WC CWF Health District Board Minutes - 08/28/2015WICHITA FALLS -WICHITA COUNTY PUBLIC HEALTH BOARD MINUTES
August 28, 2015
Wichita Falls -Wichita County Public Health District
1700 Third Street - Parker Conference Room
Wichita Falls, Texas
BOARD MEMBERS PRESENT:
Scott Plowman, Chair
Diane Stewart, R.N., Secretary
David Carlston, Ph.D.
Larry Rains, D.D.S
Robin Moreno, MHA -HAS, ACHE
BOARD MEMBERS EXCUSED ABSENCE:
Keith Williamson, M.D.
BOARD MEMBERS UNEXCUSED ABSENCE:
Julie Gibson, D.V.M., Vice -Chair
OTHERS PRESENT:
Lou Kreidler, R.N., B.S.N.
Amy Fagan, M.P.A.
Stephen Santellana
Director of Health
Assistant Director of Health
Council Liaison
I. CALL TO ORDER
Scott Plowman called the Health Board meeting to order at 12:05 pm after a quorum of members was
attained.
II. APPROVAL OF MINUTES AND ABSENCES
Scott Plowman called for the review and approval of minutes from the meeting held on Friday June 26,
2015. Diane Stewart introduced a motion to approve the minutes as presented and Dr. David Carlston
seconded the motion. The motion passed unanimously.
At this time it was noted the excused absence of Dr. Keith Williamson and the unexcused absence of Dr.
Julie Gibson.
III. PUBLIC HEALTH EMERGENCY PREPAREDNESS OVERVIEW
Al Gonzales the Public Health Emergency Preparedness (PREP) Coordinator stated PHEP is not highly
published or visible it started in 2002 after 9-11 and anthrax. The program is Centers for Disease
Control and Prevention (CDC) grant funded through the State that staffs himself and Jim Redus the
Public Health Preparedness Specialist. The staff works closely with DSHS on grant management, the
Medical and Community partners, the Independent School District, City and County Emergency
Management, and every Health Department Division.
A large part of the program is response planning the development of plans related to bioterrorism due
to the grant was generated from the September 11, 2001 catastrophe. The biggest threat is probably
the flu since it is carried by birds there are continually new versions out of China or other parts of the
country. Procedures are planned on how to get informative warnings to the public, partners, medical
and emergency management on a potential mass casualty such as an aircraft crash or highly infectious
disease such as the recent Ebola. The need and ability to mass vaccinate or provide antibiotics to the
public on a massive scale in an emergency are the medical counter measures that relate back to
bioterrorism and pandemic flu. It can never be known what is going to transpire working closely with
the community partners is huge for response findings, training, and exercises.
PHEP has the in house ability to train the FEMA courses and certification through the State of Texas
Division of Emergency Management to teach the Advanced Extensive Command courses with the
community partners to verify their compliance with the requirements. Exercises are planned and
executed with Health Department staff, community partners including Sheppard, being heavily involved
with that aspect our participation is requested in the Sheppard exercises for input.
Jim Redus the Public Health Specialist assists with the Nursing Division Environmental Disease
Detection another part of the program. The Electronic Syndromic Surveillance a web based program
called ESSENCE (Electronic Surveillance System for the Early Notification of Community based
Epidemics) is used that monitors and provides alerts for rapid or unusual outbreaks in the occurrence of
infectious diseases and biological outbreaks. The Public Health Specialist monitors on a regular bases
for syndromes and chief complaints coming out of the emergency room. Syndrome areas would be the
gastrointestinal, rashes, fever, botulism, neurological such as headaches, numbness, hemorrhagic, a
lot of the monetary agents impact these areas that is what we observe for trends that could indicate
some type of outbreak. The board contains data from the three hospitals but all that can be observed
are the chief complaints, age of individual, and zip code if it exceeds the baseline threshold it is an alert
for the Public Health Specialist to notify nursing to investigate and possibly contact the hospital for any
indications of specific findings. The only problem everywhere is the inability to receive the discharge
diagnosis the chief complaint may result in a minor, serious or chronic disease. The data feed is
complex but continues to evolve the expectations are within the next year to be able to access the
discharge diagnosis.
Another program monitored is Real-Time Outbreak Disease Surveillance (RODS) within the City are six
pharmacies that report to the RODS research at the University of Pittsburgh to watch for indicators any
buying trends in the community. As example; an increase of anti-diarrheal bought with a spike in
gastrointestinal complaints in the ER would create a picture of the possibility of an outbreak which
would trigger the need to review and notify healthcare providers to .be aware of the situation.
