Minutes

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

Thursday, February 28, 2008 - 8 a.m.

Chair Steven Kirk called the meeting of the Southern Nevada District Board of Health to order at 8:05 a.m. Stephen Minagil, Legal Counsel confirmed the meeting had been noticed in accordance with Nevada’s Open Meeting Law and that a quorum was present. Chair Kirk led the Pledge of Allegiance.

Board Members Present:

Steven Kirk — Chair, Councilman, Henderson
Ricki Barlow — Councilman, Las Vegas
Travis Chandler — Councilmember, Boulder City Alternate
Jim Christensen, MD — At-Large Member, Physician
Susan Crowley — At-Large Member, Environmental Specialist
Robert Eliason — Councilman, North Las Vegas
Chris Giunchigliani — Vice Chair, Commissioner, Clark County
Timothy Jones — At-Large Member, Regulated Business/Industry
Mary Jo Mattocks, RN — At-Large Member, Registered Nurse
Gary Reese — Secretary, Councilman, Las Vegas
Robert “Bubba” Smith — Councilmember, Mesquite
Lawrence Weekly — Commissioner, Clark County

Absent:

John Onyema, MD — Alternate At-Large Member, Physician
Tom Collins — Commissioner, Clark County Alternate
Joseph Hardy, MD — At-Large Member, Physician
Frank Nemec, MD — Alternate At-Large Member, Physician
Steven Ross — Councilman, Las Vegas Alternate
Gerri Schroder — Councilwoman, Henderson Alternate
Stephanie Smith — Councilwoman, North Las Vegas Alternate
Linda Strickland — Councilmember, Boulder City
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: Jo Alexander; Kara Bennis; Jerry Boyd; Mary Ellen Britt; Dennis Campbell; Rory Chetelat; Sylvia Claiborne; Alice Costello; Angus MacEachern; Mary Ellen Harrell; Norma Jordan; Brian Labus; Veronica Morata-Nichols; Gwen Osburn; Patricia Rowley; Glenn Savage; Jennifer Sizemore; Jane Shunney; Bonnie Sorenson; Leo Vega; Mike Walsh; Leisa Whittum; Recording Secretary: Valery Klaric

Attendance:

Oath of Office:
Chairman Kirk reported that the oath of office would be administered by Stephen Minagil Esq., Board Legal Counsel, to Travis Chandler, Alternative Councilmember from Boulder City. After Mr. Minagil administered the oath Chair Kirk welcomed Councilman Chandler to the Board and thanked him for his service.

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 363 KB 1/24/08
2. Approve Payroll / Overtime for Periods: 12/29/07 – 1/11/08 & 1/12/08 – 1/25/08
3. Approve Accounts Payable Registers: #1110: 1/03/08– 1/09/08; #1111: 1/10/08 – 1/16/08; #1112: 1/17/08 – 1/23/08; #1112: 1/17/08 – 1/23/08; #1113 1/24/08 – 1/30/08
4. Petition #03-08: PDF 119 KB Approval of Amendment Number 4 to Interlocal contract with Clark County on Behalf of Clark County Social Service for carry over funding approval through February 29, 2008 and extension of the Agreement through February 28, 2009 to Provide Ryan White Part A Services (formerly Ryan White Title I Services)
5. Petition #07-08: PDF 1.1 MB Approval of Revision of District Administrative Services Fee Schedule and Medical Procedures Fee Schedule Effective March 1, 2008
   
   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. Member Giunchigliani asked that Item 5. Petition #07-08 be set aside for discussion and clarification of the rate increases.
   
   Chair Kirk entertained a motion for approval of Items 1-4. A motion was made by Member Reese to approve the Consent Agenda as presented; seconded by Member Crowley and unanimously approved for Items 1-4.
   
   Discussion followed on Item 5. Petition #07-08 and Dr. Sands reported that the current immunization fee for one dose is $16 and the increase is for two or more doses from $20 to $25 to cover our costs for administering the immunization. The health district policy continues to waive fees for those unable to pay; those figures range from 10-20% depending on the time of the year. Requirements for the new school immunization mandates are for September with low turnout at recent clinics; increases are expected as the start of the school year approaches. Nevada Check Up covers a set fee for immunizations. Member Giunchigliani suggested tracking immunization numbers.
   
