Grand Forks Public Health Department

Thursday, April 9, 2009

I. Call Meeting to Order

The Grand Forks Board of Health met at 4:25 p.m. on Thursday, April 9, 2009, in the Health Department conference room. However, there were not enough members present to have a quorum, but the board discussed the items on the agenda. Members that were present: Judy DeMers, Don Shields, and Dr. James Hargreaves. Others present: Debbie Swanson, Haley Thorson, Wally Helland, and Keith Westerfield. Also attending were two UND nursing students; Katrina Johnson and Erika Lund.

II. Approval of Minutes of Regular Meeting, January 8, 2009

Since no quorum existed for an official meeting, approval of the minutes from the last meeting on January 8, 2009 were deferred until the next quarterly meeting in July.

III. Old Business

A. ND Immunization Update: Debbie S. explained we are now in complete implementation of the PROtect ND Kids program, though there tends to be new surprises every week relative to billing issues.

- Public Health has been asked to sign agreements with TriCare (military insurance). Even though we’ve served those patients before through our billing mechanism, now we have to enter into more agreements.

- Public Health has been having some issue with Medicaid not reimbursing for some adult immunizations, primarily refugees.

- There was an effort to put forward a bill on immunizations in the Legislative session. Senate Bill 2333 would provide additional funding to be released specifically to the local public health departments, for the investment they’re making in their immunization services.
-- $1.2 M is what was proposed in that bill, though legislators have suggested using stimulus money rather than state appropriations may be the outcome. The main desire was to request funding for immunizations, because it’s so important.
-- Stimulus funding has more stipulations and must be spent on specific programs, like flu shots in schools or getting more people shingles vaccine. This often means more work because what we get is the vaccine, but not the administration fee.

- There is no state funding for immunizations, other than what was approved in the 2007 Legislative session to implement PROtect ND Kids, and that money is to due to be expended June 30th. There is no regular line item in the state health budget for the immunization program—it’s all federally funded.

B. ND Legislative Bills Update: Haley T. started off the briefing with updates on Tobacco bills:

- The tobacco bills that were defeated are: ‘The Smoke-Free Workplace’ Bill (House Bill 1213); a small Tobacco Products Tax Bill (wholesale purchase price versus the current taxation based on weight); House Bill 2406 was an attempt to change Measure 3 funding by building college savings plans for high school graduates or college graduates remaining tobacco-free.

- A few bills that we are still watching closely are; the Measure 3 bill (Senate Bill 2063), and the Health Department bill (SB 2004). Senate Bill 2063 died on the floor this date (24-69 vote), due to amendments that stripped the initial intent of the measure, and basically gave all the funding and authority to the ND Dept of Health.

- ‘Fire-Safe Cigarette’ bill (Senate Bill 1368), initiated by a Grand Forks Fire Marshal mandating fire-safe cigarettes, has amendments that have weakened it.

Board of Health Minutes
April 9, 2009
Page 2

Debbie S. reported on Dental Bills:

- House Bill 1176, gives general supervision to hygienists, passed and will allow them to do sealants, like in school-based programs. This bill was supported by the ND Oral Health Coalition.

- The Dental Care Mobile, a bill which came out of the Bismarck area for a mobile dental clinic, passed with an appropriation of $200,000.

- Senate Bill 2356, which was funding for our local public health dental clinic, in Grand Forks and Fargo, failed in the Senate Appropriations.

- Senate Bill 2358 is the dental repayment program passed. This important legislation will ensure that the public health dental clinics have a readily supply of dentists who may want to practice in ND. However, the Appropriation Committee moved it from the General Fund, to the Community Health Trust Fund - which is tobacco funding.

- Debbie S. also mentioned that the Breastfeeding bill passed, with amendments. This bill ensures women who breastfeed in public would not be charged with indecent exposure.

Wally H. briefed for Environmental Health there was an Individual Septic Tank Inspection bill, but it had failed.

Don S. briefed that the General Appropriation Bill, for the ND Department of Health (SB 2004), had $100,000 added to it for flex spending, for the local health departments. The $100,000 spread out among the 28 local health units equate to only about $2000 for Grand Forks. It’s not much of an increase, but we’re thankful for it (it’s better than cutting the dollars).

IV. New Business

A. Salmonella Peanut Butter/Pistachio Outbreak 2008-2009: Don S. briefed that there were two salmonella outbreaks; the peanut butter one is winding down, but the pistachio outbreak is just getting started (see attachment).

- As of 15 March, 2009, there have been 691 cases of peanut butter salmonella, including 17 cases in ND; also 23% of those cases required hospitalization, and resulted in 9 deaths nationwide.

