Stories Archive - Page 11 of 18

Local Public Health Preparedness and Response to Hurricanes and Other Emergencies: High Tech and High Touch

By Umair Shah, MD, MPH, Executive Director and Local Health Authority for Harris County Public Health

This story was published in Ready or Not? 2017.

Harris County, Texas, is a large and rapidly growing community. We are the third largest county in the United States with 4.5 million residents spread over 1,700 square miles.

We are diverse in every sense of the word, making it vital to communicate in culturally competent ways. Additionally, since we are growing and people come from all over, they might not have experience with mosquito or hurricane seasons. We cannot assume our constituents, year after year, are the same. So we must continue to reach out to our community and educate.

That means we need adequate capacity within the department and a diverse team with a broad array of skills and experiences who continual drill and train.

To ensure we reach all our constituents, we are mobile—we take public health to the public. We’ve built health villages with large RV units—that focus on all aspects of health from mosquito abatement to dental services to immunizations.

We didn’t stop there – we knew to be a trusted source during an emergency we must foster a real intimate sense of community.

I mention this because, day-to-day, we rely both on high tech and high touch. We must remember the importance of both. As much as we talk about technology, social media and sophisticated surveillance systems, we cannot lose the high touch of knocking on a door or stopping to share a story, laugh or cry. At the end of the day, the high tech gets the visibility, but it’s the high touch that allows the high tech to succeed.

This is the backdrop that all our preparedness activities take.

Being Prepared

Even preceding Hurricane Katrina, we made sure that every single Harris County Public Health employee had up-to-date Incident Command Systems (ICS) training—and new staffers get this training as part of initiation.

And, every year, we practice—drills, exercises, call down lists, etc.—making sure we can perform all the tasks we’ll need to do during a response.

So, in reality, our response to Hurricane Harvey started more than a decade before the hurricane ever made landfall.

Hurricane Harvey

Before Harvey even hit, our preparedness director alerted staff and the executive team that a major response would be necessary. With this advanced warning, we put all assets in place before landfall.

We set up communications pathways and communicated to all staff, ensuring they were aware of what was coming and their roles and responsibilities.

Once we were in place, we turned to the community. Our communications team sent out messages before the storm about how to be prepared: get your kits ready; what will you do without power; what if you’re displaced; how will you care for the elderly, children and pets; and many more.

Aside from those messages, we needed to make sure people avoided flood water—there could be any number of dangers from power lines to insects to animals to sewage to toxins.

I highlight talking to the public because we’re all in this together. We can respond great from a systems perspective, but if, for instance, people lose access to medications or begin to eat unsafe foods, we could see infectious disease outbreaks or worsened chronic conditions.

In addition to communicating, building and leveraging partnerships is key to a good response.

For example, we worked with state public health and federal partners (the U.S. Air Force) to continue ground and aerial spraying for mosquitos to ensure there wouldn’t be increased levels of Zika or dengue or chikungunya. All levels of government coordinated to ensure we maintained adequate control over mosquitos and other infectious diseases.

Harris County also sheltered a number of people. Our epidemiologists relied on outside experts and volunteers to help them go cot-to-cot to make sure there wasn’t an infectious disease outbreak and that people maintained access to medicines—a high touch strategy.

This is just a small sample of all the activities we did to keep people safe. At the end of the day, a good response involves working across systems to ensure strong partnerships are in place.

Going Forward

I’m always struck by the fact that everyone talks about the importance of health during an emergency, but, when the emergency goes away, we often forget that we need to adequately resource public health agencies so they have the tools and resources to take on the next emergency.

It’s about capacity.

I worry, one day, there will be an emergency that we haven’t trained for enough and don’t have adequate resources in place. Public health can’t all of a sudden be ready to respond to a major emergency – we need to drill and train and have access to infrastructure and technology.

To better prepare for and respond to emergencies, we also must improve technology solutions, electronic surveillance activities, and infrastructure support. We need more epidemiologists and environmental toxicology experts. And, we need more social workers and community health workers to fan into the community and link folks with vital social services.

The best response features a combination of high tech and high touch. This is where our department shines day in and day out. We’ve never let one overtake the other.

Nationally, though, we can’t rest on our laurels—the next storm could be different and we need to be ready and prepared.

The Private Sector’s Role in Preparing for and Responding to Public Health Emergencies

By Nicolette A. Louissaint, Ph.D., Executive Director, Healthcare Ready

This story was published in Ready or Not? 2017.

The private sector can often respond to rapidly changing circumstances nimbly and usually knows the communities they serve incredibly well. As such, amidst an emergency, there is opportunity for private organizations to step in and fill any response gaps.

The public sector takes on an enormous burden and works tirelessly to respond to emergencies, and the private sector sees its role, especially when it operates in affected regions, to surge alongside the public sector, pivot nimbly and augment public efforts—thereby enhancing the public system’s response efforts.

Often to take advantage of public and private sector expertise, there just needs to be a connection between the two.

For example, during the Hepatitis A outbreak in San Diego, public officials reached out to the private sector for help locating a significant amount of vaccines—since one of the solutions was to do a mass vaccination campaign.

Instead of suggesting they import or special order something (possibly at an extremely high cost), Healthcare Ready (HcR), my organization, checked the levels of vaccines in pharmacies in the area. We found the private sector had enough in stock to supply what was needed. Sometimes you just need to know how and who to ask.

As evidenced by this example, one important aspect of coordinating emergency response is sharing critical information. HcR is designated by the Department of Homeland Security as an information sharing and analysis center (ISAC). So, the private sector knows they can trust us with their proprietary information—and we won’t share with any outside parties inappropriately.

This designation also gives us a fuller view of the resources in a community during an emergency. For example, during a flood, we can know where emerging challenges in the medical pipeline might be because roads are not accessible. We can inform the public sector and work on a solution to ensure vital supplies make it to the public workers who are saving lives.

The public sector knows we can provide them with accurate status of response supplies and what is or isn’t happening along the supply chain. It’s absolutely vital for the public sector to know what kind of relief they’ll be getting and when and what might be missing so they can adjust on the fly.

