County of Marin Health and Human Services

Public Health Newsletter

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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

Nearly one in three children, and nearly one in two adults in Marin are overweight or obese. Marin County healthcare providers see the impact of obesity every day, across the age spectrum. Obesity is a model condition for partnership between public health and clinical medicine because it is preventable and curable, and it is an epidemic. As one important step in combating obesity, 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 Department of Health and Human Services (HHS), supported by a resolution from the county Board of Supervisors, will be partnering with LIFT-Levantate and the Marin City Community Services District to promote 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. In addition, HHS will be working with community leaders in the Canal and Marin City through the Communities of Excellence in Nutrition, Physical Activity, and Obesity Prevention project, to examine retail marketing, product availability and pricing to help reduce access to sugar-sweetened beverages.

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. 

HIV will remain an epidemic until those infected are diagnosed and treated. The CDC estimates as many 1 in 5 individuals with HIV are unaware they are infected. Screening for HIV infection is now recommended for all adolescents and adults.

In the last several years, Marin has averaged 20 new HIV diagnoses per year. Approximately half of these individuals were diagnosed with AIDS within a year, suggesting long-standing infection at the time of HIV diagnosis. This indicates missed opportunities to diagnose and treat HIV early, to improve survival and limit further transmission within the community.

Routine HIV screening has gotten much easier to perform in the recent past. Most encounters provide an opportunity for "opt-out" testing. Patients don't need a separate consent form-- they only need to be informed of the test and given the option to decline. Testing is minimally invasive when added to routine blood work or performed at the point of care.

In order to eliminate any barriers to screening all adolescents and adults, Marin County provides free rapid HIV testing. The HIV Rapid Response line at 415-457-2002 is available to any county resident or provider. Primary care and linkage to supportive services for people living with HIV are also available.

The importance of early HIV identification, linkage to medical care, and adherence to medication in order to limit the "community viral load" is an important means of primary prevention against HIV. The HIV treatment cascade illustrates the consequences of undiagnosed and untreated disease as a driver of ongoing epidemic spread.

As of January 1, 2013, there were 562 people living with HIV in Marin. The majority are male, over 40, and 1 in 5 is over 60 years of age. Our most recent HIV surveillance report can be viewed here.

On May 7, 2013 the Marin Country Public Health Officer issued a Public Health Update regarding two cases of pertussis at Marin Catholic High School. Since that time 13 additional cases have been reported, including additional cases from Marin Catholic High School and other schools through our community. All known cases are recovering with outpatient treatment. Information has been sent to parents, contact investigations are ongoing and individuals identified as contacts have been notified and offered prophylaxis.

Providers may receive questions from families about medical evaluation, treatment, and chemoprophylaxis for pertussis. Pertussis does occur sporadically in Marin, and some natural variation in baseline activity is expected. However, pertussis incidence in Marin in the past 2 months is above normal levels, and signals active transmission within our community. This is an opportunity to reinforce the importance of vaccination—in countries with the highest vaccination rates, sporadic pertussis incidence is less than 1 case per 100,000 people per year.

Depending on the characteristics of any school- based clusters, the Public Health Officer may issue orders to exclude unvaccinated students from attending school for their protection. If such action is taken a Public Health Update will be sent to providers.  

For your convenience the California Department of Public Health Quicksheets for Pertussis Investigation and Laboratory Testing are attached to this document and also may be found at http://www.cdph.ca.gov/HealthInfo/discond/Documents/CDPHPertussisQuicksheet.pdf

Please report new pertussis cases to the Public Health Department Communicable Disease Unit at the following phone numbers, (415) 473-3038 or (415) 473-7805 Monday through Friday between 8:30 a.m. and 5:00 p.m. or fax a Confidential Morbidity Report to (415) 473-6002.

