Montana. Dept. of Health and Environmental Science.

Healthy Montanans : 1990 perspectives (Volume 1985) online

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Objective 8: By 1990, in Montana the proportion of women in anv county or
racial or ethnic groups who obtain no prenatal care during the first trimester
of pregnancy should not exceed 5 percent.



16



Objective 9: By 1990, in Montana Rhesus hemolytic disease of the newborn should
be reduced to below a rate of 1.3 per 1,000 live births.

Objective 10; By 1990, no Montana county and no racial or ethnic group in
Montana should have a rate of low birthweight infants that exceeds 3 percent of
al 1 1 ive births.

Objective 11: By 1990, 95 percent of Montana's women of childbeariiig age should
be able to choose foods wisely and understand the hazards of smoking, alcohol,
phannaceutical products and uther drugs during pregnancy and lactation.

Objective 12: By 1990, Lhe majority of infants in Montana should leave hos-
pitals 111 car safety seati.

Objective 13: By 1990, Montana should have a system in place for comprehensive
and longitudinal assessment of the impact of a range of prenatal factors (e.g.,
maternal exposure to radiation, ultrasound, dramatic temperature change, toxic
agents, smoking, use of aleuhol or drugs, exercise, or stress) on infant and
child physical and psychological development.

Objective 14: By 1990, virtually all infants in Montana should be able to
participate in primary health care that includes well child care; growth devel-
opment assessment; inmumzation , screening, diagnosis and treatment for con-
ditions requiring special services; appropriate counseling regarding nutrition,
auLciriobile safety, and prevention of other accidents such as poisonings.

Objective 15: By 1990, virtually all pregnant women in Montana at high risk of

having a fetus with a condition diagnosable in utero, should have access to

counseling and information on amniocentesis and prenatal diagnosis, as well as
therapy as indicated.



17



Objective 16: By 1990, Montana's infant mcrlality rate (deaths for all babies
up to one year of age) should be reduced to r,o more than 6 deaths per 1,000 live
births.

Objective 17: By 1990, the neonatal death rate (deaths for all infants up to Z8
days old) in Montana should be reduced to no more than 3 deaths per 1,000 live
births.



18



PREGNANCY AND INFANT HEALTH



Objective 1 : By 1990, low birth weight babies in Montana (Si pounds and under)
should constitute no more than 2.8 percent of all live births.

Rationale : Prematurity is the leading cause of infant morbidity and
mortal ity.

Discussion : Need to practice state-of-the-art medicine and prevent 1/2 of
preterm labors, i.e., employment of contemporary methods. Educational
programs directed at pregnant women and primary health care providers is
the responsibility of the State MCH program and should be supported by
State general funds.

• • * * •

Objective 2 : By 1990, the incidence in Montana of infants born with Fetal
Alcohol Syndrome should be reduced hy 25 percent.

Rationale : One out of 10 mentally retarded children are attributed to FAS.
One out of 10 cleft patients are a result of FAS. An unknown number of
cardiac patients are a result of FAS. Fetal alcohol syndrome is totally
preventable!

Discussion : The MCH prnqram at the State level must increase the effort in
taking the lead in provider and consumer education.

• * • * •

Objective 3 : By 1990, virtually all women and infants in Montana should be
served at levels appropriate to their need by a regionalized system of primary,
secondary and tertiary care for prenatal, maternal and perinatal health ser-
vices.

Rationale : Infants of high risk pregnancies do much better if delivered in
Level III hospitals as opposed to Level II hospitals and similarly in Level
II hospitals as opposed to Level I hospitals. The infant's stay is 1/3 as
long and the cost is 1/3 less than if born in a Level II hospital and
transported to a Level III hospital.

Discussion : State supported professional education and transport support
is an absolute must. This regional ization concept has been one of the



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major thrusts of IPO during its 5 years of existpnce (1979-1984). Activ-
ities to maintain regional ization must continue.

* * ♦ * *

Objective 4: Py 1990, virtually all Montana women who give birth should have
appropriately attended, safe delivery, provided in ways acceptable to them and
their families.

Rationale : Home deliveries need to meet safe levels of care. Hazards of
birth are higher with home deliveries. Alternate birthing centers are
preferable to home deliveries.

