County of Marin Health and Human Services

Public Health Newsletter

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Marin County's adult smoking population has dwindled to one of the lowest in the state. We owe this success to concerted community-wide effort over years, including Marin health care providers who daily reinforce tobacco education for patients and the public health advocates who support policies that limit community harm from tobacco.

The Smoke-Free Marin Coalition has targeted secondhand smoking and has supported some of the state's most progressive policies to provide protection for residents in multi-unit housing (MUH) complexes. San Rafael set a new bar by restricting smoking in 100% of MUH complexes. Marin businesses are also generally supportive, with many adopting voluntary policies on outdoor smoking in response to customer demand. Ten of twelve jurisdictions now have designated smoke-free outdoor dining, with substantial progress made in the past two years.

Despite these successes, there is still progress to be made. One in ten Marin adults still smoke every day or "most days" (www.countyhealthrankings.org). In the 2013 annual American Lung Association Report Card, San Rafael and County unincorporated areas were the only areas in Marin to receive an "A" grade for their smoking policies and practices; Larkspur, Mill Valley, Novato and Sausalito earned "B's"; Fairfax, Ross and Tiburon "C's"; San Anselmo a "D"; and Belvedere and Corte Madera "F's." Communities lacking strong secondhand smoke regulations including both indoor and outdoor smoking limitations lose significant points in the grading system.

Persons with mental illness and Marin's youth are high priority populations for tobacco control efforts. The Marin Tobacco and Mental Health Collaborative brings together Marin-based mental health service providers, consumers, and tobacco control groups to offer effective and culturally competent cessation support to consumers in behavioral health programs. Efforts to reduce tobacco use among Marin County youth include support to colleges implementing campus-wide smoke-free policies, assistance to schools in securing federal funding for tobacco education, and partnership with community-based programs promoting healthy choices for young people.

Effective tobacco control hinges on cohesive and consistent messages from all health advocates. Marin health care providers can recommit to this effort by offering strong messaging to patients and families about the harms of tobacco use, supporting cessation for those using tobacco, and advocating for tobacco control policies when they are being considered. Resources for people seeking to cut down on tobacco use and for the providers supporting them can be accessed at Bay Area Community Resources (www.bacr.org/programs/tobacco).

Largely funded by the Center’s for Disease Control and Prevention (CDC) and the Avon Foundation, the MWS is a large-scale breast cancer research program being conducted within the Marin County Department of Health and Human Services. From 2007 through 2009, the MWS enrolled 13,344 women, which represented 21.5% of all women of mammography age in Marin County. Detailed risk factor information, saliva specimens and mammographic breast density were collected at screening centers associated with Kaiser Permanente, Marin General Hospital and Novato community hospitals.

Enrollees completed an in-depth questionnaire which included questions regarding family history of breast cancer, reproductive history, use of exogenous hormones, alcohol intake, smoking history, diet/nutrition, environmental exposures, medications, stress measures, education level, socioeconomic status, work status and years of residence in Marin. Compositional breast density, breast cancer status, demographic data, body mass index (BMI) and family history of breast cancer was also obtained through linkage with the San Francisco Mammography Registry, one of seven registries included in the National Cancer Institute Breast Cancer Surveillance Consortium.

Key findings from the MWS include:

  • Establishing linkages between hormone replacement therapy and breast cancer.
  • Confirming that reproductive risk factors like delayed childbirth are associated with increased breast cancer risk in the MWS population.
  • Pioneering the use of human saliva as a non-invasive, cost-effective and practical method for public health screening.

The MWS is currently conducting ongoing analyses that include:

  • Utilizing our biospecimen repository of more than 8,000 saliva samples as a powerful tool to explore the genetic and environmental components of breast cancer.
  • Understanding how alcohol use affects breast health, and how adolescent risk factors such as teen smoking may be associated with breast cancer.
  • Investigating how the use of complementary and alternative medicines for menopause affects breast cancer risk.
  • Exploring improvements in breast cancer risk prediction through advanced statistical modeling techniques.

The Marin Women’s Study has grown in scope from a local, grassroots community effort to an internationally-renowned research program. While our findings may have a global impact on the prevention of breast cancer, they are most relevant to the study participants – the women of Marin. 

We are grateful for the steadfast support of the Marin County Board of Supervisors and the Marin Women’s Study steering committee which maintains the focus and vision of the project and advises the team on research and policy decisions. The advisory board consists of the following individuals:

Christopher C. Benz, MD - Buck Institute for Age Research
Christina Clarke, Ph.D. - Cancer Prevention Institute of California
Francine Halberg, M.D., FASTRO - Radiation Oncologist, Marin Cancer Institute at Marin General Hospital
Leah Kelley, M.D. Marin General Hospital, Marin Specialty Care 
Dr. Karla Kerlikowski, MD - University of California San Francisco
Mary Mockus, M.D., Ph.D. – Kaiser Permanente San Rafael Medical Center
Fern Orenstein, M.Ed. – Zero Breast Cancer Advocate and Survivor
Elad Ziv, M.D., UCSF Helen Diller Family Comprehensive Cancer Center

As of June 26, 99 cases of pertussis have been reported to Marin County's Division of Public Health for 2013. All but one were reported since mid-April. Almost all cases are among school children between 5 and 18 years of age, and 19 Marin schools were affected. The epidemic curve (see page 3) suggests transmission rates are declining. At this point in the outbreak, the most effective interventions are early identification, isolation, and treatment of cases and prophylaxis for close contacts, especially those at risk for more severe disease if infected. Increased vaccination rates within the community will help limit outbreaks in the future.

