PHIT

Public Health Issues Today

2.

Public Health System of the United States Snighda Kanakamedala

People often hear about the health care system all over the news; it is compared between nations, detailed in bills, and hotly debated. This is a system that not only encompasses the health care system, but plays an overall role in the health of a nation. Public health tackles complex issues through basic foundations that build into a stronger system. The governmentfederal, state, localplace a lot of emphasis on developing this system. The Centers for Disease Control and Prevention (CDC) outlines ten essential public health services. The National Public Health Performance Standards Program (NPHPSP), of which the CDC was a collaborator, utilizes these public health services to develop assessments of local and state public health systems as well as the local public health governance. The CDC outlines the 10 essential public health services which provide the framework for the NPHPSP: 1. Monitor health status to identify and solve community health problems.

Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and action to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure competent public and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems.

These essential public health services are implemented on three major levels: federal, state, and local. The performance of these duties is also assessed in a local public health system, state public health system, and local public health governance. The National Public Health Performance Standards Program (NPHPSP) is one of the collaborative efforts in public health. The partners involved in NPHPSP range from CDC to NACCHO to the American Public Health Association (APHA). Their mission is to improve the quality of public health practice and performance of public health systems. The NPHPSP implements its standards by focusing on three instruments of assessment: the state public health system, local public health system, and local public health governance. (Continued on page 5)

In this issue:
Obesity Awareness Infection Control in Daycare Affordable Care Act Association Updates

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PHIT MISSION STATEMENT

2009 2011

Public Health Issues Today is a publication by Rutgers University students to inform the community about current issues regarding health and policy in New Jersey. In collaboration with a broad spectrum of public health professionals, PHIT aims to provide research and raise awareness of on-going issues in society.

Philosophical Exemptions in Vaccinations Chani Burgos

Public health has made significant strides in the past century with one of its most successful accomplishments being the use of vaccines to immunize individuals. In an article published by the Journal of American Medical Association, scientists at the CDC were asked to name ten great advancements in the last ten years (from 2001 to 2010) within the spectrum that is public health. Vaccines that have helped prevent deadly communicable diseases were among the ten winners and the first to appear in the article. The marvel that is immunization has brought into play a number of other vaccinations for other not so pleasant illnesses. Although it has been globally demonstrated that immunizations have improved the health of humans, many failed to get vaccinated, particularly children as being the first in line to receive immunizations. Countless children are not vaccinated due to religious or medical exemptions. This is a cause for worry because without vaccines, epidemics of preventable diseases are at the brink of being fully abolished and could resurface. Many parents who do not fall under the categories of medical or religious exemptions still want to avoid having their children vaccinated. This need for philosophical exemption is based on personal superstitions, fears and beliefs. In New York Times article, Why Parents Fear the Needle, author Michael Willrich explains how many parents still believe that vaccinations cause autism, thanks to a deceptive 1998

Dear PHIT,
Is bottled water safer to drink than public drinking water?
Bottled water is not any safer than tap water. The difference lies in the government regulator: Bottled water is regulated as a food by the Food and Drug Administration. Tap water is covered by the Safe Water Drinking Act, administered by the Environmental Protection Agency.

paper. 40% of American parents still refuse to vaccinate their children in spite of evidence that vouches for its effectiveness, because any statistical evidence that demonstrates a slight risk associated with their use tends to alarm parents. In a 2009 study by the National Vaccine Program Office of the Centers for Disease Control and Prevention, the results demonstrated that parents would go forward with philosophical exemptions or find ways to philosophically exempt their children from becoming immunized due to fears of adverse effects from the vaccinations as well as trust issues with the government and healthcare providers. It concluded that many parents would prefer that their children be exempt from vaccinations because of their doubts towards the credibility of the information provided about the vaccine. (Continued on page 5) long-term patient outcomes while simultaneously ensuring effective, fiscally sound medical therapies. Specifically, antimicrobial stewardship programs are instituted in order to improve patient outcomes while simultaneously minimizing toxicity, secondary infections, and the rise of newly emergent antibiotic- resistant organisms. The optimized selection and dosage of antimicrobial therapies is utilized as a key strategy to achieve this feat. Antibiotic stewardship programs promote the prescription of appropriate treatment courses in order to reduce negative clinical outcomes. The design and implementation of an antibiotic stewardship program is formulated in order to reduce morbidity and mortality rates of healthcare institutions. The implementation of an efficient conservation program saves healthcare institutions substantial financial resources in addition to reducing the overall cost of medical treatment. Financial impediments serve as a barrier to the implementation of a stewardship program, however. Healthcare institutions are reluctant to provide the initial financial support needed to institute an antimicrobial conservation effort. Federal guidelines delineating the importance of antibiotic stewardship programs through statistically significant data and analysis can facilitate the implementation of an antibiotic stewardship program. Health care administrators must also be convinced of the effectiveness of antibiotic stewardship programs in non-traditional healthcare settings. To date, majority (Continued on page 6)

Antibiotic Stewardships Role in Response to the Growing Threat of Antibiotic Resistance Jacqueline Baron
Antibiotic resistance has emerged as a growing public health threat challenging the healthcare system of the United States. Prolonged hospital stays, increased incidence of adverse events, and a substantial increase in healthcare expenditure have resulted from drug-resistant infections (Hirshon et al. 1946). Furthermore, antibiotic-resistant infections, such as methicillin-resistant Staphylococcus aureus and Clostridium difficle, pose significant secondary complications to the treatment course. The threat of antimicrobial resistance is intensified by the lack of research and development devoted to the production of novel antimicrobials. In order to reverse the upward trend in antibiotic-resistant infections, healthcare institutions are partnering with infectious disease specialists to implement antimicrobial stewardship programs. These conservation programs strive to decrease the incidence of antibiotic-resistant infections while improving patient care and reducing instances of adverse patient outcomes. Antimicrobial strategies often incorporate a variety of techniques, including formulary restriction and post-prescription feedback review, as a means of accomplishing the goals of an antimicrobial stewardship program. An antibiotic stewardship or conservation program serves to improve

Parents would go forward with philosophical exemptions or find ways to philosophically exempt their children from becoming immunized

