HomeMy WebLinkAboutBoard of Health April 25 20001
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WHATCOM COUNTY COUNCIL
Board of Health
April 25, 2000
The meeting was called to order at 12:35 p.m. by Council Chair Marlene
Dawson in the Council Committee Room, 311 Grand Avenue, Bellingham,
Washington.
Also Present: Absent:
Sam Crawford None
Barbara Brenner
L. Ward Nelson
Dan McShane
Connie Hoag
Robert Imhof
1. INTRODUCTION
Chuck Benjamin, Health and Human Services Director, thanked everyone for
attending. Several staff members would be available for questions. He introduced
the newest Public Health Advisory Board member, Mr. John Worlund, who has been
elected the board's chair.
2. RECOMMENDATIONS FOR TRANSITIONING SERVICES
John Worlund, Public Health Advisory Board (PHAB) Chair, stated he has
been a civil engineer with a masters degree in environmental engineering. The first
third of his career was with the public health service by designing and building
water and sewer systems on Indian lands in Alaska and California. The next third
of his career was involved with regulatory functions. He worked with the
Environmental Protection Agency (EPA) in developing groundwater monitoring and
sampling related underground storage tanks. The last third of his career has been
in the consulting business, focusing mainly on groundwater, characterization
cleanup, and mediation assessment. In 1999, the Community Health and Wellness
Division looked at what services it could transfer to the public sector. There were
four steps involved in the process: 1. Identify services that could be transferred, 2.
Make sure there is a capacity in the community, 3. Identify the impacts on Health
and Human Services (HHS) if the service is transferred, and 4. Develop a
transition plan. Going through that process, there are three clinics that fit the
general criteria. Those clinics are the flu and vaccine clinic, STD clinic, and
international travel clinic. For each clinic, HHS held two community service
meetings with providers to make sure there was capacity and there was intent on
the part of the providers to pick up the services if they are transitioned. Those
plans were brought forward to the PHAB board, who recommended transition of all
three.
Board of Health, 4/25/2000, Page 1
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Kay Guirl, Community Health and Wellness Services Manager, gave a
presentation on why services will be transitioned out of the public health agency.
Core public health functions were defined in 1989. Nationally, those functions are
assessment, policy development, and assurance. In Washington State, the 1993
Public Health Improvement Plan added prevention, and administration, and defined
the assurance function as access and quality components.
Under the assessment function, the definition is to collect, analyze, and
evaluate health status, risk indicators, and health emergencies. This will help
identify trends in illness, injury, and death, which, as a public health agency, they
might need to address. It will help them identify environmental risk factors that, if
remediated, could prevent disease or injury. It also gives them the data to do
accurate program planning and identify what they should do as a public health
agency.
The policy development function is to assure that local policies are
developed, implemented, and evaluated that address community priorities. In this
section, they depend heavily on the assessment information to help them identify
which policies are necessary, new, or to be revised at this point. It also promotes
local regulation aimed at reducing the local public health risk and factors unique to
Whatcom County.
The prevention function is to prevent entire communities or populations from
exposure to threats that can lead to disease, injury, or early death. There are two
components of prevention that are promotion and protection. Promotion is the
health education and risk behavior reduction education. Protection has a lot to do
with many of the regulations that the environmental health system relies on.
Prevention leads to early detection, treatment, and containment of disease. That is
one of their primary goals in communicable disease.
The access and quality function is to monitor and maintain access to quality
health services. Part of that is to assure that needed services are available, assure
a community standard of care for public health concerns, and to monitor health
outcomes to evaluate the success of the public health system.
The administration function is the structure that supports the core public
health functions. That includes leadership of the department director, managers,
and supervisors. Many of the staff also provides leadership roles in the community.
It also includes planning, organizational management and fiscal management.
There are ten essential services in public health. They are the activities the
public health agencies conduct in meeting the public health core functions. The first
one is to monitor the disease prevalence and incidents and causes of early death
and injury. The second is to investigate, for example, communicable diseases.
The third is to mobilize the community to address community- identified needs in
public health. The fourth is to develop policies to support the activities in public
health. Five is to enforce local and state regulations. Six is to educate the public
Board of Health, 4/25/2000, Page 2
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whose behaviors may put them at risk for disease injury. Seven is to link
individuals to services to meet health care needs. The focus in the Public Health
Improvement Plan is to move away from those services that are otherwise available
in the community. The public health role would be to link individuals to the
community services rather than be the provider. Eight is workforce development
and assurance of their expertise and knowledge to handle public health issues.
Nine is to evaluate programs, access to services, and outcomes of health care
services. Ten is to participate in practice -based research.
Brenner asked if investigating communicable disease includes all
communicable diseases or a specific list. Guirl stated the communicable diseases
example is just an example of investigation. They also investigate spills and other
issues.
Brenner asked for a list of reportable diseases. Guirl stated she could
provide that. There is a current list and a proposed expanded list.
Guirl continued to state that they began strategic planning by looking at
services that are available in the community. There is capacity for the community
to provide. Their intent is to redirect and reassign staff to core public health
functions and services. As they go through the recommendations on three
transitioning services, they have a proposed plan on reassignment of staff currently
functioning in those service areas. Reassignments will direct resources to
prevention, assessment, surveillance, and access and quality of public health care
services. All are core to public health essential services. They are not looking at
doing away with staff. They need those resources for core public health functions.
Regarding revenue and expenditure loss for 1999 community flu clinics,
expenses and revenue were about even, not including the indirect cost for
administration or the lost revenue from pulling staff away from regular duties and
activities that generate revenue.
b. International Travel Clinic
At the International Travel Clinic, the 1999 revenue was $83,782 and the
expenses were $111,855. The discrepancy relates to how the clinic was
restructured following Dr. James' resignation. He participated in that clinic and
provided medical prescriptions for malaria and rabies prophylaxis. When he left, no
staff was able to write prescriptions for those services. The system was that clients
would come in and receive consultation and most vaccines, but would have to go to
a private physician or infectious disease physician for prescriptions. That created a
double expense for two office visits. The department's choice was to use a flat fee
at the lowest level instead of adjusting the cost for the office visit according to the
time and number of people.
