Ann Lindsay, M.D.
Humboldt County Public Health Officer

Thomas Martinelli, M.D.
Del Norte County Public Health Officer


The Arcata City Council recently did not repeal drinking water fluoridation. Arcata water has been fluoridated for 40 years. Eureka also fluoridates its water. Water in the rest of the county is not fluoridated. Many Arcata residents raised questions about the safety and efficacy of water fluoridation, exhibiting fear and concern. I am making an effort to understand the concerns of the critics of water fluoridation. It is not my habit to accept the status quo without full consideration of arguments from all sides, no matter how controversial. I will let you know if I change my mind, but it is my impression that the concerns of anti-fluoridationists are based on extrapolation of experimental data from experiments using relatively large doses of fluoride and accounts of environmental pollution from industry like steel and zinc production and uranium extraction; again at exposures significantly greater than optimum water fluoridation. It is likely that there have been "cover ups" about worker and community adverse effects from industrial pollution with fluoride.

There is no such "cover up" about the safety of water fluoridation, nor is one necessary. Environmental concerns about pollution are legitimate; safety concerns about drinking water are not. The Medical Society Executive Committee has reaffirmed its position in support of water fluoridation as a safe and effective measure.

Medical professionals may hear concerns from patients about this issue and we can help educate and reassure them. We are familiar with the notion that a substance can be therapeutic at one level, yet toxic at a higher dose. This notion is key to accepting water fluoridation. Iron is a good example that the general public can understand; a little helps, too much hurts. In the case of fluoride, one would have to drink 100 liters of water to get a toxic dose. Fluoride ingested in low doses is either used and deposited in bones and teeth, or excreted by the kidneys. It does not accumulate in the body. The following is a capsule summary of the history and scientific data so that you can discuss this issue with your neighbors, co-workers and patients.

HISTORY: Prior to 1945, a series of epidemiologic and laboratory studies confirmed the association between the environment (naturally-occurring fluoride concentrations of water supplies) and the health and cosmetic appearance of the teeth. Where the fluoride level was low there was a high prevalence of dental caries. Yet, where the fluoride level high there was a low prevalence of dental caries, but a high prevalence of dental fluorosis/enamel mottling. This led to the concept of creating an ideal environment for optimal dental health through adjusting the naturally occurring fluoride level to about 1 part per million. Two-thirds of the U.S. population is served by fluoridated water systems. Initial studies showed a 60% reduction in caries in fluoridated communities. More recently, the benefit appears to be 30-40%. The difference may be attributed to use of fluoridated toothpaste and the prevalence of fluoridated water in packaged foods and beverages. Antigo, Wisconsin, discontinued water fluoridation in 1960. By 1965, 2nd grade children had 200% more tooth decay, and 4th graders had 70% more. Antigo re-instituted fluoridation. Studies in other communities show similar results.

HOW DOES FLUORIDE WORK: Topical fluorides strengthen teeth already present in the mouth. Fluoride is incorporated into the surface of teeth making them more decay-resistant. Fluoridated drinking water probably has a topical effect as well as a systemic effect. Systemic fluorides can give topical protection because ingested fluoride is present in saliva, which continually bathes the teeth. Fluoride is incorporated into the tooth surface to prevent decay. Fluoride also becomes incorporated into dental plaque and facilitates further remineralization. It reduces the solubility of enamel in acid. It reduces the ability of plaque organisms to produce acid. Adults may also benefit from fluoridation, particularly those with receding gums, which are particularly susceptable to plaque. In addition to reducing tooth decay, water fluoridation prevents needless infection, pain, suffering and loss of teeth; improves the quality of life; and saves vast sums of money in dental treatment costs.

ADVERSE HEALTH EFFECTS: Scientific literature does not support the claims that optimally fluoridated water adversely affects the immune system, collagen, glucose metabolism, the integrity of genetic material, causes attention deficit disorder, Alzheimer's disease, osteoporosis, cancer or AIDS, aggravates kidney disease or hypothyroidism.

Anti-fluoridationists and anti-fluoride web sites cite "scientific articles," most of which have methodological problems: they are not from reputable peer-reviewed journals; they do not deal with the fluoride compounds that are actually used to fluoridate water; they study exposure levels way above that possible at 1 ppm dilution of fluoridated water; they extrapolate from animal models or in vitro research; the articles are not obtainable through a medical/dental library.

