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Homeless Shelter I William F.Weld Governor Charles D.Baker Secretary David H.Mulligan Commissioner To: From: Re: Date: w, . %aMaid%,Waz'f 00artmenb l2& greea/t% ftatr✓ ioratorr5stlt.rtei 305 t ortat ee4 2oston4.UU 02130-3597 617-522-3700, Eat. 617-522-8735 'Si F , 'F♦ M E M O R A N D U M Bureau of Communicable Disease Control All Hospitals, Clinics and Other Facilities Delivering MDPH Outpatient TB Services Edward A. Wardell, M.D. , Tuberculosis Controrfficer Massachusetts Department of Public Health Precautions to Prevent TB Transmission in the Outpatient Setting, Especially TB Clinics ^ August 18 , 1994 This memo is prompted by several inquires regarding appropriate precautions to prevent TB transmission in TB Clinics. The October 12, 1993 CDC Draft Guidelines published in the Federal Register address out-patient settings. The guidelines focus mostly on the in-patient side where most TB outbreaks have been documented. The potential for transmission is greater in hospitals and long-term treatment facilities because the duration of exposure is longer, because patients are sicker and more likely to have unsuspected TB, and because those exposed are also sicker and more susceptible to infection. We are in basic agreement with the CDC recommendations for out-patient settings, which focus on the triage of symptomatic persons who might have contagious TB to separate rooms designed to reduce the risk of airborne transmission. Note, however, that patients who visit TB clinics are usually not symptomatic, often being evaluated for a positive PPD only, or having known tuberculosis and on therapy. There is good reason to believe that TB clinics are far lower risk sites for TB transmission than emergency rooms, medical walk-in clinics, HIV-Clinics, and many other sites where unsuspected cases might be present. Because TB Clinic patients usually have had chest x-rays, unsuspected TB is far less likely than in other clinics and emergency rooms. In the last decade there have been no staff PPD conversions in the Cambridge TB clinic, and only one known conversion at the BCH TB Clinic, two of the busiest clinics in the state. Even on the in-patient side, known TB cases on therapy appear not to pose as much risk as unsuspected cases. There have been no PPD conversions among the staff of the Lemuel Shattuck Tuberculosis Treatment Unit where non-compliant and drug-resistant cases are treated. Transmission is possible in any setting, of course, but the precautions applied to TB clinics should be similar to what is a applied to other ambulatory settings. Special precautions should not be applied to clinics by category, but should be applied to symptomatic patients at risk for TB - wherever they are seen. The Draft guidelines do not require or suggest negative pressure isolation rooms for all patients in TB clinics. Rather, they recommend that appropriate isolation rooms be available for persons suspected of having contagious TB in all settings. The Draft Guidelines recommend some common sense approaches, some of which are amplified here: 1) Not scheduling TB Clinic simultaneous with HIV Clinic, neonatal clinic or any especially bpeientsa 2) registering for care,Triage procedures (questions)estions) for all patients to detect potential cases of contagious TB. 3) Administrative efforts to reduce waiting time. 4) Attention to environmental control measures: a) Adequate space so that patients are not crowded together in waiting rooms. b) Building ventilation that meets AIA or ASHRAE standards for health care facilities for total air turnovers and outdoor air. c) Consideration to reduce room probabilityet of (UV) borne infection by using upper in waiting areas, corridors and examination rooms - wherever unsuspected TB cases are likely to spend time. The greater the coverage area for air disinfection, the greater the likelihood of preventing transmission from unsuspected cases. Good air mixing in rooms with UV is required. d) For areas where upper room W is not possible, due to low ir ceilings or other factors, fan-filtration tonctirn fan add air disinfection devices may supplement "equivalent" air turnovers to existing ventilation. Note:currently lrecommended d environmental control technologi s. However,and upper room to oUV are c ventilation, all potentially useful for specific settings. l • Baystate Medical Center tranOrr nl lta'snO•llr:,l0"O:rrur� :Vrh�plir'J. Nu.3acln,Nwx 01 EMI I 11-7114.110110 NAME TO: COMPANY: a1�-t �YrKxfiLi XIG 1 +-E FAX NO: je _ /016 tL PRONE NO: 5$6 - 695-0 Fyfi d1/lo txA:e*A*RAA AA SR R W Aft RRRA****S** A *ARARARA******* RAARRR RA■AA kSR RAR x AA A***A*R FROM: IMCIOPSS/ 6'/-C-&t-tc i_ FAX NO: %dz, fla B PHONE NO: 754.— S'70 S- NUMBER OF PAGES INCLUDING COVER SHEET. u.a596p C9, • Baystate Iedical Center t i/rrvd(pt r I ((I Po.uvi �IrrpGrkI. 1l;4.Nothw4yH II I 109 413-711 441000 NAME TO: COMPANY: cdt, �> � . Baystate Medical Center funk,'of Baystate Health Systems Vnrinsncid.MossovhusCtts DI198 413.784-000e T.B. CLINIC CRITERIA People that need appointments scheduled: 1.) Anyone under age 35 with a positive PPD must be booked_ 2.) Recent converter(fromnegative to positive) 3.) Abnormal chest x-ray 4.) Symptomatic: a. weight loss b. night sweats c. cough d, fever 5. Methadone patients,no matter what age,can come in even if the PPD is negative. Anyone over an 35 with a positive PPD does not have to be seen in the clinic unless they are *911611 RISK" *HIGH RISK= 1.) HIV patients 2.) Methadone patients 3.) Foreign born 4.) Inmates 5.) Health care workers 6.) Homeless If they do not fall into the`HIGH RISK"category, a chest x-ray needs to be ordered and a refenal.form sent at that time. These referrals are for review only. Please check off the appropriate box on the referral form: Needs appointment Review only ALL referrals need to be filled out to the BOLD line. Please call the T. B. Clinic at (413)784-5435 if you have any questions. Thank you. Date: BOARD OF HEALTH CITY HALL COMPLAINT RECORD Time: Parcel: Name of Complainant: Address' Owner: Taken by: Date of Inspection: Time: Inspector Signature 0 FAX Date: Nov. 18, 1997 Number of pages including cover sheet 5 To: City Solicitor Janet Sheppard Phone Fax Phone CC: 586-2937 From: Northampton Board of Health 210 Main Street Northampton,MA 01060 Peter J.McErlain,Health Agent Phone Fax Phone (413) 587-1213 (413)587-1264 REM RES: ❑ Urgent For your review Reply ASAP I wanted to keep you posted on a potentially major problem. n Please comment The Board of Health has received a complaint, from the neighborhood opposition, concerning the amount of sleeping space provided for each occupant of the Cot Program Shelter at 123 Hawley St. While I won't be conducting an inspection until Wednesday morning(11/19/97), I have checked with the Building Inspector's office and found that bases on the submitted plan, there is adequate sleeping space for 16 occupants. (Actually 15.6 persons bases on the 50 sq.ft./person specified by Sec. 410.400(B)). There are reportedly 18 beds available at the shelter. Attached please find excerpts from Chanter II State Sanitary Code 105 CMR 410.00 which will be used as the basis for ordering a reduction in the number of to 16, if necessary. I will consult with you before issuing any orders. Please feel free to call with any questions. • AT LARGE WARD COUNCILORS Patrick M.Goggins Mary Clare Higgins 1 Judith I. Fine 2 Edwin J. Scagel 3 Maria rymoczko 4 Michael R. Bardsley 5 Linda M. Desmond 6 Brian D. Harrington 7 George E. Quinn Mr- Bruce Shallcross, President Three County Fair Association Three County Fairgrounds Northampton, MA 01060 Dear Mr. Shallcross: CITY COUNCIL CITY OF NORTHAMPTON MASSACHUSETTS August 22, 1997 As City Councilor from Ward 3, I'm writing to give some feedback about the Warped Tour Concert held last month at the Fairgrounds and to open a dialogue about