The State of Health HOUSTON HARRIS COUNTY 2015-2016 The State of Health of Houston/Harris County 2015-2016 Sponsors Harris County Healthcare Alliance Houston Department of Health and Human Services Harris County Public Health and Environmental Services University of Texas School of Public Health Center for Health Services Research Institute for Health Policy Harris Health System Episcopal Health Foundation Mental Health and Mental Retardation Authority of Harris County Harris County Pollution Control Pollution Control Services Department Suggested citation: The State of Health in Houston/Harris County 2015-2016. Harris County Healthcare Alliance, Houston, Texas. Front cover photographs by: Houston/Harris County area residents Emma Hoffman Photography (top photo) and Bob Sennhauser (center photo) at Sunday Streets Houston events, and Derrick Dickerson, HDHHS, at the West End MSC community garden (bottom photo). Back cover by Nguyen Le (top photo), and HDHHS staff members. The State of Health in Houston/Harris County 2015 - 2016 Welcome to the State of Health in Houston/Harris County. We are pleased to provide our many constituencies this broad assessment of the health of our community. Many organizations have joined together to determine the most pertinent health indicators, and gathered and organized these measures into a format that we hope will be both interesting and informative. This report provides:      current measures available to evaluate the health in our community trends in key health measures to allow readers to evaluate changes in local health status and compare these measures to national goals resources for priority setting in preventing disease, promoting health and improving access to care health care information and websites for more detailed information summaries of key public health actions to address the identified issues. Please feel free to use this information as needed for planning and decision making. We hope this report assists you in your efforts to address health‐related concerns in our community. Stephen L. Williams, M.Ed., M.P.A. Director Houston Department of Health and Human Services Lisa Mayes Executive Director Harris County Healthcare Alliance Umair A. Shah, M.D., M.P.H. Executive Director Harris County Public Health and Environmental Services George V. Masi President and CEO Harris County Hospital District Steven B. Schnee, Ph.D. Executive Director Mental Health and Mental Retardation Authority of Harris County Elena Marks President and CEO Episcopal Health Foundation Charles E. Begley, Ph.D. Co-Director University of Texas School of Public Health, Center for Health Services Research David R. Lairson, Ph.D. Co-Director University of Texas School of Public Health, Center for Health Services Research Stephen H. Linder, Ph.D. Director University of Texas School of Public Health Institute for Health Policy Bob Allen Director Harris County Pollution Control Acknowledgments Welcome to the 2015 State of Health in Houston/Harris County report. The project began in 2006 when the two local health departments joined to create a State of Health report for the city and county. Since that time, others have joined the list of supporting organizations and have loaned members of their staff to participate in the State of Health Workgroup and contribute content for the report. Sponsors for the report are:         Harris County Healthcare Alliance, project lead (HCHA) Houston Department of Health and Human Services (HDHHS) Harris County Public Health and Environmental Services (HCPHES) Episcopal Health Foundation (EHF) Harris Health System (Harris Health) University of Texas School of Public Health (UTSPH) Mental Health and Mental Retardation Authority of Harris County (MHMRA) Harris County Pollution Control Services Department (HCPCS) We hope that this report assists your planning and decision-making activities, as well as efforts to address healthrelated concerns in our community. State of Health Committee: This group defined key measures and recommendations for the report. Chair, HCHA Executive Director Lisa Mayes Christine Aldape, Baylor College of Medicine, HCHA Ryan Arnold, HDHHS Latrice Babin, HCPCS Deborah Banerjee, HDHHS LaVonne Carlson, HCHA LaPorcha Carter, HCPHES Editor: Beverly Nichols HDHHS Assistant Editor: Christine Aldape HCHA, Baylor Executive Summary: Jennifer Hadayia HCPHES Beverly Nichols HDHHS Content Contributors: HDHHS Najmus Abdullah Okey Akwari Francis Agostini Raouf Arafat Anum Arif Ryan Arnold Abel Assefa Deborah Banerjee Renee Beckham Arturo Blanco Stephen Collazo, HCHA Jennifer Hadayia, HCPHES Jane Hamilton, UT Medical School at Houston June Hanke, Harris Health System Robert Hines, HDHHS Liz James, Lesbian Health Initiative Denae King, Texas Southern Univ. Amanda Kubala, HDHHS Devin Bradberry Tristan Broussard Monica Childers Jyothi Domakonda Larry Goodman James Gomez Carolyn Gray Camden Hallmark Ilhaam (Illy) Jaffer Conrad Janus Salma Khuwaja Amanda Kubala Stephen Long Barbarah Martinez Wesley McNeely Jeffrey Meyer Kasimu Muhetaer Vishnu Nepal Beverly Nichols Loren Raun Hafeez Rehman Brenda Reyes Eunice Santos Sayla Simi Brenda Thorne Varsha Vakil Marcia Wolverton Biru Yang Yufang Zhang HCPHES LaPorcha Carter Marilyn Christian Deanna Copeland Jennifer Hadayia Kelly Johnson Kila Johnson Janet Lane Diana Martinez Bakeyah Nelson Richard Williams HCHA Christine Aldape LaVonne Carlson Harris Health June Hanke Episcopal Health Foundation Philomene Balihe Gail Bray Troy Bush Robin Landwehr, Lesbian Health Kim Lopez, Baylor College of Medicine Bakeyah Nelson, HCPHES Beverly Nichols, HDHHS April Sanders, MHMRA Sandra Wegmann, EHF Sandra Wegmann Gary Grier Baylor College of Medicine Kim Lopez City of Houston Admin. & Regulatory Affairs Tonia Brown HCPCS Latrice Babin Stuart Mueller UT Medical School at Houston Jane Hamilton UT School of Public Health at Houston Chuck Begley Stephen Linder Lesbian Health Initiative Liz James Robin Landwehr MHMRA Scott Hickey April Sanders Coalition for the Homeless Texas Department of State Health Services Elijah Brown Margaret Ciampa Eric Garza Amy Littman Derrick Shaw Rebecca Wood UT School of Public Health, Project Evaluation Team: Linda Lloyd Vishnukamal Golla Jacob Gross Page Design & Graphics: LaVonne Carlson, HCHA Photographs provided by Harris County Public Health & Environmental Services, except where specific credits are listed. Used with permission. Introduction The State of Health of Houston/Harris County focuses on the well being of the four million people who live in Houston/Harris County. Public Health emphasizes prevention and health promotion for the whole community rather than individuals, employs interventions aimed at the environment, human behavior, lifestyle and medical care, and is stimulated by threats to the health of that population. Public Health is committed to protect the community against infectious disease and environmental hazards; to collect, analyze and disseminate health data; to provide leadership, planning and policy development; and to assure community-wide quality and accessible health services. The report offers concise summaries on more than 50 health topics. Where possible, each section reports on Trends, Population Differences, Geographic Distribution, Economic Impact, Healthy People 2020 and Public Health Actions. Trends reflects the direction of the health issue over a specified period of time using statistics frequently taken from the Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is the world’s largest, on-going telephone health survey system, tracking health conditions and risk behaviors in the United States yearly since 1984. Conducted by the 50 state health departments as well as those in the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands with support from the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC), BRFSS provides state-specific information about issues such as asthma, diabetes, health care access, alcohol use, hypertension, obesity, cancer screening, nutrition and physical activity, tobacco use, and more. BRFSS also provides some measures at the county level. Federal, state, and local health officials and researchers use this information to track health risks, identify emerging problems, prevent disease and improve treatment. Population Differences brings to light the ethnic, gender and socioeconomic disparities apparent with many health issues. Geographic Distribution presents how various locales are impacted by health issues. The Economic Impact sections provide statistics on the dollars and lives lost and human suffering related to the consequences of each health issue. Healthy People 2020, developed by the U.S. Department of Health and Human Services, uses leading health indicators to measure the health of the nation and set goals for the next 10 years. The Leading Health Indicators are: Access to Care, Healthy Behaviors, Chronic Disease, Environmental Determinants, Social Determinants, Injury, Mental Health, Maternal and Infant Health, Responsible Sexual Behavior, Substance Abuse, Tobacco, and Quality of Care. Each of the 12 Leading Health Indicators has one or more objectives. The Leading Health Indicators were chosen to reflect the major health concerns in the United States at the beginning of the 21st century. More information is available at www.healthypeople.gov/. The Healthy People 2020 section of each chapter compares local measures to the national benchmarks and goals. Public Health Actions lists the actions by Public Health to address the health issue based on the Ten Essential Public Health Functions. They are: monitor health status to identify community health problems; diagnose and investigate health problems and health hazards in the community; inform, educate, and empower people about health issues; mobilize community partnerships to identify and solve health problems; develop policies and plans that support individual and community health efforts; enforce laws and regulations that protect health and ensure safety; link people to needed personal health services and assure the provision of health care when otherwise unavailable; assure a competent public health and personal health care workforce; evaluate effectiveness, accessibility, and quality of personal and population-based health services; and research for new insights and innovative solutions to health problems. Due to the breadth of health issues included, no section can go into great detail. Readers are directed to governmental and advocacy websites for further inquiry under For More Information. Much of the data presented is collected at the county level—that is, there is no distinction made between the jurisdictions of Houston and Harris County when the data are gathered. When data can be differentiated between the two jurisdictions, in many cases, the results are actually quite similar; therefore, much of the data is reported as “Houston/Harris County.” In most cases, this designation will not include information from the areas of Houston within Fort Bend and Montgomery Counties. If important differences in health data are noted between the two jurisdictions, the findings are reported separately as either “Houston” or “Harris County (excluding the City of Houston).” In this case, “Houston” is inclusive of the areas of the city within Fort Bend and Montgomery Counties . This report uses many acronyms. Please see the Appendices for definitions. Previous and current editions of this document are available on the website for download at www.houstonstateofhealth.org. In addition, the website provides links to related documents and other pertinent information. Table of Contents (to view a particular section, click the section heading) Population Facts .......................................................................................................... 1 Factors Influencing Health ...........................................................................................5 Social & Economic Indicators ...........................................................................6 Health Care Access ........................................................................................15 Insurance Access .............................................................................16 Access to Health Care ......................................................................20 Preventable Hospitalizations ............................................................24 Emergency Room Visits ...................................................................26 Mental Health-Related ED Visits ......................................................29 Health Behaviors ............................................................................................31 Tobacco Use ....................................................................................32 Secondhand Smoke .........................................................................34 Nutrition ............................................................................................36 Physical Activity ................................................................................38 Overweight/Obesity in Adults ...........................................................40 Overweight/Obesity in Youth ............................................................42 Injury Risk Behaviors ........................................................................44 Child Abuse & Neglect .....................................................................48 Alcohol & Drug Use ..........................................................................50 Use of Preventive Services ..............................................................53 Prenatal Care .....................................................................54 Immunizations ....................................................................56 Cancer Screening ..............................................................58 Oral Health .........................................................................60 Vision/Vision Screening .....................................................62 Environmental Health Indicators .....................................................................65 Air Quality .........................................................................................66 Surface Water Quality/Solid Waste ..................................................70 Water for Drinking ............................................................................72 Occupational Health .........................................................................73 Food Safety ......................................................................................74 Lead Poisoning .................................................................................76 Neighborhood Concerns ...................................................................78 Health Outcomes ........................................................................................................79 Leading Causes of Mortality ...........................................................................80 Maternal & Infant Health .................................................................................83 Adolescent Pregnancy ......................................................................84 Maternal Mortality & Morbidity ..........................................................86 Pregnancy/Infant Outcomes ..............................................................88 Pregnancy/Fetal Outcomes ...............................................................90 Chronic Diseases ............................................................................................93 Heart Disease & Stroke ....................................................................94 Cancer ..............................................................................................96 Diabetes ...........................................................................................98 Arthritis ...........................................................................................100 Asthma ...........................................................................................102 Mental Health Indicators .................................................................104 Communicable Diseases ...............................................................................109 HIV/AIDS ........................................................................................110 Sexually Transmitted Diseases ......................................................112 Tuberculosis ...................................................................................116 Vaccine-Preventable Diseases .......................................................118 Influenza .........................................................................................120 Meningitis ......................................................................................122 Hepatitis .........................................................................................124 Enteric Diseases ............................................................................126 West Nile Virus ...............................................................................128 Appendix A Demographics ......................................................................................132 Appendix B Maps of Houston and Harris County .....................................................134 Appendix C Frequently Used Websites ...................................................................136 Appendix D Healthy People 2020 Sources ..............................................................136 Appendix E BRFSS Data, Map Info .........................................................................136 Appendix F Acronyms ..............................................................................................137 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Population Facts Demographics Harris County is the third most populous county in the United States, with an estimated 4.3 million residents in 2013.1 Of those, approximately 2.2 million (51%) are residents of the City of Houston, the fourth largest city in the nation. While most of the City of Houston is contained within Harris County, Houston also extends slightly southwest into Fort Bend County and north into Montgomery County. Harris County is one of the fastest growing counties in the U.S. The county population doubled from 1970 to 2000 and increased by 20.3% from 2000 to 2010. Although growth was more rapid in the suburbs, the City of Houston population increased by 7.5% from 2000 to 2010. According to the U.S. Census population estimate, Houston’s population density in 2013 exceeded that of Harris County. Houston’s geographical area, as outlined by the Census, includes 600 square miles of land area with 3,662.3 persons per square mile. Harris County (including the City of Houston) includes 1,703 square miles with 2,545.9 persons per square mile in 2013. By contrast, New York City included 303 square miles with 27,775.0 persons per square mile in 2013. Harris County’s population is diverse—more so than Texas or the U.S. According to the 2013 American Community Survey, Harris County has a greater proportion of African American and Asian residents than Texas and the nation, and a greatly higher proportion of Hispanic residents than the U.S. population. The proportion of Hispanic residents in City of Houston (43.7%) is similar to that of Harris County (41.3%). The 2013 American Community Survey data show that an estimated 27.4% of county residents are under the age of 18, compared with 23.3% of the U.S. population. Nine percent of the county’s population is aged 65 and over, compared to 11.2% of the Texas population and 14.1% of the U.S. population. American Community Survey figures show that in 2013, male and female residents are closely balanced in Houston and Harris County. Similar trends are seen in Texas and national data. [See detailed data for Houston and Harris County in Appendix A] Total Population of the City of Houston Compared to Harris County 1980-2010 Houston Harris County 4,092,459 3,400,578 2,818,199 2,409,547 1,595,138 1,630,553 1980 1990 1,953,631 2,099,451 2000 2010 Source: U.S. Census Bureau Race and Ethnicity in Houston, Harris County, Texas and the U.S. 2013 Percent of Total Population White Black Hispanic Asian 62.4 43.7 41.6 43.9 38.4 31.7 25.8 22.6 18.4 6.3 Houston 6.4 Harris County 11.6 4.1 Texas 17.1 12.3 5.0 U.S. Source: American Community Survey 1. U.S. Census Bureau, American Community Survey. ACS demographic and housing estimates: 2013 American Community Survey 1-year estimates. http://factfinder.census.gov. Accessed October 21, 2014. 1 Population Facts, cont. Race and Hispanic Population Trends: 1980-2010 for the City of Houston, Harris County, Texas and the U.S. Much of the growth in Houston/Harris County can be attributed to an expanding immigrant population. According to the Kinder Institute, Houston has transformed from an essentially biracial city to the most ethnically and culturally diverse area in the nation. Racial and ethnic diversity is particularly striking among age groups, with non-Hispanic whites representing a majority in only persons 65 and older. The following charts show the changing racial and ethnic composition in Houston, Harris County, Texas, and the United States. City of Houston Population Distribution Race & Hispanic Origin: 1980-2010 Harris County Population Distribution Race & Hispanic Origin: 1980-2010 2 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 The graphs below depict the nature of the increasing minority population in the United States. The Hispanic population is growing more rapidly than any other group, while the white population is decreasing. The black, or African American, population has remained relatively stable as a percentage of the overall population. In the “Other” group, the population of Asians and of those who identify themselves as “Two or More Races” has been increasing. Texas Population Distribution Race & Hispanic Origin: 1980-2010 United States Population Distribution Race & Hispanic Origin: 1980-2010 Source: U.S. Census Bureau NOTE: 2010 Populations percentages include only individuals who identified as a single race for comparison with previous decades census data. 3 Population Facts, cont. Racial and Ethnic Demographic Patterns in Houston/Harris County 2010 The map below shows areas in which specific racial/ethnic groups are most populous in Houston/Harris County, according to the 2010 U.S. Census. If one racial/ethnic group represents 50% or more in a census tract, that tract is shaded to represent that group. If no group is 50% or more of the population, that census tract is coded with no racial/ethnic group predominating. Source: Data from U.S. Census, 2010. Map developed by HDHHS, Community Health Planning, Evaluation & Research. Map concept: Greg Wythe. Life Expectancy in Harris County In 2010, life expectancy for males and females in Harris County, 76.2 and 80.7 respectively, were comparative to the national average.1 The chart to the right shows the rising life expectancy rates for males and females in Harris County.2 White males and females were shown to have longer life expectancies than their black counterparts during the years of 1989 through 2009. At the same time, life expectancy rates are increasing more rapidly for black males and females compared to white males and females. Rates for Hispanics were not available. Life Expectancy in Harris County 1989-2009 85 80 75 76.6 7 4.5 71.1 79.8 78.6 81.2 71.5 68.7 70 77.4 75.2 73.5 1989 64.5 65 1999 60 2009 55 50 White Males White Females Black Males Black Females Source: University of Washington, Institute for Health Metrics and Evaluation 1. University of Washington, Institute for Health Metrics and Evaluation. County profile: Harris County, TX. Institute for Health Metrics and Evaluation Web Site. http://www.healthdata.org/sites/default/files/files/county_profiles/US/County_Report_Harris_County_Texas.pdf. Accessed June 25, 2014. 2. University of Washington, Institute for Health Metrics and Evaluation. Life expectancy U.S. counties 1989-2009. Institute for Health Metrics and Evaluation Web Site. http://www.healthmetricsandevaluation.org/. Accessed May 3, 2012. 4 Source: University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2014. www.countyhealthrankings.org. Used with permission. Factors Influencing Health The University of Wisconsin Population Health Institute researchers developed this model to describe the leading causes of illness and death. Each person starts out with their own genetic health profile, but a surprising number of variables play into overall health along the way. 5 Social & Economic Indicators Socioeconomic Indicators According to the University of Wisconsin Population Health Institute, 40% of our overall health is attributed to social and economic factors. The Centers for Disease Control and Prevention (CDC) noted, “The socioeconomic circumstances of persons and where they live and work strongly influence their health.” 1 When a population experiences poor socioeconomic circumstances, health consequences can be seen in every stage of life. Further, these conditions have a cumulative effect, so that those with the most unfavorable circumstances have the poorest health outcomes. People in lower socioeconomic levels usually run at least twice the risk of serious illness and premature death than those in higher socioeconomic levels. 2 Common indicators used to measure socioeconomic circumstances are: education, employment, income, and housing. Education that poor reading skills in third grade and lack of academic success in core subjects in ninth grade are key indicators for dropping out. In 2011, only 42% of Harris County third graders read considerably above the state passing standard and only 64% of ninth graders passed Algebra I, a core mathematical class.3 High school dropout rates are a key indicator of social and economic challenges including limited earning potential, increased unemployment, greater likelihood of criminality, and a shorter lifespan. Harris County and Houston high school graduation rates are lower than that of the U.S. Houston minority residents aged 15-19 are population. According to 2013 American Comless likely to be enrolled in school, with blacks munity Survey (ACS) data, an estimated 78.6% 2.2 times less likely to be enrolled in school and of Harris County residents aged 25 and over are Hispanics are 3.4 times less likely to be enrolled high school graduates or higher. This percentage in school than whites.4 can be compared to 75.4% of Houston residents, 81.2% of Texas residents, and 86.0% Percentage of Residents with Less than a High School of U.S. residents who are high school Diploma and 25 Years of Age or Older. graduates or higher. Within Harris County, 28.4% of adults aged 25 and over have a bachelor’s degree or higher, compared to 26.7% of Texas adults and 28.8% of U.S. adults. Children At Risk’s Growing up in Houston 2012-2014 report identified a 68.9% 4-year graduation rate for the 2006-2007 first-time freshman cohort in Harris County, compared to 71.6% in Texas and 75.5% in the U.S. In addition, 51.8% of Harris County students were at risk of dropping out; risk is indicated by being held back a grade, having failed a core classes, not performing at a satisfactory level on assessments, are pregnant or are a parent, have limited English proficiency, have been referred to the Department of Protective and Regulatory Services, are homeless, or reside in a placement facility.3 Research indicates 6 Source: American Community Survey, 5-year estimates (2008-2012) Data aggregated to the Health of Houston Survey Areas (2010) by HDHHS Office of Planning, Evaluation & Research for Effectiveness 1. Centers for Disease Control and Prevention (CDC). CDC health disparities and inequalities report — United States, 2011. CDC Web site. http:// www.cdc.gov/mmwr/preview/ind2011_su.html. Accessed March 1, 2011. 2. World Health Organization (WHO). Social determinants of health: the solid facts. http://www.euro.who.int/__data/assets/pdf_file/0005/98438/ e81384.pdf. Published 2003. Accessed March 1, 2012. 3. Children At Risk. Growing up in Houston 2012-2014. http://childrenatrisk.org/content/?page_id=8054. Published October 2012. Accessed June 24, 2014. 4. Texas Education Agency. Secondary school completion and dropouts in Texas public schools, 2011-12, 2010-11, 2009-10, county supplement and district supplement. http://www.tea.state.tx.us/acctres/dropcomp_index.html. Updated 2010, 2011, 2012. Accessed June 18, 2014. 5. Baum S, Ma J, Payea K. Education Pays 2013. CollegeBoard. http://www.dev.skylinecollege.edu/sparkpoint/about/documents/education-pays2013-full-report.pdf. Accessed June 24, 2014. 6. U.S. Census Bureau. Historical income tables: households. U.S. Census Bureau Web site. http://www.census.gov. Accessed June 24, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Economic Impact of Education Education contributes significantly to one’s income potential. On average, individuals without a high school diploma earn $25,100 per year compared to those with a high school diploma who earn $35,400 per year. College graduates with bachelor’s degrees earn $56,500 annually, while individuals with master’s, doctoral and professional degrees earn $70,000, $91,000 and $102,000 respectively.5 Households headed by high school graduates accumulate almost two times more median household income than households headed by high school dropouts; this wealth gap widens for households headed by college graduates who accumulate 3.5 times more median income than high school dropouts.6 In addition, higher education corresponds to lower unemployment rates.5 Language & Nativity Houston/Harris County has greater proportions of both foreign-born residents and residents who do not speak English at home than Texas or the U.S. American Community Survey data for 2013 show that 25.3% of Harris County residents are foreign-born, compared with 28.3% of Houston residents,16.5% of Texas residents, and 13.1% of U.S. residents. In 2013, 70.0% of foreign-born Harris County residents reported Latin America as their birthplace while 21.1% reported Asia as their birthplace. In the U.S., 51.9% of foreignborn residents reported they were born in Latin America and 29.5% reported that they were born in Asia. Of Harris County residents aged five or older, 2013 American Community Survey data indicate that 42.6% speak a language other than English at home, compared with 46.7% of Houston residents, 34.7% of Texas residents, and 20.8% of U.S. residents. Of Harris County residents who speak a language other than English at home, 19.9% report speaking English less than “very well” compared with 22.7% of Houston residents. Eighty percent of those who speak a language other than English at home in Harris County speak Spanish. Economic Impact of Language & Nativity Immigrants may find that limited proficiency in English restricts job choices and negatively impacts earnings. This is particularly true for immigrant workers who speak Spanish at home in comparison to immigrants who speak other languages. According to American Community Survey 2013 data, 25.6% of Texas residents who spoke Spanish at home lived below the federal poverty level (FPL), while 21.6% of those who spoke other foreign languages lived below the FPL. For both native and immigrant persons in Texas who only spoke English,13.0% lived in poverty. In 2013, 25.3 million foreign-born workers were in the labor force, making up 16.3% of the total U.S. labor force. Foreign-born workers are more likely to work in service occupations than native-born workers (25% vs. 17%) and less likely to work in management and professional occupations than native-born workers (30% versus 40%). For immigrants in 2013, the median weekly earnings of full-time workers was $643, compared to $805 for their native-born counterparts.7 Employment & Income According to the Texas Workforce Commission, in April 2014 the estimated unemployment rate for Harris County was 4.7%. This compares to a rate of 4.7% in Texas and 5.9% in the U.S during the same month. According to data from the American Community Survey, in 2013 the median household income in Harris County was $52,489 and $45,353 in Houston. In comparison, the median income in Texas households was $51,704 and $52,250 in U.S. households. Economic Impact of Employment & Income Many studies have found a strong correlation between overall well-being and employment. Stable employment not only provides a steady income but also provides the stability necessary for good health and often healthcare coverage; 54% of the civilian workforce has health insurance provided by their employer.8 Individuals earning higher salaries are more likely have health insurance though their employers and are more likely to have longer lifespans. In contrast, unemployed Americans are 54% more likely to have fair or poor health than those who are regularly employed. They are 83% more likely to develop a stress-related condition such as stroke, heart attack, heart disease, or arthritis.8 In terms of mental health, unemployed individuals were more likely to be diagnosed with depression and report feelings of sadness and worry.8 7. US Department of Labor: Bureau of Labor Statistics. Foreign-born workers: labor force characteristic-2013. http://www.bls.gov/news.release/pdf/ forbrn.pdf. Accessed June 25, 2014. 8. Robert Wood Johnson Foundation. How does employment—or unemployment—affect health? http://www.rwjf.org/content/dam/farm/reports/ issue_briefs/2013/rwjf403360. Updated 2013. Accessed June 25, 2014. 7 Social & Economic Indicators Poverty in Houston/Harris County In 2013, American Community Survey data indicated that 18.5% of Harris County residents and 22.4% of Houston residents lived below the Federal Poverty Level (FPL); in 2013 the FPL was $11,490 for an individual and $23,550 for a family of four.7 In comparison, 17.5% of Texas residents and 15.8% of U.S. residents live below the FPL. In Harris County, 27.1% of children under 18 years live below the FPL, compared to 34.7% of Houston children, 25.0% of Percentage of Residents with Income Texas children, and 22.2% of U.S. children. ElevBelow the Federal Poverty Level en percent of Harris County residents and 14.1% Harris County 2008-2012 of Houston residents over age 65 live below the FPL, compared with 11.0% of Texas adults and 9.6% of U.S. adults over age 65. Poverty Guidelines 2013 Persons in Family Income 1 $11,490 2 $15,510 3 $19,530 4 $23,550 5 $27,570 6 $31,590 Data Source: U.S. Department of Health and Human Services Poverty & Poor Health Poverty and other socio-economic disadvantages have been linked to many measures of poor health. The Health of Houston Survey 2010 identified how the presence or absence of seven different indicators of disadvantage impacted the general health status of survey respondents.1 Each additional indicator of disadvantage led to increasingly poor health: ► Below 100% Federal Poverty Level ► Economic hardship ► Less than high school & age 25+ ► Immigrant status ► Linguistic isolation ► Minority status ► Unemployment1 Lower income residents have been found to:  Report fewer average healthy days  Account for higher numbers of preventable hospitalizations2 8 Data Source: American Community Survey, 5-year estimates (2008-2012) Data aggregated to the Health of Houston Survey Areas (2010) by the HDHHS Office of Planning, Evaluation & Research for Effectiveness A report from Gallup, Inc. summarizing results from 200,000 surveys conducted using their Gallup-Healthways Well-Being Index,3 found that those with lower incomes report higher rates of:  Lack of health insurance and/or enough money to pay for healthcare  Obesity  Diabetes  High blood pressure  High cholesterol  Heart attacks  Asthma  Cancer  Depression  Headaches  Flu  Colds  Smoking  Poor diet  Lack of exercise 1. The University of Texas School of Public Health. Health of Houston survey, HHS 2010 a first look. Houston, TX: Institute for Health Policy, The University of Texas School of Public Health, 2011. https://sph.uth.edu/content/uploads/2010/09/HHS-8.5x11-Sep30_cover.pdf. Accessed July 18, 2014. 2. Friedan TR. CDC health disparities and inequities report—United States, 2011. Morbidity and Mortality Weekly Report. 2011;60:1-2. http:// www.cdc.gov/mmwr/pdf/other/su6001.pdf. Accessed December 13, 2011. 3. Mendez E. In U.S., Health disparities across incomes are wide-ranging. Gallup Website. http://www.gallup.com/poll/143696/health-disparitiesacross-incomes-wide-ranging.aspx. Published October 18, 2010. Accessed December 13, 2011. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Differences The map below shows where disadvantage and health status connect. The highest levels of disadvantage, shown in red, also have the greatest percent of residents who report fair or poor health. Measures of disadvantage include poverty, unemployment, lack of high school education, immigrant status, Hispanic or African American race/ethnicity, and inability to speak English well. 6 Family &Social Support Community Safety Social support arises from relationships between family, friends, colleagues, and acquaintances that allow for the cooperation between individuals for mutual benefit, trust, and civic association.4 Individuals or residents of neighborhoods with high social support have the social capital to help protect physical and mental health and facilitate healthy behaviors and choices. Community safety is not only a reflection of crime but also of unintentional injuries or accidents. Residents of unsafe neighborhoods are more likely to experience anxiety, depression, and stress which are linked to higher pre-term birth rates and low birth weight babies.5 Children are particularly affected by unsafe circumstances; they suffer from post-traumatic stress disorder and exhibit more aggressive behavior, use alcohol and tobacco, and are involved in more risky sexual behavior.5 The Robert Wood Johnson Foundation reports two measures of poor family and social support: inadequate social support and children in single-parent households.4 Twenty-five percent of Harris County residents identify themselves as having no social-emotional support, compared to the state average of 23%.4 According to the 2013 American Community Survey, 31.4% of families in Harris County are singleheaded households, with females 2.8 times more likely to be the head of the household than males. According to the 2010 Health of Houston Survey, one in five Houston residents is concerned about crime in their area.6 The crime rate in Harris County is 779 per 100,000 population compared to 449 per100,000 population in Texas.5 The number of deaths as a result of injury in Harris County and Texas is 56 deaths per 100,000 population.5 4. Robert Wood Johnson Foundation. Family and social support. County Health Rankings & Roadmaps Web site. http:// www.countyhealthrankings.org/our-approach/health-factors/family-and-social-support. Accessed July 28, 2014. 5. Robert Wood Johnson Foundation. Community safety. County Health Rankings & Roadmaps Web site. http://www.countyhealthrankings.org/ourapproach/health-factors/community-safety. Accessed July 28, 2014. 6. The University of Texas School of Public Health. Health of Houston Survey. HHS 2010 a first look. Houston, TX: Institute for Health Policy, The University of Texas School of Public Health, 2011. https://sph.uth.edu/content/uploads/2010/09/HHS-8.5x11-Sep30_cover.pdf. Accessed July 18, 2014. 9 Social & Economic Indicators Built Environment The World Health Organizations (WHO) reported that “where people live affects their health and chances of leading flourishing lives.”1 Built environment includes the collection of human-made surroundings and structures that provide the setting for human activity. Examples of the built environment include homes, commercial buildings, parks and green spaces, workplaces, and infrastructure for transportation such as railways, highways and streets. Common measures of the built environment include: population density, housing age, land usage, green space, and walkability. According to CDC, healthy community design can improve people’s health by: • Minimizing the effects of climate change • Increasing physical activity • Decreasing mental health stresses • Reducing injury • Strengthening the community’s social fabric • Increasing access to healthy food 2 • Improving air and water quality  Providing fair access to livelihood, education, and resources. Supermarket Access Supermarkets are an integral part of the built environment, providing residents with accessibility and affordability of nutritious foods. People who live in communities without a supermarket, usually low-income or rural communities, suffer disproportional rates of obesity, diabetes, and other diet-related health problems.3 Texas has the fewest supermarkets per capita of any other state and Houston falls short compared to other large metropolitan areas. In comparison to the national rate of per capita supermarkets, the Houston area lacks185 supermarkets.3 space lags in terms of accessibility, investment, and services in comparison to other major cities.4 City-wide efforts to increase green space include the construction of greenways and trails along the bayous. Once completed, 52% of Harris County residents will be within 1.5 miles of greenways, trails and parks; and park space in Houston and Harris County will increase by 1,500 and 3,000 acres respectively.4 The map to the right shows the number of large grocery stores by ZIP code in Houston/Harris County. Green Space Parks and other green spaces provide opportunities for physical activity, mental health promotion, and cultural events. Harris County, with 14.05 acres per 100 residents, does not meet the national standard of 20 acres per 100 residents.4 Despite the ample evidence of health benefits, Houston’s park Source: HDHHS 1. Friedan TR. CDC health disparities and inequities report—United States, 2011. Morbidity and Mortality Weekly Report. 2011;60:1. http:// www.cdc.gov/mmwr/pdf/other/su6001.pdf. Accessed December 13, 2011. 2. Centers for Disease Control and Prevention (CDC). Designing and building healthy communities. CDC Web site. http://www.cdc.gov/ healthyplaces/default.htm. Accessed January 30, 2012. 3. The Food Trust. Food for every child: the need for supermarkets in Houston. http://policylinkcontent.s3.amazonaws.com/FoodForEveryChild-Houston_0.pdf. Published December 2010. Accessed December 10, 2014. 10 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Homelessness People who are homeless experience multiple social and economic factors that negatively impact health outcomes. Homeless individuals are at a greater risk of poor mental health, illness and disease, and are more likely to be victims of violence. According to the Coalition for the Homeless, at least one in every 910 Houston/Harris County/Fort Bend residents is homeless. The Houston/Harris County/Fort Bend County Pointin-Time Enumeration, 2014 identified 5,351 homeless persons in Houston/Harris County/Ft. Bend in January 2014.5 This reflects a 37% decrease from the count of homeless persons in 2011 and a 16% decrease from 2013. Of those experiencing homelessness during the 2014 count, 57% were sheltered in emergency shelters, transitional housing units, and safe havens while 43% were unsheltered meaning they were found on the streets or at locations not meant for habitation.5 The number of unsheltered homeless has declined since the 2013 (47%), 2012 (53%) and 2011 (52%) counts.5 An additional 1,525 people were housed in the Harris County Jail at the time of the survey who would have been otherwise been considered homeless. The most common reasons for all homelessness include loss of a job, bills higher than earnings, and being evicted by a family member.5 to communicable diseases, violence, malnutrition, and harmful weather exposure, exacerbating their existing health conditions while adding psychiatric harm, substance abuse, and social problems.6 During the 2014 count, characteristics of those experiencing homelessness included veterans, chronically homeless individuals and families, victims of domestic abuse, persons with HIV/AIDS, persons who are severely mentally ill, and persons who experience chronic substance use.5 In previous years, local area needs assessment surveys identified that almost half of homeless individuals surveyed did not have health insurance. Significant barriers were described in their attempts to access health care; however, 68% were able to access at least minimal health services.7 Lesbian, gay, bisexual, and transgender (LGBT) youth are at an increased risk of homelessness with up to 40% of homeless youth identifying as LGBT nationwide.8 Research identifies family rejection and abuse as major factors leading to homelessness among LGBT youth.8 Homelessness creates new health problems and worsens existing ones. Living on the street or in crowded homeless shelters can expose homeless individuals 4. Center for Houston’s Future. Healthy communities: indicator report 2013. http://www.futurehouston.com/cmsFiles/Files/i2013.pdf. Accessed July 9, 2014. 5. Coalition for the Homeless. Houston/Harris County/ Fort Bend county point-in-time enumeration 2014 Executive Summary. www.homelesshouston.org. Accessed June 30, 2014. 6. National Health Care for the Homlessness Council. Homelessness & health: what’s the connection? www.nhchc.org/. Accessed June, 30, 2014. 7. Coalition for the Homeless of Houston/Harris County. Houston/Harris County 2010 homeless count & survey and 2011 homeless enumeration count. www.homelesshouston.org. Accessed October, 2011. 8. San Diego Gay and Lesbian News. America’s shame: 40% of homeless youth are LGBT kids. The Williams Institute. Published July 13, 2012. Accessed October 23, 2014. 11 Social & Economic Indicators Sexual Orientation & Gender Identity In the United States, an estimated 9.5 million adults, approximately 4% of the population,1 identify as lesbian, gay, bisexual, and transgender (LGBT), 35% of which indicate living in the south.2 The Center for American Progress reported that 41% of LGBT individuals were at or below the 139 percent of the Federal Poverty Level (FPL), with lesbian and bisexual women having the highest poverty rate.3 Of U.S. adults who identified as LGBT in the 2014 Gallup survey, 60% were white, 20% were Hispanic, 16% were black, 2% were Asian, and 2% identified as multi/other.1 Locally, approximately 5%, or an estimated 298,274 of the Houston area population, self-identify as LGBT.4 Members of the LGBT community are at increased risk for a number of health threats and also face unique health challenges. Healthcare Access Among LGBT LGBT individuals are at greater risk of negative health behaviors and health conditions than their heterosexual counterparts; however, they are less likely to seek medical services. GallupHealthways Well-Being Index 2014 data indicate that LGBT individuals are more likely to be uninsured (13.2% compared to 17.6%), less likely to be able to afford health care, and less likely to have a personal doctor, than their non-LGBT counterparts.5 Among LGBT women, disparities are even more apparent (see chart to the right). Although insurance access plays an important role in seeking medical care, negative experiences in health care settings as well as the lack of LGBT-informed care available contribute to delaying or not seeking medical care.6 Health Disparities Among LGBT Despite growing national evidence on LGBT health disparities, state and city-level data remains nominal. National data identifies health disparities in the following areas among LBGT, so local disparities are likely:  Tobacco Use  Substance Abuse  Cancer Screening, Cancer  Suicidal Ideations  Mental Health Disorders  Obesity and Eating Disorders  Sexually Transmitted Diseases  HIV/AIDS7 12 Distribution of LGBT Adults by Geographic Area2 Midw est 0.2 South 0.35 Northeast 0.19 Mountain 0.08 Pacific 0.17 Gallup Survey: Percentage who Struggle to Afford Healthcare or Medicine LGBT Non-LGBT All Adults 25% 17% Men 21% 15% Women 29% 19% Gallup Survey: Percentage Without a Personal Doctor LGBT Non-LGBT All Adults 29% 21% Men 29% 27% Women 29% 16% These health behaviors and health conditions that are more common among LGBT individuals can worsen by delaying care. Twenty-nine percent of LGB individuals report delaying or avoiding health care, compared to 17% of heterosexual adults.8 According to the National Transgender Discrimination Survey, 19% of transgender or gender non-conforming people reported being turned away from a medical provider due to their status, 28% percent reported incidence of harassment resulting in them postponing medical care, and 50% reported having to instruct their provider about transgender care.9 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Economic Impact of LGBT National data suggests that health disparities faced by the LGBT community, coupled with poverty, result in great economic impact. Some of the risk factors identified in the LGBT population include: increased rate of negative health behaviors such as smoking, an increase in emergency care utilization as a result of a lack of health insurance, and higher rates of expensive chronic health conditions due to low rates of preventative care and delay in seeking care. These factors also contribute to absenteeism or poor work performance. Examples of LGBT Health Disparities Increased:  Tobacco use  Alcoholism and other substance use  Mental health concerns, including suicide attempts  Cancer  Experience of violence and other abuse  HIV/AIDS infection  Care from emergency departments Decreased:  Insurance coverage  Medical care  Preventive screening7,8 Beginning in 2015, the Texas Behavior Risk Factor Surveillance System (BRFSS) will include questions of sexual identity and gender identification which will provide local data on personal health behaviors that affect premature morbidity and mortality.10 Healthy People 2020 In 2012, two objectives were added with the goal of gathering data and improving the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals. OBJECTIVE LGBT-1.1 Increase the number of population-based data systems used to monitor Healthy People 2020 objectives that include in their core a standardized set of questions that identify lesbian, gay, and bisexual populations. OBJECTIVE LGBT-1.2 Increase the number of population-based data systems used to monitor Healthy People 2020 objectives that include in their core a standardized set of questions that identify transgender populations Note: As of the time of this publication, baseline and target data were not available. Public Health Actions  Gather sexual orientation and gender identity data to monitor LGBT health status.  