Brenner stated the staff has a medical doctor, Dr. James Place, and
questioned why he can't write the prescriptions. Guirl stated it wasn't ever
Board of Health, 4/25/2000, Page 3
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discussed or recommended that he do that. As a .6 full -time equivalent (FTE)
employee, his time is heavily involved in the communicable disease issues.
Benjamin stated the difference is where the department uses the resources.
They decided that the International Travel Clinic isn't where the health officer
should spend his time.
Brenner questioned whether they are going to have that kind of discrepancy
no matter what. Guirl stated it is just a demonstration of what revenues they will
lose by transitioning the services, and also offsetting the expenses they would lose.
Some of the expenses will be staff time reassigned to other programs.
Dawson stated the Council provided direction that the Health Department
look only at mandated delivery services. These three things are not mandated.
Brenner questioned why the County decided not to charge what the travel
clinic visit cost. Guirl stated because of the cost to individuals who are not able to
get the full service.
Hoag asked for clarification on writing prescriptions. Guirl stated no one is
assigned to the clinic who can write prescriptions.
Hoag asked what the clinic does. Guirl stated they provide vaccinations and
consultation on reducing risk for other communicable diseases.
Hoag asked if all clients that come into the office have to also go somewhere
else, or if it is only a portion of the clients who may have a unique need that
requires a prescription because of where he or she is going. Guirl stated the
second statement was correct. Individuals going to areas where malaria
medication is recommended would need a prescription. Health Department staff
cannot do that. Also rabies services for prophylaxis require prescription
medication.
Hoag stated that in the packet are the number of office visits and vaccines.
She asked how many have to follow up with a second office visit.
Fay Jensen, Sexually Transmitted Disease (STD) Clinic and International
Travel Clinic Supervisor, stated they haven't kept that statistic. She estimated that
25 to 50 percent of clients traveling to an area need a physician visit.
Hoag questioned whether the County adjusted rates for everyone, even if he
or she didn't have to go to another physician. Guirl stated they did because the
system doesn't allow charging two fees.
Dawson asked about what activities the department would be diverting its
resources to. Guirl stated that in each section there is a draft document that looks
at how the job classifications would be reassigned. It is a draft because the division
Board of Health, 4/25/2000, Page 4
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is going through a strategic planning process. This is a draft proposal and probably
would change at the conclusion of the strategic planning process at the end of June.
Dawson asked about travel for the clerk typist.
McShane stated that person does not travel, she is part of the travel clinic.
Guirl stated the staff for the community -based flu clinics would be able to
maintain and continue their ongoing normal revenue - generating activities by
transitioning those units. They will be able to direct their time to assessment
activities, such as looking at the immunization completion rate for two - year -olds.
Hoag stated she was concerned about transitioning the travel clinic. It
seems logical for the County to provide the service. She asked how the public
service compares with community services in terms of costs and service. Guirl
stated the costs for the vaccines are higher in the community service. As a public
health agency, they are able to purchase vaccines through a federal contract.
However, with so many additional costs of having to pay for two office visits, it is
going to cut down on the duplication. She is unsure of the overall extent of the
increased cost.
Hoag asked about the cost comparison with another clinic, and how long it
takes to get the service. Guirl stated they received letters of commitment to
provide services from three clinics, including Lynden Family Medicine, Western
Washington University Health Center, and Madrona Infectious Disease Clinic.
Madrona Clinic added a third infectious disease physician and will set up a five days
per week, international travel clinic, which even the Health Department has not
provided. They estimate to have the capacity built up to provide services to an
additional 1,500 individuals. Western will take on the responsibility for students
who travel.
Hoag asked if backlog will be a problem. Guirl stated it will not.
Hoag asked about cost. Guirl stated the cost of the vaccines will be about
half.
Hoag asked about the consultation cost comparison. Guirl stated that for the
last year, the Health Department used the lowest office visit fee that a physician's
office can charge. They are using the same fee schedule. That lowest fee is about
$29. She didn't know what the other clinics would charge.
Hoag stated she was concerned because 50 to 75 percent of the clients at
the Health Department were able to get all their needs met at the department, with
cheaper vaccines and consultation costs. She didn't know that this transitions well
to the private provider. She is concerned about cutting back on services. Guirl
stated the core functions and the ten essential services of public health do not list
the international travel clinic as belonging in a public health agency.
Board of Health, 4/25/2000, Page 5
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Dawson asked for motion to get this on the floor. Of the three clinics, this is
the most non - controversial.
Imhof moved to transition the International Travel Clinic to community
providers and maintain the following roles in Health and Human Services
Department: 1. Expand post - travel communicable disease surveillance, 2. Continue
public education on the importance of travel vaccines and disease prevention
education, and 3. Reassign staff to priority public health programs. If people have
the money to travel internationally, they can pay for their own vaccines.
Motion carried 6 -1 with Hoag opposed.
C. Sexually Transmitted Disease (STD) Clinics
Guirl stated the general STD Clinic only had $400 in revenue in 1999, with
expenditures of over $37,000. The STD clinic generally serves clients who meet a
sliding fee scale of nothing because his or her income is low, or clients who are
individuals who attend the clinic and have no insurance. This has been a typical
clinic for which they've tried to get additional revenue. By transitioning the clinic, it
would save some local funds.
Imhof asked how Whatcom County compares with other counties of similar
size for the STD Clinic, in terms of numbers of people and revenue generation.
Guirl stated the STD clinics are not a major revenue - generating service for any
public health agency. Not many public health agencies still offer clinical diagnosis
and treatment for STDs. They are moving more towards the assessment and
surveillance on where to direct primary prevention. That is the public health role.