future directions. You are aware, no doubt, of the fact that before the Fair signed a contract with the Warped Tour promoter, Jon Peters, both Charlie Mazeski and Bob Czelusniak had conversations with me. To both of them I expressed my personal preference that we not have rock concerts inflicted on the neighborhood and to both of them I expressed my sense that the neighborhood was strongly opposed to such concerts at the Fair. We discussed the Fair's desire to find other ways of bringing in revenue, now that the entertainments and events traditionally held at the Fair- grounds are no longer so lucrative. I expressed my recognition that the Fair is an important pad of the vitality of Northampton and indicated that I hoped we could find a win-win solution to the Fair Association's desire to expand its repertory of activities and the neighborhood's desire to live peacefully. Regarding the Warped Tour itself. I indicated that I thought the key to a successful event would be responsiveness to neighborhood concerns in three areas: safely, traffic, and noise. Now that the event has passed and neighborhood response has been voiced, I believe we can look back on it from somewhat of a distance and begin to assess its areas of success and failure. The following represent what I see as Councilor from Ward 3- I. Communication. I appreciated having been consulted before the contract was signed, such that some neighborhood concerns were built into the contract written with the promoter. Moreover, when I initiated a telephone call to Charlie Mazeski the day before the concert, I appreciated the cooperative interaction that resulted. Mr. Mazeski arranged to make various modifications in the plans that I believe were beneficial on the day of the concert itself, such as, for example, the presence of traffic police from an early hour in the morning, so as to try to prevent accidents of the type that blocked Bridge Street before the Warped Tour in 1996 for almost an hour. Mr. Mazeski also agreed to hold the promoter to a 7:30 closing time, the time originally agreed upon. The problems with communication were two-fold. In the spring, I was told that before the concert a meeting (complete with refreshments) would be held with the neighborhood to elicit suggestions and to hear concerns. That meeting was never held. Second, it had been agreed that during the event neighbors could call the Fair telephone number and that a special mobile telephone would be used to take calls and to respond to all complaints. During the event both neighbors and the police Maria Tymoczko-- 2 found that the Fair telephone number was constantly busy. Hence the Fair was unreachable directly for large stretches of time and neighbors were in the position of having to call either the Police or their City Councilor. Clearly this issue of communication during the day of the event needs further work, such as the installation of more lines. I would appreciate being informed as to how this prob- lem will be approached during future events. One area of success in communication during this concert was the coordination of citizen complaints to the police with the team at the site. Unlike last year at the airport, this year the police did for- ward all complaints to the concert team; I believe that citizens felt less frustrated accordingly, even though the substance of their complaints was not always satisfactorily resolved. A further area in which communication could be improved regarding a major event like the Warped Tour would be a "debriefing" session after the event, bringing together promoters, Fair personnel, police, and representatives of the neighborhood, so as to share information and plan for improve- ments in the future. To sum up: an important part of the success of communications in the future is consultations before the event with the neighbors and the Councilor, adequate telephone access during the concert, and coordination of complaints to the police with the on-site team. It will also be helpful to have a "debriefing" session after the event, so that arrangements can improve from year to year 2. Security. Neighbors reported no problems to me regarding security. There was general satisfac- tion with crowd management and a consensus that the event was much more orderly than the Warped Tour was in previous years, not to mention the disastrous event in 1977. Thus, the area of security seems to have been highly successful, and particular commendation is due to the Fair and the Police, given that the Warped Tour concert was more than twice as big as in previous years and considerably bigger than was anticipated and specifically provided for. 3. Traffic and Parkinp. In general parking was well managed and cars were well directed toward the parking lots provided by the Fair. Most streets in Ward 3 were posted with temporary no- parking signs, thus relieving the neighborhood of an "invasion" of parked cars. Some parking problems did occur on North Street, Elizabeth, and Orchard, and in some cases, when the street was dangerously narrowed, cars were towed. This problem should be anticipated in the future and rec- tified with those streets being more adequately posted with the temporary no-parking signs. Regarding traffic, the traffic was well routed onto main streets, so that most streets in Ward 3 were not unduly impacted. The traffic problems were, therefore, city-wide rather than specific to the Ward, and it may be that dialogue needs to be established with the Mayor's office to see if improve- ment needs to be made. As Ward 3 Councilor I received complaints from residents of Bridge Street who reported that their street was tied up in both directions for about 3 hours total, making it difficult even to exit their driveways for necessary errands, expeditions, doctors' appointments, and so forth. It may be that in the future traffic problems such as these could be relieved by developing strategies with the pro- moters to open the gates a couple of hours earlier than the music begins, featurin&demonstrations, say, of skateboarding and other such "quiet" events before the concert itself, thus drawing the crowds in over a longer period of time. I believe that it was helpful to put the headliners on around 5-5:30, thus encouraging some guests to depart before the closing of the event. Even so, it took about 60-90 minutes to empty the parking lots at the end of the day, and residents complained about a good deal of horn-honking for more than an hour. This may be a problem that can be addressed Maria Tymoczko--3 by security personnel or even by Ieafetting cars as they enter to park, asking them to refrain from blowing horns at the end of the concert. Obviously there was an unanticipated traffic problem on 1-91 itself, for which the State Police were called. This, no doubt, will be anticipated in the future. I am still awaiting police reports on accidents associated with the event, so I cannot comment defini- tively on that issue, either positively or negatively. 