Educate the public about LGBT populations.  Develop policies and plans that support efforts to improve LGBT health, decrease disparities, and increase cultural competency among those working with LGBT persons. For More Information CDC, LGBT Health: http://www.cdc.gov/ lgbthealth/index.htm The Fenway Institute: http:// thefenwayinstitute.org/ The Williams Institute: http:// williamsinstitute.law.ucla.edu/ 1. Gates, GJ. LGBT Demographics: Comparisons among population-based surveys. Williams Institute, UCLA School of Law. Williams Institute Web site. http://williamsinstitute.law.ucla.edu/wp-content/uploads/lgbt-demogs-sep-2014.pdf. Accessed December 11, 2014. 2. Hasenbush A, Flores AR, Katanis A, Sears B, Gates GJ. The LGBT divide: a data portrait of LGBT people in midwestern, mountain & southern states. The Williams Institute. http://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBT-divide-Dec-2014.pdf. Published December 2014. Accessed December 11, 2014. 3. Baker KE, Durso LE, Cray A. Moving the needle. Center for American Progress. https://cdn.americanprogress.org/wp-content/uploads/2014/11/ LGBTandACA-report.pdf. Published November 2014. Accessed December 11, 2014. 4. James L. Lesbian Health Initiative of Houston, Inc. (LHI). Presented at 2014 Harris County Healthcare Alliance annual membership meeting, August 13, 2014. http://www.hchalliance.org/images/LHI_HCHA_8-2014_Presentation-_FNL.pdf. Accessed December 12, 2014. 5. Gates GJ. In U.S., LGBT more likely than non-LGBT to be uninsured. Gallup Web site. http://www.gallup.com/poll/175445/lgbt-likely-non-lgbtuninsured.aspx. Accessed December 11, 2014. 6. Ranji U, Beamesderfer A, Kates J, Salganicoff A. Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender Individuals in the U.S. The Henry J. Kaiser Family Foundation Web site. Published October 23, 2014. Accessed December 11, 2014. 7. Institute of Medicine (IOM), Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps: Board on the Health of Select Populations. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. http:// www.nap.edu/catalog.php?record_id=13128. Published 2011. Accessed December 11, 2014. 8. Krehely J. How to close the LGBT health disparities gap. Center for American Progress. http://cdn.americanprogress.org/wp-content/uploads/ issues/2009/12/pdf/lgbt_health_disparities.pdf. Published December 21, 2009. 9. Grant JM, Mottet LA, Tanis J. Harrison J, Herman JH, Keisling M. Injustice at every turn, a report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Taskforce. http://transequality.org/PDFs/NTDS_Exec_Summary.pdf. Published 2011. Accessed December 11, 2014. 10. Texas Department of State Health Services (TDSHS). Attachment B: 2015 CDC draft BRFSS survey outline of questions. Inclusion of Module 18 confirmed by Rebecca Wood, TDSHS. https://www.dshs.state.tx.us/chs/brfss/attachments/attach_b.shtm. Updated June 13, 2014. Accessed December 22, 2014. 13 This page intentionally left blank Photo by Cathy Phan at HOPE Clinic in Houston. Used with permission. Health Care Access Access to comprehensive, quality health care services is important for the achievement of health equity and for increasing the quality of a healthy life for everyone. Access to health services means the timely use of personal health services to achieve the best health outcomes. It requires 3 distinct steps: 1. Gaining entry into the health care system. 2. Accessing a health care location where needed services are provided. 3. Finding a health care provider with whom the patient can communicate and trust. Access to health care impacts:  Overall physical, social, and mental health status  Prevention of disease and disability  Detection and treatment of health conditions  Quality of life  Preventable death  Life expectancy 15 Insurance Access Overview While access to insurance coverage and access to health care services are not synonymous, they are highly correlated. A Kaiser Family Foundation report noted, “Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy people are.”1 Those without insurance are far more likely than the insured to report problems in getting needed medical care such as: not having a usual source of care, postponing care or going without needed care due to cost, and not being able to afford prescription drugs.1 Without a usual source of care, the uninsured are at higher risk for preventable hospitalizations and delayed diagnosis of chronic conditions. 2 Following diagnosis of a chronic condition, they are less likely to receive follow-up care and therefore their health is more likely to decline. In addition to the negative health consequences, the uninsured face higher medical bills that can quickly translate into medical debt, placing financial strain on the uninsured and their family. 2 Uninsured in Houston/Harris County Texas has the highest rate of uninsured persons in the nation, a position the state has held for many years.3 According to 2013 American Community Survey data, just over one in five Texas residents (22%) is without any form of health insurance, compared to 15% of U.S. residents. Rates of uninsurance are even higher when the elderly (primarily covered 2013 American Community Survey, 1-Year Estimates: Uninsured by Medicare) and children (often eligible for Medicaid or All Ages Under 18 18 to 64 65 & older CHIP if not covered by family United States 14.5% 7.1% 20.3% 1.0% members’ employersponsored coverage) are exTexas 22.1% 12.6% 29.9% 2.0% cluded. At all ages, uninsurance rates are higher in TexHouston CSA 22.8% 12.7% 30.1% 3.1% as than the United States, Harris County 25.4% 14.0% 33.4% 3.9% and are even higher in the Houston region (Houston-The City of Houston 28.4% 14.3% 37.3% 4.1% Woodlands Combined Statistical Area), Harris County, Source: U.S. Census. Available at www.census.gov. and the City of Houston than in Texas. Population Differences Differences in insurance status are apparent among racial and ethnic groups in the Houston area. BRFSS 2012 data indicates that 53.1% of Hispanics were uninsured in the HoustonBaytown-Sugar Land MSA, compared to 34.0% of blacks and 12.1% of whites. The Health of Houston Survey 2010 conducted by the University of Texas School of Public Health reported that both Hispanic and Vietnamese residents were uninsured at much higher rates than the overall average in Houston/Harris County. 16 Uninsured in Houston-Baytown-Sugar Land MSA 2002-2012 White 70% 60% 30% Hispanic 53.1% 64.6% 43.7% 50% 40% Black 34.0% 26.6% 35.9% 20% 10% 0% 14.6% 10.6% 12.1% 200 2 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 Source: TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Differences Map of Uninsured in Houston/Harris County ZIP The map to the left, from the 2013 Enroll America Database, shows the distribution of uninsured adults across priority target areas with identifying areas and ZIP codes in Houston/Harris County. Adults: Uninsured Reasons In his Health of Houston Survey 2010: A First Look, Dr. Stephen Linder of the University of Texas School of Public Health’s Institute for Health Policy, asked the 35% of survey respondents who reported being uninsured at some point in the last year why they were uninsured. The most frequent responses were inability to afford insurance (54%) and ineligibility because of working status, such as loss of one’s job (20%), followed by ineligibility due to citizen status and putting it off.4 Lack of Insurance Among Children The map at the right, from the Health of Houston Survey 2010: A First Look shows the percentage of uninsured children overlapped with areas where families reported barriers in accessing health services. These barriers include lack of a personal doctor, relying on emergency rooms for most care, or difficulties in obtaining medical/dental care or prescription medication due to cost or lack of insurance.4 Areas in darker shades of blue show parts of Houston/Harris County with the highest numbers of uninsured children. Children: Uninsured Reasons The Health of Houston Survey 2010 assessed the most frequent responses from parents or guardians regarding uninsured children. Adults were asked why their child was uninsured in the last 12 months and why their child was not enrolled in either Medicaid or CHIP. For children who did not have private medical insurance, cost was given as the primary factor. For the children who did not have health coverage and were not enrolled in Medicaid or CHIP, lack of eligibility was most often cited. 4 1. The Henry J. Kaiser Family Foundation. The Uninsured: A Primer, October 2011:11-12. http://www.kff.org/. Accessed November 28, 2011. 2. The Henry J. Kaiser Family Foundation. Key Facts about the Uninsured Population. www.kaiserfamilyfoundation.files.wordpress.com/2013/09/8488-key-facts-about-the-uninsured-population.pdf. Published September 2013. Accessed July 22, 2014. 3. U.S. Census. www.census.gov. Accessed July 2, 2014. 4. The University of Texas School of Public Health. Health of Houston Survey. HHS 2010 a first look. Houston, TX: Institute for Health Policy, The University of Texas School of Public Health, 2011. https://sph.uth.edu/content/uploads/2010/09/HHS-8.5x11-Sep30_cover.pdf. Accessed November 28, 2014. 17 Insurance Access, cont. Medicaid Medicaid is a jointly funded state-federal health care program, established in Texas in 1967 and administered by the Health and Human Services Commission (HHS). In October 2013, about one in seven Texas residents (3.6 million of the 26.1 million) relied on Medicaid for health insurance or long-term services and support.1 Texas was one of the states that chose not to expand Medicaid as a part of the Affordable Care Act. Without this expansion, over one million adults (17%) will fall in the coverage gap, meaning they are below the poverty line but do not have an affordable coverage option through the Affordable Care Act.2 Texas’ Medicaid caseload, services delivered to them comprise 58% of the program’s costs. As the population ages and co-occurring behavioral health needs increase, the demand for nursing homes and other long term services continues to grow, compromising 28% of total costs in 2010.3 According to the Texas Health and Human Services Commission, as of October 2013, 624,464 Harris County residents, or approximately 14% of the population, were enrolled in the Texas Medicaid program. Seventy-nine percent of these enrollees (494,678) were 18 or younger.1 Texas Medicaid pays for acute health care services (physician, inpatient, outpatient, pharmacy, lab, and X-ray) for eligible children and adults, as well as long-term services and supports for aged and disabled clients. The program primarily serves low-income families, nondisabled children, related caretakers of dependent children, pregnant women, the elderly, and people with disabilities. In 2011, women and children accounted for the largest percentage of the Texas Medicaid population with 55% female and 77% under 21. While the aged and disabled comprise 25% of Source: UT School of Public Health Children’s Health Insurance Program (CHIP) The Children’s Health Insurance Program (CHIP) is designed for children whose families earn too much to qualify for the Medicaid program, yet not enough to afford private insurance. Parents of these children may not have access to employer-sponsored insurance or, if family coverage is available, they may not be able to afford their portion of the premium costs. 18 CHIP is offered by private health plans with sponsorship from the federal and state governments. CHIP provides coverage for routine medical care, hospital care, prescription drugs, dental care, and immunizations. Only Texas residents who are U.S. citizens or legal permanent residents qualify for CHIP.4 Harris County has the highest total CHIP enrollment in Texas, with the highest rates in the southeast and western side of the county. 5,6 1. Texas Health and Human Services Commission (HHSC). Texas Medicaid enrollment statistics. HHSC Web site. http://www.hhsc.state.tx.us/ research/MedicaidEnrollment/MedicaidEnrollment.asp. Updated October 2013. Accessed July 7, 2014. 2. The Henry J. Kaiser Family Foundation. How will the uninsured in Texas fare under the Affordable Care Act? http://www.kff.org/health-reform/factsheet/state-profiles-uninsured-under-aca-texas/. Published January 2014. Accessed July 7, 2014. 3. Texas Health and Human Services Commission (HHSC). Texas Medicaid and CHIP in perspective. 9th ed. Austin, TX. http:// www.hhsc.state.tx.us/Medicaid/about/PB/PinkBook.pdf. Published January 2013. Accessed July 7, 2014. 4. CHIP: Children's Medicaid. Children’s Health Insurance Program (CHIP). CHIP Web site. www.chipmedicaid.org. Accessed December 7, 2011. 5. Courtney, P. Frequency and rates of Medicaid (total and select categories) and CHIP enrollment for every county in Texas. UT School of Public Health. February 2012. https://sph.uth.edu/content/uploads/2010/09/County-Slide-Show.pdf. Accessed July 7, 2014. 6. Courtney P. Frequency and rates of Medicaid (total and select categories) and CHIP enrollment for ZIP codes in southeast Texas. UT School of Public Health. February 2012. https://sph.uth.edu/content/uploads/2010/09/ZIP-code-Slide-Show.pdf. Accessed July 7, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Uninsured & the Affordable Care Act The Henry J. Kaiser Family Foundation produced a report on the uninsured in 2013 that reported on the gaps in the health insurance system and the effect on access to care and impact on financial security. The report stated, “The access barriers facing uninsured people mean they are less likely to receive preventive care, are more likely to be hospitalized for conditions that could have been prevented, and are more likely to die in the hospital than those with insurance.”7 AHS-1: Increase the proportion of persons with health insurance The 2010 Affordable Care Act (ACA) expanded coverage options for the uninsured and facilitates insurance selection through the Health Insurance Marketplace. The Health Insurance Marketplace allows Americans to compare qualified health plans and determine eligibility to access lower costs for health insurance through private health insurance or health programs such as Medicaid and CHIP. Health coverage for those who chose to enroll began in January 2014. Persons with Medical Insurance Area Percent National Baseline 2011 82.8 Target for 2020 100.0 Houston MSA 2012 69.7 State of Texas 2012 69.4 United States 2012 82.9 Public Health Actions   Support efforts to expand insurance access for all individuals. Provide enrollment assistance for those eligible for CHIP, Medicaid, the Affordable Care Act, and other health resources. Support efforts to expand public safety net services. Provide sound utilization data to the public, providers, insurance carriers, and others. In Texas, 733,757 individuals selected a plan through the federally-facilitated Marketplace between October 1, 2013 and March 31, 2014 (including special enrollment period activity in April). Of those enrolled, 55% are female, 38% are under the age of 35, and 84% selected a plan with financial assistance.8  Economic Impact of the Uninsured Population University of Texas School of Public Health, Health Services Research Collaborative: www.sph.uth.tmc.edu/research/centers/chsr/ hsrc/ Economic costs for the uninsured include direct costs for health care services, increased costs from the inefficient use of health care services, and indirect costs of preventable disability and lost productivity among uninsured persons. Many levels of society bear these costs, including each level of government through tax expenditures, healthcare institutions through uncompensated care, insured people through higher premiums to support cost shifting, and employers through indirect costs of disability and reduced productivity.9 In 2008, the estimated cost of health services for the uninsured was $86 billion.10 Of the total cost, $30 billion was paid out-of-pocket and the remaining $56 billion was provided as uncompensated care.10 Seventy-five percent of uncompensated care is covered by various government subsidies and the remaining is absorbed by hospitals, physicians, and private payers. With the number of uninsured expected to decline under the ACA, spending on uncompensated care is projected to decline.11  For More Information Texas Health and Human Services Commission: www.hhsc.state.tx.us/ 211: Residents can dial 211 for information about state benefits, including CHIP and Medicaid. 7. The Henry J. Kaiser Family Foundation. The uninsured: a primer, October 2013. www.kaiserfamilyfoundation.files.wordpress.com/2013/10/7451-09-the -uninsured-a-primer-key-facts-about-health-insurance.pdf. Published October 2013. Accessed July 7, 2014. 8. U.S. Department of Health and Human Services (USDHHS). How the health care law is making a difference for the people of Texas. USDHHS Web site. http://www.hhs.gov/healthcare/facts/bystate/ tx.html. Updated June 2, 2014. Accessed July 7, 2014. 9. Institute Of Medicine (IOM). Hidden costs, value lost: insurance in America. http://www.iom.edu/~/media/Files/Report%20Files/2003/ Hidden-Costs-Value-Lost-Uninsurance-in-America/ Uninsured5FINAL.pdf. Published June 2003. Accessed January 3, 2012. 10. Institute of Medicine (IOM). America’s uninsured crisis: consequences for health and health care. http://www.iom.edu/Reports/2009/ Americas-Uninsured-Crisis-Consequences-for-Health-and-HealthCare.aspx. Published February 23, 2009. Accessed July 8, 2014. 11. Buettgens M., Garrett B., and Holahan J. America under the Affordable Care Act. Urban Institute. http://www.urban.org/ uploadedpdf/412267-america-under-aca.pdf. Published December 2010. Accessed July 8, 2014. 19 Access to Health Care Access to Health Care Health insurance, local care options, physician availability, and a usual source of care are all factors associated with access to care.1 Those without adequate access to care rely heavily on safety net providers for their health care needs. The Institute of Medicine (IOM) identifies the health care safety net as “providers that organize and deliver a significant level of health care and other related services to uninsured, Medicaid, and other vulnerable patients.”1 Safety net providers include a network of public and private clinics and hospitals. As of June 2014, the U.S. Department of Health and Human Services identified approximately 6,100 primary care, 4,000 mental health, and 4,900 dental federally designated health professional shortage areas in the United States.2 Physician shortages are generally more acute in rural areas; however, metropolitan areas can have shortages due to physician location, accessibility to transportation, income level, and physical barriers. Houston/Harris County contains 19 designated medically underserved areas (MUAs) that are identified based on primary care physician ratio per 1,000 population, infant mortality rate, percentage of the population living in poverty, and percentage of the population 65 and older. In addition, five medically underserved populations (MUPs) were identified based on populations with economic barriers or cultural and/or linguistic barriers to primary care services.2 Safety Net Clinics The map to the right from the Episcopal Health Foundation shows the location and types of safety net clinics in the eight-county region. The safety net clinics offer an array of services to adults and children in community and school based settings. Of the 144 safety net clinics in the region, 105 are located within Harris County (78%).3 These safety net clinics serve nearly 1.5 million uninsured who are estimated to need approximately 4.2 million visits.3 Those unable to seek care at safety net clinics receive care in emergency rooms, private clinics, or go without care. 1. Robert Wood Johnson Foundation. Access to care. County Health Rankings and Roadmaps Web site. http://www.countyhealthrankings.org/ourapproach/health-factors/access-care. Accessed July 29, 2014. 2. U.S. Department of Health and Human Services (USDHHS), Health Resources ad Services Administration. Medically underserved areas/ populations. USDHHS Web site. http://www.hrsa.gov/shortage/mua/index.html. Accessed July 31, 2014. 3. Center for Houston’s Future. Safety net clinics. Center for Houston’s Future Web site. https://houstonindicators.com/testlevel1/health/access/ access-4-comment/. Accessed August 4, 2014. 4. Helton J, Lanagabeer J, Alqusairi D. Safety net clinic capacity expansion model. The University of Texas School of Public Health, Harris County Healthcare Alliance. http:www.hchalliance.org/images/cabinet/initiatives/safteynet/Clinic-Capacity-Expansion-Model/Safety-Net-Clinic-CapacityExpansion-Model.pdf. Published 2012. Accessed July 29, 2014. 5. Begley C, et al. Health Reform and Primary Care Capacity: Evidence from Houston/Harris County, Texas. J Health Care Poor Underserved. 2012; 23(1):386-397. http://www.sph.uth.tmc.edu/research/centers/chsr/hsrc/. Accessed July 9, 2014. 20 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Safety Net Population & Providers in Harris County Harris County is home to an array of primary, secondary, and tertiary care resources, yet one third of Harris County residents rely on safety net providers for their heath care needs. In 2010, safety net clinics reported a total of 1,061,501 patient visits.4 Of those 65% were female; 62% were between the age of 25 and 65; and 41% were black, 39% white, and 83% Hispanic Latino.4 In addition, approximately one third of the patients spoke Spanish at home as their primary language and 38% of all patients needed interpretation services at the time of the visit.4 Fifty percent of patients using safety net providers are concentrated within 34 ZIP codes in Harris County.4 When adjusting for the population, patient visits are highest in eastern Harris County. In terms of providers, the Harris County Hospital District is the largest safety net provider, serving 66.4% of all safety net patient visits, followed by Legacy Community Health Services (6.1%), Planned Parenthood (5.3%), Texas Children Hospital (5.3%), and Ibn Sina Foundation (3.8%).4 Safety Net Utilization: Houston/Harris County, 2010 4 The map to the left was developed by the University of Texas School of Public Health and the Harris County Healthcare Alliance. Visits to safety net clinics are shown based on the ZIP codes of residents. The utilization rate is calculated by visits per 1,000 population. Areas in darker blue indicate that more residents per 1,000 are using safety net clinics for their health care. The Demand for Safety Net Providers Using the Episcopal Health Foundation Project Safety Net survey of primary care clinics serving low-income and underinsured residents of the greater Houston area, Dr. Chuck Begley et al. estimated that public and private safety net providers in Houston/Harris County are meeting about 30% of the demand for primary care visits by the low income population, while the rest is met by private physicians or is unmet. Demand for primary care by this population is projected to increase by 30% under federal health reform, with growing inadequacy of safety net providers to meet the increasing need. In upcoming years, current safety net providers are anticipated to have the capacity to meet less than 25% of the demand.5 Increasing the supply of safety net providers to meet demand of the low-income population from 30% to 100% over the next nine years would require local safety net providers to expand primary care service capacity by approximately 17-18% per year. In order to maintain the current met demand (30%), the number of providers in the local safety net would have to grow 2-3% per year.4 21 Access to Health Care, cont. Safety Net Capacity The Safety Net Clinic Planning Model report developed in 2012 by the University of Texas School of Public Health and the Harris County Healthcare Alliance assessed Harris County safety net provider capacity in 2010 based on: Estimated Provider Capacity for Safety Net Clinics in Harris County by ZIP Code 2010 ♦ Physical space, ♦ Available providers, which included MDs and mid-level providers (Registered Nurses, Physician Assistants and Nurse Practitioners) ♦ Available appointments Results were summarized in the map to the right. Darker shades indicate greater capacity. Primary Care Physicians Primary care physicians provide a reliable source of health care that allows for health problems to be detected and treated before conditions become serious and require hospitalization. 1 As a result, individuals with access to primary care doctors typically have better health outcomes, reduced health disparities, and lower health expenditures. For each 1% increase in primary care physicians, average-sized metropolitan areas showed a decrease of 503 hospital admissions, 2,968 emergency room visits, and 512 surgeries.2 The demand for primary care physicians is projected to grow from 2010 to 2020 primarily due to population aging and growth, and to a lesser extent as a result of expanded insurance coverage under the Affordable Care Act (ACA).4 Based on utilization trends of primary care physicians, it is projected that the demand for primary care physicians will grow almost two times more rapidly than the physician supply.4 Without changes to the current delivery system, the growth in physician supply will not be able to fill the demand in 2020. Currently, Harris County has 81.4 primary care physicians per 100,000 population. However, these physicians are not equally available across the county. 22 Primary Care Physicians (PCPs) per 100,000 Population Harris County and Texas 2000-2013 Harris County Texas 8582.2 82.1 81.4 81.0 80.4 83 80.7 79.4 79.3 79.2 79 81 78.7 78.6 78.1 79 76.2 77 75 71.0 70.6 7370.2 70.7 70.0 69.9 69.1 69.5 71 68.1 68.3 67.7 67.9 68.4 67.7 69 67 65 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: Texas Medical Board—September-October: 2000-2013 Prepared by: TDSHS, Center for Health Statistics 1. National Association of Community Health Centers. Access is the answer: community health centers, Primary Care & the Future of American Health Care. http://www.nachc.com/client/PIBrief14.pdf. Published March 2014. Accessed July 9, 2014. 2. Kravet SJ, et al. Health care utilization and the proportion of primary care physicians. Am J Med. 2008;121(2):142-148. http://www.amjmed.com/ article/S0002-9343(07)01088-1/abstract. Accessed November 28, 2011. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Differences The map below shows the federally designated Medically Underserved Areas (MUAs) in Houston/Harris County, designated by the US Health Resources and Services Administration as having too few primary care providers, high infant mortality, high poverty, and/or a high elderly population. Healthy People 2020 Objective ASH-4: Increase the number of practicing primary care providers (includes Medical Doctors, Doctors of Osteopathy, Physician’s Assistants, and Nurse Practitioners). Note: At the time of this publication, Healthy People 2020 had created the objective, but did not have baseline and target data available. Public Health Actions  Inform the public about concerns regarding the growing need for primary care providers.  Mobilize community partnerships to study the impact and scope of primary care physician shortages and recommend strategies for improvement.  Develop policies and plans to support access to a medical home for all.  Serve as a health care safety net when other sources of care are unavailable. Source: HDHHS Community Health Statistics Program Economic Impact of Primary Care Physician Shortage With insufficient primary care physicians, people develop advanced conditions that are difficult and expensive to treat, resulting in higher healthcare costs. States with a higher primary care physician to population ratio have better health outcomes and lower costs including decreased mortality from cancer, heart disease, or stroke.5 In addition, the supply of primary care physicians is also associated with an increased life span. In 2000, an estimated five million admissions to U.S. hospitals with a resultant cost of more than $26.5 billion, may have been preventable with high-quality primary and preventive care treatment. Assuming an average cost of $5,300 per hospital admission, a five percent decrease in the rate of potentially avoidable hospitalizations alone could reduce inpatient costs by more than $1.3 billion.6 For More Information U.S. Department of Health and Human Services, Health Resources and Services Administration: www.hrsa.gov/ index.html National Center for Policy Analysis: www.ncpa.org/ Henry J. Kaiser Family Foundation: www.kff.org/ Harris Health System: https:// www.harrishealth.org/en/pages/home.aspx Harris County Health Alliance: http://www.hchalliance.org/ The University of Texas School of Public Health, Health Services Research Collaborative: www.sph.uth.tmc.edu/ research/centers/chsr/hsrc/ 3. United States Department of Health and Human Services (USDHHS), Health Resources and Services Administration. MUA/P by State and County. HRSA Web site. http://muafind.hrsa.gov/. Accessed July 9, 2014. 4. Department of Health and Human Services, Health Resources and Services Administration. Projecting the supply and demand for primary care practitioners Through 2020. http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/projectingprimarycare.pdf. Published November 2013. Accessed August 7, 2014. 5. American College of Physicians. How is a shortage of primary care physicians affecting the quality and cost of medical care?: A Comprehensive Evidence Review. Philadelphia: American Colleges of Physicians; 2008: White Paper. http://www.acponline.org/advocacy/current_policy_papers/ assets/primary_shortage.pdf. Accessed July 9, 2014. 6. U.S. Department of Health and Human Services (USDHHS), Agency for Healthcare Research and Quality. Preventable hospitalizations. AHRQ Website. http://archive.ahrq.gov/data/hcup/factbk5/factbk5a.htm. Accessed January 3, 2012. 23 Preventable Hospitalizations Overview Preventable hospitalizations (PH) are hospitalizations for conditions that could have potentially been prevented if the individual had access to and cooperated with appropriate outpatient care.1 Chronic conditions such as congestive heart failure and diabetes are particularly likely to lead to hospitalization if not cared for adequately in the outpatient setting. Preventable hospitalizations are identified through Prevention Quality Indicators (PQI) set by the Agency for Healthcare Research and Quality. PQIs are a set of measures that can be used with hospital inpatient discharge data to identify conditions for which good outpatient care or early intervention could have potentially prevented hospitalization or more severe conditions.2 Although PQIs come from hospital discharge data, they are not an evaluation of hospitals themselves but an assessment of community health.2 PQIs provide a means to identify unmet community needs and to compare performance of the local health care system across communities. These measures do not serve as definitive quality measures of the health care system in Harris County, but rather point to potential areas for improvement of care. Some Emergency Department (ED) visits are also considered preventable. A study by the UT School of Public Health identified that four in ten (39.7%) ED visits by Harris County residents were primary care related ED visits in 2011, a decrease from 2010 (40.9%) and 2009 (41.0%). 3 This number includes non-urgent, treatable by primary care, and primary care preventable visits. Trends: Preventable Hospitalizations in Harris County Adults Age 18+, 2007-2012 10,000 9,000 8,000 Congestive Heart Failure 7,000 Bacterial Pneumonia COPD* 6,000 Urinary Tract Infection 5,000 Diabetes LTC 4,000 Dehydration 3,000 Hypertension Diabetes STC 2,000 Angina* 1,000 0 2007 2008 2009 2010 2011 2012 *Angina hospitalizations include angina without procedures. Chronic Obstructive Pulmonary Disease (COPD) includes asthma in older adults. Source: TDSHS Center for Health Statistics 1. Texas Department of State Health Services (TDSHS). Harris County: Potentially preventable hospitalizations. www.dshs.state.tx.us/ph/pdf/ harris.pdf. Published May 9, 2014. Accessed November 13, 2014. 2. Agency for Healthcare Research and Quality (AHRQ). Prevention quality indicators overview. AHRQ Web site. http://qualityindicators.ahrq.gov/ modules/pqi_resources.aspx. Accessed November 13, 2014. 3. Begley C, Courtney P, Abbass I, Ahmed N, Burau K. Houston hospitals: emergency department use study, January 2011 through December 31, 2011. University of Texas Health Science Center, School of Public Health. https://sph.uth.edu/content/uploads/2013/06/Final2011ER.pdf. Published June 2013. Accessed November 14, 2014. 24 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution The map below shows the rate of primary care related ED visits per 1,000 population in 2011. The east/northeast and south central areas of Harris County, as well as the Katy area in western Harris County have high rates of preventable hospitalizations. Primary Care Related ED Visits per 1,000 Population, 2011 Economic Impact of Preventable Hospitalizations A relationship exists between preventable hospitalizations and primary care availability in Harris County. An increase in funding for primary care safety net clinics is directly related to a decrease in expenses for preventable hospitalizations. Increasing primary care availability, both at safety net clinics and at private physicians’ offices, can be a cost effective method to reduce preventable hospitalizations. During 2007-2012, Harris County hospitals recorded 192,134 potentially preventable adult hospitalizations at an estimated $7.1 billion in hospital charges.1 Public Health Actions Data source: UTSPH  Develop policies and plans built on information such as indications that providing health insurance or increasing the local safety net capacity for primary care may improve access to care and reduce preventable hospitalization.  Monitor health status to identify and solve community health problems through efforts such as tracking local PQIs.  Mobilize community partnerships and action to support development of new federally qualified health centers (FQHCs) and Community Health Clinics (CHCs), which can help to reduce preventable hospitalizations by providing affordable primary care for lowincome persons.  Support efforts to expand insurance access to all persons. Population Differences In 2011, primary care related emergency department (PCRED) visits were highest among the non-Hispanic black population, with a rate of 21.4 per 1,000 population, compared to Hispanics (10.6), non-Hispanic whites (9.1), and Asians (3.2). Females accounted for 59.3% of PCRED visits and children under the age of 18 accounted for more than one third (34.5%) of PCRED visits. PCRED visits were highest among the uninsured (32.2%) and those covered by Medicaid (28.9%).3 For More Information Agency For Health Care Research and Quality: www.ahrq.gov Preventable hospitalizations for children include low birth weight, pediatric gastroenteritis, pediatric urinary tract infection, pediatric perforated appendix, pediatric asthma, and pediatric diabetes short-term complications. —TDSHS Texas Health Care Information Collection: www.dshs.state.tx.us/thcic TDSHS Preventable Hospitalizations: http:// www.dshs.state.tx.us/ph/default.shtm Prevention Quality Indicators: http:// www.qualityindicators.ahrq.gov/modules/ pqi_resources.aspx 25 Emergency Department Visits Overview Emergency Departments Utilization The Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 was enacted by Congress to ensure access to emergency services, regardless of the patient’s ability to pay. The law mandated hospital emergency departments (ED) to screen, treat, and stabilize patients with emergency medical conditions. In Harris County, the emergency department visit rate was 31.66 visits per 100 residents in 2010, minimally higher than 30.91 visits per 100 residents in 2007. 1 Many patients visit the ED for minor emergencies and non-emergencies as well as for chronic and behavioral health conditions. In Houston/Harris County, preventable emergency department visits, identified as primary care related emergency department (PCRED) visits, accounted for 39.7% of all visits. 1 This number includes non-urgent, treatable by primary care, and primary care preventable visits. As a result, EDs are over-crowded, under-reimbursed, and carry large loads of uncompensated care.2 Access to care is an important factor in ED utilization. Among non-elderly U.S. adults whose last ED visit in the past 12 months did not result in hospital admission, approximately 79.7% report visiting the ED due to lack of access to other providers, significantly more than the 66.0% who visited the ED due to the seriousness of the medical problem.3 In addition, uninsured adults report they were more likely to visit the emergency department because they had no other place to go at the time of the last visit (61.6%), compared to adults who had private insurance (38.9%) and adults covered by public health plans (48.5%).3 Population Differences The graph to the right shows racial/ethnic differences of total ED visits and PCRED visits. Patients who identify as other race/ethnicity had the highest ED visit rate; however, the black population had the highest rate for PCRED visits.1 60 Medicaid Patients 50 Compared to privately insured adults, U.S. Medicaid patients have higher ED utilization.4 While it is commonly perceived that individuals with Medicaid are more likely to use EDs for routine care, current research has found that among nonelderly Medicaid adults, non-urgent visits account for only 10% of ED visits nationally.4 However, in Harris County, studies show that a significant percentage of urgent visits by Medicaid patients could have been treated or prevented in primary care settings.1 40 Nationally, ED visits by Medicaid adults are likely to involve more than one major diagnostic category and a secondary diagnosis of a mental health disorder.3 ED and PCRED Visit Rates* in Harris County by Race/Ethnicity, 2011 *Population per 1,000 Population 30 20 10 Total ED Visits PCRED Visits 52.5 47.8 27.5 21.4 9.1 24.2 17.2 10.6 9.6 3.2 18.8 7.2 0 Source: Begley C, Courtney P, Abbass I, Ahmed N, Burau K. Houston hospitals: emergency department use study, January 2011 through December 31, 2011. University of Texas Health Science Center, School of Public Health. https://sph.uth.edu/content/uploads/2013/06/ Final2011ER.pdf. Published June 2013. Accessed December 12, 2014. 1. Begley C, Courtney P, Abbass I, Ahmed N, Burau K. Houston hospitals: emergency department use study, January 2011 through December 31, 2011. University of Texas Health Science Center, School of Public Health. https://sph.uth.edu/content/uploads/2013/06/Final2011ER.pdf. Published June 2013. Accessed December 8, 2014. 2. Institute of Medicine (IOM). Hospital-based emergency care at the breaking point. IOM Web site. http://www.iom.edu/~/media/Files/Report% 20Files/2006/Hospital-Based-Emergency-Care-At-the-Breaking-Point/EmergencyCare.ashx. Published June 2006. Accessed December 8, 2014. 3. Gindi RM, Cohen RA, Kirzinger WK. Emergency room use among adults aged 18–64: early release of estimates from the National Health Interview Survey, January–June 2011. CDC, National Center for Health Statistics Web site. http://www.cdc.gov/nchs/data/nhis/earlyrelease/ emergency_room_use_january-june_2011.pdf. Published May 2012. Accessed December 8, 2014. 4. Sommers A, Boukus E, Carrier E. Dispelling myths about emergency department use: majority of Medicaid visits are for urgent or more serious symptoms. Res Brief. 2012; 23:1-10. http://www.ncbi.nlm.nih.gov/pubmed/22787720. Accessed December 8, 2014. 5. Smulowitz PB, Honigman L, Landon BE. A novel approach to identifying targets for cost reduction in the emergency department. Annals of Emergency Medicine. 2013; 61(3) 293-300.http://www.annemergmed.com/article/S0196-0644(12)00599-9/pdf. Accessed December 8, 2014. 26 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Economic Impact of Hospitalizations Resulting from ED Visits Objective ASH-1: Increase the proportion of persons with health insurance While medical care in emergency departments (EDs) represents only about 2% of the nation’s $2.9 trillion in health care expenditures, the ED serves as a gateway to significant costs associated with hospital admissions.5-7 The Centers for Medicare and Medicaid Services (CMS) report that hospital care represented about 30% of total health expenditures in 2011—the largest share of health care spending. The ED has become the primary source for hospitalizations in the United States and admitting a patient to the hospital from the ED is one of the more expensive, routine decisions made in health care.8 Recent studies have found that all-cause admission rates are highly variable across individual providers and EDs.9,10 Accordingly, strategies focusing on reducing hospital admissions following an ER visit may significantly reduce healthcare costs. Persons with Medical Insurance Area National Baseline 2011 82.8 Target for 2020 100.0 Houston MSA 2012 69.7 State of Texas 2012 69.4 United States 2012 82.9 Public Health Actions  Support expanded access to affordable, convenient outpatient care sites as alternatives to hospital emergency departments.  Educate people about health issues, the importance of a medical home, and resources such as 24-hour nurse advice lines to assist in determining the need for emergency department care.  Establish working relationships between hospitals and medical homes for referring patients for follow-up care and preventive services. Opportunity for Cost Savings Among a national sample of emergency departments, a recent study found substantial variation in risk-standardized hospital admission rates for many common conditions.8 Chest pain, soft tissue infections, asthma, chronic obstructive pulmonary disease, and urinary tract infections showed the greatest variation, pointing to an opportunity to improve the efficiency of ED admission practices to produce cost savings.8 Percent For More Information While the hospitalization rate across 18 Houston area hospital EDs was 7.1 in 2013 for 719,836 ER visits, hospitalization rates at each ER varied considerably (from 0.5 to 48.5).11 Houston Health Services Research Collaborative (several years of detailed reports on ED utilization): www.sph.uth.tmc.edu/hsrc/ National Center for Health Statistics: Emergency Department Visit Data: http://www.cdc.gov/nchs/injury/ injury_emergency.htm 6. Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey Household Component Data. Emergency room services-mean and median expenses per person with expense and distribution of expenses by source of payment: United States, 2006. http://meps.ahrq.gov/ data_stats/quick_tables_results.jsp?component=1&subcomponent=0&tableSeries=1&year=-1&SearchMethod=1&Action=Search. Accessed December 8, 2014. 7. Tyrance P, Himmelstein D, Wollhandler S. U.S. emergency department costs: no emergency. Am J Public Health.1996; 86:1527-1531. http:// www.pnhp.org/sites/default/files/docs/US-Emergency-Department-Costs.pdf. Accessed December 8, 2014. 8. Sabbatini AK, Nallamothu BK, Kocher KE. Reducing variation in hospital admissions from the emergency department for low-mortality conditions may produce savings. Health Affairs. 2014; 33(9):1655-1663. Accessed December 8, 2014. 9 . Pines JM, Mutter RL, Zocchi MS. Variation in emergency department admission rates across the United States. Med Care Res Rev. 2013; 70 (2):218–31. http://www.ncbi.nlm.nih.gov/pubmed/23295438. Accessed December 8, 2014. 10. Abualenain J, Frohna WJ, Shesser R, Ding R, Smith M, Pines JM. (2013) Emergency department physician-level and hospital-level variation in admission rates. Ann Emerg Med. 61(6):638-643. http://www.annemergmed.com/article/S0196-0644(13)00038-3/abstract. Accessed December 8, 2014. 11. Hamilton, J.E., Begley, C, Jeong, S. Behavioral health related ER visits. Center for Health Services Research, UT School of Public Health; Center for Excellence in Mood Disorders, UT Medical School Department of Psychiatry. 2014. 27 Emergency Department Visits, cont. Hospitalization of ED Patients with Comorbid and Complex Health Conditions Research indicates that patients with co-morbid and complex chronic health conditions are more likely to be hospitalized following an ED visit.1,2 In the U.S., comorbid and chronic health conditions comprise 31%-57% of all ED visits and result in approximately 75% of all hospitalizations that follow an ED visit. 2 Hospitalizations of ED patients with chronic health conditions result in great economic cost, amounting to 10% of total health care costs.2 Patients treated in a Harris County ED in 2013 who had a primary diagnosis related to cardiovascular disease were 1.9 times more likely to be hospitalized following the ER visit and patients diagnosed with diabetes were 2.1 times more likely to be hospitalized following the ER visit compared to patients with another primary diagnosis.3 Geographic Differences Highest rates of ED visits were in the east/northeast, south central, and west (Katy area) areas of Harris County. These areas also have the highest rates of primary care-related emergency department (PCRED) visits and PCRED visits by the uninsured.4 1. Sommers A, Boukus E, Carrier E. Dispelling myths about emergency department use: majority of Medicaid visits are for urgent or more serious symptoms. Res Brief. 2012; 23:1-10. http://www.ncbi.nlm.nih.gov/pubmed/22787720. Accessed December 8, 2014. 2. Smulowitz PB, Honigman L, Landon BE.(2013) A novel approach to identifying targets for cost reduction in the emergency department. Annals of Emergency Medicine. 2013;61(3) 293-300.http://www.annemergmed.com/article/S0196-0644(12)00599-9/pdf. Accessed December 8, 2014. 3. Hamilton JE, Begley C, Jeong S. Behavioral health related ER visits. Center for Health Services Research, UT School of Public Health. Center for Excellence in Mood Disorders. UT Medical School Department of Psychiatry. 2014. 4. Begley C, Courtney P, Abbass I, Ahmed N, Burau K. Houston hospitals: emergency department use study, January 2011 through December 31, 2011. University of Texas Health Science Center, School of Public Health. https://sph.uth.edu/content/uploads/2013/06/Final2011ER.pdf. Published June 2013. Accessed November 14, 2014. 28 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Mental Health-Related ED Visits Overview Persons who have a mental health condition or substance abuse disorder may seek treatment in the emergency department (ED) as a result of a lack of access to community-based behavioral health services.5,6 Mental health-related ED utilization is a concern to both providers and consumers because of the high cost and decreased quality of care. In addition, mental health ED visits contribute to overcrowding and the increased likelihood of medical error in the ED.1 In 2013, patients diagnosed with a primary mental health diagnosis accounted for 2.2% of all ER visits in Harris County. The top three mental health conditions treated in the ED in Harris County in 2013 included:  Mood Disorders (22.1%)  Anxiety Disorders (20.5%)  Nondependent Substance Abuse (18.1%)3 A study conducted at 18 of the Houston area EDs identified that persons visiting a ED who had a primary diagnosis of a mental health condition were 3.4 times more likely to be hospitalized following the ED visit compared to persons with a non-behavioral health primary diagnosis.3 Population Differences Of Harris County ED visits with a mental health condition or substance abuse disorder as a primary diagnosis in 2013, 46% were white, 23% were black, 23% were Hispanic, and 8% identified as other (shown in graph to the right).3 Racial/Ethnic Distribution of ER Patients with a Mental Health or Substance Abuse Primary Diagnosis in Harris County, 20133 Other 8% The Uninsured Nationally, the uninsured account for 20.6% of mental health-related ER visits.6 In Harris County, 36.8% of all patients with a primary diagnosis of a mental health disorder in the ED were uninsured in 2013.3 This difference may reflect the higher rates of uninsured persons and the limited availability of mental health services in Harris County. Hispanic 23% White 46% Black 23% Mental Health ER Visits by Payer Source in Harris County, 20133 40% Public Health Actions to Address Behavioral Health 37% 35% 30%  Work with community partnerships and state legislators to expand access to and funding for outpatient mental health services, particularly for the uninsured.  Expand access to crisis intervention services.  Facilitate efforts to coordinate medical and mental health treatment services. 27% 24% 25% 20% 15% 12% 10% 5% 0% Uninsured Medicare Medicaid Commerci al 5. Institute of Medicine (IOM). Hospital-based emergency care at the breaking point. IOM Web site. http://www.iom.edu/~/media/Files/Report% 20Files/2006/Hospital-Based-Emergency-Care-At-the-Breaking-Point/EmergencyCare.ashx. Published June 2006. Accessed December 8, 2014. 6. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007. HCUP Statistical Brief #92. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf. Published July 2010. Accessed December 8, 2014. 29 This page intentionally left blank Health Behaviors Lifestyle, health behaviors and environmental factors are responsible for about 70% of all premature deaths in the United States. Such behaviors include cigarette smoking, poor diet and lack of preventive health services. Environmental health risks include poor air and water quality, lack of food safety and lead in the home environment. Further, the level of community preparedness for public health emergencies impacts the health and well-being of all citizens. Healthy People 2020 31 Tobacco Use Overview Tobacco use is the leading preventable cause of disease and death in the United States. The Centers for Disease Control and Prevention (CDC), a component of the U.S. Department of Health and Human Services, reports that 20% of all U.S. deaths can be linked to tobacco—a causative agent in lung cancer, heart disease, and stroke. The rates of tobacco use have decreased dramatically since the 1960s, in part due to greater public awareness about the risks of smoking; however, according to the CDC, approximately one in five American adults continues to smoke. Nationally, tobacco use among youth has declined in recent years. The Youth Risk Behavior Survey (YRBS) reports that 15.7% of high school students were smokers in 2013, compared to 20.0% in 2007, and 28.5% in 2001. In Texas, similar trends are noted. The TDSHS YRBS reports that 14.1% of surveyed high school aged students in Texas smoked cigarettes in the last 30 days in 2013 compared to 21.1% in 2007 and 28.4% in 2001. In Houston, 11.3% of high school aged students report smoking cigarettes in the last 30 days in 2013 compared to 11.7% in 2007 and 21.8% in 2001. Although cigarette use has declined, recent surveys indicate that more people are using multiple types of tobacco products, particularly youth and young adults. The percentage of U.S. middle and high school students who use electronic cigarettes has more than doubled from 2011 to 2012. 