Minutes

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

Thursday, May 22, 2008 - 8 a.m.

Chair Kirk called the meeting of the Southern Nevada District Board of Health to order at 8:03 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
Ricki Barlow — Councilman, Las Vegas
Jim Christensen, MD — At-Large Member, Physician
Robert Eliason — Councilman, North Las Vegas
Lonnie Empey — Alternate 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
Linda Strickland — Councilmember, Boulder City
Lawrence Weekly — Commissioner, Clark County

Absent:

Gary Reese — Secretary, Councilman, Las Vegas
Tom Collins — Commissioner, Clark County Alternate
Susan Crowley — At-Large Member, Environmental Specialist
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

Executive Secretary:

Lawrence Sands, DO, MPH

Legal Counsel:

Stephen R. Minagil

SNHD Lobbyists:

Bryan Gresh
Gary Milliken

Other SNHD Board of Health Members/Alternates Present:

Travis Chandler — Councilmember, Boulder City Alternate
Debra Toney, RN — Alternate At-Large Member, Registered Nurse
Jimmy Vigilante — Alternate At-Large Member, Regulated Business/Industry

Staff: Mike Walsh; Angus MacEachern; Glenn Savage; Jennifer Sizemore; Bonnie Sorenson; Jo Alexander; Brenda Argueta; Mark Berghtoldt; Stephanie Bethel; Jerry Boyd; Mary Ellen Britt; Rory Chetelat; Sylvia Claiborne; Alice Costello; Kay Godby; Nelson Goo; Steve Goode; John Hammond; Mary Ellen Harrell; Forrest Hasselbauer; Nancy Hall; Garren Jakubiak; Brian Labus; Ann Markle; Mike Neszmery; Veronica Morata-Nichols; Patty O’Rourke-Langston; Gwen Osburn; Walter Ross; Patricia Rowley; Jane Shunney; Deborah Williams; Keith Zupnik; Valery Klaric and Shelli Clark, Recording Secretary

Attendance:

Recognition:

Certificate of Achievement in Financial Reporting: Comprehensive Annual Financial Report (CAFR) 2007
Mike Walsh reported that annually the Government Finance Officers’ Association reviews and rates all audited financial statements of government agencies. For the fifth consecutive year the health district has received a commendation. Mr. Walsh commended the financial program staff for their efforts and hard work. Chair Kirk commended staff as well.

EMS Responders of the Year
Dr. Sands noted that this is Emergency Medical Services Week and the EMS & Trauma System staff holds a reception annually to recognize EMS responders nominated by each agency in Clark County. John Hammond, Paramedic and EMS field representative read the names of the recipients of the 2008 EMS Responders of the Year awards: Ginger Nehrbass, American Medical Response; Nels Eastgard, Clark County Fire Department; Paul Stepaniuk, Henderson Fire Department; Captain John Torgerson, Las Vegas Fire & Rescue; Michael Cheney, MedicWest Ambulance; Steve Kreps, Mercy Air; James Michael Gleeson, Mesquite Fire & Rescue; Nick Robison, North Las Vegas Fire Department. Mr. Hammond thanked each recipient for maintaining a high level of professionalism within their agencies.

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 635 KB 4/24/08
   
   
2. Approve Payroll / Overtime for Periods: 4/05/08 – 4/18/08 & 4/19/08 – 5/02/08
   
   
3. Approve Accounts Payable Registers: #1123: 4/04/08 – 4/09/08; #1124: 4/10/08 – 4/16/08; #1125: 4/17/08 – 4/23/08; #1126: 4/24/08 – 4/30/08
   

5. Petition #16-08: PDF 277 KB Approval of Syphilis Elimination Service Awards for Calendar Year 2008
   

7. Petition #17-08: PDF 256 KB Approval of New Classification Specification for Associate Attorney, Recommended Schedule 26 ($65,281 - $91,087)
   
   Member Giunchigliani stated that she would like more information to justify the addition of an associate attorney when full-time counsel was recently hired, including the number of court cases and hearings. Chair Kirk asked for the information to be provided within the next thirty days. He further asked that the item be brought back under the Report/Discussion/Action portion of the Agenda.
   
   
8. Petition #19-08: PDF 965 KB Approval of Amendment Number 5 to Interlocal Agreement with Clark County on behalf of Clark County Social Service for Funding to Provide Ryan White Part A Services (formerly Ryan White Title I Services)

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 for items #4 and #6 to be set aside for discussion.

