In two separate incidents this summer, someone with a disability was left inside a hot van for hours. Both incidents resulted in some injury, but there were different consequences for the people responsible.

By Taylor Sisk

Two closed vans on two hot summer days. Two adults with special needs, forgotten for hours. Two state-licensed agencies in charge of their care. Different outcomes, different determinations regarding neglect – and a call for more consistency in how such incidents are addressed.

On June 20, a 70-year-old wheelchair-bound woman with dementia was inadvertently left in a van for more than six hours. The woman, a client of the Elderhaus PACE day adult-care facility in Wilmington, was treated for dehydration and spent several days in the hospital.

In two separate incidents this summer, people with disabilities were left inside hot vans for hours. Temperatures inside the vans topped 100 degrees during each incident. Photo credit flickr creative commons.

The driver of the van was charged with criminal abuse. Elderhaus PACE – which stands for Program of All-Inclusive Care for the Elderly – was cited for nine violations by the New Hanover County Department of Social Services. The state Department of Health and Human Services also took action.

On July 5, a 35-year-old resident of an Apex group home was likewise left in a van for more than six hours. The man, who has autism, was supposed to be out on a work assignment. He wasn’t found until the end of the workday. He was taken to a hospital, where he was treated for heat stroke and released.

No charges were filed and no violations cited.

High temperatures for the day in both cases were in the 80s, but the temperatures inside the closed vans reached above 100 degrees.

Same problem, different result

Vicki Smith, executive director of Disability Rights North Carolina, said that a critical factor in why charges were brought in the one case but not in the other was the difference – or at least perceived difference – in degree of physical harm suffered by the individuals.

“That’s a critical factor from the point of view of law enforcement,” she said.

But, Smith said, “the neglect is the same. They were both left by their caretakers in vehicles.”

Disability Rights head Vicki Smith

She believes those laws need to be re-examined. Smith also said she’s concerned that there are inconsistencies in how the laws are interpreted by the different state agencies tasked with monitoring facilities that care for North Carolinians with mental health, developmental disability and substance-abuse issues.

DHHS’s Division of Aging and Adult Services (DAAS) is responsible for the Elderhaus facility, while the Division of Health Service Regulation (also part of DHHS) oversees the group home.

Too many agencies are allowed to operate with obvious deficiencies that put their clients in jeopardy, she said. “That’s what surprises us.”

Smith believes there should be more diligent oversight.

State statutes apply

N.C. General Statute 14-32.3, “Domestic abuse, neglect, and exploitation of disabled or elder adults,” addresses day adult-care facilities. The statute states that a caretaker of a person with a disability or an elder adult is guilty of neglect if he or she “wantonly, recklessly, or with gross carelessness” confines or restrains a person “in a place or under a condition that is unsafe” causing mental or physical injury.

The driver of the Elderhaus van in question was terminated after the June incident.

As for sanctions against the operators of the Elderhaus facility, in addition to the nine violations cited by New Hanover County social services, the state took corrective measures.

At the time of the June incident, Elderhaus PACE was due for state recertification and because the operators had not submitted a complete recertification application to the state, DAAS issued them a provisional certification. The provisional status is in place from Aug. 1 to Oct. 31.

According to Julie Henry, assistant director of the DHHS Office of Communications, funding for the PACE program comes from the state Division of Medical Assistance, which requests a “root-cause analysis” from providers when a violation is cited.

That analysis is also submitted to the federal Centers for Medicare & Medicaid Services (CMS).

“Based on the analysis, CMS has approved our recommendation that Elderhaus suspend new enrollment in the PACE program until the program regains full certification status from DAAS,” Henry said.

In the Apex incident in July, N.C. General Statute 14-32.2, “Patient abuse and neglect,” was applicable. Under that statute, a felony has been committed if the violation indicates a pattern of abuse or neglect or if the conduct is “willful or culpably negligent” and results in serious bodily injury or death.

Wake County Assistant District Attorney Patrick Latour called the neglect an “incident of bad judgment” on the part of the operators of the Mason Street Group Home, but said no criminal charges were warranted.

According to Henry, a complaint was filed against the group home as a result of the incident and the Division of Health Service Regulation conducted an investigation.

“No deficiencies were found in the facility,” Henry said.

Broader concerns

Smith said that while the media attention on these two incidents has focused largely on the drivers of the vans, “it’s much broader than that.”

“There was a systemic failure here,” she said. The only reason charges weren’t filed in Wake County, she said, was because the man wasn’t considered to have been seriously injured.

Smith said there is also need for diligent scrutiny of all such agencies, regarding past offenses, employee screening, adequate training and more.

The Mason Street group home has had complaints lodged against it in the past, but they were either found to be unsubstantiated or proper corrective action was taken.

“We deeply regret what occurred,” said Sheryl Zerbe, a spokesperson for ResCare Inc., which operates the group home. “We have extensive controls in place to protect the people we serve.”

Elderhaus PACE administrators acknowledged that proper procedures weren’t followed when the woman under their care was left unattended.

Smith said the proper response for all parties involved is to ask, “What’s going to prevent this in the future and how can it be prevented elsewhere?”

It’s not just a matter of what’s done to the individuals who perpetrated the violation, “but the people who hired those individuals and who are responsible.”

“We hear a lot about how the staff really care for these people,” Smith said, “but there was still this fatal error. And we feel that it’s really the group home operator and the day program people who need to have mechanisms in place to catch these human errors.”

The licensing organizations that oversee them, Smith said, must also assess their policies and procedures, and another look should be taken at the laws.

“Is it the ability of one to survive neglect that determines the charge, or is it the act itself?” she asked “The discrepancy of these two cases really highlights that it’s the individual’s ability to survive that made the difference in these two situations.

“And that’s wrong.”

After months of review, a new operations guide helps state, locals manage response to abrupt adult group home closures.

By Brenda Porter-Rockwell

Just over a year ago, Amy and Larry Patton, owners of three adult care homes in the central Piedmont walked into their facility in the Montgomery County town of Mt. Gilead and ferreted away all the valuables, including ice makers and fax machines, while residents of the home slept.

The next day, residents and staff were left in a state of confusion.

State and county workers swept in to secure new homes for the combined 75 residents. Within less than two days, they had scrambled to find placement for all of the Pattons’ residents.

The state of North Carolina suspended the couple’s license to operate an adult care facility for a year. No criminal charges were filed.

Now a year later, after the Pattons abandoned their facilities, the state has developed a new plan called “Operational Guide For a Coordinated Response to the Sudden Closure of an Adult Residential Care Facility” to allow for a more strategic and coordinated response if faced with the sudden closure of a facility.

Little warning

Although rules were in place in 2013 to prevent sudden, unorganized closures – such as a 30-day notice of closure requirement – state and local officials across two counties had no coordinated plan or process to guide them through quick and decisive actions.

Serenity Care in Greensboro is one of the adult care facilities abandoned last winter by its owners, Amy and Larry Patton. Photo via google street view

The Pattons had followed the letter of state rules when in late January they told authorities they planned to close their three facilities – one in Mt Gilead and two in Greensboro – within 30 days.

They were in financial difficulty, including a defaulted $2.6 million loan a court had ordered them to pay, along with back taxes.

Only one week elapsed before they emptied out the Mt. Gilead residence.

The same scene played out at their other two adult care homes, known as Serenity Care and Serenity Gardens, in Greensboro.

Acknowledging that local workers managed to resolve the problem well, Department of Health and Human Services Secretary Aldona Wos said last January that she wanted to ensure a more orderly response should this happen again. Wos immediately tapped Dennis Streets, director of DHHS’s Division of Aging and Adult Services, to chair an inter-departmental task force.

According to a press release at the time, Wos said the plan would, “Strengthen our preparedness and response to adverse situations that could jeopardize the health and safety of vulnerable adults living in residential facilities.”

No crime and no punishment

While the Pattons’ actions might have been unethical, they did not break any laws. To the frustration of many, state or local officials were powerless to take legal action to hold the couple responsible.

Even with the operational guide in place, Streets said DHHS continues to examine additional measures to prevent sudden closures and, just as important, hold accountable those who disregard the rules.

“Are there things that can be done, administratively or through legislative action, that would be a deterrent to someone doing a sudden closure of this nature and putting people at potential risk?,” asked Streets.

Among the actionable measures being considered against negligent owners is an immediate revocation of a license. The state is also considering forbidding negligent owners from ever receiving future public funding.

Further, Streets said there is a possibility that in the future the Pattons’ actions could be considered criminal, but that would be a matter for the state legislators, who would need to amend the law.

Montgomery County Lead Assistant District Attorney Darren Allen said no laws currently exist that would’ve allowed arrest and prosecution. However, he said he hopes the legislature considers taking a harder stance.

“I would be in favor of making it a crime. It would be nice if the legislature would provide some sort of deterrent to that happening again,” said Allen.

Streets is also looking at how adult care homes have prepared emergency response plans that are associated with a natural-disaster closure as a model for the need for a sudden closure. Facilities are expected to have natural-disaster emergency plans in place.

“What we would like to do is think about it in the most practical, effective way to avoid this in the future and, if something does happen, hold the party responsible,” said Streets.

“What that exactly is, I’m not sure yet,” he said.

Response hubs

After months of planning and meeting, Streets, a 30-year veteran in the industry, said state and local officials now have the tools needed to work cooperatively when faced with a sudden closing.

“We are now in a position where we can ensure an effective sharing of information and communication among those of us at the state level when we need to support those at the local level in the event of a re-occurrence of something of this nature,” he said.

One of the most important and immediate steps taken was to create ad hoc inter-agency response hubs for both adult care homes and mental health group homes.

The response hubs, said Streets, activated only in case of an emergency, outline each agency’s respective roles as divisions – such as the Division of Health Services, Health Services Regulations, Medicaid or Medical Assistance, Mental Health, Substance Abuse and Aging and Adult Services – in the event of another occurrence.

The operational guide also includes the creation of tools like discharge tracking logs to document residents and track their discharge status. A daily situation report, another part of the plan, provides a uniform set of questions to help assess and track the status of the facility and residents and to identify any need from DHHS.

A post-event debriefing has been added to the task list to ensure continuity of care for affected residents and to identify any issues that may affect the state’s response now and in the future.

The state unexpectedly had to put their operational guide to test with another unplanned closing in New Hanover County, which occurred shortly after the closures in Montgomery and Guilford counties.

“We had a little more experience with that situation by then,” Streets said. “While not a full-blown emergency closure, we could draw on our experience and provide our local partners with the outline of this operational guide.

“We’re finding that what we’ve developed and outlined makes good sense and is working well,” he said.

At town-hall meetings around the country, Vietnam-era veterans are gathering to learn about the possible consequences of wartime exposure to Agent Orange on their children.

By Rose Hoban

When Irwin Brawley came home from Vietnam in 1969, he really didn’t want to talk about the war. He got a job at Davidson College, kept his head down, got married and had two daughters.

“It was real liberal,” Brawley said. “They were protesting the war on the campus, but I just took the low-key approach.”

A few years ago, Brawley retired from Davidson. He was also diagnosed with ischemic heart disease. Someone told him that the cause of his heart problems could have been that while performing his job as a transport driver he was sprayed with Agent Orange, the dioxin-based defoliant used widely throughout the Vietnam conflict.

Pam Scheffer-Bossardet (back to camera) helped organize the Morrisville meeting and moderated questions from the audience of about 150 people over the course of three hours. Photo credit: Rose Hoban

“They sprayed on us when we were in convoys, especially in the highlands,” he remembered.

He filed a claim to the Veterans Administration for disability compensation based on Agent Orange exposure and his claim was accepted. Now he gets about $600 per month after the VA determined about 30 percent of his disability was a result of exposure.

What really bothers Brawley now is not the problems Agent Orange may have caused for him but health issues his daughters have experienced all their lives, including autoimmune problems. One of his grandsons was born with webbed toes, and he wonders if that was because of his Agent Orange exposure.

Brawley was part of a crowd of about 150 former service members at a three-hour town-hall meeting last week at Richard’s Coffee Shop and Military Museum in Mooresville, learning about “legacy” health problems related to Agent Orange and other herbicides used widely in Vietnam. The meeting was sponsored by local groups and featured speakers from the national offices of the the Vietnam Veterans of America and the Associates of Vietnam Veterans of America, an organization that supports family members of Vietnam vets.

Legacy diseases

Since the passage of federal legislation in 1991, the Department of Veterans Affairs has recognized certain diseases suffered by Vietnam veterans could have a direct relationship to dioxin exposure. These diseases include ischemic heart disease, adult onset diabetes, Parkinson’s Disease, Hodgkins and non-Hodgkins Lymphomas and a number of types of leukemia and cancer, among other ailments.

As time has passed, more scientific evidence has accumulated to show that in addition to veterans’ problems, some children of Vietnam vets have had health problems that could also be connected to their parents’ exposure to Agent Orange, including spina bifida, cleft lip and palate, webbed fingers and fused toes and some genital deformities.

“Often, veterans won’t come [to these meetings] for themselves, but for their kids and grandkids,” said Mokie Porter, director of communications and marketing for the Vietnam Veterans of America.

In the past four years, Porter has traveled the country convening more than 50 meetings of veterans to talk about compensation for Agent Orange exposure, but this was only the first one in North Carolina. She said there’s still a lot of education to do for veterans about the possibility their children have also been affected.

Porter said legislation introduced last fall in Congress would fund research into “legacy problems” for those exposed to Agent Orange, pay for services to defendants and provide for outreach. But with only two co-sponsors, the bill has an uphill climb to get passed. She is hoping to build support for the bill through the town-hall meetings.

File and file again

Many Vietnam veterans were disengaged from the VA after returning home from the war, Porter said. While many know about possible effects of Agent Orange exposure for themselves, they don’t realize their children could have been affected as well. And because veterans are scattered across the country, it is harder to identify disease “clusters,” groups of people with unusual diseases that might have been caused by an environmental exposure.

Mokie Porter (seated, holding microphone) answers questions from one of an audience of about 150 veterans gathered at last week’s meeting in Morrisville. Photo credit: Rose Hoban

So Porter encourages veterans to file claims for compensation, even if a child’s problem has not yet been found to be connected to Agent Orange exposure.

“We need to show that there’s a problem,” she said. “If they see the volume, there’s more of a reason to address the issue.”

“At first with Agent Orange, the feds denied there were all these problems,” said Deborah Musolino from the Wilmington chapter of the Associates of Vietnam Veterans of America, who drove up for the meeting.  “Now there are so many veterans that are coming up with illnesses and disease.”

She said as scientific evidence has accumulated, the VA has continued to add to the list of illnesses recognized by the VA as related to Agent Orange.

