WC CWF Health District Board Minutes - 07/14/2017WICHITA FALLS-WICHITA COUNTY PUBLIC HEALTH BOARD MINUTES
July 14, 2017
Wichita Falls -Wichita County Public Health District
1700 Third Street - Parker Conference Room
Wichita Falls, Texas
BOARD MEMBERS PRESENT:
Julie Gibson, D.V.M., Chair
Robin Moreno, MHA-HSA, ACHE, Secretary
Scott Plowman
Larry Rains, D.D.S
BOARD MEMBERS EXCUSED ABSENCE:
David Carlston, Ph.D., Vice -Chair
Keith Williamson, M.D.
BOARD MEMBERS UNEXCUSED ABSENCE:
Kaye Knauff, DNP, RN, FNP-BC
OTHERS PRESENT:
Lou Kreidler, R.N., B.S.N.
Amy Fagan, M.P.A
Arthur J. Szczerba, M.D.
Mark Beauchamp
Eric West
Veterinarian -City
Citizen At -Large -City
Restaurant Association -City
Dentist -County
Citizen At -Large -County
Physician -City
Registered Nurse -City
Director of Health
Assistant Director of Health
Local Health Authority
County Commissioner
City Council Liaison
I. CALL TO ORDER
Dr. Julie Gibson called the Health Board meeting to order at 12:15 pm after a quorum of members was
attained.
Amy Fagan, Assistant Director introduced Patrick Mitchell the new Health District Accreditation Specialist a
good addition for the Health District with an Air Force career in media and specialty in Public Relations. He
will be able to branch out and bridge the gap between what people think the District does and what the District
actually does. Patrick has already participated in a lot of outreach events with the other staff and today being
another opportunity to learn what the District does. The expectation is to be accredited within the next year the
main focus for Patrick is to prepare the Health District documentation for upload in November. Next would be a
site visit from the Public Health Accreditation Board (PHAB) and then hopefully be accredited.
Eric West asked what benefits come from accreditation other than stature.
Amy Fagan replied that was what we asked ourselves. The PHAB took the Center for Disease Control (CDC)
10 Essential Public Health Services that CDC said all Health Departments no matter their size should
undertake and turned them into domains. Each domain has a multitude of objectives and strategies that
benefited the Health District to establish an internal core group. The internal group responsibility is to look at
the domains and the work being done to assure there is standardization and quality. Patrick as a new staff
member was asked to look at different things being done that perhaps was not being done the most effective.
As an example for about two years now the Por Vida (For Life) program recruited 22 restaurants to offer
healthy choices that the Health Coalition had Registered Dieticians review the choices. Literally it was not
being used no website traffic and only three app downloads in the last year. The quality improvement project
was presented to Patrick within a group of five to review how it was set-up, how to make the improvements,
and what work needs done to be effective and efficient. There is a lot to accreditation but the quality
improvement projects that come with it are the real wins also it is an assurance to the community that the
Health District is doing the best that can be done. No matter whether in Wichita Falls, Houston or Boston
where the Accreditation Board has been and given an Accreditation the work being done is the work that is
supposed to be done, it is easy to get off track and to do things as always done. The Health District is ready
and moving forward to do things to be a better organization.
Lou Kreidler affirmed Accreditation now is voluntary but what was told in a meeting on State funding for a grant
was the State Health Departments being accredited that the Accreditation staff would be awarded points for
grant funding so a day will come when it is not voluntary. The only Health Departments accredited in the State
are the big ones (Houston, San Antonio, Austin, Williamson County, Dallas, Tarrant County) there are not
medium sized Health departments that have been accredited it really would be great to be the first medium
sized in the State of Texas to get an Accreditation.
Amy Fagan stated that grants make up 40% of the Health District operating budget so grants are very
important.
Lou Kreidler acknowledged that grants are good they allow the Health District to do a lot more services for
people otherwise the services would not be possible.