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Tips from UNICEF

Steps to Successful Breastfeeding

1. Train all health care staff in skills necessary to promote and encourage breastfeeding

Breastfeeding Policies
Lauren Johnson Breastfeeding is beneficial for babies, and exclusive breastfeeding up to six months is encouraged for optimal child development and health. Studies have shown that those benefits also extend to new mothers and to public health in general. Reasons why a mother may choose to breastfeed include maternal closeness, healthy eating habits, and reduced risk for infection and allergies. According to a Vital Signs CDC report, A baby's risk of becoming an overweight child goes down with each month of breastfeeding. Breastfeeding promotion is a major goal of public health initiatives at the national, state, and individual healthcare facility levels. The choice to breastfeed is personal, but that choice can either be supported or undermined by what happens in the hospital in the first few days after delivery. Though most efforts are made by the formula companies to sell their products, new policies will likely cause an increase in breastfeeding practices, with a focus on providing more supportive environments for new mothers. Babies health benefits include protection from many illnesses, maternal bonding, and biological defenses against infections. This means healthier babies, happier parents, and lower health costs for individuals and governments. Mothers who choose to breastfeed also experience advantages for their own health. Achieving baby-friendly status is cost-neutral for the average hospital. It is possible to speculate that the money saved from treating disease and buying formula could surpass the amount thats needed to be spent by a hospital to improve its breastfeeding policies.

2. Inform all pregnant women about the benefits and management of breastfeeding 3. Help mothers initate breastfeeding within one hour of birth 4. Show mothers how to breastfeed and maintain lacation even if separated from their infants 5. Give infants no food or drink other than breastmilk, unless medically indicated 6. Practice rooming in allow mothers and infants to remain together 24 hours a day 7. Give no pacifiers or artificial nipples to breastfeeding infants 8. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

Marketing efforts by formula companies have been a hindering force to successful breastfeeding policies. Formula is an important alternative for mothers who truly cannot breastfeed for one reason or another, however it provides only a small percentage of the nutrients found in mothers milk. There are also hospital contraints that can prevent mothers from establishing basic breastfeeding knowledge such as not having the capacity or resources to keep mothers for a 24- hour stay or hospitals that place newborns in a separate ward to be monitored or receive treatment. Although societal and institutional factors may impede breastfeeding rates, there currently is a new major paradigm shift that regards breastfeeding as the healthier, easier, and smarter choice for new mothers. The Baby-Friendly Hospital Initiative (BFHI) seeks to increast the number of breastfed infants through a series of steps (see figure to left). The policy initiatives and mother education practices currently being used in hospitals can only be improved with time.

Emergency Preparedness
Alexandra Apostolico
For many years, there has been a struggle in the public health sector to increase public access to automated external defibrillators (AEDs) in order to increase the chance of ones survival. However, as with many issues in the public health sector, funding for such programs are often hard to come by for many public arenas. In response to a need of better access to AEDs, many PAD (public access to defibrillators) programs have been implemented and researched nationally. The benefits of increasing access to AEDs must also be weighed with the costs of implementeing and mainting such a program. Many bills that are currently in practice in New Jersey urge school boards to be equipped with AEDs and trained staff. In order for a program of this nature to be successful, there must be an increase of trained lay responders (public that is on scene at time of incident, who may or may not have specific training or affiliation with a medical or health care background) in the use of an AED. Without public awareness and training about the use of an AED, increasing access to these devices would render useless. Many are familiar with CPR, yet CPR is a technique used simply to sustain life; it does not reverse, or cure the effects of sudden cardiac arrests (SCAs). The only way to reverse SCAs is to shock the heart into a normal rhythm. This can be done in two ways: either in hospital or out of the hospital in the form of defibrillation. There must be someone on scene with knowledge of what to do and at the right moment. It is imperative to have an influx of the public trained to use AEDs because time is the biggest factor concerning the survival rate of victims experiencing sudden cardiac arrests. Additonally, programs must be implemented to increase public access to AEDs where it is economically feasible. Although formal training is not necessary in order to correctly use an AED, training of individuals in highly public settings (teachers, coaches, cashiers, doorman etc.) will reduce the hesitation when it comes to an emergency. Public access to AEDs means nothing without those who are able and willing to use them.

PHIT Fact!
New Jersey has bills in practice that urge school boards to be equipped with both AEDs and trained staff however, nowhere is this binding!

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[
Concern Flu Cold
Slow? No/mild fever? Mild? Headache free? Normal? Fine? No chills? Was the onset of illness Sudden? Do you have a Is your exhaustion Is your head Is your appetite...? Are your muscles Do you have. High fever? Severe? Achy? Decreased? Achy? Chills?

Do you know
the difference between a common cold the flu?

Every year when autumn makes its appearance and turns into winter, theres a consistent trend of people of all ages becoming sick. This trend is apparent, yet who or what exactly is the culprit? Sometimes it takes a few questions to determine the answer and more often than not, the common cold or the flu is to blame. Yet, how can one tell the difference? Refer to the chart on the left to decide whether or not you are suffering from a cold or athe flu. The flu is a viral infection caused by a respiratory virus known as the influenza virus it is preventable with a vaccine. A common cold is also a viral infection, but it is caused by varying types of viruses therefore no vaccine exists. However to avoid both the cold and flu, precautions are similar. Wash hands often, dont share cups or utensils, and avoid contact with those affected. An additional defense for the flu would be to also get the flu shot. Furthermore, dont categorize your sickness as a cold straight off the bat. If you suspect you may have the flu, its important to call your doctor right away. Bacterial diseases such as pneumonia or strep throat can also resemble the flu or cold. You can never be too safe! Aisha Akhter

NJPHA: Building Healthier Communities: A Transdisciplinary Approach to New Jerseys Obesity Epidemic
Origins & Control
Dr. George Rhoads, the Interim Dean of the UMDNJ-SPH, spoke on December 6, 2011 at New Jersey Public Health Associations annual meeting about the obesity epidemic occurring in New Jersey. He compared behaviors of people today to the creation of foie gras (French for fat liver from a purposefully fattened goose or duck) those today force-feed ourselves to the point of excess. He points out this trend is a worldwide dilemma and it affects more than health. For example, 27% of young men are rejected from the military for having a high BMI (body mass index). Having high BMIs account for 16% of diseases worldwide. avoid rather than treat obesity. If every obese person could lose the excess weight effortlessly, there would not be an obesity epidemic. For those that have suffered from obesity for many years, there are multiple and more serious health effects that are harder to treat and/or live with. A few examples are type two diabetes, orthopedic problems, joint replacements, heart attack, stroke, disability, lymphedema, cancer, and death. Obesity is not a joke; it can quickly develop into a life- threatening stage if action is not taken.