1 LGBT individuals experience stigma, discrimination, and other stressors that increase the likelihood of smoking, a risk factor for lung cancer, heart disease, and other smoking-related diseases.2 According to the CDC, smoking among LGBT individuals is higher with one in four LGBT individuals smoking cigarettes compared to one in six heterosexual individuals in 2012-2013. Trends: Houston/Harris County 2011-2013 Percent of Adult Smokers 2011-2013 17.9 19.2 21.2 16.5 2011 18.2 19.6 19.0 13.9 2012 Houston MSA 15.9 2013 Texas U.S. The Behavior Risk Factor Surveillance System (BRFSS) survey shows that the percent of adults who report current smoking in the Houston-Baytown-Sugar Land Metropolitan Statistical Area (MSA) decreased from 2011 to 2013 (see appendix for map of this area), as well as in Texas and the U.S. TDSHS Vital Statistics data indicate that in 2012, 2.1% of all women who gave birth in Harris County smoked during pregnancy, a decrease from 3.4% in 2006. In Texas, 4.4% of women who gave birth in 2012 smoked during pregnancy, double that of Harris County. Source: CDC, TDSHS BRFSS Population Differences Percent of Current Adult Smokers Houston-Baytown-Sugar Land MSA 2009-13 Male Female 28 24 21.2 20.7 21.9 23.3 19.4 20 16 White 12.9 24 20 17.7 16 13.9 10.6 10.2 15.9 9.1 8 2009 2010 2011 2012 2013 Source: CDC, TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. Black 23.3 17.8 12 32 28 Percent of Current Adult Smokers HoustonBaytown-Sugar Land MSA 2009-13 Hispanic 22.8 19.1 17.7 16.9 15.1 16.4 15.1 12 14.4 12.0 11.2 8 2009 2010 15.1 2011 2012 2013 Source: CDC, TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Harris County Deaths from Cancer of the Trachea, Bronchus, and Lung 1300 1280 60 47.8 43.3 42.1 1260 39.0 Area 20.6 Target for 2020 12.0 20 Houston MSA 2013 13.9 10 State of Texas 2013 15.9 0 United States 2013 19.0 30 1200 1180 1292 1206 1235 1214 1268 Number 2010 2011 Percent National Baseline 2008 1220 2009 Adult Current Smokers 39.2 40 2008 Objective TU-1: Reduce tobacco use by adults 50 1240 1160 Healthy People 2020 2012 Age-Adjusted Rate Source: TDSHS, Center for Health Statistics In the U.S., tobacco use is responsible for one in five deaths. -CDC Public Health Actions  Inform, educate, and empower people about the risks of smoking; provide health assessment and education about healthy lifestyles through public health clinics and outreach.  Enforce laws and regulations that protect health and ensure safety through investigation of violations of non-smoking city ordinances.  Support policies to decrease smoking. Economic Impact of Tobacco Use Between 2009 and 2012, costs related to smoking in the U.S. were approximately $289 billion per year. This includes an estimated $133 billion in direct health care expenditures and $156 billion in productivity losses.3 For each pack of cigarettes sold, at least $18.20 is lost on productivity and health care costs.4 The annual burden to taxpayers from government spending due to smoking was more than $743 per household.4 Each year in Texas, smoking leads to more than 24,500 deaths and $12.2 billion in health care costs and lost productivity.5 Tobacco harms nearly every organ in the body. Tobacco use is the leading cause of preventable disease and death in the nation. For More Information CDC: Smoking and Tobacco Use: www.cdc.gov/tobacco/index.htm Fact Sheet for Youth: www.cdc.gov/ tobacco/data_statistics/fact_sheets/ youth_data/tobacco_use/index.htm Tobacco Fact Sheets: www.cdc.gov/ tobacco/data_statistics/fact_sheets/ index.htm American Lung Association: www.lungusa.org Harris County Public Health and Environmental Services: www.hcphes.org 1. U.S. Department of Health and Human Services (USDHHS). The health consequences of smoking—50 years of progress: a report of the surgeon general. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/index.html. Published 2014. Accessed July 14, 2014. 2. American Lung Association. The LGBT community: a priority population for tobacco control. http://www.lung.org/stop-smoking/tobacco-controladvocacy/reports-resources/tobacco-policy-trend-reports/lgbt-issue-brief-update.pdf. Accessed October 22, 2014. 3. Centers for Disease Control and Prevention. Economic facts about U.S. tobacco production and use. http://www.cdc.gov/tobacco/data_statistics/ fact_sheets/economics/econ_facts/index.htm. Updated February 6, 2014. Accessed July 14, 2014. 4. Guilfoyle J. Toll of tobacco in the United States of America. Campaign for Tobacco-Free Kids. http://www.tobaccofreekids.org. Published June 16, 2014. Accessed July 15, 2014. 5. Texas Department of State Health Services (TDSHS). Texans and tobacco: a report to the 82nd Texas legislature. http://www.dshs.state.tx.us/ tobacco/reports.shtm. Published January 2011. Accessed July 15, 2014 33 Secondhand Smoke Overview Secondhand smoke, also known as environmental tobacco smoke (ETS), is a complex mixture of gases and particles that includes smoke from a burning cigarette, cigar, or pipe tip (side stream smoke) as well as exhaled mainstream smoke. In 1992, ETS was identified as a Group A carcinogen by the Environmental Protection Agency (EPA). This classification identifies ETS as a compound that has been shown to cause cancer in humans based on studies on human populations.1 Comprehensive Smokefree Indoor Air Laws 2011 Exposure to Tobacco Smoke: Report of the Surgeon General 20062 Major Conclusions of the Report 1.1 Secondhand smoke causes premature death and disease in children and in adults who do not smoke. 1.2 Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. 1.3 The scientific evidence indicates that there is no risk-free level of exposure to ETS. 1.4 Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer. Source: State Tobacco Activities Tracking and Evaluation System (STATE), CDC/NCCDPHP Thirty-six Texas municipalities have 100% smokefree workplaces, restaurants, and bars, an increase from nine in 2006. Abilene, Alton, Austin, Baytown, Beaumont, Benbrook, Brownsville, College Station, Copperas Cove, Corpus Christi, Dallas, Eagle Pass, El Paso, Ennis, Flower Mound, Granbury, Harlingen, Highland Village, Horseshoe Bay, Houston, Laredo, 1.5 Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces despite substantial progress in tobacco control. Lufkin, Marshall, Pearland, Plano, Robinson, San 1.6 Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke. Socorro, Southlake, Spring Valley, Tyler, Angelo, San Antonio, San Marcos, University Park, Vernon, and Victoria Source: Texas DSHS Texas Smoke-free Ordinance Database. TDHS Web site. http://www.dshs.state.tx.us/tobacco/ 1. U.S. Environmental Protection Agency (EPA), Office of Health and Environmental Assessment and Office of Research and Development. Respiratory health effects of passive smoking: lung cancer and other disorders. www.oaspub.epa.gov/eims/eimscomm.getfile?p_download_id=36793Similar. Published 1992. Accessed March 1, 2012. 2. The United States Department of Health and Human Services (USDHHS). The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. http://www.surgeongeneral.gov/library/secondhandsmoke. Published June 7, 2006. Accessed March 1, 2012. 3. Centers for Disease Control and Prevention (CDC). Smoke-free policies improve health. CDC Web site. http://www.cdc.gov/tobacco/ data_statistics/fact_sheets/secondhand_smoke/protection/improve_health/index.htm. Updated May 12, 2014. Accessed July 23, 2014. 4. Centers for Disease Control and Prevention (CDC). State smoke-free laws for worksites, restaurants, and bars—United States, 2000-2010. Morbidity and Mortality Weekly Report. 2011;60(15):472-475. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6015a2.htm. Accessed July 23, 2014. 34 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Smokefree Laws Healthy People 2020 Objective TU 13: Establish laws in States, District of Columbia, Territories, and Tribes on smoke-free indoor air that prohibit smoking in public places and worksites. Although most exposure to secondhand smoke occurs in the home and workplace, exposure also occurs in public places. In order to protect the health of nonsmokers, local and state legislation has been enacted to eliminate smoking in public places such as restaurants, bars, and in the workplace.3 The first statewide smokefree law went into effect in 2002 and by 2010 increased to 25 states and the District of Columbia.4 Despite legislative efforts, Texas failed to enact a statewide smokefree law in the 2011 82nd legislative session; however, local efforts have been more successful. Thirty-six Texas municipalities have adopted 100% smokefree legislation in workplaces, restaurants, and bars,5 resulting in the protection of 55% of Texas residents in 2011.6 The City of Houston enacted a smokefree ordinance in 2006 that prohibits smoking in enclosed public places, places of employment, seating areas at outdoor events, and covered public transportation facilities.7 More recent laws prohibit smoking in public housing,8 city parks, and public libraries.9 Research has shown improvements in the health of workers and the general population following smokefree laws. Areas with smokefree legislation are associated with lower rates of hospital admission and deaths resulting from: respiratory disease, coronary events, heart disease, and cerebrovascular events.3 In Texas, efforts to enact laws prohibiting smoking in public places failed during the 2011 82nd legislative session. Efforts to enact statewide laws prohibiting smoking in worksites failed in 2013. Comprehensive Smokefree Laws Area Percent National Baseline 2008 31.4 Target for 2020 100.0 Houston 2014 100.0 State of Texas 2014 13.2 United States 2014 52.9 Note: Texas reported percentage of municipalities with comprehensive smokefree laws. Public Health Actions  Educate the community about the risks and importance of avoiding secondhand smoke.  Support policies to curtail exposure to secondhand smoke in public places.  Enforce laws and regulations that protect health and ensure safety by investigating violations of the smoke free ordinances. For More Information The United States Department of Health and Human Services: The Surgeon General’s Report: www.surgeongeneral.gov/library/ secondhandsmoke/ The United States Environmental Protection Agency: www.epa.gov Texas Department of State Health Services: www.dshs.state.tx.us./tobacco/ Americans for Nonsmokers Rights and ANR Foundation: www.no-smoke.org/ American Heart Association: www.heart.org American Lung Association: www.lungusa.org 5. Texas Department of State Health Services (TDSHS). Texas Smoke-free Ordinance Database. TDSHS Web site. http://www.dshs.state.tx.us/ tobacco/ordinance.shtm. Updated April 2013. Accessed July 15, 2014. 6. Texas Department of State Health Services (TDSHS). Smoke-free Texas. TDSHS Web Site. http://www.dshs.state.tx.us/Layouts/ ContentPage.aspx?PageID=34575&id=1648&terms=smokefree. Updated April 10, 2013. Accessed July 23, 2014. 7. Houston, Texas. Municipal Code §21-236. 8. Houston Housing Authority. Houston Housing Authority implements smoke-free policy at its 25 properties throughout Houston. [press release]. Houston Housing Authority; January 28, 2014. http://www.housingforhouston.com/media/38896/houston%20housing%20authority%20implements% 20smoke%20free%20policy%20press%20release.pdf. Accessed July 28, 2014. 9. City of Houston, Mayor’s Office. City to expand smoking ban to all city parks and libraries. [press release]. City of Houston, Mayor’s Office; July 23, 2014. http://www.houstontx.gov/mayor/press/20140723.html. Accessed July 28, 2014. 35 Nutrition Overview Fruit and Vegetable Consumption According to the CDC, poor nutrition is a major cause of the obesity and diabetes epidemics in the United States. Poor nutrition, when combined with physical inactivity, is associated with many chronic diseases, such as heart disease and cancer, that cause preventable disabilities and deaths. Conversely, practicing good nutrition, being active, and maintaining a healthy weight can lower the risk of chronic conditions such as type 2 diabetes, osteoporosis, arthritis, and stroke. The CDC recommends the consumption of a variety of fruits and vegetables each day. An individual’s daily fruit and vegetable requirements depend on their caloric needs, which are determined by their age, sex, and physical activity level. According to 2013 BRFSS data, 14.5% of surveyed Houston MSA adults reported eating the recommended five or more servings of fruits and vegetables a day, compared to 14.3% of Texas adults. Forty percent of Houston MSA adults reported eating less than one fruit a day, compared to 42.7% of Texas adults and 39.2% of U.S. adults. For vegetables, 22.6% of Houston MSA adults reported eating less than one vegetable a day compared to 21.5% of Texas adults and 22.9% of U.S. adults. Key components of healthy diets are that they are low in fat (particularly saturated fat) and contain plenty of fruits and vegetables, whole grains, lean protein, and low-fat dairy. Trends: Houston/Harris County: 2007-2013 Percent of Adults Who Report Eating 5+ Fruits and Vegetables per Day Houston MSA 25.2% 25.2% 24.4% 23.8% 23.4% 22.4% Texas U.S. Fruit and vegetable intake may decline during the adolescent and teenage years—a time crucial to establishing a healthy lifestyle. In Houston, high school students report that they eat fewer fruits and vegetables than the national average. Percent of High School Students Who Report Eating 3+ Fruits and Vegetables per Day, 2013 20.6% 18.1% 14.5% 14.3% Fruits Vegetables 21.9% * * 2007 2009 2011 * 15.7% * 19.6% 18.7% 12.7% 10.8% 2013 *U.S. data unavailable. Source: CDC, TDSHS BRFSS. Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. Population Differences BRFSS 2013 data collected in the HoustonBaytown-Sugar Land MSA indicate that 14.5% of adults ate the recommended five or more fruits and vegetables a day, with more females (14.8%) reporting eating five or more fruits and vegetables than males (14.1%). In addition, fewer blacks reported eating five or more fruits and vegetables daily, compared to whites and Hispanics (shown in graph). U.S. Texas Houston Source: YRBS Percent of Adults Who Eat 5+ Fruits and Vegetables per Day Houston-Baytown-Sugar Land MSA, 2013 Male 14.1% Female 14.8% White Black 14.5% 13.1% Hispanic 14.9% Source: TDSHS BRFSS survey 36 1. Centers for Disease Control and Prevention (CDC). Fruits and veggies matter. CDC Web site. http://www.fruitsandveggiesmatter.gov/. Accessed September 25, 2011. 2. United States Department of Agriculture, Economic Research Service. Food security status of U.S. households in 2013. United States Department of Agriculture Web site. http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics.aspx. Updated September 3, 2014. Accessed December 27, 2014. 3. Children at Risk. Growing up in Houston 2012-2014: assessing the quality of life of our children. http://childrenatrisk.org/wp-content/ uploads/2013/05/01_Growing-Up-In-Houston-2012.pdf. Accessed August 1, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Food Insecurity Food insecurity, or the condition of not having access to an adequate supply of nutritious food to maintain good health, has a direct and indirect impact on physical and mental health as well as economic consequences. Texas (18.0%) ranks third in households with food insecurity, significantly greater than the national average (14.6%).2 In Harris County, 25.5% of children live in food insecure homes, with minorities at greater risk of food insecurity.3 Children in food insecure homes are more likely to be at risk for developmental delays and iron deficiency anemia, 19% more likely to have a history of hospitalization, and 51% more likely to be reported in fair or poor health.4 Pregnant women who are food insecure are more likely to give birth to preterm infants with fetal growth retardation. These mothers take longer maternity leaves and work fewer hours or leave the workforce altogether resulting in a 32% drop in family income.4 Objective NWS-14: Increase the contribution of fruits to the diets of the population aged two years and older Objective NWS-15: Increase the variety and contribution of vegetables to the diets of the population aged two years and older 5+ Fruits and Vegetables Daily in Adults Area WIC reduces rates of low birth weight infants, improves the health of children under age three, and decreases the risk of developmental delays.5 Research indicates that birth weight impacts both future education and earnings, supporting the cost-effectiveness of WIC interventions.6 In 2011, hunger cost the U.S. $167.5 billion due to lost economic productivity, more expensive public education, avoidable health care costs, and the cost of charity to keep families fed. In addition to the $167.5 billion, federal nutrition programs spend approximately $94 billion a year.7 Houston MSA 2013 14.5 State of Texas 2013 14.3 United States 2009 23.4 Public Health Actions  Educate the community about the importance of good nutrition.  Assure the provision of healthcare support where otherwise not available through activities such as providing food vouchers to low-income women and children in the WIC program and working with vendors to provide Meals on Wheels to seniors.  Support policies to improve availability of nutritious foods in food deserts. Economic Impact of Nutrition The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrient-rich foods, nutrition education, and healthcare referrals for low-income pregnant, breastfeeding, or postpartum mothers and infants and children up to age five. Studies show that every dollar spent on WIC yields savings between $1.77 and $3.13 in healthcare costs during an infant’s first 60 days of life.5 Percent For More Information Food and Nutrition Information Center: http://fnic.nal.usda.gov/ CDC: Nutrition Information: www.cdc.gov/nutrition/ index.html Spanish Information: http://www.cdc.gov/ healthyweight/spanish/healthyeating/index.html Academy of Nutrition and Dietetics: www.eatright.org Coordinated Approach to School Health Program (CATCH): www.catchtexas.org Recipe for Success: http://recipe4success.org/ Office on Women’s Health—Breastfeeding: www.womenshealth.gov/breastfeeding/index.html MD Anderson Cancer Center: http:// www.mdanderson.org/patient-and-cancerinformation/cancer-information/cancer-topics/ prevention-and-screening/food/index.html HCPHES: www.hcphes.org 4. Cook J, Jeng K. Child food insecurity: the economic impact on our nation. http://feedingamerica.org/SiteFiles/child-economy-study.pdf. Published 2009. Accessed September 20, 2011. 5. Children’s HealthWatch. WIC improves child health and school readiness. http://www.childrenshealthwatch.org/page/policyactionbriefs. Published January 2010. Accessed September 30, 2011. 6. Black SE, Devereux PJ, Salvanes KG. From the cradle to the labor market? The effect of birth weight on adult outcomes. National Bureau of Economic Research. http://www.nber.org/papers/w11796. Published 2005. Accessed October 2, 2011. 7. Shepard DS, Setren E, Cooper D. Hunger in America: suffering we all pay for. Center for American Progress. http://cdn.americanprogress.org/wpcontent/uploads/issues/2011/10/pdf/hunger_paper.pdf. Published October 2011. Accessed August 1, 2014. 37 Physical Activity Overview According to the CDC, a lack of physical activity, combined with poor nutrition, is a leading cause of preventable death, second only to tobacco use. Inactivity and poor nutrition can lead to overweight and obesity, which are linked with chronic diseases such as heart disease, diabetes, and cancer. Conversely, being active can help maintain a healthy weight and lower the risk of chronic conditions. In addition, the CDC reports that physical activity can improve mental health, particularly in decreasing depressive symptoms. The CDC recommends that adults participate in 150 minutes of moderate-intensity aerobic activity every week and muscle-strengthening activities on 2 or more days a week that work all major muscle groups. The 2013 BRFSS data show that 18.2% of surveyed adults in the Houston-Baytown-Sugar Land MSA reported meeting the recommended aerobic and muscle-strengthening exercise guidelines, compared to 17.2% of Texas adults and 20.5% of U.S. adults. CDC recommendations for children and adolescents include participation in 60 minutes (one hour) of physical activity daily. The 2013 Youth Risk Behavior Survey (YRBS) data show that 66.6% of Houston high school students were not physically active at least 60 minutes per day on five or more days during the seven days before the survey and 21.5% of students did not participate in at least 60 minutes on at least one day during the seven days before the survey. Texas statutes require that school districts adopt policies to ensure that elementary school, middle school, and junior high school students engage in at least 30 minutes of physical activity per day or 135 minutes per week.1 Nevertheless, YRBS data indicate that 78.3% of Houston high school students did not attend physical education classes daily, a greater percentage compared to high school students in Texas (61.7%) and the U.S. (70.6%). Trends: Houston/Harris County 2009-2013 Percentage of Houston MSA Population Reporting Participation in Leisure Time Physical Activity Houston MSA Texas U.S. 75.6% 75.4% 73.4% 72.7% 74.0% 73.1% 73.6% 72.8% 72.7% 72.8% 70.5% 69.9% * 2009 2010 2011 * 2012 * 2013 *U.S. data unavailable. Source: CDC, TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. Access to exercise opportunities can increase leisure time physical activity. According to the County Health Rankings, in 2014, 90% of Harris County residents had access to exercise opportunities, defined by proximity to parks and recreational facilities. In comparison, 74% of all Texas residents had access to exercise opportunities.2 The reduction in screen time for children has been an area of focus for increasing physical activity. YRBS 2013 data indicate that 33% of Houston high school students watch television three or more hours per day and 34% play video games or use a computer that is not school related for three or more hours per day. In the past month, 70.5% of surveyed adult residents in the Houston-BaytownSugar Land MSA reported that they had participated in leisure time physical activity outside their jobs, such as walking or golf. 1. Texas Education Code §28.002. 2. Robert Wood Johnson Foundation. Harris (HAS) County snapshot. County Health Rankings Web site. http://www.countyhealthrankings.org/app/ texas/2014/rankings/harris/county/factors/3/snapshot. Updated 2014. Accessed August 6, 2014. 3. Physical inactivity and obesity translates into economic impact: experts profile the cost to US health system. http://www.acsm.org. American College of Sports Medicine. Published 2007. Accessed September 12, 2011. 38 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Population Differences According to 2013 BRFSS measures for the Houston MSA, more men (25.7%) than women (12.0%) met the recommended aerobic and muscle-strengthening physical activity guidelines. Differences are also noted among educational attainment and household income. Among college graduates, 22.9% met the recommended activity levels, compared to 17.4% of high school graduates and 10.4% of those without a high school diploma. Those with a lower household income are less likely to meet physical activity guidelines. Of respondents with a household income of less than $25,000 per year, 16.9% met the recommended level of activity, compared to 25.7% of respondents with an income of $50,000 or more. In 2013, young adults reported more physical activity compared to older age groups; 37.1% of adults age 18-29 met recommended guidelines, compared to 16.4% of those aged 30-44 years, 14.7% of those ages 45-64, and 10.4% of those aged 65+ years. Percentage of Houston MSA Population Meeting Recommended Aerobic and MuscleStrengthening Guidelines White 23.3% Black 23.3% 19.6% 20.7% Objective PA-1: Reduce the proportion of adults who engage in no leisure-time physical activity. Objective PA-2.1: Increase the proportion of adults who meet current Federal physical activity guidelines for aerobic physical activity and muscle-strengthening activity. Meet Recommendations for Moderate Aerobic Physical Activity Area National Baseline 2008 43.5 Target for 2020 47.9 Houston MSA 2013 41.9 State of Texas 2013 41.7 United States 2009 49.2 Public Health Actions  Educate people to understand the importance of physical activity and how they can incorporate it into their lives.  Assure health care where otherwise unavailable by providing health assessment and education for residents served in public health clinics.  Monitor health status by tracking lifestyle and activity trends among residents and providing reports to the community.  Support policies to provide greater access to physical activity opportunities for all. Hispanic 22.1% 13.8% 2011 Percent 2013 Source: TDSHS BRFSS Economic Impact of Physical Activity Physical inactivity is associated with a number of health problems and chronic conditions that place a significant burden on the U.S. economy each year. According to a 2007 study, estimated direct medical costs related to physical inactivity such as heart disease, type 2 diabetes, and obesity were $76 billion annually.3 Additional costs include decreased worker productivity and time missed from work and school.3 For More Information Texas DSHS Nutrition, Physical Activity and Obesity Prevention: http://www.dshs.state.tx.us/obesity/ NPAOPprogrampage.shtm CDC: www.cdc.gov/physicalactivity CDC Information in Spanish: http://www.cdc.gov/spanish/hojas/ actividad_fisica.html American Heart Association: www.heart.org HCPHES: www.hcphes.org 39 Overweight/Obesity in Adults Overview According to the CDC, the United States is experiencing an epidemic of people becoming overweight or obese. Today, more than one-third of American adults identify as obese. Individuals are considered overweight if their Body Mass Index (BMI), a correlate of body fat, is within 25.0-29.9 range and considered obese if their BMI is 30.0 or above. The proportion of overweight people has increased dramatically since the 1980s. The National Center for Health Statistics (NCHS) data indicate that 35% of U.S. adults over the age of 20 are obese. Among the nation’s youth, the percentage who are overweight has more than tripled since 1980 with nearly 19% of youth ages 6-19 identified as obese. The NCHS reports that being overweight or obese increases the risk of many diseases and conditions, including:      Hypertension  Coronary heart disease Type 2 diabetes  Stroke Sleep apnea and respiratory problems  Gallbladder disease Cancers (endometrial, breast, and colon)  Osteoarthritis Dyslipidemia (high total cholesterol or high levels of triglycerides) While one of the national health objectives for the year 2020 is to reduce the prevalence of obesity among adults to less than 30.6%, current data indicate the situation is worsening rather than improving. Trends: Houston/Harris County 2009-2013 Percent Overweight/Obese* Adults, Houston MSA Houston MSA 64.4% 63.1% 63.1% Texas U.S At risk for overweight is defined as > 85th but < 95th percentile based on BMI charts. 65.1% 64.6% 64.8% 63.7% 6 3.5% 63.1% 63.4% 66.8% 66.5 % 65.8% 65.1% 2009 2010 2011 2012 66.1% The general population is becoming increasingly overweight/obese. The 2013 BRFSS reports that 64.6% of surveyed adults in the HoustonBaytown-Sugar Land MSA were overweight or obese, compared to 66.1% of Texas adults and 64.8% nationwide. 2013 *BMI of 25 or greater. Source: CDC, TDSHS BRFSS Note: See Appendix F for changes in BRFSS data collection methods from 2011 onward. Population Differences BRFSS data showed that males in the HoustonBaytown-Sugar Land MSA were more likely (42.6%) to be overweight than females (30.2%); however, females were more likely to be obese (32.7%) than males (23.8%). According to the Office of Women’s Health, lesbian and bisexual women have even higher rates for overweight and obesity. Prevalence of Overweight vs. Obese* Adults in Houston-Baytown-Sugar Land MSA 2013 Overweight + Obese Obese 77.8% 71.7% 62.5% 45.0% 38.6% 26.4% White Black Hispanic *Overweight is BMI of ≥25 and <30, Obese is BMI of ≥30 Source: TDSHS BRFSS 40 Overweight is defined as > 95th percentile based on BMI charts. Hispanics (77.8%) were more likely to be overweight or obese, compared to blacks (71.7%) and whites (62.5%). Although Hispanics were more likely to weigh over the normal weight, blacks were more likely to be obese. Middle-aged adults are more likely to be overweight or obese with people aged 18-29 having the lowest risk (37.6% are overweight/ obese) compared to those aged 30-44 (68.4%), aged 45-64 (76.1%), and aged 65+ (60.9%). T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Economic Impact of Obesity Objective NWS-9 Reduce the proportion of adults who are obese Overweight and obese individuals are more likely to develop type 2 diabetes, hypertension, coronary heart disease, gallbladder disease, osteoarthritis, and cancers of the breast, colon and endometrium. In the United States, 21% of annual medical spending is on obesity-related illnesses, resulting in an estimated cost of $190.2 billion.1 In addition, $4.3 billion is lost in productivity due to obesity-related job absenteeism.1 If current trends continue, 51% of the adult population will be obese by 2030 and health care costs related to overweight and obesity could range from $860 to $956 billion.2 In Texas, obesity rates have risen from a prevalence of 20.2% in 1998 to 31.7% in 2010.3 In 2013, nearly two-thirds (66.1%) of adults in Texas were either overweight or obese. If the state-level trend continues, expenditures will increase from $10.5 billion in 2010 to $39 billion by 2040.4 Adults Aged 20 and Older Identified as Obese Area National Baseline 2005-08 34.0 Target for 2020 30.6 Houston MSA 2013 28.3* State of Texas 2013 30.9* United States 2013 29.4* *Ages 18 and older. Public Health Actions  Educate the community about the health impacts of unhealthy weight and needed behavior changes, such as meeting physical activity and nutrition guidelines.  Develop policies and plans that promote environments with access to healthy foods and opportunities for physical activity.  Partner with other sectors, such as urban planning, to identify ways to reduce obesity. BMI Classification The chart below, from the CDC website, provides an example of the BMI classification for 5’4” and 5’ 9” adults according to weight. To calculate your BMI (adults) use the following formula: BMI= Weight (lb) / Height (in)2 x 7035 Percent For More Information Height 5' 9" 5’4” Weight BMI Considered 124 lbs or less Below 18.5 Underweight 125 lbs to 168 18.5 to 24.9 Healthy weight 169 lbs to 202 25.0 to 29.9 Overweight 203 lbs or more 30 or higher Obese 107 lbs or less Below 18.5 Underweight 108 lbs to 145 18.5 to 24.9 Healthy weight 146 lbs to 174 25.0 to 29.9 Overweight 175 lbs or more 30 or higher Obese Community Transformation Initiative Houston/ Harris County: http://www.houstontx.gov/ health/community-transformation-initiativeindexhtml Centers for Disease Control and Prevention: www.cdc.gov/obesity/index.html National Institute of Health, BMI Calculator: http://www.nhlbi.nih.gov/health/educational/ lose_wt/BMI/bmicalc.htm Texas Department of State Health Services (Obesity information in Spanish): http:// www.dshs.state.tx.us/obesity/default-sp.shtm 1. Institute of Medicine. Accelerating the progress in obesity prevention: solving the weight of the nation. Washington, DC: The National Academies Press. Published May 8, 2012. Accessed August 8, 2014. 2. Wang Y, Beydoun M, Liang L, Caballero B, Kumanyika S. Will all Americans become overweight or obese? Estimating the progression and costs of the US obesity epidemic. Obesity. 2008;16:2323-2330. http://www.nature.com/oby/journal/v16/n10/full/oby2008351a.html. Accessed March 1, 2012. 3. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System (BRFSS). CDC Web site. http:// apps.nccd.cdc.gov/BRFSS-SMART/SelMMSAPrevData.asp. Accessed September 13, 2011. 4. Texas Department of State Health Services (TDSHS). Texas overweight and obesity data sheet. www.dshs.state.tx.us/obesity/pdf/DataFacts.pdf. Published May 2010. Accessed September 13, 2011. 5. Centers for Disease Control and Prevention (CDC), Division of Nutrition, Physical Activity and Obesity. Defining overweight and obesity. CDC Web site. http://www.cdc.gov/obesity/adult/defining.html. Updated April 27, 2012. Accessed August 8, 2014. 41 Overweight/Obesity in Youth Percent Obese Among U.S. Children and Adolescents* Overview In recent decades, obesity has tripled in children and quadrupled among adolescents in the United States.1 Higher rates of overweight children are apparent in lower income groups where families generally have less access to healthy foods and fewer opportunities for physical activity. 1 Ageand sex-specific Body Mass Index (BMI), calculated from height and weight, is used to determine overweight and obesity among children. Aged 2-5 Years Aged 6-11 Years 17.5 17.0 11.310.5 5.0 4.0 6.1 5.0 6.5 5.0 12.3 Aged 12-19 Years 19.4 17.9 17.4 17.9 10.7 10.2 7.2 1971-1974 1976-1980 1988-1994 2001-2004 2005-2008 2009-2012 Source: National Health and Nutrition Examination Surveys (NHANES) *Aged 2 –19 Years, BMI at the 95th percentile and above. Immediate and long-term health effects are associated with childhood obesity. Immediate health effects include high blood cholesterol, high blood pressure, type 2 diabetes, bone and joint problems, asthma, and sleep apnea. 1 Studies have shown that overweight or obese children are more likely to become obese adults; therefore, obese children are at an increased risk for adult health problems associated with obesity. 1 Trends: Houston/Texas 2001-2013 Percentage of High School Students Classified Overweight and Obese 40% Overweight 35% Obese 30% 25% 20% 12.8% 10.5% 13.7% 15.5% 15.7% 12.3% 14.0% 16.4% 17.9% 15% 10% 5% 16.6% 14.6% 15.2% 15.6% 16.3% 17.4% 16.3% 13.6% 15.6% 0% 2001 2007 2013 2001 2007 2013 2001 2007 2013 U.S. Texas Houston Source: CDC, YRBS The 2013 Youth Risk Behavior Survey (YRBS) conducted by the CDC reported that 17.9% of Houston high school students are obese (BMI greater than or equal to the 95th percentile), compared to 15.7% of high school students in Texas. Dietary behaviors and physical activity measures shed some light on the obesity epidemic among Houston youth. Approximately one in four high school students in Houston drink soda or pop one or more times a day while 21.5% of students did not participate in at least 60 minutes of physical activity on at least one day during the seven days before the survey. In addition, 34.2% played video games or used a computer for three or more hours per day and 32.7% watched television three or more hours per day. Population Differences Significant racial and ethnic disparities in obesity prevalence can be seen among children and adolescents. In Texas, obesity prevalence is higher among Hispanic and black youth than white youth. A greater disparity between Hispanics and blacks is noted in Houston. Among female adolescents in Houston, Hispanic girls were most likely to be obese (19.8%) compared to black girls (13.6%); the same is true for males (Hispanic 24.5%, black 11.0%).2 42 Percentage of Obese Students, 2013 White Black Hispanic 22.2% 19.0% 13.1% 15.7% 15.2 % 14.6% 12.4% 12.1% * U.S. Texas Houston *Insufficient data for whites in Houston (<100). Source: CDC, YRBS 1. Centers for Disease Control and Prevention (CDC), Division of Nutrition, Physical Activity, and Obesity. Childhood overweight and obesity. CDC Web site. http://www.cdc.gov/obesity/childhood/index.html. Updated August 5, 2013. Accessed August 8, 2014. 2. Centers for Disease Control and Prevention (CDC). Youth online: high school YRBS. http://nccd.cdc.gov/youthonline/. Accessed August 8, 2014. 3. Institute of Medicine (IOM). Accelerating the progress in obesity prevention: solving the weight of the nation. Washington, DC: The National Academies Press, 2012. Accessed August 8, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Differences Healthy People 2020 The map below shows areas with the percentage of overweight/obese children aged 12 to 17 (dark blue) compared to high concentration of fast food establishments (hatched areas). Objective NWS-10: Reduce the proportion of children and adolescents considered obese Obesity in Adolescents Aged 12 to 19 Years Area Percent National Baseline 2005-08 17.9 Target for 2020 16.1 City of Houston 2013 17.9* State of Texas 2013 15.7* United States 2013 13.7* * Grades 9-12 Public Health Actions Source: Health of Houston Survey. HHS2010 A First Look. Houston, Economic Impact of Overweight in Children The financial costs associated with overweight or obese children are significant. Childhood obesity is responsible for $14.1 billion in direct medical costs, with many of these costs absorbed by Medicare and Medicaid.3 If overweight persists into adulthood for today’s children, it is projected that healthcare costs could exceed $950 billion by 2030.4 Today’s obese youth are likely to become obese adults and projections reveal greater obesity-related costs in medical care, higher costs for disability and unemployment benefits, and greater loss of productivity for employers.3 Beyond health care costs, socio-economic impacts and related costs are evident. Overweight adolescents are less likely as adults to receive education beyond high school and more likely to earn lower wages or be unemployed, be on welfare, and be single—resulting in cumulative social and economic disadvantages.5  Educate children, families, and the community about the health impacts of unhealthy weight and needed behavior change.  Work to change policies, systems, and environments so they support access to healthy foods and physical activity for children.  Partner with schools and School Health Advisory Councils (SHAC) to identify collaborative ways for reducing childhood obesity. For More Information Healthy Living Matters: http:// www.healthylivingmatters.net/ Coordinated Approach to Child Health Program (CATCH): www.catchtexas.org U.S. Department of Health and Human Services: www.surgeongeneral.gov Click: Reports and Publications, Call to Action Centers for Disease Control and Prevention (Spanish): http://www.cdc.gov/spanish/ especialesCDC/ObesidadNinos/ Walk To School Day: www.walktoschoolusa.org Fruits and Veggies—More Matters: www.fruitsandveggiesmorematters.org Let’s Move: http://www.letsmove.gov/ HCPHES: www.hcphes.org 4. Wang Y, Beydoun M, Liang L, Caballero B, Kumanyika S. Will all Americans become overweight or obese? Estimating the progression and costs of the US obesity epidemic. Obesity. 2008;16:2323-2330. http://www.nature.com/oby/journal/v16/n10/abs/oby2008351a.html. Accessed January 15, 2012. 5. Clark PJ, O’Malley PM, Schulenberg JE, Johnston LD. Midllife health and socioeconomic consequences of persistent overweight across early adulthood: findings from a national survey of American adults (1986-2008). American Journal of Epidemiology. 2010;172:540-548. http:// aje.oxfordjournals.org/content/172/5/540.full. Accessed January 15, 2012. 43 Injury Risk Behaviors Overview Homicide Homicide ranks among the top five leading causes of death among people ages 1-44. In Harris County, homicide was the 12th leading cause of death in 2012 with 356 deaths—a rate of 8.1 per 100,000 persons.2 The Harris County Child Fatality Review Team (HCCFRT) identified 32 homicide victims under the age of 18 in 2012. Thirteen (41%) of the victims were under 12 months. Violent Crime High levels of violent crime impact physical safety and psychological well-being. The rate of violent crime in Harris County is evaluated by the County Health Rankings Project. Harris County’s annual rate was 779 crimes per 100,000 population, placing it among the six highest county rates in Texas.3 Suicide Suicide is the fifth leading cause of death in the U.S. among middle-aged adults (ages 35-64 years) making it a significant public health problem for this age group.4 Nationally, middle-aged adults account for the largest proportion of suicides (56%);4 from 1999-2010, the suicide rate among this group increased by nearly 30%.5 In Harris County, there were 431 suicides in 2012, translating to a rate of 10.6 per 100,000 persons. Middle-aged adults accounted for 56% 44 Number Number of Violent Crimes In Texas, the five most common categories of injuries resulting in hospitalizations include falls, motor vehicle/traffic accidents, struck by/against, cut/pierced, and other transportation injuries. Ninety percent of all hospitalizations due to injuries reported to the Texas EMS/Trauma Registry in 2013 were unintentional while 8% were the result of assault, and 1% was self-inflicted.1 Violent Crime in Houston-Sugar LandBaytown MSA 2008-2012 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 39,598 Rate per 100,000 900.0 41,409 37,104 688.3 706.8 33,444 34,535 800.0 700.0 620.7 550.8 561.5 600.0 500.0 400.0 300.0 Rate of Violent Crime per 100,000 According to the CDC, injuries are among the top ten leading causes of death among persons of all ages. More people ages 1-44 die from preventable injuries such as motor vehicle crashes, drowning, poisoning, homicide, and suicide than from any other cause. Many factors affect injury risk, such as failure to use safety belts, impaired driving, or domestic violence. 2008 2009 2010 2011 2012 Source: Federal Bureau of Investigation: Uniform Crime Reports of all suicides, and males accounted for 76% of suicides among middle-aged adults.1 Motor Vehicle Safety According to TDSHS, in 2012, motor vehicle accidents were the leading cause of all accidental deaths in Harris County with a rate of 9.7 per 100,000 population. In 2012, HCCFRT identified 31 deaths among children under 18 attributed to motor vehicle crashes. Family Violence Family or domestic violence is defined by the Texas Family Code as “an act by a member of a family or household against another member of the family or household that is intended to result in physical harm, bodily injury, assault or sexual assault or that is a threat that reasonably places the member in fear of imminent physical harm, bodily injury, assault or sexual assault.” The 77th Legislature amended the Family Code to include dating violence. In Texas, the largest percentage of family violence reports identified other family members as the perpetrators, followed by married spouses.2 The Texas Department of Public Safety reported 35,168 family violence incidents were recorded in Harris County in 2012. Local departments making the most arrests include:     Harris County Sheriff’s Office: 11,884 Houston Police Department: 20,185 Pasadena Police Department: 1,233 Baytown Police Department: 5812 1. Texas Department of State Health Services (TDSHS), Injury Center: Data and Statistics. Mechanism of injury 2013. http://www.dshs.state.tx.us/ injury/data/. Accessed August 13, 2014. 2. Texas Department of Public Safety (TDPS). The Texas crime report for 2012. http://www.txdps.state.tx.us/administration/crime_records/ pages/crimestatistics.htm#2009. Accessed August 12, 2014. 3. County Health Rankings. Harris County, Texas snapshot. http://www.countyhealthrankings.org/. Accessed December 5, 2014. 4. CDC (2014). Web-Based Injury Statistics Query and Reporting System (WISQARS). from US Department of Health and Human Services. 5. CDC (2013). "Suicide Among Adults Aged 35–64 Years — United States, 1999–2010." MMWR. 62(17): 321-325. 62(17): 321-325. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 were female, and in 3.1% the gender of the victim was undetermined.5 Gun Violence According to the Federal Bureau of Investigation (FBI), in 2011, firearms were used in 68% of murders, 41% of robbery offenses, and 21% of aggravated assaults in the United States.6 In Harris County, TDSHS 2012 records indicate that 70% of all homicides and 54% of all suicides were the result of the discharge of a firearm. The map below shows patient’s residential ZIP codes by percentage of gunshot-related emergency department visits in Houston/Harris County. Percentage of Gunshot-Related Emergency Department Visits by Residential ZIP Code in Houston/Harris County, September 2012-August 2014 A study conducted by the City of Houston on gunshot-related emergency room visits from September 2012 through August 2014 reveals that there were a total of 900 cases of firearm injuries, including self-inflicted gunshot wounds, non-fatal gunshot wounds, and gunshot-related deaths.7 In the 762 cases where the age of victim was known, 64.7% were between the age of 18 and 34. Among all 900 cases, 86.3% of the victims were male, 10.6% of the victims Age of Gunshot-Related Emergency Department Visits in Houston/Harris County, September 2012-August 20145 40% 35% 30.7% 34.0% 30% 25% 20% 15% 10% 13.0% 13.0% 8.1% 8.0% 5% 4.9% Source: Arnold RM, McNeely W, Muhetaer K, Yang B, Arafat RR. Application of syndromic surveillance to describe gunshot-related injuries in Houston. Online Journal of Public Health Informatics. 2015; 7(1). 0% <18 18-24 25-34 35-44 45-54 55-65 65+ Trends: Houston/Harris County 1997- 2012 Age-Adjusted* Death Rate in Harris County Rate per 100,000 Population 15.3 14.4 11.0 11.0 9.7 Arrests for Murder, Rape, Robbery, Aggravated Assault, Burglary, Larceny, Auto Theft 160,000 13.3 11.6 Crime in Houston/Harris County 10.5 9.3 9.7 146,526 129,228 140,000 10.6 8.1 120,000 80,000 60,000 2002 Motor Vehicle Crashes 2007 Suicide 2012 Homicide 59,967 63,342 20,000 * 0 2008 2009 Houston Police Dept. *Age adjusted to the 2000 standard population. Source: TDSHS Vital Statistics. 129,288 63,930 55,356 40,000 1997 137,814 135,538 100,000 2010 28,582 2011 2012 Harris County Sheriff's Office * 2011 Harris County Sheriff’s Office reported 6-month data. Source: Texas Dept. of Public Safety Crime Reports 6. Office of Justice Programs, National Institute of Justice. Gun violence. NIJ Web site. http://www.nij.gov/topics/crime/gun-violence/Pages/ welcome.aspx. Updated April 4, 2013. Accessed December 5, 2014. 7. Arnold RM, McNeely W, Muhetaer K, Yang B, Arafat RR. Application of syndromic surveillance to describe gunshot-related injuries in Houston. Online Journal of Public Health Informatics. 2015; 7(1). 45 Injury Risk/Submersion Population Differences Homicide rates vary widely among demographic groups in Harris County, occurring more frequently among males, both black and Hispanic. Of the 356 deaths due to homicides in 2012, 142 (40%) were black males and 100 (28%) were Hispanic males. The homicide rate in Harris County was 8.1 per 100,000. By race/ethnicity, the homicide rate for black males was 37.2, 10.3 for Hispanic males, and 6.8 for white males. Males more frequently died of homicide, at a rate of 13.4 compared to 2.8 for women. 1 In Harris County, suicides occur more frequently among white males. Of the 431 Harris County suicide cases in 2012, 209 (48%) occurred among white males, a rate of 29.3 per 100,000. In comparison, the suicide rate was 11.2 per 100,000 among black males and 9.4 per 100,000 among Hispanic males. Suicides among white females were also higher than women of other races, a rate of 9.1 per 100,000. There were too few suicides among black and Hispanic females to calculate their rates. 1 Death Rates in Harris County by Race for Motor Vehicle Accidents, Suicide and Homicide 30 25 20 15 10 5 0 White Black Hispanic 2008 2009 2010 2011 Homicide Suicide Motor Vehicles Homicide Suicide Motor Vehicles Homicide Suicide Motor Vehicles Homicide Suicide Motor Vehicles Homicide Suicide Motor Vehicles * 2012 *In 2008, there were too few suicides among blacks in Harris County to calculate a rate. Rate per 100,000 population, age adjusted to the 2000 Accidental Drowning/Submersion Submersion injuries consist of drowning and near drowning. A drowning is defined by the TDSHS as a death due to suffocation within 24 hours of submersion under water.2 A near drowning is classified as victim survival for at least 24 hours after submersion in water. According to the CDC, three children die each day in the U.S. as a result of drowning. In Harris County, drowning is the fifth leading cause of unintentional injury deaths for all ages and the second leading cause of injury deaths in children aged one to 14 years.1 Accidental drowning and submersion deaths are reported by the TDSHS. From 2008 to 2012, 283 accidental drowning and submersion deaths were reported in Harris County. Of the 283 deaths, whites accounted for 41% of deaths, followed by Hispanics (35%), blacks (15%), and those who identify as other (9%). In 2013, 452 drownings were reported in 46 Accidental Drowning/Submersion Deaths In Harris County by Race/Ethnicity, 2008-2012 80% 75% 70% 60% 50% 41% 35% 40% 25% 30% 15% 20% 9% 10% 0% Male Female White Black Hispanic Othe r Source: TDSHS, Vital Statistics Texas, 208 (46%) of which occurred in June and July. Out of the cases with a known outcome, 13.3% of pediatric drownings and 56.1% of adult drownings resulted in fatalities.3 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 The graph below indicates accidental drowning/ submersion deaths by age range in Harris County from 2008 to 2012. The greatest number of cases was among those ages 15-24 and the least number of cases was among those less than one year old. Number of Accidental Drowning/Submersion Deaths by Age Group in Harris County 2008-2012 85+ 75-84 65-74 55-64 45-54 35-44 25-34 15-24 5-14 1-4 <1 4 14 8 24 38 37 41 39 0 10 20 30 40 50 Death Rate from Unintentional Injuries per 100,000 Area National Baseline 2007 40.4 Target for 2020 36.0 Harris County 2012 36.9 State of Texas 2012 37.2 United States 2011 40.6 60  Monitor health problems through methods such as tracking emergency room visits.  