georgia departDient of publie health ANNUAL REPORT 1963-1964 State of Georgia Department of Public Health JOHN H. VENABLE, M. D., DIRECTOR 47 TRINITY AVE. ATLANTA, GEORGIA 30334 To the Chairman of the State Board of Health and Honorable Members Dear Sirs: It is my privilege to present to you the Annual Report of the Georgia Department of Public Health for the fiscal period covering July 1, 1963 through June 30, 1964. As the report will reveal, there have been numerous modifications, expansions and additions of the Department's plans and programs during the year just past .. all designed to keep pace with technological and scientific advances as well as the social and environmental climate engendered by the rapid growth and economic development of Georgia. One of the most significant additions in 1963 was the establishment of a Mental Health Planning Project Team to develop, by July of 1965, a statewide plan to provide mental health services and research and professional training facilities for Georgians. Another advance in the mental health field was the development of two physical facilities--the Georgia Mental Health Institute and the Georgia Retardation Center .. the first nearing completion and the second in design and planning stages with property already purchased. The Civil Defense Health Service as well as the Chronic Illness and Geriatrics Service have greatly expanded their programs to provide respectively for Georgia's safety in the event of nuclear attack or other disaster and to meet the needs of an ever growing number of aged citizens. GEORGIA ORGANIZATION OF THE DEPARTMENT OF PUBLIC HEALTH I [ GENERAL ASSEMBLY OF GEORGIA I I GOVERNOR I I I STATE BOARD OF HEALTH DIRECTOR * llOII!IA DlNIIf.flll Of' "*.It 1!-"l.'nl DE PUTT r OIRECTCNI' DIVISION " MENTAL HEALTH l HOSPITALS IHOitGIA ltlllNTAI.. Ht:ALTH IMSTIT\ITI c;IIIACEWOOO STAT[ SCHQOL .. MOSI"ITAL ltllllbt:DGt:vtU.l STATt HOS~TAL l S E Ill VICE ALCOHOLIC II[HAI ILITATION COMMUNITY MENTAL. HEALTH - - - III[NTAL HEALTH PI..AJUUHG III[NTAL III[TAitDATION I 8R.&NCH " SPECIAL SER\IICES S E R JliC[ CHRONIC ILL"f[S$ .. Ci[i'tiATAICS M[OrCA'_ ~ACiliT>ES !ATT[Y STATE HOSPITAL I 'I BRANCH " PREVENTABLE OISEASlS I s E Ill .... I c CAIIIOIOVASCULAR QI\C;[AS[ CONTROL OCCUPATIONAL HEALTH S.E H.S SECTION - - - - T 8 CONTIIOL CANCER CONTROL SECTION V 0 CONTROL SECTION . CIVIL O[FliBl ~ALTH U.II:VICES PRO.PU.M STATUS 7/1/63 r " DIVISION PHYSICAL HEALTH I DIVISION " EPIDEMIOLOGY J DIVISION I " ADMINISTRATION ( fiNANCE BRANCH LOCAL HEALhl Lt....!!..JL..L LOCAL HEALTH ADMIHISTRATION BRANCH ENVIRONMENTAL H[ALTH ~....L.I.. GENERAL EHGINEERIH!i- SANITATION HOUSING HYGIENE AND ACCIOENT l"fft[V[NTION INDUSTRIAL HYGIENE WATER RESOURCES BRANCH HEALTH CONSERVATION S (, "V I ~' CRIPPLED CHILD"EN'S IIIATERNAL AND CHILO HEALTH IIUT,.ITION ICHOOL HEALTH BRANCH ['IOflltOLO&IC IIIY[ST"-'TIOIIS S E R V IC~ BIOLOGIC STUDIES SECTION DtSEAS[ANDDISA81LITT STUDIES SECTION PU8LICH[ALTH V[HRINARYSECTION BRANCH LABORATORIES ~ E R V I C (, C[i'oiHIAL LABORATORY FIELD LABORATORY REGIONAL LABORATORIES ~ ACCOUNTIN$ IIO!TATISTICI HMtltAL ITA" HPLTH tDUCATION ANO ntAIMII5 ~.....MtL VIT~ PATI[NTACCOUNTS SECTION -I LOCAL HEALTH DISTRICTS LOG~~_ -~-EAL TH DEPARTMENTS TABLE OF CONTENTS DIVISION OF ADMINISTRATION AND FINANCE Civil Defense Health Service Program. Health Education and Training Service . Personnel Service . . . . Vital Records Service . . Patient Accounts Section. 1 4 8 .11 . . 13 DIVISION OF EPIDEMIOLOGY Epidemiologic Investigations Branch .15 Veterinary Section. . . .19 Branch of Laboratories .. .20 DIVISION OF MENTAL HEALTH Division of Mental Health... Mental Health Planning Project. Community Mental Health Service Georgia Retardation Center ... Gracewood State School and Hospital Georgia Mental Health Institute . Milledgeville State Hospital ... Alcoholic Rehabilitation Service. .25 26 .28 .31 .32 .38 . .39 . .48 DIVISION OF PHYSICAL HEALTH Branch of Dental Health Branch of Dental Health . . . . Dental Public Health Service .. . . 52 . . 55 Environmental Health Branch Housing Hygiene and Accident Prevention Service . . . . 58 Addendum - Housing Hygiene and Accident Prevention Service.61 Industrial Hygiene Service .. :64 General Engineering and Sanitation Service. .67 Water Resources Service . . . 70 Environmental Health Training . . . . . . .73 Health Conservation Branch Crippled Children's Service .75 Maternal and Child Health Service . .77 Nutrition Service . . School Health Service Local Health Branch Local Health Administration Service . Northern Health Region .. Central Health Region . Southern Health Region. Preventable Diseases Branch Cancer Control Section. Cardiovascular Disease Control Service. Georgia State Employees Health Service. Occupational Health Service .. Tuberculosis Control Service ... Venereal Disease Control Section Special Services Branch Chronic Illness and Geriatrics Service Battey State Hospital . . Medical Facilities Service ....... .80 .83 .86 .88 .91 .92 .94 .96 . 100 . 104 107 110 . . 112 115 119 division of administration and finanee State of Georgia Department of Public Health JOHN H. VENABLE. M. D., DIRECTOR 47 TRINITY AYE. ATLANTA, GEORGIA 30334 The increase in industrialization within the state as well as the growth of towns and cities has caused the services of the Environmental Health Branch to expand. Planning for the future is of utmost importance if communities are to provide a healthy environment for their citizens. A program designated "Metropolitan, Urban and Community Planning for Environmental Health" has, with Health Department coordination, drawn in many state, local and federal agencies--and private citizens-- to study Georgia's present and long range human needs. Not only do we note the progress of the Health Department's programs, but also we note our employees' rich contributions to them through individual achievement of high standards of professional and personal development. Many of the staff have availed themselves of opportunities in graduate programs or seminars in their respective fields as well as participation in public health oriented organizations. Though the Department's goals appear vast and varied, our primary aim is to help each and every citizen attain the best possible physical, mental and environmental health climate so that he may develop to his fullest pote...tial. With this in mind, I am pleased to submit this annual report as evidence of our contribution to Georgia's successful development. Sincerely yours, ~.-L If. J~.Ak- John H. Venable, M. D. Director CIVIL DEFENSE HEALTH SERVICE PROGRAM Two major health problems confronting Georgians in the event of a nuclear attack have been indicated by recent studies and programs to solve each of these were implemented or expanded during this past fiscal year by the Civil Defense Health Service Program. The first is that citizens injured will not have time to seek professional assistance before they must go to a fallout shelter; therefore, a Medical Self-Help Program was initiated with the goal of training at least one member of each household in the state. A drive was inaugurated to persuade superintendents and principals to add Medical Self-Help to each high school's curriculum. The program was widely accepted and most of the students who graduate from high school henceforth will have completed the course. The second problem is that heavily populated areas, in which are located most of the larger hospitals in the state, are expected to be prime targets. To offset the potential loss of from 50 to 70 per cent of existing hospitals in an attack, the service continued the program of acquiring Civil Defense Emergency Hospitals. In fiscal 1964, 42 of these were added to total sixty-eight 200-bed hospitals stored at strategic locations throughout the state. Each hospital has sufficient supplies to operate for approximately 30 days. A hospital consists of 660 boxes requiring 1,200 square feet of storage space and is valued -1- at over $45,000. In addition, a manual was drafted for use in the emergency hospital "training center," and several hundred people attended a three-hour course that outlined the measures necessary to prepare an emergency hospital for activation and operation. With the comments and criticisms of the students and with the knowledge gained through the teaching experience and study, a final draft will be prepared for use as a guide. The training will be extended to include those responsible for management or support of these hospitals. The State was divided into seven areas for Civil Defense purposes and individuals were selected to staff each area headquarters with an organization similar to Civil Defense Health Service at the State level. This arrangement is much more practical from an administrative and communications standpoint, but is proving rather difficult from a professional viewpoint as it spreads available resources thin. The Governor approved the use of the buildings at the University of Georgia in Athens as an alternate location for the State government if it should become necessary to move during a national emergency. The Biological Sciences Building was assigned for use by the State Health Department. -2- The Governor also appointed two Task Groups, one for Health Resources and one for Water Resources, to study the problems that a national emergency would impose on the State. They will seek solutions to the problems and develop plans for the control of resources during an emergency. This past year a policy was established to familiarize students of professional schools with the provisions of the State Emergency Health Plan and programs which support it. This year, senior students of the schools of nursing were briefed; next year other schools will be included. Funds were obtained by the Service and two positions were authorized for the establishment of a facility to repair and calibrate the radiological defense instruments that are stored in each of the counties throughout the State. This will insure that they will be in good operating condition when and if they are ever needed; the program will also reduce considerably the expense of instruments lost through improper maintenance and storage. -3- HEALTH EDUCATION AND TRAINING SERVICE The creation of personal and community interest in health, the promotion of an awareness of health needs and the development of opportunities for people to learn about health is the charge of Public Health Education. Several methods are employed to accomplish these broad aims of health education and are outlined in the balance of the report. During fiscal 1964, the service sought to aid further the development of "groups for health action". By working with and through local health department personnel, voluntary agencies, school systems, other state agencies, civic and professional associations and interested citizens; health educators stimulated these groups to take action in their communities for better physical, mental and environmental health. Many new programs have been and are being implemented as a result of the enthusiasm and work of these groups. The Public Information Unit, working with most Health Department Services during fiscal 1964, continued to provide the general public with accurate and timely news relating to local and statewide public health programs in Georgia. The unit also aids in educating the public in many general