Public Health Newsletter

This month there was an outbreak of influenza A at a local skilled nursing facility.  During our investigation, the first influenza-associated fatalities were announced for California, which included an infant, an adult and an elder. These events remind us that influenza can cause serious illness or death across the lifespan.  Visit marinflu.org for links to clinical information and surveillance reports.  The first of our regular seasonal influenza surveillance reports for 2015-2016 will be released in early December.

Since 2009, Marin County has seen an increase in syphilis cases, as is being seen regionally.  In 2014, there were 20 cases reported. 19 of these were men, and most were men who have sex with men (MSM). USPSTF recommends that providers screen those at increased risk for syphilis infection, including MSM.  The CDC recently updated its Sexually Transmitted Diseases Treatment Guidelines, which are now available as a mobile app.

 

FREE flu shots! October 17th at Novato High School from 10 a.m. to 2 p.m. Available while supplies last, regardless of insurance, ages 3 years and up. Kaiser patients will have their information updated for them. The school is at 625 Arthur Street, and the clinic is open from 10 a.m. to 2 p.m

Dr. Matthew Willis, the County’s Public Health Officer, says a flu shot is the single best defense against influenza, which can lead to a lot of time missed at school or work. The flu virus can spread one day before symptoms develop and up to a week after someone becomes sick, so protect yourself, your family and friends by getting your flu shot.  

Marin HHS staff and emergency medical personnel will be on hand to administer the vaccine. All County staff members are disaster service workers as well, and they are treating the Novato flu shot clinic as a “point of dispensing” to simulate an emergency need to dispense medicine to, or vaccinate, the whole community. The recent wildfires in Lake County and the 2014 earthquakes in Napa have reminded us all about the need for training and preparedness.

“Leadership plays a great role in responding to any disaster, and Health & Human Services is committed to preparing staff for emergency response,” said HHS Projects Coordinator Kristen Seatavakin. “We are looking forward to using this chance to improve the department’s ability to respond and to recognize where we may need to build larger capacity.”

The flu begins with an abrupt onset of fever, muscle aches, sore throat and cough that often make people sick enough to keep them in bed for several days. Flu can be especially dangerous for young children, seniors, pregnant women and people with chronic illnesses such as heart disease, diabetes and asthma.

The California Department of Public Health (CDPH) recommends basic steps to prevent and stop the spread of influenza and other respiratory illnesses in addition to getting the flu vaccination. These include:

• Stay home when you are sick to avoid spreading illness to those around you.
• Do not go to work when ill, particularly if you work with vulnerable populations.
• Wear a face mask when coming within six feet of a sick person.
• If you are sick, wear a facemask before going near other people.
• Restrict visitation with vulnerable populations while you are ill.
• Cough or sneeze into your elbow or a tissue and properly dispose of used tissues.
• Wash your hands thoroughly with soap and warm water or use an alcohol-based hand sanitizer to get rid of most germs.
• Avoid touching your eyes, nose and mouth.
• Stay healthy with a balanced diet, plenty of water and adequate rest and exercise.

Stay up to date with information regarding this season’s flu activity and additional options for flu vaccination by visiting www.marinflu.org.

Marin County is known for high average life expectancy and wide health disparities between communities.  Differences in cardiovascular mortality rates drive the 17 year gap in life expectancy within our county.  In order to focus our understanding of this complex problem and to prioritize programs toward early prevention, a new Health Equity initiative concentrates on 1) childhood healthy weight and 2) access to primary care for all.  The initiative is summarized here.

Any providers in the state Vaccines for Children (VFC) program, and any healthcare workers who would like to learn more about childhood vaccines and vaccine preventable diseases are invited to an Immunization Update Conference. Co-sponsored by the health departments of Marin and Sonoma counties, this event features speakers from the California Department of Public Health Immunization Branch. Join us Friday, June 19, 8:00 -11:30 AM, at the Petaluma Health Center.  For more information or to RSVP, please call Danielle, our Marin Immunization Coordinator, at 415-473-3078 or click here.

In 2014, 21 Marin County residents were diagnosed with HIV.  In recent years, an increasing proportion of those newly diagnosed are Latinos or African-Americans and individuals under the age of 30.  Over the past four years, approximately one in four people diagnosed with HIV in Marin had AIDS upon entry into care.  Health care providers should remain aware of HIV trends and screening standards to ensure timely diagnosis and early intervention.  Please see the Marin County HIV fact sheet here. 