Comments : The State of Montana should provide delivery/medical care for
women who cannot afford hospitalization. High risk pregnancies should be
identified and treated adequately. Educational programs need to be devel-
oped and disseminated among the general public regarding the increased risk
of utilizing non-licensed lav midwives.

Neither the social or economic circumstance nor the geographical location
of mothers should dictate the level of care.

*****

Objective 5 : By 1990, no Native American populace in Montana should have an
infant mortality rate (IMR) in excess of 7 deaths per 1,000 live births.

Rationale : The infant mortality rate ^or Indian infants has been
excessive.



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IMMUNIZATION
Suinriiary of the Problem:

The seven major chilaho&d diseases - measles, mumps, rubella, polio,
diphtheria, pertussis, and tetanus - can cause permanent disability and, in
some cases, death. They all can be prevented by immunization. Prior to the
National Childhood Imaiunization Initiative of 1977 more than one-third of all
children under age 15 were not properly protected. Since 1977, two major
advances have been made: (1) All states now have school and most day care
immunization requirements; (2) the immunization status of these children has
risen to over 90^.

Outbreaks of measles and pertussis, and occasionally diphtheria ana polio,
during the early 1980's indicate that immunization must be emphasized continu-
all>. With the combination of safe, effective vaccines, public and private
programs, and a reliable disease surveillance and outbreak containment system,
infectious disease can be controlled. Also, even though vaccines are now
available to reduce the risk of influenza, hepatitis B, and pneumococcal pneumo-
nia, many high risk patients are not protected.



21



IMMUNIZATION

Priority Objectives

Objective 1: By 1990, reported cases of these vaccine preventdble diseases will
be:

a. Measles: Maintained to less than 5 cases per year.

b. Mumps: Maintained to less than 5 cases per year,

c. Rubella: Maintained to less than 5 cases per jear.

d. Congenital Rubella Syndrome (CRS): Maintained at cases per year.

e. Diphtheria: No more than one case per year,

f. Pertussis: Maintained to less than 5 cases per year.

g. Tetanus: No more than one case per year.

h. Polio: Maintain paralytic polio at cases per year.

Objective 2: By 1990, all mothers of newborns should receive instruction prior
to leaving the hospital or after home births on immunization schedules for their
babies.

Objective 3: By 1990, at least 90 percent of all children should have completed
their basic series by age 2 - measles, mumps, rubella, polio, diphtheria,
pertussis and tetanus.

Objective 4: By 1990, 97% of children in licensed day care and kindergartens
through grade 12 should be fully immunized and 100" should be in compliance with
state law.



Objective 5: By 1990, an immunizable disease reporting/surveillance system
should be in place with 100 percent of reported, suspected and confirmed cases
logged and investigated within 24 hours as appropriate.

Other Objectives

Objective 6: By 1990, influenza and pneumococcal vaccines should be available
to high risk populations through local public health agencies.

Objective 7: By 1990, at least 50 percent of people in populations designated
as targets by the ACIP shoula be immunized within 5 years of licensure of new
vaccines for routine clinical use.

Objective S: By 1990, mass immunization campaigns shall use delivery systems
already in place, and shall adopt plans to individual situations.

Objective 9: By 1990, all persons should obtain and maintain an up-to-date
official imiiiunization record from their health care provider.

Objective 10: By 1990, no comprehensive health insurance policies should
exclude immunizations.



23



IMMUNIZATION

Objective 1 : By 1990, reported cases of these vaccine preventable diseases will
be:

a. Measles: Maintained to less than 5 cases per year.

b. Mumps: Maintained to less than 5 cases per year.

c. Rubella: Maintained to less than 5 cases per yt^r.

d. Congenital Rubella Syndrome (CRS): Maintained at cases per year.

e. Diphtheria: No more than one case per year.

f. Pertussis: Maintained to less than 5 cases per ye^r .

g. Tetanus: No more than one case per year.

h. Polio: Maintain paralytic polio at cases per year.

Rationale : All the above diseases are virtually preventable through
• appropriate immunization of children and susceptible adults.

