questions

County Health Department

555 Main Street

Littletown, State 99999

Phone: (555) 123-7654

TABLE OF CONTENTS

Introduction………………………………………………………………………………..……….1

County Demographics………..…………………………………………………………………2

Physical Health and Safety…………………………………………………………………….3

Substance Use and Mental Health………………………………………………………12

Maternal and Child Health………………………………………………………………….14

Environment and Health…………………………………………………………………..16

Special Section: Air Quality in Littletown………………………………….18

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INTRODUCTION On behalf of the County Health Department and County Board of Health, we are pleased to present the Community Health Assessment Annual Report. The data contained in this report provides valuable information for county offices, community and health organizations, and businesses in prioritizing community health needs and develop strategies for improving the health of our community.

This report was developed in collaboration with local medical and health care facilities, community stakeholders, and partner organizations across the county. The data in this report includes priority areas identified for the county:

• Physical Health • Substance Use and Mental Health • Maternal and Child Health • Environment and Health • Health disparities

The comprehensive data included in this report was a collaboration between the County Health Department and Bismarck Health Systems. We wish to thank all community members who responded to surveys, school districts for participating in data collection, and local health and medical organizations for supporting this assessment.

Alexa Phillips, MD, MPH Steve Burke, MBA Director Chairman County Health Department County Board of Health

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COUNTY DEMOGRAPHICS According to the 2020 US Census, the total population of the county is 23,495 which is a 3% increase from 2010. Among residents, 50% are female, 49% are male, and 1% are non-binary.

AGE The median age is 44 years old. Over a quarter (27%) of residents are young people, age 24 or younger

Total Population by Age Groups 0-4 5-17 18-24 25-34 35-44 45-54 55-64 65+ County 4% 13% 10% 11% 12% 17% 14% 19% State 6% 18% 10% 12% 13% 15% 12% 14% United States 7% 18% 10% 13% 14% 15% 12% 13%

RACE AND ETHNICITY

In the county, 73% of residents identify as white, 15% black or African American, 7% as Asian or Pacific Islander, 5% as other or multiple races. Approximately 11% of residents identify as Hispanic or Latino.

EDUCATION Among adult residents 25 years or older, 88% have a high school diploma (or equivalent) or higher, and 19% have a college degree or higher. Approximately 12% of adult residents do not have a high school diploma or equivalent.

INCOME AND EMPLOYMENT The median income in the county is $46,210. Approximately 13% of residents live below poverty; 36% live below 200% of poverty (income less than 2 times poverty, also defined as “low income”). The unemployment rate in the county is 4%, including residents that are jobless, looking for jobs, and available for work.

0 10 20 30 40 50 60 70 80 90

White Black or African America

Asian or Pacific Islander

American Indian or Alaska Native

Two or more races Hispanic or Latino

County State

PHYSICAL HEALTH AND SAFETY HOSPITALIZATIONS

In the past year, there were 3,759 hospitalizations in the County. Overall, heart disease accounted for most (18%) of hospital diagnoses, followed by COVID-19, and injuries and poisonings.

• Among residents under 18 years old, the majority of hospitalizations (72.4%) are among newborns and neonates, followed by diagnoses of injury and poisoning (5.7%), pneumonia (4.5%), psychosis (3.0%), and asthma (3.0%).

• 31.3% of hospitalizations among residents age 18-44 were females with deliveries, with other top diagnoses including psychoses (10.8%), injury and poisoning (9.6%), intervertebral disc disorder (2.8%), and heart disease (2.7%).

• The top leading diagnoses of hospitalizations for residents age 45-64 include heart disease (13.6%), injury and poisoning (10.5%), COVID-19 (7.2%), psychoses (4.8%), and osteoarthritis and allied disorders (3.3%).

• Among residents 65 years and older, top diagnoses of hospitalizations included heart disease (24.8%), COVID-19 (20.5%), injury and poisoning (10.3%), osteoarthritis and joint disorders (10.4%), and chronic bronchitis (3.5%).

677

563

359

272 241

158 116 112 105 99

0

100

200

300

400

500

600

700

800

Top 10 Leading Diagnoses of Hospitalization Heart Disease

COVID-19

Injury and poisoning

Newborns and neonates Females with deliveries Psychoses

Joint, muscular, and vertebral disorders Chronic bronchitis and asthma

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MORTALITY

In the past year, there were a total of 243 deaths in the county. The number of deaths for the top ten causes of death are shown for the county and state.

