Friday, November 16, 2012

Michigan's Amazing Immunization Registry

Teenagers (ages 13-18) are pretty resilient. Not much stops them. Maybe that is one reason that the death of a teen is so shocking and traumatic to us.

The leading causes of death in teenagers are accidents and injuries. But diseases caused by bacteria and viruses also threaten the lives of young people. And many such diseases cause terrible illness even if they don’t cause death.  Most people are familiar with meningitis which is a serious infection of the lining of the brain that has a high death rate. Other diseases caused by bacteria and viruses that can make teenagers very sick include measles, rubella, hepatitis B and chickenpox. Fortunately all of these diseases can be prevented by immunization.

The Michigan Department of Community Health, with funding from Novartis, recently undertook an effort to increase the immunization rate among teenagers and the Mid-Michigan District Health Department (MMDHD) had a key role to play. To understand how, you need to know that in Michigan, information on immunizations is stored in a web-based database call the Michigan Care Improvement Registry (MCIR, pronounced “micker”). When someone gets a shot, the person who gives the shot puts the information into MCIR through a web browser. This is very important. No matter where you or your child go in Michigan, your health care provider has up to date information about your immunizations and knows what you need. MCIR is a state-of-the-art system and is known as one of the best immunization databases in the country. There are millions of immunizations in MCIR.

To handle all that information the state is divided into MCIR regions and local health departments have contracts to manage the data in the regions.  MMDHD has such a contract, and is responsible for the information in region 3, which includes Barry, Clinton, Eaton, Gratiot, Ingham and Montcalm counties.  Here I am just going to write about the three counties in MMDHD’s health department jurisdiction:  Clinton, Gratiot and Montcalm.

Reaching out to the families of teenagers who needed immunizations was a straightforward process. The project was led by Hazel Hall who is the region 3 MCIR coordinator. We wanted to find teenagers who needed to be immunized for polio, measles, mumps, rubella, hepatitis B or chickenpox. Hazel had to run reports in MCIR that listed the teens who needed immunizations. Using the reports, letters were printed that told what immunizations the teens needed and these letters were sent to their parents with an invitation to attend an immunization clinic. There were several thousand teens in the three counties who needed shots.  We had so many letters to send out that we used volunteers—who happened to be teenagers from Clinton County—to sort and bundle the letters.

The letters went out in July, and they really helped. Sixty-five (65%) percent of teens had up to date immunizations in July; by October it was up to 69 percent. All three counties increased three to four percent. At the end Gratiot had the highest teen immunization rate (74%) and Montcalm improved but was ten points behind (64%). Clinton was in the middle (70%).

Hazel also looked at the percentage of teenagers who had immunizations for meningitis. The percentage of teens who had an immunization against meningitis increased from 68 percent to 73 percent. It increased from 71 percent to 77 percent in Clinton and 73 to 77 percent in Gratiot. In Montcalm it increased from 63 to 67 percent.

MCIR is an amazing system, and using the information helps keep immunization rates high and keeps people safe from disease.

Hazel also looked at the individual physicians and hospitals which have high immunization rates among their patients.  I’d like to close by thanking these providers, and listing the names of those who had the highest rates.

Carson Family Care Center
Cherry Street-Montcalm Area Health Center
Greenville Family Care Center
Sheridan Care
McLaren DeWitt Family Practice
MSU Pediatrics-DeWitt
Sparrow Medical Group-DeWitt
Sparrow-St Johns Professional Associates
Alma Family Practice
Ashley Family Care Center
Family Medical Care-Ithaca
Ithaca Family Care Center

Sunday, October 7, 2012

Health Care Transformation

The Michigan Department of Community Health is working at a feverish pace to transform the way health care is delivered in the state. There is nothing unique about that--it is happening everywhere in American today, as we struggle to reduce the cost of health care, which is making insurance unaffordable and making our businesses uncompetitive.  Michigan is currently calling its health reform initiative “Community Linkages.”

However, many people do not realize that this is going to have big implications for grass-roots community organizations like those that are members of the Montcalm Human Services Coalition, Gratiot County Community Collaborative, and the Building Stronger Communities Council in Clinton County. 

One trouble with our health care system is that there is poor coordination between health care providers and community based services.  The fact is, while doctors can help you a lot when you have some kind of acute health crisis like an infection or injury, they don’t do a great job of preventing you from becoming sick in the first place, and can’t do much if the things that are making you sick have their roots in your home or community.

For example, if a physician is treating a child for asthma whose parents smoke in the home, the physician needs to be able to refer the parents to smoking cessation services. What about someone who keeps landing in the emergency room with symptoms of severe depression whose real problem is that they have been unemployed for three years?  Today doctors are stymied by the many overweight patients they see who are on their way to heart disease and diabetes for whom they seem to be able to do nothing.