4. Noise. The least successful aspect of the event was noise levels. Most of the complaints directed both to the police and to myself had to do with noise. It is not an exaggeration to say that many of the neighbors are incensed about the noise level, and this is a concern that must be vigorously addressed if the event is to be repeated in the future. The noise apparently impacted the ward differentially. Some areas (where sound was blocked by buildings) were not unduly affected. Other areas, notably in most of the neighborhood south of Bridge Street, as well as in the direction of Old Ferry Road, had sound levels that were at unacceptable levels. I cite the following complaints that I received to indicate the range of problems reported to me: --a constituent called to say she could not conduct her work (which involves paper work and reading)because the sound was so intrusive; --a constituent on Holyoke Street(approximately 3400 feet from the Fairground grandstand, or two-thirds of a mile)called to say that he could hear every word of every song and that the noise made it impossible for him to work at home; --a constituent north of the Fair called to say that, although crowd and traffic control were great, the volume of the sound was "unbearable"; --a constituent who conducts her business at home informed me that, though she does not normally get headaches, by 4:30 her head was pounding; she was not able to conduct her busi- ness and felt driven out of her home; --in my own case I can report that although I live approximately 2000 feet(almost half a mile) from the infield of the Fairground, I found the sound levels exhausting; my 19-year- old did not feel he needed to go to the Concert because he could hear the music perfectly from his bedroom, even identifying every band and every song title. It is my understanding that the police received a dozen complaints regarding noise, approximately twice what they received last year. At present I have still not been provided with the police log indicating the source of those complaints, but I am sure that the distribution of them will indicate areas of the Ward that were most troubled by the issue. Clearly such sound levels are unacceptable, and the neighborhood is entitled to protection from this sort of intrusion and, as in some cases, "assault" from the noise. I am most concerned about the inability of people to conduct their livelihoods and about the people who reported feeling physically ill. In a "debriefing" session after the concert, the Chief of Police and I discussed what can be done about noise pollution from concerts at the Fair, and I have been pursuing this line of inquiry since. We must find a way to move beyond "subjective" determinations of what constitutes acceptable sound levels: one mans meat is another man's poison. It is my understanding that the Fair sent a truck to investigate sound levels on Pomeroy Terrace and concluded that the noise levels did not need to be adjusted--even though those same noises were making it impossible for others further away to conduct their work. Obviously we need a way out of this impasse. Maria Tymoczko--4 There are laws on the books that govern sound pollution. State DEP guidelines define sound as an "air contaminant" and as such a cause of air pollution which in turn is defined as "the presence in the ambient air space of one or more air contaminants...in such concentrations and of such duration as to: (a)cause a nuisance; (b) be injurious or...potentially injurious to human...life...; or(c) unreasonably interfere with the comfortable enjoyment of life and property or the conduct of busi- ness." Noise in turn is "sound of sufficient intensity and/or duration as to cause or contribute to a condition of air pollution". DEP laws specify that police departments are entitled to enforce these laws and specify further restrictions about noise that transcends the boundaries of a single city (as the Warped Tour does, because it is audible to Hadley residents on Aqua Vita Road, for example, from whom I have heard complaints). I would also bring your attention to DEP guidelines which specify that violations of noise regula- tions exist when sound levels are increased by more than IOdB(A) above ambient levels, as measured at the property line or at the nearest inhabited residence. OSHA also has regulations that indicate objectively levels of sound that are detrimental and that people should be protected against. Finally, Northampton itself has zoning ordinances specifying that decibel levels during the daytime are not to exceed 60 decibels in residential areas, 65 decibels in business, commercial concerns, and institutions, and 70 decibels in the case of general industry. The Three County Fair falls into the category of business, commercial concerns, and institutions, and is, thus, expected to keep sound levels to 65 decibels, as measured at the property line. Clearly, by all these definitions, the Warped Tour caused noise and air pollution: causing a nuisance to neighbors, causing neighbors to feel ill, and interfering with the enjoyment of life and property and interfering with the conduct of business. Given the sound levels reported on Holyoke Street and Pomeroy Terrace, the concert also apparently violated increases permitted by the DEP over ambient levels, as well as absolute levels specified in Northampton's ordinances. This issue of protecting Ward 3 from undue noise from the Fair must be taken seriously. Citizens are entitled to such protection under the law and the Northampton Police, as well as the Building Inspector, are those designated to provide such protection. How do we go forward from here? Clearly some adjustments can be made in the areas of communication, safety, and traffic control, but the major problem that must be addressed is that of noise. Although the Three County Fair is grandfathered under zoning laws for many of its activities, rock concerts are not convered by the charter. If the Fair wants to expand in the direction of concerts, I believe it most do so in ways that are respectful of the neighborhood. I reiterate that I would like to see a "win-win" solution to the prob- lems posed by Fair activities for the neighborhood; clearly we have not yet achieved such a win-win solution. It would be unfortunate, I believe, for neighbors to feel that their only recourse is Litigation--either challenging the Fair's right to hold rock concerts and other non-traditional, non grandfathered events altogether, or challenging the Fair on specific violations of noise and air pollution. In my discussion with the Police Chief after the event, he and I discussed approaches to be taken. One thing that has become evident is that decibel meters are needed to move response to noise complaints from the subjective to the objective level; probably both the Police Department and the Fair Association should buy these instruments. It is my understanding that the costs are not high--roughly about $500.00. Second, as Chief Sienkiewicz expressed to me, it would be far preferable to see the Fair Association move toward voluntary accommodation to the neighborhood and voluntary compliance with regulations governing noise. This might be achieved by the Fair writing into contracts with concert promoters specifications that their events will not violate DEP and Northamp- ton guidelines and ordinances. Maria Tymocko-- 5 I would welcome a meeting with the Fair Association, a meeting at which we might include the Police Chief, the Mayor, and various members of the City Administration, to discuss these issues and move toward better working relations between the residents of Ward 3 and the Three Country Fair. In the meantime I hope that these concerns will be brought to the attention of the promoters of the Jazz Festival to be held at the Fairgrounds in three weeks and that the Fair Association will itself move decisively to prevent neighbors from being bothered by noise that weekend. Sincerely yours, 1 caeca Maria Tymoczko Councilor for Ward 3 cc: Mayor Mary L. Ford, Councilor Patrick Goggins, Councilor Care Higgins, Former Councilor Leonard Budgar, Police Chief Russell Sienkiewicz, Captain Michael Wall, Anthony Patillo, Wayne Feiden, Peter McEr- lain, residents of Ward 3 WILLIAM P.WELD Governor ARGEO PAUL CELLUCCI Lieutenant Governor JOSEPH GALLANT Secretary DAVID H.MULLIGAN Commissioner The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street Boston, MA 02130-3597 617-983-6200 TO: Boards of Health and TB Care Providers FROM: Sue Etkind, R.N., M.S., Director Division of Tuberculosis Prevention and Control RE: 1996 Annual TB Statistical Report DATE: August 5, 1997 Appended, for your information, is the 1996 Annual TB Statistical Report. This report is compiled each year from information