Category Archives: Asthma

Nov 7 2014

Allergic to Eggs? You Can Safety Get the Flu Shot—and Other Life-Threatening Allergy and Asthma Myths

Major medical conferences often showcase a study, perhaps two, that can change the field of practice and the health for thousands to millions. At this year’s annual meeting of the American College of Allergy, Asthma and Immunology, four studies made such an impact that the College created an infographic to better help share the findings:

  • Many—perhaps even most—people who think they’re allergic to penicillin really aren’t. And taking alternative antibiotics can cost more, be less effective and bring side effects.
  • A study in Chicago found that stocking epinephrine pens in public schools saved lives for more than a dozen kids who had potentially fatal allergic reactions, but who hadn’t been told to carry their own pen. The researchers say the lesson learned is that more schools and other public spaces need to keep supplies of the low-cost devices on hand.
  • Many doctors don’t keep up with the most recent allergy information—which means their patients may not be getting the most effective treatment. For example, 85 percent of internists polled think an egg allergy is a contraindication for the flu shot. Evidence shows the shot to be safe for people with an egg allergy.
  • Some YouTube asthma videos promote incorrect and dangerous alternative treatments for asthma that pose a risk of death if used rather than treatment based on clinical trials and scientific evidence. 
Aug 18 2014

A Public Effort to Help Kids Breathe Easier

This week, NewPublicHealth will run a series on new and creative public health campaigns that aim to improve the health of communities across the country through the use of public service announcements, infographics and more. Stay tuned to learn more about a new campaign each day.

In an effort to reduce missed school days, theEnvironmental Protection Agency (EPA), in partnership with the Ad Council, has launched a campaign to teach parents how to prevent asthma attacks in kids by identifying common asthma triggers. The “No Attacks” campaign urges parents to learn how to control factors that make a child’s asthma worse, use asthma medicines effectively and recognize when to call the doctor.

Asthma affects nearly 9 million U.S. children, with poor and minority children suffering a greater burden from the disease. Asthma can be especially serious in kids because of their small airways.

Through a series of Public Service Advertisements (PSAs) featuring a rock band of puppet characters called the “Breathe Easies,” the campaign includes online videos, radio spots and online banners (available in English and Spanish) with songs about asthma triggers at home, at school and outside. These entertaining messages inform viewers about how to prevent asthma attacks by cleaning up mold, vacuuming regularly and eliminating smoking at home; making sure their child’s school has a plan for controlling cockroaches and other pests, banning furry class pets and minimizing the use of chemical irritants in cleaning products, air fresheners and pesticides; and postponing outdoor sports and other high-energy activities to avoid exposure to high air pollution levels.

“Too many Americans, particularly children, minorities and people living in poverty, suffer from asthma, spending their time at doctor visits and hospitals instead of at school, work and play,” said Janet McCabe, acting assistant administrator for the EPA’s Office of Air and Radiation. By working with the Ad Council and other partners in communities across the country, we can make a real difference in the lives of millions of Americans dealing with asthma.”

Asthma causes U.S. children to miss 14 million school days each year, which is especially worrisome because more frequent school absences are consistently linked with worse academic performance. The good news: “School absences due to asthma can be avoided by appropriate asthma management, including appropriate use of medications and reduced exposure to triggers,” noted a report from the U.S. Centers for Disease Control and Prevention. Since there’s no cure for asthma, preventing attacks—by reducing exposure to environmental triggers and using medications appropriately—is the primary focus of treatment.

The new PSAs stem from The Childhood Asthma Campaign, which was first launched by the EPA and the Ad Council in 2001. Since the debut of that campaign, the percentage of parents who feel they can make “a lot of difference” in preventing asthma attacks has risen from 49 percent to 67 percent, according to the Ad Council’s tracking surveys. The hope is that the new PSAs will improve that percentage even more. 