The Community Linkages project seeks to transform health care by taking the care of patients in doctor’s offices, and wrapping around it easy, low-cost access to comprehensive community services to address all the needs patients may have. In the jargon of the project they want to create “community hubs” to which health care practices can subscribe to get access to these services.

Now you might ask, “Well we already have 211 and our collaborative councils, so what more do we need to do?” The “hubs” will be special in two ways.  First, they will take advantage of the electronic medical records revolution.  Doctors will be able to refer patients to community services right out of their electronic medical records.  In fact, the systems will even prompt the doctors to make such referrals.  Second, patient outcomes will be monitored to ensure that people actually benefit from the services. Let’s face it, we’ve been doing a lot of prevention work for these many years, but in many cases we can’t show that people actually got better.  Community Linkages will leverage Michigan’s new Health Information Exchange to demonstrate the value (if it is there!) of the community services.  In the examples above: Did the parents referred to smoking cessation stop smoking? Did the man referred for employment counseling have fewer emergency room visits? Did any of the patients referred to weight management lose weight?

This measurement is critical, because the State is still trying to figure out how to make Community Linkages sustainable.  It has to be able to demonstrate value and cost savings so that health care providers, employers, payors and governments will feel justified in supporting it financially.

Right now there are demonstration projects under way in Ingham County, Saginaw and Muskegon.  At the Mid-Michigan District Health Department we are very interested in getting an experiment going here, too.


Wednesday, August 29, 2012

Don't Let West Nile Keep You Indoors

A few Mid-Michigan residents have complained to me that they don’t know what to make of the reports in the news about West Nile Virus.  They tell me they are hearing that it is the worst West Nile year ever, yet they don’t think they have ever met anyone who has had the disease.  People say they don’t know whether they ought to be worried, or just ignore it. Let me tell you what I feel:  I feel deeply appreciative of the US Center for Disease Control’s (CDC) amazing ability to track rare and novel diseases, knowing that someday, when a truly deadly new disease appears, we will be warned and ready.  Meanwhile, I’m going to enjoy Michigan’s outdoors without undue fear.

West Nile Virus first appeared in the US in 1999 and is now widespread. It is transmitted by the Culex mosquito and makes a variety of mammals and birds ill.  Most years there are a few dozen human deaths from the disease in the US.  It also kills horses and birds.  There is no vaccine for the disease for humans, but horse owners should get their animals vaccinated.  Most people who get bitten by the Culex mosquito never have any symptoms and may become immune to the disease. A few people who get bitten become sick and go to the doctor and on rare occasions may die. When you hear about the number of “cases” of West Nile Virus, it is these people who have become very ill and have been tested who you are hearing about. Not included in the number of cases are the thousands who actually had the disease but had no symptoms.

This year the number of cases and deaths will likely be double what we usually see.  No one is sure of the reason--maybe the mosquitos are doing better in the warmer weather.  There have been about 100 cases in Michigan so far, and 4 deaths.  Remember that about 1,000 people are killed in car crashes in Michigan every year, and nearly 30,000 die from heart disease.  Comparing the numbers you can see that even with the increase, West Nile is not a big a threat at this time.

People ask if we should spray for mosquitos or put chemicals in ponds to kill larvae.  Some municipalities in Texas have started doing that. In general, this is likely to do more harm than good.  Effective mosquito control programs are carefully managed, and have good historical data to guide local governments on what works, what is harmful to the environment, and what is just a waste of money.  It is almost always the case that rushed anti-mosquito programs don’t kill enough mosquitos to make a difference.  If West Nile deaths continue to climb, mosquito control could be part of a prudent response.  But it would have to be done wisely to have any real benefit, and to avoid harm to the environment.  

There are some people who should not get bitten by mosquitos, because West Nile Virus could harm them.  The very old, infants, and people with illnesses like diabetes, a heart condition or an immune disorder should take precautions including wearing long sleeves, using repellant, and staying indoors at dawn and dusk.  Everyone else should remember that healthy outdoor exercise will prolong their lives and head out the door confidently.  Don’t let the headlines scare you into staying inside.

Monday, August 20, 2012

Environmental Health Activity Picks Up

Health departments deal with a wide variety of environmental concerns, but the three best known are 1) ground water including wells, 2) septic systems and land inspections to determine the suitability of property for systems, and 3) food safety, especially inspections of restaurants and other food service establishments. These inspections keep people safe from outbreaks of serious illness like e-coli, salmonella and cryptosporidium.

Through the third quarter of our 2011-2012 fiscal year MMDHD is noticing an increase in well and septic permit activity and in the number of food service inspections. Check out the table below.