public health matters. -4- The Information Unit utilizes all avenues of public communications - television and radio, daily and weekly newspapers, magazines and specialized publications -as well as using booklets, exhibits and personal appearances. In addition, two publications, GEORGIA'S HEALTH and FAX, are prepared and issued monthly to give continuity to the information program and augment efforts directed to the public media. The Training Section, since its institution 11 years ago as a formal program of the Health Department, serves as a vital link between the theory and findings of the laboratory or university and the work of the public health practictioner. OVer these years, the Training Section, which coordinates the training activities of other organizational units, has grown to include the services presented here: (1) Short term in-service specialization courses for state and local staff members numbered 133 with 1,049 persons participating. (2) Twenty-two professional public health workers from 12 foreign countries visited the state and various local health departments. (3) Stipend-supported training for the year is summarized in the following table: -5- STIPEND-SUPPORTED TRAINING July 1, 1963 -June 30, 1964 Academic Orientation Nurses 7 23 Sanitarians 33 Engineers 1 Physicians 2. Social Workers 19 Psychology Intern 12 Psychologist 3 Instructor Elementary Education 4 Optometrist 1 . ~: Biostatistical Analyst 1 Music Therapist 1 Residencies Pediatrics 2 Pathology 1 Psychiatry 3 Pedodontics 1 The Public Health Library has served public health personnel by making available to them the latest information in books and periodicals, so that the current advances and trends can be adapted and applied to public health programs in Georgia. A brief summary of some of the Library Staff activities during fiscal 1964 include: 219 new books were purchased bringing the total collection to 16,217 volumes; 1,030 reference questions were answered; 12., 700 publications were circulated or an average of 225 publications were circulated weekly to staff personnel; numerous bibliographies were completed on special topics; resource materials were furnished for work- -6- shops involving staff members; information was compiled to aid in developing programs and projects; and new personnel were introduced to the library facilities, resources and services. The Visual Communications Section performed the following numerous services during fiscal 1964. The Art Unit completed 361 jobs such as illustrations, layouts, lettering, paste-ups, exhibits and miscellaneous. The Cartography Unit performed 455 jobs such as mapping, lettering, drafting, embosograf engraving, and exhibits. Photography, prints, copy work, slides, processing and other duties produced a sum of 3,913 jobs performed by the Photographic Unit. -7- PERSONNEL SERVICE Fiscal 1964 brought the number of personnel employed in fulltime classified positions to over 6,000 . an increase of 333 over the previous year. Included in this number are those employees with responsibility to the counties, such as the local sanitarian, nurse and health officer; those employed in institutions devoted to particular health problems, and those who direct or otherwise deal with specialized programs for the whole State. In accord with their differing responsibilities, these health workers represent a variety of training and experience, ranging from less than grade school education to a dozen years of graduate study in science or medicine. The major increase, 253, occurred in Milledgeville State Hospital while the largest decrease was from Battey Hospital. Milledgeville added 16 physicians, 5 therapists, and 135 manual laborers whose jobs were formerly performed by State prisoners. The second largest increase was at Gracewood State School and Hospital, with 6 more teachers and 109 additional attendants caring for the children in cottages. Battey Hospital continued its planned decrease of personnel in response to the shortened hospital stay now required in treating tuberculosis; institutional workers and nurses (aides and orderlies) were again the groups most affected. Employment in the State office and in the counties remained relatively stable, with increases of 26 and 22 respectively. ~- In preparation for the new pay plan, adopted by the State Merit System and effective July 1, 1964, all classes of positions used in the Health Department were reviewed by the personnel officers and the major administrative heads of the department. Many of the changes decided upon will, when budget resources are available, result in more efficient departmental operation. FULL-TIME EMPLOYMENT 6-30-63 Local *939 Fulton 303 State A. R. s. *656 45 Battey 703 Gracewood 589 Milledgeville 2688 Totals 5923 6-30-64 961 306 682 44 566 756 2941 6256 *adjusted to show later information -9- EMPLOYMENT TURNOVER 6-30-64 **Appointments **Separations Net Gain Separation Rate Local 143 121 22 13% Fulton 58 55 3 18% State 213 187 26 28% A. R. s. 10 11 -1 24% Battey 95 232 -137 37% Gracewood 343 176 167 26% Milledgeville 847 594 253 21% Totals 1709 1376 333 23% **These are gross figures which include those affecting employees on temporary assignment and those in leave status. The percentage would be smaller if these were not included. -10- VITAL RECORDS SERVICE During the fiscal year just past, a total of 277,301 records representing 219,401 vital events were processed and registered in the Vital Records Service. The events recorded were 103,237 current live births, 37,103 deaths, 3,128 fetal deaths, 57,900 marriages, 10, 915 divorces and 17,118 delayed birth certificates. A total of 2,984 certificates of adoption were received, processed and new birth certificates for 2,936 adopted children were completed and filed. Legitimation proceedings for 1,498 children born out of wedlock were completed and new birth certificates filed for these children. Superior Court orders changing the legal name of 197 people born in Georgia were received and the birth certificates amended in accordance with these orders. Court Orders from the Court of Ordinary correcting errors in 6,226 registered certificates were received and the certificates were amended. More than 180,000 requests for the certification and/or verification of birth, death, marriage and divorce records were received from family members, attorneys, schools, welfare agencies, other governmental agencies, industry, and private agencies. These requests were processed, resulting in the issuance of 44,747 certified copies of birth or death records and -11- the verification of more than 100,000 other records registered in the Service. Requestors of copies or for the verification of records not registered were instructed to the end their need could be met. -12- PATIENT ACCOONTS SECTION The amount of monies collected toward the cost of care and treatment of patients in institutions under the control of the Department of Public Health, during the past fiscal year, was considerably more than that of the previous year. The increase was due to a higher per diem and the fact that more persons were meeting the requirements that make payments an obligation. More was directly collected from the patients while a marked decline appeared in the amount collected from other persons liable for the cost. The number of patients for whom funds were paid was still small compared to the total patient load. The Assessment Act of 1960 is based on taxable income only which creates an inequity in assessments. For example, numerous patients with large estates are not required to pay because there was no taxable income for the previous calendar year. The need for changes in the act are apparent so that responsible persons can be defined and assets considered in assessing. Most persons want to pay something towards the cost of care and treatment in Milledgeville and Gracewood even though they are not required to do so by law. An attorney to serve as an Appeals Officer has now been employed by the Department. This gives those assessed for payment an opportunity -13- to be heard and show cause why assessments should not be made or a determination made as to the amount required to be paid. This should help the assessment program if changes are made in the present law to provide for collection. -14- division of epide 10iology EPIDEMIOLOGIC INVESTIGATIONS BRANCH The Investigations Branch of the Division of Epidemiology is concerned with the collection and correlation of information: (1) relating to the prevalence and incidence of infectious and noninfectious disease, (2) relating to other causes of morbidity, and (3) relating to ecologic problems that have public health significance. This information is not easily available and special investigative procedures and research are necessary in order to elicit it. The problem has been approached in the following ways: -- morbidity reporting systems of two kinds: (1) a post card or telephonic communication procedure used by physicians to report through local health departments and (2) a sampling system designed as a measure of effectiveness of reporting. surveillance and confirmation of diseases on which laboratory work is done. The oldest formal surveillance system, that for Rocky Mountain spotted fever, is now in its 33rd year. The newest, for shigellosis, is in its first year. -- surveys ofabsenteeism from schools to determine the prevalence of epidemic disease, such as influenza. -- intensive field studies to determine the actual extent of disease in a group or the health status of a group. In 1963, for -15- example, a community-wide study was necessary in order to determine the significance of a locally acquired case of malaria. No other morbidity simulating malaria was discovered and the case was determined to be a highly coincidental transmission of a foreign malaria. Despite the presence of a population of Anopheles quadrimaculatus theoretically capable of maintaining malaria, the disease has not re-established a focus in Georgia although two locally transmitted cases have bem found since the end of the Korean War. Also, research studies intended to reveal the nature, fundamental characteristics, and sources of various diseases, are of utmost value. Three major research investigations continue in progress, two were begun in 1963 and others continued in reduced form which include the following: -- longitudinal studies of viral infections of animals which will infect man. In 1963, EEV continued to be abundant in mosquitoes; WEV, California and Hart Park viruses were also found but no horse or human cases developed, The possible relationships of such infections and of VSV, which appears to produce numerous unrecognized infections, to chronic and degenerative disease of man are also a concern. A serologic survey for evidence of infection with these viruses in a characterized human population in a south Georgia county is being made as another major undertaking. -16- -- a preliminary report of a study of the basic bacteriology and ecology of the bread-filler-cellophane wrapper system formed by a wrapped sandwich was published and the study is being continued with the aid of an NIH grant. -- a controlled study of a new Staphylococcus vaccine is now in its second year as part of a continuing investigation of means of enhancing immunity to staphylococci. This represents the sixth antigen