Whatcom County has better statistics than statewide. Some counties have seen a
rapid increase in chlamydia, but Whatcom hasn't had a drastic increase in
chlamydia. Prevention keeps people out of STD clinics. That is where HHS wants
to put its time.
Brenner stated this is an area that will, of course, be a loss. It is something
that she believes the County should provide for public health. She suggested
cutting back the hours, and would like to provide the service. Not every service is
going to make money or break even. The County has a responsibility for providing
the STD clinic service. She would support more staff resources. Guirl stated the
general STD clinic has decreased its hours because of access to a nurse practitioner
who can provide diagnoses and write prescriptions. They will stay in STD services
because they will not transition the teen clinic. It is a priority, and provides
continuity of care for the teens they provide services for. They aren't going to get
out of the business of STDs. They will track access issues. They do have concerns
about low- income individuals getting services in other clinics. They are going to
monitor and track that availability. There will probably be an agreement with the
other agencies who will take on the additional capacity.
Dawson stated the Revised Code of Washington (RCW) and Washington
Administrative Code (WAC) do not require the County to provide diagnosis and
Board of Health, 4/25/2000, Page 6
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treatment. She questioned whether that could be outdated in terms of HIV. Guirl
stated HIV has its own regulations. It is not a subset of the STDs.
Brenner asked if another option would be to cut back the clinic's hours. Guirl
stated that if they cut it back any further, they will not accomplish a drop in the
bucket of what needs to be done. The unique service the public health system
offers to the STD system is reporting and surveillance and partner notification,
which is an activity none of the private clinics or physicians want to assume. Those
are the two roles that the clinics are asking the County to continue.
Brenner asked about the role of consultation. It is common sense to educate
people on avoidance and protection. Guirl stated that is what they hope to expand
as the primary prevention role in the community. They anticipate that some of the
individuals who received HIV counseling and testing during the STD clinic will come
into the HIV counseling and testing clinic that is scheduled at different times.
Brenner asked how they are going to do prevention, risk reduction, and
treatment by eliminating the clinic. Guirl stated they will direct the prevention and
risk - reduction to populations of individuals. They will be able to spend more time in
schools and engage in other ways of getting the prevention message out to the
population that is not coming into the clinic.
Brenner asked if there is a higher percentage of STD among teens than
adults. Jensen stated that of the numbers they have of diagnosed STD, the
majority of the clients are in the 15 -24 age group. The majority of those diagnoses
are for chlamydia.
Brenner stated more than half of that population is out of the public school
system. Guirl stated that is just one area. They haven't put together their work
plan for activities.
Jensen stated they currently see individuals through the age of 19 in the teen
clinic. That doesn't mean there isn't a potential to expand that age limit. It could
probably go to the age of 21. The majority of STDs are diagnosed through Planned
Parenthood. They are a player who agreed to assimilate a number of clients. The
County only does about six hours of general STD clinic services now.
Imhof stated the recommendations come from people in the health industry.
He feels good about the people that have been appointed to the board and the
people who make it their profession to make these recommendations. He moved
approval of the recommendation on the STD clinic as outlined on packet page 19.
Dawson read the recommendation to transition the general STD clinic
service, while maintaining the following roles: teen clinic; STD prevention and risk
reduction; STD treatment monitoring; community provider continuing
education /training; assessment of barriers to access, and; reassignment of staff to
priority public health activities.
Board of Health, 4/25/2000, Page 7
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Hoag stated there are two groups they are talking about transitioning the
services to, and they are Interfaith Clinic and Mt. Baker Planned Parenthood. She
questioned how stable their funding is. It seems that they rely on donations. Guirl
stated Interfaith and SeaMar both provide services. Their funding comes from
multiple resources and has been stable for many years. They get federal and local
funding.
Hoag asked if a portion of their funding comes from donations.
Nelson stated it is not their primary source.
Hoag asked how the partner notification would work. Guirl stated the County
is not currently providing that service at the level they should be, if they truly want
to prevent STD. Many STDs are reportable, so the County gets case reports.
They've already established a system of referral for private providers who diagnose
HIV infection. The first step is to let the individual or the individual's physician
inform the partner. If neither are comfortable in doing that, the County would have
a role.
Hoag questioned whether she believed there would be a decrease in the level
of service or efficiency of service if everything was transitioned to the two clinics, in
terms of partner notification and prevention of the spread of disease. Guirl stated
she anticipated improvement because of planning process for transition,
maintaining, and monitoring what is happening to access.
Hoag stated she respected the fact that the County needs to look at ways to
efficiently deliver services and to protect dollars. She was concerned that the
County may be abdicating its role. She is not comfortable with it.
Dawson stated they are not, according to the RCW.
Hoag stated she is not talking about what they are legally required to do, but
about protecting public health. She is concerned they would not be as effective.
McShane asked what is driving the transitioning. Guirl stated it is difficult to
find appropriate staff for the clinic. They can't find nurse practitioners to provide
diagnoses and training. They need nurse practitioners or physicians. A second
issue is, according to the Public Health Improvement Plan, they are supposed to
look at resources available in the community and to direct public health resources
to what is not available in the community. Based on the assessment of the
agencies, they are comfortable that there is sufficient capacity in the community to
provide the service. They would maintain the public health role.
McShane asked where the Public Health Improvement Plan came from. Guirl
stated it was written in 1993. It was the first document in Washington State that
was developed to direct where public health agencies should put their efforts and
resources. It is based on core functions from the Institute of Medicine in 1989. It
is not a mandate. It is a philosophy of the public health plan role.
Board of Health, 4/25/2000, Page 8
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McShane stated this is a policy decision about what the Board of Health is or
is not willing to give up or fund.
