Minutes

Southern Nevada District Board of Health Meeting
625 Shadow Lane
Las Vegas, Nevada
Clemens Room

Thursday, November 15, 2007 - 8 a.m.

Vice Chair Chris Giunchigliani called the meeting of the Southern Nevada District Board of Health to order at 8:02 a.m., noted that a quorum was present and led the Pledge of Allegiance. Stephen Minagil, Legal Counsel confirmed the meeting had been noticed in accordance with Nevada’s Open Meeting Law.

Board Members Present:

Chris Giunchigliani — Vice Chair, Commissioner, Clark County
Ricki Barlow — Councilman, Las Vegas
Jim Christensen, MD — At-Large Member, Physician
Susan Crowley — At-Large Member, Environmental Specialist
Robert Eliason — Councilman, North Las Vegas
Joseph Hardy, MD — At-Large Member, Physician
Tim Jones — At-Large Member, Regulated Business/Industry
Mary Jo Mattocks, RN — At-Large Member, Registered Nurse
Gerri Schroder — Councilwoman, Henderson Alternate
Bubba Smith — Councilmember, Mesquite
Linda Strickland — Councilmember, Boulder City
Lawrence Weekly — Commissioner, Clark County

Absent:

Steven Kirk — Chair, Councilman, Henderson
Gary Reese — Secretary, Councilman, Las Vegas
Travis Chandler — Councilmember, Boulder City Alternate
Tom Collins — Commissioner, Clark County Alternate
Frank Nemec, MD — Alternate At-Large Member, Physician
John Onyema, MD — Alternate At-Large Member, Physician
Steven Ross — Councilman, Las Vegas Alternate
Stephanie Smith — Councilwoman, North Las Vegas Alternate

Executive Secretary:

Lawrence Sands, DO, MPH

Legal Counsel:

Stephen R. Minagil

Other SNHD Board of Health Members/Alternates Present:

Lonnie Empey — Alternate At-Large Member, Environmental Specialist
Debra Toney, RN — Alternate At-Large Member, Registered Nurse
Jimmy Vigilante — Alternate At-Large Member, Regulated Business/Industry

Staff: Mike Walsh; Dennis Campbell; Rory Chetelat; Angus MacEachern; Geoff Levin; Jane Shunney; Brian Labus; Sylvia Claiborne; Alice Costello; Deborah Williams; Patricia Rowley; Ann Markle; Bonnie Sorenson; Jo Alexander; Veronica Morata-Nichols; Glenn Savage; Mary Ellen Harrell; Patty O’Rourke-Langston; Gwen Osburn; Jennifer Sizemore; Stephanie Bethel; Leo Vega; Forrest Hasselbauer; Recording Secretaries: Shelli Clark and Diana Lindquist

Attendance:

I. Consent Agenda: These are matters considered to be routine by the Southern Nevada District Board of Health and may be enacted by one motion. Any item, however, may be discussed separately per Board Member request before action. Any exceptions to the Consent Agenda must be stated prior to approval.

1. Approve Minutes / Board of Health Meeting: (PDF 1.1 MB) 10/25/07
2. Approve Payroll / Overtime for Periods: 10/06/07 – 10/19/07
3. Approve Accounts Payable Registers: #1098: 10/04/07 – 10/10/07; #1099: 10/11/07 – 10/17/07; #1100: 10/18/07 – 10/24/07; #1101: 10/25/07 – 10/31/07

A motion was made by Member Mattocks to approve all consent items; seconded by Member Strickland and was unanimously approved.

II. Public Hearing / Action

1. Memorandum #34-07: (PDF 2.9 MB) Application for Approval for Desert Recycling to Operate a Solid Waste Management Facility – Recycling Center, Located at 2818 Marco Street, Las Vegas, NV 89115, (APN 140-17-612-016)
   
   Dennis Campbell, solid waste compliance manager spoke relative to this item. Mr. Campbell stated that Desert Recycling has met all requirements to function as a recycling center as specified in section 4 of the Recycling Center Regulations. At this time, staff recommends approval for this permit based on final inspection with the conditions as outlined in the memorandum. Jaime Ibarra, manager of the facility, was present to answer questions of the Board.
   
   Vice Chair Giunchigliani asked if building 18 had enough space to operate the facility. Mr. Ibarra said that the current building is 4,800 square feet, but eventually he hopes to expand to the next building within three years. Vice Chair Giunchigliani asked if the business would do single stream recycling or pick up materials from sites and sort on site. Mr. Ibarra said the materials are brought to the facility and sorting is done on site, including separation of metal and copper, which is then re-sold.
   
   Vice Chair Giunchigliani asked Mr. Ibarra if he understood the conditions as outlined. Mr. Ibarra responded affirmatively.
   