investigated. -- studies (a) on gamma globulin instilled into the eye as a means of controlling infectious hepatitis are being continued and (b) a new series of studies intended to explore the possibility of using electron microscopy as a means of serologic indentification of viruses in cells has been under taken. -17- Summary of Reported Communicable Diseases 1963 (With Comparisons with Earlier Trends) Median 1952-56 Regular Median Reporting 1958-62 1963 Sampling 1963 Amebiasis Brucellosis Diphtheria Encephalitis, unspec. Hookworm Infectious hepatitis Influenza Measles Meningitis, unspec. Meningococcal infections Poliomyelitis Psittacosis Rheumatic fever Rocky Mountain spotted fever Salmonellosis Shigellosis Streptococcal infections Tetanus Trichinosis Tuberculosis Tularemia Typhoid Typhus fever Whooping cough 45 210 17 13,587 232 5,975 4,854 NR 84 390 9 70 18 191 328 1,596 29 1,880 39 49 27 398 11 14 64 26 6,950 272 498 491 94 31 30 2 16 15 298 502 413 15 1,439 15 27 5 21 2 17 26 18 4,176 177 2,313 226 42 26 3 9 15 481 459 194 11 1,369 31 14 1 18 140 30 20 100 1,170 89,510 10,370 120 20 10 450 720 410 56,080 10 150 280 50 1,290 (See reports of the Laboratory Branch, Vital Records, Venereal Disease Control, and Tuberculosis Control Services for data in addition to that contained in the above table.) -18- VETERINARY SECTION The incidence of animal rabies has continued to increase during the fiscal year with a total of 94 laboratory confirmed cases reported from 15 counties. The epizootic, presently confined to the southern tier of counties, has occurred almost exclusively in wild life species. Racoons have accounted for over 87% of the total cases reported. Lateral spread of cases from the initial focus of infection has been less than anticipated. Sporadic cases of rabies in bats are reported from areas of the state that are free of the disease in terrestrial mammals. The role of bats in the epizootiology of rabies in Georgia is unknown. Rabies was diagnosed in a opossum for the first time in Georgia during the fiscal year. This unusual finding was doubly confirmed by virus isolation and neutralization procedures. In conjunction with a typhus survey in the metropolitan Atlanta area, 200 Norway rats were examined for rabies and for salmonellosis. All specimens were negative for rabies by fluorescent rabies antibody examination. Salmonella typhimurium was the most common serotype of the 12 isolations from cecal cultures. Investigations of the more unusual zoonotic diseases have resulted in the diagnosis of fatal blastomycosis in a dog and generalized tuberculosis in a pet monkey. -19- BRANCH OF LABORATORIES The Laboratory Branch, consisting of the Central Laboratory Service in Atlanta, and the Regional Laboratory Service with laboratories in Albany, Macon, and Waycross, performed a total of 1,013,998 examinations in fiscal 1964, an increase of 33,705 over fiscal 1963. Included were diagnostic, special and consultative services. The diagnostic services were performed in five sections in the Central Laboratory as follows: Microscopy, Microbiology, Sanitary Microbiology, Serology, and Virology. Supporting services were provided by the Preparation Section, Reports and Records Section, and Service and Supply Section. With the exception of a virology section, the three regional laboratories operated with the same organizational structure. Table A compares examinations made in the two services and the individual laboratories during fiscal years 1962, 1963, and 1964. Table B shows further analysis of the workload according to the five sections. TABLE A Examinations Performed by Central and Regional Laboratories Fiscal 1962., 1963, and 1964 Unit Fiscal 1962 Fiscal 1963 Fiscal 1964 Total Per Cent Total Per Cent Total Per Cent Central Laboratory Service 543,966 57 Field Laboratory Service Albany Laboratory 135,166 14 Macon Laboratory 150,655 16 Waycross Laboratory 120,581 13 Total 406,402 43 Branch Total 950,368 100 562,394 57 583,173 58 135,182 14 146,258 14 157,535 16 165,158 16 125,182 13 119,409 12 417,899 43 430,825 42 980,293 100 1,013, 998 100 -20- TABLE B Examinations During Fiscal 1964 by Sections and by Laboratories Section Total Central Laboratory Regional Laboratories Number Number Per Cent Number Per Cent Microscopy 214,643 108,931 51 105 '712 49 Microbiology 61,162 21,423 35 39,739 65 Serology 624,403 383,207 61 241,196 39 Milk 103,872 59,694 53 44,178 47 Virology 9 918 9 918 100 T FHA and VA. We have completed a draft of d,~sign and construction standards for individual sewage disposal systems for adoption. We have prepared recommendations for the design, operation and maintenance of sewage oxidation ponds for publication by the Department. Refuse collection and disposal consultation was rendered state-wide through 159 field trips into 43 counties. Maintenance permits were issued covering 1000 water impoundments. General sanitation continued expansion in effective liaison and working relationships with the State Parks Department, the US Forest Service, State Game and Fish Department, State Highway Department, and other allied agencies. Results were reviews of plans for four new water systems, improvements to 15 water systems, installation of 50 approved individual sewage disposal systems, field inspections of 92 gas heating units for venting and safety, routine water sampling program established in state parks and US Forest. Service recreational areas. Tourist court permits were issued to operate 1115 establishments; issurance of permits to 48 establishments delayed pending completion of corrections; 35 previously operating establishments were reported closed. Close cooperation was maintained with Medical Facilities Service in construction, remodeling and inspection of homes for the aged and nursing homes. School sanitation activities aimed -68- primarily at the school lunchroom and at such sectors of the school environment as were brought to our attention by complaints through local health authorities from parents, teachers, and school officials. Mosquito control on large impoundments conducted by operating agencies and reported to this office included shoreline maintenance and larviciding. Pilot studies in self-evaluation of the food service industry indicate that a satisfactory program may be ultimately developed. Food service training programs were conducted in cooperation with 25 county health departments. The shellfish sanitation program involved certification of 11 shucker packer plants, four repackers, four shellstock dealers and three reshippers handling 225,000 pounds of oyster meat from Georgia waters. A sanitary survey of approved waters is in progress. Bacteriological examination was made on 524 samples collected from shellfish waters. Official milk sanitation surveys were made on 24 milk sheds, and 29 spot checks of local milk supplies were completed, involving 129 inspections of pasteurization plants and 1246 inspections of farm dairies. There are 22 milk sheds listed on the honor roll by US Public Health Service. This Service continues to participate in the training of public health sanitarians for employment in this state. The turnover of sanitation personnel in local health departments (94 appointed versus 71 separated since January, 1960) is such that continued intensive efforts must be made to train sufficient sanitation personnel to give adequate coverage at the local level. -69- WATER RESOURCES SERVICE The Water Resources Service provides supervision over water supplies, sewerage projects, industrial waste treatment, stream quality and other allied activities. During fiscal year 1963-64 plans and specifications were reviewed and approved for 18 new municipal water supplies, nine sub-division or industrial water supplies, and extensions to 72 water supply systems. Consulting, engineering and chemical services were supplied to municipalities and industrial concerns in problems of water supply and treatment. Engineering review and approval of sewerage systems for 24 new municipal plants and 38 sub-divisions and industrial plants was completed. Extensions were approved for 45 municipal systems and five sub-divisions. The amount of $2,108,009 was granted for sewage treatment plant construction under the Federal Water Pollution Control Act, Public Law 660. These funds were allotted to eligible municipalities through the Water Resources Service. An additional $1,512,600 was granted to 12 cities for both water and sewerage systems under the Accelerated Public Works program by the U. S. Government. The stream quality program proceeded at an accelerated tempo. TWenty-nine sources of pollution were investigated and action inaugu- -70- rated to abate the pollution from these sources. Major emphasis was placed on the Etowah and Chattahoochee Rivers. Samples were collected in order to determine the physical, chemical and biological characteristics of the water. Public education and promotion of water supply and waste treatment facilities were intensified. Numerous conferences were held and public speeches made to exchange ideas on water supply and waste treatment problems. An intensified program for improvement of small water supplies throughout the state was begun. Visits were made by engineers to all supplies which were either delinquent in sending samples as required by regulations, or whose samples were of questionable quality, or unsafe bacteriologically. Investigations were made and recommendations submitted for the correction of all deficiencies. Advice on treatment problems was supplied by a chemist and an engineer to all treatment plants which requested help or were found to be in need of such service. The Water Laboratory, the Analysis Section of the Water Resources Service, made bacteriological, chemical and physical tests for water quality and water pollution control programs as well as all tests on shellfish for the General Engineering Service. -71- A total of 68,724 tests were made, an increase of 43.6% over the previous year. Of the 703 water supplies, 3.8% more supplies submitted samples regularly than during the previous year and 8.7% more supplies produced water of satisfactory bacteriological quality. -72- ENVIRONMENTAL HEALTH TRAINING The need for adequately trained personnel to meet the increasing complexities in the field of environmental health is a major problem facing all State Health Departments today. To meet this need, the Environmental Health Branch, in 1963, conducted or participated in training activities to a greater extent than in any previous year. Realizing the need for specialized training in certain areas and the cost involved in sending personnel out of state to attend specialized courses, arrangements were made to have two of these courses conducted in Georgia by specialists from the Robert A. Taft Engineering Center, Cincinnati. The two courses conducted were: 1. "Water Quality Studies" 2. "Aquatic Biology" These courses were of one week's duration, with a total enrollment of 65 students. Thirty three sanitarians participated in an orientation course which consisted of twelve weeks of classroom work and seven weeks of supervised field training. One-day courses were conducted in Macon, Waycross, Albany, Athens, and Atlanta in "Making Inspection More Efficient", "Self-Evaluation in Food Service Establishments." -73- It is felt that it will be necessary to plan more courses to be conducted in the field