W A K E C O U N T Y H U M A N S E R V I C E S P U B L I C H E A L T H R E P O R T

P u b l i c H e a l t h Prevent Promote Protect W A K E C O U N T Y H U M A N S E R V I C E S P U B L I C H E A L T H R E P O R T F O U R T H Q U A R T E R 2 0 1 1 O C T O B E R D E C E M B E R, 2 0 1 1 Wake County Human Services Public Health Division 10 Sunnybrook Road P.O. Box 14049 Raleigh, NC 27620-4049 www.wakegov.com February 17, 2012 Ramon Rojano, Human Services Director Sue Lynn Ledford, Public Health Division Director Editor-in chief: Edie Alfano Sobsey, Public Health Epidemiologist Editorial Staff: Roxanne Deter, Public Health Nurse and Carla Piedrahita, Public Health Educator Design and Layout: Michelle Ricci, Public Health Educator

Topic Table of Contents Introduction 3 Tobacco Use Tobacco Use in Adults and Youth 4 Secondhand Smoke Exposure 4 Complaints and Violations of the North Carolina Smoke-Free Restaurants and Bars Law Page Use of the Quitline 5 & 6 Physical Activity and Nutrition Overweight and Obesity 7 WIC Participation 8 School Health School Nurse Referrals 9 School Principal Survey 9 & 10 School Nurse to Student Ratio 10 Sexually Transmitted Diseases Chlamydia and Gonorrhea 11 Integration of Services 12 & 13 HIV Viral Load and Disease Transmission 13 Infectious Disease and Foodborne Illness Seasonal Flu Vaccines Given 14 Reportable General Communicable Disease Investigations 15 Cases of Tuberculosis (TB) in Wake County 15 & 16 Critical Violations in Restaurants and Food Stands 16 & 17 Communicable Disease Events 17 Chronic Diseases Cardiovascular, Breast and Cervical Cancer Screening and Counseling 18 Injury and Violence Wake County Child Maltreatment Surveillance Project 18 Emergency Preparedness CDC Public Health Preparedness Capabilities Assessment 19 Disaster Preparedness Program Monitoring 20 Healthy North Carolina 2020 Objectives 21 & 22 Acknowledgements 23 5 2

Introduction On December 16, 2011 Wake County Human Services achieved Public Health Accreditation status! North Carolina s Local Health Department Accreditation focuses on the capacity of local health departments to perform the three core functions of assessment, policy development and assurance and the 10 public health essential services (See Figure 1) at a basic, prescribed level of quality. This report helps fulfill public health essential services: Number 1: Monitor health status to identify community health problems and Number 3: Inform, educate, and empower people about health issues. It provides data on a quarterly basis to inform residents, providers, policy makers and community partners about the health and safety of Wake County residents. Figure 1 = The report is organized to align with selected Healthy North Carolina 2020 Focus Areas and Objectives (see http://publichealth.nc.gov/hnc2020/docs/hnc2020-final-march-revised.pdf). The information presented monitors the current state of health indicators in Wake County and presents some of the strategies used by Wake County Public Health programs and services to improve health outcomes. The content of this report may change to include data for analysis of health indicators identified in the Wake County Community Health Assessment, through the Human Services and Environmental Services Board or elsewhere as needed. For additional information not included in this report, point of contact information is provided for each area. We wish to thank all staff who contributed to this report and for their daily efforts toward improving the health and safety of the citizens of Wake County. Sue Lynn Ledford, Public Health Division Director Edie Alfano-Sobsey, Public Health Epidemiologist 3

To b a c c o U s e TOBACCO USE IN ADULTS AND YOUTH There has been a 25% increase in the percentage of adult smokers in Wake County since 2008. In 2010 only 16% of all adults in Wake county smoked as compared to 20% of adults in NC (see Figure 2). Figure 2 Percent of Adult Smokers in Wake County Compared to NC from 2006-2010 25 20 22.1 22.9 20.9 20.3 19.8 Percent 15 10 5 12.5 17.5 12.0 15.7 16.2 NC Wake County 0 2006 2007 2008 2009 2010 Year Source: Behavioral Risk Factor Surveillance System (BRFSS) Survey, NC Center for Health Statistics According to the North Carolina 2009 Youth Tobacco Survey (YTS), which includes Wake County Youth: 24.6% of students used any tobacco product (Male = 29.1%, Female = 19.5%) 16.0% smoked cigarettes (White = 19.4%, Black = 10.8%, Hispanic = 11.3%) 7.7% used smokeless tobacco (Male = 12.7%, Female = 2.2%) SECONDHAND SMOKE EXPOSURE From 2008-2010, the percent of people reporting no exposure to secondhand smoke in the workplace has increased from 93% to 96% in Wake County and from 84% to 91% in NC (see Figure 3). Figure 3 Percent of People Exposed to Secondhand Smoke in Wake County Compared to NC 2008 2010 1-6 days all 7 days No days 1-6 days all 7 days No days NC 5% 11% 84% 4% 5% 91% Wake 3% 4% 93% 3% 2% 96% Source: BRFSS Survey, NC Center for Health Statistics 4