Legitimate epidemiologic studies have not detected health risks to water fluoridation at 1 ppm. For example, since community water fluoridation was introduced in 1945, more than 50 epidemiologic in different populations and at different times have failed to demonstrate an association between fluoridation and the risk of cancer. Mild dental fluorosis, mottling of tooth enamel, can occur, particularly if a child also uses fluroidated tooth paste, but fluorosis does not weaken teeth.

Skeletal fluorosis, which is a serious health problem, does not occur from drinking water, but can be an occupational and environmental health risk in the proximity of industries which utilize large amounts of fluoride. In contrast, the benefits of water fluoridation are great and easy to detect.

PERSONAL FREEDOM: Some people against water fluoridation feel fluoridating a community water supply impinges on their personal freedom. They feel they are "medicated against their will." In fact, filters are available whereby individuals could de-fluoridate their water, or they could drink distilled water. Furthermore, participation in civil society in Humboldt County involves numerous examples where public policies are initiated for the common good, considering that the risks to an individual are absent or minimal. The law requiring use of helmets by motorcyclists "infringes on personal freedom" to protect society from the burden of caring for an injured individual. Vitamin D is added to milk and folic acid to cereals. Immunizations are required for children to attend school. Parents may cite religious beliefs to exempt their children from immunizations, but these un-immunized children would not be "free" to attend school if they were exposed to measles. Fluoridation is considered by the public health community to be one of the top 10 effective public health measures of the 20th century.

ALTERNATIVES TO WATER FLUORIDATION: Fluoride can be administered by prescription of a physician, and should be to children residing in non-fluoridated communities. This requires a medical visit, purchase of medication and daily administration. This is much more complicated and costly and more prone to overdosing than drinking optimally fluoridated water. Fluoride can also be administered topically, which requires regular visits to a dentist. Dental care is exceedingly difficult to come by, particularly for low-income children. Children who brush regularly, floss and eat a diet low in concentrated sweets and simple carbohydrates and with adequate calcium are less likely to get dental caries. The Humboldt Dental Advisory Group, which includes Public Health, has been working on all these alternatives for years. None is as cost effective and simple to administer as water fluoridation. Like the campaign to lower tobacco consumption, the campaign for dental health must be carried out in many different venues simultaneously.

Please contact me with questions, concerns, for pamphlets for your patients, or to volunteer to support fluoridation.


I would like to activate the Public Health Advisory Committee to research water fluoridation. It would be helpful to have input from a variety of specialists. Participants will be asked to research particular questions prior to a meeting to keep meeting time to a minimum. Also welcome are medical providers who simply want to learn more about the issue. If you are willing to serve please contact Penny Figas at the Medical Society or Dr. Ann Lindsay 268 2181 or by e-mail alindsay@co.humboldt.ca.us.

