MEETING PACKET APRIL 2018 APRIL 2018
i
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4n'FLOOR PubUcHean
I Prevent.Promote.Protect.
TEL. (978) 741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL health o,salem.com j
i Lr1RRY Rr1.MDIN,RS/REHS,CH(:),CP-FS
MAYOR HrA1A H AGENT
I
NOTICE OF MEETING
You are hereby notified that the Salem Board of Health will hold its regularly scheduled
meeting Tuesday,April 10, 2018 at 7.00 PM
City Hall Annex 120 Washington Street Room 313
MEETING AGENDA
do
1. Call to order -< I
2. Approval of Minutes
3. Chairperson Communications .
4. Public Health Announcements/Reports/Updates
a. PHN Report
b. Health Agent
c. Administrative
d. Council Liaison Updates
5. Update of Regulation 7 - Solid Waste
G. Recreational Marijuana
7. Board of Health program planning
• Kimberly Waller- Presentation on Health Department organizational models
8. New Business/Scheduling of future agenda items
• Items that could not be anticipated prior to the posting of the agenda
Larry Ra , Health Agent
cc: Mayor Kimberley Driscoll, Board of Health, City Councilors
Next regularly scheduled meeting is May 8,2018 at 7:00pm at City Hall Annex,
98 Washington Street, 1s'Floor Conference Room.
Know your rights under the open meeting law MGL chapter 30A ss. 18-25 and City
Ordinance section 2-2028 through 2-2033
This notice posted on "Official Bul t' oard'
City Hall, Salem, Mass. on APR 0
at 4,-,O? l in accordance with MGL Chap. 30A,
Sections 18-25.
CITY OF SALEM
BOARD OF HEALTH
MEETING MINUTES
February 13, 2018
I
MEMBERS PRESENT: Paul Kirby, Chair, Dr. Jeremy Schiller, Mary Lauby,Nancy Crowder, Kerry Murphy
OTHERS PRESENT: Larry Ramdin, Health Agent, Suzanne Darmody, Public Health Nurse, Maureen Davis, Clerk
of the Board, Beth Gerard, City Council Liaison, Geri Yuhas, Mary Wheeler and Denny DesRosiers, Healthy Streets,
Michele Sweeney and her colleague Patrice DeLeon, Salem State University, Dr. Kimberly Waller, Salem State
University
TOPIC DISCUSSION/ACTION
1. Call to Order 7:02pm
N. Crowder motioned to take item`45out of order. Kerry Murphy
2"d. All in favor Motion passed.
2. Mary Wheeler and Denny M. Wheeler distributed##information sheets. Official start date of the
DesRosiers, Healthy Streets - syringe exchange prog am;Was,4 2/5/2017. To date; they have picked up
Syringe Service Program over 1-200 syringes and gave out over 1,000. The program uses home
delivery n dStreet outreach At;outreach, D. DesRosiers distributes
double-sided, fold ed`informationy sheets in plastic bags to keep them dry.
-There is a list;of the now�18,Syringe Service Programs across MA,
iincluding Salem. This is the only"advertisement" of the program. Most
T findout about the program through word-of-mouth. There is a core group
of fiveor six people they see every week, once a week. Eleven
r...
.individuals total Majority of clients being seen are white males.
`OvOrddse Ates havegone down to extremely low in Salem, so not many
Naloxone (Narcan),kifs`distributed. Door knocks have helped. Decline
in ODs,;likely duelo`users using safer after being educated but also
because allot of people have died.
1. Schiller asked if the numbers are better or worse than expected.
A:Wheeler said the number of people is about what was expected,but
thenumber of syringes being distributed is higher than expected.
E Kirby asked if they have received any additional funding.
M Wheeler said no extra funding, but DPH is very appreciative that they
started the program for us anyway.
D. DesRosiers feels education to users is very helpful. Keeps some
people out of the emergency room.
They distribute "clean kits"to those users who reuse needles. Show
people how to properly clean their syringes with bleach and water if they
do decide to reuse it. It helps to reduce infection and HIV, but the goal is
for them not to reuse needles. They are given extensive education to
inject in different sites to let their veins heal and how to wipe a site
properly.
D. DesRosiers also works with Officer Vaillancourt a couple of days a
week doing needle sweeps and letting users know the community is
supporting them. They,are caring and compassionate no matter what
stage users are in. They do follow-ups whether clients are actively using,
clean, etc. to show them that if they need anything at all they are there to
help them. They partner with Lifebridge where they go at lunchtime to
educate people and to see if anyone needs any help getting into detox
programs, distribute Narcan, etc. They also work with 13-15 chronically
homeless and pass out band-aids, razors or anything else they may need
disposed of properly.
J. Schiller noted we have received no negative impact from the program.
M. Wheeler said the goal with the state is to take in more syringes than
they give out.
P. Kirby told M. Wheeler to let us know if she feels we should change the
1-for-1 ratio and the Board will speak to Chief Butler at that time.
M. Lauby asked M. Wheeler if sh6'feels the problem will ever get better.
M. Wheeler said the numbers may lessen as people die,but she doesn't
really see it getting any better There just won't be as many people to use
the drugs. About half the''people they are seeing in Salem have birthdays
in the 1990s. Them is more imtiatibainto drugs through pill use.
People go right into'potent and fatal drugs:";There are"fake pills" out
there, which arejust pressed pure Fentanyl, etc, Very frightening.
P. Kirby noted that years ago#crack use lesseried,`but M. Wheeler said
now people are afraid-of Fdntanyl, so some are going back to smoking
and shootmgcrack cocaifieiiK
P. Kirby toldiM°:Wheeler to let us know how we can support them in any
way and thanked them,for their vbrk. He asked that she provide data
• --from both their work on the program'and also the work provided by
]J 'DesRosier's and O.M FVaillancouit.
=' M L'auby motioned to take item#6 out of order. Kerry Murphy 2nd.
AlLin favor. Motion,passed.
3. Michele Sweeney, Salemy State; r 'M: Sweeney prdyide&all with information on the program. The
University- Healthcare Studies> u4, Healthcare Studies',Program is a new program that was created to help
Program � studenisfwho were not strong in the sciences,but were interested in
healthcare ;The program started in the fall of 2016 with 30 students
enrolled. Now, one year later, 180 students are enrolled. The Healthcare
Seminar class lets students explore minors. Bachelor of Science Degree
in Healthcare Studies students complete a mandatory minor and also take
electives to support the major. It is structured so the student can go in
,_,.,...-many directions. 120 credits are required to graduate. Interns,juniors
and seniors, are currently interning in many companies. For example, an
intern can work at a company for five hours, twice a week to reach 120
hours. Students can also shadow at a site for three hours. Employers can
bring a problem to the student, and they will bring it into the classroom
for real-life experiences.
She would like to be able to educate her students on what the Board of
Health actually does.
L. Ramdin said the appointed Board of Health is the legal body. They
• oversee the big picture of public health on the policy side. The Health
Dept. is the operational side of the Board of Health. We implement their
policy, plus a lot of mandated requirements placed on us by the Dept. of
Public Health. He said we would be willing to partner with Salem State
whenever the opportunity works out for both sides and gave M. Sweeney
his business card.
M. Lauby said we are slowly working on a strategic plan for an overall
population health agenda, such as what services are available for Salem
and when and where are the services. There is no funding for those
projects.
M. Sweeney would like students to have an opportunity for projects
where leadership is involved.
P. Kirby stated he works for the Medicaid Agency and could also help out
with health policy opportunities.
J. Schiller pointed out there are,.-a myriad of options with the collaboration
of the City and the University P-
L. Ramdin said lots of people are not aware of what we actually do.
K. Murphy is meeting next week`,with Patricia Zaido for Salem for All
Ages and is also workingwith the Council on Aging and will be in touch.
M. Sweeneysaid she wanted to lant a- eed with us. Man of the
p Y
students are non elinical based. They reall -..love healthcare and their
6.;.Y:
interests are very diverse.
B. Gerard feels health policy §'I&eded around here. She has a Masters in
Health Policy and is currQntly,an analyst at Salem-Hospital, but her
background is,in policy 'Vl,it U.S. health policy vs. MA health policy,
MA is'leadiiig the way in so many ways. The MA Medicaid program is
the best in the country:
w, M. Sweeneyfeels the Board can only help enrich their programs by
• sharing our kn{6wledge aril will,helgthe students focus on what they want
to do,
µ - l0;minute break,-_�
k +-
16
r-i
4. Approval of Minutes'_ M Lauby m yv , to approve minutes. N. Crowder 2°d. All in favor.
(January 9, 2018)`µ Motion passed.
E
5. Chairperson Communications N;othing'to communicate.
6. Monthly Reports-Updates';
a. Public Health fi S, ody showed all a copy of the weekly report she receives from the
Nurse's Report state. The first pediatric death from the flu in MA was a 6-year old first
grader. Over 60 deaths nationally.
K. Murphy asked if there is any change in the effectiveness of the flu
vaccine.
S. Darmody said no, she has not heard of any change.
Copy available at the BOH office.
b. Health Agent's J. Schiller was asked by a couple of people about the HEPA vac on
Report sanders.
• L. Ramdin said Salem was built tight together. We had requests to
review the HEPA vac with sanding. Martin Fair, a former Board member
who was the Health Director in North Reading at the time, went out on
f
several occasions with people who wanted it reviewed and they were still
• getting a lot of sand and dust all over the place. Dust should not travel
across your property and must be contained within a specific area.
J. Schiller asked if our decision is based on data.
L. Ramdin said it is based on direct observation. Our BOH regulation
does not allow electric sanding on any exterior surfaces. We cannot
control the dust. It is based on the requirements of DEP air pollution
regulations, which we must enforce.
L. Ramdin reminded the Board to act on situations from a public health
standpoint and not because people are talking.
P. Kirby said it looks like the Health Dept. did a great job with the water
main break on Highland Avenue•and offered his thanks.
L. Ramdin said Pequot Highlands had no heat. He is working with the
junior engineer to find out`"why because backflows were working.
He gave a copy of the;budget to the'Board. He said he has been speaking
to Lisa in Human'Resources to change the Sanitarians' title to
r
"Bnviromnental'Health Specialist", a title that is more reflective of all the
work they do.
He requested a salary.�increase'for,himself. He.has a budget meeting with
the Mayor on March 8th He pointed out he has a lot of requirements with
his position"and he is just-asking for equity for comparable positions.
B. Gerard said with the budget,the Council votes only on what the Mayor
approves ,The Council can only subtract from what is approved, they
• cannot add anything L Ramdin puts-the increase amount in his budget
aridahe Board of Health can; and does, support it.
M Lauby asked'-El-Ramdin to-se: the Board the analysis.
B Gerard said the Mayor has been doing level funding,but they must
`. look at-:compansons in surrounding communities of comparable size.
He gave the-Board collies of overdose data. Most ODs are occurring at
fiome. Most areal a.40 years old.
~s Copy available at-the BOH office.
c. Administrative No comments/questions.
Report Copy available at the BOH office.
d. City Council B `Gerard welcomed Geri Yuhas to the Board.
Liaison Updates !{The plastic bag restriction is going well. Paper bags being used.
; ^Had first passage of recreational marijuana zoning. The Mayor had B1,
B2, BPD and industrial zoning. Planning Board added B4, B5, then it
went to Ordinances, Licenses and Legal Affairs and they took out B1 and
B2. Went to floor and B2 zoning was put back in. Buffer zones were
discussed. State says 500 feet from schools,but no more. Police Chief
Butler was concerned it would be concentrated to B5.
Amendments: funeral homes and houses of worship are included in the
500-foot buffer. A 1,000-foot buffer from Salem State will not pass
• because it is illegal.
Can have up to four licenses. The first license can't be issued until
July 1 st. Must have support from the neighbors around the facility.
The Cannabis Control Commission will have a hearing at North Shore
Community College on Friday afternoon.
Second passage at next Council meeting.
L. Ramdin wanted to discuss the Maitland Farm issue. The decision was
made not to grant them a variance or change the zoning. An ordinance
change was discussed. People can get an agricultural exemption for
commercial composting, but he did not have one.
The City agricultural regulation is over five acres. The State's regulation
is two acres. Maitland is looking to move the pickling operations there.
They need to be open about their true intentions so they can be guided
through the process. L. Ramdin feels information is being withheld.
There is a problem with the neighbors feeling blindsided.
Once you cut the produce, the matter moves from agriculture into food
safety realm. 'E
L. Ramdin spoke of an article_in-the Salem News about use of marijuana
in public and enclosed spaces there are concerns about nuisance orders,
especially in shared spaces. We need`to look at the regulations. He will
send the article to4he'Board.
Beverly banned smoking totally, not just tobacco.
Smoking clubs are:currently banned in Sale n.%People are permitted to
smoke in private clubs*,One community's proposal is to charge a$50.00
monthly�fee to have a private smoking club. Tliere.are several
implications to that. ±,
L. Ramdin saidthe,chief of theinspection bureau in Denver presented at a
professional.,association and soine-:of his concerns are whether or not high
• humidity rooms are going to cause secondary mold problems, etc. Some
'of.the soil being.used coritams fertilizer that are carcinogens and the
residue is showing up in the buds
We should not make'it appear as if we are creating regulations to prohibit
marijuana use
J Schiller motioned`to approve the reports. K. Murphy 2"1. All in
ti favor,`Motion passed.
7. Board of Health program i
planning
a. Discussion of FY 2019 P Kirby and K. Murphy met with the Mayor. She is aware of the
Health Department budget;;``"additional workload on the Department with the updated Certificate of
request ;.Fitness ordinance and the number of temporary pop-up food permits.
�s
The Mayor suggested outsourcing temporary rental (Air BnB, etc.)
inspections to contractors, at least temporarily until we get caught up.
She seemed supportive of our budget changes,but also seemed to want to
discuss the inspectional services model more. She said it would allow the
Health Dept. to focus on more health-related issues and take the
inspectional part away, allowing for more strategic planning, etc.
L. Ramdin said this is not about service delivery. The skill sets required
• to perform the specific jobs will remain the same.
P. Kirby said we should give the inspectional services model a hearing.
The inspectional services model was brought up about eight years ago
and the City Council voted it down.
J. Schiller agreed and said we need to get all the information we can.
K. Murphy said the Mayor wants us to get a steering committee together
with Kimberly Waller, Beth Rennard and one of the Board members to
investigate it.
L. Ramdin agrees the Board should consider it,but knows of places that
use that model and their directors have admitted to him that it is not
working, however they will not say so publicly because they don't want
to be fired.
b. Kimberly Waller-recap K. Waller passed out sheets showing an inspectional services department
meeting with Lynn Health proposed organizational chart and personnel structure. She said she can
Department on send the PowerPoint presentation to.the Board.
inspectional services model She met with Lynn and found the pros of the inspectional services model
to be lots of cross information and meetings, as well as one-stop services
for residents applying for;permrts 4One of the cons is that the Public
Health Division feels a little isolatedand feels like what they are doing is
quite different from other departments,',-.,
It took Lynn five to seven years to put together their inspectional services
division. They contracted out some services;and it worked very well.
They saw a lot of cost savings .
J. Schiller feels we need'-to:see snore information` ]He also feels we have
to approachlit with an open mind.
K. Waller would`_like to look at;.other communities, like Chelsea.
t f s
•8. New Business/Scheduling of K Waller will have,her presentation for the March meeting.
future agenda items
t
^X.
[ri
9. MEETING ADJOURNED: 4, J Schiller motionedto adjourn the meeting. K. Murphy 2°a
All`in favor ,Motion'passed.