collected by health care providers, health departments, hospitals, and others involved in tuberculosis follow-up. In 1996, 262 cases (case rate of 4.35 per 100,000) were reported. This represents a 21 % decline from the previous year and reflects a continued, concerted effort by everyone involved in the effort to eliminate tuberculosis from the Commonwealth. Also included in this mailing are the following: the new policy for monitoring isoniazid (INH) toxicity in patients treated for TB infection and disease; the most recent TB staff list and related phone numbers and the most recent TB educational resource list/ order form. We thank you for your interest and involvement in tuberculosis control and look forward to continuing to work collaboratively in the future. Please feel free to call us at any time (617) 983-6970. INTRODUCTION Masscchusetts is ranked 30th in the United States in terms of the incidence of tuberculosis. In 1996, 262 cases (case rate of 4.35 per 100,000 population) were verified. This represents a 21 % decline since 1993 and a 39% decline since 1992. As in previous years, certain groups continue to be at much higher risk than the population as a whole. These groups are: the foreign born; the homeless; the HIV infected; injection drug users; children; the elderly; and Minority communities. This report, consisting of Uata from several sources, is a summary and analysis of calendar year 1996 tuberculosis (TB) morbidity. Tuberculosis morbidity information is collected from health care providers, including health departments, hospitals, private practitioners and other health care providers in community settings. The Division of Tuberculosis Prevention and Control, in conjunction with the local health departments, is charged with all aspects of TB control. This report also highlights Division activities during 1996 in the areas of epidemiology, case management, prevention services, clinical services and education and training. Recognition and gratitude are extended to the field staff, local health department staff, the American Lung Association of Massachusetts and it's affiliates, hospitals, nursing homes, physicians and the many other providers who are dedicated and committed to tuberculosis control. Through combined efforts, we can continue our successful efforts toward our goal of TB elimination in Massachusetts. Alfred DeMaria, Jr., M.D. E E rk LAOC nd, M.S Edward A. Nardell, M.D. Kenedy Mondesir Joanny Perez Antonio Ramos Bill Wong Leandro Fortes Yin-Chun Leung Juan Valerio Leonora Gonzalez Xue Zhi Sun CONTACT PROGRAM Joseph Pike, R.R.A., M.A. EPIDEMIOLOGY Sharnprapai, M.S. Matthew Kay Kathleen Lupien Ruth Pescatore Linda Thistle Debra Beausoleil Kathy Hendricks Blanca Cintron Ann Miller, M.P.H. April Tan POLICY & COMMUNITY SERVICES. Linda Singleton, R.N., M.P.H. Trish Gedarovich, R.N., M.P.H. Joseph Decinti Carmen Gorman Judy Martinez Sharon Penn-Medley Vacancy Marilyn Del Valle Vacancy Armando Gonzalez Meg Harding, R.N. David Fadden, M.P.H. TSA 2 TSA 3 TSA 3 TSA 3 TSA 4 TSA 4 TSA 4 TSA 5 TSA 5 Epidemiologist Director of Epidemiology Research Analyst Ill TSA 1 TSA 3 TSA 2 TSA 5 Research Analyst I Biometrician I Epidemiologist (RFLP) Biometrician (RFLP) Director of Policy & Community Services Assistant Director Program Coordinator Community Services Coordinator Community Services Coordinator Contracts Specialist Biometrician Program Coordinator, Prison Project Outreach Worker, Prison Project Outreach Worker, Prison Project TB Skin Testing Project, Program Coord. Research Analyst Skin Testing Project ADMINISTRATION I Sue Etkind, R.N., M.S. Edward A. Nardell, M.D. SUPPORT STAFF! Denise Lancto Cathy McGeown Vacancy Evelyn Thomas Constance Parke Mary Mahoney Anne Bernard IEDUCATION &TRAINING Kathleen Hursen, R.N., M.S. STAFF LISTING Division Director TB Control Officer PATIENT MANAGEMENT SERVICES Janice Boutotte, M.S., R.N., C.S. Josie Ford, R.N. REGIONAL NURSING STAFF Carol Cahill, R.N. Jo-Ann Keegan, R.N., M.S. Nancy (Taylor) Flynn, R.N., B.S. Vacancy Community Outreach Josie Ford, R.N. Vacancy Evelyn Rodriquez Wally Rivera Eddy Bien-Aime Administrative Assistant II Clerk Ill Clerk Ill Secretary/TSA 1 Secretary/TSA 3 SecretaryfTSA 2 Secretary/TSA 5 Director of Education & Training Director of Patient Management Services Assistant Director TSA 1 Nurse TSA 2 Nurse TSA 3 Nurse TSA 5 Nurse Outreach Program Manager Outreach Program Assistant TSA 1 TSA 1 TSA 5 1996 Tuberculosis Cases Overview Goals: To provide detailed description and analyses of trends in Tuberculosis (TB) cases in Massachusetts in order to identify and characterize populations at greater risk for TB. Notc. Case rates prior to 1990 were based on estimated population projected for each of those years, with the exception of case rates for race and ethnicity which were calculated using 1990 census population data. From 1990 through 1996, case rctec were calculated using 1990 census population data. All case rates are based on 100,000 population. A. Demographic Analysis In 1996, 262 cases (case rate 4.35) of TB were reported to and verified by the Division of TB Prevention and Control. This represents a 21 % decline from 1995 and a 39% decline since 1992. Between 1989 and 1992, a resurgence of TB occurred in Massachusetts, however, that trend has been reversed and Massachusetts is close to achieving the Healthy People 2000 objective case rate of 3.5 per 1000 000 population. UNITED STATES* AND MASSACHUSETTS TUBERCULOSIS CASE RATES 1975 - 1996 PER 100.000 )5 7B at 84 87 YEARS 96 6 4 2 0 —US --MA —2000 OBJECTIVE MOPUIDIYISION OF TB 'US Raw Not Yet Available The TB Division has designated communities with a) a seven year average case load of more than 4 and b) a seven year average case rate above the state case rate to be at a "Ligher risk" for TB. In 1996, Massachusetts had 15 communitids that met this definition (appendix 1 ). These 15 communities account for 68% of TB ccse. in Massachusetts. Boston continues to be the community with the highest prevalence of TB cases (87 cases, case rate 15.15). However, during the past few years Boston has continued to achieve a substantial decline in case rate due in large part to the efforts of the Boston TB Program. The decline of case rate AllalaHHOW a1 9661. I NO1103S MASSACHUSETTS TUBERCULOSIS CASES* BY TUBERCULOSIS SURVEILLANCE AREA (TSA) 1996 (N=262) TSA 4 33.5% TSA 1 12.7% faTSA I D TSA 2 .TSA S =TSA 4 OTSA 5 MDP&DMSION OF TB Sex, Race and Age: Of the 262 TB cases, 151 (58%) were male and 111 (42%) were female. 'EXCLUDES 2 CASES IN CORRECTIONAL FACNmES MASSACHUSETTS TUBERCULOSIS CASES BY GENDER 1996 (N=262) PERCENT OF CASES MOPWDIWSION OF Ta Analyses of case rates indicate that the decline of TB cases over the years has occurred in both males and females in the same relative proportion, but that male consistently have a higher case rate than females. were also noted in other communities including: Brockton, Cambridge, Quincy and Fall River. Two communities, Revere and Waltham, are no longer designated as "higher risk" communities in 1996 because of the decline in case rates in those communties. The number of TB cases and ccse rate of cities/towns by county of residence are illustrated in appendix 2. For confidentiality reasons, those communities with less than 5 cases are included in the overall county figures only. Analyses of county of residence indicate that 37% of the TB cases were residing in Suffolk County, more specifically the City of Boston, and 25% were residing in Middlesex County at time of diagnosis. Four of the 14 counties in Massachusetts; Barnstable, Berkshire, Franklin, and Hampshire, had less that 1 % of the TB cases and 2 counties; Duke and Nantucket were TB free in 1996. MASSACHUSETTS VERIFIED TUBERCUI OSIS CASES BY COUNTY 1796 (N=262) SUFFOLK 36.9 BRISTOL ESSEX 4.6 7.7 HAMPOEN 4.2 WORCES'. . 62 6.9 MDPN/ONISION OF TB MIDDLESEX 24.6 BARNSTABLE RIX,BERKSHIRE RI% FRANKLIN RI%, HAMPSHIRE 0% I.