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Public health in Washington State

Jude Van Buren DrPH, MPH, RNAssistant Secretary – Division of

Epidemiology, Health Statistics and Public Health Laboratories

Washington State Department of Health

Public Health:Public Health:

Always Working Always Working

forfor

a Safer and a Safer and

Healthier Healthier

WashingtonWashington

Public Health:Public Health:

Always Working Always Working

forfor

a Safer and a Safer and

Healthier Healthier

WashingtonWashington

Every Day in Washington Every Day in Washington State…State…

Communities are prepared for health emergencies thanks to the work of state and local public health agencies, 95 licensed hospitals, and other partners.

About 210 babies get a healthy start through early detection of treatable diseases by the Newborn Screening Program.

More than 5 million people have safe reliable drinking water because of the efforts of Washington’s state and local health agencies.

About 50 people call the state Tobacco Quit Line daily to take the first step toward kicking the habit.

Thousands of patients get safe quality health care from doctors, nurses, and other health care professionals licensed by the Department of Health.

Over 2.5 million people eat in restaurants with confidence thanks to the efforts of local health departments and our Food Safety program.

About 95 percent of kids entering school are protected against preventable diseases because of public health immunization and education efforts.

Governmental Public Health Network

Federal

State

Local

US Department of

Energy

US Health & Human Services (CDC,

HRSA)