9 34pm
Respectfully submitted, +
Maureen Davis {
Clerk of the Board
Next regularly scheduled meeting is Tuesday,March 13, 2018 at 7.00pm
At City Hall Annex, 120 Washington Street,Room 313, Salem, MA
•
• Suzanne Darmody RN BSN
Salem Board of Health
Public Health Nurse
Public Health Nurse Report
Reporting on February 7, 2018 through March 6, 2018
Disease Prevention and Health Promotion
• Investigated reportable diseases and reported case information to MDPH.
• Coordinating follow up with North Shore Pulmonary Clinic on tuberculosis cases.
• Continually recording and submitting refrigerator temperature logs, flu doses and clinic
information into the Massachusetts Immunization Information System(MIIS) for up to
date vaccine records and better continuity of care between clinics and providers.
• Posted Facebook, Twitter and Instagram posts regarding Flu prevention, the upcoming
Household Hazardous Waste Day in Beverly, Tick information and winter storm safety.
• Flu clinic at the Salem YMCA on Thursday February 8"during the after-school
programs, 5 vaccines given
• Participated in a region wide flu clinic in Danvers on Thursday February 8tn after Salem
• clinic which met Emergency Preparedness regional deliverable, 8 vaccines given.
The NSPHN's are planning to collaborate next flu season as well and hold clinics at our
local YMCA's together.
Meetings/Trainings
• Attended the Northshore Cape Ann Emergency Preparedness meeting on February 28th
for discussion regarding Emergency Preparedness deliverables and alert systems. A new
Emergency Dispensing Site coordinator has been hired to assist with updating our EDS
plans, in addition to a social media contractor.
• Attended the Salem Overdose and Awareness Prevention Coalition meeting on February
13"'for updates from stakeholders, including a presentation of the opioid data from the
Salem PD.
• Attended the Northshore PHN meeting on February 270'where we discussed flu clinics,
EP deliverables, the upcoming camp season and seminar we are hosting in April, as well
as several ongoing issues/concerns within our communities and upcoming opportunities
for programming and/or training.
• Held clinic at the Council on Aging February 28tn for blood pressure screenings and
health education with materials on hypertension and flu prevention and care at home. The
next session will be March 14tn
• The Working on Wellness grant funded discounted memberships for a second round of
• Weight Watchers for employees being held at the Council on Aging, there are 16
participants this round.
• Monthly Report of Communicable Diseases: February 2018
Disease New Carry Over Discharged/ Total#Of Running Total for
Reported Cases this Total for 2017
Closed Month 2018
Tuberculosis 0 2 0 2 2 2
(Active)
Latent 3 0 3 3 7 45
Tuberculosis*
Arbovirus* 0 0 0 0 0 0
Babesiosis 0 0 0 0 0 0
Calicivirus/No 0 0 0 0 0 4
rovirus
Campylobacte 0 0 0 0 0 8
riosis
Cryptosporidi 1 0 1 1 1 0
osis
Chikungunya 0 0 0 0 0 0
Dengue* 0 0 0 0 0 0
Ehrlichiosis 0 0 0 0 0 0
Enterovirus 0 0 0 0 0 0
Giardia 0 0 0 0 0 3
Group A 0 0 0 0 0 4
Streptococcus
Group B* 0 0 0 0 0 4
Streptococcus
Human 0 0 0 0 0 0
Granulocytic
Anaplasmosis
• Haemophilus 0 0 0 0 0 4
Influenzae
• Disease New Carry Over Discharged/ Total#Of Running Running
Reported Cases this Total for Total for
Closed Month 2018 2017
Hansen's 0 0 0 0 0 0
Disease
Hepatitis A 0 0 0 0 0 0
Hepatitis B* 0 0 0 0 0 1
Hepatitis C* 3 0 3 3 7 30
Influenza* 133 0 133 133 200 74
Legionellosis 0 0 0 0 0 1
Lyme 0 0 0 0 0 0
Disease*
(0) (0) (0) (24)
(Probable)
Malaria 0 0 0 0 0 0
• Measles 0 0 0 0 0 0
Meningitis 0 0 0 0 0 1
Mumps 0 0 0 0 0 0
(1 suspect)
Pertussis 0 0 0 0 0 2
Salmonellosis 1 0 1 1 1 7
Shigellosis 0 0 0 0 0 2
Streptococcus 0 0 0 0 0 5
Pneumoniae*
Varicella* 0 0 0 0 0 0
Vibrio 0 0 0 0 0 0
West Nile 0 0 0 0 0 0
•
Disease New Carry Over Discharged/ Total# Of Running Running
Reported Cases this Total for Total for
Closed Month 2018 2017
Yersiniosis 0 0 0 0 0 0
Zika Virus 0 0 0 0 0 0
Infection
Total 141 1 141 143 218 197
February 2018
*Notifications only, LBOH not required to follow up or investigation per DPH.
**Total reflects cases that have also been reported as suspect cases.
All Communicable disease totals above are subject to change in the event that the follow-up investigation
results in the revocation of the diagnosis.
Yearly totals for 2017 have been updated for year end with the number of CONFIRMED cases.
Summary of Current Communicable Diseases
Tuberculosis:
New arrival: I have been notified of a new arrival to the U.S. whom requires a PPD test indicated by the
Office of Immigration and Refugees. I coordinated with MDPH for PPD and an outreach worker to
provide translating assistance and completed Tuberculosis testing and have referred them to the
Northshore Pulmonary Clinic.
Active Case 1:
As part of the follow up contact investigation, all patients with positive PPDs (tuberculosis skin tests)
were referred to the NSMC pulmonary clinic for chest x-rays.This case had an x-ray suggestive of
Tuberculosis in conjunction with a large positive skin test. Medications and D.O.T. has been started 5
days per week. Sputum samples are pending final results for 60 days. However, the patient is smear
negative for acid fast bacilli and is not considered contagious. This patient will continue to be treated by
NSMC. D.O.T. and medication management has been continued until treatment in completed. A follow-
up chest x-ray showed improvement while on the Tuberculosis treatment. This patient continues to attend
their clinic appts however has been inconsistently compliant with D.O.T., I have reported my attempts
and follow up to MDPH as well as the nurse and doctors at the clinic.
A second round of contact testing is ongoing, 5 contacts have been re-tested and all results were negative,
4 others still.need to be tested but have been away for vacations.
Active Case 2: This case was diagnosed in the hospital and started on D.O.T. on January 1 lth. They
extrapulmonary tuberculosis (infection is not in the lungs)so there is no contact testing required as the
bacteria is not able to be airborne. I am seeing this patient Monday-Friday for medication management,
they are currently not working and are being followed by the pulmonary clinic and surgeon.
Cryptosporidiosis:
Case 1: This patient was reported and treated by their primary care physician and did not require
hospitalization. They were withheld from their care setting until symptoms resolved. They had no
contacts with similar symptoms. I went over proper precautions with the family and care setting to
prevent further spread as well as monitoring of symptoms in contacts. At this time there are no further
cases and this case is now closed.
Mumps:
Suspect case 1: This case was reported due to facial swelling. Before onset of swelling they were seen in
urgent care for flu symptoms and started on antivirals.Due to the nature of the swelling and likely
alternate diagnosis of flu this case remains suspect, test results are negative.
Salmonella:
Case 1: This case was hospitalized in Boston and discharged home after treatment. They are currently
formula fed and have no had any recent travel. I discussed at home precautions with mom and asked her
to monitor for symptoms within the household. They are recovered and no further cases have been
reported.
Suzanne Darmody RN BSN
Salem Board of Health
Public Health Nurse
Public Health Nurse Report
Reporting on March 7, 2018. through April 2, 2018
Disease Prevention and Health Promotion
• Investigated reportable diseases and reported case information to MDPH.
• Coordinating follow up with North Shore Pulmonary Clinic on tuberculosis cases.
• Continually recording and submitting refrigerator temperature logs, flu doses and clinic
information into the Massachusetts Immunization Information System (MIIS) for up to
date vaccine records and better continuity of care between clinics and providers.
• Posted Facebook regarding nutritious resources and recipes.
Meetings/Trainin2s
• • Attended the Northshore Cape Ann Emergency Preparedness meeting on March 28th for
discussion regarding Emergency Preparedness deliverables and alert systems. Submitted
final deliverable paperwork for this month. Meetings to be held with EDS planner and
social media contractor with individual community in the next couple months.
• Clinic at the Council on Aging March 141n for blood pressure screenings and health
education unable to be held due to snow day, next scheduled day is April 1 ltn
• Attended the Emergency Risk Communication in Practice Training on March 15tn which
provided training on how to best communicate with the community in time of
emergencies, it included PowerPoint slides, group questions and holding a practice press
conference.
• Sent all camp counselors information on applying for camp permits for the Summer 2018
season, including the application and list of required documents as well as the flyer for
the upcoming Camp Seminar we are having with DPH for the camps of the north shore in
Beverly on April 30"'
• Monthly Report of Communicable Diseases: March 2018
Disease New Carry Over Discharged/ Total#Of Running Total for
Reported Cases this Total for 2017
Closed Month 2018
Tuberculosis 0 2 0 2 2 2
(Active)
Latent 3 0 3 3 10 45
Tuberculosis*
Arbovirus* 0 0 0 0 0 0
Babesiosis 0 0 0 0 0 0
Calicivirus/No 0 0 0 0 0 4
rovirus
Campylobacte 0 0 0 0 0 8
. riosis
Cryptosporidi 0 0 0 0 1 0
osis
Chikungunya 0 0 0 0 0 0
Dengue* 0 0 0 0 0 0
Ehrlichiosis 0 0 0 0 0 0
Enterovirus 0 0 0 0 0 0
Giardia 0 0 0 0 0 3
Group A 0 0 0 0 0 4
Streptococcus
Group B* 0 0 0 0 0 4
Streptococcus
Human 0 0 0 0 0 0
Granulocytic
Anaplasmosis
• Haemophilus 1 0 1 1 1 4
Influenzae
• Disease New Carry Over Discharged/ Total#Of Running Running
Reported Cases this Total for Total for
Closed Month 2018 2017
Hansen's 0 0 0 0 0 0
Disease
Hepatitis A 0 0 0 0 0 0
Hepatitis B* 0 0 0 0 0 1
Hepatitis C* 3 0 3 3 7 30
Influenza* 21 0 21 21 221 74
Legionellosis 0 0 0 0 0 1
Lyme 0 0 0 0 0 0
Disease*
(0) (0) (0) (24)
(Probable)
Malaria 0 0 0 0 0 0
• Measles 0 0 0 0 0 0
Meningitis 0 0 0 0 0 1
Mumps 0 0 0 0 0 0
Pertussis 0 0 0 0 0 2
Salmonellosis 0 0 0 0 1 7
Shigellosis 0 0 0 0 0 2
Streptococcus 1 0 1 1 1 5
Pneumoniae*
Varicella* 0 0 0 0 0 0
V ibrio 0 0 0 0 0 0
West Nile 0 0 0 0 0 0
J
•
• Disease New Carry Over Discharged/ Total#Of Running Running
Reported Cases this Total for Total for
Closed Month 2018 2017
Yersiniosis 0 0 0 0 0 0
Zika Virus 0 0 0 0 0 0
Infection
Total 29 2 29 31 245 197
March 2018
*Notifications only,LBOH not required to follow up or investigation per DPH.
** Total reflects cases that have also been reported as suspect cases.
All Communicable disease totals above are subject to change in the event that the follow-up investigation
results in the revocation of the diagnosis.
Yearly totals for 2017 have been updated for year end with the number of CONFIRMED cases.
•
Summary of Current Communicable Diseases
Tuberculosis:
New arrival: I have been notified of a new arrival to the U.S. whom requires a PPD test indicated by the
Office of Immigration and Refugees. I coordinated with MDPH for PPD and an outreach worker to
provide translating assistance and completed Tuberculosis testing and have referred them to the
Northshore Pulmonary Clinic. Clinic appts has now been set and the patient has been notified.
Active Case 1:
As part of the follow up contact investigation,all patients with positive PPDs(tuberculosis skin tests)
were referred to the NSMC pulmonary clinic for chest x-rays. This case had an x-ray suggestive of
Tuberculosis in conjunction with a large positive skin test. Medications and D.O.T. has been started 5
days per week. Sputum samples are pending final results for 60 days. However,the patient is smear
negative for acid fast bacilli and is not considered contagious. This patient will continue to be treated by
NSMC. D.O.T. and medication management has been continued until treatment in completed. A follow-
up chest x-ray showed improvement while on the Tuberculosis treatment. This patient continues to attend
their clinic appts however has been inconsistently compliant with D.O.T., I have reported my attempts
and follow up to MDPH as well as the nurse and doctors at the clinic. Treatment is completing in April.
A second round of contact testing is ongoing, 5 contacts have been re-tested and all results were negative,
S4 others still need to be tested but have been away for vacations. 3 PPDs completed in the month of
March, one contact failed to be available for the reading and 2 others had negative results.
Active Case 2: This case was diagnosed in the hospital and started on D.O.T. on January I I"'. They
extrapulmonary tuberculosis(infection is not in the lungs) so there is no contact testing required as the
bacteria is not able to be airborne. I am seeing this patient Monday-Friday for medication management,
they are currently not working and are being followed by the pulmonary clinic and surgeon.
Acute Hepatitis C follow up:
I have been notified by DPH regarding two potential acute Hepatitis C cases. I have followed up with
both diagnosing providers. At this time,I have been contacted by one provider,their patient is almost
completed treatment and they have identified known risk factors,they were likely infected prior to 10
years ago. These cases do not have any known relation. Follow up is on going for the second case.
Haemophilis Influenzae:
Case 1: This case was not immunized due to their age,they are immunosuppressed due to an underlying
illness. Per MDPH the isolate was non-typable and close contacts did not need to receive prophylaxis.
Case report was completed and the case is now closed.
Group A streptococcus: This case follow up was completed by myself and an epidemiologist from
MDPH. They was not previously hospitalized during the incubation period and denied recent drug abuse,
this case was likely community acquired. They were hospitalized and treated. There are no known
• contacts with symptoms and no further cases. This case is now closed.
•
Health Agent report February 2018
Announcements/Update
• Geraldine Yuhas was confirmed unanimously by the City Council as a member of the Board
of Health and has taken her oath of office
• Dr. Jeremy Schiller was reappointed to the Board of Health, term ending February 22, 2021.
The appointment was confirmed by the City Council on February 22, 2018.
• The Operations Manual for Health Departments was completed and distributed to local
Health Departments in Beverly, Danvers, Lynn, Marblehead, Nahant, Swampscott, Peabody,
and Salem. The manual provides information on mandated activities of the Health
Department and was funded by the Northshore Shared Public Health Services. The manual
was developed by Janet Mancini and Larry Ramdin.
• I will be out of office on April 30 and Mayl attending NEHA Board of Directors meeting
• I will be out of office from June 25-29 as I will be attending NEHA Annual Education
Conference
Community Outreach
• The Northshore Shared Public Health Services is seeking to develop a community IPM
• plan that can be used to reduce the pest burden in the 8 communities.
Meetings and Trainings
• Meeting was held with principals of Mass Bay Colony Brewery and to discuss public
health implications of their operation and serving food/pop-ups. Elizabeth Gagakis and
Larry Ramdin did a walk thru of the proposed establishment to offer advice to the owner.