Throughout 2024, Marin County has been experiencing an outbreak of pertussis (aka whooping cough). Outbreaks are commonly occur every 3 to 5 years. As of September 30, 2024, Marin County Public Health (MCPH) has investigated 355 cases. The number of cases have been declining since September.  In October and November, MCPH has investigated 14 pertussis cases.

Pertussis is a common, highly contagious bacterial disease. Most adolescents and adults recover without complications, but it can be deadly for infants. Within 3-5 days of antibiotic treatment, the disease is no longer transmissible to others. 

Pertussis vaccines are effective, but not perfect. They offer good levels of protection during the first two years after getting the vaccine, but the protection decreases over time (“waning immunity.”)  For this reason, we tend to see pertussis more in middle and high school age populations. Those who are vaccinated tend to have less severe disease.

Vaccination remains the best defense against pertussis, along with appropriate screening, treatment, and prophylaxis for high risk contacts.  Anyone who is around an infant less than one year of age should have current pertussis vaccination.

Marin County Public Health recommends:

It is most critical for ill persons who are either high risk or may expose someone who is high risk to be evaluated by their health care provider.  Persons considered at “high risk” of pertussis include infants (< 1 year old), pregnant women (especially in the third trimester), and anyone who spends time with infants or pregnant women.  Health care providers may prescribe antibiotics to treat ill individuals or to prevent illness in healthy high risk household members who have been in contact with a person who is sick.

1. Vaccinate infants, children, adolescents, and adults according to the ACIP schedule and implement cocooning around infants. Most importantly, pregnant women should receive the Tdap vaccine between 27-36 weeks of pregnancy to protect infants.
2. Think pertussis. If other household members are or have been recently sick with a respiratory illness, particularly if with violent coughing fits and vomiting after coughing, discuss with your health care provider. People who have been vaccinated for pertussis often present with mild symptoms.    
3. Test for pertussis. People who have been vaccinated for pertussis often present with mild symptoms. Have a high index of suspicion and a low threshold for testing and evaluating individuals for pertussis.  Testing is most critical for symptomatic persons who are either high risk or may expose someone who is high risk. Persons considered at “high risk” of pertussis include infants (< 1 year old), pregnant women (especially in the third trimester), and anyone who may expose infants or pregnant women.
4. Treat pertussis cases with a course of appropriate antimicrobial therapy. The recommended antimicrobial agents for treatment or chemoprophylaxis of pertussis are azithromycin, clarithromycin, and erythromycin.
5. Stop the spread.  If you or your child is sick with pertussis, prevent spreading the illness to others by:

• Staying at home until at least 3 days of antibiotics are completed, or if the sick person did not receive antibiotics, stay at home until 21 days since the cough started.

• Coughing and sneezing into the elbow, not the hand.  Use tissues and put used tissues in the waste basket.

• Wash hands frequently.

Please contact Marin County Public Health, Monday through Friday 8:30 a.m. through 5:00 p.m., if you have any questions or concerns.  

P 415 473 4163
F 415 473 6002
MarinCD@marincounty.org 

Marin County Public Health contacts cases to determine if there are high risk individuals who need chemoprophylaxis. High risk household contacts will be referred to their usual source of care for chemoprophylaxis.

Additional Information

Centers for Disease Control and Prevention (CDC). Pertussis (Whooping Cough) 
California Department of Public Health (CDPH). Pertussis (Whooping Cough)

On October 6, 2022, Centers for Disease Control and Prevention (CDC) issued this Health Alert Network (HAN) Health Advisory about a recently confirmed outbreak of Ebola virus disease (EVD) in Uganda caused by Sudan virus (species Sudan ebolavirus).  Currently, neither Centers for Disease Control and Prevention (CDC) nor WHO recommend any restrictions for travel in relation to this current outbreak. While the risk of EVD into California remains very low, infectious diseases are regularly imported into California.  We encourage providers to maintain their routine practice of asking patients with acute, febrile illness about recent travel, including international travel to Africa.

There is no Ebola in Marin County. 

Marin is prepared to respond to a communicable disease outbreak, including Ebola.  Marin County Health and Human Services (HHS) is working with local hospitals and the California Department of Public Health (CDPH) to ensure that clinicians and hospitals countywide are educated and prepared.

It is very unlikely that a case of Ebola virus will occur in Marin. However, should a suspect case arise in Marin County, Public Health and our health care partners are prepared to intervene quickly, safely and effectively. We work collaboratively with our emergency medical services, hospitals, clinics and private providers to practice countywide response plans that assure the safety and health of our community. 

As the global situation evolves, Public Health will provide updates that may be relevant to Marin County here and through local Advisories and Alerts. 