- The peanut butter salmonella came from two manufacturing plants; Georgia and Texas, due to contamination of bird droppings on the assembly line, a leaky roof (Georgia), and filthy conditions (Texas) that caused cross-contamination (after processing) of at least 30 tons of peanut butter. Most of it was in large containers that were distributed to nursing homes, schools, etc. Also a lot of it was in the manufacturing of peanut butter paste that was used to make cookies, ice cream, etc. Over 3,500 products have been recalled. However, it didn’t affect the brand-name jars of peanut butter.

- The FDA says that consumers should not eat any pistachio products, until they investigate it. The second-largest producer of pistachio in the U.S. (located in California), have distributing pistachio products to large manufacturers, so they don’t even know yet how many products are affected. It’s estimated that they are tracking down 55 million pounds of pistachios, across 36 wholesalers. The FDA however, doesn’t have the legal authority to order a recall of products.

B. National Association of Local BOH Membership 2009: Grand Forks Public Health Department is a member of the National Association of Local BOH (see attachment). Membership cards providing web site information access were distributed.

Board of Health Minutes
April 9, 2009
Page 3

C. Immunization Appointment System: Debbie S. provided an update on Grand Forks Public Health new appointment system for immunizations (see attachment):

- With the complexity compression that is occurring in the area of immunizations, we felt that we could no longer provide just as a ‘walk-in’ service, so we are now taking appointments for immunizations. It has greatly reduced waiting time, increased client satisfaction, and improved the quality of our service. It is
not uncommon to give many immunizations to a child on one visit. We needed to be able to have two staff members available administer those shots.

- We had to do a lot of quality improvement as a result of this. The next step in this process will be to enhance our technology, such as software for appointment scheduling, electronic health records, etc., to make it a more efficient system. Dr. Hargreaves suggested researching the software that Altru uses - Epic.

D. Influenza Season 2009 Update: Debbie S. briefed that for the 2008-9 season, as of March 31, 2009, there have been a total of 1258 cased of influenza in ND; total number of cases down from last year and the ND Dept of Health reports that the flu season peaked on March 7th (see attachment).

E. ‘Give Kids A Smile’ Day: Debbie S. reported that this is the first time trying this event which was held on February 13, 2009. For the first event, they started out small with 24 kids (see attachment).

- It was a collaboration between Northern Valley Dental Health Coalition, Northeast District Dental Association, and Valley Community Health Centers Dental Clinic. It was supported by the American Dental Association with this year as the test pilot. There are still children needing dental care so the program will be expanded next year.

- Debbie S. thanked Dr. O’Connell, one of the dentists who volunteered for screening, and also saw kids at his practice. He was also featured in the Grand Forks Herald article with a photo. Debbie also expressed appreciation for the ‘leap of faith’ that the Valley Community Health Centers’ board took in establishing the dental clinic in Grand Forks. Their main operation is in Northwood and Larimore, ND. Debbie asked if the BOH could send a letter of thanks for establishing the dental clinic, because it’s meeting a need for a wide region (which the BOH agreed to do).

F. Vaccination Expedition Conference: Debbie S. gave a briefing for Kathy Dunn, who is the co-chairman, with Shannon Hansen from Altru, for the Greater Grand Forks Immunization Coalition.

- The coalition is sponsoring the immunization conference, which is held every three years, on
May 28 & 29, 2009, at the Alerus Center. This is a quality event with great speakers, with one of this year’s topic on immunization safety (see attachment).

G. 2009 Flood Update: Don S. was sending out daily flood updates to Community Groups and BOH members (see attachment).

- As of this date, the Red River is going down, currently at 44 feet, and the crest was at about 48 feet. They are projecting another crest of about 48-51 feet starting next week through the weekend. Since that is well within the parameters of our flood control system of 60 feet, our main goal is to help others, like Fargo and areas north of Grand Forks.
-- The state has put a medical staging facility at the Public Safety Center. There are contingency plans to use that, as needed, for evacuation of special-needs people that need assistance. One was put in Grand Forks (other in Bismarck), because Fargo’s flooding, plus Jamestown and Valley City are watching the Sheyenne River’s level.
-- In Grafton: the projected crest in Park River is 15-17 feet (April 14-15), but they figure it will be at 16 feet. The dikes in Grafton are at 16 feet, so they are working hard to put more sandbags on top of their permanent dike system. Up north, the river is 7-10 miles wide.
- Grand Forks medical and long-term care facilities received 82 patients from Fargo, and also 62 extra prisoners were sent to Grand Forks from Fargo.
Board of Health Minutes
April 9, 2009
Page 4

V. Next Regularly Scheduled Meeting4:15 p.m., Thursday, July 9, 2009, at Public Health conference room.

VI. Other:
- Judy D. congratulated Debbie Swanson on winning the 2009 Grand Forks Athena Award, given for community leadership and mentorship to other women.

