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2016 Regional School and Public Health Nurse Meeting CDPHE update CDPHE Update • Communicable Disease Updates • Suicide Prevention • Substance Use - Narcan Tuberculosis What is tuberculosis? • A bacterial infection that spreads from person to person through the air. How is it spread? • When a person with TB disease coughs, sneezes, speaks or sings, the bacteria can remain in the air for several hours. Latent TB Infection • People who have become infected but do not yet have TB disease are not infectious, do not have any signs or symptoms of disease, and can be treated before they develop TB disease Tuberculosis (cont) TB Disease • People who are not treated when they have latent TB infection are at risk of developing TB disease and spreading tuberculosis PREVENTION • People who have come into contact with an infectious person are tested and treated to prevent them from developing infectious TB disease later in life. Source: http://www.cdc.gov/tb/publications/factsheets/gener al/tb.htm Infectious TB Disease Symptoms TB bacteria most commonly grow in the lungs, and can cause symptoms such as: • A bad cough that lasts 3 weeks or longer • Pain in the chest • Coughing up blood or sputum (mucus from deep inside the lungs) Other symptoms of TB disease may include: • Weakness or fatigue • Weight loss • No appetite • Chills • Fever • Sweating at night Source: http://www.cdc.gov/Features/TBsymptoms/index.html 2011-2012 School-Based Tuberculosis Contact Investigation • Index patient had infectious TB disease, with cough, fever, and night sweats for two months. School contact investigation – Medically evaluated/sought: – TB disease: – LTBI: 1,249/1,381 1 162 • Partnerships for public health: 81 people from health departments and schools were mobilized for screening (885 person-hours) and LTBI treatment (890 person-hours). Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6239a1.htm Please Notify CDPHE • Suspected cases of TB are reportable to CDPHE, please call (303) 692-2638 for more information. • Ann Scarpita, TB Nurse Consultant, RN, can consult with you at (303) 692-2656 or [email protected]. • Melissa Broudy, TB Training Coordinator, can provide education (303) 692-2638 or [email protected]. Reporting Chickenpox Cases to Public Health • CDPHE will be making minor updates to the case report form in the coming months and will notify schools when the new form is available. • Please use CDPHE’s “Report a Disease” page to find the most recent version: https://www.colorado.gov/cdphe/report-a-disease • CDPHE is involved in a new project that more closely tracks outbreaks of chickenpox so schools may be contacted more frequently with additional questions on reports. • Contact your local PH epidemiologist or Breanna Kawasaki (303-692-6235) at CDPHE with questions or if you think you have an outbreak in your school. Animals in school and child care settings • New health and sanitary regulations for child care centers and schools • Reptiles, amphibians and live poultry (e.g. chicks and ducklings) are prohibited in classrooms with children who are kindergarten age or younger • This includes hatching eggs in an incubator Live poultry in schools • Live poultry (e.g. chicks, ducks, incubating eggs) prohibited from – classrooms with kids kindergarten age or younger – communal areas (like offices, halls, gyms) that kids kindergarten age or younger use • Discouraged in other classrooms where children engage in frequent hand to mouth behavior (special needs) Live poultry in child care centers • In settings where all kids are < 5 yrs: – live poultry (e.g. chicks, ducks, incubating eggs) prohibited • In settings that also have kids ≥ 5, live poultry are prohibited in: – classrooms with kids kindergarten age or younger – communal areas (like offices, halls, gyms) that kids kindergarten age or younger use – discouraged in other classrooms where children engage in frequent hand to mouth behavior (special needs) Helpful Communicable Disease Branch Website Links • Main CDPHE website: https://www.colorado.gov/cdphe • Report a Disease (lists of reportable conditions and information on how to report cases): https://www.colorado.gov/pacific/cdphe/report-a-disease • Communicable Disease Manual (disease-specific chapters, case investigation forms, and guidance and timelines for investigation): https://www.colorado.gov/pacific/cdphe/communicable-disease-manual • Infectious Disease Guidelines (includes guidance for special settings such as schools, child care, and health care facilities): https://www.colorado.gov/pacific/cdphe/infectious-disease-guidelines • Outbreak Investigations Page (guidelines, resources and forms for outbreak investigation): https://www.colorado.gov/pacific/cdphe/outbreak-investigationguidelines • Reportable Disease Data (counts of reportable conditions by age, county and report month): https://www.colorado.gov/pacific/cdphe/coloradoreportable-disease-data Data “Statistics are merely aggregations of numbers with the tears wiped away.” - Dr. Irving Schikoff Sources of information/data National National Violent Death Reporting System (NVDRS) http://www.cdc.gov/injury/wisqars State Colorado Violent Death Reporting System (COVDRS) Colorado Health Information Dataset http://www.chd.dphe.state.co.us/topics.aspx?q=Mortality_Data http://www.chd.dphe.state.co.us/cohid/Default.aspx Colorado Child Fatality Review System https://www.colorado.gov/pacific/cdphe/cfps-data-and-information Healthy Kids Colorado Survey http://www.chd.dphe.state.co.us/topics.aspx?q=Adolescent_Health_Data Value of Data Inform programming Target limited resources to certain populations Inform access points Measure efficacy and outcomes Leading Causes of Death: United States Residents, 2011‐2013 173.7 169.8 169 163.2 Heart disease Cancer Chronic lower respiratory… Stroke Unintentional injuries Alzheimer's disease Diabetes Influenza and pneumonia Kidney disease Suicide 0 42.5 42.1 37.9 36.2 39.1 39.4 24.7 23.5 21.6 21.2 15.7 15.9 13.4 13.2 12.3 12.6 40 80 120 160 Age‐adjusted death rate per 100,000 population 2011 2012 2013 200 Source: National Center for Health Statistics, Centers for Disease Control Suicide in Colorado In 2014, there were: 52 HIV deaths 172 Homicides 486 Motor vehicle deaths 553 Breast cancer deaths 668 Influenza & Pneumonia deaths 826 Diabetes deaths 1,058 deaths by Suicide Suicide is the 7th Leading cause of death in CO for all ages Source: Vital Statistics Program, Colorado Department of Public Health and Environment Leading Causes of Death, Ages 10‐18 In 2014: 3 Drowning deaths 9 Poisoning deaths (unintentional) 16 Homicides 18 Cancer deaths (all types) 35 Motor Vehicle deaths 50 Suicides Suicide is the 2nd leading cause of death for those ages 10‐24 Source: COHID CO Suicide deaths and rates ages 10‐18, 2009‐2014 Year n Rate* 2009 48 8.0 2010 40 6.8 2011 39 6.4 2012 42 6.8 2013 48 7.6 2014 50 7.8 *per 100,000 population Source: COHID Suicide deaths by age and gender, 2010‐2014 900 792 800 Number of Suicides 700 656 614 629 600 484 500 400 291 300 185 200 100 279 202 177 128 178 88 4520 80 31 12 0 0‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84 85+ Age Group (years) Males Females Source: Vital Statistics Program, Colorado Department of Public Health and Environment Age‐Specific Rate (per 100,000 population) Age‐specific suicide rate, 2010‐2014 32 30 28 26 24 22 20 10‐17 18 16 14 12 10 8 6 4 2 0 18‐24 25‐44 45‐64 65+ 2010 2011 2012 Year 2013 2014 Source: Vital Statistics Program, Colorado Department of Public Health and Environment Suicide Deaths in Colorado Ages 10‐14 (2010‐2014) • Overall suicide rate 3.7/100,000 – 65 total suicide deaths – 69% male – 29% by firearm • Overall U.S. suicide rate –1.5/100,000 ( 1,241 deaths) Source: COHID Suicide Deaths in Colorado Ages 15‐18 (2010‐2014) • Overall suicide rate 11.3/100,000 – 154 total suicide deaths – 72% male – 41% by firearm • Overall U.S. suicide rate – 7.3/100,000 ( 4,992 deaths) Source: COHID Percent of suicides by age group Suicide methods by age group, Colorado residents (2009‐2013) 80.0 70.0 60.0 50.0 Poisoning 40.0 Hanging 30.0 Firearms 20.0 Other 10.0 0.0 0‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84 85+ Age group (years) Source: Violent Death Reporting System, Colorado Department of Public Health and Environment Percent of suicides by age group Suicide methods by age group, Colorado residents (2009-2013) 80.0 70.0 60.0 50.0 Poisoning 