Updated:  October 16, 2022

Influenza transmission in health care settings presents risk to both health care workers (HCW’s) and their patients, many of whom are vulnerable to severe influenza disease. Influenza vaccination of HCW's protects against influenza infection, illness, and mortality. Marin County health care facilities, in agreement with Health Officer orders, have joined other Bay Area health facilities in adopting policies requiring HCW’s to be vaccinated or to wear a mask in patient care areas.  Read more.

Marin healthcare providers see the impact of excessive calorie consumption every day, across the age spectrum. Diabetes and obesity are model conditions for partnership between public health and clinical medicine because most cases are both preventable and curable. Health practitioners in Marin County are working to limit the harmful consumption of sugar-sweetened beverages (soda sweetened with sugar, corn syrup, or other caloric sweeteners including sweetened juices, sports and energy drinks).

According to the CDC, consumption of sugar-sweetened beverages is a major driver of the obesity epidemic. Over the past decade, per capita intake of calories from sugar-sweetened beverages has increased by nearly 30% nationally, partly due to marketing strategies targeted to children and adolescents.

This summer, Marin County Public Health, supported by a resolution from the county Board of Supervisors, will again be promoting the “Soda Free Summer.” The Soda Free Summer includes measures to educate residents on how to read labels for the amount of sugar in beverages and how to make healthier drinks with water, fresh fruit and herbs. “Rethink Your Drink” events will be held through the summer at a variety of community-based organizations and summer programs for youth.

Health care providers play a vital role in reinforcing healthy eating and active living messages in each encounter. Combined with upstream interventions like the Soda Free Summer, we can begin to reverse the growing burden of obesity as a more integrated health system.

Between 3/5/18 and 4/3/18, measles has been confirmed in six unvaccinated patients who are residents of Santa Clara County (5) and Alameda County (1). One additional linked case has been confirmed in Nevada. All cases are linked to an unvaccinated traveler who was exposed in Europe and developed measles after returning to the San Francisco Bay Area.

Measles is very infectious, and airborne transmission can occur in settings with large numbers of people like healthcare facilities, schools, child care facilities, shopping centers, public transportation, airports, and amusement parks. Marin County Public Health is advising physicians to be vigilant in identifying and appropriately managing suspected measles cases to avoid ongoing transmission and ensuring that their patients and staff are up-to-date with immunizations.

If you, a family member, or friend develop a rash with a fever ≥101°F (38.3°C) contact your health care provider immediately.  

Additional Resources

Centers for Disease Control and Prevention.  Measles (Rubeola)

California Department of Public Health.  Measles

Marin County EMS Agency has achieved the 2014 Mission: Lifeline® EMS Silver Level Recognition Award. This award is based upon the achievements in care delivered in 2013.

ST elevation myocardial infarction (STEMI) is among the most critical emergencies that Emergency Medical Services routinely respond to.  Timely and well coordinated response between all aspects of the response system is critical for survival. As an EMS agency that delivers education in ST elevation myocardial infarction (STEMI) identification, access to 12 lead ECG and develops protocols derived from STEMI Guidelines, our medics are driving improvements in the care and outcomes of STEMI patients.

Collaboration among pre-hospital and hospital providers is the essence of Mission: Lifeline. The American Heart Association recognizes the vital importance Emergency Medical System providers provide to the overall success of Mission: Lifeline STEMI Systems of Care. The correct tools and training allow EMS providers to rapidly identify the STEMI, promptly notify the destination Center and trigger an early response from the awaiting hospital personnel.

The criteria to achieve the Mission: Lifeline EMS Silver award is based on meeting the achievement measures for at least one and up to three calendar quarters with no single measure scoring below 75%. The individual measures are as follows:

• Percentage of patients with non-traumatic chest pain > 35 years of age, treated and transported by EMS who receives a pre-hospital 12 Lead ECG.
• Percentage of STEMI patients transported to a STEMI Receiving Center, with pre-hospital First Medical Contact (FMC) to Device (PCI) < 90 Minutes.
• Percentage of STEMI patients transported to a STEMI Referring Center with arrival (to Referring Center) to Fibrinolytic Therapy administration in <30 Minutes.

For more information and for a listing of all Mission: Lifeline EMS Award Recipients, please visit : www.heart.org/mlemsawards 

Marin County has seen a consistent elevation in pertussis incidence during the past year. Since April 1, 2013, 224 pertussis cases have been reported to Marin County Public Health.  This is compared to five cases in 2012.

The vast majority of cases are among school-aged children and most are associated with school-based clusters. Providers can help limit further spread of disease by following these simple steps. These are especially important in limiting transmission in schools.