Diagnose and investigate problems and hazards through programs such as the Harris County Child Fatality Review Team (HCCFRT), which evaluates child deaths and can refer cases to law enforcement or physician review as needed.  Inform people about injury risk behaviors by educating professionals and the public about suicide warning signs, the importance of using seatbelts, how to prevent falls and drownings, and other safety and public health prevention measures. Source: TDSHS, Vital Statistics Economic Impact of Injuries The burden of injury and violence in the United States totals to more than $406 billion annually in medical costs and lost productivity.4 States and localities absorb much of the expense of injuries by providing emergency care for uninsured, health and workers’ compensation benefits for employees, welfare services for children, and enforcement of state and local public safety laws. According to the National Safety Council, the estimated costs of motor vehicle accidents are $1,410,000 per death, $78,900 for a nonfatal disabling injury, and $8,900 for property damage crashes including non-disabling injuries. Estimations on the cost by injury are as follows:    Rate Public Health Actions 52 26 0 Healthy People 2020 Objective IVP-11: Reduce unintentional injury deaths $72,700 for an incapacitating injury $23,400 for a non-incapacitating evident injury, $13,200 for a possible injury. The estimated costs above are a measure of dollars spent and loss of income due to fatal and nonfatal unintentional injuries.5 For More Information CDC National Center for Injury Prevention & Control, for US injury/death statistics. See also the WISQUARS section for multiple reports: www.cdc.gov/injury/ index.html Texas Department of Family and Protective Services, Watch Kids Around Water: https://www.dfps.state.tx.us/ Relocation Essentials/Crime Reports: www.relocationessentials.com/aff/www/ tools/crime/crime.aspx 1. Texas Department of State Health Services (TDSHS). Vital statistics, Texas health data. TDSHS Web site. http://soupfin.tdh.state.tx.us/. Updated August 20, 2014. Accessed December 4, 2014. 2. Texas Department of State Health Services (TDSHS). Submersions occurring in swimming pools,1998. Texas Department of Health,1999 Epidemiology Annual Report.1999. 3. Kader, E. EMS/trauma registry: 2013 submersion report. Texas Department of State Health Services (TDSHS), Injury Epidemiology and Surveillance Branch. http://www.dshs.state.tx.us/injury/data/. Published August 2014. Accessed December 4, 2014. 4. Finkelstein EA, Corso PS, Miller TR, Associates. Incidence and Economic Burden of Injuries in the United States. New York: Oxford University Press; 2006. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2652974/, Accessed August 13, 2014. 5. National Safety Council. Estimating the costs of unintentiional injuries, 2012. http://www.nsc.org/NSCDocuments_Corporate/Estimating-the-Costsof-Unintentional-Injuries-2014.pdf. Published February 2014. Accessed August 13, 2014. 47 Child Abuse & Neglect Overview Child maltreatment is defined by the Centers for Disease Control and Prevention (CDC) as “any act or series of acts of commission [abuse] or omission [neglect] by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.” In 2013, there were 156 child abuse or neglect fatalities in Texas; 24 (15%) occurred in Harris County.3 Maltreatment impacts a child’s physical and psychological health throughout their lifetime. It disrupts proper brain development, which can lead to sleep disorders, attention deficit disorder, and hyper activity.1 In addition, abused children are more likely as adults to have eating disorders, depression, be obese, and have other chronic diseases. They also have an increased incidence of alcoholism, drug abuse, smoking, suicide attempts, and sexually transmitted diseases. 2 The CDC reports that one-in-four girls and one-in-six boys in the U.S. are sexually abused before the age of 18. In 2013, 13% of completed CPS investigations in Harris County were alleged victims of sexual abuse.3 Sex offenders may be jailed for this crime; however, once paroled, they may live in the local area. Trends: Houston/Harris County 2008-2013 Completed Alleged Child Abuse/Neglect Investigations Number of Children (Thousands) The number of alleged abuse or neglect victims assigned to Harris County Child Protective Services (CPS) exceeded 31,384 in 2013, the lowest since 2004. Of the 31,384 completed investigations in Harris County, 5,929 children were confirmed to be abused or neglected.3 Despite these high numbers, the rate of children in Harris County confirmed as having been abused or neglected is 5.0 per 1,000 children, compared to 9.3 in Texas.3 55 50 45 40 35 30 25 20 15 10 5 0 During 2013, 2,327 children 2008 2009 2010 2011 2012 2013 were placed in permanent living Neglectful Supervision Abandonment arrangements; 22.2% were Physical Neglect Medical Neglect returned to their families with Physical Abuse Refusal to Assume Responsibility court approval, 23.7% were Sexual Abuse Emotional/Verbal Abuse placed with relatives, and 44.3% Source: Harris County Child Protective Services, Annual Reports were placed in adoptive homes.3 In 2013, 1,010 adoptions were completed in Harris County and an additional 1,293 children were waiting to be adopted as of June 30, 2014.3 1. U.S. Department of Health and Human Services (USDHHS), Administration on Children, Youth, and Families (ACF). Child maltreatment 2003. Washington (DC): Government Printing Office; 2005. http://www.acf.hhs.gov/programs/cb/pubs/cm03/index.htm. Accessed March 1, 2012. 2. Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine.1998;14(4):245–58. http://www.ncbi.nlm.nih.gov/pubmed/9635069. Accessed March 1, 2012. 3. Harris County Protective Services for Children and Adults. Annual Report– 2013 Statistics and Funding Programs for 2014. http://www.hc-ps.org/ annual%20report%202014.pdf. Accessed January 1, 2015. 4. Gelles, Richard J., & Perlman, Staci. Estimated Annual Cost of Child Abuse and Neglect. Chicago IL: Prevent Child Abuse America. https:// www.preventchildabusenc.org/assets/preventchildabusenc/files/$cms$/100/1299.pdf. Published April 2012. Accessed August 15, 2014. 5. Burstain, J. Child Protective Services in Texas: buying what we want. Center for Public Policy Priorities Web site. http://library.cppp.org/ files/4/2012_01_CP_BudgetCPS.pdf. Published January 2012. Accessed August 15, 2014. 48 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Age Distribution of Children in Harris County Placed in Protective Custody Maltreatment of Children 100% 19% 80% 60% 40% 20% Objective IVP-38: Reduce nonfatal child maltreatment 17% 23% 19% 20% 18% 20% 20% 26% 25% 16% 16% 17% 18% 16% 16% 17% 17% National Baseline 2008 9.4 20% 19% 20% 21% Target for 2020 8.5 21% 22% 21% 21% Houston/Harris County 2013 5.0 27% 27% 25% 23% State of Texas 2013 9.3 United States 2012 9.2 Area 0% 2008 2009 2010 2011 2012 2013 Under 2 3 to 5 6 to 9 10 to 13 Population Differences Instances of child abuse are not specific to a victim’s age or gender. From 2008 to 2013, the age distribution of children placed in protective custody in Harris County has remained fairly stable. An equal distribution of males and females is noted for children in protective custody. Over the five year period, the ethnic proportion of children put into protective custody has remained relatively constant. Black children (50%) account for the greatest percentage of children in protective custody, followed by Hispanic children (29%), white children (15%), and other (6%). Race/Ethnicity of Children in Harris County Placed in Protective Custody 80% 60% 2% 2% 2% 2% 25% 25% 25% 25% 17% 16% 15% 15% 56% 57% 5% 6% 28% 29% 15% 15% 52% 50% 40% 57% 20% 58% 2009 2010 Black White Economic Impact of Child Abuse The estimated annual cost of child abuse and neglect in the United States was $80 billion in 2012. Direct costs ($33.3 billion) include medical treatment, mental health services, law enforcement, and child welfare costs. Indirect costs ($46.9 billion) include early intervention services, housing services, juvenile delinquency, and adult prosecution.4 In 2012, Texas budgeted $1.2 billion to pay for child abuse and neglect services.5 Of the $1.2 billion, 53% is spent on foster care, adoption, and permanency care assistance program payments and services. In Harris County, $141 million was spent by the federal, state, and local government on CPS in 2013.3 Public Health Actions  Assure quality accessible community-wide health and human services that support positive child rearing and development.  Educate to promote and encourage healthy behaviors that will foster positive development of Houston/Harris County children.  Mobilize partnerships to evaluate deaths and risks for children. For More Information 0% 2008 *Rate is reported cases per 1,000 children under 18 years 14 to 17 Source: Harris County Child Protective Services, Annual Reports 100% Rate* 2011 2012 2013 Hispanic Other Family and Protective Services: www.dfps.state.tx.us National Association of Counsel for Children: www.naccchildlaw.org Collaborative for Children: www.collabforchildren.org Source: Harris County Child Protective Services, Annual Reports 49 Alcohol & Drug Use Overview Alcohol Use Excessive alcohol consumption includes binge drinking, heavy drinking, and any drinking by a pregnant woman or people under the age of 21.1 Excessive alcohol use can lead to the development of alcohol dependency or alcoholism. Alcoholism is a diagnosable disease characterized by a strong craving for alcohol, continued use despite harm or personal injury, the inability to limit drinking, physical illness when drinking stops, and the need to increase the amount drunk in order to feel the effects. 2 The CDC reports that excessive alcohol use is the fourth leading cause of preventable death in the United States. Alcohol abuse results in 88,000 deaths each year and 2.5 million years of potential life lost, shortening lives by an average of 30 years. Linked to risk factors such as risky sexual behaviors, violence, drowning, and impaired driving, alcohol abuse is responsible for one-third of all traffic-related deaths. Over time, alcohol abuse can lead to the development of long-term health conditions including cirrhosis of the liver, heart disease, cancer, and depression. Illegal Drug Use From 2010-2012, an estimated 6.5% of those aged 12 and older in the substate region including Harris County used an illicit drug in the past month, which is lower than the Texas rate (7.1%) and national rate (8.9%). Of these same residents, 2.7% used an illicit drug other than marijuana in the past month and 4.0% used prescription-type nonmedical pain relievers, compared to the national rate of 4.6%. 3 Research suggests that 20-30% of the LGBT population abuse substances, compared to 9% of the general population. However, in 2008, less than 6% of facilities offered specialized substance abuse treatment for LGBT clients.4 Trends: Houston/Harris County 2002-2011 Arrests for Drug Offenses by Houston Police Department 25,000 20,000 Includes drug possession and sale-manufacturing 19,450 21,250 19,762 16,761 15,000 13,205 13,577 13,515 12,916 16,446 14,983 10,000 5,000 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 The chart to the left shows rising numbers of arrests for drug offenses in Houston from 2002 through 2008. In 2009, these numbers began to drop with 14,983 arrests in 2011, the lowest since 2006. BRFSS data showed that fewer residents in the Houston-Baytown-Sugar Land MSA (14.9%) reported binge drinking (having five or more drinks on one occasion for men and four or more drinks for women) in 2013, than in 2011 (19.1%). Source: Bureau of Justice Statistics Population Differences Heavy drinking, defined as more than two drinks per day for men and more than one drink per day for women, is more common among males (6.8%) than females (4.6%). Differences among racial and ethnic groups indicate that blacks had the highest rate (9.7%) of heavy drinking compared to whites (6.4%) and Hispanics (3.0%) in 2013; however, Hispanics have the highest rate (18.8%) of binge drinking compared to blacks (13.8%) and whites (12.5%). 50 Percent Adults Engaging in Heavy Drinking* Houston-Baytown-Sugar Land MSA White 9.7 7.3 Black Hispanic 9.7 8.4 2.0 5.6 6.4 3.0 1.3 2011 2012 2013 *Heavy drinking defined as > 2 drinks per day for men and > 1 drink for women in the past 30 days Source: TDSHS BRFSS 1. Centers for Disease Control and Prevention (CDC). Alcohol and public health: frequently asked questions. http://www.cdc.gov/alcohol/faqs.htm. Updated November 7, 2014. Accessed September 2,2014. 2. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders fourth edition (DSM-IV), Washington, DC, 1994. http://allpsych.com/disorders/dsm/. 3. Substance Abuse and Mental Health Services Administration (SAMHSA). 2010-2012 National Survey on Drug Use and Health: substate region estimates. http://archive.samhsa.gov/data/NSDUH/substate2k12/toc.aspx. Accessed September 3, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Geographic Distribution Past Month Illicit Drug Use of Persons Aged 12 or Older, by County Type: 2012 Percent Using in Past Month 10 9.9 Objective SA-12: Reduce drug-induced deaths. Rate of Drug-Induced Death per 100,000 9.2 8.3 Area 8 5.9 6 4.8 4 2 0 Large Metro Small Metro Nonmetro Nonmetro Nonmetro Urban Less Urban Rural Source: National Survey on Drug Use and Health, SAMHSA, 2012. Economic Impact of Alcohol & Drugs Every resident of the U.S. carries the economic burden of alcohol and drug use. The cost of excessive alcohol consumption in the U.S. was estimated at $223.5 billion in 2006, approximately $746 for each U.S. resident.5 The cost of drug abuse due to loss of productivity, health care costs, and criminal justice costs was estimated at $193 billion in 2007.6 The total economic cost of alcohol and drug abuse in Texas was $25.9 billion in 2000.7 Alcohol abuse alone accounted for $16.4 billion (63% of total cost), while drug abuse or dependency accounted for $9.5 billion (37% of total cost). The cost of alcohol and drug abuse in Texas translates to $1,244 per person in the state, exceeding the national average. During this time $127 million of state and federal funding was dedicated to prevention services.7 Research indicates that every dollar spent on substance abuse treatment saves $4 in healthcare costs and $7 in law enforcement and other criminal justice costs.8 Employer costs can be reduced by use of Employee Assistance Programs (EAP) that provide education, early intervention, and referral of employees with substance abuse problems and can save employers from $5 to $16 for every dollar invested.9 Rate National Baseline 2007 12.6 Target for 2020 11.3 Harris County 2010 11.1 State of Texas 2011 10.5 United States 2011 14.0 Public Health Actions  Educate persons served by public health, such as pregnant women, TB patients, the mentally ill, and those with HIV/AIDS about the health effects of substance abuse.  Inform the community about substance abuse concerns through health education presentations and publications.  Mobilize community partnerships to develop plans to support individual- and communitybased drug abuse treatment and prevention programs. In 2013, 14.9% of surveyed Houston MSA residents reported binge drinking, which is defined by five or more drinks on one occasion for males and four or more drinks for females. For More Information Texas Department of State Health Services: www.dshs.state.tx.us/MHSA/ Council on Alcohol and Drugs Houston: www.council-houston.org/ Alcoholics Anonymous: www.aahouston.org U.S. Drug Enforcement Administration: www.justice.gov/dea/index.shtml 4. Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies. Substance abuse treatment programs for gays and lesbians. http://www.samhsa.gov/data/spotlight/Spotlight004GayLesbians.pdf. Published June 2010, Accessed September 5, 2014. 5. Bourchery EE, Harwood HJ, Sacks JJ, Simon CJ. Economic costs of excessive alcohol consumption in the U.S [abstract]. American Journal of Preventive Medicine. 2011;41(5):516-524. http://www.ncbi.nlm.nih.gov/pubmed/22011424. Accessed December 15, 2011. 6. Office of National Drug Control Policy. How illicit drug use affects business and the economy. Whitehouse Web site. http://www.whitehouse.gov/ ondcp/ondcp-fact-sheets/how-illicit-drug-use-affects-business-and-the-economy. Accessed September 3, 2014. 7. Liu LY. Economic cost of alcohol and drug abuse in Texas: 2002 update. Texas Commission on Alcohol and Drug Abuse, DSHS Website. http:// www.dshs.state.tx.us/sa/.../economics/EconomicCostsDec2000.pdf. Accessed December 15, 2011. 8. Office of National Drug Control Policy. Cost benefit of investing early in substance abuse treatment. Whitehouse Web site. http:// www.whitehouse.gov/sites/default/files/ondcp/Fact_Sheets/investing_in_treatment_5-23-12.pdf. Published May 2012. Accessed September 3, 2014. 9. U.S. Department of Labor (USDL). What works: workplaces without drugs. USDL Web site. http://www.labor.ny.gov/workerprotection/safetyhealth/ PDFs/WSLP/Cost%20Benefit%20D%20and%20A%20prevent.pdf. Accessed December 15, 2011. 51 This page intentionally left blank Use of Preventive Services Clinical preventive services, such as routine disease screening and scheduled immunizations, are key to reducing death and disability and improving the Nation’s health. These services both prevent and detect illnesses and diseases—from flu to cancer—in their earlier, more treatable stages, significantly reducing the risk of illness, disability, early death, and medical care costs. Yet, despite the fact that these services are covered by Medicare, Medicaid, and many private insurance plans under the Affordable Care Act, millions of children, adolescents, and adults go without clinical preventive services that could protect them from developing a number of serious diseases or help them treat certain health conditions before they worsen. Healthy People 2020 53 Prenatal Care Overview The American College of Obstetrics and Gynecology recommends that all pregnant women receive prenatal care beginning in the first trimester. Prenatal care includes regular health check-ups, risk assessments, and education regarding nutrition and proper physical activity during pregnancy. Expectant mothers should also receive education about the birthing process and basic infant parenting skills. The National Institutes of Health (NIH) reports that adequate prenatal care is closely tied with the birth of healthy babies. Inadequate prenatal care has been linked to low birth weight, prematurity, and increased maternal and infant mortality. In Harris County, from 2009-2012, 41% of pregnant women began prenatal care after their first trimester. The Texas Pregnancy Risk Assessment Monitoring System (PRAMS) identified common reasons for not accessing timely prenatal care; the most common reasons included not having Medicaid or lack of money, the inability to get an appointment, and not knowing they were pregnant. These findings have remained consistent from 2007 through 2011. Trends: Houston/Harris County 2009-2012 In 2005, a new birth certificate was implemented in Texas to include data for monitoring the onset of prenatal care. Prenatal Care First Received for Births in Harris County 100% 5.8 9.5 4.0 8.8 4.4 7.6 4.1 8.2 31.2 31.5 29.8 29.1 53.5 55.6 58.2 58.5 80% The onset of prenatal care within the first trimester has increased statewide and locally. In 2012, 58.5% of births in Harris County received prenatal care within the first trimester, an increase from 53.5% in 2009. A similar trend was observed in Texas with 6.8% more births initiating prenatal care in the first trimester in 2012, compared to 2009. 60% 40% 20% 0% 2009 2010 1st Trimes ter 2nd Trimester 2011 2012 3rd Trimester None Source: TDSHS Population Differences The TDSHS 2012 reports indicate that in Harris County, 58.5% of all births received prenatal care within the first trimester. Racial and ethnic differences are noted in the percentage of women who receive prenatal care within the first trimester: 69.2% of white births, 52.6% of black births, and 54.5% of Hispanic births (shown in graph to the right). Differences are also noted in birth outcomes, with Hispanic women in Harris County giving birth to fewer babies with low birth weight (7.2%) in 2012, compared to babies born to black (14.4%) and white (7.4%) mothers. 54 Percentage of Births in Harris County that Received Prenatal Care in the 1st Trimester White 69.1 Black Hispanic 70.2 66.2 66.6 64.3 62.9 53.5 46.6 49.7 2009 46.6 Other 69.2 52.6 64.3 54.5 52.6 46.8 2010 2011 201 2 Source: TDSHS. This figure is not directly comparable to years before 2005 due to the implementation of a new birth certificate in Texas in 2005. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Healthy People 2020 Objective MICH 10.1: Increase the proportion of pregnant women who receive early and adequate prenatal care. 2011 Harris County Births with Prenatal Care (PNC) Beginning in the First Trimester Women Beginning Prenatal Care in the First Trimester of Pregnancy Area Percentage of 2011 births in Harris County in which the mother began prenatal care during the 1st trimester. Location is based on mother’s residence ZIP code. No ZIP code achieved the Healthy People 2020 goal of 77.9%. Source: Texas Department of State Health Services, Center for Health Statistics, October 2013. Map by June Hanke, Harris Health System. Family planning is also related to the use of prenatal care in that it prevents unintended pregnancy. A woman with an unwanted pregnancy is less likely to seek prenatal care and more likely to have a preterm birth or other complications. A 2014 Guttmacher Institute analysis on publicly funded family planning programs determined that every dollar invested yields savings of $7.09, resulting in a net government savings of $13.6 billion in 2010.3 National Baseline 2007 70.8 Target for 2020 77.9 Harris County 2012 58.5 State of Texas 2012 62.6 United States 2010 73.1 Public Health Actions  Provide prenatal care to low income women and link women to prenatal services in the community.  Educate women about prenatal health, caring for themselves and their infants after delivery, the importance of vaccinations, and the availability of Medicaid and CHIP resources.  Provide food vouchers for low-income pregnant women through the WIC Nutrition Program.  Promote contraception to prevent unwanted pregnancies.  Support policies to ensure accessible prenatal care for all women. Economic Impact of Prenatal Care Inadequate prenatal care has been linked to multiple health concerns for mother and child, particularly preterm birth. Premature births account for one in eight births in the United States and can lead to long-term health problems and lifelong disabilities. In the U.S., costs for preterm births were estimated at $26.2 billion, or roughly $51,600 per preterm infant in 2007.1 Additional medical costs continue throughout the first year of a preterm infant’s life at an average of $54,149. In contrast, medical care for a newborn without complications costs $4,389 during his or her first year of life.2 Percent For More Information Medline Plus: www.nlm.nih.gov/medlineplus/ prenatalcare.html March of Dimes: www.marchofdimes.com The National Women’s Health Information Center: http://womenshealth.gov/ publications/our-publications/fact-sheet/ prenatal-care.html?from=AtoZ U.S. Dept. of Health and Human Services, Office on Women’s Health: www.womenshealth.gov 1. Behrman RE, Butler AS. Preterm birth: causes, consequences, and prevention. Washington: Institute of Medicine; National Academies Press (US); 2007. http://www.ncbi.nlm.nih.gov/pubmed/20669423. Accessed September 21, 2014 2. March of Dimes Foundation. The cost of prematurity to U.S. employers. http://www.marchofdimes.org/materials/premature-birth-the-financialimpact-on-business.pdf. Published December 2013. Accessed September 21, 2014 3. Frost JJ, Sonfield A, Zolna MR, Finer LB. Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program. Guttmacher Institute. The Milbank Quarterly. 2014;92(4):667-720. http://www.guttmacher.org/pubs/journals/MQFrost_1468-0009.12080.pdf. Accessed January 1, 2015. 55 Immunizations Overview Immunizations, one of the greatest public health achievements, has lead to the control of once common diseases such as polio, measles, mumps, pertussis, and tetanus. Immunizations protect those inoculated against the disease as well as those who did not receive the immunization by reducing the spread of infection. The Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP) recommend following the schedule for childhood vaccinations. Currently, children from birth to six years of age receive vaccines inoculating against 14 diseases. Most vaccines require numerous doses at different ages, which are offered at child wellness visits by the child’s medical provider. Additional vaccinations are recommended for adolescents and adults. For example, the CDC recommends that adolescents receive the HPV vaccination series at age 11 or 12, and adults over the age of 65 receive one-time vaccinations against herpes zoster and pneumococcal pneumonia. Also, annual influenza (flu) vaccinations are recommended for everyone over the age of six months. Influenza and pneumonia remain deadly diseases, particularly for the elderly. Vital statistics indicate that influenza/pneumonia rank as the eleventh leading cause of death in Harris County. Trends: Houston/Harris County 1999-2013 As of 2013, the CDC’s National Immunization Survey (NIS) indicated that 82.4% of Houston infants received the recommended vaccinations (series 4:3:1:3:3:1), compared to 74.2% of Texas infants and 76.0% of U.S. infants. This series of vaccinations controls for many of the most deadly childhood diseases including diphtheria, teta- 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% nus, pertussis, polio, measles, mumps, rubella, Hib (Haemophilus influenzae type b) disease, hepatitis B, and chicken pox. In 2013, the NIS indicated that 58.0% of female adolescents aged 13-17 in the City of Houston had completed the HPV 3-dose series, lower compared to state (68.6%) and national (69.8%) percentages. Percentage of Vaccinated Children 19-35 Months For adults aged City of Houston 65 and older, Texas 2013 BRFSS reported that 60.7% of sen4:3:1:3:3 iors in the HoustonBaytown-Sugar Land 4:3:1:3:3:1 MSA had received the 4:3:1:3:3:1:4 influenza vaccination in the past year and 60.8% had been vaccinated against pneumonia. In Texas, 61.0% had received an influenza shot in the past year (62.8% nationwide) and 67.9% had been vaccinated against pneumonia (69.5% nation1999 2000 2001 2 002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 wide). The 4:3:1:3:3 series of vaccines includes the following: four or more doses of DTaP (dipththeria, tetanus, pertussis), three or more doses of poliovirus vaccine, one dose of measles, containing vaccine such as MMR (measles, mumps, rubella), three or more doses of Hib (Haemophilus Influenzae), and three or more doses of Hep B (Hepatitis B). The 4:3:1:3:3:1 series adds the chicken pox vaccine and was recommended after 2002. The 4:3:1:3:3:1:4 series adds four doses of the pneumococcal conjugate vaccine (PCV7) and was recommended after 2008. Source: CDC National Immunization Survey Note: Varicella was added in 2002, Pneumococcal conjugate vaccine (PCV7) was recommended after 2008. 56 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Population Differences Many people still do not have adequate immunizations, particularly children and adults in the lowest socioeconomic levels. BRFSS 2013 data show that of adults 18-64 in the Houston-Baytown-Sugar Land MSA, females were more likely to have gotten the influenza vaccine in the past year (33.1%) compared than males (24.3%). Of these same adults, racial/ethnic differences are minimal, with Hispanics least likely (25.2%) to get vaccinated against influenza compared to whites (29.8%) and blacks (28.1%). Objective IID-8: Increase the proportion of children aged 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella and PCV vaccine. Children Aged 19-35 Months Who Received the Recommended Vaccines* Area Percent National Baseline 2009 44.3 Economic Impact of Immunizations Target for 2020 80.0 Vaccines protect not only individuals but entire communities, resulting in great economic benefits for society. Routine childhood immunization prevents approximately 42,000 early deaths and 20 million cases of disease, resulting in net savings of $13.5 billion in direct costs and $68 billion in societal costs.1 City of Houston 2013 82.4 State of Texas 2013 74.2 United States 2013 76.0 A pH1N1 vaccination study during the 2009 influenza pandemic estimated cost savings of pH1N1 vaccinations prior to the outbreak for persons 6 months to 64 years under various assumptions.2 For those without high risk conditions, incremental cost-effectiveness ranged from $8,000 to $52,000 per qualityadjusted life-year depending on age and risk status. For children and working-age adults, pH1N1 pre-exposure vaccinations are costeffective compared to other preventive health interventions.2 The table below illustrates the cost-benefit analysis of commonly used vaccines. *4DTaP, 3 Polio, 1MMR, 3Hib, 3 HepB, 1Varicella (Series 4:3:1:3:3:1) Public Health Actions  Mobilize partnerships such as the Vaccines for Children (VFC) program through which 500 private and public providers have given free immunizations to low-income children in Houston and Harris County.  Provide education to the public through outreach programs to promote vaccination.  Provide care where otherwise unavailable through provision of immunizations to lowincome mothers and children. For More Information CDC National Immunization Program: www.cdc.gov/vaccines For Every $1 Spent: DTaP saves $27.00 MMR saves $26.00 Texas Department of Health Immunization Branch: www.dshs.state.tx.us/immunize Perinatal Hep B saves $14.70 PKIDS: www.pkids.org Varicella saves $2.73 Inactivated Polio (IPV) saves $5.45 Source: Every Child by Two website. http://www.ecbt.org/ index.php/facts_and_issues/article/economic_benefits HDHHS Immunization Bureau: www.houstontx.gov/health/Immunizations/ Vaccines for Children Program: http:// www.cdc.gov/vaccines/programs/vfc/ index.html 1. Zhou F et al. Economic evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics. 2014; 133(4): 577-585. http://pediatrics.aappublications.org/content/133/4/577.short. Accessed September 5, 2014. 2. Prosser LA, Lavelle TA, Fiore AE, Bridges CB, Reed C, Jain S, Dunham KM, Meltzer MI. Cost-effectiveness of 2009 pandemic influenza A(H1N1) vaccination in the United States [abstract]. PLoS ONE 2011; 6(7): e22308. doi:10.1371/journal.pone.0022308: http://www.ncbi.nlm.nih.gov/ pubmed/21829456. Accessed December 18, 2011. 57 Cancer Screening Overview The use of screening tests to detect cancers during early stages allow for more effective treatment with fewer side effects and an increased chance of survival. Although not all cancers have screening tests, cervical, colorectal, and breast cancer screenings detect cancers early, allowing for lifesaving or lifeextending treatment. The National Cancer Institute (NCI) reports on cancer prevention, screening, testing, and treatment. The NCI indicates that fecal occult blood tests (FOBT) reduce deaths from colorectal cancer by 15-33% and regular mammograms decrease the chance of mortality for women aged 40-74 from breast cancer by 15-20%. In addition, Pap smear screening has shown to decrease cervical cancer incidence and mortality by at least 80%. Trends: Houston/Harris County 2006-2012 Percent Women Aged 40 and Older Had a Mammogram in the Past Two Years Houston MSA 80% 77% 75% 67% 71% 76% 73% Texas 71% 70% U.S 75% 69% 68% 74% 60% In 2012, 15.0% of adults aged 50 and over in the Houston MSA reported a fecal occult blood test in the past two years, compared to Texas (13.0%) and U.S. (14.2%) percentages. 40% 20% 0% 2006 2008 2010 2012 Source: TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. Population Differences The uninsured and racial/ethnic minorities are more likely to be diagnosed with cancer at a later stage leading to more extensive and more costly treatment with poorer health outcomes.1 TDSHS 2012 BRFSS data for the Houston MSA indicate that income and education levels are related to whether women get mammograms and pap smears. Among women with incomes of $50,000 or more, 88.7% reported a pap smear in the past three years compared to 72.1% of those with incomes of $25,000 or less. Among college graduates, 78.2% reported a mammogram in the past two years compared to 70.8% of those with a high school diploma. In the Houston MSA, minimal differences are noted between men and women who reported having had a fecal occult blood test in the past two years. In 2012, 14.4% of females and 15.8% of males age 50 and over reported having the test. In Texas, men and women are just as likely to report having the test (13.0%). 58 CDC 2012 BRFSS data indicate that 77.0% of women aged 18 and older in the HoustonBaytown-Sugar Land MSA (Houston MSA) had received a Pap smear test within the past three years, compared to state (74.6%) and national (78.0%) percentages. In 2012, 65.9% of adults aged 50 and over in the Houston MSA reported ever having had a sigmoidoscopy or colonoscopy, compared to 62.6% in Texas and 67.3% in the U.S. Had a Mammogram Within Two Years Had a Pap Smear Within Three Years Houston-Baytown-Sugar Land MSA 2012 Mammogram 82% Pap Smear 77% 70% 74% 63% * White Blac k Hispanic Source: TDSHS BRFSS People can take control of their health and cancer risk by staying away from tobacco, maintaining a healthy weight, getting regular physical activity, eating plenty of fruits and vegetables, limiting alcohol consumption, protecting their skin, getting regular checkups and screenings, and knowing their risk. —The American Cancer Society T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Economic Impact of Early Cancer Detection The cost of cancer in the U.S. in 2009 was estimated at $216.6 billion: $86.6 billion for direct medical costs and $130.0 billion for indirect mortality costs.1 In Texas alone, costs were estimated at $30.4 billion in 2013; this estimation includes direct medical costs and morbidity and mortality losses.2 Early detection and treatment not only improve health outcomes, but also reduce treatment expenses, morbidity and mortality. For every dollar spent on screening and prevention by the Cancer Prevention & Research Institute of Texas, more than seven dollars were saved in treatment costs.2 The economic impact of cancer screening can be evaluated in terms of cost effectiveness per life-year saved, an evaluative technique which divides the cost of a procedure or medication by life-year extended. Any value less than $50,000 is usually considered costeffective. Estimated costs per year of life saved are:  Colorectal cancer screening (annual guaiac FOBT): cost saving– $56,3003  Breast cancer screening (mammography): $37,0004  Cervical cancer screening: $34,500-56,4005 The U.S. Preventive Services Task Force recommends that adults receive regular screening for certain cancers: Breast cancer: Women aged 50-74 should receive mammography screening every two years. Cervical cancer: All women aged 21-65 should initiate screening for cervical cancer with Pap smear by age 21 and receive continued screening every three years. Colon cancer: Clinicians should screen adults aged 50–75 for colon cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy. Healthy People 2020 Objective C-17: Increase the proportion of women who receive a breast cancer screening based on the most recent guidelines. Women Who had a Mammogram in the Last Two Years, Aged 50-74 Area Percent National Baseline 2008 73.7 Target for 2020 81.1 Houston MSA 2012 69.0* Texas 2012 68.4* United States 2012 74.0* *Adults ages 40 and older. Public Health Actions  Inform, educate, and empower people about the importance of early cancer detection through screening tests.  Link people to needed personal health services through referrals for cancer screening.  Assure the provision of health care when otherwise unavailable by providing cancer screening for low income persons.  Mobilize partnerships with public health organizations, universities, medical centers, and other groups to monitor cancer rates and research causes of racial disparities. For More Information National Cancer Institute: www.cancer.gov CDC Division of Cancer Prevention and Control: www.cdc.gov/cancer/ American Cancer Society: www.cancer.org Texas Cancer Registry, for cancer information and statistical data: www.dshs.state.tx.us/tcr/default.shtm State Cancer Profiles: www.statecancerprofiles.cancer.gov 1. American Cancer Society. Cancer facts & figures 2014. American Cancer Society Web site. http://www.cancer.org/acs/groups/content/ @research/documents/webcontent/acspc-042151.pdf. Accessed September 8, 2014. 2. The Perryman Group. An economic assessment of the cost of cancer in Texas and the benefits of the Cancer Prevention and Research Institute of Texas (CPRIT) and its programs: 2013 update. http://www.cprit.state.tx.us/images/uploads/rp_cprit_impact_2013.pdf. Published December 2013. Accessed September 22, 2014. 3. Vogelaar IL, Knudsen AB, Brenner H. Cost-effectiveness of colorectal cancer screening. Epiemiol Rev. 2011;33:88-100. http:// epirev.oxfordjournals.org/content/33/1/88.full.pdf+html. Accessed September 9, 2014. 4. Stout NK, Rosenberg MA, Trentham-Dietz A, Smith MA, Robinson SM, Fryback DG. Retrospective cost-effectiveness analysis of screening mammography. J Nat Cancer I. 2006;98(11):774-782. http://jnci.oxfordjournals.org/content/98/11/774.full.pdf+html. Accessed October 6, 2014. 5. Goldie SJ, Kim JJ, Myers E. Chapter 19: Cost-effectiveness of cervical cancer screening. Vaccine. 2006;24S3:S3/164-S3/170. http:// www.hu.ufsc.br/projeto_hpv/CAP%2019%20-%20CUSTO%20EFICACIA%20SCREENING.pdf. Accessed October 6, 2014. 59 Oral Health Overview Oral health is essential for overall health and well-being. The American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) recommend scheduling a child’s first dental visit when the first tooth appears but no later than his or her first birthday. Adults and children are recommended to regularly visit the dentist, twice a year for children and once or twice a year for adults, since many common oral diseases are preventable. The most common oral diseases are dental caries (tooth decay) and periodontitis (advanced gum disease affecting the surrounding bone of the teeth). Tooth decay affects more than one-fourth of children aged 2-5 and half of those aged 12-19 while advanced gum disease affects 4-12% of adults in the United States.1 Both conditions are preventable and treatable, but if left untreated can lead to pain, infection, and partial or complete tooth loss. Chronic oral infections and periodontal disease have been linked to other health conditions such as diabetes, heart disease, stroke, lung disease, and low birth weight and prematurity among infants.1 High rates of untreated oral health problems are the consequence of poor oral health access. Currently, 19.3% of Texas residents live in dental Health Professional Shortage Areas. 2 Trends: Houston/Harris County 2008-2012 Adults Who Visited a Dentist/Dental Clinic Within the Past Year Houston MSA 75% 70% 65% Texa s 71.3% U.S. 69.7% 67.2% 65.9% 64.5% 62.6% 61.7% 60.4% 58.8% 60% 55% 2008 2010 In 2012, 60.4% of adults in the HoustonBaytown-Sugar Land MSA reported visiting a dentist or dental clinic in the past year, compared to 58.8% of Texas adults and 67.2% of U.S. adults. In 2010, BRFSS data indicated that 10.1% of adults 65 and older In the Houston MSA had all of their natural teeth extracted, which is fewer than those 65 and older in Texas (14.1%) and the U.S. (17.0%). 2012 Source: CDC, TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. Adults in Houston-Baytown-Sugar Land MSA Who Visited Dentist/Dental Clinic Within the Past Year, 2012 80% Houston MSA Texas 68.8% 66.3 % 60% 50.3% 54.2% 52.9% 48.8% 40% 20% 0% White Source: TDSHS BRFSS 60 Black Hispanic Population Differences BFRSS indicates that 60.4% of adults residing in the Houston MSA visited a dental professional in 2012. Of this group, whites were more likely to see a dentist within the past year, at 68.8%, compared to Hispanics (52.9%) and blacks (50.3%). A similar difference is noted in Texas. In addition, individuals with higher education and greater income had higher percentages of dental visits. Individuals with a high school diploma were less likely (54.7%) to have gone to the dentist within the past year compared to college graduates (79.8%). Among individuals with an income of $25,000 or less, 40.4% visited the dentist within the past year compared to 77.3% of those with an income of $50,000 or greater. 1. Centers for Disease Control and Prevention (CDC), Oral Health. Preventing cavities, gum disease, tooth loss, and oral cancers at a glance 2011. CDC Web site. http://www.cdc.gov/chronicdisease/resources/publications/AAG/doh.htm. Updated July 29, 2011. Accessed September 10, 2014. 2. Henry J. Kaiser Family Foundation. Oral health in the U.S.: key facts. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8324.pdf. Published June 2012. Accessed September 10, 2014. 3. Task Force on Community Preventive Services. Guide to community preventive services: oral health. http://www.thecommunityguide.org/oral/ fluoridation.html. Accessed March 1, 2012. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Fluoridation Fluoridation of community drinking water systems is considered an effective and inexpensive method to reduce tooth decay. Studies of tooth decay in children before and after community water fluoridation show a median decrease in tooth decay of almost 30% after fluoridation.3 The annual cost per capita to fluoridate community water ranges from $0.40 to $2.50.3 Objective OH-7: Increase the proportion of children, adolescents, and adults who used the oral health care system in the past 12 months. Despite the evidence on the effectiveness of fluoridated drinking water, nearly half of the states do not meet federal targets.2 In 2014, HCPHES reported that over 227,800 persons in Harris County, or approximately 5% of the total population, are served by residential drinking water systems that did not meet the minimum level of fluoridation to benefit oral health. National Baseline 2007 44.5 Target for 2020 49.0 Houston MSA 2012 60.4* State of Texas 2012 58.8* United States 2012 67.2* Oral health is impacted by tobacco use, alcohol use, dietary choices, access to health services, and health insurance. — CDC Economic Impact of Dental Care The socioeconomic impact of oral health is extensive, particularly in vulnerable populations such as children. Each year children miss more than 51 million school hours due to dentalrelated illnesses. Over a lifespan, oral diseases often become complex, resulting in a loss of more than 164 million hours of work each year by employed adults due to dental illness and office visits.4 Preventive care such as fluoridation, early check-ups, and sealants are cost-effective, some even result in cost savings. Every dollar invested in water fluoridation is estimated to yield approximately $38 of savings in dental treatment costs.5 Children who had their first dental visit by age one have average dental costs that are 40% lower over a five year period than children who had not seen a dentist within the first year.6 Children receiving sealants in school-based programs have 60% fewer new decays in the pit and fissure surfaces of back teeth. These school-based programs are cost-saving when delivered to high -risk populations.7 Dental Visit in the Previous Year Aged 2 and Older Area Percent *Ages 18 and older. Public Health Actions  Provide education to the community about the importance of nutrition and drinking fluoridated water to promote good oral health.  Promote routine dental care and oral hygiene and provide dental care when otherwise unavailable for low income pregnant women and children.  Mobilize partnerships to improve access to dental health services and ensure fluoridation of water. For More Information American Dental Association: www.ada.org Texas Dental Association: www.tda.org Greater Houston Dental Society: www.ghds.org Texas Oral Health Coalition: www.txohc.org HCPHES: www.hcphes.org Surgeon General’s Report on Oral Health: www.surgeongeneral.gov 4. National Institute of Dental and Craniofacial Research, Data & Statistics. Oral health in America: a report of the surgeon general. NIDCR Website. http://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/executivesummary.htm. Accessed December 30, 2011. 5. Centers for Disease Control and Prevention (CDC), Oral Health. Cost savings of community water fluoridation. CDC Website. http://www.cdc.gov/ fluoridation/fact_sheets/cost.htm. Updated July 2010. Accessed September 10, 2014. 6. Savage MF, Lee JY, Kotch JB, Vann WF. Early preventive dental visits: effects on subsequent utilization and costs. Pediatrics.2004;4:418-423. http://pediatrics.aappublications.org/content/114/4/e418.full. Accessed December 30, 2011. 7. Centers for Disease Control and Prevention (CDC), Oral Health. Preventing dental caries with community programs. CDC Website. http:// www.cdc.gov/fluoridation/fact_sheets/cost.htm. Updated July 2013. Accessed September 10, 2014. 61 Vision/Vision Screening Overview Healthy vision is important for communication, learning, work, play, and interacting with others. Blindness or vision impairment is among the top ten disabilities among adults 18 years and older and affects 1-5% of preschool children.1,2 Vision loss has serious implications for the individual as well as those who care for them as it hinders their ability to read, drive, perform daily tasks, and attend personal affairs. The U.S. Preventative Services Task Force recommends an initial comprehensive eye exam between ages three and five. Early detection of childhood vision disorders increases the likelihood of effective treatment; however, less than 15% of preschool children receive an eye exam and less than 22% receive vision screening.2 Vision impairment at a young age can affect school performance and reduce the quality of life. In Texas, children enrolled in a licensed child care center, a licensed child care home, or school program are required to have vision and hearing screening at age four or kindergarten and again in 1st, 3rd, 5th, and 7th grade. As a result, approximately 2,600,000 children are screened in Texas annually for vision impairments.3 In Harris County, the 20 Independent School Districts (ISDs) provide the required vision screenings. During the 2013-2014 school year, 433,073 students were screened at 19 of the 20 ISDs; 8.9% were referred for further evaluation and/or glasses. Over half of these children received follow-up exams; however, 17,536 (45.5% of those referred) remained untreated.4 Trends: Texas 2011-2013 Vision Difficulty in Harris County 2011-2013 <5 5-17 18-64 83 ,144 46,860 53,090 26,820 7,472 1,992 2011 65+ Total 91,003 84,736 49,879 27,893 26,263 9,147 2,503 2012 5,697 1,267 2013 The CDC Vision Health Initiative reports that vision impairments in people younger than age 40 are mainly caused by refractive errors and accidental eye injuries. Refractive errors affect 25% of children and adolescents and can often be corrected with prescription eyewear. Vision impairment is monitored by the U.S. Census American Community Survey (results profiled in the chart to the left). The survey asks if the respondent is blind or has serious difficulty seeing, even when wearing glasses.5 This number is a small percentage of the total population compared to those who have vision problems corrected by eyeglasses. Source: US Census Bureau, American Community Survey Population Differences Among adults who reported a vision impairment in the Houston-Baytown-Sugar Land MSA, those with lower incomes had a higher prevalence of vision impairment: 30.5% of those with an income of less than $25,000, 16.0% with an income of $25,000-$49,000, and 12.2% with an income of $50,000 or more. The overall percentage of those with vision impairment the Houston MSA was 18.5%, compared to 17.9% in Texas and 15.2% in the U.S. Houston MSA Adults with Vision Impairment, 2012 24% 23% 19% 18% 14% White Black Hispanic Male Female Source: TDSHS BRFSS survey 62 1. Centers for Disease Control and Prevention (CDC). Vision Health Initiative (VHI). CDC Web site. http://www.cdc.gov/visionhealth/index.htm. Updated June 2014. Accessed September 12, 2014. 2. U.S. Preventive Service Task Force (USPSTF). Screening: visual impairment in children. Screening for visual impairments in children ages 1-5 years. USPSTF Website. http://www.uspreventiveservicestaskforce.org/uspstf11/vischildren/vischildart.htm. Accessed September 12, 2014. 3. Texas Department of State Health Services. Vision and hearing screening. http://www.dshs.state.tx.us/vhs/default.shtm. Accessed Sept. 13, 2014. 4. Texas Department of State Health Services, Vision, Hearing and Spinal Screening Program. Data provided by request. 5. U.S. Census Bureau. American Community Survey. http://www.census.gov/acs/www/methodology/questionnaire_archive/. Accessed Sept.13, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Healthy People 2020 Objective V-1: Increase the proportion of preschool children aged 5 and under who receive vision screening Prevalence of Vision Impairment & Blindness Persons Age 40 and Older, 2007 Percent of Preschool Children Aged 5 and Under Who Received Vision Screening Area Percent National Baseline 2008 40.1 Target for 2020 44.1 Harris County 2013-2014 14.5* State of Texas 2013-2014 13.5** United States 2008 Source: TDSHS Economic Impact of Vision Loss Vision loss and eye disorders lead to extensive costs in medical care, lost productivity, and longterm care. The chart below illustrates the economic burden in the United States, totaling $139 billion. Of the total cost, $10 billion is spent in Texas; $4.9 billion in direct costs and $5.1 billion in indirect costs.7 Studies have linked untreated vision problems to low literacy and educational attainment, lower labor productivity, and increased criminality.8 Vision problems are often overlooked as a contributing factor in drop-out rates, juvenile delinquency, and adult criminality. For instance, previously undetected vision problems were found in up to 74% of adjudicated adolescents.8 40.1 *The TDSHS Vision, Hearing and Spinal Screening Program reported that 49,393 Pre-K children were screened in the 2013-2014 school year in Harris County, compared to the 2013 under 5 population of 340,938 in Harris County. **During the 2013-2014 school year, 260,110 Pre-K children in Texas received vision screening that was reported to TDSHS, compared to the total under 5 population of 1,926,498 in Texas. Public Health Actions  Monitor vision health and public compliance with vision screening and visual disorders.  