HUNTERDON COUNTY DIVISION OF PUBLIC HEALTH SERVICES 2013 ANNUAL REPORT

HUNTERDON COUNTY DIVISION OF PUBLIC HEALTH SERVICES 2013 ANNUAL REPORT www.co.hunterdon.nj.us/health.htm

ENVIRONMENTAL HEALTH Environmental health is the largest group within the Division of Public Health. Programs include safe drinking water, retail food, hazardous materials response, facility inspections, rabies control, septic systems plan reviews and inspections, housing complaint investigations, public health nuisance and noise complaint investigations, air pollution facility inspections and complaint investigations, and lead poisoning investigations. Numerous facilities throughout the county are inspected every year. These include dry cleaners, establishments with generators and boilers, kennels, pet shops, body art facilities, public pools, youth camps, day camps, businesses with wells, compost facilities, class A and B recycling facilities, and the county transfer station. This year tanning salons were also inspected. Complaint investigation is a large part of the job of the environmental staff. Appropriate enforcement action is taken when necessary to ensure compliance with all regulations enforced by the environmental division. In 2013 a total of 360 complaints were received resulting in 617 initial and follow up investigations. A total of 123 notices of violation were issued as well as 14 penalty assessments. The air program assessed $ 53,325 in penalties, the majority for odor violations, $3,000 in the solid waste program, and $6,000 in the public non community water program. ENVIRONMENTAL DIVISION COMPLAINTS RECEIVED AND INVESTIGATED JANUARY 1, 2010-DECEMBER 31, 2013 2010 2011 2012 2013 AIR POLLUTION 38 184 99 63 RETAIL FOOD 54 61 55 46 HAZMAT 73 94 84 73 HOUSING 63 46 35 29 SEPTIC 53 53 35 51 SOLID WASTE 56 55 53 55 OTHER 61 57 62 43 TOTAL 398 550 423 360

ENVIRONMENTAL HEALTH When a solid waste complaint is received an inspector is assigned the complaint to investigate. This photo shows illegal dumping of solid waste at property in Hunterdon County. The owner of the property was issued a Notice of Violation with an order to remove the solid waste from the property and dispose of it at a permitted facility. When the health department receives notification of a child with an elevated blood lead level an environmental investigation is done at the home of the child to determine the source of the lead. The house pictured was found to have lead paint that was in poor condition. This photo shows the house in the middle of a lead abatement. A Notice of Violation was issued to the owner and a lead abatement company was hired by the owner to abate all lead hazards in the house. The work was completed and the child s blood lead level has gone down. Outdoor wood boilers in New Jersey must comply with state air pollution regulations. The regulations mandate that outdoor wood boilers produce no smoke except for three minutes in any 30 minute period. A homeowner found in violation of this standard would be subject to a penalty. Under our contract with New Jersey Department of Environmental protection, this department is authorized to enforce these regulations. Another large program is the septic program. All septic plans are reviewed by this Division. All aspects of the installation are inspected and all final paperwork relating to the system are reviewed. A notice of completion is issued by this division. For 2013, 1504 septic system installation inspections were performed, and 710 septic plans were received at this office for review. The county health division inspects all aspects of the installation of a septic system like the one shown here to ensure that the installation is in compliance with the state septic code.

One of the larger programs in the environmental health division is the retail food program. In addition to routine inspections, staff also reviews plans for new establishments, conducts preoperational inspections and spot check inspections, inspects food vendors at temporary events and investigates complaints relating to retail food establishments. Our inspectors work with both public health nursing investigating potential food-borne illness outbreaks. This year our department met with the municipal clerks at one of their quarterly meetings to discuss the retail food licensing, the inspection process, and how the county and the municipalities can work better together. As part of the retail food inspection process we are able to track those violations that are foodborne illness risk factors, as you can see by the chart below the area of most concern is the category of proper hand washing. In 2014 the department will be increasing outreach and education to food establishments targeting the area of proper hand washing and food handling. In the area of recycling, the county recycling webpage was completely revised and a recycling brochure was produced for distribution to the public. In 2014 surveys will be sent to over 1,500 businesses in the county. The information received from these business will be helpful in calculating the counties recycling rate. Our office works to provide timely information to the public. We continually update our website to provide the most updated information and attend local board of health meetings as requested. We have inspectors available every day to answer questions from the public either over the phone or at our front counter. For a six month period between March and August of 2013 our clerical team managed 4,908 phone calls and 3,233 residents at our front counter. This year the area of our front counter was reconfigured to provide more area to meet with the public. Environmental Health Revenues 2013 $180,000 $160,000 $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 CEHA Grant Food Establishments Permits Penalty Assessments