Cause of Death County (Population=23,495)

State (Population=3,156,890)

Chronic Liver Disease and Cirrhosis 3 644 Kidney Disease 5 833 Alzheimer’s Disease 9 1017 Diabetes Mellitus 7 1089 Cerebrovascular Disease 10 1256 Chronic Lower Respiratory Diseases 12 1651 Unintentional Injury 10 2169 COVID-19 31 4943 Heart Disease 45 6731 Cancer 48 7767 Other causes 54 3528 Total Deaths 234 28100

• The average life expectancy of residents in the County is 78.6 years overall, but lower for

American Indian/Alaskan Native (73.7) and African American/Black (73.9) compared to White (80.2), Hispanic (82.1), and Asian (87.4) residents.

• Mortality among female residents (576.2 per 1000,000) is lower compared to male residents (827.9 per 100,000).

• Cancer remains the top cause of mortality in the County following by heart disease and COVID-19.

• Among mortality due to cancer, most common sites including lung (56.3%), colon (14.5%), breast (12.5%), and prostate (8.3%).

• COVID-19 moved from the second leading cause of mortality in the previous year to the third leading cause for this year.

• The County has a higher mortality rate for almost all leading causes of death compared to the State with notable exceptions of chronic lower respiratory disease, cerebrovascular disease, and Alzheimer’s disease.

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CHRONIC DISEASE Chronic diseases include conditions that last one year or more and are the leading causes of death in the U.S. (pre-COVID-19 pandemic). According to the Centers for Disease and Prevention (CDC), 6 out of 10 adults have a chronic disease. These conditions may require ongoing healthcare services and can negatively impact quality of life. Most chronic diseases can be prevented or managed through lifestyle and behavioral change, and many of these share similar risk factors (poor nutrition, inadequate physical activity, smoking or tobacco use, excessive alcohol use). Other factors that increase risk of chronic diseases include age, sex, family history, and socioeconomic environment. In the County, racial, ethnic, and socioeconomic disparities impact prevalence of chronic disease, access to health care, and use of services. The following chronic conditions were selected as indicators of population health for the County based on top health need, hospitalizations and health care services, and mortality.

Cancer

• In the past year, there were 218 new cancer diagnoses in the County. The top five most common cancer diagnoses were breast cancer (79 diagnoses), lung cancer (43 diagnoses), skin cancer (27 diagnoses), prostate cancer (19 diagnoses), and colorectal cancer (18 diagnoses)

• Risk Factors: The highest risk factor for cancer is age, with over half of new diagnoses occurring in adults over 65 years of age. Other risk factors include smoking, obesity, environmental exposure, and family history. Among all new diagnoses of lung cancer, 39 were among current and former smokers compared to 4 new diagnoses among residents that never smoked.

• Disparities: African American/Black residents have the highest cancer mortality rate compared to residents of other races or ethnicities. African American/Black males are 1.5 times more likely to be diagnosed with prostate cancer and 2.5 times more likely to die from prostate cancer compared to white residents. Non-Hispanic white females are slightly more likely to be diagnosed with breast cancer compared to other races/ethnicities, but African American/Black females are more likely to die from breast cancer compared to other race/ethnicities races.

Preventive screenings

Females age 21-29 years: a Pap test every 3 years; Females 30+: combined Pap and HPV test every 5 years

Regular screenings for colon cancer at age 45, with more regular screenings for those with family histories

Starting at age 45 years, females should have a mammogram every year

Indicators 21% of County adults females have never had a pap smear

26% of County residents age 45-74 have never been screened for colon cancer

Among County female residents age 45-74, 17% have never had a mammogram

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Heart Disease and Stroke

• Heart disease was the second leading cause of death in the County. Men had a 67% higher heart disease rate compared with women.

• Older adults (≥65 years old) had higher rates of heart disease, hypertension, and high cholesterol compared to younger residents.

