Minutes

Southern Nevada District Board of Health Meeting
625 Shadow Lane
Las Vegas, Nevada 89106
Clemens Room

Thursday, December 13, 2007 - 8 a.m.

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

Board Members Present:

Steven Kirk Chair, Councilman, Henderson
Chris Giunchigliani Vice Chair, Commissioner, Clark County
Gary Reese Secretary, Councilman, Las Vegas
Ricki Barlow Councilman, Las Vegas
Jim Christensen, MD At-Large Member, Physician
Susan Crowley At-Large Member, Environmental Specialist
Joseph Hardy, MD At-Large Member, Physician
Tim Jones At-Large Member, Regulated Business/Industry
Mary Jo Mattocks, RN At-Large Member, Registered Nurse
Bubba Smith Councilmember, Mesquite
Lawrence Weekly Commissioner, Clark County

Absent:

Robert Eliason Councilman, North Las Vegas
Linda Strickland Councilmember, Boulder City
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
Gerri Schroder Councilwoman, Henderson Alternate
Stephanie Smith Councilwoman, North Las Vegas Alternate
Debra Toney, RN Alternate At-Large Member, Registered Nurse

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
Jimmy Vigilante Alternate At-Large Member, Regulated Business/Industry

Staff: Mike Walsh; Dennis Campbell; Rory Chetelat; Angus MacEachern; Deborah Williams; Patricia Rowley; Ann Markle; Bonnie Sorenson; Eddie Larsen; Mark Bergtholdt; Jane Shunney; Brian Labus; Sylvia Claiborne; Alice Costello; Jerry Boyd; Rose Wang; Mary Ellen Britt; Robert Newton; Keith Zupnik; 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 Valery Klaric

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 925 KB) 11/15/07
2. Approve Payroll / Overtime for Periods: 10/20/07 – 11/02/07 & 11/03/07 – 11/16/07
3. Approve Accounts Payable Registers: #1102: 11/01/07 – 11/07/07; #1103: 11/08/07 – 11/14/07; #1104: 11/15/07 – 11/29/07
4. Petition #42-07: (PDF 372 KB) Approval of New Classification Specification for Community Health Nurse I/II, Recommended Schedule 20 ($48,072 - $67,002) / Schedule 22 ($53,216 - $74,195) and Case Manager, Recommended Schedule 23 ($55,974 - $78,081)
5. Petition #43-07: (PDF 287 KB) Approval of Revised Classification Specification for Environmental Health Training Officer, Recommended Schedule 23 ($55,974 - $78,081)
6. Petition #44-07: (PDF 272 KB) Request Delegation of Authority from State Board of Health to Develop a System of Data Collection Concerning Waiting Times of Patient Transfer from Emergency Medical Services to Hospital Pursuant to Senate Bill No. 244
   
   Chair Kirk asked Dr. Sands if there were changes to the agenda. Dr. Sands confirmed there were no changes. Chair Kirk called for a motion to approve the Consent Agenda as presented.
   
   A motion was made by Member Reese to approve the Consent Agenda as presented; seconded by Member Mattocks and was unanimously approved.

II. Public Hearing / Action

1. Memorandum #33-07: (PDF 2.5 MB) Application for Approval for Abbie’s Recycling to Operate a Solid Waste Management Facility – Recycling Center, Located at 6351 Vegas Valley Drive, Las Vegas, NV 89142 (APN 161-10-701-003)
   
   Chair Kirk declared the public hearing open.
   
   Dennis Campbell, solid waste compliance manager spoke relative to this item. Mr. Campbell stated that Abbie’s Recycling has met all requirements to operate 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. David Christensen, owner and president of Abbie’s Recycling, was present to answer questions of the Board.
   
   Chair Kirk asked Mr. Christensen if he understood the conditions as outlined. Mr. Christensen responded affirmatively.
   
   Chair Kirk asked if anyone from the public wished to speak to this matter. No one came forward to speak and Chair Kirk closed the public hearing.
   
   Member Giunchigliani said that Abbie’s Recycling program was fine. She asked if there is a belief that someone may be functioning without a permit, how staff would verify that information. Mr. Campbell replied that when information is received an inspector is sent out to research what type of operation is being conducted, and if that business is operating without a permit, Solid Waste & Compliance would initiate enforcement actions against the company. Once verified a cease and desist order is given, the site is cleaned and the company would be instructed to obtain a permit. Member Giunchigliani asked how the process would be different if it were for a construction waste project and sending materials for recycling. Mr. Campbell said a facility would be designated as a materials recovery facility (MRF) if the materials are taken to a site, sorted and then taken to another disposal site. She further asked how many businesses are qualifying for the green building rebates. Mr. Campbell said the district has not been involved with the green project; our function is to determine whether or not a facility is permitted. Member Giunchigliani asked that this information be verified for any green project. Mr. Campbell said that all permitted agencies are current on the health district’s website as of yesterday.
   
