Dutchess County Department of Health

Transcription

1 Dutchess County Department of Health 2005 Annual Report Healthy People In Healthy Communities William R. Steinhaus County Executive Michael C. Caldwell, MD, MPH Commissioner of Health

2 Each year, we move in the forefront to achieve the Department of Health s mission toward protection and promoting the health of individuals, families, communities, and the environment of Dutchess County. The County Department of Health has made great strides to prevent and reduce the burden of chronic and infectious diseases, to inform, educate and empower our residents about health issues, and to protect the health and lives of our residents. In 2005, the Department of Health continued to make strides toward preventing and reducing the burden of chronic and infectious diseases, informing and educating our residents about health issues, advancing community partnerships, and protecting the health and lives of our residents. The major accomplishments in 2005 include: Establishment of the Dutchess RX Prescription Drug discount Program Enforcing regulations that protect us against Environmental Hazards Completion of the Community Health Assessment Enhancement of our Emergency Preparedness Responding to the Flu Vaccine Shortage Strengthening The Medical Examiner s Office Participating in Clinical Trials The 2005 Dutchess County Department of Health Annual Report provides an opportunity to review our accomplishments. We welcome your input and your participation in making Dutchess County a healthy community. Sincerely, William R. Steinhaus County Executive Michael C. Caldwell Commissioner of Health 2

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4 Dutchess County Department of Health 2005 Organizational Structure Board Of Health Commissioner Of Health Public Health Information Admin Health Planning & Education Environmental Water Laboratory Environmental Health Medical Examiner Clinical Physician Public Health Nursing and Communicable Disease Dutchess County Department of Health Poughkeepsie District Office 387 Main Street - Poughkeepsie, NY Voice: TTY: Fax: Millbrook District Office Collegeview Beacon District Office (Fax) (Fax) (Fax)

5 VISION AND MISSION STATEMENTS The Dutchess County Department of Health is a diverse group of capable experienced individuals and motivated professionals whose Mission is to protect and promote the health of individuals, families, communities, and the environment of Dutchess County. Our Vision is to build on our tradition of excellence, leadership, and compassion, using the best available science and resources to promote the highest standards of Public Health in response to emerging issues to protect and assist our community. We Value The practice of prevention The on-going assessment of the strengths and health needs of our community Research and its application to Public Health practice The pursuit of innovative solutions to Public Health practice Ethical principals in the work place Culturally sensitive, courteous and respectful treatment of people Excellence in all areas of Public Health Each other s input to guide decision-making Encouragement of staff to develop to their full potential Community service and volunteerism Public and private partnerships Written policies and procedures to guide our daily operations Sensitivity and accommodation of special needs populations Open and honest communications Best use of people and resources Respect for and management of confidential information A quality work environment and safety in the work place 5

6 Public Health Core Functions The Dutchess County Department of Health is committed to the core functions of Public Health and strives to deliver the essential services necessary for people to live healthy lives. The following is a summary of the Public Health functions. The Core Functions of Public Health are: 1. Assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities; 2. Formulating public policies, in collaboration with community and government leaders, designed to solve identified local and national health problems and priorities; 3. Assuring that all populations have access to appropriate and cost effective care, including health promotion and disease prevention services, and evaluation of the effectiveness of that care. 6

7 Fiscal Information 2005 Total Receipts by Source $21,352,444 General Fund Subsidy Grants Clinic Fees Environmental Health Other Charges Vital Statistics Home Visiting Total Expenditures by cluster $31,178,341 Assessment and Health Information Support Services Environmental Health Health Services $35,000,000 $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $ Expenditures Revenues Statistics as given by DCDOH Administration These charts illustrate the Dutchess County Department of Health s major sources of income and expenditures for the fiscal years 1999 to They reflect all receipts and expenses incurred by the Department. New York State Aid (Public Health Law, Article 6) continues to be the major funding source for our various Public Health activities. However, the trend in recent years illustrates more reliance on grants and fees for services. Due to the growth in our revenues, we have been able to increase the level of services provided to the community. In 2005, Dutchess County Department of Health received 15 different grants which totaled $2,425,356. These grants have covered a variety of Public Health concerns including diabetes, youth tobacco use prevention, nutrition, heart health, Bioterrorism and Emergency Preparedness, Lyme disease, HIV/AIDS, West Nile virus, lead poisoning, rabies, immunizations, tuberculosis, and improving the home health of our Dutchess County families. The individual amounts of these awards range from $10,500 to $667,000. Note: This budget does not include the Ryan White Title I federal funding to provide services to persons with HIV/AIDS, for which the Department serves as administrative agency. 7

8 A. PREVENTING AND REDUCING THE THREAT OF DISEASES Flu/Pneumococcal Vaccine Program In the fall of 2005, we held 30 flu clinics at various sites throughout the county to ensure we had enough vaccine to adequately serve those residents who attended these clinics. By the end of 2005, a total of 6,871 individuals had received flu vaccine, with 4,790 of them aged 65 and older. Additional supplies of flu vaccine from the New York State Department of Health were offered to private providers who experienced a shortage earlier in the season, to enable them to provide the vaccine directly to their high-risk patients. Childhood Immunization Program The Childhood Immunization Program provides all recommended childhood vaccines to children in Dutchess County. The program offers clinics throughout Dutchess County as well as educational opportunities to schools, community agencies, health care providers, and parents. As evaluation of immunization rates in private medical practices has been a priority, data is collected from participating medical practices by immunization program staff. The results of the analysis are used to establish accurate immunization levels and to improve immunization rates in private practices. This information is used to target programs and services to areas with the highest rates of under immunized children. In 2005, 88% of children seen at public clinics were fully immunized by age two. The HealthyShot immunization tracking and recall computer software program is being utilized. This software is part of the New York State Immunization Information System that also includes an immunization registry. The registry allows private health care providers, local health units, and schools to share immunization information. This software assists in preventing additional vaccinations for children due to lost or unavailable immunization records. In addition, reminder cards sent via the computerized tracking and recall features of the system help to increase immunization rates. The Childhood Immunization Program staff continues to work toward the goal of increasing the use of this system among health care providers in Dutchess County. Adult Vaccine Program Travel Vaccination Program The International Travel Vaccination Program and the Adult Vaccination Program provide vaccination and health information to travelers and other adults. In 2005, 414 individuals received important travel advice and vaccinations against at least sixteen diseases: (e.g., typhoid fever, yellow fever, hepatitis A and meningitis). In addition, 326 individuals received adult immunizations at the Adult Immunization Clinics conducted. Immunizations for international travel are available on the second and fourth Wednesday of every month, by appointment, at the Dutchess County Department of Health s main office in Poughkeepsie. Adult immunizations are given on these same days with no appointment necessary. Individuals can also call to make an appointment. 8