Marin Municipal Water District (MMWD) community water supplies have been fluoridated since 1973. Recently, regional anti-fluoridation advocates have mobilized to remove fluoride from community waters. Marin County Health and Human Services recognizes fluoridation as an evidence-based, safe and effective means to support oral health. Providers may get questions from patients about this issue. For the Public Health Officer letter of support for community water fluoridation as a public health “standard of care,” see below.  For American Academy of Pediatrics patient information click here.

June 27, 2013

Mr. Larry Russell
Board President
Marin Municipal Water District
220 Nellen Avenue
Corte Madera, CA  94925

Dear Mr. Russell,

As the Public Health Officer for the County of Marin, I support community water fluoridation.  As an advocate for the well being and highest attainable standard of health for every person in Marin, I recognize the importance of disease prevention.  Water fluoridation helps prevent dental disease and gives everyone, especially children who may have limited access to care, a chance to thrive without pain and poor self-esteem from diseased teeth.

Every U.S. Surgeon General for the past 50 years has endorsed fluoridation of community water as a safe and effective means to prevent tooth decay. This year, Surgeon General Regina Benjamin endorsed community water fluoridation as "one of the most effective choices communities can make to prevent health problems while actually improving the oral health of their citizens."  Dr. Benjamin wrote. "In fact, each generation born since the implementation of water fluoridation has enjoyed better dental health than the generation that preceded it." 

Public health protections that are built into the environment, equally available to everyone, are more effective than those that require behavior change from each individual. Community water fluoridation is akin to advances in road safety, food safety, basic sanitation and the monitoring of water and air quality as public health interventions that offer built-in protections for all citizens. 

Leading scientific and medical organizations have examined the evidence regarding community water fluoridation and have come out in support, including the American Medical Association, American Academy of Pediatrics, American Academy of Family Physicians, American Nurses Association, Centers for Disease Control and Prevention, and the World Health Organization. The Marin County Department of Health and Human Services, the Marin Medical Society, the Marin Oral Health Advisory Committee, and the Marin Dental Society join this list of informed supporters of community water fluoridation.

Thank you for your attention to this important issue for our community, and please do not hesitate to contact me if I can provide any additional support.

Sincerely,

Matthew Willis, MD MPH
Public Health Officer
County of Marin
Department of Health and Human Services
899 Northgate Dr, Suite 104
San Rafael, CA, 94903
415-473-4163 T
415-473-2326 F
mwillis@marincounty.org

Marin County's adult smoking population has dwindled to one of the lowest in the state. We owe this success to concerted community-wide effort over years, including Marin health care providers who daily reinforce tobacco education for patients and the public health advocates who support policies that limit community harm from tobacco.

The Smoke-Free Marin Coalition has targeted secondhand smoking and has supported some of the state's most progressive policies to provide protection for residents in multi-unit housing (MUH) complexes. San Rafael set a new bar by restricting smoking in 100% of MUH complexes. Marin businesses are also generally supportive, with many adopting voluntary policies on outdoor smoking in response to customer demand. Ten of twelve jurisdictions now have designated smoke-free outdoor dining, with substantial progress made in the past two years.

Despite these successes, there is still progress to be made. One in ten Marin adults still smoke every day or "most days" (www.countyhealthrankings.org). In the 2013 annual American Lung Association Report Card, San Rafael and County unincorporated areas were the only areas in Marin to receive an "A" grade for their smoking policies and practices; Larkspur, Mill Valley, Novato and Sausalito earned "B's"; Fairfax, Ross and Tiburon "C's"; San Anselmo a "D"; and Belvedere and Corte Madera "F's." Communities lacking strong secondhand smoke regulations including both indoor and outdoor smoking limitations lose significant points in the grading system.

Persons with mental illness and Marin's youth are high priority populations for tobacco control efforts. The Marin Tobacco and Mental Health Collaborative brings together Marin-based mental health service providers, consumers, and tobacco control groups to offer effective and culturally competent cessation support to consumers in behavioral health programs. Efforts to reduce tobacco use among Marin County youth include support to colleges implementing campus-wide smoke-free policies, assistance to schools in securing federal funding for tobacco education, and partnership with community-based programs promoting healthy choices for young people.