40.0 Hanging 30.0 Firearms Other 20.0 10.0 0.0 0-14 15-24 25-34 35-44 45-54 55-64 Age group (years) 65-74 75-84 85+ Age‐adjusted suicide rates by county of residence classification, Colorado residents (2009‐2013) County Classification Number Urban Rural Frontier 3,943 581 129 Age‐adjusted rate (95% CI) 17.5 (16.9‐18.0) 19.8 (18.1‐21.4) 19.0 (15.6‐22.4) Source: Violent Death Reporting System, Colorado Department of Public Health and Environment Suicide Attempts in Colorado In the US, for each death by suicide an estimated 25 attempts are made For those surviving an attempt, the vast majority do not later die by suicide 2000 160 1500 120 1000 80 500 40 0 0 10‐14 15‐19 20‐24 25‐44 45‐64 65‐84 Age Group in Years Males Males Females Data Source: Hospital discharges from the Colorado Hospital Association * excluding persons who died or were discharged to hospice 85+ Females Rate per 100,000 population Number of discharges in 3 years Hospitalizations for Suicide Attempts* by age group and gender: Colorado residents, 2010‐2012 Suicide Hospitalization in Colorado Ages 10-14 (2009-2013) • Overall hospitalization rate 32.2/100,000 – 545 total hospitalizations – 80% female – 73% by solid/liquid drug overdose Source: COHID Suicide Hospitalization in Colorado Ages 15-18 (2009-2013) • Overall hospitalization rate 121.4/100,000 – 1,649 total hospitalizations – 66% female – 79% by solid/liquid drug overdose Source: COHID 2013 Healthy Kids CO Survey Completed by 9th through 12th graders in public high schools in Colorado • 24.3 percent reported feeling so sad or hopeless almost every day for two weeks or more in a row that they stopped doing some usual activities during the past 12 months (LGB – 59.4%; Hispanic Female – 38.7%). • 14.5 percent reported seriously considering attempting suicide during the past 12 months (LGB – 48.5%; Native Hawaiian/other Pacific Islander Male – 26.5%; Black female – 24.6%). • 6.6 percent attempted suicide one or more times during the past 12 months (LGB ‐ 28.2%; Native Hawaiian/other Pacific Islander Male – 15.7%; American Indian/Alaska Native – 14.5%). Office of Suicide Prevention www.coosp.org • Mission – To serve as the lead entity for statewide suicide prevention and intervention efforts, collaborating with Colorado communities to reduce the number of suicide deaths and attempts in the state. • OSP Activities – Suicide Prevention Commission (SB 2014‐088) – Hospital Initiative (HB 2012‐1140) – Man Therapy – www.mantherapy.org – Bridging the Divide: Suicide Prevention and Awareness Summit – Public information and education campaigns, clearinghouse, & presentations – Community grant making – Children’s Hospital Means Restriction Education – CO Gun Shop Project Pilot High Risk Populations & Communities • LGBTQ Youth • Hispanic/Latino Youth (Females) • Active Duty Military & Veterans • Working‐age Men • Older Adults Sources of Strength School‐based suicide prevention through promotion of protective factors and development of resiliency ED‐CALM CALM Center on Access to Lethal Means at Dartmouth ED‐CALM Firearm Deaths in Colorado, 2005‐2013 Source: Violent Death Reporting System, Colorado Department of Public Health and Environment CO House Bill 2012 ‐ 1140 •88 CDPHE licensed short‐term, critical access, licensed general, and Psych hospitals in CO •Information and materials at time of discharge for patients and families • Assessment of hospitals to identify current practices, gaps and needs Suicide Prevention Commission of Colorado Initial Priorities ❖Expanding and streamlining efforts to provide effective follow up care after emergency department discharge ❖Expanding efforts to provide effective follow up care after inpatient discharge ❖Promoting practices for reducing suicide risk among primary care patients ❖Improving and integrating training for members of specific professional groups Colorado Crisis Services - 24/7 Walk In Clinics Respite Care facilities Acute Care Units Mobile Crisis Teams Crisis Line with Peer Support and follow up 1-844-493-TALK - Services available regardless of county, region, or insurance Education Community Who: K-12 Education What: (in an ideal world) Full Spectrum Prevention Programming and Protocols: Toolkit with formal