Discussion : All of these diseases are at all time low levels due to health
protection activities such as passage of school and day care requirements,
and ensuring children are immunized appropriate for their age. Reported
care for each of the diseases since d.re:

1980 1981 1982 1983



Measles


2








4


Mumps


42


13


s


5


Rubella


44


3


7


4


CRS











C


Diphtheria





1








Pertussis


3


12


1


2


Tetanus














Polio















A high ranking is given to this objective, since morbidity reports over the
past 10-15 years have demonstrated that vaccines are cost effective.
However, even though the vaccines are effective, some morbidity is inevita-
ble due to immigration. The attainment of these objectives depends on the
resources available to maintain low levels of morbidity.



• * * * *



Objective 2 : By 1990, all mothers of newborns should receive instruction prior
to leaving the hospital or after home births on immunization schedules for their
babies.

Rationale : This objective emphasizes the first major opportunity to inform
mothers of newborns about the importance of irmunizations.

24



Discussion : This objective is currently being met in Montana. Achieving
the 1990 objective, however, is dependent upon resources increasing with
corresponding population growth.

Currently, 60 out of 51 hospitals distribute the SChES educational packet
to the new mothers.

A need for an anticipated birth rate for future years would be useful.

• • ♦ ♦ *

Objective 3 : By 1990, at least 90 percent of all children should have completed
their basic series by dye 2 - measles, mumps, rubella, polio, diphtheria,
pertussis and tetanus.

Rationale : Early vaccination will maintain small numbers of susceptibles
from religious or medical contraindications, thus low morbidity.

Discussion : Several random sample surveys have been done in Montana with
resultant levels dt or near the 90% goal.

Accurate methods need to be developed to determine immunization status of
two year olds.

Resources are a major constraint in attaining this objective. Since
approximately 70% of all Montana children are immunized through their
private physician, major responsibility of attaining this objective falls
on the private physician.

*****

Objective 4 : By 1990, 97% ot children in licensed day care and kindergartens
through grade 12 should be fully immunized and 100% should be in compliance with
state law.

Rationale : This is ranked high because the Legislature and health offi-
cials regard immunizations as imperative for protecting the children of
Montana. In addition, day care facilities and schools provide access to
immunization record audits to identify incomplete records.

Discussion : Annual random surveys currently conducted reflect at least 90%
of all children in day care and kindergarten through 12th grade are fully
immunized.

The attainment of this objective depends on the cooperation of public and
private health providers. There is a need to educate health providers
about Montana irnmynization regulations, recommended schedules, and report-
able diseases.

*****

Objective 5 : By 1990, an immunizable disease repi^rting/survei 1 lance system
should be in place with 100 percent of reported, suspected and confirmed cases
logged and investigated within 24 hours as appropriate.

25



Rationale : The purpose of this objective is to implement a system to

control outbreaks of disease. A high ranking is assigned because it is

imperative that control measures be established to interrupt the "chain of
transmission of disease."

Discussion : Currently, a predominantly passive surveillance system exists

in Montana. This system has identified wery low levels of morbidity of
these vaccine preventable diseases.



An accurate surveillance system needs to be established at
levels in order to help verify if these low morbidity levels
or not.



local health
are accurate



or not



Execution will require a greater effort by local public health departments
in order to complete investigations within 24 hours.



26



SEXUALLY TRANSMITTED DISEASES

Summary of the Problem:

Nationally, over 10 million cases of sexually transmitted diseases (STD) occur
annually, 96 percent of them in the I5-to-29 year olds. The most comrion STDs
are trichomoniasis, gonorrhea, non-gonococcal urethritis, genital herpes, and
syphilis. In 1950 tht reported syphilis rate was 146 per 100,000. The rate
decreased to 30 per 100,000 by 1978, resulting in approximately 30,000 new cases
of syphilis per year. During the same time span the gonorrhea rate increased
from 192 casts per 100,000 to 463 cases per 100,000. In each j^ear between 1967
and 1976, reported Cases of gonorrhea incrtased between 10 and 15 percent.
Between 197b and 1978 the annual increase was less than 1 percent; but the toial
number of cases of gonorrhea still exceeded 2.5 million. In addition to the
large number of syphilis and gonorrhea tases, 3 million cases of trichomoniasis,
2.5 cases of non-gonococcal urethritis, and 500,000 cases of genital herpes
occur annually. The most serious complication caused by sexually transmitted
agents are pelvic inflammatory disease, sterility, infant pneumonia, infant
death, birth defects, and mental retardation.

Montana experiences the same problems as the national statistics address but
maybe not at the same levels. The problems of control and complication from
these diseases are no different.