Nelson stated he gets the impression that the issue is about what the
County's Health Department provides versus what the community provides. It is
not a disconnect. The community is dependant upon the Health Department and
also the community access for public health. They work closely together. As a
health care provider, he utilizes the Health Department for information and
assistance in public health matters. In return, the Health Department has relied on
the community for public health matters and resources. It is not a disconnect.
They are taking the resources and working better for the community.
Dawson stated they are redefining their partnership.
Brenner shared Hoag's concerns. She assumes the Health Department will
do monitoring and bring back any problems to the Board of Health. Guirl stated
they would.
(Clerk's Note: End of tape one, side A.)
Motion carried 6 -1 with Hoag opposed.
a. Community Influenza Clinics
Guirl stated they took a look at what was happening in the community. They
conducted six weeks of flu clinics in past years. In the last few years, the number
of vaccines they have used has decreased over the years, because of community
capacity. Another concern is about having to hire extra help to staff clinics and
having to pull permanent staff away from other duties, which created a barrier
problem in other services areas. They felt this service could be transitioned. They
conducted the community process and identified numerous pharmacies and other
sources that provide flu vaccines. St. Joseph's Hospital also provides vaccine
clinics. There are other contractors who come into Whatcom County that also
provide that service. Visiting Nurse Health Services submitted a letter of
commitment to meet the capacity of the vaccines the Health Department provided.
They have agreed to conduct those clinics at the same sites, so access will not be
decreased. The Health Department will continue to provide flu vaccines in their
regular clinics so that anyone coming in can get the vaccine there. The Health
Department's role with influenza will change. They will still participate with the
community partners in planning dates for clinics and provide community
notifications. They will also use the clinic staff to do more surveillance on influenza.
They are interested in the incidents of influenza in long -term care facilities.
Imhof moved approval of transitioning the influenza services, recommended
on page one of the Board packet.
Board of Health, 4/25/2000, Page 9
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Dawson read the recommendations to maintain the following roles: facilitate
community planning, publicity, and public relations regarding influenza; increase
the HHS role in assessment, surveillance, and quality assurance, and; provide
influenza vaccine at the HHS offices during regular clinic hours.
Nelson moved to amend the recommendations by including the role to
increase public awareness to other adult immunizations. Other immunizations are
necessary. Nationally, there is an increasing trend in which adults are not getting
their immunizations regularly or are behind on immunizations necessary for public
health. They can play a positive role in educating the community, working with
health care providers, and offering other immunizations.
Motion to amend carried unanimously.
Motion as amended carried unanimously.
3. SOLID WASTE RULES
Worlund stated that in 1998 a Task Force came up with 18 recommendations
and presented those recommendations to the Board of Health on October 19.
There were recommendations made at that time to go back and revisit them. That
has been done. The HHS staff drafted modified solid waste regulations and
incorporated those recommendations made by the Board. In addition, other things
were done to make sure everyone was on board. There was a stakeholder task
group formed that was made up of hospital representatives, laboratories,
veterinarians, small medical clinics, waste treatment facilities, and dental clinic
representatives. That task force read the recommendations to make sure that there
wasn't any problem with them. That meeting was held on February 8 to discuss
their comments. Their recommendations were incorporated. There was another
presentation made to the County's Solid Waste Advisory Committee, who went
through the same drill and suggested some wording changes. Their comments
were incorporated. It then went back to the Public Health Advisory Board, who
looked at it and made further recommendations that were incorporated. That is the
package that is before the Board of Health.
(Clerk's Note: Imhof left the meeting at 1:25 p.m.)
Brenner stated she didn't realize that there was another task force that did
this. She objected. Some of those different special interests were represented on
the Medical Waste Task Force. She didn't even know that group was formed. The
entire purpose for the Medical Waste Task Force was to have the broadest possible
interests.
Regina Delahunt, Environmental Health Services Manager, stated that when
the group was brought together in February, the instructions to the group were that
the preliminary draft incorporated the recommendations of the committee. None of
the recommendations could be changed in the regulations. They wanted to see if
there were tweaks that could be made that would make implementation of those
Board of Health, 4/25/2000, Page 10
1 regulations easier for the people. The recommendations remained the same. If
2 they made any comments on the recommendations, they were told that the
3 recommendations are what they are, and are what will be incorporated.
4
5 Brenner questioned whether this is only about the administration of it.
6 Delahunt stated that is correct. It is only about how they put the recommendations
7 into the verbiage of the regulations and the administration of the regulations.
8 There were no changes to the recommendations.
9
10 Delahunt discussed the revisions to Whatcom County Code 24.06 regarding
11 the solid waste regulations for the County. The packet of information contains a
12 summary of the areas where changes have been made to the regulations. The
13 major areas include revisions to the bio- solids, or sewage sludge, sections of the
14 regulations. They also made revisions to the solid waste permit section. They
15 added a new bio- medical waste section, which was the main focus of the revisions.
16 They also made changes to the enforcement section of the regulations. The
17 sewage sludge, or bio- solid, section of the code has been deleted from the code. A
18 couple of years ago, the state adopted new bio -solid regulations, which are WAC
19 173 -308. That removed sewage sludge /bio- solids from the realm of solid waste. It
20 is now regulated under the state water regulations. It is a beneficial use material.
21 There is an extensive set of regulations related to it, but it is not a solid waste. The
22 County was required to remove that from its existing solid waste code. There is a
23 memorandum of agreement with the state Department of Ecology (DOE) for the
24 local health department to oversee the bio- solids program in the County. They still
25 oversee the bio- solids program. It is an extensive set of regulations that, in a lot of
26 ways, are more stringent than what the County originally had.