Aug 6 2012

Public Health News Roundup: August 6

CDC Reporting Uptick in Swine Flu Cases this Year
The Centers for Disease Control and Prevention is reporting a total of 29 cases of influenza A (H3N2) variant (swine flu) virus since July 2011. The virus has not yet been shown to be significantly transmissible to humans, but it contains a variation that was seen in the 2009 H1N1 virus, which raises concern. CDC announced late last week that it is working on a vaccine for the H3N2 and will start clinical trials this year. According to the U.S. Department of Agriculture, the virus may be circulating widely in swine, but has not been shown to be transmissible to people eating properly handled and prepared pork products. Recent cases were found in people who had contact with infected swine at county fairs. CDC is urging anyone who has contact with animals to wash their hands before and after with soap and running water. Additional precautions include:

  • Never eat, drink or put things in your mouth while in animal areas. Don’t take food or drink into animal areas.
  • Young children, pregnant women, people 65 and older and people with weakened immune systems should be extra careful around animals.
  • If you have animals — including swine — watch them for signs of illness and call a veterinarian if you suspect they might be sick.
  • Avoid close contact with animals that look or act ill, when possible.
  • Avoid contact with pigs if you are experiencing flu-like symptoms.

The virus has not been shown to be transmissible by eating pig products. Read more on flu.

Study: Heat is More Deadly Than Other Forms of Extreme Weather
Research funded in part by the National Science Foundation finds that extreme heat may kill more people than hurricanes. Richard Keller, a professor of medical history and bioethics at the University of Wisconsin-Madison, is completing a review of three August weeks of blistering temperatures in Europe in the summer of 2003. He found that 70,000 died of heat-related causes. Many who died were older, poor and lived in poorly ventilated apartments. Keller said the single greatest risk factor for dying during the heat wave was living alone. He said one concern is that public housing is often built with more attention paid toward staying warm in winter than in staying cool in summer. Read more on weather.

FDA Approves Generic Version of Singulair
The U.S. Food and Drug Administration has approved the first generic versions of Singulair for use in adults and children to control asthma and allergy symptoms. The versions approved include tablets, chewable tablets and powder. “For people who suffer from chronic health conditions such as asthma and allergies, it is important to have effective and affordable treatment options,” said Gregory P. Geba, MD, MPH., director of the Office of Generic Drugs in FDA’s Center for Drug Evaluation and Research. “The generic products approved today will expand those options for patients.” Read more on asthma.

Aug 2 2012

Asthmapolis: Public Health Data in Action

Hundreds of people in Louisville, Ky., who regularly use an asthma inhaler will soon be doing much more than just helping themselves whenever they take a puff. Through a demonstration project created by Asthmapolis, an innovative technology firm based in Madison, Wisc., data collected by a sensor in the inhalers of the project participants will help Asthmapolis and city leaders in Louisville better understand when and where people with asthma develop symptoms. The goals of the project are to help identify patients who need more help controlling the disease, and to help identify community-wide asthma triggers that can be improved or eliminated. Enrollment in the project began last month and will last for twelve months for each participant.

Asthmapolis was co-founded two years ago by David Van Sickle, a former Epidemic Intelligence Service Officer with the Centers for Disease Control and Prevention, and a Robert Wood Johnson Foundation (RWJF) Health and Society Scholar at the University of Wisconsin School of Medicine and Public Health. Van Sickle did one of the pilot studies of an earlier version of the technology now in use in Louisville during his years as an RWJF scholar and credits the program with the opportunity to do cross-disciplinary work in order to explore the feasibility of the project and collect the initial data. “I also had access to mentors, such as John Mullahy, Stephanie Robert, and David Kindig, at the School of Medicine and Public Health, to get 360 degree feedback on what I was up to,” says Van Sickle.

In addition to a number of academic trials, Asthamopolis has two key projects underway – the one in Louisville and a similar scale-up in Sacramento where the firm has partnered with Dignity Health and the California Health Care Foundation to see how the technology can specifically benefit the needs of the under-served. Interim results could be available in nine months and published results as soon as next summer.

Van Sickle calls the data being collected in the sensors “a vital sign for asthma,” which is critical he says because we need accurate and reliable information, rather than what doctors and communities must typically rely on, which is self-reported information that Van Sickle says is known to be unreliable. “We want to use technology as a fulcrum to make self-management and monitoring more effective, using a bottom up approach” says Van Sickle.

Significant signals the firm will be looking for include inhaler use at night, an indication of more serious asthma, and symptoms both at home and at work and at all times of day and night—signs of uncontrolled or worsening disease.

Why sensors? “Sensors make the absence of data meaningful, where before it was ambiguous,” said Van Sickle.