A motion was made by Member Giunchigliani to approve the Consent Agenda, with the exception of item #4 and item #6 which were deferred for discussion; seconded by Member Mattocks and was unanimously approved.

4. Petition #12-08: PDF 316 KB Approval of Interlocal Agreement between Las Vegas Metropolitan Police Department and Southern Nevada Health District for transfer of $100,000 for Management of Medical Records Seized per Search Warrant
   
   Member Giunchigliani wanted to have the record noted that the amount is for $100,000 and asked to clarify that the City is paying $491,000 for records management. Dr. Sands said that the health district received $100,000 from the state health division as part of a sub-grant specific to managing the health records contract; the City allocated $161,000 of the $500,000 fine for the balance of the medical records management contract. The original bid was negotiated from $419,000 to $261,000. Member Giunchigliani expressed her gratitude to the City of Las Vegas for their assistance in this matter.

A motion was made by Member Giunchigliani to approve item #4 as presented; seconded by Member Mattocks and was unanimously approved.

6. Petition #18-08: PDF 524 KB Approval of New Classification Specifications for Community Outreach Coordinator, Recommended Schedule 21 ($50,587 - $70,501) and Community Outreach and Information Specialist, Recommended Schedule 20 ($48,073 - $67,007) and Revised Classification Specification for Public Information Manager, Recommended Schedule 29 ($76,078 - $106,132)
   

A motion was made by Member Giunchigliani to table item #6 until the next regularly scheduled meeting of the Southern Nevada District Board of Health; seconded by Member Hardy and was unanimously approved.

II. Public Hearing / Discussion / Action

1. Memorandum #11-08: PDF 1 MB Public Hearing to Consider/Adopt Amendments of the Clark County Trauma System Regulations – continued from April.
   
   Chair Kirk declared the public hearing open.
   
   Mary Ellen Britt, regional trauma coordinator spoke relative to this item. Ms. Britt briefly mentioned the changes to the regulations which include providing a definition for pediatric centers for the treatment of trauma in concert with those used by the Nevada State Health Division (NSHD) and the American College of Surgeons (ACS), in section 100.085 and throughout the document; language was added to address patients refusing transport to a trauma center in section 200.250 again to be in agreement with NSHD trauma regulations; language added to clarify authorization of new trauma centers based on demonstrated needed for additional trauma services in the community and clarified the renewal process for level III centers in section 300.000; language was added to section 300.100 to streamline the authorization process to seek approval from the Board of Health only one time; section 400.000 includes an abbreviation for the Regional Trauma Advisory Board (RTAB); section 500.000 is a new section which addresses the description and authorized activities of the Regional Trauma Medical Audit Committee from a procedure manual into regulations, as was approved by the Board in December 2006. All changes to the regulations were approved by the RTAB and unanimously endorsed.
   
   Member Giunchigliani referred to section 200.250 and asked if there is a standard form of release used state-wide. Ms. Britt said a form was developed by the EMS & Trauma System Office for use in Clark County. 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.
   
   A motion was made by Member Giunchigliani to approve the application as submitted with the conditions outlined in the memorandum; seconded by Member Mattocks and was unanimously approved.
   
   
2. Memorandum #13-08: PDF 3.6 MB Application by MedicWest Ambulance (MWA) and American Medical Response (AMR) for a Variance to Emergency Medical Services Regulations 800.010 Required Staffing and 900.010 Ambulance Service: Critical Care Transport Services.
   
   Chair Kirk declared the public hearing open.
   
   Rory Chetelat, EMS & trauma system manager, spoke relative to this item. This item is resultant of MedicWest Ambulance (MWA) having difficulty staffing critical care ambulances with nursing staff. The program was piloted in 2006 as an opportunity for paramedics to expand their skill set; the program was found to be of use and successful and was approved by the Medical Advisory Board (MAB). MWA is asking for a variance to remove the nursing requirements of minimum staffing to be replaced with critical care transport paramedics, which has proved to be very successful. Conditions to the variance, which would be in effect only until December 31, 2008 to ensure the variance meets the community needs and is a safe alternative include:
   
   
   • MWA and American Medical Response (AMR) are to provide the selection criteria for how calls will be assigned between EMS-RNs (AMR) and CC-ENTPs and CC-EMTs (MWA);
   • Documentation of all critical care transports on a monthly basis for review (AMR);
   • Documentation will include at minimum the number of types of each call and the level of attendant assigned to that call

Chair Kirk asked John Wilson if he had anything to add. Mr. Wilson said his goal is to meet the community needs and ensure there are adequate resources available, while recognizing that nurses are very valuable in the community.