27
28 Brenner questioned which definitions are new and which are existing.
29
30 Michele Jenkins, Environmental Health Specialist, stated the only definitions
31 in the existing regulations are for Health Officer and Board of Health. In the new
32 draft regulations, there are many new regulations, except for Board of Health and
33 Health Officer. The Health Officer definition in the draft is under Director.
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35 Delahunt stated the other section that was changed related to solid waste
36 permits. They changed some of the provisions related to public hearings. In the
37 past, they've had public hearings for all permit renewals and new permits. For
38 many of the renewal public hearings, the only people that showed up at the
39 hearings was the Health Department staff and the applicant. For non - controversial
40 facilities such as drop boxes, no one came to the hearing. They made a change to
41 the regulations so that a public hearing for a renewal is held only if there is a
42 request for a public hearing. They will still have the standard public hearings for
43 any new facilities, variances, or changes to operations.
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45 They also changed some of the provisions related to the length of permits.
46 The state rules have changed and they allow for issuance of a solid waste permit for
47 up to five years. They have changed the rules to allow for up to five years for
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certain types of facilities. Generally, it is those without significant environmental
monitoring, such as drop boxes.
Hoag questioned whether they would still have public notice on the renewals.
Delahunt stated they would. All of the public notices will still be the same. They will
still send it out to the adjoining property owners and anyone who has requested it.
They won't have the actual hearing unless someone requests it.
They've also made changes to the appeals process. The appeals process in
the existing regulations conflicts with state rules. During a recent appeal, the
Hearing Examiner informed them that the conflict existed. The Hearing Examiner
directed them through the proper appeals process.
Brenner questioned the difference. Delahunt stated the current appeals
process says that an appeal would go to the Health Officer, who would forward it to
the Hearing Examiner, and then it would go to the County Council and then to
Superior Court. The state rules say that appeals on solid waste permit issues go to
the health department, and then to the state Pollution Control Hearings Board, and
then to the court.
Regarding bio- medical waste, there was quite a process to put together the
bio- medical waste rules. They have incorporated all the recommendations into the
draft rules. They added a new bio- medical waste section to the rules. The only
recommendation that has been modified in the draft is recommendation number
twelve, related to stocks and cultures. They will probably talk about that at the end
of the presentation. They added a new section, which is an enforcement section.
The existing code doesn't have a specific enforcement section in it. They thought it
would be a good idea to include one, so they did. They included a reference to the
administrative notice and civil penalty section that they currently have in the Health
Code, section 24.07 of the Whatcom County Code. By including the bio- medical
waste section, there will be certain areas where there will be additional workloads
for the Health Department. She wanted to describe those sections so the Board of
Health would have a feel for what the regulations will mean in terms of Health
Department workload.
As far as permitted facilities, they only have one permitted facility. Work on
that facility is supported by fees, which are charged back to the facility. There is a
possibility with the new regulations that they will have additional bio- medical waste
treatment facilities in the county. Those will have to have enforcement and
permitting. They have approximately 495 medical waste generators in Whatcom
County. They also have one transporter, which will need to be regulated as well.
The draft regulations don't require generators to obtain permits or even to register
with the Health Department. They do require that generators follow the rules.
They need to segregate their waste. They need to have separate containment, and
they need to make sure it goes to a treatment facility and not in the waste stream.
The Health Department can approach it in different ways. They can have routine
inspections of generators. It could be complaint- driven or they could do spot
inspections. They need to come to an understanding about how that program is
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going to be operated as far as the level of enforcement and the oversight they will
provide for the generators. It would also be important to initially have a strong
educational component to the regulations to let generators know that the
regulations do exist, what the requirements are, and what their responsibilities are,
under the law.
There is only one transporter currently. The Health Department will need to
register its vehicles, review and approve any spill plans that are developed, assure
that the drivers have adequate training, and provide routine inspection of the
vehicles. That will not be a significant quantity of work. There are not too many
vehicles and they could charge a fee for inspecting the vehicles.
Currently, the Health Department does most of the things listed. The work
will not expand too much as long as they have only one facility. If they have more
than one facility, it will be an additional workload. Also, they will put together a
plan for having sharps collection facilities for homeowners in the county. That will
be a body of work to get those sharps collection facilities established.
Crawford asked that this be continued.
Benjamin stated they will have to schedule a public hearing.
(Clerk's Note: Crawford left the meeting at 1:45 p.m.)
4. PUBLIC SESSION
Dave Bader, 1721 - 35th Street, stated he is a Solid Waste Advisory
Committee (SWAC) member and a disposal facility representative. The SWAC
appreciated the regulations. The Health Department did a good job of putting them
together. He talked to HHS regarding variances, section 24.06.05. The Health
Department concurred with him. There is a mix -up in the process for variances. It
requires that they go through a process outlined by DOE. When a variance is
requested for a regulation that is created locally and is more stringent than the
state law, then the local process should be responsible for offering that variance,
without DOE concurrence. If they rely on the state regulation as it is written, they
must get written concurrence by DOE before the County can offer a variance for a
locally generated regulation. He would like to see a stipulation that a variance
request for a locally generated regulation would not require concurrence from the
DOE.
Benjamin stated they should get a legal review on the protocol.
McShane stated they might not be ale to sidestep a state rule that says they
need to go to the DOE, but an individual could get the local variance approval first
before going to the state.
Benjamin stated they would review the process with the Prosecuting
Attorney's office.
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Richard Ferguson, St. Joseph's Hospital Microlab Supervisor, stated he came
with the hospital staff to answer questions regarding the memo he submitted
earlier. They all want the same thing, but there is a lot of jargon that, if not
changed, would cost the facility millions of dollars to pay for things that are not
necessary. A few changes to the language won't affect safety and would keep the
hospital from having to do major building and hiring.
Brenner stated she had questions. On page three of their memo it says that
staphylococcus and streptococcus are not problematic to the average healthy
person and only cause disease when a person's immune system is compromised
and a portal of entry exists. Even under those conditions, she agreed that could
happen. However, there is much information about new antibiotic - resistant strains
affecting healthy people. Ferguson stated the way they are transmitted is still the
same. One would have to have something jabbed through the skin that contained
a large quantity of the organism on it or the enteric pathogen would have to be
transmitted to the mouth. Their practices ensure that there are not those kinds of
accidents at the hospital. There are more bad bugs, but the modes of transmission
are the same.