Musolino said that national organizers are encouraging veterans to file claim for their children’s health problems. And even if those claims are denied, at some point in time the scientific evidence may show there is a connection to Agent Orange.

“File a claim; they’ll deny it. But maybe at some point, they will accept it,” Musolino said. “What happens with the VA is that from the date of application they go back, and that’s when you get the compensation; the date of application, not the date that the claim is approved.”

“It might take years and years. But if there is an award given, we’re hoping these children and grandchildren may receive some benefit.”

Key state

“The population is a little more amenable to coming forward and being part of organizations and potentially getting access to care, where years ago they wouldn’t have,” said Allan Perkal, who drove down to Morrisville from Asheville. Perkal is a Vietnam veteran and a retired counselor who worked with his compatriots with post traumatic stress disorder.

He’s planning on arranging another town-hall meeting in Asheville this fall, while Musolino is planning a meeting for this summer in Wilmington.

Of the 735,000 veterans who live in North Carolina, 256,000 of them are Vietnam-era veterans. The median age of North Carolina’s veterans is 61 years old. Data courtesy Carolina Population Center

North Carolina has a large percentage of veterans. According to data from the Carolina Population Center at UNC-Chapel Hill, the state has more than 736,000 veterans living here, 35 percent of whom were in Vietnam (about 256,000 veterans).

When asked if veterans really don’t know yet about Agent Orange, Perkal said it was surprising how many veterans didn’t think the problem applied to them.

“There’s a major aspect of avoidance and denial and things they haven’t done with their health or things they’ve done to aggravate their health issues, but not gone in for treatment,” said Perkal, who noted that many veterans felt mistreated by the VA system when they first returned from the war and never sought further help from the VA. “They’re out there; they’re by themselves, feeling alienated from things that could help them out.”

Perkal said he was looking forward to getting more meetings organized and getting the word out among his network in Western North Carolina.

“The word coming from other veterans always makes a difference, because the trust issues are always a problem with Vietnam veterans,” Perkal said. “It’s one veteran at a time.”

Leaders of North Carolina’s accountable care organizations weigh in on how the new model of organizing patient care is changing the way they do business.

Interviews by Rose Hoban & Hyun Namkoong

After months of deliberation, state Department of Health and Human Services leaders announced a plan to  transform the delivery of health care in North Carolina’s Medicaid program. The plan calls for physicians, hospitals, clinics, therapists and other health care providers to organize themselves into accountable care organizations to provide beneficiaries with care.

Health economists have long argued that the current physician fee-for-service system incentivizes health care providers to do lots of “stuff” to patients – lab tests, procedures, extra visits – with little incentive to coordinate care among the different specialists a patient might see.

Leslie McKinney, MD. Image courtesy WakeMed Physician Practices

But under an accountable care organization blueprint, health care providers bear financial accountability for the quality of care and how well patients do. If a patient is readmitted into the hospital frequently or ends up in the emergency department repeatedly, the doctors who control that patient’s care lose money. But if a patient remains healthy, stays out of the hospital, expresses satisfaction with his or her care, and the ACO meets quality benchmarks, the organization shares in the savings.

More than a dozen ACOs are already in operation in North Carolina and several have already received incentives for quality and cost savings.

North Carolina Health News spoke to leaders from two North Carolina ACOs and asked them about their experiences:

NCHN: Why form an ACO?

John Rubino, vice president, WakeMed Key Community Care (Raleigh): Most of what’s happening in health care is market driven. You can’t have a system that spends two times as much money as other industrialized countries and comes out 34th in the world in health statistics. You can’t compete. So all the payers, insurers, employers and government are saying we’re spending too much and not getting the quality we want. That’s why an ACO. It’s value driven and the value is defined by giving a good product at a lower cost.

Kelly Schaudt, chief operating officer, Physicians Healthcare Collaborative (Wilmington): We are able to have a [more complete] picture of patients because we not only have their information in the medical records but also we are able to receive from [the federal Centers for Medicare and Medicaid Services] claims data that allows us to see the true costs associated with their health care.

Leslie McKinney, president, WakeMed Key Community Care: We all believe there may be some real efficiencies when you can combine very strong primary-care practitioners focused on providing high quality with a health system that has same objectives.

John Rubino, MD. Image courtesy Raleigh Medical Group

NCHN: Who are you caring for?

Rubino: The Medicare ACO that WakeMed Key Community Care started working with in January 2014 has about 30,000 covered Medicare lives. We have about 15,000 other commercial lives, coming from WakeMed employees. All this will go into one basket, and we will have another 30,000.

Schaudt: We began participating Jan. 1, 2013 in a Medicare shared savings program. We also have a commercial ACO with Blue Cross and Blue Shield of North Carolina. We’re wholly owned by Wilmington Health and all of the physicians participating in the ACO are Wilmington Health physicians.

NCHN: How long have you been in operation?

McKinney: Key started in April 2012. No one has been doing it for a long time.

Schaudt: We began participating in January 2013.

NCHN: What are you doing differently?

Schaudt: We’ve got a hotline for emergency department physicians underway. If they saw one of our patients prior to accountable care, they would have just admitted him to the hospital. But now, if it’s a borderline case, they can call and leave a message on our hotline, get information. Our primary-care physicians have committed that if they receive a message about one of their patients being discharged from the ER, then they will see the patient within 24 to 48 hours for appropriate follow-up care.

McKinney: Let me tell you a patient story: We had a person who’d developed diabetes to the point where they needed insulin. So our nurse care coordinator went to see the person at his home and saw the person was drinking lots of Kool-Aid. She watched him dump sugar into the Kool-Aid and was able to identify what was driving his sugars up. Now he’s not on insulin.

That one visit – there was the answer staring at us!

Kelly Schaudt. Image courtesy Physicians Healthcare Collaborative

Schaudt: Another initiative we have underway, when we discharge patients from the hospital, with [chronic obstructive pulmonary disease] or congestive heart failure or complicated diabetes, we have a nurse practitioner who is a “transitions of care” extender. She goes and visits patients in the home and makes sure patients understand instructions, checks on medication adherence, helps get them to the one-week follow-up appointment and makes sure they don’t get readmitted within 30 days of hospital discharge.

Rubino: What we’ll have with care coordinators is they’ll be embedded in certain physician groups. Raleigh will have a care coordinator who will interact with doctors and there’ll be a much tighter relationship between the doctor and the care coordinator to help the patient than traditional home health.

The insurance companies try this all the time with various programs to call patients houses to check on how they’re doing, but it’s never really worked, in part because the patients are suspicious of the insurers.

NCHN: Some of this sounds like the kind of things done in managed care.

Rubino: Well, a lot of the care is managed these days. But number one, the dollars saved stay in North Carolina, which is one huge difference. And the docs will have more control. In managed care, when insurance companies do it from a distance, it’s much more painful to the doctors in terms of increased overhead, prior authorization for everything and not a lot of gain coming back to the people doing the work.

NCHN: So can you say it’s really working? Is it possible to make money and provide better quality?

Rubino:  It certainly is a process before you see the savings. You get one piece done and then another and another; it’s cumulative. I think there are good examples of people doing this and saving money. I can tell you the folks in New Bern [at Coastal Carolina Quality Care] have done well. They were early on to become a Medicare ACO; they got funding from the government to hire care coordinators. They saw their bed days in hospitals went down and emergency department visits went down. They did pretty good for the first year out; they managed some problems, logistical issues.

McKinney: You can’t assume one model for an ACO will work for everything. You have to think about a population and look around to see what works well. There will be different models for behavioral health, for example.

NCHN: What about you folks?

Rubino: [I]n the first year of our contract … we didn’t do that much and still beat the market by a substantial amount. We have more room to get better. I think it’ll ultimately work.

Schaudt: We are in the process of reporting first-year quality data to [the Centers for Medicare and Medicaid Services]. We’re giving them data on 33 quality measures; we’re required to report it. Then that establishes our benchmarks for quality and CMS will set targets for the next year.

NCHN: Final thoughts?

Schaudt: As we move forward, we are going to be expected to share data, to demonstrate quality. As we talk about cost, we expect that cost is something that is going to be transparent. I think by our participating in an ACO, it is helping us prepare for the future of health care. We are prepared to be transparent with our information, our quality data is fully transparent and I just see that continuing to evolve.

Rubino: We have to change our way of thinking, switching more to thinking about how to keep people healthy versus just treating them when they’re sick. We’re just used to patients coming to us when they’re sick and there’s a problem. Now we’re building a system to follow patients and encourage them to do the right things.

Wilmington’s Oakdale Cemetery holds hundreds of graves from an Ebola-like epidemic that swept the city in 1862.

By Rose Hoban

One hundred fifty-two years ago this week, thick black smoke hovered in the skies over Wilmington, carts collecting dead bodies trundled over the roads and uncollected rubbish produced a stench that permeated the city. Gravediggers at Oakdale Cemetery, just outside of town, buried at least a dozen bodies a day. Half of the city’s 10,000 residents had fled to the homes of friends and relatives. But the ones without means or a destination huddled behind to wait out the plague, along with those who served them as physicians, caregivers and tenders of the dead.

One of the few headstones in the field of more than 400 yellow fever victims belongs to Elizabeth Day, who died on Oct. 15, 1862. Hundreds are buried in adjacent graves, hastily dug to accommodate the mounting dead through September and Ocober. of that year. Photo credit: Rose Hoban

During the end of the week of Oct. 17, 1862, 453 Wilmingtonians came down with yellow fever. In the week of Oct. 24, 111 died, making it the most deadly week of the epidemic.

Overall, between late August and the first frost in November, 1,505 people contracted the disease; of those, 654 died.

Yellow fever, a “hemorrhagic” fever, similar to the Ebola virus disease, starts innocuously with a fever, chills and diarrhea. But within days, bleeding in the gastrointestinal tract produces black diarrhea and vomit, along with abdominal pain, as can Ebola. In the final throes, patients begin to bleed from the gums, nose and bowels.

The similarities between yellow fever and Ebola have not been lost on David Rice, the New Hanover County health director, who led a group of about 30 people around Oakdale on Saturday. He is also an amateur historian of health care in North Carolina.

Rice said he’s been thinking about the panic, fear, superstition and stigma that accompanied the arrival of yellow fever as he’s prepared his community for the possibility of a case of Ebola.

“I’ve lived it the last couple of weeks,” Rice told the group.

Entire families eliminated

Rice said no one is really sure how the yellow fever epidemic started. It might have arrived on a blockade runner or another ship with a sick crew. As the city was also in the throes of the Civil War, many whispered that Union soldiers had snuck a sick patient into the city – a 19th-century accusation of bioterrorism.

What is certain is that the summer of 1862 had been rainy, leaving many ponds and flooded areas where yellow fever carrying mosquitoes could breed. But at that time, people were unaware that this was how the disease spread.

Food was scarce because of the war, people were undernourished and many of those usually tasked with keeping the streets cleaned and encroaching water at bay were off fighting.

Some stayed behind, and their job became one of collecting bodies, as recorded by epidemic survivor John Dillard Bellamy, who was 8 years old at the time.

“I recollect, well, having stood in our home on Market and Fifth Streets, watching wagon-loads of corpses go by to Oakdale Cemetery,” he wrote.

Oakdale superintendent Eric Kozen (pink shirt) and New Hanover County Health Director David Rice (blue shirt, hat) stand in the “public grounds,” the common burial site of more than 400 yellow fever victims. The two led a tour through the cemetery Saturday telling the story of the 1862 yellow fever epidemic that peaked in this week of that year. Photo credit: Rose Hoban

Those manning the “death carts” retrieved bodies from the terrified families of the deceased, said Eric Kozen, superintendent of Oakdale. At the time, people did not know how yellow fever was transmitted and did not want to keep the bodies inside their homes, for fear of contagion, so bodies were left by the side of the road. Whole families died, one after the other.

For more than 400 of those bodies, their final resting place was a mass burial ground on a high point in Oakdale.

“As bodies were being brought here to the cemetery, we were receiving anywhere from about 10 to 15 a day during the height of the epidemic,” along with those who died of other causes, Kozen said.

They were not mass burials, with a one pit receiving dozens of bodies; instead, they were methodically done in 28 rows, each 20 to 30 yards long. One is simply marked “children.”

“The husband would die; he would be buried in a certain gravesite. His wife would pass, sometimes three days later. They would open that same grave, bury her with him. Children would follow thereafter. So we actually had up to four or five people being buried in the same grave in a month’s time frame,” Kozen said. “It would wipe out entire families.”

In the push to get bodies interred, few gravestones were erected. Instead, what remains is a field punctuated by stately oaks, camellias and azaleas, and, since Kozen’s arrival, thousands of daffodils in the spring.

“It was pretty scary stuff,” Kozen said. No one knew how the disease got around or the best way to handle the sick and the dead.

“That’s where that whole public fear came in, and that’s why cemeteries were developed on the edges of towns.”

Oakdale superintendent Eric Kozen stands in front of the grave of Phineas Fanning, who stayed in Wilmington to supervise collection of the dead during the 1862 yellow fever epidemic. Fanning also ran the cemetery after the superintendent died. Despite his heroic service to the city, when his life ended a few years later Fanning was nearly destitute, a late economic victim of yellow fever. Photo credit: JJ Bauer

Fallen caregivers

As with the Ebola epidemic, many health care workers who fought yellow fever became victims. They’re also buried at Oakdale, along with those they cared for.

The brilliant Dr. James Henderson Dickson reported the very first cases of yellow fever on Sept. 17, 1862 to state officials.

“Since Tuesday the 9th, I have seen five cases of the disease,” he wrote. “Of these, two have died, one is discharged as a convalescent, and two are still under treatment with doubtful prospects.”

Dickson’s friend John Lamb Pritchard, pastor of First Baptist Church, asked Dickson whether he should visit a sick patient. From an account read by Rice, Dickson told his friend, “‘I reckon you will have to do as I do. It is like war, we must have to take our chances. You will have to go and see many during their illness.’”

Rice read from an account of Dickson’s final patient visit. The doctor stood in the door, propping himself up on the doorposts as he advised his patient.

“‘I cannot come in. I have the fever now,’” Rice read.

By the end of September, Dickson was dead.

Rev. Pritchard sent his family from town, but remained to tend to his remaining flock. Rice read from his diary, where he wrote, “‘Must a minister fly from disease and danger and leave poor people to suffer for want of attention? Did the Saviour ever draw back?’”

Pritchard too died of yellow fever, along with his colleague Robert Drane, the rector of St. James Episcopal Church. Drane’s sister, who remained to help him, died as well.