While the immediate benefit will be for the hundreds enrolled, the value to entire communities is also a key focus of the company, and of the demonstration project underway in Louisville. NewPublicHealth spoke with Ted Smith, the city’s director of innovation and economic development, who is the spearheading the Asthmapolis project.

Read more

Jun 13 2012

National Prevention Strategy Series: Estelle Richman, Department of Housing and Urban Development

Estelle Richman Estelle Richman, Department of Housing and Urban Development

The National Prevention and Health Promotion Strategy offers a comprehensive plan to increase the number of Americans who are healthy at every stage of life. A cornerstone of the Strategy is that it recognizes that good health comes not just from quality medical care, but also from the conditions we face where we live, learn, work and play—such as healthy homes, clean water and air and safe worksites. The strategy was developed by the National Prevention Council, which is composed of 17 federal agencies including the Department of Education, the Department of Housing and Urban Development and others.

As the Strategy is rolled out, NewPublicHealth will be speaking with Cabinet Secretaries, Agency directors and their designees to the Prevention Council about their prevention initiatives. Follow the series here.

This week, NewPublicHealth spoke with Estelle Richman, Senior Advisor to the Secretary of the Department of Housing and Urban Development.

NewPublicHealth: Why was it important for the Department of Housing and Urban Development (HUD) to be involved in the development of National Prevention Strategy?

Estelle Richman: HUD’s mission is to create strong, sustainable, inclusive communities and affordable housing for everyone. HUD is more than bricks and mortar. We need to get away from thinking that housing is just about putting a roof over your head. It’s your home, and your family’s health and safety and your children’s education are all dependent on where that home is. HUD views housing as a platform for improving a wide range of outcomes.

That’s what makes HUD dovetail perfectly with the National Prevention Strategy; the whole concept of affordability of housing and the quality of neighborhoods and the understanding of that influence on health. HUD invests about $50 billion annually on affordable housing and community development and these investments impact health. We don’t do it alone and none of our partners can do it alone. But together we can bring significant experience and expertise to the table so that we can truly mitigate and help prevent health hazards.

NPH: What approach is HUD taking to address the challenges of health related to housing?

Estelle Richman: One of the most obvious places where we make a substantial difference is the physical environment of housing, including a focus on lead-based paint hazards, mold and pests and all the many things that contribute to respiratory disease, allergies and other illnesses.

Another factor not always immediately connected is housing affordability and health. Many households are now paying more than 60 percent of their income in order to remain in their homes. And if you’re paying a huge amount of your income just to pay your rent or your mortgage, then you’re cutting something else—such as food, health care, medicine and transportation. That puts people at risk for both physical and mental health problems. Children in families that have been behind on rent are more likely to be in poor health, have increased risk of developmental delays and suffer from food insecurity than children whose families are stably housed.

NPH: What are some of HUD’s key initiatives in helping to foster sustainable, healthy communities?

Estelle Richman: We know that physical and mental health depends on sustainable and economically vital neighborhoods where we have access to transportation, good schools, safe places for children to play and places to go shopping for healthy and wholesome foods.

HUD’s Moving to Opportunity for Fair Housing Demonstration Program has shown that moving to better neighborhood environments is associated with improved mental and physical health for adults, lower rates of extreme obesity, lower rates of diabetes, less psychological stress and less major depression for adult women. So being able to stabilize where you live and the quality of your housing can make a difference.

We’re trying to reach some of these same goals through our Choice Neighborhoods Program, which is part of a partnership between HUD, the Department of Education, the Department of Justice, the Department of Health and Human Services and the Department of the Treasury. Choice Neighborhoods actually builds on the success of Hope VI, which was begun in the 1990s and was set up to transform some of the worst public housing by developing mixed-income communities. In Philadelphia, for example, when they were able to switch to Hope VI, you saw a distinctive change in those neighborhoods. Schools got better, neighborhood stores moved in, transportation became more accessible. When we talk about Choice Neighborhoods now, we consider employment assets, quality education, and a wider range of stakeholders, including nonprofits, private firms, local government and public housing authorities.

NPH: What changes can be made to housing and home standards to help improve home and neighborhood safety?

Estelle Richman: We believe the home environment is a major influence on health and well-being and that threats to housing quality include everything from excess moisture, mold, allergens, and poor indoor air quality, to structural deficiencies and lead contamination.