if the needs of the individual sanitarian are to be met. Consideration should also be given to requesting local health departments to set up an annual training budget to supplement the state program. -74- health eonservation braneh CRIPPLED CHILDREN'S SERVICE At the beginning of fiscal 1964, Crippled Children's service had 221,993 children on its state register, of which 10,482 were treated during the year. The register is remarkably accurate through the close relationship with local county health departments; the service is kept informed of patients who move from the state, expire, or cannot be located. Children made 24,660 visits to clinics, (the average patient attends clinics three times a year) while 21,534 hospital days care and 13,250 days of convalescent care were offered by the Service. The orthopedic and plastic surgery case loads reflected some growth as did the cardiac, amputee, and physical medicine patients. Cases of children with hearing problems and with seizure problems are increasing rapidly. Presently there are special seizure clinics in Cordele, Columbus, Savannah, Macon, and Atlanta. There are hearing clinics in Augusta, Macon, and Atlanta. There are many supportive services in Georgia to help the crippled child. The Benevolent and Protective Order of Elks has for a number of years maintained a travel fund from which public health personnel can draw to pay transportation for children coming to clinics and hospitals. This fund is limited and county people work yery hard to find local resources for this purpose. The State Department of -75- Education, Division of Exceptional Children, helps with the appropriate placement of many of our children in public schools. The Department of Family and Children Services is most helpful with children whose homes are not suitable for treatment to be carried out and arranges faster home care as indicated. The Service's most effective resource is the local health department. Each time a child reports to a clinic, or to a hospital, a copy of notes made at that time are sent to the county of his residence. The personnel there are always kept up-to-date on what the Service is doing for the child. In turn, they keep the Crippled Children's Service informed of home situations and of problems arising to prevent the child from reporting to clinic or hospital. Local health departments are very active in helping parents plan for the care of a child in a cast or special apparatus. They draw on local resources so that the child can be adjusted to his social and educational environment in his local conununity. The clinic team operating the Central Hearing Clinic has offered service to Cave Spring School for the Deaf. From time to time a clinic is held at Cave Spring where children are evaluated to determine whether or not hearing aids would be helpful to them; hearing aids already being worn are either repaired there or in Atlanta. Of the total student population at Cave Spring 64 children have been active at one time with Crippled Children's Service and is hoped that all of these can be activated and given whatever help they may need. -76- MATERNAL AND CHILD HEALTH SERVICE The Haternal and Child Health Service is charged by law to protect and promote the health of mothers and children in Georgia. The focus of the service has been upon preventing and combatting health factors which would keep individuals from becoming economically dependent members of society. In 1963 there were 99,360 births, of which 7,68l~ were home deliveries by 382 midwives. We can anticipate that 2,500 to 3,000 of these approximately 100,000 babies will be mentally retarded, 100 will be completely dependent and require institutional care, 400 will be semidependent, and 2,000 will be marginalally dependent. As late as 1934 the maternal death rate was 78.2 per 10,000 live births. In 1963 it was reduced to 5.3. Even though this is an astounding improvement, Georgia must materially improve both the maternal and infant mortality rates in order to compare favorably with the national average. There has been an alarming and persistent rising death rate among the one through 11 months age group in the last eight years, which has raised the infant mortality rate. A majority of congenital defects, both mental and physical, are directly associated with the complications of pregnancy and heredity. Therefore, primary effort is placed upon family planning and good prenatal care, terminating in hospital delivery by a physician, and upon continuous -77- well child supervision. To date, there are 18 community plans for indigent hospitalization for delivery, four of which have been recently initiated, and four more are under study. During the year, 16,476 patients were admitted to prenatal medical care, 24,429 to prenatal nursing care and 4,182 to postnatal medical care; 106 counties have maternal clinics with physicians' services. Stress has been placed on the prevention of iron deficiency anemia. Almost all patients are now given oral iron as early in pregnancy as possible; 250 cases of extremely severe anemia were provided with parenteral iron, where routine oral therapy was inadequate or impractical. The service assisted and promoted a special project of intensive antenatal, natal and postnatal care for the indigent and medically indigent high risk patients and their infants. This project is sponsored through the Richmond County Health Department and is a coordinated effort of the Hedical College of Georgia and 11 perimeter county health departments. The Children's Bureau provides 75% of the funds. One hundred and thirty-one counties have well-child conferences with physician participation. There are nursing conferences for mothers and children in 19 counties. Over 52,990 immunizations against diphtheria, tetanus and whooping cough were completed during infancy and through the first four years of life. About 2.5,582 in this age group received Salk polio vaccine. -78- A number of health department clinics routinely use a urine test screening for phenylketonuria at the sixth or eighth week. One case, a $100,000 life cost care problem if undetected in the first few months of life, was found by this activity. A hospital newborn screening program for this preventable cause of mental retardation has been set up. Hospitals have tested 13,402 infants. One case has been found by this method and is under dietary management. A special project in mental retardation, the Child Development and Evaluation Center in Muscogee County Health Department, is providing services to a 12-county area. This, too, is a Children's Bureau underwritten activity. Plans have been submitted for similar projects in DeKalb, Rockdale and Chatham Counties. The number of clinics for the infant auditory screening program, aimed at early detection of developmental and/or hearing problems, are increasing. In-service training in maternal and child health is part of the basic work of the staff. An institute was held in hospital premature care and other less formalized experiences in family planning were held for nurses. A seminar on obstetrics and newborn care was sponsored for physicians. -79- NUTRITION SERVICE Planning for more effective coordination of Nutrition Services was emphasized this fiscal year. For this purpose, a committee cons:.:_sting of health officers, nurses, nutrition staff members and members from other state services reviewed the current situation and the history of the service to make recommendations for future steps. In C(loperation with the Maternal and Child Health Service and the Georgia Jaycees, the nutrition staff promoted the use of surplus commodities to improve the health of mothers and babies through more adequate nutrition. The staff demonstrated the commodities to the Jaycettes at a state meeting in Macon. Georgia, which is the only state in the United States to use this program, has 36 counties participating. The joint survey of child-caring institutions made with the Family and Children's Services is nearly complete and the results have been partially tabulated. ~fuen completed, some necessary training sessions wi 11 be planned. The nutrition staff is also assisting in planning a correspondence course for supervisory food service personnel in small hospitals and also for annual regional institutes. Other agencies such as the School Lunch Program, the Vocational Education Department, various colleges and schools, the Georgia Nutrition -80- Council, the Teen-Age Project, the Diabetes Association and the Tuberculosis Association cooperated with the Nutrition Service in various joint projects. The U. S. Public Health Service nutrition consultant in the cariovascular disease program developed materials for use by those requiring fat-controlled diets and low sodium diets. She also worked with the regional nutritionists and the dietary consultant in Medical Facilities Service to conduct in-service education programsfor local health departments. The junior nutrionist in the Central Region was placed in District #26 for a period of 18 months to develop a comprehensive Community Th1trition Program. She worked with maternal clinics, schools, educational groups, low-income families, practical nurses and others to seek what problems are present and to make recommendations for better nutrition planning in the district. The dietary consultant also engaged in joint planning with the League of Nursing for a workshop to occur next year to up-grade nutrition education in nursing schools. She also temporarily taught,for demonstration purposes,a group of nurses from the Medical College at Augusta who are being trained at Georgia State College. The nutrition personnel participated in orientation, in-service training, Crippled Children's clinics, prenatal and well-child clinics, schools, classes for obese patients, consultations with other agencies -81- on standards, individual patient conferences and classes for dental assistants, practical nurses, school lunch supervisors, and day care directors. They attended and participated in numerous national, state, and local conferences and workshops. A special workshop in Nutrition Consultation was also held for staff members. Since many of the nutrition publications were out of date, the staff, with the help of a temporary nutrition consultant and a commercial artist, edited and reprinted several pieces used for education of the public. Next year additional literature will be up-dated and reprinted. -82- SCHOOL HEALTH SERVICE The School Health Service concentrated the major portion of its staff time on hearing and vision conservation programs. The staff has also been engaged in two other projects: one in cooperation with the Children's Bureau, and the otper in a local small city school system and health department. The Service also offered consultative services to local health departments concerning the teaching of health subjects in the schools. School Health answered requests of voluntary and schoolrelated agencies (P.T.A.) for talks and any other need the service was competent to fill. Ninety counties representing 262,207 children in 2.25 schools had vtsion screening. Of the number tested, 20,043 children failed, and 9,607 were reported to have received follow-up care. The Georgia Lions Lighthouse finances vision corrections for many of the medically indigent children. In 668 schools in 101 counties, there were 