What we’ve learned from 2017’s Hurricanes

After this hurricane season, we realized that the private sector can do a lot fast and rapidly fill gaps to supplement public sector efforts by getting around bureaucracy.

When faced with an emergency response, we initially focus on resuming supply chain operation and work to support any patients who might be falling through the gaps that naturally occur. The public sector can rely on us to gain insight into what the private sector sees—with us being a central hub coordinating private sector information.

One recent example: There was a small group of patients on St. Thomas who needed a specific drug that could only be prescribed every 30 days. The public sector folks asked us to look for ways to get the drug from Puerto Rico and onto a plane that was making routine trips between the islands after the hurricane.

As we looked into that, we also were able to reach out to the pharmacies on St. Thomas that we knew had re-opened. And we asked them to speak with their distributors who supply them with medicine. We actually found that one pharmacy had the necessary medicine and it was already on the island. We just had to connect the dots.

While this sounds easy written down, there are many competing priorities and everything is in flux during an emergency response. With the public sector relying on the private sector for these kinds of responsibilities it can free them up to handle other vital activities.

How we can better use the private sector?

While there many examples of public and private sectors working well together, too often the private sector is only looked at a supplier, notably of money and medicine, which is frustrating because clearly the private sector wants to and can help in other ways.

This might seem like a minor problem—but if the public sector is only engaging with the private sector amidst a crisis or when money is needed, the relationships aren’t developed that are necessary to work alongside one another during an emergency. A lot of emergency preparedness and response is about knowing the right organization or person to contact to obtain the life saving measure/supply you need.

Currently, in most places, states have just one Emergency Management Coordinator for the entire private sector—encompassing industries like transportation, healthcare, agriculture, food, etc. It really isn’t feasible for the level of coordination that needs to happen to go through a single node.

As such, there should be a coordinator for each industry, setup in advance with regular meetings to fold private sector emergency capabilities into the public sector’s response plans—so when a hurricane makes landfall we all know what to do.

Hurricane Katrina: What we learned, Then and Now

By Karen DeSalvo, Former Acting Assistant Secretary for Health, U.S. Department of Health and Human Services

This story was published in Ready or Not? 2017.

There are a significant amount of vital lessons that need to and have been learned from the preparation for, response to, and recovery from Hurricane Katrina. One long-term lesson that I think is worth highlighting and has shown its importance during recent weather-related emergencies is the need for public health to take a significant leadership and coordinator role before, during and after an emergency.

In the immediate aftermath of Hurricane Katrina, it was evident that connections were missing—whether it be local public health to state officials, public health to first responders, or public health to the community.

Public health leaders simply weren’t the chief health strategists for their communities. The field was focused on an important set of discrete responsibilities or program but not on the need to build connections with community leaders, first responders and other critical infrastructure that could ensure people had safe places to go and access to medications and other critical supports.

With this realization, it was apparent public health had to connect more with the full gamut of organizations and people involved with an emergency response. And, since then, we have done so not only in New Orleans, but in communities across the country.

For example, during subsequent hurricanes in New Orleans, public health was able to work directly and quickly with hospitals and other care facilities to know if power was on and what beds and medications were available.

And, if you look at the response in Houston, you’ll note that public health was everywhere. They were in communities meeting people and alerting them to potential dangers and infectious diseases, what food and water was safe, etc. And, they were all over social media in a culturally competent way, reaching more and more people.

If you compare the Houston Harvey response to Katrina, it should be apparent that one of the benefits in Houston was the high level of connectedness between public health and the community they serve.

How we can better Prepare for the Next Emergency

In addition to public health continuing to be the coordinator for health for our communities in disaster and every day, to better respond to the next public health emergency, the nation needs to:

Expand funding;
Improve the foundational capabilities of public health;
Better leverage technology;
Increase training; and
Focus on the underlying health and resiliency of our communities—particularly those who are most vulnerable.

We need more funding for public health—we need public health departments at the local and state levels to have the foundational capabilities required to respond to public health emergencies but also to help build resilience between events. These funds can’t be categorical, they have to provide core funding that can be nimble for a community to address their biggest health needs. For instance, parts of California might be more prone to wildfires while the Gulf Coast needs to focus on hurricanes. If we don’t have these capabilities in place, we’re forcing our public health workers to just react, rather than prepare to respond.

We also need more funding to go directly to local health departments. States have a huge responsibility during an emergency and often can’t funnel as many resources as you’d think to the local level. During Katrina, we saw this front and center.

While more funding is important, it must be paired with concrete expectations and accountability. Every single health department in the country should be accredited which will help ensure that they can stand up emergency operations when necessary.

When Katrina hit, we were using flip phones, Blackberries and an early version of Google maps. We’ve come a long way with technology in little over a decade, but our preparedness hasn’t quite kept up. We must do better with technology.

We have a great start with this by better leveraging the Department of Health and Human Services’ emPOWER, an online tool that houses and provides Medicare claims data to hospitals, first responders, and health officials to help map the electricity needs during an emergency. emPOWER enables responders to prioritize evacuations and can identify vulnerable populations who will need follow-up services. But it’s limited to the Medicare population. This type of tool must be expanded to or created for Medicaid and, where appropriate, private payers. First responders and public health must have real-time population level data.

An additional reason more resources are needed is to increase drills and training that specifically focuses on local leadership and the U.S. Public Health Service Commissioned Corps. Annually, public health workers should drill in a vulnerable area alongside the Commissioned Corps—an invaluable resource. Currently, when the Commissioned Corps deploys to an emergency the connections with local responders aren’t there and often the Commissioned Corps can be underutilized.

Lastly, we simply must do more to improve the resiliency of our communities. The healthier a group of people are, the better they respond to an emergency.

In-between emergencies, public health must use data and find opportunities to engage more with vulnerable populations. For example, this could include creating pilot programs with Medicare providers, home health organizations and others involved with the care of older adults. We must improve the health of our older population and, at the same time, have the processes in place that can maintain their connection to care during an emergency that might result in evacuations and/or loss of power.

The nation’s preparedness has improved immensely since Hurricane Katrina—we must keep improving.

Local Public Health Responsibilities During Wildfire Emergencies

By Dr. Karen Relucio, Chief Public Health Officer, County of Napa

This story was published in Ready or Not? 2017.