   Vice Chair Giunchigliani declared the public hearing open and asked if anyone from the public wished to speak to this matter. No one came forward to speak and Vice Chair Giunchigliani closed the public hearing.
   
   A motion was made by Member Eliason to approve the application as submitted with the conditions as outlined in the memorandum; seconded by Member Strickland and was unanimously.
   

III. Report / Discussion / Action

1. Memorandum #37-07: (PDF 463 KB) Approval of Fiscal Year 2006-2007 Audit Report by External Audit Firm Stewart, Archibald & Barney
   
   Michael Walsh, director of administration, introduced Glenn Goodnough and Ethan Kent from Stewart, Archibald & Barney, who would present the results of the audit to the Board.
   
   Ethan Kent, general manager, and Glenn Goodnough, partner, presented the audit report to the Board. Mr. Kent said that he would like to express thanks to the financial services section for their cooperation and assistance during the audit.
   
   Mr. Kent referenced page 1, paragraph 3, which reads: “In our opinion, the financial statements…present fairly, in all material respects, … the governmental activities, the business-type activities, each major fund, and the…remaining fund information of the Southern Nevada Health District, as of June 30, 2007, … in conformity with accounting principles generally accepted in the United States of America.” Mr. Kent said this was a clean opinion on the financial statements.
   
   There are two basic types of financial statements: government-wide and individual-fund. In regard to government-wide statements, total assets were $39.2 million, liabilities were $8.5 million and leaving total government-wide net assets of $30.7 million. This information was on page 16 of the report. Pages 17 and 18 show the government-wide revenues and expenses, with total government-wide revenue of $66.8 million with total government-wide expenses of $65 million, which left an increase of net assets of $2.8 million, bringing the total-government-wide net assets to $30.7 million.
   
   Page 19 shows the governmental funds financial statements, showing total assets of $24.2 million, total liability of $2.7 million, and the total governmental fund balance of $21.5 million. Page 20 displays the revenue and expenses of the governmental funds, showing total revenue of $59.9 million, total expenditures of $56.5 million, transfers out of the governmental fund of $500,000, which led to a net change in fund balance of $2.9 million, bringing the total governmental fund balance to $21.5 million.
   
   Page 65 is the independent auditor’s report on internal control and compliance on financial reporting in accordance with government auditing standards. Mr. Kent referred to the fifth paragraph, last sentence which reads: “We did not identify any deficiencies in internal control over financial reporting that we consider to be material weaknesses…” The second paragraph of page 66 reads: “We noted [a] certain matter that we reported to the management of the District is a separate letter dated November 2…” Page 67 is the independent auditor’s report on compliance with federal funds, which is the single audit report. He referenced the third paragraph which reads: “In our opinion, the District complied, in all material respects, with the requirements referred to above that are applicable to each of its major federal programs for the year ended June 30, 2007.” There were no findings for the single audit report.
   
   Mr. Kent referred to another letter, with specific notification to the Board that professional standards require notification of significant accounting policies, accounting estimates, audit adjustments, disagreements with management if any, consultations with other independent accountants if any, issues discussed prior to the attention of the independent auditors and difficulties encountered in performing the audit if any. There were none noted.
   
   Glenn Goodnough said that there was one recommendation as a result of the audit – he recommended that an audit committee of the Board of Health be established. The principle of the committee is good governance and the preservation and maintenance of that going forward. The audit committee would provide oversight of financial reporting, internal controls and auditors’ activities. Board members can participate, or external members can be hired to participate, and the committee will help the Board be involved with the audit process independent of employees of the District. This committee is not required or mandated for governmental agencies, but it makes good business sense.
   
   Vice Chair Giunchigliani referenced page 66 which states the audit does not look for compliance with Nevada Revised Statute (NRS) and asked who did ensure compliance. Mr. Kent said no instances of non-compliance were noted. She asked if an audit committee could look at this area. Mr. Goodnough said there was no specific opinion on that one piece; however an audit committee could address any risk or area they feel relevant. The audit committee meets with the auditor prior to the audit to discuss areas of concerns and what they would like to see highlighted. A closing conference is also held and items found during the audit are discussed, which may not rise to the level of reporting, but may be relevant. The auditors will continue to report directly to the Board, and keep the communication flow open. Vice Chair Giunchigliani asked if employees can participate in the committee. Mr. Goodnough said the committee can be designed as the Board feels appropriate, and employees can be invited to participate at various times of the meeting and be excused at others.
   
   Member Jones referenced the revenue and expenses of governmental programs on page 7 and noted that the environmental health revenue was slightly higher than expenses. He referenced the recently approved fee increase and asked if the audit reflected the total cost transferred to that division. Mr. Walsh said that only direct costs of the program are reflected. The mechanics of the current budget still hold and the indirect support costs are in place. The audit report does not reflect the reallocation of overhead expenses for financial statements. Member Jones asked if the future audits would show the administrative cost in the expenses. Mr. Walsh said that is left to the discretion of the auditors. Member Jones felt it was best to show this information.
   