   A motion was made by Member Giunchigliani to approve the application as submitted with the conditions outlined in the memorandum; seconded by Member Jones and was unanimously approved.
   

III. Report / Discussion / Action

1. Formation of Southern Nevada District Board of Health Audit Committee(PDF 741 KB)
   
   Michael Walsh, director of administration, spoke relative to this item. Mr. Walsh referenced the information in the board books from the American Institute of Certified Public Accountants (AICPA) relative to formation of audit committees, which was recommended by the audit firm. The district has purchased the toolkit, but it has yet to arrive; once it arrives copies will be available for all board members. Items of interest include the table of contents from the toolkit, such as creating a charter, assessing the potential members’ financial experience, points to consider when engaging external resources including selection of public auditors. The current contract for Stewart, Archibald & Barney has expired and the district is planning to solicit bids for the next audit period, at the direction of the audit committee if created.
   
   Staff contacted the various local entities to ascertain what is done locally in regard to audit committees. Currently only Boulder City and the City of Las Vegas have designated audit committees. The City of Las Vegas has a five-member committee appointed by the mayor. The committee, which was created in 1998, meets quarterly to review and evaluate public reports, general effectiveness of the audit program, discuss potential audit assignments, and oversee and reinforce compliance with the City’s internal audit policy.
   
   Boulder City just created their committee and detailed information was not available; however the committee will meet regularly but not less than monthly.
   
   Member Reese stated that the City employs an audit team that reviews every department and every function within the City, with a seven year cycle. The audit committee oversees the team. The auditor is a city employee working for council, and has done much to save time and money for the City.
   
   Chair Kirk verified that the audit committee provides more than financial oversight. Member Reese confirmed that the City’s audit team audits internal procedures as well as performing an audit of individual departments. Chair Kirk asked if this was the type of committee the Board and district is considering. Mr. Walsh said the type of committee would be at the Board’s pleasure. He anticipates that the toolkit will provide more information including what the AICPA’s recommendations are for an audit committee. Most documentation he reviewed pertains to publicly traded organizations, and audit committees are mandatory for these types of organizations. Mr. Walsh feels it would be helpful to make a distinction between a finance committee and an audit committee. Member Reese said the City’s audit committee is multi-tasking and oversees the audit team. Mr. Walsh stated that the district does not employ an internal audit department due to the size of the district, but it can be created if the Board so chooses.
   
   Member Jones referred to the entities that did not have audit committees and asked if it were by choice or because it had not been considered. Mr. Walsh replied that our survey was solely to see if the various entities had an audit committee; staff did not pursue additional information if an entity did not have an audit committee.
   
   Member Giunchigliani said that she intends to pursue establishing an audit committee at Clark County. She feels strongly that an audit committee is a vital component of an agency, as so many other government agencies have committees in place.
   
   Mr. Walsh indicated that Clark County has a very active and significant internal audit department which reports directly to the Commissioners. Member Jones said that typically an audit department is separate from an audit committee. Mr. Walsh said an audit department is generally employees of that organization, and they report directly to the Board or council of that agency in both private and government arenas.
   
   Member Hardy wished to clarify that if an audit committee were created it would not be a sub-committee of the Board, but rather a committee composed of both Board members and private citizens. Mr. Walsh said he believed that the audit committee would be a sub-committee and Member Hardy concurred with this statement; however interested parties could participate if desired once the audit committee determines how it would proceed.
   
   Mr. Walsh said that creating a charter at the Board level, determining the rules and instructions to provide to the committee on a go-forward basis would be the first priority.
   
   Member Hardy said he felt the Board was not ready to proceed with a charter at present; it would behoove them to appoint a sub-committee who could create recommendations for the full Board to make a charter.
   
   Member Kirk asked if the sub-committee would define the objectives of said committee. Member Hardy replied that this is what he anticipates, as well as determining likely participants. Chair Kirk said that once the toolkit is received, then the Board would hear recommendations from Dr. Sands and Mr. Walsh as to who could serve on the committee, including Board members and employees, as the Board is not aware of everyone’s experience in financial matters. Mr. Walsh said that a few members with financial experience to serve on the committee, such as the chair, would be sufficient, and the committee would have access to staff and be able to ask questions.
   
   Chair Kirk suggested that over the next month those interested in serving on the committee could contact Dr. Sands. Staff will formulate a list for the Board’s review. The Board will determine how large the committee will be, what background each person brings to the committee, and research blueprints from other organizations with audit committees. He said that this will be a progressive act over the next few months.
   
   Member Giunchigliani agreed with Chair Kirk’s suggestions and felt that January might be the time to take some action, following a review of the toolkit and survey interested participants. She asked for a delineation of audit committee roles and responsibilities from organizations with an active internal audit committee versus those without as there can be different expectations. She felt that three to five members would be sufficient, but she would like to compare that with organizations of comparable size. If the audit committee were to be a sub-committee of the Board, she would like to see if others would like to serve including employees, union representatives or outside organizations. She is interested in seeing the composition of other audit committees for the Board to review.
   
