.0% 1 0 0.0% 0.0% 75 0.3% Non-Profit 6 85.7% 7 961 92.9% 4.7% 1035 4.0% Professional 0 0.0% 2 0 0.0% 0.0% 384 1.5% Recreation 1 100.0% 1 149 100.0% 0.7% 149 0.6% Services 2 100.0% 2 155 100.0% 0.8% 155 0.6% State Governme 1 100.0% 1 101 100.0% 0.5% 101 0.4% Utilities 3 60.0% 5 780 61.9% 3.8% 1260 4.9% Unknown 2 50.0% 4 * 4 worksites did not self identify, therefore no calculation on number of employees was made for these worksites.
TABLE 4. Summary of McLennan County worksite survey response (N=75) (%) worksites (%) of all worksites with policy surveyed Question Count (Yes) (n=58) (n=75) Have a tobacco use policy? 58 77.3%
Does the Policy include: Permits in designated area only? 39 67.2% 52.0% Creates tobacco-free facility? 20 34.5% 26.7% Creates tobacco-free facility, plus 25ft from entrances, exits, air 16 27.6% 21.3% intakes and open windows? Creates tobacco-free property? 14 24.1% 18.7%
Workplace have signs? 41 70.7% 54.7%
Prohibit smoking in vehicles while 48 82.8% 64.0% working?
Workplace have policy to inform 45 77.6% 60.0% on existing tobacco policy?
Offer cessation courses? 19 25.3%
How is the policy enforced? Fees or fines 1 1.7% 1.3% Employee demerit 16 27.6% 21.3% Violator is asked to leave premise 18 31.0% 24.0% Tobacco policy is not enforced 13 22.4% 17.3% Did not respond 10 17.2% 13.3%
Administrative support? * High 42 60.0% Medium 16 22.9% Minimal 12 17.1%
Employee support? * High 32 45.7% Medium 22 31.4% Minimal 16 22.9% *N=70 20 TPHA Journal Volume 66, Issue 4 methods to inform employees/customers regarding tobacco policy: cancers, where McLennan County rates have not29. 41 (70.7%) display tobacco-free signage, 45 (77.6%) report a process for informing employee/customers regarding the tobacco-free policy. Comprehensive smoke-free policy is associated with decreased hos- The majority of worksites, 48 (82.8%), reported a policy disallow- pitalizations due to cardiac, cerebrovascular and chronic obstruc- 30,31 ing smoking in work vehicles and private vehicles while on the job. tive pulmonary disease . This survey indicates large employ- When asked if the worksite offered tobacco cessation support for ers throughout McLennan County have different levels of tobacco employees, 19 of 75 (25.3%) did. protection for their employees and customers. Ultimately, 81.3% of large employers in McLennan County have the ability to reduce the Worksites were questioned about enforcement of their tobacco- risk of exposure to tobacco and secondhand smoke through stronger free policy, 1 (1.7%) indicated using fees or fi nes, 16 (27.6%) used tobacco protection policy integration. employee demerit, 18 (31.0%) requested that the violator leave the premises and 13 (22.4%) were not enforced in any fashion. There Limitations were 10 (17.2%) worksites who did not respond to this question. There are several large retail and governmental employers in McLen- Support for a 100% tobacco-free worksite was perceived by those nan County who were not surveyed regarding tobacco-free policies. surveyed as greater among the administration compared to the em- Those industries responding to the tobacco survey may not represent ployees. Several respondents mentioned not feeling as though they the breadth of industry in McLennan County. A copy of worksite could give an accurate account of the facility employees or adminis- tobacco-free policies reported by wellness coordinators or human tration, resulting in 5 worksites failing to respond. resources administrators was not requested nor reviewed as a part of this study. Information bias could be present due to one repre- DISCUSSION sentative from each worksite responding as an ambassador without The McLennan County worksite tobacco study sought to assess required documentation of the policies. The survey tool used tobac- 118 worksites and succeeded with 75 large employers in an effort co-free and smoke-free language, therefore it is possible for some to inform local stakeholders and health offi cials on worksite tobac- confusion of the terms when referencing smoke-free and tobacco- co-free policies. An overall response rate of 64% was thought to be free. Tobacco-free restricts all tobacco products from the worksite successful, as previous surveys conducted by WMCPHD have not where smoke-free specifi cally restricts products that produce smoke. reached this rate. Presenting the worksites with multiple options to For future WMCPHD surveys, a