To b a c c o U s e COMPLAINTS AND VIOLATIONS OF THE NORTH CAROLINA SMOKE-FREE RESTAURANT AND BARS LAW As of January 2, 2010, restaurants and bars and many lodging establishments in North Carolina were required to be smoke-free by enforcement of SL2009-27 (G.S. 130A-496) known as the North Carolina Smoke-Free Restaurants and Bars Law. In 2010, as a result of public attention to this new law through media and educational campaigns, 242 complaints about violations of this law were filed involving 81 establishments. In 2011, the number of complaints declined. In 2010 and 2011, 13 violations of this law were issued by WCHS involving some repeat offenders. 300 Figure 4 Number of Complaints and Violations of the North Carolina Smoke- Free Restaurants and Bars Law in Wake County Businesses during 2010 and 2011 250 242 200 Number 150 # complaints 100 50 81 30 27 13 13 #businesses #violations 0 2010 2011 Year Source: NC State Careline Reports and Wake County Human Services Site Visits and Violation Letters USE OF THE NC QUITLINE The NC Quitline started in November 2005. The purpose of the Quitline is to provide NC citizens a FREE resource to aid in quitting tobacco use. The Quitline offers four counseling sessions either by phone, and/or online. As of February 2, 2012, the Quitline is available 24 hours a day. Healthcare providers can refer someone to the Quitline by fax and a quit coach will call them. Additionally, even though supplies are limited, callers who enroll and qualify are offered FREE nicotine replacement therapy (NRT) medication in the form of patches, gum or lozenges. The Quitline number is 1-800-QUITNOW (1-800-784-8669). During February and March 2010, enrollment in the Quitline increased (see Figure 5) because of media coverage about the new North Carolina Smoke-Free Restaurants and Bars Law and other promotional activities through Wake County Human Services (WCHS) Project ASSIST (American Stop Smoking Intervention Study). Radio advertisements and health professionals were most effective in informing people about the Quitline (see Figure 6). 5

250 To b a c c o U s e Figure 5 Number of Wake County Residents Registered in Quitline in 2010 & 2011 200 150 Number 100 2010 2011 50 0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Month Source: NC Quitline Monthly Data Reports for Jan. Dec. 2010 and Jan. Dec. 2011 Figure 6 Percent of Wake County Respondents Answering the Quitline Question " How did you hear about the Quitline?" in 2010 compared to 2011. N= 496 Website Tv Radio Outdoor ad Newspaper Health Professional 2011 2010 Health Dept Family/Friend Employe r/worksite 0% 5% 10% 15% 20% 25% 3 0% Source: NC Quitline Monthly Data Reports for Jan. Dec. 2010 and Jan. Dec. 2011 Contact: Sonya Reid, Health Promotion Chronic Disease Prevention Section 919-250-4553 sreid@wakegov.com 6

P h y s i c a l A c t i v i t y a n d N u t r i t i o n OVERWEIGHT AND OBESITY Figure 7 Overweight or Obese % BRFSS Respondents Who Have a Body MassIndex (BMI) > 25 BMI 70 60 50 40 30 60.1 63.1 58.1 55.8 62.9 64.6 65.4 66.5 61.8 61.9 61.1 59.9 Underweight: BMI <18.5 Recommended Range: BMI 18.5 to 24.9 Overweight: BMI 25.0-29.9 Obese: BMI >30 20 10 0 2003 2004 2006 2007 2009 2010 Year NC Wake A measure of body mass index (BMI) is often used to identify possible weight problems. Adults with BMI of 25-29.9 are considered overweight and adults with a BMI of 30 or above are considered obese. During 2010 in North Carolina, 66.5 % of adult respondents were overweight or obese compared with 60% of Wake County respondents (see Figure 7). Wake County Human Services (WCHS) top priority is to reduce obesity among preschool, school age and adult populations by 2% through nutrition and physical activity by 2014 *. Services provided in WCHS programs, such as Health Promotion and Disease Prevention ** and the Special Supplemental Nutrition Program for Women and Children (WIC), routinely address this issue as well as partnerships with the Wake County Public School System that focus on reducing obesity in children. This is consistent with Healthy North Carolina 2020 Objectives for Physical Activity and Nutrition (see Healthy North Carolina 2020 Objectives: Physical Activity and Nutrition page 21). * Wake County State of the County s Report, 2011 (http://www.wakegov.com/humanservices/communityhealth/default.htm) ** Health Promotion and Disease Prevention Annual FY 11 Report Contact: Sonya Reid, Health Promotion Chronic Disease Prevention Section 919-250-4553 sreid@wakegov.com 7