Develop partnerships that can provide a vision screening safety net for low income children.  Inform, educate, and empower people about vision screening through publications, trainings, and other media.  Link people to needed personal health services through vision referrals. Vision is also linked to school performance and childhood development. In the U.S., 66% to 74% of adults with literacy problems fail vision screening tests. Better vision leads to a more literate and productive workforce. A 1% rise in literacy scores has been estimated to result in a 2.5% relative rise in labor productivity and a 1.5% increase in gross domestic product per person. Centers for Disease Control: www.cdc.gov/visionhealth/index.htm Economic Impact of Vision Loss and Eye Disorders in the U.S. Totaling to $139 Billion6 National Eye Health Education Program: www.nei.nih.gov For More Information TX Department of State Health Services: www.dshs.state.tx.us/vhs/vision.shtm Prevent Blindness: www.preventblindness.org 6. Wittenborn, John S. & Rein, David B. Cost of vision problems: the economic burden of vision loss and eye disorders in the United States. NORC at the University of Chicago. Prepared for Prevent Blindness America, Chicago, IL.. 2013. http:// costofvision.preventblindness.org. Accessed September 15, 2014. 7. Prevent Blindness. Economic burden of eye disorders and vision loss by state. Prevent Blindness Web site. http:// costofvision.preventblindness.org/map. Accessed September 15, 2014. 8. Zaba JN. Children’s vision care in the 21st century and its impact on education, literacy, social issues, and the workplace: a call to action. J Behav Optom. 2011;22(2):39-41. http://oepf.org/jbo/ journals/22-2%20Zaba.pdf. Accessed September 18, 2014. 63 This page intentionally left blank Environmental Health Indicators Environmental Health consists of preventing or controlling disease, injury and disability related to interactions between people and their environment. Poor environmental quality is estimated to be directly responsible for approximately 25% of all preventable ill health in the world, with diarrheal diseases and respiratory infections heading the list. Because the effect of the environment on human health is so great, protecting the environment has been a mainstay of public health practice since 1878. National, Tribal, State, and local efforts to ensure clean air and safe supplies of food and water, to manage sewage and municipal wastes, and to control or eliminate vector-borne illnesses have contributed significantly to improvements in public health in the United States. 65 Air Quality Overview How Big is Particle Pollution? The Clean Air Act of 1970, with revisions in 1977 and 1990, required the Environmental Protection Agency (EPA) to establish National Ambient Air Quality Standards (NAAQS) to provide protection to public health and public welfare. Standards were identified for six criteria pollutants: carbon monoxide, lead, nitrogen dioxide, ozone, fine particulate matter, and sulfur dioxide.1 Of these six pollutants, two are of most concern in the Houston area: ozone (O3) and fine particulate matter (PM2.5). Human Hair Approx. 70 ave. micrometers PM2.5 Fine particles Less than 2.5 micrometers PM10 Inhaleable course particles 2.5-10 micrometers Ozone at ground level is formed by man-made pollutants such as motor vehicle exhaust, industrial emissions, gasoline vapors, and chemical solvents, as well as by natural compounds that react in the Fine Beach Sand 90 micrometers presence of sunlight. Exposure to ozone can irritate the respiratory system, causing difficulty breathing, or Image courtesy of EPA, Office of Research and Development aggravate respiratory conditions such as asthma, emphysema, and bronchitis. Air quality experts also believe that repeated exposure to ozone can cause permanent lung damage.1 The EPA is proposing to revise the 2008 NAAQS for ozone from 0.075 parts per million (ppm) to a level within the range of 0.065 to 0.070 ppm.2 According to preliminary data from January 1, 2012 to November 17, 2014, the Houston-Galveston-Brazoria (HGB) area does not meet the 2008 standard for ozone and would not meet the proposed standard.3 Fine Particulate Matter (PM 2.5) is a mixture of airborne, microscopic solid particles and/or liquid droplets of 2.5 microns or less in diameter. PM2.5 consists of acids, organic chemicals, metals, dust particles, and allergens. Short-term exposure can aggravate lung disease and increase the risk of heart attacks and arrhythmias for people with heart disease. Long-term exposure to PM2.5 is associated with reduced lung function, development of bronchitis, and premature death.1 In the HGB area, particulate levels have been decreasing; all five regulatory periodic PM2.5 monitors met the NAAQS for fine particulate matter in 2012-2014 (shown in figure to the right).4,6 66 Source: HDHHS Bureau of Pollution Control and Prevention with data from EPA and TCEQ 1. Environmental Protection Agency (EPA). National Ambient Air Quality Standards (NAAQS). EPA Web site. http://www.epa.gov/ttn/naaqs/. Updated November 21, 2013. Accessed November 29, 2014. 2. Environmental Protection Agency (EPA). EPA’s proposal to update the air quality standards for ground-level ozone. EPA Web site. http:// www.epa.gov/glo/actions.html#nov2014. Accessed November 29, 2014. 3. Texas Commission on Environmental Quality (TCEQ). Compliance with eight-hour ozone standard. TCEQ Web site. http://tceq.net/cgi-bin/ compliance/monops/8hr_attainment.pl. Updated November 17, 2014. Accessed November 29, 2014. 4. Texas Commission on Environmental Quality (TCEQ). Data by year by site by parameter. TCEQ Web site. https://www.tceq.texas.gov/cgi-bin/ compliance/monops/yearly_summary.pl. Updated November 19, 2014. Accessed November 29, 2014. 5. Mayor’s Office of Environmental Programming, City of Houston, TX. Reports are available at the Green Houston Web site, http:// www.greenhoustontx.gov/reports.html. Accessed December 30, 2011. 6. Environmental Protection Agency (EPA). Design value report. http://www.epa.gov/airtrends/values.html. Updated November 17, 2014. Accessed November 29, 2014. 7. American Lung Association, State of the Air 2014. People at risk. American Lung Association Web site. http://www.stateoftheair.org/2014/keyfindings/people-at-risk.html. Accessed December 10, 2014. 8. American Lung Association, State of the Air 2014. Harris County. American Lung Association Web site. http://www.stateoftheair.org/2014/states/ texas/harris-48201.html. Accessed December 10, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Trends: Houston-Galveston-Brazoria (HGB) 2009-2014 The chart to the right shows ozone concentration trends from 2009 to November 2014 in the HGB area compared to the NAAQS.3,6 Monitors with ozone trend lines above the 2008 NAAQS (red dotted line) are not meeting the standards for public health protection. Areas not meeting standards from 2012 to November 2014 include Manvel Croix Park, Westhollow, and Conroe Relocated. The locations of these monitors are shown on the map on the following page (Conroe Relocated not shown in map). Source: Provided by City of Houston, Pollution Control and Prevention with data from EPA and TCEQ. Populations at Risk or not they have a pre-existing condition. According to the American Lung Association, of over 4.2 million people living in Harris County in 2014, more than 369,564 were over 65 (8.7%) and more than one million were under 18 years of age (27.6%).8 All areas in the Houston/Harris County region are exposed to unhealthy levels of at least one air contaminant—a result of urban concentrations of vehicle exhaust and industrial emissions. Communities closest to large sources of air Those who fall into high risk categories toxins are at greatest risk of detrimental health should monitor the air quality on a daily basis effects from air toxic pollution. In Houston/Harris through local weather reports, newspapers, and County, the greatest sources of air toxic pollution online sources and should avoid exercising outare next to and around the Houston Ship Chandoors when pollution levels are high. nel.5 Residents and employees in this area should monitor their health closely, Population of Harris County with High-Risk looking for warning signs of long-term Pre-Existing Medical Conditions effects of air pollution. Other individuals at high risk are those with pre-existing medical conditions that are easily affected by exposure to airborne contaminants. These conditions are primarily respiratory ailments, but also include cardiovascular disease and diabetes, all of which account for about 23% of the Harris County population in both children and adults (shown in chart to the right).8 Adults over the age of 65 and children under the age of 18 are also more susceptible to air toxins, whether Pediatric Asthma, 91,322 Adult Asthma, 208,914 No High-Risk Pre-Existing Conditions, 3,290,918 COPD, 149,358 Cardiov ascular Disease, 209,659 Diabetes, 303,529 Source: American Lung Association, State of the Air 2014 67 Air Quality, cont. Geographic Distribution The map below shows the locations of regulatory air quality monitors operated by the City of Houston (labeled in bold and capital letters) with grants from the Texas Commission on Environmental Quality (TCEQ) and EPA, and also other monitors operated by the TCEQ and Houston Regional Monitoring. Regulatory continuous ozone air quality monitors are depicted as circles, and regulatory periodic fine particulate matter (PM2.5) monitors are shown as triangles. Both assess compliance with NAAQS. Monitors for Volatile Organic Compounds (VOCs) are depicted as squares.1,2 ,8 Census tracts are shaded in gray to show the EPA's estimated increased cancer risk from inhalation of outdoor air pollution, presented in cancer cases per million population.3,4 Ozone NAAQS were set in 2008 at 0.075 parts per million. Recently, the EPA has proposed new, more restrictive, standards of 0.065 to 0.070 parts per million.9 Measures from the monitors are: ● Red—3 monitors do not meet the 2008 standard (0.075 parts per million) Houston Air Quality Monitoring Map January 1, 2012 to November 17, 2014 ● Orange—11 more monitors (a total of 14) may not meet a new standard of 0.070 parts per million ● Yellow—7 more monitors (a total of 21) may not meet a new standard of 0.065 parts per million6 In the Houston area, Galena Park, highlighted on the map in orange, is on the TCEQ Air Pollution Watch List for persistent elevated concentrations of the air toxic benzene, a known carcinogen.5,7 68 Source: HDHHS Bureau of Pollution Control and Prevention with data from EPA, TCEQ, and Census. 1. City of Houston Geodatabase. Accessed November 24, 2014. Provided by request. 2. Texas Commission on Environmental Quality (TCEQ). Download TCEQ GIS data. TCEQ Web site. http://www.tceq.state.tx.us/gis/download-tceqgis-data. Updated November 20, 2014. Accessed November 24, 2014. 3. Environmental Protection Agency (EPA). Technology transfer network air toxics: 2005 national-scale air toxics assessment (NATA), US cancer risks by tract. (2005) http://www.epa.gov/ttn/atw/nata2005/tables.html. Published 2005. Accessed November 24, 2014. 4. U.S. Census Bureau. TIGER/Line 2000 Census Tract shapefile. Census Web site. http://www.census.gov/cgi-bin/geo/shapefiles2010/main. Accessed November 24, 2014. 5. Texas Commission on Environmental Quality (TCEQ). Air pollutant watch list. TCEQ Web site. https://www.tceq.texas.gov/toxicology/ AirPollutantMain/APWL.html. Accessed November 21, 2014. 6. Texas Commission on Environmental Quality (TCEQ). Compliance with eight-hour ozone standard. TCEQ Web site. http://tceq.net/cgi-bin/ compliance/monops/8hr_attainment.pl. Updated November 17, 2014. Accessed November 29, 2014. 7. Texas Commission on Environmental Quality (TCEQ). Air permits division geodatabase. Accessed March 5, 2014. 8. Texas Commission on Environmental Quality (TCEQ). Data Collected by Automated Gas Chromatographs. TCEQ Web Site. http:// www.tceq.texas.gov/airquality/monops/agc/autogc.html. Accessed November 29, 2014. 9. Environmental Protection Agency (EPA). EPA’s proposal to update the air quality standards for ground-level ozone. EPA Web site. http:// www.epa.gov/glo/actions.html#nov2014. Accessed November 29, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Ozone Precursors Objective EH-2.3: Increase trips to work made by mass transit Ozone precursors, nitrogen oxides (NOx) and volatile organic compounds (VOCs), form ground-level ozone in the presence of sunlight. NOx sources are shown in the chart below. The largest sources of VOCs are from solvent use, dry cleaning, gasoline stations, and large industries.10 Many VOCs are also listed by the EPA as hazardous air pollutants or air toxics.11 Percent of Trips to Work Made by Mass Transit Area Sources of NOx10 Power plants, petroleum refineries, chemical manufacturing industries, etc. 27% On-road vehicles 43% Use of solvents, Airports, dry cleaning, gasoline stations, locomotives and marine etc. 6% 12% Percent National Baseline 2008 5.0 Target for 2020 5.5 Harris County 2013 3.0 Texas 2013 1.6 United States 2013 5.2 Public Health Actions Non-road vehicles and contruction equipment 12%  Research new insights and innovative solutions to fight identified pollutant risks.  Research locally generated metal particulate pollution to identify potential health risks and methods to reduce emissions.  Organize partnerships for actions such as settlement agreements between local government and industry to reduce emissions.  Enforce laws and compliance with regulations, and monitor air contaminants. Economic Impact of Air Quality Costs resulting from poor air quality include taxes to enforce pollution laws, reduced yield from crops and forests, increased health risks, loss of productivity, and premature death. In the Houston Ship Channel and other industrial areas, long term exposure to air pollution increases cancer risk by a factor of 1,000, resulting in great economic and societal costs.12 According to the EPA, for every dollar invested in pollution reductions, there is a return of more than $30.13 In 2010, reductions in ozone and fine particulate matter have prevented an estimated 160,000 cases of premature mortality,130,000 heart attacks, 86,000 hospital visits, 13 million lost work days, and 1.7 million asthma attacks in the U.S.13 Another study, involving the 39 largest school districts in Texas, indicated that high carbon monoxide (CO) levels significantly increased school absences. The substantial decline in CO levels over the past two decades has yielded economically significant health benefits.14 For More Information AirNow: www.airnow.gov EPA: www.epa.gov/air/oaqps/cleanair.html Environmental Defense: http://www.edf.org/ Air Alliance: http://www.airalliancehouston.org/ Harris County Pollution Control Department: http://www.hctx.net/pollutioncontrol/ or call (713) 920-2831. HDHHS, Daily Mold and Pollen Report: http:// www.houstontx.gov/health/Pollen-Mold/ or call 713-393-3920 The Mayor’s Office of Environmental Programming: www.greenhoustontx.gov 10. Houston-Galveston Area Council. https://www.h-gac.com/home/default.aspx. Accessed November 24, 2014. 11. Environmental Protection Agency (EPA). National Ambient Air Quality Standards (NAAQS). EPA Web site. http://www.epa.gov/ttn/naaqs/. Updated November 21, 2013. Accessed November 29, 2014. 12. Galveston-Houston Association of Smog Prevention. Where does Houston’s smog come from? http://airalliancehouston.org/wp-content/uploads/ WheredoesHoustonSmogComeFrom.pdf. Published October 2003. Accessed January 26, 2012. 13. Environmental Protection Agency (EPA). The Clean Air Act and the economy. http://www.epa.gov/air/sect812/economy.html. EPA Web site. Accessed December 12, 2014. 14. Currie J, Hanushek EA, Kahn EM, Neidel Ml, Rivkin SG. Does pollution increase school absences? The Rev of Econ and Stat. 2009;91(4):682– 694. http://www.usapr.org/paperpdfs/53.pdf. Accessed December 30, 2011. 69 Surface Water/Solid Waste Overview Clean water is crucial to the health of Houston/Harris County residents. Water provides residents a source of nutrition, recreation, and relaxation. In order to maintain water quality, surface water is monitored by a regional program as well as by several agencies including, but not limited to, the City of Houston Department of Health and Human Services (HDHHS), Harris County Pollution Control Services Department (PCS), and the Texas Commission on Environmental Quality (TCEQ). The Houston-Galveston area supports a population of over six million people and has over 16,000 miles of waterways and shorelines. Over 80% of these waters fall below the state water quality standards for one or more parameters. The most common water quality issues include:  Bacteria–high bacteria concentrations can cause illness if ingested or if direct skin contact occurs. High concentrations are present in 47% of stream miles.  Dissolved oxygen –low oxygen levels render the waterway intolerable for fish and other aquatic species resulting in death of aquatic life. Low oxygen levels are present in 24% of stream miles.  Toxic contaminants–high levels of dioxins and Source: Data from Texas Department of State Health Services, map by Houston Advanced Research Center polychlorinated bi(HARC), Galveston Bay Status and Trends project. Available at www.galvbaydata.org. Used with permission. phenyls (PCBs) in fish tissue and other seafood can cause serious long-term illnesses. High levels of dioxins and/or PCBs are present in 76% of tidal waterways.  Nutrients–contribute to algal blooms in waterways that may result in the depletion of oxygen as well as foul taste, odor, and discoloration of drinking water. Twenty-nine percent of stream miles exceed state screening levels for nutrients.1 Due to these pollutants, contact recreational activities and the consumption of fish or shellfish may be unsafe. The map above shows seafood consumption advisories for the Houston Ship Channel and Galveston Bay. The map information recommends limited or no consumption of seafood from these red or orange areas due to contaminated waters. Trends in Water Quality In 2014, the Houston-Galveston Area Council’s report identified changes in water quality within a sevenyear assessment period. Although most waterways do not meet state water quality standards, more stream miles are stable or improving rather than degrading. Twenty-one percent of stream miles have shown improvement in bacteria levels, 5% have shown improvement in dissolved oxygen levels, and 11% have shown improvement in nutrient levels. 70 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Fats, Oils, Grease (FOG) Each household can improve water quality by proper disposal of common cooking oils/fats. Washing grease and cooking oil residue down the drain causes solid grease to build up and block sewer lines, resulting in overflowing manholes and sewer material floatables. These contaminants add to the degradation of surface Sewer pipe clogged with water quality. grease The San Jacinto Waste Pits Superfund Site The San Jacinto River Waste Pits superfund site was listed by the Environmental Protection Agency (EPA) as a national priority in March 2008 and was issued an Action Memorandum for a time critical removal in April 2010. The presence of polychlorinated dibenzo-p-dioxins, polychlorinated dibenzofurans, and metals required time-critical removal to stabilize the waste pits and prevent human and benthic contact.2 As an interim containment measure, until a final remedy cleanup is selected for the site, a geotextile cap (a permeable cloth or fabric used with soil or rock) was placed on the pit located north of I-10 within the San Jacinto River to prevent dispersion of toxic waste.2 This area has been used by residents for both fishing and recreation for many years. As a result of the contamination, a fish advisory has been issued by Texas Department of State Health Services. Economic Impact —Illegal Dumping Road Way Spills There has never been a shortage of solid waste in our community; however, dumped liquid material, such as grease and oil, and hazardous materials cause the most concern. These materials are not only aesthetically unpleasant, they also degrade surface water quality. The cost associated with cleaning up a solid waste site/spill varies between incidents and could be as little as $500 to upwards of over $1 million.3 According to the CDC’s Office of Analysis and Epidemiology, National Center for Health Statistics, the 2010 objectives for making water bodies safe for fishing and recreation (Obj. 8-8a and b), fish consumption advisories (Obj. 8-10a and b), and risk posed by hazardous sites (Obj. 8-12b through d) have been archived. The reports indicate that these items were archived because the data source could not produce consistent, comparable data. Objectives related to monitoring exposure to environmental chemicals were archived because the measures used to monitor them were below the limits of detection, the public health concern could not be tracked by a related chemical, or it was not deemed a significant public health concern by the CDC.4 Public Health Actions  Enforce laws and regulations to ensure safety by monitoring surface water, hazardous waste sites, landfills, illegal dumpsites, and wastewater treatment plants.  Mobilize partnerships to address poor water quality through activities such as stakeholder meetings and voluntary waterway clean-ups.  Educate the public on the importance of proper waste disposal, prevention of sanitary sewer overflows, and everyday habits that can negatively affect water quality.  Inform the public of seafood consumption advisories to prevent illness. For More Information City of Houston residents who want to determine if streams or other surface water are safe for recreation can contact the HDHHS Bureau of Water Resources Protection: 832-393-5740. Additional information is available at: www.houstontx.gov/health/Environmental/the% 20new%20phepage.html Harris County, outside the City Limits. Harris County Pollution Control Services: www.hctx.net/pollutioncontrol or call 713-9202831 Houston Bayou Preservation Association for monthly data about local bayous: www.bayoupreservation.org 1. Houston-Galveston Area Council. How’s the water? 2014 Basin highlights report. http://www.h-gac.com/community/water/resources/documents/ crp_basin_highlights_report_2014.pdf. Accessed November 3, 2014. 2. Environmental Protection Agency (EPA). San Jacinto River waste pits. EPA Web site. http://www.epa.gov/earth1r6/6sf/pdffiles/san-jacinto-tx.pdf. Updated October 2014. Accessed December 1, 2014. 3. Harris County Pollution Control, written communication February 17, 2012. 4. U.S. Department of Health and Human Services (USDHHS), National Center for Health Statistics. Healthy People 2010 final review. http:// www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf. Published December 2012. Accessed December 1, 2014. 71 Water for Drinking Overview The Federal Safe Drinking Water Act authorizes the Environmental Protection Agency (EPA) to set health-based standards for public drinking water to protect the public against naturally-occurring and man-made threats to the water supply. Such threats include animal and human waste, improper disposal of chemicals, naturally occurring substances such as radium 226, and poorly maintained water treatment and distribution systems. The standards apply to every public drinking water system in the U.S. Public drinking water systems serve at least 25 people per day for at least 60 days per year or have at least 15 service connections. Like most states, Texas has the authority to implement statewide drinking water standards that are at least as stringent as those outlined by the EPA. Within Harris County, there are approximately 1,200 public drinking water systems, ranging from the City of Houston's, which is the largest in Texas, to many that are among the state's smallest. HCPHES focuses its efforts on smaller systems such as those maintained by mobile home parks, subdivisions, child-care facilities, and small businesses. HCPHES conducts approximately 23 plant inspections each month to determine if a drinking water system has exceeded federal standards on certain contaminants, including those that can affect human health. If a system is in exceedance, HCPHES coordinates with the system as well as with state and federal partners to address issues and, if necessary, identify alternate drinking water sources. Drinking water standards within Houston are measured and enforced by the City of Houston Department of Public Works and Engineering. Public Residential Drinking Water Systems in Exceedance of Selected Contaminants, Harris County, 2011 Contaminant Source Health Risks after Long-term Consumption Erosion of natural deposits, runoff from orchards, glass and electronics production wastes Skin damage, problems with circulatory system, increased risk of cancer Gross Alpha Particles, excluding Radon & Uranium Erosion of natural deposits Increased risk of cancer Radium 226 Erosion of natural deposits Increased risk of cancer Combined Uranium Erosion of natural deposits Increased risk of cancer, kidney toxicity Arsenic Systems in Exceedance Residents Served by System(s) 9 42,981 7 18,684 3 17,595 3 6,270 There are 1,200 public drinking water systems in Harris County. Testing times differ for all areas from once a year to once every three years. In 2009 the standard for the acceptable amount of arsenic in water was decreased, which may explain the increase in the number of systems with exceedance of arsenic in Harris County. Source: HCPHES Environmental Public Health Division, 2011. For More Information HCPHES: www.hcphes.org City of Houston, Public Works and Engineering: www.houstontx.gov 72 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Occupational Health Overview The toll of workplace injury, illness, and death in the United States is significant. Healthy People 2020 highlights that workers spend a quarter of their lifetimes and up to half of their waking lives at work or commuting. Despite improvements in occupational safety and health, workers continue to suffer from work-related injuries, illnesses, and deaths. According to the U.S. Department of Labor, the Texas nonfatal occupational injury rate has remained constant with 2.9-3.0 injuries and illnesses per 100 full-time workers from 2009 to 2012. From 2003 to 2012, Texas recorded as few as 433 work-related fatalities in a year (2011) to as many as 536 fatalities in a year (2012). Locally, there were 90 fatal occupational injuries in the Houston-Baytown-Sugar Land MSA in 2012, compared to 119 in 2009 and 125 in 2007.1 The top five events or exposures that caused fatal occupational injuries in the Houston MSA include homicides, falls, motor vehicle accidents, contact with objects and equipment, and exposure to harmful substances.1 Of the 90 fatal occupational injuries that occurred in the Houston MSA in 2012, 27% were in construction and extraction occupations, 27% occurred in industries classified as transportation and material moving occupations, and 11% occurred among installation, maintenance, and repair occupations.1 In 2011 and 2012, falls were the most common cause of occupational injuries resulting in death, followed by struck by an object or equipment, homicide, and motor vehicle accidents. 1 Population Differences In 2011 and 2012, there were a total of 195 fatal occupational injuries in the Houston-BaytownSugar Land MSA, 194 of which reported race/ ethnicity. Of those fatalities, 45.9% were Hispanic, 35.1% white, 13.4% black, and 5.7% Asian. Males accounted for 178 (91.3%) of all fatal occupational injuries.1 In 2012, 90 of the 536 (16.8%) occupational injury deaths in Texas occurred in the HoustonBaytown-Sugar Land MSA. Of all Texas fatalities, 508 (94.8%) were men and 28 (5.2%) were women. Whites accounted for 48.9% of deaths, followed by Hispanics (37.5%), blacks (11.2%), and Asians (2.2%).1 Public Health Actions  Inform the public about occupational health issues and hazards.  Develop policies and plans to support individual and community efforts to improve worker safety.  Enforce laws and regulations to protect worker health and ensure safety. 1. U.S. Department of Labor, Bureau of Labor Statistics. Workplace injuries. www.bls.gov. Accessed October 28, 2014. Houston-Baytown-Sugar Land MSA Occupational Injury Deaths 2011-2012 25 20 20 18 20 17 13 15 10 10 5 5 9 14 7 6 3 0 2011 2012 Homicide Suicide Motor Vehicle Accidents Falls Struck by Object or Equipment Exposure to Harmful Substance or Environment Source: U.S. Department of Labor, Bureau of Labor Statistics For More Information U.S. Department of Labor, Bureau of Labor Statistics: www.bls.gov Texas Department of Health: http://soupfin.tdh.state.tx.us Texas Workforce Commission: www.twc.state.tx.us Texas Department of Insurance: www.tdi.state.tx.us/wc/index.html 73 Food Safety Overview Although the food supply in the United States is monitored and inspected, the CDC estimates that foodborne illnesses (caused by bacteria and other pathogens in contaminated food) lead to almost 48 million illnesses,128,000 hospitalizations, and more than 3,000 deaths every year. Each stage in the journey from farm to table can impact food safety including production, transportation, storage, preparation, and consumption. The Campylobacter bacteria is one of the most common causes of diarrheal illness in the United States, affecting over 1.3 million people annually and killing approximately 76 people per year. Most cases of campylobacteriosis are associated with eating raw or undercooked poultry meat or from crosscontamination of other foods by these items. Most people recover from the infection without any medical treatment; however, in severe cases, antibiotics are used.1 While individuals can protect themselves at home by following basic food-handling precautions, the public must trust that restaurants and other retail food establishments have complied with food safety guidelines based on the Texas Food Establishment Rules. Establishments that do not comply with city or county regulations may be issued citations, temporarily closed, or have permits to operate revoked. To protect the public, food products may be recalled due to contamination from events such as a fire, flood, power outage, sewage back-flow, extended interruption of water service, food-borne disease outbreak, or an unsanitary condition such as pest infestation. Food service inspections in Houston/Harris County include fast food and five-star restaurants, coffee shops, bakeries, catering facilities, delis, bars, schools, daycares, movie theaters, gas stations, vending machines, mobile units, outdoor and indoor events such as the Houston Livestock Show and Rodeo, supermarkets, church kitchens, processing plants, and meat markets. Inspectors typically perform 5-6 inspections each day. Trends: Houston/Harris County 2011-2013 Inspections Within the City of Houston 2011 2012 2013 Total Facilities on 1/1* 13,583 13,612 13,564 Violations of the City Food Ordinance 53,127 79,127 76,923 582 521 661 Complaints Received 2,176 2,347 2,728 Alleged Food-Borne Illnesses Received 322 386 437 Establishment Closures 610 535 582 26,070 29,412 32,210 Citations Issued to Establishments Total Inspections *Includes mobile units but not temporary food establishments Source: HDHHS Bureau of Consumer Health Services Harris County Inspections Unincorporated Harris County and 21 Municipalities (Excludes City of Houston) 2011 2012 2013 Total Establishments* 6,868 7,132 7,053 Violations, Texas Food Establishment Rules 21,548 23,705 28,139 Citations Issued to Establishments 532 666 1210 Complaints Investigated 382 383 429 Alleged Food-Borne Illnesses Received 110 98 160 Establishment Closures 67 66 77 17,482 15,716 17,086 Total Inspections *Includes mobile units but not temporary food establishments Source: Harris County Public Health & Environmental Services 1. Centers for Disease Control and Prevention (CDC). Campylobacter, CDC Web site. http://www.cdc.gov/nczved/divisions/dfbmd/diseases/ campylobacter/#what. Updated June 3, 2014. Accessed September 12, 2014. 2. United States Department of Agriculture (USDA), Food Safety and Inspection Service. Foodborne illness: what consumers need to know. http:// www.fsis.usda.gov/wps/wcm/connect/602fab29-2afd-4037-a75d-593b4b7b57d2/Foodborne_Illness_What_Consumers_Need_to_Know.pdf? MOD=AJPERES. Updated May 2011. Accessed September 15, 2014. 3. Scharff RL. Economic burden from health losses due to foodborne illness in the United States. J Food Prot. 2012;75(1):123-131. http:// www.marlerblog.com/uploads/image/s18.pdf. Accessed September 15, 2014. 74 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Mobile Food Units There are approximately 800 food trucks and trailers in the City of Houston that prepare or serve unpackaged foods. The Houston Food Ordinance requires each of these mobile units to visit an approved commissary to perform all servicing operations, including cleaning, filling fresh water tanks, and emptying waste water tanks within the 24-hour period preceding operations. An RFID (radio-frequency identification) tag is attached to each unit to monitor commissary visits and confirm compliance. Mobile food units are required to comply with all food safety regulations, including those pertaining to food protection, employee practices, temperature control, and cleaning. Objective FS-1: Reduce infections caused by Campylobacter species Reduce Infections Caused by Campylobacter (Cases per 100,000 Population) Area Rate National Baseline 2006-08 12.7 Target for 2020 8.5 Harris County 2012* 5.2 State of Texas 2012* 9.1 United States 2013 13.8 *Texas and Harris County rates are based on projected census data obtained from the DSHS Center for Health Statistics. Public Health Actions Population Differences Everyone is at risk of food-borne illnesses; however, some people are at greater risk for experiencing more serious symptoms or even death. Those at an increased risk include infants, young children, pregnant women and their unborn babies, older adults, and people with weakened immune systems (e.g. HIV/AIDS, cancer, diabetes, kidney disease, transplant patients).2 Economic Impact of Food Illnesses In 2012, the estimated cost of food-borne illness was $77.7 billion for the 31 identifiable pathogens and those food-borne illnesses for which no pathogen source was identified.3 This estimate includes medical costs, illness-related mortality, and monetized quality-adjusted life years (QALYs) to account for pain, suffering, and functional disability.  Enforce laws and regulations that protect health and ensure safety by licensing restaurants, inspecting food establishments, and responding to public complaints.  Educate food establishment owners and workers about safe food-handling practices and inform the public about the results of restaurant inspections.  Monitor health through the national surveillance program administered by the CDC to track campylobacter infection rates. For More Information City of Houston Food Ordinance: https://www.municode.com/library/tx/houston Food Inspection Results at HDHHS: http://houston.tx.gegov.com/media/index.cfm HCPHES: www.hcphes.org Texas Department of State Health Services, Food Establishment Group: www.dshs.state.tx.us/foodestablishments Food-Borne Illness: http://www.cdc.gov/ foodsafety/index.html USDA Food Safety and Inspection Service: www.fsis.usda.gov 75 Lead Poisoning Overview A high level of lead in the bloodstream can lead to irreversible developmental delay, learning disabilities, behavioral problems, seizures, and even death. In January 2012, the CDC decreased the reference value of blood lead levels, an estimate of exposure that is likely to be without an appreciable risk of adverse health effects over a lifetime, from 10 µg/dl to 5 µg/dl. Today approximately half a million of U.S. children under the age of six have blood lead levels above this reference value, a value at which public health action is recommended.1 Children under the age of six, particularly those living in older housing, are at greatest risk for lead poisoning. The primary source for lead poisoning in children is lead chips and lead dust given off by lead -based aging paint. Lead-based paint was banned in 1978; however, based on 2013 American Community Survey estimates, Harris County still has nearly 690,000 pre-1980 occupied residences. Other common sources of lead poisoning include: lead-contaminated water, artificial turf, lead glazed pottery (jarros/jars) and tiles, folk medicine (Azarcon and Greta), imported toys and candies, toy jewelry, and contaminated soil.1 Both the City and County Health Departments provide follow-up lead screening for high-risk populations and refer children with high blood lead levels to their health care provider for case management or treatment. Most children with elevated blood lead levels live in pre-1950 housing. Within the 610 Loop, 25% of homes were built before 1950; in some ZIP codes, the number is as high as 35%. Trends: Houston/Harris County 2000-2011 HDHHS and HCPHES test children in high risk areas for blood lead levels. In 2011, HDHHS tested 49,411 children under age six and identified 242 (0.5%) with elevated blood lead levels. HCPHES tested 25,796 children under age six and identified 72 (0.3%) children with elevated blood lead levels. The chart to the right shows blood lead level trends for children tested by HDHHS and HCPHES. The decreasing incidence of children with elevated blood lead levels can be attributed in part to the Department of Housing and Urban Development (HUD) programs administered through local public health organizations to remediate houses with dangerous paint. 5% 4% Percentage of Tested Children Under Age Six in Houston & Harris County with Positive Tests for Elevated Blood Lead Levels HCPHES —bright orange HDHHS—dark orange 3.8% 3.1% 3.3% 3% 1.9% 1.9% 2% 1.6% 1% 0.5% 0.4% 0.6% 2.0% 1.6% 1.6% 0.9% 0.8% 0.5% 0.2% 0.5% 0.8% 0.5% 0.4% 0.4% 0.4% 0.4% 0.3% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: HDHHS and HCPHES Case Files Population Differences The prevalence of lead poisoning correlates along socioeconomic divisions. Those in lower socioeconomic levels, of racial/ethnic minority, and recent immigrants are at greater risk of lead exposure. 1 In addition, children in lower socioeconomic levels are less likely to receive prompt and adequate medical care for elevated blood lead levels. Based on 2013 ACS estimates, Harris County has a high percentage of children (27.1%) living below the federally determined poverty level, placing the county at a high risk for childhood lead poisoning cases. The CDC reports that some racial/ethnic groups and income levels are disproportionately affected by lead exposure. Black children (5.6%) are twice as likely to have elevated blood lead levels than white children (2.4%) and nearly three times more likely to have elevated levels than Hispanic children (1.9%). ____________________________________________________________________________________ 76 1. Centers for Disease Control and Prevention (CDC). Lead. CDC Web site. http://www.cdc.gov/nceh/lead/. Updated June 19, 2014. Accessed September 16, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Healthy People 2020 Objective EH 8.1: Eliminate elevated blood lead levels in children. High Risk* ZIP Codes, Houston 2012 Children Ages 1-to-5 Years with Blood Lead Levels Exceeding 10 µg/dl Area Sources: HDHHS Bureau of Children’s Environmental Health, TDSHS Childhood Lead Poisoning Prevention Registry. *High Risk is determined by CDC and HUD for pre-1978 housing. Targeted ZIP codes are areas in color. Additional targeted ZIP codes exist outside the Houston city limits, notably Baytown, Pasadena, Channelview, Galena Park and La Porte. Call 713-274-6374 for more information. Elevated Lead in Pottery National Baseline 2005-2008 0.9 Target for 2010 0.0 Houston/Harris County 2011 0.4 State of Texas 2011 0.2 United States 2011 0.3 Public Health Actions  Monitor health status to identify and solve community health problems by testing children in high-risk areas for elevated blood lead levels and referring identified children to appropriate medical care.  Link people with necessary health services through referral of children positive for lead poisoning.  Diagnose health hazards by assessing houses with crumbling lead-based paint, particularly those with young children in the home.  Enforce laws and regulations to remediate houses with lead-based paint. The pottery below, purchased in Houston, has lead content that exceeds FDA lead use limits. Source: HDHHS Children’s Environmental Health Lead Test Reports Economic Impact of Lead Poisoning Lead poisoning can lead to developmental delays, intellectual deficits, and behavioral problems, with costs for health care, special education needs, lower earnings, the impact of behavior problems, and crime.2 The cost of medical and special education can be $5,600 for each seriously lead-poisoned child.1 Returns on investments in lead hazard control are substantial, especially when targeted at early intervention in communities most at risk. These returns have estimated cost savings of the following ranges:  Health care $11-$53 billion  Lifetime earnings $165-$233 billion  Tax revenue $25-$35 billion  Special education $30-$146 million  Attention deficit-hyperactivity $267 million  Crime (direct costs) $1.7 billion.3 Each dollar invested in lead paint hazard control results in a return of $17-$221.3 Percent For More Information U.S. Department of Housing and Urban Development: www.hud.gov/offices/lead State of Texas: www.dshs.state.tx.us/lead City of Houston: www.houstontx.gov/health/ Environmental/leadprogrampage.html HCPHES Lead Hazard Control Program: http://www.hcphes.orgdivisions_and_ offices/environmental_public_health/ lead_information National Safety Council: http://www.nsc.org/ news_resources/Resources/Documents/ Lead_Poisoning.pdf 2. Bernard SM. Should the Centers for Disease Control and Prevention’s childhood lead poisoning intervention level be lowered? Am J Public Health. 2003; 93(8):1253–1260. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447949/. Accessed January 3, 2012. 3. Gould E. Childhood lead poisoning: conservative estimates of the social and economic benefits of lead hazard control. Environ Health Perspect. 2009;117(7):1162-1167. http://dx.doi.org/10.1289/ehp.0800408. Accessed January 3, 2012. 77 Neighborhood Concerns Overview According to the Health of Houston Survey 2010, neighborhood problems such as stray dogs and cats, pollution, crime, and other environmental concerns are more common in lower income areas of Houston/ Harris County. In addition, areas with multiple environmental concerns have more residents with health problems. The map below shows areas where residents reported the most environmental concerns, with red and yellow denoting the highest numbers of concerns. These are overlapped with the highest quartile of those reporting poor or fair health, shown in the hatched parts of the map. 1 Houston area residents listed these problems as their concerns, in order of frequency reported: 1     Stray dogs/cats 37% Crime 26% Drinking water 19% Dumping 17%     Air pollution, traffic 17% Limited fruits/veggies 16% Air pollution, industry 15% Water pollution, runoff 10% The Administration and Regulatory Affairs records the number of bite cases for the City of Houston. In 2013, 2,250 bite cases were recorded, with over half of cases (1,216) reported as dog bites. Of dog bite cases, 235 (19%) victims were under the age of ten.2 Additional concerns reported during HDHHS AIM (Assessment, Intervention, and Mobilization) projects undertaken in select Super Neighborhoods3 included needs for:  Better educational opportunities  Better access to good jobs and other economic opportunities  Improved access to health care  More and better recreational facilities, especially for school-aged children  Improved public transportation  Remediation for overgrown lots, trash, and abandoned cars and homes  Interventions for prostitution/crime/drugs  Improved community safety Map source: Health of Houston Survey 2010: A First Look 1. The University of Texas School of Public Health (UTSPH). Health of Houston survey, HHS 2010 a first look. Houston, TX: Institute for Health Policy, The University of Texas School of Public Health, 2011. https://sph.uth.edu/content/uploads/2010/09/HHS-8.5x11-Sep30_cover.pdf. Accessed February 20, 2012. 2. City of Houston, Administration and Regulatory Affairs. Bite cases recorded for year 2013 PIR 3941. Provided by request. 3. City of Houston, Planning & Development Department. http://www.houstontx.gov/planning/Demographics/demog_links.html. See also http:// www.houstontx.gov/superneighborhoods/index.html. Accessed February 20, 2012. 78 Health Outcomes Overarching goals for healthy outcomes include:  Attain high quality, longer lives free of preventable disease, disability, injury, and premature death.  Achieve health equity, eliminate disparities, and improve the health of all groups.  Create social and physical environments that promote good health for all.  Promote quality of life, healthy development, and healthy behaviors across all life stages. Healthy People 2020 79 Leading Causes of Mortality When considering the leading causes of death and disability, HCPHES, HDHHS and other public health organizations examine factors that impact death and disability throughout a person’s lifetime including infant, adolescent, maternal, and senior health concerns. In 2012, the most recent year for which comprehensive vital statistics data are available, there were 23,409 deaths in Harris County. The leading causes of death in all racial/ethnic groups were heart disease and cancer, accounting for 45% of all deaths. Each cause of death is evaluated in terms of: 1. Total number of deaths 2. Mortality rate, which is the number of deaths per 100,000 population. Overall mortality rates are compared to the population of Houston/Harris County. A mortality rate for a racial/ethnic group is compared to that racial/ethnic population. 3. Age-adjusted rate, which takes into account the age of death. This is important because, for example, whites are in the majority among those over age 65 in Houston/Harris County, so whites would be expected to show the highest mortality rate for heart disease or cancer. However, when the statistics are adjusted to account for the differences in age groups, blacks are seen to have higher age-adjusted mortality rates for both of these diseases. Leading Causes of Mortality, Harris County, 2012 Total Deaths Mortality Rate Age-Adjusted Mortality Rate* All Causes 23,409 551.4 744.9 Cancer 5,284 124.5 160.3 Heart Disease 5,147 121.2 171.9 Accidents 1,342 31.6 36.9 Stroke 1,222 28.8 41.9 Chronic Lower Respiratory Disease 957 22.5 33.2 Diabetes 720 17.0 21.9 Septicemia 672 15.8 22.1 Kidney Disease 503 11.8 17.1 Chronic Liver Disease and Cirrhosis 456 10.7 11.9 Suicide 431 10.2 10.6 Influenza and Pneumonia 383 9.0 13.4 Alzheimer’s Disease 380 9.0 14.8 Homicide 356 8.4 8.1 Cause of Death *Deaths per 100,000 persons, age-adjusted to the 2000 Census population. Age adjustment is a method that eliminates differences in rates that result from age differences in population composition. Source. Texas Department of State Health Services, Center for Health Statistics, 2012. Available at http://soupfin.tdh.state.tx.us/. Accessed September 17, 2014. 80 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Leading Causes of Mortality by Race/Ethnicity, Harris County, 2012 Cause of Death Age-Adjusted Mortality Rate* and (Rank) White Black Hispanic 792.2 977.1 532.5 Heart Disease 181.3 (1) 229.1 (1) 117.5 (1) Cancer 169.9 (2) 217.7 (2) 107.8 (2) Stroke 38.9 (5) 62.1 (3) 33.0 (3) Accidents 46.5 (3) 34.3 (6) 27.3 (4) Chronic Lower Respiratory Disease 43.6 (4) 31.1 (7) 14.4 (9) Septicemia 20.2 (6) 36.0 (5) 20.7 (6) Diabetes 16.0 (9) 38.6 (4) 26.1 (5) Kidney Disease 14.2 (10) 27.2 (8) 15.4 (8) Alzheimer’s Disease 17.2 (8) 17.5 (10) 7.4 (11) Influenza and Pneumonia 13.7 (11) 17.0 (11) 11.2 (10) Chronic Liver Disease and Cirrhosis 12.2 (12) 8.3 (15) 15.9 (7) Suicide 19.0 (7) 6.1 (16) 5.3 (14) Homicide 4.5 (16) 20.7 (9) 6.6 / 6.2 (12) All Causes *Deaths per 100,000 persons, age-adjusted to the 2000 Census population ** Rate could not be calculated Source: Texas Department of State Health Services, Center for Health Statistics, 2012. Available at http://soupfin.tdh.state.tx.us/. Accessed September 18, 2014. 81 This page intentionally left blank Maternal & Infant Health The health of mothers, infants, and children is of critical importance, both as a reflection of the current health status and quality of life of a large segment of the U.S. population and as a predictor of the health of the next generation. Pregnancy can provide an opportunity to identify and address existing and future health risks for women and their children. Healthy birth outcomes and early identification and treatment of health risks can prevent death and disability and improve the quality of children’s lives. The risk of maternal and infant mortality and pregnancyrelated complications can be reduced by increasing access to quality preconception (before pregnancy) and interconception (between pregnancies) care. Infant mortality is an important measure of a nation’s health and a worldwide indicator of health status and social well-being. In the United States, racial and ethnic disparities in mortality and morbidity still exist, particularly for African Americans. The rate for African Americans remains over twice that of whites. 