clear distinction between smoke- respond,may have contributed to the successful response rate23. Those free and tobacco-free will be outlined to better describe and compare worksites responding to the survey via USPS were less likely than smoke-free policies vs. tobacco-free policies. Electronic cigarettes those that responded using the electronic tool or telephone interview were not specifi cally mentioned in the survey tool. Early studies have to report the name of the worksite (n=4). Worksites that responded shown that electronic cigarettes are not emission free and further re- to the mailed survey showed a statistically signifi cant increase in re- search is needed to better understand the health effects from active sponse rate when compared to those that responded through email and passive exposure to vaping32,33. (p-value <0.001) and phone interview (p-value <0.001). Email and phone interview response rates were not signifi cantly different (p- REFERENCES 1. Gillison ML, Zhang Q, et al. 2012. Tobacco smoking and increased risk value=0.281) compared to one another (Table 2). of death and progression for patients with p16-positive and p16-negative oro- The majority, 58 (77.3%), of worksites indicated having a tobacco- pharyngeal cancer. J Clin Oncol. 30(17):2102-11 2. Stewart S, Cardinez C, Richardson L, et al. 2008. Surveillance for cancers free policy; this can partially be attributed to municipal smoke-free associated with tobacco use--United States, 1999-2004. Morb Mortal Wkly ordinances. Only 19 (25.3%) of the worksites reported offering to- Rep Surveill Summ Wash DC 2002. 57(8):1-33. bacco cessation support. This low percentage could be due to the 3. Centers for Disease Control and Prevention (CDC). 1999. Tobacco use- specifi c question on the survey not clearly defi ning cessation support -United States, 1990-1999. MMWR Morb Mortal Wkly Rep. 48(43):986-93. or who offered the cessation support. Several of the respondents in- 4. Singh K, Bonaa KH, Jacobsen BK, Bjork L, Solberg S. 2001. Prevalence dicated that they offered employees cessation resources through their of and risk factors for abdominal aortic aneurysms in a population-based insurance provider. If the question was phrased to include offering study: The Tromso Study. Am J Epidemiol. 154(3):236-244. these resources through their insurance provider as well, the response 5. Luo J, Margolis KL, et al. 2011. Association of active and passive smok- ing with risk of breast cancer among postmenopausal women: a prospective to the cessation resources question might have changed. cohort study. BMJ.342: d1016. Asking the respondent to give a statement on the administrative and 6. Taylor R, Najafi F, Dobson A. 2007. Meta-analysis of studies of passive smoking and lung cancer: effects of study type and continent. Int J Epidemiol. employee support for a strong 100% tobacco-free worksite was seen 36(5):1048-1059. to be subjective. This made several respondents uneasy, accounting 7. Jefferis BJ, Lowe GDO, Welsh P, et al. 2010. Secondhand smoke (SHS) for several omissions to those questions. The majority (82.8%) of exposure is associated with circulating markers of infl ammation and endo- worksites with policies included clauses that did not allow smoking thelial function in adult men and women. Atherosclerosis. 208(2):550-556 in vehicles while doing job related tasks. This is the only question on 8. Öberg M, Jaakkola MS, Woodward A, et al. 2011. Worldwide burden of the survey that asked specifi cally about smoking; the rest referred to disease from exposure to second-hand smoke: a retrospective analysis of data all tobacco use. Secondhand smoke exposure in vehicles can be 10 from 192 countries. Lancet. 377(9760):139-146 times more concentrated than the level considered unhealthy by the 9. Treyster Z, Gitterman B. 2011. Second hand smoke exposure in children: environmental factors, physiological effects, and interventions within pediat- U.S. Environmental Protection Agency24. rics. Rev Env Hlth. 26(3):187–195 Studies have shown that comprehensive smoke-free laws contribute 10. Wu CF, Feng NH, Chong IW, et al. 2010. Second-hand smoke and chron- ic bronchitis in Taiwanese women: a health-care based study. BMC Public to lower smoking rates24,26. In 2013, 21% of McLennan County resi- 27 Health. 