Number and percent of residents with cardiovascular conditions

<65 years old (N=19,031)

≥65 years old (N=4,464)

Angina or congestive heart disease 381 (2%) 357 (8%) Congestive heart failure 571 (3%) 402 (9%) High blood pressure 3997 (21%) 2812 (63%) High cholesterol 4377 (23%) 2500 (56%) Heart attack or myocardial infarction 761 (4%) 670 (15%) Stroke 382 (3%) 312 (7%)

• Risk Factors: Age is the highest risk factor for heart disease. Among 45 deaths from heart disease in the past year, 39 (87%) were among residents age 65 and older. However, other risk factors including smoking, obesity, and family history are also significant risk factors.

• Disparities: Significant race/ethnic disparities in heart disease and related conditions have been identified in the County. Black/African American residents have a 1.3 times higher rate of stroke and 1.5 times higher rate of death related to hypertension compared to white residents. Residents with poverty-defined income levels had higher rates of hypertension (35%) compared to residents with income above poverty level.

Target goals Reduce proportion of adults with hypertension to 27%

Increase proportion of adults who have had their blood cholesterol checked in the past 5 years to 82%

Decrease proportion of adults with high total blood cholesterol (TBC) to 14%

County 26% of adults have been diagnosed with hypertension/high blood pressure

61% of residents have had their blood cholesterol check in the past 5 years. 24% have never had a cholesterol screening

29% of adults have been diagnosed with high cholesterol

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Diabetes

• In the County, 9% of adults have been diagnosed with type 2 diabetes, increasing to 22% among adults 65 and older. Three percent (3%) of adults have been diagnosed as pre- diabetic.

• Risk factors: Type 2 diabetes is largely preventable, and risk include obesity, sedentary lifestyle, family history, and age over 45 years. Additionally, heart-related conditions also increase risk. Among residents with diabetes, 84% had high blood pressure and 83% had high blood cholesterol.

• Disparities: Black/African American residents were two times more likely to have been diagnosed with type 2 diabetes compared to white residents. Lower income is associated with higher rates of type 2 diabetes.

Number and percent of adult residents diagnosed with type 2 diabetes

Men (N=9,555) Women (N=9,751)

White, non-Hispanic 497 (8%) 444 (7%) Black/African American, non-Hispanic 201 (15%) 191 (14%) Hispanic/Latino 103 (12%) 105 (12%) Asian/Pacific Islander 60 (9%) 48 (7%) American Indian/Alaska Native 48 (10%) 54 (11%)

Asthma

• In the County, 15% of adults and 10% of children (<18 years old) have been diagnosed with asthma.

• Littletown has a higher rate of asthma compared to the rest of the County.

Number and percent of residents with diagnosis of asthma Children (<18 years old) Adults (≥18 years old) Littletown (N=5,675) 123 (12%) 884 (19%) Rest of the County (N=17,820) 272 (9%) 2070 (14%)

• Risk factors: Known risk factors for asthma include having a parent with asthma,

sensitization to irritants and allergens, respiratory infections in childhood, environmental exposure to irritants and pollution, and obesity.

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• Disparities: Low income and racial/ethnic minority populations experience highest disparities in rates of asthma. Adult women and children also have higher rates of asthma. Additionally, residents with specific occupational exposures may be more likely to be diagnosed with asthma.

• In response to public concern regarding potential exposure to pollutants from the Chemade Manufacturing Plant in Littletown, a screening program for childhood asthma has been initiated through the local school district. Preliminary data from a sample of 200 students has been compared to diagnostic findings from the Littletown Medical Center

Results of asthma screening compare to diagnostic test results Asthma+ Asthma- Screening+ 16 69 85 Screening- 8 107 115 Total 24 176 200

INJURY AND POISONING

Injuries and poisonings include both intentional and unintentional harm to the body. The most common types of unintentional harm include poisonings, motor vehicle accidents, and falls. Intentional injuries include those that result from self-inflicted injury, suicide, and homicide.

• Rates of adverse events and poisoning deaths related to prescription misuse and non- prescription use of opioids increased in the past year.

• Firearms were the main cause of suicide and homicide deaths.