P h y s i c a l A c t i v i t y a n d N u t r i t i o n WIC PARTICIPATION The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides nutrition education, breastfeeding promotion and support, referrals to healthcare, and food vouchers for pregnant women, mothers of infants, and children under five years of age who have nutrition-related health problems and income at or below 185% of poverty. WIC is a federally-funded program administered by NC Department of Health and Human Services (DHHS). Additional County funds (5% of total budget) support WIC services in Wake County. Figure 8 19,400 Active WIC Participation 2009 -September 2011 19,200 19,000 C a s e l o a d 18,800 18,600 18,400 18,200 18,000 17,800 17,600 17,400 The temporary fall in WIC participation during August to December 2009 is attributed to high staff vacancy rates causing a decreased ability to serve current and new participants during that time. The creation of six new direct client services positions and staff hiring for eighteen vacant positions resulted in improved client to staff ratios with program growth since January 2010. The caseloads continued to decline through April 2011 (also observed in the North Carolina WIC Program statewide) but participation in Wake County has shown a rebound as of May and June 2011 (most recent data available). Contact: Sharon Dawkins, Women, Infants and Children Section 919-250-4728 Sharon.Dawkins@wakegov.com 8

School Health SCHOOL NURSE REFERRALS In the first quarter of 2011-2012, there was a 13% increase in the number of students referred to the school nurse compared to 2010-2011 (see Figure 9). When comparing the second quarter of 2010-2011 to the second quarter of 2011-2012, there was a 20% increase. School nurses are receiving more referrals each year. Figure 9 Unduplicated* Number of Students Referred to the School Nurse Comparison of 2010-2011 and 2011-2012 School Year 1st Quarter (July-September) and 2nd Quarter (October-December) Number 8000 6000 4000 2000 6302 5578 5017 4178 2010-2011 School Year 2011-2012 School Year 0 1st Quarter Quarter 2nd Quarter *Each student a school nurse has contact with throughout the school year is counted once to get the unduplicated number of students referred to the nurse. Students who are screened for vision and those participating in group presentations are not included in this number. SCHOOL PRINCIPALS SURVEY Figure 10 Increasing Numrsing Time Responses Categorized Open Ended Responses to Survey Question: "How Can the School Heath Program Help You?" 28 of 41 survey participants responding to this question wrote in references to increase nursing time 2010-2011 School Year More time 5 days a week More services More days More than 1 day More Nurses More hours 2 days Principals of Wake County Public Schools (WCPSS) respond to a yearly survey given by WCHS School Health Nursing Program. Survey results indicate that principals want nurses to spend more time and provide more health services to the students in their schools (see Figure 10). 0 2 4 6 8 10 Number of Responses Source: Principal Survey 2010-2011, WCHS School Based Nursing Service, June 2011 9

School Health Figure 11 Catagorized Open Ended Responses of WCPSS Principals to Survey Question: "What are the most important challenges facing your school?" 50 out of 77 respondents answered this question 2010-2011 School Year Limited Nurse Resources Limited School Staff Resources Quantity and Quality of Health Concerns Chronic Life Threatening illnesses Diabetic & special programs Physical Health and Behavorial Health Concerns Parent Concerns Access to health care Responses Communication Poor Living Conditions Absenteeism 0 5 10 15 Number of responses for each category *Some respondents gave multiple answers to the question. Source: Principal Survey 2010-2011, WCHS School Based Nursing Service, June 2011 Principals are responsible for the education, health and welfare of children in their schools. They listed challenges facing their schools in a survey. The emergency and daily care of students with chronic and complex health conditions such as diabetes, severe allergies, feeding tubes and catheterizations are provided by non-medical school staff trained by school nurses. As nurses split their time between three schools, the limited nursing resources are a challenge for principals (see Figure 11). SCHOOL NURSE TO STUDENT RATIO The school nurse to student ratio is a measure used across the state of North Carolina and the United States. The recommended ratio of nurses to students helps assure students are healthy and able to participate in school. The school nurse to student ratio is significantly higher in Wake County compared to the recommended standard and other North Carolina Counties. The standard ratio is one nurse for 750 students. In 2010-2011, the ratio in Wake County was one nurse for 2,715 students. In NC the ratio was one nurse for 1,201 students. Figure 12 Contact: Roxanne Deter, Public Health Division 919-250-4637 rdeter@wakegov.com 10