-ANO NANTUCKET ARE TB TREE 'I OTRER CASES ARE STATE AT LARGE PERCEN OF BASES Tuberculosis Surveillance Area (TSA) represents the geographic district to which the regional TB offices serve. Thn state has 4 regional TB offices: TSA1 (Western Massachusetts), TSA7 (Metro Boston), TSA3 (Northeast), TSAS (Southeast) and the City of Boston TB program which has been denoted as TSA4 for statistical purposes only. Compared to 1995, the decline in cases seen in 1996 occurred predominantly in TSA1 (49%) and TSA3 (20%). 2 80 60 40 20 0 88 89 90 91 MASSACHUSETTS TUBERCULOSIS CASE RATES BY RACE/ETHNICITY 1988 - 1996 PER 100,000 92 93 YEAR 91 95 80 60 40 20 0 96 I■-WHITEINON-HISPANIC .-BLACK/NON.HISPANIC BHISPANIC —ASIAN I MOPH/DWISION OF TB Analyses of relative risk indicate that persons of color are much more likely to have TB than white (Black RR = 16.3, Hispanic RR =8.1 , Asian RR=30.3). TUBERCULOSIS CASE RATES BY RACE/ETHNICITY MASSACHUSETTS, 1996 RACE/ETHNICITY it CASES CASE RATE RELATIVE RISK WHITE/NH 84 1.59 1 BLACK/NH 71 25.87 16.27 HISPANIC 37 12.87 8.09 ASIAN, P.I. 69 48.11 30.26 MBPH/DIVISION OF TB NH=NON.HISPANIC 1 Americ n Indian case in 1996 In 1996 4.2% of the TB cases were among children < 15 years of age. Of the 11 children who were identified as cases, the majority (8 cases, 72.7 %) were children of color. Analyses of case rates indicate that the case rate of children has remained stable over time at 1 .0 to 2.0 per 100,000 population. The case rate for children of color continues to be much higher than white children. However, there has been an encouraging decline in case rate among children of color during the past 3 years. In 1996, the case rate for children of color was 3.8 as compared to 5 MASSACHUSETTS TB CASE RATES BY GENDER 1988 - 1996 PER 100,000 12 a 6 6 2 0 2 10 a 6 4 2 85 89 90 91 92 93 94 YEAP. I`MALE FEMALE 95 96 0 MOPH/DIVISION OF TB The majority of the 1996 TB cases (68%) were among persons of color: Black 27%, Hispanic, 14%, Asian 26% and Native American <1 %. MASSACHUSETTS TUBERCULOSIS CASES BY RACE/ETHNICITY 1996 (N=262) W HITEINON HISPANIC_ 32.1% ASIAN/PACIFIC ISLANDER 26.3% AMERICAN INDIAN 0.4% MOPH/DIVISION OF TB BLACKINON HISPANIC 27.1% HISPANIC 14.1% PERCENT OF CASES Analyses of case rates of race/ethnicity over time indicate that for white and Hispanic, th_ case rates hav- -e nained stable. For blacks, the case rate has continued to decline from a rate of 48.1 in 1991 to 25.9 in 1996. For Asians, the case rate had been steadily increasing from a rate of 42.3 in 1988 to a high of 75.3 in 1995. However, for the first time in many years the case rate among Asians declined to 48.1 in 1996. 4 white cases were age 65 and older (white 50% vs person of color 11 %). MASSACHUSETTS 1996 TUBERCULOSIS CASES BY AGE AND RACE/ETHNICITY AGE WHITEINH BIACXMN HISPANIC ASIAN ANEWGN INDIAN TOTAL 61-14 6 6% 15 21.1% 5 13.6% 10 14.5% 6 0% 35 13A% 25.44 21 25% 30 53.5% 20 54.1% 32 66,5% 0 0% 111 42.4% 6566 16 19% A 19.7% 0 21.6% 16 333% 1 100% 66 21% 65+ 42 50% • 56% 4 106% 11 15.9% 0 0% 61 23.3% TOTAL 54 71 37 69 1 262 MDPH/DIVISION OF TB In 1996, 61 TB cases (23%) were age 65 or older. Analyses of the case rates indicate that during the past 10 years there has been an overall decline in the case rate of this age group, from a high of 18.8 in 1985 to a low of 7.4 achieved in 1995 and in 1996, the lowest the state has ever achieved. 20 15 10 5 RATE OF TUBERCULOSIS IN PERSONS AGE 65 AND OVER MASSACHUSETTS 1985 - 1996 PER 100,000 0 85 86 87 88 MOPH/DIVISION OF TB 89 90 91 92 93 94 95 YEAR -CASE RATE B. Clinical Characteristics: Site of Disease 7 96 20 15 10 5 0 0.21 for white children. MASSACHUSETTS TUBERCULOSIS IN CHILDREN <AGE 15 CASE RATES BY RACE/ETHNICITY 1988 -1996 PER 100.000 2 0 8 6 4 2 0 88 89 90 91 92 93 94 95 96 YEAR TOTAL WHITE -NON-WHITE MDPH/D'WSION OF TB 12 10 a 6 4 2 0 Analyses of the 1996 cases by age group indicate that 35 cases (13.4%) were between the ages of < 1 - 24, 111 cases (42.4%) were between 25 - 44 years of age, 55 cases (21 .0%) were between 45 - 64 years of age, and 61 cases (23.3%) were age 65 and older. MASSACHUSETTS TUBERCULOSIS CASES BY AGE GROUP AND YEAR 1988 - 1996 0 % CASES 50 0 88 89 90 91 92 YEAR 93 94 95 96 e-0-24 YRS. +25-44 YRS. -45-64 YR5. - 65+ MOPH/ONISION OF TB 0 Analyses of thel 996 TB cases by race and age group indicate that white cases tended to be older than persons of color. A smaller proportion of white cases were in the age category of < 1 - 24 (white 6% vs person of color 17%) and in the age category of 25 - 44 (white 25% vs person of color 51 %). A greater proportion of 6 PERCENT OF TUBERCULOSIS CASES WITH MULTIPLE SITES MASSACHUSETTS 1985 - 1996 12 % CASES 10 8 6 4 2 0 05 SE 87 08 89 90 91 MOPl4DWNSION OF Is YEAR 92 —%OF CASES 93 94 95 96 8 6 2 0 Chest Radiography Results: Of the 262 TB cases in 1996, 171 cases (65%) presented with non-cavitary disease at the time of diagnosis. Forty-two cases (16%) presented with cavitary disease, 47 ca.,es (18%) had normal radiographic results and 2 cases (< 1 %) either did not have chest x-ray done or the results were unknown. MASSACHUSETTS TUBERCULOSIS CASES BY X-RAY RESULT 1996 (N=262) NON CAVITARY 655% NORMAL 1].9% PERCENT OF CASES MOPH/pVISION OF TD CAVITARY 15.0% UNKNONM/NOT DONE 08% Skin Test °^_ i-3. Of the 262 TB cases in 1996, 204 cases (78%) had a significant or positive skin test reaction 11 cases (4%) had a negative rear-«ion, 17 cases (7%) were documented anergic, 14 cases (5%) had an unknown results and 16 cases (6%) did not have skin testing done. There has been a decline in the proportion of TB cases that did not have skin testing done, from 11 % in 1995 to 6% in 1996. 9 Of the 262 TB cases reported in 1996; 175 cases (67%) presented with pulmonary as the primary site of disease. This is followed by lymph cervical - 27 cases (10%), pleura -18 cases (7%), and miliary - 8 cases (3%). The remaining 34 cases (13%) had other primary sites of disease. MASSACHUSETTS TUBERCULOSIS CASES BY PRIMARY DISEASE SITE 1996 (N=262) PERCENT OF CASES MOPIWIWSION OF TO In 1996, 20 cases (8%) had multiple sites of disease. When these cases were analyzed, 14 cases (70%) had pulmonary involvement,t,t2 involvement,10% 1ceasc cervical lymphatic cervical involvement, 1 case (5%) - pleura s - other lymphatic site, 1 case (5%) - bone/joint site and 1 case (5%) - other site of disease. Although a variable trend in the proportion of cases with multiple sites of disease has been noted over time, there appears to be an overall increase in the proportion of TB cases with multiple sites of disease. s The following analysis of drug resistant cases are based on the 26 cases reported with drug resistant disease in 1996. Of the 26 cases with drug resistant TB, 6 (23.1 %) were resistant to INH alone, 8 cases (30.8%) were resistant to INH and Streptomycin (SM), 9 cases (34.6%) were resistant to SM alone, 3 cases (11 .5%) were resistant to other drugs. In 1996, Massachusetts had no cases that were resistant to at least INH and RIF (multi-drug resistant tuberculosis - MDR TB). MASSACHUSETTS TUBERCULOSIS CASES BY DRUG RESISTANCE PATTERN, 1996 (N=26) INH C23.1% INH/SM 30.6% NO MDR TB CASES WERE SEEN IN I994 I SM 34.6% PERCENT OF DRUG RESISTANT CASES MOPH/DIVISION OF TB OTHER 11.5% The proportion of TB cases with drug resistant TB has remained about 13 - 15% of the total case load since 1989. Two of the 1996 drug resistant cases are co- infected with HIV. MASSACHUSETTS TUBERCULOSIS CASES BY SKIN TEST RESULTS 1996 (N=262) SIGNIFICANT 78% UNKNOWN 5% MOFWDINSION OF TB PERCENT OF CASES ANERGIC 7% NOT DONE 6% OT SIGNIFICANT 4% C. Bacteriologic Confirmation: In 1996, 210 (80.2%) of the 262 TB cases were bacteriologically confirmed with a positive culture. This represents a bacteriologically substantiated incidence rate of 3.49 per 100,000 population. Of the 210 bacteriologically confirmed cases, 26 cases (12.4%) have drug resistant disease. Sixteen of these cases (61 .5% of 26 cases, 7.6% of 210 cases) were resistant to Isoniazid (INH) either alone or in combination with another regimen. TUBERCULOSIS DRUG RESISTANCE, MASSACHUSETTS 1996 # CASES `% TUBERCULOSIS CASES 262 100 TUBERCULOSIS CASES WITH DRUG RESISTANCE 26 9.9 80 2 • BACTERIOLOGICALLY CONS IRMSD TB CAbES 26 124 4 BACTERIOLOGICALLY CONFIRMED CASES WITH DRU., :IESISTANCE BACTERIOLOGICALLY CONFIRMED CASES WITH ISONIAZID RESISTANCE 16 7.6 (ALONE OR IN OTHER COMBINATION) *Bacteriologically substantiated incidence rate of 3.49 per 100,000 population. D. Cases '.L I Drug Resislo„ce: Note: Drug resistance is defined as greater than 1 percent resistance to any concentration of that drug. Multi-drug resistance is defined as being resistance to at least two drugs which must include Isoniazid (INH) and Rifampin (RIF). 