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1 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 Q U A R T E R L Y R E P O R T J A N U A R Y M A R C H Wake County Human Services Public Health Division 10 Sunnybrook Road P.O. Box Raleigh, NC MAY 18, 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 1

2 Table of Contents Topic Introduction 3 County Health Rankings 4 Tobacco Use Quitline Use 7 School Health School Nurse to Student Ratio 8 School Staff Training 9 School Health Services 10 Outreach National Association of Counties (NACo) Prescription Drug Discount Card Program Infectious Disease and Foodborne Illness Reportable General Communicable Disease Investigations 12 Page Critical Violations at Wake County Restaurants/Food Stands 12 & 13 Emergency Preparedness Strategic National Stockpile Plan 13 Sexually Transmitted Infections Integrated Testing Services 14 & 15 Pregnancy Rates Pregnancy Rates for Year Olds in Wake County 16 & 17 Wake County Prenatal Clinic Clients Healthy North Carolina 2020 Objectives 19 & 20 Acknowledgements

3 Introduction Wake County Human Services (WCHS), an accredited health department, continues to strive to perform the three core functions of assessment, policy development and assurance and the 10 public health essential services (see Figure 1). 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. Figure 1 Information is provided on a quarterly basis about health and safety trends for Wake County residents, providers, policy makers and community partners to better inform decision making. Strategies used by WCHS Public Health programs and services to improve health outcomes are also featured in these reports. For additional information, point of contact information is provided for each area. This issue highlights the results of the national County Health Rankings. See inside how WCHS ranked! 3

4 County Health Rankings For the third year in a row, Wake County has been named Healthiest County in North Carolina, according to a report released on April 3, 2012 by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation (See Figure 2). Community members such as businesses, government, faith-based organizations, health care, educational systems, and public health work together with philanthropists and investors to achieve these outstanding results. The report assesses the overall health of counties in all 50 states by using a standard formula to measure how healthy people are and how long they live. Counties are ranked within each state. The findings ranked Wake first in overall health outcomes and second for other health factors among all 100 North Carolina counties. Figure 2 1 Data Source: County Health Rankings and Roadmaps The four measures used to assess the level of overall health for North Carolina by County were: The rate of people dying before age 75 The percent of people who report being in fair or poor health The number of days people report being in poor physical and poor mental health and The rate of low-birth-weight infants. The report also looked at factors that affect people s health within four categories: Health behavior Clinical care Social and economic factors Physical environment (see Table 1). 4

5 Table 1 Wake County Health Outcomes and Health Factors 2012 Wake County Error Margin National Benchmark* North Carolina Rank ( of 100) HEALTH OUTCOMES 1 Mortality 1 Premature Death 5,212 5, 042-5,382 5,466 7,961 Morbidity 1 Poor or fair health 12% 11-13% 10% 18% Poor physical health days Poor mental health days Low birthweight 7.7% % 6.0% 9.1% HEALTH FACTORS 2 Health Behaviors 2 Adult smoking 15% 14-17% 14% 22% Adult obesity 26% 24-28% 25% 29% Physical inactivity 18% 17-20% 21% 25% Excessive drinking 15% 13-16% 8% 13% Motor vehicle crash death rate Sexually transmitted infections Teen birth rate Clinical Care 4 Uninsured 14% 13-15% 11% 18% Primary care physicians 835:1 631:1 859:1 Preventable hospital stays Diabetic screening 89% 86-91% 89% 87% Mammography screening 73% 71-76% 74% 70% Social and Economic Factors 3 High school graduation 84% 78% Some college 77% 76-78% 68% 61% Unemployment 8.4% 5.4% 10.6% Children in poverty 15% 13-17% 13% 25% Inadequate social support 18% 16-20% 14% 21% Children in single parent households 26% 25-28% 20% 34% Violent crime rate Physical Environment Air pollution-particulate matter days Air pollution-ozone days Access to recreational facilities Limited access to healthy foods 6% 0% 10% Fast food restaurants 52% 25% 49% *90th percentile, i.e. only 10% are better. NOTE: Blank values reflect unreliable or missing data. Data Source: County Health Rankings and Roadmaps 5