VII. Adjournment – The meeting ended at 5:12 p.m.

Respectfully submitted,

James Hargreaves, MD, Secretary
by: Keith Westerfield
Office Specialist, Senior
Public Health Department

Attachment: - BOH Issue Statements, April 9, 2009

Board of Health
Issue Statements
April 9, 2009

Topic: Salmonella - Peanut Butter and Pistachio Outbreak Update

Contact: Don Shields 787-8100

Background: Center for Disease Control (CDC) is collaborating with public health officials in many states and the United States Food and Drug Administration (FDA) to investigate a multistate outbreak of human infections due to Salmonella serotype Typhimurium. The numbers of illnesses associated with peanut butter have been dropping since mid December.
As of Sunday, March 15, 2009, 691 persons infected with the outbreak strain of Salmonella Typhimurium have been reported from 46 states. The number of ill persons identified in each state is as follows: Alabama (2), Arizona (14), Arkansas (6), California (76), Colorado (18), Connecticut (11), Florida (1), Georgia (6), Hawaii (6), Idaho (17), Illinois (11), Indiana (10), Iowa (3), Kansas (2), Kentucky (3), Louisiana (1), Maine (5), Maryland (10), Massachusetts (48), Michigan (38), Minnesota (43), Missouri (15), Mississippi (7), Montana (2), Nebraska (1), New Hampshire (13), New Jersey (24), New York (34), Nevada (7), North Carolina (6), North Dakota (17), Ohio (100), Oklahoma (4), Oregon (13), Pennsylvania (19), Rhode Island (5), South Dakota (4), Tennessee (14), Texas (10), Utah (7), Vermont (4), Virginia (21), Washington (24), West Virginia (2), Wisconsin (5), and Wyoming (2). Additionally, one ill person was reported from Canada.

Among the persons with confirmed, reported dates available, illnesses began between September 1, 2008 and March 15, 2009. Patients range in age from <1 to 98 years. The median age of patients is 16 years which means that half of ill persons are younger than 16 years. 21% are age <5 years, 17% are >59 years. 48% of patients are female. Among persons with available information, 23% reported being hospitalized. Infection may have contributed to nine deaths: Idaho (1), Minnesota (3), North Carolina (1), Ohio (2), and Virginia (2).

Peanut Corporation of America (PCA) manufactured the peanut butter and peanut butter paste (in excess of 25 tons) at plants in Georgia and Texas in 2008. PCA is now in bankruptcy proceedings, and it is no longer able to communicate with customers of recalled products. Major national brands of jarred peanut butter found in grocery stores are NOT on the recall list.

Pistachio – Salmonella (March 30, 2009): The FDA and the California Department of Public Health (CDPH) are investigating Salmonella contamination in pistachio products sold by Setton Pistachio of Terra Bella Inc, Calif. The company has stopped all distribution of processed pistachios and will issue a voluntary recall involving approximately 1 million pounds of its products. Because the pistachios were used as ingredients in a variety of foods, it is likely this recall will impact many products. In addition, the investigation at the company is ongoing and may lead to additional pistachio product recalls.

The contamination involves multiple strains of Salmonella. Salmonella can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. Thus far, several illnesses have been reported by consumers that may be associated with the pistachios. It is not yet known whether any of the Salmonella strains found in the pistachio products are linked to an outbreak. The FDA is conducting genetic testing of the samples to pursue all links.

Issue Statements
Page 2
April 9, 2009

FDA is working closely with the pistachio industry and recommends that consumers avoid eating pistachio products until further information is available about the scope of affected products.

FDA will provide a searchable database of affected products at and will continue to update the public.

FDA first learned of the problem on March 24, when it was informed by Kraft Foods that it’s Back to Nature Trail Mix was found to be contaminated with Salmonella. Kraft had identified the source of the contamination to be pistachios from Setton and conducted a recall.

Action: None. For Information only

Topic: National Association of Local Boards of Health (NALBOH) Membership

Contact: Don Shields 787-8100

Background: The Grand Forks Board of Health is a member of the NALBOH and as such, has access to quarterly newsletters, data, statistics and trends written for boards of health ( See membership card (handout) for each member.