PHIT Fact!
America has the highest rate of obesity in the world.

Policy Making
At the conclusion, Dr. Rhoads pointed out that we must address obesity in kids and we can achieve this best through policy. Similar to the action taken on lead, we must understand the danger of obesity and combat it in several ways. Improving school lunches, increasing physical activity, providing education on healthy eating, and selling fruits and vegetables.

Early & Late Health

If obesity hits early, there are a range of health problems that can occur. These include high blood pressure, increase in lipids, cardiovascular risk, loss of self-esteem, psychiatric problems, compromised ability to exercise, and even sleep apnea. It is best to prevent obesity through education and good eating habits early because it is easier to

New Jerseys obesity rate has increased by 90% in the past 15 years!

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Public Health System of the United States (continued) Snighda Kanakamedala

(Continued from page 1) Overall NPHPSP seeks to provide standards all the while identifying areas of state and local improvements so that day-to-day public health issues as well as public health emergencies receive effective responses. The statewide performance improvement planning requires implementing multiple assessments in order develop statewide action plans. The definition assigned to the local public health system is merely extended to accommodate health and well-being to the state level (State public health system). In order to have a representative assessment, an ideal group is one which is broadly representative of the public health system partners. The local system improvement planning requires planning of every responding local public health system based on CDC quantitative reports as well as ideas from prior assessments. The local public health system is defined as any organization or entity that contributes to the health or well-being of a community. The Local Public Health System includes the ten essential services it is tasked with upholding and also includes specific model standards under each service. Finally, the governance body improvement planning requires that a plan is formed for the board of health and that the boards work with local health officials and agencies to identify a plan for

improvement. Governing bodies are defined as the individual, board, council, commission, or other body with legal authority over the primary governmental public health agency, usually defined as the health department (Local Public Health Governance). The authority not only varies by state but also within state jurisdictions. It seeks to keep moving towards continuous quality improvement so that the board of health members understand their role and strengthen their abilities as overseers of public health.

Dear PHIT,
What can I do with a Public Healh major?
Public health is a multi-disciplinary field with areas such as health policy and management, behavioral science and health education, epidemiology, environmental and global health. A bachelors degree is for areas like health education and environmental health. A masters degree is for management, administration, and university teachings. A doctoral degree is for the highest levels of administration, research, or university teaching positions.

Philosophical Exemptions in Vaccinations (continued) Chani Burgos

(Continued from page 2) Unfortunately, these parents fail to see the necessity for childhood vaccinations for a variety of reasons. Children who are of age to go to school are the most vulnerable group when it comes to susceptibility of preventable infectious diseases and thus have the highest attack rates of these diseases. Children are at risk of contracting diseases, a chain reaction occurs where people in their peripheral are also at risk of transmission of these diseases. Even if only some children are vaccinated, outbreaks can happen and cause epidemics because epidemics occur even in immunized populations when clusters of susceptible individuals exist and are exposed to a contagious individual. This is precisely why all children must attain proper vaccinations; if all children are vaccinated, the vaccination will remain strong and immunity will not dull out. In terms of the betterment of public health, herd immunity is an important concept within the scope of immunizations. According to the National Institute of Allergy and Infectious Diseases, if a significant portion of a populace is protected from a disease through vaccination, then the majority of the community is not at risk because there will be only a very small likelihood of an outbreak. Herd immunity not only saves the lives of those who may not be able to be immunized, but also creates a positive impact on the economy. In an article published by the Journal of the Academy of Pediatrics, herd immunity for the disease, Hepatitis A has

demonstrated to have decreased the number of monies spent on immunizations for the disease. The decline of the disease was much higher than expected for only protecting individuals who had the vaccine. It was then concluded that there was such a decrease in the disease courtesy of herd immunity. As a form of public health intervention, it concluded that herd immunity had the ability to make prevention programs for infectious diseases more cost-effective. Research has demonstrated that when philosophical exemptions are allowed, the number of under-vaccinated children across the states rises. The state of New Jersey allows only medical and religious exemptions. Although New Jersey does not have philosophical exemption in place, it does not mean people have not tried. Marianne McEvoy, Registered Nurse and former president of the New Jersey Association for Public Health Nursing Administrators stated that about a year ago or so many individuals instigated adding philosophical exemptions to the list of New Jersey exemptions. NJPHNA went as far as to document the reasons why it would be unacceptable to allow philosophical exemptions in New Jersey and demonstrated it to the Senate. The war regarding philosophical exemptions is a debate nationwide. If there is a separation of church and state, yet religious exemptions are allowed, by not allowing philosophical exemptions, does this mean that the government is imposing and controlling what we have a say in? Or is it a question of the publics health is more important than an individual belief? One thing is for sure: vaccines have given a great deal to the advancement of public health.

Public health tackles complex issues through basic foundations that build into a stronger system.

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Dear PHIT,
What is public health?
Public health is the science of protecting and improving the health of entire populations. Public health professionals try to prevent issues from happening or re-occurring through educational programs, policies, services, research, and regulating health systems and some health professions. Public health is the fight for health care equity, quality, and accessibility.

Antibiotic Stewardships Role in Response to the Growing Threat of Antibiotic Resistance (continued) Jacqueline Baron
(Continued from page 2) of the research supporting the effectiveness of antimicrobial stewardship has been conducted in tertiary or university-associated medical centers. Impediments to the successful implementation of an antimicrobial stewardship program include lack of financial resources or available staff. Therefore, continuing research through randomized, clinical trials and surveillance-based techniques are needed to convince the medical community of the efficacy of antimicrobial stewardship programs in health care settings of varied sizes and geographic localities. In coming years, the advocates of antimicrobial stewardship must build on the broad applicability of antimicrobial conservation efforts across a variety of medical settings. Additional studies evaluating the effectiveness of antimicrobial strategies incorporating large sample sizes and the reduction of confounding variables may be used to evidence the great measures of change that can be implemented as a result of an antibiotic stewardship program.

Get PHIT

Eurelle Hao

advocates of antimicrobial stewardship must build on the broad applicability of antimicrobial conservation efforts across a variety of medical settings.