123,484 children whose hearing was screened by puretone audiometer. Of those tested, 6,296 failed, and 3,343 were reported to have received medical care. The new feature of the hearing program clinics with hearing screening examinations by otologists is now in its second year of operation and has proved to be popular and useful to local health departments. Twentynine clinics were held, and about 1,771 children from 43 counties received this service. -83- School Health Service has continued to work cooperatively with a local health department and medical school in the operation of the first local health department sponsored speech and hearing clinic. In a second local health department the Service has done some planning for the purpose of submitting a special project to the National Institute of Health in October that would make possible the establishment of a second local health department speech and hearing clinic. School Health Service assisted the Tuberculosis Control Service in initiating interest in more tuberculin testing. This year 81,665 school children were tested; 2,180 (2.7%) reacted positively, and 35 had active disease. An additional 63 cases were found in contacts of school children. With funds supplied by the Children's Bureau, a health survey was carried out for the negro children at the Georgia School for the Deaf. Each of 164 children received a pediatric, otologic, audiologic, ophthalmologic, and psychological examination. Some of these children received medical and audiological follow-up services from project funds, and others received medical treatment from the Crippled Children's Service, voluntary agencies, and private resources. A study was conducted at Sumter Cbunty Health Department to test the validity of a questionnaire for the detection by the teacher of emotional disturbance in -84- children and was submitted to NIH and was approved but not funded. Until such time as funds become available, School Health will attempt to carry out the project with its own budgetary allocation for pediatric and clinical psychological examinations for school age children. A plan is being developed, with the cooperation of the School Child Health Committee of the Georgia Academy of Pediatrics, to make pediatric examinations and clinical psychological tests available to children who are failing to progress in school because of physical, mental or emotional problems. The School Health Service sponsored a five-day course in the principles of audiometry for public health nurses, at the Georgia Center for Continuing Education. -85- loeal health braneh LOCAL HEALTH ADMINISTRATION SERVICE During the past fiscal period considerable attention has been directed to the coordination of program development and expansion of existing programs in local health departments. Of the 159 counties of the state of Georgia, 114 are covered by district personnel with 42 other organized local health departments. At the present time Union, Pickens, and Towns Counties have no prospective local health department activity. Considerable effort has been expended in these counties to establish active local health departments, but the lack of qualified personnel has been a serious obstacle. There were 28 districts during this period with district directors of public health, with a total of 30 out of 38 districts active with either a district director of public health or district director of environmental sanitation, and/or a district director of public health nursing. The matter of staffing in local health departments during the past fiscal year has been that all efforts in terms of recruiting, training, and orientation have, at best, only maintained the status quo. There were six public health center projects approved during the 1964 fiscal year in the counties of Dougherty, Fulton- Roswell, Gilmer, Paulding, Troup, and Warren amounting to $858,000. -86- July 1, 1964 was the effective date of the new pay plan covering positions of the State Merit System which involved considerable time on the part of the Branch of coordinating the adjustments as they affected local health department personnel. Both the Branch and the Service have been involved in extensive studies relating to both grant financing and state-local relationships as they apply to distribution of available resources and area needs. It is anticipated that these efforts will be valuable in the planning and programming of health services to the people of Georgia. -87- NORTHERN HEALTH REGION Ten out of the 13 planned health districts in the Region were functioning as activated districts during fiscal year 1964. Districts 11, 22, and 23 remain unorganized districts although definite interest has been shown by vari0us counties in Districts 22 and 23 to organize. Encouragement for organizing has been withheld to some extent by a temporary moratorium on the formation of new districts. Among counties not having a full-time health department, Pickens County is ready to establish a health department as soon as a qualified public health nurse can be recruited. Towns County is showing definite interest and will probably establish one s~on. Union County is showing some interest and it is hoped this interest increases to a point sufficient to warrant more serious efforts of outside assistance. A District Director of Public Health was employed for District 16 on August 1, 1963. Nine districts thus had full time medical directors. District 29 continued to be served on a part-time basis by the Regional Medical Director. Toward the end of the period a District Director of Public Health was recruited for District 29 and he is at present in orientation training. Seven of the activated districts were served by a district director of nurses and eight had a district director of environmental sanitation. The district nurse in District 31 retired and District 32 employed a district nurse during the period. -88- On July 1, 1963, the engineering and sanitarian consultants of the Regional Office were transferred to the General Engineering Sanitation Service. Counties now having no sanitarians are served by personnel from the latter service on request from the counties or the Region through the Local Health Branch. One s e cretary was transferred to the Local Health Branch as part of this re-organization. As of December 31, 1963, in the activated districts, the number of health workers employed in the various health departments throughout the Region was as follows: 12 physicians, 217 nurses, 92 sanitarians and engineers, 126 clerks, and 133 other employees. Twenty-two nurses, 6 sanitarians, and 16 clerks were employed in the unactivated districts. Six health investigators served the area exclusive of those doing special projects. Ten organized counties operated without a local sanitarian and one county without a local public health nurse. Regional office personnel consisted of two nurse consultants, two nutrition consultants, a medical director, and a secretary. Construction of three new health center buildings under the Hill-Burton Program were completed in White, Catoosa and Wilkes Counties. The White County and Catoosa County centers were opened and Wilkes County Health Center will open shortly. Two new health -89- center buildings were placed under contract (Hill-Burton); one in Paulding County and the other in Fulton County. Lincoln County is constructing health center space in an addition to the Court House Building financed in part under the Area Redevelopmen t Adm in istr ation Program. -90- CENTRAL HEALTH REGION Among the continued programs during fiscal 1964 was the blood pressure study in one of the counties in the region. In-service education for consultant nurses also continued with most training centers being located in or around Atlanta. In-service programs were planned for local health departments in such public health areas as tuberculosis, mental health, interviewing, family planning, maternal and child health evaluation and records. Tuberculosis services with diagnostic and evaluation clinics were reduced from 23 counties to eight with the majority of project workers being transferred to other areas. Progress was made during the past fiscal year in curbing the spread of syphilis. Though it is increasing in some counties .. one of the larger counties in the region showed a 72 per cent decrease in reported cases. This is due primarily to epidemiological treatment of primary and secondary contacts. It is felt that these same results can be accomplished in the majority of counties in the region with little or no trouble. At the beginning of fiscal 1964 all of Central Health Region engineers and sanitarians were transferred to the Atlanta office; thus, with this transfer the number of services offered to the public in this area was drastically reduced. Other loss of personnel included the transfer of the Regional Nutritionist and the resignation of the Regional Dental Consultant. -91- SOUTHERN HEALTH REGION The staff of Southern Health Region conducted an overall guidance, supervisory, consultative and educational service to individual counties and districts as needed during the past fiscal year. In addition to the Crippled Children's Institute held in June, 1963, three regional meetings were conducted. Topics were mental health, tuberculosis, review of immunization policies and an extensive discussion of records. Other short in-service activities covered the areas of stroke rehabilitation, heart, mental health and the Commission on Aging. Our nurses, in addition to rout ine activ i ties, have concentrated on better records, better selection of patients for X-ray clinics, correction of defects found from vision and hearing surveys, promotion of Medical Self Help classes in the schools and community .. and continued teaching of Mother and Baby Care classes in schools. Both Irwin and Turner Counties have new Hill-Burton buildings while Marion County moved into better quarters during fiscal 1964. Schley County opened its health department in July, 1963, and plans are currently underway for construction of a health center in Wheeler County, Alamo, Georgia. During National Children's Dental Health Week, many of the cities in the Southern Region presented outstanding dental educational programs and were given state-wide publicity for their contributions. Featured -92- activities included: public announcement of two new fluoridated water systems; two poster contests; essay contest; Junior League Follies presentation for dental health; School Science fair project--"The Effects of Mouth Bacteria on Tooth Decay"; a pre-fluoridation survey; and numerous talks on dental health before school and civic groups. Our regional staff personnel fluctuated with the transfer to Atlanta of one Regional Engineer and two Regional Sanitarians; however, headquarters are yet maintained in Albany and Waycross. One Regional Consultant Nurse was transferred and two stenographers in Waycross and Albany offices resigned. Also, in July of 1963 the Administrative Officer in the Macon Regional Office was given the responsibility for direction of the Albany and Waycross offices. -93- preventable diseases braneh CANCER CONTROL SECTION There was a substantial increase in the cost of operating the cat,cer program during fiscal 1964; therefore, it was necessary to transfer additional funds to the cancer budget in order to keep the program operating without