Amy Fagan announced to the Board of two new grants the Community & Clinical Health Bridge (CCHB) and
Cancer Control Prevention. Typically the grants are a competitive bid process but the State contacted the
Health District because of the Wichita County poor health outcomes the State said if an application was made
the changes are the Health District would receive the grants. Part of the goal with the CCHB grant is to
advance into the technology age. The clinic and laboratory have converted to electronic health records and
environmental to the public health information management system. The plan is to implement all the work
already done into a Wellness Resources Database which basically would be all the community resources into
an electronic format to integrate with the electronic health records in the existing health systems. The idea is
when a patient visits a physician the office would be accessible to resources available in the community with
the ability to print and hand the information to the patient as a referral so it would be easier for the patient to
make behavioral health changes. Commitments have come in from United Regional Physician Group, Clinics
of North Texas, and Community Health Care Center/Family Health Center next is to pursue Electric Hospital
which has the Iowa Park Clinic and some other small agencies.
Lou Kreidler explained the other grant is a Cancer Control Prevention program that Wichita County has some
of the highest traits of cervical cancer and colon rectal cancer in the State of Texas. The grant will focus on
the human papillomavirus (HPV) vaccine which has been shown to prevent several strains of HPV responsible
for cervical cancer and awareness of the importance of colon rectal screening and early detection. These are
very important to the Health Department because the Lab Administrator passed away from colon rectal cancer
it hit close to home so when the grant opportunity came up it meant a lot. A close family member had cervical
cancer she had not been vaccinated and think about all the other young ladies whom are not vaccinated when
it can be preventable. The Health District will work with the physician offices to; increase the number of
screenings, assist with public awareness on when to have a screening, use the Wellness Resources Database
for the public's access to care.
11. APPROVAL OF MINUTES AND ABSENCES
Dr. Julie Gibson called for the review and approval of minutes from the meeting held on Friday May 12, 2017.
Dr. Larry Rains introduced a motion to approve the minutes as presented and Scott Plowman seconded the
motion. The motion passed unanimously.
At this time it was noted the excused absence of Dr. David Carlston, Dr. Keith Williamson, and the unexcused
absence of Kaye Knauff, RN.
111. Epidemiology (EPI) Update
Lou Kreidler provided an Epidemiology (EPI) update to inform the Board what had been going on with mumps
in the community and of an additional case of mumps since the last meeting in May. The case was at the end
of the school year in a young man that went to Hirschi High School that was linked to his mother who had
mumps initially so that was two cases. Two more cases of mumps had been linked to the young man at
Hirschi all the individuals had been at a football camp together it would be considered an outbreak. When the
cases are confirmed a press release will be sent out to inform the community of the outbreak. The Health
District has worked with the coaching staff, football students and schools at the end of the school year the
school sent out notices to all parents and students. Mumps are in the community and have been seen in
vaccinated individuals so it is under CDC investigation. The desire would be not to see any more cases but
with a 21 day incubation period there is real potential to see a continuation of mumps in the community.
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Another issue to discuss is Zika being mosquito season a Zika Task Force was organized consisting of
Nursing staff, Environmental staff, Preparedness staff, Amy Fagan and Lou Kreidler that met weekly to
establish a plan. If an individual that traveled comes up positive the Health District has a response and if an
individual did travel or had contact with someone whom traveled it would be considered a local case. Texas
had two local cases one in Brownsville the other in Houston with about 48 or 49 Zika cases a percentage of
those have been pregnant women. Currently two tests are pending coming out of Wichita Falls the one lives
in Clay County should it come back positive it will not be considered a Wichita County case it just originated
from a Wichita Falls physician office the region will handle the case. On the other one she had not traveled
her husband traveled then she became pregnant a month afterwards the possibility is there so her physician
has screened her as Zika protocol the results are not back. Most likely a positive Zika travel is going to happen
in the community the Zika Task Force worked hard to get protocols In place to be ready for when it happens.