• I conducted an in-service training on use of a pH meter and measuring the pH of Sushi
rice with the environmental Health staff
• Janice Orta Attended FDA Foodborne Illness Investigations Workshop
• Elizabeth Gagakis was re-certified as a Certified Food Manager with the National
Restaurant Association
Environmental Health Activities
• Visited Pequot Highlands to determine cause of water loss from boiler with Engineering
Department and Weston and Sampson. The visit did not reveal any new information. The
loss may be attributed to a pressure loss in the system. Findings inconclusive.
• Larry Ramdin is working with the Palmer Cove Community Garden to address concerns
about the soils and I recruited Cornell University to assist.
•
• Inspections
Item Monthly Total 2018 YTD 2017 Total
Certificate of Fitness 56 118 383
Inspection
Certificate of Fitness 0 1 47
re-inspection
Food Inspection 16 42 249
Food Re-inspections 9 17 83
Retail Food 4 4 33
Inspections
Retail Food 1 1 14
re-inspection
• Temporary Food 2 2 249
General Nuisance 0 4 34
Inspections
Food— 0 1
Administrative
Hearings
Housing Inspections 4 14 99
Housing re- 2 5 46
inspections
Rodent Complaints 0 0 46
Court 1 3 4
Hearings/filings
•
Item YTD 2018 2017 Total
Trash Inspections 69 116 906
Orders served by 1 1 4
Constable
Tanning Inspections 0 0
Body Art 0 1 0
Swimming pools 0 0 22
Bathing Beach 0 0 123
Inspection/testing
Recreational Camps 0 0 6
Lead Determination 0 0 1
Septic Abandonment 0 0 2
Septic System Plan 0 0 0
Review
Soil Evaluation 0 0 0
Percolation tests 0 0 0
II
Total 165 287 2338
Health Agent Report March 2018
Announcements/Update
• Health Department and other offices housed at 120 Washington Street, City Hall Annex,
will be moving to 98 Washington as of April 17. The offices at 98 Washington Street will
open at noon on that day. The Health Department will be housed on the third floor.
• I had my budget meeting with the Mayor and Finance Dept. Staff on March 28. The
Budget hearing before the City Council Administration and Finance Committee will be
held on June 5, in the City Council Chambers.
Community Outreach
• I am continuing to work with the Community Gardens group on the Palmer Cove garden
and its further use.
Meetings and Trainings
• Environmental Health Staff attended Annual DEP seminar hosted by MHOA on March
28.
• Suzanne Doty and Larry Ramdin attended an "Emergency Risk Communication
Seminar" that was hosted by the HMCC. It is a deliverable for this year.
• Larry Ramdin attended a meeting a meeting of the Short term rentals working group, to
discuss developing policies relevant to short term residential rentals in Salem
Environmental Health Activities
• Meetings were held with the owners of 3 potential food establishments to discuss the
permitting procedure.
• Meetings were held with the owners of Bodega Retail Food store and we provided
information on the requirements for permitting. The owners provided all the required
information and a permit was issued.
• Larry Ramdin responded to an emergency request from the Police Department on a
property that had significant health violations that placed the resident at risk. The
occupant voluntarily vacated the house. The house was cleaned and occupant allowed to
re-occupy the premises.
Inspections
Item Monthly Total 2018 YTD 2017 Total
Certificate of Fitness 52 170 383
Inspection
Certificate of Fitness 0 1 47
re-inspection
Food Inspection 20 62 249
Food Re-inspections 8 25 83
Retail Food 6 10 33
Inspections
Retail Food 4 5 14
re-inspection
• Temporary Food 1 3 249
General Nuisance 5 9 34
Inspections
Food— 0 0 1
Administrative
Hearings
Housing Inspections 5 19 99
Housing re- 1 6 46
inspections
Rodent Complaints 4 4 46
Court 0 3 4
Hearings/filings
• Item YTD 2018 2017 Total
Trash Inspections 52 168 906
Orders served by 0 1 4
Constable
Tanning Inspections 0 0
Body Art 0 1 0
Swimming pools 0 0 22
Bathing Beach 0 0 123
Inspection/testing
Recreational Camps 0 0 6
•
Lead Determination 0 0 1
Septic Abandonment 0 0 2
Septic System Plan 0 0 0
Review
Soil Evaluation 0 0 0
Percolation tests 0 0 0
Total 157 444 2338
Health Dept. Clerical Report FY 8 0
Burial 5 rmits Certpermits Plan Reviews Fitness
$icate50 of
Copies / Fines Revenue Permit Fees
Jul -17 $900.00 $4,350.00 $630.00 $1,800.00 $300.00 $7,980.00 Food Service Est. <25seats $140
August $700.00 $1,670.00 $270.00 $1,500.00 $4,140.00 2s-99 seats $28o >99 seats $420
September $900.00 $4,530.10 $270.00 $2,350.00 $200.00 $8,250.10 Retail Food <l000sq' $70
October $1,225.00 $2,910.80 $540.00 $1,550.00 $6,225.80 1000-10,000 $28o >10,000 $420
November $1,075.00 $10,620.00 $90.00 $1,450.00 $50.00 $13,285.00 Temp.Food 13days s3s
December $825.00 $64,390.00 $0.00 $1,400.00 $900.00 $67,515.00 4-7 days s7o >7days s
January-18 Example of>7 day temp food permit.-
$1,625.00 $7,845.00 $180.00 $2,450.00 $1,600.00 $13,700.00 14(days)divided bY7=2 x s7o=$140
February $1,025.00 $1,695.00 $270.00 $4,100.00 $600.00 $7,690.00 Frozen Desserts $25
March $0.00 Mobile Food $210
April $0.00 Plan Reviews New s18o
May $0.00 'Remodel s90
June Catering s25 per event/s2oo
$0.00 catering kitchen
Body Art Est. $315
Total $8,275.00 $98,010.90 $2,250.00 $16,600.00 $3,650.00 $128,785.90 Body Art Practitioner s135
Review Plans s18o
Fiscal Year Budget 2018 Suntan Est. $140
Rec.Day Camp $10
Sala Starting Ending Expenses Ext.Paint Removal s35
Full Time $412,115.00 $180,815.77 Starting Ending Transport Off.Subst. s1o5
Part Time $43,354.00 $24,332.09 $32,500.00 $15,910.40 Tobacco Vendors $135
Overtime $5,800.00 $1,189.30 SwimminaPools Seasonal $140
Balance $461,269.00 $206,337.16 Health Clinic Revolving Account Annual$210 Nonprofit$40
$9,905.38 Title V Review s18o
Well Application s18o
Disposal works s2251i8o
•'
Breakdown of Permits and Fines
February 2018
Permit Description Total Permits Issued Permit Cost Total
Annual Food - Non-Profit 1 $25.00 $25.00
Annual Food - <25 seats 2 $140.00 $280.00
Annual Food -25-99 seats 1 $280.00 $280.00
Annual Food - Retail <1,000sq' 1 $70.00 $70.00
Food -Temporary Pop Up (1-3 days) 22 $35.00 $770.00
Body Art Practitioner 1 $135.00 $135.00
Burial Permit 41 $25.00 $1,025.00
Certificate of Fitness 82 $50.00 $4,100.00
Late Filing Fee 2 $100.00 $200.00
Plan Review- Remodel 3 $90.00 $270.00
Tobacco Permit 1 $135.00 $135.00
Tobacco Violation - 1st Offense 2 $100.00 $200.00
Tobacco Violation -2nd Offense 1 $200.00 $200.00
Total #= 160 1 YTD = 1,482 otal = $7,69-0 00
Health Dept. Clerical Report FYIA8
Burial Permits CertPermits Plan Reviews Fitness
$icate 0 Copies/ Fines Revenue Permit Fees
July-1 7 $900.00 $4,350.00 $630.00 $1,800.00 $300.00 $7,980.00 'Food Service Est. <25 seats $140
August $700.00 $1,670.00 $270.00 $1,500.00 $4,140.00 25-99 seats $28o >99 seats $420
September $900.00 $4,530.10 $270.00 $2,350.00 $200.00 $8,250.10 Retail Food <l000sq' $70
October $1,225.00 $2,910.80 $540.00 $1,550.00 $6,225.80 l000-lo,000 s28o >10,000 $420
November $1,075.00 $10,620.00 $90.00 $1,450.00 $50.00 $13,285.00 Temp.Food 1-3 days s3s
December $825.00 $64,390.00 $0.00 $1,400.00 $900.00 $67,515.00 4-7days s7o >7days s
January-18 Example of>7 day temp food permit:
$1,625.00 $7,845.00 $180.00 $2,450.00 $1,600.00 $13,700.00 i 14(days)divided bY7=2 x$70=$140
February $1,025.00 $1,695.00 $270.00 $4,100.00 $600.00 $7,690.00 Frozen Desserts $25
March $925.00 $2,325.00 $720.00 $2,150.00 $100.00 $6,220.00 Mobile Food $210
April $0.00 'Plan Reviews New s18o
May $0.00 Remodel sgo
June Catering $25 per even t/$2oo
$0.00 catering kitchen
Body Art Est. $315
Total $9,200.00 $100,335.90 $2,970.00 $18,750.00 $3,750.00 $135,005.90 Body Art Practitioner s135
Review Plans s18o
Fiscal Year Budget 2018 Suntan Est. $140
Rec.Day Camp $10
Salary Starting Ending Expenses Ext.Paint Removal $35
Full Time $412,115.00 $145,380.59 Startinq Ending Transport Off.Subst. slo5
Part Time $43,354.00 $21,171.28 $32,500.00 $15,331.32 Tobacco Vendors $135
Overtime $5,800.00 $1,101.10 Swimming Pools Seasonal $140
Balance $461,269.00 $167,652.97 Health Clinic R e volving A cco un t 'Annual$210 Nonprofit$40
S9,905.38 Title V Review s18o
Well Application s18o
Disposal works $225/i8o
Breakdown of Permits and Fines
March 2018
Permit Description Total Permits Issued Permit Cost Total
Annual Food - <25 seats 3 $140.00 $420.00
Annual Food - 25-99 seats 2 $280.00 $560.00
Annual Food - Retail <1,000sq' 2 $70.00 $140.00
Food -Temporary Pop Up (1-3 days) 13 $35.00 $455.00
Food - Temporary Non-Profit 1 $25.00 $25.00
Body Art Establishment 1 $315.00 $315.00
Body Art Practitioner 1 $135.00 $135.00
Burial Permit 37 $25.00 $925.00
Certificate of Fitness 43 $50.00 $2,150.00
Exterior Paint Removal 1 $35.00 $35.00
Late Filing Fee 1 $100.00 $100.00
Plan Review- New or Major Renovation 3 $180.00 $540.00
Plan Review- Remodel 2 $90.00 $180.00
Septage Hauler 1 $105.00 $105.00
Tobacco Permit 1 $135.00 $135.00
[Total #= 112 1 YTD = 1,594 otal = $6,220.00
Confirmed Ong ,
• s
CITY OF SALEM, MASSACHUSETTS
Kimberley Driscoll
Mayor
January 25, 2018
Honorable Salem City Council
Salem City Hall
Salem,Massachusetts 01970
Ladies and Gentlemen of the City Council:
I am very pleased to appoint Geri Yuhas, of 28C Federal Street,to the Salem Board of Health to
fill the remainder of the three-year term of Nancy Crowder, which will expire on April 14, 2019.
I hope you will join me in thanking Ms. Crowder for her service on the Board of Health and for
her commitment to our community.
• Ms. Yuhas retired in 2012 after a 49-year career as a registered nurse. For the first thirteen years
of her career she worked on the staff at a variety of hospitals,including Philadelphia General
Hospital—the institution where she earned her nursing diploma-Detroit General Hospital,
Mount Auburn Hospital, and Salem Hospital. The bulk of her professional career,however,was
as a pediatric nurse practitioner at Marblehead Pediatrics for 36 years, following her certification
in that field from Northeastern University in 1976. Ms. Yuhas is an engaged volunteer in our
community,having served on the board at My Brother's Table and,most recently,as a member
of Green Salem,our city recycling committee.
I strongly recommend confirmation of Ms.Yuhas' appointment to the board.We are fortunate that
she is willing to serve our community in this important role and lend her expertise and dedication
to the Board of Health and its work.
Very truly yours,
Kimberley Driscoll
Mayor
City of Salem
•
Salem City Hall• 93 Washington Street•Salem, MA•01970-3592 p: 978.745.9595•f: 978.744.9327
Confirmed On
CITY OF SALEM, MASSACHUSMS
Kimberley Driscoll
May
or
February 22, 2018
Honorable Salem City Council
Salem City Hall
Salem,Massachusetts 01970
Ladies and Gentlemen of the City Council:
I reappoint, subject to City Council confirmation,Dr. Jeremy Schiller,of 14 Broad Street,to the
Salem Board of Health for a term of three years to expire February 22,2021.
I enthusiastically recommend confirmation of his reappointment to the Board of Health and ask
• that you join me in thanking him for his continued dedicated service and commitment to our
community.
Very truly yours,
Kimberley Driscoll
Mayor
City of Salem
•
Salem City Hall• 93 Washington Street• Salem, MA•01970-3592• p: 978.745.9595•f: 978.744.9327
The Governance Functions
NALBOH is the national voice for the boards that govern health departments and shape
public health policy. Since its inception, NALBOH has connected with board of health
members and elected officials from across the country to inform, guide, and help them
fulfill their public health responsibilities in their states and communities. Driven by a
mission to strengthen and improve public health governance, NALBOH worked with CDC
and other national partners to identify, review, and develop the following model of six
functions of public health governance.
Policy development: Lead and contribute to the development of policies that protect,promote,and
improve public health while ensuring that the agency and its components remain consistent with the laws
and rules (local,state,and federal) to which it is subject.These may include,but are not limited to:
• Developing internal and external policies that support public health agency goals and utilize the
best available evidence;
• Adopting and ensuring enforcement of regulations that protect the health of the community;
• Developing and regularly updating vision,mission,goals,measurable outcomes,and values
statements;
• Setting short-and long-term priorities and strategic plans;
• Ensuring that necessary policies exist,new policies are proposed/implemented where needed,and
existing policies reflect evidence-based public health practices;and
• Evaluating existing policies on a regular basis to ensure that they are based on the best available
evidence for public health practice.
Resource stewardship:Assure the availability of adequate resources(legal,financial,human,
technological,and material) to perform essential public health services.These may include,but are not
limited to:
• Ensuring adequate facilities and legal resources;
• Developing agreements to streamline cross-jurisdictional sharing of resources with neighboring
governing entities;
• Developing or approving a budget that is aligned with identified agency needs;
• Engaging in sound long-range fiscal planning as part of strategic planning efforts;
• Exercising fiduciary care of the funds entrusted to the agency for its use;and
• Advocating for necessary funding to sustain public health agency activities,when appropriate,from
approving/appropriating authorities.
Legal authority: Exercise legal authority as applicable by law and understand the roles,responsibilities,
obligations,and functions of the governing body,health officer,and agency staff.These may include,but are
not limited to:
• Ensuring that the governing body and its agency act ethically within the laws and rules(local,state,
and federal)to which it is subject;
• Providing or arranging for the provision of quality core services to the population as mandated by
law,through the public health agency or other implementing body;and
• Engaging legal counsel when appropriate.
Partner engagement: Build and strengthen community partnerships through education and engagement
to ensure the collaboration of all relevant stakeholders in promoting and protecting the community's
health.These may include,but are not limited to:
• Representing a broad cross-section of the community;
• Leading and fully participating in open,constructive dialogue with a broad cross-section of
members of the community regarding public health issues;
• Serving as a strong link between the public health agency,the community,and other stakeholder
organizations;and
• Building linkages between the public and partners that can mitigate negative impacts and
emphasize positive impacts of current health trends.