Action: None. For Information only

Topic: Immunization Appointment Scheduling

Contact: Debbie Swanson, Kathy Dunn 787-8100

Background: Providing vaccination services has become increasingly complex during the past several months as a result of new vaccines added to the immunization schedule and changes in the ways vaccination services are reimbursed. During the past few years, many new combination vaccines have been added to the childhood immunization schedule, additional vaccines are provided at entry to middle school and adults increasingly are seeking vaccines as a result of new recommendations to protect their health. Twenty years ago, we provided just six vaccines. That number has grown to more than 24 and often the youngest patients need seven vaccinations at one visit.

Grand Forks Public Health Department serves a growing population of New Americans with complex vaccination requirements and necessary translation services. During 2008, the state of ND changed the immunization delivery system requiring public health departments to implement billing systems to collect insurance payments. This complexity compression has led to the decision to offer immunization services by appointment rather than as a “walk – in” service in order to improve the quality of care we provide.

Issue Statements
Page 3
April 9, 2009

We began offering immunizations by appointment on three days each week. This schedule has flexibility for expansion and contraction to meet the seasonal needs of the population and to optimize the efficiency of our operations. All immunization processes have undergone a thorough quality improvement review as a result and client satisfaction will be monitored in the future. The first few weeks of the schedule have proceeded very smoothly, clients were served in a timely manner and walk-in appointments were able to be accommodated during the first week.

Action: For information only

Topic: 2009 Seasonal Influenza Update

Contact: Debbie Swanson 787-8100

Background: As of March 31, 2009, there have been a total of 1258 confirmed cases of influenza in North Dakota. At this time last year, there were 3,421 cases of flu. Of the cases reported in 2009, 917 are Type A unspecified and the remaining are Type B, Type A-H1, Type A-H3 and unknown. The highest numbers of persons with confirmed influenza are in Cass, Burleigh, Grand Forks, Stark and Morton Counties and the age range most affected are children less than 19 years old ( 769 cases). This information is subject to change weekly and the updated information may be found at: Flu vaccine is plentiful and patients can receive a vaccination anytime during the season to protect from influenza.

Action: For information only

Topic: Give Kids a Smile Day

Contact: Debbie Swanson 787-8100

Background: The Northern Valley Dental Health Coalition, Valley Community Health Centers Dental Clinic and the Northeast District Dental Association sponsored the first ever Give Kids a Smile® event on February 13, 2009 in Grand Forks.

Give Kids a Smile® is a program of the American Dental Association and the mission is to provide chair side education, preventative and restorative dental care to children who do not have access to care.

A total of 24 children were screened at the dental clinic and were subsequently referred to local dentists in the community who agreed to provide restorative care. The value of the dental care donated is approximately $24,000. The event was also supported by a grant from the ADA and Sullivan Schein for dental supplies and Grand Forks Public Health Department, Grand Forks County Social Services and Northeast Human Service Center employees who donated their casual attire/jeans day funding to the event.

Thanks to James O’Connell, DDS, a member of the Grand Forks Board of Health, who was a volunteer at the screening and provided restorative care to children in his office!

Issue Statements
Page 4
April 9, 2009

Topic: Vaccination Expedition 2009- The Adventure Continues

Contact: Kathy Dunn 787-8100

Background: Grand Forks Public Health, along with the Greater Grand Forks Immunization Coalition and the North Dakota Department of Health are sponsoring their fourth region-wide immunization conference on May 28 and 29, 2009, at the Alerus Center in Grand Forks, North Dakota. We are anticipating more than 300 healthcare providers from across North Dakota and Minnesota to attend. This conference will provide the highest quality educational offering for healthcare providers in the area.

Dr. William Atkinson, MD, MPH, Medical Epidemiologist for the National Immunization Program, Centers for Disease Control; Gary Marshall, MD, University of Louisville School of Medicine; Greg Poland, MD, Mayo Clinic; and Bob Upgren, Achievement Expert and Master Chalk Artist will be our keynote speakers. Topics included in the conference agenda are vaccine safety, childhood and adult immunization, special populations, innovative vaccine strategies and disease outbreaks in rural areas. Continuing education credit will be available for healthcare professionals.

Action: For Information Only

Topic: Spring 2009 Flood Update

Contact: Don Shields 787-8100

Background: The Grand Forks Board of Health members received daily public health updates of flood related issues during key periods of Spring 2009 flooding. During this period information was provided on river levels, weather conditions, medical evacuation, shelters, assistance, sand bag operations, and Health and Human Service agency coordination. The Grand Forks Emergency Operations Center (EOC, 701-780-8213) was operating with a public health representative and answering questions and coordinate flood issues.

Flood Related Injuries/Deaths as Reported by the North Dakota Department of Health Bismarck, ND March 30, 2009: Deaths: 2, Injuries: 62, Illnesses: 11

Action: For information only