   Chair Kirk said that the proper course of action would be to gather additional information, review the toolkit and have a discussion at the January meeting to discuss appointment membership to the committee.
   
   A motion was made by Member Reese to accept Chair Kirk’s recommendation to gather additional information, review the toolkit and have discussion at the January Board of Health meeting relative to appointing members to the sub-committee; seconded by Member Giunchigliani and was unanimously approved.
   

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.

Chair Kirk invited any individuals wishing to address the Board on matters under their jurisdiction to come forward. No one came forward and Chair Kirk closed the Citizen Participation portion of the meeting.

V. Health Officer & Staff Reports

Chief Health Officer – Health Alert Network

Dr. Sands referred to a memo given to the Board members regarding the Health Alert Network (HAN). The district is participating in this effort with the Nevada State Health Division, which was developed and funded by the Centers for Disease Control (CDC). This allows staff to provide rapid information to critical partners in the event of an emergency. Currently we are recruiting staff and defining roles among staff and partners in the community. We would like to include Board members as part of the HAN. The HAN Coordinator may contact Board members for additional information in order to ensure everyone is registered in the system.

Childhood Lead Poisoning Prevention Program – Dr. Lawrence Sands, Chief Health Officer; Glenn Savage, Environmental Health Director

Dr. Sands asked Glenn Savage to join him for review of the Childhood Lead Poisoning Prevention Program (CLPPP). He would like to provide a brief overview and history of the district’s lead poisoning prevention activities which lead to the current grant program, as well as review the progress the program’s first year of the federal grant, the current direction of the program and future plans to ensure its long-term sustainability.

Lead is a toxic substance which attacks many of the body’s organs and systems. A primary concern of lead exposure is the neurological development and behavior in children. Recently CDC released new blood level guidelines indicating that there is no safe level of exposure. While higher levels can result in mental retardation, seizures, comas and death, lower levels of exposure result in loss of IQ points, learning disabilities and behavioral issues. There is no treatment for lead exposure other than chelation therapy for very high levels of exposure. The effects of lead poisoning are often irreversible. The best way to prevent lead poisoning is to practice primary prevention by finding and eliminating sources of lead exposure in the community.

A common source of lead exposure is lead-based paint, which was commonly used in homes built prior to 1978. Others sources of lead exposure are diverse and can include various means. SNHD responds to FDA issued recalls as well as recalls from other agencies. The Orange County Register began publishing information in the late 1990’s concerning lead poisoning, and developed the “Toxic Treat Poster” in 2004 which depicted examples of 112 distinct brands of imported candies containing dangerous levels of lead. This poster has been a valuable resource for environmental health staff to identify these candies in our community. This lead to a lead poisoning surveillance program in 2004 when the Office of Epidemiology received a small sub-grant from the state health division through CDC’s Environmental Public Health Tracking System Program. The funding was used to subsidize a pilot program conducted by HealthInsight to provide physician education on childhood lead poisoning and allowed the hiring of an epidemiologist to conduct surveillance on the occurrence of lead exposure in Clark County.

In 2005 collaboration between SNHD and UNLV School of Public Health commenced to test for lead in suspect product, such as candies, obtained locally which pose a threat to children. In June 2005 a grant application was submitted to the Federal Department of Housing and Urban Development to fund a lead hazard education outreach and control program to investigate the prevalence of lead contamination in homes in high-risk communities throughout Clark County. Unfortunately SNHD was not selected as a grant recipient.

In 2006 the health district applied for and was awarded a five-year grant by CDC under its Childhood Lead Poisoning Prevention Program. The grant was developed in partnership with the UNLV School of Public Health and was made available to the health district with approval of the Nevada State health Division as its bona fide agent. The overarching goal for year one was to develop an elimination plan that would lead to a comprehensive childhood lead poisoning prevention program for Clark County. At the conclusion of the grant, the expectation is that SNHD will expand the program to include the entire state of Nevada.

Program staff and partners have done a remarkable job in making progress in many areas during the first grant year, including the establishment of a Strategic Advisory Coalition (SAC) and adoption of a charter, developing and completing a plan to eliminate childhood lead poisoning as a significant risk in Clark County, developing a screening and case management plan for children under the age of six with a focus on Medicaid-eligible children, identifying potentially high-risk areas of Clark County for lead exposure hazards based on pre-1978 housing in each zip code, creating brochures and information for physicians as well as other education and outreach materials in both English and Spanish to provide to the community. The Board of Health adopted regulations in November 2006 making it mandatory to report positive blood lead level (BLL) screenings to the health district, which were subsequently adopted by the State Board of Health in December 2006. Staff were trained as lead risk assessors as well as additional training and education was provided to physicians, child care professionals and other community members to raise awareness of lead exposure and poisoning in the community.