Sexually Transmitted Diseases CHLAMYDIA AND GONORRHEA Preliminary data from the Communicable Disease Branch, NC Division of Public Health from 2008-2011 indicates that the case rates per 100,000 population for chlamydia (400.1 to 527.0) and gonorrhea (112.6 to 150.4) continue to increase (see Figure 13). Figure 13 600 500 400 300 200 100 0 400.1 Chlamydia and Gonorrhea Case Rate (per 100,000 population) in Wake County from 2009-2011 502.8 112.6 138.6 150.4 2009 2010 2011 527.0 Chlamydia Gonorrhea Source: Communicable Disease Branch NC Division of Public Health Several strategies have been implemented to address the high rates of gonorrhea and chlamydia in Wake County. These include: Expedited Partner Therapy (EPT). Partners of those who are diagnosed with chlamydia or gonorrhea are offered treatment without having to be seen first by a health care provider. This helps treat these diseases faster. Wake County Human Services (WCHS) clinics began offering EPT last quarter. Field Delivered Therapy (FDT). Beginning November 29, 2011, FDT to treat clients for chlamydia and/ or gonorrhea infections was implemented by Disease Intervention Specialists (DIS) and the Disease Intervention Nurse. As of February 7, 2012, infected clients with positive laboratory results for either disease ranging from 1/1/11 to 10/28/11 and who were lost to follow up for treatment, were identified and enrolled in this program. Medications were delivered to 32 clients with chlamydia, 6 with gonorrhea and 1 with both gonorrhea and chlamydia infections. In the near future, WCHS HIV/STD Counselors will also assist in FDT. Comprehensive Risk Counseling and Services (CRCS) are being provided by WCHS HIV/STD Health Educators to STD clients referred by the clinics. CRCS is a best practice strategy that provides intensive, individualized counseling for adopting and maintaining HIV risk reduction behaviors. Individuals who enroll in CRCS receive free one-on-one risk-reduction counseling and support and work with their counselor to develop personalized goals for behavior change. Consultation and support for community partners. Since December 2011, HIV/STD Health Educators provide consultation to 4-H staff providing education for youth ages 12-18 yrs. old. The HIV/STD Community Outreach Program has been working with area colleges and universities using HIV/STD peer educators (a best practice strategy). These efforts provide prevention education to those who are at the highest risk. Strengthening the Black Family, Inc. is also incorporating prevention messages and training to young people participating in its youth leadership program 11

Sexually Transmitted Diseases Parents Matter. Parents Matter is an evidence-based program that is provided by HIV/STD Health Educators to help parents of preteens become better health teachers for their children and protect them from the negative outcomes of unhealthy sexual behaviors. The five sessions (2.5 hours each) build parents knowledge and skills so they can better communicate their personal values about sex to their children. This program also provides current STD information that can be shared with family members and helps parents develop strategies to help children understand sexual messages in the media. The program is intended for parents with children 9 12 years old and is available in English and Spanish. INTEGRATION OF SERVICES To increase detection of and treatment for all STDs in high risk populations, testing services for HIV, syphilis, chlamydia, gonorrhea, hepatitis C and TB are integrated by offering them at the same time to clients at community as well as clinical testing sites. Enhanced testing is made possible through the CDC Program Collaboration and Service Integration (PCSI) and other grant funding. Figure 14 shows the number of tests performed at community sites and the positivity test rates for HIV, syphilis, gonorrhea, chlamydia and hepatitis C from October to December 2011. From March 2011 to December 2011, 198 at risk clients were also tested for TB at non-traditional testing sites (Wake County Human Services data). Number of Tests and Test Positivity Rate (%) at Non-Traditional Testing Sites in Wake County from October to December 2011 500 (9.6 %) 500 (1.4%) 39 (12.8%) 680 (0.4%) 682 (0.1%) HIV Syphilis Gonorrhea Chlamydia Hepatitis C Figure 14 Non-traditional testing sites are community locations where HIV/STD counseling and testing services would not customarily be provided (churches, shelters, colleges and universities, etc.) Source: Wake County Human Services Figure 15 Note: Totals in Figures 14, 15, and 16 show the number of tests administered followed by the percentage of tests with positive results. Number of Tests and Test Positivity Rate (%) at Substance Abuse Centers in Wake County from October to December 2011 61(0%) 76 (15.8%) 61 (0%) 90 (0 %) 91(0%) HIV Syphilis Gonorrhea Chlamydia Hepatitis C Source: Wake County Human Services 12

Sexually Transmitted Diseases Number of Tests and Test Positivity Rate (%) at Expanded Testing Sites in Wake County from October to December 2011 Figure 16 406 (6.9%) 398 (0%) HIV Hepatitis C testing is not offered at Expanded Testing Sites (jail, detention). 406 (2.5%) 407 (2%) Syphilis Gonorrhea Chlamydia Source: Wake County Human Services (WCHS) HIV VIRAL LOAD AND DISEASE TRANSMISSION Figure 17 Source: WCHS CAREWare Copies/ml Average Viral Load Among Clients at Wake County Human Services from 2007-2011 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 20072008200920102011 YEAR Average All Average All on ART Average All Not on ART Linear (Average All) Linear (Average All on ART) Linear (Average All Not on ART) Viral load is a measure of the amount of HIV viral nucleic acid in the blood of a person infected with HIV. This measure is used to monitor the status of HIV infection in a newly diagnosed patient, to guide recommendations for therapy, and to predict the future course of the infection. A low viral load indicates that HIV is not actively reproducing and that the risk of disease progression is low. Wake County Human Services monitors the viral load counts annually among clients who have been in the system for at least six months during the year of analysis. Since 2007 the overall average viral load and average viral load among clients on antiretroviral therapy (ART) has generally decreased although it increased again during 2011 (see Figure 17). However, the median for those on ART has decreased from 48 in 2007 to 20 copies /ml in 2011 indicating that clients now have lower viral loads. Of note, a recently published study (Cohen et al., 2011) demonstrated that early treatment of HIV infection by ART before the disease progresses and while the immune system is healthy is an important public health measure to prevent transmission of this disease to others. Contact: Yvonne Torres, HIV/STD Community Section 919-250-4479 ytorres@wakegov.com or Edie Alfano-Sobsey, Epidemiologist Public Health Division 919-212-9674 Edie.AlfanoSobsey@wakegov.com 13