interruption. Total expenditures for patient care amounted to slightly more than $500,000. This represents an increase of approximately $50,000 over the figure for the previous year. There was some increase in the case load but this alone was not sufficient to materially affect the cost of the program. During the year, 2509 patients submitted applications for state-aid as compared with 2470 during the previous year, an increase of about 1.5 per cent or $6,000. While the continuing increase in the per diem rate paid for hospital care was a sub~tantial factor in contributing to an increased cost of approximately $1.::,000, a more important factor was a sharp increase in expenditures on the part of two clinics. The clinic cost increase was due to prolonged periods of hospitalization for certain types of patients; a~ a result of this experience, a quota has been assigned to each clinic for fiscal 1965. All of the approved clinics continued to operate throughout the year. No additional clinics met the minimum requirements for approval. -94- It has now been six years since a new clinic has applied for approval. Actually, the number of treatment centers now in operation is quite adequate to handle the existing load of indigent cancer patients. In November, 1963, the clinic directors met at the Emory University Clinic for the purpose of discussing problems of mutual interest. The meeting was well attended and the general feeling was that the discussions were of definite value. A second meeting, which was also very productive, was held in Macon in April, 1964, during the meeting of the Medical Association of Georgia. Present regulations require that hospital insurance be collected and either deducted from the patient's bill or refunded to this office. In the past, there has been some laxity in that connection, particularly on the part of several of the larger clinics. As a result, more complete insurance collections were made and refunds during the past six months have increased about two and onehalf times over the figure for the corresponding period of the previous year. Present indications are that at least $25,000 in insurance may be collected.annually. -95- CARDIOVASCULAR DISEASE CONTROL SERVICE The Cardiovascular Disease Control Service cooperates closely with the Georgia Heart Association, the Heart Disease Control Program of the U. S. Public Health Service, and other public and private agencies in developing and continuing research and service programs designed to detect, correct and prevent cardiovascular abnormalities and diseases. Thirty-two professional and non-professional service personnel were engaged in the various research and community service programs in Georgia this year. The Atherosclerosis Study, initiated in 1957, is comparing two different religious orders, the Trappist and Benedictine monks, in an attempt to elicit the factors--dietary, social, psych0logical and others-which may contribute to the disease. The number of monasteries participating in the study rose this year to 29 with almost 2800 individuals. The second phase of the Baldwin County Hypertension Study began on January 1, 1964. This study is designed to determine the incidence and prevalence of hypertension in a selected population and to demonstrate the applicability and effectiveness of public health measures in detection and control. Hypertension clinics have also been established at Georgia Baptist Hospital in Atlanta and at Talmadge Memorial Hospital in Augusta for advanced diagnostic work-up on indigent hypertensive patients; these -96- clinics operate primarily as referral facilities and accept patients from all areas of the state. The heart clinics system also has been encouraged to follow more Jf the hypertensive patients in its caseload. The Stroke Rehabilitation Program has concentrated on education and consultation primarily. Programs are developed through lectures to medical societies and the training of para-medical personnel in local health departments, hospitals, nursing homes, nursing schools (registered and practical), and nursing associations. Specialized consultation has been provided upon request to physicians and public health nurses with difficult cases involving physical therapy; this year two physical therapists visited 544 patients in the state and a third therapist was added to meet the increasing work load. The Congenital Heart Disease Program has continued to cooperate with the Crippled Children's Service in providing personnel and equipment for di.agnosis, treatment and care of afflicted children through clinics, laboratories and hospitals. The Rheumatic Fever Prophylaxis Program continued through which prophylactic medication is furnished free of charge to private physicians and heart clinics for the protection of approximately 2,000 indigent patients against the recurrence of rheumatic fever. Congestive Heart Failure Programs, designed to maintain treatment regimens of digitalis, digoxin and allied medications, are sup- -97- ported and carried out through the heart clinics system. A specialized nurse consultant is now available to physicians and to nurses who have difficult or poorly controlled patients in their caseloads. A training program in mouth-to-mouth resuscitation and closed chest cardiac message has been instituted and made available to hospital personnel and public health nurses. The Cardiovascular Disease Control Service and the Georgia Heart Association continue to sponsor 15 heart clinics throughout the state for diagnostic evaluation, surgery, treatment, all types of care and medication for indigent heart disease patients. A cardiovascular nurse consultant and a nutritionist were added to the staff which has resulted in expanding the services in each of the areas for consultation, assistance and training of nurses and paramedical personnel in problems related to cardiovascular diseases. This past fiscal year a study was also undertaken to determine the value of using routine tuberculosis chest X-rays to discover unknown cases of heart disease and to return lapsed patients to treatment. Secondary screening clinics have been set up on a trial bases and patients whose X-rays reveal possible cardiovascular abnormalities are referred for re-examination and evaluation. As part of the physician education effort, the service continues to furnish complimentary subscriptions to the Heart Bulletin to physicians, -98- hospitals and medical students throughout Georgia. In addition, the service staff developed a nursing manual entitled "Care of the Stroke Patient at Home, A Guide for Public Health Nurses" as a supplement to the USPHS publication "Strike Back at Stroke". This booklet has been distributed to the public health nurses in Georgia and to about 300 nursing personnel in other states. -99- GEORGIA STAIE EMPLOYEES HEALTH SERVICE The major objective of the Employees Health Service is to enable employees to better serve the state. This is accomplished through: (1) counseling employees on health practices; (2) providing annual screening tests; and (3) administering first aid and emergency service. The purpose of the screening tests is to aid both the employee and his private physician in evaluating the health status of the employee. These tests include checking weight, blood pressure, vision, hearing, plus a chest x-ray, urinalysis, hemoglobin, white blood cell count, serology, blood typing, and blood sugar determinations. Medical care beyond first aid is not offered because the Service is designed to motivate employees to assume the responsibility for their own health, and seek medical evaluation and treatment from their private physician. During the reporting year, the staff has consisted of one fulltime physician, two nurses, two medical technicians and two secretaries. This staff is considered adequate for the workload being undertaken. However, if a pre-employment physicial examination under the Merit System is implemented, additional staff members and increased working space will be required. There were 1194 employees screened during the reporting period. This is a decrease of 103 over the preceding year. There were 1157 -100- abnormalities recorded among the number screened. As in previous years, the majority of abnormalities were overweight and defective vision and hearing. There were 19 employees who were found to have hypertension. Abnormal hemoglobins were detected in 39 employees and abnormal urinalyses in 30 others. These conditions were made known to the employee with the recommendation that he or she seek medical interpretation from his or her private physician. Tabulated below are the statistics comprising the various activities of the Employees Health Service during the fiscal year 1964 as compared with those of a like period for the preceding year: FY 1963 FY 1964 Screenings 1297 1194 Screening Revisits 1473 772 Counseling and First Aid 3897 3876 Innnunizations 3164 577 Other 12 50 Total pt'ocedures 162.35 15711 Health literature picked up 5600 3137 Tuberculin skin tests 930 866 Various specific laboratory procedures have been tabulated and are set forth in the following table: -101- November 26, 1962-June 30, 1963 Blood Typing 331 Hemoglobin 856 W.B.C. 800 Differential 33 Serology 588 Blood Sugar 797 Urine Complete 828 Urine Sugar or albumin 123 X-Rays 1133 B.S.T.T. (Beginning 2/18/63) 49 FY 1964 454 132.6 1226 31 1012 ll05 1264 160 1557 32 There were no new programs carried out during the reporting period. -102- Results of Screening tests for Fiscal Year 1964 - Georgia State Employees Health Service Total number screened 1194 Defects: Overweight 76 Hypertension 19 Hemoglobin 39 Glucose tolerance test 11 Chest X-Ray 3 Serological test for syphilis 12 TBC skin test 87 Hearing 23 Distant vision 93 Near vision 191 Visual Fields 6 -103- OCCUPATIONAL HEALTH SERVICE The primary function of the Occupational Health Service is to protect the health of all employed people in Georgia through the promotion of good health practices; provision of a consultation service to private physicians, local health department~, management, and insurance carriers; and a preventive health service for state employees. The staff consists of nine members: two physicians, two nurses, two medical technicians, and three secretaries. Seven of these staff members are employed in the State Employees Health Service. There is considerable under-reporting of occupational diseases and conditions since the only sources of information are the insurance claims submitted to the Horkmen's Compensation Board, and death certificates filed with the Vital Records Service. During fiscal year 1964, seven of the deaths reported were due to silicosis as a suspected contributory cause, and two to pneumoconiosis as a significant condition contributing to death. Occupational disease claims filed with the Horkmen's Compensation Board totaled 319. These reports were from 2.37 employers in 59 counties, and four out-of-state employers in two states. These reported conditions were as follows: dermatitis - 159; chemical injury -104- to the skin - 47; chemical injury to eyes - 53; overexposure to organic phophorus compounds - six; inhalation of fumes and gases 46 (two reported as metal fume fever); possible lead intoxicationthree; carbon monoxide poisoning - one; actinic ray ophthalmia - one; pneumoconosis -one; tendonitis -one; and histoplasmosis, contracted while