Responding to two wildfire events has taught me that public health has a significant role in wildfire emergency response. The role of public health includes shelter assessment, coordinating medical and mental health support in the shelter, ensuring environmental health and safety, and public health messaging.

During our first response in September 2015, there was a 75,000 acre fire that destroyed 1,300 structures, resulting in the evacuation of more than 1,000 people, which required us to open and support an evacuation center. The fire was predominantly in Lake County, which is adjacent to Napa County.

When something like this occurs, local public health works with our emergency management agency, fire and law, other County agencies and community partners to respond. Immediately, Napa County opened a shelter at the fairgrounds in Calistoga and stood up the emergency operations center.

Napa County Public Health took on the responsibility of assessing the health needs of most of the evacuees by using a modified community assessment for public health emergency response (CASPER). While Red Cross was on site, they only handled doing health assessments of the people that chose to stay inside the shelter. Surprisingly, we had many people show up in cars or RVs or with their own tents and with pets. Because animals were not allowed inside the building, they stayed outside on the fairgrounds property. It became our job to conduct health needs assessments of the majority of the 1,000 evacuees.

Additionally, our other role was providing medical support within the evacuation center. We worked with our local Federally Qualified Health Center, healthcare providers from our local medical centers and Medical Reserve Corps from Napa and neighboring counties to see patients. Most of the medical visits involved refilling medications and treating people who had respiratory issues from smoke inhalation or exacerbation of underlying health issues (diabetes, allergies and asthma). Thankfully, there were only a few people with slight injuries from the evacuation itself. We also provided flu and Tdap vaccinations.

It was also apparent that mental health needed to be addressed for the evacuees in a comprehensive way. We leaned on other local jurisdictions and nonprofits and were able to enlist a number of mental health professionals to come onsite. We quickly found that it was best to do more ad hoc checks and have the mental health professionals serve as support staff. They found it was easier to talk to folks—and avoid the stigma that might come with needing mental health services.

Another important aspect of our response was environmental health. These professionals ensured the shelter was safe and clean and that food was prepared and served safely. They went into the shelter and found donated food served potluck style, not at the appropriate temperature. In addition, there weren’t enough hand washing stations or bathroom facilities and the pets of evacuees were relieving themselves in areas where people were walking. We felt this was a prime setup for a gastrointestinal virus outbreak, which would make the situation worse. Our folks figured out how to maintain the integrity of food, installed more portable toilets and hand sanitizing stations, and provided bags for pet waste.

Throughout the response, public health information included a smoke advisory, heat advisory, and repopulation safety for evacuees once they went back to their homes. We also had to ensure people knew they shouldn’t sort through the debris without personal protective equipment.

This was great preparation for our recent fire in October 2017—which started at the same time our region was experiencing hurricane level winds of 50 to 90 miles per hour, resulting in rapid spread of the fire to our county and Sonoma County. The first 72 hours was focused on evacuations and safety.

We opened three different evacuation centers on that first evening and immediately began the plans for the type of medical coordination that we did in 2015. We also coordinated ambulance strike teams all over the region to help evacuate residential care and skilled nursing facilities.

In many ways our response was similar to 2015, except the scope of this emergency was much bigger and the recovery is much more complex. We had to declare a local emergency and a local health emergency to receive assistance for toxic ash and debris cleanup which is still in progress. Residential wildfire debris can include toxic materials such as asbestos, heavy metals, dioxins and polycyclic aromatic hydrocarbons that can be harmful to human health, and cleanup needs to be done carefully by experts. At this point, debris cleanup is still underway.

Additionally, we opened a local assistance center to help those who have lost properties, homes, and jobs. And, there are many crews working on erosion control in burn areas around water reservoirs, as we are now having heavy rains and anticipate debris flow and possible water contamination.

While we have begun to create an almost turnkey response plan to wild fires, we could always be better prepared, especially for the recovery phase. And, we really need to know a lot more about the long-term health impact of wildfires. For instance, will we see cancer rates go up? Will health inequities be worsened due to loss of homes and income? If so, is that something public health can work to prevent during the response or in the aftermath?

We also need more information and research on the impact of toxic debris and additional long-term health consequences as a result of repopulating an area that has suffered wildfire damage. The only studies that come close to looking at long-term health impacts of fire debris are the 2001 World Trade Center attacks. We can speculate on health impacts based on knowing what is contained in ash but, to my knowledge, there hasn’t been a long-term health impact study about residential wildfires. It is hard to make decisions and align future resources when we are uncertain about the long-term effects.

Q/A with Celeste Philip, MD, MPH Surgeon General and Secretary of the Florida Department of Health

This was published in Ready or Not? 2017.

TFAH: What are state public health responsibilities before a storm?

Dr. Philip: The Florida Department of Health (DOH) is designated as the lead agency for State Emergency Support Function 8 (EFS8), health and medical services. DOH coordinates the availability and staffing of special needs shelters; supports patient evacuation; ensures the safety of food and drugs; provide critical incident stress debriefing; and provides surveillance and control of radiological, chemical, biological and other environmental hazards.

DOH administers two statewide preparedness grants to build local capacity within the public health and health care community. The federal Public Health Emergency Preparedness (PHEP) grant supports all 67 county health departments (CHD) and public health laboratories in developing community preparedness, epidemiological surveillance and investigation, and medical countermeasure delivery. The Hospital Preparedness Program (HPP) funds 10 health care coalitions to build capabilities for medical surge, continuity of health care delivery, and preparedness partnerships among local health care partners.

TFAH: What are state public health responsibilities after a storm?

Dr. Philip: ESF8 assesses and stabilizes the public health and medical system; supports the ongoing sheltering of persons with special medical needs; coordinates patient movement and evacuations of health care facilities; conducts public health messaging; monitors, investigates and controls any threats to human health; and coordinates disaster behavioral health services with a sister agency.

During Hurricane Irma, ESF8 assisted with 76 patient movement missions that supported the transport of hospital, skilled nursing facility and assisted living facility clients. We conducted more than 1,000 post-impact facility inspections and more than 2,600 tests of public and private water systems and operated 113 special needs shelters.

TFAH: How do state health departments coordinate the public health response to a major storm?