I n f e c t i o u s D i s e a s e s a n d F o o d b o r n e I l l n e s s SEASONAL FLU VACCINES GIVEN Figure 18 Figure 19 Figure 18 represents the number of seasonal influenza (flu) vaccine doses administered to children and adults at Wake County Human Services (WCHS) clinics and outreach activities. The totals do not include the H1N1 influenza doses administered during the 2009/2010 pandemic response. * During the 2009/2010 flu season, WCHS conducted an American Recovery and Reinvestment Act (ARRA) funded, school-located seasonal flu initiative in addition to traditional flu clinic operations. The project provided flu vaccine to nearly 6300 children. Source: NC Immunization Registry (NCIR) and WCHS Weekly Flu Tally Reporting Clinic E State-supplied doses of flu vaccine are provided to Vaccines for Children (VFC) program eligible children and pregnant women. Private purchased doses are provided to Medicare and Medicaid patients, self-paying clients and Wake County staff. Figure 19 shows sources of flu vaccine provided for the last 5 flu season years. Seasonal flu vaccine is traditionally offered at WCHS between October and April. The flu season of 2009/2010 included a school-located American Recovery and Reinvestment Act (ARRA) funded seasonal flu initiative that administered 6300 doses to children at 21 public, private and charter school sites in Wake County. Source: NC Immunization Registry (NCIR) and WCHS Weekly Flu Tally Reporting Clinic E 6/2011 Contact: JoAnn Douglas, Immunization Outreach 919-250-4518 jdouglas@wakegov.com 14

I n f e c t i o u s D i s e a s e s a n d F o o d b o r n e I l l n e s s REPORTABLE GENERAL COMMUNICABLE DISEASE INVESTIGATIONS Figure 20 180 160 140 120 100 Investigations 80 60 40 20 0 Reportable Communicable Disease Investigations January -December 2011**** 30 18 70 46 7 111 53 51 41 127 167 28 Jan - Mar Apr - Jun Jul - Sep Oct - Dec Foodborne Illness* Tickborne Illness** Hepatitis B*** *Foodborne Illness includes Campylobacter, E. coli shiga toxin producing, Hepatitis A, Salmonella and Shigella **Tickborne Illness includes Rocky Mountain Spotted Fever, Lyme Disease and Ehrlichiosis ***Hepatitis B includes new infections, long term infections and those acquired through pregnancy/ Birth ****Number reported by NC Electronic Disease Surveillance System (NCEDSS) as of February 10,2012. Figure 20 shows the investigations of food and tickborne illnesses and hepatitis B. The increase shown in tickborne illness investigations during October through December is likely due to diagnoses reported late in the summer and early fall months and to delayed reporting due to other outbreak investigations (see Communicable Disease Events page 17). TUBERCULOSIS (TB) CASES Wake County Human Services has the legal responsibility and authority to coordinate all TB control efforts in Wake County. This includes reducing the number of people who become infected, providing preventive treatment to those who are infected and ensuring that people with TB disease get appropriate treatment. Figure 21 shows the number of active TB cases WCHS TB control reported to the North Carolina Division of Public Health and the Centers for Disease Control and Prevention (CDC). Figure 21 Number of Active Cases Number of Active TB Cases Reported to Centers for Disease Control and Prevention (CDC) Wake County Human Services TB Control 2005-2011 60 50 40 30 20 10 0 2005 2006 2007 2008 2009 2010 2011 Source: Wake County Human Services Tuberculosis Control Annual Report Total Number Cases reported to CDC 15

I n f e c t i o u s D i s e a s e s a n d F o o d b o r n e I l l n e s s Figure 22 Percent of Active TB Cases by Race WCHS TB Control 2010 and 2011 100% 50% 0% 19% 41% 43% 14% 38% 45% 2010 (N=37) 2011 (N=29) Asian White Black Source: Wake County Human Services Tuberculosis Control Annual Report Figure 22 shows the percentage of active TB cases by race. Figure 23 shows the percentage of active TB cases who were born outside of the US. Figure 23 Percent 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent of WCHS Active TB Cases Foreign Born Compared to Those Born in the United States 2005-2011 50% 63% 65% 60% 68% 37% 54% 46% 35% 40% 32% 2005 2006 2007 2008 2009 2010 2011 66% 34% Source: Wake County Human Services Tuberculosis Control Annual Report Percent cases were foreign born Percent cases were were USborn CRITICAL VIOLATIONS IN RESTAURANTS AND FOOD STANDS "Critical Violation Risk Factors are those that increase the chance of developing food-borne illness and are categorized by CDC as poor personal hygiene (1-5), food from unsafe source (6-9), cross contamination/ contaminated equipment (10-12), inadequate final cook temperature (13), improper holding/time-temperatures (14-18). Figure 24 on page 17 shows that most of the critical violations involved cross contamination of foods and contaminated equipment. 16