Shaping NJ is the state of New Jersey partnership for the Nutrition, Physical activity and Obesity Program. The Shaping NJ goal is to reduce obesity and promote healthy and active communities. Shaping NJ works in communities, health care facilities, work sites, child care, and schools. The program focuses on environmental and policy changes around obesity and chronic disease prevention. Obesity is a serious publich health issue that puts citizens at greater risk of chronic diseases like diabetes, hypertension, and heart disease. It is not enough to promote physical activity and healthy eating habits. People need access to healthy foods and safe environments for play and recreation. Shaping NJ encourages a high intake of fruits and vegetables, physical activity, and the practice of breastfeeding. Nutrition is significant in health promotion and disease prevention. Eating right can help reduce the risk of obesity and chronic diseases. Physical activity gets the heart pumping and strengthens muscles. Scheduling 30 minutes for physical activity makes a whole difference in a persons lifestyle. For the busy adult, before or after work is an ideal time to jog, walk, or cycle. Children are encouraged to partake in recreational activities and play. In regards to breastfeeding, research shows that breast milk is the best food for a baby. Breastfeeding contains nutritional, economical, and emotional benefits for a mother and baby. Shaping NJ focuses on these key behaviors: TV Viewing Fruit & Vegetable Consumption Energy Dense Food Consumption Physical Activity Sugar-Sweetened Beverage Consumption Breastfeeding

DECREASE

INCREASE

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Economic Crisis, Budget Cuts and Their Effects on Local Health Departments Mona Hariri
Public health works towards improving the overall health of a population at a community- based level through the emphasis of illness and injury prevention, as well as the reduction of 1 preventable chronic disease . The global economic crisis has led to massive budget cuts, affecting the growth of developing countries. Furthermore, the sharp decline of the United States economy has led to significant budget reductions and increased levels of unemployment. Individuals without health insurance in the community, as a result of job loss, are now relying more on the assistance of health care systems. In turn, the increasing demands, and insufficient availability of resources heavily pressure public health infrastructure. As a direct result of decreased funding and weakening public health infrastructure, local health departments are finding it more and more difficult to protect the general health of a community-based population, thus resulting in adverse consequences and strain. Budget cuts have made a rough impression globally. The global economic criss has resulted in the loss of millions of jobs worldwide, especially developing countries, who suffer the most. When developed countries such as the U.S., U.K, France and Germany face such economic struggles, international financial aid distributed to developing countries is dramatically reduced. According to BBC News, in 2009, a predicted 51 million jobs globally could have been lost due to the global economic crisis. Without proper federal funding to public health systems, services provided have greatly reduced in quality. Public health services require stable infrastructure, which is at risk due to a lack of funding. Resource reductions, such as staff cuts, negatively impact the capacity of public health systems to respond to health hazards in a timely manner. The purpose of public health infrastructure is to provide care to increasing demands as well as to implement productive public health practices. Public health infrastructure is weakening through cost reductions, and the repercussions are not only negatively affecting those whom have lost their jobs, but also the individuals who remain on staff. Before the Great Recession, the state of New Jersey was already in an economic crisis; thus, their ability to overcome the reduction in funding has been difficult. To compensate, the state has reduced funding to various organizations in New Jersey, one being health care. For example, Governor Chris Christie put a freeze on New Jersey FamilyCare enrollment for adults. The Freeze on New Jersey Family Care became effective as of March 1, 2010. Therefore, parents within 134% - 200% of the Federal Poverty Level, which were not previously enrolled in New Jersey FamilyCare will not be allowed to enroll. This action will directly affect 39,000 adults. According the U.S. Bureau of Labor statistics in comparison to other states in the nation, New Jersey lost more jobs. In addition, between 2008 and 2009 New Jersey lost over 114,000 jobs. To add to this deficit, in January 2010 over 9,100 positions disappeared. As financial and human capital are depleting in the state of New Jersey, the need for population-based health care is essential. Public health services require stable infrastructure, which is at risk due to a lack of funding. Resource reductions, such as staff cuts, negatively impact the capacity of public health systems to respond to health hazards in timely manner. The purpose of public health infrastructure is to provide care to increasing demands as well as to implement productive public health practices. As more public health workers become unemployed, the ability of workers in the field, to manage and protect the health of the population, reduces. Furthermore, with reduced funding towards public health methods, health care services with become disjointed due to a lack of preventative based services. For example, many health departments around the nation are cutting back on the number of community-based prevention services such as pregnancy prevention or clinical mental health services. Decreased federal investments in healthcare and the surplus of individuals without health insurance, leaves state and local health departments saturated with individuals seeking medical assistance. Health departments are responsible for protecting the health of the public. In most situations, local health departments (LHDs) are the first to arrive on scene during an on scene during an epidemic breakout. Although local health departments are essential to protecting the overall health of the community, they often go unnoticed. One LHD official stated, Unless there is an outbreak, no one even knows that we exist. We operate diligently and quietly in the background, keeping our community healthy and safe. Funding for LHDs comes from a combination of local taxes, as well as state and federal grants. In response to the economic downturn, federal and state grants have not been able to fully provide for the high demands of local health departments, thus, adding to the already insecure public health infrastructure. Countrywide, about $300 million has been removed from local health department budgets in 2008.The decrease in funding resources has negatively affected LHDs to fulfill their responsibilities and effectively generating health care delivery. Assessments, policy developments, and assurance are important roles to health changes in the community. Assessments are evaluation and information on the release of hazardous substances. According to the Agency for Toxic

FACT According the U.S. Bureau of Labor statistics in comparison to other states in the nation, New Jersey lost more jobs.