10:44 dents stated that they are current smokers . That is approximately 11. Fetterman JL,Pompilius M,Westbrook DG, et al. 2013. Developmental 3% higher compared to the State of Texas and US average, 18.2% Exposure to Second-Hand Smoke Increases Adult Atherogenesis and Alters (2012) and 18.1% (2012) respectively28. Data from Texas Cancer Mitochondrial DNA Copy Number and Deletions in apoE2/2 Mice. PLoS Registry shows the incidence and mortality rates for lung and bron- ONE 8(6): e66835. chial cancers are both higher in McLennan County compared to the 12. Peinemann F, Moebus S, Dragano N, et al. 2011. Secondhand Smoke Ex- statewide average. From the years 1995 to 2011 the statewide aver- posure and Coronary Artery Calcifi cation among Nonsmoking Participants of age has seen a downward trend in incidence for lung and bronchial a Population-Based Cohort. Environ Health Persp. 119(11):1556-1561. TPHA Journal Volume 66, Issue 4 21 13. Arefalk G, Hergens MP, Ingelsson E, et al. 2012. Smokeless tobacco 24. California Environmental Protection Agency (CEPA): Air Resources (snus) and risk of heart failure: results from two Swedish cohorts. Eur J Prev Board. Secondhand Smoke In Cars Fact Sheet. California Environmental Cardiol. 19(5):1120-1127 Protection Agency (CEPA) Air Resources Board, U.S. Environmental Protec- 14. Whitehead TP, Metayer C, Park J-S, Does M, Buffl er PA, Rappaport SM. tion Agency (U.S. EPA) Available at: http://www.arb.ca.gov/toxics/ets/docu- 2013. Levels of nicotine in dust from homes of smokeless tobacco users. ments/ets_cars.pdf. Accessed April 21, 2014. Nicotine Tob Res Off J Soc Res Nicotine Tob. 15(12):2045-2052. 25. Regidor E, Pascual C, Amort F, Martínez D. 2013. The effect of the 15. King BA, Patel R, Babb SD. 2014. Prevalence of smoke-free home rules smoke-free law in Spain on quit ratio and inequalities in smoking cessation: – United States, 1992-1993 and 2010-2011. MMWR Morb Mortal Wkly Rep. an observational study. Lancet. 382:S85. 63(35):765-769. 26. Nagelhout GE, Willemsen MC, Vries H. 2010. The population impact of 16. U.S. Department of Health and Human Services. The Health Consequenc- smoke-free workplace and hospitality industry legislation on smoking behav- es of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon Gen- ior. Findings from a national population survey. Addiction. 106(4):816-823. eral. U.S. Department of Health and Human Services, Centers for Disease 27. Ruggiere P, Short J. 2013. 2013 McLennan County Community Health Control and Prevention, National Center for Chronic Disease Prevention and Needs Assessment.; Available at: http:// www.waco-texas.com/cms-healthde- Health Promotion, Offi ce on Smoking and Health; 2006:11. partment/page.aspx?id=204. 17. Dunbar A, Gotsis W, Frishman W. 2013. Second-Hand Tobacco Smoke 28. Center for Disease Control and Prevention. 2012. Behavioral Risk Factor and Cardiovascular Disease Risk: An Epidemiological Review. Cardiol Rev. Surveillance System Survey Data 2001-2012. Atlanta, Georgia: U.S. Depart- 21(2):94–100. ment of Health and Human Services, Centers for Disease Control and Preven- 18. American Nonsmokers’ Rights Foundation. 2014. Overview List – How tion; Available at: http://apps.nccd.cdc.gov/brfss/. many Smokefree Laws? Available at: http://www.no-smoke.org/pdf/medi- 29. Cancer data have been provided by the Texas Cancer Registry, Cancer aordlist.pdf. Accessed April 30, 2014. Epidemiology and Surveillance Branch, Texas Department of State Health 19. Texas Department of State Health Services, Texas Smoke Free Ordinance Services, 211 E. 7th Street, Suite 325, Austin, TX78701, http:// www.dshs. Database. 2013. List of Texas Municipalities with SHS Ordinances: McLen- state.tx.us/tcr/default.shtm, or (512) 305-8506. nan County.; Available at: http://shsordinances.uh.edu/MuniList.aspx. Ac- 30. Tan CE, Glantz SA. 2012. Association between smoke-free legislation cessed April 30, 2014. and hospitalizations for cardiac, cerebrovascular, and respiratory diseases: a 20. Nagelhout GE, Vries H, Boudreau C, et al. 2012. Comparative impact of meta-analysis. Circulation. 126(18):2177-2183. smoke-free legislation on smoking cessation in three European countries. Eur 31. Hahn EJ, Rayens MK, Adkins S, Simpson N, Frazier S, Mannino DM. J Public Health. 22(1): 4-9. 2014. Fewer Hospitalizations for Chronic Obstructive Pulmonary Disease in 21. Greater Waco Chamber of Commerce. 2013. Customized Report: Major Communities With Smoke-Free Public Policies. Am J Public Health.e1-e7. Employers.; Available at: http://www.wacochamber.com/customreports.php. 32. Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Accessed April 22, 2013. Sobczak A. 2013. Secondhand Exposure to Vapors From Electronic Ciga- 22. U.S. Census Bureau, 2008-2012 American Community Survey. Selected rettes. Nicotine Tob Res Off J Soc Res Nicotine Tob. Epub ahead of print: Economic Characteristics for McLennanCounty.U S Census Bur. Available December 11, 2013 at:http://factfi nder2.census.gov/faces/tableservices/jsf/pages/productview. 33. Schober W, Szendrei K, Matzen W, et al. 2013. Use of electronic ciga- xhtml?pid=ACS_12_5YR_DP03. Accessed April 21, 2014. rettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of 23. Yun GW, Trumbo CW. 2000. Comparative Response to a Survey Ex- e-cigarette consumers. Int J Hyg Environ Health. S1438-4639(13)00153-3. ecuted by Post, E-mail, & Web Form. J Comput-Mediat Commun. 6(1):0-0.
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22 TPHA Journal Volume 66, Issue 4 Public-Private Partnerships: Multidisciplinary Plans to Reduce Child and Adolescent Obesity Tracey Smith Page, DNP, RN, FNP-BC1, Lisa Campbell, DNP, RN, APHN-BC2 1Frontera Pediatrics, Del Rio, TX; Texas Tech University Health Sciences Center, Lubbock, Texas 2Population Health Consultants, Victoria, TX; Texas Tech University Health Sciences Center, Lubbock, TX
ABSTRACT since life expectancy for obese individuals may be shortened by fi ve Background: The alarming rates of childhood obesity are a national to twenty years.5 Although obesity is a global health burden, Texas is concern associated with physical, psychosocial, and fi nancial bur- experiencing a higher rate of obesity than the rest of the country.4 Su- dens. With this knowledge, a family nurse practitioner recognized san Combs, Texas State Comptroller, issued a report which identifi ed the need to develop community based interventions to address child- the problem and urged statewide interventions. Despite this action, hood obesity. the percent of overweight or obese Texans continued to rise to 66.7% Methods: A select team of community leaders were assembled to de- in 2011.4 This increase in obesity, accompanied by the signifi cant velop a multidisciplinary, community collaboration centered on the fi nancial bur¬den, has far-reaching implications that affect all seg- utilization of public-private partnerships. A logic model was used to ments of society. If current obesity trends in Texas continue, obesity identify resources, interventions, and projected outcomes. related expenses are predicted to cost Texas businesses $32.5 billion Results: A collaborative community organization was founded, and annually by the year 2030.4 subcommittees were established to address concerns within fi ve main categories (leadership, physical activity, nutrition, environment, and Coordinated, sustained interventions for child health and nutrition communication). The logic model continues to function as a founda- programs that include healthcare, school, home, and community tion for building public-private partnerships with a common goal of based interventions are in need because interventions that combine reducing childhood obesity in Del Rio, Texas. all four sectors are the most successful in reducing childhood obe- Conclusions: Combining the use of a logic model with the develop- sity.12 ment of public-private partnerships is an effective method for es- tablishing a community collaborative aimed at reducing childhood Framework obesity. The complexity of childhood obesity prevention and treatment in- Key Words: childhood obesity, public-private partnerships, logic terventions can be effectively addressed using core concepts of the model Neuman Systems Model of Nursing (NSM). Central to NSM is the defi nition of the client as the individual as well as the surrounding INTRODUCTION family, group, and community.13 NSM also recognizes the need to The American Medical Association voted to classify obesity as a address physical, psychological, sociocultural, developmental, and disease at its 2013 Annual Meeting.1 Although this does not have spiritual variables in the internal, external, and created environ- legal implications, the vote signifi es the recognition of obesity as a ments.13 Combining the NSM with public-private partnerships aids complex disease requiring a broad range of interventions for both in developing a comprehensive plan to meet the challenges associ- prevention and