Continuous improvement:Routinely evaluate,monitor,and set measurable outcomes for improving
community health status and the public health agency's/governing body's own ability to meet its
responsibilities.These may include,but are not limited to:
• Assessing the health status of the community and achievement of the public health agency's
mission,including setting targets for quality and performance improvement;
• Supporting a culture of quality improvement within the governing body and at the public health
agency;
• Holdinggoverning body members and the health director health officer to high performance
g g Y / g
standards and evaluating their effectiveness;
• Examining structure,compensation,and core functions and roles of the governing body and the
public health agency on a regular basis;and
• Providing orientation and ongoing professional development for governing body members.
Oversight:Assume ultimate responsibility for public health performance in the community by providing
necessary leadership and guidance in order to support the public health agency in achieving measurable
outcomes.These may include,but are not limited to:
• Assuming individual responsibility,as members of the governing body,for actively participating in
governing entity activities to fulfill the core functions;
• Evaluating professional competencies and job descriptions of the health director/health officer to
ensure that mandates are being met and quality services are being provided for fair compensation;
• Maintaining a good relationship with health director/health officer in a culture of mutual trust to
ensure that public health rules are administered/enforced appropriately;
• Hiring and regularly evaluating the performance of the health director;and
• Acting as a go-between for the public health agency and elected officials when appropriate.
All public health governing entities are responsible for some aspects of each function.No one function is
more important than another.For more information about the six governance functions,please visit www.
nalboh.org.
Approved by the NALBOH Board of Directors-November 2012
National Association of Local Boards of Health
www.nalboh.org
CITY OF SALEM BOARD OF HEALTH
REGULATION #7
The effective date of this Regulation shall be January 1, 2009.
Section 1.0 Authority
The Board of Health, City of Salem, Massachusetts, acting under the authority of Chapter 111,
Sections 31, 3 1 A and 31B, of the Massachusetts General Laws, has adopted the following
Regulation#7, replacing Board of Health Regulation#7 adopted on August 21, 1979 and amended
on July 16, 1985.
Section 2.0 Rationale
2.1 The City of Salem Board of Health is promulgating rules and regulations that provide
requirement for the proper placement, collection and disposal of solid waste by residents and
allowed small businesses in order to prevent public health nuisances that could lead to disease and/or
environmental contamination.
2.2 Trash placement, collection, and disposal by those other than residents and allowed small
businesses must be done in a sanitary manner, in accordance with all applicable local, state and
federal rules and regulations, and must not create a public health nuisance.
Section 3.0 Definitions for the Purpose of these Regulations
3.1 Allowed Small Business:
Those small businesses as listed in the "City of Salem, Massachusetts, Contract for Solid Waste and
0Recyclable Materials, Collection and Disposal, dated July 1, 2008."
3.2 Bag
Plastic sacks designate to store solid waste with sufficient wall strength to maintain physical
integrity when lifted by the top. The volume of the bag shall not exceed 35 gallons and the total
weight of its contents shall not exceed 50 pounds.
3.3 Bulky Waste
Included, but is not limited to, items weighing over 50 pounds or too large to place in a trash barrel
such as furnituyre of a mattress, but excludes yard waste and construction debris.
3.4 Construction Debris
Waste building materials resulting from construction,,remodeling, repair and demolition operations.
3.5 Containers
A receptacle for solid waste or recyclable materials with a capacity of no greater than 35 gallons
constructed of plastic, metal, or fiberglass, having handles or construction to provide adequate
strength for lifting, and having a tight fitting cover. The mouth of such container shall have a
diameter greater than or equal to that of the base. The weight of the container and its contents shall
not exceed 50 pounds.
3.6 Hazardous Materials
.Gasoline, waste oil, liquid oil based paints, turpentine, paint thinners, shellac, pesticides, auto
batteries, explosives, propane tanks, gas cylinders, PCB's, radioactive materials, medical wastes, any
other materials designated hazardous by the United States Environmental Protection Agency (EPA),
the Massachusetts Department of Environmental Protection(DEP), or the Massachusetts Department
of Public Health(DPH).
3.7 Household
,)The single residential unit within a single or multi-family complex.
3.8 Recyclable Material
Material that has the potential to be recycled and is identified listed and accepted as such, by North
Shore Recycled Fibers or other recycling companies.
3.9 Solid Waste
Useless, unwanted or discarded solid or liquid material, as per 310 CMR (Code of Massachusetts
regulations) 19.006. The term"liquid" refers to the incidental liquids discarded in trash containers or
bags. Solid waste consists of rubbish, residential garbage, and small business waste. Solid Waste
does not include cardboard, hazardous materials, recyclable materials, white goods, yard waste, or
any material placed in a waste ban category by the DEP.
3.10 White Goods
Stoves, refrigerators, water coolers, bubbles, dishwashers, clothes dryers, washing machines,
freezers, air conditioners, dehumidifiers, microwaves, TV's and computer screens.
3.11 Yard Waste
Yard Waste consists of grass, leaves, brush; and tree, vine, or shrub trimmings.
3.12 Mixed Paper
All colors and textures of paper that can be ripped.
catalogs, copy paper, envelopes, tissue rolls, file folders,junk mail, magazines,
.13rochures,
newspaper, paper bags, phone books, soft cover books, writing tablets, etc.
Boxes, cereal, pasta, cookie, shoe, office supplies, etc.
Staples, paper clips, labels, and envelopes with plastic windows are OK.
No dirty take-out containers,juice boxes, foil-lined paper, Tyvek or Mylar envelopes, photographs,
or hard covered books.
4.0 Responsibilities
4.1 Residential/Allowed Small Business
The occupant or occupants of every single or two family dwelling; the owner or agent of every
dwelling having three or more dwelling units and; the owner or manager of every allowed small
business, shall provide containers for the storage of solid waste as described in this regulation.
4.2 Commercial
The owner of every business, other than the allowed small businesses, shall provide, keep clean and
in good repair proper and sufficient solid waste receptacles for the storage of solid waste. Such
owner shall provide for the collection and removal of the solid waste by him/herself or by a private
collector, at sufficient intervals, and in a manner to prevent a nuisance as may be determined by the
Board of Health.
5.0 Conditions of Collection
5.1 Time of Placement
l5.1.1 Tightly covered containers may be placed curbside for municipal collection no sooner than 6
a`PM the evening before the scheduled collection.
5.1.2 Bags may be placed curbside for municipal collection no sooner than 6 AM the morning of the
scheduled collection.
5.1.3 All containers and bags must be placed curbside no later than 7 AM on the day of collection
and must be removed from the sidewalk on the same day as the collection.
5.2 Solid Waste Weight Limit
Each household and allowed small business may place no more than 3 containers or 3 bags or a
combination of containers and bags totaling no more than 3 and weighing no more than a total of 50
pounds each; plus one bulky waste item, at curbside for municipal collection.
5.3 Solid Waste Acceptable Materials
Only items included in the solid waste definition in this regulation may be placed curbside in
containers or bags for collection.
5.4 Bulky waste
One bulky waste item per week may be placed for collection per household and allowed small
businesses.
5.5 Cardboard
0 Cardboard must be separated from solid waste, flattened and either bundled in lengths of no more
than 3 feet and weights of no more than 50 pounds or placed in paper bags or appropriate recycling
containers.
5.6 Hazardous Materials
Hazardous materials , such as those banned from regular solid waste disposal in accordance with 310
(:MR 19.017, must be handled according to local, state and federal rules and regulations.
5.7 Recyclable Materials
Recyclable materials may be placed curbside for collection on the same day as regular solid waste
collection.
There is no limit on the amount recyclable materials collected curbside. Recyclable materials
include mixed paper, and commingled glass, aluminum, metal, and plastics #1 through#7.
Recyclable materials may not be contaminated by significant amounts of substances in accordance
with 310 CMR 19.006.
Recycled materials must be placed in City-approved bins (available for sale); or your own containers
with appropriate labeling.
U:p-to-date information regarding handling recyclable materials may be obtained at the City
Engineer's office. (978)619-5679.
5.8 White Goods
White goods not containing Freon and not including TV's and computer monitors, shall be collected
by appointment as arranged between the resident or allowed small business and the City's Solid
Waste Contractor. (978)745-0635.
Disposal of TV's, computer monitors and white goods containing Freon requires purchase of a
sticker from the Department of Public services prior to scheduling collection with the City's
contractor. (978)744-3302.
5.9 Yard Waste
Yard waste may not be included in regular municipal collection. It will be collected 5 times per year
on a schedule agreed upon by the city and the city's contractor, or brought to the Transfer Station on
Swampscott Road.
Yard waste must be placed in yard waste paper bags or open containers clearly marked as "yard
waste."
Trimmings may be bundled in lengths no more than three feet long. Branches may not have a
diameter greater than 3 inches long and weigh no more than 50 pounds.
Section 6.0: Miscellaneous Provisions
6.1 No person shall disturb, remove or collect any solid waste, bulky waste, recyclable material,
white goods, or yard waste from any premises without consent of the owner, nor any waste placed
,out for collection upon any sidewalk or way except employees or contractors of the City.
6.2 No person, firm, business, or corporation shall place or keep any container, bag, box, crate, or
any other receptacle containing solid waste or recyclable materials on any sidewalk in the City
except for removal or collection by the City, its Contractor or a private collector, place curbside
appurtenant to the place such person, firm, business, or corporation resides or has a place of
business.
'section 7.0: Penalties
Whoever violates any provisions of these rules and regulations may be fined up to $1,000.00 by the
Board of Health. Each day that these violations exist may constitute a separate offense. In
accordance with MGL c.40s.21D, non-criminal'disposition and the issuance of a ticket may be used
as a penalty of this regulation.
Section 8.0: Severability
If any section, subsection, sentence, clause, phrase, or portion of these regulations is for any reason
held invalid or unconstitutional by any court of competent jurisdiction, such provisions and such
holdings shall not affect the validity of the remaining portions thereof.
City of Salem
Board of Health
120 Washington Street
Salem, MA 01970
Janet Mancini, Acting Health Agent
Paulette Puleo, Chairperson
Martin Fair
Christina Harrington
Barbara Poremba
•Carol Rainsville
Noreen Casey
Marc Salinas
A Summary of the Regulation was published in the Salem News on
after a vote of the board of Health on 12-09-2008 with 6 affirmative, 0 negative, 0 abstaining,
Paulette Puleo, Chairperson
Date: 2-10-09
•
• CITY OF SALEM BOARD OF HEALTH
REGULATION #7
COLLECTION OF DISPOSAL OF
GARBAGE AND REFUSE
Re: the amendment of adding Part A to section 3.10 of the CITY OF SALEM BOARD OF
HEALTH REGULATION 7 - COLLECTION AND DISPOSAL OF GARBAGE AND REFUSE
Section 3.10. The new amendment will read as follows and take effect Aug. 5, 1985.
3.10 A DOWNTOWN BUSINESS DISTRICT
CONTAINERS OR BUNDLES OF HOUSEHOLD AND ORDINARY COMMERCIAL
WASTE, GARDEN AND LAWN WASTE, FOR THE DOWNTOWN BUSINESS DISTRICT.
These shall be placed at the outer edge of the sidewalk appurtenant to the premises of the owner not
later than 9: a.m. on the day of collection, and not before 5:00 a.m. on the day of collection, and shall
be removed from the sidewalk on the same day as emptied. No commercial establishment in the
DOWNTOWN BUSINESS DISTRICT shall place or cause to be placed more than four (4)
standard size barrels, bags, or bundles (not to exceed 1001bs. in weight per unit when full or 400 lbs.
total weight) per week, OR more than(10) smaller barrels, bags, or bundles with the total weight of
all units not to exceed 400 lbs. when full, per week. The streets which are termed as DOWNTOWN
BUSINESS DISTRICT, and will be affected by this regulation are as follows:
• North Street West
Norman Street South
Margin Street West
Washington Street East
New Derby Street South
Derby Street South
Hawthorne Blvd. East
Essex Street North
Brown Street North
St. Peter's Street East
Federal Street across to Washington Street to North Street or to North
Compiled and Submitted by
Robert E. Blenkhorn, Health Agent
October 24, 1984
Approved July 16, 1985
By Board of Health
Arthur Kingsley, Chairman
Vincent DiBona
Arthur J. Johnson
George H. Levesque
Arthur J. Kavanaugh, Jr., M.D.
Pater H. Sandon
• CITY OF SALEM PUBLIC HEALTH REGULATION #7
Requirements for Placement, Collection and Disposal of Solid Waste by Residents,
Mandatory Recycling for Residents and Businesses within the City of Salem and
Solid Waste Disposal/Recycling Haulers Licensing and Operations
Section I. Scope of Authority
The Salem Health Department adopts the following regulation pursuant to authorization granted
by M.G.L. c 111 s. 31 and 31B, 310 CMR 11.02 and 310 CMR 19.0 et seq. The regulation shall
apply, as specified herein, to all residents, institutions and businesses, existing and new, within
the City of Salem. This regulation was adopted on and shall be effective November
1, 2018.
Section II. Purpose of the Regulation
These regulations are intended to preserve the public and environmental health and are designed
to 1) keep banned recyclable materials and certain toxic materials out of the solid waste stream,
2) regulate and license haulers of solid waste and recyclables and 3) establish requirements for
the proper placement, collection and disposal of solid waste by residents and allowed small
businesses in order to prevent public health nuisances that could lead to disease and/or
environmental contamination.
• Section III. Definitions
For the purpose of this regulation, the following words and phrases shall have the following
meanings:
A. Allowed Small Business: Those small businesses as listed in the "City of Salem,
Massachusetts, Contract for Solid Waste and Recyclable Materials, Collection and
Transportation, dated July 1, 2015."
B. Bag-Official Overflow Bag: 35 Gallon.Plastic bag for excess solid waste that does not
fit in the City carts. Bags are available for purchase at local stores including Crosby's
and Winer Brothers. Volume shall not exceed 35 gallons and total weight of a bag
and its contents shall not exceed 50 lbs.
C. Bulky Waste: Included, but is not limited to, items weighing over 50 pounds or too
large to place in a solid waste barrel such as furniture or a mattress/box spring, but
excludes yard waste and construction debris and other waste ban items per
105CMR310
D. Construction Debris: Waste building materials resulting from construction,
remodeling, repair and demolition operations and as set forth in the Department's
Regulations relative to waste bans.
E. Containers: A receptacle for solid waste or recycling. For the purposes of curbside
• collection of solid waste, a Contractor designated and supplied 64-gallon cart. For
purposes of recycling, a Contractor designated and supplied 96-gallon cart. The term
• "cart" shall mean a 64-gallon(solid waste) or 96-gallon(recyclables) commercially
manufactured plastic container with wheels and attached lid provided by the City's
Solid Waste Collection Contractor(Contractor) for the storage and setout of solid
waste and recyclables. An acceptable container may also include smaller containers,
approved by the Contractor on a case by case basis.
F. Department: The City of Salem Board of Health Office.
G. Facility: A licensed solid waste resource recovery or recycling plant, transfer station
or approved sanitary landfill or assigned or permitted composting site.
H. Hazardous Waste or Material: Any waste that is defined and regulated under 310
CMR 30.00.
I. Household: The single residential unit within a single or multi-family complex.
J. Leaf and Yard Waste: Any deciduous and coniferous seasonal deposition, grass
clippings, weeds, hedge clippings, garden materials and brush. Licensee: Any
person(s) or company, which has applied for and obtained the appropriate license to
collect solid waste within the limits of the City of Salem.