Reportable Disease Outreach is done with visits made to the healthcare providers along with a Health
District nurse to educate and provide materials on diseases that are reportable by law due to the
concern that some diseases are more serious than others to public health.
PHEP maintains situation awareness through social media and email subscription from the CDC, World
Health Organization (WHO) and other organizations that can be monitored daily for disease trends
around the world. Information on anything of concern is reported to the Director, Assistant Director and
Nursing.
The program speaks to the public at events with Emergency Management to: Be Informed - Make a
Plan - Be Prepared.
IV. RABIES EVENT
Amy Fagan the Assistant Director of Health gave an assessment on the rabies incident that involved the
Henrietta puppies she thought it was beneficial for the Board to know how the process worked. The
process consisted of many components from the initial response a lot was learned along with plenty that
needed to be done on the education side.
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For the rundown on Tuesday July 14, 2015 the Assistant Director received a call from Katrena Mitchell
the Animal Services Administrator that was in a vehicle with the Local Rabies Authority the newly
appointed Animal Control (AC) Supervisor Amanda Davis in the position for a week headed to a farm in
Henrietta. They had been notified a puppy AC had sent in for testing a day before tested positive for
rabies the puppy came from a litter of nine from an older couple that lived on a farm in Henrietta. The
Farmhand had posted on Craigslist some adorable puppies for free. People showed up at the farm if
they liked a puppy took one the couple had no method of tracking no contact information on those that
took a puppy it was a crucial challenge to figure out the exposure time when the rapid puppy was actually
at the farm. Initially that was at 11:45 am at 4:30 pm was the press release a lot of things went into quick
action the Health District had to coordinate with the Clay County Sheriff Office whom are responsible as
the Local Rabies Control Authority (LRCA) their Captain Tannahill advised they knew nothing about
rabies. Correspondence was made with the Regional DSHS offices the region informed Captain
Tannahill the LRCA could be shared with Wichita if both parties agreed which behooves both
communities since some of the puppies had been located in Wichita County. The Health District worked
close in association with the Clay County Sheriff Office and they expressed their gratitude. Clay County
gathered information from the site came to the Health District for a conference call with the DSHS Region
2/3 office Doctor of Veterinary Medicine (DVM) Dr. Stonechipher in Arlington. The Doctor several years
back had spoken on Rabies to the Health Board her presentation was all true, it was amazing on how
quickly both parties went into effect because of the exposure time it was at a critical count down time.
Coordination was made with Dr. Stonechipher and another Regional DSHS employee stationed in
Abilene that has done a lot of the LRCA coordination on rabies the press release went out at 4:30 pm
and #helpfindpuppy. The goal was to find the o(her eight puppies in the litter to educate those people
and find anyone exposed to the puppy at the farm. The next day Wednesday July 15, 2015 the LRCA
with the Clay County Sheriff office went to the farm picked up the three adult dogs that later tested
negative for rabies. Concern was that most people think the momma dog gave rabies to the puppies but
not so rabies are transmitted through saliva most typically from contact with skunks. The puppies stayed
in the barn later discovered two of the adopted puppies smelled of skunk so the puppy probably tangled
with a skunk that wandered into the barn. The press release on Tuesday was incredibly successful to
locate seven of the eight puppies. Two puppies had been taken to a Duncan, Oklahoma shelter then
euthanized after three days that made for some critical components it was not known if the dogs were
systematic and the shelter kept no logs no record of individuals in contact with the dogs one woman was
pregnant and got the prophylaxis just in case. One puppy adopted by a Wichita Falls resident had a
weekend party with 22 people over that could have been potentially a disaster. Another Wichita Falls
resident that adopted two puppies related the puppies smelt like skunk. Two puppies adopted by an
Iowa Park family that had an in home day care had one doing great played with the kids and the other
one that had not been well died was buried in the backyard.
Within the 72 hour operation everything that could go wrong went wrong it was a true test of fortitude a
lot was learned. As example the bus in route to pick up the heads by 3:30 pm in order to get the results
the next day broke down and no one else would transport hazardous materials. Health alerts had been
sent out to the medical community for advisement but most physicians have not seen a human case of
rabies and not accustomed to the diagnosis or treatment which was a challenge. The social media was
used with the #helpfindpuppy campaign to get the information out to people but puppy number nine was
not found. It was perceived that people speculated with the Animal Services puppy killer reputation
people would rather hold the puppy instead of the puppy be euthanized and tested. Coordination was
made with the Clay County Sheriff Office, DSHS Regional office and DSHS Physicians at Austin on
conference calls for the 3-4 days morning and afternoon. The physicians at the State level involved in
the planning and talk through was supportive never tried to demand what to do it was impressive. Also
coordinated with the Oklahoma Department of Health Chief Epidemiologist and Head Public Information
Officer (PIO) since locations of the puppies had been in both Texas and Oklahoma what was said had to
be consistent with what was said at the Texas and Oklahoma State Level. In the incident alone was
dispensed a 25 contact as the function as the Local Rabies Depot.