Dr. Philip: Preparedness and response are driven by local leadership, personnel and assets. In Florida, each CHD coordinates and works directly with their local Emergency Management to meet the preparedness and response needs of their community. If the county Emergency Operations Center (EOC) cannot meet the local need, they request assistance through the state EOC via a web-based system that allows us to track and ensure completion of mission requests.

Based on these mission requests, the state ESF8 assesses regional and state assets. If the requested resources are not available in-state, ESF8 next looks to resources available from other states through the Emergency Management Assistance Compact (EMAC), or, in the case of a declared state of emergency, potential federal assets such as Disaster Medical Assistant Teams.

TFAH: Why are federal investments in public health critical on an ongoing basis?

Dr. Philip: During a major event, we are often shoulder-to-shoulder with our federal partners in the state EOC. This includes representatives from HHS, ASPR, and also FEMA who help to coordinate any requests we make for federal assistance.

Federal investment is critical for building a public health infrastructure that has the capacity to prepare for and recover from weather and other hazardous situations. If states are better prepared to respond, requests for federal assistance may be lessened. With the close succession of Hurricanes Harvey, Irma, and Maria, and wildfires in California, federal response agencies had to sustain their efforts across time and location which may not be feasible in the future.

TFAH: What federal programs and supports are critical for preparedness and response?

Dr. Philip: Both the PHEP and HPP statewide preparedness grants are important for public health preparedness and response. Preparedness programs in various HHS agencies hold meetings that provide training and networking opportunities for states.

TFAH: What is needed from the federal government to improve preparedness and response?

Dr. Philip: Knowing and having a relationship with our federal counterparts that will be deployed to the state EOC improves communication and manages expectations more effectively. A federal system that allows for tracking of deployed assets would improve situational awareness and real-time decision-making.

Better coordination of credentialing health care professionals between states would be helpful for patients who evacuate with their provider and for providers coming into disaster areas.

Streamlined and flexible funding to allow for nimble response as needed would greatly enhance public health’s ability to be effective.

TFAH: What lessons did you learn from the most recent storm? Was there anything different or new that happened?

Dr. Philip: Hurricane Irma posed a unique challenge because the track was very unpredictable, meaning that more hospitals decided to evacuate and more residents decided to shelter. This storm at some points was 500 miles wide – which exceeded the width of our state. And, personnel could not be moved around in advance of the storm as the track changed to support other counties in the new path. EMAC, federal and contracted assets were mobilized to support sheltering operations but some counties had to wait until the storm passed to receive additional staffing.

Because of the surge in last minute registrations to special need shelters, comprehensive planning and placement for each registrant could not be conducted resulting in the shelter having to accept clients with medical needs that exceeded the shelters’ level of care capacity.

Moving forward, we recognize a need to anticipate future storms that may impact much, or all of the state, a scenario not contemplated prior to Hurricane Irma. For DOH, statewide emergency response efforts could be bolstered by improving planning for our special needs residents, including better training and increased collaboration with other state agencies and the private sector to support Floridians with special needs.

Kentucky Injury Prevention and Research Center’s Work to Prevent Substance Misuse

In 2005, the Kentucky Injury Prevention and Research Center (KIPRC) began focusing on transportation-related injuries under the state’s Fatality Assessment Control and Evaluation Program. KIPRC travels to sites of worker fatalities, investigates the causes, and ultimately makes behavioral, administrative and engineering control recommendations that would prevent future occupational deaths.

The first investigation was of a truck driver who was only 23 miles from his start point when he went through a busy intersection then up an embankment before crashing. The toxicology report found that he had methamphetamines and benzodiazepines in his system.

The next month, they had another case that was related to drugs. KIPRC quickly made the recommendation to build a statewide drug database focused on identifying truck drivers who tested positive for drugs and ensuring that job applications to other trucking companies would be aware of their previous substance use history.

From that point, analyses of multiple data sets became an integral part of Kentucky’s efforts to fight what became the opioid epidemic.

Comprehensive Data Sources

After they identified the drug-related pattern in transportation-related truck driver deaths, they examined all their data sources—spanning emergency department, trauma, crash, inpatient hospital, mortality, and workers’ compensation data, etc.—and produced comprehensive reports on drug overdoses.

The information KIPRC provided resonated with what the State Department for Public Health was finding—as they had begun to see spikes in drug overdoses in the data they monitor and manage.

KIPRC collaborated with the state’s prescription drug monitoring program called KASPER, which produces reports showing all Schedule II through V prescriptions dispensed for a person over a specified time period.

To further enhance the PDMP reports, the Bureau of Justice Assistance funded KIPRC and the PDMP to develop and implement an algorithm that calculates milligram morphine equivalents and make them available to physicians in PDMP patient reports to inform appropriate opioid prescribing. This also included a separate algorithm to calculate overlapping opioid and benzodiazepine prescriptions.

Additionally, the PDMP added a flag to the electronic reports that identifies elevated MME situations where it might be appropriate for the physician to also co-prescribe naloxone, mostly when the physician is prescribing opioid medications. To further the use of naloxone, KIPRC worked with the Kentucky Department of Criminal Justice Training to train more than 900 law enforcement officers on the proper use and administration.

In 2016, KIPRC helped create training for advanced practitioner registered nurses on the epidemic. During the training, nurses were educated on querying the PDMP, possible alternative opioid prescribing strategies, Kentucky’s opioid prescribing regulations, and care of patients with pain in both acute and primary care settings. Later that year, the program was extended to physicians. And, to date, more than 1,500 controlled substance prescribers have received training.

KIPRC additionally performs ad hoc data requests, allowing counties and state agencies to ask for a certain slice of data that is specific to their communities and populations. It can also be broken down by age, substance, and whether there are overlapping diagnoses for illnesses like HIV, Hepatitis C and endocarditis.

Going forward, a KIPRC epidemiologist is overlaying public health and public safety data that looks at heroin and methamphetamine trafficking arrests, possession arrests and related emergency department visits, hospitalizations, and overdose deaths to find hot and cold spots. Future analyses will include fentanyl and other drugs as well as comprehensive drug seizure data.KIPRC also manages the Drug Overdose Fatality Surveillance system, which draws on multiple data systems (autopsy reports, death certificates, coroner investigation, the state PDMP, etc.).