9 Children in Foster Care Public Health Nurses provide developmental surveillance on children newborn to age five years who are placed in foster care. The nurses work with the foster care DSS workers and foster parents to assure these children are provided routine health assessments, developmental screenings and referral to needed services. A public health nurse is regularly scheduled at DSS to review medical records. The nurse assists to have medical records ready for adoption proceedings and make recommendations for needed medical follow-up. From April 2002 to December of 2005, the nurses have provided services to 98 children. Rabies Program During 2005, the Environmental Health Services Division conducted or participated in six free rabies clinics in the Towns of Pleasant Valley, Hyde Park, East Fishkill, Glenham, Beacon and LaGrange resulting in the inoculation of 741 domestic animals with rabies vaccine. The Department authorized the post-exposure treatment of 54 persons following their exposure to rabid or suspected rabid animals. Public Health Nurses complete the series of rabies vaccinations given to persons who have had an exposure to a known or suspected rabid animal. A change in the number of companies producing this vaccine and a vaccine recall made the program more challenging than usual. Public Health Nurses have administered rabies vaccine to 44 individuals in Tuberculosis Control Program In 2005, the DCDOH served 65 individuals through the Tuberculosis Control Program s Pulmonary Clinic. Individuals receive medical evaluations to rule out active tuberculosis as well as provide HIV testing and counseling services. Out of the 7 individuals diagnosed with active tuberculosis in Dutchess County, 2 individuals received medical treatment and follow-up through the Tuberculosis Control Program, three by their private physician and the other 2 were through DOCs. All individuals diagnosed with active tuberculosis received Directly Observed Therapy (DOT) by Program staff to insure medication compliance and reduce the risk of disease transmission. 9

10 Active TB Cases from 2002 to Community Dept. of Corrections Statistics as reported by Dutchess County Department of Health Communicable Disease Control Division Sixty-five (65) individuals were enrolled in the Tuberculosis Control Program s Latent Tuberculosis Infection (LTBI) Program. These individuals do not have active disease and are not infectious but are still recommended for treatment to insure they do not develop active tuberculosis later on in life. Patients enrolled in the LTBI Program received a regimen of prescribed medications and regular nursing assessments to evaluate and follow up any complications or side effects from treatment. Screening for tuberculosis through Mantoux Skin Testing continued to be done through weekly clinics. In 2005, 667 individuals were screened through Mantoux clinic. Individuals attending these clinics request screening for employment and school requirements, volunteer activities, and entrance into drug/alcohol rehab centers and homeless shelters. The Tuberculosis Control Program also collaborates with community health centers and the Dutchess County Jail to provide targeted testing for high-risk individuals. Maternal Child Health Home Visiting Program Public Health Nurses play an extensive role in monitoring and improving maternal and child health in the County. In 2005, public health nurses received a total of 672 referrals and made a total of 2,440 visits in the context of maternal child home visiting. There was a 16% decrease in the number of referrals made to the MCH Program this year along with a 24% decrease in the number of home visits. Both of these decreases are due to nursing staff vacancies. The program participated in several new collaborative ventures in Public health nurses collaborated with Vassar Brothers Medical Center s Centering Pregnancy Program and Astor Early Childhood s Maternal Depression Support Program. In 2005, the distribution of services was as follows: Metropolitan area (Poughkeepsie C/T, Hyde Park) 56.1% Southern area (Wapp.Falls, E. Fishkill, Beekman, Pawling, Fishkill, Beacon) 24.1% Rural area (Pine Plains, Northeast, Washington, Amenia, Dover, 19.8% LaGrange, Pleasant Valley, UnionVale) 10

11 Newborn Screening Program Public Health Law sections 2500-a and mandate that all infants born in New York State receive metabolic testing for 44 diseases and an Infant hearing screening. The testing and blood specimens are done in the first 48 hours of the baby s life. If repeat testing or additional testing is needed the local health department is notified. A public health nurse follows up to make sure all additional tests are completed. In 2005, there were 35 infants who received these services. Certified Home Health Agency (CHHA) Long Term Home Health Care Programs (LTHHCP) Our CHHA and LTHHCP provide skilled nursing, Home Health Aides (HHAs), and other support services to Dutchess County residents in their homes. Increased regulatory requirements for paperwork required by insurance companies and regulatory agencies continue to be a challenge. In 2005, Public Health Nurses administered flu vaccine to 95 high-risk residents in their homes in addition to their regular caseload. The home care supervisory staff provides consultation and serves in advisory roles on several planning committees, including: The Elder Abuse Task Force, The Hudson Valley Home Care Providers Association, Eastern Dutchess County Rural Health Care Network, The Home Care Association of Dutchess County, and the Sharon Primary Health Network Certified Home Health Agency (Unit of Services) Nursing 7,900 Physical Therapy 1,292 Occupational Therapy 38 Home Health Aide 2,078 Medical Social Worker Long Term Home Health Care (Unit of Services) Nursing 1,762 Physical Therapy 586 Occupational Therapy 11 Home Health Aide 921 Personal Care Aide 3539 Nutrition 2 Medical Social Worker 213 Home Delivered Meals 2,641 Personal Emergency Response Service (PERS) 364 Social Day Care 1,620 Statistics as reported by the Dutchess County Department of Health Nursing Division Eastern Dutchess Maternity Clinic 11