The Nevada State Legislature issued a proclamation in 2007 and the Nevada State Medical Association passed a resolution supporting development of the program and advocating childhood lead screening, reporting of elevated levels to health authorities, and the provision of public and professional education.

Through the BLL screening initiative, more than 10,000 children aged six and younger were screened over a two-year period. This is an improvement over previous years, however, only one percent of Medicaid-eligible children in Clark County are represented in this data. Of the children tested, less than one percent demonstrated a BLL of 10 µg/dL or higher, which is when treatment is required. These results support the need for the program to place a greater emphasis on primary prevention activities focused on identifying and eliminating sources of lead in our community. While the program began as a surveillance project, it has since evolved to place an increased emphasis on environmental hazard assessment, investigation and remediation as a major focus. In recognition of this increased emphasis and to ensure the program’s long-term sustainability, management of the project was recently transferred from the office of epidemiology to the environmental health division. Dr. Sands introduced Glenn Savage, SNHD Environmental Health Director, to discuss the current status of the project and plans for its future development.

Glenn Savage stated that Environmental Health accepted management of the program in November 2007. Dr. Sands continues as the principal investigator, and involved staff finance, public information, disease investigators, epidemiologists, project coordinator, inspectors, nursing staff and clerical support. Many staff members are passionate about this program and are working to further develop the project.

HealthInsight and the Southern Nevada Area Health Education Center (AHEC) have developed online courses for physicians to understand lead exposure and poisoning prevention. UNLV School of Public Health continues to be very involved in the project and provide advocacy and data management collection groups, and perform both evaluation and research. The grant calls for establishment of various work groups including:

• Primary prevention workgroup – develops educational materials and outreach to both health care providers and community about the risk of lead exposure. Messages are directed to the at-risk populations and will available in different languages.
• Screening and case management workgroup – committed to increasing the screening rates in children less than six years of age and managing those cases of children with an elevated BLL.
• Surveillance workgroup – develops active and timely collection, storage, analysis and reporting of data.
• Legislative affairs workgroup – works to improve existing legislation, codes, ordinances and policies in an effort to eliminate childhood lead exposure as a concern throughout the state.
• Evaluation workgroup – provides ongoing evaluation of the program and assess how well information is conveyed to the community, and ensures materials are understandable and relevant.

Various state and local partners include the US EPA; Nevada Medicaid; Nevada State Health Division; WIC; Washoe County; Carson City; Clark County; the cities of Las Vegas and North Las Vegas and their code enforcement teams, building inspectors, community outreach; AHEC; Anthem Blue Cross/Blue Shield; Sierra Health Services, Nevada Health Centers, Clark County Medical Society, Catholic Charities, LUCES and the Clark County Credit Union.

Goals and objectives for the program include elimination of lead exposure as a potential health risk for children, maintaining an advisory committee, foster ongoing partnerships, expand elimination plans statewide, develop legislation for the 2009 session, increase BLL screenings, provide better case management for children, provide community education, conduct environmental investigations, offer remediation plans for those impacted by lead and share results with community partners.

In January, staff will conduct evaluations of child care facilities using XRF equipment to assess lead concerns. If lead levels are found, evaluations will be further conducted, including screening children for BLL and offer ideas to correct issues, including remediation plans. Staff is working with UNLV to offer free home lead-risk evaluations. Staff is working on development of regulations concerning sanitation and safety of rental dwellings, whether apartments or houses, and discussions are underway with the City of Las Vegas, Clark County and Henderson. SNHD is hosting the Western Regional Lead Conference in June 2008, where participants will share information regarding their lead programs and learn from one another’s successes. This will coincide with the Nevada Environmental Health Association (NvEHA) conference and inspectors will be trained in conducting healthy homes evaluations. Healthy homes evaluations include assessment of: lead, asthma, allergens, mold, insect, pest, rodents, pesticides and other toxic chemicals, environmental, tobacco, smoke, combustion byproducts, radon, asbestos, take-home hazards, unintentional injuries, uncontrolled moisture, inadequate ventilation, soil, gases other than radon, hazardous building materials, drinking water, contamination, sewage back-up, swimming pools, noise and vibration, firearms, faulty construction, pets, ozone generating appliances and food handling sanitation.

Environmental health staff will be trained and work with the community to try and help homeowners and renters and work to improve their lives. Staff is hopeful that remediation plans can be developed to raise the standards of housing to a higher level. Healthy homes is an effort to protect children and families from household health and safety issues, and staff will build upon the lead hazard control program to develop a larger scope.

Mr. Savage referenced the large media attention on lead issues, including toys, jewelry, sunglasses and most recently poker chips. This is a concern to both environmental health and the district is very involved and passionate about this program.