NPH: And what is the approach to minimizing risks such as lead poising from lead-based paint?

Estelle Richman: Our Office of Healthy Homes and Lead Hazard Control is looking at this. We know that housing that was built before 1978 may have lead-based paint, with homes built before 1940 having the highest levels of lead in paint. So it really doesn’t matter if you make a million dollars—if you’re living in a house built before 1978, the odds that there’s lead somewhere in that house is high enough that everyone needs to be concerned about their children. So the standard has to be set high enough that we protect everyone.

NPH: What is HUD doing in the area of secondhand smoke in homes and who are your partners?

Estelle Richman: That is a big agenda items for many divisions of the Department.

Our partners in this are the Housing Authorities, some of the landlords, and just about anyone else who’ll talk to us. My best example of this is the Boston Housing Authority, which is on track to now to implement a total smoke-free policy this fall. They found that their asthma rates were twice as high as those for residents living in non-subsidized housing. They have done a lot of work over the last several years educating themselves, their clients, and offering folks as much support as possible to stop smoking, and now they’re ready to implement a smoke-free policy.

There are several other cities that have announced that they are looking at instituting smoke-free policies—San Antonio, Minneapolis, Portland, Oregon and all of the housing authorities in the State of Maine are among them. We’re offering whatever technical assistance we can to help them do it. We’re working in partnership with HHS, the American Academy of Pediatrics and the American Lung Association and trying to gather many other community supporters.

As we push, I think we will always find folks who believe that they want to continue to smoke, but we’re also finding that there are many people who are ready for smoke-free policies in their housing.

NPH: What are some current efforts of working across sectors to improve housing and better health in that housing?

Estelle Richman: Our Section 811 Project Rental Assistance Demonstration Program is a rental demonstration program to provide housing for people who have disabilities. It provides $85 million in funding to state housing agencies and other appropriate entities to provide long-term housing rental assistance for approximately 2,800 people. Many of these folks will have physical disabilities and will often need assistant care or assistive technology in order to live in the housing, which means that most of them will also be involved with the state Medicaid Agency, as well as their state Health and Human Services Agency.

To develop the program we worked hand in hand with the Centers for Medicare and Medicaid Services. I can’t tell you the number of positive emails I received. People were anxiously awaiting it. It is fully integrated with non-disabled populations, which was critical to the disabled community. To be a part of the program, a state housing agency must partner with the state Medicaid agency to submit a grant. So this is a true partnership. It’s integrated housing, it’s supportive housing and it helps get people out of institutions.

NPH: What are examples of partnerships you have within the Federal government?

Estelle Richman: We meet with our partners at HHS every week. We talk about our joint projects and about projects that we would like to work on together. We’re also a very strong partner with the Department of Veterans Affairs (VA). You may know that we’re working with the VA around eliminating veterans' homelessness by 2015. There is also an HHS part of it so that we can know that our veterans who are coming home not only have good health care, but they also have a place to live. As I’ve said, we all have to have partners and it is, in essence, the core of that partnership that helps us make progress. The National Prevention Council has actually brought these partners together and I credit them for being part of what keeps us working together. It’s very easy in some of these very large bureaucracies to drift off and do your own mission and I think one of the things the National Prevention Council does is help us all realize that we all share prevention, we all work on it together.

NPH: What are some of the other critical partners in communities?

Estelle Richman: In any level of government, the level you need to get to is the level of where the people are. So you need to get down to neighborhoods, you need to get to communities and when you go down in communities, you really need to talk to your hospital and health care systems, community neighborhood groups, schools and PTAs. Also what rises to the top of the page real quickly is transportation. If you have not figured out how to get transportation as a partner then you’re going to have a hard time getting prevention, promotion and health care to work outside the city center.

Each community is different. You need to talk to the folks and get a feel for what’s going to make a difference in that particular community.

NPH: Tell us about the Partnership for Sustainable Communities.

Estelle Richman: It is a multi-partner collaboration among HUD, the Department of Transportation and the Environmental Protection Agency. These two agencies have not always been traditional partners for HUD. Through the Partnership, we are coordinating federal housing, transportation, and environmental investments and looking at things like water infrastructure, roads, sidewalks, transit lines, and job creation opportunities as all of those things are necessary for a healthy and vibrant community life. Several of the Sustainable Communities grant recipients are partnering with the public health sector, including in conducting health impact assessments, increasing access to fresh foods, and encouraging active living that includes opportunities for exercise in one's daily commute and routine. They’re realizing that to improve public health, it’s critical to actually support and create the communities that are not only going to be economically sustainable, but that also maximize environmental, energy-efficient and socially sustainable design and development strategies.