   A motion was made to approve Item 5. Petition #07-08: Revision of the District Administrative Services Fee Schedule and Medical Procedure Fee Schedule Effective March 1, 2008 by Member Giunchigliani, seconded by Member Mattocks and unanimously approved.

II. Public Hearing / Action

1. Memorandum #03-08: PDF 2 MB Application for Approval for Las Vegas Metal Recycling LLC to Modify an Existing Solid Waste Management Recycling Permit, Located at 5001 Copper Sage Street, Las Vegas, NV 89115 (APN 123-32-301-013 and 123-32-301-014)
   
   Chair Kirk declared the public hearing open.
   
   Dennis Campbell, Solid Waste Compliance Manager, stated that Las Vegas Metal Recycling LLC has met all requirements to function as a recycling center as specified in section 4 of the Recycling Center Regulations. Staff recommends granting approval for this permit based on final inspection to modify their existing permit to operate the recycling center with the conditions as outlined in the memorandum.
   
   Chair Kirk asked Mr. Chuck Bailey and Mr. Tom Davis if they understood the conditions as outlined and they responded affirmatively. Las Vegas Metals Recycling, LLC occupies two parcels (APN 123-32-301-013) and 123-32-301-014) comprising approximately 4.1 acres. In response to a question asking if the facility handles complete cars they responded that they employ a full-time clerk to check titles, have a $50,000 bond posted with the DMV, conduct VIN inspections and have a waste oil handling system in place. They stated this includes an ownership and name change; the facility formerly operated as Sheer Force Demolition, Inc.
   
   Chair Kirk 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 Chair Kirk closed the public hearing.
   
   A motion was made by Member Crowley to approve the application as submitted with the conditions outlined in the memorandum; seconded by Member Giunchigliani and unanimously approved.
   
   
2. Variance Request: PDF 1 MB Variance Request to Operate a Public Bathing Place not in Compliance with the Nevada Administrative Code (NAC) 444, Public Bathing Places, NAC444.130.1; (APN #162-20-701-021)
   
   Chair Kirk declared the public hearing open.
   
   Glenn Savage, Environmental Health Director, introduced Lorraine Forston, Senior Environmental Health Specialist, who spoke relative to this item. Mr. Savage stated the variance application is to allow Lifestyles at City Center to construct a set of swimming pools that are not in compliance with the NAC listed above. These sections require an uninterrupted handhold around the full perimeter of a swimming pool and which requires the depth around the pool to be no more than 10% obstructed in total. This pool design incorporates an infinity or negative edge on one side of two of the pools, which does not provide a handhold as required and does not allow for easy egress along the infinity or negative edge. This is an issue both from the aspect of bather safety and pool cleaning. Additionally, each pool has built in planters that also obstruct the decks and this combined with the infinity edge feature brings them to the 10% allowable by regulations, specifically, 33%, 19% and 16%. In order to mitigate the potential health and safety concerns presented by non-compliance with the regulation the petitioner has agreed to the following conditions: require lifeguards during open hours and both electronic and human security during closed hours; provide elevated lifeguard chairs and stations; guarantee specific staffing when certain predetermined bather loads have been reached (mitigating the lack of proper handholds and the limited access of egress from the pools); and provide specialized training and equipment to allow for cleaning the pool and the areas of the deck obstructions. Melody Cicillo, MGM Mirage Project Manager, stated that disabled patrons can access through another portion of the deck to gain access to the actual pool and reported that plans are awaiting final approval. Each pool would be furnished with a sleeve and portable ADA compliant chair, and scuba training will be provided for cleaners to access sides of the pools. Mr. Savage stated that in accordance with the agreement the finer details of security, lifeguards and positioning will continue to be worked out. Staff recommends approval for this permit based on final inspection and recommendations stated in the memorandum.
   
   Chair Kirk asked if they read and agreed and understood the conditions as outlined and they responded affirmatively. Chair Kirk 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 Chair Kirk closed the public hearing.
   
   A motion was made by Member Weekly to approve the application as submitted with the conditions outlined in the memorandum; seconded by Member Crowley and unanimously approved. Mr. Jones recused himself from the vote as he is employed by MGM Mirage.
   

III. Report / Discussion / Action

No reports were scheduled

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 the citizen participation portion of the meeting was closed.