The results are used to inform legislative policymaking and provide info to stakeholders to advocate. For example, data pulled from the 2013-2015 reports found that in one-third of overdoses, gabapentin was involved. With this knowledge, the state made gabapentin a Schedule V substance and fully integrated it into the PDMP in July 2017.

Kentucky is the only state in nation that requires—when no specific cause of death is determined—decedent testing for controlled substances. Previously, 70 percent of drug overdose death certificates listed the specific drug(s) involved in drug overdose deaths. Now, 81 percent of drug overdose death certificates list the specific drug(s) involved in the fatal overdose.

Going Beyond Data

A KIPRC community coalition specialist goes into counties with the highest overdose death rates to provide technical assistance and strategic planning to establish or improve drug overdose prevention programs and initiatives.

KIPRC is also establishing a website with a substance use disorder treatment availability locator – so people can get help. They are working with every single treatment provider in the state to update their treatment slot availability on a nightly basis. The website will become live in January 2018 and will include available level of care, treatment type and payment type accepted.

North Carolina’s Comprehensive Approach to Preventing and Reversing Drug Overdoses

Early in 2000, state public health surveillance identified a surge of deaths in North Carolina. The Centers for Disease Control and Prevention conducted an investigation into the increase, finding the main driver was unintentional drug overdoses from prescription drugs.

In 2003, the Governor created the Task Force to Prevent Deaths from Unintentional Drug Overdoses, which helped establish the North Carolina Controlled Substances Reporting System (CSRS), which was the state’s prescription drug monitoring program (PDMP).

Since then, North Carolina has implemented a variety of measures to prevent deaths from drug overdoses. With increased access to data from the PDMP and a brighter light shined on the issue, public health continued to collect data, finding, in 2007, that Wilkes County, in the northwest part of the state, had the third highest drug overdose death rate in the country.

Child Fatality Task Force

North Carolina’s Child Fatality Task Force (CFTF)—a standing committee of the general assembly that is composed of 10 legislators and numerous technical advisors—is essentially the policy component of the state’s child death review system.

CFTF provides a unique opportunity for the public health community to present data and bring in outside experts, including law enforcement and subject matter and harm reduction experts. Everyone sits in a room, discusses policies and gets on the same page. Most bills addressing the overdose epidemic since 2010 have come from CFTF, including revisions to CSRS and increasing/improving naloxone access laws.

Project Lazarus

Established in 2007, Project Lazarus— a public health model based on the twin premises that overdose deaths are preventable and that all communities are responsible for their own health—was one of the first initiatives designed to respond to the extremely high overdose mortality rates in Wilkes County.

“Project Lazarus Offers Communities & Individuals Access To:

Coalition formation, capacity building, & sustainability.
Chronic pain management.
Safe prescribing practices for providers.
Opioid overdose education, awareness, & safe medication usage materials.
Naloxone, the opioid overdose rescue medication.
Project Pill Drop, a community based medication disposal program.
Lazarus Recovery Services, a peer guided recovery support program.
Local & state data on overdose and poisoning rates.
Local & state funding sources for overdose prevention work.”

The University of North Carolina Injury Prevention Research Center (UNC IPRC) evaluated Project Lazarus and found an initial drop in the overdose death rate of 40 percent, which grew to a 69 percent decline in 2011. The program has since be brought statewide.

University of North Carolina Injury Prevention Research Center

The University of North Carolina Injury Prevention Research Center (UNC IPRC) is a key partner in addressing the overdose epidemic. UNC IPRC provides evaluation, research, training, and technical assistance to partners and programs working to combat the opioid epidemic.

Drug Takebacks

In 2009, Safe Kids North Carolina, located in the Office of the Chief Fire Marshall worked with the State Bureau of Investigation and a diverse group of partners to develop Operation Medicine Drop. Since its establishment, Operation Medicine Drop has collected and safely disposed of 89.2 million pills at more than 2,000 events and established a network of permanent drop boxes that serve most counties in the state.

NC DHHS noted that drug takeback programs are a great way to get the community involved and raise public awareness of the issue—it gives everyone a little skin in the game when they realize that items in their medicine cabinet could be fueling the drug epidemic. This process helped move the conversation upstream to ensuring people knew of the problems and the steps they could take to prevent people from developing a substance use disorder.

PDMP

North Carolina has worked to improve CSRS to be a valuable tool to prescribers and dispensers to better manage pain and appropriate prescribing. In 2012, the Child Fatality Task Force convened a study group that resulted in the Revision to the CSRS Law in 2013. They added delegate accounts, shortened the time dispensers have to report data, and enabled proactive reporting from CSRS to licensing boards and prescribers.

In 2014, the Program Evaluation Division of the General Assembly conducted an extensive evaluation of CSRS, concluding that further funding and improvements of CSRS should be included in the state budget bill of 2015.

In 2017, the STOP Act— the most comprehensive bill in the state to address the opioid epidemic—became law. The Act includes mandated use of CSRS, limits on prescribing opioids in line with CDC’s Prescribing Guidelines, expansion of naloxone distribution, and numerous other provisions to address the opioid epidemic.

To develop the Act and identify evidenced-based strategies, NC DHHS worked with UNC IPRC, CDC’s Prevention for States Program, and national experts, including Corey Davis at the Network for Public Health Law.

The 911 Good Samaritan Law/Naloxone Access Act

Expanding access to naloxone has been an important part of North Carolina’s strategy to address the overdose epidemic and was a founding principle of Project Lazarus. The North Carolina Harm Reduction Coalition (NC HRC) has worked with the Law Enforcement community to gain their support for enactment of a series of naloxone laws since 2013.

Since the successful passage of naloxone-related legislation, NC HRC distributed more than 41,000 overdose rescue kits and confirmed 7,408 overdose reversals in North Carolina. Working with law enforcement agencies to develop naloxone programs has resulted in 164 law enforcement agencies with officers carrying naloxone and 403 reported law enforcement reversals by naloxone.