The grave of James Quigley, superintendent of the Oakdale Cemetery at the beginning of the 1862 yellow fever epidemic. He died on Oct. 17. His grave was unmarked until only a few years ago, when the trustees of Oakdale erected a monument in his honor. Photo credit: JJ Bauer

“Someone asked, why did they remain?” Rice said. “Well, we have duties; we can’t abandon our duties.”

Another of those who stayed was Phineas Fanning, who supervised collection of the dead, provided “subsistence for the destitute who could not flee” and oversaw protection of abandoned property. Fanning also took over operations of the cemetery after the superintendent, James Quigley, died in the middle of the epidemic. Rice said Fanning himself was left destitute by the end of the Civil War.

Echoes sound today

The epidemic served to galvanize many of Wilmington’s leaders to work against a repeat of the horror.

Physician Thomas Fanning Wood survived because he was away, serving as a Confederate surgeon. Rice noted that Wood lost his first wife and family to infectious disease and “he saw injury and illness, and he didn’t want our communities facing that in the future.”

Now Wood is known as the “father of public health” in North Carolina.

“He went back and forth to the legislature begging them to start the public-health movement, and they finally gave in to him because he was so persistent,” Rice said, noting that the General Assembly gave Wood a mere $100 to get the state’s public-health service started.

Rice quipped that public health remains under-resourced.

Another Confederate surgeon, Solomon Sampson Satchwell, became the first president of the N.C. Medical Society. Wood started the N.C. Medical Journal.

And although Rice does tours of the cemetery for the Friends of Oakdale, his day job has had him consumed with Ebola preparedness for weeks. He said he’s had numerous panicked calls about Ebola to his office. But he expressed greater concern over rabies.

And he urged people on the tour to get vaccinated against the flu.

New Hanover County Health Director David Rice stands by the grave of Dr. Thomas Fanning Wood, who survived the yellow fever epidemic because he was away serving in the Civil War. Wood, however, lost his first family to infectious disease. He returned to post-epidemic Wilmington, where he practiced medicine and agitated for the initiation of public-health efforts in North Carolina. Photo credit: Rose Hoban

“The [Ebola] fear is at an all-time high with this, and it’s ridiculous,” said Rice, who has been working in public health since before the days of AIDS. “My concern is that people are being ostracized, like the gay community was [with AIDS].

“Now it’s the west African community, and it’s not their doing. And closing the borders is not best practice.”

Every generation, it seems, has a dread disease to be faced by patients, caregivers and the public, he said.

“It’s the same as yellow fever. You have to learn about the diseases, you have to contain them, you have to stop them.… Same thing with Ebola; you have to educate and contain,” he said.

To prepare, Rice recently convened all local officials who might have anything to do with Ebola response, from airports and ports to schools to hospitals. He also convened a media-education session.

“My thought is that we haven’t had to respond to a hurricane, let’s respond to a hurricane-like condition called Ebola,” he said, asserting that his county is ready.

And Rice said the historian in him was continually making connections between Ebola and yellow fever.

“If you don’t visit the history of what has occurred, you’re apt to repeat it,” he said. “We try to make those connections from the past so we can better serve in the future.”

People with mental health issues making the transition to more independent living will get a bit more help with a new program.

By Rachel Herzog

Sometimes people with mental health issues can have a hard time getting back on their feet when leaving a psychiatric hospital or being released from jail. But for the past two and a half years, the Critical Time Intervention program has helped these folks in Orange and Chatham counties transition to new homes.

The CTI team in Chapel Hill has served about 130 people during that time, said CTI project director Bebe Smith during an event to highlight CTI at NC State University’s McKimmon Center Wednesday morning.

Bebe Smith brought CTI to Orange and Chatham Counties. Image courtesy Bebe Smith

CTI aims to help individuals with mental illness who need a little assistance navigating the world, Smith said. Now the program is expanding its reach across the state.

Productive practice

In North Carolina, CTI began as a pilot program out of UNC-Chapel Hill. Before that, it was a project pioneered in New York City.

Daniel Herman, a researcher at New York’s Hunter College, worked on developing the program.

He said that while New York City had opened housing programs to help homeless individuals with severe mental illness and started offering outreach services, many of these people would lose their housing within a matter of months or even weeks and be back in the shelter or on the streets. Herman called this the “revolving door” phenomenon.

“What CTI was intended to do was to try to provide a way to break that cycle by trying to think a little more carefully about how to help people get settled and situated in their community or their new housing place,” Herman told several dozen social workers and mental health advocates during Wednesday’s meeting.

The new centers, which will launch in June in North Carolina, are being run by the mental health managed care organizations Alliance Behavioral Healthcare, Coastal Care, Partners Behavioral Health Management and Cardinal Innovations Healthcare Solutions. The new Alliance center will serve Cumberland County, Cardinal will expand the UNC program’s work into Alamance County, CoastalCare will run the program in Onslow and New Hanover counties and Partners will create three new teams in Gaston County.

Different centers will adjust the CTI model to focus on different at-risk populations. The Alliance center will help individuals transitioning out of detention centers, Coastal Care will help individuals transitioning out of hospitals and Partners will help homeless individuals.

Filling the gaps

Smith doesn’t know how many people the new centers will serve yet, but it will be a lot, she said.

“I think we’ve had some pretty significant gaps in our mental health system,” she said. “I think that with CTI we can start filling some of those gaps and help people who are not connected to services in the community.”

People with mental health issues being discharged from the hospital or released from jail often end up homeless without some help to make the transition. Photo courtesy Tom Brandt, flickr creative commons

The Washington, D.C. nonprofit Coalition for Evidence-Based Policy ranked CTI as a top-tier program. In one study, individuals who completed a CTI program retained their housing at a higher rate than people who didn’t get CTI services. In another, based on re-hospitalization data, the average cost saving for individuals who completed the CTI program was $24,000 over 18 months.

Smith cited the 2011 elimination of case management as a challenge that made transitioning people more difficult. Under case management, counselors did one-on-one work to help individuals meet their food, shelter and income needs, but the service was eliminated in favor of care coordination by MCOs.

Thava Mahadevan, director of operations at UNC’s Center for Excellence in Community Mental Health, is overseeing the expansion into Alamance County. He said the teams are getting to know the community and meeting with law enforcement officers, homeless shelter operators and hospital officials.

“The hope is that we should be able to build as a service division at some point,” Mahadevan said.

Training for the teams at all four centers will take place at the UNC School of Social Work.

Much of the improvement in health and longevity over the past century can be attributed to better sanitation. But more recently, this important public health function has become an afterthought in municipal budgets.

By Gabe Rivin

Cost, rather than a concern for public health, can take priority when local officials decide whether to expand water and sewer lines into unserved areas, a new study by UNC-Chapel Hill researchers found.

The researchers found that even in densely populated communities, officials focused on the large costs of water and sewer services rather than on the health benefits that off-the-grid citizens stand to gain.

Municipal sewer systems transport human waste from homes and businesses and treat it in centralized wastewater plants. Photo courtesy Wikimedia Commons

The finding is significant because in North Carolina about 30 percent of residents rely on private wells for their drinking water, according to the N.C. Department of Health and Human Services. Some 48 percent of residents use septic systems to treat their sewage, the department estimates, though those figures are based on U.S. Census data from 1990, the last year the information was collected.

Nationally, an estimated 15 percent of Americans use private water wells and 25 percent use septic systems, both about half the rate for North Carolina.

If improperly monitored, these water and sewage systems can threaten the public’s health, the researchers warn in their study published Aug. 13 in the American Journal of Public Health. Well water is not covered by federal drinking-water standards. This means its safety is largely a question for homeowners who use drinking-water wells.

“The existing literature has put health concerns as a major factor for why we should extend water and sewer services to as many people as possible,” said Julia Naman, the lead author of the study.

The researchers also raised concerns about the prevalence of septic systems in North Carolina. When used properly, these systems can treat harmful pathogens in human waste, allowing residents to safely dispose of their sewage, according to Mike Hoover, a retired professor of soil science at N.C. State University and an expert in septic systems.

But septic systems can fail – and often do, Hoover said. DHHS estimates that 6 to 10 percent of septic systems fail annually in North Carolina. But Hoover said that, on average, 10 to 20 percent of septic systems fail each year.

This can be a problem.

Untreated septic wastes from a failed system can seep into groundwater, which residents draw from their wells as drinking water. Sewage can also overflow into the streets and into nearby bodies of water, spreading potentially harmful pathogens to humans who come in contact with it.

An expensive option

In urban areas throughout North Carolina, residents rely on public sewers and public drinking water.

When these residents use their toilets, waste travels through their home’s sewage pipes and then into a system of municipal sewers. Sewers ultimately lead to public wastewater treatment plants.

A municipal drinking water plant. Unlike at a private well, water is treated at a central location, then pumped through pipes to residents. Photo courtesy Wikimedia Commons

Drinking water can take a similarly circuitous route. Municipal plants draw water from lakes and rivers, among other sources. They then filter and sanitize the raw water, removing pathogens and solid matter. The clean water is then pumped through a network of water pipes and storage tanks, which deliver water to residents’ kitchen sinks.

Federal legislation – the Clean Water Act and the Safe Drinking Water Act – set standards for these services in order to protect the public’s health.

But water and sewer systems are expensive to build and maintain. And extending services into sparsely populated rural areas can be prohibitively expensive.

“We cannot afford financially to sewer up the United States,” Hoover said. “If we were to do that, there would literally be no money left for schools, for senior citizen centers, for libraries.”

Short on money, short on data

The UNC researchers acknowledge that these services are impractical for some rural residents. But some areas in North Carolina, they say, are close to cities with municipal services, and are densely populated. And yet these areas are still without municipal water and sewer services.

“You would not be able to tell the difference if you went from a city neighborhood to one of these communities,” Naman said.

Julia Naman, the lead author of the study. Photo courtesy Julia Naman

The researchers sought to understand this phenomenon. So they interviewed influential community members in three counties: Hoke, Transylvania and New Hanover. These counties have unincorporated neighborhoods that lack water or sewer services, or both, and are near cities with these services.

The researchers interviewed a wide range of people, all of whom are involved in the decision to extend services. These included staff at public utilities, health officials, legislators, zoning officials, city and county managers and community members.

After conducting interviews, a consistent theme emerged. The high costs of water and sewer services, above all, weighed on communities’ decisions whether to extend services. The public’s health was generally a low priority in these discussions.

“Health is very central to this issue,” Naman said. And yet, she added, “Very few people, one, recognized the health risks that are associated with wells and septic tanks, and, two, were basing their decision-making off of these health risks.”

At the same time, the researchers said, septic system failures may go underreported. Health departments mainly place the responsibility on residents and neighbors to report a failure. But with potentially high repair costs to bring a system into compliance with state rules, residents may hesitate to request repair permits.

And that can cause a data gap for counties and cities, Naman said.

“They don’t have systematic data to prove that these communities are facing considerable health risks,” she said. “Without this systematic data, the county officials and city officials will assume that everything is fine, and the community members won’t have their problems addressed.”

Naman said that in New Hanover County, anonymous surveys helped fill this gap.

Going it alone

State officials acknowledge that off-the-grid residents have a greater responsibility to protect their own health.

A diagram illustrating a residential septic system. Graphic courtesy U.S. EPA

“Having one’s own system puts one in control,” said Larry Michael, who heads the Environmental Health Section at DHHS. “Routine maintenance is essential to having your own decentralized wastewater system and/or well.”

Beyond maintaining wells, residents must also “take initiative to regularly sample for contaminants,” Michael said.

But he said municipal systems can also be sources of concern. Municipal systems can leak or get blocked up, causing a potential health hazard on a much larger scale, he said. That’s particularly true for aging infrastructures, he added.

N.C. State’s Hoover echoed this claim. He also questioned the assumption that sewers are always preferable to septic tanks.

“What I spent my career trying to tell people is, septic systems can be a permanent, dependable form of wastewater treatment,” he said. “But not so if they’re ignored and not maintained and not utilized correctly.”

By Kirk Ross

Coastal Review Online

With a March primary and an early start to the session, the N.C. General Assembly’s environmental oversight committees have begun prepping legislation for this year’s short session, including a potential revision to a coal ash bill passed two years ago.

The legislature’s Environmental Review Commission devoted much of last week’s meeting to coal ash. Tom Reeder, an assistant secretary for the N.C. Department of Environmental Quality, gave commission members an assessment of the effects overseeing coal ash cleanup will have on his agency and leveled a blistering attack on the federal Environmental Protection Agency for its role in draining coal ash ponds in the state.

Tom Reeder, an assistant secretary for the environment. Image courtesy N.C. DENR

Reeder said DEQ is stretched “to the breaking point” to keep up with a timetable mandated in a bill the legislature passed in 2014 that requires the cleanup of the 32 ponds at 14 Duke Energy power plants.

He also sharply criticized EPA officials in Atlanta for not moving faster on proposed changes to federal permits for wastewater discharge that would allow decanting and dewatering to begin at most of the ponds. Those are the first steps in the cleanup process.

DEQ in December approved an updated discharge permit for ponds at Duke Energy’s L.V. Sutton power plant in New Hanover County, one of four high-priority sites where excavation and removal of coal ash has already started. The permit allows the plant to begin drawing down water in the ponds at the rate of one foot a week.

Reeder expressed frustration in getting the water out of the remaining ponds, charging that the EPA took more than 15 months to approve decanting at the sites and is currently holding up approval on permit modifications that would allow dewatering at 13 sites.

Decanting is the removal of the surface water in the pond, while dewatering is the final step in removing the rest of the water ahead of excavation.

“Until we get the water out of those ponds, we’re going to continue to have groundwater contamination, we’re going to continue to have threats from this water to dams and surface water,” Reeder said. “The key thing is we’ve got to make those ponds dry.”

Legislators shared his frustration. “We may not know what steps 25 and 30 are, but we certainly know what steps one and two are, and that is decanting and dewatering,” said Rep. Jimmy Dixon (R-Duplin).

A map displaying Duke Energy’s 14 coal ash sites. Duke now owns Progress Energy’s former sites. Graphic courtesy N.C. DENR

During questioning by commission members, Reeder said DEQ Sec. Donald van der Vaart is considering what Dixon termed “unilateral action” to move forward with the revised pollution-discharge permits and start dewatering the ponds without EPA approval.

In a response to a request from for details on the move, Crystal Feldman, DEQ deputy secretary for public affairs, said EPA approval of the discharge permits is a courtesy and not a requirement.

“When given a permit to review, EPA may offer comments, object to or remain silent on the permit. DEQ may issue the permits if EPA does not object. As a courtesy, in recent years DEQ has waited for explicit EPA approval before issuing coal-ash permits despite it not being required by law,” Feldman wrote in an email. “Assistant Secretary Reeder noted that we may no longer provide that courtesy.”

Feldman said the department has yet to decide how to proceed on the permits.