Brenner stated she agreed that the hospital does a good job of ensuring
worker safety and protection. She has affidavits from Recomp workers, and the
state Department of Labor and Industry has literature, that there are routine needle
sticks at the facility. There are needle sticks with waste that has been put
together, including the stocks and cultures. No one has any idea how concentrated
those things are when they get to the facility. The recommendation for level two
was hers. It is not about the generators. In general, the generators do a good job.
Her concern is with transporters and the facility. Sometimes people can be
exposed through a portal of entry and not become actively sick, but can pass those
organisms along to someone who is more susceptible. That is her concern. The
same kind of worker care may not be given at Recomp as is given at the hospital.
She and Councilmember Crawford took a tour of the Recomp facility. Stericycle is
the lessor. Stericycle also operates some of the stuff going on out there. There are
new super bugs. She received emails from staff and former staff of the Center for
Disease Control (CDC). According to them, level two presents problems and needs
to be taken care of onsite. Ferguson stated some of it is opinion. He has a large
body of people he knows who work at the University of California at Los Angeles
(UCLA) and Harvard Medical School. It may be a matter of semantics, but level two
organisms excludes tuberculosis, measles, and things that are highly contagious.
They are talking about culture plates and stocks, not needles or glassware. He is
not sure that the opinions Councilmember Brenner received have a basis in the
policy. Some people may have different opinions from what is proposed by a body.
They've demonstrated that there is no evidence that anyone has gotten anything
from the culture plates that go into the trash at safety level two labs.
Brenner stated she spoke to Wayne Turnburg, who is on staff with the State
Department of Health, wrote a book on bio- hazardous waste, and is one of the top
experts in the country. He supports having stocks and cultures treated on site. He
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and others brought recommendations to the state. Two of the biggest lobbyists
against this have been a doctors' association and the Washington State Hospital
Association, of which St. Joseph is a member. Also the Washington State Hospital
Association has a for - profit subsidiary contracting with Stericycle, which is opposed
to this because it makes its money transporting this stuff. Other politics are playing
into this. Also, the hospital wouldn't have to purchase an autoclave that costs
$100,000. There are many that are much less expensive.
Ferguson stated it depends on the size and volume.
Brenner agreed. The Medical Waste Task Force recommended that level two
be disinfected, not autoclaved. They were specific that level two only had to be
immersed in a disinfectant. That wouldn't cost much to do. It would entail a
change in mindset and operation. If the autoclave did cost more than $100,000, it
would be comparable to the cost of transporting the material. As a member of the
Medical Waste Task Force, two onsite providers gave presentations and provided
information that showed it is cheaper in the long run to do onsite treatment. Those
providers also said that the people who bundle and package the materials could be
trained to do autoclaving or disinfecting. The footprint of the equipment is no
bigger than the storage area for the transporter to pick up the material. There are
a lot of differences of opinion.
Hoag stated that according to her information, the Hepatitis B virus is a bio-
safety level two. It also said that extreme caution with contaminated needles and
sharp instruments must be emphasized and that transmission by aerosol is not
known, but there is potential risk. She questioned whether any of this is on glass
slides, when talking about stocks and cultures. Ferguson stated anything that could
be spread is not on glass slides. The only thing that contacts glass slides in the
laboratory are items taken from a smear.
Hoag questioned whether Hepatitis B could end up on a glass slide because
of blood. Ferguson stated it is not likely. In the process of putting it on a slide, it
goes through a fixation process where it is heated to about 200 degrees. If that
were even possible, the heat fixation and the acid alcohol de- colorization involving
the steaming process would kill anything. When they talk about cultures and
stocks, they are talking about bacteria, yeast, and possibly fungi. These are things
that can be grown in a petri dish. Hepatitis B viruses are usually germane to tubes
of blood, syringes, and needles that are a different situation. They only deal with
cultures of stocks in the clinical laboratories.
Hoag stated Hepatitis B is a particular concern of her. Someone has to
analyze the sample taken. She questioned what it ends up on when someone does
that. Ferguson stated it ends up in an analyzer. Analyzing is done by looking for
anti - bodies that were made by the organism being present in the body at a certain
time. For those kinds of tests, the tube of blood is in a centrifuge and spun down to
pack the red cells. The serum, or plasma, is removed. That component is put into
an analyzer, which looks for the anti -body. The spent part, the serum, goes into a
waste container with a sealed system.
Board of Health, 4/25/2000, Page 15
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Hoag stated that the workers at the facility don't know what they are
handling. When the hospital handles the material, the staff knows what they are
dealing with and can take the proper precautions. She questioned whether there is
anything on glass containers that can break and puncture a bag.
Sue Rhodes, St. Joseph's Hospital Infection Control Professional, stated they
should not forget about the work practices they should all follow all the time. In
the hospital, they always wear protective eyewear, gloves, and gowns. Every
employer has a duty to educate his or her staff and provide barriers.
Hoag stated her concern is that bags are sometimes broken and there are
leaks. At that point, the workers don't know what they are dealing with. The
hospital staff knows what they are dealing with and can properly protect
themselves according to what it is that they are dealing with. It seems logical that
if one is dealing with something that can cause a problem, it is more appropriate to
treat it when he or she knows what they are dealing with.
(Clerk's Note: End of tape one, side 8.)
Hoag questioned whether any of the Hepatitis B could end up in glass
containers that can break or puncture a bag. Rhodes stated they assume it does.
That is their mindset in the hospital.
Dawson stated the information says that any bag containing medical waste
shall be placed in a rigid container. She questioned whether the infected material
was all placed in plastic bags prior to the new regulation.
Brenner stated rigid containers include cardboard boxes. Those cardboard
boxes have routinely leaked. They can get smashed down.
