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1. Public health in Washington StateJude Van Buren DrPH, MPH, RNAssistant Secretary – Division of Epidemiology, Health Statistics and Public Health LaboratoriesWashington State Department of Health YOUR LOGO HERE

2. Every Day in Washington State… Public Health:Always Working fora Safer and Healthier Washington • Communities are prepared for health emergenciesthanks to the work of state and local public health agencies, 95 licensed hospitals, and other partners. • About 210 babies get a healthy startthrough early detection of treatable diseases by the Newborn Screening Program. • More than 5 million peoplehave safe reliable drinking water because of the efforts of Washington’s state and local health agencies. • About 50 people call the stateTobacco Quit Line daily to take the first step toward kicking the habit. • Thousands of patients get safe quality health carefrom doctors, nurses, and other health care professionals licensed by the Department of Health. • Over 2.5 million peopleeat in restaurants with confidence thanks to the efforts of local health departments and our Food Safety program. • About 95 percent of kids entering schoolare protected against preventable diseases because of public health immunization and education efforts.

3. Governmental Public Health Network US Department of Agriculture Local Health Jurisdictions Washington State Board of Health State Health Departments Tribes

4. Washington State Local Health Jurisdictions Island County – 77,200 Kitsap – 243,400 Mason – 53,100 Thurston – 231,100 Whatcom County Health Department Pend Oreille 184,300 Ferry Stevens 7,500 42,100 12,300 San Juan County Department of Health and Community Services Skagit County Department of Health Okanogan County Health District Northeast Tri-County Health District 15,700 113,100 39,800 Island County Health Department Clallam County Department of Health and Human Services Snohomish Health District Chelan 67,800 671,800 70,100 Douglas Jefferson County Health and Human Services Chelan-Douglas Health District 35,700 Kitsap County Health District Lincoln County Health Department Spokane Regional Health District 28,200 Public Health – Seattle and King County 10,200 436,800 Mason County Department of Health Services Grays Harbor County Public Health and Social Services Department 1,835,300 Grant County Health District Adams County Health District Kittitas County Health Department Whitman County Health Department Tacoma-Pierce County Health Department 70,400 80,600 773,500 37,400 42,800 Thurston County Public Health and Social Services Department 17,300 Pacific County Public Health and Human Services Department Garfield County Health District Lewis County Public Health Franklin Benton Yakima Health District 72,900 64,200 21,500 2,400 160,600 Columbia County Public Health District 231,800 Benton-Franklin Health District Wahkiakum County Department of Health and Human Services Asotin County Health District 57,900 Cowlitz County Health Department Walla Walla County Health Department Skamania County Health Department 3,900 21,100 4,100 96,800 10,600 Klickitat County Health Department Clark County Health Department 19,800 403,500 Washington State Total Population as of June, 2006 – 6,375,600

5. SECRETARY Mary C. Selecky Board of Health COMMUNICATIONS Tim Church, Director POLICY, LEGISLATIVE, & CONSTITUENT RELATIONS Brian Peyton, Director PUBLIC HEALTH EMERGENCY PREPAREDNESS & RESPONSE John Erickson, Director FINANCIAL SERVICES Lois Speelman, Assistant Secretary Epidemiology Center for Health Statistics HUMAN RESOURCES Kathy Deuel, Director EPIDEMIOLOGY, HEALTH STATISTICS, & PUBLIC HEALTH LABORATORIES Jude VanBuren, DrPH Assistant Secretary PUBLIC HEALTH SYSTEMS PLANNING & DEVELOPMENT Allene Mares, Director HEALTH SYSTEMS QUALITY ASSURANCE Karen Jensen Assistant Secretary COMMUNITY & FAMILY HEALTH Mary Wendt Assistant Secretary ENVIRONMENTAL HEALTH Gregg Grunenfelder Assistant Secretary Public Health Laboratories INFORMATION RESOURCE MANAGEMENT Frank Westrum, Chief Information Officer Informatics Health Professions & Facilities Infectious Disease & Reproductive Health Drinking Water RISK MANAGEMENT Dennis Anderson, Director Customer Service Radiation Protection Maternal & Child Health Shellfish & Water Protection Inspections & Investigations Community Wellness & Prevention ADJUDICATIVE SERVICES UNIT Laura Farris, Senior Health Law Judge Environmental Health & Safety Environmental Health Assessments WASHINGTON STATE Department of Health Organizational Chart w March 2009 PERFORMANCE & ACCOUNTABILITY Susan Ramsey STATE HEALTH OFFICER Maxine Hayes, MD, MPH DEPUTY SECRETARY Bill White Legal Services Community Health Systems