While we promote the prudent use of antibiotics, providers are reminded to provide antibiotic prophylaxis to all household contacts of a pertussis case. Within families, secondary attack rates are high, even when household contacts are current with immunizations. Administration of antimicrobial prophylaxis to asymptomatic household contacts within 21 days of onset of cough in the index patient can prevent disease. In this setting, telephone-based triage and direct prescription of prophylaxis for asymptomatic contacts is reasonable if a clinic visit would otherwise delay prophylaxis. The recommended antibiotics for treatment or prophylaxis of pertussis are azithromycin, clarithromycin and erythromycin. Trimethoprim-sulfamethoxasole can also be used. See CDC recommendations for post exposure prophylaxis of case contacts here. http://www.cdc.gov/pertussis/outbreaks/PEP.html

Providers caring for patients who require pertussis treatment or prophylaxis but lack insurance should call the Health Department at 415-473-4163.

With schools now out for the summer, new case reports have declined. There have been no reported hospitalizations or deaths in Marin. A high proportion of sick children are fully vaccinated. This is part of a regional pattern of increased incidence and is being analyzed by the CDC to review vaccine efficacy. Patients and families can be reminded that while vaccination does not confer 100% immunity, it remains our best line of defense against serious disease.

According to the 2012 Hospital Breastfeeding Rates Report, 98.6% of women delivering at Marin General Hospital in 2010 initiated breastfeeding. By hospital discharge, 17% of those mothers were giving formula (MGH breastfeeding rates) and after hospital discharge, breastfeeding rates decreased significantly. Exclusive breastfeeding rates at three months for the Bay Area are 40% (MIHA data from CDPH). Exclusive breastfeeding rates for participants of the Marin County Women, Infants and Children Supplemental Nutrition Program (WIC) are less than 25% at six months. How can we support mothers to reach their breastfeeding goals?

Peer breastfeeding support has been shown to be an effective strategy to increase breastfeeding rates and is the theme for this year's World Breastfeeding Week. Peer support acknowledges that beyond her own personal resolve to breastfeed, a mother relies on a circle of support that includes family, community members, childcare workers, and policy makers.

Since 2006, Marin's WIC Program has had a Breastfeeding Peer Counseling Program, supporting over 600 low-income women annually. WIC peer counselors have been trained to provide new mothers with breastfeeding information and support in the WIC office at Marin General Hospital and are available by phone outside of normal hours. For those mothers needing clinical breastfeeding support, WIC has Certified Lactation Consultants (IBCLC) available four days a week both in the WIC office and in the mother's home, if needed. WIC breastfeeding rates have nearly doubled since the Peer Counseling Program started. Low-income families and those with Medi-Cal can be referred to WIC for breastfeeding help at 473-3094 (phone) or 473-4056 (fax).

Three Marin residents were exposed to measles on the flight from Dusseldorf, Germany to Los Angeles International Airport on July 2, 2013. The case's symptoms included a maculopapular rash, coryza, fever, and sore throat. The Marin residents were vaccinated against measles and did not become ill. Two other passengers, an unvaccinated German exchange student and an infant who was not fully vaccinated, have developed measles since the flight.

This serves as a reminder of the ongoing risk of measles in the increasingly global environment and of the role of vaccine in preventing disease.

MMR (measles, mumps, and rubella vaccine) and IVIG (intravenous immune globulin) can be used as post-exposure prophylaxis.

  • MMR vaccine given to a person 6 months or older within 72 hours of exposure to a measles case may provide protection against the disease.
  • Pregnant women with known exposure and who lack evidence of measles immunity should receive 400 mg/kg of intravenous immune globulin (IVIG).
  • Severely immunocompromised persons, irrespective of evidence of measles immunity, should receive 400 mg/kg of IVIG.

Immunity through vaccination remains the most effective way to prevent disease.

For the vaccination schedule and information about measles disease and post-exposure prophylaxis, please see California Department of Public Health Measles Investigation Quicksheet-June 2013 at:

http://www.cdph.ca.gov/programs/immunize/Documents/CDPHMeaslesInvestigat....

Every day doctors see patients who are at risk for behavioral health concerns, including suicide. People with diabetes are twice as likely to have depression as those without diabetes; those with asthma are 2.3 times more likely; and those with a cardiovascular disease are 1.43 times more likely to have an anxiety disorder. Untreated mental health issues increase the likelihood of suicidality.

While the signs of suicide may not always be obvious, there are warning signs that can be identified in primary care settings.

  •  Forty-five percent of those who die by suicide were in contact with their primary care provider in the month before they died. That rate is even higher for older adults.
  • People with chronic diseases are at higher risk for depression and other mental health concerns. They can be screened with simple tools for depression, anxiety, substance use, and suicidality.
  • Increased drug or alcohol use, reckless behavior, changes in sleep, sudden mood changes and other signs may be revealed during a visit to the doctor.
  • Having attempted suicide in the past or knowing somebody closely who died by suicide increases a person’s risk of suicide.
  • For youth, bullying or being bullied is associated with increased risk of suicide and other mental health concerns.

Directly addressing concerns, such as asking if a person, “Are you thinking about suicide?” does not increase their risk – it opens the door to getting help. In addition to possibly saving a life, addressing behavioral health concerns in primary care settings can improve patients’ physical health, as well as reduce the time and resources needed to effectively serve patients.

For more information about suicide prevention in Marin County contact: AMY/MELISA??.

For more information about providing behavioral health services in primary care settings, contact Kristen Gardner (kgardner@marincounty.org).

AMY/MELISA  - insert plug for Kevin H event

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