protocols for schools to follow All staff trained in Mental Health First Aid and Suicide Prevention specific course Schools to have evidence-based program and compliments Increase funding for behavioral health staff in school/available Primary Prevention- Social/Emotional Learning in elementary schools How: Start with Top Level Buy in from Administration, Superintendents, Principals Why: Suicide is the second leading cause of death among our youth Colorado age-specific rate is considerably higher than the national average Healthy Kids Colorado survey provides notable data to support need Trainings Applied Suicide Intervention Skills Training (ASIST) www.livingworks.net safeTALK www.livingworks.net Question, Persuade, Refer (QPR) www.qprinstitute.com The Yellow Ribbon Program www.yellowribbon.org Kognito Online Trainings www.kognito.com Colorado Mental Health First Aid www.mhfaco.org See more at sprc.org/bpr Colorado Statewide Resources Office of Suicide Prevention www.coosp.org Suicide Prevention Coalition of Colorado www.suicidepreventioncolorado.org Carson J Spencer Foundation www.carsonjspencer.org Sources of Strength www.sourcesofstrength.org Yellow Ribbon Suicide Prevention www.yellowribbon.org National Resources Suicide Prevention Resource Center www.Sprc.org/bpr American Foundation for Suicide Prevention www.Afps.org American Association of Suicidology www.Suicidology.org National Action Alliance for Suicide Prevention www.Actionallianceforsuicideprevention.org Zero Suicide Initiative www.Zerosuicide.com Prescription Drug Surveillance School Nurse Leadership Meeting 1/13/16 Rebecca Hebner, MPH Substance Abuse Prevention Systems Coordinator Prescription Drugs: Every Day MISUSE=700 INJURIES=12 DEATHS=2 In 2014, there were 870 prescription drug overdose deaths in Colorado. Eighty deaths were among 15-25 year olds. Almost 5,000 people were hospitalized, more than MVA, homicides or firearms. This is just a fraction of the harms to the 6% of Coloradans age 12+ who misuse prescription drugs. Prescription Drugs: A Growing Problem Number of drug overdose deaths involving opioid pain relievers and other drugs, Colorado residents, 1999-2014 Prescription Drugs: Focus on Opioids 39% Opioid pain relievers contributed to at least 338 of the 870 drug overdose deaths in 2014. Source: Colorado death certificate data 2014, Health Statistics Section 4. Health Statistics Section, Colorado Department of Public Health and Environment. Definition used based on W M, Chen LH, Makue DM, Anderson RN, Minino AM. Drug poisoning deaths in the United States, 1980-2008 NCHS d brief, no. 81. Hyattsville, MD: National Center for Health Statistics, 2011. Local Prescription Drug Abuse Data INJURY MISUSE 1 1 1 2 5 2 5 DEATHS 2 5 3 3 4 4 Opioid Mortality (rate per 100,000 population, 2013) Opioid ED Visits (rate per 100,000 population, 2013) Nonmedical Use of Rx (percent of population age 12+, 2010-12) 3 4 Region 1 Region 2 Region 3 Region 4 Region 5 Colorado 5.4 6.1 4.8 9.3 2.8 5.6 10.8 15.9 17.1 24.1 10.4 15.2 5.9 5.7 5.2 4.9 5.2 5.6 What is an Opioid? • Any natural, synthetic or semi-synthetic narcotic drug that acts like opium in the body. methadone, Examples: oxycodone, hydrocodone, and fentanyl. • Highly addictive, and misuse can be life threatening. • “Other opioids” refer to opioids other than heroin and are not available over the counter. Boyer EW. Management of opioid analgesic overdose. N Engl J Med 367:2: 146-155. International Classification of Diseases, 9th Revision, Clinical Modification. SCHOOL NURSES But what about youth? National Survey On Drug Use And Health Healthy Kids Colorado Survey Prescription Drug Misuse Surveillance A couple of definitions: • Medical use but not as the prescription directs1 • Nonmedical or recreational use2 • Taking someone else’s prescription drug, even for medical use 1. http://www.colorado.gov/cs/Satellite/CDHS-BehavioralHealth/CBON/1251581819035 accessed on 11/15/2012 2. NIDA http://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction accessed on 2/21/13 Substance Abuse Mental Health Services Administration (SAMHSA) National Survey on Drug Use and Health “On how many days in the last 12 months did you use any prescription pain reliever that was not