83 Adolescent Pregnancy Overview Adolescent pregnancy has implications for both the mother and child. According to the TDSHS, teenage mothers are less likely to receive adequate prenatal care, less likely to gain adequate weight during pregnancy, and are more likely to smoke than older mothers. Children born to teenage mothers are also at greater risk of low birth weight, disability, and mortality during the first year of life. Higher rates of premature births among younger mothers is noted in Harris County. According to the TDSHS, in 2012, 14.1% of births to mothers 19 and under were premature, compared to 11.5% of births to mothers aged 20-29. Academic performance is also affected for adolescent mothers and their school-aged children. Teenage mothers are less likely to finish high school and therefore may lack job skills to find or keep a job.1 Children of adolescent mothers are 50% more likely to repeat a grade and generally perform lower on standardized tests. Children of teen parents also suffer higher rates of abuse and neglect than children of mothers who delay child bearing. Nationally, Texas ranked fifth out of 51 (50 states and the District of Columbia) in teen birth rates among females 15-19 in 2011.2 Multiple pregnancies among teenage mothers is also a national concern with nearly one in five births to teenage mothers ages 15-19 being a repeat teenage birth. According to the CDC, Texas had the largest percentage (22%) of teen births that were repeat births in 2010. Trends: Rates and Cases in Houston/Harris County 2005-2012 Births to Mothers Ages 15-17 in Harris County Number of Births and Percent of All Births 3,500 Number of Births 2,500 2,000 1,500 4.2% 4.4% 4.3% 4.3% 4.1% Percent 2,595 6% 2,366 2,054 3.8% 3.6% 3.0% 1,000 4% 2% 500 0 0% 2005 2006 2007 2008 2009 2010 2011 2012 Percent of All Births 3,000 Number 3,096 3,065 3,055 2,938 2,800 TDSHS 2012 Vital Statistics data reported 2,146 births to mothers ages 17 and younger, accounting for 3.2% of all births in Harris County, In comparison, 3.5% of Texas births are to mothers 17 and younger. Following the national trend, births to teenage mothers in Harris County have declined since 2008. The TDSHS Vital Statistics 2012 Annual Report indicates a birth rate of 27.8 births per 1,000 females aged 15-17 in Harris County, compared to 26.5 in Texas and 14.1 in the U.S. For teenage girls 13-17 in Harris County, the birth rate was 17.3 per 1,000 teenage girls, compared to 16.5 in Texas. Source: TDSHS Births to Mothers 17 and Younger Harris County, 2012 Population Differences Number of Births Compared to older mothers, adolescent mothers are less likely to receive early and regular prenatal care, more likely to smoke during pregnancy, more likely to deliver preterm, and their babies are more likely to die in the first year of life.1 Number and Percent of All Births in Racial Group 1600 1400 1200 1000 800 600 400 200 0 Number Percent 6% 4.4% 3.6% 4% 2% 1.1% 270 632 2295 White Black Hispanic Percent of All Births TDSHS reports indicate that of births to teenage mothers ages 17 and younger in Harris County, 8.0% were born to white mothers, 20.9% were born to black mothers, and 69.7% were born to Hispanic mothers. 0% Source: TDSHS 84 1. March of Dimes. Teenage pregnancy. http://www.marchofdimes.org/materials/teenage-pregnancy.pdf. Accessed September 21, 2014. 2. Department of Health and Human Services (DHHS), Office of Adolescent Health. Adolescent health facts. http://www.hhs.gov/ash/oah/adolescent -health-topics/reproductive-health/states/pdfs/tx.pdf. Accessed October 15, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Percent Births to Mothers 17 Years and Younger: Harris County, 2011 Healthy People 2020 Objective FP-8.1: Reduce the pregnancy rate among adolescent females aged 15 to 17 years Pregnancy Among Females Age 15-17 Rate per 1,000 Area 0.0 Zero or no data 0.1 - 4.0 4.1 - 7.3 7.4 - 9.1 9.2 Location based on mother’s residence ZIP code. Source: Data from TDSHS, Center for Health Statistics. October 2013. Map by June Hanke, Harris Health System. Economic Impact of Adolescent Pregnancy In 2010, adolescent pregnancy and childbirth cost U.S. taxpayers an estimated $9.4 billion per year. A child born to a teenage mother costs an average of $1,682 per year from birth to age 15. These costs include public sector health care costs, child welfare costs, costs due to higher incarceration rates among children of teenage parents, and lost revenue due to lower taxes paid by the children of teenage mothers over their lifetimes.3 Adolescent pregnancies in Texas cost at least $1.1 billion in 2010.4 The 33% decline in Texas’ teen birth rate since 1991 has resulted in state savings of $701 million in 2010.5 Comprehensive educational programs that address a broad range of social and behavioral issues such as access to birth control, life skill development, academic support, and job training have been shown to reduce adolescent participants’ pregnancy rates.6 Rate National Baseline 2005 40.2 Target for 2020 36.2 Harris County 2012 27.7* State of Texas 2012 26.5* United States 2010 30.1 *Rates furnished by request from the Texas Department of State Health Services. Public Health Actions  Advocate for prevention services and education.  Assure the provision of health care when otherwise unavailable through case management services for pregnant teens such as home visits, prenatal education, breastfeeding promotion, referral assistance, and parenting skills.  Mobilize partnerships to alleviate health problems through support and implementation of programs that provide family support and education during the child’s early years. For More Information TDSHS Family Planning: www.dshs.state.tx.us/famplan National Campaign to Prevent Teen Pregnancy: www.thenationalcampaign.org Planned Parenthood Gulf Coast: www.ppgulfcoast.org Teen Pregnancy in the Black Community: http://www.blackwomenshealth.com CDC: http://www.cdc.gov/TeenPregnancy/ index.htm Text4baby: https://www.text4baby.org/ 3. The National Campaign to Prevent Teen and Unplanned Pregnancy. Counting it up: key data. http://thenationalcampaign.org/resource/counting-itkey-data-2013. Published December 2013. Accessed September 21, 2014 4. The National Campaign to Prevent Teen and Unplanned Pregnancy. Counting it up: the public costs of teen childbearing in Texas in 2010. https:// thenationalcampaign.org/sites/default/files/resource-primary-download/fact-sheet-texas.pdf. Published April 2014. Accessed September 19, 2014. 5. The National Campaign to Prevent Teen and Unplanned Pregnancy. Counting it up: total costs to taxpayers associated with teen childbearing in 2010. https://thenationalcampaign.org/resource/counting-it-total-costs-taxpayers. Published April 2014. Accessed September 19, 2014 6. Lonczak HS, Abbott RD, Hawkins JD, Kosterman R, Catalano RF. Effects of the Seattle social development project on sexual behavior, pregnancy, birth, and sexually transmitted disease outcomes by age 21 years. Arch Pediatr Adolesc Med. 2002;156(5):438–447. http://archpedi.amaassn.org/cgi/content/full/156/5/438. Accessed September 21, 2014. 85 Maternal Mortality & Morbidity Overview Maternal mortality is a sentinel event that reflects only a small percentage of severe maternal morbidity (maternal illness or disease). Researchers estimate that for every maternal death, another 50 women experience a severe complication resulting from pregnancy.1 Maternal deaths are infrequent (a total of 27 deaths in 2008 in Harris County); however, pregnancy-related deaths are increasing nationwide. Factors that increase a women’s risk of maternal mortality include: obesity, chronic medical conditions such as hypertension, preexisting cardiac and renal disease, diabetes, asthma, cesarean section delivery, lack of prenatal care, and multiparity such as having twins or triplets. Additional risk factors such as age (over 35) and socioeconomic status also contribute to maternal deaths.2,3,4 Trends: Harris County, Texas and the U.S. 2003-2011 Maternal Mortality Rate per 100,000 Live Births Harris Cou nty U.S . 30 Texas HP 2020 Goa l 24.9 23.2 25 15 10 5 22.2 17.6 18.2 20 13.9 13.4 11.4 12.0 9.0 2003-05 2005-07 2007-09 2009-11 Source: CDC Wonder Data, October 2014 Population Differences TDSHS Harris County reports show marked racial disparities in maternal mortality, a pattern also seen in many areas of the U.S. Minority women accounted for approximately 77% of maternal deaths in Harris County. Black women have the highest maternal mortality rates in Harris County, accounting for 42.9% of all deaths from 2003-2012. The age of the mother is also an important factor in maternal mortality. From 2003-2012, mothers over the age of 34 accounted for 36.5% of all deaths. Maternal mortality rates in the United States and Texas have steadily increased since 2003. A similar trend is noted in Harris County but at an even greater rate. In Harris County, maternal mortality rose from 12.0 maternal deaths per 100,000 live births in 2003-2005 to 24.9 in 20062008, then declined slightly to 23.2 in 20092011. In 2009-2011, Harris County had a high maternal mortality rate (23.2) compared to Texas (22.2) and U.S. (17.6) rates. The death of a mother is considered a sentinel event that is a measure of a community’s medical care system. Percent of Maternal Deaths by Race/Ethnicity Harris County 2003-2012 50% 42.9% 40% 30% 30.2% 22.8% 20% 10% 4.2% 0% White Black Hispanic Other Source: TDSHS, September 2014 Note: Maternal deaths: All O codes (O00 –O99) 1. Callaghan WM, MacKay AP, Berg CJ. Identification of severe maternal morbidity during delivery hospitalizations, United States 1999-2003. Amer J of Obs & Gyn. 2008;199(2):133.e1-133.e8. http://www.ajog.org/article/S0002-9378(07)02332-0/abstract. Accessed October 2014. 2. Florida Department of Health. PAMR 1999-2008 Florida pregnancy-related mortality report: why are Florida mothers continuing to die? http:// www.floridahealth.gov/%5C/statistics-and-data/PAMR/pamr-1999-2008-report.pdf. Accessed November 2014. 3. California Department of Public Health. The California Pregnancy-Associated Mortality Review: report from 2002-2003 maternal death reviews. http://www.cdph.ca.gov/data/statistics/Pages/CaliforniaPregnancy-AssociatedMortalityReview.aspx. Published April 2011. Accessed October 2014. 4. New York City Maternal Mortality Review Project Team, Bureau of Maternal, Infant, and Reproductive Health (BMIRH). Pregnancy associated mortality: New York City 2001-2005. http://www.nyc.gov/html/doh/downloads/pdf/ms/ms-report-online.pdf. Accessed October 2014. 86 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Geographic Distribution Objective MICH–5 : Reduce the maternal mortality rate Maternal Deaths, Harris County 1999-2011 Maternal Mortality Rate per 100,000 live births Area Number of maternal deaths per 100,00 live births in Harris County 1999 to 2011 combined data. Source: TDSHS. Map by Harris Health System. Maternal deaths are costly beyond medical expenses. Each maternal life lost to premature death is estimated at a loss of $3-5 million to society.3 12.7 Target for 2020 11.4 Harris County 2009-2011 23.2 State of Texas 2009-2011 22.2 United States 2009-2011 17.6 Deaths Within One Year of Pregnancy and Caused by Pregnancy Complications Harris County Texas U.S. 40 36.3 35 In 2011, the Agency for Health Care Research and Quality identified that pregnancy and childbirth account for 7 of the top 20 most expensive conditions requiring hospitalizations covered by Medicaid.5 During 2008, total costs for hospitalizations with pregnancy and/or delivery-related complications resulted in $17.4 billion nationwide, nearly 5% of total hospital costs.6 Cesarean delivery is associated with a much higher risk of complication than vaginal delivery. According to Vital Statistics, the U.S. cesarean section rates increased by 60% from 1996 to 2009. In 2012, cesarean sections were performed in 32.8% of U.S. births and in 34.8% of Harris County births. National Baseline 2007 Pregnancy Related Deaths per 100,000 Live Births: Economic Impact of Adverse Pregnancy Outcomes Maternal hospitalizations with pregnancyrelated complications result in greater costs; hospitalizations with complications cost $4,100 for non-delivery stays and $3,900 for delivery stays, compared to $2,600 for deliveries without complications in 2008.6 Women with severe pregnancy-related morbidity such as hemorrhage, eclampsia, pulmonary embolism, renal failure, or stroke have even higher hospital costs. In addition, disability resulting from complications of pregnancy, such as a stroke, will have lifelong health care expenses. Rate 30.5 29.8 30 25 26.1 23.0 20.4 20 14.9 12.9 2003-05 23.5 23.9 21.9 19.9 17.2 15 10 33.4 32.0 15.8 20.1 17.2 17.7 2005-07 21.1 18.1 2007-09 2009-11 Source: CDC Wonder 2014, Analysis by Harris Health System Public Health Actions    Monitor health rates and advocate for support for the recommendations of the Maternal Mortality Review Taskforce to prevent maternal deaths and morbidity. Educate women on maternal death and morbidity risk factors. Mobilize community partnerships and action to improve maternal health. For More Information Every Mother Counts: www.everymothercounts.org/ Amnesty International: www.amnestyusa.org/ our-work/campaigns/demand-dignity/ maternal-health-is-a-human-right AWHONN: http://www.pphproject.org/ 5. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. HCUP Statistical Brief #160, August 2013. Agency for Healthcare Research and Quality (AHRQ), Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.pdf. Accessed October 13, 2014. 6. Elixhauser A, Wier LM. Complicating conditions of pregnancy and childbirth 2008. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project. Statistical Brief #113, May 2011. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.pdf. Accessed October 2014. 87 Pregnancy/Infant Outcomes Overview Early prenatal care is important to ensure the health of mothers and their infants (see prenatal care section). It is equally important for women to receive a medical visit prior to becoming pregnant to assess for risk factors. This is particularly true for women with chronic disorders such as diabetes and high blood pressure to assure a healthy pregnancy and infant outcome.1 Improper prenatal care, short intervals between pregnancies, socioeconomic stressors, poor health of mothers, and unavoidable genetic defects all contribute to poor pregnancy outcomes. Infant and maternal outcomes include low birth weight (under 2.5 kilograms or 5.5 pounds), premature birth, infant death (less than a year of age), and maternal death. Breastfeeding is the ideal method for providing nutrition for the healthy growth and development of infants. Breast milk promotes sensory and cognitive development and reduces recovery time and infant mortality from common childhood illnesses such as diarrhea and pneumonia. 2 Breastfeeding is not recommended for babies whose mothers have HIV infection. Other behaviors such as positioning infants on their backs to sleep and creating a safe sleep environment serve as protective measures to reduce the incidence of Sudden Infant Death Syndrome (SIDS), the leading cause of death among babies between one month and one year of age. 3 Trends: Houston and the U.S. 2005-2012 Infant Mortality Rate per 1,000 Live Births 7.0 6.5 U.S. 6.9 6.7 6.8 Harris County 6.6 6.8 6.5 6.4 6.2 6.0 5.9 5.9 5.5 6.3 6.1 6.1 6.2 The infant mortality rate (deaths per 1,000 live births in the first year of life) in the United States has declined 12.8% over the past decade but still remains among one of the highest infant mortality rates of any industrialized nation. The 2012 U.S. rate of 6.1 deaths per 1,000 live births tops those of Japan (2.2), Sweden (2.4), Germany (3.3), Australia (3.5), and the United Kingdom (4.0).5 6.0 The death of an infant can be viewed as a sentinel event that is a measure of a community’s overall social and economic well-being.4 5.6 2005 2006 2007 2008 2009 2010 2011 2012 Source: TDSHS Population Differences TDSHS reports for Harris County show marked racial disparities in infant mortality, a pattern noted in many areas of the U.S. Blacks have the highest rate of infant mortality among all races with a rate of 12.0 per 1,000 live births in 2012, an increase from 9.3 in 2008 The age of the mother is also an important factor in the birth outcome. Premature birth, or birth before 37 weeks gestation, is a risk factor for infant death and is more common among teenage mothers and mothers over age 35. 88 Infant Mortality* Rates in Harris County, 2008-2012 14.0 10.0 2008 12.0 11.4 12.0 2010 9.3 9.1 2012 8.0 6.0 5.5 5.5 4.4 5.1 4.4 4.0 5.5 4.9 3.5 2.0 0.0 White Black Hispanic Other *Infant mortality rate is deaths per 1,000 live births. Source: TDSHS 1. The American Congress of Obstetricians and Gynecologists (ACOG). The importance of preconception care in the continuum of women’s health care. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/The-Importance-of-PreconceptionCare-in-the-Continuum-of-Womens-Health-Care. Published September 2005. Reaffirmed 2012. Accessed October 9,2014. 2. World Health Organization (WHO). Nutrition: exclusive breastfeeding. WHO website. http://www.who.int/nutrition/topics/exclusive_breastfeeding/ en/. Accessed October 9,2014. 3. U.S. Department of Health and Human Services (USDHHS), National Institute of Child Health and Human Development. About SIDS and safe infant sleep. Safe to Sleep Web site. http://www.nichd.nih.gov/sts/about/Pages/default.aspx. Accessed October 9, 2014. 4. U.S. Department of Health and Human Services (USDHHS), The National Fetal and Infant Mortality Review Program. Fetal and infant mortality review: making a difference in the community. http://www.nfimr.org/site/assets/docs/NFIMRBrochure.pdf. Published 2009. Accessed October 9, 2014. 5. The World Bank. Mortality rate, infant (Per 1,000 Live Births). The World Bank Web site. http://data.worldbank.org/indicator/SP.DYN.IMRT.IN. Accessed October 9, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Healthy People 2020 Objective MICH-1.3: Reduce the number of infant deaths (within year one) Infant Mortality in Houston/Harris County 2007-2011 Infant Deaths Rate per 1,000 live births Area Infant death rate per 1,000 live births, five year aggregate (2007-2011). Source: Texas Department of State Health Services, Center for Health Statistics, October 2013. Map by Harris Health System. Harris County Births with Low Birth Weight (LBW), 2011 Rate National Baseline 2006 6.7 Target for 2020 6.0 Harris County 2012 6.0 State of Texas 2012 5.8 United States 2012 6.1 Economic Impact Harris County In 2009, the average cost paid by Medicaid for the hospitalization of a low birth weight baby (under 2.5 kilograms or 5.5 pounds) in Harris County was $61,841 and $152,792 for a very low birth weight baby (less than 1.5 kg).8 Public Health Actions     Source: Texas Department of State Health Services, Center for Health Statistics, October 2013. Map by June Hanke, Harris Health System. Economic Impact of Adverse Pregnancy Outcomes In addition to the significant emotional toll, premature births have a staggering economic impact on families and businesses. Infant and maternal health care for a premature infant costs employers an additional $58,917; 12 times more than a baby born without complications. The economic cost to employers is substantial with approximately 11% of children covered by employer health plans born prematurely.6 U.S. costs for preterm births were estimated at a minimum of $26.2 billion in 2005.7 These costs include medical care ($1.9 billion), early intervention services ($611 million), disabilities more common in premature infants of special education ($1.1 billion), and lost household and labor market productivity ($5.7 billion).7 Monitor health status to identify and alleviate community health problems by tracking infant mortality rates and disseminating results to the community. Promote healthy practices throughout pregnancy and during early infant development. Serve as a safety net when services are otherwise unavailable. Mobilize community partnerships to identify barriers to healthy pregnancy and medical care, and develop solutions for action. For More Information March of Dimes: www.marchofdimes.com Premature Children: www.prematurity.org Sudden Infant Death Syndrome: www.firstcandle.org Genetic Counseling: www.kidshealth.org National Fetal and Infant Mortality Review: http://www.nfimr.org 6. March of Dimes. Premature birth: The financial impact on businesses. http://www.marchofdimes.org/materials/premature-birth-thefinancial-impact-on-business.pdf. Published December 2013. Accessed October 9, 2014 7. Behrman RE, Butler AS, Eds. Preterm birth: causes, consequences and prevention. National Academies Press. 2007: 398. http:// www.nap.edu/openbook.php?record_id=11622&page=398. Accessed February 20, 2012. 8. Medicaid FFS/PCCM & HMO cost for Harris County newborns by birth type for CY2006-2009 research team, strategic decision support HHSC. 2010. http://transform.childbirthconnection.org/reports/cost/. Accessed February 20, 2012. 89 Pregnancy/Fetal Outcomes Overview In 2012, Houston/Harris County registered: Fetal health and mortality are important indicators for  67,353 live births assessing pregnancy outcomes; however, they are often  402 infant deaths overlooked as public health concerns. Fetal death, often  403 fetal deaths termed stillbirth, refers to intrauterine fetal death at anytime during pregnancy. When the fetus is over 20 weeks of gestation, Vital Statistics records are maintained to track deaths.1 Fetal deaths prior to 20 weeks gestation are generally referred to as miscarriages and are not tracked through death certificates. The CDC reports that there are as many fetal deaths (over 20 weeks gestation) as infant deaths. Factors that contribute to fetal death include: Lack of prenatal care1 Chronic health conditions such as obesity, hypertension, and diabetes 2 Teenage pregnancy Mothers over 35 years of age Multiples (twins, triplets, etc.) Women with more than two previous pregnancies Race/ethnicity (Blacks and Native Americans have the highest rates of fetal mortality)        Trends: Infant and Fetal Mortality Rates Infant & Fetal Mortality Rate per 1,000 Live Births Harris County 2005-2012 7.0 FMR 6.8 6.5 6.3 5.9 6.0 5.5 5.8 5.6 5.9 6.4 Fetal Mortality Rates, by Period of Gestation IMR 6.5 6.3 6.5 Total 6.0 6.2 6.2 5.7 6.0 28 weeks or more 5.6 20-27 weeks 5.0 2005 2006 2007 2008 2009 2010 2011 2012 Includes unknown and 20+ week fetal deaths. Source: TDSHS Population Differences 90 1995 1990 2005 2000 Source: CDC/NCHS. National Vital Statistics System Fetal Mortality Rate in Harris County, 2008-2012 TDSHS Harris County reports show marked racial disparities in fetal mortality, a pattern also noted in maternal and infant mortality. Blacks have the highest rate of fetal mortality with a rate of 9.3 fetal deaths per 1,000 live births in 2012, compared to 6.6 for Hispanics and 5.3 for whites. 14 As with infant mortality, national data indicates that the age of the mother is an important factor in the birth outcome. Teenage mothers and mothers over 35 have higher rates of fetal mortality while women ages 25-34 have the lowest rates.1 2 11.8 12 2008 11.0 2010 9.3 10 2012 8 6 5.5 5.4 5.6 5.3 4.7 5.2 3.8 4 2.9 3.1 0 White Black Hispanic Other Fetal mortality rate is fetal deaths per 1,000 live births. Fetal death is gestation of 20 weeks and over, including unknown gestation. Source: TDSHS 1. MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and perinatal mortality, United States, 2006. National Vital Statistics Reports. Hyattsville, MD: National Center for Health Statistics. 2012: 60(8). http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_08.pdf. Accessed October 9,2014 2. MacDorman M, Kirmeyer S. The challenge of fetal mortality. NCHS Data Brief, No 16. Hyattsville, MD: National Center for Health Statistics. 2009. http://www.cdc.gov/nchs/data/databriefs/db16.pdf. Accessed October 9, 2014. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Healthy People 2020 Objective MICH-1.1 Reduce the rate of fetal Fetal Mortality in Houston/Harris County 2007-2011 deaths at 20 or more weeks of gestation Fetal Deaths Rate per 1,000 live births Area Rates of fetal death per 1,000 live births plus fetal deaths, five year aggregate (2007-2011) data. Source: Texas Department of State Health Services, Center for Health Statistics. October 2013. Map by Harris Health System. National Baseline 2005 6.2 Target for 2020 5.6 Harris County 2012 6.0 State of Texas 2011 5.2 United States 2006 6.1 Fetal Deaths per 100,00 Live Births Harris County 2005-2012 Causes of Fetal Death       Birth defects are present in 15%-20% of stillborn babies. Placental problems cause 25% of stillbirths. Poor fetal growth is present in 40% of stillbirths. Infections involving the mother, fetus, or placenta appear to cause 10%-25% of stillbirths. Chronic health conditions of the mother impact about 10% of stillbirths. Umbilical cord accidents may contribute to 2% to 4% of stillbirths. Social Impact of Fetal Death The loss of a pregnancy can have a major impact on families. Research indicates that relationships have a higher risk of dissolving after a miscarriage or stillbirth. Miscarriages account for approximately 15% of pregnancies and stillbirths affect close to 1% of all births; therefore, a large number of U.S. couples are affected. In a study population, the chances that a couple would dissolve following a miscarriage increased by 22%; following a stillbirth, the chances increased by 40%.4 3. March of Dimes. Pregnancy loss. March of Dimes Web site. http:// www.marchofdimes.com/baby/loss_stillbirth.html. Updated February 2010. Accessed October 9, 2014. 4. Gold K. Marriage and cohabitation outcomes after pregnancy loss. Pediatrics, 2010; 125(5):e1202-e1207. http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2883880/. Accessed October 13,2014 White 14 12 3 Rate 10.8 10.3 8 4 2 10.0 Hispanic 11.0 10.4 9.3 8.6 10 6 Black 11.8 5.6 4.6 5.2 4.3 5.5 5.3 5.5 4.7 4.9 4.5 5.4 5.8 5.6 5.2 5.2 5.3 0 2005 2006 2007 2008 2009 2010 2011 2012 Source: TDSHS 2011 with analysis by June Hanke, Harris County Hospital District. Public Health Actions    Monitor health status to identify and alleviate health problems by tracking fetal mortality rates and disseminating results to the community. Educate women about health matters in the preconception and interconception period. Mobilize community partnerships and action to identify and solve health problems, with advocacy for maternal and infant health and development of policies to support the health of mothers. For More Information Centers for Disease Control (CDC): http://www.cdc.gov/nchs/fetal_death.htm National Fetal–Infant Mortality Review Program: http://www.nfimr.org/ American College of Obstetricians and Gynecologists: www.acog.org March of Dimes: www.marchofdimes.org 91 This page intentionally left blank Chronic Diseases Chronic diseases such as heart disease, cancer and diabetes are responsible for seven out of every ten deaths each year. Costs associated with these three chronic diseases account for 75% of the nation’s health spending. Diabetes also poses a significant public health challenge for the United States. In 2010, 1.9 million new cases of diabetes were diagnosed in people over 20 years of age. Arthritis is the leading cause of disability in the United States, affecting one in five adults. Asthma is responsible for about 500,000 hospitalizations, 5,000 deaths, and 134 million days of restricted activity a year. Yet most of the problems caused by asthma could be averted if persons with asthma and their health care providers managed the disease according to established guidelines. Healthy People 2020 93 Heart Disease & Stroke Overview Heart disease and stroke are among the leading causes of death and disability in the United States. Heart disease is the leading case of death, followed closely by stroke, which ranks fourth in the U.S and third in Harris County. Heart disease has persisted as the leading cause of death in Harris County; however, stroke rose from the sixth leading cause of death in 2008 to the third leading cause of death in 2012—a mortality rate increase from 24.6 in 2008 to 41.9 in 2012. According to the CDC, more than one in three adults in the U.S. has some form of cardiovascular disease (CVD), including heart disease and stroke. Lowering or controlling for cholesterol levels and blood pressure can reduce the rates of CVD. According to 2013 BRFSS data, 5.5% of surveyed adults living in the Houston-Baytown-Sugar Land MSA (Houston MSA) reported having been diagnosed with some form of heart disease, compared to 5.7% of Texas adults. Of those aged 65 and over in Harris County, nearly one in five respondents reported having been diagnosed with some form of heart disease. Locally, racial differences are noted with more white and black survey respondents reported having been diagnosed with heart disease than Hispanic respondents; 8.2% of black respondents and 6.9% of white respondents, compared to 3.1% of Hispanic respondents. Trends: Houston/Harris County 2007-2013 BRFSS 2013 data show that among adults surveyed in the Houston MSA, 80.2% had had their cholesterol checked in the past five years, compared to 74.8% of Texas adults and 76.4% of U.S. adults. Of Houston MSA respondents who had their cholesterol checked, 38.0% had been told their blood cholesterol was high, compared to 37.7% in Texas and 38.4% nationwide. High blood pressure is often a component of heart disease. Survey data indicate that 32.8% of surveyed adults in the Houston MSA had been diagnosed with high blood pressure in 2013, compared to 31.2% of Texas adults and 31.4% of U.S. adults. High Blood Pressure Awareness, Adults 2007-2013 Houston MSA 30% 20% Even modest elevations in blood pressure increase the risk of CVD. In the Houston MSA, 2013 BFRSS data indicate that Hispanics were least likely to report high blood pressure, at 24.0%, compared to 45.5% of blacks and 39.5% of whites. The percentage of those reporting high blood pressure rose with age. Only 10.4% of those aged 18-29 reported high blood pressure, compared to14.2% of those aged 30-44, 43.2% aged 45-64, and 68.8% aged 65 and over. 27.2% 27.8% 26.5% 28.7% 30.7% U.S. 30.8% 32.8% 31.4% 31.3% 29.1% 31.2% 27.8% 10% 0% 2007 2009 2011 2013 Source: CDC, TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. Population Differences Heart disease mortality rates vary among demographic groups in Harris County, with higher rates among males in all racial/ethnic groups. In 2012, the overall mortality rate for heart disease was 171.9 deaths per 100,000 population—217.2 among men and 136.7 among women. Texas Heart Disease Mortality Rate, Harris County 2007-2012 Rate per 100,000 Population, Adjusted for Age Black 300 White Hispanic 254 250 200 220 210 218 220 230 177 146 229 204 150 100 223 143 124 132 2009 2010 166 105 181 118 50 2007 2008 2011 2012 Source: TDSHS, Vital Statistics According to the Office on Women’s Health, lesbian and bisexual women were found to have a higher prevalence of risk factors for CVD including greater rates of obesity, smoking, and increased stress. 94 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Geographic Differences Objective HDS-3: Reduce stroke deaths Rate per 100,000 of Deaths from Stroke Area Rate National Baseline 2007 43.5 Target for 2020 34.8 Harris County 2012 41.9 State of Texas 2012 41.7 United States 2011 41.4 Age-Adjusted to the 2000 Standard Population Public Health Actions Source: HDHHS Community Health Statistics. Note: Age-adjusted rates are not presented for areas with fewer than 25 deaths Years of Potential Life Lost is an estimate of the years of life lost if a person dies before the age of 65.  Mobilize community partnerships to improve health awareness and health status through collaboration among public and private sector partners, such as managed care organizations, health insurers, federally funded health centers, businesses, schools, and emergency response agencies.  Link people to personal health service programs to provide low income, underinsured or uninsured residents with knowledge, skills, and opportunities to delay and control for chronic diseases such as CVD.  Link people to a primary care clinic and establish a medical home.  Inform, educate, and empower people about CVD, the signs and symptoms of heart disease and stroke, and when to call 911. Economic Impact of Heart Disease and Stroke Combined, heart disease and stroke cause more than one-third of all U.S. deaths.1 In 2010, an estimated $444 billion was spent on cardiovascular disease (CVD) treatment, medication, and lost productivity from disability. Treatment alone costs the U.S. one in every six health care dollars.1 With the aging population, it is estimated that two in five Americans will have CVD by 2030. At this time expenditures on CVD are projected to exceed one trillion dollars in total direct and indirect medical costs.2 In 2010, Texas hospitalization charges related to CVD, including stroke, amounted to nearly $20 billion, accounting for nearly one fourth of all hospital charges in Texas.3 Texas Medicaid reimbursement costs for CVD medical claims, including ischemic heart disease, stroke, congestive heart failure, and hypertension, resulted in a cost of nearly $250 million.3 In the Houston MSA, hospital discharge data indicate that congestive heart failure resulted in over $636 million in hospital charges. Stroke hospital charges cost an additional $584 million.4 For More Information TDSHS CVD and Stroke Program: http:// www.dshs.state.tx.us/heart/Texas-HeartDisease-and-Stroke-Program---Home.aspx CDC:www.cdc.gov/DHDSP/index.htm CDC Fact Sheets (Spanish): http:// www.cdc.gov/dhdsp/spanish/ American Heart Association: www.heart.org 1. Centers for Disease Control and Prevention (CDC). Heart disease & stroke prevention: addressing the nation’s leading killers: at a glance 2011. http://www.cdc.gov/chronicdisease/resources/publications/AAG/dhdsp.htm. Accessed September 18, 2014. 2. American Heart Association. Forecasting the future of cardiovascular disease in the United States. http://www.heart.org. Accessed November 18, 2011. 3. Texas Department of State Health Services (TDSHS). Cardiovascular disease in Texas 2012. http://www.dshs.state.tx.us/heart/. Accessed September 29, 2014. 4. Texas Department of State Health Services (TDSHS). Fact sheets for CVD in Texas. http://www.dshs.state.tx.us/wellness/ factscitiesandcounties.shtm. Accessed Nov. 18, 2011. 95 Cancer Overview Cancer is a disease caused by the uncontrollable growth of abnormal cells that in some cases metastasize, or spread to other tissues. Cancerous cells can involve any tissue in the body and has different forms in each tissue; therefore, there are over 100 different types of cancer. Most cancers are named based on the type of cell or organ in which they originate. According to the CDC and TDSHS, cancer is the second leading cause of death in the United States and Texas. It is estimated that one in two men and one in three women will be diagnosed with cancer in his or her lifetime. In 2011, the National Program of Cancer Registries (NPCR) ranked Texas 48 th of the 50 states in cancer incidences—406.7 cases per 100,000 population.1 The TDSHS estimated 16,534 new cancer cases and 6,373 cancer-related deaths in Harris County in 2014. A person’s cancer risk can be reduced through lifestyle changes such as avoiding tobacco, better nutrition, and exercise. In addition, recommended cancer screenings can lead to earlier detection and increased likelihood of survival. Trends: Harris County 2007-2012 Deaths from Top Five Cancers Harris County TDSHS statistics for 2007-2012 indicate that the top three cancer diagnoses for men in Harris County were lung cancer, colorectal cancer, and prostate cancer. For women, the top diagnoses included lung cancer, breast cancer, and colorectal cancer. As a result of advances in treatment, death rates from cancer have declined in recent years; decreasing from 178.7 deaths per 100,000 population in 2007 to 160.3 in 2012. Rate per 100,000 Population Medical advances, such as the vaccine for the Human Papillomavirus (HPV) and targeted therapy, are improving cancer prevention and treatment. HPV can cause cervical cancer, which caused 56 deaths in Harris County in 2012. Type of Cancer 2007 2008 2009 2010 2011 2012 Lung 46.6 47.8 43.3 42.1 39.0 39.2 Colorectal 17.9 16.7 16.3 17.0 14.8 15.1 Breast 15.3 14.6 12.7 12.2 13.2 13.7 Pancreas 10.1 10.9 10.4 11.0 10.6 10.6 Liver 7.4 8.6 8.5 8.5 8.9 8.8 Source: TDSHS, Texas Health Data, available at http:// soupfin.tdh.state.tx.us/ Population Differences 600 Avg. Annual Cancer Incidence Rates 2007-2011 Orange: Women Blue: Men 500 400 300 200 100 All Races White Hispanic Texas Texas Black Harris County Harris County Texas Harris County Texas Harris County Texas 0 Harris County Blacks had the highest rates of cancer diagnoses in Harris County for both men and women—615.0 cases per 100,000 men and 410.0 cases per 100,000 women. For both men and women, Asians had the lowest rate of cancer diagnoses—297.4 for men and 233.9 for women. 700 Cases per 100,000 From 2007-2011, the Texas Cancer Registry reported an average of 14,623 new cases of cancer diagnosis in Harris County per year, a rate of 455.3 per 100,000 population. Blacks were more frequently diagnosed with cancer, with a rate of 489.2 cases per 100,000 population, followed by whites (453.3) and Hispanics (339.5). Asian Source: Texas Cancer Registry Americans who identify as LGBT have increased risks for cancer, but are less likely to receive screenings due to health insurance access, fear of discrimination by medical professionals, and previous negative experiences with the health care system.2 Lesbian and bisexual women are as likely to get cervical cancer as heterosexual women but are ten times less likely to receive a Pap smear screening.3 In addition, transgender men with female genitalia often neglect pelvic examination due to previous shaming by health care providers. In terms of breast cancer, lesbians have the greatest number of risk factors including higher smoking rates, never having children, obesity, and alcohol use. It is also reported that gay men have higher rates of HPV infection and when coupled with high tobacco use, increases their risk for anal and other cancers. 2 96 1. U.S. Cancer Statistics Working Group. United States cancer statistics: 1999–2011 incidence and mortality web-based report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2014. www.cdc.gov/uscs. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Healthy People 2020 Objective C-1: Reduce the overall cancer death rate New Cases of Invasive Cancer in Texas by County, 2007-2011 Rates per 100,000 population Overall Cancer Mortality Rates Per 100,000 Population Area Rate* National Baseline 2007 179.3 Target for 2020 161.4 Harris County 2012 160.3 State of Texas 2012 159.5 United States 2011 185.1 *Age-adjusted to the U.S. Standard Population. Deaths from Cervical Cancer in Harris County Number of Deaths Source: Texas Cancer Registry Economic Impact of Cancer In addition to the high human cost of cancer, cancer results in great economic harm to affected individuals, businesses, and society through premature morbidity and mortality, increased health care expenditures, and lost productivity. In 2009, the cost of cancer in the U.S. was estimated at $216.6 billion: $86.6 billion in direct medical costs and $130.0 billion in indirect mortality costs.4 In Texas, the cost of cancer in 2013 was an estimated $30.4 billion in direct medical costs and morbidity and mortality losses.5 In addition, cancer resulted in an estimated total loss of $74.4 billion in gross product and nearly 750,000 jobs. In the Gulf Coast region, where Harris County is located, $17.6 billion was lost in gross product and 161,501 jobs were lost due to cancer.5 The cost of cancer medication and treatment continues to rise. In 2010, a female over 64 with lung cancer was expected to have $60,533 in care costs during the initial diagnosis year, with continuing annual costs estimated at over $8,130, until the last year of her life, when costs were estimated to increase to $92,524.6 Number 70 60 60 55 51 3 Rate 50 53 55 56 2.3 40 20 0 2 1.9 1.5 1.5 1.4 1.5 1.5 1.5 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 1 0 Death Rate per 100,000 80 Source: TDSHS, Rate per 100,000 population Age adjusted to the 2000 standard population Public Health Actions  Inform, educate, and empower people to control for risk factors of cancer through healthy living and smoking cessation.  Mobilize partnerships with public health organizations, universities, medical centers, and other groups to address concerns such as racial disparities in cancer rates. For More Information CDC: www.cdc.gov/cancer Texas DSHS Cancer Registry: www.dshs.state.tx.us/tcr/default.shtm Texas DSHS Breast and Cervical Cancer Control: www.dshs.state.tx.us/bcccs/ 2. Margolies, L. The same, only scarier—the LGBT cancer experience. American Cancer Society Web site. http://www.cancer.org/cancer/news/ expertvoices/post/2014/06/05/the-same-only-scarier-the-lgbt-cancer-experience.aspx. Published June 5, 2014. Accessed September 22, 2014. 3. Peitzmeier SM. Promoting cervical cancer screening among lesbians and bisexual women. The Fenway Institute. http://www.fenwayhealth.org/ site/DocServer/PolicyFocus_cervicalcancer_web.pdf?docID=10661. Accessed December 22, 2014. 4. American Cancer Society. Cancer facts & figures 2014. American Cancer Society Web site. http://www.cancer.org/acs/groups/content/@research/ documents/webcontent/acspc-042151.pdf. Accessed September 8, 2014. 5. The Perryman Group. An economic assessment of the cost of cancer in Texas and the benefits of the Cancer Prevention and Research Institute of Texas (CPRIT) and its Programs: 2013 Update. http://www.cprit.state.tx.us/images/uploads/rp_cprit_impact_2013.pdf. Published December 2013. Accessed September 22, 2014. 6. National Cancer Institute. Cancer prevalence and cost of care projections. http://costprojections.cancer.gov/annual.costs.html. Accessed November 30, 2011. 97 Diabetes Overview Diabetes mellitus is a metabolic disease characterized by persistent hyperglycemia or high blood sugar. It requires medical diagnosis, treatment, and management through lifestyle changes. The U.S. Department of Health and Human Services recognizes three main forms of diabetes: type 1, type 2, and gestational diabetes, which is diagnosed during pregnancy.  Type 1 diabetes, usually diagnosed in children and young adults, occurs when the body does not produce insulin, a hormone needed to convert sugar, starches, and other foods into energy.  Type 2 diabetes begins as insulin resistance, a disorder in which the cells do not use insulin properly. Over time the body does not produce enough insulin.  Gestational diabetes occurs in pregnant women with high blood glucose levels with no prior diagnosis of diabetes. Treatment is needed to normalize maternal blood glucose levels to avoid complications in the infant.1 Complications from Diabetes2,3 Medical Condition Impact Heart Disease 1.7 times greater risk Stroke 1.5 times greater risk High Blood Pressure 71% of diabetic adults High Blood LDL Levels 65% of diabetic adults Leading cause in adults, age 20-74 Blindness Kidney Failure Leading cause Nervous System ~50% of diabetic adults have nerve damage Amputations Causes > 60% of lower limb amputations Greater frequency and severity in diabetics Dental Disease Since the first therapeutic use of insulin in 1921, diabetes has been a chronic but treatable condition. Treatment has improved greatly over the years; however, patients must be very diligent about maintaining appropriate blood sugar levels. The most concerning health risks are long-term complications (listed in the table above). An estimated 21 million Americans have diagnosed diabetes and an additional 8.1 million (27.8%) have diabetes but are undiagnosed. In Harris County, diabetes is the seventh leading cause of death—a rate of 21.9 deaths per 100,000 population. According to 2013 BRFSS data, 10.8% of surveyed adults in the Houston-Baytown-Sugar Land MSA reported they had been told by a physician that they have diabetes, compared to 10.9% of surveyed adults in Texas. Trends: Harris County 2003-2013 Percent Ever Diagnosed with Diabetes 2004-2013 Death Rate from Diabetes, 2008-2012 Harris County and Texas Harris County 29 27 25 23 Texas US 11.4% 11% 25.4 25.0 23.1 23.0 21 19 21.6 19.6 17 22.1 21.8 9% 21.9 7% 19.0 5% 15 2008 2009 2010 2011 2012 Source: TDSHS Vital Statistics Note: Death Rate per 100,000 Population. Rates are age-adjusted to the 2000 standard population. 98 Houston MSA Texas 3% 10.8% 9.2% 8.8% 6.8% 7.1% 7.8% 8.5% 8.9% 5.8% 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 Source: CDC, TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Population Differences Objective D-3: Reduce the diabetes death rate Percent at Risk Diabetes Prevalence 2013 Houston-Baytown-Sugar Land MSA 15% Deaths from Diabetes Per 100,000 Population 14.8% 12.1% 10.8% 10.3% 11.3% 10% Area 9.3% Rate National Baseline 2007* 74.0 5% Target for 2020* 66.6 0% Harris County 2012 21.9 State of Texas 2012 21.8 United States 2011 23.7 Percent of persons participating in the survey who have been told by a doctor they have diabetes. Excludes gestational diabetes. Source: TDSHS BRFSS Economic Impact of Diabetes In 2012, the estimated cost of diabetes in the United States was $245 billion: $176 billion in direct medical costs and $69 billion attributed to disability, work loss, and premature death.2 In Texas, diabetes is responsible for approximately $18.5 billion in spending, with an estimated $12.3 billion in direct medical costs and $6.2 billion in indirect costs.3 Sixty percent of all medical costs related to diabetes is paid by the public sector through Medicare and Medicaid. In addition, Texas spends $21 million in diabetes prevention programs.3 After adjusting for population, age, and sex differences, diabetic patients’ estimated health care costs were 2.3 times higher than nondiabetic patients. The 2007 national study estimated that one out of every ten health care dollars is spent on diabetes treatment.1 Due to an aging population and current sedentary lifestyle choices, the CDC estimates that up to one third of the American population will have diabetes by 2050.5 Diabetes can be treated and managed by healthy eating, regular physical activity, and medication to lower blood glucose levels. —CDC Age adjusted to the 2000 standard population *The National Baseline and Target are set by Healthy People 2020 and measure deaths related to diabetes. The following three measures track diabetes as listed as the primary cause of death on death certificates. Public Health Actions  Monitor health and mortality of diabetics to identify and solve barriers to prevention and management.  Inform people about the importance of healthy behaviors and lifestyle to prevent diabetes.  Educate diabetics about chronic disease selfmanagement and how to improve risk factors related to diabetes.  Link people to needed health assessments and referrals for treatment. For More Information Texas Diabetes Council: www.dshs.state.tx.us/ diabetes CDC: www.cdc.gov/diabetes www.cdc.gov/spanish American Diabetes Association: www.diabetes.org National Library of Medicine: www.nlm.nih.gov/medlineplus/diabetes.html 1. US Department of Health and Human Services, National Diabetes Information Clearinghouse (NDIC). National diabetes fact sheet. http:// www.diabetes.niddk.nih.gov/dm/pubs/statistics/#fast. Accessed October 26, 2011. 2. Centers for Disease Control and Prevention (CDC). National diabetes statistics report, 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/ national-diabetes-report-web.pdf. Accessed September 22, 2014. 3. Centers for Disease Control and Prevention (CDC). Diabetes health concerns. CDC Web site. http://www.cdc.gov/diabetes/consumer/problems.htm. Updated November 7, 2012. Accessed September 23, 2014. 4. Health and Human Services Commission. Report of direct and indirect costs of diabetes in Texas. http://www.hhsc.state.tx.us/reports/2012/directindirect-costs-diabetes-texas.pdf. Published December 2012. Accessed September 23, 2014. 5. Center for Disease Control and Prevention (CDC). Press release: number of Americans with diabetes expected to double or triple by 2050. http:// www.cdc.gov/media/pressrel/2010/r101022.html. Accessed November 17, 2011. 99 Arthritis Overview With the aging of the Baby Boomers, it is estimated that 67 million adults will have arthritis by 2030. According to the CDC, arthritis, a condition that results in joint pain, swelling, and stiffness, is the leading cause of disability in the U.S. Arthritis includes over —Arthritis Foundation 100 different diseases and conditions that affect joints and the surrounding tissue. Some forms of arthritis can affect multiple organs and cause widespread symptoms. The most common types of arthritis are osteoarthritis and rheumatoid arthritis. Other arthritic diseases include gout, systemic lupus erythematosus, and fibromyalgia. Osteoarthritis, the most common form of arthritis, begins with the breakdown of cartilage in the joints. As people age, they are more likely to develop symptoms of osteoarthritis. Other factors, such as being overweight or obese, having joint injuries, and working in certain occupations, increase the risk of developing osteoarthritis. There is currently no cure for osteoarthritis; therefore, treatment focuses on relieving symptoms and maintaining or improving function. Approximately one of five U.S. adults report doctor-diagnosed arthritis. Moreover, arthritis is often experienced with other chronic conditions or diseases. The CDC reports that nearly half (47%) of U.S. adults with arthritis have at least one other disease or condition. Over half of adults with heart disease (57%) or diabetes (52%) and more than one-third of those with high blood pressure (44%) or obesity (36%) also have arthritis. Trends: Houston/Harris County 2007-2013 Percent of Adults Reporting Activity Limitation Due to Arthritis Houston MSA 47.7 47.2 Texas 52.1 53.0 53.7 52.5 34.6 33.0 2007 2009 2011 2013 Physical activity can reduce pain and improve function, mental health, and quality of life of people living with arthritis; however, those with arthritis are less likely to be physically active. 1 The prevalence of adults who experience activity limitations due to arthritis has been increasing, with a marked change between 2007 and 2009. In 2013, 52.5% of adult respondents in the Houston MSA identified limitation in activity due to arthritis, compared to 53.7% of Texas adults. Source: TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods Population Differences Arthritis is more likely to be diagnosed as age increases and is more common among women. According to 2013 BRFSS data, 20.5% of adults in the Houston-Baytown-Sugar Land MSA reported doctor-diagnosed arthritis. Adults with incomes less than $25,000 were more likely to report doctor-diagnosed arthritis (28.6%) compared to those with higher incomes (18.1% for adults with an income of $50,000 or more). This pattern is also seen at the state and national levels. 