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and Disease Registry (ATSDR), factors which must be considered in all public health assessments are: (1) nature and extent of contamination, (2) demographics (population size and susceptibility), and (3) pathways of human exposure (past, current, future). Policy formation can assist in the reduction of multiple causes of health concerns. For example, policy development can require all children below the age of two to receive a type of vaccination. When LHDs attempt to implement a policy, they will present their issue to the county or city executives or boards, to mandate and enforce the policy. Such policies can include the requirement of vaccinations in schools, setting up health clinics in the community, or improved disease supervision in the local community. Increasingly, assessment and policy development work address preparedness for biological threats and other emergencies where the local health department frequently plays a leadership role since disease outbreaks, environment hazards, and natural disasters such as floods and earthquakes affect human and environmental health profoundly. Without the support of the local population through assurance, LHDs would have difficulty functioning. Although, assessment and policy development are essential roles of LHDs, assurance builds trust and confidence in LHDs within a community. The purpose of assurance is to clearly and effectively communicate to the public the identification of an outbreak and efforts taken to safeguard community health. Interactive communication with local citizens in a community reduces uncertainty and chaos through informing and educating citizens regarding steps they can take to improve their health status. Effective communication between LHDs and individuals in a population created community partnerships. Thus, improving the trust these community members have in the LHDs, promotes collaborative change in preventative efforts. Funding resources are received from a combination of local, state and federal government capital. The federal government provides the greatest amount of funding from a diverse range of resources,: (1) the Centers for Disease Control and Prevention (CDC), (2) the Health Resources and Services

Ferhoncus de plub Omare foremne

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Administration (HRSA), and (3) the Substance Abuse and Mental Health Service Administration (SAMSHA). With the U.S. economy in turmoil, many of the health administrations previously listed are also facing budget cuts, thus, affecting their overall funding allocated to LHDs. Roughly 17% of financial income is received from the state, but it has passed through the federal government. However, with negative effects still being felt from the Great Recession, responsibilities of LHDs are being negatively impacted. LHDs can no longer afford to staff as many health care workers as in previous years. Between 2009 and June 2010, in 28 states around the nation, over half of LHDs lost staff. In addition, more than half (52%) of all LHDs experienced adverse repercussions in 2010, loosing over 6,000 employees which decreased the working capacity by one-third. Furthermore, the individuals who are still employed face the repercussions of tight budgets though the in inability of LHDs to offer salary rises due to wage freezes. One health officer stated, We have not been able to offer raises and the lagging salary scale we operate by has been a detriment in recruiting and retaining qualified people. When positions become available, they are not filled quickly. When attempting to employ interested candidates, one local health officer stated, Due to the low wages offered to new employees, I will begin an interview stating the salary amount. There have been times when individuals will stop the interview because he/she will not work for the amount offered. LHDs have difficulty offering competitive salaries because of the drastic reduction in funding, which in turn, has many many qualified professionals switching to more competitive, higher paying fields. With the recent downturn of the U.S. economy, LHDs are faced with fewer resources. To make up for reduced funding, LHDs have been forced to cut effective prevention programs and other programs essential to protecting the health of their communities. Furthermore, with the drastic reductions in prevention programs, many susceptible populations will seek medical attention in emergency room visits, thus, increasing the burden of healthcare cost on the economy.

LHDs frequently use public health laboratories, during the assessment of potential disease outbreaks. Many LHDs depend on the state-operated public health laboratories to analyze test samples and provide accurate results. While public health laboratories are essential for the collaborative entity of LHDs, one public health laboratory director cautioned, CDC provides categorical funding, which is in essence organizing my lab and determining what we do. But CDCs categorical funding has allowed the state general funds to be reduced. In total, 96% of all governmental laboratories have had some form of detrimental budget cuts resulting in reduced staffing, and the inability to purchase quality equipment. Public health laboratories are now less prepared to respond to emergency scaled events in a timely manner due to decreasing capital from the state government. The repercussions on public health laboratories directly affect their ability to function at maximum potential. The Affordable Care Act, recently passed by Congress and endorsed into law by President Barak Obama in March 2010, will help protect the health of the population. With the recent passage of this law, $650 million will go towards a Wellness and Prevention Fund, in hopes of improving the nations health through focused prevention programs. The Affordable Care Act improves health care accessibility and improves the burden of health care costs on the nation through various measures, one of which includes increased funding to preventative care. Since the burden of medical costs will be reduced due to more citizens becoming insured than uninsured, more focus can be put towards prevention techniques and public health goals. Moving forward, preventative care programs have the potential to save millions of lives by diagnosing medical conditions at an early stage before they become life threatening. Focusing more attention, and federal funding towards organizations, which offer prevention programs, can greatly reduce long-term costs and health consequences of the nation. These efforts can be done through community partnerships and educating the public about the importance of organizations, like LHDs, which offer such services. With economic hardships increasing stresses endured by the nations citizens, preventative care is essential to improve the health of these individuals. The new health care reform, passed by President Barack Obama, leaves hope for individuals.

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personally affected by the Great Recession. This is because, as more citizens in the U.S. are losing their main source of income and becoming uninsured, access to preventative care programs can significantly reduce the long-term burden our nation will face. Improvements to public health infrastructure heavily rely on the populations ability to recognize the positive impacts public health has on community-health. Although, as LHDs are faced with prioritizing which services are more important, the perception of availability to health services may shift in a community. Therefore, less members of the population are utilizing these services, increasing the risk of chronic medical repercussions, which could have been avoided. Building a solid foundation of community trust and participation in local advocates increases the likelihood of policy initiatives, thus, speeding up positive changes, which can be made in organizations offering preventative services such as LHDs.

Do You Know What You Drank This Morning? Kristina Reveron

FACT
Governor Chris Christie put a

freeze on New Jersey FamilyCare enrollment for adults. The Freeze on New Jersey Family Care became effective as of March 1, 2010. Therefore, parents within 134% - 200% of the Federal Poverty Level, which were not previously enrolled in New Jersey FamilyCare will not be allowed to enroll. This action will directly affect 39,000 adults.