treatment.1 This is seen as the fi rst step in achiev- ated with childhood obesity. ing greater fi nancial reimbursement and infl uencing public policy to support obesity-related interventions. This is particularly important Public-Private Partnerships because childhood obesity rates continue to climb for the majority Developing public-private partnerships, built through collaboration of children in America.2 Hispanic children in the United States are and innovation, can be effective in accomplishing health improve- experiencing a disproportionate rise in weight and weight-related ment by creatively leveraging community resources.14 The World health problems,3 and Texas is experiencing a higher rate of obesity Health Organization recognizes that public-private partnerships have and related expenses than the rest of the country.4 This fi nancial bur- many different forms and may be comprised of private businesses, den is accompanied by loss of productive adult years because life governmental agencies, and community organizations of any size expectancy for obese children may be shortened by fi ve to twenty or legal status.14 Crucial elements for public-private partnerships years.5 include collaboration based on common interests and sharing of re- sources and skills.6,14 Public-private partnerships allow for coordina- For the fi rst time in history, there is cause for global concern as over- tion of services that reduce duplication of activities as a means of weight people now outnumber those who are undernourished and effectively utilizing resources.6 Public-private partnerships are also hungry.6 National rates for childhood overweight and obesity are more likely to be successful in achieving public health goals than in- high (28.2%); Texas childhood overweight and obesity rates (31.6%) dividual efforts.6 Childhood obesity interventions require actions in surpass the national average.7 Compounding the problem is the large individual, family, community, and school based environments,12,15 Hispanic population in Texas (38.2%),8 since Hispanic children are making the development of public-private partnerships a logical en- experiencing a disproportionate rise in weight and weight-related deavor. health problems.3,9 Co-morbidities affecting obese children negative- ly impact cardiovascular, gastrointestinal, renal, metabolic, musculo- METHODS skeletal, reproductive, respiratory, and psychological health.10 There A family nurse practitioner experienced in the clinical management of have been recent improvements in national obesity rates for children pediatric obesity recruited representatives from varied backgrounds ages 2-5 years, but rates for all other ages continue to rise.2 Unfor- to develop a public-private partnership to address childhood obesity tunately, the ill effects of childhood obesity extend well beyond the in Del Rio, a medically underserved Texas city on the border with childhood years because the risk of disease associated with obesity Mexico. Children in this community comprise 29.4% (N=35,766) in adolescence remained a factor in adult health regardless of adult of the total mainly Hispanic (84.1%) population.16 The core team weight.11 members represent the local hospital, school district, private busi- ness, faith community, and parents of obese children. A meeting was The fi nancial burden is accompanied by loss of productive years arranged to explore the need for a community-wide plan to address TPHA Journal Volume 66, Issue 4 23 childhood obesity. The expertise of a public health nurse consultant REFERENCES was used in the development of a logic model (Figure 1). 1. Frellick M. AMA Declares Obesity a Disease. 2013. www.medscape.com/ viewarticle/806566. Accessed March 16, 2014. A logic model serves as a guide for identifying key stakeholders, 2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the united states, 2011-2012. JAMA. 2014; 311(8):806-814. interventions, resources, and evaluation of success.17 It provides an 3. Guzman A, Irby MB, Pulgar C, Skelton JA. Adapting a tertiary-care pedi- overview of the expected course of action and can be used as needed atric weight management clinic to better reach Spanish-speaking families. J for securing grant funding. A logic model was developed during the Immigr Minor Health 2012; 14(3):512-515. meeting of core team members and augmented with contributions 4. Combs S. Gaining Costs, Losing Time. 2011. www.window.state/special- from individuals absent from the meeting. The logic model repre- rpt/obesitycost/. Accessed February 23, 2014. sents the intent for interventions in childhood obesity in schools and 5. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life public commons with participation from city and county offi cials, expectancy in the United States in the 21st century. N Engl J Med. 2005; private business owners, healthcare workers, and interested individu- 352(11):1138-1145. 6. Kraak VI, Story M. A public health perspective on healthy lifestyles and als. This logic model will serve as a historical record of the group's public-private partnerships for global childhood obesity prevention. J Am initial efforts to reduce and prevent childhood obesity in the commu- Diet Assoc. 2010; 110(2):192-200. nity and provide a framework for annual evaluation and annual revi- 7. Centers for Disease Control. Adolescent and School Health. 2014. www. sions to refl ect the progress and program enhancements over time. cdc.gov/healthyyouth/obesity/facts.htm. Accessed April 7, 2014. 8. United States Department of Commerce. State and County Quickfacts. RESULTS 2014. www.quickfacts.census.gov/qfd/states/4800.html. Accessed April 9, The logic model development resulted in the formation of a pub- 2014. lic-private partnership now known as Child Health, Activity and 9. Elder JP, Arredondo EM, Campbell N, et al. Individual, family, and com- munity environmental correlates of obesity in Latino elementary school chil- Nutrition Community Events (CHANCE). CHANCE is a commu- dren. J Sch Health. 2010; 80(1):20-30. nity-based program that incorporates community prevention strate- 10. Hopkins KF, Decristofaro C, Elliott L. How can primary care providers gies to address childhood obesity (Figure 2). The underpinnings of manage pediatric obesity in the real world? J Am Acad Nurse Pract. 2011; CHANCE are collaboration, coordination of activities, and effective 23(6):278-288. communication in order to build a healthy community focused on the 11. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term mor- prevention and treatment of childhood obesity. bidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992; 327(19):1350-1355. A leadership committee was formed to recruit collaborative team 12. Wang Y, Wu Y, Wilson RF, et al. Childhood Obesity Prevention Programs: Comparative Effectiveness Review and Meta-Analysis. Rockville, MD: members and provide leadership and oversight of four subcommit- Agency for Healthcare Research and Quality; 2013. tees focusing on physical activity, nutrition, environment, and com- 13. Neuman B. The Neuman Systems Model of Nursing. 2005, http://www. munication. The subcommittees are tasked with establishing pri- neumansystemsmodel.org/NSMdocs/NSM%20overview%20as%20PDF. orities within their domain and identifying specifi c evidence-based pdf. Accessed March 16, 2014. strategies to reduce or prevent childhood obesity (Figure 2). Every 14. World Health Organization. Public-Private Partnerships for Health. 2014, CHANCE team member is responsible for participating in evidence- www.who.int/trade/glossary/story077/en/. Accessed March 16, 2014. based interventions with measurable goals for success. 15. Whitlock EP, O'Connor EA, Williams SB, Beil TL, Lutz KW. Effective- ness of weight management interventions in children: a targeted systematic review for the USPSTF. Pediatrics. 2010;125(2):e396-e418. CONCLUSION 16. United States Department of Commerce. State & County Quickfacts, Del The fi nancial impact of childhood obesity on the Texas economy is Rio (city), Texas. 2014. quickfacts.census.gov/qfd/states/48/4819792.html. increasing and the life expectancy of obese children is decreasing. Accessed March 16, 2014. This combination requires attention; however, addressing the bur- 17. Taylor-Powell, E, Henert E. Developing a logic model: Teaching and dens of childhood obesity will require multiple strategies and inno- training guide. Madison, WI: University of Wisconsin-Extension, Coopera- vative programs to improve the health of the children. Public-private tive Extension, Program Development and Evaluation, 2008. http://www. partnerships are a key aid in collaboration and coordination of re- uwex.edu/ces/pdande. Accessed March 6, 2014. sources within communities and form the foundation for sustainable interventions in the prevention and treatment of childhood obesity.