NPH: What had the National Prevention Council brought to the table that was not there before?

Estelle Richman: When you have an initiative like the National Prevention Council, you set goals, you set measurable outcomes and you also have skin in the game of what the big group is doing. You’re held accountable, but you’re asking to be held accountable. And it’s not accountable to your silo, it’s accountable to the larger group.

And I think it’s that choice of accountability to the larger group for health care that affects all of us. The concern about health care is not an issue just for struggling families or folks in foreclosure or families that are in the lower incomes. Health care is something we are all concerned about. In the end, it holds us all accountable for better communities.

>>Catch up on the rest of the National Prevention Strategy series on NewPublicHealth.

Jun 1 2012

Public Health News Roundup: June 1

Cancer Rates Predicted to Soar Worldwide by 2030

Cancer cases are expected to increase 75 percent throughout the world by 2030, according to a new study published in Lancet Oncology. In the poorest nations, cancer cases could increase by 90 percent.

The study, which used 2008 data on 184 countries from the International Agency for Research on Cancer, finds that while cases of cervical and stomach cancer may be declining, other types of cancer including colorectal, breast and prostate cancer are increasing, likely because of lifestyle changes including higher fat diets and less exercise.

The researchers also say current smoking rates in poorer countries could mean higher lung cancer rates in the future. Read more on global health.

USDA To Test for Six Additional E. coli Strains in Beef

The U.S. Department of Agriculture (USDA) Food Safety and Inspection Service (FSIS) will begin a zero-tolerance policy for six additional strains of E. coli in raw beef starting Monday June 4. FSIS will routinely test raw beef for the six additional strains. If contamination is found the beef cannot be sold, and distributed meat will be recalled.

The additional strains can cause severe illness and even death especially in young children, older adults and people who immune system is weakened. Read more on food safety.

Smoking in Pregnancy Can Impact Children in Teen Years

Black and Latino children whose mothers smoked during pregnancy are more likely to suffer from acute asthma symptoms in their teens than asthma sufferers whose mothers did not smoke, according to a new study by researchers at the University of California at San Francisco. The study was published in the Journal of Allergy and Clinical Immunology.

The study looked at data on 2,500 Latino and Black children with asthma between the ages of 8 and 17 and found that if mothers smoked while pregnant, their children had about a 50 percent increase in uncontrolled asthma, even when other factors such as income and exposure to secondhand smoke were taken into account. "Kids who are 17 years old still show the effects of something they were exposed to during the first nine months of life," says Sam S. Oh, PhD, MPH, a postdoctoral scholar in epidemiology at the UCSF Center for Tobacco Research and Education, who is the lead author on the study. Read more asthma news.

May 31 2012

Asthma: A Plan to Eliminate Disparities


Several federal agencies, including the Environmental Protection Agency, the Department of Housing and Urban Development and the Department of Health and Human Services, have released the Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities.

Of the seven million U.S. children with asthma, minority children and poor children are impacted disproportionately. Black and Puerto Rican children, for example, are diagnosed with asthma at double the rate of white children.

The inter-agency task force will focus on bringing together all of the difference sectors that need to take action to make a difference in reducing asthma disparities, including transportation, agriculture, housing and more.

“You can get great care for asthma at your doctor’s office, but it won’t do much good if they don’t know how to treat it at your school,” said HHS Secretary Kathleen Sebelius in a speech launching the task force. “And you can have a great community health center down the street, but it will be hard to stay healthy if the air in your neighborhood is polluted.”

The goal of the action plan is to coordinate efforts to improve asthma management and prevention, including:

  • Reduce barriers to asthma care.
  • Build local capacity to deliver integrated, community-based asthma care systems.
  • Identify the children, families and communities most impacted by asthma disparities.
  • Increase understanding of the cause or causes of asthma and test interventions that may prevent the onset of asthma.

>>Read the action plan.

>>Read a post on Washington Post’s The Root DC Live blog by Nadine Gracia, MD, deputy assistant secretary for minority health (acting) in the Office of Minority Health at the Department of Health and Human Services.