Dawson stated there is a concern that the infected waste could have a
seepage problem. It should not be contained in a corrugated box.
Hoag questioned whether the glass containers would be considered a stock
or a culture at that point. She questioned the definition of stocks and cultures.
McShane stated it sounds as if the blood vial is not in the area of the culture
lab at the hospital. Ferguson stated it is directed mostly at the things that can
grow and propagate.
Brenner stated they are considered stocks and cultures under the new
definition. She appreciates how the hospital operates. The materials leak when
they come off the trucks, and the materials come from places other than St.
Joseph's Hospital. When she was at the facility, there was a horrible stench. There
was so much condensation that stuff was dripping on them. It was a rotted smell.
In a facility like that, stuff gets out and can incubate in moisture. She felt very
uncomfortable at the facility. Most of the workers get a certain amount of training.
Board of Health, 4/25/2000, Page 16
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Many have not received extensive training. Up to three months is all they need to
have. This facility has a high turnover rate. Before a person goes through a
rigorous training, he or she may have moved on to something else. Regarding the
practice of disinfecting the hospital waste, she couldn't imagine that the CDC and
the Occupational Safety and Health Administration (OSHA) would oppose that
practice. There are state laws and federal laws. The state laws are the weakest
biomedical waste laws in the country. The federal laws are even weaker. It wasn't
the County's purpose to base what it is doing on what the state and federal laws
require. Whatcom County is one of the few communities in the country that has a
regional facility. Regulations are based on the fact that Whatcom County is in a
different situation than other communities. Whatcom County requires more
stringent overview.
Dawson stated a public hearing would be scheduled.
McShane questioned the connection between the material presented by the
hospital and how the draft regulation affects the hospital lab. Ferguson stated his
reason for being involved is to figure out a way to be safe from the beginning to the
end of the process. The way it is written, he is trying to figure out a way to help
without unintentionally penalizing the hospital. Things are working now, but there
is a possibility that problems can occur when things leave their facility. He is trying
to figure out how to do that without costing a lot of money at the hospital. There is
limited space to add things. The classification of cultures and stocks bio- safety
level 2, and having to disinfect them, wouldn't be a bad thing. However, for them
to actually do that with an autoclave and the permitting process would be hard for
them to do. Disinfecting works for small volumes. In the micro lab, there are three
large bins they fill up with excess plates. To fill those up with disinfectant would
make them impossible to lift and it would leak out.
Brenner stated she had suggestions that she would discuss with Ferguson
after the meeting.
Ferguson stated the point of what they are doing is to continue what they are
doing and add something that would help prevent problems on the way to the
ultimate disposal facility.
Hoag stated the Council doesn't think there is a problem with St. Joseph's
Hospital, but rules and regulations have to be for all generators and have to ensure
that treatment is safe.
Nelson stated there is a new antibiotic that may take care of a new
generation of infectious diseases. Historically, research and development went by
the wayside. That will change. There will be many new antibiotics that will come
out. That doesn't mean these things should be ignored. The medical profession is
paying attention and trying to adjust to the changing environment. He questioned
the life expectancy of organisms outside of the body. Ferguson stated they live on
the plate for a week or so. If sealed in airtight bag, they will last a week or so.
Some will die faster than others will. If those bags were to leak during transport, it
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would not hurt the person. The only point is that person doesn't know where the
bag came from or what is in it.
Brenner stated St Joseph's Hospital stuff is not going to this facility.
Nelson asked if these are organisms that are already in their everyday lives.
Ferguson stated they are everywhere, but in a culture there is a larger
concentration. The only ones that could be a problem would be the enteric
pathogens.
Nelson asked if they could find the cultures in a meat market. Ferguson
stated yes.
Hoag stated they couldn't find Hepatitis B in a meat market.
Nelson asked if they could be found in agricultural communities in high
concentrations. Ferguson stated there are higher concentration in rural areas.
Hoag stated some level two organisms, like Hepatitis B, cannot be found in
every place.
Ferguson stated that when they find antibodies, it doesn't mean the
organism is there. It only means the organism was there at some point.
Hoag stated that is not the point. The point he is trying to make is that these
are everywhere. They are not everywhere.
Ferguson stated they are. He can pull Hepatitis out of the bay easily.
(Clerk's Note: McShane left the meeting at 2 :25 p.m.)
Nelson stated there are going to be restrictions imposed upon the agricultural
community, which does inoculations. He questioned whether there will be impacts
from adult family homes with a few patients.
Brenner stated it is focused on labs.
Ferguson stated it does affect non -labs, but that could be fixed. Small
practices, such as urology clinics, do limited plating. They would be impacted.
They can do some improvement and need to include all possibilities and delineate
some of the rules to be helpful for all.
Hoag asked about sewage sludge. She questioned whether state regulation
preempts the Council, or just says it will not be a solid waste. Delahunt stated it
preempts the County from regulating it as a solid waste.
Hoag questioned whether it preempts the County from regulating it at all.
Delahunt stated she would check.
Board of Health, 4/25/2000, Page 18
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Hoag asked how they will know if they exist and if there is compliance by
generators if there is not a permit. Delahunt stated they are not requiring
everyone to get a permit, but will educate them on the rules and then come up with
options for fines.
Hoag asked how they find out that a generator exists. Delahunt stated they
know what types of facilities would generate bio- medical waste. It would go by
Standard Industrial Classification (SIC) codes, which are listed on the business
application with the state. The County can get a listing of SIC codes from the state.
They would periodically review the list of SIC codes. That is how they also came up
with their estimates.
Nelson asked for copy of a business application that would show an SIC code.
Hoag asked about section 24.06.05 on page 47, regarding permits. There
has been a suggestion by the public about not renewing a permit when a problem
needs to be addressed. She questioned whether there such language in the new
regulation. Delahunt stated the solid waste regulations require the applicant be in
compliance with all other regulations. The public may say the applicant is not in
compliance, but DOE says they are because they are under a consent order and
they are complying in accordance with that order.
