NCH HEALTHCARE SYSTEM COMMUNITY NEEDS ASSESSMENT TABLE OF CONTENTS

Transcription

1 NCH HEALTHCARE SYSTEM COMMUNITY NEEDS ASSESSMENT TABLE OF CONTENTS I. Overview of the NCH Healthcare System II. III. IV. Our Community Approach/Methodology a. Historical Community Needs Assessment b. Assessing Community Health Needs c. Other Available Data Findings a. Life Expectancy and Mortality b. Chronic Disease c. Health Behaviors and Actual Causes of Death d. Oral Health e. Health of the Older Population f. Mental Health g. Access to Care h. Maternal and Infant Health i. Infectious Diseases V. Response To Findings a. Unaddressed Identified Needs b. Community Benefit Plan VI. Attachments

2 OVERVIEW OF THE NCH HEALTHCARE SYSTEM The NCH Healthcare System is a not-for profit 51(c) (3) community health care system with multiple facilities throughout and the surrounding areas. NCH has evolved over the last 57 years becoming one of the most progressive healthcare systems in the country embracing new technology and evidence-based medicine. NCH offers advanced comprehensive care while adopting new, effective ideas in medicine and healing. Founded by local residents, NCH opened March 7, 1956 with 5 beds, and now offers a wide range of services, and physicians in dozens of locations throughout Southwest Florida. The NCH Downtown Naples Hospital has 39 beds and the NCH North Naples Hospital provides 325 beds. Services offered by the NCH Healthcare System are extensive. Inpatient services include: medical, surgical, cardiac, orthopedic, pediatric, obstetrics, rehabilitative, psychiatric, oncology, emergency treatment, and diagnostics. Outpatient services include: rehabilitation, home care, walk-in centers, wound healing, wellness, nutrition, and more. Home to the first and only Open Heart Surgery Program in, NCH has been a pioneer in the cardiac arena for almost two decades. Today, the NCH Heart Institute, with a team of 13 dedicated physicians and additional staff members specialize in the expert management of cardiovascular and peripheral vascular disease in one centralized, convenient location on the Downtown Naples Hospital campus. NCH has come a long way since its beginnings. It has been nationally recognized for quality and is an important player in a competitive healthcare market. Relationships with quality healthcare organizations outside of NCH also serve to strengthen our capabilities. NCH is the first hospital in Florida and the first in the Southeastern US to become a member of the Mayo Clinic Care Network. As a result of this new membership which began in 212, our patients now have the added advantage of access to Mayo s highly regarded expertise. Here s a snapshot of today s NCH Healthcare System: We treat more than 37, patients every year. One in eight patients comes from outside our immediate area attracted by our reputation for quality. We deliver more than 2,9 babies each year.

3 We do 11, surgeries a year including 395 open heart cases. We have 89, emergency room visits every year. Our medical staff encompasses more than 636 physicians; each equipped with the most advanced state-of-the-art medical technology and committed to providing the most competent care for our patients. NCH is the largest non-governmental entity in. Behind these statistics is a caring cadre of 3,8 staff members, a 2-member Board of Trustees of local leaders and 1,1 motivated, community volunteers, all dedicated to improving the quality of life four our patients, their families and friends. OUR COMMUNITY The NCH Healthcare System s primary service area is and secondary service area includes Estero and Bonita Springs located in southern Lee County. Approximately 12% of our discharges historically are from outside the primary and secondary service areas due to the huge influx of part time residents and tourists from January through April. The permanent population of is currently estimated at 331,238. Additionally, the permanent population of Bonita and Estero is estimated at 75,44. The map below illustrates the percentage breakdown of discharges by zip for fiscal year ended September 3, 212. Collier Pt Volume Q4 21 Q3 212 % Patients by Zip Code (1.4%) (7.2%) (6.6%) (6.7%) (4.9%) (6.7%) (3.7%) (.8%) (8.5%) (1.2%) (6.4%) (3.6%) (.14%) (4.4%) (.13%) (4.7%) (.1%) (.31%) (.22%) (.15%)

4 is very diverse with over a 31% minority rate in the permanent population. The table below illustrates the most recent breakdown of by race. RACE POPULATION PERCENT White 276,86 68.% Hispanic 99, % Black 21, % Asian 4, % Other 4, % is one of the most affluent counties in the country populated with numerous areas of low income and poverty level residents. With the average household income at $94,483, over 41% of the population reports an average household income is below $5,. The table below illustrates average household income estimates as of March 31, 213. HOUSEHOLD POPULATION PERCENT $ - $19, 21, % $2, - $49,999 49, % $5, - $74,999 31, % $75, - $99,999 21, % $1, - $149,999 23, % $15, - 19, % APPROACH/METHODOLOGY Historical Community Needs Assessment Our leadership team is actively involved and participates in many community related organizations and groups that are continually assessing unmet needs within. We have historically worked with our Board of Trustees, Children s Alliance, Collier County Public Schools, the Immokalee Foundation, Children s Medical Services, and other agencies throughout our community in assessing and collaborating in efforts to improve the health of our community. NCH provides many health-enhancing educational programs and resources in

5 promoting health to the community. The current programs and resources provided to the community include the following: Health seminars Community health fairs Free diagnostic and screening testing. The neighborhood health clinic (Physician led access network of ) Heart programs through the American Heart Association (Annual Heart Walk) Cancer survival awareness Patient support groups Partnering with the Spirit of Women Two Wellness Centers von Arx Diabetes Center of Excellence Pastoral Care Services Provide space for other NFP organizations at no cost Sponsor and supporter of clinical nursing schools In addition to the programs listed, NCH is also working with the Safe & Healthy Children s Coalition of to develop programs for drowning prevention, childhood obesity, safe sleep efforts, and breastfeeding programs. The details of the program are listed below: Drowning Prevention Efforts SWIM Central Targets children ages 3-5 years attending socio-economically disadvantaged daycares and preschools. (Since 212, over 775 children have participated with 6,61 lessons taught) Water Smart Babies In-Service Training Involves swim instructors from all major certified aquatic centers in Collier and South Lee counties. (All aquatics facilities participated with over 3 aquatic directors during Sept 212 in-service) Hot Summer Nights Making a Splash Mock drowning and rescue, CPR and competitive swimming demonstration. (Over 3 middle school students participated in 212 and 65 in 213)

6 Splash Initiative and Water Proof FL 45 at risk families received water safety education and door alarms. (2 water watchers, 1 English and 1 Spanish brochures distributed) Water Smart Babies Booklets pediatricians distribute brochures containing water safety information at well visits for children 9 months to 4 years old. (Over 15, English, 8, Spanish, and 2, Creole brochures distributed) Submerged Vehicle Workshop Multiple Scenarios presented in which a vehicle was submerged in a canal with members of the CCSO dive team inside. (9 first responders from Lee, Broward, Miami, and participated) Childhood Obesity Prevention Whole Foods Market Kids on the Go Kids on the Go was developed to encourage children to exercise and to adhere to a healthier lifestyle. (8 students from grades 3-5 from area elementary schools have participated) Color Collier Healthy Run 2 mile run/walk. (Inaugural event, over 7 people participated) Run for Fun Free events to give families an opportunity to engage in aerobic exercise. Each week, track and field meets are hosted at local high school tracks. (15 families participated in 212 Summer) Breastfeeding Programs NCH Birthplace Implemented breastfeeding policy which requires nursing education on the benefits of breastfeeding and how to troubleshoot with breastfeeding moms. Also collaborated with obstetricians to decrease formula distribution in the antepartum period and to distribute educational materials for expectant parents on the benefits of breastfeeding. Developed Breastfeeding Resources Rack Card (1, Spanish and English rack cards have been distributed)

7 Safe Sleep Efforts Safest Sleep Put Your Baby Alone On His/Her Back In a Crib Campaign All nursery nurses at NCH participated in a required SIDS reduction class. (112 pack n plays were purchased for families in need and over 35 This Side Up oneseis 2 Safe Sleep brochures, and 2 Safe Sleep posters have been distributed) Sudden Infant Death Syndrome & UnSafe Sleep Lectures First lecture audience involved representatives from 4 community service agencies. 3 preschool directors from the SW Florida Early Learning Coalition participated in the second lecture. 6 Edison Community College Nurse students participated in the third lecture. Assessing Community Health Needs Commencing in 212, NCH participated in the Community Assessment Design Group with key participants being the Health Department, City and County Government, and the Chamber of Commerce. The initial scope of the group was to design a community strengths/opportunities survey. A survey was prepared and sent out to the health care leaders, community focus groups and health care staff. Identified problem areas included the following: Sufficient job employment Economic opportunities Access to affordable housing Drug and alcohol abuse Safe roadways for bicyclists and pedestrians Primary care resources Access to affordable health food Access to long-term care beds Communicable Disease Obesity Chronic Disease Mental Health Dental Health

8 Health of the Elderly Access to care Disabilities Unintentional Injuries Subsequently, the Leadership Focus Group (Attachment A) met to discuss both the positive and negative factors that influenced these areas. The next step in the process was to conduct geographical area community focus groups. These groups were chosen to reflect and include the diversity of community locations, ethnicity, and socio-economic factors. The distinct areas of the county represented unique demographic and socioeconomic characteristics. The differences were valuable and useful for assessing and prioritizing healthcare needs within our community. In addition, we provided input into the analysis on various health indicators which included the following: Population Socioeconomic characteristics Infectious disease Health behaviors and health status Mortality indicators Maternal and infant health Health of the older population Access to health care Mental health Chronic diseases Injuries The detailed analysis is contained at the end of this report in Attachment C.

9 Other Available Data NCH reviews nationally publicized data that assesses specific unmet needs related to minorities, seniors, women, and children based on income, education, and culture. NCH also reviews Press Gainey Patient Satisfaction Reports and utilizes input from our discharge planning and case management on community needs. In addition, our Foundation works closely with other community not for profit foundations assessing unmet needs for under privileged groups and individuals in our community. Attachment B contains the various chapters develop by the Collier County Health Department which NCH was involved in data gathering and review of this information which is contained in Attachment C of this report. FINDINGS A major component of NCH s assessment of the CHNA is based on the Community Health Status Report completed early July213. The executive summary is as follows: Life Expectancy and Mortality has the distinction of having the highest female life expectancy at birth among all of the counties in the United States at 85.8 years. Men in the county also benefit from a very high level of life expectancy at birth when compared to the rest of the country and is only surpassed by 3 other counties in the United States. Hispanic residents of live almost 3 years longer than non-hispanics residents over the course of a lifetime. The significantly lower infant mortality among Hispanics in the county contributes heavily to these higher levels of life expectancy. This Hispanic survival advantage in longevity increases with age to the effect that by age 65, 91.2 percent of the Hispanic population in have survived competing causes of mortality compared with 86 percent of the non- Hispanic population. In 211, the 1 leading causes of death in by rank order were: cancer, heart disease, chronic lower respiratory disease, stroke, unintentional injuries, Alzheimer s disease, diabetes mellitus, chronic liver disease and cirrhosis, kidney disease and Parkinson s disease. These 1 leading causes accounted for 77 percent of all deaths occurring in the county.