Tetanus and Diphtheria Immunization and the Elderly

The shortage of Tetanus and Diphtheria Toxoids Adsorbed For Adult Use (Td) is over and providers can return to using the vaccine for all routine indications, including booster shots. One patient group of particular concern is the elderly, because they may not be up-to-date on their booster immunization or may have never had a primary series of shots for immunization against tetanus or diphtheria. Although 95% of American children entering school are immunized against tetanus and diphtheria as part of their childhood immunization schedule, the protection wanes over time and must be reinforced throughout life with a combined booster shot every ten years, usually starting around 11 or 12 years of age.(1) Tetanus bacteria naturally occur in nature and diphtheria bacteria are passed from person to person; cases of each disease are relatively rare in the United States, but every case is vaccine-preventable.A recent study of America’s serologic immunity to tetanus and diphtheria has some disturbing findings for older people. Several cases of tetanus are reported annually with deaths occurring most commonly in elderly patients. Elderly patients may be at increased risk for tetanus infectionsbecause they naturally have a weaker immune system, may be under-immunized or have failed to be immunized at all against the disease.To determine the general public’s protection against tetanus and diphtheria, serum samples were obtained from 18,045 people age 6 years and older who participated in the US Centers for Disease Control and Prevention’s (CDC) Third National Health and Nutrition Examination Survey (NHANES III). About 39% of all Americans age 6 years and older lack protection against diphtheria and 28% lack protection against tetanus.(2) The level of protection is lower in older Americans: 62% of persons 60 years and older are not protected against diphtheria and 50% are not protected against tetanus.(3)The recent return of routine TB boosters after a year long shortage of the vaccine gives providers a practical reason to review tetanus and diphtheria immunization status with every adolescent or adult patient, especially the elderly. Additionally, three recent cases of tetanus infection in Puerto Rico are an excellent reminder of how vulnerable elderly patients can be. In the Puerto Rico cases three patients, ages 68, 76 and 86 years, contracted tetanus. One patient suffered a puncture wound after stepping on a rusty nail, while the other two patients were infected from dirty splinter wounds. The 68 and 86 year-old patients died from their infections while the 76 year-old survived following nearly eight weeks ofhospital treatment; the patients appeared to have no prior immunization against tetanus and
diphtheria.(4)The majority of tetanus cases reported in the U.S. during 1989-1997 occurred in persons who had not completed a three-dose primary tetanus toxoid vaccination series or for whom vaccination histories were uncertain; no tetanus deaths occurred in persons who received primary tetanus vaccination.(5) Many adult patients, especially the elderly, may not know that they need a tetanus and diphtheria booster shot. The CDC recommends that providers discuss tetanus and diphtheria immunization with all adult patients and reinforce their primary immunization with a combined booster of tetanus and diphtheria toxoids every ten years. If a patient has not received a primary series of three shots of tetanus and diphtheria toxoids, the primary series should be administeredaccording to the CDC’s recommendations.
1 McQuillan GM, Kruszon-Moran D, Deforest A, Chu Sy, and Wharton M, Serologic Immunity to Diphtheria and Tetanus in the United States, Annals of Internal Medicine, May 7, 2002, vol 136, p. 660.http://www.annals.org/issues/v136n9/abs/200205070-00008.html 2 Ibid, p. 662 3 Ibid, p. 6654 Centers for Disease Control and Prevention. Tetanus-Puerto Rico, 2002. MMWR 2002; vol 51, pp. 613-614.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5128a1.htm5 Ibid, p. 615.

Please share the following information with your patients.
Free disposal of home-generated needles is available at four locations in Humboldt County. The Humboldt Waste Management Authority has sponsored the program in which residential generators of medical needles, “sharps”, can dispose of the needles free of charge. A home-generated sharp is a medical needle, such as used by diabetics. This service is not available to commercial entities. The sharps must be contained in a sealed plastic container. Designated sharps containers are available at some pharmacies. Old bleach bottles or liquid detergent bottles also work well. The container’s lid should be securely taped and the word “sharps” should be written on the container. Containers of sharps can be dropped off at the Hawthorne Street Transfer Station in Eureka, Eel River Disposal in Fortuna, Arcata Community Recycling in Arcata, and Humboldt Sanitation in McKinleyville during open hours. The container should be given to operations staff, and not put with regular garbage. Residents should not dispose of sharps with their garbage because of the risk to the waste collection staff and staff at the transfer station and the landfill.

Over a third of the word's annual 56 million deaths are a result of 10 risk factors , all of which can be better controlled. The World Health Organization released a report last month, "Preventing Risks, Promoting Healthy Life" which reported that most of the top 10 risks are due to either a remediable need or forms of overindulgence.
The 10 risk factors most significant worldwide were: childhood and maternal underweight; unsafe sex; high blood pressure; tobacco; alcohol; unsafe water and inadequate santitation and hygiene; high cholesterol; indoor smoke from solid fuels; iron deficincy; and obesity and overweight.
It is a striking finding that in poor countries there are 170 million underweight children, over three million of whom will die this year as a result, yet there are more that one billion adults worldwide who are overweight and at least 300 million who are clinically obese. About half a million people in North America and Western Europe will have died this year from obesity-related diseases. Diseases linked to excessive alcohol consumption, obesity and physical inactivity are not only the dominant ills in middle and high income countries. They are becoming more prevalent in the devloping world, where they create a double burden on top of infectious diseases. This epidemic of noncommunicable diseases is related to increased consumption of industrially processed fatty, salty and sugary foods. This report suggests that preventive efforts would be wise policy!