Figure 24 300 250 200 150 100 I n f e c t i o u s D i s e a s e s a n d F o o d b o r n e I l l n e s s Number of Critical Violations Associated with CDC Risk Factors* at Wake County Restaurants/Food Stands October-December 2011 Oct-11 Nov-11 Dec-11 50 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Risk Factors Risk Factor* Items 1-5: Poor Personal Hygiene Item 13: Final Cook Temperature Items 6-9: Food from Unsafe Source Items 14-18: Holding/Time-Temperature Items 10-12: Cross Contamination/ Contaminated Equipment Contact: Andre Pierce Wake County Environmental Services 919-865-7440 apierce@wakegov.com COMMUNICABLE DISEASE EVENTS Rabies Exposure Investigation During September 2011, a kitten named Silverbelle that was adopted from the Wake County Animal Shelter tested positive for rabies. This began an extensive investigation to trace human and animal exposure to the kitten involving multiple partners in several counties. Twenty two people were evaluated for possible rabies exposure. Of these, 17 were exposed and referred for post exposure treatment. No other human exposures to Silverbelle were identified after media alerts were issued to the public. The total cost of this investigation including Wake County Human Services staff time, Wake County Animal Control staff time, quarantine fees and treatment for post-exposure prophylaxis is estimated at over $100,000. E. coli O157:H7 Outbreak On October 25, 2011, Wake County Human Services and Environmental Services staff, partnering with the NC Division of Public Health, began an investigation of an enteric illness outbreak caused by infection with E. coli O157:H7 bacteria. More than 50 calls were received by Wake County Communicable Disease Section staff about the outbreak. A total 25 cases of illness were identified in residents from Wake (13), Sampson (6), Wilson (2), Cleveland (1), Durham (1), Johnston (1), and Orange (1) counties. Eight (32%) were hospitalized and 4 (16%) experienced a severe complication of the disease, hemolytic uremic syndrome. The NC Division of Public Health conducted a case-control study interviewing all 25 cases as well as 77 individuals who attended the fair, but did not get sick. The results of the study determined that visiting the Kelley Building at the North Carolina State Fair, a structure where sheep, goats, and pigs were housed and competed in livestock shows during the fair, was a likely source of exposure for this illness. The investigation was written up in the Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. To view the report, visit http://www.cdc.gov/mmwr/pdf/wk/mm6051.pdf (p. 1745). Contact: Ruth Lassiter, Epidemiology and Surveillance Section, 919-212-7344 ruth.lassiter@wakegov.com 17

C h r o n i c D i s e a s e s CARDIOVASCULAR, BREAST AND CERVICAL CANCER SCREENING AND COUNSELING Cardiovascular ( July 1, 2010 to June 30, 2011) Provided 1,111 blood pressure checks; detected 71 individuals with hypertension stage 2 and secured care for 43 of them lacking a medical home. According to the NC Heart Disease and Stroke Prevention Branch, the average lifetime cost of a stroke in the US is estimated at $103,576 per stroke event. Health Promotion staff assisted in securing medical care for those 43 individuals resulting in a potential cost savings of $4.3 million dollars. Left untreated, those individuals run the risk of stroke and the huge medical costs associated with the event. Provided 923 body mass index measures; detected 33% were overweight and 50% obese Provided 627 cholesterol checks; detected 50% with high cholesterol Provided one-on-one counseling for 100% of people who had a blood pressure check, a cholesterol check or a body mass index measure Breast & Cervical Cancer Screening ( July 1, 2010 to June 30, 2011) Provided 335 mammograms; detected 10 breast cancers. Provided 78 cervical screenings via WCHS Breast and Cervical Cancer Control (BCCCP) Clinic. These screenings were provided for women who are ineligible to receive family planning services but need access to women's preventive cancer screenings. Source: Wake County Human Services Health Promotion Chronic Disease Prevention Section, FY '11 Annual Report Contact: Sonya Reid, Health Promotion Chronic Disease Prevention Section 919-250-4553 sreid@wakegov.com I n j u r y a n d Vi o l e n c e WAKE COUNTY CHILD MALTREATMENT SURVEILLANCE PROJECT The John Rex Endowment has recently awarded funding to address improvements to child maltreatment systems in Wake County. The purpose of the Wake County Child Maltreatment Surveillance (CMS) project is to partner with Wake County agencies working on child maltreatment to assess current data, identify data gaps, and implement changes that could become the basis for a comprehensive CMS system. Wake County will benefit from an improved understanding of the problem of child maltreatment which can help inform and guide decisions around child maltreatment prevention. The CMS system hopes to add to the current child maltreatment work done in Wake County by addressing the following objectives: Develop standard and agreed upon data definitions for child maltreatment. Monitor the prevalence of child maltreatment, including maltreatment perpetrated by family caregivers and non-family caregivers. Use multiple sources of data to provide a broader picture of child maltreatment. Identify science-based measures for collecting indicators of, and risk and protective factors associated with child maltreatment. Collect summarizing and reporting data on a yearly basis to measure trends over time. Provide more information about child maltreatment, specifically enhancing data around cases that do not involve Child Protective Services or result in a fatality. Source: Megan Shanahan, Wake County Child Maltreatment Surveillance Coordinator Contact: Edie Alfano-Sobsey, Epidemiologist Public Health Division 919-212-9674 Edie.AlfanoSobsey@wakegov.com 18