V. Health Officer & Staff Reports

• Sierra Health Services acquisition by United Health Group
  Dr. Sands directed attention to the second page of the press release from the Attorney General’s office regarding acquisition of Sierra Health Services by United Health Group stating that Southern Nevada Health District will be receiving $2 million in funding specifically to provide free immunizations to dependents of employees of small businesses as well as to provide home nursing visitation.
  
  
• Hepatitis C Investigation
  Dr. Sands discussed the hepatitis C investigation conducted by SNHD. He reported that close to 40,000 patients seen at the Endoscopy Center of Southern Nevada, 700 Shadow Lane, Las Vegas were notified that they may have been exposed to hepatitis or HIV. He stated it is an extremely serious situation representing a serious breach in safe injection practices. Investigations of reported cases of acute hepatitis C received in early January lead to identification of a connection with the Endoscopy Center of Southern Nevada. Brian Labus, Senior Epidemiologist, will provide details of the investigation and response plan, Jennifer Sizemore, Public Information Officer, will respond to questions about communication plans and Lisa Jones, State Bureau of Licensure and Certification, is on hand to discuss licensure and facility inspections. Dr. Sands commended the health district staff for doing a superb job in investigating, organizing and planning the response.
  
  Brian Labus, Senior Epidemiologist, presented an overview of the hepatitis C investigation. He stated that acute symptoms occur in a small percentage of people infected with the virus and can take weeks to months before they show up. The disease can result in serious liver problems such as cirrhosis or liver cancer.
  
  The cluster was initially identified on January 2, 2008 and the department policy required us to follow up on every report and interview patients. Multiple reports of acute hepatitis C infections were received from physicians treating these patients resulting in an investigation of each report by the SNHD Office of Epidemiology who called the patients and looked at data such as risk factors, symptoms and lab tests to confirm that it truly is acute hepatitis C. One question specifically asked has to do with endoscopy and medical procedures in general, based on previous in other states. Three cases of acute hepatitis C were identified and all of them reported undergoing procedures at the Endoscopy Center of Southern Nevada.
  
  Normally an average of two cases of hepatitis C is seen annually in Clark County. Three cases who had procedures were identified with two having procedures on the same day, September 21, and one on July 25. When commencing our investigation we contacted the Centers for Disease Control and Prevention due to the unordinary findings and requested that an expert from the CED be sent to assist with the investigation.
  
  The field investigation started January 9, 2008 when CDC representatives arrived taking 1-1/2 weeks to complete. Issues discovered with the disease transmission had to do with the reuse of syringes and reuse of single use vials designed for one patient and not for multiple patients. The clinic reported and we observed this as a standard practice at the clinic and records showed that supplies purchased would not serve the number of patients treated there.
  
  In response to whether this practice could be going on at other clinics Mr. Labus responded that it is something that we are concerned about. Dr. Sands stated that the only way that we would be aware of this at the health district is if we had cases of disease reported requiring us to investigate a particular center that may have cases of disease reported requiring us to investigate to identify a particular center that may have similar practices or if licensing bureau surveyors observed these practices.
  
  Lisa Jones, Bureau of Licensure and Certification, stated this concern is valid and may be a very common practice adding that they are familiar with it in facilities that they license. It is common practice for multiuse of medication bottles. Not reusing medication vials and syringes normally would be a two-fold safety measure, but the practice of reuse of these items might be occurring anywhere. She stated that she appreciated the coordinated effort focused on the event at this specific facility and illness outbreak, which shows the need for education.
  
  Brian Labus reported the transmission occurred with injection of anesthesia when they would draw a syringe of anesthesia and inject it into the patient, and if that patient infected with hepatitis C, backflow into the syringe could contaminate the needle and syringe with blood of the patient you’re injecting. If a second dose was needed for the patient the facility would discard the needle and replaced with a fresh needle resulting in a contaminated syringe with a clean needle that goes back into the vial of medication and when going back into that vial would be contaminated and used on subsequent patients, even with clean needle and syringe, it would infect those additional patients. Single use only vials and equipment are designed to protect the patient from exposure to disease and should be discarded and not reused. Safe injection practices are widely understood that reuse of syringes or needles, and if labeled for single use only, is not permitted and should not be reused for additional patients. These problems were identified in the field investigation and were brought to the attention of the clinic who complied with the findings.
  