10 It should be emphasized that the 1 leading causes of death do not all necessarily coincide with the causes of major public health importance. Premature and preventable causes of death within a community tend to become public health priorities since these causes or conditions affect the health status of the total population and a reduction in morbidity and mortality levels increases life expectancy and the quality of life at the county level. Chronic Disease Chronic diseases are the leading causes of death and disability in all counties in the United States. Seventy percent of all deaths among residents are due to chronic diseases, with heart diseases, cancers and stroke accounting for over 5 percent of all these deaths annually. Approximately 1 out of every 2 adults in have at least one chronic condition or disease. The burden of chronic disease is felt at all levels. For individuals it means limitations to function, health, activity and work which affect the quality of their lives, as well as the lives of families and friends. For the community it means increases in medical costs, uncompensated care and worker productivity. Cancer became the leading cause of death in Collier in 211 despite the fact the mortality rate for all cancers declined by 26 percent in the past two decades. Cancer has become the leading cause of death due to its high incidence and prevalence in the older population groups, in particular those 45 years of age and over and the decrease in heart disease death rates. The leading cause of cancer deaths in is lung cancer, which accounted for 27 percent of all cancer mortality in 211. has seen a substantial decline in this sitespecific mortality rate since 1992, directly attributable to the decrease in the percentage of adults engaged in cigarette smoking. Between 1992 and 211 the mortality rate from breast cancer declined by 24 percent in Collier County. Hispanic females experienced a very steep 74 percent reduction in the breast cancer mortality rate between 24 and 211. Health education from health care providers and the public health sector has undoubtedly contributed to increased screening and earlier detection reducing the burden of mortality.

11 Cerebrovascular disease is the 4 th leading cause of death in. In 211, stroke accounted for almost 6 percent of all deaths within the county. Among females mortality from stroke accounted for 41 percent more deaths than in males in 211. Diabetes is the 7 th leading cause of death in. The most significant risk factor for the development of diabetes is obesity and overweight. Diabetes is also a significant cause of heart disease and stroke and the leading cause of kidney failure. It is estimated that presently 27 percent of the total population, over 1 in 4, 65 years of age and older have diabetes. The risk of death among persons with diabetes is 2 times that of persons the same age without diabetes. Chronic liver disease and cirrhosis is the 8 th leading cause of death in the county. Excessive alcohol consumption is the major risk factor for liver disease followed by chronic hepatitis C and more recently obesity, which is now also a risk factor for the disease. Increasing obesity levels coupled with the high rate of consumption of alcohol in translates into projected increases in morbidity and mortality due to chronic liver disease and cirrhosis for future years. Health Behaviors and Actual Causes of Death The actual causes of death are major external and modifiable influences and factors that contribute to specific causes of death in our communities and its populations. These life style and behavioral factors are correlated and associated with a plurality if not a majority of all deaths. Almost one half of all deaths in are potentially preventable, based on the premise that major actual causes of mortality can be modified through education and access to care. Tobacco use is the leading cause of preventable mortality followed by overweight and obesity resulting from physical inactivity and poor diet habits. Together these two actual causes were responsible for 72 percent of all preventable causes of death in in 211. Cigarette smoking is the leading cause of preventable mortality in, followed by obesity. Cigarette smoking has been scientifically associated as a cause in a myriad of diseases including numerous types of cancer, heart diseases and stroke, respiratory diseases and unfavorable maternal outcomes. In, 16.7 percent of the adult population identified themselves as current smokers; this is a decline of almost 3 percentage points since 22.Approximately 1 out of every 5 deaths in the county can be attributed to smoking. The lower the income and educational attainment the higher the smoking rates. Marriage appears to be a

12 protective factor in Collier; the married population has significantly lower smoking rates than non-married couples. In 21, 22.4 percent of adults indicated they were obese. An increase in the prevalence of obesity and overweight is related to a higher incidence of numerous chronic diseases including stroke, hypertension, cancer, diabetes and cardiovascular disease and premature mortality. Educational attainment is a protective factor against obesity in Collier County, with only 18.4 percent of adults with a four year college degree or beyond classified as obese compared with 34.8 percent with only a high school degree. The proportion of adult residents who engaged in heavy or binge drinking increased by over 2 percentage points between 22 and 21 to 19.2 percent. Males engaged in heavy or binge drinking at much greater rates than females in the county. Income level is a predictor of heavy or binge drinking; the higher the annual income($ 5, or more), the more prevalent the overconsumption of alcohol. A significantly greater proportion of the population 65 years and older (12.6 percent) engaged in heavy or binge drinking. A strong statistical association exists between alcohol consumption and alcohol impaired driving. On average in 54 residents are killed annually in motor vehicle crashes with approximately 25 percent attributed to alcohol use. Oral Health Oral health is central to a person s overall health, well-being and quality of life. Between 21 and 211, the number of licensed dentists increased by 71 percent in Collier County. The majority of the dental care in the country is provided by dentists in private practice. Adults without private insurance have limited access to dental services at the County Health Department or federally qualified health centers. The only dental care option for many low income people who lack access to preventative dental services is the hospital emergency room. In, between 2 and 211, there was 192% increase in hospitalizations from preventable dental conditions for people under 65 years of age. Collier Country residents with higher income and higher education are more likely to visit a dentist or dental clinic than persons with lower income and education. Health of the Older Population

13 Since 199, the percentage of residents in ages 65 and over has increased by 148 percent, from 35,182 to 87,144 in 211. The median age of the population is getting older while the population cohort 65 years of age and over has been experiencing rapid growth. The older population of, persons 65 years and above numbered 87,144 in 211. This represents 27 percent of the total county population or over one in every 4 residents. As this older population increases to an estimated 144, by the year 23, other concurrent factors will affect the health and wellbeing of this generation. Increased levels of life expectancy will translate into necessity for increased geriatric health care service resources and availability. An increase in the demand for Assisted Living and Skilled Nursing beds projected in the immediate future due to both increases in longevity and the projected number of Alzheimer s disease cases. During 211 within over 11, residents 65 years of age and older had Alzheimer s disease; by 23 using conservative population estimates, over 18,6 residents will be diagnosed with the disease. Falls beginning at ages 75 to 84 years rises exponentially to a rate of over 45 per 1, populations at ages 85 years and over. Falls in this age group are often associated with the need for hospitalization, rehabilitation services and decreased levels of independence. A significantly greater proportion of the population 65 years and older (12.6 percent) engaged in heavy or binge drinking. Mental Health Many studies have shown a link between depression and adverse health behaviors such as smoking, alcohol consumption, physical inactivity and sleep disturbance. residents experienced a remarkable increase in the percentage of individuals that reported poor mental health from 27 to 21. Over this four year period the percentage of residents reporting poor mental health status increased to 17.2 percent, or 1 in 6 persons. Males were much more likely to have experienced poor mental health than females and those in the age group years of age had the highest incidence while those 65 years and older had the lowest. Both income level and educational attainment were correlated with mental health status in, the higher the income and the more education both translated into improved mental health status.

14 Access to Care Private health insurance coverage is an integral mainstay for access to healthcare services for the core working population years of age and vital to the personal well-being and health of individuals. In Collier Country rates of health insurance coverage have been declining over the past two decades. This downward movement in health insurance coverage was exaggerated by the recession beginning in 26 which pushed the uninsured population to historical heights as unemployment spiraled upwards. In 211, almost 24 percent of the total resident population of was uninsured. Of the core working population years of age in Collier County, 38.5 percent were without health insurance. When controlling for race and ethnicity, whites, blacks and Hispanics in Collier Country are more likely to be uninsured than their counterparts in the state of Florida. Health insurance coverage rates in are highly correlated with the education attainment and income level. As the education level and income level increases, the percentage of the uninsured population decreases- a classic inverse correlation. The association being that within the core working population years of age, persons with higher education status are more likely to be employed at an income level that provides for or facilitates health insurance coverage as benefits to the employee. Maternal and Infant Health Maternal and infant health is the foundation for a vibrant and prosperous society. The infant mortality rate for declined to a new low of 5. infant deaths per 1, live births in 211. The Hispanic infant mortality rate in the county was almost 6 percent lower -2.8 per 1, live births-than the non-hispanic rate -6.9 per 1, live births. Pregnant women in Collier County continue to improve upon their health behaviors by decreasing their reliance on alcohol and tobacco use. lags behind the state of Florida for three indicators related to adequate prenatal care: Births with first trimester prenatal care, births with late or no prenatal care and births with adequate prenatal care. Infectious Diseases

15 While the great majority of diseases in and the United States causing morbidity and mortality in the 21 st century are non-communicable in nature, public health emerging infectious diseases continue to play a significant role in the health of communities. The risk of mosquito borne encephalitis, dengue and malaria remain an ever present underlying risk in due to the unique climate and weather conditions particularly during the raining season. Dengue Fever has emerged in recent years in the keys of Monroe County, only a few hours away via highway and is an emerging threat to. Between the year 2 and 211 the incidence of all communicable diseases increased by 2 percent in the county. Three of the 5 leading communicable diseases in are enteric or gastrointestinal related. During 211, salmonella, campylobacter and giardiasis accounted for 5 percent of all reported infectious diseases in the county. The prevention of human rabies in is a public health priority due to the high risk wild life species encountered naturally in the environment and the rapid land growth and development over the past two decades. In percent of all reportable health conditions involved animal bites requiring post-exposure prophylaxis (PEP) to prevent the potential onset of rabies. Between 21 and 211 the number of animal bites to humans requiring PEP increased by over 9 percent. The average rate of Tuberculosis in Collier, once considered to have been virtually eliminated from the United States, has been trending upward since 27 when the trend statewide and nationally has been declining. In medically underserved low income populations tend to have a high rate of tuberculosis exposure and infection. These vulnerable population groups disproportionately represent the majority of tuberculosis cases in the county. RESPONSE TO FINDINGS Upon review of the findings of the (CHNA) the NCH Leadership Team reviewed the findings. Upon review a prioritization session was completed which was based on the mission, vision and core values of the NCH Healthcare System with a primary focus on the goal of becoming the healthiest county in the United States. Upon much discussion the team came up with five key areas of focus which include: Cardiovascular Health

16 Cancers Diabetes Maternal and Infant Health Obesity Unaddressed Identified Needs Although several community needs were identified, NCH must focus our existing clinical strengths and infrastructure where we can maximize our resources to benefit the greatest number of people in the community. NCH will continue to re-evaluate the unaddressed identified needs and pursue action when and where resources allow. Community Benefit Plan We are committed to promoting existing and potential new programs to the community in response to the (CHNA). Please refer to Attachment B for plan details.