Last year the District had a couple of travel cases that when it was known the tests had been sent off the
Nursing and Environmental staff went out for a home visit. Nursing took condoms did education about safe
sex practices it can be transmitted from partner to partner through sexual activity and the virus can live in a
man's sperm for an extended amount of time. Environmental did an environmental survey around, inside the
home, took mosquito repellant, larvicide and discussed the 5 D's. The Aedes mosquito that carries Zika does
not fly very far so if you have the mosquitoes in or around the home more than likely you are breeding them.
Mark Beauchamp asked is the Zika virus in mosquitoes kind of like it is with humans where not all mosquitoes
have it in them.
Lou Kreidler replied that is correct when someone traveled are tested for Zika what is done is to get them to
wear mosquito repellant, check around their house to check for mosquitoes it is about keeping the
communities mosquito population clean. What happens is they have traveled gone to one of the Zika infected
areas returned and does not feel real bad and has Zika then they get bitten by a mosquito that introduces Zika
into the community mosquito population.
Scott Plowman remarked if the mosquito bites you the mosquito can get Zika.
Lou Kreidler added that unlike the West Nile Virus where birds are a primary host. A bird has West Nile a
mosquito bites the bird the mosquito gets West Nile from the bird then the mosquito can transmit West Nile to
a human. if the human has West Nile the mosquito bites the human the mosquito cannot get West Nile from
the human and transmit it to another human. Zika has had a lot of focus because the public needs to be
cautious to avoid being bitten by mosquitoes to maintain a pure mosquito population none to date have been
positive.
IV. TB PROGRAM OVERVIEW
Lou Kreidler introduced Sheila Hubenka the TB Program Manager that joined the Health District a year ago to
present an overview of the TB program. Sheila Hubenka stated last year 26 individuals were treated for latent
TB infection and 2 individuals with active TB. This year as of today treating 9 patients with latent TB infection
have 2 referrals and 4 patients for active TB. The difference between latent TB and active TB infection are
individuals with latent TB cannot get other individuals sick what has happened the individual was unaware of
exposure to TB sometime in their life. TB a slow growing bacteria that takes about 8 weeks to become sick
and it might take another 8 weeks to 3 months for the Doctor to diagnose since TB mimics other things as well.
The exposure with latent TB the body has done its job it kind of walls off the bacteria to not become sick but
the TB bacteria lives on and waits for an opportunity to become active. About 1 in every 10 people that have
latent TB will become active at some time in their life. Uncontrolled diabetics are at a higher risk for the latent
TB to become active as well as immunosuppressed or rheumatoid arthritis individuals being prime candidates.
Individuals diagnosed with the latent TB infection are not sick cannot get others sick just at risk to get sick so
the TB program prefers to treat the individual while latent. Active TB individuals are sick, can be very sick,
even walk around fine but sick and can get others sick. Active TB can be anywhere in the body the most
common being the pulmonary in the lungs those individuals are usually very sick and can really get others
sick. Sometimes ft mimics cancer, other pulmonary, congested heart failure but when the sputum and x-ray
are checked it is TB, it also can be in the brain and bone. Most recently was a case in the eye it is ocular TB
very uncommon the country with the most cases of ocular TB is Japan.
What is interesting about TB to Sheila is that every case is different and she learns something every time. The
Health Department TB program only covers treatment of individuals in Wichita County the program is tasked
with finding the TB. Active TB is not hard to find the program gets notification from the Hospital or Doctor of a
person with active TB than arrangements are made to meet and get the person on the program. Latent TB is
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harder to find because most people do not think to go in and be checked for TB. Anyone can be tested that
walks into immunizations and asks to be tested for TB the cost is $20, insurance or Medicare pay for the test.
Most likely if a person does not have a reason to be tested they do not come in to be tested. The TB program
tries to do target testing in the high risk populations those individuals homeless, low income in congregated
settings with outreach at the Salvation Army, Faith Mission and Faith Refuge. Other high risk populations are
those foreign-bom that came to the United States within the last 5 years most come from endemic TB
countries unaware of a possible exposure. TB works with immigration a lot to try to get in those individuals
getting their immigration paperwork done because of the requirement to be TB tested. Also work with anyone
that has had a past positive skin test to get them tested and treatment if needed.