prescribed for you or that you only took for the experience or feeling it caused?” NSDUH: Youth Misuse Trends Nonmedical Use of Pain Relievers in the Past Year, by Age Group 12-17, 2009-2014 trends NSDUH: by Sub-state Regions Nonmedical Use of Pain Relievers in the Past Year, by Age Group 12-17 and Sub-state Region: based on 2010, 2011, and 2012 NSDUHs Colorado Substate Region % (CI) = 7.10% (5.76 - 8.73) Region 1 6.89% (4.77 - 9.86) Region 2 & 7 7.36 % (5.59 - 9.62) Region 3 7.04% (5.03 - 9.78) Region 4 6.83% (4.69 - 9.86) Region 5 & 6 6.45% (4.33 - 8.91) 5&6 1 2&7 3 4 NSDUH: source of misused Rx 72% of people who misuse drugs get them from friends or relatives. Colorado Department of Public Health and Environment Healthy Kids Colorado Survey: High School Students “During your life, how many times have you taken a prescription drug (such as OxyContin, Percocet, Vicodin, codein, Adderall, Ritalin, or Xanax) without a doctor’s prescription? Colorado Average = 13.6% HKCS: by Health Statistics Regions Nonmedical Use of Pain Relievers, Ever Use, 2013 High School Students Health Statistics Region HSR 1: Logan, Morgan, Phillips, Sedgwick, Washington and Yuma HSR 2: Larimer County HSR 3:Douglas County HSR 4:El Paso County HSR 5:Cheyenne, Elbert, Kit Carson and Lincoln HSR 6:Baca, Bent, Crowley, Huerfano, Kiowa, Las Animas, Otero and Prowers HSR 7:Pueblo County HSR 8:Alamosa, Conejos, Costilla, Mineral, Rio Grande and Saguache HSR 9:Archuleta, Dolores, La Plata, Montezuma and San Juan HSR 10:Delta, Gunnison, Hinsdale, Montrose, Ouray and San Miguel Rx Misuse by HS 9.5% Health Statistics Region Rx Misuse by HS HSR 11: Jackson, Moffat, Rio Blanco and Routt 9.9% 13.6% HSR 12:Eagle, Garfield, Grand, Pitkin and Summit 12.4% 12.8% HSR 13:Chaffee, Custer, Fremont and Lake 19.2% 14.6% 9.0% 15.4% 18.5% 14.9% HSR 14:Adams County 19.5% HSR 15:Arapahoe County 12.7% HSR 16:Boulder and Broomfield 11.5% HSR 17:Clear Creek, Gilpin, Park and Teller 19.8% HSR 18:Weld County 14.2% HSR 19:Mesa County 13.9% 15.2% 15.9% HSR 20:Denver County HSR 21:Jefferson County 11.1% n/a HKCS: by Health Statistics Regions Nonmedical Use of Pain Relievers, Ever Use, 2013 High School Students STRATEGIES FOR SCHOOL NURSES What can we do for youth? Colorado Plan to Reduce Prescription Drug Abuse Strategies: 1) Improve surveillance data 2) Strengthen prescription drug monitoring program (PDMP) 3) Educate prescribers and providers 4) Increase safe disposal 5) Raise public awareness 6) Enhance access to treatment 7) Expand access to naloxone Improve Surveillance Data ✓Keep participating in Healthy Kids Colorado Survey! ✓ 2015 HKCS has more questions about prescription drug misuse: ✓Ever Use ✓Current Use (past 30 days) ✓How easy to access? ✓How wrong for someone your age? Increase Safe Disposal ✓ Most teenagers who abuse prescription drugs are given them for free by a friend or relative.1 ✓ Find a safe disposal box near your school: Google “Colorado Drug Disposal” Encourage parents, guardians and staff to safely dispose of unwanted or unused medication. ✓ Sites to expand statewide 1. National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. Raise Public Awareness ✓ Speak Now: Office of Behavioral Health’s resource for parents and teachers to talk to youth about drug use ✓ TakeMedsSeriously.com: safe use, safe storage, safe disposal of prescription drugs ✓ Smart Choices, Safe Kids: family and community information to protect children around substances ✓ Other resources to promote ✓ Rocky Mountain Poison and Drug Center: 1 (800) 2221222 ✓ Good Samaritan Law: 911 immunity and naloxone administration ✓ OBH’s Treatment Directory: >600 facilities, treatment often successful with younger audiences Expand access to Naloxone ✓ Your school can request standing orders for Naloxone from CDPHE as aka Narcan, the opioid reversal drug, available injectable or nasal spray ✓ Relatively cheap (<$50 a dose), long shelf life, heat/cold stable ✓ “No down side” –Naloxone Workgroup of Colorado Consortium for Prescription Drug Abuse Prevention ✓ Trainings available: Harm Reduction Action Center, among others, including online. Questions? [email protected] What about heroin? Not currently a major issue among Colorado high school students