   Vice Chair Giunchigliani said the committee could direct the auditors to include certain information in the next audit report.
   
   Member Jones referenced page 15 and health care benefits for retirees. He referred to the change in public employees’ funding and choice for agencies to fully fund retiree healthcare benefits. Vice Chair Giunchigliani said that in September 2008 all employee groups either must come fully into the state with their active members and retirees, or the retirees must stay with a local entity. Member Jones asked if affected health district employees would be a management decision or negotiated with employees directly. Vice Chair Giunchigliani said the county has developed a committee to determine the impact and see how to provide healthcare benefits for retirees.
   
   Mr. Kent said that standard disclosures in reporting can be required in the liability that do not affect the health district. This refers to GAAP 33 and 45. We record liabilities if set aside for when and if employees retire. Mr. Walsh said that there are a few options for entities, and differences relate to accruing interest and earning money on the investment. If an irrevocable trust is established, the opportunity for a higher interest rate exists. The district must start noting this on the books this year and whether we fund or not is our option; but we must show the amount of liability.
   
   Vice Chair Giunchigliani suggested this be an agenda item for the future in working with other local government entities in dealing with health insurance benefits for retirees. There are a variety of options and this would be worthwhile discussion.
   
   Member Weekly said that in Clark County staff is meeting with potential retirees and consider different options.
   
   Vice Chair Giunchigliani said that there is the potential loss of employees across the entities as this may be the only option for insurance coverage upon retirement.
   
   A motion was made by Member Weekly to approve the audit report; seconded by Member Barlow and was unanimously approved.
   
   
2. Municipality Briefings Regarding Proposed New Main Facility – Status Report and Direction to Staff
   
   Dr. Sands and Michael Walsh met with each jurisdiction’s city manager over the last month, as well as the mayor of Mesquite, to discuss the plan presented here previously regarding a new main facility. Mr. Walsh said that each manager was given a copy of the presentation that Board members received from PGAL. Everyone was very receptive and understood the issues related to keeping our current building operational, including the importance of public health in the community. Each entity is facing the same situation with lower taxes and modifications to their respective budgets.
   
   There wasn’t any offering of monetary assistance; however partnerships were discussed where building space could be provided and we could provide staff to bring services to the community. This discussion was held in Mesquite and Tim Hacker, the city manager, is looking into this option. Mesquite is very interested in environmental health services. The district would also like to set up space for nursing and health cards, similar to the Laughlin design.
   
   Mr. Walsh stated that we are migrating to a PC-based testing method for health cards, versus the movie. Once this is implemented, applicants can apply in the office directly and large facilities will not be needed for viewing the movie. We have been working with Wynn Resorts to develop this new testing procedure.
   
   Vice Chair clarified that no jurisdiction was willing to offer monies to assist in building the new facility. Mr. Walsh said that North Las Vegas is looking to replace the City Hall building, and he asked about using that old space, however it has already been allocated for other services. We will continue to explore other opportunities and partnerships. If we are able to save general funds by having partnerships, we can devote more general funds to covering capital expenses, including the off set of county bonds. In this scenario, the county would need to expend the monies up front, but as tax revenues increase, we would be able to reimburse the county – this would be over a period of twenty-five years.
   
   Mr. Walsh said that another option would be to scale back the size of the facility or decentralizing, which we are beginning to do with various leases, however both scenarios require considerable capital money. We do not need to purchase land to build on the Shadow Lane property, as it is owned by the county.
   
   Mr. Walsh said he plans to meet with Virginia Valentine and share the information given to the Board. He will ask for her advice on how to proceed, which may include going before the Board of County Commissioners again in the future.
   
   Member Weekly said the bottom line is how important this project is to everyone. It is very important to Clark County. He said in looking at how the County handled the problem with UMC, projects in each district had to be looked at and prioritized, including putting some aside for the time being in order to fund more pressing issues. He said that UMC is very important, and it’s the same with the health district. If something were to happen, the health district is a first responder, and many people do not realize this or how important this response can be. He said that some spokespersons will need to come forward and state how important this project is, whether one of the municipalities or a rural area, and we need to determine who the real players are. He said that Clark County will not shoulder this financial burden by itself – everyone has to pitch in and do their part.
   
   Mr. Walsh said that each entity sees the tremendous value of the health district and the services provided. Member Weekly said he knows how it works, and that everyone looks at their budgets; however everyone becomes very territorial when looking at individual districts and it looks good when elected officials can claim certain projects as their own. Everyone wants to provide quality services to their constituents, when it’s a service like the health district that is important to the entire community, we need to decide whether it’s more important to provide a new park or save a person’s life.
   
