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A REGIONAL HEALTH PROFESSIONAL NEWSLETTER Lyme Winter, Volume 25, No. 1 Norovirus 2014 From the desk of H. Lauren Vogel, D.O., Medical Director Norovirus is a very contagious virus that causes gastrointestinal upset. It is transmitted person to person and from fomites, contaminated food and water. Common symptoms include nausea, vomiting, diarrhea and abdominal pain. Fever and headache are common associated symptoms. The acute illness may last 1-3 days, with complete resolution expected. Because Norovirus infection is highly contagious, outbreaks may occur which involve groups of family members or groups attending a social function where food is served. Patients can be infectious with Norovirus in their stool before symptoms appear. The virus may remain in the stool for up to two weeks after resolution of the symptoms. There is no lasting immunity from the infection. Young children and the elderly are at most risk for complications from the infection. Complications are most often due to dehydration secondary to the diarrhea and vomiting associated with the acute illness. Norovirus is the most common cause of acute gastroenteritis in the United States. Each year, it causes 19-21 million illnesses and contributes to 56,000-71,000 hospitalizations and 570-800 deaths. Norovirus is also the most common cause of food borne-disease outbreaks in the United States. Norovirus can spread quickly in closed places like daycare centers, nursing homes, schools, and cruise ships. Most Norovirus outbreaks happen from November to April in the United States. The Branch-Hillsdale-St. Joseph Community Health Agency reports laboratory confirmed cases of communicable diseases, including Norovirus outbreaks, on a monthly basis through its website at www.bhsj.org. During 2013, each of the three counties reported the following: • Branch County – 2 cases, • Hillsdale County – 1 case, and • St. Joseph County – 11 cases. Norovirus 2014 1 Flu Updates 3 Medical Waste Inspections 4 Health Insurance Deadline Approaches 4 If you would like to subscribe to this Newsletter electronically, please send an email with the words “subscribe to HP Newsletter” to Theresa Christner, Health Education Director at [email protected]. (continued on page 2) Page 1 Known Causes of Foodborne Illness Outbreaks, U.S., Norovirus 2014 (continued) 2006-2010 In addition, the health department receives reports of gastrointestinal illness from both schools and day cares through its online communicable disease reporting system. This system allows the health department to monitor gastrointestinal symptoms on a weekly basis, so that in the event of an outbreak, it can better identify the source of the outbreak, the event site and its sentinel case, as well as plan for the outbreak’s containment. In 2013 the following gastrointestinal illnesses were reported for each of the three counties: • Branch County – 2,784 cases (which represents an increase from 2012 when the county reported 2,004 cases); • Hillsdale County – 1,868 cases (which represents an increase from 2012 when the county reported 1,359 cases); • St. Joseph County – 942 cases (which represents an increase from 2012 when the county reported 793 cases); Other / Multiple 4% Chemicals 6% Parasites 1% Norovirus 49% Bacteria 40% Source: CDC.gov, 2014 Resources: • Norovirus Illness: Key Facts [2 pages] • Norovirus: Facts for Food Handlers [2 pages] • Norovirus in Healthcare Facilities Fact Sheet [2 pages] • Norovirus in Healthcare Settings • A Norovirus Outbreak Control Resource Toolkit for Healthcare Settings • EPA’s Registered Antimicrobial Products Effective Against Norovirus (Norwalk-like virus) [11 pages] There is no specific treatment for Norovirus gastroenteritis. Supportive care with maintenance of hydration, control of nausea and vomiting and pain management as necessary are appropriate. Antibiotics should not be prescribed unless a bacterial pathogen is documented. Prevention of infection is the most important aspect of total patient care. Guidelines for prevention include frequent hand washing using running water and soap. This is important to do before handling food. Alcohol-based hand sanitizers can be used in addition to hand washing, but they should not be used as a substitute for washing with soap and water. All fruits and vegetables should be washed thoroughly before any preparation. All shellfish should be cooked thoroughly before consuming. Quick steaming of foods will not kill Norovirus. Food prepared and not consumed should be discarded. Parents caring for sick children should not be involved with food preparation. Patients with gastrointestinal symptoms should not handle or prepare food for at least 3 days after full recovery from all symptoms. Surface areas should be disinfected using a bleach solution. Use a chlorine bleach solution with a concentration of 1000– 5000 ppm (5–25 tablespoons or 2.5-12 ounces of household bleach [5.25%] per gallon of water). This solution requires a contact time of 10 to 20 minutes to be effective. Other disinfectants registered as effective against Norovirus by the Environmental Protection Agency (EPA) may also be used. Whenever possible, gloves should be worn when handling soiled materials and soiled clothes should be washed with a detergent at the maximum available cycle length before machine drying them. Page 2 Flu Updates According to the current CDC’s FluView report, flu activity in Michigan has been categorized as being widespread. Flu activity is likely to continue for some time. Anyone aged 6 months and older who has not gotten a flu vaccine yet this season should get one now, especially if they are in a part of the country where activity is still increasing. All flu vaccines are designed to protect against 2009 H1N1 viruses which are the most common flu viruses so far this season. It's also important that people with high risk conditions who develop flu-like symptoms or anyone with severe illness consult a health care provider to see whether influenza antiviral drugs might be needed. High risk populations include: • Children younger than 5, but especially children younger than 2 years old • Adults 65 