24 TPHA Journal Volume 66, Issue 4 Figure 1. CHANCE Logic Model
Outputs Outcomes -- Impact Inputs Activities Participation Short (1 year) Medium (2 years) Long (3-5 years)
Stakeholders* CHANCE formal Stakeholders CHANCE - community Established Reduce childhood structure development collaborative formation communication hub overweight and obesity In kind donations from Leadership Team by 10% stakeholders National Leadership National Leadership Leadership capacity Academy for the Children and their Academy for the Public’s building Grant funding Advertising – newspaper, Public’s Health families Health participation church bulletins, hospital application CHANCE sponsored website, stakeholder activity and nutrition meetings Evidence based events interventions in physical activity, nutrition and built environment
Assumptions External Factors Children, families and community desire healthy life. Cultural norms must be considered.
Overweight and Obesity is undesired. Impact of national healthcare changes is unknown.
Quality Measures Childhood overweight and obesity rates in school district Reduction in school absences secondary to illness Number of children participating in events
Number of participating stakeholders
*Stakeholders – individual children and their family, government (city, county and state), hospital, school district, faith-based community, Boys and Girls Club, youth sports leagues, WIC, law enforcement agencies, healthcare providers, newspapers, radio, private businesses, county agriculture department, military base, promotoras, border organizations
Figure 1 is adapted with permission from Taylor-Powell E, Steele S, & Douglah M. Planning a program evaluation. University of Wisconsin-Extension-Cooperative
Extension, Program Development and Evaluation Unit Web Site. Copyright 1996 Board of Regents of the University of Wisconsin System.
Figure 2. Child Health, Activity and Nutrition Community Events (CHANCE) initial strategies to prevent and reduce childhood obesity
Leadership Physical Activity Nutrition Environment Communication Committee Subcommittee Subcommittee Subcommittee Subcommittee Representative Increase daily Increase Advocate for Develop of schools, physical activity awareness of safe walkways marketing healthcare, at home and school district and common strategies private school nutrition grounds Establish business, Promote program Support website community community Decrease creation of bike Distribute organizations events (5k consumption of paths in newsletter and faith based walks, guided sugar community highlighting populations hikes, sporting sweetened Increase events Provide events) beverages availability of Increase leadership and Decrease Encourage public access awareness of oversight for inactivity and breastfeeding physical fitness childhood subcommittees reduce screen Support local structures in obesity and time farmer’s market parks prevention and fresh strategies produce suppliers
TPHA Journal Volume 66, Issue 4 25 In Memorium Dr. Ron Anderson
Dr. Ron Anderson, former CEO of Parkland Hospital in Dallas passed away on Thursday, September 11, 2014 at his home in Duncan- ville from liver cancer. He was 68 years old.
Dr. Anderson was an life member of TPHA. More than that, Dr. Anderson was arguably public health’s greatest friend and advocate. Dr. Anderson’s passion for public health and to serve the less fortunate was not only admirable, but it also set the supreme example for those of us whom he left behind to carry on his legacy. He was the ideal example of a servant leader as well as an innovator. His main concern was that the people of Dallas, and especially those who were less fortunate, received the best possible health care. His steadfast commitment to the underserved in Dallas was stellar.
His career spanned well over three decades at Parkland. During his tenure at Parkland, He led many improvements there, eventually developing Parkland into the premiere facil- ity for treating trauma and burns. Dr. Anderson also oversaw a successful bond election to build a new facility and just recently the Parkland Board of Managers unanimously approved a plan to honor Dr. Anderson with a commemorative statue in the new hospital and to name Parkland’s new medical/surgical outpatient clinic after Dr. Anderson.