   Vice Chair Giunchigliani said that trying to come up with the capital should be part of the conversation with county management, including potential for interlocal agreements for assistance. This district belongs to everyone, not just Clark County. Capital costs are being sought, not operating costs.
   
   Mr. Walsh said that the Board could provide direction, including meeting with county management and providing a summation. Member Weekly said that Chair Kirk, Vice Chair Giunchigliani or any other Board member who is willing, to meet with the cities and county and stress the importance of making monies available from each individual budget.
   
   Vice Chair Giunchigliani said that in meeting with county management, to ask what Board members would like to be involved and work with their local governments to explore other interlocal means to get some sort of financial assistance, even if it’s not this year. She would like to see development of partnerships, veering away from the isolation technique and working for the entire county.
   

IV. Citizen Participation:

Citizen participation is a period devoted to comments by the general public about matters relevant to the Board's jurisdiction. Items raised under this portion of the Agenda cannot be acted upon by the Board of Health until the notice provisions of Nevada's Open Meeting Law have been complied with. Therefore, no vote may be taken on a matter not listed on the posted agenda and any action on such items will have to be considered at a subsequent meeting.

Vice Chair Giunchigliani invited any individuals wishing to address the Board on matters under their jurisdiction to come forward.

Member Weekly asked for an agenda item regarding the childhood lead poisoning prevention program and hear from Dr. Sands regarding the direction of this program. He is extremely concerned about a situation which occurred recently. Vice Chair Giunchigliani verified that this item would be placed on the December agenda, including the grant, how the funding is allocated and how the program started and how it is intended to conclude.

Vice Chair Giunchigliani also asked for an agenda item to discuss the creation of an audit committee.

There were no further comments and Vice Chair Giunchigliani closed this portion of the agenda.

V. Health Officer & Staff Reports

Chief Health Officer

Dr. Sands reminded Board members of the holiday/service awards dinner, and all members received invitations. He asked those interested to submit their RSVP to Shelli as soon as possible.

This past week marked the first anniversary of the passage of the Nevada Clean Indoor Air Act (NCIAA). There have been promos on the radio and sound clips on our website from community interviews done at the Bite of Las Vegas event. The clips are community members discussing how the NCIAA has benefited their lives. Today is also the annual Great American Smoke-out, and staff has been working not only on lessening exposure to second-hand smoke but to promote smoking cessation. Staff has developed various partnerships throughout the healthcare community to provide brief interventions as part of an office visit.

Member Hardy asked if dates had been established for public workshops concerning the NCIAA regulations. Stephen Minagil, legal counsel, stated that we are nearing completion of the draft regulations among staff. There have been productive meetings with Washoe County, Carson City and the state health division. Everyone is in agreement with developing issues and how guidelines and regulations should be done. Next week the draft will be sent to all government agencies for final revisions then public workshops will be established throughout the state, not just Clark County, as the state has indicated they wish to take the lead and present the regulations to the State Board of Health. If everyone is in agreement, state-wide regulations will be developed.

Member Hardy asked if the Board can get a copy of the regulations when they are ready to be sent for review. Mr. Minagil said he will make them available.

Member Crowley said that many Board members have an interest in the regulations and may attend the workshops. She asked what would happen if a quorum is established at a workshop. Mr. Minagil said they would be coming as individuals and not deliberating on a given issue, and not taking action. Dr. Sands said that each local health authority would be involved with sponsoring workshops across the state, including evening workshops so that everyone can participate.

Member Hardy again asked about the likelihood of a quorum at a workshop and actual participation in the conversation as there may be discomfort in listening versus participation. He asked for clarification for the Board’s role in the discussions. Mr. Minagil said he would be prepared for this situation and advise members accordingly when it should occur. Vice Chair Giunchigliani said that some people are very passionate about this issue and there is a fine line that shouldn’t be crossed. Mr. Minagil said that any deliberation or action must be agendized and in an open forum. Member Hardy said that it may be wise to agendize this discussion so that if Board members attend the workshops, they can participate and alert the public that this discussion could take place.

Methicillin Resistant Staphylococcus Aureus (MRSA) Update – Brian Labus, Senior Epidemiologist

Dr. Sands said that due to the amount of media coverage, he invited Brian Labus to update the Board relative to Methicillin Resistant Staphylococcus Aureus (MRSA) in the community. This is not a new issue – it is something we’ve bee tracking for some time.

Member Hardy asked if the presentation (attachment #1 PDF 2.2 MB) could be made available on CD for Board members.

Mr. Labus said the media is reporting an outbreak of MRSA in the community, but it is better termed as an outbreak of MRSA-related media coverage. There is no change in situation related to MRSA itself – it is a change in public awareness. The disease has not changed, there are just more people talking about the disease.