In 2016, the Naloxone Standing Order Law—enables any pharmacy in the state to offer naloxone without a prescription under the state health director’s standing order—Became law. The Standing Order Law was developed in response to requests from the retail pharmacy industry, which wanted to easily offer naloxone in their pharmacy outlets across the state.

After passage, DHHS developed a resource web site with UNC IPRC that contains technical resources on how to use the standing order. Nearly 1,400 pharmacies in the state offer naloxone under the standing order law.

The 911 Good Samaritan Law waived prosecution for individuals experiencing or witnessing an overdose who seek help by calling 911. The law also removed civil liabilities for doctors who prescribe naloxone and bystanders who use naloxone to attempt to save someone’s life and allowed community organizations to dispense naloxone with medical provider oversight.

Syringe Exchange

In 2016, North Carolina became the first state in the south to legalize syringe exchanges with passage of House Bill 972.

The years of work on harm reduction and everyone working together broke down the historical resistance of syringe exchanges and they were able to decriminalize needles. Advocates performed demonstration projects and worked with law enforcement early to identify legislation that the law enforcement community would find acceptable and help them in their daily work.

In addition, the argument was made that needle exchanges could save the state money—DHHS noted that Medicaid charges for Hepaticas C treatment went from $3.8 million in 2011 to $85 million in 2016

Following the legalization of the syringe exchanges, DHHS developed the Safer Syringe Initiative and registered 22 syringe programs in the first year of the law—reaching 19 counties.

Initially, to pass the Bill, language was included that prohibited the use of public funds to support exchanges. When the STOP Act passed, it included provisions that only prohibited the use of “State Funds,” enabling local health departments and other governmental units to use local funds to do needle exchange.

The DHHS sees needle exchanges and drug take programs as a way for communities to take direct action in the overdose epidemic.

Colorado’s Work to Prevent Substance Misuse and Suicides

Substance Misuse Prevention

In 2012, when the full scope of the opioid epidemic begun to become apparent, Colorado officials looked to the Colorado Department of Public Health and Environment (CDPHE) to make sense of the issue.

CDPHE synthesized, streamlined and provided important data to understand the problem and convened the important stakeholders and government divisions—across many disciplines.

Initially, CDPHE operated as an integrator by identifying best practice strategies, generating surveillance reports, and facilitating a series of roundtables focused on different aspects of the issue, from prescribing to dispensing to public awareness to treatment. State agencies used the information from these important convenings to create the Colorado Plan to Reduce Prescription Drug Abuse.

To better monitor progress, state-level leadership created the Colorado Consortium for Prescription Drug Abuse Prevention (Consortium), which provides a statewide, interuniversity/interagency framework designed to facilitate collaboration and serves as the strategic lead for implementing the Plan with active participation from the Governor’s Office and various state agencies.

The Consortium is comprised of nine work groups: Data and Research, the Prescription Drug Monitoring Program (PDMP), Provider Education, Public Awareness, Treatment, Safe Disposal, Naloxone, Heroin Response, and Friends and Affected Family Members. Each work group is co-chaired by a state agency and a university representative. As a whole, the Consortium comprises over 300 local, state and federal members. The Consortium’s structure helps facilitate collaboration between state agencies and university partners, making it possible to easily apply for, receive and leverage funding.

For their part, CDPHE focuses a significant amount of attention on primary prevention, specifically prescriber education and making the state’s PDMP easier to use and better integrated into practice. In Colorado, the PDMP is located in the Department of Regulatory Agencies, which handles professional licensing. During the 2014 legislative session, Colorado legislators passed a bill that aligned Colorado’s PDMP with best practice strategies including allowing: delegated access, unsolicited reports, mandated enrollment, and access by out-of-state pharmacists. This legislation also gave CDPHE access to PDMP data as a public health surveillance tool.

With the data in hand and important partners via the Consortium, CDPHE is using funds from the Centers for Disease Control and Prevention to implement and evaluate several pilot projects aimed at improving use of and access to the PDMP, including: integrating the PDMP with the state’s two health information exchanges; connecting electronic health records and the PDMP at eight outpatient clinics; and linking the PDMP to a software application that will allow improved access to the PDMP and better assess provider adherence to prescribing guidelines.

In addition to work on the PDMP, the Consortium encouraged multiple sectors to advocate for the purchase of naloxone—which the Attorney General decided to fund as a pilot in the 16 counties with the highest overdose rates. In conjunction, another member of the Consortium developed an app to track reversals from using naloxone. CDPHE is conducting an evaluation of the project. But, after just 2 months of data collection, there were nearly 150 reported overdose reversals. As the data continues to be collected, the results should make the case that there is a positive return on investment and that law enforcement is willing to use it.

Suicide Prevention

In July 2012, the Office of Suicide Prevention at CDPHE, Cactus Marketing Communications and the Carson J Spencer Foundation partnered to launch www.ManTherapy.org. The website aims to reach working-age men, who account for the highest number of suicide deaths in Colorado annually.

The three goals of Man Therapy are: 1) to change the way men think and talk about suicide and mental health; 2) to provide men (and their loved ones) with tools to empower them to take control of their overall wellness; and, 3) long-term, to reduce the number and rate of suicide deaths among men. Man Therapy removes traditional mental health language from the conversation and uses humor to help men feel welcome and at ease while visiting the site. The website provides information on depression and suicide, substance use, anger and anxiety, and includes statewide resources specific to finding support and services related to each issue.

In 2015, the Office of Suicide Prevention and the Commission identified Zero Suicide as a priority to better align, integrate and emphasize suicide prevention in Colorado’s health systems. In 2016, Colorado became the first state to pass legislation encouraging healthcare organizations and systems to adopt the Zero Suicide framework, which works to train primary healthcare staff to provide better treatment to individuals who might be contemplating suicide.

Additionally, the Office of Suicide Prevention partnered with Children’s Hospital Colorado, the Colorado School of Public Health, and the Harvard Injury Control Research Center to develop the Emergency Department Counseling on Access to Lethal Means (ED-CALM), which teaches emergency department providers how to educate parents/guardians of suicidal youth about the techniques and importance of restricting access to lethal means in the home.