“The EPA is struggling with how to handle these types of permits because they are the first of their kind in the nation, which has caused long delays in the permitting process,” Feldman wrote. “If DEQ is faced with a choice between protecting the environment or the federal bureaucracy, protecting the environment will win every time.”

EPA officials in Atlanta said they are moving forward on permits that would allow dewatering following procedures set out in a memorandum of understanding with the state. DEQ has forwarded to EPA two proposed final permits that include dewatering, explained Davina Marraccini, an agency spokeswoman.

EPA completed its review of the first permit and has asked for a 90-day delay, which ends on Feb. 10, on the other. Such a delay is authorized by law, she said, and is included in a memo that the state signed.

Legislators at the meeting said the timetable in the cleanup bill could be adjusted this session.

Chromium standards debated

Also during the ERC meeting, commission members looked into an interagency debate between DEQ and state public health officials over setting threshold levels of contaminants for a well-testing program near coal ash sites.

The focus was on do-not-drink notices sent by the state Department of Health and Human Services based on testing around the 14 coal ash sites. In all, more than 476 private drinking-water wells near the sites were tested. Of that total, 424 well owners, about 89 percent, were issued do-not-drink notices by the department, with 369 of those notices triggered by levels of hexavalent chromium and vanadium that exceeded the standard used by health officials.

Reeder told legislators that the standards for hexavalent chromium was set far lower than federal drinking-water standards for public water systems. Nearly every public water system in the state would get a similar notice if the standard was applied, he said.

Legislators also questioned the notices, saying they alarmed residents and forced them to switch water sources unnecessarily.

Rep. Rick Catlin (R-Wilmington) Photo courtesy NCGA

Rep. Rick Catlin (R-New Hanover) said the notices have had a negative effect that in many cases outweighed the risk. He said future do-not-drink notices shouldn’t go out unless there is clearer evidence.

“Wait until we have that information to tell them to quit drinking their water, because we are impacting them kind of unfairly [compared] to the way we’re impacting everybody else,” Catlin said.

State Health Director Randall Williams stressed that the risk evaluations were recommendations to residents and not regulations. He said the chromium standard used was based on public health standards for risk of cancer due to lifetime exposure at the levels of the well tested.

“We’d rather error on the side of caution,” Williams said.

The department, he said, is waiting for new data and will re-evaluate its risk assessments, including looking at background levels for the areas tested.

“We’re in the midst of evolving science,” he said, adding that there has yet to be a standard set for hexavalent chromium and it is treated differently by different government agencies.

An aerial shot of the Dan River Steam Station, the power plant from which ash spilled into the Dan River. Duke stores coal ash, a byproduct of electricity generation, in wet ponds. Photo courtesy Duke Energy

DEQ and DHHS have been charged with preparing a study for the ERC on how to set proper levels for hexavalent chromium and vanadium, two known coal ash constituents that carry a high risk to public health. Few states have regulations on either. The study is due by April 1.

Grady McCallie, policy analyst with the N.C. Conservation Network, said although it focuses on just two constituents, the outcome of the study could have a significant effect on how the state determines the extent and amount of groundwater contamination.

“The underlying issue is an important one and broader than just hexavalent chromium,” McCallie said in a recent interview. “How do you handle substances that change over time and those that are naturally occurring in some wells and not in others?”

DEQ officials have repeatedly pointed to naturally occurring levels of various toxic coal ash constituents, such as arsenic, as a challenge in determining whether high levels in groundwater can be directly attributable to coal ash basins.

Research and response teams in North Carolina are preparing.

By Rose Hoban

It’s cold in North Carolina right now. So people aren’t sitting on their porches swatting at mosquitoes.

But even when the weather warms up and the local bloodsucking bugs start flying, the question for many people is: Is it possible to get the Zika virus in North Carolina?

Commonly known as the Asian Tiger mosquito, Aedes albopictus is capable of transmitting dengue and Zika. More commonly, however, Aedes aegypti is the culprit. Photo courtesy Wikimedia creative commons

The answer, according to researchers from UNC-Chapel Hill, is, essentially, “No.”

“There’s not zero risk of anything, but I wouldn’t worry about transmission of Zika in the U.S.,” said Aravinda de Silva, an infectious-disease researcher at UNC who specializes in dengue virus, another mosquito-borne virus in the same family as Zika.

Though there are mosquitoes in the U.S. capable of carrying Zika, de Silva said there’s an exceedingly slim chance of someone in this country getting Zika from a mosquito.

There have been small outbreaks of dengue in Key West and along the Texas-Mexico border. But da Silva said Zika diagnoses in the U.S. will overwhelmingly come from travelers who bring it home from their Caribbean or Latin American vacation.

“Let’s put the U.S. aside for a moment. There’s more globally; all these people living in endemic areas,” he said. “There are huge populations living in these large urban centers, millions and millions of people who are at risk of getting dengue, and those same populations are at risk of getting Zika.”

“If it wasn’t for  the microcephaly, it wouldn’t be unique,” said UNC infectious-disease specialist David Weber, referring to a strongly suspected link between Zika infection in pregnant women in Brazil and a sharp uptick in a birth defect known as microcephaly.

“Otherwise, [Zika] is just a mild illness, which is why there’s been so little research,” he said.

According to da Silva and Weber, who both presented last week, researchers from the university are mobilizing to study the disease.

Even as the UNC researchers were presenting, a study was released in the New England Journal of Medicine showing direct links between even mild Zika infections in pregnant women and the birth defect. What is disturbing to the authors of that study was that only about a third of the women tested actually had a fever; the rest never knew they were sick.

Air conditioning and window screens

Zika is closely related to dengue, which has been spreading widely in Latin America and the Caribbean for the past few years. Commonly known as “breakbone fever,” dengue usually causes mild fever. But in a limited percentage of patients, its muscle and joint pains can be just plain awful.

Yet out of the estimated 390 million cases of dengue worldwide in 2013, only 794 were diagnosed in the U.S. Most of those were travelers who acquired the disease while abroad.

Aedes aegypti is the mosquito responsible for the spread of Zika virus. Map courtesy Centers for Disease Control and Prevention, 2013

There has been some local transmission in the U.S., but the spread has been limited. Even in places in the U.S. like Key West and along the Texas-Mexico border where there are the right kind of mosquitoes – namely, Aedes aegypti and Aedes albopictus – and the weather is warm enough, there’s reduced risk of those bugs actually carrying disease from one person to another.

“This has mostly to do with lifestyle factors such as air conditioning and window screens, which limit the spread of mosquito-borne viruses here,” said Helen Lazear, a UNC microbiologist who studies mosquito-borne diseases, during last week’s presentation.

In a recent Key West dengue outbreak, there were only 28 confirmed cases of locally transmitted disease between August 2009 and March 2010.

More than the U.S.

Lazear floated the suspicion that prior infection with dengue, as is common in Brazil and other countries where Zika is currently raging, can actually make Zika cases worse.

According to Lazear and da Silva, Zika triggers the immune response created after a person has gotten dengue.

Aravinda da Silva runs a lab at UNC-Chapel Hill dedicated to studying dengue virus, a mosquito-borne disease closely related to Zika. Photo courtesy UNC-Chapel Hill

“Unfortunately, dengue and Zika are too close and it’s very difficult with the [existing test] to see whether someone is having a dengue or a Zika infection,” da Silva said.

That makes it harder for researchers to actually confirm that a patient has Zika while they’re still sick. Instead, the best diagnosis is made using sensitive DNA-based testing; but that’s expensive and needs to be done in a lab.

UNC researcher Sylvia Becker-Dreps, who has been doing epidemiology research in Nicaragua for a decade, will be leading a collaboration between UNC and a university in that country to study Zika.

“Right now, it’s mostly a naîve population; they’re only starting to get their first cases, something between 300 and 600 cases detected in Nicaragua,” Becker-Dreps said.

The idea is to help the government with its response, but resources in that country are poor and Becker-Dreps said the ministry of health is only testing every tenth blood sample it receives.

She said one of the most important things to do is monitor what happens with pregnant women as the disease spreads across Nicaragua.

“The rainy season begins in May,” she said. “So the epidemic is only arriving now in Nicaragua. Then wait nine months and see.”

It’s important to understand what’s happening with Zika now, da Silva said, because inevitably the disease will make the jump to Asia, with its megacities of tens of millions of people.

“You have huge populations living in these large urban centers, millions and millions of people who are at risk of getting dengue, and those same populations are at risk of getting Zika,” he said.

Even if only a small proportion of pregnancies in Zika-infected women in those megacities end with babies having birth defects, it could still be tens of thousands of cases.

Staffing up

Closer to home, state public health officials are leveraging the publicity around Zika to beef up their surveillance and response capacity around bug-borne diseases.

North Carolina was one of the only states in the country to have a small cadre of entomologists, embedded in the Division of Public Health, to track mosquito-borne diseases and other diseases carried by bugs, known as “vector-borne” diseases.

But the vector-borne disease branch was eliminated during budget cutting in 2010 and 2011.

Now the Division of Public Health is looking for two entomologists, one to be based in Raleigh and the other to do fieldwork throughout the state, according to Danny Staley, who heads the division.

Essentially, that’s the same level of staffing as in the older program.

Staley said a number of counties, including New Hanover and Brunswick, have active vector-control programs. Those counties have historically been mosquito hot spots.

Staff go out, either in response to complaints or to known hot spots, he said, and look for birdbaths or containers with larvae.

Staley said spraying has fallen out of favor as the preferred method of mosquito control. Instead, public health interventions are more targeted: Teams go to hot spots, look for larvae, trace the feeding patterns of the mosquitoes and monitor what happens after they apply larvacide or drain waters.

“You can have three or four broods coming off of one container in a day,” Staley said.

He said the newly hired state-level entomologists will coordinate with local departments and will track what’s happening statewide to prepare for “new and novel viruses that are coming our way.”

“Last year, it was chikungunya; a few years earlier, it was West Nile virus,” Staley said.

As happens often in public health efforts, funds get cut when there’s no disease activity; then when there’s an outbreak, agencies scramble to rebuild.

“I will say that North Carolina is not unique in this situation,” Staley said. “In Florida and other states, there are similar situations; programs that were once very popular have faded.”

The entomologist job postings closed last week. Staley said the division is “aggressively” moving to get the new hires in place before North Carolina’s mosquitoes get active.

Furanylfentanyl mixed into heroin has been catching users unawares, and overwhelming attempts to save them.

By Rose Hoban

Word is spreading around the state about a deadly form of opioid that’s killed at least 19 people in North Carolina since the new year.

The problems have been caused by a drug known as furanylfentanyl, a powerful form of the synthetic opiate fentanyl.

Furanylfentanyl chemical structure. Image courtesy Wikimedia Creative Commons

Fentanyl itself is about 80 times as potent as morphine, about 20 times stronger than heroin, and is used frequently in surgery and for pain control for cancer patients. On the street, fentanyl has been known as China White and can be deadly when it’s mixed into heroin.

And furanylfentanyl is even more potent than regular fentanyl.

There have been overdoses and deaths in New Hanover County attributable to heroin laced with something much stronger, confirmed Deputy Chief Mitch Cunningham of the Wilmington Police Department.

“We believe that the save we had today, it was likely present,” Cunningham said Tuesday afternoon, referring to a situation in which someone from his department administered a drug to reverse an overdose.

Stonger

Ruth Winecker,  chief toxicologist in the state Office of the Chief Medical Examiner, said she first had a suspicion there was something stronger than fentanyl in September when an overdose case came in.

“At first, we did not know what it was. On our regular screen, we detected a compound called 4ANTP,” which she explained is a byproduct created when labs alter fentanyl.

“We knew we had a fentanyl-like drug in that case,” Winecker said.

Months later, in February, another case came in, then another and another. By then, Winecker had done the work to be able to identify furanylfentanyl more easily.

Ruth Winecker, chief toxicologist in the office of the Chief Medical Examiner. Photo courtesy UNC-Chapel Hill

“We occasionally see new and different research chemicals used in medical and pharmaceutical research. We find them in our casework,” she said, but very rarely.

“But with 19 of these,” Winecker said, “that’s extreme.”

Anna Dulaney, a toxicologist with the Carolinas Poison Center, confirmed that her office has also been hearing about laced heroin.

“That’s what a lot of people are concerned about, among EMS workers and emergency department personnel,” she said.

Dulaney said her big concern was that heroin laced with furylfentanyl is far more potent than users expect and can be lethal at much lower doses.

Cunningham said his department started distributing naloxone, a drug that can reverse opiate overdose, last week, and that they’ve already documented two rescues from overdose.

Robert Childs heads the North Carolina Harm Reduction Coalition, which promotes the use of naloxone to reverse opiate overdose and distributes naloxone kits. He said since he moved to the Wilmington area four months ago, he’s gotten documented reports of at least 400 people who have had overdoses reversed by naloxone.

“I’ve never encountered anything like it,” he said. “There was one weekend where we had four or five rescues; it was all fentanyl related.”

Many forms of fentanyl

There are at least 30 different chemical offshoots of fentanyl and, according to Winecker, it’s not that complicated for a “moderately sized lab” to alter fentanyl into one of these even more potent analogs.

Winecker said she contacted colleagues in Europe once she identified furanylfentanyl to see if they had seen it before. They had.

Image courtesy Ryohei Noda, flickr creative commons

Fentanyl analogs have been circulating around Eastern Europe for more than a decade, with the highest use documented in Estonia, where it has caused hundreds of deaths, according to a 2015 review in the International Journal of Drug Policy. According to the IJDP, “production facilities have been seized in Bulgaria, Greece and Portugal,” and other illicit labs creating these analogs have been found in Russia, Belarus and the Ukraine.

There’s also precedent for something stronger to be present in the heroin that’s been sold here.

In the U.S., a different fentanyl analog known as acetyl fentanyl was circulating in the northeast between March 2013 and May 2014, when there were 14 deaths in Rhode Island attributed to the drug. Three deaths in North Carolina occurred as a result of acetyl fentanyl in 2014.

Winecker said the Office of the Chief Medical Examiner routinely autopsies overdose victims in order to keep track of what’s happening with these new chemicals. And her office is in the process of acquiring an even more sophisticated piece of equipment that can measure the mass of chemicals, to more readily identify novel compounds such as furanylfentanyl.

“Overdoses are amounting to about one of four autopsies now,” said State Health Director Randall Williams.

“The people who’ve passed away, many of them probably thought that ‘heroin is not good, but I’ve done it before, I know what I’m dealing with,'” Williams said. “Then it’s too late.”

Many vials

Part of the problem is that when a person overdoses, they might not be aware that multiple vials of naloxone would be needed to revive them.