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Lynette Williams the Nursing Administration stated as the Local Rabies Depot it acquires the
responsibility to dispense the vaccines to the physicians. When an individual is bitten or exposed they
have to get a HRIG and vaccines administered by a physician. If the physician gets the weight and
writes a prescription it is brought in by the patient the medication is dispensed on ice for them to return
directly back to the physician to be administered the vaccines. Those with insurance get the HRIG and
first dose of vaccine here and the next three doses at Walgreens on 9th Street. Those without insurance
get dispensed all vaccines to them to take to their physician to administer.
In addition Amy Fagan said because both the HRIG and post -exposure prophylaxis vaccine are
incredibly expensive the State requires the patient to sign a State form that assures repayment of the
cost as they can but most do not. That was a real decision maker a lot of money or your life one of the
two choices had to be made. Most being under the age of 30 had never seen rabies plus with it not
being well known needed to be educated. One family of four or five total cost associated with dispense
was over $14,000 dollars. Lynette Williams worked with one gentleman that had trouble with his
insurance company and said he would take his chances. She questioned him on the decision to take the
chance she advised that something could be worked out to get him the vaccine that he should not take
that chance. Jennifer Moreno whom works for Lynette had heard some people with exposure came in
got the post -exposure with her foresight she did a preorder so there was enough HRIG and vaccine for
the initial group of people. Some HRIG and vaccine did have to be pulled in from Abilene and other
Depots it arrived at 10:20 am for the Saturday clinic that was opened at 10:00 am by Dr. Mattar of the
Family Health Center and Lynette Williams. It could have been bad if there had not been the proper
amount of HRIG or vaccine available. Many of the patients had no medical home or physician they did
not know where to go for care so they were referred and seen by Dr. Mattar at the Family Health Center.
Dr. Mattar was a super hero took in those initial patients and brought down the cost to $17.00 he opened
up had the Saturday clinic. The other part some in the second group went to the emergency room to be
turned away and prayed they would not exhibit symptoms since their exposure was in the countdown
timeline they also were taken care of by Dr. Mattar he made it happen. The challenges confronted were
important it indicated what needed to be refined.
Lynette Williams stated that a health advisory was sent to all the physicians and hospitals with an
example on how to write a prescription along with what was needed to be done.
Amy Fagan added in addition on the Tuesday the call was received that evening after the press release
she called all her contacts at each hospital (Kell, United Regional, Electra, Bowie) and advised them to
be aware of the potential that someone could walk in with rabies. People were making decisions on the
adorable cute puppy versus a human that was exposed to rabies they could not believe doing anything
bad to a poor puppy even though it meant five kids not getting treatment because they could not
determine a exposure was a surprise.
Dr. Carlston asked if it is a public education problem do they need to be educated for when it happens
again.
The Public Health District functions as a Local Rabies Depot the hospital did have the Depot for a while
but did not want to continue. Public Health is to provide that health, education and outreach to those
who may not have any understanding exactly like, with how something in the populous could be
communicable and how it is a responsibility to do what you can so that the rest of the populous is not
exposed so it is important to investigate. Also of importance is to get the rabies vaccine for your
domesticated animals it was discovered a lot of people did not have their animals current. When an
animal has been potentially exposed sometimes the rules change if the animal had the vaccine or not, so
people need to understand the difference. A better choice may be made because they would not have to
be euthanized or be kept in high isolation if the pet had been vaccinated.
Lou Kreidler explained if the animal had been vaccinated they would only have to be held for a 10 day
observation when not vaccinated it is 90 day isolation. They cannot be isolated at home it has to be at a
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vet office or Animal Services facility with an approximate $1,000 cost for a 90 day isolation so most
individuals are not financially able to do that.