assigned to South America - one. These data are utilized for study in an effort to determine the best methods of control. When indicated, local health departments are notified of the occurrence of occupation-related mortality and morbidity and offered assistance in follow up. This assistance includes both the medical and engineering aspects of field investigations. The latter is provided by the Industrial Hygiene Service and includes dust counts, air analyses, noise level determinations, and radiation detection plus a general evaluation of the total environment of the place of work. The research program in the kaolin industries continued in the form of completing statistical correlation of findings. This field project terminated in August, 1962. The Director and Occupational Health Nurse Consultant continue to actively participate in national, state, and local meetings and seminars concerned with occupational health. Cooperation with schools of medicine and nursing has been maintained through participation in -105- lectures and conferences. The promotion in district health departments of the idea of Local Government Employee Health Service, patterned after the State Employees Health Service, continues. There is great potential here for demonstrating effective prevention or early case finding of chronic illness on a large representative segment of the population. The probability of health districts finding sufficient funds to initiate such projects appears at present somewhat remote; even though theoretically they cannot afford to continue to ignore the occupational health approach which deals with those who produce the wealth we need as well as those who represent the population we serve. -106- TUBERCULOSIS CONTROL SERVICE Tuberculosis control showed continued progress during fiscal year 1964 through the application of the various programs in the service. Evaluation clinic service was provided to 113 counties. In addition, this service was available from local resources in several urban areas. Difficulty in obtaining local funds to pay the patient travel costs has been reported in several instances. The number of X-ray clinics held in local health departments as well as the number of persons (suspects and contacts) attending these clinics again showed an increase over the previous year. The cost of X-ray film purchased by the Tuberculosis Control Service decreased approximately $32,000. This was due to the fact that the Department of Public Health discontinued supplying x-ray films to certain local health departments effective July 1, 1963. In lieu of furnishing film, the Department now participates in the salaries of qualified full-time x-ray technicians employed by local health departments. Both the number of patients furnished free drugs to complete hospital instituted chemotherapy, and the number receiving chemoprophylaxis, showed an increase over the previous year. More Isoniazid and slightly less Para-aminosalicylic Acid was distributed. -107- In accordance with previously reported plans, three people were left in Macon to continue service of our tuberculosis project in central Georgia. The remaining investigators were moved into four public health districts, (fourteen counties) in northwest Georgia, which have high tuberculosis rates. Excellent relationships have been established with district and county health personnel in the new area. The problem case load has been considerably reduced in northwest Georgia. Ten per cent of the suspects referred from the 70 MM and 14 X 17 X-ray films are found to be active cases of tuberculosis. Examination of contacts of newly reported cases still proves to be our most productive source of finding new cases. Further plans contemplate assigning investigators to all public health districts with counties that fall within the Atlanta metropolitan area, as soon as additional investigators are available. One investigator has been assigned to District #30, in which Clayton County is a part of the Atlanta metropolitan area; and another is scheduled for assignment to District #29, in September,l964, in which Gwinnett County is a part of the Atlanta metropolitan area. There was an overall decrease of 10.41o in new cases reported during the period July 1, 1963 -June 30, 1964, as compared to the same period a year ago. The breakdown shows a decrease of 6.21o in Group A (Active and Probably Active) and a decrease of 44.41o in Group B (All Other Reportable Cases). -108- There was a decrease in the number of deaths (30), a rate of 3.5 per 100,000 was compared with 419 per 100,000 for the previous year. There have been many requests from over the state for assistance in the local tuberculosis programs, but due to a limited staff, we have been unable to fill these requests. The percentage of far-advanced cases being admitted to Battey is less than it was several years ago, but it still ranges from 191o to 441o of total new cases found in the larger counties. A probable solution would be to provide sufficient funds and personnel to find these cases early when treatment is most successful and before they become spreaders of disease. -109- VENEREAL DISEASE CONTROL SECTION In fiscal year 1964, 2,861 total syphilis cases were reported to the department. This is an 11.6% decrease from that reported for fiscal year 1963. The 1,197 cases of primary and secondary syphilis reported in fiscal 1964 represent a 17.8% increase over the 1,016 cases reported for fiscal 1963. The 10,652 cases of gonorrhea reported in fiscal 1964 represent 6.3% increase over cases reported for fiscal 1963. The 422 cases of other venereal diseases (Chancroid, GI, and LGV) reported for fiscal 1964 represent a 1.4% increase over cases reported in fiscal 1963. The 17.8% increase in primary and secondary syphilis cases in fiscal 1964 is attributable to a true rise in the incidence of syphilis. During the last half of fiscal 1964, we have increased the percentage of epidemiologic treatment of named sex contacts of primary and secondary syphilis fr0111 43% to appi'oximately 901.,. We believe that the closing of this loophole in the epidemiology of primary and secondary syphilis will result in decreased incidence of the disease in fiscal 1965. During fiscal 1964 out health investigators made a total of 29,094 investigations. From these investigations 2,466 previously unknown and untreated new cases of venereal disease were brought to treat- -110- ment. Of these, 1,086 were primary and secondary syphilis cases. All of the 1,197 cases of primary and secondary syphilis re- ported for fiscal 1964 were interviewed for contacts and suspects by our health investigators. Of the 455 cases of early latent syphilis reported, 454 cases were interviewed. All reactive serologic specimens processed in public health, hospital and private laboratories during fiscal 1964 were followed up by our health investigators. It is worthy of note that no private physician or health department refused our investigators permission to interview a lesion case of syphilis during the fiscal year. During fiscal 1964 the private physicians of Georgia treated 461o of our total reported syphilis cases; 241. of the reported primary and secondary syphilis cases and 101. of the reported gonorrhea cases. Our Area VD Diagnostic and Treatment Centers treated 541. of the total syphilis cases reported; 761o of the primary and secondary syphilis cases reported; 901o of the gonorrhea cases reported; and 1001. of the other VD (Chancroid, GI and LGV) cases reported. -111- -~~------:.,__, '%~"ot-- .c;; ,-;' " c \)... .'/.lc~,~\-~\ ''_,; ~ ..0F~- c:; ," "~"?'5;J(-' ~?, \--\ t~ ~ ' -=:: speeial serviees braneh CHRONIC ILLNESS AND GERIATRICS SERVICE After organization of the Chronic Illness and Geriatrics Service July 1, 1962, plans were made for training of health investigators to supplement the staff in local health departments. The first class of five completed their training and were assigned to health districts in January, 1963. In July, 1963,a medical director was recruited for the Service and reported for assignment and orientation in October, 1963. At this time recruiting was stepped up in order to fill existing vacancies in the Service and plans were made for active programs in the field of chronic illness and geriatrics. In January, 1963, three health investigators were assigned to health districts in Griffin, Dublin, and Athens with one assigned as liasion investigator with the Cardiovascular Service to coordinate activities between the two Services. The chief health investigator remained active in planning and coordinating training programs fot the new class of five health investigators recruited for a nine months training period beginning July 1, 1963. One investigator resigned in April to accept a position with the U. s. Public Health Service leav- ing the three in Griffin, Dublin, and Athens. -112- On April 1, 1964, after completion of nine months training, five additional nealth investigators were assigned to districts in Columbus, Dalton, Savannah, Augusta, and Moultrie, making a total of eight assigned to local health departments. These investigators, under the direction of the district medical director, assisted the staff in making surveys of local needs relative to chronic illness and geriatrics as well as planning and implementing programs to meet these needs. The health investigators have been able to relieve the public health nurse of some administrative duties allowing her more time for professional activities. As time goes on these activities will be expanded to further meet service objectives. In May of 1964 six additional health investigators were recruited to begin training the first of July. It was found that the training period could be reduced from nine to six months, retaining everything essential to their work, thereby allowing earlier assignment in the field to supplement local health department staffs. Present plans are to train six investigators each year until at least one man is assigned to each district. Recruiting of other personnel continued on an active basis with the addition of: a dietitian in March, nurse consultant in March, institutional nurse consultant in April, and a physical therapist in June. It is hoped that the staff will be complete for full -113- activity early in the next fiscal year, with the addition of three nurse consultants, specialized nurse consultant, social worker and a second physical therapist. It was necessary to add the second stenographer during the year to handle the workload of a growing Service. Frequent visits were made to the Dalton Home Care Project during the year as well as to the on-going home care program in Columbus. After the first part of the fiscal year, teams were organized for visits to nursing homes and homes for the aged. These visits were made on request through the local health departments for the purpose of professional instruction, in-service training and upgrading when deemed necessary. Many requests were received from nursing homes prior to opening in order to brief the staff on operative procedures and techniques. It will be necessary in the next fiscal year to organize more teams in order to comply with the numerous requests received for this type service. Working in close association with the Georgia Diabetes Association, Arthritis and Rheumatism Foundation and the Society for Prevention of Blindness, programs