Going Upstream

CDPHE has a number of efforts dedicated to upstream approaches to preventing youth substance misuse, violence and suicide. For example, CDPHE is currently funding 48 Colorado communities to implement Communities That Care, an evidence-based public health framework that encourages communities to take part in looking at their data, identify evidence-based strategies to address community problems, and implement those strategies to address those issues. The experience uncovered the connections between substance misuse and suicide rates and shown that efforts to prevent substance use work well on preventing suicides and violence.

To help youth even more, CDPHE implemented the Sources of Strength program, a school-based youth initiative focused on redefining school level social norms that has been shown to build positive feelings of connectedness between youth and their peers and communities.

In the program, youth advisors are carefully handpicked from different segments from the school to create leaders from all the peer groups. Those leaders are then educated on suicide prevention basics and are tasked with coming up with positive campaigns that are upbeat and engaging. Because they are peers, the activities are better positioned to get a wider population involved in activities—and research shows that kids involved in activities who are connected to their community are much less likely to commit suicide.

In addition to preventing suicides, building these protective factors extends to preventing sexual violence prevention, bullying and other dangerous and/or risky behaviors. Through the pilot programs, Colorado has begun to see reductions in sexual violence and bullying. CDPHE is currently partnering with researchers at the University of Florida and the University of Rochester to do a rigorous evaluation of Sources of Strength at 24 Colorado high schools to measure the impact the program has on preventing the perpetration of sexual violence, bullying and suicide.

The District of Columbia’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

The District of Columbia is at the national forefront of efforts to reduce childhood lead poisoning, enacting several prevention-focused laws. Reflecting a long legacy of lead usage – an estimated 75 percent of housing predates the 1978 ban on residential use of lead-based paint – the District also mandates universal screening, requiring two lead tests for all children by age two.

The law at the center of the city’s efforts to combat lead poisoning is the District’s Lead Hazard Prevention and Elimination Act of 2008, amended in 2011 (D.C. Official Code § 8-231.01 et seq.). This law prohibits the presence of a lead-based paint hazard in dwelling units, common areas of multifamily properties, and day care and prekindergarten facilities constructed before 1978. Under the law, any paint in or on a pre-1978 dwelling unit or “child-occupied facility” that is not intact is automatically considered hazardous.

Clearance Examination

A key preventive provision in the District’s lead law (see implementing regulations) is the required clearance examination whenever a pre-1978 residential rental property is about to be occupied by a pregnant woman or a child under age six. Specifically, the property owner must furnish a passing clearance report, issued within the previous 12 months, providing documented proof that the individual rental unit contained no lead-based paint hazards, including deteriorated lead-based paint or lead-contaminated dust or soil. This information must be disclosed before a buyer or renter is obligated under contract to purchase or lease the unit.

A related provision extends this requirement to units occupied or visited by a child or pregnant woman. Additionally, if owners discover lead-based paint in their properties, they must disclose it to their tenant within 10 days.

Lead-Based Paint Presumption

The District’s lead law also expands the definition of “lead-based paint hazard” to presume that any paint in or on a pre-1978 residential or child-occupied facility is lead-based. Any paint that is peeling, chipping, cracking, flaking, or otherwise not intact is automatically considered to be a lead-based paint hazard, unless proven otherwise.

This broader definition facilitates the District’s proactive approach to lead-based paint hazards. Any time there is a “reasonable belief” that a lead-based paint hazard may be present, the Government of the District of Columbia is empowered to inspect residential housing or child-occupied facilities (DC Official Code § 8-231.05(a)). Under this authority, inspections can take place for a variety of reasons, including a tenant complaint or knowledge that a particular neighborhood has a higher prevalence of lead hazards.

The law allows the Government of the District of Columbia to enter a property and conduct a lead risk assessment to determine if lead-based paint hazards may exist. If a lead hazard is found, the property owner may be issued an Administrative Order to Eliminate Lead-Based Paint Hazards. The order specifies the type and location of the hazard and how and when it must be eliminated. Additionally, the property owner is charged for recovery of costs associated with conducting the risk assessment.

Eliminating the lead-based paint hazard must follow specific safe practices. Once the work is complete – to ensure that no lead-based paint hazards remain – the owner must hire a District-certified risk assessor to perform a clearance examination.

The law also states that contractors that disturb paint during work in a pre-1978 property must use lead-safe practices, which includes containing the immediate work area to protect the occupants. A Cease and Desist Order, a Notice of Violation, and/or a Notice of Infraction can be issued to any contractor who fails to do so.

The District may require landlords to arrange and pay for temporary relocation of tenants whose homes contain lead-based paint hazards. In addition, the landlords must make all reasonable efforts to relocate tenants in the same school district or ward and near public transportation.

The law also includes tough disclosure requirements. Owners are required to disclose any “pending actions” ordered by the District and any reasonably known information about the presence of lead-based paint or lead-based paint hazards.

Renovation, Repair and Painting Permitting Requirement

Another preventive measure applies to contractors seeking renovation permits. They must provide proof of training as required under EPA’s Renovation, Repair, and Painting Rule to the permitting office at the District’s Department of Energy and Environment (DOEE). DOEE provides a list of individuals and business entities certified by DOEE to conduct lead-based paint activities in the District.

Universal Lead Screening and Reporting

The District also passed the Childhood Lead Screening Amendment Act of 2006 (D.C. Official Code § 7-871.01 et seq.), mandating that all District children be tested twice by the time they are two-years-old, once, between 6 and 14 months, and the second time between 22 and 26 months. Additional screening is required up to age six if the child has received no prior screening and whenever there are other risk factors. Laboratories must report all test results to DOEE’s Childhood Lead Poisoning Prevention Program. Similarly, health care providers must notify the DOEE about lead-poisoned children within 72 hours.

To increase compliance with the District’s lead screening and reporting law, DOEE provides education to health care providers and builds community awareness, especially among at-risk populations. DOEE has also created formal data-sharing agreements with several District agencies to identify and reach out to families who need to update their children’s screenings.

DOEE provides case management to families whose child has an elevated blood lead level, including help with follow-up testing, education, and referrals. In addition, a DOEE lead inspector conducts an environmental investigation and provides a risk assessment report detailing where lead-based paint hazards were found, with instructions for the property owner about necessary steps to eliminate the hazards. The law also allows DOEE to be reimbursed by the District’s Medicaid agency for lead risk assessments it conducts in the homes of Medicaid-enrolled, lead-exposed children.