PUBLISH WITH THE TEXAS PUBLIC HEALTH JOURNAL! Promote the work of your program Highlight your important public health work Share your public health practice comments & opinion editorials OUR JOURNAL IS Peer-reviewed by public health experts Indexed in EBSCO OUR READERS and SUBSCRIBERS INCLUDE Legislators and staff Schools of public health libraries Public health practitioners around Texas CHECK OUT NEW AUTHOR GUIDELINES ON THE JOURNAL PAGE OF WWW.TEXASPHA.ORG
26 TPHA Journal Volume 66, Issue 4 Texas Public Health Association 91st TPHA Annual Education Conference in Austin, Monday February 23- Wednesday February 25, 2015 About our Annual Education Conference The Texas Public Health Association’s Annual Education Conference offers a variety of oral presentations and posters on various public health topics including original research, program implementation and evaluation, community assessments, public health methods, theories, and issues relating to health promotion and disease prevention, public health nursing, outbreak investigations, disaster preparedness and response, epidemiology, biostatistics, environmental health, social determinants of health and social justice, population health, health administration, public health partnerships, public health accreditation, school health, aging, and health policies that affect individuals, groups, communities, and populations at any age or stage in life. TPHA is a statewide community for discussion, sharing best practices, and networking among public health professionals in Texas. Learn more about TPHA at http://www.texaspha.org/
TPHA Journal Volume 66, Issue 4 27 TPHA HONORARY LIFE MEMBERS
1948 V. M. Ehlers* 1974 Ardis Gaither* 1990 Robert Galvan, MS, RS 1949 George W. Cox, MD* 1975 Herbert F. Hargis* 1991 Wm. F. Jackson, REHS* 1951 S. W. Bohls, MD* 1975 Lou M. Hollar* 1992 Charlie Norris* 1952 Hubert Shull, DVM* 1976 M. L. McDonald* 1993 T. L. Edmonson, Jr.* 1953 J. W. Bass, MD* 1977 Ruth McDonald 1994 David M. Cochran, PE 1954 Earle Sudderth* 1978 Maggie Bell Davis* 1995 JoAnn Brewer, MPH, RN* 1956 Austin E. Hill, MD* 1978 Albert Randall, MD* 1996 Dan T. Dennison, RS, MT, MBA 1957 J. V. Irons, ScD* 1979 Maxine Geeslin, RN 1997 Mary McSwain, RN, BSN 1958 Henry Drumwright 1979 William R. Ross, MD* 1998 Robert L. Drummond 1959 J. G. Daniels, MD* 1980 Ed L. Redford* 1999 Nina M. Sisley, MD, MPH 1960 B. M. Primer, MD* 1981 W. V. Bradshaw, MD* 2000 Nancy Adair 1961 C. A. Purcell* 1981 Robert E. Monroe* 2001 Dale Dingley, MPH 1962 Lewis Dodson* 1982 William T. Ballard* 2002 Stella Flores 1963 L. P. Walter, MD* 1983 Mike M. Kelly, RS 2003 Tom Hatfi eld, MPA 1964 Nell Faulkner* 1983 Hugh Wright* 2004 Janet Greenwood, RS 1965 James M. Pickard, MD* 1984 Hal J. Dewlett, MD* 2005 Charla Edwards, MPH, RN 1966 Roy G. Reed, MD* 1984 C. K. Foster 2006 Janice Hartman, RS 1967 John T. Warren* 1985 Edith Ehlers Mazurek 2007 Jennifer Smith, MSHP 1968 D. R. Reilly, MD* 1985 Rodger G. Smyth, MD* 2008 Catherine D. Cooksley, DrPH 1969 James E. Peavy, MD* 1986 Helen S. Hill* 2009 Hardy Loe, M.D. 1970 W. Howard Bryant* 1986 Henry Williams, RS* 2010 John R. Herbold, DVM, PhD 1970 David F. Smallhorst* 1987 Frances (Jimmie) Scott* 2012 Bobby D. Schmidt, M.Ed 1971 Joseph N. Murphy, Jr.* 1987 Sue Barfoot, RN 2013 Sandra H. Strickland, DrPH, RN 1972 Lola Bell* 1988 Jo Dimock, RN, BSN, ME 2014 Jacquelyn Dingley, RN, BSN, 1972 B. G. Loveless* 1988 Donald T. Hillman, RS* MPH, MBA 1973 Barnie A. Young* 1989 Marietta Crowder, MD *deceased
TPHA Life Members Minnie Bailey, PhD Robert MacLean, MD David R. Smith, MD Ned V. Brookes, PE Sam Marino Kerfoot P. Walker, Jr., MD Oran S. Buckner, Jr., PE, RS Annie Lue Mitchell Alice V. White Burl Cockrell, RS Laurance N. Nickey, MD Exa Fay Hooten Eduardo Sanchez, MD, MPH
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