Effective tobacco control hinges on cohesive and consistent messages from all health advocates. Marin health care providers can recommit to this effort by offering strong messaging to patients and families about the harms of tobacco use, supporting cessation for those using tobacco, and advocating for tobacco control policies when they are being considered. Resources for people seeking to cut down on tobacco use and for the providers supporting them can be accessed at Bay Area Community Resources (www.bacr.org/programs/tobacco).

Largely funded by the Center’s for Disease Control and Prevention (CDC) and the Avon Foundation, the MWS is a large-scale breast cancer research program being conducted within the Marin County Department of Health and Human Services. From 2007 through 2009, the MWS enrolled 13,344 women, which represented 21.5% of all women of mammography age in Marin County. Detailed risk factor information, saliva specimens and mammographic breast density were collected at screening centers associated with Kaiser Permanente, Marin General Hospital and Novato community hospitals.

Enrollees completed an in-depth questionnaire which included questions regarding family history of breast cancer, reproductive history, use of exogenous hormones, alcohol intake, smoking history, diet/nutrition, environmental exposures, medications, stress measures, education level, socioeconomic status, work status and years of residence in Marin. Compositional breast density, breast cancer status, demographic data, body mass index (BMI) and family history of breast cancer was also obtained through linkage with the San Francisco Mammography Registry, one of seven registries included in the National Cancer Institute Breast Cancer Surveillance Consortium.

Key findings from the MWS include:

  • Establishing linkages between hormone replacement therapy and breast cancer.
  • Confirming that reproductive risk factors like delayed childbirth are associated with increased breast cancer risk in the MWS population.
  • Pioneering the use of human saliva as a non-invasive, cost-effective and practical method for public health screening.

The MWS is currently conducting ongoing analyses that include:

  • Utilizing our biospecimen repository of more than 8,000 saliva samples as a powerful tool to explore the genetic and environmental components of breast cancer.
  • Understanding how alcohol use affects breast health, and how adolescent risk factors such as teen smoking may be associated with breast cancer.
  • Investigating how the use of complementary and alternative medicines for menopause affects breast cancer risk.
  • Exploring improvements in breast cancer risk prediction through advanced statistical modeling techniques.

The Marin Women’s Study has grown in scope from a local, grassroots community effort to an internationally-renowned research program. While our findings may have a global impact on the prevention of breast cancer, they are most relevant to the study participants – the women of Marin. 

We are grateful for the steadfast support of the Marin County Board of Supervisors and the Marin Women’s Study steering committee which maintains the focus and vision of the project and advises the team on research and policy decisions. The advisory board consists of the following individuals:

Christopher C. Benz, MD - Buck Institute for Age Research
Christina Clarke, Ph.D. - Cancer Prevention Institute of California
Francine Halberg, M.D., FASTRO - Radiation Oncologist, Marin Cancer Institute at Marin General Hospital
Leah Kelley, M.D. Marin General Hospital, Marin Specialty Care 
Dr. Karla Kerlikowski, MD - University of California San Francisco
Mary Mockus, M.D., Ph.D. – Kaiser Permanente San Rafael Medical Center
Fern Orenstein, M.Ed. – Zero Breast Cancer Advocate and Survivor
Elad Ziv, M.D., UCSF Helen Diller Family Comprehensive Cancer Center

Marin Public Health Recommendations

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. 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.

According to the 2012 Hospital Breastfeeding Rates Report, 98.6% of women delivering at Marin General Hospital in 2010 initiated breastfeeding. By hospital discharge, 17% of those mothers were giving formula (MGH breastfeeding rates) and after hospital discharge, breastfeeding rates decreased significantly. Exclusive breastfeeding rates at three months for the Bay Area are 40% (MIHA data from CDPH). Exclusive breastfeeding rates for participants of the Marin County Women, Infants and Children Supplemental Nutrition Program (WIC) are less than 25% at six months. How can we support mothers to reach their breastfeeding goals?