17 ATTACHMENT A LEADRSHIP FOCUS GROUP ATTENDEES Senior Friendship Center District Schools Avow Hospice Naples Community Hospital Physician Led Access Network Planning Services Board of County Commissions School Board Medical Society YMCA Health Department Women s Health Federation Mental Health Association of Southwest Florida Children s Medical Services Catholic Charities Neighborhood Health Clinic Physicians Regional Medical Center Greater Naples Chamber of Commerce Safe and Healthy Children s Coalition Planned Parenthood of Drug Free Collier Community Health Planning Board NAACP Emergency Medical Services (EMS)

18 Community Benefit Category Name of Program Description of Program Method of Evaluation Registered Dietitian grocery store tours Patient and parents or grandparents can learn how to utilize food stamps to purchase nutritious foods to match diet requirements. Service volumes SHAC - School Health Advisory Committee Focus on school district wellness issues for Title 1 schools. Service volumes OBESITY MANAGEMENT Youth Obesity Support Group 1:1 visits with dietitian in which all pediatrics qualify for discounted $6. rate Service volumes Safe & Healthy Kids Coalition Mandated screening and Ht/Wt/BMI metrics reported back to school and number of screened obese children presented to coalition and targeted activities are determined. Service volumes MATERNAL AND INFANT HEALTH DIABETES MANAGEMENT ONCOLOGY Breast feeding initiatives Breast Feeding Coalition of Phone call program for breast feeding success Substance Abuse Newborns Coalition Pediatric and Adult Immunization Coalition von Arx Diabetes Center Healthy Lifestyle Support Groups Free Pre-Diabetes Seminar Mammogram screening through NCH Breast Navigator CP-3 Screening Promoting and supporting initial latch (breast feeding) within first hour for all births. Increase lactation consultants from 1. FTE to 2. FTE and promote and support exclusive breastfeeding by having lactation available Mon-Sat 7am - 8pm and until 2am when census dictates. Follow up calls at 24 hours, 3 days, 2 weeks, 3 months, 6 months, and 12 months. Host member of this coalition focused on decreasing the incidence of NS babies in. Promoting maternal immunization of Tdap prior to discharge if not already received. This program has been approved by the American Diabetes Association as meeting the National Standards for Diabetes Self- Management Education which utilizes the NCH Foundation Fund. One day of every month, free sessions are provided through the von Arx Diabetes Center. Provided through von Arx Diabetes Center, a free seminar is provided to educate on lifestyle changes in order to reduce risks. Assistance program through Susan G. Komen Foundation on a consistent basis that offers screening, biopsies, surgery and medications Cancer prevention screening in collaboration with the American Cancer Association program through blood draws and stratifying data and identifying risks for all types of cancers Initial latch rates with goal of 95% Exclusive breast feeding rates Service volumes Service volumes Service volumes Expended funds from Foundation SPF Fund Service volumes Service volumes Volume, Diagnosis & Outcomes Volume, Risks, Diagnosis, Follow and outcomes CARDIOLOGY Community Outreach Screening Program (Blood Pressure/cholesterol, BMI, lipids and glucose Community Outreach Heart Failure Clinic Community Lecture Programs Program presented in underserved areas to include Golden Gate, East Naples and Immokalee. Program presented in underserved areas to include Golden Gate, East Naples and Immokalee. Cardiovascular education programs held at the NCH Heart Institute and presented by MDs, ARNPs, Clinical Educators. Volume, Risks, Diagnosis, Follow and outcomes Service volumes Service volumes NCH Heart Institute Screening Vascular screening program at discounted rates to be expanded to mobile screenings Service volumes

19 ATTACHMENT C

20 Population Characteristics Demography is the study of human population. In public health the population is monitored and analyzed, since its size, distribution, structure, age composition and growth are associated with mortality and morbidity levels, life expectancy, risk factors and access to care. These demographic analyses of the community are an epidemiological tool which assists the County, State and the Country in the assessment of the health status at all levels. The population levels are utilized in all aspects of public health measurements, including crude numbers, rates, ratios, proportions, incidence and prevalence levels and in the calculation of life expectancy. Population trends allow for health care professionals and analysts to strategically plan for levels of utilizations of health services within communities and other geographical areas as well as assess current un-met and future health needs in specific sub-groups and vulnerable populations. All population characteristics are associated with known levels of quality of life which in turn result in statistically predictable health status outcomes within a particular community. Since public health is population based, the coupling of demography with epidemiology results in a community health status assessment that will assist us to improve the health of the County through integrated community efforts by following the data and analyses as they uncover familiar and emerging trends at the local level. Age Distribution, Gender and Population Growth Between 199 and 21, the resident population of grew at a swift pace of 3.8 percent per year, this compares to Florida at 2. percent and the United States at 1.1 percent during the same time period. In terms of actual numbers, s population increased by 169,421, from 152,99 in 199 to a total of 321,52 by 21. 1

21 Population Figure: 1 Resident Population in, , 3, 25, 2, 15, 1, Resident Population in, , Source: Florida CHARTS/US Census Bureau While the annual average growth rate was the greatest between 199 and 2, 5.2 percent, the resident population of is projected to increase by 175,491 by 24, resulting in a significantly slower rate of growth of 1.5 percent per year for the period 21 to 24. (Figure 2) Table 1: Population Rate of Growth, 199, 2 and Annual Rate of Population Growth Percentage Change 76.9% 65.3% 27.9% Population 199 Census - 152, 99 2 Census - 251, Census - 321, 52 Source: Florida EDR: Florida Demographic Estimating Conference, Updated October 211. Annual Rates of Population Growth calculated by the CCHD Epidemiology Program After two decades of accelerated population increases, s growth rate appears to follow the pace of the state of Florida through the year 24. 2

22 Population Table 2: Population by Geographical Area, 199, 2 and 21 Geographical Area 199 Percent 2 Percent 21 Percent Immokalee 14, , , Greater Collier County 137, , , Countywide Total 152,99 251, ,52 Source: Comprehensive Plan Section, Data Current as of June, 212 Figure: 2 Total Population Projections,, , 5, 4, 3, 2, 1, Source: Bureau of Economic and Business Research, Florida Population Studies, Bulletin 163 By gender, the distribution of the population increased from a ratio of 12 females to every 1 males in 199 to 13 females to every 1 males by 21.As a biological and epidemiological rule, more males are born alive than females, the average live birth ratio in the United States is approximately 16 males for every 1 females born alive. 3

23 Age In, as in all counties in the United States, mortality rates are higher for males than for females at all ages. This variance in death rates results in life expectancy at birth being on average 5 years greater for females than for males. This ultimately results in a greater female population beginning around years of age and increasing over males for every age group thereafter. Figures 3, 4 and 5 display the population pyramids for 199, 2, and 21 for. Figure: 3 Population by Age Distribution and Gender,, 199 1, and Over 829 5, ,88 11, ,618 9, ,549 7, ,299 9, ,11 1, ,853 4, ,731 3, ,191 3, ,88 4,41 Female 5-9 Male 4,443 3, ,672 1,227 Under 1 1,261-15, -1, -5, 5, 1, 15, Population 4

24 Age Age Figure: 4 Population by Age Distribution and Gender,, 2 3, and Over 2,128 11,162 17, ,263 17,452 17, ,95 15, ,342 16, ,271 13, ,343 5, ,86 6, ,342 6, ,5 7,27 Female 5-9 Male 7,356 5, ,558 1,518 Under 1 1,529 2, -2, -15, -1, -5, 5, 1, 15, 2, Population Figure: 5 Population by Age Distribution and Gender,, 21 5, and Over 4,183 15,54 24, ,713 22,229 23, ,778 21, ,14 17, ,856 15, ,266 7, ,234 8, ,181 8, ,12 8,312 Female 5-9 Male 8,842 6, ,44 1,872 Under 1 1,944-3, -25, -2, -15, -1, -5, 5, 5, 1, 15, 2, 25, 3, Population Source: Florida CHARTS/US Census Bureau 5

25 s As can be visualized in these graphical presentations of the age and gender distribution, between 199 and 21, while the total population of increased by 18 percent for the 2 year period, dramatic shifts in the age distribution occurred reflecting the ongoing demographic transition in the State of Florida and the United States. This demographic change produced by the baby boomer cohort is a consequence of this generation entering and spanning middle age to their retirement years. a) This highly visible demographic shift will have a significant impact on healthcare access and provision and socioeconomic dynamics for and Florida during the 21st century. Examining figure 3 for 199 and figure 4 for 21, this demographic transition is clearly evident. Between 199 and 21 the population years of age in increased by 11 percent, while those aged years experienced an increase of 176 percent. In terms of numbers, the most dramatic increase occurred in those 85 years of age and older, 34 percent. Figure: 6 Median Age, 199, 2 and Collier Linear Median (Collier Age Median in s Age) Source: Florida CHARTS/ US Census Bureau a) The Baby boomer generation consists of those persons born during the demographic post- World War II baby boom between the years 1946 and

26 The median age b) increased in by 5.1 years between 199 and 21. This is a direct consequence of the aging of Collier s population as visually described by the 3 population pyramids above (Figure 3, 4 and 5). In 199, a total of 61,73 households resided in. By 21, this number had increased by 159 percent to 133,179. The proportion of family households declined from 71 percent of all households in 199 to 67 percent by 21. Conversely, the percentage of non-family households increased from 29 percent in 199 to 33 percent in 21. This transition in social habitation trends may be related to the increasing prevalence of marginal economic conditions resulting from the great recession which began in 27. Table 3 shows these trends for the 2 year interval. Table 3: Households by Family Status, 199, 2 and Percent 2 Percent 21 Percent Total households 61,73 12, ,179 Family households (families) Nonfamily households 43, , , , , , Source: US Census Bureau/ American Community Survey Ethnicity Between 199 and 21 the Hispanic population in Collier grew by 31.2 percent. While Hispanics constituted less than 14 percent of the population in Collier in 199, by 21 the proportion increased to almost 26 percent. This upward trend is expected to increase at an annual rate of approximately 2.3 percent between 21 and 24, when the Hispanic population in is projected to surpass 16,. (Figure 7 and 8) b) Defined as the age at which one half of the population is older and one half of the population is younger. It is a good indicator of the age composition of a population. 7

27 Percentage Population Figure: 7 Hispanic Population Projections,, , 16, 14, 12, 1, 8, 6, 4, 2, Source: Bureau of Economic and Business Research, Florida Population Studies, Bulletin 163 Figure: 8 Population by Ethnicity, 199, 2, and 21 1% 8% 6% 4% Hispanic or Latino 2% Non Hispanic or Latino % Source: Bureau of Economic and Business Research, Florid Population Studies 8

28 Population Figure: 9 Population Projection by Ethnicity in, , 35, 3, 25, 2, 15, 1, Hispanic Non-Hispanic 5, Source: US Census Bureau Race Between 199 and 21 the Black population in increased by 196 percent from 7,342 to 21,762 respectively. Table 4 shows the population distribution over the 2 year period by race. Table 4: Population by Race, 199, 2 and Percent 2 Percent 21 Percent Black 7, , , White 146, , , Other 1,14.7 3, , Source: CHARTS/ US Census Bureau 9

29 Between 199 and 21, experienced a shift in the distribution of the number of residents born in the United States compared to the number which were foreign born. Table 5: Population by Place of Birth, 199, 2 and 21 Place of Birth 199 % 2 % 21 % Born in United States Born outside United States 133, , , , , , Foreign born 15, , , Persons born outside of the United States are residents or citizens born abroad while foreign born refer to persons who were not US citizens or residents when born outside of the country. Source: U.S Census Bureau/ American Community Survey In table 5 this shift is visible. Between 199 and 21 the number of foreign born residents increased by 371 percent to account for about 24 percent of the total population in 21. During the same period the US born population in decreased from 88 percent of the total county population in 199 to just below 75 percent of the total number of residents in 21, a decrease of 13.2 percent. (Table 6 and Figure 1) Table 6: Foreign-born population by Birth Place, 2 and 21 World Region of Birth of Foreign Born 2 Percent 21 Percent Europe 7, , Asia 1, , Africa Oceania Latin America 34, , Northern America 2, , Source: U.S Census Bureau/ American Community Survey 1

30 Population Figure: 1 U.S and Foreign Born Population,, 199, 2 and 21 25, 2, 21, ,145 15, 1, 133,913 U.S Born Foreign born 5, 74,872 46,71 15, Source: U.S. Census Bureau/ American Community Survey When analyzing the data by region of the world, approximately 76 percent of the foreign born residential population of in 21 originated from Latin America. These demographic transitions are also having an impact on socio-cultural influences throughout the county within households as well as in the educational system. In 199 about 83 percent of residents spoke English only, by 21 the number declined to 69 percent. Inversely, in 21 almost 31 percent of residents spoke a language other than English at home, up from 17 percent in 199. (Table 7) Table 7: Population by Language Spoken at Home, 199, 2 and Percent 2 Percent 21 Percent English only 118, , , Language other than English 24, , , Source: Census Data/ American Community Survey 11