According to recent news and tests, most well water in the United States is not safe for drinking or personal use because of environmental pollution and contamination. Bacteria, chemicals, and elements pollute water sources, exposing many people to serious conditions and illnesses each and every day. These contaminates are beginning to seep into private water wells, and cause issues throughout the state of New Jersey. At this point in time, all of the sources of water are contaminated with some sort of pollutant. Contamination of drinking water has been an ongoing issue in private water wells in the state of New Jersey. Arsenic is one of the leading contaminants of drinking water, and has proven to be unsafe if ingested. It is also important to discuss how ground water gets contaminated, and how water could be prevented from arsenic contamination. The Environmental Protection Agency, and The New Jersey Environmental Health Association strives to reduce levels of arsenic in private water wells. People in the community should be aware that there is a Private Well Testing Act in place. The Private Well testing Act will be discussed in detail throughout the paper. The goal of the PWTA is to ensure that people that are purchasing properties that use private wells are protected and aware of the quality of water that is being dispersed from the well prior to their purchase. Arsenic is associated with numerous health risks that can affect properties and people that use private water wells; therefore, it is significant to do research and inform the community and homeowners on what they can do to reduce water from becoming contaminated by arsenic. Arsenic is an element that is produced by nature and can be found in the Earths crust and all throughout the environment. There have been many uses for the element. It is interesting to note th th that during the 18 -20 century, arsenic was used in medicine for various reasons. It was commonly used in the treatment of cancerous tumors, and is still used today, but only in subtle doses that are not toxic to the human body. Although in some cases, arsenic may be used for the betterment of life, it causes a number of environmental issues in the state of New Jersey. The contamination drinking water by arsenic has caused various toxic epidemics throughout many communities. Arsenic and its isotopes are commonly categorized as toxic and poisonous elements. Therefore, it is obvious that it may not be ingested in large amounts, especially in drinking water. Studies have shown that even a low dose of arsenic compromises the human bodys immune system, which can result in serious illness or death, in some cases. The International Agency for Research on Cancer classifies arsenic as a group 1 carcinogen, which means that it is an agent that causes cancer in humans. Predominately, arsenic is used as a wood preservative. Arsenic naturally exists in 2 forms in ground water, as arsenite or arsenate. The element may change in the environment, but it cannot be degraded. Due to the fact that arsenic is a natural element that exists in the earth, it can be found all throughout the environment and in ground water. The Department of Environmental Protection states that the chemical and physical properties of the geologic material may enable the arsenic to become mobile (Buchanan), and this is where arsenic may become dangerous to human consumption. Results from testing conducted by the New Jersey Geological Survey indicate that elevated levels of arsenic exist in some aquifers of the Piedmont Province where arsenic has been detected at levels above 5 parts per billion (ppb). Levels as high as 60-80 ppb have been detected in drinking water in this area (PWTA Program). The Environmental Protection Agency steps in and conducts research and tests to see where the levels are at in surrounding towns and counties. When this study was conducted, 49 out of 238 wells were over the limit of 5ppb. Because of increased levels of arsenic, in September of 2002, all private water wells were required to test of arsenic in the water if there located in the 10 copunties of the Peidmont region. In the past, arsenic was used as a pesticide, before other ingredients were available. As a result, arsenic is used by farmers and crop holders in fertilizers and as pecticides. Therefore, if they sprayed arsenic pesticides on the soil or ground, there may be a possibility for it to get into a well and contaminate the water. The other ingredients in the pesticide can interact with arsenic to make it mobile and toxic for consumption and ingestion. So, water may be contaminated by arsenic solely because arsenic exists naturally in the earth, or it may be as a result of man that continues to utilize arsenic for agricultural reasons. Since arsenic occurs naturally in the environment, soil, and nature, it may enter the air, water, and land from wind-blown dust, and may get into water from runoff and leaching. A 2008 article from the Environmental News Service observes the increase of radioactive arsenic in drinking water near Trenton, NJ. (Continued on page 11)

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PHIT Fact!

In 2009, 36.6% of adults in New Jersey consume fruit 2 or more times per day compared to the 32.5% of adults in the U.S.

The State and Local Public Health System of New Jersey Snigdha Kanakamedala
The New Jerseys Department of Health and Senior Services developed standards that correlate with the national standards and thus the ten essential services. According to the Department of Health and Senior Services, New Jerseys governmental public health system is being modernized to ensure the highest level of local health department practice and performance. In 2003, new regulations were developed so that the system could experience the potential benefits such as a healthier populations, improved handling of emergencies and disasters, improved data collection and analysis, increased capacity to partner with private and nonprofit health systems to leverage resources, improved infrastructure to strengthen all local programs, and increased ability to focus resources, target areas of need and develop justifications for additional funding. The local board of health refers to any board of health with the authority to regulate public health or sanitation by ordinance. The term local health agency, on the other hand, refers to any local, regional, or county agency or department that is administered by a full-time health officer and conducts a public health program pursuant to law. One of the most often asked question is to define the meaning of public health. New Jersey local standards define it as organized societal efforts to protect, promote, and restore the peoples health, and societal activities undertaken to assure the conditions in which people can be healthy. The standards make sure to specifically point out that this does not only mean government-based efforts but organized community efforts that prevent, identify, and counter threats to the health of the public. The definition assigned to the local public health system is extended to accommodate health and well-being to the state level. In order to have a representative assessment, an ideal group is one which is broadly representative of the public health system partners. The New Jersey state public health system performance assessment (SPHSPA) found on the website of the New Jersey Local Board of Health Association is an example of the NPHPSPs assessment and how quality improvement is achieved. It goes through all the essential services and standards and looks at where improvement was made, where improvement can be made and attempts to foster a conversation about each service. For example, the assessment concludes that workforce improvement achieved the least improvement. Pinpointing the issues, ranging from the need for improved technology to how specific populations like immigrant groups are difficult to reach, assures that a system gets better.

New Jersey Schools Receive Grants to Advocate Fruit and Vegetable Consumption Eurelle Hao

prevent, identify, and counter threats to the health of the public.

The New Jersey Department of Agriculture and Rutgers Cooperative Extensions Department of Family and Community Health Sciences have granted nine New Jersey schools to receive $7500 mini-grants for programs to encourage good nutrition to students. These programs will encourage students to consume more fruits and vegetables, as well as learn about good nutrition and promote locally grown produce. Aura Elementary School in Elk Township; Cape May City Elementary School in Cape May; Chesterfield Township Elementary School; Ethel McKnight Elementary School in East Windsor; Francis A. Desmares Elementary School in Flemington; Knowlton Township Elementary School; Mount Prospect Elementary School in Basking Ridge; Queen City Academy Charter School in Plainfield; and Uptown School Complex in Atlantic City are the nine schools chosen to pilot this nutritious program. These schools are required to utilize their min-grants to promote healthy eating through interactive lessons and activities that will link classroom education to the foods served in their cafeteria. A school garden will also be planted in each of these nine schools. The schools must grow at least three different vegetables that will be harvested and sampled by the students. The mini-grants are part of a $340,250 Team Nutrition Training Grant from the United States Department of Agriculture to train foodservice professionals, increase fruit and vegetable consumption, and promote locally grown produce in school meals. New Jerseys Department of Agriculture will work with Rutgers Cooperative Extensions Department of Family and Community Health Sciences on this two-year grant project.