• If pertussis is suspected, test, treat and isolate cases for 5 full days of antimicrobial therapy or until testing is able to rule out pertussis.
• Post-exposure antimicrobial prophylaxis is recommended for symptomatic and asymptomatic close contacts.
• Symptomatic close contacts are to be excluded from school or work until a minimum of 5 days of effective antibiotic treatment.
• After 21 days of cough, antimicrobial therapy is no longer indicated for treatment of pertussis, regardless of whether treatment was offered earlier in the course of disease.

Ensure that all children and adults are up to date with recommended pertussis vaccine.

For more information on pertussis diagnosis, treatment and infection control, please visit: http://www.cdph.ca.gov/HealthInfo/discond/Documents/CDPH_Pertussis%20qui...

For information on pertussis laboratory testing: see http://www.cdph.ca.gov/programs/immunize/Documents/PertussisLaboratoryTe...  

Report pertussis cases to Marin County Communicable Disease Prevention and Control by fax (415) 473-6002 or phone (415) 473-7805 within 24 hours.

Marin City is making amazing strides towards health and wellness for its residents.  The State of California has taken notice and Marin City will receive a visit from the California State Office of Health Equity on February 7th.  The Office of Healthy Equity was formed at the state level to provide a key leadership role in reducing health and mental health disparities to vulnerable communities.  The State is interested in the overall effort to revitalize Marin City, spearheaded by Marin City Community Services District (MCCSD) in collaboration with many partners.

As health professionals, we know that most of what contributes to health happens in our neighborhoods and communities.  I applaud the local leaders and policy makers such as the MCCSD Board, General Manager Johnathan Logan, Domenica Giovannini, and Terrie Green for their commitment to health.

Some of the exciting developments include:

• The MCCSD Board passed a Wellness Policy setting a nutritional standard for food and drink and designated all service district facilities to be Smoke-Free. The policy’s implementation starts on February 1, 2014.
• The fully funded $5M George “Rocky” Graham Park is scheduled to be completed in the spring of 2015. The innovative park design was chosen by the community and will feature community art, an amphitheater, and a mixed use synthetic field.   
• Marin City CX3 (Communities of Excellence) Project is a state initiative focused on assessing food accessibility and quality in Marin City and implementing changes based on community priorities.
• Marin City Fitness Center & Boxing Gym is open to the public and houses work-out equipment, a full-sized boxing gym, and a multi-purpose space. MCCSD is currently developing programming and a membership schedule that includes a sliding fee scale.
• MCCSD was awarded the contract to redevelop The Marin City (Betty Times) Ball Field by the Sausalito/Marin City School District. Phase one (starting this summer) will include installation of a turf field designed for use by multiple sports and will be available for use by the entire county/surrounding areas through rental agreements.  
• MCCSD has launched a Capital Campaign to redevelop the current Manzanita Recreation Center and other agency facilities. This will update and expand facilities, allowing for increased programming and mixed use.

To learn more or to get involved with any these projects, please contact the Marin City Community Services District at 415-332-1441 or marincitycsd@gmail.com. 

Influenza activity remains widespread in Marin County and regionally.

As of January 22, 2014, there have been 29 flu-related deaths reported in persons under aged 65 year in the ten-county Bay Area region, including two in Marin. Many of the deaths have occurred in persons who did not receive this year’s flu vaccine.

Laboratory testing of specimens has shown an overwhelming predominance of the H1N1 virus over H3N2, both of which are components of this year’s seasonal vaccine.

Since its emergence in 2009, the current strain of H1N1 has been shown to cause more severe disease in those with obesity, chronic cardiovascular or pulmonary disease, any immune deficiency, pregnant women, and in some cases, otherwise healthy young adults.

All isolates so far appear to be sensitive to oseltamivir and zanamivir.  For those in whom treatment is indicated, treatment should be started as early as possible in advance of laboratory confirmation. Currently, supplies of antivirals and flu vaccine are adequate in Marin County.

There have been no bed shortages in Marin hospitals.

The Marin County Department of Health and Human Services continues to recommend persons over six months of age should be considered for receiving the flu vaccine. The healthy adolescent through middle aged population should also be vaccinated, and this group may need special motivation from providers to be immunized.

For regular updates on Marin County influenza activity visit www.marinflu.org

For additional information

http://www.cdc.gov/flu/professionals/antivirals/index.htm

http://www.cdph.ca.gov/healthinfo/discond/Pages/Influenza%28Flu%29.aspx

Remember, it’s not too late to vaccinate!