Environmental Health Activities Category 2013 Complaints received 360 Initial and follow up complaint investigations 617 Notices of Violation issued 123 Penalty Assessments issued 14 Penalties assessed $62,325 Retail food initial inspections completed 653 Spot Check and follow up retail food inspections 99 Retail food preoperational inspections 40 Temporary event food vendor inspections 267 Retail food establishment Plan reviews 45 Dry cleaner inspections 4 Emergency generator/boiler inspections 46 Solid waste vehicle spot checks 43 Solid waste roll off container spot checks 55 Solid waste facility inspections 5 Right to know outreach phone calls 25 Right to know outreach visits 25 Septic system plans received 710 Septic system approvals issued 672 Septic installation field inspections 1504 Well installation inspections 196 Public non-community water system inspections 103 Construction referral permits issued 145 Rabies specimen transport to Trenton lab 106 Recreational bathing pool pre-op and spot check inspections 86 Kennel/pet shop inspections 25 Septic/well final certifications issued 637 Animal Bite reports processed 291

PUBLIC HEALTH PREPAREDNESS Communicable disease and outbreak investigations Education on communicable disease to help prevent spread of illness Monitoring on increase in illness Emergency department and influenza-like illness surveillance Monitoring of school absenteeism Reports to establish disease trend data 1229 individual cases of disease investigated; 541 cases deemed confirmed or probable Fourteen communicable disease outbreaks investigated; at least 349 individuals affected. MRC volunteer Nella Hamtil (right) provides health information during a POD Management Training/Drill Public Health Information Sharing The preparedness group manages and operates a notification system called LINCS (Local Information Network & Communications System) for the distribution of public health messages to community partners and public health staff. In 2013, 136 LINCS messages were disseminated on topics that ranged from novel corona virus to measles and mumps outbreaks. Volunteer Management Public Health Preparedness coordinates the Medical Reserve Corps (MRC), under the direction of the MRC Coordinator 120 members currently on the MRC roster 60% medical professionals, 40% non-medical volunteers MRC volunteers participated in several training this year including shelter operations training, POD management training, and psychological first aid, and also participated in a medical needs shelter exercise. Emergency Public Information & Warning Risk Communication Emergency Preparedness Trainings Health Education

Selected Public Health Preparedness Trainings TOPIC TARGET AUDIENCE DATES # SERVED Shelter Operations Training MRC volunteers, Health Division staff 1/22/2013 1/24/2013 28 Psychological First Aid MRC, CERT, Health Division Staff 5/28/2013 5/30/2013 10/16/2013 56 Mass Prophylaxis Preparedness & Planning Health Division staff, MRC, CERT, Public Safety, municipal OEMs, information services staff, other LINCS agencies 6/17/2013 6/18/2013 48 POD Management Training Health Division staff, MRC, CERT, HMC, other LINCS agencies 8/19/2013 40 Medical Needs Shelter Operations Training Health Division Staff, MRC 10/16/2013 12/2/2013 12/3/2013 20 Selected Health Education Programs LOCATION/EVENT DATE # SERVED Go Red Day 2/14/2013 60 Delaware Township Community Health Fair Hunterdon Developmental Center Health Fair 6/22/2013 100 9/11/2013 300

Medical Countermeasures Dispensing/Material Management Inventory management medical needs sheltering and emergency clinic materials are housed and maintained in a primary location on the County Complex Rt. 12 campus, and at two satellite locations in the County. First responder program created to provide pre-or post-exposure medications to first responders in an emergency. Fixed facility program: targeted to business and schools willing to dispense emergency medications to staff in lieu of attendance at an emergency clinic. Respiratory protection fit testing program Emergency clinic planning and management Planning for and participation in state and local preparedness drills and exercises A social worker creates a discharge plan for a patient during the MNS exercise. Mass Care The health division, under ESF 8a, is tasked with opening and managing Medical Needs Shelters during emergencies. On September 30, 2013 the division s preparedness group conducted a full-scale medical needs shelter (MNS) Exercise at the Rt. 12 County Complex, Building 1. Eighty-five individuals comprised of MRC volunteers, health division staff, county and municipal CERT volunteers, American Red Cross, other LINCS agency personnel, and the New Jersey Department of Health participated in the exercise. The exercise was designed to test new standard operating procedures developed as a result of lessons learned from sheltering operations during Hurricane Sandy in 2012, and to acquaint Hunterdon County agencies with the Division of Health s plan for future medical needs sheltering operations. A CERT volunteer conducts an intake assessment on a patient. Division of Health staff conduct a triage assessment in the parking lot of the Rt. 12 County Complex.