Member Crowley referenced a child visiting a physician and lead poisoning is recognized, and the subsequent involvement of environmental health staff. For those residing in older homes, she asked if resources are available to them. Mr. Savage indicated that the district’s Grants Research & Development Specialist is currently working to find resources, including foundations, to assist in this matter. With the existing grant we can evaluate, but additional funding sources are necessary to proceed to the next step. During evaluations, staff may find some of the sources of lead which can be removed, but other sources may not be easily identified and will require additional resources.

Member Christensen said that the signs and symptoms of lead intoxication, or elevated BLL are very difficult to recognize; it becomes a situation where a history of the patient’s socio-economic background or where he may live in order to properly diagnose the condition. Lead poisoning is so often missed that it is not recognized until a patient’s hair begins to fall out. Dr. Sands said the legislative affairs committee is looking at future legislation to identify when children need to be routinely screened for lead, and to provide more education to providers and healthcare professionals to ensure they are more sensitized to the issue and know what specifically to look for. Member Christensen said that health screenings are done on the way-side as they are unfunded mandates.

Member Jones said that we need to know exactly where the exposure occurs, be it houses, candy or toys. Perhaps the patient came from other community and has previous exposure. He expressed concern about the resources necessary to inspect homes, but recognized that the expense may yield greater results.

Mr. Savage said that home and personal remedies are another area of exposure, such as the use of heavy metals in certain cultures. Other models are being used to see if they can be applied here. A local church with a child care facility attached has peeling paint, and staff will work with the church to test the paint and try to assist the children in that particular facility. The question is raised who will pay for the BLL screening.

Member Barlow inquired as to the process for checking paint for lead. Mr. Savage said that staff uses an XRF machine which provides a range of parts per million for lead in the materials, be it paint, jewelry, etc. Samples of the objects in concern can be run through a lab, which provides a more specific analysis and determine the level of lead. Member Barlow asked about the turn around time. Mr. Savage replied that with the XRF results can be seen in as little as an hour; however lab results are dependent upon the number of samples to be run and may take several weeks.

Chair Kirk asked if the Southern Nevada Public Health Laboratory is used in this process. Mr. Savage said that outside labs are used.

Member Barlow asked for information that he can provide to his constituents who reside in older areas of the community. He expressed appreciation for staff’s current efforts, but asked how target areas can be better reached to provide information. Mr. Savage said that the first step is to build trust between citizens and government, whether through faith-based outreach and partnerships or neighborhood service. Citizens need to trust officials to enter their homes and provide assistance when needed, and demonstrate the passion we have to eradicate this problem and understand that some people are not able to pay for the remediation but provide resources that can provide assistance.

Member Barlow asked what families can do in the interim when resources are unavailable to make their homes healthy. Mr. Savage referenced the US Department of Housing website and information available for those living in homes built prior to 1978:

• Wipe down flat surfaces with a damp paper towel
• Mop smooth floors using a damp mop weekly to control dust
• Take off shoes when entering a house
• Vacuum carpets and upholstery to remove dust
• Use a vacuum with a high-efficiency collection bag
• Pick up loose paint carefully with a paper towel and discard in the trash

Simple information such as this can negate or minimize the issue. Mr. Savage recognized that staff needs to work with elected officials to make that information available to targeted areas throughout Clark County.

Member Barlow asked about using PSAs, radio spots, news and other mediums to spread the information. Mr. Savage said that he has spoken with Jennifer Sizemore about a segment for HDtv as well as other news media including foreign language stations. Member Barlow asked for the website addresses to which Mr. Savage referred.

Member Weekly expressed his disappointment over the handling of the lead program including the grant. He said that he had contacted CDC for history on the grant origin and the purpose thereof. He said that he would make the information available to other Board members. He said that he has received numerous calls from his constituents expressing their concern over the lead issues. He said he had contacted the district to receive further information and was unable to have his questions answered. He expressed concern that he has not seen any reports depicting the administration of grant dollars and how outreach is conducted in the high-risk target areas. He has not been contacted regarding outreach programs. Member Weekly thanked Mr. Savage for the information he presented.

Member Giunchigliani said she was not aware of the amount of the grant and asked where the district lists grant allocations and how the dollars are administered. She said this should be done for all grants in the district. She said the audit committee could review grants as a priority.

Mr. Walsh indicated that lists of grants have not been provided to the Board; however reporting obligations are done monthly and annually to the grantors. Progress reports are filed as requested. Member Giunchigliani replied that the Board should be aware of what grants are awarded, the term of the grants, and any charges to determine whether or not to move forward. She said that she was not aware of the lead grant until Member Weekly became involved with his constituents. Older neighborhoods are inundated with numerous problems, and once we discover the problems, how can we mitigate them. We need to explore other venues to assist with remediation.