31 Seasonal Population in like many Florida counties draws a relatively large number of seasonal residents and visitors during peak season as well as year around. The largest proportion of seasonal residents tend to be those 65 years and older. The average age of visitors is just over 48 years of age; this is primarily due to the beaches of being a family tourist attraction. In 21 the number of tourists visiting was 1,338,8, a decrease of 5.3 percent from the prior year. Table 8: Peak Season Population, Estimates and Projections, 199, 2 and 21 Geographical Area 199 Percent 2 Percent 21 Percent Immokalee 26, , , Greater Collier County 184, , , Countywide Total 21,719 39, ,183 Source: Comprehensive Planning Department Between 199 and 21, the peak season population for grew by 84 percent from 21,719 to 387,183. While coastal and greater seasonal population increased at an annual growth rate of 2.3% over the 2 year period, the peak population of Immokalee declined significantly to account for only 7.5 percent of the total County high season population in 21. In 199, Immokalee s peak season population had accounted for 12.6 percent of Collier County s total. A myriad of socio-economic and political factors account for this reversal in Immokalee s growth trend; namely economic international trade dynamics and changes in federal immigration policies and enforcement. 12

32 Population Figure: 11 6, Resident and Peak Season Population, Estimates and Projections, , 4, 3, 2, 1, Collier Resident Population Collier Peak Season Population Source: Comprehensive Planning Section, 212 Peak Season Population As evidenced in Figure 11 the peak season and the resident population in have been growing and are projected to continue to increase at a constant and parallel rate between 21 and 23. On average the peak season population is projected to be approximately 21 percent larger than the resident population. Between 21 and 23, the annual rate of growth for the resident and peak season population is estimated to both be 1.7 percent respectively. Table 9: Peak Season Population Estimates and Projections, 2, 21, 215, 22, 225 and Collier Resident Population Collier Peak Season Population 254, ,52 341, ,585 48, ,367 39, , , , ,583 53,717 13

33 Socio-Economic Characteristics The relationship between socio-economic levels, living standards, health status, the quality of life and life expectancy have been well documented, studied and proven scientifically for centuries. The well-established statistical association existing between income level and educational attainment which consequently leads to healthier communities and populations is accepted in the United States. Increased socio-economic status allows individuals to obtain health insurance and pay for medical services, afford livable and safe housing and nutritional food. A decline in levels of income has detrimental health effects and consequences for the entire population, especially children. Children living in poverty are subject to greater health and developmental risks than adults. Infants and children in poverty have higher rates of morbidity and mortality and face a greater likelihood of unintentional injuries. Children in poverty also are more likely to lack access to healthcare and less likely to reach a desirable level of educational attainment. is one of the more affluent communities in the State of Florida, yet examination of socio-economic and other trends of well-being show that we are not immune to challenges affecting the country over the past 6 years. Income Income and monetary resources have been correlated with levels of health historically as a means for individuals to obtain heath insurance, pay for health care, afford healthy foods, adequate housing and access basic necessities such as clothes and transportation. This holds ground until a certain family and individual income level is reached statistically. Table 1 and 2 provide the Median Household Income for and Florida for 1989, 1999 and 29. Table: 1 Median Household Income, and Florida 1989, 1999 and 29 Florida 1989 $3,883 $26, $45,37 $36,39 29 $53,934 $44,755 Source: U.S. Census Data 1

34 Table: 2 Real Median Household Income (Adjusted in 29 Dollars), and Florida 1989, 1999 and 29 Florida 1989 $51,581 $44, $57,976 $46,74 29 $53,934 $44,755 Source: Federal Reserve Economic Data Table 3 provides the distribution of household income for and Florida for the periods 199, 2 and 21. While during 21, only 5.4 percent of Households had a combined income of less than $ 1,, in Florida the figure was 8 percent percent of households had an income of $15, or greater during 21, a proportion almost twice that of the State of Florida 6.2%. Between 199 and 21, median household income increased in by 75 percent, from $3,883 to $ 53,934 respectively. In Florida the increase in income rose by 68 percent during the same time period, from $26,589 to 44,755. Table: 3 Distribution of Household Income, and Florida 199, 2 and 21 Florida Income Distribution Less than $1, 8.6% 6.% 5.4% 15.1% 9.6% 8% $1, to $24, % 15.6% 13.6% 3% 21.2% 18.7% $25, to $49, % 29.9% 27.2% 34.1% 31.7% 28.6% $5, to $74, % 19.4% 2.2% 12.9% 18.5% 18.4% $75, to $99, % 1.9% 11.4% 4.1% 8.7% 1.7% $1, to $149, % 9.1% 1.5% 2.3% 6.3% 9.5% $15, and greater 4.6% 9.% 11.6% 1.5% 4.1% 6.2% Source: U.S. Census Bureau 2

35 In 27 the unemployment level in and Florida began to increase significantly in and peaked in Collier in 29 and in Florida in 21. This has had a detrimental effect on household income. As the number of men and women working fulltime, year round decreased between 26 through this writing. Real median household income has declined in Collier and Florida since 27 and 28 respectively (Table 4). It is still below the peak median household income that occurred in Table: 4 Median Household Income in, Florida and the United States, (Adjusted in 211 dollars) $6,114 $62,343 $62,538 $63,892 $55,562 $54,393 $5,569 Florida $48,886 $5,75 $51,854 $49,99 $46,99 $45,81 $44,299 United States $53,274 $54,47 $55,39 $54,349 $52,66 $51,625 $5,52 Source: U.S. Census Bureau, American Community Survey Between 25 and 211, real median household income adjusted in 211 dollars, declined by 15.9 percent in from $ 6,114 to $5, 564, respectively. These income levels declined by 9.4 percent for Florida, and by 5.3 percent for the United States during the same period (Table 4). The trend of median household incomes for and Florida increasing upward began in 25 until the recession of 27. Between 28 and 29, Collier County, Florida and the United States experienced deflation C) (Figures 1 and 2). C) A reduction in consumer and wholesale prices generally accompanied by rising unemployment, falling production and limited investment. 3

36 Income Figure: 1 Real Median Household Income (Adjusted in 29 Dollars), and Florida, 199, 2 and 21 $7, $6, $5, $4, Real Median Household Income, (Adjusted in 29 Dollars) Collier County $3, $2, $1, Real Median Household Income, (Adjusted in 29 Dollars) Florida $ Source: U.S. Census Bureau, American Community Survey 4

37 Income Figure: 2 Median Household Income in, Florida and the United States, (Adjusted in 211 dollars) $65, $6, $55, Florida United States $5, $45, $4, Source: U.S. Census Bureau, American Community Survey During the two years period (28-29) household income in and Florida decreased by 13. percent and 6. percent, respectively. Real median household income has not yet recovered in the United States to pre-21 recession all-time highs. 5

38 Number Figure: 3 Women, Infants and Children Program Participation, , 1, 1,2 8, 7,998 6, 5,398 5,14 4, 3,644 2, Source: WIC Program The Women, Infants and Children Nutrition Program of the U.S. Department of Agriculture provides food and nutritional assistance to pregnant and new mothers and children less than 5 years of age. Between 199 and 21, the number of WIC participants in increased by over 174 percent, from 3,644 to 1,2. Figure 3 shows the steep increase over the 2 years period. 6

39 Income WIC Participants Figure 4 Number of Participants in the Women, Infants and Children Program and Median Household Income (in 211 dollars),, $65, 12, $6, $55, 1, 8, 6, $5, $45, 4, 2, $4, Median Income WIC Participants Source: U.S. Census Bureau, American Community Survey and WIC Program Table: 5 Number of Participants in the Women, Infants and Children Program and Median Household Income (in 211 dollars),, Median Household Income $6,114 $62,343 $62,538 $63,892 $55,562 $54,393 $5,569 WIC Participants 7,998 8,439 9,63 1,372 1,79 1,2 9,319 Source: U.S. Census Bureau, American Community Survey and WIC Program 7

40 Participants Figure 5 Number of Children and Adults Participating in the Supplemental Nutrition Assistance Program,, Florida, , 4, 35, 3, 25, 2, Children Adults All Individuals 15, 1, 5, Source: Supplemental Nutrition Program and Department of Children and Families, Tallahassee, Florida, 212 8

41 Income Children Participants Figure 6 Number of Children Participants in the Supplemental Nutrition Program and Median Household Income (in 211 dollars),, $65, 2, $6, 15, $55, 1, $5, $45, 5, $4, Median Income Children Participants Source: U.S. Census Bureau, American Community Survey, Supplemental Nutrition Program and Department of Children and Families, Tallahassee, Florida, 212 While real median family income decreased by almost 16 percent in during the period 25 to 211, the number of WIC participants increased by 16.5 percent. This correlation between income level, health status and health related outcomes, has been documented by health economists and public health experts during the last century. Since the Recession of 27 these statistical relationships have become more evident as they emerge in various socioeconomic indicators. 9

42 Between 1989 and 29, the number of residents in living in poverty increased by percent from 14,891 to 39,648 respectively. At the State level the percentage increased by 63.9 percent (Table 6). Table: 6 Number of Children and Total Population Living in Poverty, and Florida 1989, 1999 and 29 Florida Under Age 18 in Poverty 5,2 8,137 12, ,84 669, ,326 All Ages 14,891 23,252 39,648 1,655,523 1,939,545 2,712,692 Source: U.S. Census Bureau The number of children under 18 years of age living in poverty in increased by over 138 percent for the 2 year period while in Florida overall the increase was 44 percent. Florida s lower growth rate in poverty during the 2 years interval can be attributed to a higher baseline of persons living in poverty. The poverty rate in grew at a significantly greater rate for children and for adults between 1989 and 29, than for the State of Florida (Figure 7). 1

43 Percentage Figure: 7 Percent of Children Under Age 18 Living in Poverty, and Florida, 1989,1999, and 29 25% 2% 15% 1% Florida 5% % Source: U.S. Census Bureau Homelessness in Figures 8 and 9 show the number of homeless residents in for the period as defined by admissions to St. Matthews House in Naples. Between 27 and 29 admissions increased by over 92 percent from 128 to By 211 this number had declined to 1,514, which is 47 percent above the first year with data available, 27. On average males comprise approximately 77 percent of all of the homeless in, although the female percentage of admission has increased from 2 percent in 27 to 24 percent in 211 (Table 7). The average length of stay per family admitted at St. Matthews House increased from 55 days in 27 to 6 days in 211. While female s length of stay declined by 4 percent over the 5 year period, the length of stay for males increased by 8 percent to 62.9 days in 211 (Table 9).Overall, these trends are in line with other socioeconomic measures and indicators such as unemployment levels resulting from the great recession beginning in

44 Admissions Admissions Figure: Homeless Population Admissions a) by Gender,, All Homeless Males Female Figure: 9 16 Number of Homeless Children Admissions a) by Gender, Collier County, All Children Males Female Source: a) Admissions to St. Matthews s House, Inc. 12

45 Table 7: Number of Homeless Shelter Admissions by Gender,, Gender 27 Percent 28 Percent 29 Percent 21 Percent 211 Percent Male Female Total Table 8: Number of Homeless Shelter Admissions by Race,, Race 27 % 28 % 29 % 21 % 211 % White Others Total Table 9: Number of Homeless Shelter Admissions by Average Length of Stay (in Days),, Average Length of Stay Adult Male Adult Female Family