Public Health Nursing and Education (PHNE) STAFFING: 4 Public Health Nurses (3FT&1PT) 3 Support Personnel (2FT&1PT) SERVICES: Communicable Disease Investigation, Surveillance and Education Immediate and 24 hour reportable disease investigation TB control and case management Vector-borne disease investigation Maternal Child Health Services Childhood Vaccine Program Childhood Lead Poisoning Investigation School Immunization Audits Improved Pregnancy Outcome Program Book Grant Adult/Senior Health Program Low-income Women s Health Program Brunch and Learn Program Blood Pressure Screening Paternity/Parentage Testing Community Health Improvement (Partnership for Health) Healthcare Disparity - Access to Prenatal Care Aging Related Issues Community Resources Health Related Consultations 2013 STATISITCS Communicable Diseases The total number of disease cases reported to PHNE in 2013 is 1671* (as of 1/24/2014. The final number of confirmed, probable and possible cases for 2013 is still pending review by NJDOH.) There were 15 outbreaks investigated by Public Health. The top five reported diseases are: Disease Case 1. Vector-borne Diseases (Lyme, 1552 Ehrlichiosis, Rocky Mountain Spotted Fever) 2. Hepatitis C 152 3. Food-borne Illness 86 (Campylobacteriosis, Giardiasis, Salmonellosis...etc.) 4. Influenza 70 5. Varicella 48 Lyme disease is the most reported vector borne illness and Hunterdon County has a higher prevalence than neighboring counties. In addition to PHNE investigating the disease reports, Lyme disease educational flyers were given to community agencies, municipalities, and MDs to publicize tick checks and disease awareness.

Graph above: Lyme disease prevalence per 10,000 people (note: 2013 cases count is based on available data as 1/31/14; final case count will not be available until April 2014.) TB control and case management- One active pulmonary TB case was reported in 2013. The case completed treatment via directly observed treatment (DOT). To be efficient and minimize inconvenience for the patient, video phone call technology via smart phones was utilized this year. This significantly decreased the number of field visits from five days a week to once a week for the duration of the TB treatment, significantly saving transportation and staffing costs. Refer to the table below for statistics and services. 2013 Disease outbreak: Measles No cases of measles have been reported in the past five years in Hunterdon County. In 2013 there were a total of 15 cases reported in New Jersey last year with 12 confirmed cases in Hunterdon. The first case was exposed overseas and transmitted to unimmunized children and household members. Because measles is highly infectious, public health promptly investigated the case and implemented quarantine measures to prevent the spread of illness while providing education to the patients. Active TB Cases 1 Suspect Cases 2 New Immigrant TB Evaluations 1 TB Contacts 10 Services Visits (home, office, hospital) 80 Professional Contacts 29 Other Contacts (education, 199 general assistance, etc.) TB Skin Test 47 Pictured left, Public Health Nurse Stephanie Beach conducts Video DOT. VDOT provides the similar level of adherence monitoring at a fraction of the cost, and with much greater acceptability to patients than in-person visit.

Maternal Child Health Services Childhood vaccine program - Works with Hunterdon Medical Center affiliated practices to provide immunizations for noninsured and underinsured children who meet certain federal poverty guidelines. Vaccine Related Visits 2013 20 No. of Vaccinations Given 2013 44 Graph above shows a decrease in deficiencies from 2012. However, based on observation from audits, there is an increase in religious and medical exemptions. Childhood lead poisoning program provides education and surveillance for children with lead poisoning. PHNE collaborates with the environmental health staff to investigate cases with a blood lead level over 10. No. of New Cases 2013 5 No. of Home Visits 2013 8 There were five new lead poisoning cases in 2013. Most exposures occur from lead paint. One case was hospitalized for chelation treatment, and two cases are still being monitored for elevated lead levels. School immunization audit 48 daycare centers and preschools are audited annually. 52 public and private schools are audited once every 2-3 years contingent upon grade level. 2013 Total school audits and reaudits 87 # of records reviewed 8604 # of records with deficiencies 202 Total deficiency rate (Public, 2.35 Private and Nursery schools) Improved pregnancy outcome program (IPO) provides referral, support and education for at-risk pregnant women who reside in Hunterdon County. The primary goal is to help ensure a healthy outcome for mother and child by coordinating the delivery of essential prenatal care and by providing postpartum education. In addition to being individual-focused, PHNE collaborates with health providers and hospitals to improve access to prenatal care on a systems level. Pictured right, Public Health nurse- Jennifer Pfurr provides a Preparation for Childbirth class to a group of expectant mothers. There were four group- lessons offered in 2013. 2013 Women Admitted 99 Newborns Admitted 74 Among the women being admitted, 18% of them are younger than 20 or older than 35. 99% of the clients are under the federal poverty level.