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Continued from page 9 Tens of thousands of New Jersey residents are drinking polluted water from private wells, according to a new state report, and radioactive contamination is the most common violation of state standards. (Drink Safe Water in NJ). The Private Well Testing Program, which will be further explained throughout the paper, samples thousands of private water wells near Trenton, NJ and other cities throughout the state. The samples show a significant increase in the amount of contaminants in the water. In 2008, 51,000 of the private wells were tested, and 12 percent failed the standard levels of contaminants allowed in drinking water. This means that 12 percent of the residences that were tested were drinking contaminated water for years that they were not aware of. Out of all contaminants, including nitrates and fecal matter, arsenic was sampled in 1,445 of the wells, and arsenic was found in more of the private wells than any other contaminant. Knowledge regarding such types of conatminants may prove to be very beneficial. The article explains that the public is ignorant of the dangers of drinking well water because there is no requirement to inform neighbors of a polluted well in their vicinity, and there is no requirement to clean up the pollution (Enviornmental News Service). High costs of fixing contamination issues may result in homeowners disregarding the issue at whole. At times like this, people may turn the other cheek and continue to drink contaminated water, and let their families and neighbors continue to consume the arsenic into their bloodstream. The state of New Jersey does not require contamination problems in private wells to be fixed. The Private Well Testing Act and its regulations state that it is not required to treat water if a standard level is exceeded, and this is where the problems begin to occur. The Environmental Protection Agency has a standard for the levels of contaminants in a public water supply. The EPA has set the arsenic standard for drinking water at 10 parts per billion. This standard was enforced in January 23, 2006, which provided more protection to citizens who have been exposed to contaminants in the past. The Safe Drinking Water Act does not cover private wells. Unfortunately, the Environmental Protection Agency does not set standards for private water supplies. It is encouraged by the EPA that if a private well goes above 10ppb then a homeowner should fix the problem and reduce exposure to arsenic. This is given as a suggestion, and not a mandatory action, therefore, not every homeowner is obligated to decrease the amount of arsenic in their private well. This allows for a continuance of contamination and a possible spread to neighbors water supply, etc. There were studies conducted in other countries which found that there was harmful health affects associated with arsenic. Studies show that people who regularly for many years drank water containing arsenic at 100 ppb to 300 ppbdeveloped several kinds of cancer (Toxic Substances Arsenic), including lung, liver, kidney, prostate, and skin cancer. These people also had darkened skin spots on their palms and soles of their feet. The darkening of certain parts of the skin is linked to skin cancer and other skin diseases. Breathing in large amounts of any toxic substance can affect a humans respiratory system. The inhalation of arsenic can cause severe irritation to the nose and lining of the lungs. The Agency for Toxic Substances and Disease Registry claims that Exposure to lower levels can cause nausea and vomiting, decreased production of red and white blood cells, abnormal heart rhythm, damage to blood vessels, and a sensation of "pins and needles" in hands and feet. These are symptoms for low levels of arsenic, which proves that increased levels could cause other unfavorable symptoms within the human body. A known disease caused by the consumption of arsenic is arsenicosis. The World Health Organization categorizes it as a water-related disease throughout the world. WHO states that Drinking water rich in arsenic over a long period leads to arsenic poisoning or arsenicosis (World Health Organization). Arsenicosis is caused by the toxic substance of arsenic, which has been exposed over a span of 5-20 years. Arsenic- rich water over a long period results in various health effects including skin problems such as color changes on the skin, and hard patches on the palms and soles of the feet, skin cancer, cancers of the bladder, kidney and lung, and diseases of the blood vessels of the legs and feet, and possibly also diabetes, high blood pressure and reproductive disorders (World Health Organization). Arsenicosis could also be a result of occupational safety and health because there are industrial occupations that handle arsenic, which have shown to have their workers be exposed to the toxin. Arsenic contamination in water may also be due to industrial processes such as those involved in mining, metal refining, and timber treatment (World Health Organization). The problem associated with arsenicosis is that since it has delayed effects and is not reported or documented well, people are not aware of its severity in their communities. Some people may not even be aware that this disease exists worldwide. The Private Well testing Act wants to ensure that purchases and people who are leasing the properties served by private wells are fully aware of the quality of the drinking water source prior to sale or lease to a home or business. The PWTA was signed on March 2001 and became effective Septber 2002. The PWATA requires tat the wells be tested for 29 contaminants, which include bacteria, nitrate, lead and 26 organic chemicals. In the graphic representation of the tests for

Arsenic and E. Coli, an illustration of the private wells from September 2002 to April 2007 have been shown. A total of 51, 028 wells were tested and about 13% of the estimated 400,000 private wells in NJ are used for drinking. Mercer and Hunterdon Counties exceeded the standard levels several times. Bergan, Essex, Hudson, Hunterdon, Mercer, Middlesex, Morris, Passaic, Somerset, and Union were tested for arsenic contamination as well along with Sussex and waren counties for high levels of arsenic in their soil. If levels are out of the norm, the PWTA database distributes a copy of the results to the county or local health department. Bottled water and boiling water are short temr solutions to this issue. Homeowners who have private wells may think of switching over to public water systems .There are two different types of treatments that are used. One is called a point-of-entry treatment, and it is a system that treats the water for the household. The second one is called a point-of-use system which treats the water at the kitchen tap, similar to a water filter. It is important that the homeowner consults with a health official or health department that will give them the best option and resources to decrease their health risks of exposure to arsenic.

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Forest Benefits

They support up to 90% of known terrestrial species and offer a variety of habitats for plants, animals, and micro-organisms 1 acre of forest absorbs 6 tons of carbon dioxides and puts out 4 tons of oxygen this is enough to meet the annual needs of 18 people! Trees help conserve soil and water, control avalanches, prevent desertification, protect coastal areas, and stabilize sand dunes During a heavy rain, a healthy forest can absorbs as much as 20,000 gallons of water in an hour Trees also shade buildings which reduces air conditioning use, resulting in reduced amounts of carbon dioxide emitted by power plants Healthy trees can add up to 15% to residential property value
Njparksandforests.org

Annual Address on the State of Health of New Jersey:

Healthy People, Healthy Communities

Alexsandra Apostolico

On November 3 , 2011, Commissioner Ms. ODowd, gave her annual address at the 2011 New Jersey Department of Health and Senior Services Conference. Many issues were addressed concerning the functionality and ability of the public health sector to continue to provide outstanding care in the state of New Jersey. Usual topics were discussed such as vaccines (especially pertaining to the present flu season) every year it is estimated that businesses spend on average 10.4 billion dollars annually towards flu-ridden employees. Health departments around New Jersey must continue to dispute the propaganda campaigns against adverse effects of vaccines, particularly pertaining to mental health. Ms. ODowd also addressed the issue of obesity in New

rd

Jersey (as well as the rest of America) and the benefits of Baby-Friendly hospitals, which promote the act of breast-feeding with new moms. Along with the many benefits of breastfeeding for both the mom and baby (increased immunity, uterine health etc) it is now shown that breastfeeding can reduce childhood obesity by up to 30%. Ms. ODowd also discussed her interest in involving palliative care (which focuses on pain, stress, and symptom relief in serious or terminally ill patients), Ms. ODowd expressed her own personal interest in this issue. Ms. ODowd also stressed the need for creating a self- sustained infrastructure as well as facing the everlasting challenges with funding and budget cuts.