6. Department of Health’s Budget in Context:Federal Funds are Major Fund Source *Includes estimated Women, Infant, and Children (WIC) and AIDS Drug Assistance Program (ADAP) rebates of $64.1 million. February 2009

7. Department of Health’s Budget in Context:Majority of funds are passed through to community partners February 2009

8. Drug poisonings are a leading cause of death • Drug overdoses kill more people in Washington than motor vehicle crashes. • From 1995-2007, there was a 19-fold increase in opioid-related deaths. • The use of methadone for chronic pain increased 1,300% from 1997-2006, and Oxycodone by 600%. • Our state’s drug overdose death rate is higher than the national rate.

9. Prescription monitoring* Helps detect and prevent prescription drug abuse Tamper-proof prescription pads Prevents fraud Drug take-back programs Promotes safe disposal of drugs Combating Drug Misuse and Abuse • Shown to be safe and effective in pilot programs • *Currently suspended

10. Climate Change: Predicted Changes in NW Climate • Increased average winter and summer temperatures (~ 1 degree F / decade) • Precipitation pattern changes • Increased precipitation • Reduced spring snow pack • Increased storm intensities • Increased flooding and drought • Increased surface water temperatures • Reduced weather predictability

12. Executive Order 07-02 (Feb 7, 2007) • Washington’s Climate Change Challenge • Drivers are global – Effects are local • Technical workgroups – greenhouse gas emission reductions; clean energy economic goals. • Preparation & Adaptation workgroups: PAWG: Health, Agriculture, Forestry, Water, Coastal.

13. Health Implications of Climate Change • Health effects of excessive heat. • Health effects of air pollution. • Health effects associated with infectious diseases. • Health effects of extreme weather events and rising sea levels. • Psychological and social disruption effects.

14. Mosquitoes Ticks Hantavirus Cryptococcus gattii Environmental Changes Will Affect Zoonotic & Vector-Borne Diseases

15. Key Preparation & Adaptation Strategies • Enhanced surveillance • The built environment • Emergency planning and preparedness

16. Two overarching considerations from the Health PAWG • The clear need for public engagement and involvement. • The importance of social justice considerations in all actions taken to address climate change impacts.

17. National Public Health Week – April 7–13, 2008 Climate Change: Our Health In The Balance It’s time for Public Health to have a voice in the conversation.

18. Current activities: • Senator Rockefeller working on a climate change bill aimed at better organizing and prioritizing state activities on the issue. • Climate Action Team proposals forwarded for legislative consideration by outside groups. • CDC request for Climate Change grant applications.

19. Biomonitoring Grant Proposal to evaluate Arsenic exposures Goals: • 1) to determine background urinary arsenic levels in population • 2) to determine if there are specific populations in state that are at higher risk for arsenic exposure • 3) To inform and educate those with higher risk Methods: • Collect urine samples to evaluate speciated arsenic levels to determine exposure to arsenic in specific and general populations • Randomly identify households - gather urine samples of all individuals 6 yrs and older in household. (all must have lived in house 6 months or longer • Evaluate through epi studies risk factors for exposure and adverse health outcomes for exposed populations

20. Arsenic Properties Environmental fate Elemental: Properties: Cannot be destroyed in environment – only changes form • When broken down into smaller particles: enters air, water and dust • Organic forms dissolve in water – finfish & shellfish accumulate • Most of arsenic in water will end up on soil or sediment in water