K. Recyclables: As established set forth in 310 CMR 19.00 including, but not limited to
glass containers, plastic containers, aluminum, metal containers and newspapers.
Glass containers as defined shall be made of clear, brown or green glass, and shall
exclude blue and flat glass (commonly known as window glass), dishes, pottery and
crockery. Plastic containers shall be household plastic containers #s 1, 2, 3, 4, 5, and
7, excluding plastic film(plastic bags, for example). Aluminum as defined shall
include cans, but exclude foil and containers or trays used in the packaging of food.
Metal containers as defined shall be made entirely of ferrous metal(iron or steel) and
may exclude all pressurized cans and cans which have contained hazardous materials.
Paper, cardboard and paperboard products including newspaper as defined shall mean
unsoiled newsprint, including newspaper advertisements, supplements, comics,
enclosures, magazines, catalogues and telephone books.
L. Restricted Materials: As set forth in 310 CMR 19.00 including, but not limited to lead
batteries, leaves, tires, white goods, other yard waste, aluminum containers, metal or
glass containers, single polymer plastics, recyclable paper, cathode ray tubes, asphalt
pavement, brick and concrete, metal and wood.
M. Solid Waste collection vehicle: Any vehicle used for the delivery of solid waste
and/or recyclable material. Said vehicle shall be in a safe, clean condition and in
good repair, and appropriately marked identifying the haulers name, working phone
number and place of business.
N. Solid Waste: Useless, unwanted or discarded solid material, resulting from municipal
or household activities that is abandoned by being disposed or incinerated or is stored,
treated or transferred pending such disposal, not including any hazardous waste,
special wastes.
O. Special Waste: A solid waste that requires special handling (i.e. demolition/
construction material) or disposal techniques or methodologies to protect the public
health or safety or the environment.
P. White Goods: Stoves, refrigerators, water coolers, bubblers, dishwashers, clothes
dryers, washing machines, freezers, air conditioners, and dehumidifiers. White Goods
shall be classified as either Freon/refrigerant containing or non-Freon/refrigerant
. containing types.
2
Section IV. Requirements for Placement, Collection and Disposal of Solid Waste
A. Time of Placement: City issued carts may be placed curbside for municipal collection
no sooner than 6 PM the evening before the scheduled collection. All carts and
overflow bags must be placed curbside no later than 7 AM on the day of collection
and must be removed from the sidewalk on the same day as the collection.
B. Solid Waste Acceptable Materials: Only items included in the solid waste defmition
in this regulation may be placed curbside in carts or overflow bags for collection.
C. Bulky waste: Two bulky waste items per household per recycling week may be
placed for collection per household and allowed small businesses.
D. Hazardous Materials: Hazardous materials, such as those banned from regular solid
waste disposal in accordance with 310 CMR 19.017, must be handled according to
local, state and federal rules and regulations.
E. Recyclable Materials: Recyclable materials may be placed curbside in City or
Contractor issued carts for collection on the same day as regular solid waste
collection on a bi-weekly schedule, see city website for schedule. Material placed in
the cart must have the potential to be recycled and is identified, listed and accepted as
such and which is not commingled with non-recyclable solid waste or contaminated
by toxic substances as per 310 CMR 19.006. Up-to-date information regarding
handling recyclable materials is located at www. salem.com/recycling-and-trash or by
calling the City Engineer's office (978) 619-5673.
F. E-Waste: May be disposed of privately. The City provides quarterly e-waste
collection. Most items are free. See city website for details.
G. Yard Waste: Yard waste may not be included in regular municipal collection. It will
be collected on a schedule agreed upon by the city and the city's contractor or
brought to the Transfer Station on Swampscott Road seasonally. Yard waste must be
placed in yard waste paper bags or open containers clearly marked as "yard waste."
Trimmings may be bundled in lengths no more than three feet long. Branches may
not have a diameter greater than 3 inches long and weigh no more than 50 pounds.
H. Miscellaneous:
1. No person shall disturb, remove or collect any solid waste, bulky waste,
recyclable material, white goods, or yard waste from any premises without
consent of the owner, nor any waste placed out for collection upon any sidewalk
or way except employees or contractors of the City.
2. No person, firm, business, or corporation shall place or keep any container, bag,
box, crate, or any other receptacle containing solid waste or recyclable materials
on any sidewalk in the City except for removal or collection by the City, its
Contractor or a private collector. Waste or recyclable material may be placed
curbside adjacent to the place such person, firm, business, or corporation resides
or has a place of business.
1. Commercial collection:
3
i
• The owner of every business, other than the small businesses which have been
provided bins by the City and who follow the rules established for municipal curbside
collection, shall provide, keep clean and in good repair proper and sufficient solid
waste receptacles for the storage of solid waste and recycling. Such owner shall
provide for the collection and removal of the solid waste and recycling by him/herself
or by a private collector, at sufficient intervals, and in a manner to prevent a nuisance
as may be determined by the Board of Health. Tightly covered containers may be
placed curbside for private collection no sooner than 6PM the evening before the
scheduled collection and must be removed from the sidewalk on the same day as the
collection. In the event bags are utilized for private collection, bags may be placed
curbside for collection no sooner than 6 AM the morning of the scheduled collection
and must be removed from the sidewalk on the same day as the collection.
Section V. Mandatory Recycling Regulation
A. Solid waste collected by the City of Salem or any licensed rubbish hauler shall not
contain recyclables or restricted materials. Each generator of waste and/or property
owner/manager shall separate from non-recyclable rubbish all recyclables, as defined.
B. Waste generators are responsible for ensuring that they do not contract for the
disposal of recyclables or restricted materials with their solid waste.
C. Owner/Manager of a property shall be responsible for immediate removal of all solid
waste and/or recyclables placed on or near the side of a street for collection which does
not comply with the rules and regulations of the Salem Health Department. Failure to
remove within 24 hours shall result in a fine being issued.
D. No person shall willfully or maliciously disturb or handle the contents of or tip over or
upset any container placed for the collection of solid waste or recycling.
Section VI. Solid Waste Disposal/Recycling Haulers Licensing and Operations
A. General:
1. Any person or company engaged in the collection of solid waste and recyclables
pY
shall obtain a license from the City of Salem. Solid waste and recyclables collected
shall be brought to a Department of Environmental Protection(DEP) approved solid
waste disposal facility.
2. The licensee shall provide Integrated Solid Waste Services, defined as providing
bundled service for the collection of both Solid Waste and Recyclables for each
Customer to allow compliance with the DEP solid waste bans found at 310 CMR
19.
3. All licensed solid waste disposal/recycling companies serving residential, municipal
and commercial/industrial/institutional customers in the City of Salem shall provide
customers with bundled service for the collection of both solid waste and
recyclables at a rate that reflects the cost of both services. An approved recycling
service consist of a recycling collection, minimum bi-monthly(twice a month).
4
• 4. Individuals engaging in yard waste collection and/or removal of bio-degradable
waste shall obtain a permit from the Health Department and shall indicate the site of
final disposal and maintain records on an annual basis for examination.
B. Licensing_procedure:
1. All persons collecting solid wastes in the City of Salem shall obtain a license from
the Health Department prior to commencing with its collection.
2. At the time of application or as otherwise specified, the licensee shall submit to the
Health Department the following information:
a. A completed application form.
b. A non-refundable $100 application fee for each vehicle.
c. A list of the residential, municipal and commercial/industrial customers
serviced by the collection. Supplied yearly.
d. A description of the collection vehicle(s) to be used, including the make, model,
registration, year, type and size of compactor, and the company name appearing
on the vehicle(s).
3. An exact figure of the tonnage of solid waste and recyclables that have been
collected from residential/commercial sites shall be submitted to the Health
Department monthly on company letterhead and signed by company representative.
4. The Health Department reserves the right to require all vehicles collecting solid
waste in Salem to have a marking thereon indicating they are licensed in Salem.
5. A licensee has the right to be heard by the Board of Health to discuss its
application by making written request to the Department.
C. Insurance:
1. Each applicant shall furnish the Health Department with certificates from an
insurance company, licensed to do business in the Commonwealth of Massachusetts
showing the applicant carries public liability and property insurance. Certificates of
insurance shall be furnished each year upon the renewal of the license.
2. The applicant shall make certain that the above insurance policy is not cancelled
prior to notification of the Health Department. This notification shall be not less
than (30) days prior to the cancellation.
D. Operation Procedures:
1. The license shall expire on December 31" following the date of issue unless
sooner revoked and shall be renewable annually on the first day of January subject
to review and approval by the Health Department
2. No license shall be transferable except with the approval of the Health Department.
3. The licensee shall deliver all solid waste collected within the corporate limits of
Salem to a licensed solid waste resource recovery plant, transfer station or approved
sanitary landfill.
4. The licensee shall provide recycling service to allow compliance with the DEP solid
waste bans and the Board of Health bans by the effective dates of those bans. `
5. All recyclables must be collected at a minimum bi-monthly(twice a month).
Licensees are required to collect both paper products and co-mingled
• (glass/plastic/metal) at each pickup.
5
i
6. The licensee shall take all reasonable care in the collection of solid waste and
recyclables. Solid waste and recyclables shall not be scattered about the streets or
onto private property. Solid waste and recyclables which are spilled, shall be
immediately picked up by the licensee and removed with other wastes. Failure to
comply may result in fines up to $100.00 per incident.
7. The Health Department reserves the right to inspect collection vehicles and loads at
reasonable times in order to ensure that they comply with all applicable state and
local laws, by-laws and regulations.
8. Any violation of these regulations or any other applicable laws or regulations by the
licensee will be grounds for suspension, modification or revocation of said license.
9. The individuals empowered to enforce the provisions of these regulations shall be
the Agent of the Health Department and any member of the Department, or any
Police Officer of the City.
10. Licensees are required to provide their customers with a list of acceptable waste
types and recyclables according to Department regulation and with a list or
description of proper packaging or bundling methods.
11. The licensee shall pick up from residential, commercial, institutional and industrial
service recipients within the city limits between the hours of 7:OOam and 8:OOpm.
12. The licensee shall provide adequately sized receptacles for solid waste and
recycling if necessary and maintain in a clean insect resistant manner free from
odors, leaks, rodents and insects.
13.Licensees shall not store recyclables or solid waste in the vehicle on public ways
overnight without permission of the Board of Health.
• E. Indemnification:
1. Licensees may enter into arrangements for the collection of solid waste and
recyclables with condominium units, residential apartment complexes in excess of
six(6) units and commercial/industrial/institutional customers of the City. The
licensee will be paid directly by the customer. The City shall have no liability for
payment to the licensee for any residential or commercial/industrial/institutional
collection and disposal work that is not included in the City's contract.
2. The licensee shall take all responsibility for the work and take all reasonable
precautions for preventing injuries to persons or damage to property; shall bear all
losses resulting to the collection company on account of the quantity or character of
the work; shall indemnify and hold harmless the City of Salem, its officers, agents
and servants from all claims relating to labor and materials furnished to do the
work, and for all injuries to any person or corporation received or sustained by or
from the licensee and its employees doing the work, in consequence of any
improper materials, implements or labor used therein: and to any act, omission or
neglect of the licensee and its employees.
3. The licensee agrees to indemnify the City for any liability that may arise from the
improper treatment, storage or disposal of hazardous wastes collected within the
City.
F. Suspension, Modification or Revocation of licenses:
•
6
• Any solid waste/recycling collection license may be suspended, modified or revoked by
the Health Department upon receipt of evidence satisfactory that the licensee has not
conformed to the requirements of these regulations or to any applicable state or federal
statute, regulation, rule or order regarding the transportation or disposal of solid waste
or the collection and disposal of solid waste or recycling. Appeals of any such
suspension, modification or revocation may be directed to the Board of Health within
ten(10)business days of said suspension, modification or revocation.
Section VII. Enforcement
Enforcement of this regulation shall be by criminal complaint in the district court and/or non-
criminal disposition ticket M.G.L. Chapter 40, § 21D. Agents of the Health Department shall
have the power to enforce the provisions of this regulation. The City shall also have the option of
seeking equitable relief to enjoin violations of the rules and regulations of the Board of Health.
Section VIII. Penalties
A violation of these regulations may be punished by a fine set forth in City Ordinance Chapter I-
10. Each day of failure to comply with the regulations shall constitute a separate violation.
Section IX. Severability
In case any section, paragraph or part of this regulation is for any reason declared invalid or
• unconstitutional by any court of last resort, every other section, paragraph or part shall continue
in full force and effect.
7
NOTICE
PROPOSED AMENDMENT TO SALEM BOARD OF HEALTH REGULATION #7
The Salem Board of Health will accept public comment at its regular meeting, May 8, 2018 at 7pm in the
first floor conference room of 98 Washington St.,Salem, MA and written comments until May 18, 2018
on proposed amendments to PUBLIC HEALTH REGULATION #7. Comments may be emailed to
Health@salem.com or mailed to the Board at the above address. The proposed Regulation
amendments set forth the time and manner of curbside placement of solid waste and recyclable
material; limits items that may be disposed as solid waste; mandates recycling of all recyclable material;
requires a Board of Health license for solid waste disposal/recycling haulers; regulates hauler
operations; and mandates haulers provide bundled services to customers to ensure proper disposal of
solid waste and recycling of recyclable materials. A copy of the regulations may be found at www.
salem.com/health or by visiting the Board of Health Offices,98 Washington St.,Salem, MA.
•
� ,..."` HHS Public Access
r9 f
Author manuscript
D wary�� JAMA. Author manuscript; available in PMC 2015 April 20.
c
Published in final edited form as:
JAMA.2015 January 20;313(3): 241-242.doi:10.1001/jama.2014.17057.
v
0
The Implications of Marijuana Legalization in Colorado
Andrew A. Monte, MD,
Department of Emergency Medicine, University of Colorado, Aurora
Rocky Mountain Poison and Drug Center, Denver, Colorado
Richard D.Zane, MD, and
Department of Emergency Medicine, University of Colorado, Aurora
D
9 Y Y
c
Kennon J. Heard, MD, PhD
0 Department of Emergency Medicine, University of Colorado,Aurora
a) Rocky Mountain Poison and Drug Center, Denver, Colorado
c
Zn
n The legalization of marijuana in Colorado has had complex effects on the health of its
r~ citizens.Physicians have the responsibility to present a balanced perspective,identifying
both the potential health benefits and risks associated with marijuana use.In this Viewpoint,
we discuss the history of marijuana policy in Colorado and the expected and unexpected
effects of increased marijuana availability.Other states considering marijuana policy
liberalization may learn from the experiences in Colorado.
h History of Colorado Marijuana Policy
In November 2000,the Colorado state constitution was amended to allow for the use of
sv
medical marijuana by patients with"chronic debilitating medical conditions."I Few patients
c
used medical marijuana until October 2009,when the US Attorney General distributed
N guidelines for federal prosecution of the possession and use of marijuana,ceding jurisdiction
n
- of marijuana law enforcement to state governments.The combination of permissive local
law and the federal policy change effectively liberalized the sale and use of medical
marijuana in Colorado.Anyone with one of the conditions outlined by Colorado law could
be issued a medical marijuana license with no expiration date.The number of licenses
increased from 4819 on December 30,2008,to 116 287 on September 30,2014.