Leading causes of morbidity and mortality by injury and poisoning Injury Deaths Unintentional falls 932 1 Motor vehicle accidents 113 4 Self-inflicted injury, including suicide 56 1 Unintentional Poisoning, including opioid misuse 49 3 Homicide -- 1 Total 1150 10

• Risk factors: Older age is the primary risk factor for unintentional falls, accounting for 87% of all fall-related injury. Younger residents, age 18-24, are at higher risk for motor vehicle accidents, self-inflicted injury, and unintentional poisoning.

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• Disparities: Residents with mental health and substance use disorders have disproportionately higher rates of injury, specifically self-inflicted injury and unintentional poisoning.

INFECTIOUS AND COMMUNICABLE DISEASE

Infectious disease outbreaks are monitored by the County Health Department, including over 80 diseases that are required to be reported to the State Health Department per the State Administrative Code. COVID-19 was the most commonly reported communicable disease for the second year in a row with a total of 3,615 cases reported in the past year. The most commonly reported communicable diseases after COVID-19 in the County continue to be sexually transmitted infections (STIs), including chlamydia, gonorrhea, and syphilis.

Number of residents with new diagnosis of selected communicable diseases by age group

<18 years old (N=3,994)

18-24 years old (N=2,350)

25-44 years old (N=5,404)

≥45 years old (N=11,747)

COVID-19 385 297 702 2,231 Chlamydia 35 80 91 23 Gonorrhea 23 38 48 12 Syphilis 3 6 9 1 Hepatitis C 17 33 29 15 Salmonella 10 4 7 14

Sexually Transmitted Infections (STIs)

• Chlamydia, the most common STI in the County (229 residents with a new diagnosis in the past year), is one of the major causes of infertility ectopic pregnancy, pelvic inflammatory disease, and chronic pelvic pain. Approximately two-thirds (67.8%) of cases were diagnosed among female residents, primarily due to screening during well women exams and prenatal visits.

• Gonorrhea is the second most common STI (121 residents with a new diagnosis this year). Syphilis cases were lower in the past year (19 cases) compared to the previous year (39 new cases), mainly related prevention efforts during the County syphilis outbreak. The County Health Department reported 4 new HIV diagnoses this year.

• Risk Factors: Primary risk factors for STIs include sexual intercourse without a condom, multiple sexual partners, and history of STI diagnosis. Younger residents are at increased risk for STI, and residents under 24 years of age accounted for over half of new chlamydia, gonorrhea and syphilis infections. Non-prescription drug use and misuse of alcohol also contribute to higher sexual risk behavior.

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• Disparities: Black/African American, Hispanic/Latino, and American Indian residents have

higher rates of STIs compare with white residents. STIs also disproportionately impact disadvantaged and lower income populations, particularly those with less access to health care. Sexual and gender minority residents have higher rates of STIs resulting from stigma and discrimination in health care settings, discomfort disclosing sexual behavior, and lack of appropriate health care services.

COVID-19

• The COVID-19 epidemic continues to impact the County community. In total, 6783 cases of COVID-19 and 293 COVID-related deaths have been reported. In the past year, there were 3,615 new COVID-19 cases and 31 deaths in the County.

• 3254 (90%) of new cases and 29 (93.5%) of deaths were among residents that had not been vaccinated.

• Risk factors: Residents at highest risk for serious illness or mortality due to COVID-19 infection in older individuals, those with asthma or chronic lung disease, immunocompromised, and individuals with diabetes, cancer or cardiovascular disease.

• Over 30 vaccine clinics were conducted in the past year. Vaccination rates for COVID-19 remain low for the County compared to State vaccinations.

HEALTH BEHAVIORS

More than half (57%) of County adult residents reported their health status as good or very good, and 16% reported their health as poor. Residents that were more likely to report their health as poor included those over 65 years of age (26%), had an income below poverty level (23%), diagnosed with type 2 diabetes (40%), had high blood pressure (33%), or had high cholesterol (30%).

82.3 54.3

22.1

89.2 67.9

34.5

0

50

100

At least one dose Fully vaccinated Booster dose

Percent of Population Vaccinated for COVID-19

County State

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Adult Health Behavior

Chronic disease risk among adults is associated with specific risk factors, including diet, exercise, and other behaviors.