  Review of information collected and lab results identified three additional acute hepatitis C cases from specimens tested on five of the six acute patients identified in our field investigations. One person had a procedure on July 25 and five people had procedures on September 21. Of the five on September 21, we have been able to test four of them and genetically found the virus came from the same source indicating a clear transmission from one vial to multiple patients. The patient tested that had the July 25 procedure showed a different source and a recurring problem.
  
  Review of information and details from the clinic, who indicated that none of their procedures changed and were using multi-use vials the same way since March, 2004 lead to determination that anyone was at risk as the facility used unsafe injection practices for almost 4 years. This resulted in notification of nearly 40,000 people that they were potentially exposed and recommended testing for hepatitis, hepatitis C and HIV.
  
  We approached the clinic for the list of patients, addresses and information on February 7, 2008 and received the list Friday, February 22, 2008 with 39,562 patient names and also asked for the procedure date for these patients and information provided was from the filling system, so we could not verify the list was complete. Another concern is the transient nature of the community. The mailing company used to distribute the letters has a system in place that goes to the national postal change of address database which updated over 5,000 addresses that would not have been deliverable. There are still 1,400 people for which we did not have valid addresses, so mailing alone would not be sufficient to reach everyone needing notification.
  
  Patient notification of potential exposure to these viruses yesterday, February 27, 2008, sending letters for the period from March 2004 to January 11, 2008 and a press conference was held in an attempt to reach them began February 27, 2008, sending letters for the period from March 2004 to January 11, 2008 and a press conference was held in an attempt to reach these additional people. The call center 759-INFO is provided for information and our website is also updated with information.
  
  How do we deal with this and prevent it from it from happening? Monday’s CBS Evening News reported the same situation occurring with 18 different states with outbreaks. An article in The Journal of Hepatology stated that healthcare should not be a risk factor for hepatitis C transmission and reported over 600 reported outbreaks in the literature of late with these types of practices. The practices are common worldwide, but are absolutely not acceptable. It’s making sure people do the right thing and educate clinics and facilities regarding safe injection practices. Regulation is a difficult issue because not all facilities doing injections are regulated; i.e., physician and dental offices and individual providers. A physician from the CDC summarized it by saying there is no excuse for this, it’s on the order of driving against traffic on the freeway, it’s that reckless. Brian concluded saying it is absolutely unacceptable and we need to find a way to stop it.
  
  Brian clarified the role of the Health District stating the district is involved when an outbreak is identified, and does not perform inspections or look at ongoing practices of healthcare facilities. The district investigates the outbreak when identified and determines the cause. Licensing and certification of health care facilities is done by the State of Nevada.
  
  Discussion followed at length and Board of Health members expressed outrage that these practices could occur placing the community in such grave danger as people place their trust in physicians and rely on their expertise. They were adamant that if this is a common practice it must be stopped; you cannot place a value on life. This is a failure not caused by inanimate objects, but the failure of management and personal practices of health care providers trying to save money and cut corners and putting the public at incredible risk.
  
  In response to questions as to how to reach the individuals and the nature of our transient community Dr. Sands responded that we’re looking to do everything possible to notify people through the mail, media including postings on national websites accessed by other health departments. We are trying to use every mechanism possible to reach affected people as well as look at what’s worked in other situations and are doing everything that we possibly can.
  
  Brian Labus added that the media approach is an attempt to reach those who may have moved from the area and a technical bulletin was sent to the medical community so that physicians who referred their patients can also recommend testing to them. There are resources available for patients diagnosed with hepatitis C and the health district website which lists clinics with sliding fees and low cost clinics with support groups and pharmaceutical companies that provide low cost or no cost drugs. A significant number of underinsured patients are not expected as the procedure is expensive and not typically one that you would pay for on your own if you were uninsured.
  
  Lisa Jones reported administrative sanctions do not have a provision for restitution of harm and only specify a very prescriptive method of applying a monetary penalty, but it does provide for those funds to be used for patient well being and promoting patient care; sanction funds could be available at the state level.
  
  Dr. Christensen replied to a question asking if the State Board of Health was entertaining adopting updated regulations or standards that allow this practice to be very clear stating that is already a very clear and basic practice.
  