100 Percent Adults Reporting Some Form of Arthritis Houston-Baytown-Sugar Land MSA, 2013 28.6% < $25,000 Source: TDSHS BRFSS 18.2% 18.1% $25,000-$49,999 $50,000+ T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Healthy People 2020 Objective AOCBC-2: Reduce the proportion of adults with doctor-diagnosed arthritis who experience a limitation in activity due to arthritis or joint symptoms. Projected Percent Increase Adults with Arthritis from 2005—2030, by State Adults with Activity Limited by Arthritis or Joint Symptoms Area ≥100% 50-99% 30-49% 20-29% 10-19% Decrease Source: Centers for Disease Control and Prevention To help prevent arthritis:  Be physically active  Maintain a healthy weight  Protect your joints from injury  See your doctor for management strategies —CDC Economic Impact of Arthritis Arthritis is the number one cause of disability in the United States. According to the CDC, over fifty million people, or approximately one in five Americans, have doctor-diagnosed arthritis. The CDC reports that the total cost attributable to arthritis and other rheumatic conditions in the United States was approximately $128 billion in 2003. This figure includes $80.8 billion in direct medical expenditures and $47.0 billion in lost earnings. The total value is equivalent to 1.2% of the 2003 U.S. gross domestic product. Total costs by state, estimated by the CDC, ranged from $226 million in the District of Columbia to $12.1 billion in California. In 2003, Texas was estimated to have $8.7 billion in direct and indirect costs related to arthritis and rheumatic conditions. The CDC also reports that national medical costs attributable to these conditions grew by 24% between 1997 and 2003. As the population ages, the prevalence and cost of arthritis is projected to increase. By 2030, it is estimated that one-fourth of the population will have some form of arthritis.2 Percent National Baseline 2008 39.4 Target for 2020 35.5 Houston MSA 2013 53.7 State of Texas 2013 52.5 United States 2012 40.4 Public Health Actions  Increase awareness of the use of physical activity to manage arthritis pain, ease arthritis symptoms, increase function, and prevent further physical disability.  Inform, educate, and empower people to address chronic disease concerns such as arthritis, including the appropriate use of medications, communicating effectively with health professionals, and evaluating new treatments. For More Information Centers for Disease Control and Prevention: www.cdc.gov/arthritis Arthritis Foundation: http://www.arthritis.org/ National Institute of Arthritis: www.niams.nih.gov Kids Get Arthritis, Too is a branch of the national Arthritis Foundation. Children may suffer from juvenile idiopathic arthritis (JIA), considered the most common form of juvenile arthritis. JIA begins before age 16 and involves swelling in one or more joints lasting at least six weeks. —Arthritis Foundation 1. Centers for Disease Control and Prevention (CDC). Arthritis: meeting the challenge of living well. CDC Web site. http://www.cdc.gov/ chronicdisease/resources/publications/aag/pdf/2013/arthritis-aag-2013_508.pdf. Accessed September 25, 2014. 2. Arthritis Foundation. Raising our voices to fuel arthritis research. Arthritis Foundation Web site. http://www.arthritis.org/research-update-raisingvoices.php. Accessed January 2, 2012. 101 Asthma Overview In the United States, nine people die each Asthma is a chronic (long-term) lung disease that day from asthma. — CDC affects both children and adults. When a person has asthma, the airways, or inner tubes, that carry air in and out of the body are inflamed. This makes airways very sensitive to any irritants or allergens, such as secondhand smoke, dust, furry pets, poor air quality, or mold.1 When airways react to these unwanted substances, they narrow, which cause episodes of wheezing, shortness of breath, and coughing. When symptoms are severe, the episode may be called an asthma attack. The exact causes of asthma are unknown and there is no available cure; however, symptoms are manageable. The best ways to prevent and control asthma attacks are to take medications as prescribed and avoid asthma triggers. In the United States, over 25 million Americans currently suffer from asthma. In children, asthma is one of the most common chronic childhood disorders, affecting an estimated 7.1 million children and ranking third in leading causes of hospital admissions for children under age 15. 2 A telephone survey conducted by the American Lung Association estimated that over 91,000 children and 209,000 adults in Harris County have been diagnosed with asthma.3 Trends: Houston/Harris County 2003-2013 Current Asthma 2003-2013 U.S. 11% 10% 8.8% 9% 8% Texas 7.6% 6.9% 7.3% 7% Houston MSA 8.9% 6.8% 6% 5% 6.1% 6.1% 4% 4.9% Source: CDC, TDSHS BRFSS Note: See Appendix E for changes in BRFSS data collection methods from 2011 onward. Population Differences According to 2013 BRFSS data, women were more likely than men to report current asthma (7.0% versus 3.0%) in the Houston-BaytownSugar Land MSA. Blacks and whites, 9.2% and 7.4% respectively, were more likely to report current asthma than Hispanics (1.8%). With respect to education, high school graduates were more likely to report current asthma than persons without a high school diploma. The BRFSS telephone survey includes questions about the prevalence and severity of asthma. Participants are asked if they have ever been diagnosed with asthma, and if they respond yes, they are asked if they still have asthma. The percentage of local adults who report current asthma decreased from its peak in 2006 (8.5%) through 2010 (4.9%). In fact, the percentage of Houston MSA adults with asthma shifted below the U.S. and Texas percentages in 2008. In 2012, 5.2% of Houston MSA adults reported current asthma, compared to 7.3% of Texas respondents. Percent with Asthma, Houston MSA 2013 Male 3.0% Female 7.0% White 7.4% Black 9.2% Hispanic 1.8% 0% 2% Source: TDSHS BRFSS 102 4% 6% 8% 10% T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Prevalence of Adult Asthma, United States by State, 2009 Objective RD-2.2: Reduce hospitalization for asthma Hospitalization Rates per 10,000 People Ages 5-64 Area % of all adults ≥9% 8%->9% 7%->8% 5%->7% Source: CDC, 2011 National Asthma Profile Economic Impact of Asthma In 2007, the national annual cost of asthma was estimated at nearly $56 billion: $50 billion in direct costs and $6 billion in indirect costs such as loss of productivity due to missed work or school.3 In 2009, there were nearly 480,000 hospitalizations, 1.9 million emergency department visits, and 8.9 million doctor visits related to asthma. In Texas, asthma-related hospitalization costs totaled to more than $620 million in 2011.4 In the Texas Health Service Region 6 (Houston Area), the 2011 hospital admittance rate with asthma as the primary diagnosis was 7.7 per 10,000 admissions, lower than the state rate of 9.4.4 As one of the most common chronic childhood disorders, asthma is one of the leading causes of school absenteeism. In 2008, a total of 14.4 million school days were missed by children who had an asthma attack the previous year.2 Rate National Baseline 2007 11.1 Target for 2020 8.7 Texas Health Service Region 6 2011* 7.7 State of Texas 2011* 9.4 United States 2010 10.5 *All ages. Note: Texas Health Service Region 6 includes Harris County and the surrounding counties. Public Health Actions  Monitor health status and disease prevalence to provide data for health planning to alleviate environmental triggers of asthma.  Inform, educate, and empower people about asthma risk factors and management through publications, trainings, and other media sources.  Enforce laws to manage air pollution which can aggravate asthma. For More Information Centers for Disease Control: www.cdc.gov/ asthma/default.htm Facts about asthma in Spanish: www.cdc.gov/asthma/es/faqs.htm TX Department of State Health Services: www.dshs.state.tx.us/asthma/default.shtm Asthma limits physical activity and results in missed school and work days. — CDC American Lung Association: www.lungusa.org National Asthma Education and Prevention Program: www.nhlbi.nih.gov 1. Centers for Disease Control and Prevention (CDC). Asthma’s impact on the nation. http://www.cdc.gov/asthma/impacts_nation/ asthmafactsheet.pdf. Accessed September 25, 2014. 2. American Lung Association. Asthma and children fact sheet. http://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-children -fact-sheet.html. Updated September 2014. Accessed September 25, 2014. 3. American Lung Association, State of the Air 2014. Texas: Harris County. http://www.stateoftheair.org/2014/states/texas/harris-48201.html. Accessed September 25, 2014. 4. Texas Department of State Health Services (TDSHS). Asthma health facts 2011. http://www.dshs.state.tx.us/asthma/data.shtm#New_Asthma. Updated November 2013. Accessed September 25, 2014. 103 Mental Health Indicators Overview Mental health refers to positive emotional and psychological well-being. On the other hand, mental illnesses are health conditions that are characterized by changes in thinking, mood, or behavior that are associated with distress and/or impaired functioning. Mental illnesses can cause severe impairment in one’s ability to cope with daily life and can impact physical health. Some mental illnesses, such as depression, may lead to suicide. According to the CDC, mental and emotional illnesses rank among the top ten causes of disability in the United States. The Mental Health and Mental Retardation Authority of Harris County (MHMRA) provided the following 2010 Harris County estimates:1 Estimated Number of Adults with Mental Health Disorders in Harris County, 2012 200,000 177,913 150,000 100,000 50,000 66,476 34,286 40,910 0 Schizophr enic Major Disorders Depressive Disorders Bipolar D isorders Obsessive Compulsive Disorders Source: Estimates provided by Harris County MHMRA using 2012 Texas State Data Center population estimates and the U.S. Surgeon General’s prevalence estimates.  Nearly 500,000 adults suffer from a mental illness, 137,000 of which have a severe mental illness.  Nearly 150,000 children and adolescents between 6 and 18 years old have a mental illness, 89,000 of which have a serious emotional disturbance. According to the MHMRA, the high rate of uninsured residents in Harris County has resulted in many untreated mental health illnesses. In 2012, over half of severely mentally ill adults could not access treatment from public or private health systems and 74% of children and adolescents with a serious emotional disturbance did not receive needed services from the public mental health system. 1 Approximately 15% of those waiting for services deteriorate into crisis and require intervention at psychiatric emergency centers, inpatient hospitals, or in jail.2 During the 2010 fiscal year, the public mental health system in Harris County (MHMRA and Harris County Psychiatric Center) was able to provide services to about 29,000 persons—about 4,600 youth and 24,800 adults.1 In Harris County, the criminal justice system treats many of those with mental health conditions, particularly among the uninsured. Twenty-four percent of Harris County residents in jail have a current or past mental illness diagnosis.2 Mental illness is even more apparent in the juvenile justice system; of the 9,100 children referred to the Harris County Probation Department in 2012, 69% had a diagnosable mental illness.1 The chart above provides an estimate of adults in Harris County with mental health disorders using the U.S. Surgeon General’s prevalence estimates. Trends: Houston/Harris County 2009-2013 Adults With 5+ Days Poor Mental Health U.S. 19.9% In Past 30 Days Texas Houston MSA 20.8% 19.9 % 20.1% 20.8% 17.5% 19 .7% 1 9.9% 21.0% 20.1% 20.4 % 14.6% * 2009 2010 * * 2011 2012 2013 *U.S. data unavailable. Source: CDC, TDSHS BRFSS See Appendix E for changes in BRFSS data collection methods from 2011 onward. 104 Harris County MHMRA estimated that in 2010 about 500,000 adults and 150,000 youth experienced a mental health condition or emotional disturbance.1 The BRFSS assesses mental health by asking survey participants if they had five or more days of poor mental health, including problems with stress, depression, and emotions, during the past 30 days (see chart at left). Females in the Houston MSA are more likely to report five or more days of poor mental health at 18.7%, compared to males at 10.0%; and more younger persons reported this concern, at 21.5% for ages 18-29, compared to 5.6% for those 65 and older. Rates among racial/ethnic groups are similar. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Population Differences The 2013 BRFSS data for the HoustonBaytown-Sugar Land MSA shows that women more frequently reported five or more days of poor mental health (18.7%) compared to men (10.0%). In addition, those with incomes of $50,000 or more were less likely to report poor mental health (11.5%), compared to those with incomes below $25,000 (21.5%). The chart to the right shows reported mental health differences by race/ethnicity since 2009. Geographic Distribution The map to the right shows areas where serious psychological distress (SPD) is most prevalent in Houston/Harris County. SPD was determined by questions asked as part of the Health of Houston Survey, led by Dr. Stephen Linder.3 Adults With 5+ Days Poor Mental Health in a Month White Black Hispanic 29.1% 24.7% 24.2% 24.7% 25.0% 24.2% 21.4% 18.4% 18.8% 18.6% 21.8% 15.4% 2009 16.3% 15.0% 14.1% 2010 2011 2012 2013 Source: TDSHS BRFSS Note: See Appendix E for recent changes in BRFSS data collection. Percent of Adults with Serious Psychological Distress by Quartiles Houston/Harris County 2010 Mental Health Services: Usage and Need The second map to the right shows the percentages of people who obtained mental health services at least once in the 12 months leading up to the survey. Darker shades represent higher percentages of those who sought and received care. The hatched areas indicate the highest percentage of persons who reported needed mental healthcare. Spring Branch-Carverdale, Edgebrook-Ellington, and Addicks-Bear Creek had the highest percentages of people who needed services and obtained care.3 Barriers to Receiving Mental Health Services Source: UT School of Public Health, Health of Houston Survey Percent of Adults with Mental Health Visits and Perceived Need by Quartiles Houston/Harris County 2010 In the Health of Houston Survey 2010, 8% of Houston/Harris County adults reported seeing a mental health professional in the last year. An additional 9% reported needed professional mental health assistance, but were unable to obtain care. Of those who were unable to access mental healthcare, nearly 60% identified cost as the principal barrier, followed by feeling uncomfortable (31%), concerned that someone would find out (22%), and having trouble getting an appointment (17%). In addition, 38% of residents who did not get the help they needed faced more than one barrier in seeking mental health care.3 Source: UT School of Public Health, Health of Houston Survey 1. MHMRA of Harris County. Data provided by request. 2. Mental Health Needs Council, Inc. Mental illness in Harris County, 2013. http://mhneedscouncil.com/mhnc-2013-report/. Accessed October 30, 2014. 3.The University of Texas School of Public Health. Health of Houston survey, HHS 2010 a first look. Houston, TX: Institute for Health Policy, The University of Texas School of Public Health, 2011. https://sph.uth.edu/content/uploads/2010/09/HHS-8.5x11-Sep30_cover.pdf. Accessed July 18, 2014. 105 Mental Health Indicators, cont. The Burden of Mental Illness The impact of mental illness on the overall burden of disease in developed countries, such as the United States, has been estimated at 15%. In addition, mental disorders account for 25% of years lost to disability and premature mortality.1 Overuse of Emergency Rooms People with serious mental illnesses of major depression, bipolar disorder, schizophrenia, and obsessive compulsive disorder are likely to overuse intensive, high-cost medical services rather than preventive care.2 Adults with a mental illness are more likely to use an emergency room (38.8% versus 27.1%)3 and are 3.4 times more likely to be hospitalized following an ER visit than those without a mental illness.4 Co-Existing Physical Health Problems Mental and physical health conditions are risk factors for each other and the presence of one can complicate treatment for the other. For example, individuals with mental illnesses have greater risk factors, such as smoking and obesity, that lead to an increased likelihood of chronic diseases. In the United States, 68% of adults with mental health conditions also have medical conditions.5 Research indicates that individuals with mental illness have shortened life spans; however, the causes of death are similar to those without a mental illness. Percent Diagnosed with Diabetes With a Co-Existing Mental Disorder Nearly half of individuals with a co-existing seriSource: Bazelon Center for Mental Health Law. Getting it together: ous mental illness and physical condition had at least one chronic illness severe enough to limit daily functioning. Furthermore, those with serious mental disorders are twice as likely to suffer from multiple major medical conditions and those with both a mental illness and a substance abuse disorder are the most likely to have medical problems. 7 According to MHMRA, 28% of adults with a severe mental illness in Harris County report co-occurring substance abuse. Among those with serious mental illnesses, people with schizophrenia have particularly high rates of medical conditions. A study examining the prevalence of 12 physical health conditions among individuals with schizophrenia found that two thirds (65%) had at least one lifetime medical condition and 36% had more than one lifetime condition.7 Problems with eyesight, teeth, bowels, and high blood pressure were most common. Of those who reported doctor-diagnosed high blood pressure, 57.7% currently had the condition and 80% of those were currently receiving treatment.7 The chart above compares the prevalence of diabetes among the general population with those suffering from serious mental illnesses. Traditionally, it has been reported that the lifespan for individuals with schizophrenia is about 10 years shorter than the national average; however, the National Association of State Mental Health Program Directors has suggested that the estimate falls short. Lifespans for individuals with schizophrenia may be shortened by as many as 25 years.2 106 1. Texas Department of State Health Services (TDSHS). The health status of Texas, 2011. www.dshs.state.tx.us. Published June 2013. Accessed September 30, 2014. 2. Parks J, Svendsen D, Singer P, Foti ME. Morbidity and mortality in people with serious mental illness. National Assn of State Mental Health Program Directors, Alexandria, VA. 2006. http://www.dsamh.utah.gov/docs/mortality-morbidity_nasmhpd.pdf. Accessed January 23, 2012. 3. Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality. The NSDUH report: physical health conditions among adults with mental illnesses. http://archive.samhsa.gov/data/2k12/NSDUH103/SR103AdultsAMI2012.pdf. Published April 5, 2012. Accessed September 30, 2014. 4. Hamilton JE, Begley C, Jeong S. Behavioral health related ER visits. Center for Health Services Research, UT School of Public Health. Center for Excellence in Mood Disorders. UT Medical School Department of Psychiatry. 2014. 5. American Hospital Association. Bringing behavioral health into the care continuum: opportunities to improve quality, costs, and outcomes. http:// www.aha.org/research/reports/tw/12jan-tw-behavhealth.pdf. Published January 2012. Accessed September 30, 2014. 6. Bazelon Center for Mental Health Law. Getting it together: how to integrate physical and mental health care for people with serious mental disorders. 2004:6-9. http://www.bazelon.org/LinkClick.aspx?fileticket=FamA0HBviIA=. Accessed October 6, 2014. 7. Dixon L, Postrado L, Delahanty J, Fischer PJ, Lehman A. The association of medical comorbidity in schizophrenia with poor physical and mental health. The Journal of Nervous and Mental Disease, 1999;187:486-502. http://ovidsp.ovid.com.ezproxyhost.library.tmc.edu/ovidweb.cgi? T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00005053-199908000-00006&D=ovft&PDF=y. Accessed October 6, 2014. 8. Insel TR. Assessing the economic costs of serious mental Illness. Am J Psychiatry. 2008;165:663-665. http://ajp.psychiatryonline.org/article.aspx? articleid=99862#T21T1. Accessed January 2, 2012. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Economic Impact of Mental Health The annual costs of serious mental illness in the U.S. have been estimated at $317 billion in direct health care expenditures, loss of earnings, and disability benefits.8 This estimate excludes costs associated with mental illness such as incarceration, homelessness, and early mortality which are estimated to more than $1,000 per year for every man, woman, and child in the United States.8 A separate study estimated the loss of earnings associated with the most common mental disorders in the U.S. at $193 billion each year.9 Texas ranks 49th in state per capita mental health services expenditures at $38.99, well below the national average of $120.56.10 Insufficient public funding can result in economic loss, homelessness, increased juvenile and adult criminal justice system involvement, and a decrease of approximately 25 years in life expectancy. In Houston, mental illnesses account for more than $5.6 billion in lost productivity and annual earning.11 Community-based services offer the most cost-effective care within the public mental health system. In Texas, the average per day cost of community-based services is $12 for adults and $13 for children, compared to $401 for a state hospital bed, $137 for a jail bed, and $1,265 for an emergency room visit.12 Objective MHMD-1: Reduce the suicide rate. Rate of Suicide per 100,000 Area Rate National Baseline 2007 11.3 Target for 2020 10.2 Harris County 2012 10.6 State of Texas 2012 11.8 United States 2011 12.7 Public Health Actions  Monitor mental health trends by tracking treatment facility admissions and cooccurring conditions such as chronic disease, substance abuse and criminal justice.  Provide health care where otherwise unavailable by diagnosing and treating lowincome persons with severe mental illness.  Mobilize community partnerships to identify and solve mental health problems through support of organizations such as the Mental Health Association and the MHMRA Intellectual and Developmental Disabilities Planning Advisory Council. For More Information Texas educators are required by Senate Bill 460 to be trained to identify students with mental or emotional disorders, to intervene in a positive manner, and to provide support in an educational setting. -Texas SB460, September 1, 2013 National Mental Health Association: www.nmha.org Houston Mental Health Association: www.mhahouston.org National Institute of Mental Health: www.nimh.nih.gov CDC: www.cdc.gov/mentalhealth/index.htm MHMRA: www.mhmraharris.org/ Texas DSHS: www.dshs.state.tx.us/mentalhealth.shtm Suicide & Crisis Center: www.sccenter.org Suicide Prevention Resource Center: http://www.sprc.org/ 9. Kessler RC, Heeringa S, Lakoma MD, Petukhova M, Rupp AE, Schoenbaum M, Wang PS, Zaslavsky AM. The individual-level and societal-level effects of mental disorders on earnings in the United States: Results from the National Comorbidity Survey Replication. Am J of Psychiatry. 2008;165:703-711. http://ajp.psychiatryonline.org/article.aspx?. Volume=165&page=703&journalID=13. Accessed January 2, 2012. 10. Kaiser Family Foundation. State mental health agency (SMHA), per capita mental health services expenditures, 2010. http://kff.org/other/stateindicator/smha-expenditures-per-capita/. Accessed October 1, 2014. 11. Mental Health Policy Analysis Collaborative, University of Texas School of Public Health. The consequences of untreated mental illnesses in Houston. http://www.mhtransformation.org/documents/reports/external/The%20Consequences%20of%20Untreated%20Mental%20Illness%20In% 20Houston.pdf. Published September 2009. Accessed September 30, 2014. 12. Mental Health America of Texas. Saving minds, saving money. MHA Texas Web site. http://newsite.mhatexas.org/page/legislature-2011. Published 2011. Accessed January 2, 2012. 107 This page intentionally left blank Communicable Diseases Infectious diseases remain major causes of illness, disability and death. Moreover, new infectious agents and diseases are being detected, and some diseases considered under control have reemerged in recent years. In 2008, imported measles resulted in 140 reported cases—almost a three-fold increase in one year. In addition, antimicrobial resistance is evolving rapidly in a variety of hospital- and community-acquired infections. Approximately 42,000 adults and 300 children die yearly from vaccine treatable diseases. Infectious diseases such as pneumonia and influenza cause 56,000 deaths a year and are the eighth leading cause of death in the United States. Infectious diseases, such as the H1N1 virus, also must be considered in a global context. Increases in international travel, migration, importation of foods, inappropriate use of antibiotics on humans and animals, threat of bioterrorism, and environmental changes multiply the potential for worldwide epidemics of all types of infectious diseases. International cooperation and collaboration on disease surveillance, response, research, and training are essential to prevent or control these epidemics. Healthy People 2020 109 HIV/AIDS Overview Acquired Immunodeficiency Syndrome (AIDS) was first reported in the United States in 1981 and has since become pandemic. AIDS is caused by the Human Immunodeficiency Virus (HIV), a virus that attacks cells of the immune system and destroys the body’s ability to fight off infections. At the beginning of the epidemic, people died within about 10 years of becoming infected with HIV. In 1996, the introduction of highly active antiretroviral therapy (HAART), commonly known as triple cocktail, significantly slowed the progression of HIV to AIDS and AIDS to death. According to the TDSHS, the HIV/AIDS mortality rate in Harris County decreased from 7.3 deaths per 100,000 population in 2008 to 4.7 deaths per 100,000 population in 2012. HIV infection is most often spread by direct contact with blood or with semen or vaginal fluid during unprotected sex with an infected partner. It is also spread among injection drug users by sharing needles contaminated with HIV. In addition, an infected mother can pass HIV to her baby during pregnancy or delivery, as well as through breastfeeding. The CDC estimates that more than 1.1 million persons are currently living with HIV in the United States and one in six does not know their status. According to the HDHHS 2010 estimation, approximately 20,022 persons are living with HIV or AIDS in Houston/Harris County, a rate of 489 per 100,000 population. Of those living with HIV, 74% are male, 50% are black, 25% are white, and 23% are Hispanic.1 Trends: Houston/Harris County 2004-2013 Newly Diagnosed Adult* HIV Cases, Regardless of AIDS Status, in Houston/Harris County 1334 1350 1300 1289 1275 1275 1250 1223 1242 1185 1187 1200 1150 1127 1129 1100 1050 While AIDS has been a reportable condition in Texas since the 1980s, HIV infection did not become reportable until 1999. Reported new HIV cases among adults, regardless of AIDS status, in Houston/Harris County have decreased in the last three years, with 1,242 cases reported in 2013. The CDC estimates that 20% of HIV/AIDS infections are undiagnosed; therefore, based on HDHHS estimates, close to 4,000 persons in Houston/Harris County may be infected with HIV but are not aware of their status. 1000 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 *Adult cases defined as 13 years of age and older. Source: HDHHS Bureau of Epidemiology Quarterly Report, 2014. Summary of Houston/Harris County cases. http://www.houstontx.gov/ health/HIV-STD/hivaidspage.html. Accessed October 3, 2014. Population Differences Forty-two percent of reported HIV cases, regardless of AIDS status, from 1999 to mid-2014 in Houston/Harris County were transmitted by male to male sex, 25% by heterosexual sex, and 8% by intravenous drug use. Male to male transmission is most common mode of transmission overall; however, heterosexual transmission is the most common among the black population.2 Cumulative HIV Infection Diagnoses by Mode of Transmission Houston/Harris County 1999-6/30/2014 10000 8000 Hispanic White Black 3015 6000 1237 2924 394 4000 2000 3547 223 322 1278 3929 Male to Male Sex Injection Drug Use Heterosexual Sex 0 Source: HDHHS Bureau of Epidemiology 110 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Healthy People 2020 New HIV Diagnoses in Houston/Harris County 20111 Objective HIV-4: Reduce new AIDS cases among adolescents and adults Rate of New AIDS Cases per 100,000 population Area Source: Houston/Harris County eHARS. Background rate is rate of new HIV diagnoses for Houston/Harris County in 2011 at the time of data run. New AIDS Cases 2011 Rate per 100,000 population 20 18.6 15 10.2 10 10.3 5 0 Harris County Texas Economic Impact of HIV/AIDS Thirty years after the discovery of HIV, HIV/ AIDS continues to exert a heavy economic toll in the United States. Lifetime medical costs for people who become infected with HIV are estimated at $20 billion a year in the U.S.3 In 2009, Texas spent $1.6 billion in total lifetime treatment costs from new diagnoses of HIV infection.4 Texas Medicaid alone spent $208 million on 11,127 enrollees with HIV/AIDS, translating to $18,671 in spending per enrollee in 2010.5 HIV prevention has generated substantial economic benefits. For every HIV infection that is prevented, an estimated $380,000 (2010 dollars) is saved in the cost of providing lifetime HIV treatment.4 National Baseline 2007 13.8 Target for 2020 12.4 Houston/Harris County 2011 18.6 State of Texas 2013 9.3 United States 2011 10.3 Public Health Actions  Monitor HIV/AIDS trends through routine surveillance and partner services.  Support policies that enable knowledge of HIV status such as routine HIV testing.  Support programs that provide linkage to care for the newly diagnosed.  Inform people living with HIV about ways to decrease HIV transmission through viral load suppression and prophylaxis, including during pregnancy and delivery.  Support programs that provide HIV care and treatment services to low-income persons living with HIV/AIDS. United States Source: CDC, TDSHS, HDHHS Rate For More Information CDC: www.cdc.gov/hiv TDSHS: www.dshs.state.tx.us/hivstd HDHHS: www.houstontx.gov/health/HIV-STD HCPHES: http://www.hcphes.org/ AIDS InfoNet: www.aidsinfonet.org AIDSmap: www.aidsmap.org 1. Houston Department of Health and Human Services (HDHHS). The 2013 Houston area integrated epidemiologic profile for HIV/AIDS prevention care services planning. http://www.houstontx.gov/health/HIV-STD/2013_Epi_Profile%20--APPROVED--05-09-13.pdf. Accessed October 3, 2014. 2. HDHHS Bureau of Epidemiology Case Records. Provided by request. 3. Centers for Disease Control and Prevention (CDC), HIV/AIDS. Projecting possible future courses of the HIV epidemic in the united states. CDC Web site. http://www.cdc.gov/hiv/resources/factsheets/us-epi-future-courses.htm. Accessed January 23, 2012. 4. Centers for Disease Control and Prevention (CDC). HIV cost-effectiveness. CDC Web site. http://www.cdc.gov/hiv/prevention/ongoing/ costeffectiveness/. Updated April 16, 2013. Accessed October 3, 2014. 5. Kaiser Family Foundation (KFF), State Health Facts. Texas: Medicaid enrollment and spending on HIV, FY2010. KFF Web site. http://kff.org/ hivaids/state-indicator/enrollment-spending-on-hiv/. Accessed October 3, 2014. 111 Sexually Transmitted Diseases Overview The occurrence of sexually transmitted diseases (STDs) such as chlamydia, gonorrhea, and syphilis is an indicator of unprotected sexual contact, a primary risk factor for HIV infection. The CDC reports that individuals who are infected with STDs are two to five times more likely than uninfected individuals to acquire HIV due to increased susceptibility from breaks in the skin and inflammation. Among those infected with HIV, co-infection with another STD increases the infectiousness of HIV, which increases the likelihood that HIV will be transmitted to a sex partner. STDs can cause infertility, adverse pregnancy outcomes, pelvic inflammatory disease, and cancer. The CDC estimates that 20 million new infections occur each year with nearly half occurring among the nation’s youth ages 15-24. Many cases of reportable STDs go undiagnosed and some highly prevalent infections such as human papillomavirus (HPV) are not required to be reported; therefore, reportings are likely to underestimate the true burden of disease. Any sexually active person can be infected with gonorrhea, chlamydia, and/or syphilis. These diseases are spread through vaginal, anal, or oral sex. In addition, some STDs can be passed from mother to child during pregnancy or birth. Trends: Chlamydia and Gonorrhea in Houston/Harris County 2003-2013 Chlamydia cases in Houston/Harris County have more than doubled from 2003 to 2013, with 23,239 cases reported in 2013. The chlamydia infection rate in Houston/Harris County for all age groups has steadily increased with a rate of 519.51 cases per 100,000 population in 2012, surpassing Texas (494.8) and U.S. rates (456.7).2 STD Rates per 100,000 population Houston/Harris County 2003-2013 Chlamydia Rate per 100,000 600 500 400 Gonorrhea 538.2 423.5 305.4 300 200 120.1 153.4 In 2012, new cases of gonorrhea in Houston/Harris County totaled 6,522, a rate of 153.6 per 100,0001, compared to 126.5 in Texas and 107.5 in the U.S.2 149.2 100 0 Compared to other U.S. counties, Harris County ranked 3rd in number of cases of chlamydia and 5th in cases of gonorrhea in 2012. —CDC STD Surveillance Year of Diagnosis Source: HDHHS STD*MIS Surveillance Records Population Differences — Chlamydia and Gonorrhea Chlamydia is the most commonly reported STD in the U.S., followed by gonorrhea. Highest rates for both diseases are among sexually active teenagers and young adults. The gonorrhea rate among the black population (458.8 per 100,000) was 4-10 times greater than that of other racial/ethnic groups in Houston/Harris County in 2013.1 Chlamydia is detected more often in females than in males, while gonorrhea rates are similar between the two sexes. In Houston/Harris County, 17,568 females were diagnosed with chlamydia (a rate of 811.8 per 100,000 population) in 2013 compared to 5,674 males (a rate of 263.4 per 100,000 population). 1 112 Gonorrhea Rates by Race/Ethnicity Houston/Harris County 2009-2013 600 White Hispanic Black Other 500 400 300 200 100 0 2009 2010 2011 Source: HDHHS STD*MIS Surveillance Records Note: Rates are per 100,000 population 2 012 2 013 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Gonorrhea in Houston/Harris County, 2013 Healthy People 2020 Objective STD-6.1: Reduce gonorrhea rates among females aged 15 to 44 years Gonorrhea Rates per 100,000 population Females Aged 15 to 44 Area Source: HDHHS STD*MIS Surveillance Records Note: Population is 2010 Census-Houston/Harris County. Chlamydia in Houston/Harris County, 2013 Source: HDHHS STD*MIS Surveillance Records Note: Population is 2010 Census-Houston/Harris County. Economic Impact of Sexually Transmitted Diseases (STDs) The estimated direct medical cost of the eight common STDs in the United States in 2012 is $16 billion per year (2010 dollars).3 This estimate does not include loss of productivity or other indirect costs. Chlamydia and gonorrhea, the two most commonly reported infectious diseases in the U.S.,4 resulted in estimated annual medical costs of $516.7 million and $162.1 million respectively in 2008.5 Rate National Baseline 2008 279.9 Target for 2020 251.9 Houston/Harris County 2012 357.3 State of Texas 2012 300.1 United States 2012 264.7 Genital Human Papillomavirus (HPV) and Other STDs Genital human papillomavirus (HPV) is the most commonly sexually transmitted infection in the United States, costing the U.S. $1.7 billion in total lifetime direct medical costs for those infected (in 2012 dollars).5,6 There are more than 40 strains of HPV that can infect the genital areas, mouth, and throat. Most people who contract HPV do not have symptoms and clear the infection on their own; however, some strains can cause genital warts or lead to cancer of the cervix or other parts of the genital-rectal area. The HPV vaccine is recommended for girls and boys ages 11 to 12 to prevent multiple strains of HPV.6 In 2013, the National Immunization Survey indicated that 58.0% of female adolescents aged 13-17 in the City of Houston had completed the HPV 3-dose series, which is lower than both state (68.6%) and national (69.8%) percentages. Genital herpes is common in the US; however most infected persons are asymptomatic or have mild symptoms. There is no cure, but treatment is available to alleviate symptoms.7 Other STDs such as bacterial vaginosis and trichomoniasis can be cured with antibiotics.4 1. Houston Department of Health and Human Services. STD*MIS Surveillance Records. 2014. 2. Centers for Disease Control and Prevention (CDC), Division of STD Prevention. Sexually transmitted disease surveillance 2012. http:// www.cdc.gov/std/stats12/surv2012.pdf. Published January 2014. Accessed October 2, 2014. 3. Centers for Disease Control and Prevention (CDC). Incidence, prevalence, and cost of sexually transmitted infections in the United States. http:// www.cdc.gov/std/stats/sti-estimates-fact-sheet-feb-2013.pdf. Published February 2013. Accessed October 2, 2014. 4. CDC, CDC Features. STDs are a major public health issue. CDC Website. http://www.cdc.gov/features/stdawareness/. Accessed January 2012. 5. Owusu-Edusei K, Chesson HW, Gilft TL et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. 2013;40(3):197-201. http://journals.lww.com/stdjournal/Abstract/2013/03000/The_Estimated_Direct_Medical_Cost_of_Selected.3.aspx. Accessed September 3, 2014. 6. Centers for Disease Control and Prevention (CDC). Human papillomavirus (HPV). CDC Web site. http://www.cdc.gov/std/HPV/STDFact-HPV.htm. Updated March 20, 2014. Accessed October 3, 2014. 7. Centers for Disease Control and Prevention (CDC). Genital herpes. CDC Web site. http://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm. Updated February 13, 2013. Accessed October 3, 2014. 113 Sexually Transmitted Diseases, cont. Overview-Syphilis Syphilis is a sexually transmitted disease (STD) caused by the Treponema pallidum bacteria. Once diagnosed, it can easily be treated with penicillin or other antibiotics; however, if left untreated, it can cause long-term complications. Primary and secondary syphilis are the earliest and most easily transmissible stages of syphilis and, if left untreated, can progress to latent, late, and/or neurosyphilis. Syphilis has also been shown to facilitate the transmission of HIV and increase the likelihood of poor pregnancy outcomes (i.e., fetal death, infants born with physical and mental developmental disabilities). Syphilis-causing bacteria Treponema pallidum Photo courtesy of CDC Syphilis has been known as the “The Great Pretender” as its symptoms are similar to that of many other diseases. The CDC estimates that 55,400 individuals are newly infected each year, 15,667 (28%) of which are primary and secondary syphilis. Trends: Syphilis in Houston/Harris County 2003-2013 Primary and Secondary Syphilis Cases and Rates in Houston/Harris County 2003-2013 Case Cou nt Rate 500 400 300 200 14 12 10 8 6 4 100 2 0 0 Rate per 100,000 Population Number of Cases 600 Source: HDHHS STD*MIS Surveillance Records Population Differences—Syphilis The largest proportion of primary and secondary syphilis cases occur among males. In 2012, men who have sex with men (MSM) accounted for 75% of all primary and secondary syphilis cases.3 Racial/ethnic disparities have persisted since the 1990s. Nationally, the black population has higher rates of primary and secondary syphilis than any other racial/ethic group. In Houston/ Harris County, black men have a rate five times that of white men and six times that of Hispanic men.2 Similar disparities among black and white men are noted nationally; however, the disparity among black and Hispanic men is much greater in Houston/Harris County.2.3 According to CDC, the national primary and secondary syphilis rate in 2013 (5.3 per 100,000 population) was more than double the lowest rate of 2.1 in 2000.1 Locally, from 2000-2007 Houston/Harris County had an upward trend of primary and secondary syphilis cases. In 2008, this trend reversed, with a decrease in cases that was sustained through 2011. In 2012, the rate spiked to a high of 11.6 cases per 100,000 population but decreased to a rate of 7.0 in 2013.2 In 2013, 302 primary and secondary syphilis cases were reported to the HDHHS, a rate of 7.0 cases per 100,000, compared to the state rate of 5.6 cases per 100,000.2 Primary and Secondary Syphilis Rates by Sex and Race/Ethnicity in Houston/Harris County, 2013 Rate per 100,000 population Male Female 37.8 7.6 8.9 1.4 White 6.3 * Black Hispanic *Rate for Hispanic females was <1.0. Source: HDHHS STD*MIS Surveillance Records 1. Centers for Disease Control and Prevention (CDC). Primary and secondary syphilis— United States, 205-2013. Morbidity and Mortality Weekly Report (MMWR). 2014; 63(18);402-406. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6318a4.htm. Accessed October 2, 2014. 2. Houston Department of Health and Human Services. STD*MIS Surveillance Records.2014. Provided by request. 3. Centers for Disease Control and Prevention (CDC). Syphilis. CDC Web site. http://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm. Updated January 7, 2014. Accessed October 2, 2014. 114 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Primary and Secondary Syphilis Houston/Harris County, 2013 Healthy People 2020 Objective STD-7: Reduce domestic transmission of primary and secondary syphilis among males Primary/Secondary Syphilis in Males Rate per 100,000 population Area Source: HDHHS STD*MIS Surveillance Records Note: Population is 2010 Census-Houston/Harris County. The map above shows the 22 ZIP codes in Harris County with primary and secondary syphilis rates higher than 7.3 per 100,000 population in those ZIP codes with more than five cases. Nineteen ZIP codes, marked in brown, had rates higher than 14.6 per 100,000 population. Harris County’s rank in cases of primary and secondary syphilis: 2011: 8th among all U.S. counties 2012: 4th among all U.S. counties —CDC STD Surveillance Economic Impact of Syphilis The lifetime direct medical costs and indirect costs per case of syphilis have been estimated at $572 and $112 respectively (in 2006 dollars). These estimates do not include costs from congenital syphilis, which is spread by an infected mother to her infant through the placenta, nor do they include HIV infections, which are more likely when the exposed individual has syphilis.4 Screening and early detection are key to averting costs associated with disease progression and long-term complications. Treatment for early stage syphilis was estimated to be $41.26 (in year 2001 dollars) compared to $2,061.70 for late syphilis.5 Rate National Baseline 2008 7.4 Target for 2020 6.7 Houston/Harris County 2012 19.4 State of Texas 2012 10.7 United States 2012 9.3 Public Health Actions  Inform and educate people about the risks of unprotected sex and the adverse outcomes associated with STDs.  Provide care where otherwise not available for low-income persons including education, counseling and testing, case management and clinical services for STDs/HIV.  Develop policies and plans and mobilize community partnerships to support community health efforts to decrease STDs.  Support initiatives such as the National Plan to Eliminate Syphilis to enhance public health services, target interventions, and improve effectiveness of prevention efforts. For More Information TDSHS: www.dshs.state.tx.us/hivstd CDC: www.cdc.gov/std National Institute of Allergy and Infectious Diseases: http://www.niaid.nih.gov/topics/std/ Pages/default.aspx American Sexual Health Association: www.ashastd.org City of Houston STD: http://www.houstontx.gov/ health/sexually-transmitted-disease-stdinformation Harris County Public Health and Environmental Services: www.hcphes.org/ 4. Chesson H, Collins D, Koski K. Formulas for estimating the costs averted by sexually transmitted infection (STI) prevention programs in the United States. Cost Effectiveness and Resource Allocation. 2008; 6(1):10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2426671/?tool=pubmed. Accessed January 24, 2012. 5. Blandford JM, Gift TL. The cost-effectiveness of single-dose azithromycin for treatment of incubating syphilis. Sex Transmit Dis 2003; 30(6):5028. http://journals.lww.com/stdjournal/Fulltext/2003/06000/Syphilis_Outbreaks_Among_Men_Who_Have_Sex_With.6.aspx#. Accessed January 24, 2012. 115 Tuberculosis Overview Risk factors associated with TB cases reported in Texas in 2013 include: being Tuberculosis (TB) is a bacterial disease primarily affecting the lungs. TB can take one of two forms—an foreign-born, abusing alcohol, having diabetes, being a prison/jail inmate, having active version (TB disease) or one that lies dormant HIV/AIDS, homelessness, or being a within the body (latent TB infection or LTBI). TB transmission occurs through the air when an individual with healthcare worker. —TDSHS TB disease coughs, sneezes, laughs, or sings. Transmission usually takes place only after prolonged close association with someone who has the disease. Patients with TB disease require treatment with multiple drugs for at least six months, 1 preferably by directly observed therapy (DOT). Those with LTBI can develop active TB later in life. Individuals at higher risk for this progression include young children, people with HIV/AIDS, diabetics, cancer patients, and those recently infected with TB. Progression to active TB can usually be prevented by taking a single drug for nine to twelve months.1 TB was once the leading cause of death in the United States, but the use of antibiotics greatly reduced the rates of infection and mortality. Worldwide, TB rates have been on the decline; however, strains of TB resistant to multiple forms of antibiotics have increased. 2 Drug-resistant TB results from misuse of the drugs, either inappropriately prescribed medication or patient failure to complete the treatment course. Treatment for drug-resistant TB comes with severe side effects including depression, psychosis, hearing impairment, hepatitis, kidney impairment, loss of mobility, and vision impairment. Nationally, 9% of those treated for drug-resistant TB die.3 Trends: Houston/Harris County 2003-2013 Tuberculosis Case Rate (per 100,000) 20 18 16.9 16 14 12 10 7.2 8 6 4 5.1 2 0 Houston Texas U.S. 11.7 6.2 4.2 8.5 4.6 3.0 200 3 200 4 200 5 200 6 200 7 200 8 200 9 201 0 201 1 201 2 201 3 According to the HDHHS, 186 new cases of TB were diagnosed in Houston in 2013, representing 15.2% of the 1,222 new cases reported in the state of Texas by the TDSHS. An additional 101 cases of TB were reported in Harris County outside the city limits of Houston. While the case rate in Houston has decreased from 2008 to 2013 (11.7 to 8.5 cases per 100,000 respectively), the rate is still more than twice the national rate. In 2013, Harris County had more cases of TB than any other county in Texas. Source: TDSHS and HDHHS Case Files Number of Reported TB Cases in Houston Population Differences The number of TB disease cases reported among blacks and Hispanics is higher than persons identifying as white or other. In 2013, Hispanics represented 51% of newly infected TB cases in Houston; blacks represented 23%. In Texas, differences are also noted by place of birth. According to the TDSHS, 46.6% of TB cases reported in 2011 were among foreign-born individuals. In Harris County, 62.1% of TB cases were foreign-born in 2010. White Black Hispanic 250 37 31 200 150 105 129 38 38 97 103 100 50 0 91 30 27 86 95 78 81 69 59 29 22 19 17 17 43 21 2008 2009 2010 2011 2012 2013 Source: TDSHS and HDHHS Case Files 116 Other 300 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Texas Counties with the Most TB Cases, 2013 County Harris Healthy People 2020 Objective IID-29: Reduce tuberculosis (TB) Tuberculosis Rates New Cases per 100,000 Cases 287 Dallas 191 Bexar 75 Tarrant 70 Hidalgo 64 Cameron 53 El Paso 49 Travis 41 Webb 35 Collin 30 Area Source: Texas Department of State Health Services (TSDHS), TB-HIVSTD and Viral Hepatitis Unit. TB statistics: the big picture. https:// www.dshs.state.tx.us/idcu/disease/tb/statistics/. Published January 2013. Accessed November 11, 2014. Economic Impact of Tuberculosis The global cost of tuberculosis amounted to $6.4 billion in 2014, accounting for 95% of TB cases. The global cost includes funding for prevention, diagnosis, and treatment. In order to account for the remaining 5%, it would require an additional $2 billion a year, resulting in a total of $8 billion.2 In the United States, tuberculosis is typically treated on an outpatient basis; however, hospitalization was needed 58,500 times in 2006, resulting in $752 million in expenses.4 Cost increases with drug resistance: TB treatment costs $17,000 in direct treatment cost, multidrug resistant TB costs $260,000 ($134,000 in direct treatment cost and $126,000 in productivity loss during treatment), and extensively drugresistant (XDR) TB costs $554,000 ($430,000 in direct treatment costs and $124,000 in productivity loss during treatment).3 In 2013, the CDC provided $11,397,985 to fund state and local health departments for TB prevention and control activities, including surveillance, case management, and directly observed therapy to ensure that those with TB are compliant with their medications and treatment protocols. These funds also supported identification and evaluation of persons exposed to TB, lab services, regional training, and clinical and epidemiological research.5 Rate National Baseline 2005 4.8 Target for 2020 1.0 City of Houston 2013 8.5 State of Texas 2013 4.6 United States 2013 3.0 Public Health Actions  Assure the provision of healthcare where otherwise unavailable by monitoring cases of TB and providing supervision of medication treatment.  Diagnose and investigate the problems and hazards of TB in the community.  Monitor TB rates and cases in Houston/ Harris County.  