10 MASSACHUSETTS DRUG RESISTANT TUBERCULOSIS CASES BY PLACE OF BIRTH, 1996 (N=26) SOUTHEAST ASIA 46.2% HAITI UNITED STATES 11.5% 30.8% OTHER 11.6% PERCENT OF CASES MOPWONISION OF TO Analyses of the 26 drug resistant TB cases by place of residence at the time of diagnosis indicate that Boston accounted for 16 (62%) of the cases and the remaining 10 (28%) cases were seen throughout the rest of the state. E High Risk Group Profiles 1 . Cases in Foreign Born Persons: The foreign born (defined as all persons born outside of the United States and its territories) remain the highest risk group for TB in Massachusetts. In 1996, 159 (61 %) of the TB cases were among the foreign born. Foreign born cases have consistently accounted for a greater proportion of the Massachusetts TB case load over time. A decade ago, foreign born cases accounted for one third of the cases as compared to 61 % in 1996. Over time, the number of US cases has decreased, while the number of foreign born cases has only increased slightly. Of the 159 foreign born cases identified in 1996, persons from Vietnam were the largest group with 27 cases (17%), followed by Haitians - 24 cases (15%), Chinese - 11 cases (7%), Cambodians - 10 cases (6%), Dominicans - 9 cases (6%), :Tdians - 7 eases (4%) and Cape Verdians - 6 cases (4%). The remaining 65 cases (41 %) were from 40 different countries. 13 PERCENT OF BACTERIOLOGICALLY CONFIRMED TB CASES WITH DRUG RESISTANCE MASSACHUSETTS 1986 - 1996 25 • OF CASES 25 20 15 10 5 0 68 89 90 91 MOP/VOW/SION OF TB 92 93 -%OF CASES! 94 95 20 15 10 5 96 0 Analyses of the 1 996 drug resistant cases by race/ethnicity indicate that persons of color accounted for the majority of the cases (77%). There are some differences in the racial/ethnic breakdown of drug resistant cases as compared to the overall 1996 TB cases. Specifically, a greater proportion of drug resistant cases were Asian as compared to the overall 1996 cases (50 % vs 26%). MASSACHUSETTS DRUG RESISTANT TUBERCULOSIS CASES BY RACE/ETHNICITY, 1996 (N=26) BLACK 19.2 HISPANIC T.7% ASIAN/PACIFIC ISLANDER 50.0% MOVN,DIV'90"OF TB PERCENT Analyses of the drug resistant cases by the place of birth indicate that 18 (69%) of the 26 cases were born outride of the United States. Countries of origin overall include; United States - 8 cases (31 %), Vietnam - 7 cases (27 %), Haiti - 3 cases (12%), and the remaining 8 cases (31 %) were from Algeria, Cambodia, China, Dominican Republic, Hong Kong, Japan, South Korea, and Uruguay. 12 Note: data reported prior to 1993 for homelessness was limited to persons who were homeless at the time of diagnosis. In 1993, the CDC revised the definition of homeless to include persons who had been homeless within a year prior to diagnosis. It is estimated that there are more than 6,000 homeless persons in Boston and approximately 23,000 homeless persons statewide. Case rates were calculated based on these figures. Of the 262 TB cases reported in 1996, 17 cases (6%, case rate 73.9 per 100,000 population) were reported to have been homeless within the past year. 40 30 20 10 0 TB CASES AMONG THE HOMELESS MASSACHUSETTS, 1975 - 1996 C OF CASES 75 78 MOPWD/VISION OF TO 81 84 87 YEAR =CASES 90 93 96 40 30 20 10 0 Of the 17 homeless cases in 1996; 10 cases (59%) were from Boston and 7 cases (41 %1 were from outside of Boston. For the homeless, the INH / SM resistance pattern associated with an outbreak in 1984 - 1985 has decreased significantly - two homeless cases with INH / SM resistance were reported in 1994, two more were reported in 1995, and one was reported in 1996. 15 TUBERCULOSIS CASES BY PLACE OF BIRTH MASSACHUSETTS 1984 - 1996 80 % CASES 80 70 70 0 N.,. 60 50 - 50 40 40 cere- 30 30 20 84 85 86 87 88 89 90 YEAR 91 92 93 94 95 I+-US BORN °FOREIGN BORN MOPHIDIVISION OF TB 20 96 When cases were analyzed by geographic region, the majority of the cases were from the United States and Canada - 97 cases (37%), Asia - 68 cases (26%), and the Caribbean 42 cases (16%). MASSACHUSETTS TUBERCULOSIS CASES PLACE OF BIRTH BY WORLD REGIONS 1996 NAMER 37.0% AFRICA 9.5% EUR. OTHER 4.6'% _ - pwA 19.1% CENAMER 2.7% CARRIBEAN 15.0% (N=262) MOPH/DIVISION OF TB VIETNA 39.7% ASIA 25.0% S.AMER 4.2% PERCENT OF CASES CAMBODIA 147'% (N=68) NDIA 0.3% CHINA 162% 2. Cases in the Homeless Population: A homeless person is defined as a person who lacks a fixed, regular, and adequate night-time residence, including a person who resides in shelters, welfare hotels, on the streets, or in a single room occupancy hotel, and who is not paying rent, does not own a home and is not steadily living with relatives or friends. 14 were in correctional facilities at time of diagnosis, which includes county and state facilities. MASSACHUSETTS TUBERCULOSIS CASES IN CORRECTIONAL FACILITIES 1988 -1996 OF CASES 25 , 2 20 20 15 15 10 10 0 68 69 90 91 92 93 94 95 96 YEAR IimYOF CASES MOPMVWS/ON OF TB 4. Cases in Long Term Care Facilities: In 1996, 7 cases (2.7%) were reported to be in a long term care facility at time of diagnosis, w'icn In^ludes 5 from nursing homes, 1 from a long term residential facility and 1 from a mental health residential facility. TUBERCULOSIS CASES IN RESIDENTS OF LONG TERM CARE FACILITIES MASSACHUSETTS 1988 - 1996 9 OF CASES 20 15 10 5 0 as 89 MOFrv.umyvN OF iB 91 92 YEAR 93 94 95 96 20 15 10 0 5. TB/AIDS Cases: In Massachusetts, the TB Division and the AIDS Division work in close collaboratic, and have been the TB registry with the AIDS registry yearly siocc 1992. In 1993, the AIDS definition was revised to include anyone infected with HIV and TB ,1iscc,, of any site. Because TB diagnosis and AIDS diagnosis can differ in time, the proportion of TB cases with AIDS will rise a little with each match. Between 1982 - 1996, there were 462 TB/AIDS cases identified. In 1996, 21 17 0 25 20 5 10 5 TB CASES AMONG THE HOMELESS MASSACHUSETTS, 1988 - 1996 OF CASES 88 89 90 91 82 93 94 95 96 YEAR 0 25 20 5 10 5 0 ANON-BOSTON CASES BOSTON CASES INDRUG RESISTANCE MDPN/OMSION OF TB A profile of the 17 homeless cases indicates that 2 cases (12%) were reported to be co-infected with HIV, 2 cases (12%) were reported to !-.ave used drugs within the past year, 9 (53%) were reported to have used excessive aicohol within the past year and 3 (18%) had drug resistant TB (INH , SM, INH/SM). HOMELESS TUBERCULOSIS CASES BY SOCIAL CHARACTERISTICS 1991 - 1996 70 60 50 40 30 20 10 0 9.OF CASES 1991 199 1993 1994 1995 1996 YEAR I.ETOHIOTHER ODRUGS/IVDU/OTHER 82HIV/OTHER MOPHAIVISION OF TB 70 60 50 40 30 20 10 0 3. Cases in Correctional Facilities: In 1990, an outbreak of tuberculosis with widespread transmission occurred at a prison located in the southeastern part of the state. This outbreak led to a massive screening effort (12,000 prisoners and staff). Following this outbreak and the massive screening and educational program which followed, routine screening of inmates was instituted at all the State prison facilities. In 1996, 4 (1 .5%) TB cases 6 MASSACHUSETTS TB/AIDS AND AIDS* CASES BY RACE 1982 - 1996 (TB/AIDS = 462 CASES 70 60 60 40 30 20 10 0 OF CASES WHITE BLACK HISPANIC RACE NGS CASES EXCLUDES'NOSE DIAGNOSED WON I OTHER 70 60 60 40 b 20 10 0 AIDS SURVEILLANCE PROGRAM MDPILDMLON OF TB Of the 462 TB/AIDS cases reported between 1982 - 1996, 173 cases (37%) were born outside of the United States and its territories. When the proportion of foreign born TB/AID cases are analyzed, the majority,132 cases (76%), were Haitians. MASSACHUSETTS TB/AIDS CASES BY PLACE OF BIRTH 1982 - 1996 US 56.9% (N=462) FOREIGN BOR 37.4% (N=173) OMER 23.7% HAM ]6a% AIDS SURVEILLANCE PROGRAM mOPHIDIVISION OF TA Analyses of TB disease site of the TB/AIDS cases indicate that 291 cases (63%) had pulmonary disease and 171 cases (37%) had extra-pulmonary disease. 