46 Education The relationship between health outcomes and educational attainment is well known in the United States and globally. The reasons for this are multi-faceted including that a higher level of education usually results in higher incomes. Educational level is linked to access to healthcare as health insurance is usually linked to jobs requiring a specific level of educational attainment. The labor market and its distribution also contributes to health outcomes. Unemployment rates in the U.S. are higher for individuals without a high school diploma compared to those who are college graduates. Recent statistics show that the college graduate unemployment rate averages to be 3 to 3 1/2 times less that of those who did not graduate high school. Those with lower educational attainment are more likely to be affected by variations in unemployment and by consequence are more likely to be uninsured. Table 1 shows the educational attainment in the population 25 years of age and over for Collier County and Florida for 199, 2 and 21. Between 199 and 21 the percent of the population in graduating from high school without perusing any further education declined from 3.2 to 27.9 percent, in Florida the percent increased from 3.2 to 3.3 percent. During the same 2 years period the percentage of individuals with bachelors and graduate degrees increased by 4 or more percentage points in Collier and by between 2.8 to 4.8 points in the State of Florida. In Figure 1 it is evident that the greatest relative increases in higher level of educational attainment in occurred between 199 and 2. The percentage of students graduating high school has been steadily increasing in. For school year the graduation rate was 81.3%, an 8.8% increase from 72.5% in school year Table 1: Highest years of School Completed in the Population 25 s and Over, and Florida, 199, 2 and 21 Florida Less than High School 21.% 18.3% 15.2% 25.5% 2.1% 14.7% High school graduate 3.2% 26.2% 27.9% 3.2% 28.7% 3.3% Some College 26.6% 27.6% 26.1% 26.% 28.8% 29.1% Bachelor's degree 14.9% 18.2% 18.9% 12.% 14.3% 16.8% Graduate or professional degree 7.4% 9.7% 11.9% 6.3% 8.1% 9.1% Source: U.S. Census Bureau 14

47 High school graduate Bachelor's degree Graduate or professional degree High school graduate Bachelor's degree Graduate or professional degree High school graduate Bachelor's degree Graduate or professional degree Percentage Figure: 1 Educational Attainment in Population 25 s and Over, and Florida, (199,2, 21) 35% 3% 25% 2% 15% Florida 1% 5% % Source: U.S. Census Bureau 15

48 Table 11: Educational Attainment in and Florida, 199, 2 and 21 Florida High school graduate or higher (Percent of population 25 years of age) Bachelor's degree or higher (Percent of population 25 years of age) 79% 81.8% 84.8% 74.5% 79.9% 85.3% 22.3% 27.9% 3.8% 18.3% 22.4% 25.9% Source: U.S. Census Bureau 16

49 High school graduate or higher (Percent of population 25 years of age) Bachelor's degree or higher (Percent of population 25 years of age) High school graduate or higher (Percent of population 25 years of age) Bachelor's degree or higher (Percent of population 25 years of age) High school graduate or higher (Percent of population 25 years of age) Bachelor's degree or higher (Percent of population 25 years of age) Percentage Figure: 11 Educational Attainment in and Florida,199, 2, and 21 9% 8% 7% 6% 5% 4% Florida 3% 2% 1% % Source: U.S. Census Bureau 17

50 Rate Unemployment Figure 12 shows the mid year unemployment rates for and the State of Florida for the period 199 to 211. In the unemployment rate ranges from a low of 3.4 percent in July of 26 to a high of 12.3 in 29, during this same period the state rate ranged from a low of 3.5 in 26 to a high of 11.3 in July of 21. As can be seen in the graph, the unemployment rates of the county have been highly correlated with those of the State of Florida over the two decades, particularly since the year 2. Beginning in 27 the rates for Collier and the State spiraled upward hovering around 12 percent and 11 percent in 21, respectively. As of July 211, the rate for had declined to 1.5 and Florida to 1.4. As of this writing, the trend at the county and the state level is a gradual downward moving slope. Figure: 12 Unemployment Rates in and Florida, Collier County Mid Rate Florida Source: U.S. Census Bureau 18

51 Table: 12 Unemployment Rates in and Florida, Florida Source: U.S. Census Bureau A causal relationship between unemployment and health status has been established. Unemployment is associated with a decline in health status and quality of life. Lack of employment is limited to various physical health outcomes including morbidity, mortality and suicide. Unemployment is correlated with numerous unhealthy behaviors including tobacco and alcohol consumption, poor diet and lack of exercise. All of these behaviors are risk factor for the development of disease and potential mortality. During the 1 years Interval, 21 to 211, the distribution of the labor force by industrial sectors experienced several dramatic shifts. The number of persons employed in the construction industry declined by over 38 percent from 14,261 in 21 to 8,774 in 211. This was the sector with the greatest job loses of the decade, due to the housing bubble of 26 with the great recession immediately following in pursuit in 27, affecting new home construction since the former date. Other work force sectors negatively impacted by the economic crisis in Collier County have been natural resources and mining, -27%, manufacturing, -15%, information technology, -14% and professional and business services, almost 4 percent. The largest increases in employment have been in the educational and health services sector, percent and in leisure and hospitality, +34 percent (Table 13). Table 14 gives the percentage distribution of persons employed by sector. In 21 almost 13 percent of all persons employed in were in the construction industry, by 211 this declined to 7.6 percent. Between 21 and 211 the total number of persons employed in Collier County increased by 4.8 percent while at the same time the population grew by almost 23 percent. Contributing causes of this wide difference are; the aging Baby Boomer generation, the continuous influx of new retired residents and the economic crisis of 27. Table: 13 Average Annual Employment in, by sector, 21 and

52 Sector Percentage Change Natural Resource and Mining 7,26 5,14-27 Construction 14,261 8, Manufacturing 2,98 2, Trade, Transportation and Utilities 21,493 21, Information 1,76 1, Financial Activities 6,22 6, Professional and Business Services Education and Health services 12, , ,44 17, Leisure and Hospitality 16,873 22, Other Services 4,561 4,98 +8 Government 1,771 12, All Sectors 11, , Source: Florida Department of Economic Opportunity, Labor Market Statistical Center, Quarterly Census of Employment and Wages Program. Table: 14 Distribution of the Labor Force, by sector, 21 and 211 Sector Natural Resource and Mining 6.4% 4.3% Construction 12.9% 7.6% Manufacturing 2.6% 2.1% Trade, Transportation and Utilities 19.5% 19.% Information 1.5% 1.3% Financial Activities 5.5% 5.5% Professional and Business Services Education and Health services 11.3% 1.4% 1.9% 15.1% Leisure and Hospitality 15.3% 19.5% Other Services 4.1% 4.2% Government 9.8% 1.9% Source: Florida Department of Economic Opportunity, Labor Market Statistical Center, Quarterly Census of Employment and Wages Program. 2

53 Participants Poverty and Food Assistance The Supplemental Nutrition Assistance Program of the U.S. Department of Agriculture provides benefits that are used to purchase food at grocery stores, convenience stores and some farmer s market and co-op food programs. Current requirements for eligibility are a household monthly net income of less than 1% of the federal poverty guideline. Table 15 and Figure 13 show the total number of individuals, adults and children receiving food assistance in between 1993 and 211. While the exponential population growth beginning in the 199 s has accounted for a constant increase in the number of individuals receiving food assistance, between 27 and 211, the number of children receiving food stamps increased by 33 percent while the number of adults increased by 39 percent. Figure 14 shows the correlation between median household income and children necessitating nutritional assistance. Figure: 13 45, 4, 35, 3, Number of Children and Adults Participating in the Supplemental Nutrition Assistance Program,, Florida, , 2, Children Adults All Individuals 15, 1, 5,

54 Income Children Participants Figure: 14 Number of Children Participants in the Supplemental Nutrition Program and Median Household Income (in 211 dollars),, $65, 2, $6, 15, $55, 1, $5, $45, 5, $4, Median Income Children Participants 22

55 Table: 15 Number of Children and Adults Participating in the Supplemental Nutrition Assistance Program,, Florida, Children 8,89 8,38 6,738 6,546 5,8 4,51 3,375 3,4 2,89 3,177 3,244 4,739 5,177 4,45 4,428 6,633 16,741 19,25 19,98 Adults 6,923 6,652 5,6 5,446 4,14 3,276 3,128 3,77 3,17 3,384 3,617 4,947 4,941 4,65 4,837 6,989 17,179 19,767 21,32 All Individuals 15,12 14,69 12,338 11,992 9,184 7,786 6,53 6,117 5,97 6,561 6,861 9,686 1,118 9,1 9,265 13,622 33,92 38,792 41,12 23

56 Infectious Diseases in Epidemiology is the science which monitors and evaluates the distribution and causes of diseases, health-related states or conditions within specific populations. Within the Health Department our priority in the Epidemiology Program are infectious diseases and other threatening public health conditions. In the State of Florida each of its 67 counties has a component of the Department of Health referred to as the County Health Department. The Collier County Health Department has jurisdiction over the public s health both that of residents and visitors, within the geopolitical boundaries of. During calendar year 211, the Division of Epidemiology and Health Assessment in investigated a Total of 442 reportable diseases and conditions (this figure excludes the number of HIV/AIDS, STDs and tuberculosis cases which are investigated and reported by other Health Department program entities). Between the year 2 and 211 the reportable infectious disease incidence rate in increased by 2 percent. If population growth is not taken into account, the number of diseases increased by over 52 percent over this same interval. While the Florida statutes require that a number of communicable diseases be reported to the local health departments as they occur by physicians, hospitals, urgent care centers and labs, in five diseases and conditions account for over 71 percent of all investigations carried out by the Epidemiology Program. Table 1: Five Leading Communicable Diseases and Health Conditions Reported to the Epidemiology Program of the Health Department, 211. Rank Order Disease or Condition Number of Cases Percentage of ALL Reportables to CCHD-EPI 1 Salmonella Campylobacter Animal Bites(Post Exposure Prophylaxis Recommended) Giardiasis Varicella Total

57 While is a relatively small geopolitical footprint within Florida, accounting for only approximately 1.7 percent of the state s total resident population, due to its unique location on the peninsula, only 1 miles west of Miami the gateway to Latin America and the Caribbean, various demographic, socio-economic and epidemiologic risk factors have a tendency to make this part of Southwest Florida an emerging epi-center for infectious diseases that are foreign to North America or that had been eliminated from the country in the prior century. After the February 21 earthquake in Haiti, the poor health and sanitation infrastructure that had always existed in the island nation rapidly deteriorated culminating in a large scale cholera epidemic first reported to the CDC and WHO in late October of that year. By December of 21 over 1, cases of cholera and over 2, deaths form the disease had been reported from Haiti. In November of 21, the Epidemiology Program of the Health Department reported the first imported cholera case (Naples, FL) in the United States and Florida from the 21 Haitian Epidemic. Due to prior internal planning for such an event and a very quick public health response and thorough investigation by the Collier Epidemiology Program of the Health Department no secondary transmission of the disease was reported in our community or county. Three of the five leading communicable diseases are conditions reported to Epidemiology are enteric or gastrointestinal related in terms of signs, symptoms and manifestation. Salmonella, campylobacter and giardiasis accounted for 223 cases or 5 percent of all reportable conditions in in 211, Table 1. Salmonella is a bacterial infection usually causing diarrhea, fever and abdominal cramps. In some cases the diarrhea may be so severe that the patient needs to be hospitalized. The incidence in Florida and in has been increasing over the last 1 years. In 211 rate per 1, population was 38.8 cases, an increase of 87 percent since the year 2, Figure 1. 2

58 Rate per 1, Figure 1. Reported Cases of Salmonella in and Florida, Florida Campylobacter is one of the most common bacterial causes of diarrheal illness in the United States. It is estimated that over 2.4 million persons in the U.S. every year are affected by this disease; therefore a majority of cases go undiagnosed and unreported. Symptoms of campylobacter include diarrhea, cramping, abdominal pain and fever. Between 2 and 211 the rates for the state and remained fairly constant and basically unchanged with the exception of a few fluctuations for both areas, although historically the overall campylobacter incidence in Collier has been on average 3 to 4 times higher than that for Florida. This has been attributed to a high level of reporting by hospitals and health care providers in Collier while for the overall state testing for the disease is not as widespread as in the more affluent coastal counties which results in a lower underreported true rate, Figure 2. 3