Marin County has comparatively high numbers of parents who refuse required childhood vaccinations. This fall, Marin County Public Health and the Office of Education conducted a survey of kindergarten parents to better understand the beliefs of those who refuse vaccinations. A new law requiring a discussion with a medical provider prior to obtaining a vaccine exemption goes into effect January 1, 2014. The results of this survey can stimulate community dialog and inform providers as they help families navigate choices. 

Tobacco Sales Status Among Marin Retail Pharmacies 

As of November 2​2, 2013

Preferred Retail Pharmacies that do NOT sell tobacco products

Retail Pharmacies that DO sell tobacco products

Published in September 2013, "Help Your Patients Quit Tobacco: An Implementation Guide for Community Health Centers" is a new, free guide to integrating tobacco cessation support in a health care setting. Some of the topics covered in the guide include:

• The “5 A’s – Ask, Advise, Assess, Assist and Arrange (follow-up),” the gold standard evidence-based protocol for tobacco cessation interventions. 
• Pharmacotherapy options for smoking cessation including dosage recommendations. 
• Billing codes for the Affordable Care Act (ACA) and Medicare reimbursement for on-site cessation counseling. 
• Realistic discussions of implementation challenges. 
• Suggestions for how to chart tobacco screening and subsequent cessation interactions with patients. 

For Marin-based information on cessation classes or in-person tobacco cessation education staff trainings, please contact Beth Lillard at Bay Area Community Resources see blillard@bacr.org, 415.755.2334. To find out more about BACR’s tobacco work, go to www.bacr.org/tobacco. 

Although influenza season officially begins in late September, influenza activity usually peaks in December or January.  Influenza seasons range in severity from mild to severe.  Given the variation in timing and severity of influenza activity each season, frequent assessment of influenza data at a countywide level is needed to understand the extent to which influenza may be impacting Marin residents.  Knowledge of local influenza patterns can also guide clinical decision-making in testing and treatment. The Marin Influenza Surveillance Update is prepared and distributed weekly during influenza season to share influenza activity data with clinicians, other healthcare professionals, and the community. 

The report is a team effort consisting of the following partners:

• Medical centers in Marin, including Kaiser San Rafael Medical Center, Marin General Hospital and Novato Community Hospital/Terra Linda Urgent Care, provide de-identified clinical and laboratory data.
• County of Marin Department of Health and Human Services staff analyze the data and prepare the report.
• State and national public health agencies publish weekly reports that are referenced for context.

The Marin section of the report summarizes laboratory testing and visits to local emergency departments for influenza-like illness.  Additional measures are presented for the state and national levels including mortality and graphic spread across the United States. 

The first edition of this year’s Influenza Surveillance Update will be distributed in mid-October.  The report will be sent to clinicians by email and can also be accessed at www.MarinFlu.org.  

Prescription drug misuse is the nation’s fastest growing health problem and a serious concern in Marin County.¹  In Marin, more people die from misusing prescription drugs than from motor vehicle accidents.²  Prescription drug misuse is defined as the non-medical use of physician prescribed medication. The most commonly misused prescriptions include opiates, benzodiazepines, and amphetamine-related stimulants.

Prescription drugs are becoming a new gateway drug. Of the 3 million people who began using illicit drugs in 2010, over 25% began by misusing prescription drugs.³  Among young people, prescription drugs are the most commonly abused drug following marijuana.⁴  Marin County 11th graders misuse prescription pain killers, sedatives, and barbiturates as much as their California peers. The rate of stimulant misuse among Marin County 11th graders however, is 25% greater than the state average.⁵  Prescription drug misuse is a complex public health problem, contributing to intentional and unintentional drug poisonings, fatal overdoses, and community violence.

The Marin County Department of Health and Human Services (HHS) is convening a group of key stakeholders to gain a clearer understanding of the issue and to create a comprehensive plan for reducing prescription drug misuse in our community.

Additionally, HHS and Boston University are offering a CME conference in San Rafael to support safe and effective management of pain on January 18, 2014, location pending. www.scopeofpain.com.

For more information please contact Kristen Law

1.   Whitehouse.gov (2011), “Epidemic: Responding to America’s Prescription Drug Abuse Crisis,” accessed 09/19/2013. 
2.   National Highway Traffic Safety Administration, Fatality Analysis Reporting System. California Department of Public Health, EpiCenter Injury Surveillance Query
3.   Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, accessed 09/23/2013. 
4.   Office of National Drug Control Policy, “Prescription Drug Abuse,” accessed 09/16/2013.
5.   California Healthy Kids Survey, 2009-2011