Scott Plowman asked if the test is the same as it used to be.
Sheila Hubenka replied no that the skin test is a single needle similar to a little bug bite under the skin and on
the targeted testing a blood test is done. The skin test is only about 75% accurate and the blood test 99%
accurate.
Lou Kreidler cited part of the reason for blood tests on the targeted testing a transit population is with the skin
test it needs to be read in 48 to 72 hours and to find them again to read is a problem.
Sheila Hubenka said the blood test results still take about 48 hours there is about an 80% chance of finding
the person again to give them their results. There still are a handful of individuals not found but Jason Wheat
in HIV Prevention works with TB to find some of the homeless individuals he knows all the tricks to find people.
Handouts were presented with the difference between latent TB infection and active tuberculosis then
informative graphics on TB. TB has always been recorded a couple of years behind due to the fact it is slow
growing and takes time to get in all the data so the most recent is 2015 data. In 2015 there were 9,557 of TB
cases reported in the United States that averages out to 1 in about every 100,000. Wichita County population
is about 132,000 in 2016 TB treated 2 cases being below the national average this year have treated 4 cases
at the national average. It has been questioned is it because TB has done a better job at finding TB or is there
more TB here it is unknown. An average active TB case gets treated 180 days of medicine that does not count
the Doctor visits, labs and x-rays, labs are done monthly, if pulmonary x-rays every 3 months.
Dr. Rains asked what the medication protocol was.
Sheila Hubenka responded that on active TB cases there is a two phase protocol the first phase called the
intensive phase or RIPE-Rifampin, Isoniazid, Pyrazinamide, Ethambutol medicines given. Anytime with
Isoniazid the B-6 is given to support the nerve system and bone marrow. All active cases are treated under
direct observed therapy which means someone in the TB program watches the client take their medicine. The
client must have 40 doses of RIPE observed 8 weeks with improvement before going on to the second stage.
All the criteria must be met for the second stage Isoniazid, Rifampin and B-6 under direct observed therapy for
the remaining 18 to 26 weeks. Along with the monthly lab work and Doctor every 30 days it is a time
consuming process to be diagnosed with active TB. Anyone diagnosed with latent TB has a 1 in 10 chance to
become active so it would be advised to take the medicine in hope to prevent becoming active later. The client
is always checked for susceptibilities to assure susceptible to the medicines used if not extensively drug
resistant.
Only 1 TB case of the total 2015 cases in the United States was extensively drug resistant with a cost of
almost a half million dollars to treat the case and 88 were multidrug resistant out of that 1 was in Wichita
County with a cost of $154,000 per case to treat. The remaining 9,468 cases typical average TB drug -
susceptible was $18,000 per case to treat. In 2014 Texas had 1,269 cases of tuberculosis these are just active
TB cases. It is not required to report latent TB cases the Health District does report latent TB cases but the
State does not figure them into the statistics just the active cases. Tuberculosis screening is very important.
Risk Factors Associated with TB Cases Reported in Texas in 2014
60.5% Foreign-bom
20.0% Diabetes
16.5% Alcohol Abuse
11.4% Prison/Jail
5.1% HIV/AIDS
4.6% Homeless
1.9% Health Care Workers
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The TB program endeavors to seek out and treat latent TB individuals because that is how to eliminate TB to
treat it when it is latent. Tuberculosis disease is only the tip of the iceberg there are two types of TB
conditions: TB disease and latent TB infection. People with TB disease are sick from active TB germs usually
have symptoms and may spread TB germs to others. People with latent TB infection do not feel sick, have no
symptoms, cannot spread TB germs to others but if the TB germs become active can develop TB disease.
Millions of people in the United States could have latent TB infection not knowing it and not being treated.