US Environmental Protection Agency

Schools of Public Health

Washington State Board

of Health

State Health Departments

US Department

of Agriculture

Local Health Jurisdictions

Tribes

Washington State Local Health Jurisdictions

Adams County Health District

Benton-Franklin Health District

Chelan-Douglas Health District

Clallam County Department of Health and Human Services

Clark County Health Department

Columbia County Public Health

DistrictCowlitz County Health Department

Garfield County Health District

Grant County Health District

Island County Health Department

Jefferson County Health and Human Services

Kitsap County Health District

Kittitas County Health Department

Klickitat County Health Department

Lewis County Public Health

Lincoln County Health Department

Mason County Department of Health

Services

Northeast Tri-County Health District

Okanogan County Health District

Pacific County Public Health and Human Services

Department

Public Health – Seattle and King County

San Juan County Department of Health and Community Services

Skagit County Department of Health

Skamania County Health Department

Snohomish Health District

Spokane Regional Health District

Tacoma-Pierce County Health Department

Thurston County Public Health and Social Services Department

Wahkiakum County Department of Health and Human Services

Walla Walla County Health Department

Whatcom County Health Department

Whitman County Health Department

Yakima Health District

Grays Harbor County Public Health and Social

Services Department

Asotin County Health District

Chelan

Douglas

Ferry StevensPend

Oreille

BentonFranklin

17,300

21,100

160,600

70,10067,800

403,500

4,10096,800

35,700

7,500

64,200 2,400

80,60070,400

Island County – 77,200Kitsap – 243,400Mason – 53,100

Thurston – 231,100

28,200

1,835,300

37,400

19,800

72,900

10,200

39,800

21,500

12,300

773,500

113,100

10,600

671,800

436,800

42,100

3,900

15,700

57,900

184,300

42,800

231,800

Washington State Total Population as of June, 2006 – 6,375,600

WASHINGTON STATE

Department of HealthOrganizational Chart March 2009

SECRETARYMary C. Selecky

Board of Health

STATE HEALTH OFFICERMaxine Hayes, MD, MPH

Infectious Disease & Reproductive Health

Maternal & Child Health

Community Wellness & Prevention

COMMUNITY & FAMILY HEALTH

Mary WendtAssistant Secretary

Epidemiology

Center for Health Statistics

Public Health Laboratories

Informatics

EPIDEMIOLOGY, HEALTH STATISTICS, & PUBLIC

HEALTH LABORATORIESJude VanBuren, DrPH

Assistant Secretary

Drinking Water

Radiation Protection

Shellfish & Water Protection

Environmental Health & Safety

Environmental Health Assessments

ENVIRONMENTALHEALTH

Gregg GrunenfelderAssistant Secretary

POLICY, LEGISLATIVE, & CONSTITUENT RELATIONS

Brian Peyton, Director

Health Professions & Facilities

Customer Service

Inspections & Investigations

HEALTH SYSTEMS QUALITY ASSURANCE

Karen JensenAssistant Secretary

PUBLIC HEALTH SYSTEMS PLANNING & DEVELOPMENT

Allene Mares, Director

COMMUNICATIONS Tim Church, Director

PUBLIC HEALTH EMERGENCYPREPAREDNESS & RESPONSE

John Erickson, Director

FINANCIAL SERVICES Lois Speelman, Assistant Secretary

HUMAN RESOURCES Kathy Deuel, Director

INFORMATION RESOURCE MANAGEMENT Frank Westrum, Chief Information Officer

RISK MANAGEMENT Dennis Anderson, Director

ADJUDICATIVE SERVICES UNIT Laura Farris, Senior Health Law Judge

PERFORMANCE &ACCOUNTABILITY

Susan Ramsey

PERFORMANCE &ACCOUNTABILITY

Susan Ramsey

DEPUTY SECRETARYBill White

Legal Services

Community Health Systems

Dedicated Funds*

$240.1 Million23%

Fees$130.6 Million

13%

General Fund - State

$166.9 Million 16%

Federal$496.1 Million

48%

Department of Health’s Budget in Context:

Federal Funds are Major Fund Source

*Includes estimated Women, Infant, and Children (WIC) and AIDS Drug Assistance Program (ADAP) rebates of $64.1 million.*Includes estimated Women, Infant, and Children (WIC) and AIDS Drug Assistance Program (ADAP) rebates of $64.1 million.

February 2009

Department of Health’s Budget in Context:

Majority of funds are passed through to community partners

All Other Objects$177.5 Million

17%

Salaries & Benefits

$235.2 Million23%

Pass Thru$621 Million

60%

February 2009

Drug poisonings are a leading cause of death

• Drug overdoses kill more people in Washington than motor vehicle crashes.

• From 1995-2007, there was a 19-fold increase in opioid-related deaths.

• The use of methadone for chronic pain increased 1,300% from 1997-2006, and Oxycodone by 600%.

• Our state’s drug overdose death rate is higher than the national rate.

0

100

200

300

400

500

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Num

ber o

f dea

ths

Prescription Opioid & alcohol or illicit drug

Prescription Opioid Only

23

447

Combating Drug Misuse and Abuse

• Prescription monitoring*– Helps detect and prevent

prescription drug abuse

• Tamper-proof prescription pads– Prevents fraud

• Drug take-back programs– Promotes safe disposal

of drugs

– Shown to be safe and effective in pilot programs

* Currently suspended

Climate Change: Predicted Changes in NW Climate

• Increased average winter and summer temperatures (~ 1 degree F / decade)

• Precipitation pattern changes– Increased precipitation– Reduced spring snow pack– Increased storm intensities– Increased flooding and drought– Increased surface water temperatures– Reduced weather predictability

All models predict warming in the Northwest

444546474849

5051525354

1900

s

1920

s

1940

s

1960

s

1980

s

2000

s

2020

s

2040

s

De

gre

es

F

warmest scenario

average

coolest scenario

observed

Executive Order 07-02 (Feb 7, 2007)

• Washington’s Climate Change Challenge

• Drivers are global – Effects are local

• Technical workgroups – greenhouse gas emission reductions; clean energy economic goals.

• Preparation & Adaptation workgroups: PAWG: Health, Agriculture, Forestry, Water, Coastal.

Health Implications of Climate Change

• Health effects of excessive heat.

• Health effects of air pollution.

• Health effects associated with infectious diseases.

• Health effects of extreme weather events and rising sea levels.

• Psychological and social disruption effects.

Environmental Changes Will Affect Zoonotic & Vector-Borne Diseases

• Mosquitoes• Ticks• Hantavirus• Cryptococcus gattii

• Enhanced surveillance

• The built environment

• Emergency planning and preparedness

Key Preparation & Adaptation Strategies

Two overarching considerations from the Health PAWG

• The clear need for public engagement and involvement.

• The importance of social justice considerations in all actions taken to address climate change impacts.

National Public Health Week –

April 7–13, 2008

Climate Change: Our Health In The Balance

It’s time for Public Health to have a voice in the conversation.

Current activities:

• Senator Rockefeller working on a climate change bill aimed at better organizing and prioritizing state activities on the issue.

• Climate Action Team proposals forwarded for legislative consideration by outside groups.

• CDC request for Climate Change grant applications.