In Wilmington, Cunningham said that, for example, in the overdose “save” that took place on Tuesday, more than one vial of naloxone was needed to reverse the loss of breathing that comes as a result of opioid use.

Fentanyl chemical structure. Image courtesy Wikimedia Creative Commons

Kendra, one of the Harm Reduction Coalition’s naloxone distributors, said she’s had reports of 25 fentanyl-related reversals in Wilmington alone, each reversal requiring two or three doses to bring someone back to life after they stopped breathing.

Another outreach worker, Mike Page, said he knew of at least one case where four vials were required, instead of the usual one.

“People that are used to using a certain brand, if you will, or a certain stamp, a new batch is coming in with that same stamp and it’s a lot more potent,” Page said. “People that are used to using a certain amount are using that same amount, like two or three times as strong, so the overdose rates are skyrocketing.”

“There’s the need for possible higher doses of reversal agents, like naloxone, to reverse the fentanyl,” Dulaney said. “Typically, with heroin, you would give one dose of either to reverse. Sometimes in the emergency department, we use smaller doses because we don’t want to put a patient into withdrawal.”

Naloxone comes in two commonly used forms: an intranasal spray that has 2 milligrams in a vial and an intramuscular injection form that has 0.4 milligrams in a vial. A higher dose is needed for nasal use because it’s not all absorbed right away.

“One concern is that if a bystander is using this for someone, they may not have enough to reverse the overdose,” Dulaney said. “That’s why we always advocate calling 911.”

Testimony by North Carolina’s state epidemiologist sheds light on discord among health experts on the decision to rescind do-not-drink advisories for wells near coal ash waste.

By Catherine Clabby

Note: This article has been altered to add a response from the Department of Environmental Quality.

As state regulators prepare to release risk assessments of Duke Energy coals ash waste impoundments this week, a state health official divulged that some health officials opposed the state’s reversal of warning that drinking wells near the waste posed health risks.

Megan Davies, the state epidemiologist and epidemiology section chief in the Department of Health and Human Services, in sworn testimony also disclosed that politics, not just health-risk assessments, played a role in the March DHHS decision to back off from do-not-drink advisories for the wells.

State Epidemiologist Megan Davies. Photo courtesy N.C. DHHS

The physician divulged too that she had reservations about the accuracy of the first line in the state’s safe-to-drink letters sent to well owners. It said: “We have reviewed the do not drink usage recommendation because we have determined your water is as safe to drink as water in most cities and towns across the state and country.”

Davies revealed this and more under oath during a pre-trial deposition taken May 4 by the Southern Environmental Law Center, which represents environmental groups in a lawsuit against Duke Energy regarding clean up of its coal ash.

DHHS leaders criticized release of Davies’ deposition. “It is misleading that the Southern Environmental Law Center would release partial information before our citizens have the complete facts,” said DHHS Communications Director Kendra Gerlach.

Crystal Feldman, deputy secretary for the state Department of Environmental Quality, agreed that the deposition is misleading. “Dr. Davies’ deposition only provides one viewpoint,”  Feldman said.

SELC released a transcript of the deposition just days before the deadline – this Wednesday – when the DEQ is due to release risk assessments from coal ash impounded on 10 of 14 Duke Energy properties. The assessments could decide how fast and how aggressively clean up of the waste must occur on all sites.

Coal ash waste dumps at four sites already designated as high risk by the state’s Coal Ash Management Act must be excavated and closed by 2019. That includes the L.V. Sutton Energy Complex in New Hanover County, Dan River station in Rockingham County, Allen Steam Station in Gaston County and Asheville Steam Station.

Intermediate-risk sites must be excavated and closed by 2024; low-risk ponds must be closed, but not excavated, by 2029.

Better to wait

Well owners and environmentalists have criticized the DHHS and DEQ move in March to rescind 2015 DHHS advice that people not drink water in 320 drinking wells located near Duke Energy coal ash waste sites. That came after tests of the wells detected contaminants associated with coal ash, mostly hexavalent chromium and vanadium.

Duke Energy’s Asheville Steam Electric Generating Plant coal ash ponds. The DEQ has ranked the ponds as high risk and ordered them closed by 2019. Photo courtesy Duke Energy.

“The initial ‘do-not-drink’ advisory was a very cautious recommendation,” the March letter said. “In fact the recommendation regarding one of the elements is based on a potential one in a million risk for an average person consuming well water everyday for more than 70 years. Now that we have had time to study and review more data, we have concluded that it’s appropriate to return to drinking and using your water for cooking and other uses.”

Davies said she and Danny Staley, director of the DHHS Division of Public Health, favored waiting until the source of two contaminants in the well water was made clear before telling residents that drinking their water was safe.

Some well owners and environmentalists suspect coal ash is the source of both.

“We both felt it made more sense to wait on source determination,” Davies said under oath during her deposition. “That is relevant because if it were a contaminant, there might be ongoing contamination of wells with the increase in levels. So we felt we should wait until all the information was in and DEQ had made a determination, and then communicate with the well owners in that full context.”

DEQ has said groundwater, the primary source of well water, has been contaminated underneath all of the Duke Energy properties with coal ash waste but the risk of the contamination to drinking water is not clear. DEQ’s assessment of whether contaminants from coal ash could reach drinking wells is one thing that state risk assessments expected this week could clarify.

Politics in play?

The picture Davies paints of discussions among state health officials is more complex than the policy-focused description that DEQ Assistant Secretary Tom Reeder described recently.

“DHHS went back and revised original health-risk evaluation. They decided to make their recommendation consistent with federal safe drinking-water rules,” Reeder said while giving a talk last month at UNC-Chapel Hill.

Davies said Randall Williams, deputy secretary of health services, shared her worry that people advised to drink water from other sources would experience stress as a result, a potential health threat. But Williams also voiced concern that state legislators might limit state public involvement in assessing well water if the letter was not dispatched.

“So was Dr. Williams concerned that if you did not send out a ‘do-not-drink’ letter, that members of the General Assembly might restrict the administrative authority of the Department of Public health?… Did he express that concern?,” asked Frank Holleman, senior litigator for the SELC.

“Yes,” answered Davies, whose organization issued do-not-drink advisories based on screening levels established by state epidemiologists.

Two bills introduced in the House and Senate after the letters were sent would limit local, county and state officials from releasing health advisories for wells and public drinking water to cases where federal or state regulatory contaminant standards are exceeded.

Davies stressed that she did not favor releasing a letter that said the well water was as safe to drink as most public water systems in the state and the country, which are regulated by federal standards, when the letter did not disclose to well owners that federal rules do not yet regulate hexavalent chromium or vanadium in drinking water.

Safe as what water?

Also, the claim that well water was as safe as most public drinking-water supplies contradicted what she’d seen regarding levels of hexavalent chromium in public drinking water in Raleigh and Charlotte, which were lower than those detected in some wells near coal ash sites, Davies said.

“They are, on average, lower than those measured … in the drinking wells under the [Coal Ash Management Act] sampling,” Davies said.

California and North Carolina share the lowest groundwater standard for hexavalent chromium in the country. The standard, 10 parts per billion, is used to determine levels at which polluters must clean up. Only eight states in the U.S. have groundwater standards for vanadium; North Carolina’s is 8 ppb.

Drinking water contaminated with hexavalent chromium has been associated with increased risks of stomach tumors, Davies said during her testimony. Vanadium has been observed to create effects to kidneys and blood cells in toxicological studies of lab animals, she said.

Holleman queried Davies closely on discrepancies between the March letter’s claim and sampling of well water in Salisbury, near the Buck Steam Station treatment plant. One well test found levels of hexavalent chromium of 21.8 micrograms per liter, about 300 times more than the state screening level, Holleman said, citing a state notification to the well owner.

“Would you agree that this gentleman’s well water is less safe than the well water in Salisbury?… This well water has more hexavalent chromium in it, and therefore a higher associated risk for the adverse health effects of hexavalent chromium, which is cancer, right?” Holleman asked.

“Yes,” Davies said.

“And would you agree, therefore, the water in this gentleman’s well is not as safe as the drinking water at the Salisbury Public Water System, which has less than one parts per billion?,” he asked.

“Based on the hexavalent chromium level, yes,” Davis answered.

In cross-examination, Brent Rosser, a Charlotte attorney representing Duke Energy, emphasized the low increase in cancer risk represented by the state’s hexavalent chromium screening level.

“The one-in-a-million risk standard is higher than the lifetime odds of death from getting struck by lightning, a lethal dog bite, and a cataclysmic storm; correct?” Rossner asked.

“Yes,” said Davies.

“And, in fact, if my math is correct, the one in a million standard is over seven times more likely – or I guess you are seven times more likely to get struck by lightning and be killed than to develop cancer under the one in a million standard. Does that sound right?,” he said.

“Approximately, yes,” Davies responded.

Public health mission

But a second exchange with Holleman regarding the screening levels noted this: “The standard you used is the one in a million standard, which is the standard generally accepted in the field of toxicology and epidemiology; is that correct?,” Holleman asked.

“It is the standard laid out in the 2L Rule,” a state rule that regulates state groundwater quality, Davies responded. “And it is a generally accepted standard in the field of health-risk evaluation.”

Holleman also noted that the letters rescinding the do-not-drink orders referred to the state’s health mission of protecting North Carolinians.

“Now, the next to the last sentence says, ‘Our mission at the Department of Health and Human Services and the Department of Environmental Quality is to protect the health and safety of all North Carolinians.’ Do you believe this letter supported that mission or was consistent with that mission?” Holleman asked.

Davies’ answer was one word.

“No.”

Safe To Drink Letter (Text)

Davies Deposition (Text)

DEQ says all Duke Energy coal ash waste must be dug up, but wants permission to be more lenient if improvements occur.

By Catherine Clabby

State regulators have raised the risk designations for some of Duke Energy’s coal ash dumps, a move that could require 25 impoundments to be dug up by 2024.

Or not.

The Department of Environmental Quality wants the power to lower risk rankings in 18 months if the utility proves that coal ash is not polluting nearby drinking water and repairs dams at its waste sites.

Duke Energy’s Asheville Steam Electric Generating Plant coal ash ponds. The DEQ has ranked the ponds as high risk. Photo courtesy Duke Energy

Classifying risks posed by coal ash waste sites is a key step to North Carolina’s efforts to force Duke Energy to shut down coal ash ponds on 14 properties storing about 100 tons of coal ash. This drive began in 2014 after a spill at a Duke Energy in Rockingham County property dumped 39,000 tons of coal ash into the Dan River.

That event prompted an investigation that resulted in Duke Energy pleading guilty to nine criminal violations of the federal Clean Water Act and agreeing to pay a $68 million criminal fine and spend $34 million on environmental projects.

On Wednesday, it became clear for the first time that Duke Energy is considering providing alternative water supplies to water-well owners living near its waste. While in early planning stages, utility staff are considering running municipal water line extensions to affected homes, digging new community wells or providing filtration devices.

Low, medium or high

DEQ officials said they must ask legislators for permission to re-determine risk designations down the road because the state’s Coal Ash Management Act required the agency to prepare final risk designations by Wednesday.

“The deadlines in the coal ash law are too compressed to allow adequate repairs to be completed. It also does not allow for revisions to the classifications based on new information,” DEQ Sec. Donald R. van der Vaart said in a written statement. “Making decisions based on incomplete information could lead to the expenditure of billions of dollars when spending millions now would provide equal or better protection.“

That same law previously designated eight impoundments as high risk, requiring their fast-track excavation by 2019.

Lowering a dump’s risk status would save Duke Energy a lot of time and money. Low-risk sites need only be closed and capped by 2029, meaning water could be drained from a coal ash pond but waste would stay put. Dumps designated as an intermediate risk must be closed and dug up by 2024.

A map displaying Duke Energy’s 14 coal ash sites. Duke now owns Progress Energy’s former sites. Graphic courtesy NC DENR

Duke Energy CEO Lynn Good said the utility wants all 25 sites now ranked intermediate to be labeled low risk. The company is drilling more monitoring wells at DEQ’s request, but studies the company commissioned to date indicate they do no environmental harm, she said.

“We disagree with intermediate ranking,” Good said. “That would be the most extreme option costing the most money and creating decades of disruption to communities without additional benefits.”

Alternative drinking water

By way of example, Good said coal ash stored at the utility’s Marshall Steam Station in Catawba County totals the equivalent of 800,000 truckloads. If the company moved 100 trucks a day from there every day of the year, hauling away the waste would take more than 20 years.

Duke Energy is using trains to haul waste from some sites.

Good stressed that she believes DEQ has the authority to change the risk assessments without obtaining legislative approval, but that DEQ’s leadership does not agree it has that power.

Coal ash’s effects on drinking water is one of DEQ’s biggest concerns. The waste has polluted groundwater underneath all 14 utility properties stashing coal ash, DEQ Assistant Secretary Tom Reeder has said. And contaminants linked to coal ash, typically stored in unlined pits, have been detected in wells.

Duke Energy CEO Lynn Good discusses ash basin closure options. Video courtesy Duke Energy

But it’s not simple to pinpoint coal ash as the source of the contamination. Two suspect contaminants – hexavalent chromium and vanadium – can occur naturally in North Carolina, for instance.

Duke Energy says research it has submitted to DEQ indicates that groundwater flowing near ash basins travels away from neighbor’s wells, except for at its Sutton Plant in Wilmington, where the utility has taken steps to address it. But the utility recognizes that studies conducted by outside experts may not provide the level of assurance that some people are looking for, Duke spokesman Erin Culbert said.

“Proving alternative drinking-water sources would give well owners peace of mind and enable the utility to preserve a wider range of options when shutting down its basins,” she said.

The state’s reversal this spring regarding 2015 health advisories it issued to owners of hundreds of wells near coal ash waste is one of the most controversial aspects of DEQ’s drive to force Duke Energy to clean up its coal ash.

Draft DEQ rankings last December designated 12 dumps as intermediate risks and four as low risk. Nine were placed in an uncertain category labeled “low-to-intermediate” due to gaps or deficiencies with data submitted by Duke Energy, Reeder of DEQ said at the time.

DEQ collected public comments on its earlier rankings in writing and in person, staging meetings in March in every county hosting coal ash containment sites.

The new ranking list “reflects countless hours of scientific and technical work by both state engineers and Duke Energy as well as thousands of comments by the public,” van der Vaart’s statement said.

Rankings released Wednesday confirm that digging up all coal ash in North Carolina is the best solution, said Brooks Rainey Pearson, a lobbyist for the Southern Environmental Law Center. The fact that DEQ might reclassify the sites in 18 months, after statewide elections in November, including a re-election bid for Gov. Pat McCrory, concerns her, she said.

“That sounds a lot like not making a final classification as the Coal Ash Management Act required, but moving the situation down the road,” she said.