There is clear evidence that both the quality- of the services and the attitudes
with which they are delivered are important in attracting those who need STD
services. While existing programs are interrupting the transmission of syphilis
and gonorrhea, many vulnerable groups may not yet be adequately served. To
approach them effectively will r-equire not only the efforts of STD clinics and
investigators, but also those of family planning clinics, private physicians,
diagnostic and public health laboratories, and schools and other educational
institutions.



27



SEXUALLY TRANSMITTED DISEASES

Priority Objectives

Objective 1: By 1990, reported gonorrhea incidence should be reduced to a rate
of 130 cases per 100,000 population.

Objective 2: By 1990, reported incidence of gonococcal pelvic inflammatory
disease (GPID) should be reduced to a rate of 10 cases per 100,000 females.

Objective 3: By 1990, reported incidence of primary and secondary syphilis

should be maintained to a rate of 2 cases per- 100,000 population per ytar, with

less than 1 case per 100,000 of congenital syphilid in children under 1 year ot
age.

Objective 4: By 1990, Q^Qvy public school system will provide STD health
education as part of the school curriculum beginning no later than 7th grade.

Objective 5: By 1987, at least 95 percent of health care providers seeing
suspected cases of sexually transmitted diseases should be capable of diagnosing
and treating all currently recognized sexually transmitted disease.

Other Objectives

Objective 6: By 1990, the incidence of serious neonatal infection due to
sexually transmitted agents, especially herpes and chlamydia, will be reduced.

Objective 7: By 1990, all public health clinics will provide treatment and
contact referral for persons infected with non-gonococcal urethritis.

Objective 8: By 1990, the proportion of persons aware of the protective value
of condoms will be increased.

Objective 9: By 1990, data should be available in adequate detail (but in
statistical aggregates to preserve confidentiality) to determine the occurrence
of non-gonococcal urethritis, genital herpes and other sexually transmitted



diseases in each local area, and Co recommend approaches for preventing sexually
transmitted diseases and their complications.

Objective 10: By 199C, surveillance systeniS should be sufficiently' improved so
that at least 50 percent of sexually transmitted diseases diagnosed in medical
care facilities are reported, and that uniform definitions are used nationwide.



29



SEXUALLY TRANSMITTED DISEASES

Objective 1 : By 1990, reported gonorrhea incidence should be reduced to a rate
of 130 cases per 100,000 population.

Rationale : The primary concern is the consequences of sexually transmitted
diseases for infants, fetuses and women. Tiie reduction of the reservoir of
gonorrhea eventually will lessen the risks to these groups.

Discussion : Reported morbidity is an indicator of morbidity, not an actual
count. As with other sexually transmitted diseases, the exact degree of
underreporting is unknown, but thought to be significant. With help from
private physicians, it is anticipated that reporting will improve.

Morbidity is not evenly distributed through the population. High risk
groups can be identified by age, sex, geographical location and ethnicity.
Identification of such risk groups, and working with numbers of those
groups to develop eaucatiunal and service programs, should be a promising
strategy.



Objective 2 : By 1990, reported incidence of gonococcal pelvic inflammatory
disease (GPID) should be reduced to a rate of 10 cases per 100,000 females.

Rationale : GPID is a cduse of undesired infertility and poor outcome of
pregnancy which are the most common serious complications of gonorrhea in
females.

Discussion : Most GPID cdses are seen by private physicians (usually in
emergency rooms in hospitals). Timely treatment of gonorrhea can prevent
GPID. Most females are asymptomatic until the development of GPID clinical
symptoms appear. A majority of GPID females have been infected by asymp-
tomatic males, or by identified and treated symptoniatic males where no
follow-up of contacts was initiated. The best strategy is to prevent the
disease in the first place. Also, by reducing the reservoir of gonorrhea,
the incidence of late complications will be reduced. Public health re-
sources will be applico to attempt to counsel infected persons with a focus
on the treatment of contdcts and the prevention of reinfection with
gonorrhea.

• • * * *

Objective 3 : By 1990, reported incidence of primary and secondary syphilis
should be maintained to a rate of 2 cases per 100,000 population per year, with
less than 1 case per 100,000 of congenital syphilis in children under 1 year of
age.

Rationale : Congenital syphilis is a preventable condition.