>>Read an update on the plan from Kaiser Health News.

May 25 2012

Public Health News Roundup: May 25

States Using Too Little of Tobacco Revenues for Cessation Programs

A study in the current Morbidity and Mortality Weekly Report, published by the Centers for Disease Control and Prevention (CDC), finds that states have spent a very small percentage of their tobacco tax revenues on programs to prevent kids from smoking and help smokers quit. From 1998 to 2010, the states collected a combined $243.8 billion in revenue from legal settlements with the tobacco industry and from cigarette taxes, but appropriated only $8.1 billion for tobacco prevention and cessation programs, or just 3.3 percent of the states’ tobacco revenues and less than 28 percent of the CDC’s recommended amount. States that made investments in comprehensive tobacco control programs have seen cigarette sales drop about twice as much as in the nation overall, according to the report.

According to the Campaign for Tobacco-Free Kids, it would take less than 15 percent of total state tobacco revenues to fully fund tobacco prevention programs in every state. Read the latest tobacco news.

Read more

May 14 2012

Public Health News Roundup: May 14

Fitness in Middle Age Can Mean Lower Health Costs Later On

Physically fit, healthy middle-aged adults have significantly lower health care costs as they age, compared to their less physically fit counterparts, according to research presented at the American Heart Association’s Quality of Care and Outcomes Research 2012 Scientific Sessions.

The study tracked Medicare coverage in 20,489 healthy people, who had not had a prior heart attack, stroke or cancer over a ten year period. Compared to people in the lowest fitness category, those in the highest categories at age 51 had significantly lower healthcare costs after age 65. Read more on physical activity news.

Young People Still Getting Sunburns and Indoor Tans

Young adults are increasing their risk for developing skin cancer, according to two studies by the Centers for Disease Control and Prevention and the National Cancer Institute.

One study, of people aged 18-29, found that 50 percent reported at least one sunburn in the past year, despite an increase in protective behaviors such as sunscreen use, seeking shade, and wearing long clothing to the ankles. Another report found that indoor tanning is common among young adults, with the highest rates of indoor tanning among white women aged 18 to 25 years. Read the latest on cancer prevention.

Prenatal Smoking Linked to Worse Asthma in Kids

Children whose mothers smoked during pregnancy may have more uncontrolled asthma, according to a new study in the Journal of Allergy and Clinical Immunology. The study was conducted on nearly 2,500 largely black and Latino children ages eight to 17. Close to 20 percent of mothers of Black children, and 5.5 percent of Hispanic mothers, smoked while pregnant and the study found that those children had a harder time controlling asthma symptoms. Read up on asthma.

May 4 2012

Public Health News Roundup: May 4

Asthma in U.S. Now at Highest Levels

A new report from the National Center for Health Statistics finds that asthma prevalence in the U.S. increased from 7.3% in 2001 to 8.4% in 2010, when 25.7 million persons had asthma. Those are the highest levels of the condition ever reported in the U.S.

Additional findings include:

  • For the period 2008–2010, asthma prevalence was higher among children than adults, and among multiple-race, black, American Indians or Alaska Natives, than whites.
  • For the period 2007–2009, blacks had higher rates for asthma emergency room visits and hospitalizations than whites, and a higher asthma death rate. Compared with adults, children had higher rates for asthma primary care and emergency room rates, similar hospitalization rates, and lower death rates.

May is Asthma Awareness Month. Read more.

CDC Issues Guidance on Helmet Protection during a Tornado

The Centers for Disease Control has released a statement that says that the agency does not have research on the effectiveness of a helmet to prevent head injuries during a tornado, but acknowledges that head injuries are common causes of death during tornadoes and that people may decide to use helmets to protect their heads.

However, the agency points out that the time to react when a tornado is imminent may be very short, so people who opt for helmets should know where they are as part of a preparedness plan, and not use them as an alternative to getting to a shelter.

Read more on preparedness.

Social Media Use on the Rise at State and Local Health Departments

The Nation’s Health, a newspaper published by the American Public Health Association, has released a new survey of 200 local and state health departments that found that 56 percent of state and 53 percent of local health departments used Facebook to communicate, an increase from earlier surveys. About 180 departments use Twitter accounts.

Read more on state and local health departments.