Staphylococcus aureus is a very common bacteria, carried by approximately one third of people on their skin. Some bacteria have developed resistance to different antibiotics. MRSA refers to a Staphylococcus aureus bacterium that has a resistance to an antibiotic called methicillin. One percent of people carry this bacteria on their skin, making it a common organism in the community. It can be treated with antibiotics, however as more resistance is added, treatment is more difficult and therefore more expensive, including longer treatment regimens.

This is a communicable disease, and coming into contact with infected individuals can spread the bacteria. Good prevention is the best protection against contraction.

MRSA generally presents as a skin infection, and most individuals do not seek medical treatment. Most cases are treated in the community due to the mild nature of the infection. However more severe cases may require hospitalization due to a subsequent blood borne infection or serious infection of a wound. The Centers for Disease Control and Prevention (CDC) estimate that 100,000 cases of serious evasive MRSA occur annually, with 20,000 of those resulting in death. People in Southern Nevada die weekly as a result of MRSA; hospitalization occurs constantly and is a major issue for each hospital. Recent media coverage surrounds invasive MRSA infections, not the mild infections, but serious infections where hospitalization is necessary.

There are different strains of MRSA with the same acronym, which adds to confusion as well. There are both community and hospital associated strains, CA-MRSA or HA-MRSA, and the acronyms also refer to community or hospital acquired strains. Strains can be common to hospitals, where patients acquire in the hospital then transmit to the community; strains can be seen only in the community then transmitted in a hospital setting. Sorting the true source of the strain can be very difficult and takes more advanced genetic testing. There are two different overlapping diseases and two different types of transmission settings.

Vice Chair Giunchigliani asked if the general term of “staph infection” is the same type of infection. Mr. Labus said it can be, or it can be a strain from the community that was present on a nurse or circulating in the hospital itself. SNHD only tracks infection based on laboratory confirmed numbers of infections because the more detailed information is not available. Member Christensen said that patients from high-risk groups are now screened and isolated at time of admission to avoid transmission.

Mr. Labus referred to the county-wide Antibiogram, which lists all bacteria commonly seen and antibiotics commonly used. In 2005-06 there were 29,000 reported staph infections and almost all were tested for sensitivity to Oxocillin, which is used for Methicillin – 42% of those were sensitive, which means 58% of the cases seen as staph infections were in actuality MRSA infections. There were over 16,000 MRSA cases reported in a two-year period. There has been discussion about making MRSA a reportable disease where physicians would need to report every single case. If a report comes in, staff must conduct interviews which are generally non-conclusive due to the number of factors involved. MRSA is under surveillance, but not in the same manner as other infectious diseases. Staff tracks MRSA and looks for trends and what is occurring; however making it reportable could in fact harm public health as the work involved would not be productive. The voluntary systems currently in place are working well and allowing staff to gather necessary information. There are actually tens of thousands of infections occurring annually, but only a small percentage are serious enough to require testing, which is then reported as MRSA.

Regardless of knowledge of infections in schools, hospitals or other settings, the same precautions must be followed at all times. Identification of one case in a school setting does not warrant closure of the school. Ongoing cleaning and steps must be taken to prevent future occurrences.

Due to the media coverage of MRSA, there has been a surge in Google searches on the Internet in recent weeks. The community wants to know what is going on with MRSA.

MRSA is transmitted by skin-to-skin contact. In addition, shared items can also be a source of transmission, such as gym equipment, towels and bars of soap. Prevention steps include proper hand-washing. Hospitals take different steps, but in the community hand-washing is the best defense. Proper cleaning of gym equipment and locker rooms to remove bacteria can also prevent transmission. Member Jones asked if there were anything different in the hospitality area. Mr. Labus said that most cleaning products do kill MRSA. If resorts are taking precautions against Norovirus, which is a more difficult organism to kill, MRSA and other organisms will likely be destroyed. There was discussion of the hygiene hypothesis; rates of certain diseases can increase as sanitation improves because of exposure to different pathogens at different times during a person’s life.

MRSA was first identified in 1961. Antibiotic resistance is a result of the natural evolution of any bacteria. The community is encouraged to visit their physicians and allow medical professionals to determine when and what types of antibiotics are appropriate. Antibiotics are inappropriate for viral infections. When antibiotics are prescribed for a bacterial infection, patients must take the full course and not stop treatment once feeling better. Antibiotics should not be shared with others. Following these steps also helps stop the spread of resistance.

Vice Chair Giunchigliani inquired as to the proper disposal of medications. Dr. Sands said that this issue has arisen a number of times. It is not recommended to flush unused medications down the toilet. Proper disposal methods include packaging the medicine and disposing of it with toxic waste; another method is to securely package the medications so that tampering cannot occur and dispose of the package with the garbage. Vice Chair Giunchigliani asked if this was incorporated into the general education provided by the District. Dr. Sands indicated this has been discussed and is under consideration for inclusion.