Discussion : Improved case finding and better reporting will raise the
reported incidence of primary and secondary syphilis. In the long run,
however, they will reduce actual incidence. The workgroup expects to see
the reduction by 1990.

30



Professional and public education are major strategies in the reduction of
the incidence of syphilis.



*****



Objective 4 : By 1990, every public school system will proviat CTD health
education as part of the school curriculum beginning no later than 7th grade.

Rationale : The focus is on school systems rather than students, since it
may be more feasible to monitor junior and high school curricula.

Discussion : Inclusion of STP health education into school curriculum is
important for prevention.



* * * *



Objective 5 : By 1987, at least 95 percent of health care providers seeing
suspected cases of sexually transmitted diseases should be capable of diagnosing
and treating all currently recognized sexually transmitted disease.

Rationale : Detection of sexually transmitted disease is important for the
health of the pregnant woman and the newborn.

Discussion : As improved laboratory testing becomes available monitoring
herpes infections among women should improve.



31



HEALTH PROTECTION

Toxic Agent Control

Occupational Safety ana Health

Accident Prevention ana Injury Control

Oral Health

Surveillance and Control of Infectious Diseases



32



TOXIC AGENT CONTROL



Suiraiidry of the Problem:

Toxic compounds can have diverse, serious effects. Exposure to toxic chemicals
or physical hazards can produce chronic lung disease, developmental impairment,
cancer, chronic degenerative diseases, neurological changes, and immunologic
diseases.

If high exposure causes serious disease, the same ill effects may occur in
people exposed to much lower duses over a long period. The most widely dis-
cussed effect of hazardous substances is cancer. Research has suggested that 90
ptrcent of human cancers are due to environmental factors, but usually include
factors of diet, alcohol and cigarette smoking.

It is estimated that of the four million chemical compounds which have been
synthesized or isolated from natural materials, more than 55, COO are produced
commercially. Over Z,000 chemicals are suspected carcinogens in laboratory
animals, with epidemiologic studies suggesting that 25 of these chemicals are
carcinogenic in humans.



33



TOXIC AGENT CONTROL



Priority ObJectivfeS

Objective 1: By 1990, virtually all wastewater management or process water
systems established after 1980 should be in substantial compliance with Montana
surface and ground water quality standards and/or federal effluent guidelines.

Objective 2: By 1990, virtually all of Montana's community public water systems
should meet Federal and State standards for safe drinking water.

Objective 3: By 1990, virtually all Montana communities should be meeting all
Montana and federal primary ambient air quality standards.

Objective 4: By 1990, all hazardous waste treatment, storage and disposal
facilities in Montana will be licensed.

Objective 5: To refine present monitoring efforts within the environmental
sciences division and continue to coordinate and incorporate these efforts
through 1990.

Other Objectives

Objective 5: Through 1990, continue to contribute scientific monitoring data to
federal data storage systems.

Objective 7: By 1990, at least half of all Montana adults should be able to
accurately report an accessible source of information on toxic substances to
which they may be exposed.

Objective 8: By 1990, at least half of all Montanans 15 years and older should
be able to identify the major categories of environmental threats to health and
note some of the consequences.



34



Objective 9: By 1990, at least 70 percent of Montana's primary care physicians
should be able to identify the principal health consequences of exposure to each
of the major categories of environmental threats to health.

Objective 10: By 1990, at least 90 percent of Montana children identified with
lead toxicity in the to 5 age group will have been brought under medical and
environmental management.

Objective 11: By 1990, Montanans should have access to an acute cure facilit>
with the capability to provide or make referrals for screening, diagnosis and
treatment of suspected exposure to toxic agents.

Objective II: By 1990, Montanans residing in an area of a population density
greater thati 20 per square mile, or an area of particularly high risk, should be
pr'ctected by an early warr,ir;g system to detect environmental hazards posing
serious imminent health threats.

Objective 13: By 1990, e^ery populated area in Montana should be reachable
within 6 hours by an emergency response team in the event of exposure to an
environmental hazard posing an acute health threat.

Objective 14: By 199C, at least 75 percent of all Montana city council members
in urban communities should be able to report accurately whether the quality of
their air and water has improved or wcrstnea over the decade and to identify the
principal substances of concern.

Objective 15: By 1990, Montana should develop contingency plans (regarding


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