Educate those with TB or at risk of TB about needed health care. For More Information CDC National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination: www.cdc.gov/nchstp/tb TB Education and Training Resources: www.findtbresources.org TDSHS: www.dshs.state.tx.us/IDCU/disease/tb Heartland National TB Center: www.heartlandntbc.org International Union Against Tuberculosis and Lung Disease: www.tbrieder.org 1. Centers for Disease Control and Prevention (CDC). Basic TB facts. http://www.cdc.gov/tb/topic/basics/default.htm. Updated March 13, 2012. Accessed November 11, 2014. 2. World Health Organization (WHO). Global tuberculosis report 2014. http://www.who.int/tb/publications/global_report/ gtbr14_executive_summary.pdf?ua=1. Accessed November 11, 2014. 3. Centers for Disease Control and Prevention (CDC). Treatment practices, outcomes, and costs of multidrug resistant and extensively drug-resistant tuberculosis, United States, 2005-2007. Emerg Infect Diseases. 2014; 20(5). http://wwwnc.cdc.gov/eid/article/20/5/13-1037_article. Accessed November 15, 2014. 4. Health Care Cost and Utilization Project (HCUP). Statistical brief # 60: tuberculosis stays in U.S. hospitals, 2006. www.hcup-us.ahrq.gov/reports/ statbriefs/sb60.pdf. Published October 2008. Accessed January 2, 2012. 5. Centers for Disease Control and Prevention (CDC), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Texas—2013 profile. http://www.cdc.gov/nchhstp/stateprofiles/pdf/Texas_profile.pdf. Accessed November 17, 2014. 117 Vaccine Preventable Diseases Overview Immunizations protect individuals and the people around them from disease. In Houston/Harris County, cases of once common diseases such as measles, mumps, and tetanus are at or near zero due to safe and effective vaccination. The vaccine for chickenpox (varicella) was introduced in 1995 and since that time the number of cases continues an overall decline. 1 Most vaccines are given to children; however, seniors also benefit from vaccinations to reduce the risk of pneumonia and shingles, and the annual flu vaccine is recommended for everyone aged six months and older. According to the TDSHS, influenza/pneumonia was the tenth leading cause of death in Harris County in 2012, with those 65 and older accounting for 82% of influenza/pneumonia deaths. The human papillomavirus (HPV) vaccine is recommended starting at 11 or 12 years old for girls and boys, and up to the age of 26 for women. The HPV vaccine protects women from cervical cancer. 2 Vaccine preventable diseases have decreased; however, the viruses and bacteria that cause them still exist. For example, polio, diphtheria, and other deadly diseases are no longer a concern in the United States, but they still survive in other parts of the world. For this reason, all recommended vaccinations are necessary for good health. Trends: Houston/Harris County 2003-2013 Most vaccine preventable diseases are rarely seen in Houston/Harris County; however, chickenpox (varicella) and whooping cough (pertussis) still infect hundreds of local residents. Since the 2003 low of 41 pertussis cases in Houston/Harris County, reported cases of pertussis have increased dramatically, with 355 cases reported in 2013. Pertussis, or whooping cough, is an infectious bacterial disease that can lead to pneumonia, seizures, and death. Many pertussis cases are never diagnosed, contributing to the spread of the disease. The CDC reports that pertussis is most common among infants and young children; in some cases pertussis can be fatal, particularly in those less than one year of age. Children who do not receive all recommended vaccinations contribute to the persistence of diseases such as pertussis. Among cases reported to Harris County Public Health and Environmental Services from 2005 to 2010, only 41.8% of infected infants were appropriately vaccinated for their respective age.3 Number of Reported Vaccine-Preventable Disease Cases and (Rate per 100,000) Houston/Harris County, 2007-2013 2007 2008 2009 2010 2011 2012 2013 1217 (30.9) 792 (19.9) 567 (13.9) 324 (7.9) 318 (7.6) 423 (9.9) 181 (4.2) Measles 0 <5 <5 0 <5 0 <5 Rubella 0 0 0 0 0 0 0 Mumps <5 <5 <5 5 <5 <5 6 (0.1) Pertussis 96 (2.4) 159 (4.0) 267 (6.6) 115 (2.8) 95 (2.3) 164 (3.9) 355 (8.2) Tetanus 0 0 0 0 0 0 0 Chickenpox Note: Data for totals less than five is not released due to the possibility of individual identification Source: HDHHS and HCPHES Epidemiology Case Files 1. Centers for Disease Control and Prevention (CDC). Varicella disease questions and answers. CDC Web site. http://www.cdc.gov/vaccines/vpdvac/varicella/dis-faqs-gen.htm. Updated June 13, 2008. Accessed April 6, 2009. 2. Centers for Disease Control and Prevention (CDC). Human papillomavirus (HPV). CDC Web site. http://www.cdc.gov/hpv/vaccine.html. Updated Fecruary 5, 2013. Accessed December 10, 2014. 3. Zangeneh A. Spatial analysis of pertussis cases in Harris County from 2005-2010. Texas Med. Ctr. Dissertations (via ProQuest). 2011. http://digitalcommons.library.tmc.edu/dissertations/AAI1497696/. Accessed December 21, 2011. 4. Centers for Disease Control and Prevention (CDC). Reduction in racial/ethnic disparities in vaccination coverage, 1995-2011. MMWR. 2014;63 (01):7-12. http://www.cdc.gov/mmwr/preview/mmwrhtml/su6301a3.htm. Accessed December 4, 2014. 5. Zhou F et al. Economic Evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics. 2014;133(4):577-585. http://pediatrics.aappublications.org/content/133/4/577.short. Accessed September 5, 2014. 118 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution Pertussis Incidence, 2013 (Cases per 100,000 population) Healthy People 2020 Objective IID-1.10: Reduce, eliminate, or maintain elimination of varicella (chicken pox) in persons aged 17 or under Cases of Varicella (Chicken Pox) in Children aged 17 and under Area Number of Cases National Baseline 2008 586,000* Target for 2020 100,000* 181** Houston/Harris County 2013 Source: TDSHS, Infectious Disease Control Population Differences Nationally, disparities in vaccination coverage between non-Hispanic white children and children of other racial/ethnic groups have declined for recommended routine vaccinations. Significant differences in decreased vaccination rates are only present for non-Hispanic American Indians/Alaska Natives compared to non-Hispanic whites.4 Lower immunization rates are more common among the uninsured and individuals of lowest socioeconomic levels. BRFSS 2013 data indicate that insured adults (39.1%) in the HoustonBaytown-Sugarland MSA are nearly twice as likely to get the seasonal influenza vaccine than uninsured adults (19.7%). Economic Impact of Vaccine Preventable Diseases It is less costly for society to prevent vaccine preventable diseases than to treat them. Routine childhood immunization prevents approximately 42,000 early deaths and 20 million cases of disease, resulting in net savings of $13.5 billion in direct costs and $68 billion in societal costs.5 Shingles vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP) to reduce the risk of shingles and its associated pain in people 60 years and older. -CDC State of Texas 2013 1,874** United States 2012 190,000* *Baseline and national numbers are based on reportings from the National Health Interview Survey. **Texas and Houston/Harris County numbers are reported cases of chickenpox by local physicians. Public Health Actions  Monitor and improve community health through surveillance of cases of vaccine preventable diseases and monitoring of immunization rates.  Assure the provision of healthcare when otherwise unavailable by providing immunizations to low-income persons.  Mobilize community partnerships and action to identify barriers to eliminating VPDs.  Increase participation in community-wide efforts to increase awareness of the benefits of immunization for the increase of immun- For More Information Texas DSHS Infectious Disease Control Unit: www.dshs.state.tx.us/idcu/health/ vaccine_preventable_diseases CDC Vaccines and Immunizations: www.cdc.gov/vaccines Immunization Action Coalition: www.vaccineinformation.org National Foundation for Infectious Diseases: www.nfid.org/factsheets World Health Organization: www.who.int/ immunization 119 Influenza Overview Influenza (flu) is a viral infection that is caused by viruses that attack the upper respiratory tract—nose, throat, and bronchi. There are multiple types of flu viruses; however, the types of viruses that are currently circulating are influenza type A and type B. Type A is divided into two subtypes, H3N2 and H1N1. The subtype H3N2 is responsible for most of the deaths caused by the flu. In most healthy people, the infection usually lasts about a week and is characterized by a sudden onset of high fever, headache, cough, and sore throat. Fatigue and runny nose are possible symptoms, with vomiting and diarrhea being more common in children than in adults. The flu is highly contagious; an infected person can pass the infection to other people from about one day before symptoms present themselves to up to five to seven days after becoming ill. A person with the flu can infect others who are as far as six feet away. It is believed that the virus is spread through droplets made when people infected with the flu cough, sneeze, or talk. The droplets can then land in mouths or become inhaled by people nearby. Becoming infected by a sick person is the most common means of transmission so it is recommended that people who feel ill stay home from work or school so that they can lower the risk of infection to other people. Children, the elderly, and people with compromised immune systems are at high risk of serious flu complications. While there is no cure for the flu, there is a seasonal vaccine that provides protection against influenza viruses that research indicates will be most common during the flu season. Other preventative measures include good hygiene such as washing hands thoroughly with soap and water. Trends: Houston/Harris County 2008-2014 During the 2013-2014 influenza season, two influenza-associated pediatric deaths were reported in Houston. The City of Houston Bureau of Laboratory Services tested 470 surveillance specimens during the 2013-2014 influenza season, 138 (29.4%) of which resulted in positive lab results. Of the 138 positive results, 116 (84.1%) were from the 2009 H1N1 strain. Comparison of Influenza-Like Illness (ILI) ED Visits Houston/Harris County 0.07 % of Total ED Visits 0.06 0.05 2009 H1N1 0.04 0.03 0.02 0.01 0 Month 2008-2009 Source: HDHHS 120 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Population Differences Although most people who become infected with the flu will have a mild illness, some people are at high risk for developing flu-related complications such as pneumonia, bronchitis, sinus infections, and ear infections. People determined to be high risk for flu-related complications include children under five years of age, particularly those younger than two years of age, adults 65 years of age and older, pregnant women, and American Indians and Alaskan Natives.1 In addition, the flu can worsen chronic health conditions in persons with asthma, chronic lung disease, heart disease, and diabetes, among others. Objective IID-12.12: Increase the percentage of adults aged 18 and older who are vaccinated annually against seasonal influenza Influenza Vaccination Adults 18 and Older Area Economic Impact of Influenza The economic burden of influenza-attributable illness in adults amounts to $87.1 billion (2003 dollars), $10.4 billion in direct medical costs and $16.3 billion in lost earnings due to illness and loss of life.2 The remaining cost accounts for the intrinsic value of human life. The cost-effectiveness of annual childhood influenza vaccination among children not at highrisk ranges from $12,000 per quality-adjusted life year (QALY) saved for children 6-23 months to $119,000 per QALY saved for children 12-17 years of age. Among children ages 5-17 at high risk, vaccination costs $1,000 to $10,000 per QALY saved.3 Furthermore, among adults aged 50-64 and 65 and over, the cost-effectiveness of vaccination results in $980 per QALY saved in persons 65 and older and $28,000 QALY saved for persons 50-64 years of age.4 Costeffectiveness is determined at $50,000 or less per QALY gained or saved. Vaccination of adults aged 65 and older saves $17 per person vaccinated.4 In Harris County, an estimated $533 million is spent on direct medical costs and indirect costs related to loss of productivity from school, work absenteeism, or death due to seasonal influenza.5 Percent National Baseline 2010-2011 38.1 Target for 2020 70.0 Houston MSA 2013 33.9* State of Texas 2013 35.8* United States 2011-2012 39.2 *Texas and Houston MSA percentages reported by calendar year. Public Health Actions  Inform, educate, and empower people about health issues such as the importance of frequent hand washing, especially among those caring for infants and toddlers; and encourage use of the seasonal influenza vaccine to reduce the number of at-risk individuals.  Diagnose and investigate health problems in the community in order to respond quickly to clusters of outbreaks and identify sources of infection. For More Information CDC Influenza: http://www.cdc.gov/flu/ index.htm Flu.gov: http://www.flu.gov/ HDHHS Flu Facts: http://www.houstontx.gov/ health/flu/Flu_Facts/Default.htm TDSHS: http://www.texasflu.org/ 1. Centers for Disease Control and Prevention (CDC). People at high risk of developing flu-related complications. Updated September 9, 2014. Accessed November 17, 2014. 2. Molinari NA, Ortega-Sanchez IR, Messonnier ML, Thompson WW, Wortley PM, Weintraub E, Bridges CB. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine. 2007;25(27):5086-96. http://www.sciencedirect.com/science/article/pii/ S0264410X07003854. Accessed November 17, 2014. 3. Prosser LA et al. Health benefits, risks, and cost-effectiveness of influenza vaccination of children. Emerg Infect Diseases. 2006;12(10). http:// wwwnc.cdc.gov/eid/article/12/10/05-1015_article. Accessed November 18, 2014. 4. Maciosek MV, Solberg LI, Coffield AB, Edwards NM, Goodman ML. Influenza vaccination: health impact and cost-effectiveness among adults aged 50 to 64 and 65 and older. Am J Prev Med. 2006;31(1):72-79. http://www.ajpmonline.org/article/S0749-3797(06)00120-6/abstract. Accessed November 18, 2014. 5. Mao L, Yang Y, Qiu Y, Yang Y. Annual economic impacts of seasonal influenza on US counties: spatial heterogeneity and patterns. International Journal of Health Geographics. 2012;11(16). http://www.ij-healthgeographics.com/content/11/1/16. Accessed November 17, 2014. 121 Meningitis Overview Meningitis, usually caused by a viral, bacterial, or fungal infection, is the inflammation of the membranes that cover the brain and spinal cord. Viral meningitis, also known as aseptic meningitis, is the most common type of meningitis. According to 2012 TDSHS records, 123 cases of viral/aseptic meningitis were reported in Houston/Harris County, an incidence rate of 2.9 cases per 100,000 population. Viral meningitis is usually less severe and resolves without treatment, while bacterial meningitis can be severe, resulting in hearing loss, learning disability, brain damage, or even death. Transmission of many of the viruses and bacteria that cause meningitis occurs through direct contact with an infected person’s fluids, such as those released during coughing or sneezing. This usually happens when a healthy person comes into contact with an infected person or touches a contaminated surface and then touches his or her eyes, nose, or mouth. The CDC reports that 90% of viral meningitis cases are caused by enteroviruses, thought to be frequently spread among children who are not yet toilet trained. Trends: Harris County/Texas 2000-2012 Reported Cases of Aseptic Meningitis Rate per 100,000 Population Harris County 12.2 11.2 8.2 11.9 9.3 5.9 5 0 Texas 15.3 14.0 15 10 Years with a high rate of aseptic meningitis infection in Harris County correspond to years of high rates in Texas, suggesting that the causes of infection are shared. Since 2005, Harris County has had a lower rate than Texas. 6.9 6.3 2.4 8.9 7.4 1.4 2.0 7.2 7.5 6.6 7.5 5.0 4.7 4.8 Aseptic meningitis is one of the presentations of West Nile virus (WNV) infection; therefore, it contributes to the total number of cases recorded. Following a 2002 outbreak, Houston/Harris County began active surveillance of WNV. 5.0 4.4 3.6 2.9 Source: TDSHS Case Files Population Differences Children under one year of age are at highest risk of aseptic meningitis infection. Their immature immune system puts them at more than a 100-fold greater risk compared to persons with a mature immune system. Among the school age population, the risk of becoming infected with meningitis varies; some years the risk is high among elementary aged children, while other years it is not. Aseptic meningitis rates are higher among whites and Hispanics, compared to blacks. In 2012, rates per 100,000 population was 2.5 for whites, 2.5 for Hispanics, and 1.2 for blacks. 122 Ages of Reported Cases of Aseptic Meningitis Harris County, 2012 40 35 35 30 25 20 14 15 10 6 7 5 0 Source: TDSHS Case Files 8 10 17 12 10 4 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Seasonal Distribution Healthy People 2020 Objective IID-7.2: Three or four doses of Haemophilus influenza type b (Hib) vaccine by 19 to 35 months Cases of aseptic meningitis in Houston/Harris County peak in warmer months. In most years, this peak occurs during the months of May and June. Percent of children aged 19 to 35 months received 3 or more doses of Hib* Reported Cases of Aseptic Meningitis by Month Harris County, 2012 16 14 12 Area 17 18 14 14 15 14 11 9 10 8 7 6 10 6 4 2 5 1 0 Percent National Baseline 2008 54.8 Target for 2020 90.0 Houston 2013 95.0 State of Texas 2013 94.1 United States 2013 91.9 *Hib vaccination prevents meningitis, pneumonia, and other serious infections caused by the bacteria Haemophilus influenzae type b. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Source: TDSHS case files Economic Impact of Meningitis The severity and economic burden of meningitis varies based on the type of meningitis. In 2006, there were 72,000 meningitis-related hospitalizations in the United States, resulting in an aggregate cost of $1.2 billion.1 The average cost per stay for an individual with bacterial meningitis was $33,100, compared to $6,800 for an individual with viral meningitis, and $29,000 for an individual with fungal or other type of meningitis.1 Outpatient costs for individuals with less serious viral meningitis average at $450.2 Bacterial meningitis accounted for 22% of meningitis-related hospitalizations, but 43% of the total cost.1 According to the CDC, the best method for the prevention of bacterial meningitis is vaccination against the three types of bacteria that can cause bacterial meningitis: Neisseria meningitides (meningococcus), Streptococcus pneumonia (pneumococcus), and Haemophilus influenzae type b (Hib). The meningococcal vaccine is recommended for adolescents aged 11-18, adults over the age of 55, and those at an increased risk of meningococcal disease, the leading cause of bacterial meningitis in people aged 2-18. The costs of vaccinations can range up to $1503 for the required college-entrance vaccination; however, many universities subsidize the cost for their students. Public Health Actions  Inform, educate, and empower people to practice health-promoting behaviors such as hand washing, especially among those caring for infants and toddlers; and encourage the use of the meningitis vaccine to reduce the number of at-risk individuals.  Diagnose and investigate health problems in the community in order to respond quickly to clusters of outbreaks and identify sources of infection. In June 2013, the Texas State Legislature amended SB 62, requiring all entering students who are under the age of 22 at public and private institutions of higher education to provide evidence of vaccination against bacterial meningitis or a signed affidavit declining the vaccination. This regulation does not apply to students taking online or other distance education courses. For More Information CDC Aseptic Meningitis: http://www.cdc.gov/ meningitis/viral.html CDC Bacterial Meningitis: http://www.cdc.gov/ meningitis/bacterial.html TDSHS: www.dshs.state.tx.us/idcu/disease/ meningitis 1. Holmquist L, Russo A, Elixhauser A. Statistical brief #57: Meningitis-related hospitalizations in the United States, 2006. Healthcare Cost and Utilization Project (HCUP). http://www.hcup-us.ahrq.gov/reports/statbriefs/sb57.pdf. Published July 2008. Accessed November 20, 2014. 2. Parasuraman TV, Frenia K, Romero J. Enteroviral meningitis: cost of illness and considerations for the economic evaluation of potential therapies. Pharmacoeconomics. 2000;19:3-12. http://www.ncbi.nlm.nih.gov/pubmed/11252544. Accessed January 2, 2012. 3. Centers for Disease Control and Prevention (CDC). CDC vaccine price list. http://www.cdc.gov/vaccines/programs/vfc/awardees/vaccinemanagement/price-list/. Updated August 1, 2014. Accessed November 20, 2014. 123 Hepatitis Overview Hepatitis is an infection that results in the inflammation of the liver. The infection can be caused by drugs, toxic substances, and several infectious agents including different viruses labeled hepatitis A, B, C, D, or E. Hepatitis B, C, and D viruses are transmitted by contaminated blood and blood products. Hepatitis B is commonly spread through sexual contact and can be contracted by infants born to infected mothers. Types A and E are transmitted via the fecal-oral route. All of the viruses can cause fatigue, vomiting, diarrhea, abdominal pain, jaundice, dark urine, and pale stools. Hepatitis B and C may lead to liver cancer, cirrhosis, and even death. Prevention and treatment for each virus type varies. According to the CDC, viral hepatitis is a silent epidemic with more than five million Americans living with hepatitis, most of who are not aware they are infected. Early stage symptoms are often mild, but chronic hepatitis can cause severe impairment, cancer, and/or death. Viral hepatitis is the leading cause of liver cancer and the most common reason for liver transplant. Approximately 15,000 Americans die each year from liver cancer or chronic liver disease associated with viral hepatitis. Most cases of hepatitis in the Houston area result from the hepatitis B and C viruses. The best prevention against contracting hepatitis B is through vaccination. Vaccination is recommended for those at greatest risk, such as persons who are exposed to blood on the job, intravenous drug users, persons with multiple sex partners, and persons who engage in high-risk behaviors. Trends: Houston/Harris County 2003-2013 Reported Cases of Hepatitis B in Houston* 400 0 Number of Cases 250 0 89.0 79.7 64.3 160 122.7119.4 140 120 79.7 64.4 150 0 80 60 100 0 500 0 100 1256 1557 1258 1739 2652 2470 3267 2839 1750 2694 2621 353.3 400 9000 3000 20 1000 0 *Rate is cases per 100,000 population. Cases include both acute and chronic cases reported to HDHHS. Source: HDHHS Epidemiology Disease Surveillance Registries Population Differences In the City of Houston between 2011 and 2013, racial differences in newly reported cases of hepatitis B with known race/ethnicity are illustrated in the chart to the right. Among the 7,065 hepatitis B cases with reported race/ethnicity, the Asian population had the highest reported rate of 165.0 cases per 100,000 population, followed by whites (35.5), blacks (31.7), and Hispanics (13.9). 245.1 0 200 125.4 94.4 78.0 150 100 50 3919 2949 1523 2450 4078 3869 6425 5735 2074 5382 7758 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 0 *2003-2005 decline appears to be an artifact of reporting by health care providers; upward trend since 2005 may be due to increased surveillance and testing, as well as electronic laboratory reporting. Source: HDHHS Epidemiology Disease Surveillance Registries Hepatitis B Rates in the City of Houston Asian 165.0 Hispanic 13.9 Black 31.7 White 35.5 0 25 50 75 *Rate is cases per 100,000 population. 124 300 250 208.7 191.3 6000 196.0 5000 150.9 4000 2000 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 273.2 7000 40 350 311.9 8000 Rate per 100,000 300 0 135.5 Rates 100 125 150 175 Rate per 100,000 136.0 122.2 Cases 10000 180 158.6 350 0 200 0 Rates NUmber of Cases Cases Reported Cases of Hepatitis C in Houston* T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Economic Impact of Hepatitis Healthy People 2020 Viral hepatitis represents a substantial health and economic burden. Three viruses, hepatitis A virus (HAV), hepatitis B virus (HBV) and hepatitis C virus (HCV), cause most viral hepatitis cases in the United States.1 Objective IID-25: Reduce new hepatitis B infections in adults aged 19 and older New Hepatitis B Cases Rate per 100,000 population (persons aged 19 years and older) The CDC reported estimates on the total annual costs of hepatitis A, B, and C.    Area Rate Hepatitis A: $353 million (in 2004 dollars), $92 million in medical costs and $261 million in work loss. National Baseline 2007 2.0 Target for 2020 1.5 Hepatitis B: $886 million (in 2004 dollars), $368 million in medical costs and $518 million in work loss. Harris County 2013* 0.7* State of Texas 2013* 0.5* Hepatitis C: $824 million (in 2004 dollars), $272 million in medical costs and $552 in work loss.2 United States 2012* 0.9* In Texas, nearly $32 million of federal, state, and local funds are spent on the prevention, treatment, and care of hepatitis.3 Hepatitis A and B vaccines are highly effective in preventing HAV and HBV infection. Without childhood HAV vaccination, the 2005 birth cohort of four million children would be expected, over their lifetimes, to have 199,000 HAV infections, 74,000 cases of acute hepatitis A, and 82 deaths, resulting in total costs of $134 million in medical costs and productivity loses.4 Every $1.00 spent on perinatal hepatitis B vaccination is estimated to save $14.70 in medical costs.5 *All Ages Public Health Actions  Monitor health status and hepatitis disease prevalence data for health planning to solve this community health problem.  Inform, educate, and empower people about hepatitis B and C through publications, trainings, and other media sources.  Enable people, such as those with HIV/AIDS, to prevent and treat hepatitis through community outreach.  Assure provision of health care when otherwise unavailable by providing immunizations to low-income residents and referring others to local medical providers. For More Information An estimated 5.3 million Americans are living with hepatitis; most do not know they are infected. —CDC CDC: www.cdc.gov/hepatitis TDSHS: www.dshs.state.tx.us/idcu/disease/ hepatitis National Prevention Information Network: www.cdcnpin.org/scripts/hepatitis/index.asp Hepatitis Foundation International: www.hepfi.org 1. U.S. Department of Health & Human Services. Viral hepatitis: the secret epidemic. HHS Web site. http://www.hhs.gov/asl/testify/2010/06/ t20100617b.html. Accessed January 24, 2012. 2. Centers for Disease Control and Prevention (CDC), Hepatitis. National viral hepatitis elimination strategy. CDC Web site. http://www.cdc.gov/ hepatitis/Resources/MtgsConf/NatVHPrevConf2005/Tuesday/B6_Bresnahan.pdf. Accessed January 24, 2012. 3. Texas Department of Health and Human Services (TDHHS). HIV and viral hepatitis prevention and treatment resources in Texas. http:// www.dshs.state.tx.us/hivstd/reports/hepresources.shtm. Published February 2013. Accessed November 20, 2014. 4. Rein DB, et al. Cost-effectiveness of routine childhood vaccination for hepatitis A in the United States. Pediatrics. 2007;119(1):12-21. http:// www.pediatricsdigest.mobi/content/119/1/e12.full. Accessed January 24, 2012. 5. National Alliance of State and Territorial AIDS Directors, Hepatitis Appropriations Partnership. FY2012 Viral hepatitis funding recommendations. NASTAD Web site. http://www.nastad.org/Docs%5C102534_HAP.pdf. Accessed January 24, 2012. 125 Enteric Diseases Overview Enteric diseases, such as salmonellosis and Escherichia coli (E. coli) infection, affect the gastrointestinal system and are usually associated with contaminated food or poor hygiene. Common symptoms of enteric diseases include diarrhea and vomiting, although in some cases, more serious illness or death may occur. The CDC estimates that each year roughly one in six Americans (or 48 million people) get sick and 3,000 individuals die of food-borne diseases. Most cases of enteric disease are relatively mild and go unreported; however, some cases can cause severe problems. One infection that can lead to serious health problems is Vibrio vulnificus, a bacterial organism that thrives in warm coastal waters such as Galveston Bay and the Gulf of Mexico. Vibrio vulnificus is transmitted through the consumption of raw, undercooked, or contaminated shellfish or through wound exposure to contaminated water. 1 Though rare, food-borne Vibrio infection in humans can cause life-threatening complications. Trends: Houston/Harris County 2006-2013 Number of Reported* Enteric Disease Cases and (Rate per 100,000) Houston/Harris County 2006 2007 2008 2009 2010 2011 2012 2013 Salmonella 505 (13.0) 523 (13.3) 771 (19.3) 482 (11.8) 621 (15.2) 634 (15.2) 739 (17.4) 718 (16.6) Shigella 546 (14.0) 716 (18.2) 819 (20.5) 343 (8.4) 233 (5.7) 104 (2.5) 187 (4.4) 816 (18.8) Campylobacter 106 (2.7) 141 (3.6) 189 (4.7) 158 (3.9) 247 (6.0) 154 (3.7) 281 (6.6) 282 (6.5) E.coli (all Shiga toxin producing) 23 (0.6) 38 (1.0) 54 (1.4) 18 (0.4) 51 (1.2) 105 (2.5) 135 (3.2) 183 (4.2) Hepatitis A 42 (1.1) 52 (1.3) 26 (0.7) 14 (0.3) 6 (0.1) 10 (0.2) 7 (0.2) 11 (0.3) Vibrio (food-borne) 11 (0.3) 8 (0.2) 10 (0.3) 12 (0.3) 4 (0.1) 8 (0.2) 1 (0.02) 2 (0.05) *Data for 2013 are preliminary and are subject to change. Healthy People 2020 targets for many of these diseases can be seen on the following page. Sources: HCPHES and HDHHS Epidemiology Case Files Population Differences Males in Houston had a higher rate (35.4 cases per 100,000 population) of food-borne illness than females (28.6) in 2012.2 Among reported cases of Salmonella, the most common enteric disease in Houston in 2012, whites had the highest case rate(11.1 per 100,000) followed by Hispanics (9.2 per 100,000), Asians (7.9 per 100,000) and blacks (6.4 per 100,000).2 Young children are at greater risk of foodborne illness than adults. The chart to the right shows the differences in the number of cases of three of the most common enteric diseases according to age group. 126 Number of Cases per Age Distribution of Selected Foodborne Diseases in Houston, Texas 2012* 80 Salmonellosis Shigellosis Campylobacter 70 60 50 40 30 20 10 0 <1 1-4 5-19 20-34 35-54 55-74 75+ *Cases per 100,000 population Source: HDHHS Office of Surveillance and Public Health Preparedness T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Healthy People 2020 Population Differences cont. Rate of Reported Enteric Diseases, Houston Cases per 100,000*, 2012 Asian Objective FS-1: Reduction in infections caused by key pathogens transmitted commonly through food (Salmonella species) Food-borne Pathogen Salmonella Species 12.7 Hispanic 23.8 Black 12.8 White 2 1.8 0 10 20 30 * Race information is incomplete for 37% of enteric disease cases. Geographic Differences Area Cases Per 100,000 National Baseline 20062008 15.0 Target for 2020 11.4 Houston/Harris County 2013 16.6 State of Texas 2013 18.4* United States 2012 16.4 *Texas estimate based on projected census data. Salmonellosis Cases per Square Mile Houston, 2009-2013 Other Healthy People 2020 Target Rates Food-borne Pathogen Cases Per 100,000 Campylobacter 8.50 E. coli (STEC) O157 0.60 Listeria monocytogenes 0.20 Public Health Actions  Educate people about enteric diseases and how to prevent them.  Monitor disease incidence and trends through methods such as NORS (National Outbreak Reporting System) and PFGE (pulsed field gel electrophoresis).  Investigate health problems in the community through collaborative efforts among health and regulatory agencies.  Enforce laws and regulations by licensing and inspecting facilities that serve food. Source: Houston Department of Health and Human Services (HDHHS) Economic Impact of Enteric Diseases Enteric diseases collectively pose enormous medical and societal cost on communities and individuals. The estimated annual cost of illness for E. coli, Salmonella, and Shigella are listed below.  Shiga toxin-producing E. coli (STEC O157): $271 million  Salmonella: $3.7 billion  Shigella: $138 million3 These estimates (in 2013 dollars) include medical costs due to illness and the cost of lost productivity and premature death. For More Information Centers for Disease Control and Prevention: http://www.cdc.gov/foodsafety/index.html Texas Department of State Health Services: http://www.dshs.state.tx.us/idcu/health/ foodborne_illness/ 1. Texas Department of State Health Services (TDSHS), Infectious Disease Control. Vibrio vulnificus. CDC Web site. https://www.dshs.state.tx.us/ idcu/disease/vibrio/vulnificus/. Updated November 24, 2014. Accessed December 8, 2014. 2. Harris County Public Health and Environmental Services (HCPHES) and Houston Department of Health and Human Services (HDHHS) epidemiology case files. Provided by request. 3. United States Department of Agriculture, Economic Research Service. Cost estimates of foodborne illnesses. http://ers.usda.gov/data-products/ cost-estimates-of-foodborne-illnesses.aspx. Updated October 7, 2014. Accessed December 8, 2014. 127 West Nile Virus Overview West Nile virus (WNV) is a mosquito-borne disease that affects the central nervous system. Disease severity may vary from asymptomatic, showing no symptoms, to severe neurological disease. According to the CDC, approximately 70-80% of people infected with WNV will not show any symptoms, while the remaining will show symptoms of fever, headache, body aches, nausea, vomiting, and may have swollen lymph glands or a skin rash on the chest, stomach, or back. About one in 150 people infected with WNV will develop a severe infection. Severe symptoms include high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness, and paralysis. Recovery from a severe infection may last from several weeks to months, and in some cases neurological effects may be permanent. Approximately 10% of those who develop neurological infection due to WNV result in death.1 Although there are no medications or vaccinations to prevent or treat WNV infection, mild symptoms can be alleviated with over-the-counter medication and severe cases can receive supportive treatment. The best measures to prevent WNV infection include using insect repellent with long-lasting protection, wearing protective clothing, installing or repairing mosquito screens, and reducing the number of mosquitoes in or around the home by emptying standing water.1 Trends: Houston/Harris County 2002-2013 Reported West Nile Cases/Deaths Houston/Harris County Cases Deaths 2005 70 1 2006 123 9 2007 28 2 2008 8 1 2009 12 2 2010 45 3 2011 23 0 2012 115 4 2013 9 0 In Houston/Harris County, the first human case of WNV was reported in 2002. That same year, the greatest number of deaths from the virus was reported, a total of 12 deaths. Since then the number of annual cases has fluctuated, with high incidence years in 2006 and 2012. WNV counts vary considerably from year-toyear based on a number of environmental factors that affect the reservoir for the virus (often birds) and the vector for the virus (mosquitos).1 Most cases of WNV infection occur from June through September. Source: HDHHS and HCPHES Case Files Population Differences While a person of any age can be infected with the virus, incidence rates are highest among those aged 65 and older. An older person, perhaps with a weaker immune system, is more likely to develop a severe West Nile infection than a child or adult under the age of 55. People who work outside or participate in outdoor activities are at highest risk for the virus due to their increased exposure to mosquitoes.1 West Nile Virus Infection Rate in Houston/ Harris County by Age Group Rate per 100,000 Population 14 12 0-18 10 18-24 25-34 8 35-44 6 45-54 4 55-64 65+ 2 0 2011 128 2012 Source: HDHHS and HCPHES case files 2013 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Geographic Distribution The graph below shows ZIP codes where mosquitos with West Nile virus were found. WNV Positive Mosquitos by ZIP Code, 2014 Map based on 2014 data published by HCPHES Mosquito Control Division Economic Impact of West Nile Virus Public Health Actions Since the first U.S. cases of WNV in 1999 through 2013, hospitalized cases have resulted in a total cost of $778 million.2 During this time, over 37,000 cases were reported to the CDC; however, this is likely to be a vast underestimate of the true burden of disease. Of all cases, Texas reported 4,253 (10.8%) cases, the second highest incidence in all states.  West Nile symptoms can last from a few days to several weeks. Some symptoms such as headaches and fever can be mitigated with medical care and medication; however, most severe cases of infection result in encephalitis or meningitis. Medical costs for monitoring and possible complications in these cases can reach several thousand dollars.3   Use of insect repellent with long-lasting protection and wearing protective clothing is key to preventing WNV infection. —CDC   Educate the public about the importance of using DEET-containing insect repellent. Monitor health status and infection by use of geographical information system (GIS) software along with mosquito and avian data. Educate physicians about mosquito-borne diseases and encourage reporting of fevers, rashes, encephalitis, and other symptoms. Provide mosquito spraying in high-risk areas. Inform the community about eliminating mosquito breeding grounds. For More Information Centers for Disease Control and Prevention: www.cdc.gov/ncidod/dvbid/westnile City of Houston: www.houstontx.gov/health/ Epidemiology/westnile.html HCPHES: www.hcphes.org TDSHS: http://www.dshs.state.tx.us/idcu/disease/ arboviral/westnile/ DEET Information at the EPA National Pesticide Information Center: http:// npic.orst.edu/ingred/deet.html 1.Centers for Disease Control and Prevention (CDC). FAQ: general questions about West Nile virus. CDC Web site. http://www.cdc.gov/westnile/faq/ genQuestions.html#where. Updated November 22, 2013. Accessed December 18, 2014. 2. Staples, JE, Shankar, M, Sejvar, JJ, Meltzer, MI, Fischer, M. Initial and long-term costs of patients hospitalized with West Nile virus disease. American Journal of Tropical Medicine and Hygiene 2014; 90(3): 402-409. 3. Centers for Disease Control and Prevention (CDC). West Nile fact sheet. CDC Web site. www.cdc.gov/ncidod/dvbid/westnile/wnv_factsheet.htm. Accessed November 30, 2006. 129 This page intentionally left blank Appendices The following appendices are included here for further reference:  Appendix A: Demographics  Appendix B: Maps of Houston & Harris County  Appendix C: Frequently Used Websites  Appendix D: Healthy People 2020 Sources  Appendix E: BFSS Data, Map Information  Appendix F: Acronyms. 131 Appendix A: Demographic Tables DEMOGRAPHIC TABLES 2010 Annual Estimates of the Population: April 1, 2000 to April 1, 2010 Home Page: http://factfinder2.census.gov City of Houston Harris County State of Texas United States April 1, 2010 Census 100% Count 2,099,451 4,092,459 25,145,561 308,745,538 April 1, 2000 Census 100% Count 1,953,631 3,400,578 20,851,820 281,421,906 April 1, 2000 Estimates Base 1,974,304 3,400,578 20,851,792 281,424,602 7.5% 20.3% 20.6% 8.8% Source: Population Division, U.S. Census Bureau Percent Change, 2000 to 2010 2013 American Community Survey 1-Year Estimates *All Percentages based on Population in Households* Source: U.S. Census Bureau 2013 Household Population Sample Total 2,197,374 4,336,853 26,448,193 316,128,839 * Although the American Community Survey (ACS) produces population, demographic and housing unit estimates, it is the Census Bureau’s Population Estimates Program that produces and disseminates the official estimates of the population. Race/Ethnicity: 2013 City of Houston 43.7% Harris County 41.6% State of Texas 38.4% United States 17.1% 25.8% 22.6% 6.3% 0.2% 0.0% 1.3% City of Houston 25.1% 9.5% City of Houston 1,415,901 31.7% 18.4% 6.4% 0.2% 0.1% 1.4% Harris County 27.4% 9.0% Harris County 2,717,715 43.9% 11.6% 4.1% 0.2% 0.1% 1.6% State of Texas 26.6% 11.2% State of Texas 16,673,656 62.4% 12.3% 5.0% 0.7% 0.2% 2.2% United States 23.3% 14.1% United States 210,910,615 High-school graduates or higher 75.4% 78.6% 81.2% 86.0% Bachelor’s degree or higher 29.2% 28.4% 26.7% 28.8% City of Houston 28.3% 622,844 70.5% 19.9% 4.1% 4.5% City of Houston 2,025,289 944,965 46.7% 22.7% 37.6% 4.2% 3.3% 1.5% Harris County 25.3% 1,096,330 70.0% 21.1% 4.1% 3.7% Harris County 3,995,915 1,702,469 42.6% 19.9% 34.1% 4.5% 3.0% 1.0% State of Texas 16.5% 4,369,271 71.1% 19.5% 4.3% 3.8% State of Texas 24,521,695 8,517,040 34.7% 14.0% 29.4% 2.7% 2.0% 0.6% United States 13.1% 41,347,945 51.9% 29.5% 11.6% 4.4% United States 296,358,760 61,748,740 20.8% 8.5% 13.0% 3.3% 3.6% 1.0% Hispanic ethnicity (of any race) Non-Hispanic ethnicity by race: White Black or African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Two or more races Age Group: 2013 Residents under age 18 Residents age 65 and over Educational Attainment: 2013 Population 25 years and over Foreign-born: 2013 Foreign-born Residents Place of birth for foreign-born: Latin America Asia Europe Africa Language spoken at home: 2013 Population 5 years and over Number speaking language other than English Language other than English Speak English less than “very well” Spanish Asian and Pacific Islander languages Other Indo-European languages Other languages 132 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Income & Poverty: 2013* INCOME IN THE PAST 12 City of Harris State of Houston County Texas Median household income $45,353 $52,489 $51,704 All people below poverty 22.4% 18.5% 17.5% Individuals age 18 to 64 years of age below poverty 18.9% 15.8% 15.5% Children under age 18 below poverty 34.7% 27.1% 25.0% Adults age 65 and over below poverty 14.1% 10.9% 11.0% * Poverty Threshold for 2013: One person (unrelated individual) = $11,490; Four persons = $23,550 Source: U.S. Census Bureau, Housing & Household Economic Statistics Division Households: 2013 City of Harris State of Houston County Texas Total households: 815,266 1,497,363 9,110,853 MONTHS Total families United States $52,250 15.8% 14.8% 22.2% 9.6% United States 116,291,033 496,384 1,025,208 6,322,542 76,680,463 Percent of families with own children < 18 28.7% 34.2% 33.3% 28.6% Married-couple families 38.9% 46.9% 50.0% 48.0% 17.5% 22.6% 22.5% 19.1% 5.9% 5.7% 5.1% 4.8% 2.3% 2.4% 2.4% 2.3% 16.2% 15.9% 14.4% 13.1% 8.9% 9.1% 8.4% 7.2% 39.1% 31.5% 30.6% 34.1% 31.7% 25.7% 25.0% 27.7% 7.3% 6.1% 7.8% 10.1% City of Houston 56,650 Harris County 125,773 State of Texas 760,334 United States 7,188,581 35.3% 34.6% 40.6% 37.3% City of Houston 1,644,878 Harris County 3,148,444 State of Texas 19,318,495 United States 241,556,724 4.7% 5.2% 7.7% 8.1% City of Houston 9.8% Harris County 9.3% State of Texas 11.7% United States 12.6% Population under 5 years with a disability 0.8% 0.7% 0.9% 0.8% Population 5 to 17 years with a disability 5.5% 4.8% 5.5% 5.4% Population 18 to 64 years with a disability 8.2% 8.0% 10.0% 10.5% 37.2% 36.6% 39.9% 36.4% % of married-couple families with own children < 18 Male householder, no wife present % of male-headed families with own children < 18 Female householder, no husband present % of female-headed families with own children < 18 Non-family households Householder living alone 65 years & older Grandparents: 2013 Number of grandparents living with own grandchildren under 18 years in households Responsible for grandchildren VETERAN STATUS: 2010 Civilian population 18 years and over Civilian veterans DISABILITY STATUS OF THE CIVILIAN NONINSTITUTIONALIZED POPULATION: 2013 Total Civilian Noninstitutionalized Population Population 65 years and over with a disability 133 Appendix B: Maps Map of Houston/Harris County Houston City Limits in Harris, Fort Bend and Montgomery Counties Map developed by HDHHS Community Health Statistics, 2009. Note: The Houston city limits have had only very minor adjustments since 2009, so the map is essentially the same for 2015. 134 T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Map of Houston-Baytown-Sugar Land MSA Houston-Baytown-Sugar Land Metropolitan Statistical Area 2015 Metropolitan Statistical Area Source: Definition: U.S. Office of Management and Budget, 2009, with counties included in the MSA. Map created by HDHHS Office of Health Planning and Evaluation, 2006. http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf Note: The Houston-Baytown-Sugarland Metropolitan Statistical Area is unchanged since creation of this map in 2006. 135 Appendix C: Frequently Used Websites U.S. Census Bureau: www.census.gov American FactFinder, for local Census data: http://factfinder2.census.gov Texas State Data Center (state level liaison to the U.S. Bureau of the Census): www.txsdc.utsa.edu Texas Department of State Health Services Home page: www.dshs.state.tx.us BRFSS survey data: www.dshs.state.tx.us/chs/brfss/ Birth and death certificate data, population, trauma data: http://soupfin.tdh.state.tx.us/ Centers for Disease Prevention and Control Home page: www.cdc.gov/ SMART BRFSS local reports: http://apps.nccd.cdc.gov/brfss-smart/SelMMSAPrevData.asp Healthy People 2020: www.healthypeople.gov Appendix D: Healthy People 2020 Sources The first two measures on each table, the National Baseline and the Target for 2020, are taken from the Healthy People website, available at www.healthypeople.gov. Most of the following measures, for the Houston-Galveston-Sugar Land MSA, Texas, and the United States, are from the Texas Department of State Health Services, Behavioral Risk Factor Surveillance System, available at http:// www.dshs.state.tx.us/chs/brfss/. In some cases, the BRFSS results are taken from the CDC SMART BRFSS website. When other sources are used, they are noted below: Secondhand Smoke: Local and Texas data from TDSHS, national data from CDC. Obesity in Youth: CDC Youth Risk Behavior Surveillance System Survey. Injury Risk: Harris County and Texas rate from TDSHS Vital Statistics, national rate from CDC. Child Abuse: Local and Texas statistics from CPS in Harris County Annual Report, national data from the U.S. Department of Health and Human Services, Administration for Children and Families. Alcohol and Drug Abuse: Local data from SAMSHA, state data from TDSHS Vital Statistics, national data from CDC Vital Statistics. Prenatal Care, Adolescent Pregnancy, Pregnancy/Infant Outcomes: Local and Texas data from TDSHS, national data from CDC. Maternal, Infant, and Fetal Mortality: Local and state data from TDSHS Vital Statistics, national data from CDC Vital Statistics. Immunizations: CDC National Immunization Survey. Air Quality: American Community Survey. Food Safety: Local measures from HDHHS and HCPHES Case Files. Texas measures from TDSHS. National measures from CDC. Lead Poisoning: Local measures from HDHHS and HCPHES Case Files. Texas measures from TDSHS. National measures from CDC. Mental Health: Harris County and Texas data from TDSHS Vital Statistics, national data from CDC Vital Statistics. Heart Disease, Cancer, Diabetes: Harris County and Texas data from TDSHS Vital Statistics, national rates from CDC Vital Statistics. Asthma: Harris County and Texas hospital discharge data from TDSHS, national from CDC. Communicable Diseases: Local and Texas data are from HDHHS and HCPHES Case Files and TDSHS. National data and some state data are from CDC. Appendix E: BRFSS Data, Map Information BRFSS data has been collected since 1984 through landline phone surveys to households. In 2011, the survey was amended to include cell phones. Surveys collected since 2011 reflect changes in weighting methodology (raking) and the addition of cell phone only respondents. 136 Map Disclaimer: Many of the maps showing health measures in Houston/Harris County were prepared by the HDHHS Office of Surveillance and Public Health Preparedness, Community Health Statistics section. These maps represent the best information available to the City. The City does not warrant their accuracy or completeness. Field verifications should be done as necessary. T HE S T AT E O F H E ALT H IN H OUST ON / H ARR IS C OUNT Y 2015 - 16 Appendix F: Acronyms AAFP ACIP AIDS AMI BRFSS BMI CDC CFRT CHIP CPS CVD DHHS DOT E. coli ED EMS EMTALA EPA ER ETS FDA FPL HCHA HCHD HCPHES HDHHS HGB HHCCFRT HHSC HISD HIV HSR HUD IOM LBW LGBT LTBI MHMRA MMR MSA MSM MUA MUP NAAQS NCHS NHANES NIH NIS PCC PCP PM 2.5 PQI SIDS YRBS American Academy of Family Physicians Advisory Committee on Immunization Practices Acquired Immunodeficiency Syndrome Annual Median Income Behavioral Risk Factor Surveillance System Body Mass Index U.S. Centers for Disease Control and Prevention Child Fatality Review Team Children’s Health Insurance Program Harris County Child Protective Service Cardiovascular Disease U.S. Department of Health and Human Services Directly Observed Therapy Escherichia coli Hospital-based Emergency Department Pre-hospital Emergency Medical Services Emergency Medical Treatment and Active Labor Act U.S. Environmental Protection Agency Emergency Room Environmental Tobacco Smoke Federal Drug Administration Federal Poverty Level Harris County Healthcare Alliance Harris County Hospital District Harris County Public Health and Environmental Services City of Houston Department of Health and Human Services Houston-Galveston-Brazoria Houston/Harris County Child Fatality Review Team Health and Human Services Commission Houston Independent School District Human Immunodeficiency Virus Health Service Region Department of Housing and Urban Development Institute of Medicine Low Birth Weight Lesbian, Gay, Bisexual, and Transgender Latent TB Infection Mental Health Mental Retardation Authority of Harris County Measles, Mumps, Rubella Metropolitan Statistical Area Men Who Have Sex With Men Medically Underserved Area Medically Underserved Population National Ambient Air Quality Standard National Center for Health Statistics National Health and Nutrition Examination Survey National Institute of Health National Immunization Survey Poison Control Center Primary Care Physician Fine Particulate Matter Patient Quality Indicators Sudden Infant Death Syndrome Youth Risk Behavior Survey 137 Explore more than 50 topics that reveal factors influencing health and health outcomes, in these key categories: Trends Population Differences Geographic Distribution Economic Impact Healthy People 2020 Public Health Actions