Member Eliason asked Mr. Wilson if he agrees with the outlined conditions, and Mr. Wilson responded affirmatively.

Member Jones asked if the Board of Nursing had any input or if they would be part of the evaluation process. Mr. Wilson said the Board has not been part of the discussion. Member Jones recommended that he seek input from the Board.

Chair Kirk clarified that this provision is only for transport between facilities due to one hospital not having the necessary resources required by a patient. The pilot program has shown that more experienced paramedics are able to meet the needs of the patient during transport and has not taken a critical care nurse away from a facility during transport. Mr. Wilson said this program is currently being run in twenty-six states. Staff is required to have rotations with the medical director to keep their skills active and current, as well as expanding their skills and training on medications to safely manage patients during transfers.

Member Mattocks expressed concern about drugs during transport and limitation of certain medications that can be given by paramedics. Jeff Davidson, medical director for MWA, addressed the Board. He said that the goal is to integrate the program so that the practice is similar throughout the County, including medications and necessary training so that scopes of practice are similar as well.

Member Hardy asked who is in charge of the patient from the time the patient leaves one facility and is accepted by another. Dr. Davidson said that the patient is under his direction during transport. If there is a problem in route, Dr. Davidson is responsible for that patient.

Member Giunchigliani asked if there is justification for reasons for transfer. Mr. Wilson said that there are numerous reasons for transfer, listing one example of Centennial Hills as a new hospital may not have resources for open heart surgery for an acute MI at a particular time. Member Giunchigliani asked if the documents requesting transfer are available for review, and expressed concern about transfer of patients to UMC. Mr. Wilson said that there are relatively few transfers between hospitals. Member Giunchigliani said that because UMC has more specialized care available there are more transfers to that facility.

Member Christensen spoke as a medical director in the Valley Health System and said that they do not transfer patients to UMC. Member Mattocks said that EMTALA requires transfer forms be completed with an accepting physician and accepting representative from that hospital before a transfer can be authorized.

Member Giunchigliani wants to ensure that transfers are not being done unnecessarily and that the paperwork does in fact justify the transfers to UMC. Mr. Wilson said that he can supply any information she is seeking.

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.

A motion was made by Member Giunchigliani to approve the variance as submitted with the conditions outlined in the memorandum; seconded by Member Mattocks and was unanimously approved.

3. Memorandum #02-08: PDF 1.9 MB Application for Approval for B B Recyling, Inc. to Operate a Solid Waste Management Facility – Recycling Center located at 3563 Procyon Street, Suite A, Las Vegas, Nevada 89103 (APN 162-17-201-006)
   
   Chair Kirk declared the public hearing open.
   
   Glenn Savage, director of environmental health, and Walter Ross, environmental health engineer/supervisor, solid spoke relative to this item. Mr. Savage said the B B Recycling will collect, store and process only recyclable materials which have been separated at the source and will be shipped to others to manufacture new products, including ferrous and non-ferrous metals, and lead-acid batteries. The facility will be open 6:00am – 3:30pm Monday – Friday, and 7:00am – 12:00pm Saturday and open to the general public. Mr. Savage stated that B B 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. Ben Bors, owner and Petya Balova, engineer were present to answer questions of the Board. Mr. Savage added that due to some problems with business licensing and operating without a permit, Mr. Bors ceased his own operations and went through the permit application process.
   
   Chair Kirk asked if Mr. Bors had additional information he wished to add and how he would handle the issue of illegal copper. Mr. Bors said that he is aware of where copper comes from and he asks customers where they obtain their materials if there is a concern, and he will not accept it. If there is a police report or other notice of stolen property, he will question where the materials came from as well. Mr. Bors confirmed that he asks for identification from all customers and keeps a log book even if he refuses the materials.
   
   Member Weekly said that he is working on legislation for next year and there is a need to hold recycling companies more responsible. He said the recycling businesses need to do more than just asking for ID, and work with law enforcement to track where materials are coming from. Another suggestion is to present a check or coupon versus cash for materials when the items are accepted.
   