V. PERTUSSIS UPDATE
Deborah Booher the Epidemiology Charge Nurse stated as of this summer since June 2 the area has
seen a surge in pertussis. Pertussis is a highly contagious respiratory disease found only in humans that
is caused by the Bordetella pertussis bacteria. The infection causes a violent series of coughing fits
ending in a high-pitched intake of breath that sounds like a "whoop" which gives the disease the
whopping cough name. Coughing fits can be so severe that patients may vomit, lose consciousness, or
turn blue from lack of oxygen. Most commonly it affects infants and young children it can be fatal for
infants less than a year old. Anyone of any age can develop whooping cough but the fatalities of older
children, adolescents, and adults are generally low. It affects infants 6 months or less especially those
that have not been immunized are had their full set. The best way to prevent pertussis is to get
vaccinated. Cocooning is to vaccinate those around the infant the mother, father, siblings, grandparents,
caregivers, baby sitters, day care staff which protects everybody in the end. CDC recommends pregnant
women get vaccinated around the third trimester, their partners and others in the household. Pertussis
does change about every three to four years no matter what state or social economic area. One case
later last year was an elderly woman hospitalized with pertussis 2 'h weeks after her Private Care PCP
gave her a pertussis vaccine. It has been seen this year from June 2 to August 14 there have been 14
confirmed cases in 13 children and 1 adult from 2013 to 2014 Texas saw a decrease. There had been a
3 month old up to a 34 year old woman that had no idea how she got it the children at home tested
negative she had a nagging cough went to the Doctor tested positive. In August got knowledge of a
case in Holliday, Archer City and a pair of siblings in Petrolia.
Lou Kreidler stated that a press release had been sent out and a health alert notice to all physicians that
advised of the increase in pertussis to be aware when patients come in. The woman with the nagging
cough may have been tested because of the press release and alert but a review of the dates would be
needed. Anything not in Wichita County is not in our jurisdiction so those are not counted in our numbers
at the State. Deborah was asked to keep those out of county records because what happens is the
patient physicians are in Wichita Falls which is initially reported to the Health District then we discover
where they live then those reports go back to their region. They are so close those cases are important
for comparison because of the need to know what could lend to the incidents in our entire area. Last
year with the one case of pertussis it is a huge increase for this year.
Scott Plowman asked how long does pertussis last.
Deborah Booher responded if not treated it can last from six to12 weeks. The records indicate 14 cases
in 2012, 2 cases in 2013, 1 case in 2014, and to date 14 cases confirmed in 2015.
Lou Kreidler replied an older adult with pertussis it generally is just a nagging cough that will not go away
you may feel bad for a few days when it first starts and may not realize what is going on. There had
been infants who got it from a grandparent whom said they coughed all the time but thought it was
allergies since they never felt bad. It is not as a dangerous disease in adults and in children the problem
is in the infants they do not get their first vaccination until 2 months old then get the last dose of vaccine
before they go to school so even though they are up to date they are not fully vaccinated until school
age. It really is those kids that we have to protect in relation to what Deborah was talking about
cocooning to make sure that everyone that is going to be around that child has had a vaccine or not
allow them to be around that child especially if they are sick have a cough or not feel well, to be that
person to say your ill you cannot be around my baby. It is really dangerous and it is the infants who die
from pertussis.
Deborah Booher said there are 5 vaccine doses the first at 2 months, second at 4 months, third at 6
months, fourth between 12 to 15 months, fifth at 4 to 6 years old entering prekindergarten that follows
with a booster upon Junior High School entry.
Lou Kreidler added from a recommendation that came out 2-3 years ago when an adult comes in and
needs a tetanus they are given the Tdap (Tetanus, Diphtheria, Pertussis) if they are not allergic to any of
the components so that gives them that immunity good for ten years.
VI. WEST NILE VIRUS UPDATE
Lou Kriedler provided a West Nile Virus update with some unusual occurrences. A case in a gentleman
with some underlining health issues that had encephalitis was sent to Baylor the prognosis was bad but
now back in rehab expected to go home. There have been 9 positive pools of mosquitos the
Environmental Health Department has an active mosquito surveillance program with traps set out all
around Wichita Falls. Mosquitos can fly up to 20 miles for a blood meal the positive pools are spread out
all over the city some around Fairway, Ninth Street, and the Base. Every time upon issuance of a press
release the media asks exactly what area were they identified in, but when the area is mentioned the
public reaction is it is not in our area we do not have to worry about the mosquitos. Susan Morris
advised yesterday that there are 43 species of mosquitos known of in our county with a new one
identified. There has been just one case this year, some years there have not been any the most there
has been was 5 or 6 cases. Several years ago there was one death that lived in Archer County and one
in Wichita County. Most people who get West Nile will get mild flu like symptoms recover and never
know they had West Nile. It is really dangerous in those older or with underlining health conditions those
we had in the area were in that group. We still need to follow all the precautions to protect ourselves.
VII. NEXT MEETING DATE
October 23, 2015
VIII. ADJOURN
The meeting adjourned at 1:05 pm.
SCO -H- PIDCAJIAA�
Print Name
Scott Plowman Chair Julie Gibson D. V. M., Vice -Chair, or Diane StewartR.N. Secreta
ry
Wichita Falls -Wichita County Public Health Board
City -County Board