21. Arsenic Sources Where is it found? – Naturally and anthropoegenic • Industrial processes: Tacoma and Everett – smelters – coal fired plants • Spokane, Tri-County and Clark Co areas - Pockets of natural arsenic in basalt formations – from ground water sources of drinking water • Commercial products – commercial arsenic containing pesticides: orchards, vineyards, cotton dessicants, cattle and sheep dips, paints and pigments, antifouling paints, leaded gasoline and firs salts multicolor flame) • Pressure treated lumber – CCA – copper chromated arsenic • Foods: wines, tobacco ( because of herbicides and pesticides) • Shellfish and finfish – bivalves, certain cold water and bottom-feeding fish – finfish and seaweed

22. Arsenic Exposure Ingestion – ( 60 – 90% absorption in GI tract) • From swallowing dirt or air particles and getting into gastrointestinal system From eating arsenic laden fish or shellfish Inhalation ( 60 – 90% absorption across lung membrane) • From breathing air containing arsenic • Living in areas unusually high in arsenic • Working in a job that involves arsenic production: copper or lead smelting – wood treating or pesticide application • Dermal – minimal absorption

23. Bioaccumulation and testing for Arsenic Exposure • After absorption in lungs or GI tract – Arsenic initially accumulates in the liver, spleen, kidney, lungs and GI Tract - clearance in several days • After 2 – 4 weeks after exposures – arsenic remaining is found in keratin rich tissues such as skin, hair, and nails -lesser extent – bones and teeth - Arsenic is excreted primarily through kidneys • Arsenic is excreted primarily through kidneys - - best route (least harm/impact to person) to evaluate low level chronic exposure to arsenic

24. Toxicology of Arsenic Exposure • Two mechanisms of arsenic toxicity - impairs tissue respiration: • Arsenic binds with sulfhydryl (-SH) groups and disrupts – SH containing enzymes – inhibition of TCA cycle ( Krebs cycle), gluconeogenesis and oxidative phosphorylation • Substitution of As(V) for phosphorus in many biochemical reactions - leads to loss of high energy phosphate bonds – and uncouples oxydative phosphorylation

25. Health Effects of Arsenic Exposure • Skin lesions • Hemorrhagic gastroenteritis • Liver toxicity • Anemia • Cardiovascular effects - vasospasm - Peripheral vascular insufficiency (Gangrene) • Neurologic effects - Peripheral neuropathy • Dermal changes – pigment changes and some malignant cancers All hallmarks of chronic arsenic ingestion Arsenic is strongly associated with lung and skin cancer in humans – esp work related exposures at high levels • May cause other internal cancers as well – (hepatic angiosarcoma – rare form of cancer) *

26. How to evaluate if populations with higher exposures have more adverse related health effects Epidemiological studies Case control study– retrospective Case: people with adverse health outcome Controls: people without adverse health outcomes: Blackfoot disease, Raynaud’s syndrome, peripheral neuropathy, Cancers: rare liver cancer, dermal, Look at: exposure levels in urine of those with disease and those without, Statistically evaluate whether people with adverse health conditions had higher levels of arsenic: Odds Ratio Rate of having adverse outcome – given exposure Rate of having adverse outcome – given no exposure

27. How to evaluate if populations with higher exposures have more adverse related health effects Epidemiological studies Prospective or Cohort Study: Look at: exposure levels in urine of all people – follow them over time – to see if those with exposure have higher levels of disease than those without or with lesser exposure Statistically evaluate whether people with higher exposures of arsenic had more disease and what kinds of disease: adverse health conditions had higher levels of arsenic Calculate: relative risk Evaluate the statistical significance of the finding

28. Proving Disease Causation: Does the association meet the criterai for determining causality? • Strength of association – statistically significant or could “chance” be at play? • Consistencies with other studies? • Is association – disease specific? • Appropriate time relationship? • Dose response relationship • Plausible relationship? • Coherence – biologically plausible? • Experimental evidence – in- vivo,in-vitro

29. Public health in Washington StateJude Van Buren DrPH, MPH, RNAssistant Secretary – Division of Epidemiology, Health Statistics and Public Health LaboratoriesWashington State Departmen of Health YOUR LOGO HERE