Member Giunchigliani said that Member Weekly brought an issue forward due to a change in staffing; however the Board will not deal publicly with personnel matters. She said that an answer is necessary in how the grant came about and why the change was made. She urged staff to work with the Board to avoid this type of problem in the future. Member Giunchigliani referenced Mr. Savage’s comment about targeting childcare facilities. Mr. Savage said this could be in home or structured facilities. She suggested that group homes also be a target. Brochures should be available in languages other than English and Spanish. She referred to the Healthy Homes program and asked if this program were targeted with budget cuts. Dr. Sands said this is a federal program and is not affected by the potential cuts. She expressed concern over lack of mitigation funds and suggested that we look at creating funds for public health disasters, specifically referencing an issue involving PCE from a dry cleaning establishment in her district which affects residents’ homes, and how to provide relief when necessary. She said that we need to ensure that BLL screenings are done routinely.

Member Christensen said that there is no reimbursement for screenings as it is an unfunded mandate. Physicians try to perform screening, especially with high risk patients; however general pediatricians do not routinely screen patients for lead exposure. Member Giunchigliani asked if blood draws routinely include lead screening. Member Christensen said that it is called heavy metal screening.

Member Giunchigliani said there are additional items to explore and she expressed interest in participating in the various workgroups. She wants her constituents to understand their rights. She asked if code enforcement and building inspectors know what to look for and suggested they be involved in workgroups as well.

Member Weekly referenced Mr. Savage’s comment about building trust. Member Weekly’s radio program yielded numerous calls from concerned citizens seeking help and wanted to know how to get their homes tested. He said trust is not an issue – they want more information on how to keep their families safe.

Chair Kirk asked how many staff members are involved with the lead poisoning program. Mr. Savage said there are currently six FTEs encompassing employees from nursing, environmental health and epidemiology. It will take more dedicated staff to make a successful program. Chair Kirk asked to verify that the grant amount is $529,000 annually and if the grant is matching. Dr. Sands said there is a certain amount of in-kind which the district is able to provide. Mr. Savage said that complaints are received and investigations are conducted under the public health protection umbrella because funding is not available for everything that needs to be accomplished.

Chair Kirk expressed concern that the problem is significant and serious. Plans are to expand the program to the entire state. He feels that focus should be on certain identified neighborhoods before resources are expended in other areas. He wants to ensure that we have a good handle on the program before we move forward.

Dr. Sands said part of the elimination plan is to identify and prioritize where to concentrate as a community. This grant is typically received by a state health department; however the state designated SNHD as their bona fide agent. CDC expects that every state have a lead poisoning prevention program.

Member Barlow asked if code enforcement teams could reach out to SNHD and alert staff of plans to check conditions of various properties. Mr. Savage said we currently partner with the City of Las Vegas in inspecting various hotels, apartments and other facilities. Staff will continue to work with code enforcement and keep the communication open.

Member Christensen said to perform a quick epidemiologic study, grid it and swab it. He suggested an aggressive sampling in target areas and verify the information. A good demographic that is reliable and accurate is vital for the community.

Member Giunchigliani asked if a copy of the original grant proposal and what was approved be made available to the Board. This would help to understand the mission and what was expressed initially to qualify for the grant. She suggested monthly training for code enforcement so that health district staff would not be called out for each complaint. Mr. Savage said if inspections are coordinated, staff can use the equipment and determine if there is an issue.

Dr. Sands said that one component for the second year is home assessments, which is being coordinated by the UNLV School of Public Health. There are two methods of doing the surveillance, one of which is tracking children showing elevated BLLs; the other would be for UNLV staff to visit those areas where there are large numbers of existing homes built prior to 1978 and perform housing assessments.

Member Giunchigliani said this needs to be the primary focus. Dr. Sands said that UNLV’s focus is housing assessments. Member Christensen asked if numbers are available of children with elevated BLLs. Dr. Sands said that 25% of children screened have some detectable level of lead; however no level of lead is acceptable.

Member Jones asked if screenings were done due to illness or for other reasons. Dr. Sands said that the children were screened for various reasons; however screening is mandatory for Medicaid recipients, Nevada Checkup and Headstart programs. The screening data is not truly representative due to lack of systematic screening.

Member Barlow asked if it is possible within the grant to purchase home kits for those living in homes built prior to 1978. If kits were available for those living in targeted areas, instructions could be provided and staff could test the samples. Mr. Savage said he will explore this option with CDC. We need to show our willingness to help those in high-risk areas and he is willing to explore various manners of outreach. Member Barlow said he would like to work with Mr. Savage on obtaining home assessment kits for those living in his district.

Dr. Sands said that the initial public health tracking grant in 2004 was to provide education to increase the number of screenings performed. This continues to be a focus of the current grant to obtain a more representative sample. Chair Kirk asked if there is any way to tell where the lead exposure comes from. There is supportive data showing numerous homes where problems exist and need to see if there is a higher concentration in particular area over another. There is enough empirical data to move forward now and not wait. He stressed that staff needs to map out a way now to continue this program permanently in the event the grant is not funded after 2010.