E m e r g e n c y P r e p a r e d n e s s CDC PUBLIC HEALTH PREPAREDNESS CAPABILITIES ASSESSMENT Today, in addition to responding to emergencies that affect the health and safety of citizens, public health systems and their respective preparedness programs face many challenges. Federal funds for preparedness have been declining, causing state and local planners to express concern over their ability to sustain the real and measurable advances made in public health preparedness. State and local planners likely will need to make difficult choices about how to prioritize and ensure that available resources are directed to priority areas within their jurisdictions. The Centers for Disease Control and Prevention (CDC) implemented a systematic process for defining a set of public health preparedness capabilities to assist state and local health departments with their strategic planning. The first step in the strategic planning process is to conduct a Public Health Capabilities Assessment utilizing the CDC defined review process. The Public Health Preparedness Capabilities are organized into 15 categories and then additionally a number of functions for each category: Community Preparedness (4 functions) Community Recovery (3 functions) Emergency Operations Coordination (5 functions) Emergency Public Information and Warning (5 functions) Fatality Management (5 functions) Information Sharing (3 functions) Mass Care (4 functions) Medical Countermeasure Dispensing (5 functions) Medical Material Management and Distribution (6 functions) Medical Surge (4 functions) Non-Pharmaceutical Interventions (4 functions) Public Health Laboratory Testing (5 functions) Public Health Surveillance and Epidemiological Investigation (4 functions) Responder Safety an d Health (4 functions) Volunteer Management (4 functions) Additionally under each function, there are several assessment areas for priorities, skills, training and equipment required by the CDC assessment tool. This assessment process is to be completed by March 2012, as directed by NC Public Health Preparedness & Response section. Since September 2011, this comprehensive assessment for Wake County has occupied the majority of time for the Preparedness Coordinator and has involved a time commitment from other staff in WCHS and other Wake County agencies. 19

DISASTER PREPAREDNESS PROGRAM MONITORING E m e r g e n c y P r e p a r e d n e s s OM 2011. WCHS Disaster Preparedness Program staff responded to 8 situations in Wake County. Figure 25 shows the number of public health situations by quarter responded to in 2011 by Wake County Human Services, Wake County Environmental Services and partners. Figure 25 WCHS Disaster Preparedness Program Monitoring (As of January 18, 2012) 3.5 No. of Public Healt h Situations* in Wake County 3 2.5 2 Number of Situations 1.5 1 0.5 0 (Jan-Feb-Mar) (Apr-May-Jun) (Jul-Aug-Sep) (Oct-Nov-Dec) No. of Public Healt h Situations* responded to by WCHS/WCES No. of Public Healt h Situations Responded to with Partners** * A Situation can be an incident, an event, or any observable or predictable occurrence. It is a generic term referring to occurrences of any scale that may require some form of Emergency Response and Management, and that requires tracking and information exchange. ** Partners = Any agency or groups outside of WCHS/WCES Contact: Brian McFeaters, Public Health Emergency Preparedness Section 919-212-9394 bmcfeaters@wakegov.com 20