12 In 2005, the EDMC enrolled 61 pregnant women for prenatal care. During this time there were 45 deliveries. Two women delivered prematurely; one at 29 weeks, and one, a set of twins at 30 weeks. There has been a 5% increase in the Hispanic population. More than 30% of the EDMC population is Latino, primarily from Mexico and Guatemala, with a majority living on the farms in Eastern Dutchess. The Smoking Cessation Program continues to make diligent efforts on a regular basis to promote the adverse effects of smoking on both the pregnant woman and the unborn child. During 2005, 20 women were counseled. Five women quit smoking throughout the duration of their pregnancy and post partum period. Ten women significantly reduced the amount of tobacco used. Five women acknowledged that they were not ready to quit. In 2004, the American College of Obstetricians and Gynecologists (ACOG) recommendations changed and recommended Cystic Fibrosis screening for all women receiving prenatal care. In order to comply with this recommendation, the Eastern Dutchess Maternity Clinic staff had to find a way to provide the screening that was not included in the New York State Department of Health s Prenatal Care Assistance Program (PCAP) rate. Arrangements are in place to provide this screening and have the cost billed directly to Medicaid. Since the recommendations have been in place, all women enrolled in the Eastern Dutchess Maternity Clinic have received education and screening for Cystic Fibrosis. Children With Special Needs The Early Intervention Program provided services to over 1,286 infants and toddlers with disabilities and their families with an expenditure of $5.5 M. The Preschool Special Education Program provided services to 986 children ages 3-5 with an expenditure of $10.5 M. Both programs have responded to the growing number of Spanish-speaking children and families in each program by contracting with bilingual teachers and therapists in every discipline, and collaborating with St. Francis Preschool on a program of speech therapy groups for young children with severe speech delays in their native language. Parents also attend the sessions to learn techniques in supporting their children s language development. Busing is provided for families unable to supply their own transportation. Childhood Lead Poisoning Prevention Program 12

13 The focus of the Childhood Lead Poisoning Prevention Program (CLPPP) continues to be increased testing. In 2005, 121 children were diagnosed with having a lead level of 10, which is an increase from 106 children in In addition, in 2005, 12 children were diagnosed with increased lead levels of 20 or higher as opposed to 19 in Program staff conducted 51 educational programs, outreach and health fairs for area health care providers, community agencies, parent groups, and Women Infant and Children s Nutrition program sites (WIC) throughout Dutchess County. The major outreach events of the year included the Greater Hudson Valley Home Show and 2005 Kid s Expo where materials and education were made available to the public. Sexually Transmitted Infections Program Testing, diagnosis, and treatment of sexually transmitted infections are available twice a week. All services are free, confidential, and available without an appointment. Free Hepatitis A &B vaccines are available to all clinic patients 18 years and older. Cervical and breast cancer screening is available for high risk women who meet financial/medical criteria established by the New York State Department of Health Healthy Women s Partnership. Referrals are made for all patients with additional service needs. There were 1,300 visits in STD CLINIC VISITS 1,113 1,152 1,245 1, Data as reported by Dutchess County Department of Health Communicable Disease Control Division Dutchess County DOH Sexually Transmitted Disease Data Chlamydia Gonorrhea Primary Syphilis Secondary Syphilis Early Latent Syphilis Data as reported by Dutchess County Department of Health Communicable Disease Control Division Gonorrhea morbidity has been consistently below the 200 case reports for 8 years. 13

14 Chlamydia became reportable in August of 2000 and is now the most common reported STD Increased Chlamydia morbidity is probably attributable to Public Health Advisor efforts, reporting and NAAT testing methods initiated in Dutchess County Department of Health s Communicable Disease Control Division partners with Healthy Women s Partnership (HWP) to provide PAP smears, clinical breast exams, and mammography referrals for eligible women. GlaxoSmithKline Pharmaceutical Cervical Cancer Vaccine Clinical Research Trial under contract Fishkill Obstetrics and Gynecology provides clinical evaluation and care for research participants. Hepatitis C virus screening services patients screened in 2005, 219 in 2004 and 246 patients in Hepatitis A and B Immunization - expanded access to Hepatitis A and B vaccine in the HIV/TB increases access to vaccine for high-risk patients. Activity Hepatitis Vaccines Administered Data as reported by Dutchess County Department of Health Communicable Disease Control Division HIV Counseling and Testing Program HIV counseling and testing is available by appointment or walk-in. All testing is free of charge and both "anonymous" and "confidential" testing is offered. Confidential counseling and testing is also available in conjunction with STD and TB clinics. Partner Notification Assistance Program (PNAP) and testing is available to persons living with HIV/AIDS who should inform partners of possible exposure to HIV. The tables below provide data for HIV tests given at various clinic sites and the number of HIV tests given from by Dutchess County Department of Health s Communicable Disease Control Division staff Number of HIV Tests by DCDOH at various clinics STD clinic HIV clinic Methadone Camp Beacon 818 PNAP Number of HIV Tests given by DCDOH from

15 ,006 1,076 1,113 1, Data as reported by Dutchess County Department of Health Communicable Disease Control Division Street Outreach: The Dutchess County Department of health s outreach team restructured and intensified its outreach program in The summer program venues focused on street outreach including high areas of congregations such as Main Street, Poughkeepsie and various parks as well as programs serving the homeless populations such as The Lunch Box (soup kitchen) and the Living Room (housing and other services). Outreach to men having sex with men (MSM) was accomplished by outreach in two high traffic local bookstores where sexual activity takes place. In the off season efforts are re-focused to target local colleges, a population which is identified by DCDOH as high risk. In 2005 there were 23 outreach events reaching 638 persons. Rapid Testing: Rapid HIV testing was implemented in July Our primary purpose in initiating this was to increase the number of persons tested for HIV who received their results. Previous types of HIV tests had a 1 2 week turn around time for receiving results. An increasing number of persons tested never returned to receive their results. Prior to beginning the rapid test our return rate was down to approximately 60%. In 2005 we have done 1,196 rapid tests. Our percentage of those receiving their results has been 96%-100%. Quality Improvement: A new chart audit tool was developed for HIV counseling and testing in the first half of 2004 as a part of the Department-wide strategic planning Quality Assurance initiative. Peer audits and case presentations are done quarterly. This has improved the quality of patient care by involving the HIV counselors in the audit process, thus making it a learning experience for all. HIV Prevention and Community Education and Outreach: HIV/STD prevention education is targeted to high risk populations and offered regularly at multiple sites throughout Dutchess County. These sites include substance abuse treatment centers, alternative to incarceration programs, centers serving the homeless, soup kitchens, adolescent programs and mental hygiene centers. In 2005, 73 programs were presented reaching 2043 persons. As a result of these Community Education and Outreach efforts, HIV Counseling and Testing continues to increase. In 2004, 1043 HIV tests were performed identifying 9 HIV + persons and in 2005, 1243 were done identifying 12 HIV + persons. 15