59 Rate per 1, Figure 2. Reported Cases of Campylobacteriosis in and Florida, Florida It should be noted that the reason for the variability or wide fluctuations in s rate in any of these disease specific graphs is due to the concept of random variation. with a relatively small resident population of 324,422 in 211 is only 1.7 percent that of Florida s 18,934,175 (due to this difference in population size Florida s denominator will be much more stable than s and is not subject to variable fluctuation due to relative changes in the numerator). Giardiasis is a diarrheal disease caused by a microscopic parasite. This parasite is found in soil, food or water that has been contaminated with feces of infected humans or animals. Although giardiasis occurs worldwide, in the U.S. it is more commonly found in lakes, rivers, springs, ponds and streams. Prevalence appears to be higher in the Caribbean and other Latin American countries than in Florida and the United States. Between 2 and 28 the rate for giardiasis in declined by 76% (from 21.2 to 5.1) only to increase to 1.8 per 1, population in 211 for an actual decrease of 49.1 percent over the 12 year interval, Figure 3. The rate for the State declined by 28 percent between 2 and 211. One of the major correlates of the giardiasis incidence in through 211 has been the total number of refugees received through the Federal Refugee Resettlement Program by the county. Between 25 and 211 absorbed 3,399 foreign refugees. As a mandatory requirement, all refugees participating in this program are tested and screened for select communicable and infectious diseases, including giardiasis. 4

60 Rate per 1, Figure 3. Reported Cases of Giardiasis in and Florida, Florida Shigellosis is an acute bacterial disease involving the small intestine and colon. Most cases are acquired as a result of the bacterium passing from the stool or soiled hands from one person to the month of another. As with most infective diseases frequent hand washing with soap significantly reduces the risk of acquiring the disease. Shigellosis is more prevalent and may be recurrent in environment where low hygiene standards exist. It is more common in warm weather and majority of cases in the United States occur in children 2-4 years of age particular in child care settings. Between 2 and 211 the rate of reported cases of shigellosis declined by 71 percent from 11.8 to 3.4 per 1, population. The rate for Florida increased by 74 percent over the same period. The most common associated shigellosis risk factor in is being a toddler or an employee in a child care facility, Figure 4. 5

61 Rate per 1, Figure 4. Reported Cases of Shigellosis in and Florida, Florida Hepatitis A is a contagious disease of the liver caused by infection with the hepatitis A virus. The disease is spread when the virus is taken in by mouth from contact with contaminated food, objects or drinks contaminated by the feces of an infected person. Hepatitis A is more prevalent in countries and areas with poor sanitary conditions and low levels of personal hygiene exist. While incidence of hepatitis A is low in the United States and other developed countries, in Central and South America endemicity can be very high with case rate reaching 15 per 1, population annually. Between 2 and 211, the rate of reported cases of hepatitis A decreased significantly to.6 per 1, population for both and Florida. In this decline in the hepatitis A rate was a reduction of 75 percent, in Florida the decrease amounted to 84 percent, Figure 5. While annual fluctuations in reported cases have occurred, these rates are the lowest in 4 decades and are directly attributed to the introduction of the hepatitis A vaccine in

62 Rate per 1, Figure 5. Reported Cases of Hepatitis A in and Florida, Florida Varicella or chickenpox is an acute infectious disease caused by Varicella zoster virus (VZV). varicella occurs worldwide, some data suggest that varicella infection occurs more commonly among adults than children in tropical areas. In the pre-vaccine era varicella was endemic in the United States, and virtually all persons acquired the disease by adulthood. The mode of transmission is by direct contact, person-to-person, droplet or airborne spread of vesicle fluid, or secretions of the respiratory tract. In Florida immunization against varicella is recommended for children following their first birthday unless they have had the disease. Varicella became a reportable disease in Florida in late 26. Between 27 and 211 cases in declined by 4 percent, in Florida cases decreased by 35 percent over the same period, Figure 6. 7

63 Rate per 1, Figure 6. Reported Cases of Varicella in and Florida, Florida

64 Pertussis or whooping cough is an acute bacterial infectious disease caused by Bordetella pertussis. Pertussis outbreaks have been described since the 16 th century, the organism was first isolated in 196. During the 2 th century, pertussis was one of the most common childhood diseases and a major contributor to childhood mortality in the United States. Beginning with the widespread use of vaccine, pertussis incidence declined more than 8 percent compared with the pre-vaccine years. Recent years however, have experienced a re-emergence in the United States predominately due to unvaccinated children. Pertussis remains a major public health problem among children in developing countries with an estimated 3, deaths resulting from the disease annually. It is also endemic within the United States. Between 2 and 211 the number of reported cases of pertussis in adjusted for population has increased from.4 to 5.9 per 1,. This amount to a 1,375 percent increase in only 11 years. (Figure 7). Contrasting with the total state s reported cases; has had on average consistently higher incidence. The frequency of individual cases of pertussis reported in increased from 1 in the year 2 to a record 19 cases during calendar year 211. Since 28, has experienced 3 significant outbreaks of pertussis, most involving children that were unvaccinated against the disease. Since 28, 4 or two thirds of the pertussis cases reported since the year 2 have occurred. Figure 8, highlights the 28 and 211 outbreaks with a bimodal distribution. Nationally pertussis cases and outbreaks are increasing, during 212, 49 states and Washington, D.C. reported an increase in disease frequency compared with 211. Among children, infants have the highest incidence due to their lack of immunity, followed by children ages 7 to 1 years of age. Children who are unvaccinated have more than an eightfold greater risk for pertussis than children who are fully vaccinated with DTaP Pertussis is a vaccine preventable disease whose incidence can be significantly reduced through health education on the science of vaccine protection. 9

65 Number of Cases Rate per 1, Figure 7. Reported Pertussis Cases in and Florida, per 1, Population, Florida Figure 8. Frequency of Reported Cases of Pertussis in, Series

66 In in percent of all reportable health conditions or about 1 in every seven investigations involved animal bites requiring post-exposure prophylaxis (PEP) to prevent the potential onset of human rabies. Between 21 and 211 the number of animal bites to humans requiring PEP increased by over 9 percent. When adjusted for population growth the number increased just over 8 percent. To place Collier s situation in perspective with some other counties that are contiguous with Collier or portions of the Everglades, Table 2 shows the number of reported animal bites requiring post exposure prophylaxis per 1, ranked by county in South Florida. Table 2. Animal Bites with PEP Recommended per 1, Population Rank Order (211) County Resident Population (211) 1 Lee ,454 2 Collier ,422 3 Miami-Dade ,521,194 4 Monroe ,65 5 Palm Beach ,327,313 6 Broward ,753,678 Broward, Miami-Dade and Monroe counties have large surface areas with wild life of varying species and large populations potentially at risk with the exception of Monroe, yet the reported animal bite rates for these three counties is significantly lower than that of Collier and Lee counties. This would tend to establish a correlation between rates of reported animal bites and Gulf Coast counties in SW Florida. In South Florida it appears that the populations of Collier and Lee counties (total of 951,876 in 211) are at much greater risk of being exposed and bitten by a potentially rabid animal than the populations of Broward, Miami-Dade, Monroe and Palm Beach counties (total of 4,347,477). This assumes relatively complete or equivalent levels of reporting. Tourists and visitors are likely to be more vulnerable to a wild animal bite due to their lack of knowledge on the local situations and have been frequent victims of bites in, Figures 9 and 1 display these trends in. 11

67 Number of Bites Rate per 1, Figure 9. Reported Animal Bites Requiring PEP* in and Florida, * Post-exposure Prophylaxis Florida Figure 1. Reported Animal Bites Requiring PEP* in, * Post-exposure Prophylaxis 12

68 Number of Cases Rate per 1, Total Reportable Disease Cases Between the years 21 and 211 reportable disease incidence in increased by 29 percent. Between 26 and 211 this increase was 5 percent. A similar pattern was seen for the State of Florida. The reasonable public health explanation for this uptick in Collier is the economic recession and its related impact on the community. continues to have among the highest reportable disease case rate throughout Southwest Florida, Figures 11 and 12. Figure 11. Total Reportable Disease Cases in and Florida, (excluding HIV/AIDS, STDs and Tuberculosis) Florida Figure 12. Total Reportable Disease cases by Month in, 21 and 211 (Excluding HIV/AIDS, STDs and Tuberculosis)

69 Rate per 1, Enteric Diseases in Enteric disease incidence in as a category has historically been consistently greater than the Florida State average. Between 26 and 21 the enteric disease for Collier and Florida followed an almost identical pattern, during this 5 year period the enteric disease rate increased by 47 percent while in Florida the increase was only 29 percent. is considered to have fairly complete disease reporting levels when compared to the state as a whole, this is reflected in the higher reported disease incidence, Figure Figure 13. Reported Enteric Disease Cases in Outbreaks in and Florida, Florida

70 Number of Cases Annual Seasonal Variation of Leading Reportable Cases and Conditions in 21 and 211 Animal Bites While activity is highly variable by month and year both 21 and 211 saw a peak in animal bite incidence during the month of July, while during 211 the month of March experienced the highest number of reported cases over the 2 year period. Further investigation over a 1 year period is required in order to validate a pattern, Figure 14. Figure 14. Animal Bites Reported by Month to the Epidemiology Program in Collier County, 21 and Jan Mar May Jul Sep Nov Month

71 Number of Cases Campylobacter Activity remains variable by month; however June had the highest incidence for 211, while July of 21 had the peak incidence for the entire period. Further investigation over a 1 year period would be needed in order to validate any consistent seasonal pattern, Figure 15. Figure 15. Campylobacteriosis Cases Reported by Month to the Epidemiology Program in, 21 and Jan Mar May Jul Sep Nov Month 16

72 Number of Cases Giardiasis For 21 and 211, October and February are coincident peak months for reported cases. April through July-August appears to have increased incidence for both years. August of 211 had the highest incidence during the 2 years analyzed. As with other reported pathogens in, further assessment would be required to establish a definitive pattern, Figure 16. Figure 16. Giardiasis Cases Reported by Month to the Epidemiology Program in, 21 and Jan Mar May Jul Sep Nov Month

73 Number of Cases Salmonella When examining for any seasonal pattern in 21 and 211 it is evident that: a) Salmonella incidence was higher in 211 than in 21 a pattern being seen throughout the State and United States. b) Incidence increases upwardly by month beginning in March for 21 and in March during 21. While cases peaked in 211 in September, 21 experienced it s highest incidence of the year in the month of December. Salmonella is the major enteric of public health interest in Collier County as well as Statewide. It is responsible for over 28 percent of all infectious diseases reported in to Epidemiology Program, Figure Figure 17. Salmonella Cases Reported by Month to the Epidemiology Program in, 21 and Jan Mar May Jul Sep Nov Month 18

74 Number of Cases Cases Investigated but not Reportable Almost 5 cases were investigated in by the Epidemiology Program of the Health Department in 211 that resulted in not being reportable diseases not meeting the Department of Health s case definition criteria in the final analysis (Established public health criteria by the U.S. Centers for Disease Control and the Florida Department of Health). By month March and December had peaks of incidence for 211, while on 21 the highest incidence occurred in July. Although further analysis will be needed, there may have been a possible association with the Holiday season during 211. Figure Figure 18. Cases Investigated but not Reportable by the Epidemiology Program of the Health Department by Month, Jan Mar May Jul Sep Nov Month 19