D In November 2012,Amendment 64,which legalized the retail sale,purchase,and possession
C of marijuana for state residents and visitors older than 21 years,was approved by 55%of
pvoters.During the following year,the state legislature appointed policy advisors to
n
v
73
C Copyright 2014 American Medical Association.All rights reserved.
to
05 Corresponding Author:Andrew A.Monte,MD,Department of Emergency Medicine,University of Colorado,Leprino Bldg,
-' Seventh Floor,Campus Box B-215,12401 E 17th Ave,Aurora,CO 80045(andrew.monte@ucdenver.edu).
r r Conflict of Interest Disclosures:All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of
Interest.Dr Monte reported that he sits on the Colorado Retail Marijuana Public Health Advisory Committee coordinated through the
• Colorado Department of Public Health and Environment.Dr Heard reported having received grants from McNeil Consumer
Healthcare.No other disclosures were reported.
Role of the Funder/Sponsor:The funder had no role in the preparation,review,or approval of the manuscript.
i
Monte et al. Page 2
determine a tax structure,outline dispensary regulations,and determine the public health
implications of the legalization.Retail marijuana stores began sales to consumers on January
1,2014.Medical and retail marijuana products are the same,although regulations vary
between the 2 marketplaces.For example,there is no minimum age restriction,and only
state residents can legally buy medical marijuana in Colorado.As of November 3,2014,497
C: medical marijuana dispensaries and 292 retail dispensaries were licensed in Colorado.2
N
0
Expected Health System Effects of Legalization
Increased availability led to increased health care utilization related to marijuana exposure.3
Exacerbation of chronic health conditions was expected.Tetrahydrocannabinol(THC)is
associated with psychosis,anxiety,and depression symptoms,making exacerbation of
underlying psychiatric disorders inevitable.However,it is difficult to fully quantify the
D scope of this increased health care utilization because marijuana use is often coincident with
h other behaviors that contribute to health care visits.For example,the combination of
p marijuana plus ethanol increases the risk of motor vehicle collisions more than either
substance alone. Serum THC concentrations are not readily available,so assessing causality
is difficult.
Cn
However,there has been an increase in visits for pure marijuana intoxication.These were
previously a rare occurrence,but even this increase is difficult to quantify.Patients may
present to emergency departments(EDs)with anxiety,panic attacks,public intoxication,
vomiting,or other nonspecific symptoms precipitated by marijuana use.The University of
Colorado ED sees approximately 2000 patients per week;each week,an estimated 1 to 2
• patients present solely for marijuana intoxication and another 10 to 15 for marijuana-
associated illnesses.
D
c
o
Medical Marijuana Use
0
Patients with some seizure disorders may benefit from the cannabidiol component in
marijuana,and several clinical trials will soon enroll patients(NCT02224690,
N NCT02224560,NCT02224703,NCT02091375,NCT02224573).Marijuana likely has anti-
inflammatory effects4 and may benefit some patients with inflammatory bowel disease.5
Marijuana may have a safer therapeutic window than opioids for pain control,and an
observational study found fewer opioid-related deaths in states with liberal marijuana laws.6
However,it is unlikely that marijuana is effective for the wide range of health problems
approved under Colorado law.1
Legalization of marijuana has increased opportunities for clinician scientists to study the
D positive health effects of marijuana due to increased availability;however,federal
0 designation of marijuana as a Schedule I drug continues to limit investigators' ability to
I conduct high-quality,nationally funded clinical trials.The use of medical marijuana for a
wide range of disorders is inconsistent with the science supporting its effectiveness,
highlighting the need for high-quality research.
•
JAMA.Author manuscript;available in PMC 2015 April 20.
Monte et al. Page 3
Unexpected Health System Effects of Legalization
Experimentation with new ways to use and produce THC products has resulted in
unexpected health effects,including an increased prevalence of burns,cyclic vomiting
syndrome,and health care visits due to ingestion of edible products.
N The University of Colorado burn center has experienced a substantial increase in the number
of marijuana-related burns.In the past 2 years,the burn center has had 31 admissions for
marijuana-related burns;some cases involve more than 70%of body surface area and 21
required skin grafting.The majority of these were flash burns that occurred during THC
extraction from marijuana plants using butane as a solvent.
The frequent use of high THC concentration products can lead to a cyclic vomiting
syndrome.Patients present with severe abdominal pain,vomiting,and diaphoresis;they
D often report relief with hot showers.A small study at 2 Denver-area hospitals revealed an
c
oincrease in cyclic vomiting presentations from 41 per 113 262 ED visits to 87 per 125 095
ED visits(prevalence ratio, 1.92)after medical marijuana liberalization(A.A.Monte,MD,
unpublished data,December 2014).
c
N The most concerning health effects have been among children.The number of children
0
evaluated in the ED for unintentional marijuana ingestion at the Children's Hospital of
�« Colorado increased from 0 in the 5 years preceding liberalization to 14 in the 2 years after
medical liberalization.3 This number has increased further since legalization;as of
September 2014, 14 children had been admitted to the hospital this year,and 7 of these were
• admitted to the intensive care unit.The vast majority of intensive care admissions were
related to ingestion of edible THC products.
D
3 Challenges of Edible Marijuana Products
0
Edible products are responsible for the majority of health care visits due to marijuana
intoxication for all ages.This is likely due to failure of adult users to appreciate the delayed
effects of ingestion compared with inhalation.Prolonged absorption complicates dosing,
0 manufacturing inconsistencies lead to dose variability,and the appealing product forms lead
to unintentional ingestion by children.
Smoking marijuana results in clinical effects within 10 minutes,peak blood concentrations
occur between 30 and 90 minutes,and clearance is complete within 4 hours of inhalation.?
Oral THC does not reach significant blood concentration until at least 30 minutes,with a
peak at approximately 3 hours,and clearance approximately 12 hours after ingestion.?
D
C Ten to 30 mg of THC is recommended for intoxication depending on the experience of the
0 user;each package,whether it is a single cookie or a package of gummy bears,theoretically
0
contains 100 mg of THC.Because many find it difficult to eat a tenth of a cookie,
unintentional overdosing is common.Furthermore,manufacturing practices for marijuana
edible products are not standardized.This results in edible products with inconsistent THC
concentrations,further complicating dosing for users.According to a report in the Denver
JAMA.Author manuscript;available in PMC 2015 April 20.
Monte et al. Page 4
Post,products described as containing 100 mg of THC actually contained from 0 to 146 tng
of THC.B
Initially,nonmedical edible products were required to be sold in a childproof package,
v
although medical marijuana did not have this requirement. Childproof packaging
requirements are now consistent across both retail and medical products,but there is no
c
n dosing recommendation for medical marijuana.To complicate matters further,the
packaging is inconsistently effective and not applied to a dosing unit.This means that a
product may be sold in a childproof container,but once the package is opened,the product is
readily accessible to children.Although ingestion of 100 mg of THC in an adult may result
in delirium or severe physiologic impairment,this dose is unlikely to cause respiratory
arrest,which may occur in children at this dose.
D Edible or capsule formulations may be a preferable route of administration when compared
C with inhalation for individuals with legitimate medical indications for the drug.However,
p there is no reason these products should be packaged in a manner that is appealing to
children or makes them easily confused with nonmarijuana products.Furthermore,the
concentration of THC must be systematically measured and reported.No one would tolerate
a medication that contained a variable amount of the active ingredient. Standardizing the
production and premarket testing of edible products may help limit inadvertent overdoses.
Conclusions
While many users feel they have benefited from marijuana legalization in Colorado,there
• have also been untoward adverse health effects.The risks of use must be consistently
communicated through health care practitioners and public health officials,especially for
cedible products that pose unique risks for exposed adults and children.Ultimately,additional
3 research is needed to quantify the benefits and risks of marijuana utilization so health care
professionals can have well-informed discussions with medical and recreational users.
v
Acknowledgments
� Funding/Support:Dr Monte's work is supported by grants from the National Institutes of Health
-0 (1K23GM110516-01,UL1 TR001082,and 1R56DA038366-01).
References
1.Col Const art XVIII. § 14.
2.MED licensed facilities.Colorado Dept of Revenue;https://www.colorado.gov/pacific/enforcement/
med-licensed-facilities.Accessed November 8,2014
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JAMA Pediatr.2013; 167(7):630-633.[PubMed:23712626]
0 4.Nagarkatti P,Pandey R,Rieder SA,Hegde VL,Nagarkatti M.Cannabinoids as novel anti-
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5.Esposito G,Filippis DD,Cirillo C,et al.Cannabidiol in inflammatory bowel diseases:a brief
overview.Phytother Res.2013;27(5):633-636.[PubMed:22815234]
n6.Hayes MJ,Brown MS.Legalization of medical marijuana and incidence of opioid mortality.JAMA
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Intern Med.2014; 174(10):1673-1674. [PubMed:251561481
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8.Baca R.Edibles'THC claims versus lab tests reveal big discrepancies.Denver Post.Mar 9.2014
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c
0
D I
c
0
v
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JAMA.Author manuscript;available in PMC 2015 April 20.
Morbidity and Mortality Weekly Report
Exposure to Electronic Cigarette Advertising Among Middle and ;
High School Students — United States, 2014-2016
Kristy Marynak,MPPI;Andrea Gentzke,PhDI;Teresa W Wang,PhDI;Linda Neff,PhDI;Brian A.King,PhDI
Electronic cigarettes (e-cigarettes) are the most commonly those who selected"never,""rarely,"or"I do not[use/visit the
used tobacco product among U.S.middle and high school stu- source]" were classified as "not exposed" (6).The number of
dents(1).Exposure to e-cigarette advertisements is associated exposure sources were summed for each student and reported
with higher odds of current e-cigarette use among middle and as the percentage of all students who were exposed to one,two,
high school students(2-4).To assess patterns of self-reported three,or four sources.
exposure to four e-cigarette advertising sources (retail stores, Data were weighted to account for the complex survey design I
the Internet,television,and newspapers and magazines),CDC and adjusted for nonresponse. Prevalence estimates and 95%
analyzed data from the 2014,2015,and 2016 National Youth confidence intervals of exposure to each source,and to any source,
Tobacco Surveys (NYTSs). Overall, exposure to e-cigarette were computed.Estimates of exposure were assessed overall and
advertising from at least one source increased each year dur- by sex,race/ethnicity,school grade,current(past 30-day) use of
ing 2014-2016 (2014: 68.9%, 18.3 million; 2015: 73.0%, e-cigarettes, and current(past 30-day) use of any other tobacco
19.2 million;2016:78.2%,20.5 million). In 2016,exposure product.t Within each year,t-tests were used to assess statistically
was highest for retail stores(68.0%),followed by the Internet significant differences between levels of each covariate relative to
(40.6%), television (37.7%), and newspapers and magazines the referent group(p<0.05).Between-year differences in the overall
(23.9%). During 2014-2016, youth exposure to e-cigarette percentage ofstudents exposed to each advertisement source dur-
advertising increased for retail stores (54.8% to 68.0%), ing 2014-2016 were assessed using the Wald F test and posthoc
decreased for newspapers and magazines (30.4% to 23.9%), corrections for multiple hypothesis testing(p<0.0167).5
ind
did not significantly change for the Internet or television. Among U.S. middle and high school students during 2014—
comprehensive strategy to prevent and reduce youth use 2016, exposure to e-cigarette advertisements from any source
of e-cigarettes and other tobacco products includes efforts to increased from 68.9% (18.3 million) to 78.2% (20.5 million)
reduce youth exposure to e-cigarette advertising from a range (Figure 1) (Table). In 2016, exposure was highest for retail
of sources,including retail stores,television,the Internet,and stores (68.0%, 17.7 million), followed by the Internet(40.6%,
print media such as newspapers and magazines(5). 10.6 million),television(37.7%,9.7 million),and newspapers and
Data were analyzed from the 2014,2015,and 2016 NYTSs, magazines(23.9%,6.2 million).In 2016,exposure to advertising
a crass-sectional,paper-and-pencil survey administered to U.S., from any source was more prevalent among females(79.9%)than
students in grades 6-12.*NYTS utilizes a three-stage cluster males (76.5%); non-Hispanic whites (79.6%) than Hispanics
sampling design to generate a nationally representative sample (77.0%) and students of other non-Hispanic races/ethnicities
of public and private school students.Sample sizes and response (73.6%); 8ih (78.5%), 1 Oth (81.0%), 11 th(79.3%),and 12th
rates for 2014,2015,and 2016 were 22,007(73.3%), 17,711 graders(79.0%)than 6th graders(75.0%);high school students
(63.4%), and 20,675 (71.6%),respectively. (79.2%)than middle school students(76.9%);current e-cigarette
Participants were asked "how often do you see advertise- users(82.8%)than nonusers(77.9%);and current users of other
ments or promotions for electronic cigarettes or e-cigarettes" tobacco products(82.7%) than nonusers (77.6%). Exposure to
from the following four sources: 1),"when you are using the each advertising source was higher among current e-cigarette users
Internet"; 2) "when you read newspapers or magazines"; and other tobacco product users than nonusers during 2014,
3) "when you go to a convenience store, supermarket, or 2015,and 2016(Table).
gas station"; and 4) "when you watch television or go to the
movies." Movies were omitted from the question after 2014. t Current use of other tobacco products is based on respondents'self-reported use
Response options for each question were "I do not [use/visit of cigarettes,cigars[includes cigars cigarillos,and little cigars],smokeless tobacco
„ "never";
„ "rarely';
„ [includes chewing tobacco/snuff/dip,snus,and dissolvable tobacco],hookah/
the source] never ; sometimes ; most of the time"; waterpipe,regular pipe,and/or bidis at least one day in the past 30 days.
and"always."Consistent with previous research,students who 5 Statistical tests for differences in e-cigarette advertisement exposure sources by
reported "sometimes," "most of the time," or "always" were year(2014, 2015, and 2016)were assessed by the Wald F-Test(ANOVA);
p-values<0.05 were considered statistically significant.Posthoc comparisons
classified as "exposed" to advertisements from each source;
p for changes in e-cigarette advertisement exposures between years(2014-2015,
2015-2016,and 2014-2016),were assessed as model-adjusted risk differences
*https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm. from predicted marginals in logistic regression (t-test).A p-value<0.0167,
adjusted for multiple comparisons,was considered statistically significant. {
y
294 MMWR / March 16,2018 /Vol.67 / No.10 US Department of Health and Human Services/Centers for Disease Control and Prevention I
Morbidity and Mortality Weekly Report
FIGURE 1.Percentage'of U.S.middle and high school students exposed to e-cigarette advertisements through any source,t retail stores,§the
Internet,9 television/movies,}and newspapers and magazinestt—National Youth Tobacco Survey,United States,2014-2016
100
90
2014
y 80 - ® 2015
o 2016
a 70
a
c 60
v
v
2 50
N
y 40
rr
(O
c 30
m
a 20
10
0
Any source Retail Internet TV/Movies Newspaper or magazine
Advertisement exposure source
Between-year differences in the percentage of students exposed to each advertisement source during 2014-2016 were assessed using the Wald F test and posthoc
corrections for multiple hypothesis testing(p<0.0167).
t Statistically significant increases occurred during 2014-2015,2015-2016,and 2014-2016.
§Statistically significant increases occurred during 2014-2015,2015-2016,and 2014-2016.
Statistically significant increase occurred during 2014-2015.
"*Statistically significant increase occurred during 2014-2015;statistically significant decrease occurred during 2015-2016.Movies were removed as an exposure
source after 2014.
tt Statistically significant decreases occurred during 2015-2016 and 2014-2016.