16 Inter-Departmental Partnership: In attempt to outreach to a higher-risk population, the Department continued HIV counseling and testing at the Methadone Program Clinic in 2005 and expanded HIV counseling and testing at STD Clinics. The Department counseled and tested 20 methadone patients and 818 STD clinic patients from a total of 1,243 individuals tested in Ryan White Care Act, Title I Program Over the past five years, the prevalence of AIDS is steadily increasing, from 536 cases in 2000 to 801 in There were 182 new AIDS cases reported from January 2004 to December This is a 14% increase from the previous year for AIDS incidence in Dutchess County. Among the new cases, men accounted for 80% of the cases compared to women, who accounted for 20%. Both men and women in the EMA are twice as likely to have AIDS as compared to national AIDS incident rates. Prior to Dutchess County s designation as an Eligible Metropolitan Area (EMA) in 1995, there was no established continuum of HIV/AIDS care. Many People Living With HIV (PLWH) were first diagnosed in the hospital emergency room, presenting with opportunistic infections, or through limited Department of Health testing. There were few local support services. With receipt of Title I funding in 1995, Planning Council was created by the County Executive to establish an effective compassionate and comprehensive system of health care and other support for people living with HIV/AIDS in Dutchess County. In 2005, Ryan White Title I funds were allocated to services that would keep PLWH in primary care and get into care those who know their HIV positive status but are not in care Ryan White Title I Program Report (March 1, 2005-February 28, 2006) SERVICE CATEGORY Primary Care, including individual medication adherence support, medical case management and mental health assessment and treatment by a dedicated licensed social worker. Mental Health and Substance Abuse Provides substance abuse and mental health support services, Conducts outreach and education to Intravenous drug users that are living with HIV disease. ACCOMPLISHMENT/OUTCOME Primary Care services were provided to two hundred and five (205) clients living with HIV disease, of which one hundred and ninety one (191) were provided with appropriate specialty care referrals. Thirty three (33) clients were provided with an individualized medication adherence intake and assessment. Forty-two (42) unduplicated clients were seen between two clinical professionals. Fifteen (15) clients participated in substance abuse and mental health groups led by Certified Social Workers. The group provides intensive support for clients experiencing compounding problems in addition to their HIV diagnosis. The field-based return to service component of the program reaches clients who have not been attending primary care visits and/or mental health or substance abuse support visits. Fifty-six (56) IDUs were reached through this program to reduce harm and risk and facilitate linkage to care. 16

17 2005 Ryan White Title I Program Report (March 1, 2005-February 28, 2006) SERVICE CATEGORY Case Management, including Assessment of client s needs and personal support system, development of an individual service plan, monitoring and reevaluation to determine the effectiveness of interventions. At intake, case managers confirm client s linkages with primary care services. Early Intervention Program (EIS). The EIS Program s scope is to locate, engage and link PLWH who are not currently accessing the health care system. The program is charged with providing street level outreach in non-traditional times & venues. Transportation Transportation is provided only for medical, case management, mental heath and substance abuse services. Emergency Financial Assistance provides consumers with financial assistance for utility, phone and prescription medicine. Home Delivered Meals provides home delivered meals to those recently released from the hospital or home bound for medical reasons. ADAP The AIDS Drug Assistance Program (ADAP) provides medications for the treatment of HIV disease. ACCOMPLISHMENT/OUTCOME In FY 2005, a total of sixty six (66) clients were served between two providers. Thirty-six (36) African Americans and nine (9) Hispanics were served by this category. Case managers assess clients needs and personal supports, mutually develop individual service plans, monitors and reevaluates to determine the effectiveness of interventions. Referrals are made to an array of services such as ADAP, transportation and financial assistance. PLWH/A are also linked to rehabilitation, employment and educational services depending on their need and health condition. Medical and community case managers regularly case conference to support continuity of care and medical adherence. An interdisciplinary team of providers case conferenced twenty four (24) clients during the reporting period. In FY 2005, the SHARP team had one thousand 1,943 encounters with 1,832 individuals at risk in the Dutchess County EMA. The program located and engaged 123 PLWH, connecting 21 of them to primary care and support services. The program receives Minority AIDS Initiative (MAI) funds and has successfully targeted minority high risk populations. The SHARP team located 34 African American and 11 Hispanic PLWH who are not enrolled in primary medical care. Actual monthly rides and client counts reports are based on reconciled vendor bills. During the FY 2005 period, the Transportation program provided 501 service units to 79 unduplicated clients. These numbers include 486 vendor rides and 15 bus/train vouchers. The program assisted twenty-eight (28) eligible clients, including that required emergency assistance for telephone, utilities and medications, and ten (10) that accessed the program s food pantry. The program notes that all of the prescription assistance requested has been for non-antiretroviral and other non-hiv related medication. In FY 2005, 8,640 meals were delivered to 48 eligible clients. Two clients were referred by Fishkill Home Care and are in the late stage of disease progression. Clients who are assessed by their physician and feeling better are able to be transitioned from the program and are given nutritional advisement, using meals provided as a model representation of a balanced nutritious meal that they would adopt. In FY2005, 194 eligible clients received assistance with medications fur the treatment of HIV disease. 23 new eligible clients were served. 17

18 Other major activities in 2005 should also be noted: Several quality-based projects were undertaken to increase the quality of care throughout the Title I funded continuum. The overarching quality theme for supportive service providers (case management, mental health, substance abuse, early intervention services nutrition, and emergency services) was to ensure access to and maintenance in HIV Primary Care Services. The Dutchess County Department of Health was proactive in monitoring and planning for changes to Medicare Part D for both consumers and providers. Medicare changes came into effect January 1, These changes have a significant impact on those clients covered by Medicare, but perhaps more significantly to Dutchess Title I clients, Medicaid and ADAP as well. The majority of local Title I clients are covered by these forms of publicly funded insurance. To assess local impact, the Department of Health requested quantitative and qualitative data from funded providers regarding Persons Living with HIV/AIDS (PLWH) ability to navigate Medicare s changes in benefits, and absorb the financial consequences of Medicare Part D changes. A Technical Assistance training was provided by Christine Rivera from New York State Department of Health s Uninsured Care Programs (ADAP) and was attended by more than 40 local health and human service providers. The Grantee plans to address any subsequent issues and plan for the inevitable additional changes to the publicly funded insurance sources and impact on local clients In FY 2005, the Planning Council completed a Needs Assessment and Comprehensive Services Plan for the EMA. The purpose of the comprehensive plan was to guide the planning council in the development of a coordinated system of care for PLWH. It included clear goals, objectives and strategies for action as well as mechanisms for assessing progress. A peer-based treatment adherence program was implemented, providing eligible clients with HIV specific treatment adherence services. Services include: individual counseling, peer facilitated support group, and adherence education. Lyme Disease & Other Tick-borne Infections Lyme disease and other tick borne diseases continue to be a major concern in Dutchess County even though the number of cases have decreased since Dutchess County Department of Health continues to offer education, prevention, and surveillance activities. Confirmed Cases of Tick-Borne Disease as reported to the NYS Department of Health Disease /01/2004 to /20/2004 Lyme Disease 1, ,400 Ehrlichiosis Babesiosis Rocky Mountain Spotted Fever Data as reported by Dutchess County Department of Health Communicable Disease Control Division 18