Services categories 2013 Counseling and Education 1394 General Assistance 2430 Professional Contacts 2261 Postpartum Education 92 Interpretation 179 Service Locations Home Visits 193 PHNE Office Visits 739 Other Visits (hospital, doctor 32 office, etc.) Adult/senior health program Programs Count DNA/Buccal (parentage) tests 33 BP Screening at Flu Clinic 350 (collaborated efforts with Preparedness Division) Brunch and Learn Program 15 (B&L) - educational seminars for seniors B&L program participants 202 The most recent birth statistics indicate 2013 program participants have reduced incidence of low birth weight infants compared to 2012 countywide data. Note: Countywide data based on New Jersey Electronic Birth Certificate Data System obtained from Central Jersey Family Health Consortium. 2012 statistics are the most recent available. Pictured left, Go- Red-Event to promote awareness of heart disease, the event held at senior center with BP screening, exercise programs, nutrition, medication and other health infor-

MOSQUITO AND VECTOR CONTROL The mosquito & vector control program offers a full range of mosquito control and insect surveillance activities to the Hunterdon community. The program s primary focus is mosquito abatement. There are approximately 36 mosquito species within Hunterdon County. Some species play a role in disease transmission. Others cause nuisance, and some species have no health implications whatsoever. Each year populations of each species are monitored throughout the county and abatement activities are implemented when necessary. Severe weather can cause trees to up-root. Water that collects in the area left void by the root mound provides ideal habitat for mosquito production. Although it is a uncommon occurrence, uprooted trees became a more significant problem because of the damage by Super Storm Sandy. Personnel reduce the potential of mosquito habitat by restoring root mounds in the ground and eliminating mosquito habitat. Programs offered: Mosquito and black fly (gnat) surveillance and control Bed bug education Tick and Lyme disease education Disease surveillance and monitoring Tick-borne diseases present a threat to human health in Hunterdon County. The blacklegged tick (pictured to the left) serves as the most significant vector of disease. Tick-borne diseases within the county include Lyme disease, ehrlichiosis, babesiosis, anaplasmosis and Rocky Mountain spotted fever. Powassan virus, although not yet confirmed in the county, represents an emerging tick-borne illness in the region. Source reduction is an important component of effective mosquito management. Mosquito larvae grow in artificial containers such as discarded tires (photo to the right). Staff from the mosquito control program facilitate tire clean-up projects to reduce mosquito habitat in the county. A tree blown over by Super Storm Sandy Vector control personnel offer educational materials that describe the life history of tick species that are commonly found in Hunterdon. Information is available that discusses diseases transmitted by ticks, such as Lyme disease, babesiosis, anaplasmosis and ehrlichiosis. Larval stage of the black fly species, Simulium jenningsi.

Mosquito Abatement Activities by Municipality for the Year 2013 Municipality # Traps Set Mosquito Samples Tested Positive WNV Samples Insecticide Treatments Alexandria 79 6 1 23 Bethlehem 12 1 0 2 Bloomsbury 3 0 0 0 Califon 18 6 1 7 Clinton Town 26 6 0 22 Clinton Twp 149 40 6 79 Delaware 88 32 2 11 East Amwell 111 39 4 4 Flemington 84 6 0 45 Franklin 158 39 9 10 Frenchtown 49 15 1 12 Glen Gardner 0 0 0 0 Hampton 5 3 1 0 High Bridge 49 7 0 9 Holland 5 2 1 0 Kingwood 157 31 4 30 Lambertville 30 10 1 2 Lebanon 0 0 0 2 Lebanon Twp 44 4 0 0 Milford 16 3 2 16 Raritan 216 42 8 141 Readington 259 83 15 45 Stockton 22 5 1 6 Tewksbury 15 7 1 0 Union 31 5 0 0 West Amwell 46 17 0 9 Total 1,672 409 58 475

Mosquito Surveillance Activities from 2008-2013 in Hunterdon County 2008 2009 2010 2011 2012 2013 # Traps Set 1,654 1,210 1,317 1,160 1,591 1,672 # Mosquitoes Collected 242,000 267,000 150,000 128,000 158,000 149,000 # Mosquitoes Tested for WNV 17,651 24,419 15,170 14,403 17,776 16,759 # Mosquito Samples Tested 413 580 360 318 465 409 # Positive Samples 11 52 27 65 96 58 % WNV positive samples 2.7 9.0 7.5 20.4 20.6 14.2 # Pesticide Applications 210 540 265 456 204 475 West Nile virus intensity in Hunterdon County in 2013 Mosquito abatement activities in Hunterdon County in 2013