   Member Eliason asked if painted copper from air conditioner condensation lines and radiators are accepted. Mr. Bors replied he has not refused this type of material, unless it was by unconventional means that the materials arrived at his facility. Member Giunchigliani stated that if materials are given to someone when they are no longer needed that some sort of authorization would be helpful to alleviate concern over where materials were obtained. Mr. Bors said that if he is aware of materials which are conspicuously marked by a company, he can take further action if these types of stolen materials are submitted for recycling and take further action.
   
   Member Giunchigliani asked Mr. Bors what his step was in establishing his recycling business. Mr. Bors said he went to business licensing first, who referred him to zoning, fire, air quality and then to the health district as the last step. Walter Ross, environmental health engineer/supervisor stated that a land use approval and a business license are required when applicants come in for a permit.
   
   Mr. Savage said that in discussions with Metro if during the enforcement process solid waste management facilities are found doing criminal activities, the permit can be revoked at any time.
   
   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.
   
   A motion was made by Member Giunchigliani to approve the application as submitted with the conditions outlined in the memorandum; seconded by Member Mattocks and was unanimously approved.
   

III. Report / Discussion / Action

1. Determining how/when Material Recovery Facilities are demonstrating compliance when obtaining a permit and otherwise (Member Giunchigliani requested item)
   
   Member Giunchigliani expressed concern over the different processes with each jurisdiction in regard to licensing and asked for clarification on the entire permitting process, as well as what occurs with those businesses operating without a permit.
   
   Glenn Savage, environmental health director gave a brief history on the regulatory process for solid waste management facilities, which dates back to the 1990s. At the time there were many businesses operating and were instructed to obtain a health district permit, A completed application includes engineering plans, all necessary jurisdictional approvals, operational plans for the facility, what type of materials will be handled, and other items as needed by the Board. Once the application was complete, the packet comes before the Board for approval, not to issue a permit, as the issuance of the permit is conditional upon meeting all requirements at the final inspection. The conditions may involve other jurisdictions approval before final permit issuance as well.
   
   Between 2000 and 2002 there were several construction clean up agencies that came before the Board and asked for a permit, which were denied. In 2002 a federal lawsuit was filed against Clark County, Public Services and the Board of Health. It was later determined that the Board has the authority to issue permits and there were some allowances made for construction clean up companies. As a result, staff began working on definitions for materials recovery facilities (MRF) and business plans for those handling mixtures of solid waste and recyclables and on site sorting. Staff worked with Mr. Minagil to issue cease and desist orders for those in violation of the regulations, be it for a MRF, recycling center or transfer station. Cases were brought before the hearing officer and penalties were severe in some cases. Businesses were instructed to complete the application process and become permitted. There are currently six construction clean up companies approved/permitted on the Clark County business license list; however there are 84 licenses approved by Clark County. There are some of these businesses which are small businesses that perform office cleaning and do not require a permit. Mr. Savage said that there needs to be a process where staff can review the business operation and possibly offer an exemption from permitting. Currently there are a number of cease and desist orders in place and they will be coming before the hearing officer in the near future.
   
   Member Giunchigliani asked what is required for a business to be a MRF. Mr. Savage said that a pad must be in place for materials sorting, however there are further requirements which differ by jurisdiction. Member Giunchigliani suggested that applicants come first to the health district, and staff would then verify that air quality, zoning, etc. can move forward, and come back to the health district for final permit issuance, and the business license could be granted simultaneously.
   
   Each jurisdiction has different requirements for what is designated as a MRF, and Clark County does not have a definition. Mr. Savage said it would be helpful if all jurisdictions, including the County, would adopt the health district’s definitions to use in business licensing for consistency. The second step would be to work with business licensing and ensure thoroughness of the application and issue the license simultaneously with the permit, as is currently done with the food programs and hotels.
   
   Member Barlow said that we need to find common ground and how to best rectify the differences in operations between the jurisdictions in order to have a better application process. Mr. Savage said that there is a good working relationship with code enforcement in each jurisdiction and having a common set of rules across the board would help the process run smoother.
   