75 Norovirus Noroviruses are a group of Norwalk like viruses and the most frequent cause of acute gastroenteritis illness in all age groups in the United States. Norovirus causes 21 million cases of acute gastroenteritis in the U.S. annually affecting about 1 out of every 14 americans per year. With the application of electron microscopy during the 197 s, the Norwalk group of viruses (coined for a school gastroenteritis outbreak that occurred in Norwalk, Ohio in 1968) was discovered as the pathogen causing the vast majority of foodborne viral illness - particularly evolving outbreaks. Norovirus is a highly contagious virus. The virus can be transmitted from an infected person, contaminated food or water or by coming into contact with contaminated surfaces. Norovirus spread very quickly within closed places such as daycare centers, nursing homes, schools and cruise ships. The majority of norovirus outbreaks occur between November and April in the United States and Florida. The incubation period for norovirus ranges from approximately 12 to 48 hours and the average duration of illness is between 24 and 72 hours. The disease is self-limiting for most people and while there is specific treatment available for norovirus, ill individuals should drink plenty of liquid to prevent dehydration. 2

76 Number Of Outbreaks Figure 19 shows the number of suspected and confirmed norovirus outbreaks in for the period 27 to 211. Figure 19. Number of Confirmed and Suspected Reported Norovirus Outbreaks,, While norovirus is not a mandatory reportable disease in itself in the State of Florida, any outbreak of a disease or condition found in the community or a setting that is of public health significance is reportable by Florida administrative code While the annual number of reported outbreaks of norovirus in between 27 29, and 211 were in line with our expected averages, between January and April 21 the community experienced a tremendous surge in the number of norovirus outbreaks and related cases resulting in the highest incidence of the virus recorded locally in public health history. During this 4 month interval (January April 21), 16 outbreaks were reported from 12 different long term health care facilities in the county. Testing by the Epidemiology Program of the Health Department revealed that all sampled specimens tested were positive for norovirus G2 virus. 21

77 Number of Cases Figure 2 renders a typical epidemic curve from one of the long term care facilities reporting a norovirus outbreak in during 21. Figure 2. Epidemic Curve of a Norovirus Outbreak in a Long Term Health Care Facility,, January 12 January 13 January 14 January 15 January 16 January 17 Date Figure 2 is a classic example of an epidemic curve of a norovirus outbreak with good reporting. The distribution on this example follows a normal bell shaped distribution due to the short incubation period, the short duration and self limiting nature of norovirus and the quick proactive infection control effort of the Health Department and the facility. The curve shows the onset of the outbreak with 2 cases on January 12 th, peaking with 15 new cases on January 14 th and subsequently tapering off by January 17 th with only 1 newly reported case. This epidemic curve is a textbook rendition of a norovirus outbreak within an enclosed facility; it adheres to the incubation period and the duration of illness intervals. 22

78 Mosquito Borne Disease Mosquito Borne Diseases are an indigenous risk in Southwest Florida due to the geographical location, climate and its wet and warm season and conditions which favors significant breeding and propagation of the mosquito population annually. There are 3 major mosquito - borne viruses which may be considered endemic to Florida and therefore a potential public health concern in. While the actual annual risk of a human contracting any mosquito-borne disease in is low, case fatality rates for these diseases are high in comparison to most other infectious diseases found in Southwest Florida. Because these 3 diseases are viral, antibiotics do not assist for treatment and antiviral agents have not been shown to be effective. Table 3 lists the 5 major mosquito-borne diseases of interest in Southwest Florida with the number of cases reported in for the period Table 3. Mosquito Borne Diseases in, Disease EEE a) _ 4 WNV _ SLE b) _ - _ Malaria c) 2 Dengue c) _ 4 (Imported) 2 (Imported) _ _ Source: CCHD, Epidemiology and Health Assessment Program a) Equine cases b) Last reported case of SLE in was in 1993 with a total of 3 cases c) Imported cases 23

79 Number of Cases Figure 21. Mosquito Borne Diseases in, EEE WNV SLE Malaria Dengue St Louis Encephalitis (SLE) was the most common mosquito borne human pathogen in the U.S. before the introduction of West Nile Virus (WNV). In, SLE outbreaks last occurred in 199, 1993 and Less than 1% of SLE infected individuals are symptomatic and the majority of infections remain unreported and undiagnosed. The case fatality rate in Florida for SLE has ranged from 4 to 3 percent. Fatal cases almost always occurred in persons 5 years of age and older. West Nile Virus (WNV) was first discovered in Uganda in 1937 and remained out of the western hemisphere until the 1999 outbreak in the northeastern U.S. The virus is closely related to SLE and cross reacts with SLE during serological testing. WNV was first detected in Florida in 21. The first WNV case in was reported in 22.About 8 percent of those infected are asymptomatic and as with SLE, individuals over 5 years of age are at increased risk of severe disease. Eastern Equine Encephalitis (EEE) was first identified in the 193 s in the eastern United States. In Florida, between 1957 and 211 only 85 sporadic cases in humans have been reported for an average of 1.6 cases per year. has not reported a human EEE case in public health history. 4 equine cases of EEE were reported in in 21. While, only approximately 1 in every 23 persons bitten by an infected mosquito may develop severe symptoms, about 33 percent of all patients with clinical EEE symptoms will die from the disease. 24

80 Dengue fever is an important mosquito-borne disease globally that has recently begun to emerge in parts of Florida. The infection is acquired through the bite of specific species of mosquitoes: Aedes aegypti and Aedes albopictus, both of which are found in Florida and. Until 29, the last dengue fever epidemic in Florida occurred in In the summer of 29, local dengue transmission occurred in Key West, Fl. Between 29 and 21 a total of 83 indigenous dengue cases were reported from Key West, locally acquired cases of dengue were also reported in other counties of South Florida during In there have been a total of 4 reported imported dengue cases between The Health Department continues to maintain active epidemiological surveillance and vigilance while partnering with mosquito control to ensure that the probability of mosquito borne disease transmission remains low in the community. 25

81 Tuberculosis Historical Summary Tuberculosis is a mycobacterial disease that is a major cause of disability and mortality in most of the world, especially developing and emerging countries. Initial infections usually go unnoticed. Approximately 1 percent of the population infected will eventually develop active disease, half of them during the first 2 years following infection, 9% of untreated individuals will never develop active tuberculosis. Industrialized countries such as the United States showed downward trends of mortality and morbidity of tuberculosis for many decades, however during the 198 s reported cases increased in the developed counties as areas and population groups with a high prevalence of HIV infection or with a relatively large proportion of persons from high prevalence countries grew. Tuberculosis death and illness rates increase with age and in older persons the incidence rates are higher in males than in females. As population from these developing countries migrate to the United States the risk of potential disease transmission increases depending upon the underlying prevalence rates of these source countries. Historically the incidence of tuberculosis in has been higher than that of the state of Florida, particularly for the time period prior to 197 through the 199 s. Only during select recent years have tuberculosis case rates in Collier been lower than those of the state, however this trend has not been consistent and reversed in 21 due to the various socio-economic and epidemiological risk factors that tend to surface during downturns in the local and national economies as well as the geo-political influences and factors which due to Florida s geographical location in the Western Hemisphere results in a larger proportion of vulnerable populations seeking Southwest Florida as a final residential destination. In Florida medically underserved low-income populations, many of which are high-risk racial and ethnic minorities, have a high rate of tuberculosis exposure and infection. These population groups disproportionally represent the majority of TB cases in and the state. Although has had a number of successes over the past 2 years in decreasing TB morbidity in select time periods it still faces formidable challenges in preventing and controlling tuberculosis in the community. 26

82 Rate This analysis refers to the calendar year period This 7 year interval has been selected as it is the most recent period with detailed data available and therefore reflects the current situational analysis of as of this writing and it provides stable enough numbers for valid statistical inferences to be made for public health and epidemiological planning purposes at the local level. Figure 22. Number of Tuberculosis Cases per 1, Population,, Tuberculosis Cases Rate 6 4 Average Rate for Between 25 and 211 reported a total of 156 cases resulting in an annual average rate of 7. cases per 1, population for this time period. Figure above shows the variation in the annual rate by year. While the rate declined by approximately 23 percent in 25, and by 22 percent in 26 and by 23 percent in 29 it increased by 82 percent, almost doubling, in 28 and by 62 percent in 21 before leveling down to 6.8 per 1, population for 211, the average rate for 7 years period (25-211) is exactly 7., Figure

83 Number of Cases Age, Race, Ethnicity and Country of Origin By race during this period, 66 percent of the cases were among whites, 3 percent were black, while 4 percent were categorized as other races. As is expected with tuberculosis males in accounted for the majority of cases 67% compared with 33% female. By ethnicity, Hispanics accounted for over 54 percent of all TB cases reported in during this period. Nationally, Hispanics accounted for 29 percent of all cases reported in the U.S., although this still was the largest ethnic proportion across all states. This is due to the fact that in the Hispanic population comprises approximately 3 percent of the community while Asians and Blacks other high risk populations only account for about 1 percent and 6 percent of the total population, respectively. In at least 25 percent of households speak a language other than English at home. This in itself is obviously not a risk factor; however, it serves as a marker to quantify the potential for imported infections in terms of the total number of susceptible individuals in from countries where TB is more prevalent than in the U.S. Figure 23. : TB Cases by Ethicity, Hispanic Non Hispanic

84 Number of Cases While in the United States between 25 through 211, the top five countries of origin of foreignborn persons with TB were Mexico, Philippines, Vietnam, India and China in Collier Count, foreign borne the top source countries as TB cases by rank order included Mexico, Haiti, Guatemala, Cuba Bolivia, Honduras and South Africa. By age of case, those between 25 to 44 years of age accounted for about 47 percent of all Collier County cases while for the U.S. as a whole, this age group comprised almost 34 percent of the total number of cases - most cases reported in Collier were in this age group the same as throughout the United States Drug Resistance Although the Florida Department of Health does provide the population with a number of public health services, we do not offer primary care for the community. 87 percent of the TB cases did not have general access to health care in the form of health insurance. Likewise cases for which TB was drug resistant in accounted for 9% of TB patients for which data are available. For Florida the figure is 7%. Figure 24. : Resistant and Non Resistant TB Cases, Resistant Non resistant

85 Number of Cases HIV Co-Infection Worldwide, tuberculosis is the leading cause of death for persons with HIV infection. A coinfection with HIV complicates the treatment plan of TB. Both drug interactions and malabsorption are challenges that must be overcome in the case management of co-infected individuals. During the period a total of 14 cases or 13 percent in were co-infected with HIV. In Florida as a whole during the same period the percentage was 15.9 (1.32 cases). 5 Figure 25. : Frequency of TB Cases HIV Coinfected, Of the 11 cumulative cases that were treated at the Health Department during the period cases or 3% expired and 2 or 2% were lost to followup. 3

86 Number of Refugees Refugee Resettlement Program and Tuberculosis Testing As the community of continues to grow, the area will most likely continue to attract the foreign-born population from Latin America and the Caribbean, which contain high risk prevalence areas for TB. Between 25 and 211 Florida received 172,62 arrivals through the Federal Refugee Resettlement Program. continued to rank 7th out of Florida s 67 counties in the total number of refugees received during this 7 year period with a cumulative total of 3,399.(counties with larger annual resettled refugees include: Miami-Dade, Hillsborough, Duval, Palm Beach, Orange and Broward, by rank order). It should be noted that based on the latest data available, Florida apparently continues to receive the largest population of persons eligible for the Federal Refugee Resettlement Program and South Florida accounted for 85 percent of all in the United States resettled refugee arrivals during 211. This trend is expected to continue in future years, Figure 26. As a mandatory requirement, all refugees participating in the Federal Resettlement Program must be tested and screened for select communicable and infectious diseases, including TB. Figure 26. Number of Refugees Resettled in,