6 County Health Rankings AREAS FOR IMPROVEMENT Although Wake County achieved a high health ranking, several areas to explore for improvement have been identified from this and other Wake County reports (such as the Wake County Community Assessment, and State of the County Report) based on weight of health factor, trend, comparison to NC state average or magnitude of difference from a national benchmark. These include: Children in poverty (Increased from 11% in 2008 to 15% in 2010.) Obesity (Since 2006, 25% or more of Wake county residents are obese.) Violent Crime (The violent crime rate was 333/100,000 population from ; almost 5 times higher than the national benchmark of 73/100,000 population.) Excessive Drinking ( Fifteen percent (15%) of Wake county adults participate in heavy or binge drinking compared to 13% of adults in NC from This is about twice as high as the national benchmark.) Sexually Transmitted Infections (Increased from 365/100,000 population in 2008 to 394/100,000 population in 2009; almost 5 times higher than the national benchmark of 84/100,000 population.) Physical Environment (Wake County s physical environment ranked 93rd out of 100 counties because of unhealthy environmental conditions based on air pollution, access to recreational facilities, limited access to healthy foods and number of fast food restaurants.) Contact: Edie Alfano-Sobsey, Public Heath Division Edie.AlfanoSobsey@wakegov.com 6

7 Tobacco Use QUITLINE USE Figure 3 Number of Wake County Residents Registered With Quitline During January-March Jan Feb March Data Source: NC Quitline Monthly Data Reports The purpose of the Quitline is to provide NC citizens a FREE cessation resource to aid in quitting tobacco use. The Quitline offers 24/7 counseling sessions either by phone and/or online. Quit coaches call people who are referred to the Quitline by healthcare providers. While supplies last, 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). During the first three months of 2012, enrollment in the Quitline increased compared to the same time in 2011 and 2010 (see Figure 4). The Centers for Disease Control and Prevention (CDC) Office of Smoking and Health, the NC Department of Health and Human Services (DHHS), and Wake County Human Services Project ASSIST (American Stop Smoking Intervention Study) collectively provided multiple media campaigns during the months of January-March. The media outlets used were radio, television, web ads and local newspapers. The campaign began in January and DHHS and CDC ads continue to air. Figure 3 is a reflection of the importance of social media in public health. Educating the public on available resources like the Quitline is essential to getting people the support needed to quit using tobacco. Contact: Sonya Reid, Health Promotion Chronic Disease Prevention Section sreid@wakegov.com 7

8 School Health The Wake County Human Services School Health Program promotes the health, safety and educational success of students in the Wake County Public School System (WCPSS). The WCHS School Health Program does this by partnering with WCPSS, families, physicians, hospitals and community agencies using evidence based practices and professional standards of care. This partnership includes: training school staff with no medical background to perform medical procedures and administer medications; responding to health concerns that interfere with academic success; and assisting families in accessing needed resources. Additionally, the program promotes the public health and safety of Wake County residents through emergency preparedness and the prevention, investigation and control of communicable diseases in the school system. STUDENT TO SCHOOL NURSE RATIO The student to school nurse ratio is a measure used across the state of North Carolina and the United States to assure students are healthy and able to participate in school. The student to school nurse ratio is significantly higher in Wake County as compared to the recommended standard as well as to other North Carolina counties (see Figure 4). In Wake County, the number of students per school nurse is over twice the average of other North Carolina counties. Figure 4 Number of Public School Students Per School Nurse Wake County and North Carolina Trend from to School Years 3000 Number of Student s to One Nurse , ,201 North Carolina Wake Note: The standard studentto school nurse ratio of 750 students to one school nurse nurse has been adopted by the North Carolina Public Health Taskforce, the North Carolina Department of Public Instruction and teh NC Division of Public Health and is based on recommendations made by the American Academy of Pediatrics, the Centers for Disease Contol and Prevention, and the National Association of School Nurses. Source: NC Annual Survey of School Health Services, NC DHHS 8

9 School Health SCHOOL STAFF TRAINING Figure Number Of Procedures School Nurses Trained WCPSS Non-Medical School Staff to Perform through School Year Procedures The number of procedures school nurses train nonmedical staff to perform increased 300% over a nine year time span (see Figure 5). School Year Data Source: Wake County Human Services School Based Public Health Nursing Program Monthly Report Figure 6 Types of Procedures Wake County Public Schools Nebulizer Treatment 4% Diastat (Rectal Valium) 7% Diabetes Related Proc edure 27% Other 5% Epinephrine Auto Injector 57% Use of epinephrine auto injectors for severe allergy makes up 57% of the medical procedures performed in the schools (see Figure 6); food allergies are the most prevalent type of allergy. Comprehensive preventive and emergency care plans are developed by the school nurse and school staff is trained to give medication through injections, insulin pumps, rectal suppositories and inhalers. Data Source: Wake County Human Services School Based Public Health Nursing Program Monthly Report 9

10 School Health SCHOOL HEALTH SERVICES The large number of assessments and counseling is attributed to assessment of each student referred to the nurse with corresponding counseling when a health concern is identified. From October to December, assessments increase significantly due to vision screening. As the year progresses, services that take more time to complete such as case management, follow up of students referred for health concerns and working with families to help their child access care increase (see Figure 7). Figure 7 Number of School Based Public Health Nurse and Dental Hygienist Services Including Assessment, Counseling, Referral and Follow Up to Secure Care for Wake County Public School Students Quarterly Service Activity School Year 1457 Jul-Sept Case Mananged Services/Family Intervetions/Home Visits Oct-Dec Follow up/referral/assurace Student Secures Care Health Counseling Jan-Mar Assessment of Health Conditions Number of Services Source: Wake County Human Services School Based Monthly Reports Contact: Roxanne Deter, Public Health Division rdeter@wakegov.com 10