Member Jones asked if there is a way to know where exposure occurred for those children showing elevated BLLs. We need to focus on where the exposure is occurring. Dr. Sands replied that we perform investigations when elevated BLLs are reported, but the source of exposure is not always eminent.

Member Hardy suggested that all CLPPP meetings be placed online, including the minutes, so everyone can be notified, not only for notification but education. He asked to verify that the grant cycle began in July 2006 and will end in June 2010. He asked Mr. Savage to clarify how the XRF machine operates and evaluates for lead. Mr. Savage said that samples are used for testing and is approximately $20,000 per machine. Member Hardy asked if homeowners could provide samples, such as a paint chip, in a sandwich bag and bring to the health district for testing. Mr. Savage said that soil samples and dust wipes can also be tested.

Member Jones asked if the machine details whether it is lead or lead acetate or something similar. Mr. Savage said it will define if the sample contains lead-bearing material, and may require further testing at a laboratory facility and the leachable amount coming from the sample.

Member Hardy asked to clarify that 10,000 children were screen and 2,500 tested positive for some lead exposure. A percentage of that number where those children requiring treatment, which equates to less than one percent. Dr. Sands said that with the recent change in exposure guidelines, any detectable level of lead has an impact on children’s health, development and behavior. Member Hardy said that we need to be current in all available information and educate the healthcare community. He expressed his appreciation to staff for their efforts and said that more information and education will lead to more involvement, which will ultimately lead to more protection. He said that children are exposed through ingesting the lead, not via skin contact.

Member Smith asked if any follow up had been done with the children showing elevated BLLs, including home investigation. Dr. Sands said that this is done on a prioritization basis, starting with those children showing the highest levels of lead exposure. When laboratory reports are received, they may not have enough personal information to locate the affected children. Staff exerts every effort to work with the labs and obtain the most information possible. The passage of reportable disease regulations was key in ensuring staff has the information for follow-up when needed. Member Smith suggested that we focus our attention on those areas first and try to resolve those issues. If staff is able to find that child and evaluate the home, what steps are taken at that point? Dr. Sands said that broad community partnerships are vital to have the resources available to address these issues, including remediation and have a plan that works for the community at-large.

Member Smith referenced the contaminated toys and candy and asked if we have taken measures to stop the sale of candies. He said he still sees the candy in Mesquite and the posters are displayed in medical offices. He asked if warnings can be distributed with the sale of the candy, such as the warning label on cigarettes. Dr. Sands said the toxic treat poster is three years old and the information has changed – some candies are no longer sold, the composition has changed, and newer candies are available. Mr. Savage said that a recall was done on certain candies and two candy manufacturers took offense. Staff worked with UNLV School of Public Health and the FDA to take the candy from the shelves. The result is a lower presence of these candies in the community.

Member Hardy asked if the water used in production of the candy is the source of contamination. Mr. Savage said that there were contaminated chilies in the candy, as a result of lead contaminated water feeding the plants; perhaps the chilies were dried in an area where the air was contaminated. The spoons, sticks and wrappers were also sources of lead.

Chair Kirk thanked staff for the presentation. Member Weekly also thanked staff for placing the item on the agenda and asked for a meeting with both Chair Kirk and Dr. Sands to discuss his concerns and findings.

Status of On-Line Restaurant Inspection Reports – Eddie Larsen, Information Technology Manager; Glenn Savage, Director of Environmental Health; and Michael Walsh, Director of Administration

Dr. Sands invited Glenn Savage, Michael Walsh, and Eddie Larson, information technology manager, to provide an update on the status of on-line restaurant inspection reports. Mr. Walsh said that a request was made to have the restaurant reports automated and available online in a real-time basis. The current system in use is very antiquated and does not communicate with modern software, including the web server. Staff is actively searching for a replacement product.

Mr. Larsen said that current VAX system is over twenty years old and has not been updated for codes since 1986 as the system is no longer coded. Some of the issues with VAX, though dependable, the data cannot be automated or exported. The information can be copied, but will be a manual process. Our web servers are hosted by a third-party vendor, and part of a UNIX® system. To summarize, the information from VAX must be put in a format acceptable to UNIX® and further data manipulation is necessary to convert to the website. There is a large amount of data coming from VAX, and not all pertains to restaurants. Staff would need to define the records line by line and extract the information from 200,000 to 60,000; some restaurants have multiple permits and staff would need to determine which permit to post the information to.

It is a high priority to find a newer system for this information that is windows-based and can be populated in real-time from the inspectors. Currently if an establishment is downgraded to a “C” the information would not be available on line for several days, and the letter grade can change during that time.

Chair Kirk asked how the process is currently occurring, including data and posting in the newspaper. Mr. Savage said that the report is completed by the inspector and submitted to the supervisor. Once reviewed, the paperwork is entered into the VAX and weekly a copy of downgrades is provided to the local newspaper. That information can be up to a week old at time of review and by the time the information is published in the newspaper, the establishment could be back to an “A” grade.