2011-2012 YTD
Expected Final
On-Site Sewage Applications
Well Applications
Food Service Inspections

The table shows that we expect to do 45 more septic system inspections this year than last, 73 more wells, and over 300 more food service inspections. I share these numbers with you because they indicate that there may be an increase in economic activity in our area. In general, requests for inspections precede construction and renovation projects. We see the same trend across all three counties. This is great news! It is MMDHD’s goal to be sure all these projects are completed as quickly as possible. However, you should also know that this activity places some strain on our sanitarians who are working very hard to keep up with the demand.

In fact, we increased our output over the first three quarters of 2011-12 with a slightly reduced workforce. Because of budget shortfalls in 2011-12, we had to reduce the hours of work of some employees. The reduced hours combined with the increase in the demand for inspections has meant that the queue of folks waiting for inspections has gotten longer. On average the wait for an inspection has increased from 5 to 8 days.

We are aware that this has led to a few cases to frayed nerves on the part of folks trying to get a permit or inspection. There are a couple of things that can be done about this: First, over the winter, construction work slows down and our work load will too. This winter we plan to touch base with the municipalities to be sure local code enforcement personnel understand the importance of promptly directing homeowners and businesses that are making changes to well, septic or food service systems to the health department. If we are contacted at the beginning of a project we can ensure that things are done correctly from the start. The municipalities can help ensure that this happens.

Second, I’d like to remind residents that if you don’t think you got a fair deal getting a permit or inspection, you have a right to appeal to the Board of Health. All you have to do is call the health department and ask for an appeal. Don’t be afraid to call. Usually just making a call leads to a problem getting cleared up. In fact, we handle very few appeals because the truth is our sanitarians usually do an outstanding job. But I think knowing that you don’t have to accept an inspector’s first judgment can make the process less intimidating.

In addition to handling our increased workload this summer, we have also been trying to help residents affected by dry wells. Wells go dry all the time for a variety of reasons including problems with the well itself. But this summer dry weather combined with increased irrigation caused an increase in dry wells. This problem has been especially serious in Gratiot County where the subsoil and rock are less permeable to water.

Many parts of Michigan are seeking increases in irrigated agriculture, which by itself is not a bad thing. In spite of the dry weather, we grew plenty of human and animal food crops. However, as this trend continues, we will need to do a better job of managing our ground water. I grew up out west. There are many places out west now where you can no longer farm, because people resisted water management and eventually pumped all the water out of the ground. Michigan, with an abundance of clean, tasty ground water is far from facing that problem. But to avoid it altogether we will have to balance residential and agricultural uses better, and irrigate more efficiently. Pay attention to Senate Bill 1008 which proposes to reinstate DEQ powers to mediate conflicts over ground water. Senator Roger Kahn is one of the sponsors of this bill.

If you have been affected by a dry well, especially if you live in Gratiot County, go to the health department’s website at and fill out a Well Assessment form.

First Blog Post

Welcome to the first post on the Mid-Michigan District Health Department's (MMDHD) new blog.  I am Marcus Cheatham, the Health Officer.

I am very excited to have become the Health Officer of MMDHD, a role I've held for just under three months.  You may not know that, in public health circles in Michigan, MMDHD is regarded as a great assignment. My predecessor, Kim Singh, built a very high quality operation characterized by high levels of professionalism and attention to service and quality. The Board of Health of MMDHD is extremely engaged in driving the Department forward and ensuring our success, and I am grateful for their leadership.

Before coming to MMDHD I was Assistant Deputy Health Officer at the Ingham County Health Department. I rarely went north of the Clinton County line except for family vacations. While my wife, Debra, and I are maintaining our home in East Lansing for days when I work in Clinton County, we are renting a house in Sidney in Montcalm County about six minutes from MMDHD’s main office in Stanton, where I work most days. Getting to know people in the three counties we serve: Clinton, Gratiot and Montcalm has been wonderful.  The warm welcome we have received has been overwhelming. 

Finally, I have to say how fortunate I feel to be working with the employees at MMDHD.  Wherever you look in the Department, whether it is in clinical programs, environmental health, finance and administration or information technology you find outstanding, talented people.  I’m not just saying that—the main reason I applied to be health officer here is that MMDHD is a health department that is working. I hope the employees who built the Department feel proud of what they have accomplished.

With this blog, I hope to create a way for the Department to regularly communicate with the community about local public health issues and public policy related to health. The blog is intended encourage discussion and to inform residents about the value of what the health department is doing.  While the blog may occasionally contain health tips, its main purpose is not health education--there are plenty of sources for that--it is communication.  Rather than try to tell you everything going on in the Department every time I blog (which might be overwhelming—for you, too!), I will try to have a focus. I won’t be the only voice here; many of my Department colleagues will be featured in this blog.