Peer breastfeeding support has been shown to be an effective strategy to increase breastfeeding rates and is the theme for this year's World Breastfeeding Week. Peer support acknowledges that beyond her own personal resolve to breastfeed, a mother relies on a circle of support that includes family, community members, childcare workers, and policy makers.

Since 2006, Marin's WIC Program has had a Breastfeeding Peer Counseling Program, supporting over 600 low-income women annually. WIC peer counselors have been trained to provide new mothers with breastfeeding information and support in the WIC office at Marin General Hospital and are available by phone outside of normal hours. For those mothers needing clinical breastfeeding support, WIC has Certified Lactation Consultants (IBCLC) available four days a week both in the WIC office and in the mother's home, if needed. WIC breastfeeding rates have nearly doubled since the Peer Counseling Program started. Low-income families and those with Medi-Cal can be referred to WIC for breastfeeding help at 473-3094 (phone) or 473-4056 (fax).

Three Marin residents were exposed to measles on the flight from Dusseldorf, Germany to Los Angeles International Airport on July 2, 2013. The case's symptoms included a maculopapular rash, coryza, fever, and sore throat. The Marin residents were vaccinated against measles and did not become ill. Two other passengers, an unvaccinated German exchange student and an infant who was not fully vaccinated, have developed measles since the flight.

This serves as a reminder of the ongoing risk of measles in the increasingly global environment and of the role of vaccine in preventing disease.

MMR (measles, mumps, and rubella vaccine) and IVIG (intravenous immune globulin) can be used as post-exposure prophylaxis.

  • MMR vaccine given to a person 6 months or older within 72 hours of exposure to a measles case may provide protection against the disease.
  • Pregnant women with known exposure and who lack evidence of measles immunity should receive 400 mg/kg of intravenous immune globulin (IVIG).
  • Severely immunocompromised persons, irrespective of evidence of measles immunity, should receive 400 mg/kg of IVIG.

Immunity through vaccination remains the most effective way to prevent disease.

For the vaccination schedule and information about measles disease and post-exposure prophylaxis, please see California Department of Public Health Measles Investigation Quicksheet-June 2013 at:

http://www.cdph.ca.gov/programs/immunize/Documents/CDPHMeaslesInvestigat....

Every day doctors see patients who are at risk for behavioral health concerns, including suicide. People with diabetes are twice as likely to have depression as those without diabetes; those with asthma are 2.3 times more likely; and those with a cardiovascular disease are 1.43 times more likely to have an anxiety disorder. Untreated mental health issues increase the likelihood of suicidality.

While the signs of suicide may not always be obvious, there are warning signs that can be identified in primary care settings.

  •  Forty-five percent of those who die by suicide were in contact with their primary care provider in the month before they died. That rate is even higher for older adults.
  • People with chronic diseases are at higher risk for depression and other mental health concerns. They can be screened with simple tools for depression, anxiety, substance use, and suicidality.
  • Increased drug or alcohol use, reckless behavior, changes in sleep, sudden mood changes and other signs may be revealed during a visit to the doctor.
  • Having attempted suicide in the past or knowing somebody closely who died by suicide increases a person’s risk of suicide.
  • For youth, bullying or being bullied is associated with increased risk of suicide and other mental health concerns.

Directly addressing concerns, such as asking if a person, “Are you thinking about suicide?” does not increase their risk – it opens the door to getting help. In addition to possibly saving a life, addressing behavioral health concerns in primary care settings can improve patients’ physical health, as well as reduce the time and resources needed to effectively serve patients.

For more information about suicide prevention in Marin County contact: AMY/MELISA??.

For more information about providing behavioral health services in primary care settings, contact Kristen Gardner (kgardner@marincounty.org).

AMY/MELISA  - insert plug for Kevin H event

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