for diabetes, arthritis, and glaucoma have been worked out and will be implemented in as many areas as possible during the next fiscal year. -114- MEDICAL FACILITIES SERVICE During 1963, Medical Facilities Service continued its comprehensive program of assistance to local communities for the improvement of patient care facilities and services. This assistance was provided through the following: (1) Community Survey and Areawide Planning Program to aid communities in planning for new, expanded and improved medical care facilities and services; (2) ArchitecturalEngineering and Equipment Program to review and approve plans and specifications to assure the construction of efficient, safe, properly designed and equipped facilities; (3) Hospital and Nursing Home Licensure Program to inspect and encourage hospitals and nursing homes to meet standards established under the Georgia Hospital Regulations Act; (4) Consultative and educational services to communities, governing bodies, and administrators with special operational and community problems. Federal and state appropriations for the construction program were slightly decreased from the previous year. This resulted in a reduction in the number and size of projects that could get under way during the fiscal year and increased the backlog of applications waiting approval. SixtY-nine applications were pending for grant-inaid assistance with an estimated construction cost of $73,364,000. -115- Grant projects placed on the construction schedule and approved for grant-in-aid during fiscal year 1963 were as follows: TYPE PROJECT NUMBER General Hospital - Including Additions 9 Psychiatric Hospitals 1 Public Health Centers and Auxiliaries 6 Nursing Homes - Including Additions 6 Diagnostic and Treatment centers 2 ~ 453 52 355 Tongrange planning on an areawide basis was emphasized. Appropriate planning guides were developed for grant applicants in making surveys and preparing a "Program-Project Narrative." These pre-planning activities are now required of all sponsors, vrior to architectural drawings, cost estimates, and consideration for grant-in-aid approval. The Medical Facilities Construction Section reviewed, according to established standards, all plans and specifications submitted for all eligible Hill-Burton projects and other hospital and nursing home projects. Proposed sites were inspected with comments to sponsors and -116- their architects. Plans and specifications reviews and frequent onsite inspections provided the sponsors, architects and engineers with consultative services and recommendations relative to functional planning architecture; structural, electrical, and mechanical engineering; equipment procurement and preventative maintenance. In the Hospital Licensure Section there was also evidence of improvement in the quality of hospitals and hospital services. The number of hospitals operating under full licensure permit increased from 143 to 160. Four new hospitals were opened, one completely renovated and two closed. The number of facilities operating under provisional permit decreased from 63 to 49. Some of these are making good progress toward correcting the deficiencies. In Nursing Home Licensure there was continued evidence of in~ creased quality and quantity in nursing home facilities and personnel. The number of licensed institutions increased from. 150 with a capacity of 5,366 beds to 166 with a capacity of 6,641 beds. The majority of the newly licensed facilities were of new construction and qualified for permits in the more skilled classifications thus continuing the strong movement toward 24-hour nursing care in the nursing homes in the state. Of the 31 unlicensed homes representing 475 beds known to be in existence at the beginning of the year, eight were closed. Five new unlicensed homes, however, were found in operation, leaving a residue of 28 known unlicensed homes with a capacity of 363 beds. -117- Consultation in clinical laboratory, food service and nursing administration and accounting procedures were provided to medical facilities in the state. -118- BAITEY STATE HOSPITAL The applications for admission to Battey State Hospital during the current fiscal year declined from 1,738 during the fiscal year 1962-63 to 1,506--a reduction of 13%. A newly established application review board screened those applications for patients thought to be non-tuberculous or not in need of hospitalization, with a resulting rejection of 120 applications (8% of the total number received). The decreased number of applications plus more stringent screening saw the admissions come down from 1,642 in 1962-63 to 1,373--a drop of 16%. There was no appreciable change in the stage of disease of those patients admitted. Eleven per cent had minimal tuberculosis, 31% moderately advanced tuberculosis, 34% far advanced tuberculosis, 3% primary tuberculosis, 3% other types of tuberculosis, 14% were suspected but not proved cases of tuberculosis on admission, and 4.5% were proved non-tuberculous on admission. One thousand eighty-four of the 1,373 patients were admitted for the first time (78%). Six hundred ninety-five of the 1,084 patients admitted for the first time had a positive sputum. Admission sensitivity studies for isoniazid, streptomycin and PAS are routine. Those patients who had at least 20 colonies growing in the tube with the lowest concentration of the drug employed were resistant. This is not necessarily a completely true picture, as some of these patients -119- had never received chis drug and these low concencrations did not mean that these patients would not respond to one of these drugs. This is the strictest criteria that can be used, even though from a clinical standpoint it is not necessarily completely accurate. There were only 20 patients who showed resistance to the three major drugs and only six who showed resistance to both isoniazid and streptomycin among the 664 newly admitted patients with infections due to M. tuberculosis (roughly 4%). The treatment program continued to be highly successful. A sputum conversion rate of over 95% in the newly treated cases with cavitary tuberculosis is constant among those patients who will remain in the hospital and accept therapy. Follow-up studies on patients converted and discharged revealed that the relapse rate is about one per cent. A retreatment program of drug resistant cases was instituted in March of 1962. Ethambutol, a new experimental drug, ethionamide and kanamycin, three drugs never previously used in this institution, along with any other drugs to which the patient might still have drug susceptibility were employed in this program. At the end of the year we had obtained a sputum conversion rate in this group of patients of approximately 80%. This also resulted in the discharge of a number of patients with long periods of hospitalization and resulted in an increase in our average length of stay. -120- There was not a thoracic surgical death during the year. The volume of cases decreased. Only six per cent of those discharged has major thoracic surgery. The clinical research projects contribute greatly to the overall medical care program. Constant review of the results of therapy and application of these results are responsible for the high conversion rate and excellent therapy program. The hospital is currently engaged in three clinical trials, studying the new drug ethambutol, in conjunction with other drugs. Two of these trials are United States Public Health Service Therapy Trials and one is the retreatment drug resistant research project with Lederle Laboratories. There was an increase in the amount of tuberculosis bacteriology work. All patients have a minimum of one sputum examination every two weeks. The total work load in the x-ray Department was slightly above that of the previous year. All patients are routinely x-rayed once a month. An expansion of the hospital IBM system during the year enabled development of a system whereby a monthly medical audit on all patients within the hospital is available. This expanded system will also expedite installation of a complete inventory system for all departments. The medical care program was completely reorganized to better utilize personnel and beds. This brought about a closure of a number of wards. The admission service was abolished as of January 1, 1964. After that date, patients were admitted in rotation to the remaining functioning -121- wards and each physician was then responsible for total patient care. At the end of June, the medical program became one operating service rather than two separate services, one for colored and one for white patients. This was an administrative combination of services as the patients remained in the same wards as previously utilized. On July 1, 1963, there were 689 patients, 701 full time paid employees, and 76 colored female prisoners assigned for work. At the end of the fiscal year Battey had 547 patients, 559 full time paid employees, and three working female colored prisoners. Major reductions in the work force came in nursing, housekeeping, food service, maintenance, poultry and farm operations, and laundry. The food service department began converting from ward kitchen operations to central tray service on May 20, 1963, and as a result 19 separate cooking facilities were closed. The last was the special diet kitchen on August 5, 1963. The reduction in personnel required that central tray service be reduced from two production lines to one; yet patient feeding is accomplished within one hour and fifteen minutes. One thousand, four hundred ninety-eight patients were discharged from the hospital during the fiscal year. Only 10% of these patients were discharged against medical advice. Sixty-five of the discharged were death (4%). Only 17 of these 65 deaths were due to tuberculosis {1%). Twenty-three per cent of the patients discharged had minimal tuberculosis, 40% moderately advanced tuberculosis, and only 17% far -122- advanced tuberculosis. Of the 121 patients discharged with a positive sputum, 34 had atypical tuberculosis and 87 had M. TBC infections. Twenty-two of these patients had positive cultures reported after discharge. The average length of stay for patients discharged with a diagnosis of tuberculosis increased from 195 up to 208 days. This increase was due to the numbers of successfully treated drug resistant patients with long periods of hospitalization that were discharged. Completed discharge reports were mailed out from the hospital on the same day or within two days after the discharge of all patients. In addition to this, by the end of the year monthly reports were being sent to every health department on the status of each patient in the hospital. Battey's per diem cost for the fiscal year 1962-63 was $15.81; for the fiscal year 1963-64 it was down to $15.37 a day. Due to a difference in fund allocation, monies spent for out-patient care were separated from monies spent for in-patient care this year. This would account for a reduction of nearly $1.25 per day. In addition to that, inventory was reduced from one designed for 700 to 800 patients to one designed for approximately 300 patients. It is believed that the reduction in inventory amounted to approximately $1.25 a day. In this coming fiscal year, when purchases will become more current again, per diem costs will show a definite increase. -123- 2M/l/65