HEALTH DEPT NEWS November 2001

Ann Lindsay, M.D.
Humboldt County Public Health Officer

The response to bioterrorism is only as strong as the local public health departments in each community. Our daily public health operations are the same operations that would respond to bioterrorism, a flu pandemic or a large outbreak of food-borne illness. Local medical providers and laboratories regularly report occurrence of significant communicable diseases and medical conditions to public health. Public health, particularly the Health Officer and Public Health Nurse responsible for communicable disease, review the reports, conducting more in depth investigations when necessary. We report to the state Department of Health Services (DHS) by mail, internet, phone, fax or radio if necessary. They, in turn, have established communication networks with other counties and the federal Center for Disease Control and Prevention (CDC). The CDC has 80 Disaster Medical Assistance Teams (DMAT) available for dispatch if needed and ?push packages? of pharmaceuticals staged to arrive within 12 hours at any location in the country in need.
Our local response is aimed at containment of risk and prevention of new cases. We coordinate the response of the medical community, educate the general community and medical community if necessary and insure that people receive proper treatment of their condition. If necessary, the Health Officer has the power to quarantine. In a situation of disaster proportions, the Humboldt County Office of Emergency Services would be activated according to protocols under the direction of the Sheriff’s Department and Board of Supervisors. When HAZMAT (hazardous material) is involved we coordinate with Environmental Health in the Public Health Branch and specially trained response units from Eureka Fire Department. If terrorism were suspected, the FBI would lead in the investigation.
The Public Health Laboratory (level A lab) is a critical component of our local response. The local lab can perform some tests locally, but is also the conduit from private labs in the whole North Coast to the state laboratory in Emeryville (level C lab) and the CDC lab (level D). Tests are available through this network which can identify anthrax, pestis (bubonic and pneumonic plague), and tularemia within 6 hours. Unfortunately, all public health labs in the state are understaffed, the state lab by as much as 50% of their microbiologists. Senator Wes Chesbro has proposed SB616 to make resources available for training public health microbiologists, but it did not make it into law this year. It will be considered as a two year bill. Planning is underway locally to upgrade the ventilation of our PH lab until resources for a much needed larger facility are available.
In addition to general disaster planning, the Health Officer, Laboratory Director, Environmental Health Director and the HAZMAT team from Eureka Fire have had specific bioterrorism training. Public Health participated in an evaluation of bioterrorism preparedness by the federal Department of Justice which will clarify strengths and deficiencies of the public health infrastructure.
Public Health, the Humboldt/Del Norte County Medical Society and the Consortium for Continuing Medical Education are planning bioterrorism training for local medical providers. The California DHS is designing a system for improved emergency communication to all California Health Officers regarding alerts. Tools for response would be available electronically, including epidemiologic investigation formats and educational materials. The system is scheduled to be operational by 12/31/01. DHS plans to expand reportable conditions to include several more agents which could signify a bioterrorism event. DHS is also planning additional training for private laboratories on bioterrorism. They hope to institute automatic electronic reporting to the local and state health department of all laboratory tests ordered and reported.
Meanwhile, what can you do? Red Cross (443-4521) has an excellent pamphlet available to help you plan your disaster preparedness at home. Or you could organize a Neighborhood Emergency Services Team (NEST). Again, Red Cross can be of help. You may also want to discuss worksite disaster plans with your staff.
For more information on bioterrorism and possible agents:
Center for disease Control and Prevention http://www.bt.cdc.gov
California Dept. of Health Services http://www.ca.gov/ (Hospital Bioterrorism Report Planning Guide for Hospitals)
Johns Hopkins University http://www.hopkins-biodefense.org
* * * * *
Humboldt County Department of Environmental Health has received a grant from U.S EPA to provide training and assistance to reduce and/or remove mercury containing devices from health care facilities. In an effort to assist, the California Department of Health Services (DHS), and the Hospital Alliance Association (HospAA), will help present a FREE one-day workshop to providesuch training the all interested health care providers in Eureka and the surrounding areas. The event will be help at the Arcata Community Center on November 7th, 2001 from 8:30AM to 1:00PM. Mark your calendars for this worthwhile event!This workshop is provided for all staff members from Hospitals, Clinics, Hospice Providers, Skilled Nursing Providers, Medical Offices, Intermediate & Primary Care Clinics, Blood Banks, Dialysis Clinics, Dental Offices, and Veterinarian Offices to participate in this FREE event. A
Continental breakfast and lunch will also be provided FREE of charge.Mr. Peter Bloom, R.E.H.S., of Humboldt County Department of Environmental Health will be glad to answer any questions, please feel free to call him at (707) 441-2005. If you would like the DHS to assist you with a mercury assessment of your facility, you're welcome to contact me at (916) 327-6056, or
mailto:cgarcia@dhs.ca.gov <mailto:cgarcia@dhs.ca.gov> to arrange anappointment for Wednesday (11/7/2001), after 1pm or Thursday morning(11/8/2001) sometime before noon.Cindy GarciaEnvironmental Health Specialist IIIDept. of Health Services(916) 327-6056 office(916) 323-9869 fax(916) 815-2413. The energy crisis is real, so every Californian needs to take immediate action to reduce energy consumption. For a list of simple ways to reduce energy demand and cut costs, go to the Web-site at:
http://www.consumerenergycenter.org/flex/index.html_Be the change you want to see in the world...... 