Mr. Labus said that certain areas have developed an “antibiotic round-up” where people can come and dispose of medications. Another concern is that medications can lose their effectiveness over time, or can break down into toxic compounds that can cause further problems. Awareness is not just about antibiotics, but any medication in general. Vice Chair Giunchigliani referred to Republic Services’ contract to provide a drop-off location four times a year for toxic waste disposal. She asked to clarify that this would be the place to dispose of medications. Dr. Sands said that this is a satisfactory option.

Member Crowley said that businesses are beginning to set up sanitization stations and asked if the health district made these stations available to the public. Dr. Sands replied that several stations are available for employees. Member Crowley said this would be a wonderful addition in public areas to stress the need for cleanliness. Mr. Labus said that hand sanitizers should not replace proper hand-washing techniques, as the sanitizers do not eliminate all organisms present on the skin. Hand sanitizers can be used as a supplement to hand-washing, and in times when soap and water are not present. Member Crowley suggested that having the stations available at the entrance and exit to the building, as well as the entrance to the Clemens Room as hand-washing facilities are not available – these areas are busy public areas. Dr. Sands said that staff will look into this.

Member Barlow said he had read an article that the hand sanitizers do not work as well as originally thought, especially with contagions. Mr. Labus confirmed this statement and said that with soap and water and contagions are washed down the drain. Alcohol hand sanitizers kill some bacteria better than viruses. This is dependent upon contact time to kill certain organisms. Hand washing is always the best option and hand sanitizers are not a substitute, but a supplement.

Member Jones said in his research, hand-washing and hand sanitizers were the best defense against Norovirus. Mr. Labus said that it is dependent upon the product used and the time duration on the hands. People are encouraged to use both methods when possible. It is important for hand-washing to be down properly, in warm water rubbing the hands together for at least twenty seconds, creating friction, and to wash all matter down the drain.

Vice Chair Giunchigliani asked if the current health card movie discusses hand-washing and not substituting hand sanitizers. Ann Markle, health records manager, said that the movie addresses hand-washing techniques. Member Barlow asked when the movie was last updated; he said he received a complaint that the movie is the same as numerous years ago. Ms. Markle said the movie was updated three years ago. Once the kiosk testing is in place within the next year, the movie will be obsolete. The testing procedure will be updated by environmental health staff at least every six months.

Member Hardy inquired about gyms and fitness facilities and if regulations exist concerning these types of establishments. Glenn Savage, environmental health director, said that staff is looking to incorporate health club regulations with the massage parlor regulations currently under development. Currently staff inspects pools and spas at the facilities and looks at the other areas, but there is nothing specific at present. Committees are working to develop the regulations. The Las Vegas Metropolitan Police Department is part of the committee. Mr. Savage said that solid waste staff recommends triple bagging medications and placing in a coffee can for disposal. This helps to eliminate salvaging, and if the landfills are functioning properly, any material that may escape containment will be taken care of by the landfill process.

Vice Chair Giunchigliani suggested that this information be incorporated into our community outreach education. She also suggested including the information on channels 2 and 4, or public service announcements. Mr. Savage recommended a segment on HDtv. Mr. Savage said that Republic Services has a medical waste facility in the community and staff will contact them regarding this matter.

Member Schroder asked how to recognize the signs of MRSA. She asked if it could be something on the skin that someone scratches and it could get worse and become an open infection. Mr. Labus said that it starts as a mild infection than migrates deeper and spreads out. Staff recommends that medical attention be sought if the infection gets worse, becomes hot to the touch, begins to drain or becomes painful. She asked if the symptoms persist for a long period of time, or come and go, if this is indicative of a MRSA infection. Mr. Labus said that this is indicative of an under-lying problem, not necessarily related to an infectious disease and medical care is needed. She also asked how to determine the seriousness of the MRSA infection and if quarantine is necessary. Mr. Labus said that this is up to the medical provider and the potential spread of the infection and if it could become life threatening.

Member Strickland asked if someone has had MRSA and been treated, is that person more prone to re-infection. Mr. Labus said there is no immunity to MRSA infections and a person is just as susceptible to reoccurrence as someone who has not had the infection. Treatment is generally with an antibiotic which will destroy the bacteria; however if it is present in the home, reoccurrence can occur. Member Christensen said that re-infection rate is higher in the hospitals; infected patients are treated until cultures are clear, they are then discharged, but can come back because the bacteria is present in the hospital. Infection control staff are doing more inspections throughout hospitals to ensure proper sanitization and hand-washing is occurring. Member Strickland referenced the photos in the presentation and asked if a minor infection is treated if the physician would advise the patient that it was a MRSA infection. Member Christensen said the only way to diagnose MRSA is to perform a culture. Physicians should discuss isolation techniques, proper cleansing in the home, getting the patients on appropriate antibiotics, and learn the entry point once the infection has cleared. Mr. Labus said that problems occur when patients go through a quick care type of facility, and patients may not learn the culture results which take three to four days to develop. Member Christensen said that call-back mechanisms should be used, but are not always followed.