   Member Giunchigliani suggested that the health district hold a workshop with key contacts from each jurisdiction and start working to improve the communication process and establish common definitions. It was further suggested that there be an expansion of the Comprehensive License Information Processing System (CLIP) used by the County to all jurisdictions so that licensing can interact and share information. This software is currently being improved so that all agencies within County offices can share information, including the health district. Mr. Savage said that staff is currently working on replacement of the VAX system and is working with contractors to ensure that the software can communicate with all the local jurisdictions.
   
   Member Empey said that if a food facility permit is suspended, the business license becomes void. He asked if the same process could occur with solid waste facilities, and still use the hearing officer process.
   
   Member Jones asked the amount of environment hazard existing for establishments operating without a permit. Mr. Savage said the district has the right to do inspections at reasonable hours; however the concern is what materials are brought on to the property, such as asbestos, paint, solvents and other materials that can cause run off and contaminate the ground water supply and soil contamination. In review of the list of licensed businesses we cannot tell what materials are being brought on site – it would take a physical inspection. Currently there are no applications in process for these businesses, and they may be very small operations.
   
   Member Hardy said that we have definitions in place for the different types of permit and have the right to inspect those businesses operating without a permit to look for potential health issues. We need to work in concert with all the jurisdictions for common ground. He expressed concern about issuing physical exemptions from the permitting process. If there is a violation of the definition, then a penalty should follow. Mr. Savage clarified that a small business may be located in a store front and all supplies are in that facility, and this would fall outside the scope of current definitions of solid waste management facilities as no waste is being generated. Staff could inspect the business and note that there is health district exemption.
   
   Chair Kirk stressed the importance of regular inspections to ensure compliance and that we need to look at more closely regulating these types of businesses.
   
   Member Eliason asked how the jurisdictions are notified if a permit is suspended. Mr. Savage said it can be done via telephone or email. There is a good working relationship with the entities and staff works together to ensure everyone is notified in a timely manner.
   
   Member Giunchigliani asked how we can verify that appropriate steps are being taken to comply with all conditions of an application, or those operating without a permit. Mr. Savage said that if conditions are not met a cease and desist order is issued. If the environment is impaired in any way, the operation cannot continue until a permit is secured. Mr. Minagil encourages transporters to take their materials to a permitted facility instead of those who are non-permitted.
   
   Tom Standish, attorney for Pro Star Drop Box LLC, which is one of the companies who has completed the permitting process. Completing the permit application process with the health district is the first step, then the applicant must complete the building process, which is contingent upon the individual jurisdiction’s requirements. Mr. Standish said his concern is the time between the time a license is granted, but not approved for operation and the time the final certificate of occupancy is granted by the County. There are only two facilities in the county that can accept construction debris. If one or both of these facilities were not allowed to operate, there would be a tremendous problem with removal of construction debris with all the projects underway in the county. Mr. Standish said it has taken a long time for Pro Star Drop Box to complete the necessary requirements, due to the large difference in jurisdictional requirements. He hopes that other companies are being cited if they are in violation, or operating without a permit, just as his client has been. He asked for an interim regulation to allow his client to operate legally and still be in compliance while completing requirements for operation of the entire facility. He said his client has been working on completing the necessary requirements for final permit issuance but it is taking time. He asked for temporary regulations to control seepage, including a temporary pad or use of magnesium chloride; construction of a chain link fence to control blowing of trash; dust control by wetting the soil; and vermin control. He would like to work with the County and the health district to develop a regulation to allow licensed-approved agencies not yet permitted to operate legally in the interim while conditions are being met.
   
   It was verified that Evergreen, Wolfe and Republic Services are currently permitted as MRFs. Lunas Construction Clean-Up has two approved applications, Par-3 Landscaping has one approval and Pro Star Drop Box also has one approval. The state recently permitted a landfill in the next county.
   
   Member Giunchigliani asked if the Board should explore issuance of permits with temporary conditions. Member Christensen asked if there is a way to fast track the applications if someone is doing all they can to meet the necessary conditions. Mr. Savage said he has suggested to applicants numerous times to speak with the local jurisdiction about what can be done to expedite the process.
   
   Chair Kirk thanked Member Giunchigliani for bringing this item forward for discussion.
   
   A motion was made by Member Giunchigliani to give direction to staff to provide all local jurisdictions with the definitions for all solid waste management facilities for potential ordinance changes, and to pursue establishing a workshop with all jurisdictions in the next month, including code, business license, air quality, building, fire and zoning to find common ground; seconded by Member Eliason and was unanimously approved.
   