Mr. Walsh said in addition to investigating a new software system, we are looking at the possibility of wireless connections for the inspector to write the report and transmit directly to the internal system. If this is successful, we can place the most current data on the website. If we place information on our website now, the information is not timely and there is concern about liability if a patron becomes ill. Chair Kirk agreed that the information is not timely at present and supports having the wireless technology available.

Chair Kirk asked what the goal is and where we are headed. Mr. Walsh said it is still too early in the process to put a price on it. The product must be replaced. We need to find the right software, make sure it meets our needs, test it and install. Mr. Larsen said that with minimum data requirements by environmental health alone, there is much to accomplish. He anticipates having the project complete by the end of the summer, but cannot commit to that time frame.

Chair Kirk suggested checking with other health authorities to see what types of software and programs are used. Mr. Larsen said he has had discussions with Maricopa County to see if their product will meet our needs.

Update on Mumps Outbreak – Brian Labus, Senior Epidemiologist

Dr. Sands invited Brian Labus forward to update the Board relative to the mumps outbreak. Staff has been working on investigating suspect mumps cases for the past several weeks in a close knit social community. There have been other reports of mumps independent of that initial cluster. There is no link between the clusters at present. Outbreaks are occurring throughout the country.

Many physicians have not seen the symptoms of mumps because the number of mumps cases has declined significantly since the vaccine was made available in the 1960’s. Symptoms include swelling of the salivary glands along the cheek and jaw line, and can occur on one or both sides of the face. Staff is working to education physicians about how to diagnose and treat mumps. Testing for mumps is not conclusive either, and the best course is to treat someone symptomatic as though the patient has mumps. The vaccine is only 95% effective, which means that 5% of the population is still susceptible to infection even if the entire population is vaccinated.

Mumps is spread through respiratory transmission spread through droplet transmission, which are small, air-size droplets from the mouth. The droplets are large enough to not stay air-borne for long, and the disease is not spread as easily as influenza. Transmission occurs when people are in close contact with one another.

Part of the problem is resultant of the low vaccination rate in infants in southern Nevada. School-aged children vaccination rates are aligned with the rest of the nation as the MMR vaccination is required for school admittance. Surveillance is under-way and local physicians are being educated about mumps. If a health care provider suspects mumps, Epidemiology needs to be contacted immediately. Those symptomatic are excluded from school or work for a period of six to nine days. Surveillance will be conducted at the local school or day care center to see if there is additional spread of the disease. We are working with local laboratories so that Epidemiology is notified as soon as a test is ordered versus waiting for results which may take up to a week, and staff is able to begin intervention immediately.

We are working to find all cases in the community and keep infected individuals home to avoid spread of the disease. We are working to educate the community and promote vaccination. There is no source identified at present. Mumps has not been eradicated yet and can occur, even with vaccination.

Member Jones referenced the outbreak in Iowa last year and asked if the outbreaks included adults with a second infection. Mr. Labus said that infants through older adults and did not strike one particular age group, though infections were prevalent among college-aged individuals. Most individuals born prior to 1957 have immunity to mumps; however it is recommended that all individuals get vaccinated as a precaution. Children are vaccinated beginning between twelve and fifteen months, with a booster between ages four and six; adults that have not been vaccinated can receive the immunization anytime and two doses are required four or more weeks apart.

Member Jones asked if a secondary inoculation is needed if someone were vaccinated as a child. Mr. Labus said that immunization records are necessary to demonstrate vaccination; if a record cannot be produced a full series is recommended. Member Christensen said that updated adult vaccination guidelines were made available last week.

Mr. Labus said that it is expected that most of the cases in an outbreak will occur among vaccinated individuals, not because the vaccine is ineffective but due to low vaccination rates. Vaccinations are not perfect.

Member Hardy asked about side effects of the vaccine. Dr. Sands replied that side effects are minor and include redness and soreness. As the vaccine is a combination of measles, mumps and rubella side effects can be from any of the vaccine components. It is not possible to receive the mumps vaccination by itself.

Member Christensen said that mumps is often seen among those traveling to foreign countries. Mr. Labus said that other countries do have high occurrence of outbreaks. Some countries ceased administering the MMR vaccine due to concerns about autism, which have been unfounded. Eliminating the vaccine did not change the occurrence of mumps infection.

Chair Kirk thanked Mr. Labus for his report.

VI. Informational Items - DULY NOTED

VII. Adjournment

There was no further business to come before the Board. Chair Kirk mentioned that the next meeting of the Southern Nevada District Board of Health will be held January 24, 2008. Chair Kirk concluded the meeting at 9:50 a.m. and wished everyone a Merry Christmas.

SUBMITTED FOR BOARD APPROVAL

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

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