Number and percent of adult residents reporting select health indicators Men (N=9,555) Women (N=9,751) Overweight 3440 (36%) 3315 (34%) Obese 2962 (31%) 2828 (29%) < 3 servings of fruits and vegetables per day (average)

1624 (17%) 1755 (18%)

>3 servings sugar-sweetened beverages per day (average)

2293 (24%) 1852 (19%)

<30 minutes of vigorous exercise at least 3 times per week (average)

4109 (43%) 4973 (51%)

Smoking, current 2198 (23%) 1657 (17%)

Adolescent Health Behavior

• Among youth 12-17 years old, 15% are overweight and 15% are obese. 54% reported using strategies to lose weight, including exercise (47%), lowering calorie intake (31%), fasting for 24 hours or more in past 30 days (7%), using non-prescription diet pills, powders, or liquids (6%), vomiting or using laxatives (2%).

• Over a quarter (27%) watched 3 or more hours of television per, and 44% reported 3 or more hours daily of total screen time, including computers, tablets, and video games.

• Most (54%) adolescents were physically active, including vigorous exercise or activity for at least 60 minutes, 5 times per week.

• 7% of adolescents currently used tobacco products.

SUBSTANCE USE AND MENTAL HEALTH

SUBSTANCE USE

Alcohol consumption

• Heaving drinking is associated with health risks, including liver damage, cancers, and untreated mental health disorders.

• Adults consumed 3.6 drinks on average in the past month; adolescents consumed 2.7 drinks on average in the past month.

• Binge drinking is defined as 5 or more alcoholic beverages on a single occasion.

• Among current adult drinkers, 16% reported drinking alcohol while on prescription medication.

• Among adolescents, 19% reported riding in a vehicle driven by someone who had been drinking alcohol in the past 30 days.

Recreational Drug and Prescription Medication Misuse

• 15% of adults and 5% of adolescents used medications not prescribed to them or they took more than prescribed to feel good, high, or more active.

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• 18% of adults and 21% of adolescents used recreational drugs in the past 30 days, including marijuana, cocaine, heroin, inhalants, LSD, ecstasy, opioids, and methamphetamines; among all recreational drug use, marijuana was the most common used (76% among adult drug users and 85% among adolescents).

Number and percent of residents using recreational drugs and/or prescription medication misuse Adults(N=19,306) Adolescents (N=1,645) Misused prescription drugs, past 30 days

2896 (15%) 82 (5%)

Recreational drug use, past 30 days

3475 (18%) 345 (21%)

Recreational marijuana use, past 30 days

2509 (13%) 296 (18%)

Non-prescription or misuse of opioids, past 30 days

2317 (12%) 33 (2%)

MENTAL HEALTH

One in ten County residents reported having 8-29 days in the past 30 days when their mental health was not good. Mental health is a concern across all age groups, but younger adult residents (age 18-44) were more likely to be seen at a health care facility for a mental health disorder (28% vs. 13% among adults 45 and over).

Percent and number of diagnoses of select mental health disorders by age group Children

(age 5-11), N=1,410

Adolescents (age 12-17), N=1,645

Adults age 18-44, N=7,753

Adults age 45 and older, N=11,748

Anxiety 24 (1.7%) 526 (32%) 1240 (16%) 1292 (11%) Depression 56 (4%) 461 (28%) 1706 (22%) 2232 (19%) Stress 0 (0%) 148 (9%) 465 (6%) 235 (2%) Post-traumatic stress disorder

0 (0%) 13 (0.7%) 233 (3%) 470 (4%)

Bipolar disorder 2 (0.1%) 16 (1%) 986 (13%) 1293 (11%) Schizophrenia 0 (0%) 0 (0%) 39 (0.5%) 47 (0.4%) Psychosis (episodic) 0 (0%) 16 (0.7%) 116 (1%) 106 (0.9%)

• 17% of adults and 22% of youth are taking medication for one or more mental health disorder.

• The County reported one death from suicide in the past year. However, 6% of adolescents and 2% of adults attempted suicide.

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MATERNAL AND CHILD HEALTH

PREGNANCY AND BIRTHS

• In the past year there were 253 live births out of a total of 345 pregnancies

• 71% of mothers took a multivitamin with folic acid during their pregnancy.

• Among all pregnancies, 4% of women smoked tobacco products, 3% used marijuana, 25%

experienced depression during pregnancy, and 6% experience domestic violence.