Vice Chair Giunchigliani asked how to differentiate between a MRSA infection, herpes or encephalitis. Mr. Labus said that different diseases cause skin infections, and that is why a physician should be consulted. Dr. Sands said that infections causing pain or extreme redness should be treated by a physician.

Immunization Exemptions – Veronica Morata-Nichols, Public Health Nurse Manager and Bonnie Sorenson, Director of Clinics & Nursing Services

Dr. Sands said that the media has also covered stories of immunization exemptions recently, and staff is developing a policy for this matter as a number of people seeking exemptions come through the office. Staff would like to ensure clients are properly educated before seeking an exemption from immunizations. Veronica Morata-Nichols and Bonnie Sorenson presented information to the Board concerning the immunization exemption education course under development (attachment #2 PDF 743 KB).

Ms. Sorenson said she and Ms. Morata-Nichols had the opportunity to attend the National Immunization Grantee meeting last week, and the number of people seeking exemptions nationally is escalating. The time is right to develop an education program to ensure clients are making informed decisions. There continues to be a belief that immunizations contribute to the occurrence of autism in children, as well as other misinformation. We are not denying clients exemptions – staff are helping clients to make informed decisions. Staff will keep statistics to see how many clients participate in the classes and make different decisions regarding exemptions.

Ms. Morata-Nichols said that immunizations protect individuals against acute and chronic infectious diseases. Some newer vaccinations help prevent against certain types of cancer, such as hepatitis B which leads to liver cancer and Gardasil, or Human Papillomavirus vaccine, which protects against HPV. In addition to the society and economic costs of vaccines, there are morbidity and pre-mature deaths resulting from various vaccine-preventable diseases. There are currently thirteen vaccines available for children, and by the time they reach adulthood, seventeen vaccines are available. As most are combination vaccines, the actual number of available vaccines is higher.

There are several exemptions in place at this time and each exemption sought is reviewed individually. There are between ten and thirty clients seeking exemptions on a monthly basis. Ten of these clients are referred to Dr. Sands’ office for final consideration of the exemption. Approximately six of these ten are actually granted exemptions. Member Christensen said that individual providers also exempt patients from vaccinations so the number of exemptions granted is much higher. This is becoming a national problem and solutions are being sought.

The exemption education program was developed to ensure that clients can make educated and well-informed decisions whether or not to be immunized. Once the policy has been signed and the program is unfolded, clients seeking exemptions will receive an educational packet and there is one for adults and one specific for childhood immunizations. Ms. Morata-Nichols shared a portion of the educational video which clients will view (attachment #3 PDF 15 KB), which provides detailed information about vaccine-preventable diseases and which also portrayed a child having a coughing spell as a result of pertussis.

Member Jones inquired about the vaccination program in effect for college students. Ms. Morata-Nichols indicated that an update will be provided at the December Board of Health meeting regarding new mandates, including vaccination for meningococcal disease. This will be required for those students living in dormitories. The law is pending signature. The Immunization Coalition supported this bill. Once passed, the bill went before the State Board of Health, the Legislative Council Bureau, and finally to the Secretary of State for signature.

Vice Chair Giunchigliani clarified that the State Board of Health and/or the Legislature determines what immunizations are required in the state, but local health authorities can augment the requirements. She further asked who is allowed to provide exemptions. Dr. Sands said that he is authorized to exempt clients from vaccinations, as are individual physicians. There are only two types of exemptions available in Nevada, those being for medical reasons, which must be verified by the client’s personal physician, and religious beliefs, for which there are no documents required. The majority of requests coming through Dr. Sands’ office are based on religious beliefs. Ms. Sorenson said that in some states clients can seek personal exemptions.

Vice Chair Giunchigliani asked if personal physicians are required to track exemptions. Member Christensen said that letters are provided to clients when needed for school enrollment. Dr. Sands said a number of pediatricians have adopted a practice that patients are only accepted if they agreed to immunization. She further asked if the health district is notified when individual physicians grant exemptions. Dr. Sands said that this information is not shared with the health district.

Member Christensen said this information is retained by the school district. Vice Chair Giunchigliani suggested that the school district submit quarterly lists be submitted to the health district for our own records. Dr. Sands said that we receive an annual survey sent by the State listing the number of exemptions on file.

Member Christensen commented that for conscientious objectors no amount of education will change their opinions regarding immunizations. Vice Chair Giunchigliani said that she has seen no research supporting immunizations leading to autism in children. Ms. Sorenson said that removing thimerosal from vaccines showed no difference in the numbers of children with autism.