Without treatment there is a 10% risk for developing TB disease those with HIV infection or rheumatoid
arthritis are at a higher percentage risk to become active. Actual statistics on latent TB from 2015 to March
2016 is that up to 13 million people in the United States could have latent TB infection without treatment 1 in
10 become active. The difference in latent and active TB treatment is a young relatively healthy person could
do one dose for 12 weeks and be done versus the 180 days for a typical active TB patient A lot of the times
the active TB patients if drug resistant go past the 180 days on up to 2 years. Treating latent TB infections at
$500 is less costly than to treat TB disease at $17,000.
Dr. Gibson asked what the recommendations are to the general public.
Sheila Hubenka responded that $20 is a small insurance to be tested most insurances pay for it she would like
to see everybody be tested but to get everybody tested is a mammoth task.
Lou Kreidler said there used to be a requirement that hair dressers had to have a TB skin test because of their
work in close proximately to people and also school teachers but neither one of those populations are required
now. There had been some outbreaks in schools but not since she was Director of Nurses. There was a case
at Faith Mission the gentleman was homeless needing to be isolated so it was a challenge on where to place
the gentleman. Calls were made to area hotels to get a room then the ventilation was an issue because the
rooms were co -joined next to each other. It was discovered he had VA benefits but no way to get to
Oklahoma City so Lou put him into her vehicle along with the Director of Nurses at the time and drove him to
Oklahoma City so he would have a place to stay. There just was not a lot of good options which the City
generally does not transport patients but it was that or figure out where to house him until it was decided he
did not have active TB.
Dr. Gibson said it might be a good idea to have her employees tested.
Sheila Hubenka replied she thought it is a good idea for anyone to be tested as Lou said hair dressers are in
close proximity as teachers are to children and smaller day cares are not required to be tested but they should
be tested. It is a small price to pay for that knowledge you are okay and not going to give it to someone it is
being responsible to be tested.
Lou Kreidler also added that it is not a required test for those going into school either.
Sheila Hubenka said it is required for college students but students can get all the way through college and not
be treated if needed. The latent TB treatment is simple if you do not qualify for the three HPV which is the one
dose a week TB will dispense bottles of medicine to you it is either 4 or 9 months depending on which
medicine the Doctor decides to prescribe.
Lou Kreidler confirmed that the State pays for all the medication so the City's budget does not bear the cost
the Health Department has a Class C Pharmacy. When TB has an individual diagnosed the Doctor signs an
order then TB sends that information to Austin and Austin sends TB the medication.
Mark Beauchamp asked if someone is on the County Indigent Health then County does not pay for that
medication.
Lou Kreidler specified that the TB drugs and STl medications given out at the STD clinic all come from the
State of Texas. The Health Department has two small grants one is a TB -State and one a TB -Federal grant
one pays about $29,000 and the other about $32,000 and it costs the Health Department about $135,000 on
an average year to run the program that staffs three all work in other programs to maximize their time and
usage a minimal amount. So when Sheila talks about half a million dollars that is not what it cost the Health
Department or the eighteen thousand dollars for the multi -drug resistant the City does not Hear the cost of
those medications It is what it cost the State.
Dr. Gibson asked does the Health Department have Outreach where a nurse might come to a place of
business and test everybody.
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Lou Kreidler replied if you want we can set that up.
Mark Beauchamp asked if the County requires jailers to be tested.
Sheila Hubenka answered yes the jailers are tested.
Mark Beauchamp said the Indigent office has a highly susceptible population that comes in should the 6 ladies
in the office be tested.
Sheila Hubenka advised yes because of working with those in that high risk population she would be happy to
schedule it for him.
Amy Fagan announced Dr. Knauf whom recently came on the Board is moving back to North Carolina where
she comes from due to her retired military husband got a job there so the Board will have a RN vacancy to fill.
V. NEXT MEETING DATE
Friday September 8, 2017 was noted as the next meeting date.
VI. ADJOURN
Dr. Julie Gibson adjourned the meeting at 12:50 pm.
Julie Gibson, D.V.M.. Chairr, David Cartston. Ph.D. Vice -Chair. or Robin Moreno MHA-NSA ACNe Secretafy
Wichita Falls -Wichita County Pubk Healt_ h Boarr1
City -County Board