Healthy North Carolina 2020 Objectives Every ten years since 1990, the state of North Carolina sets objectives aimed at improving the health of North Carolinians. Below are the objectives that are set for the year 2020 organized by focus area. The Wake County Human Services Public Health Report is organized to align with selected Healthy North Carolina 2020 Focus Areas and Objectives For more information about North Carolina s health objectives and how they are decided, visit the North Carolina Division of Public Health web page at http://publichealth.nc.gov/ hnc2020/objectives.htm. Tobacco Use Current 2020 Target 1. Decrease the percentage of adults who are current smokers 20.3% (2009) 13.0% 2. Decrease the percentage of high school students reporting current use of any tobacco product 3. Decrease the percentage of people exposed to secondhand smoke in the workplace in the past seven days 25.8% (2009) 15.0% 14.6% (2008) 0% Physical Activity and Nutrition Current 2020 Target 1. Increase the percentage of high school students who are neither overweight nor obese 72.0% (2009) 79.2% 2. Increase the percentage of adults getting the recommended amount of physical activity 46.4% (2009) 60.6% 3. Increase the percentage of adults who consume five or more servings of fruits and vegetables per day 20.6% (2009) 29.3% Injury and Violence Current 2020 Target 1. Reduce the unintentional poisoning mortality rate (per 100,000) population 11.0 (2008) 9.9 2. Reduce the unintentional falls mortality rate (per 100,000) population 8.1 (2008) 5.3 3. Reduce the homicide rate (per 100,00) population 7.5 (2008) 6.7 Maternal and Infant Health Current 2020 Target 1. Reduce the infant mortality racial disparity between whites and African Americans 2.45 (2008) 1.92 2. Reduce the infant mortality rate (per 1,000 live births) 8.2 (2008) 6.3 3. Reduce the percentage of women who smoke during pregnancy 10.4% (2008) 6.8% Sexually Transmitted Diseases and Unintended Pregnancy Current 2020 Target 1. Decrease the percentage of pregnancies that are unintended 39.8% (2007) 30.9% 2. Reduce the percentage of positive results among individuals aged 15 to 24 tested for chlamydia 9.7% (2009) 8.7% 3. Reduce the rate of new HIV infection diagnoses (per 100,000) population 24.7% (2008) 22.2 Substance Abuse Current 2020 Target 1. Reduce the percentage of high school students who had alcohol on one or more of the past 30 days 35.0% (2009) 26.4% 2. Reduce the percentage of traffic crashes that are alcohol-related 5.7% (2008) 4.7% 3. Reduce the percentage of individuals aged 12 years and older reporting any illicit drug use in the past 30 days. 7.8% (2007-2008) 6.6% 21

Mental Health Current 2020 Target 1. Reduce the suicide rate (per 100,000 population) 12.4 (2008) 8.3 2. Decrease the average number of poor mental health days among adults in the past 30 days 3. Reduce the rate of mental health related visits to emergency departments (per 100,000) population 3.4 (2008) 2.8 92.0 (2008) 82.8 Oral Health Current 2020 Target 1. Increase the percentage of children aged 1-5 years enrolled in Medicaid who receive any dental service during the previous 12 months 46.9% (2008) 56.4% 2. Decrease the average number of decayed, missing or filled teeth among kindergartners 1.5 (2008-09) 1.1 3. Decrease the percentage of adults who have had permanent teeth removed due to tooth decay or gum disease 47.8% (2008) 38.4% Environmental Health Current 2020 Target 1. Increase the percentage of air monitor sites meeting the current ozone standard of 0.075 ppm 2. Increase the percentage of the population being served by community water systems (CWS) with no maximum contaminant level violations (among persons on CWS) 3. Reduce the mortality rate from work-related injuries (per 100,000 equivalent full time workers ) 62.5% (2007-09) 100.0% 92.2% (2009) 95.0% 3.9 (2008) 3.5 Infectious Disease and Foodborne Illness Current 2020 Target 1. Increase the percentage of children aged 19-35 months who receive the recommended vaccines. 77.3% (2007) 91.3% 2. Reduce the pneumonia and influenza mortality rate (per 100,000 population) 19.5% (2008) 13.5% 3. Decrease the average number of critical violations per restaurant/food stand 6.1 (2009) 5.5 Social Determinants of Health Current 2020 Target 1. Decrease the percentage of individuals living in poverty 16.9% (2009) 12.5% 2. Increase the four year high school graduation rate 71.8% (2008-09) 3. Decrease the percentage of people spending more than 30% of their income on rental housing 94.6% 41.8% (2008) 36.1% Chronic Disease Current 2020 Target 1. Reduce the cardiovascular disease mortality rate (per 100,000 population) 256.6 (2008) 161.5 2. Decrease the percentage of adults with diabetes 9.6% (2009) 8.6% 3. Reduce the colorectal cancer mortality rate (per 100,000 population) 15.7 (2008) 10.1 Cross Cutting Current 2020 Target 1. Increase average life expectancy (years) 77.5 (2008) 79.5 2. Increase the percentage of adults reporting good, very good, or excellent health 81.9% (2009) 90.1% 3. Reduce the percentage of non-elderly uninsured individuals (aged less than 65 years) 20.4% (2009) 8.0% 4. Increase the percentage of adults who are neither overweight nor obese 34.6% (2009) 38.1% 22

A c k n o w l e d g e m e n t s Contributors to this Public Health Quarterly Report are: Edie Alfano-Sobsey Debbie Bissette Sharon Dawkins Roxanne Deter JoAnn Douglas Lydia Loyd Brian McFeaters Michael McNeil Carla Piedrahita Andre Pierce Michelle Ricci Ronda Sanders Megan Shanahan Yvonne Torres February 17, 2012 23