19 Laboratory and Physician Reports of Tick-Borne Disease as reported to the Dutchess County Department of Health Disease /01/2004 to /20/2004 Lyme Disease 5,783 4,542 3,605 Ehrlichiosis Babesiosis Rocky Mountain Spotted Fever Data as reported by Dutchess County Department of Health Communicable Disease Control Division Other Common and Emerging communicable diseases The Dutchess County Department of Health Communicable Disease Control Division continues to respond to all common and emerging communicable disease with a timely response to assure control measures are implemented rapidly. This response has resulted in significant reductions for common reported infectious diseases such as giardiasis and salmonella. Reported Cases of Giardiasis in Dutchess County, NY Data as reported by Dutchess County Department of Health Communicable Disease Control Division 19

20 Reported Cases of Salmonella in Dutchess County, NY Data as reported by Dutchess County Department of Health Communicable Disease Control Division West Nile Virus (WNV) In 2005, there were no reported human cases of West Nile Virus (WNV). The Department continues to conduct surveillance of dead birds and mosquitoes. A total of 404 dead birds were reported in 2005, which is more than 2004 (215) but less than reported in 2003 (865) or in 2002 (656). Of the 404 birds reported, there were 206 crows, 17 house sparrows, 15 blue jays, and 166 other species. The majority reported was from the City and Town of Poughkeepsie and the Town of Pleasant Valley. Fifteen birds were found positive for WNV in the City of Poughkeepsie, two in the Town of Poughkeepsie and 12 in the city of Poughkeepsie prior to April of (See Number of birds sighted by township on chart below). A total of 5,494 mosquitoes were collected and 166 adult mosquito pools were submitted for WNV testing during the 2005 season. Three mosquito pools collected in the Town of Poughkeepsie 8/17 and 8/31 were found positive for WNV. The Department continues to address the issue of the West Nile Virus during 2005 through treatment of more than 9,000 catch basins throughout Dutchess County with biological mosquito larvicide in order to reduce the transmission of this virus within the community. 20

21 Number of birds sighted by township 2005 Municipality Jan Feb Mar Apr May Jun Jul AugSep Oct Nov Dec Total Percent City of Poughkeepsie Pleasant Valley Poughkeepsie East Fishkill LaGrange Hyde Park Wappinger City of Beacon Fishkill Pawling Red Hook Beekman Village of Rhinebeck Clinton Amenia Dover North East Rhinebeck UnionVale Pine Plains Village of Tivoli Village of Wappingers Falls, Wappinger Washington Village of Millerton Village of Pawling Village of Red Hook Unknown Total

22 B. INFORM AND EMPOWER PEOPLE ABOUT HEALTH ISSUES Health information, health education, and health communication activities designed to reduce health risk and promote better health are crucial to ensure a healthy community. Putting Public Health on the community agenda is one of the critical tasks local health departments are called to do. The Dutchess County Department of Health accomplished this by increasing its communication with the public through the media, participating in health fairs and other community events, as well as engaging in direct community educational presentations. Health Communication Activities The Commissioner s Column in the Poughkeepsie Journal appeared on the second Sunday of each month during This regular column provided on going communication with the general public on a variety of health topics, raising awareness and understanding of public health issues. Press releases and PSAs were sent out to weekly to all local media. In 2005, a total of 48 press releases and PSAs were sent out on a variety of topics. The Dutchess County Department of Health s web page on the County website was also regularly updated to provide information to the public. In 2005 there were a cumulative number of 174,591 hits were recorded for Dutchess County Department of Health s pages, an average of 478 hits per day. Hotlines were set up and ran for Lyme and West Nile Virus as well as the Adult Public Flu Clinic Program. All hotlines were heavily used, with variation during seasonal periods (i.e. summer months pick for WNV, Lyme and fall for Flu). Dutchess County Department of Health staff also organized and/or participated in special events such as Lyme Disease Week, Breast Cancer Month, and World AIDS Day. The Dutchess County Department of Health continues to receive requests for presentations for health programs from day care providers, Pre School, elementary, middle and high schools, colleges, and camps. Public Health Nursing staff, Public Health Advisors, Sanitarians, and Public Health Education Coordinators combined provided over 400 educational presentations during the year, reaching more than 8,000 individuals (combined children and adults). Pre- and post-tests as well as satisfaction surveys were utilized for 80% of these presentations and revealed an overall good satisfaction as well as good retention of the information presented. 22

23 Community Education In 2005 there were a total of 9 educational presentations in schools and Community Based Organizations given on Tobacco Use Prevention, reaching a total of 177 students/youths/adults. Evaluation of the presentations conducted revealed the following: The program was rated as excellent by 75% of the recipients and very good by 25% Pre and post tests surveys revealed an increased in awareness among the majority of the students (Maintained 67.6% and Increased 27.6%). Several West Nile Virus educational activities were conducted, ranging from mass mailing to health fairs, press releases, website posting, telephone hotline, educational presentations to target audiences, and distribution of information during public events. In 2005, there were a total of 287 calls through the West Nile Virus hotline. A total of 43 callers were mailed WNV literature on topics such as West Nile virus, mosquitoes and public health, personal precautions, and steps that can be taken around the home or business to prevent mosquito breeding. A total of 103 Nutritional and physical activity educational presentations including Eat Well Play Hard strategies, portion distortion and portion size were conducted, reaching 1893 students/adults Diabetes education/awareness was offered at one (1) scheduled Diabetes Sundays reaching 1139 parishioners in Diabetes Sunday is a ten-minute educational awareness program offered to the faith community. A simple definition of diabetes, current statistics, risk factors, signs, and symptoms are provided for the audience. There were also 15 presentations offered regarding diabetes and healthy eating for people with diabetes, reaching 283 individuals. In 2005, fifty-seven (57) presentations were given on Stress Management and Cardio-vascular Health and CPR Heartsaver classes to 525 employees, schools and at risk minority populations in the community and at the local jail. Evaluations consistently reported increased knowledge and satisfaction with the program. In order to promote better life skill choices, a total of fifteen (15) teen pregnancy prevention using the Empathy Belly were given to 382 middle and high school students throughout Dutchess County. Sixty-eight (68) presentations were given promoting good oral care to a total of 1322 students and teachers at various elementary and preschools within Dutchess County. In 2005 there were 75 educational programs on HIV/AIDS/STD/HEPATITIS reaching 2,088 participants in schools, substance abuse centers, mental hygiene community facilities, alternative to carceration and correctional facilities. There was 100% overall satisfaction and raised awareness. A total of fifteen (15) LYME educationals were done reaching 887 students and adults. Pre/Post tests surveys revealed an increase of awareness with 75% maintaining and 23% increased knowledge. 23