Vice Chair Giunchigliani asked if there is in-take screening at Child Haven to determine vaccination status. Ms. Morata-Nichols said that Vaccines for Children (VFC) coordinator goes to Child Haven and assesses each child’s immunization level .The immunization rates are low at this time, but staff is working with Child Haven to improve their rates.

Ms. Sorenson said that this further supports the needs for an immunization registry to know what immunizations a given child has received. Currently the registry is on hold due to the current budget situation.

Member Hardy said that he had heard differently. Member Hardy said that the people seeking exemptions are low compared to the at-risk population which typically has a lower immunization rate. Ms. Sorenson said that the immunization survey was a “snap-shot in time” for children under twenty-four months of age. Staff sees many children receiving vaccinations at twenty-seven to thirty-two months, missing the cut-off for the survey. By the time of school entrance, Clark County’s immunization rates are consistent with national levels. Ms. Morata-Nichols said that staff is working with providers and various national programs, including Every Child by Two, to continue improving immunization rates. The immunization registry is vital to success. Ms. Sorenson pointed out that in the future, all national immunization surveys (NIS) will be done via registries. Member Christensen said that funding is contingent upon improvement of immunization rates.

Member Hardy indicated that the issue of exemption/non-exemption was discussed in the Interim Finance Committee. He suggested that individuals express their concerns. It was also suggested that Dr. Sands prepare a letter on behalf of the Board of Health to show support for the registry.

Member Schroder referred to the questionnaire in the pamphlet and expressed concern over some of the reasons listed for clients declining vaccinations. She asked how staff deals with clients who are adamant that no vaccinations be given to their children. Ms. Sorenson said that several of our nurses are skilled at speaking with the clients and helping to remove the barriers. Some people do not care to be educated and will not listen, and some are very emotional about the subject as well. Ms. Sorenson explained that children with exemptions are excluded from school during an outbreak of a vaccine-preventable disease until the incubation period is over.

Dr. Sands said there are numerous groups in the community appearing to be very credible, and have been very successful lobbying in Washington regarding compulsory immunization. It’s not just about personal beliefs in immunization – it is also a person’s right to choose. There are numerous outlets promoting how vaccinations can harm an individual to how a vaccination infringes on personal freedoms. This is a public health issue about a social contract, to be able to ensure the health of the community everyone must accept that though there may be little risk for most individuals, some may suffer some of the risks. There is risk with any procedure, which can be either temporary or permanent, but that is part of the contract – in order to protect the community, the individual aspect takes a secondary position.

Ms. Morata-Nichols said that the, hope for the program is that for those seeking exemptions, either for themselves or their children, will see the harm the diseases inflict. She said that the volunteers who perform call-backs for immunization reminders were very young and did not know what some of the vaccine preventable diseases were, but were able to relate to Chicken Pox as this is one of the most recent vaccines. It is very easy to get an exemption, and the program will provide education to ensure the client makes an informed decision.

Dr. Sands said that all clients will receive vaccination education, not just those seeking exemptions. The same education will be available for everyone. By so doing, the community will understand the importance of vaccination and why it is recommended, including any potential risks associated with each vaccine.

Vice Chair Giunchigliani asked if autism information will be included, as many still believe there is a connection between autism and vaccinations. Ms. Morata-Nichols said that information will be included. She also said that flu shots are still available for those who have not received the vaccination yet.

Member Barlow said that he has heard that by getting a flu shot one is more susceptible to getting the flu. Dr. Sands said that the vaccine reduces a person’s risk for getting the strain of flu circulating in the community. It provides good protection, and even if a person does get the flu, the symptoms and duration of illness are minimized.

Vice Chair Giunchigliani asked if adults who have not had chicken pox should be vaccinated. Dr. Sands said that Varivax can be given to adults, and will help with shingles prevention. For adults over the age of 50, Zostavax is available to help prevent shingles. By immunizing the population, the risk of transmission of chicken pox in the community is lessened, including for those who have not been immunized or have not had the virus.

Member Eliason said that as a child his siblings had the chicken pox, and his own children also have the virus, and he has never had the chicken pox. Dr. Sands recommended that he have his immune status checked, as he has been exposed and not had the infection. Member Barlow said he is in the same situation, and it was stated that he should also have his immunity checked.

Dr. Sands reminded the Board members of the Thanksgiving luncheon at 11am this morning, and extended an invitation for them to attend. A food drive is also being conducted.

Vice Chair Giunchigliani wished everyone a happy and safe holiday.

VI. Informational Items - Duly Noted

VII. Adjournment

There being no further business to come before the Board, Vice Chair Giunchigliani adjourned the meeting at 9:42 a.m.

SUBMITTED FOR BOARD APPROVAL

Lawrence Sands, DO, MPH, Chief Health Officer
Executive Secretary

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