Doc makes it his mission to bring subspecialists to rural southeastern North Carolina.

By Taylor Sisk

Fernando Moya, requires little sleep – which is fortunate, given that his days are stretched pretty thin.

Moya, a neonatologist, is founder, president, and CEO of Coastal Children’s Services, a pediatric subspecialty group. The practice is based in Wilmington, but, by design, has no stand-alone offices of its own. Moya’s objective in creating Coastal Children’s Services was to enhance quality neonatal care in Wilmington and then reach out into the largely rural southeast, placing neonatologists and other pediatric subspecialists where they’re needed most.

In additional to its offices at Wilmington’s New Hanover Regional Medical Center, the practice now has pediatric specialists in four hospitals in the region: Onslow Memorial Hospital, Camp Lejeune Naval Hospital, Southeastern Regional Medical Center, and Columbus Regional Healthcare System.

Fernando Moya’s objective was to enhance quality neonatal care in Wilmington and then reach out into largely rural southeastern North Carolina.

On a recent Tuesday morning at Southeastern Regional in Lumberton, Moya is clutching an extra-large cup of Dunkin’ Donuts coffee and sporting a day’s growth of stubble. He’s just had, he allows, “a rough night” in the neonatal ICU. But he’s eager to discuss his ambitions for pediatric care here in Robeson County, a county with the state’s lowest median household income, at $30,248, and some of its worst health indicators.

Coastal Children’s Services has been providing care at Southeastern Regional since August of last year. Moya hasn’t yet hired someone to oversee operations here, so he’s still very hands-on. But that’s his modus operandi anyway: right in the thick of things. He spends a few days each month practicing throughout the region.

“I like to be here because I like to try to bring the enthusiasm of what we’re trying to do,” Moya says. “I enjoy it.”

An opportunity to make a difference

A native of Chile, Moya began his pediatric training there and completed it at Yale. He remained on faculty at Yale for 6 years, served as associate director of neonatology at Louisiana State University and then chief of the division of neonatal-perinatal medicine at the University of Texas McGovern Medical School in Houston.

In 2005, he was recruited to come to Wilmington. Negotiations had begun to build a children’s hospital at New Hanover Regional, and Moya was attracted by the opportunity to bolster neonatal care in the area. He now serves as associate director of neonatology at New Hanover Regional and medical director of the Betty Cameron Children’s Hospital.

At the time of his arrival, the nearest NICU was in Fayetteville, nearly 100 miles away. Moya began to plot a regional strategy, with New Hanover Regional as the hub and Level 2 NICUs in the surrounding more rural areas.

Alan Stiles, UNC Health Care system’s vice president for Network Development and Strategic Affiliation and former chair of pediatrics at the N.C. Children’s Hospital, says that what Moya is providing was much needed.

“The southeastern region of North Carolina mainly has smaller rural hospitals with limited capacity to do more than stabilize and send premature or sick newborns to larger hospitals, often at great distances from their families and home,” Stiles says.

According to research conducted by NC Child, in Orange County — home of the UNC Health Care system — there are 3.4 infant deaths per 1,000 live births and life expectancy at birth is 81.7 years. In Robeson County, only a 2-hour drive away, there are 13.4 infant deaths per 1,000 live births and life expectancy at birth is 74.2 years.

Providing care where most needed

Moya founded Coastal Carolina Neonatology in 2009. His first regional alliance was with Onslow Memorial in Jacksonville, an hour from Wilmington.

In May 2010, he launched a broader initiative, Coastal Children’s Services, an LLC, which today employs 25 physicians and about the same number of advanced practice clinicians. Pediatric subspecialists now practice either in the hospitals or in already established practices throughout the region.

“Our vision has been to bring the care to [the hospitals], help them elevate the level of care, and keep as many patients as they can there,” Moya says. “We’ll support them locally. Whatever cannot be managed there will go either to Wilmington or elsewhere, with the appropriate triaging.”

Stiles, who calls Moya a “highly accomplished neonatologist and academic leader,” emphasizes the importance of the relationships with academic medical centers that Moya has forged to ease transfers when necessary.

Joann Anderson, president and CEO of Southeastern Regional and past president of the American Hospital Association’s Small and Rural Hospital Council, has embraced Moya’s initiative: “With Dr. Moya’s help, our staff is learning to care for more complex health care issues in neonates.

“By doing this, we’re hoping to be able to keep the infant near its support family while potentially improving outcomes because care is more readily accessible.”

Results take time. But according to NC Child data, the number of children up in Onslow County (where Moya formed his first alliance) receiving early-intervention services in their first 3 years rose by 45 percent from 2009 to 2013.

How it works

Making this work, Moya says, entails several critical elements.

First, “we recruit extraordinary people who can multitask.” That means, for example, that Janet Hoffer, who handles marketing and PR, also assists with education initiatives. It also means an all-hands approach to administrative duties.

Second is keeping overhead low. Being based in hospitals and established practices helps considerably in that effort.

Moya says he negotiates “reasonable contracts” with the hospitals, providing a number of services at cost. “It would be very hard to try to milk a lot of resources out of hospitals that are struggling,” he says.

Education and research

Coastal Children’s Services is also cultivating alliances beyond the region. The University of Chicago Medicine Celiac Disease Center, for example, has provided training, and Moya hopes to establish his practice as an affiliate.

He and his colleagues host three annual conferences, offering “world-class” speakers, Moya says. A recent symposium speaker was Richard Polin, MD, a member of the American Academy of Pediatrics’ Committee on Fetus and Newborn and co-author of the widely used Workbook in Practical Neonatology.

Hosting such events, Moya says, is central to the mission: “We have the connections, we have the insight, we have the motivation. And we also learn ourselves.”

The practice also conducts clinical research — both its own and in multi-center trials — and New Hanover Regional is now a member of the Pediatric Trials Network.

Unacceptable outcomes

North Carolina’s infant mortality rate (in 2014, 7.1 deaths per 1,000 live births) has consistently been among the nation’s highest. It’s considerably worse in the southeastern region of the state.

Moya believes that in an area so close to nationally recognized medical centers, including UNC and Duke, such outcomes are unacceptable.

“We hope to be a vehicle to summon that collective strength,” he says. For that to happen, “We need to partner with others, improve access to general care, then some specialty care. And then let’s try to recognize the time needed to interact, educate, and improve quality — and then see where those rewards go.”

“When he approached me about collaborating, he described his vision and reasons for it,” Southeastern Regional’s Joann Anderson says. “He told me he believed a regional approach to issues related to infant mortality was needed.

“I fully support that vision.”

The report is only produced every four years and examines markets in the entire U.S.

By Rose Hoban

The performance of some health systems in North Carolina has improved during the past four years, but according to a new report, they could serve people better if the state expanded Medicaid.

In a report that’s issued every four years, the Commonwealth Fund found that some North Carolina “hospital referral regions” improved on measures such as access to care and avoidable hospitalizations. But, in general, areas in states that have expanded Medicaid, as allowed under the Affordable Care Act, have seen more improvement in efficiency, access to preventive care and better outcomes.

Image courtesy: Parker Knight, flickr creative commons

“We do find there’s a strong relationship between access to care and quality of care,” said Douglas McCarthy, a senior researcher at the Commonwealth Fund. “Although it’s still too early to judge the long-term effects of the Affordable Care act, improvement in these domains could contribute to better outcomes in the long term.”

The New York City-based Commonwealth Fund, is a foundation that focuses on research about improving the health care system. This is the second time the organization has examined the performance of 309 hospital referral regions across the country, areas that delineate health care markets. In the Commonwealth Fund methodology, there are nine of these referral regions in North Carolina.

Medicaid expansion was not the only factor that drove improvement in health-care outcomes, said Sarah Collins, who studies health care coverage and access for the organization.

“If you look at the top 16 states that had the biggest improvement in coverage and access, about half were in Medicaid expansion states and the others were not,” Collins said.

She noted that other factors, such as a four-year-old Medicare program that penalizes hospitals with too many patient readmissions, as well as better reporting about injuries in nursing homes, have moved the needle on improving the way health systems deliver care.

‘Poverty is not destiny’

While the study found a strong relationship between low income and poor outcomes, Commonwealth Fund president David Blumenthal noted that some low-income communities performed well. He said some have even improved “dramatically,” largely due to collaboration within communities.

Blumenthal pointed to Stockton, Calif., a city that declared bankruptcy in 2013 after the city’s housing market and tax base collapsed during the depths of the Great Recession.

North Carolina’s hospital referral regions, as defined by the Commonwealth Fund.

In recent years, that city has embraced a nurse-led program to support pregnant African-American women for a year after the birth of their infants. Meanwhile, local hospitals encouraged more breastfeeding. That helped the infant mortality rate to drop in Stockton. The city also allowed a nonprofit organization to run health clinics in four local high schools. The clinics provided check-ups, gave flu shots and helped address students’ behavioral health issues.

Closer to home, Collins said, in Wilmington, where 39 percent of households have incomes less than 200 percent of the federal poverty level ($48,600 for a family of four), rankings on health outcomes improved and exceeded those in most other parts of North Carolina.

See box below for how each hospital region’s ranking changed over time.

“The share of adults 18 and older who went without care because of costs went from 20 percent in 2011 to 13 percent in 2013-14,” she said. Collins added that many of the people who got insurance in a ACA marketplace plan were some of the highest-risk people who had the greatest health care needs.

“I think people shifted from probably skimpier, poorer coverage in individual markets and small group markets to much more comprehensive coverage in the [ACA] marketplaces,” Collins said. “So even in the non-expansion states you see the effects of the Affordable Care Act’s expansion of insurance.”

Adam Zolotor, head of the North Carolina Institute of Medicine, said that areas of North Carolina with more improvement have been doing some innovative things.

“It was interesting to me to see Asheville and Wilmington near the top of the list; those are both health systems that are doing a good job with care management around avoidable readmissions,” Zolotor said. “Mission Health in Asheville is one of the better hospital systems in the state in terms of patient and family engagement.”

However, he said, in some instances an area’s poverty might overwhelm the positives of a local hospital system.

Zolotor said that’s probably the case in Durham, where Duke University Medical System has entered into collaborations with local clinics to address community needs. Nonetheless, Durham’s ranking dropped in this survey.

“And Vidant [in Greenville] is great for their work in patient and family engagement, but the health system is covering the poorest third of the state,” Zolotor said. “It’s hard to improve their health outcomes without improved access to care and improved insurance rates.”

Frayed safety net

Many markets that saw improvement during the past four years shared one feature — they have robust networks of community health centers. Even though the Commonwealth researchers did not look specifically at those clinics, they said there’s other data showing the positive effect of the clinics on a community.

Ben Money, head of the NC Community Health Center Association. Photo courtesy NCACHC

“From our case studies, we do hear anecdotally how important community health centers are,” McCarthy said. “In Stockton, about half of the Medicaid beneficiaries that are enrolled in the county health plan are served by community health centers. The collaboration between the plan and those clinics is really critical.”

Collins said in the 19 states that haven’t expanded Medicaid, community health centers have kept the safety net intact.

“There are many lower-income people who remain uninsured,” she said.

But Ben Money, the head of the North Carolina Community Health Center Association, bemoaned state leaders’ resistance to expanding Medicaid.

“We’re doing well with the resources that we have, but we could do far better with the resources we could get through Medicaid expansion,” he said.

Money noted that the federal Bureau of Primary Health Care, which provides funding and support for community health centers, has not been giving any extra help to centers in non-expansion states.

“I can’t blame a federal agency that says why should we give you money to do what you could be doing if your state expanded Medicaid,” he said.

“Why treat you differently if your state hasn’t taken advantage of a resource?” he asked. “It’s like if your kid says ‘I’m hungry, but I won’t eat my peas. Give me ice cream.’ Well, you gotta eat your peas first.”

Hurricane Matthew flooding will produce multiple hazards at home, indoors and out. Accurate information and time are required to help families cope.

By Catherine Clabby

There’s little worse than the vast flooding Hurricane Matthew has unleashed in North Carolina. Dirty water has breached homes, storefronts, nursing homes. People have been trapped in cars stalled in rushing water. Death tolls are rising.

But as people of this coastal state know too well, the trouble will not fade when Matthew’s floodwaters recede.

A rising crest of health threats is also on its way, public health experts say, including some unexpected risks. Families already battered by flood damage need to take steps to protect themselves all over again.

After flooding from Hurricane Irene in 2011, some North Carolinians had a big clean up on their hands. Sea Level, NC, Sep 7 2011 –Flood damage from Hurricane Irene. FEMA photo/Tim Burkitt

“People get very concerned about dirty water, that fuel oil might have leaked or sometimes their septic tanks. In reality, most of that doesn’t pose much of a health risk,” said Dr. Julie Casani, head of the state public health division’s Public Health Preparedness and Response branch.

“I worry more about people getting injured during the cleanup.”

Floyd, Fran and friends

Experience from previous storms backs that up. After a flood, homes that normally are shelters become altered environments hosting all sorts of hazards, contributing to an expected post-flooding uptick in emergency department visits.

For six weeks after Hurricane Floyd struck in 1999, incidence of bone and tissue injuries, respiratory problems, gastrointestinal trouble and heart disease were higher at 20 hospitals in 18 counties than they were over the same period the previous year.

Suicide attempts, dog bites, fevers, skin problems, and people seeking help with basic medical needs such as oxygen and medication refills, dialysis and vaccines all were more common during the six weeks after Floyd. So were spider bites, diarrhea, asthma attacks and injuries from assault, gunshot wounds and rape.

People can take steps to protect themselves. To begin with, people should stay clear any water that is slow to drain, said John Morrow, PItt County public health director. Its depth can be deceptive and may pose a drowning risk, the most common cause of death from floods.

“Just stay out of the water, period. Particularly children,” Morrow said. “They are too likely to say I’m just going to swim out there and get my ball.”

The exhaust or fumes from a portable generator could kill you in minutes if you breathe it in. Image courtesy the Centers for Disease Control and Prevention.

Casani agrees. “You can’t see what you can’t see. While plodding through water you may not be able to see something that is submerged. People can get cut. Or they trip and fall or sprain an ankle.”

Air it out

During a flood cleanup, people sometimes bring petroleum-powered devices — generators and power washers included — inside their homes or garages. That should never occur, Morrow said, because the carbon monoxide emissions can be deadly.

“Exhaust collects. Before you know it, you get dizzy and can’t get to fresh air or turn the thing off in time,” he said.

Ten cases of carbon monoxide poisoning were reported in weeks after Hurricane Floyd, compared with none during a comparable period in the previous year.

There is plenty to do indoors. And while water laced with chemicals or sewage is not the biggest threat people will encounter while cleaning up their homes, that remains a potential risk. So cleaning with protective gloves and boots is recommended.