19 (8%) the TB cases were co-infected with HIV. PERCENT OF TB CASES DIAGNOSED WITH AIDS 1982-1996 (TB/AIDS= 462 CASES) •F OF CP.SE6 25 25 20 15 ,0 5 0 - - - .i1111111�II 05 86 82 63 u YEAR I.713/AIDS 20 15 10 5 0 NZ$.,E,.E,LUNGE PROGw. *w,wATIGN OF TB Of the 462 TEI IDS cases identified between 1982 - 1996, 365 (79%) were male and 97 cases (21 %) were female. MASSACHUSETTS TB/AIDS AND AIDS* CASES BY GENDER 1982 - 1996 (TB/AIDS = 462 CASES) %OF CASES 100 / 00 60 40 20 1•7B/AIDS DAIDS 100 80 60 40 '0 MALE GENDER AIDS CASES EXCLUDE THOSE DIAGNOSED MD TS FEMALE AIDS SURVEILLANCE PROGRAM MDPWOMSJON OF I Persons of color accounted for the majority of the TB/AIDS cases (342 cases, 74%). WIIen compared to Li le reported AIDB cases, a greater propertion of TB/AIDS cases were black (21 % vs 54%). Is MASSACHUSETTS TB/AIDS AND AIDS* CASES BY AIDS RISK BEHAVIORS 1982 -1996(TB/AIDS=462 CASES) %OF CASES SO SS ImEammAE Al SEMAINsc S PRIMARY RISK FACTORS •AIDS CkSES EXCIMPES THOSE 04 GN 5E0 WTI TB LeNDETFAMIN EP SO 25 IS IC AIDS URYEI NCE PROGRAM AIDPWWWVON OF TB Analyses of TB/AIDS cases by residence at time of AIDS diagnosis indicate that 224 cases (49%) lived in Boston, 135 cases (29%) lived outside of Boston and SMSA accounts for 103(22%) of the cases. In addition, 7 cities account for 72% of the TB/AIDS cases, with 49% of the cases from the City of Boston. 50 42 30 20 10 0 MASSACHUSETTS TB/AIDS AND AIDS* CASES BY RESIDENCE 1982 - 1996 (TB/AIDS = 462 CASES) %OF CASES BOSTON SMSA RESIDENCE RESIDENCE AT 11ME OF AIDS DIAGNOSIS •AIDS CASES EXCLUDES TMOSE DIAGNOSED WOK TB REST OF STATE 50 <0 30 20 10 0 AIDS SURVEILLANCE PROGRAM MENDVDDISION OF 713 21 MASSACHUSETTS TB/AIDS CASES' BY PRIMARY TB DISEASE SITE 1982 - 1996 (TB/AIDS = 462 CASES) ROLMONARY W% PLEURAL 5% LYMPHATICICERVICAL f% ENINGEM. 3% OTHER 12% LYMPNATICOTHER MIWRY E% 4% AIDS SVRVFJLLANLE PROGRAM MDP OW"SION OF TB Analyses of TB/AIDS cases by AIDS risk behavior indicate that males having sex with males (MSM) is still the greatest risk factor for AIDS, but not for TB/AIDS. For TB/AIDS cases the primary risk factor appears to be injecting drug use 169 cases (37%), followed by MSM, 78 cases (17%). Compared to the AIDS cases, a greater proportion of TB/AIDS cases have undetermined AIDS risk behavior (8% vs 33%). The number of TB/AIDS cases with undetermined risk behavior has increased greatly since foreign birth is no longer considered an AIDS risk behavior. MASSACHUSETTS TBIAIDS AND AIDS' CASES BY AIDS RISK BEHAVIORS 1962- 1996 (TB/AIDS = 462 CASES) OF CASES MSM IOU MSM OU BLOOD TRANSFUSION AIDS PRIMARY RISK FACTORS AIDS SURVEILLANCE PROGRAM Inni.mALE SEA WAX MALE •ino.ALIELTION DRUG USE BIDS CASES EXCLUDES THOSE DU4xmEOWix IS MOPNNMSON OF TB 20 MASSACHUSETTS TB/AIDS CASES BY CITY OF RESIDENCE* 1982 - 1996 (TB AIDS = 462 CASES) 50 % CASES 50 40 ■ AS 30 20 10 0 MBOCB •RFSIGERCE AT TYE OF TB DIAGNOSIS Coal WOMB 50•MIL 30 20 10 0 AIDS SURVEILLANCE PROGRAM MOPWOMSIOH OF 7B 6. HIV infected Prevalence in Select Sub-populations: There are limited data available about the prevalence of HIV infection in Massachusetts. The Division of TB Prevention and Control recommends that each case of TB be assessed for HIV infection risk and be offered voluntary HIV counseling and testing. In 1996, 72 cases (28%) of the TB cases were known to have been tested for HIV and 21 cases (8%) tested positive for HIV. 22 Massachusetts Department of Public Health,Division of Tuberculosis Prevention and Control Case Rates of Tuberculosis Cases(per 100,000 population)for 15 Higher Risk Communities, with Seven Year Average for 1990-1996 COMMUNITY 1996 1995 1994 1993 1992 1991 1990 7 Year Average Boston 15.15 16.19 18.81 20.02 22.29 24.55 25.95 20.42 Brockton 10.78 2.16 8.62 14.01 23.71 23.71 22.63 15.09 Cambridge 10.44 8.35 10.44 9.39 13.57 9.39 . 14.61 10.89 Chelsea 17.42 24.38 6.97 27.86 20.90 34.83 17.42 - 21.40 Fall River 3.24 2.16 8.63 4.31 5.39 16.18 5.39 6.47 Framingham 7.69 4.62 6.15 13.85 1.54 9.23 10.77 7.69 Lawrence 7.12 15.67 9.97 5.70 17.09 15.67 8.55 • 11.39 Lowell 9.67 13.53 13.53 14.50 11.60 11.60 14.50 12.71 Lynn 7.39 13.54 11.08 14.77 121! '739 16.00 11.78 Malden 5.57 16.70 5.57 9.28 20.41 14.85 9.28 11.67 New Bedford 5.00 9.01 5.00 10.01 6.00 9.01 11.01 7.86 Quincy 8.24 8.24 10.59 11.77 15.30 10.59 3.531 9.75 Somerville 9.19 10.50 7.87 13.12 15.75 18.37 6.561 11.62 Springfield 2.55 13.38 5.73 7.01 8.92 7.01 8.28 7.55 Worcester 6.48 8.25 5.30 10.01 9.43 8.25 7.07 7.83 Case Rate for Massachusetts 4.35 5.48 5.47 6.08 7.11 7.25 7.43 6.17 APPENDIX 1 Massachusetts Department o=Health, vrst=abet- Prevention and Number uber Cases for 15 Higher Risk Communities,and the Remainder Communities Reporting 1M991 Seven Year Averages — :OMMUNITY 1996111.0111111E2 MOE Boston Brockton Cambrid Chelsea Fall River Lawrence Total 336 Remaining Communities 114 147 84 Ill 1181 139 154 i Total Cases in State 262 330; - Higher risk community dd defined havingven year average case load of more than 4 and a seven __ __ year average case rate above the state case rate 366 428 N NUMBER OF TOWNS WITH CASES OF TB w BY COUNTY OF RESIDENCE a d NUMBER OF TOWNS WITH NUBER OF TOWNS WITH COUNTY COUNTY <5 CASES =>5 CASES <5 CASES =>5 CASES BARNSTABLE 1 0 HAMPSHIRE 1 0 BERKSHIRE 1 0 MIDDLESEX 21 4 BRISTOL 4 1 NANTUCKET 0 0 DUKES 0 0 NORFOLK 10 1 ESSEX 5 2 PLYMOUTH 5 1 FRANKLIN 1 0 SUFFOLK 2 2 HAMPDEN 5 0 WORCESTER 5 1 nannuin►ViglfN OF TB ServiceNet August 3, 1998 Mary L. Ford,Mayor City of Northampton City Hail, 210 Main Street Northampton,MA 01060 Integrated Human Service Systems Adu - 4k . it J�f L' r`ll� Dear Mayor Ford, On behalf of the Northampton Shelter Sunday Coalition, I am requesting your permission to hold our annual door-to-door collection of donations known as "Shelter Sunday." Money raised on Shelter Sunday benefits seven Northampton agencies which serve the homeless;Grove Street Inn,Jesse's House, SRO Outreach Project, Salvation Army, Necessities%Necesidades, and the Survival Center, and the Interfaith Community Cot Shelter. The solicitation will take place on Sunday October 25, 1998 beginning at noon. Additionally I am requesting permission to do canister solicitation at several sites on the afternoon of Shelter Sunday,October 25th. Last year we solicited in front of Thomes Market, SIS,City Hall, Stop and Shop and Foster Farrar, with the permission of these stores to do so. We will be seeking permission this year and will only do so upon their agreement. Thank you for your support and consideration. Sincerely,Si q'A Rebecca Muller Director of Housing and Shelter Services PERMISSION IS HEREBY GRANTED to SERVICE*NET,on behalf of NORTHAMPTON SHELTER SUNDAY* COALITION,to conduct its annual tag day and door-to-door collection on SUNDAY,OCTOBER 25, 1998 beginning at noon. r/7( cc: Police&Recreation Depts.,Board of Health MARY FORD, MAYOR August 4,1998 129 King Sheet•Northampton, MA 01060•413.585.1300•Fax 413.582.4252•wwwservicenetinc.org•Susan L Stubbs, C.E.O. f• � Recycled Paper BOARD OF HEALTH MEMBERS 'NTHIA DOURMASHKIN,R.N.,Chair ANNE BORES,M.D. 2OSEMARIE KARPARIS,R.N.,MPH PETER J.McERIAIN,Health Agent (413)587-1214 FAX(413)587-1264 CITY OF