• Among all live births, 8% were born with low birthweight, weighing less than 5lbs 8oz, and 9% were born preterm.

Number and percent of birth types and early prenatal care by race/ethnicity Low

birthweight Preterm delivery

Cesarean birth

Early prenatal care

White, non-Hispanic 12 (7%) 13 (8%) 51 (31%) 141 (86%) Black/AfricanAmerican, non-Hispanic 5 (15%) 4 (12%) 14 (39%) 23 (64%) Hispanic/Latino 3 (10%) 4 (11%) 8 (29%) 16 (59%) Asian/Pacific Islander 1 (7%) 2 (11%) 5 (30%) 13 (72%) American Indian/Alaska Native 2 (16%) 2 (13%) 4 (31%) 8 (62%)

• Infant mortality in the past 5 years has been 8 per 1,000 live births in the County.

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CHILD HEALTH

• Breastfeeding was reported for children less than 3 months (17%), 4 to 6 months (12%), 7 to 12 months (4%), and more than one year (2%).

• 84% of children age 0-11 years visited their primary care provider for preventive care in the past year, and 77% of children age 19-35 months completed the series of recommended vaccinations

• 76% of children age 0-11 years old had a dental care visit in the past year.

• Among children age 0-11, 14% had more than one type of health condition

• 9% of children age 5-11 reported feeling so sad or hopeless almost every day for two weeks or more in a row that they stopped doing usual activities

Number and percent of social factors among children, age 5-11 Male

(N=691) Female (N=719)

Currently participating in extracurricular activities 532 (77%) 597 (83%) Bullied (past year) 145 (21%) 101 (14%) Experienced 3 or more adverse childhood events (ACEs) 76 (11%) 108 (15%)

Number and percent of select health diagnoses among children, age 0-11 Male

(N=1,266) Female (N=1,318)

Asthma 152 (12%) 105 (8%) Attention Deficit Disorder (ADHD/ADD) 139 (11%) 53 (4%) Autism or Autism Spectrum Disorder 38 (3%) 7 (0.5%) Development delay 101 (8%) 79 (6%) Learning disability 51 (4%) 13 (1%) Speech or language delay 127 (10%) 66 (5%)

ENVIRONMENT AND HEALTH

Outdoor Air Quality

Poor air quality contributes to adverse health, including asthma and other respiratory diseases. The Air Quality Index (AQI), monitored by the U.S. Environment Protection Agency (EPA), characterizes the outdoor air quality at a given location. As the AQI increases, and increasingly higher proportion of the population is likely to experience adverse health effects. AQI values are divided into ranges, and each range is assigned a descriptor and color code. AQI measurements for the county were available for 348 days in the past year.

Specific air pollutants of interest in the county include carbon monoxide (CO), lead (Pb), nitrogen dioxide (NO2), volatile organic compounds (VOC), and particulate matter smaller than 2.5 microns in diameter (PM2.5). The table and graph show emissions by identified source. Emissions of pollutants in the county are primarily attributed to mobile sources.

Indoor Air Quality

Most people spend the majority of their time indoors, and the quality of the air they breathe in indoor spaces can affect health as much as pollutants in outdoor air. Indoor air quality can be impacted by numerous sources in homes and businesses, including mold, dust, solvents and cleaners, carbon dioxide, pet dander, tobacco smoke, ambient chemicals, and lead. The state does not regulate indoor air quality and the county does not have policies for indoor air quality monitoring. While there are no federal standards for permissible exposures to pollutants such as mold, smoke, dust, or other contaminants, the EPA does have standards for permissible exposures to radon and lead, and the county has conducted studies to assess levels in residential homes.

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Radon. Radon is a naturally occurring air pollutant resulting from uranium breaking down in soil, in which radon is emitted into the air as radioactive gas. Radon has been linked to increase risk of lung cancer. Radon levels of 4 pCi/L or higher are considered hazardous. The average county household has a radon concentration of 1.7 pCi/L which is considered a level that does not pose a significant health threat to residents. However, data collected and compared to geologic formations indicate greater potential for elevated indoor radon in specific zip codes within the county. A study of 2,110 home in the county found 53.6% had radon concentrations above 4 pCi/L, with 83% of these in Zone 1 zip codes.