“You don’t want flood water to come in contact with your face or mouth. The risk of sickness is low. But pathogens can pass through cuts and scrapes,” said Tim Kelley, the director of the environmental health program at East Carolina University.

After a flood, wall board needs to be removed and mold treated with bleach and other cleaners before rebuilding can recur. Photo credit:
Angela Schmeidel Randall, Flickr Creative Commons

The North Carolina State University Extension offers detailed guidance on how to proceed with cleanups at home after a flood. A priority is to shovel out mud or silt before it dries and to wash down flooded walls and floors with hoses and then get them dry.

Drywall acts like a sponge, extension materials warn, and it might be necessary to remove wall board above the flood line. Wet insulation also must go. Sometimes holes must be drilled into the siding to fully dry walls, a process that can take months.

Much of that effort is required because of mold growing inside a home. Mold isn’t a health risk to everyone, but it can be a serious risk to people with asthma and allergies, or people with suppressed immune systems due to HIV infection, cancer treatments or other health conditions.

“One of the things about eastern North Carolina is that we’re surrounded by mold. You can’t avoid it, it is so damp and musty. There are thousands of species,” said Paul Barry, from the Department of Public Health at ECU.

The state Department of Public Safety recommends people treat every item touched by floodwaters as contaminated and disinfect those items with household cleaning products. It also recommended that people stay clear of any flood-damaged material that may contain asbestos. Discard mattresses, upholstered furniture, carpets and padding, and books and paper products touched by floodwaters, department officials urge.

Choose caution

Then there’s food and drinking water safety to attend to.

Updated information on water system advisories is hereState Health Director Randall Williams on Tuesday urged people in multiple counties to boil their water, including portions of Bladen, Carteret, Chatham, Chowan, Columbus, Cumberland, Currituck, Dare, Duplin, Franklin, Hertford, Hoke, Johnston, Lenoir, New Hanover, Onslow, Pender, Perquimans, Robeson, Sampson, Wake, Wayne and Wilson counties.

Image and content courtesy Centers for Disease Control and Prevention

When it comes to food, be conservative, health officials say. Discard any food touched by floodwaters, including edibles in cans, bottles or jars. Food that was in a refrigerator or freezer that reached more than 40 degrees should be thrown away, the N.C. State University Extension materials recommend.

If all the above isn’t enough, there are also disease-carrying insects to worry about. Mosquitoes lay their eggs in water and multiply more quickly after big rains and floods. State health officials recommend people wear insect repellent and empty any standing water in birdbaths, tires, flowerpots and other containers.

Casini, who lost a home to damage from Hurricane Isabel in Maryland in 2003, stressed that natural disasters, and all the challenges that follow, put a strain on anyone’s mental health.

She encourages people to slow down and not try to put everything back together at once, indoors or out.

“This isn’t your standard fall cleanup. This is happening in treacherous conditions,” Casini said.

Instead, do only what is feasible to tackle safely, she said. Try to get your family on what feels like a normal schedule. And reach out to other people in the same boat.

“Maybe they were never your friends,” Casini said. “But something like this becomes a collective experience.”

People with mental health issues making the transition to more independent living will get a bit more help with a new program.

By Rachel Herzog

Sometimes people with mental health issues can have a hard time getting back on their feet when leaving a psychiatric hospital or being released from jail. But for the past two and a half years, the Critical Time Intervention program has helped these folks in Orange and Chatham counties transition to new homes.

The CTI team in Chapel Hill has served about 130 people during that time, said CTI project director Bebe Smith during an event to highlight CTI at NC State University’s McKimmon Center Wednesday morning.

CTI aims to help individuals with mental illness who need a little assistance navigating the world, Smith said. Now the program is expanding its reach across the state.

Productive practice

In North Carolina, CTI began as a pilot program out of UNC-Chapel Hill. Before that, it was a project pioneered in New York City.

Daniel Herman, a researcher at New York’s Hunter College, worked on developing the program.

He said that while New York City had opened housing programs to help homeless individuals with severe mental illness and started offering outreach services, many of these people would lose their housing within a matter of months or even weeks and be back in the shelter or on the streets. Herman called this the “revolving door” phenomenon.

“What CTI was intended to do was to try to provide a way to break that cycle by trying to think a little more carefully about how to help people get settled and situated in their community or their new housing place,” Herman told several dozen social workers and mental health advocates during Wednesday’s meeting.

The new centers, which will launch in June in North Carolina, are being run by the mental health managed care organizations Alliance Behavioral Healthcare, Coastal Care, Partners Behavioral Health Management and Cardinal Innovations Healthcare Solutions. The new Alliance center will serve Cumberland County, Cardinal will expand the UNC program’s work into Alamance County, CoastalCare will run the program in Onslow and New Hanover counties and Partners will create three new teams in Gaston County.

Different centers will adjust the CTI model to focus on different at-risk populations. The Alliance center will help individuals transitioning out of detention centers, Coastal Care will help individuals transitioning out of hospitals and Partners will help homeless individuals.

Filling the gaps

Smith doesn’t know how many people the new centers will serve yet, but it will be a lot, she said.

“I think we’ve had some pretty significant gaps in our mental health system,” she said. “I think that with CTI we can start filling some of those gaps and help people who are not connected to services in the community.”

The Washington, D.C. nonprofit Coalition for Evidence-Based Policy ranked CTI as a top-tier program. In one study, individuals who completed a CTI program retained their housing at a higher rate than people who didn’t get CTI services. In another, based on re-hospitalization data, the average cost saving for individuals who completed the CTI program was $24,000 over 18 months.

Smith cited the 2011 elimination of case management as a challenge that made transitioning people more difficult. Under case management, counselors did one-on-one work to help individuals meet their food, shelter and income needs, but the service was eliminated in favor of care coordination by MCOs.

Thava Mahadevan, director of operations at UNC’s Center for Excellence in Community Mental Health, is overseeing the expansion into Alamance County. He said the teams are getting to know the community and meeting with law enforcement officers, homeless shelter operators and hospital officials.

“The hope is that we should be able to build as a service division at some point,” Mahadevan said.

Training for the teams at all four centers will take place at the UNC School of Social Work.

The post Mental Health Transition Program Scales Up Across State appeared first on North Carolina Health News.

Much of the improvement in health and longevity over the past century can be attributed to better sanitation. But more recently, this important public health function has become an afterthought in municipal budgets.

By Gabe Rivin

Cost, rather than a concern for public health, can take priority when local officials decide whether to expand water and sewer lines into unserved areas, a new study by UNC-Chapel Hill researchers found.

The researchers found that even in densely populated communities, officials focused on the large costs of water and sewer services rather than on the health benefits that off-the-grid citizens stand to gain.

The finding is significant because in North Carolina about 30 percent of residents rely on private wells for their drinking water, according to the N.C. Department of Health and Human Services. Some 48 percent of residents use septic systems to treat their sewage, the department estimates, though those figures are based on U.S. Census data from 1990, the last year the information was collected.

Nationally, an estimated 15 percent of Americans use private water wells and 25 percent use septic systems, both about half the rate for North Carolina.

If improperly monitored, these water and sewage systems can threaten the public’s health, the researchers warn in their study published Aug. 13 in the American Journal of Public Health. Well water is not covered by federal drinking-water standards. This means its safety is largely a question for homeowners who use drinking-water wells.

“The existing literature has put health concerns as a major factor for why we should extend water and sewer services to as many people as possible,” said Julia Naman, the lead author of the study.

The researchers also raised concerns about the prevalence of septic systems in North Carolina. When used properly, these systems can treat harmful pathogens in human waste, allowing residents to safely dispose of their sewage, according to Mike Hoover, a retired professor of soil science at N.C. State University and an expert in septic systems.

But septic systems can fail – and often do, Hoover said. DHHS estimates that 6 to 10 percent of septic systems fail annually in North Carolina. But Hoover said that, on average, 10 to 20 percent of septic systems fail each year.

This can be a problem.

Untreated septic wastes from a failed system can seep into groundwater, which residents draw from their wells as drinking water. Sewage can also overflow into the streets and into nearby bodies of water, spreading potentially harmful pathogens to humans who come in contact with it.

An expensive option

In urban areas throughout North Carolina, residents rely on public sewers and public drinking water.

When these residents use their toilets, waste travels through their home’s sewage pipes and then into a system of municipal sewers. Sewers ultimately lead to public wastewater treatment plants.

Drinking water can take a similarly circuitous route. Municipal plants draw water from lakes and rivers, among other sources. They then filter and sanitize the raw water, removing pathogens and solid matter. The clean water is then pumped through a network of water pipes and storage tanks, which deliver water to residents’ kitchen sinks.

Federal legislation – the Clean Water Act and the Safe Drinking Water Act – set standards for these services in order to protect the public’s health.

But water and sewer systems are expensive to build and maintain. And extending services into sparsely populated rural areas can be prohibitively expensive.

“We cannot afford financially to sewer up the United States,” Hoover said. “If we were to do that, there would literally be no money left for schools, for senior citizen centers, for libraries.”

Short on money, short on data

The UNC researchers acknowledge that these services are impractical for some rural residents. But some areas in North Carolina, they say, are close to cities with municipal services, and are densely populated. And yet these areas are still without municipal water and sewer services.

“You would not be able to tell the difference if you went from a city neighborhood to one of these communities,” Naman said.

The researchers sought to understand this phenomenon. So they interviewed influential community members in three counties: Hoke, Transylvania and New Hanover. These counties have unincorporated neighborhoods that lack water or sewer services, or both, and are near cities with these services.

The researchers interviewed a wide range of people, all of whom are involved in the decision to extend services. These included staff at public utilities, health officials, legislators, zoning officials, city and county managers and community members.

After conducting interviews, a consistent theme emerged. The high costs of water and sewer services, above all, weighed on communities’ decisions whether to extend services. The public’s health was generally a low priority in these discussions.

“Health is very central to this issue,” Naman said. And yet, she added, “Very few people, one, recognized the health risks that are associated with wells and septic tanks, and, two, were basing their decision-making off of these health risks.”

At the same time, the researchers said, septic system failures may go underreported. Health departments mainly place the responsibility on residents and neighbors to report a failure. But with potentially high repair costs to bring a system into compliance with state rules, residents may hesitate to request repair permits.

And that can cause a data gap for counties and cities, Naman said.

“They don’t have systematic data to prove that these communities are facing considerable health risks,” she said. “Without this systematic data, the county officials and city officials will assume that everything is fine, and the community members won’t have their problems addressed.”

Naman said that in New Hanover County, anonymous surveys helped fill this gap.

Going it alone

State officials acknowledge that off-the-grid residents have a greater responsibility to protect their own health.

“Having one’s own system puts one in control,” said Larry Michael, who heads the Environmental Health Section at DHHS. “Routine maintenance is essential to having your own decentralized wastewater system and/or well.”

Beyond maintaining wells, residents must also “take initiative to regularly sample for contaminants,” Michael said.

But he said municipal systems can also be sources of concern. Municipal systems can leak or get blocked up, causing a potential health hazard on a much larger scale, he said. That’s particularly true for aging infrastructures, he added.

N.C. State’s Hoover echoed this claim. He also questioned the assumption that sewers are always preferable to septic tanks.

“What I spent my career trying to tell people is, septic systems can be a permanent, dependable form of wastewater treatment,” he said. “But not so if they’re ignored and not maintained and not utilized correctly.”

The post Public Health a Low Priority for Water and Sewer Extensions, Study Finds appeared first on North Carolina Health News.

By Kirk Ross

Coastal Review Online

With a March primary and an early start to the session, the N.C. General Assembly’s environmental oversight committees have begun prepping legislation for this year’s short session, including a potential revision to a coal ash bill passed two years ago.

The legislature’s Environmental Review Commission devoted much of last week’s meeting to coal ash. Tom Reeder, an assistant secretary for the N.C. Department of Environmental Quality, gave commission members an assessment of the effects overseeing coal ash cleanup will have on his agency and leveled a blistering attack on the federal Environmental Protection Agency for its role in draining coal ash ponds in the state.

Reeder said DEQ is stretched “to the breaking point” to keep up with a timetable mandated in a bill the legislature passed in 2014 that requires the cleanup of the 32 ponds at 14 Duke Energy power plants.

He also sharply criticized EPA officials in Atlanta for not moving faster on proposed changes to federal permits for wastewater discharge that would allow decanting and dewatering to begin at most of the ponds. Those are the first steps in the cleanup process.

DEQ in December approved an updated discharge permit for ponds at Duke Energy’s L.V. Sutton power plant in New Hanover County, one of four high-priority sites where excavation and removal of coal ash has already started. The permit allows the plant to begin drawing down water in the ponds at the rate of one foot a week.

Reeder expressed frustration in getting the water out of the remaining ponds, charging that the EPA took more than 15 months to approve decanting at the sites and is currently holding up approval on permit modifications that would allow dewatering at 13 sites.

Decanting is the removal of the surface water in the pond, while dewatering is the final step in removing the rest of the water ahead of excavation.

“Until we get the water out of those ponds, we’re going to continue to have groundwater contamination, we’re going to continue to have threats from this water to dams and surface water,” Reeder said. “The key thing is we’ve got to make those ponds dry.”

Legislators shared his frustration. “We may not know what steps 25 and 30 are, but we certainly know what steps one and two are, and that is decanting and dewatering,” said Rep. Jimmy Dixon (R-Duplin).

During questioning by commission members, Reeder said DEQ Sec. Donald van der Vaart is considering what Dixon termed “unilateral action” to move forward with the revised pollution-discharge permits and start dewatering the ponds without EPA approval.

In a response to a request from for details on the move, Crystal Feldman, DEQ deputy secretary for public affairs, said EPA approval of the discharge permits is a courtesy and not a requirement.

“When given a permit to review, EPA may offer comments, object to or remain silent on the permit. DEQ may issue the permits if EPA does not object. As a courtesy, in recent years DEQ has waited for explicit EPA approval before issuing coal-ash permits despite it not being required by law,” Feldman wrote in an email. “Assistant Secretary Reeder noted that we may no longer provide that courtesy.”

Feldman said the department has yet to decide how to proceed on the permits.

“The EPA is struggling with how to handle these types of permits because they are the first of their kind in the nation, which has caused long delays in the permitting process,” Feldman wrote. “If DEQ is faced with a choice between protecting the environment or the federal bureaucracy, protecting the environment will win every time.”

EPA officials in Atlanta said they are moving forward on permits that would allow dewatering following procedures set out in a memorandum of understanding with the state. DEQ has forwarded to EPA two proposed final permits that include dewatering, explained Davina Marraccini, an agency spokeswoman.