11 Outreach NATIONAL ASSOCIATION OF COUNTIES (NACo) PRESCRIPTION DRUG DISCOUNT CARD PROGRAM The National Association of Counties (NACo) Prescription Drug Discount Card Program was initiated in Wake County in September The card is ready for immediate use, with no form to fill out or fee for enrollment, and provides a discount for prescription medications that are not already covered by insurance or other prescription discount program. Cards can be obtained from card displays located at Wake County government buildings with public access, including regional centers, public libraries, town halls, and at retail pharmacies throughout Wake County. Table 2 shows card usage and price savings in Wake County from Table 2 Calendar Year Total Utilizers Avg. Price Savings Percent of Price Savings ,888 $ % ,836 $ % ,389 $ % ,163 $ % Total 193,276 $ % Data Source: National Association of Counties Total Utilizers gives an indication of how many residents the program is helping Average Price Savings Average price savings per prescription Percent of Price Savings Percentage price savings per prescription Contact: JoAnn Douglas, Immunization Outreach jdouglas@wakegov.com 11

12 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 COMMUNICABLE DISEASE INVESTIGATIONS Investigations Reportable Communicable Disease Investigations + January -March 2011 and Foodborne Illness* 16 Tickborne Illness** Hepatitis B*** Jan-Mar 2011 Jan-Mar 2012 Figure 8 + Number reported by NC Electronic Disease Surveillance System (NCEDSS) on May 2, *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. More foodborne illness and fewer tickborne illness and hepatitis B investigations were conducted in the first quarter of 2012 compared to the first quarter of 2011 (see Figure 8). Contact: Ruth Lassiter, Communicable Disease Surveillance Section, ruth.lassiter@wakegov.com CRITICAL VIOLATIONS AT WAKE COUNTY RESTAURANTS/FOOD STANDS The average number of critical violations per inspection decreased during the last quarter (January to March 2012) for the first time in several years (see Figure 9), possibly due to increased outreach and educational activities by the Wake County Environmental Health and Safety Division staff. 2.5 Average Number of Critical Violations per Inspection at Wake County Restaurants from January 2010 to March 2012 Figure 9 Average Number of Critical Violations Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Data Source: Wake County Environmental Services Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 12

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 CRITICAL VIOLATIONS AT WAKE COUNTY RESTAURANTS/FOOD STANDS Number of Cri cal Viola ons Associated with CDC Risk Factors * at Wake County Restaurants/Food Stands January March 2012 Figure 10 * CDC Risk Factors Data Source: Wake County Environmental Services Items 1-5: Poor Personal Hygiene Items 6-9: Food from Unsafe Source Items 10-12: Cross Contamination/ Contaminated Equipment Item 13: Final Cook Time Items 14-18: Holding/ Time-Temperature "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 10 shows that most of the critical violations involved cross contamination of foods and contaminated equipment. Contact: Andre Pierce, Wake County Environmental Services apierce@wakegov.com STRATEGIC NATIONAL STOCKPILE PLAN E m e r g e n c y P r e p a r e d n e s s During the first quarter of 2012, the Wake County Strategic National Stockpile (SNS) Plan was completely re-written to comply with the CDC Technical Analysis Review (TAR) of such plans. The SNS Plan provides information on how to request the CDC stockpile of medications and support equipment during a biological incident, how the materials are to be received and how the materials are to be distributed to the entire population of Wake County within a 48 hour window. The previous Wake County SNS Plan was an operational plan which did not meet the requirements of the current CDC TAR. The re-write provides extensive details about actions to be taken should the SNS be required in Wake County and many details on possible scenarios for medication distribution to the population of Wake County in the event a terrorist incident. Contact: Brian McFeaters, Public Health Emergency Preparedness Section bmcfeaters@wakegov.com 13