Overall in 2016, 28.3% of students reported exposure to (17.7 million) were exposed to e-cigarette advertising in retail
e-cigarette advertising from one source, 21.2% from two stores in 2016; approximately two in five were exposed on the
sources,16.7%from three sources,and 1.2.0%from four sources Internet(10.6 million)or television(9.7 million),and nearly one
(Figure 2).Retail stores were the most common exposure source in four(6.2 million)were exposed in newspapers and magazines.
everyyear(2014:54.8%;2015:59.9%;2016.68.0%),whereas Given the Surgeon General has established that a causal relation-
newspapers and magazines were the least common exposure ship exists between traditional tobacco advertising and youth
source(2014:30.4%;2015:31.0%;2016:23.9%).The Internet tobacco product initiation(7),and given the association between
was the second most common exposure source in 2014(39.8%) e-cigarette advertising exposure and e-cigarette use among youths
and 2016 (40.6%); in 2015, television (44.5%) exceeded the (24, efforts to reduce youth e-cigarette advertising exposure
Internet(42.6%)as the second most common exposure source. are an important component of comprehensive youth tobacco
During 2014-2016, middle and high school students' prevention efforts(5).
exposure to e-cigarette advertising significantly increased for During 2014-2016,current users of e-cigarettes and other
retail stores (from 54.8% to 68.0%), significantly decreased tobacco products reported higher prevalence of exposure to
for newspapers and magazines (from 30.4% to 23.9%), and e-cigarette advertising than nonusers. This is consistent with
did not significantly change for Internet and television. research documenting an association between e-cigarette adver-
tising exposure and e-cigarette use (2-4). However, this,rela-
tionship might not be limited to e-cigarettes;previous research
In 2016,an estimated four in five(20.5 million)U.S.youths, has demonstrated that among U.S.youths aged 12-17 years,
including 8.9 million middle school students and 11.5 million receptivity to e-cigarette marketing is associated with suscep-
high school students,were exposed to e-cigarette advertisements tibility to conventional cigarette smoking (8). Prevention of
from at least one source,a 13%increase over 2014.Exposure in youth exposure to e-cigarette advertising might, therefore,be
retail stores increased 24%.in 201.6 compared with 2014, and important for prevention of youth use of all tobacco products.
was the primary factor responsible for the increases in exposure The Surgeon General has concluded that e-cigarette mar-
from any source during 201.4-2016.Nearly seven in 1.0 youths keting employs strategies similar to conventional cigarette
US Department of Health ana Human Services/Centers for Disease Control and Prevention MMWR / March 16,2018 / Vol.67 / No,10 295
Morbidity and Mortality Weekly Report
TABLE.Prevalence of exposure to e-cigarette advertisements*among U.S.youths by sex,race/ethnicity,school level,and use of e-cigarette
and other tobacco products by exposure source-National Youth Tobacco Survey,United States,2014-2016
%(95%Cl)
Newspapers and
Demographic characteristic/Year Retail stores Internet Television/Movies' magazines Any source
Overall
2014 54.8(53.6-56.0) 39.8(38.5-41.1) 36.5(35.3-37.7) 30.4(29.3-31.6) 68.9(67.7-70.0)
2015 59.9(58.2-61.7) 42.6(40.8-44.4) 44.5(42.7-46.2) 31.0(29.9-32.2) 73.0(71.3-74.5)
2016 68.0(66.9-69.1) 40.6(39.5-41.8) 37.7(36.1-39.3) 23.9(22.9-24.9) 78.2(77.1-79.1)
Overall population estimate(in millions)t
2014 14.4 10.5 9.6 8.0 18.3
2015 15.7 11.1 11.6 8.1 19.2
2016 17.7 10A 9.7 6.2 20.5
Sex
Male(referent)
2014 54.6(52.9-56.4) 38.5(37.1-39.8) 36.7(35.2-38.2) 28.7(27.6-29.9) 69.0(67.6-70.3)
2015 58.1(56.1-60.0) 39.4(37.6-41.3) 42.9(40.9-45.0) 28.3(27.0-29.7) 71.3(69.3-73.1)
2016 66.3(64.9-67.7) 37.5(36.3-38.7) 34.8(33.2-36.5) 21.8(20.6-22.9) 76.5(75.2-77.7)
Female
2014 54.9(53.5-56.3) 41.1(39.4-42.9)§ 36.4(34.8-38.0) 32.1(30.2-34.1)§ 68.8(67.3-70.3)
2015 62.1(60.1-64.0)§ 46.0(43.8-48.2)§ 46.0(44.3-47.9)§ 33.8(32.2-35A)§ 74.9(73.0-76.6)5
2016 69.8(68.3-71.1)§ 43.7(42.2-45.3)§ 40.5(38.5-42.5)§ 26.0(24.7-27.3)§ 79.9(78.7-81.0)5
Race/Ethnicity
White,non-Hispanic(referent)
2014 56.7(55.0-58.4) 40.2(38.5-42.0) 35.2(33.7-36.6) 31.1 (29.7-32.5) 70.4(68.8-72.0)
2015 63.8(61.3-66.2) 44.2(41.8-46.6) 46.0(43.5-48.4) 33.1(31.7-34.6) 75.3(73.2-77.2)
2016 713(69.9-72,8) 41.0(39.3-42.6) 36.2(34.1-38.4) 25.1(23.6-26.6) 79.6(78.3-80.8)
Black,non-Hispanic
2014 51.7(49.4-53.9)1 41.3(38.5-44.2) 42.2(40.0-44.3)1 32.2(30.0-34.5) 68.6(66.3-70.8)
2015 56.7(54.2-59.1)1 41.8(39.2-44.6) 47.1(44.9-49.3) 279(25.6-30.3)1 72.8(70.6-75.0)1
2016 63.6(61.5-65.7)1 39.7(373-42.2) 43.8(41.3-46.3)1 21.0(19.4-22.7)1 78.5(76.4-80.5)
Hispanic
2014 55.6(53.8-57.4) 39.4(37.8-41.1) 37.4(35.6-39.4)1 29.2(27.1-31.3) 68.9(67.2-70.6)
2015 55.8(53.7-57.9)1 40.4(38.3-42.6)1 42.2(40.1-44.3)1 29.4(27.8-31.1)1 70.5(68.4-72.6)1
2016 65.9(64.4-67.5)1 41.9(40.2-43.6) 39.1(37.1-41.2)1 2.3.4(22.0-24.9) 77.0(75.3-78.6)1
Other,non-Hispanic
2014 44.4(39.2-49.7)1 32.6(28.3-37.2)1 29.9(26.1-33.9)1 25.3(22,1-28.7)1 58.3(52.4-63.9)1
2015 51.1(47.5-54.7)1 39.3(35.1-43.6)1 35.6(32.8-38.5)1 26.6(23.3-30.2)1 63.8(59.7-67.6)1
2016 62.6(58.6-66.4)1 37.0(33.5-40.6) 31.9(27.5-36.6) 22.9(20.1-25.8) 73.6(70.0-76.9)1
Grade level
6th grade(referent)
2014 50.6(47.2-54.0) 32.8(30.8-34.8) 31.8(29A-34.3) 24.1(22.1-26.2) 64.7(61.9-67.3)
2015 52.7(49.2-56.2) 35.5(31.9-39.4) 40.8(37.5-44.2) 24.4(22.1-26.9) 66.7(62.7-70A)
2016 62.9(60.0-65.8) 38.4(35.4-41.5) 34.4(31.3-37.5) 17.2(15.5-19.2) 75.0(72.4-77,4)
7th grade
2014 55.0(51.7-583) 36.7(34.4-39.0)** 35.6(32.8-38.5)*" 25.9(24.0-28.0) 67.8(65.1-70.3)
2015 60.3(57.5-63.1)** 403(37.5-43.1)** 44.2(41.1-47.4)** 27.4(24.5-30.4) 72.6(69.8-75.3)*"
2016 66.2(63.5-68.7)** 41.4(38.7-44.2) 36.9(34.0-39.9) 21.0(19.2-22.9)** 77.3(75.1-79A)
8th grade
2014 52,6(48.9-563) 37.6(34.7-40.5)** 34.6(32.2-37.1)*" 25.0(21.5-28.9) 66.6(63.4-69.6)
2015 59.7(56.4-63.0)** 41.2(37.4-45.1)1* 433(39.7-47.3) 29.6(27.1-32.2)** 73.9(70.7-76.9)**
2016 67.8(65.1-70.3)** 38.5(35.8-41.3) 36.6(33.7-39.7) 22.0(19.9-24.3)- 78.5(76.4-80.4)**
9th grade
2014 54.7(52,1-57.2) 39.2(37.0-41.4)** 37.2(34.9-39,7)** 32.0(30.1-34.0)** 68.7(659-71.4)
2015 60.4(S7.8-62.8)** 45.4(42.8-48.0)" 46.6(44.3-49.0)** 32.2(30.1-34.3)** 74.8(72.8-76.7)'*
2016 68.0(65.5-70.5)** 39.5(37.3-41.8) 37.4(34,6-403) 23.7(21.9-25.5)"* 77.6(75.4-79.7)
See table footnotes on next page.
296 MMWR ! March 16,2018 / Vol.67 / No.10 US Department of Health and Human Services/Centers for Disease Control and Preventioi
i
Morbidity and Mortality Weekly Report
TABLE.(Continued)Prevalence of exposure to e-cigarette advertisements*among U.S.youths by sex,race/ethnicity,school level,and use of
• e-cigarettes and other tobacco products by exposure source National Youth Tobacco Survey,United States,2014-.2016
%(95%CI)
Newspapers and
Demographic characteristic/year Retail stores Internet Television/Movies magazines Any source
10(h grade
2014 56.2(53.6-58.8)"" 43.4(40.9-45.8)** 38.9(36.5-41.3)*" 34.0(31.6-36.5)** 71.3(68.8-73.7)**
2015 60.2(57.5-62.8)" 43.8(40.6-47.0)"* 43.7(41.2-46.3) 32A(30.0-34.9)"" 72.5(70.0-74.9)*"
2016 71.6(69.4-73.8)** 44.0(41.6-46.4)** 39.8(37.3-42.4)** 27.8(25.5-30.2)1* 81.0(78.9-82.9)*"
11th grade
2014 57.8(54.9-60.6)* 45.5(433-47.6)** 39.9(37.1-42.7)** 35.9(33.7-38.1)" 71.8(69.3-74.1)"*
2015 63.1(58.9-67.2)** 45.8(42.9-483)"* 45.9(42.8-49.0)** 35.5(32.7-38.4)"* 74.1(70.8-77.1)"*
2016 69.8(67.4-72.1)"* 41.6(39.2-44.0) 40.4(37.4-43.4)*" 26.9(24.6-29.4)** 79.3(77.3-81.3)*"
12th grade
2014 56,8(54.2-59.3)"* 44.1(41.7-46.6)"* 37.8(34.5-413)"* 37.1(34.7-39.5)" 71.9(69.6-74.1)"
2015 64.4(61.2-675)"* 46.8(43.3-50.3)"* 46.8(44.3-49.3)"* 36.9(34.8-39.1)"* 77.0(74.4-79.4)""
2016 70.8(67.9-73.5)"" 41.3(38.3-44.2) 38.7(35.3-42.2) 29.6(27.7-31.6) 79.0(76.5-81.3)-
Schoollevel
Middle school(referent)
2014 52.8(50.9-54.7) 35.8(34,2-37.4) 34.1(32.3-35.8) 25.0(23.8-26.3) 66.4(64.9-67.9)
2015 57.6(55.1-60.1) 39.0(36.3-41.8) 42.8(40.0-45.7) 27.1 (25.5-28.9) 71.1(68.4-73.6)
2016 6S.6(63.9-67.3) 39.5(37.7-41.3) 36.0(33.9-38.1) 20.1(18.9-21.4) 76.9(75.2-78.5)
High school
2014 56.3(54.7-57.9)tt 42.9(41.4-44.4)tt 38A(36.8-40.1)tt 34.6(33.3-36.0)1-t 70.9(69.3-72.4)It
2015 61.9(60.1-63.7)tt 45.4(43.8-4 7.0)1 t 45.7(44.2-47.3)tt 34.1(32.9-35.4)tt 74.5(73.1-75.9)tt
2016 70.0(68.4-71.6)tt 41,6(40.2-42.9) 39.0(36.9-41.2')tt 26.9(25.8-28.0)tt 79.2(77-8-80.6)tt
Current(past 30-day)use of e-cigarettes
Current nonuser(referent)
2014 53.1(51.9-54.4) 38.3(37.0-39.5) 35.5(34.3-36.8) 29.3(28.3-30.4) 67A(66.3-68.6)
2015 59.0(57.1-60.8) 40.9(39.0-42.7) 43.8(41.9-45.8) 29.7(28.5-30.9) 71.9(70.1-73.6)
• 2016 67.7(66.6-68.7) 40.0(38.8-41.2) 37.2(35.6-38.9) 23.5(22.5-24.6) 77.9(76.8-78.9)
Current user
2014 70.5(67.3-73.6)§§ 55.2(52.4-57.05 46.2(43.6-48.8)§§ 41.9(38.6-45.3)§§ 82.6(80.4-84.7)§§
2015 68.4(64.8-7 1.8)§§ 5&8,53.7-59.8)1§ 49.1(46.5-51.7)§§ 41.3(38.6-44.0)§§ 81.8(79.3-84.1)§§
2016 74.3(70.7-77.6)§§ 47.1(43.4-50.8)§5 42.2(39.1-45.4)§§ 28.3(24,8-32.0)§§ 82.8(79.8-85.5)§§
Current(past 30-day)use,other tobacco product"
Current nonuser(referent)
2014 53.0(51.8-54.2) 38.1(36.8-39.5) 35.3(34.0-36.6) 28.8(27.7-29.9) 67.3(66.1-68.4)
2015 59.0(57.2-60.8) 41-2(39.3-43.2) 43.7(41.9-45.6) 29.7(28.5•-30.9) 72.1(70.4-73.8)
2016 675(66.4-68.6) 40.1(39.0-413) 36.8(35.2-38.5) 23.4(22.3-24.5) 77.6(76.6-78.6)
Current user
2014 66.0(63.6-68.4)6§ 50.2(47.5-53.0)§§ 44.2(42.1-46.4)§§ 40.8(38.3-43.3)§§ 79.0(77.0-80.9)§§
2015 66.4(63.6-69.0)0 51.8(48.8-54.7)§§ 49-2(46.8-51.7)§§ 40.0(37.8-42.3)§§ 78.6(76.0-81.0)§§
2016 72.6(69.4-75.6)§§ 44.7(419-47.6)§§ 44.8(41.6-48.0)§§ 28.3(25.8-30.9)§§ 82.7(79.7-85.4)§§
Abbreviation:Cl=confidence interval.
Exposure to each e-cigarette advertisement source was assessed by the following questions:Retail Stores:"When you go to a convenience store,super market,or gas
station,how often do you see ads or promotions for e-cigarettes?";Internet:"When you are using the internet,how often do you see ads or promotions for e-cigarettes?';
Television(TV)/Movies;In 2014,Television/movie exposure was assessed by the question"When you watch TV or go to the movies,how often do you see ads or promotions
for e-cigarettes?"In 2015-2016,onlyTV exposures were assessed:"When you watch TV,how often do you see ads or promotions for e-cigarettes?";and Newspaper and
Magazines:"When you read newspapers or magazines,how often do you see ads or promotions for e-cigarettes?"For all questions,response options included"Never,
Rarely,Sometimes,Most of the time,or Always°A"not applicable"(N/A)response was also included to capture respondents who did not use each advertising source.