Brenner stated the County should say that the applicant be in compliance
with the standards that are set, not the orders. If the County requires that the
applicant be in compliance with solid waste standards, it would remove the problem
regarding renewal of a permit.
Hoag stated that according to the public testimony, the company was given
deadlines they did not meet. This is a problem in other industries. The County is
giving a person a permit when there is an ongoing problem in the first place. The
County would require much less staff and taxpayer money if they make sure a
permit is not renewed unless the conditions of the original permit are met. She
would like to see something like that in the language. She requested
recommended language.
Dawson stated they may create a greater problem if the business is not in
business. The business may provide a service.
Hoag stated that if the business owner knows he or she will not get the
permit, which is where his or her money comes from, the problem would get fixed.
Brenner stated that if that sentiment goes out publicly, every violator would
beat a path to Whatcom County.
Dawson stated if there is competition, that is okay.
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Hoag stated even if there is no competition, they should be held to the
standard.
Dawson stated the County could fine them.
Hoag stated a fine is a cost of doing business. In addition, it has to be
worked through compliance staff and bring it to court. The County would lose
money on fines.
Delahunt agreed. If a facility is going to renew an application, they should
be in compliance with applicable laws and regulations. The issue is that when the
County renews a permit, they ask other state agencies to comment on whether
they are in compliance. If another agency says the applicant is in compliance, it is
difficult for the County to disagree.
Hoag asked for suggested language.
Brenner suggested that they must be in compliance with state standards.
Hoag asked about the solid waste handling facility time span for permits.
Delahunt stated it is one year.
Hoag asked if the draft regulation extends it from a one -year permit to a
five -year permit. Delahunt stated that is correct. The state used to require one -
year permits, but now it is five years.
Hoag asked if this is to be compliant with the state. Delahunt stated the
County could leave it at one year, but the County could be more stringent. Instead
of saying that any facility can be issued a five -year permit, they felt it was
appropriate for the non - controversial facilities that don't require a lot of monitoring,
such as drop box facilities, to have a five -year permit.
Hoag questioned whether would Recomp would qualify as moderate risk
facility. Delahunt stated it would not because of the medical waste.
Hoag asked if Recomp would have a one -year permit. Delahunt stated that
is correct.
Brenner asked about the demolition debris landfill. Delahunt stated that
would also be a one -year permit as well.
Hoag asked if they increased the permit fee. Delahunt stated they would
have an annual fee, but it would be more of an inspection fee.
Hoag questioned whether it would affect the County's revenue. Delahunt
stated it would not.
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Brenner asked Delahunt to give an example of a moderate risk waste facility.
Delahunt stated the moderate risk waste facility is the toxics disposal facility where
they collect the household hazardous waste.
Hoag questioned the civil penalties and what penalties are assessed if there
are violations. Delahunt stated those penalties are collected on a daily basis, for
every day one is out of compliance. The first violation is $100 per day. The second
violation is $200 per day, and the third violation is $300 per day.
Dawson stated they would schedule this for a public hearing.
Hoag moved to add the language from the draft. It is appropriate to have it
for the public hearing.
Brenner stated she wanted that language, for the public hearing, in that
paragraph to say, "bio- safety level two, three, and four" in section 24.06.04(2)(d).
Delahunt stated that changes the entire intent.
Brenner stated they are talking about contagious agents. They need to
identify level two agents. She suggested an amendment to the last sentence in
section 24.06.04(2)(d), "Such cultures of a bio- safety level two, including but not
limited to...." Level two needs to be mentioned somewhere.
Delahunt stated mentioning level two at the beginning of the paragraph will
mean that all bio- safety level two would have to be treated. If they add level two
to the second sentence, it would mean that cultures of level two that include
infectious agents associated with diseases. That wouldn't change the intent or
require that all level two be treated.
Brenner stated some bio- safety level two organisms are not associated with
infection to humans. She didn't mind leaving those out. Delahunt stated they are
not respiratory or associated with respiratory transmission.
Hoag stated they don't specify respiratory in the second sentence.
Nelson suggested they work on the language and propose an amendment
when they have a hearing.
Hoag stated she wanted to hear the rationale. Delahunt stated the initial
recommendation from the PHAB and the Board of Health was that bio- safety level
three and four stocks and cultures had to be treated on site. After that
recommendation was approved, there was some concern that there may be some
tuberculosis cultures in bio- safety level two laboratories.
Brenner stated she brought that up. The concern also included salmonella
and other things. Delahunt stated that, as a result of the issue surrounding the
potential for tuberculosis to be associated with bio- safety level two labs, a
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recommendation was made at the PHAB to add the second sentence. That would
alleviate the potential of the respiratory transmission, should there be some
tuberculosis in a bio- safety level two laboratory.
Hoag stated it only covers the respiratory. It doesn't cover such things as
Hepatitis B. Delahunt stated that is correct.
Ferguson suggested that they change the language to organisms within the
bio- safety level two that are known to be disease causing. Those diseases could be
listed. He chose to list the enteric pathogens and herpes as the only group that
warranted any special interest. He didn't mention tuberculosis because he didn't
consider it a type two, but if there are semantic problems, any transmissible
disease could be named. That works better for them. He thinks the Hepatitis B
issue is covered, but he will check into it more.
Hoag moved to adopt language in the draft in section 24.06.04(2)(d) without
the level two language. If people want it changed or have a concern, they could
address it at the public hearing.
Motion carried unanimously.
ADJOURN
The meeting adjourned at 2:45 p.m.
Jill Nixon, Minutes Transcription
These minutes were approved by Council on June 13 , 2000.
ATTEST:
Dana Brown - Davis, Council Clerk
WHATCOM COUNTY COUNCIL
WHATCOM COUNTY, WASHINGTON
Marlene Dawson, Council Chair
Board of Health, 4/25/2000, Page 22