87 The Tuberculin purified protein derivative (PPD) skin test is the standard method for determining whether a person has been infected with Mycobacterium Tuberculosis. A positive PPD is not indicative of active TB and may be due to a latent or dormant TB infection. A positive PPD usually signifies that an individual has been exposed to the tuberculosis bacterium. When an individual does have a positive PPD result, follow-up with other tests such as chest x-rays must be carried out in order to look for signs of active TB disease. It should be emphasized that one third of the world s population (over 2 billion persons as of 211) have been infected with TB. By geographical distribution, approximately 8% of the population in many Asian and African countries test positive when a PPD is administered while only between 5 and 1% of the US population generates positive test results. It is estimated that between 2 to 5% of population of Latin America and the Caribbean have been exposed to TB (this percentage will vary by country and within countries). Data received from tuberculin skin tests for refugees screened at the Health Department for the period are shown in table 4. Table 4. PPD Positive Test Results from Refugees Resettlement Program Participants,, Number with Positive PPD Percentage of All Tests Positive

88 The number of TB skin tests varied by year between , however, the number of positive PPDs increased by 58% during this period. Although has had a number of successes over the past 2 years in decreasing TB morbidity in select time periods, there remains a disproportionate burden of TB among ethnic minorities as in the United States and it still faces formidable challenges in preventing and controlling TB in the community. Geographical Distribution of TB Cases While has the largest surface area of any county east of the Mississippi River, the vast majority of the population is concentrated on the Gulf Coast area and a very large peri-urban concentration in what is referred to as the Estates. The total resident population of the county was approximately 334, during 211. Between 25 and 211 the population of increased by 6. percent in contrast to an increase of 21.5 percent between the years 2 and 24. Population growth has significantly declined over the past 5 year period, however, the distribution of a number of health conditions including tuberculosis and other diseases related to socio-economic status, education, employment and income levels continue to be proportionately higher in select population subgroup of the county. Immokalee, a small agrarian community approximately 45 miles northeast of the city of Naples, is a major supplier of tomatoes and other produce to the United States. This type of labor and lifestyle is historically and presently associated with poverty, public health risk and vulnerable populations. While Immokalee accounts for anywhere between 6 and 8 percent of the total county resident population at a given point in time it accounted for almost 43 percent of all tuberculosis cases between 25 and 211. The estimated Tuberculosis case rate for Immokalee for this most recent period is over 6 times that of Greater and Naples. The graph in Figure 27 displays the disproportionate burden of Tuberculosis in Immokalee. 33

89 Number of Cases Figure 27. and Immokalee: TB Cases by Ethnicity, Hispanic Non Hispanic 1 Immokalee Collier Ethnicity 34

90 Number of Cases Rate per 1, Sexually Transmitted Diseases (STDs) Chlamydia Chlamydia trachomatis infection is the most frequently reported notifiable disease in the United States, Florida and. It is the most prevalent of all STDs in the country and in Collier County. Chlamydia infections in women are usually asymptomatic and can result in pelvic inflammatory disease (PID) which is a major cause of infertility, ectopic pregnancy and chronic pelvic pain. As is the case with other inflammatory STDs, chlamydia infections can facilitate the transmission of human immunodeficiency virus (HIV). Pregnant women infected with chlamydia can also pass the infection to their infants during delivery, potentially resulting in neonatal ophthalmia and pneumonia. Due to the burden of disease and the risks associated with infections, CDC recommends that all sexually active women younger than 25 years of age receive an annual chlamydia screening. Figure 28. Reported Chlamydia Cases and Rates by, Number of Cases Rate 35

91 In, between 25 and 211 the total number of reported chlamydia cases increased from 585 to 726, an increase of over 24 percent, adjusted per 1, population the rate increased by 17 percent from to Based on monitoring of case counts and the annualized rates per 1, population the morbidity trend is clearly on an upward slope, Figure 29. Age and Gender Figure 29. Reported Chlamydia Cases by Gender,, Male Female During the period the ratio of female to male cases of chlamydia in ranged from 4.1 in 25 to 1.9 in 21. This variation in incidence by sex is in keeping with national trends and its distribution. On average in between 25 and 29 the ratio of female to male reported chlamydia cases was 2.6. This implies that almost 3 times as many cases of chlamydia were reported in females compared to males in. Sexually active females are at much greater risk of acquiring chlamydia than males in Florida and in the United States. 36

92 Table 5. Ratio of Female to Male Chlamydia Cases,, Female/Male Ratio / / / / / / / Average 3511/ Table 6. Reported Chlamydia Cases by Select Age Group,, Age Group Total Percent During the period , the highest age-specific rates of reported chlamydia are in 2-24 year age group for both females and males. The ratio of the female case rate to the male case rate for this age group was 2.5. The second highest age-specific groups in were among those years of age, with females having almost 6 times the frequency as males 37

93 Number of Cases Table 7. Reported Chlamydia Cases by Select Age Group and Gender,, Age Group Female Percent Male Percent Figure 3. Reported Chlamydia Cases by Select Age Groups and Gender,, Male Female Age Group Between the years 25 to 211 the reported chlamydia rate for females years of age increased by 14 percent from to 23. per 1, population. The rate for the male population in during the same period increased by an astounding 114 percent; from 41.2 to per 1,. The total combined chlamydia rate for those years of age increased by 2 percent; from in 25 to per 1, population in

94 Number of Cases Rate per 1, Figure 31. Reported Chlamydia Cases by Gender, s of Age, Total Rate 15 1 Female Rate Male Rate Figure 32. Reported Chlamydia Cases by Gender and Race,, African American Female African American Male White Female White Male Gender and Race 39

95 Rate per 1, While the Hispanic population of accounted for approximately 3 percent of the total resident population in 211, between 25 and 211 the number of Hispanic chlamydia cases were a disproportionate 42 percent of all cases. While this percentage remained fairly constant within the 7 year period, when rates per 1, population are analyzed, the Hispanic chlamydia rate increased by 4 percent during this period, from in 25 to 34.6 per 1, for 211. Figure 33. Reported Chlamydia Cases by Ethnicity,, Hispanic non-hispanic Although the chlamydia rate for the non-hispanic population increased by approximately one third during this 7 year interval, the actual baseline rates for non-hispanics is about one-half, the rate for Hispanics, Figure 33. 4

96 Number of Cases Rate per 1, Gonorrhea Gonorrhea is caused by Neisseria gonorrhea, a bacterium that can grow and multiply easily in warm, moist areas of the reproductive tract including the cervix, uterus and fallopian tubes in women, and in the urethra in women and men. Gonorrhea can also grow in the mouth, throat, eyes and anus. Gonorrhea is a very common communicable disease. CDC estimates that more than 7, individuals get new gonorrheal infections each year. However, due to under-reporting, less than 5% of these cases are reported annually throughout the United States. Figure 34. Gonorrhea Reported Cases and Rates by,, Number of Cases Rate Between 25 and 211, 696 cases of gonorrhea were reported in. The annual number has declined steadily from 123 in 25 to 8 cases in 211, a decrease of 35 percent. The only variation that was observed in this pattern was an increase in reported cases during 26 and a slight increment in 211. Adjusted for population the overall gonorrhea reported case rate decreased by 36 percent between 25 and 211, from 38.3 to 24.7 per 1, population. 41

97 Age and Gender Figure 35. Reported Gonorrhea Cases by Gender,, Male Female The ratio of female to male gonorrhea cases ranged from 1.2 in 29 and 21 to.7 in 211. Unlike chlamydia where the risk of disease is on average 3 times greater for females than males, the risk by sex of acquiring gonorrhea in appears to be equivalent on average for both males and females, Table 8. Table 8. Ratio of Female and Male Gonorrhea Cases,, Female/Male Ratio / / / / / / / Average 345/ The age distribution pattern of gonorrhea cases in is very similar to that of chlamydia, with the 2-24 year age group accounting for 35 percent of all reported cases for followed by the age group and then years of age. 42

98 Number of Cases Table 9. Reported Gonorrhea Cases by Select Age Group,, Age Group Total Percent Table 1. Reported Gonorrhea Cases by Select Age Group and Gender,, Age Group Female Percent Male Percent Figure 36. Reported Gonorrhea Cases by Select Age Groups and Gender,, Male Female Age Group 43

99 Number of Cases Rate per 1, Figure 37. Reported Gonorrhea Cases by Gender, s of Age, Male Rate Female Rate 15 Total Rate Between the period the gonorrhea rate for both sexes years of age increased by 26 percent from 19.8 per 1, population to Males experienced a dramatic increase during the same period from 172. to 26.5 per 1, population a growth of over 51 percent. Females demonstrated a much slower increase in reported gonorrhea cases from to per 1, population an increase of just over 15 percent. Race and Ethnicity Figure 38. Reported Gonorrhea Cases by Gender and Race,, African American Female African American Male White Female White Male Gender and Race 44

100 Rate per 1, By gender and race, white males accounted for 42 percent of all gonorrhea cases in Collier County between 25 and 211. Overall Hispanics accounted for 25 percent of all gonorrhea cases between 25 and 211. Figure 39. Reported Gonorrhea Cases by Ethnicity,, Hispanic non-hispanic By ethnicity, while Hispanics account for approximately 3 percent of s total population, their burden of disease is higher than expected. The Hispanic reported average gonorrhea rate per 1, population is about 35 percent greater than that of the non-hispanic population. Between 25 and 211 the Hispanic gonorrhea rate increased by 1 percent, while the rate for the non-hispanic population decreased by over 44 percent. 45

101 Syphilis Syphilis is a genital ulcerative disease that causes significant complications if left untreated and facilitates the transmission of HIV infection. Untreated early syphilis in pregnant women results in perinatal mortality in as much as 4 percent of cases and pregnancy may lead to infection of the fetus in 8 percent of cases. Syphilis is passed from person to person through direct contact with syphilis sore. Sores occur on the external genitalia, vagina, and anus or in the rectum. These sores can also occur on the lips and in the mouth. Between 21 and 211, the number of early latent syphilis cases reported in the United States decreased by 3.4 %, and the number of cases of late latent syphilis increased by 2.7 % The total number of all forms of syphilis reported to the CDC increased by.4 percent in 211. The primary and secondary syphilis (Infectious syphilis) rate in the United States remained at 4.5 cases per 1, during 211. In 211 the primary and secondary syphilis rate in Florida was 6.6 per 1, population, in the same year the rate for was.8 per 1,.This rate in has ranged from a low of.3 in 25 to 8.7 per 1, in 26, over the past 7 years. Trend analysis at the county level appears to indicate that overall syphilis is declining on average over the medium term; however caution must be exercised in any statement of conclusiveness as syphilis and the other STDs are known to be underreported in all communities and jurisdictions in the U.S. and Florida For the 7 year period 25 to 211, the total number of reported syphilis cases in ranged from a low of 16 in 211 up to 69 in 26. Total syphilis case rates ranged from 4.9 in 211 to 22.7 per 1, population in 26. The median syphilis case rate for the 5 year period was 13.7 per 1, population. While the total syphilis rate for Collier Count decreased in 211 by 42 percent compared to 21, cases of secondary syphilis remained at the same level. 46

102 Number of Cases Figure 4. Reported Syphilis Cases in, Table 11. Reported Syphilis Cases by Type,, Diagnostic Stage Primary Syphilis Secondary Syphilis Early Latent Syphilis Late Latent Syphilis Latent Syphilis Unknown Duration

103 Figure 41. Reported Syphilis Cases by Gender,, Male Female For the period ; 3 percent of the syphilis cases were latent syphilis of unknown duration, 25 percent were late latent syphilis, 24 percent were early latent syphilis, 12 percent were secondary syphilis and 9 percent were classified as primary syphilis. Less than 2 percent of the cases were classified as congenital syphilis. Figure 42. Reported Syphilis Cases by Type,, Primary Syphilis 27 Secondary Syphilis Early Latent Syphilis 74 Late Latent Syphilis 76 Latent Syphilis Unknown Duration Congenital Syphilis 48