14 Sexually Transmitted Infections (STIs) The number of cases reported from Wake County to the NC Division of Public Health for calendar year 2010 to 2011 decreased for syphilis (9.5%) and HIV/AIDS ( 12.6%) but increased for gonorrhea (8.5%) and chlamydia (5%). New cases reported from January to March 2012 were syphilis (18), HIV/AIDS (59), gonorrhea (326) and chlamydia (1062). INTEGRATED TESTING SERVICES Testing services for HIV, syphilis, chlamydia, gonorrhea, and hepatitis C are integrated by offering simultaneously to clients at community as well as clinical testing sites. Integrated testing increases detection and treatment of all STIs in high risk populations. This enhanced testing is made possible through the CDC Program Collaboration and Service Integration (PCSI) and other grant funding. Tables 3, 4, and 5 show the number of tests performed at community sites and the positivity test rates for HIV, syphilis, gonorrhea, chlamydia and hepatitis C comparing October thru December 2011 to January thru March Table 3 Number of Tests and Test Posi vity Rate (%) at Non-Tradi onal Tes ng Sites in Wake October-December 2011 January- March 2012 Test Number Tested % Posi ve Number Tested % Posi ve HIV Syphilis Gonorrhea Chlamydia Hepa s C Data Source: Wake County Human Services HIV/STD Community Program Non-traditional testing sides are community locations where HIV/STD counseling and testing services would not customarily be provided (churches, shelters, colleges, and universities). 14

15 Sexually Transmitted Infections (STIs) Table 4 Number of Tests and Test Posi vity Rate (%) at Substance Abuse Centers in Wake County October -December 2011 January -March 2012 Test Number Tested % Posi ve Number Tested % posi ve HIV Syphilis Gonorrhea Chlamydia Hepa s C Data Source: Wake County Human Services HIV/STD Community Program Table 5 Number of Tests and Test Posi vity Rate (%) at Expanded Tes ng Sites* in Wake County October -December 2011 January -March 2012 Test Number Tested % Posi ve Number Tested % Posi ve HIV Syphilis Gonorrhea Chlamydia Hepa s C* Data Source: Wake County Human Services HIV/STD Community Program * Jails, detention. Hepatitis C testing is not offered at Expanded Testing Sites. Contact: Yvonne Torres, HIV/STD Community Section ytorres@wakegov.com 15

16 Pregnancy Rates PREGNANCY RATE FOR YEAR OLDS IN WAKE COUNTY AND NORTH CAROLINA From 2006 to 2010, both North Carolina and Wake County saw their pregnancy rates for ages and ages decline (see Figures 11 and 12). Figure 11 Pregnancy Rate per 1,000 Age Wake County and North Carolina Rate Per Source: North Carolina State Center for Health Statistics Wake North Carolina Figure Pregnancy Rate per 1,000 Age Wake County and North Carolina Rate Per Wake North Carolina Source: North Carolina State Center for Health Statistics 16

17 Pregnancy Rates PREGNANCY RATE FOR YEAR OLDS IN WAKE COUNTY BY RACE AND ETHNICITY In 2010, the Hispanic pregnancy rate (50.5 per 1000) for ages was almost twice that of African- American non-hispanic and almost seven times more than the white non-hispanic pregnancy rate (see Figure 13). Figure 13 Pregnancy Rate Ages by Race and Ethnicity Wake County 2010 N= 335 Hispanic 50.5 African American-Non- Hispanic 30.3 White Non-Hispanic Rate per 1000 Source: North Carolina State Center for Health Statistics In 2010, the pregnancy rate was five times higher for Hispanic and 4 times higher for African-American non-hispanic teens ages compared to white non-hispanics of the same age (see Figure 14). Figure 14 Pregnancy Rate Ages By Race and Ethnicity Wake County 2010 N=719 Hispanic Af. Am. Non- Hispanic White Non- Hispanic Rate Per 1000 Source: North Carolina State Center for Health Statistics 17

18 Pregnancy Rates WAKE COUNTY HUMAN SERVICES PRENATAL CLIENTS BY AGE The Wake County Human Services Prenatal Clinic served more teens each year from (see Figure 15). Figure 15 Number Of Prenatal Clients Ages Wake County Human Services r e120 b m u100 N d te 80 lica p u 60 d n U Calendar Year Figure 80 Age 15 Age 16 Age 17 Age 18 Age 19 Source: Wake County Human Services Patient Care Management System. Contact: Roxanne Deter, Public Health Division rdeter@wakegov.com 18

19 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 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) Reduce the unintentional falls mortality rate (per 100,000) population 8.1 (2008) 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) Reduce the infant mortality rate (per 1,000 live births) 8.2 (2008) 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% ( ) 6.6% 19

20 Mental Health Current 2020 Target 1. Reduce the suicide rate (per 100,000 population) 12.4 (2008) 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) (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 ( ) 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 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% ( ) 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 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% ( ) 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) (2008) 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) 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% 20

21 A c k n o w l e d g e m e n t s We wish to thank all staff for their daily efforts toward improving the health and safety of the citizens of Wake County. Contributors to this Public Health Quarterly Report are: Edie Alfano-Sobsey Roxanne Deter JoAnn Douglas Brian McFeaters Andre Pierce Michelle Ricci Ronda Sanders Ramsay Hoke Yvonne Torres May 18,