24 THE DUTCHESS RX PRESCRIPTION DRUG DISCOUNT PROGRAM Dutchess County launched a discount card program to help consumers cope with the high price of prescription drugs. The Department of Health was assigned the responsibility for implementing the program. The free prescription drug discount cards was made available under a program sponsored by the National Association of Counties (NACo) that offers average savings of 20 percent off the retail price of commonly prescribed drugs. The program is administered by AdvancePCS, a division of Caremark Rx, Inc. of Nashville, Tenn. The cards may be used by all county residents, regardless of age, income, or existing health coverage, and are accepted at 58 pharmacies throughout the county. A national network of more than 54,000 participating retail pharmacies also will honor the NACo prescription discount card. There is no enrollment form, no membership fee and no restrictions or limits on frequency of use. Cardholders and their family members may use the card any time their prescriptions are not covered by insurance. As of December 2005, more than 500 residents had used the prescription discount card to fill 8,051 prescriptions, saving $110,097 with an average of 23% savings per prescription. Prescription Discount Drug Program Status Report Month February March April May June July August September October November December Total Residents Served Per Month Total Residents Served YTD Total Prescriptions Covered Per Month Total Prescriptions Covered YTD Price Savings Per Month Price Savings YTD % Price Savings Per Prescription $98 $98 32% $734 $832 31% $1,107 $1,939 25% $7,286 $9,225 23% ,414 $11,358 $20,583 22% 410 1, ,356 $12,653 $33,236 23% 425 1,488 1,012 3,368 $13,086 $46,322 22% 496 1,984 1,185 4,553 $15,518 $61,840 23% 541 2,525 1,225 5,778 $16,306 $78,146 23% 505 3,030 1,165 6,943 $16,023 $94,169 23% 500 3,530 1,108 8,051 15, ,097 23% 24

25 C. COMMUNITY PARTNERSHIPS Several initiatives addressing chronic diseases were implemented including programs addressing childhood obesity, healthy heart, tobacco use, asthma, and diabetes. All of these initiatives were prevention programs involving the community through coalition building and public private partnership. Our community health assessment for was also completed through the partnering with the community. Dutchess County Healthy Families Dutchess County Healthy Families (DCHF) is a grant-funded program that provides comprehensive services that focus on the promotion of the well-being and safety of children. DCHF is a collaboration of public and private agencies at the local level. The program provides voluntary home visiting services by culturally diverse para-professionals to expectant parents and families with infants in cities of Poughkeepsie and Beacon and the towns of Poughkeepsie and Hyde Park. Program activities focus on education and support services for promoting healthy pregnancies and birth outcomes and prevention of child abuse and neglect. The Dutchess County Department of Health the lead agency for the grant and subcontracts with the Mid-Hudson Family Health Institute to provide the intensive home visiting on a weekly basis until the child is at least 6 months old and periodically thereafter based on the needs of the family until the child enters either Head Start or school. Public Health Nursing staff meet regularly with DCHF staff to make joint visits and to provide education and evaluation of developmental screening tests performed on children enrolled in the program and referrals to the Early Intervention Program when necessary. Public Health Nurses provided trainings on child development, care of the newborn, child safety and many other public health topics to the DCHF staff on a quarterly basis. DCHF served 1,050 families in 2005 and provided case management through their Community Health Workers program for another 140 families. In addition, the Public Health Nursing Supervisory staff meets regularly with the DCHF staff and Vassar Brothers Medical Center (VBMC) staff for discharge planning as well as serving on the DCHF Advisory Board. Operation Heart Beat In collaboration with the American Heart Association, the Operation Heart Beat program s objective is to increase the chances of survival for anyone having a cardiac arrest in Dutchess County. To achieve this objective, strategies include CPR training to high school students in Dutchess County before graduation, and implementation of Public Access Defibrillators (PAD). For the September 2004 to June 2005 school year, approximately 1,500 middle and high school students had received CPR training. Dutchess County Department of Health is also responsible for the County s PAD program, to install nine Automated External Defibrillators (AEDs) in eight designated County buildings. In 2004, the final buildings were completed and implemented in the Department of Social Services, Office of Aging and Planning, Department of Mental Hygiene, and the Beacon Health Center. In 2005 an additional nine (9) AED s were purchased: seven (7) for DC Mental Hygiene and two (2) placed in the Parks Department. Fifteen (15) Heartsaver AED classes were given reaching 132 employees. 25