  Lisa Jones, Bureau of Licensure and Certification, responded to questions asking if there are additional clinics associated with the Endoscopy Center responding that two additional endoscopy centers are operated by this facility; one is brand new and received their initial licensure. The second facility has been notified and concern about deficiencies will be communicated to the appropriate nursing and physician licensing boards. At the onsite visit of the second facility it was very clear that these were practices communicated by management. The recent inspection at the third facility showed they were well versed an on board with the process.
  
  Mrs. Jones reported that the bureau has two schedules of survey activity and does state licensing and is a contract agency for the centers for Medicare and Medicaid services for Medicare certification. Frequency for licensing is driven by Bureau policy because there is nothing in the law that speaks to a mandated timeframe, which has been set at three years and during the federal process it varies every year depending on the funding Congress authorizes and the priorities they want to give to different types of providers. Licensure and certification is more complaint driven. When notified by the health district they initiated their investigation.
  
  In response to questions asking if the State Board of Health will look at being more practical in these situations Lisa Jones responded that they started with inspection of sister facilities and followed with other similar facilities that may be doing a high volume and stated that additional reviews will follow. Their instruction will be to adhere to manufacturer instructions.
  
  Mr. Kirk asked about the frequency of surveys performed and the criteria followed. Lisa Jones responded that in the Bureau of Licensure and Certification there are medical facilities defined by statute and facilities the bureau oversees for Medicare certification that do not go through the licensure process or approximately 33 different types of facilities or entities.
  
  Survey schedules of the Medicare driven inspections have very prescribed requirements for annual surveys of nursing homes, every three years for the home health agency, residential facilities for adult group care facilities have a statue statutory requirement for an annual onsite inspection. The bureau struggles for staff and has 25 health facility surveyors performing field inspections throughout the state and including medical labs it is approximately 1500 providers.
  
  During 2007 the bureau reviewed over 2,600 complaints and addressed about 140 referrals for unlicensed facilities. There are differing time frames and some are complaint driven and a cursory review indicated an average of inspections at surgery centers was 4 years.
  
  Dr. Christensen stated that this behavior brings a black eye to the entire medical profession as well as a sense of personal outrage, but he added that there is a huge amount of medicine done right and the system works right 99.9% of the time. Although this results in lack of trust in physicians it is necessary to put your faith in the system and ask appropriate questions. The bottom line is that a conscious decision was made to throw out all the rules and cut corners.
  
  Board of Health Member Requests and Recommendations:
  
  
  • Commissioner Reese reported that the City Attorney and Business License Department are looking into what recourse they may have and stated that it is the duty of elected officials to ensure that this does not happen. Member Reese requested running a special message on Channel 2 in the next few weeks to reach affected people.
  • Chairman Kirk asked Dr. Sands to keep the Board informed on this matter on a regular basis.
  • Member Barlow offered to provide information at an upcoming Access City Council taping and requested a fact sheet for this purpose.
  • Member Giunchigliani suggested Chanel 4, use of public radio and public service announcements. She also suggested looking for funding for the uninsured needing retesting and contingency funds for those testing positive. She requested updates on inspection findings of the second clinic and whether there is a need for additional notification resulting from those findings and suggested that State Board of Health regulations include language for restitution and a mechanism for a funding source to assist individuals that are found when there is an outbreak of some kind of medical issue that would be recouped from companies or businesses that involved. She also recommended anonymous notification for people to report facilities.

  Dr. Sands stated that we are all devastated about the hepatitis C situation and notification right now is the most important issue to ensure people are notified and tested. It is an issue that the medical community will discuss well into the future.

• Chief Health Officer Review Committee
  Mr. Kirk reported that pursuant to the Board of Health Bylaws, he will chair the Chief Health Officer Review Committee and appointed members Mr. Weekly, Dr. Hardy and Dr. Christensen. He asked for an additional member and Member Giunchigliani volunteered. The committee will meet over the next month or two and will bring their report to the Board in March or April. Dr. Sands’ office will coordinate the meeting.

VI. Informational Items

VII. Adjournment

There was no further business to come before the Board. Chair Kirk reported that the next meeting of the Southern Nevada District Board of Health will be held March 27, 2008. The meeting adjourned at 9:55 a.m.

SUBMITTED FOR BOARD APPROVAL

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

/vjk