NORTHAMPTON MASSACHUSETTS 01060 OFFICE OF THE BOARD OF HEALTH Mr. William Gillen &Ms. Kathy Ford Ford Gillen Architects 409 Main Street Amherst,MA 01002-2364 Dear Mr. Gillen&Ms. Ford: Re: Memorial Hall Shelter 210 MAIN STREET NORTHAMPTON,MA 01060 This letter will confirm that on April 29, 1999, the Northampton Board of Health voted to approve the variance of 105 CMR 410.250 (A) of the State Housing Code, and allow the use of the basement area of Memorial Hall as an emergency shelter. Specifically, the variance waives the requirement that natural light/windows be provided in area equal to a minimum of 8%of the floor space in the shelter. The variance was issued because the intended use would take place only in the evenings of fall,winter and spring, after daylight hours when there would be no benefit in having windows. In addition,window installation could only be accomplished with great difficulty and at great expense,due to the structural condition of the Memorial Hall foundation. The Board of Health strongly agrees with the notion that it would be much more beneficial to provide shelter than to provide windows,which would not yield any light during the hours that the shelter would be occupied. Please do not hesitate to contact me with any questions concerning this matter. Thank you. Sincerely, Peter J.McErlain Health Agent cc: Brett Jacobus Peg Keller V]?AA 0R-1Prl. rtrdifr 41vs/91 PuyittSs p.,,3/44 cn o L. Crt cn REVAMP HI � �� � � 1 L cn ROOM MA NEW sioRAGL X SrtOw �SHOWLX Cr`.'.nnwK - Q EL R L \IL Q BLDG STORAGE ,ND wP KITCHEN OFFICE G5 5f 5 'ono Poo 10SF O 1 mN _- _ C__ I C � �CIOSE arm L-_ _ 1 —ry :L I a �waMEn car — o BUILDING STbancE TELLPNONE WOMEN'S s kWING LOONGC/]WING 00 Si. (a PERSONS 3ss S.F. 3 275 S.F. ti • NEW EXTERIOR ��] f l HU STAIR wIE LOBBY MEN LOT SIMI< COVERING I MO— ROOF fOVININC IIC �� 21.11" ONIINISHE i IIN @% f INV PUN OM1K VAILIIY co DRINKING ° . 515 s W/G _ EXISTING LE TRIO O 10 PERSONS L �� 1 ELECTRIC WIRING STORAGE FOUNTAIN p�j I5O Si. HENS SIFEPING rsi 2 �i GGi S P1� I J OFFICE - TO➢A11F 01 51 — As 1 1 �� I I 1 PERSON AA N - - CDT cOi LOT RnOIA 1 EXISTING BOILER ROOM o I AL AT STORAGL i ii t 7 1 I f POS5N1! FUTURE flot o - - rl _ VFW snnollwlNUaws ��SV ,Aar/E17.II Lsol PlIAAol S,r,F o as cn 2 a • Atosiotti&t. *Pea. 1 r CD r_ r - STORAGE '' lEP REMAIN AS S 3 - _ JL _ 1 COUNCIL ON AGING 0'0 LVL r�FLO - FRAMNG. LLP O L.) STORAGE a ROOM ® ® 0 I --y w �• 1-41/444 51M f2- cn 11 vEEERANS vooR 0 rill ,Er j /1999 14:39 4132562453 0 R D GILLEN- I L L E N A R C H I T E C T S FORD GILLEN March 23, 1999 Mr.Peter McErlain City!loll Northampton Health Dept. tY 210 Main St. Northampton,MA 01060 RE. Memorial Hall Shelter&Elevator 1OB Na: 9910 Dear Peter: I am requesting,on behalf of our client,the City of Northampton,a variance for this project from Section 410.250 of the State Sanitary Code concerning natural light: "The owner shall provide for each habitable room other than a kitchen: (A) transparent or translucent glass which admits light from the outdoors and which is equal in area to no less than S%of the entire floor area of that room." We are requesting this variance because: 1 The intended use of the Shelter will be for evening hours only. There will in fact be no daylight during the months of operation in the fall,winter and early spring. 2. The facility proposed is in the basement and there is no opportunity at this site to provide natural light without a hardship of considerable expense. t has the power to grant this request since it is not a condition I deemed the endanger Department health or safety as listed in Section 410.750,items A-O. deemed o®danger or impair Enclosed is a floor plan of the current design. The design will be subject to change in the next few weeks as the contract drawings are being prepared and we meet further with the Committee. Whatever the final design,there will still be rooms with cots and rooms with no natural light. Please advise when the hearing will be and we will come to further explain and/or answer questions. Sincerely, William V. Gillen R1;9910\082 Enclosure cc: Brett Jacobus Kathy Ford 409 MAIN STREET AMHERST,MA 01002-2364•Tel 413 253 2528•Fax 413 256 1553 • FordGillea @esteem A Marreeh"ndts C•rporetiea Assessment of Occu apnc ISle inn. ,Nort Floor o Boa c -- ld Fire Station O Total Occupancy Space* Sleeping Space Capacity** Ladies Sl Rm#1 Total 1648 sq.ft. Maximum Occupancy =16 Max. 14 Total Sleeping Capacity - = 16 Space&Use Requirements per 105 CMR 410.000,State Sanitary Code Chapter B *Total Floor Space Available in Habitable Areas=Minimum of 150 sq. ft. for 1 st occupant and 100 sq. ft. for each additional occupant ** Sleeping Space Available,Minimum of 50 sq. ft.per person Based on the submitted floor plan the maximum number of occupants is sixteen (16). This includes both clients and staff. ,0 : 00:4 = et ofr 9) 1 off/ I 13 A )3 D_ -; i (A 69/ 0 ,71 X_ 9 . x,2,0 --� ti ..,t a ( ,�J _y I 0 3 .t / % EtM, -, q i - /, , � th s 3 so/ a ^J �.Y \_ 77 Ql c] n =Se �,LIZIC. --x, 11 /G Xt \,v The Board of Health has the following concerns about the proposed use of the WaLetaepartment Building on Prospect St. for m-r• - ._• 1 Space Requirements — the State Sanitary Code requires a minimum of 150 sq. ft. of habitable* space for the first occupant and 100 sq. ft. per each additional occupant; this space must include a minimum 50 sq. ft. of sleeping space per occupant. 2. Plumbing Requirements — the State Sanitary Code requires a minimum of one (1) toilet, one (1) wash basin, and one (1) shower or tub for every eight (8) occupants. 3. Temperature Requirements — It is strongly recommended that the existing heating system be professionally inspected, prior to occupancy, in order to determine whether or not the system is capable of meeting the minimum heat/hot water requirements, (Heating Min. 68°F from 7:00 a.m. to 11:00 p.m. and 64°F from 11:01 p.m. to 6:59 a.m., and Hot Water Min. 110°F -- I30°F available on demand) Any necessary upgrade of heating system must be completed before occupancy. 4. Smoke Detectors must be installed per City Ordinance. 5. All means of egress must comply with state building code requirements. 6. Chemical Safety — all Water Depaitment chemicals ( Chlorine, Welding gasses, gasoline etc.) must be safely stored so as not to pose a safety hazard, there may be additional State Building Code requirements * Habitable Space means every room or enclosed space used or intended to be used for living, sleeping, cooking, or eating purposes, excluding rooms containing toilets, bathtubs or showers and excluding laundries, pantries, foyers, communicating corridors, closets, hallways, stairways and storage spaces. C..) El z " N C9 IXI SHOWER SHOWER\ >HOWEI? � .— T n � new r�oi DITCH N OFFICE F. - F Y m 7 _ I A X � -T- N2W U.O. NCW MO Gj] LV wa a 6 COT LOUNGE/DINING N 0 m 1 _ 400 S.F. I w WW 0 WOMEN'S _ � � 0'1 m X I'. J S 11 / L 'U (4 PERSONS) Cpl/ J - N New exleR�oR "' I STAIR WITn LO MEN COT BUNK ROOF COVERING .T. d' J a ,NISE- �31 C9 ce j G'OT co COT QOT C4 _ J L UNFINISHED UTILITY V MEN'S SLEEPING C 480 s. . EX. ELECTRIC WOMEN PERSONS} (7 G/ o 1 - ___I L J L_ �_I L_ _ new III ID Z. i -:1 270 s.f.6-4 ) s0 s r 1 P. �i1'__ .. _C cot ��,g-) COT W a 0 c I —K BUNK 1 I GUNK J - BUN! --_-- __ a 1 - F wa p- cc C.)Y . �- E _ Y POSSIBLE FUTURE LIGHT WELLS AND WINDOWS C a DO- 3oa_ CELLAR PLAN a � °°,: az a EXTENT REA C> r L_J BUILT ILT OUT T FOR SHELTER "'- lo ow a v II P_. n J>1SHOR- rte - rOWE r. 1HOWER 1 P— new m r ril RIC � - L TELEPHONE WOMEN'S - `=-LEEPING200 S.F. �_ -y1 4 PERSONSI MECHANICAL - �J --- ROOM LOBBY MEN COT BUNK ��___ 180 S.F. - - H -- I -UNISEX p r L �7 C COT co COT COT core, wcpue•• Illipt.V...or° orzwKwe i FOUNTAIN ROOM A� MEN'S SLEEPING �- WOMEN 8]3 SF. 116 ___ PF_RSONv1 ._ -Lr_.-T=c, Fr- r --- 1 270 270 s( l -BUNK ] I BUNK BUNK II I r -1 1 r - -- _ POSSIBLE FUTURE LIGHT —I wens AND WINDOWS —1 1 0 2' 4' 10' 20'