In several studies, the most recent outlined in Clinical Laboratory News, seven to ten percent of physician office laboratories (PLOs) were practicing outside their waived scope, "most of the time unbeknownst to themselves." Generally, PLOs exceed their waived certificate due to management rather than testing errors.
For example, most waived tests come in kit form with specific directions from the manufacturer. The test is classified as waived when, and only when, these directions are followed exactly. If your staff does not follow them, the test is no longer considered waived, and in fact, becomes high complexity. Suddenly you are practicing outside your waived scope. (The same is true for moderate complexity tests.)
The solution? Make sure your staff reads the latest version of the manufacturer's instructions. To identify the latest version, highlight the date on the insert before adding it to the procedure manual. Then every time a kit is opened, compare the dates. If they are different, discard the old, replacing it with the new.
To keep staff up to date, set up a page listing your testing personnel with a space at the top for filling in the test name. (E-mail me at the address below, and I'll be happy to forward you a template.) Require that each tester read the package insert and sign (and date) that they have read and understood it.
Now you have proof that your staff understands (and presumably is following) the package insert, keeping your PLO within its waived bounds.
Have questions? Contact Kathy Hansen and she will answer them in this space: e-
mail: kmhansen@snowcrest.net, fax: (530) 547-5260, or phone: (530) 547-5273.


The Department of Health Services has worked with community partners to develop
guidelines for the prevention and control of head lice. Information can be found on their web site: www.dhs.ca.gov/ps/dcdc/htnml/publicat.htm (scroll down to Vector Borne disease Section). Key points in the guidelines included the following:
1) Make sure the problem is really head lice. Only lice nits are glued to thehair, and they will not slide up and down the hair shaft.
2) Lice and nits should be removed daily from the child's hair with a metal nit or flea comb. Plastic combs do not work well.


Ann Lindsay, M.D.
Public Health Officer, Humboldt County 

A large and growing body of evidence indicates that children are more sensitive than adults to the neuro-toxic effects of lead, and no blood lead level is recognized as safe.   In children, low levels of lead exposure have been associated with developmental delays as well as decrements in:  intelligence, short term memory, perception integration, visual motor functioning and behavior.  For that reason, prompt identification of children at risk is essential.
These are the requirements for health care providers doing assessments on children between ages of 6 months and 6 years:
•           Provide oral or written guidance on lead poisoning at each assessment at 6 months to 6 years.
•           Screen (order blood-lead tests for) children in publicly supported programs at both 12 months and 24 months.  Publicly supported plans include Medi-Cal, CHDP, WIC, and Healthy Families.
•           Assess whether children in publicly supported programs are at risk of lead poisoning by asking, "Does your child live in, or spend a lot of time in, a place built before 1978 that has chipped or peeling paint or that has been recently renovated?"
•           Order a blood-lead test if the answer is "yes" or "I don't know."
This standard of care is a minimum.  Any child may receive a blood-lead test at the discretion of the practitioner or at parental request.
Humboldt County Public Health Branch is now offering finger stick protocol training at provider offices.  The training includes a 12-minute video, presentation, specimen-collection kits, laboratory forms, and incentives for children receiving blood tests.   Training may be scheduled through the Child Health and Disability Prevention Program at (707) 476-4994.

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