Lead. Lead is a significant harmful environmental pollutant contributing to increased risk for multiple diseases, including high blood pressure, kidney disease, nerve disorders, cognitive dysfunction, and muscle and joint disorders. Babies and young children are at particular risk for lead poisoning that can result in developmental delay, reduced intelligence, behavioral problems, anemia, and liver and kidney damage. Lead-based paint found in older homes (pre-1950s) is the most significant source of lead exposure in the U.S. Paint removed or flaked away from surfaces can lead to airborne particles in homes that can be ingested through breathing or handling lead- infused dust. All Medicaid-enrolled children are required to have a blood test for lead between the ages of 1 and 2 years of age and recommended for all young children.

Age group Pre-1950s housing Tested for elevated blood lead level

Blood lead level ≥5μg/dL

Age 1 to 2 years 13.1% 37.1% 1.0% Age under 2-6 years 13.1% 28.7% 1.5%

Air Quality and Health

Respiratory illness is a common adverse health condition associated with poor air quality, including wheezing and coughing, shortness of breath, asthma attacks, exacerbated COPD, and lung cancer. Other conditions associated with air pollution include heart attacks and strokes, metabolic disorders, preterm and low weight birth, and susceptibility to infection.

Disparities. Air pollution and other air quality concerns are significantly associated with health. Individuals living in dense urban populations with higher concentrations of people living in poverty and people of color experience poorer air quality and are more vulnerable to related health conditions, primarily due to health disparities. Neighborhoods in close proximity to busy roadways and industrial areas are more likely to experience higher levels of air pollution

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Risk Factors. Populations at highest risk for pollution-related health conditions include pregnant people and fetuses, infants and children, people over 65 years old, individuals with existing lung conditions, and current or former smokers.

SPECIAL SECTION: AIR QUALITY ASSESSMENT, LITTLETOWN

The County Board of Health initiated an independent review of air quality following concerns about potential air pollutants resulting from a chemical plant (Chemade) in Littletown. Multiple reports of increased respiratory illness were reported by residents of Littletown to the County Health Department over the last 12 months. Two assessment studies were conducted:

• Case-control study comparing proximity between residence and Chemade using medical record data from the Littletown Medical Center of patients presenting with respiratory illness (cases) and patients presenting for routine exams or other conditions (controls).

• Ecological study using state health department environmental data on air quality compared to medical record data of respiratory illness from the Littletown Medical Center.

RESULTS Case-control study. The case-control study included 100 cases and 100 controls. Among cases, 46% lived within one mile of Chemade, and 31% of cases lived within the same area around Chemade. Individuals that lived within a mile of the chemical plant had a significantly higher odds of having a respiratory illness compared to residents that lived a mile or more away (OR=1.9, 95% confidence interval 1.06-3.38, p=0.03).

It was noted that the neighborhoods around the Chemade chemical plant had a disproportionately older population, a population more susceptible to health impacts from poor air quality. Data on respiratory illness and proximity to the Chemade plant were stratified by older and young residents.

Age ≥ 65 years old Age < 65 years old Proximity to Chemade Proximity to Chemade < 1 mile ≥ 1 mile Total < 1 mile ≥ 1 mile Total Respiratory illness

Yes 34 41 75 11 31 42 No 28 37 65 4 14 18

Total 62 78 140 16 45 60

Proximity to Chemade < 1 mile ≥ 1 mile Total Respiratory illness

Yes (cases) 46 54 100 No (controls) 31 69 100

Total 77 123 200

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Ecological study. Littletown has six neighborhood zones, defined by the Littletown City Planning Commission based on U.S. Census Tract. The Chemade chemical manufacturing plant is located in Zone 5, approximately 2 miles from the County Speedway Racetrack and 0.7 miles from Interstate 28 in the north region of Littletown (see map).

The state health department provided data on the 6-month average daily air quality (AQI measured in for each neighborhood zone. State air quality data were compared to total respiratory illness reported in medical records at the Littletown Medical Center for each neighborhood. The correlation graph compares air quality and total number of cases of respiratory illness over a six month period.

Neighborhood AQI, PM2.5 Respiratory Illness Population 1 23.1 68 1003 2 17.9 41 1012 3 9.6 19 802 4 36.3 123 998 5 41.4 117 973 6 6.7 27 887