IV. Public Comment:

Public comment 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.

Diana Daniels, Southern Nevada Health District employee spoke to the Board and asked for corrections to the minutes of the Chief Health Officer Annual Review Committee meeting. She said that she represented some employees, and spoke to some employees. She also said that there was discussion about the employee satisfaction survey and a survey, including an uncut version, which can be shared with Board members on request and the redacted version to employees; there was also a survey about negotiations. Ms. Daniels agreed with Member Giunchigliani’s assessment that the request for an associate attorney be reviewed.

Ann Markle, health records manager, addressed the Board and stated she has worked for the district for forty years. She said that there have been problems under previous administration. There were no surveys conducted for previous Chief Health Officers in conjunction with their reviews. She said that all employees, including the managers, work hard and give their best to the district.

V. Health Officer & Staff Reports

• Hepatitis C Investigation: Brian Labus, Senior Epidemiologist
  
  Dr. Sands invited Brian Labus forward to update the Board relative to the hepatitis C investigation. All Board members received a copy of the investigation report published by the Centers for Disease Control and Prevention (CDC) in the Morbidity and Mortality Report (MMWR), in addition to information regarding chronic infections potentially linked to the endoscopy clinic.
  
  Mr. Labus said that lab results were received from patients testing positive and attempted to match positive patients to the list of clinic patients. As patient information differed on lab results and the clinic staff list, staff made phone calls to survey those tested to ensure the proper person was being contacted and to look for potential risk factors, including prior infection before visiting the clinic. The seventy-seven cases had procedures done at the clinic in the right time frame, tested positive after their procedures and reported none of the other significant risk factors. It doesn’t mean they contracted the disease at the clinic, however they were able to exclude all other risk factors except having a procedure at the clinic.
  
  National hepatitis C data indicates that 50% of patients diagnosed with hepatitis C admit to having one of the major risk factors. In doing our investigation we have no way to verify the information provided by patients when questioning about risk factors, so we need to take patients at their word. Following the first preliminary analysis of data, the seventy-seven people with chronic hepatitis C were found to have none of the major risk factors, and they tested negative before entering the clinic for procedures performed between March 2004 and January 11, 2008. These are possible links to the clinic, but we cannot confirm that the infection was acquired at the clinic as we were able to do with the acute cases.
  
  The information in the MMWR and CDC trip report does not contain new information, but brings to light that this is a national problem, not only in Nevada.
  
  Member Smith asked if any of the seventy-seven cases were secondary infections due to someone else being infected. Mr. Labus confirmed that these cases did have procedures performed at the clinic and are not secondary infections. Secondary transmission is contingent upon risk factors.
  
  Mr. Labus said that these cases had no prior knowledge of infection before having procedures done at the clinic; they may have been positive but there is no way to tell. The acute cases differ as we can look at the six to eight months prior to onset of symptoms and find genetic links to the same source.
  
  We are currently waiting for some tests to confirm genetic linking to the clinic, so numbers have not changed at this point. Genetic testing on patients who had procedures done prior to 2005 will not be beneficial as the virus mutates rapidly and would not demonstrate a genetic link at this time. There are some possible lab results, but at this point we cannot determine the actual source. As all clients have the same strain of hepatitis C it is logical that there is one source infection. At this point it has been difficult to confirm all clients testing positive for acute infection had procedures were done in one room by the same practitioner. There were two practitioners working who now have injunctions from practicing; a third physician was on site earlier in the day. There were also two CRNAs involved as well, and staff is continuing to investigate while waiting for test results. There was no indication that the same scope was used on the infected patients.
  
  Member Eliason said that trust has been broken and that is most damaging to everyone.
  
  Chair Kirk thanked Mr. Labus for his report and the information shared.
  
  
• Childhood Lead Poisoning Prevention Program (CLPPP): Keith Zupnik, Project Coordinator; Denise Tanata-Ashby, Executive Director for the Nevada Institute for Children's Research and Policy at UNLV
  
  Dr. Sands said that a presentation on the Interim Report had been made to the Legislative Committee on Health Care at the May 6, 2008 meeting, and the report was made available to all Board members. Recommendations made to the Committee will be shared today. Project team members were available to answer questions.
  