26 SmokeFree Dutchess The SmokeFree Dutchess Coalition is made up of physicians, businesses, schools, not for profit agencies, and individuals interested in preventing smoking related morbidity and mortality in Dutchess County. In 2005, the SmokeFree Dutchess Coalition continued to work on five main objectives: promote cessation among adults and youth, prevent initiation among youth and young adults, decrease social acceptability of tobacco use, eliminate exposure to environmental tobacco smoke, and maintain an effective tobacco control infrastructure. To achieve these goals the coalition promoted the NYS Smokers Quitline by running quit and win contests within the three area hospitals and one college. In conjunction with the quit and win contest a media campaign was implemented utilizing television and radio to promote the Quitline to our residents. Another media promotion was the Smoke Free Homes and Car encouraging residents to take the pledge keeping their cars and homes tobacco free. Smokefree Dutchess held an annual breakfast recognizing residents of the quit and win contest. Children s Health Initiatives The Department of Health continued to oversee the County-allocated funds for comprehensive Youth Tobacco Use Prevention and Childhood Obesity Prevention and Intervention Programs under the auspices of the Children s Health Initiatives, a subcommittee of the Children Services Council. The Department contracts with the United Way of Dutchess County for the administration of the grants which includes overseeing the RFP process, monitoring and evaluating the programmatic and fiscal activities of the service providers. In 2005, the County Executive allocated funds to the Children s Health Initiative (CHI) to look into the increasing problem of childhood obesity. CHI funded a prevalence study in the summer of About 11,000 patient charts from a pediatric provider were reviewed. The sample was representative of the county. Data was analyzed by the Department of Health Epidemiologist and Biostatisticians. Body Mass Index (BMI) was calculated using the Center for Diseases Control and Prevention recommended formula (BMI 85th to < 95th percentile were considered At risk for Overweight ; and BMI = 95th percentile - Obese ). Patient BMI was compared with the reference age & gender specific BMI used in the US Growth Charts. About 19% of the children were found to be obese ; and 17% were at risk for overweight. Prevalence was higher in males than in females. The problem seems to begin early and increase with age. On November 9 th, 2005, CHI co-sponsored a Conference with the Medical Society where the data was presented. 26

27 Childhood Obesity in Dutchess County Overweight/ Obese 19% Normal 61% At risk for Overweight 17% 36% At Risk for Overweight or Overweight/Obese Underweight 3% Source: Childhood Obesity Study 2004, Dutchess County Department of Health & Children s Services Council Additionally, some pilot obesity prevention projects were also funded by the CHI. Youthful Habits was a 10 weeks after school program targeting children with an elevated BMI in the 4 th grade at Netherwood Elementary. The Hyde Park Elementary School also was granted funds to pilot a before school program entitled Healthy Choices. Both programs were successful in meeting their outcomes, including increasing physical activity and consumption of fruits and vegetables by the participants. Parents of the children involved also reported satisfaction with the programs. In 2005, funds were also used to continue the effective anti-tobacco campaign targeting youth between the ages of 8 and 13. Five agencies received tobacco prevention funding: The Martin Luther King Cultural Center in Beacon, the Mid Hudson Children Museum, the Dutchess County Council on Alcohol and Chemical Dependency, Inc, Saint Francis Hospital, and the Dutchess County Medical Society. All five agencies were successful in achieving their expected outcomes. AGENCY PROGRAM OUTCOME D.C. Council on Alcoholism Martin Luther King Cultural Center Mid Hudson Children s Museum St. Francis Hospital Health Care Foundation Children s Media Project Tobacco Youth Free initiative The Theater Project Teens Against Tobacco Use Preventing Alcohol & Drug Abuse Through Primary Prevention Smokescreens 458 students received Life Skills training 155 students completed the TATU training, and 46 made presentations to elementary school children. 25 teachers completed the smokescreens media literacy training 24 parents completed media literacy training 38 youths enrolled with 15 youths taking part in two plays. Youth were also involved in design and painting of a mural, and created 15 banners to display in school settings. 51 youths received TATU training They also created an anti-tobacco video 1,209 students (3 rd, 4 th and 5 th graders) received Get Real About Tobacco and Here s Looking At you curricula Approximately 300 students (8 th graders) participated in media literacy around tobacco facts and designed posters 27

28 Diabetes Coalition The Dutchess County Diabetes Coalition continues to be proactive. One professional educational program for health care professional (nurses, nutritionists, physician assistants, and pharmacists) was offered through the Mid Hudson Catskill Coalition for the Prevention of Diabetes which DCDOH is part of to 100 participating professionals. The Department continued to offer community education programs to local residents in senior housing and local churches. The programs are advertised through church bulletins and posted in the senior centers and pharmacies. All sessions include standards of care for person with diabetes. Community Health Assessment The Dutchess County Department of Health released its Health Assessment in early February 2005, providing accurate, up to date information that allows the examination of the health status of the population for the purposes of: Determining the general and disease-specific health of the community; Assessing the underlying causes of poor health in the community Evaluating the effectiveness of program initiatives to maintain or improve health status; Planning the utilization of resources to address health needs. The Community Health Assessment is available on the county website and contains statistics on the health status of the community and its subgroups, community health needs and community resources. Community involvement included working with other stakeholders, such as local hospitals and other service providers, as well as members of the public. Through focus groups, stakeholders participation offered qualitative information regarding health needs, resources available, and community health priorities. Other Coalitions The Department s personnel regularly participated in various other coalitions, including, but not limited to, the Dutchess County Health 2000 Coalition, Eastern Dutchess Rural Health Network, Dutchess County Housing Consortium, Family and Consumer Science Committee, American Cancer Society, Healthy Women s Partnership, Domestic Violence Prevention Coalition, Teen Pregnancy Prevention Network, American Heart Association, Children Services Providers Network, and the Children Services Council. 28

29 D. PROTECTING THE HEALTH & LIVES OF DUTCHESS COUNTY RESIDENTS The Dutchess County Department of Health is responsible for the enforcement of sanitary codes, especially in the food industry; the protection of our drinking water supply, the enforcement of clean air standards, and the follow up of hazards and exposure-related diseases identified in occupational and community settings. Enforce laws and regulations that protect health and ensure safety The Dutchess County Department of Health is responsible for the enforcement of sanitary codes, especially in the food industry; the protection of our drinking water supply, the enforcement of clean air standards, and the follow up of hazards and exposure-related diseases identified in occupational and community settings. In 2005, 31 Environmental Health Services Division Administrative actions resulted in penalties totaling $31,500 Food Service and other permitted facilities Inspections The total number of inspections conducted by Community Sanitation personnel for all regulated activities equaled 4,701 during The Department s Food Service Facility (FSF) inspection numbers (2,384 inspections in 2005) reflected the continuing growth of the industry within Dutchess County. Clean Indoor Air, Tobacco Sales and Tobacco Use The New York Adolescent Tobacco Use Prevention Act, known as ATUPA- prohibits selling cigarettes to minors, and requires retailers to obtain positive proof that the person buying the cigarettes is over the age of 18. Additionally, the Dutchess County Sanitary Code requires retailers to obtain a Dutchess County permit to sell tobacco products. The Dutchess County Department of Health conducts regular compliance inspections, including compliance checks where minors attempt to purchase tobacco. 29