Biomonitoring Grant Proposal to evaluate Arsenic exposures

Goals:• 1) to determine background urinary arsenic levels in population • 2) to determine if there are specific populations in state that are at

higher risk for arsenic exposure • 3) To inform and educate those with higher risk

Methods: • Collect urine samples to evaluate speciated arsenic levels to

determine exposure to arsenic in specific and general populations

• Randomly identify households - gather urine samples of all individuals 6 yrs and older in household. (all must have lived in house 6 months or longer

• Evaluate through epi studies risk factors for exposure and adverse health outcomes for exposed populations

Arsenic Properties

Environmental fate Elemental: Properties: Cannot be destroyed in environment –

only changes form

• When broken down into smaller particles: enters air, water and dust

• Organic forms dissolve in water – finfish & shellfish accumulate

• Most of arsenic in water will end up on soil or sediment in water

Arsenic Sources

Where is it found? – Naturally and anthropoegenic• Industrial processes: Tacoma and Everett – smelters – coal fired

plants• Spokane, Tri-County and Clark Co areas - Pockets of natural

arsenic in basalt formations – from ground water sources of drinking water

• Commercial products – commercial arsenic containing pesticides: orchards, vineyards, cotton dessicants, cattle and sheep dips, paints and pigments, antifouling paints, leaded gasoline and firs salts multicolor flame)

• Pressure treated lumber – CCA – copper chromated arsenic • Foods: wines, tobacco ( because of herbicides and pesticides)• Shellfish and finfish – bivalves, certain cold water and bottom-

feeding fish – finfish and seaweed

Arsenic Exposure

Ingestion – ( 60 – 90% absorption in GI tract)• From swallowing dirt or air particles and getting into

gastrointestinal system

From eating arsenic laden fish or shellfish

Inhalation ( 60 – 90% absorption across lung membrane)• From breathing air containing arsenic• Living in areas unusually high in arsenic• Working in a job that involves arsenic production: copper

or lead smelting – wood treating or pesticide application • Dermal – minimal absorption

Bioaccumulation and testing for Arsenic Exposure

• After absorption in lungs or GI tract – Arsenic initially accumulates in the liver, spleen, kidney, lungs and GI Tract - clearance in several days

• After 2 – 4 weeks after exposures – arsenic remaining is found in keratin rich tissues such as skin, hair, and nails -lesser extent – bones and teeth - Arsenic is excreted primarily through kidneys

• Arsenic is excreted primarily through kidneys - - best route (least harm/impact to person) to evaluate low level chronic exposure to arsenic

Toxicology of Arsenic Exposure

• Two mechanisms of arsenic toxicity - impairs tissue respiration:

1) Arsenic binds with sulfhydryl (-SH) groups and disrupts – SH containing enzymes – inhibition of TCA cycle ( Krebs cycle), gluconeogenesis and oxidative phosphorylation

2) Substitution of As(V) for phosphorus in many biochemical reactions - leads to loss of high energy phosphate bonds – and uncouples oxydative phosphorylation

Health Effects of Arsenic Exposure

• Skin lesions• Hemorrhagic gastroenteritis• Liver toxicity• Anemia• Cardiovascular effects - vasospasm - Peripheral vascular

insufficiency (Gangrene) • Neurologic effects - Peripheral neuropathy • Dermal changes – pigment changes and some malignant cancersAll hallmarks of chronic arsenic ingestion

Arsenic is strongly associated with lung and skin cancer in humans – esp work related exposures at high levels

• May cause other internal cancers as well – (hepatic angiosarcoma – rare form of cancer)

*

How to evaluate if populations with higher exposures have more adverse related health effects

Epidemiological studiesCase control study– retrospectiveCase: people with adverse health outcomeControls: people without adverse health outcomes:

Blackfoot disease, Raynaud’s syndrome, peripheral neuropathy, Cancers: rare liver cancer, dermal,

Look at: exposure levels in urine of those with disease and those without,

Statistically evaluate whether people with adverse health conditions had higher levels of arsenic: Odds Ratio

Rate of having adverse outcome – given exposureRate of having adverse outcome – given no exposure

How to evaluate if populations with higher exposures have more adverse related health effects

Epidemiological studiesProspective or Cohort Study: Look at: exposure levels in urine of all people –

follow them over time – to see if those with exposure have higher levels of disease than those without or with lesser exposure

Statistically evaluate whether people with higher exposures of arsenic had more disease and what kinds of disease: adverse health conditions had higher levels of arsenic

Calculate: relative riskEvaluate the statistical significance of the finding

Proving Disease Causation: Does the association meet the criterai for determining causality?

1) Strength of association – statistically significant or could “chance” be at play?

2) Consistencies with other studies?3) Is association – disease specific?4) Appropriate time relationship? 5) Dose response relationship6) Plausible relationship?7) Coherence – biologically plausible?8) Experimental evidence – in- vivo,in-vitro

YOUR LOGO HERE

Public health in Washington State

Jude Van Buren DrPH, MPH, RNAssistant Secretary – Division of

Epidemiology, Health Statistics and Public Health Laboratories

Washington State Departmen of Health