EPA completed its review of the first permit and has asked for a 90-day delay, which ends on Feb. 10, on the other. Such a delay is authorized by law, she said, and is included in a memo that the state signed.

Legislators at the meeting said the timetable in the cleanup bill could be adjusted this session.

Chromium standards debated

Also during the ERC meeting, commission members looked into an interagency debate between DEQ and state public health officials over setting threshold levels of contaminants for a well-testing program near coal ash sites.

The focus was on do-not-drink notices sent by the state Department of Health and Human Services based on testing around the 14 coal ash sites. In all, more than 476 private drinking-water wells near the sites were tested. Of that total, 424 well owners, about 89 percent, were issued do-not-drink notices by the department, with 369 of those notices triggered by levels of hexavalent chromium and vanadium that exceeded the standard used by health officials.

Reeder told legislators that the standards for hexavalent chromium was set far lower than federal drinking-water standards for public water systems. Nearly every public water system in the state would get a similar notice if the standard was applied, he said.

Legislators also questioned the notices, saying they alarmed residents and forced them to switch water sources unnecessarily.

Rep. Rick Catlin (R-New Hanover) said the notices have had a negative effect that in many cases outweighed the risk. He said future do-not-drink notices shouldn’t go out unless there is clearer evidence.

“Wait until we have that information to tell them to quit drinking their water, because we are impacting them kind of unfairly [compared] to the way we’re impacting everybody else,” Catlin said.

State Health Director Randall Williams stressed that the risk evaluations were recommendations to residents and not regulations. He said the chromium standard used was based on public health standards for risk of cancer due to lifetime exposure at the levels of the well tested.

“We’d rather error on the side of caution,” Williams said.

The department, he said, is waiting for new data and will re-evaluate its risk assessments, including looking at background levels for the areas tested.

“We’re in the midst of evolving science,” he said, adding that there has yet to be a standard set for hexavalent chromium and it is treated differently by different government agencies.

DEQ and DHHS have been charged with preparing a study for the ERC on how to set proper levels for hexavalent chromium and vanadium, two known coal ash constituents that carry a high risk to public health. Few states have regulations on either. The study is due by April 1.

Grady McCallie, policy analyst with the N.C. Conservation Network, said although it focuses on just two constituents, the outcome of the study could have a significant effect on how the state determines the extent and amount of groundwater contamination.

“The underlying issue is an important one and broader than just hexavalent chromium,” McCallie said in a recent interview. “How do you handle substances that change over time and those that are naturally occurring in some wells and not in others?”

DEQ officials have repeatedly pointed to naturally occurring levels of various toxic coal ash constituents, such as arsenic, as a challenge in determining whether high levels in groundwater can be directly attributable to coal ash basins.

The post Government Agencies Point Fingers Over Coal Ash Delays appeared first on North Carolina Health News.

Research and response teams in North Carolina are preparing.

By Rose Hoban

It’s cold in North Carolina right now. So people aren’t sitting on their porches swatting at mosquitoes.

But even when the weather warms up and the local bloodsucking bugs start flying, the question for many people is: Is it possible to get the Zika virus in North Carolina?

The answer, according to researchers from UNC-Chapel Hill, is, essentially, “No.”

“There’s not zero risk of anything, but I wouldn’t worry about transmission of Zika in the U.S.,” said Aravinda de Silva, an infectious-disease researcher at UNC who specializes in dengue virus, another mosquito-borne virus in the same family as Zika.

Though there are mosquitoes in the U.S. capable of carrying Zika, de Silva said there’s an exceedingly slim chance of someone in this country getting Zika from a mosquito.

There have been small outbreaks of dengue in Key West and along the Texas-Mexico border. But da Silva said Zika diagnoses in the U.S. will overwhelmingly come from travelers who bring it home from their Caribbean or Latin American vacation.

“Let’s put the U.S. aside for a moment. There’s more globally; all these people living in endemic areas,” he said. “There are huge populations living in these large urban centers, millions and millions of people who are at risk of getting dengue, and those same populations are at risk of getting Zika.”

“If it wasn’t for  the microcephaly, it wouldn’t be unique,” said UNC infectious-disease specialist David Weber, referring to a strongly suspected link between Zika infection in pregnant women in Brazil and a sharp uptick in a birth defect known as microcephaly.

“Otherwise, [Zika] is just a mild illness, which is why there’s been so little research,” he said.

According to da Silva and Weber, who both presented last week, researchers from the university are mobilizing to study the disease.

Even as the UNC researchers were presenting, a study was released in the New England Journal of Medicine showing direct links between even mild Zika infections in pregnant women and the birth defect. What is disturbing to the authors of that study was that only about a third of the women tested actually had a fever; the rest never knew they were sick.

Air conditioning and window screens

Zika is closely related to dengue, which has been spreading widely in Latin America and the Caribbean for the past few years. Commonly known as “breakbone fever,” dengue usually causes mild fever. But in a limited percentage of patients, its muscle and joint pains can be just plain awful.

Yet out of the estimated 390 million cases of dengue worldwide in 2013, only 794 were diagnosed in the U.S. Most of those were travelers who acquired the disease while abroad.

There has been some local transmission in the U.S., but the spread has been limited. Even in places in the U.S. like Key West and along the Texas-Mexico border where there are the right kind of mosquitoes – namely, Aedes aegypti and Aedes albopictus – and the weather is warm enough, there’s reduced risk of those bugs actually carrying disease from one person to another.

“This has mostly to do with lifestyle factors such as air conditioning and window screens, which limit the spread of mosquito-borne viruses here,” said Helen Lazear, a UNC microbiologist who studies mosquito-borne diseases, during last week’s presentation.

In a recent Key West dengue outbreak, there were only 28 confirmed cases of locally transmitted disease between August 2009 and March 2010.

More than the U.S.

Lazear floated the suspicion that prior infection with dengue, as is common in Brazil and other countries where Zika is currently raging, can actually make Zika cases worse.

According to Lazear and da Silva, Zika triggers the immune response created after a person has gotten dengue.

“Unfortunately, dengue and Zika are too close and it’s very difficult with the [existing test] to see whether someone is having a dengue or a Zika infection,” da Silva said.

That makes it harder for researchers to actually confirm that a patient has Zika while they’re still sick. Instead, the best diagnosis is made using sensitive DNA-based testing; but that’s expensive and needs to be done in a lab.

UNC researcher Sylvia Becker-Dreps, who has been doing epidemiology research in Nicaragua for a decade, will be leading a collaboration between UNC and a university in that country to study Zika.

“Right now, it’s mostly a naîve population; they’re only starting to get their first cases, something between 300 and 600 cases detected in Nicaragua,” Becker-Dreps said.

The idea is to help the government with its response, but resources in that country are poor and Becker-Dreps said the ministry of health is only testing every tenth blood sample it receives.

She said one of the most important things to do is monitor what happens with pregnant women as the disease spreads across Nicaragua.

“The rainy season begins in May,” she said. “So the epidemic is only arriving now in Nicaragua. Then wait nine months and see.”

It’s important to understand what’s happening with Zika now, da Silva said, because inevitably the disease will make the jump to Asia, with its megacities of tens of millions of people.

“You have huge populations living in these large urban centers, millions and millions of people who are at risk of getting dengue, and those same populations are at risk of getting Zika,” he said.

Even if only a small proportion of pregnancies in Zika-infected women in those megacities end with babies having birth defects, it could still be tens of thousands of cases.

Staffing up

Closer to home, state public health officials are leveraging the publicity around Zika to beef up their surveillance and response capacity around bug-borne diseases.

North Carolina was one of the only states in the country to have a small cadre of entomologists, embedded in the Division of Public Health, to track mosquito-borne diseases and other diseases carried by bugs, known as “vector-borne” diseases.

But the vector-borne disease branch was eliminated during budget cutting in 2010 and 2011.

Now the Division of Public Health is looking for two entomologists, one to be based in Raleigh and the other to do fieldwork throughout the state, according to Danny Staley, who heads the division.

Essentially, that’s the same level of staffing as in the older program.

Staley said a number of counties, including New Hanover and Brunswick, have active vector-control programs. Those counties have historically been mosquito hot spots.

Staff go out, either in response to complaints or to known hot spots, he said, and look for birdbaths or containers with larvae.

Staley said spraying has fallen out of favor as the preferred method of mosquito control. Instead, public health interventions are more targeted: Teams go to hot spots, look for larvae, trace the feeding patterns of the mosquitoes and monitor what happens after they apply larvacide or drain waters.

“You can have three or four broods coming off of one container in a day,” Staley said.

He said the newly hired state-level entomologists will coordinate with local departments and will track what’s happening statewide to prepare for “new and novel viruses that are coming our way.”

“Last year, it was chikungunya; a few years earlier, it was West Nile virus,” Staley said.

As happens often in public health efforts, funds get cut when there’s no disease activity; then when there’s an outbreak, agencies scramble to rebuild.

“I will say that North Carolina is not unique in this situation,” Staley said. “In Florida and other states, there are similar situations; programs that were once very popular have faded.”

The entomologist job postings closed last week. Staley said the division is “aggressively” moving to get the new hires in place before North Carolina’s mosquitoes get active.

The post Though Zika Unlikely a Risk in N.C., Local Efforts Are Scaling Up appeared first on North Carolina Health News.

Furanylfentanyl mixed into heroin has been catching users unawares, and overwhelming attempts to save them.

By Rose Hoban

Word is spreading around the state about a deadly form of opioid that’s killed at least 19 people in North Carolina since the new year.

The problems have been caused by a drug known as furanylfentanyl, a powerful form of the synthetic opiate fentanyl.

Fentanyl itself is about 80 times as potent as morphine, about 20 times stronger than heroin, and is used frequently in surgery and for pain control for cancer patients. On the street, fentanyl has been known as China White and can be deadly when it’s mixed into heroin.

And furanylfentanyl is even more potent than regular fentanyl.

There have been overdoses and deaths in New Hanover County attributable to heroin laced with something much stronger, confirmed Deputy Chief Mitch Cunningham of the Wilmington Police Department.

“We believe that the save we had today, it was likely present,” Cunningham said Tuesday afternoon, referring to a situation in which someone from his department administered a drug to reverse an overdose.

Stonger

Ruth Winecker,  chief toxicologist in the state Office of the Chief Medical Examiner, said she first had a suspicion there was something stronger than fentanyl in September when an overdose case came in.

“At first, we did not know what it was. On our regular screen, we detected a compound called 4ANTP,” which she explained is a byproduct created when labs alter fentanyl.

“We knew we had a fentanyl-like drug in that case,” Winecker said.

Months later, in February, another case came in, then another and another. By then, Winecker had done the work to be able to identify furanylfentanyl more easily.

“We occasionally see new and different research chemicals used in medical and pharmaceutical research. We find them in our casework,” she said, but very rarely.

“But with 19 of these,” Winecker said, “that’s extreme.”

Anna Dulaney, a toxicologist with the Carolinas Poison Center, confirmed that her office has also been hearing about laced heroin.

“That’s what a lot of people are concerned about, among EMS workers and emergency department personnel,” she said.

Dulaney said her big concern was that heroin laced with furylfentanyl is far more potent than users expect and can be lethal at much lower doses.

Cunningham said his department started distributing naloxone, a drug that can reverse opiate overdose, last week, and that they’ve already documented two rescues from overdose.

Robert Childs heads the North Carolina Harm Reduction Coalition, which promotes the use of naloxone to reverse opiate overdose and distributes naloxone kits. He said since he moved to the Wilmington area four months ago, he’s gotten documented reports of at least 400 people who have had overdoses reversed by naloxone.

“I’ve never encountered anything like it,” he said. “There was one weekend where we had four or five rescues; it was all fentanyl related.”

Many forms of fentanyl

There are at least 30 different chemical offshoots of fentanyl and, according to Winecker, it’s not that complicated for a “moderately sized lab” to alter fentanyl into one of these even more potent analogs.

Winecker said she contacted colleagues in Europe once she identified furanylfentanyl to see if they had seen it before. They had.

Fentanyl analogs have been circulating around Eastern Europe for more than a decade, with the highest use documented in Estonia, where it has caused hundreds of deaths, according to a 2015 review in the International Journal of Drug Policy. According to the IJDP, “production facilities have been seized in Bulgaria, Greece and Portugal,” and other illicit labs creating these analogs have been found in Russia, Belarus and the Ukraine.

There’s also precedent for something stronger to be present in the heroin that’s been sold here.

In the U.S., a different fentanyl analog known as acetyl fentanyl was circulating in the northeast between March 2013 and May 2014, when there were 14 deaths in Rhode Island attributed to the drug. Three deaths in North Carolina occurred as a result of acetyl fentanyl in 2014.

Winecker said the Office of the Chief Medical Examiner routinely autopsies overdose victims in order to keep track of what’s happening with these new chemicals. And her office is in the process of acquiring an even more sophisticated piece of equipment that can measure the mass of chemicals, to more readily identify novel compounds such as furanylfentanyl.

“Overdoses are amounting to about one of four autopsies now,” said State Health Director Randall Williams.

“The people who’ve passed away, many of them probably thought that ‘heroin is not good, but I’ve done it before, I know what I’m dealing with,'” Williams said. “Then it’s too late.”

Many vials

Part of the problem is that when a person overdoses, they might not be aware that multiple vials of naloxone would be needed to revive them.

In Wilmington, Cunningham said that, for example, in the overdose “save” that took place on Tuesday, more than one vial of naloxone was needed to reverse the loss of breathing that comes as a result of opioid use.

Kendra, one of the Harm Reduction Coalition’s naloxone distributors, said she’s had reports of 25 fentanyl-related reversals in Wilmington alone, each reversal requiring two or three doses to bring someone back to life after they stopped breathing.

Another outreach worker, Mike Page, said he knew of at least one case where four vials were required, instead of the usual one.

“People that are used to using a certain brand, if you will, or a certain stamp, a new batch is coming in with that same stamp and it’s a lot more potent,” Page said. “People that are used to using a certain amount are using that same amount, like two or three times as strong, so the overdose rates are skyrocketing.”

“There’s the need for possible higher doses of reversal agents, like naloxone, to reverse the fentanyl,” Dulaney said. “Typically, with heroin, you would give one dose of either to reverse. Sometimes in the emergency department, we use smaller doses because we don’t want to put a patient into withdrawal.”

Naloxone comes in two commonly used forms: an intranasal spray that has 2 milligrams in a vial and an intramuscular injection form that has 0.4 milligrams in a vial. A higher dose is needed for nasal use because it’s not all absorbed right away.

“One concern is that if a bystander is using this for someone, they may not have enough to reverse the overdose,” Dulaney said. “That’s why we always advocate calling 911.”

 

 

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