Respondents were categorized as"Exposed"if they reported seeing ads or promotions"sometimes;"most of the time,or"always."Respondents were categorized as
"Unexposed"ifthey reported seeing ads or promotions"never,"or"rarely:'Individuals who reported N/A were included in the analysis in the"Unexposed"group.A composite
measure of any advertisement exposure(any source)is assessed based on exposure to retail,internet,television/movies,and print ad exposures.
"Population estimates rounded down to the nearest 0,1 million.
s Significantly different from males at p<0.05 based on paired t-test.
Significantly different from non-Hispanic white at p<0.05 based on paired t-test.
Significantly different from 6th grade at p<0.05 based on paired t-test.
tt Significantly differentfrom middle school at p<0.05 based on paired t-test.
§§Significantly different from noncurrent users at p<0.05 based on paired t-test.
Based on respondents'use of cigarettes,cigars,smokeless tobacco(includes chewing tobacco/snuff/dip,snus,and dissolvable tobacco),hookah/waterpipe,regular
• pipe,and/or bidis on at least one day during the past 30 days.
US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / March 16,2018 / Vol.67 / No.10 297
Morbidity and Mortality Weekly Report
FIGURE 2.Percentage of U.S.middle and high school students who were exposed to e-cigarette advertising,by number of exposure sources*—
National Youth Tobacco Survey,United States,2014-2016
100
❑ One source
❑ Two sources
30 El Three sources
"a All four sources
a
n. 25
x
v
i
C
20
.0.
_ w
O
15
Y 'fit
v
ar 10 �
5-
0
2014 2015 2016
Year
*The four exposure sources were retail stores,the Internet,television/movies,and newspapers and magazines.Movies were removed as an advertising source after 2014.
advertising tactics that have been proven to appeal to youths, or proximity to schools, prohibiting self-service displays, and
. such as themes of romance, freedom, and rebellion.; celebrity requiring face-to-face transactions for all e-cigarette purchases(6).
endorsements;and health claims(5,7).Exposure to e-cigarette Additional potential strategies include regulation of advertising
advertising might reduce youths' perception of harm associ- with demonstrated youth appeal or broad youth reach at retail
ated with e-cigarettes and increase their beliefs that e-cigarettes stores,on television,online,and in print tnedia;and high-impact
can be used where smoking is prohibited (8). Product design tobacco education campaigns that warn youths about the dangers
features might also influence use.. For example, JUUL, the of any tobacco product use,including e-cigarettes(5,6).
top-selling U.S.e-cigarette brand,11 is an e-cigarette shaped like The findings in this study are subject to at least four limita-
a USB flash drive that has a high nicotine concentration (9). tions.First,self-reports of advertising exposure might be subject
According to news reports and social media posts,students are to reporting bias.Moreover,current e-cigarette users might be
using JUUL in school classrooms and bathrooms (9).**'l'r In more likely to recall exposure than nonusers.Second.,the NYTS
addition,e-cigarettes are marketed and promoted using strate- might not be representative of all U.S.youths,because it does
gies that are not legally permissible for conventional cigarettes, not capture those who are homeschooled, have dropped out
including television,sports,and music event sponsorships,in- of school,or are in detention centers.However,data from the
store self-service displays, and advertisements placed outside Current Population Survey indicate that 98.5%,98.0%, and
of brick-and-mortar businesses at children's eye level (5,10). 93.0% of U.S. youths aged 10-13, 14--15, and 16-17 years,
As ofAugust 2016,the Food and DrugAdministration enforces respectively, were enrolled in a traditional school in 2016.1-1
restrictions on e-cigarette sales to minors,including those over the Third,advertising exposure might be underestimated because
Internet.%Additional actions to reduce youths' tobacco access exposure from other potential sources such as sporting events,
and advertising exposure could include requiring that e-cigarettes radio, billboards, or movies was not assessed. Finally, the
are sold in adult-only facilities, limiting tobacco outlet density removal of movies as a source of exposure after 2014 limited the
comparability of television e-cigarette advertisements between
1 hopWells//w%J'arg w.tt-Secud tit.LLC.Nielsen:nimeno AllC7i/wh'Rep LII_in schoong /.18. years.However,this change likely resulted in an underestima-
*`hops:/(www.reddic.comlrljuul/comments/61is7ilwhats_juul_in_school/.
tt hetps://vnvw.youtube.comhvatch?v=CIYQtVsOELY. tion of exposure in 2015 and 2016.
https://www.fda.gov/downloads/7'obaccoProducts/
GuidanceCoinpliance.Regulatorylnfortnation/Retail/UCM520813.pdf. 11 hrips://vAvw.cetisu.-guv/dat-dt:tbles/2016/demo/sc:hool-enrollment/2016-cps.buml.
•
298 MMWR / March 16,2018 f Vol.67 / No.10 US Department of Health and Human Services/Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
Summary Conflict of Interest
• What is already known about this topic? No conflicts of interest were reported.
B-cigarettes arethe most commonly used tobacco product 'Office on Smoking and Health, National Center for Chronic Disease
among U.S.middle and high school students.E-Cigarette Prevention and Health Promotion,CDC.
advertising is associated with e-cigarette use among youths, Corresponding author.Krisry Marynak,KMarynak@cdc.gov,770-488-549.3.
and employs themes and strategies that are similar to conven-
tional cigarette advertising tactics that have been proven to References
appeal to youths. 1.Jamal A,GenrzkeA,Hu SS,et al.'Iobacco use among middle and high
Whatis added by this report? school students—United Srares,2011-2016.MMWR Morb Mortal Wkly
In 2016,an estimated 4 in 5(20.5 million)U.S.middle and high Rep 2017;66:597-603.https://doi.org/10.15585/minwr.mm6623a]
school students were exposed toe-cigarette advertisements 2.Singh 1;Agaku 1T,Arrazola RA, et al. Exposure to advertisements and
electronic cigarette use among US middle and high school students.Pediatrics
from-at least one source,a significant increase over 2014 and 2016;137:e20154155.https://doi.oig/10.1542/peds.2015.4155
2015.Nearly seven in 10 youths 07.7 million)were exposed to 3.Hammig B,Daniel-Dobbs P,Blunt-Vinci H.Electronic cigarette initiation
e-cigarette advertising in retail stores in 2616,while apprbXi- among minority youth in the United States.Am J Drug Alcohol Abuse
mately two in five were lexpos,4on the Internet oir gntelevi•' 2017;43:306-10.hrrps://doi.org/10.1080/00952990.201.6.1203926
slon,and nearly one in four were exposed through r+ewspapers 4.Mancev DS, Cooper MR, Clendennen SI., Pasch KE, Perry CL.
and magazines E-cigarette marketing exposure is associated with e-cigarette use among
US youth.J Adolesc Health 201658:686-90.https://doi.org/10,1016/i.
What"are the implications for public hiedlth practice?. jadohealtb.2016.03.003
As partof comprehensive oath tbbae7co'previfAti6r'efforts,', 5.US Department of Health and Human Services.E-cigarette use among youth
apf1ro86he5f6't uceayou ccesstoe=tijarettesarid s2 and young adults:areportoftheSurgennGenetal,Atlanta,GA.USDepartment
exposure„too veTtising S►ald1hcluderegulation of youth-. of Health and Human Services;,CDC;2016.hops://wwwufc.govltobacto(
>f+ented.mark ting,re t1lGtft�tl ail youth:* k aC das +tistic /s /e c rslpdf/201Gsgenretrr_ 08.pdfcessooaCC - _
6.SinghT,Marynak K,Arrazola RA,Cox S,Rolle 1V,King BA.Vital signs:
products inreta+Isettttlgs and high JplfYactyouth f9dus,e M' exposure to electronic cigarette advertising among middle school and
Xaixaccci education carxi�jns "
high school students—United States,2014.MMWR Morb Mortal W"kly
Rep 2016;64:1403-8.littps://doi.org/10.15585/mmwr.mrn6452a3
Exposure to e-cigarette advertisements increased among 7.US Department of Health and Human Services.Preventing tobacco use
among youth and young adults:a report ofthe Surgeon.General.Atlanta,
U.S. middle and high school students during 201.4-2016, CA: US Department of Health and Human Services, CDC; 2012.
• As part of comprehensive youth tobacco prevention efforts, https://Nvww.cdc.gov/tobacco/data_statistics/sgr/201.2/index.htm.
approaches to reduce youth access to e-cigarettes and exposure 8.Pierce J11, Sargent JD, White Mtv1, et al. Receptivity to tobacco
advertising and susceptibility to tobacco products. Pediatrics
to e-cigarette advertising could include regulation of youth- 2017;139:e20163353.hops://doi.org/10.1.542/peds.2016-3353
oriented marketing, restrictions on youth access to tobacco 9.Hafner J. Juul e-cigs: the controversial vaping device popular
products in retail settings, and high-impact youth-focused on school campuses. USA Today. October 31, 2017. hops://
www.usatoday.com/suni-y/nioncy/tiation-now/2017/1 0/31/
tobacco education campaigns(5).These approaches,coupled. juul.e-cigs-controversial-vaping-device-popular-school-ctmptrses/818.325001/
with comprehensive state tobacco control programs, have 10.Ganz O, Cantrell J, Moon-Howard J, Aidala A, Kirchner TR,
the potential to prevent and reduce youth use of all tobacco Vallone D. Electronic cigarette advertising at the point-of-sale: a
gap in tobacco control research. Tob Control 20I5;24(el):e110-2
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ro baccocon trol-2013-051337
•
US Department of Health arid Human Services/Centers for Disease Control and Prevention MMWR / March 16,2018 / Vol.67 / No.10 299
• MAHB Memo#5
MAHB Position Paper on Need for BOH Supervision and Hiring of Staff
Prepared by Marcia Benes
MAHB Executive Director
Feb. 15, 2004
Elected and appointed Boards of Health have broad statutory authority to protect the public and
environmental health of their community dating back to Paul Revere, who was Chairman of the
first Board of Health in Boston. The CDC has identified ten essential governance responsibilities
for local boards of health, including monitoring health status, ensuring the proper investigation and
diagnosis of health problems and hazards, and informing and educating residents about health
issues. Boards of Health are empowered to respond quickly and knowledgeably to public health
emergencies where rapid response can prevent a bad situation from worsening and to avoid the
bureaucratic delays inherent to government.
As community leaders, board members are also responsible for mobilizing community partnerships
to solve health problems, developing policies that support a healthy community, and enforcing
regulations to protect health and secure safety. Board members must also assure the provision of
health care when otherwise unavailable.
When people eat in restaurants, send children to camp, drink private well water, buy hotdogs from
• a side walk vendor, rent an apartment that loses heat in mid-winter, worry about a chemical spill, or
a cancer cluster in the neighborhood, dispose of their trash or seek flu shots during an epidemic,
they are dependent upon a functioning board of health. It is for this reason the board of health
serves as an arm of the state legislature and is responsible for enforcing state laws and regulations.
The management and oversight role of the board of health is essential to ensure that the health
department is providing necessary services and meeting the needs of all residents. One important
aspect of this is the management and oversight of the professional staff who are employed by the
boards of health to act as their agents. Because these legitimate and essential services often put the
board of health or their agents in conflict with the regulated community, there is often a degree of
tension between the board of health and other members of municipal government. Boards of Health
serve to protect their professional staff from competing priorities and arbitrary, politically
motivated decisions.
One result of this natural conflict has been an increase in municipal efforts to usurp the authority of
boards of health to employ and supervise agents and assistants pursuant to G.L. c.111, §27 and
place the authority in other branches of municipal government. These efforts take various forms.
Some municipalities have amended their charters to provide that the Town Manager retains all
hiring and firing authority (Lexington). Others have utilized, G.L. c.41, §108A, which enables
towns to enact Wage Classification Plans through town meeting. This has been used in Milford in
an attempt to usurp the Milford Board of Health's authority to set the salary of its health agent.
There is no case law to support Milford's position that §108A trumps c.111, §27. In other cases,
board of health agents have been inserted into the"inspectional services" department. Under these
• conditions, BOH agents are supervised by building inspectors who have no expertise in public
health.
This trend to move the hiring and supervision of health agents to another town official, usually the town
manager, inhibits the ability of health agents to perform their jobs. The main argument for this change is
to consolidate management and facilitate communications between departments, but it is unsuportable.
Ironically, this issue comes at a time when the CDC and Congress are increasingly aware of the need to
strengthen the local public health infrastructure. Internet and telecommunications advances have resulted
in a National Health Alert Network which will, when fully implemented, connect every health department
with the state and federal government for routine reporting and crisis management. As Incident Command
Systems become fully integrated into every community as part of enhanced post 9-11 emergency
preparedness, the argument for centralized control by one town-wide appointing authority grows even
weaker.
Boards of Health have a legal and fiduciary duty to protect the pubic health above all else. Other town
officials have other obligations. In looking at issues like homeland security, it is crucial that boards of
health are front and center so that the public health issues surrounding infectious disease outbreaks, such
as when to issue quarantine and isolations orders are dealt with from a public health perspective. One only
needs to look at how and why China failed to respond to the initial SARS outbreak to see why an
independent board answerable only to public health is critical to protecting the public health.
When the board of health loses managerial control over the agents and health directors to a local town
official lacking the statutory responsibility for public health, important public health policies and
enforcement actions are more likely to be viewed through a political lens. Conversely, the board of health
is more likely to hire qualified professional staff, since these individuals are acting as agents of the board,
and the board itself will be generally more responsive to public health issues than other town officials.
People for whom the board of health is the only recourse against health threats and nuisances find
it more difficult to have problems addressed when town officials with no background in public
health intervene, or take a defensive position in favor of the regulated community.
If this trend had occurred 10 years earlier, it is doubtful that the boards of health would have made
nationally recognized progress on tobacco control. Most of our state might still be dining in smoke
filled restaurants, and minors would have easier access to tobacco.
Boards of health have the motivation to attend voluntary certification programs to learn about their
statutory responsibilities and to develop the necessary leadership skills and competencies. At these
programs, board members learn that violations of public health can not be grandfathered or
permitted to continue because of economic hardship. The emphasis is on prevention, whether it be
lead poisoning, food poisoning or groundwater contamination. Based upon what is being reported
to MAHB, other town officials are often more attuned to commercial interests than to public
health, and often view local health regulations and enforcement actions with hostility. For example
the closing of a popular lake due to high coliform levels can result in unfavorable publicity for the
town. In the movie Jaws, local officials were more concerned about attracting tourist dollars than
warning people away from dangerous waters. In real life, this scenario is played out many times
•
• each year in the conflict between restaurant owners and those seeking clean indoor air. It was a
major factor in the initial spread of SARS.
I` In the event of an emergency, it is not difficult to imagine a scenario where the town administrator
would seek to modify or delay the imposition of quarantine or other measures because of
conflicting local interests or because they don't want to "unnecessarily cause a panic". By contrast,
a well informed board of health, in contact with MDPH, CDC and MAHB, working closely with
professional staff, can assist their community by assessing and accurately communicating the risks
of a situation. There is an unbroken link from the CDC through the state DPH, to local boards of
health and their staff which should not be lightly broken.
It is increasingly difficult to encourage qualified people to serve in town government. There is no
incentive for qualified person to run for the board of health or accept an appointment if their agents
work for another individual, or if they retain responsibility when anything goes wrong but no
authority to direct their agents to prevent a problem from occurring. Many public health
professionals recognize the important role of the elected or appointed board of health in protecting
them from political pressure by serving as a buffer between the regulated community and other
members of town government, who often no knowledge of public health issues and policy.
•
•