30 Compliance Checks Results From January 1, 2005 through September 30, 2005 # of retailers # of vending machines # of inspections conducted # of tobacco violation with minors 7 with adults 7 sales to minors 0 sale to adult 1 self service violation Dutchess County Sanitary Code Article 25 requires all private schools and public school districts each year to file a smoking policy with the DCDOH by September 30 th. Additionally, public and private schools that include grades 6 thru 12 are to report smoking/possession violations on school grounds twice per year. Schools Public School Districts (N=30) September 1 st August 31 st 2005 % Submitting smoking % Submitting violation on policies 1st report period % Submitting violation on 2nd report period 62% 94% 80% Private schools (N=33) 37% 80% 53% The public schools submitting reports on smoking/possession violations reported 213 students to be in violation during the 2003/2004 school year. Among the private schools reporting on smoking/possession violations, 8 students were found to be in violation. The number of students referred to the DCDOH during the 2003/2004 school year was 14 of which 5 went to hearing. Environmental Hazards The Environmental Health Services Division conducts environmental lead assessments in homes, schools, and daycares where a child with an elevated blood lead level greater than 20 micrograms per deciliter spends a significant amount of time. In 2005, the Department has conducted 20 environmental investigations resulting in 12 Notice and Demand hearings requiring the discontinuance of conditions conducive to lead poisoning. The Dutchess County Department of Health conducted a review of all spill reports provided to this Department in 2005 by the New York State Department of Environmental Conservation. Spill reports are required to be made anytime there is a release of any petroleum products regardless of quantity into the environment. These reports include reports of releases or spills from petroleum bulk storage facilities, commercial facilities, tank test failures, contaminated soils from tank removals, overfills to tanks, automotive accidents, improper disposal, abandoned drums, and vandalism. In 2005, approximately 15% of 297 spill reports are related to gas stations with petroleum bulk storage capacities greater than 1,100 gallons Spill reports regarding vehicles, transformers and unknown sources accounted for 28% of the reports received. Spills at private residences including tank test failures, contaminated soil, housekeeping issues, equipment malfunction and improper installation accounted for 35% of the 2005 spill reports. Of these 70% were related to tank test failure, contaminated soil and tank replacements. 30

31 Engineering During 2005, over 1,825 engineering plans were received by the Department for review and over 1,855 were reviewed. The Dutchess County Department of Health Environmental Health Services Division received 567 applications to construct residential sewage disposal systems in Of these, 226 were for lots within subdivisions. Of the 567 applications received, 430 were issued building permits. The remainders are pending further action. The plan approval process was a demanding one in 2005, as the following summary indicates: Residential Sewage Individual lots 302 Individual lots (redesigned) 51 Subdivisions 21 (Comprising 305 lots) Subdivision lots redesigned 63 Individual lots in NYC watershed 17 Subdivisions within NYC watershed 0 (Comprising 0 lots) Commercial Sewage New design 61 projects Redesign 17 projects Public Water Supplies Modification or new construction NYC Watershed 25 projects 17 projects Public Water Supplies The Environmental Health Services Division regulates 722 public water supplies (PWS), 196 of which are considered community supplies, by which is meant that the water is consumed by yearround residents. There are 30 community supplies that each provides water to at least 1,000 individuals. Over 50,000 people rely on water from the cities of Beacon and Poughkeepsie; another 40,000 obtain their water from the town of Poughkeepsie. These larger community supplies (> 1,000 consumers) along with 60 others are regulated by the engineering staff. The remainder are monitored by the Department s Water Enhancement program staff. Water supplies at facilities under permit (restaurants, motels, camps, day care centers, etc.) are inspected by the public health sanitarians assigned to one of the three district offices. During 2005, inspections and subsequent follow-up visits at public water supplies totaled over 700. There were 481 violations issued as a result of these inspections. Over the course of the year, organic chemicals sampled by water suppliers (550 samples) and the Department (140); inorganic 31

32 samples were also sampled by water suppliers (370) and the Department (120). The number of bacteriological samples taken by water supplies and this Department equaled 6,150. The greater share of the field investigations and data processing tasks involving public water supplies is the responsibility of the division s Water Enhancement Program, which operated under a grant of $374,000 from New York State. In September 2004, the Water Enhancement Program was once again evaluated and once again commended for outstanding work by the New York State Department of Health Field Coordinator for the Metropolitan Region. Samples are taken regularly at Public Water Supplies to analyze for a variety of organic chemical contaminants. Among the many water supplies that are monitored in this fashion, 43 are at gasoline service stations, generally in association with a convenient mart or as part of a small plaza or mall. The organic chemical of primary concern at these locations is the petroleum additive MTBE (methyl-tertiary-butyl-ether). In the event of a petroleum spill or a leaking storage vessel, MTBE, being highly soluble in water, finds its way quickly into drinking water sources. There have been 38 separate sampling events at these 43 locations since January 2005 that disclosed the presence of MTBE. Of those, 24 showed the chemical to be at concentrations in excess of the maximum contaminant level (MCL) of 10 micrograms/liter. The range of detection was wide: 0.6 micrograms/liter at the low end, to 2000 micrograms/liter at the high end. All the supplies that exceed the MCL are currently treating the source to remove MTBE. Although MTBE as a gasoline additive has been discontinued since January 2004, this contaminant is still monitored by the Dutchess County Department of Health and public water supplies. Bioterrorism In 2005, Dutchess County made progress in many areas of emergency preparedness planning and response. The planning effort has shifted focus to encompass an all hazards approach. This has enabled the department to implement one plan that is applicable to an event of any nature or magnitude, arising from natural and intentional disasters. The focus of the emergency preparedness has been to collaborate with local partners for a more unified response. Some of these partners include hospitals; long-term care facilities, regional resource center, law enforcement and legal council, neighboring counties and states. Wth the help of the legal councils from the County Attorney s Office, we developed an Isolation and Quarantine Policy. This policy will be implemented in a communicable disease event where the potential for rapid spread of the disease is a cause for concern. A training session was conducted to enable the legal community and the law enforcement to understand and help implement the policy. Forty-seven (47) participants attended this training. The department successfully identified, assessed and completed the documentations on 10 Point of Distributions Centers where mass prophylaxis can be provided for county residents. We also conducted a tabletop exercise testing our communication with the New York State Environmental Assessment Group (EAG), based on the established protocols form the coordination of local environmental health assessment, response roles and capabilities. 32