  Keith Zupnik presented a PowerPoint regarding the Childhood Lead Poisoning Prevention Program (CLPPP), including recent accomplishments, updates and a brief overview of the program (attached PDF 1.5MB). Past accomplishments include creation of a Strategic Advisory Coalition, implementation of surveillance, environmental investigations with case management, development of a five-year elimination plan and publication of the Interim Report which details the impact of lead exposure on childhood development, screening data, lead sources in Nevada, as well as current and future program activities.
  
  Between August 2006 and December 2007 there 8,500 children screened for lead exposure; between January 2008 and April 2008 an additional 3,500 children were screened. UNLV and UMC will be joining efforts to screen 4,500 children and the focus will be on those who are uninsured/underinsured. A Lead Care analyzer machine was approved earlier this year which tests for lead exposure by a fingerstick and to date 700 children have been screened using this method.
  
  Primary prevention is the effort to prevent lead exposure before children have a detectable level in their blood. There are 109 child care facilities built prior to 1978 and inspections have been completed on 39; 24 of which had some sources of lead exposure and 18 of those sources were untraditional sources, such as toys, jewelry, pottery and the like. UNLV is also doing housing-based primary prevention and, as a result of a joint press release in December 2007, sixty-four home inspections were completed in target zip codes which showed twenty-four lead hazards and thirty-nine potential lead hazards.
  
  In order to facilitate community-based primary prevention educational materials were developed in both English and Spanish, including PSAs, bus stop advertisements, radio spots, television appearances and presentations. The health district is hosting the EPA Regions IX and X lead conference next month, and the theme is transitioning from lead poisoning elimination to the Healthy Homes Project.
  
  The initial grant from the CDC was a way to implement the CLPPP; we need to secure additional funding, community participation and partners to participate and keep the program moving forward. We are also obligated to expand the program state-wide. Plans are to mimic the program across the state for continuity including personnel in key positions. The natural transition from CLPPP is to a comprehensive healthy homes program for asthma triggers, vermin, housing for the underprivileged and unsanitary conditions in rental housing. All target zip codes are listed in the Interim Report.
  
  Denise Tanata-Ashby, chair of the Legislative Affairs Workgroup, addressed the Board briefly. Legislative recommendations include introducing the Healthy Homes concept to allow the local health authorities to enact regulations to support healthy homes programs in the state; screening of all children at both twelve and twenty-four months of age for lead exposure; testing of pregnant women for lead exposure; proof of lead testing for all children under the age of six enrolling any time in a child care facility, kindergarten or pre-school; language will be included for exemptions due to religious beliefs; mandatory reporting of all lead testing to the local health authority for children under the age of 18 years, including lab reports to contain the name, date of birth, gender, race, full address, name and phone number of parent/guardian and other information deemed appropriate by the local health authority, test results would be reported within five days of testing and include the date the test was administered, the type of tests performed, normal detection limits for the test, results and the lab’s interpretation of the test; and the ability for local health authorities to develop regulations for electronic submission of all reports.
  
  Member Strickland asked about the media attention to lead in artificial grass. Mark Bergtholdt, environmental health supervisor said that staff is researching this information and there is conflicting information whether the lead is released into the environment. No action is currently taking place because no recalls have occurred and industry claims there is no release into the environment. She asked if data is available for how many children were screened per zip code. Brenda Argueta, disease investigator & intervention specialist said the report only listed those children with a detectable blood lead level; the number of children screened can be provided upon request.
  
  Member Smith asked about non-traditional sources of exposure and what is the focus. Mr. Zupnik said that education is the top priority. Current research shows that any level of lead can cause permanent brain damage and loss of IQ points. We are fortunate to have UNLV as a partner to do research through collateral grants. If a product is found to be suspect and FDA is not working on it, our staff and partners will take action. Some products are not targeted for children specifically so the lead levels can be higher. Education needs to occur at all levels and engage the community, health care providers, parents, political leaders, and both governmental and non-governmental groups in spreading the message and attack the problem. There are many physicians who are not testing for blood lead level exposure and there is a great deal of work to be done.
  
  Chair Kirk thanked Mr. Zupnik and staff for their presentation and remarks.

VI. Informational Items - DULY NOTED

VII. Adjournment

There was no further business to come before the Board and Chair Kirk concluded the meeting at 10:10 a.m.

SUBMITTED FOR BOARD APPROVAL

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

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