Lead-Safe and Healthy Homes

In 2011, DOEE published a Strategic Plan for Lead-Safe and Healthy Homes, the first-ever District-wide agenda for maintaining homes free of lead hazards, asthma triggers, and other environmental health threats. The plan was developed with extensive input and feedback from community groups, providers, environmental experts, and sister agencies.

In 2012, DOEE launched the District’s first full-fledged Healthy Homes program. Local health providers and social service agencies identify families with children or pregnant women in distress due to lead exposure, poorly controlled asthma, or hazardous conditions, and refer those families to DOEE. Participants receive a comprehensive home environmental assessment, family education, an asthma management diagnostic, and case management coordination. Once health and safety threats are identified and systematically documented, DOEE issues a technical assistance report to the property owner to help them correct the identified hazards. The agency also provides a customized care plan to help clients avoid additional exposure while waiting for hazards to be addressed. DOEE’s case managers monitor progress as the identified hazards are eliminated.

DOEE also designed the District’s Lead-Safe and Healthy Homes Hub to help teach residents about possible health risks at home. This interactive site features a variety of healthy homes topics, including lead, mold, secondhand smoke, pest infestations, and radon, and describes how residents can help prevent exposure to these hazards.

Results

For Fiscal Year 2015, the District reported that it had 196 new confirmed cases of children below age six with a blood lead level at or above CDC’s reference value of 5 µg/dl. Overall, District data suggest a downward trend in children’s lead exposure, with approximately 98 percent of children under six testing below the 5 µg/dL action level. DOEE’s Healthy Homes documented improvements in 80 percent of the 137 homes it managed in 2012, the program’s first year. Over time demand for the Healthy Homes program has grown, with 202 households served in Fiscal Year 2016.

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In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.

The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Washington State’s Efforts to Prevent and Respond to Childhood Lead Exposure

“While no imminent public emergency has been discovered, recent detections of lead in some water systems are highlighting the important roles our water utilities, schools, public health departments and the state play in ensuring we all have access to safe, clean drinking water. This directive will better ensure we’re working in coordination and leveraging resources effectively to tackle lead at all its primary sources, whether it’s water, paint, or soil.” – Governor Jay Inslee

Background

In May 2016, in the wake of recent detections of lead in drinking water systems in the state, Governor Jay Inslee issued a directive to the state Department of Health and partner agencies to reduce lead exposure in Washington State. The directive instructs the Department of Health to take a series of actions to reduce lead exposure and help those with lead poisoning. It calls for additional investments in and funding for foundational public health services and infrastructure to help prevent, reduce, and remediate lead from water as well as other sources, such as paint.

The governor’s instructions focus on reducing environmental exposures to lead and making sure that children with lead poisoning receive all necessary case management and public health services. It directs the state Department of Health to take the actions and report back to the governor on budget and policy recommendations relating to these actions.

Partner with Other Sectors to Prevent and Reduce Lead Exposure

Governor Inslee’s directive instructs the Department of Health to work with schools, child care facilities, residential landlords, and public water system operators to prevent and reduce exposure to lead.

Key Partner: Schools

The directive instructs the Department of Health, the Washington State Board of Health, and the Office of Financial Management to review and update school health and safety regulations as needed (also known as the “School Rule”). They also should compile a budget decision package to put the regulations in place, beginning with those that pertain to lead exposure.

The Department of Health must continue providing technical assistance and guidance related to voluntary water quality testing schools can perform. This will help ensure that testing meets water sample collection protocol standards. In addition, the Department is asked to conduct workshops for schools that will heighten awareness about water quality and how to correctly test and repair any problems they find.

Key Partner: Child Care Settings

The directive instructs the Departments of Early Learning and Health, in collaboration with the Office of Financial Management, to determine the need for and feasibility of requiring child care providers located in buildings constructed before 1978 to complete an evaluation for potential sources of lead exposure. This includes drinking water testing.

Key Partner: Residential Landlords

The directive instructs the Department of Health to assess the feasibility of possible policy changes associated with developing a Lead Rental Inspection and Registry program. This step would require residential rental properties built prior to 1978 to register and complete a lead inspection and show proof of safety every time new tenants move in.

Key Partner: Public Water System Operators

The directive instructs the Washington State Department of Health to work with large public water system operators (those with more than 15 home/business connections or that serve 25 or more people per day for more than 60 days annually) to identify within two years all lead service lines and lead components in water distribution systems.

The directive also instructs the health department to make the removal of lead service lines and other lead components a top priority when it provides low-interest loans to eligible public water systems to address public health concerns. The department is also directed to work with stakeholders to develop policy and budget proposals, with the aim of removing all lead service lines and lead components in large public water systems within 15 years. This would make Washington State the first state to set such a goal.

Improve Lead Screening Rates and Provide Case Management and Remediation Services

To help those who already have lead poisoning, the governor has asked the Department of Health to work with the Healthcare Authority and the Office of the Insurance Commissioner to increase lead screening rates for the children on Medicaid at highest risk, provide case management services to children with lead poisoning and their families, and determine whether private payers provide coverage for lead screening and case management services or if further coverage policy change is called for.

Governor Inslee also asked the Department of Health to work with stakeholders and other partners to make the blood level monitoring system more efficient. This step entails transitioning the Child Blood Lead Registry to a fully electronic reporting system–and developing an adequate funding mechanism so that local health departments can fully implement home visits and other investigative work necessary to identify and remediate lead exposure.

Federal Funds to Expedite Lead Removal in Drinking Systems

Finally, the governor has asked the Department of Health to partner with the Department of Ecology and the Environmental Protection Agency to seek federal funds to expedite lead removal in drinking systems, require lead testing in childcare settings, and support revisions to the federal Lead and Copper Rule. The rule requires water utilities to monitor drinking water, control corrosion, and inform the public when lead or copper concentrations exceed a designated threshold.

“Lead is all around us, and the governor’s directive is a positive step in the right direction of reducing lead exposure.”

– Secretary of Health John Wiesman

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The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.