years of age and older • Pregnant women • Also, American Indians and Alaskan Natives seem to be at higher risk of flu complications. In addition, people who have the following medical conditions are considered high risk: • Asthma or Chronic lung disease (such as COPD and cystic fibrosis) • Neurological and neurodevelopmental conditions • Heart disease (such as congenital heart disease, congestive heart failure and coronary artery disease) • Blood disorders (such as sickle cell disease) • Endocrine disorders (such as diabetes mellitus) • Kidney or liver disorders • Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders) • Weakened immune system due to disease or medication (such as people with HIV or AIDS, or cancer, or those on chronic steroids) • People younger than 19 years of age who are receiving long-term aspirin therapy • People who are morbidly obese (BMI of 40 or greater). A summary of key indicators follows: • From September 29, 2013 to February 15, 2014, the Michigan Department of Community Health has reported 322 laboratory confirmed cases of influenza. Of these cases, 94% of them were identified as Influenza 2009 A/H1N1pdm. • Region 1, which includes Clinton, Eaton, Gratiot, Hillsdale, Ingham, Jackson, Lenawee, Livingston and Shiawassee Counties, has reported 317 cases of labconfirmed influenza cases between September 29, 2013 and February 25, 2014. Hillsdale has reported 14 cases. Of these lab-confirmed cases, all but one • • • • • have been identified as type A, and the majority of those subtyped have been identified as H1N1. Hillsdale County already reports one death due to flu in a senior citizen. Region 5, which includes Allegan, Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph and Van Buren Counties, has reported 88 cases of labconfirmed influenza cases between October 1, 2013 and February 25, 2014. Branch has reported four of these cases, while St. Joseph has reported three cases. Of these labconfirmed cases, nearly 1/2 of these have been identified as type A and the majority of those subtyped have been identified as H1N1. St. Joseph County also reports one senior citizen death. High rates of hospitalization have been associated with lab-confirmed cases. The mean age of those hospitalized is in the late 40s. This is consistent with CDC findings which report that 60% of those hospitalized have been in people 18 to 64 years old. This pattern of more hospitalizations among younger people was also seen during the 2009 H1N1 pandemic. Michigan Influenza Antiviral Resistance Data (as of February 20th): For the 2013-14 season, 95 2009 A/H1N1pdm and 8 A/H3 influenza specimens have been tested at the MDCH Bureau of Laboratories for antiviral resistance. None of the influenza specimens tested have been resistant. Influenza-associated Pediatric Mortality (as of February 20th): Two pediatric influenza-associated mortalities in Mid-Michigan and Southeast Michigan have been reported to MDCH for the 2013-14 season. CDC requires reporting of flu-associated pediatric deaths (<18 yrs), including pediatric deaths due to an influenzalike illness with lab confirmation of influenza or any unexplained pediatric death with evidence of an infectious process. Page 3 Health Insurance Deadline Approaches The Branch-Hillsdale-St. Joseph Community Health Agency is working with the Michigan Department of Environmental Quality (DEQ) to provide medical waste inspections of healthcare facilities. The purpose of this new pilot program is to determine the effectiveness of Medical Waste Regulatory Program when conducted by local health departments. On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (ACA), which puts into place comprehensive health insurance reforms that impact many Americans, including those people residing in the tri-county health jurisdiction. Branch-Hillsdale- St. Joseph residents now have the opportunity to purchase health insurance through the Health Insurance Marketplace. While much of the news media outlets have focused on system development and connectivity issues, little attention has been placed on who the law applies to or what it requires. Between now and March 31, 2014, our agency’s sanitarians will be contacting 50 medical waste producing facilities to schedule an inspection time. These inspections will include a very basic evaluation which will be used to determine the following: Steve Todd, Health Officer, explains “One of the four key provisions of the ACA is the individual responsibility requirement or individual mandate – which provides that all citizens obtain basic health coverage by March 31, 2014, obtain an exemption or pay a fee when filing a federal income tax return.” The law also established the ‘Health Insurance Marketplace’ which helps consumers know what types of health coverage are available, as well as if they qualify for assistance with lowering coverage costs through either premium tax credits and/or cost sharing reductions. The Branch-Hillsdale-St. Joseph Community Health Agency is providing in-person assisters to county residents in need of support during this enrollment process. Whether the facility’s registration is consistent with the type of medical waste producer activity Whether the facility has a complete medical waste management plan. Whether the medical waste is properly stored Whether the facility has records documenting staff training and medical waste shipments. What are in-person assisters? In-person assisters are professional individuals that are trained to help consumers looking for health coverage options through the new federal Marketplace, including help with completing online or paper applications. Services are free to the public. According to Steve Todd, “We have nine staff people who have met the Medicaid/Medicare training requirements and have earned the title ‘Certified Application Counselor.’ In addition, we have one staff person who has completed the more extensive 25-hour Navigator training program. These nine people can help residents to understand the new law requirements, exemptions, premium tax credits and cost-sharing reductions, as well as penalties and appeal procedures.” At the conclusion of the inspection, you will be provided a copy of the inspection report which will include any recommendations from the inspector. No follow-up inspections are anticipated. What information is needed to apply through the Marketplace? • • • • To learn more about this pilot project or to receive a copy of the inspection report form, please feel free to contact the Rebecca Burns, Environmental Health Director at 269-273-2161, ext. 228 or at [email protected]. The following information is needed to make an application for coverage: • • • • Social Security number (SSN) Birth date Paystubs, W-2 forms, or other information about your income Policy/member numbers for any current health coverage (continued on page 5) Page 4 Health Insurance Deadline Approaches, cont. • • Information about any health coverage from a job that’s available to you or your family Document number (if you’re an eligible immigrant who wants health coverage) What are the Categories? • • How is this information used? First, the information collected through the Marketplace is verified through the Internal Revenue Service (IRS) and the Social Security Administration (SSA). Once the information has been confirmed as being correct, it is used to make eligibility determinations. In Michigan, when residents apply for insurance coverage through the Marketplace, their information will be used to determine if they could be eligible for Medicaid programs – including the new Healthy Michigan Plan. Information for these individuals and/or family members is then shared electronically with the Michigan Department of Human Services, who makes the final eligibility determination for Medicaid enrollment. Each client receives an eligibility determination from the Marketplace. The eligibility determination indicates if the client and/or families members are eligible to enroll in a Qualified Health Plan (QHP), Medicaid or Healthy Kids. It also will let them know if they can lower their health coverage costs through premium tax credits or cost-sharing reductions. What are Qualified Health Plans (QHPs)? QHPs are health plans that are certified by the marketplace and that: • Provide essential health benefits, • Follow established limits on cost-sharing • And meet other requirements. What are Essential Health Benefits? The ACA requires all health plans to cover a comprehensive package of items and services, which include: • Ambulatory Patient Services • Emergency Services • Hospitalization • Maternity and newborn care • Mental Health and substance use disorder services (including behavioral health treatment) • Prescription Drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and Wellness Services and Chronic Disease Management • Pediatric Services, including oral care. • • • Five Health Plan Bronze Health Plan – insurance company pays 60% of covered medical expenses; Silver Health Plan – insurance company pays 70% of covered medical expenses; Gold Health Plan – insurance company pays 80% of covered medical expenses; Platinum Health Plans – insurance company pays 90% of covered medical expenses; Catastrophic Health Plans – meet all of the QHP requirements, but cover only three primary care visits each year until the consumers meet the plans’ deductible. Only for those under 30 years of age or who receive a hardship exemption. What are Premium Tax Credits? Premium Tax Credits reduce the cost of QHP premiums to eligible consumers. Consumers can either claim premium tax credits during the tax filing process or request payment directly to insurance companies (as ‘advance payments’). Advance payments of the premium tax credit are reconciled during the tax filing process. Household size, income and the cost of available plans determine premium tax credit eligibility. Therefore, if a consumer makes more money over the course of the year than projected at the time they requested advance payments of the premium tax credit, consumers will need to repay the extra amount via their annual tax return. If consumers make less money, they can receive an additional refund on their tax return. The Marketplace provides documentation to the tax filer and to the IRS to support this process. If a consumer requests advance payments, they must file a tax return. Page 5 Health Insurance Deadline Approaches, cont. What are Cost-Sharing Reductions? Cost-sharing reductions limit the amount of out-of pocket costs for health benefits (like deductibles and copayments) associated with a QHP through the Marketplace. There are several categories of cost-sharing reductions based on annual household income and family size. Each insurance company applies these differently, based on their specific health plan design. Consumers who are eligible for cost-sharing reductions can review their reduced costs when they go to compare their health plan options. In general, cost-saving reductions are only available to consumers who select a plan at the silver level of coverage. When will the Healthy Michigan Plan begin? The Healthy Michigan Plan, which expands Medicaid to adults (18 to 64 years) with incomes at 133% of poverty, is expected to roll out in early April. Steve Todd states “In our communities, we currently estimate that there are over 33,000 people across the three counties that are receiving Medicaid insurance. With the Healthy Michigan Plan expansion of Medicaid, we expect that number to grow by another 8,000 to 9,000.” With a higher need for providers that accept Medicaid patients, section 1202 of the Affordable Care Act requires payment by State Medicaid agencies of at least the Medicare rates in effect in calendar years 2013 and 2014 for primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. To learn more about the ACA and the Health Insurance Marketplace, visit our website and click on the Marketplace button. There you will find useful information and tools that can help you, your staff and/or your patients navigate health care reform. Deadline for Open Enrollment is March 31, 2014. BRANCH-HILLSDALE-ST. JOSEPH COMMUNITY HEALTH AGENCY Coldwater Office 570 N. Marshall Road Coldwater, MI 49036 517-279-9561 Hillsdale Office 20 Care Drive Hillsdale, MI 49242 517-437-7395 Three Rivers Office 1110 Hill Street Three Rivers MI 49093 269-273-2161