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Association Update: New Jersey Health Officers Association Mr. Robert Gogats, a member of the New Jersey Health Officers Association (Country interest), is currently in the process of a merger that this organization is undertaking with NJHOA (New Jersey Health Officers Association), which has been long awaited and long overdue. By the end of November, township health officers and county health officers will work together to solve New Jerseys public health issues. Mr. Gogats expressed his concern about budget cuts across the board that will cut back on spending in the short run, but will have a major impact on future responses to outbreaks of disease. This is clearly a dire issue that NJCHOA is dealing with. Mr. Gogats expressed his concern that there is not enough communication with the public about the importance of public health in their everyday lives. If the public realizes the direct impact that the public health sector plays in their overall well-being, budget cuts may be confronted with more protest from the public. In response to the Annual Address on the State of the Health of New Jersey, given by Commissioner Ms. ODowd , Mr. Gogats agrees that changes [need to be made in order to] be able to afford the title wave of diabetes, mental health issues and disease prevention we are heading towards.

The New Jersey Society for Public Health Education is a state-level branch of SOPHE, the national organization which assists health educators in furthering their professional goals and contributing to better practices for health education. NJSOPHE advocates policies that further health education, as well as creating collaborative partnerships among public health organizations and improving health education goals statewide. In 2012 in particular, advocacy will be centered on topics selected by board members as the most urgent. NJSOPHEs initiatives involve collaborative partnerships among groups like the American Hospital Association and Rutgers University. Currently, NJSOPHE leaders are taking a critical look into what can be done about obesity, fitness, and nutrition in New Jersey communities. NJSOPHE is now collaborating with ShapingNJ, a Department of Health and Senior Services 1 project with a strategic plan to promote healthy lifestyles . ShapingNJ involves a set of 23 core strategies aimed at making the healthy choice the easy choice for everyone.

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Ferhoncus de plub Omare foremne Lemacord Promwn

Trenz Pruca Aliquam de Mantis Leo Praesen Mauris Vitaequam Diam Nobis Senmaris Calla Ipsum Eget Toque Aliquam de Manti Fringilla Viverr

Seargente de Fermentum Urna Semper Chauncey de Billuptus Orci Aliquam Vivamus Nunc Nobis Eget Sed accumsan Libero Fermen Pede Vestibulum Bibendum

Uam Scelerisque Maecenas Interdum Cras Maecenas Curabitur Leo Tortor Rasellus Quisque Porta Urna Sodales Aliquam Mattis Felis Veli Ligula Morbi congue Magna Odio Pede Eget Purus

Class aptent taciti sociosqu ad per inceptos

Tristique velit vel praesent
Aliquam mattis, ipsum quis fringilla lacinia, purus justo consectetuer velit, in sodales elit ante id dui. Sed sodales fermentum sapien. Maecenas sapien velit. Curabitur porta lacinia mi. Sed nec nisl nec urna consequat commodo. Vestibulum facilisis. Mauris vitae quam id augue scelerisque rutrum. Aliquam erat volutpat. Mauris lacinia consectetuer est. Class aptent taciti sociosqu ad litora torquent per conubia nostra. Lorem ipsum dolor sit amet, consectetuer adipiscing elit acinia. Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Aliquam mattis, ipsum quis fringilla lacinia, purus justo consectetuer velit, in sodales elit ante id dui. Sed sodales fermentum sapien. Maecenas sapien velit. Mauris vitae quam id augue scelerisque rutrum. Aliquam erat volutpat. Mauris lacinia consectetuer est. Class aptent taciti sociosqu ad litora torquent per conubia nostra. Lorem ipsum dolor sit amet, consectetuer adipiscing elit. disse turpis, hac massa morbi erat, amet condimentum pulvinar augue. Quam lorem pede proin lectus laoreet, est sit sed quis, odio ac mollis nulla in, ad cursus sit ante. Lacus risus felis volutpat, magna euismod leo, maecenas at aenean cras gravida eu consectetuer, fusce convallis etiam lorem ipsum velit pellentesque.

Vestibulum ante:
Volupat est ipsum quis
Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus.

Est eu pede laoreet Curabitur vulputate viverra

Enim ridiculus aliquet penatibus amet, tellus at morbi, mi hac, mus sit mauris facere. Natoque et. Sit nam duis montes, arcu pede elit molestie, amet quisque sed egestas urna non, vestibulum nibh suspendisse. Molestie eros leo placerat porttitor, et felis faucibus id urna, quam luctus ante eros etiam tellus, vel diam. Ante delectus laoreet felis turpis porta, nunc sem suspenNec etiam dui accusamus, morbi at elit ipsum sit diam, velit feugiat vel dictum donec at eget. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Fusce consequat porttitor arcu. Vestibulum ut nunc. Sed dictum ante vel lacus. Pellentesque quis est eu pede laoreet elementum. Aliquam pellentesque lorem ipsum ante vitae ligula nec.

Elementum lectus
Nunc elit odio, pulvinar at, tristique quis, mattis vel, elit. Phasellus tincidunt suscipit urna. Aliquam pellentesque ante vitae ligula. Hasellus tempus sem nec tellus. Praesent et dol or ac sapien vehicula bibedum. Donec eu Atempus ante.

Sed et lacus quis enim mattis nonummy

Molestie ornare amet vel id fusce, rem volutpat platea. Magnis vel, lacinia nisl, vel nostra nunc eleifend arcu leo, in dignissim lorem vivamus. Justo vel ante sed augue facilisis, quisque donec wisi, lorem fringilla aliquam, et lacus. Duis ipsum justo in, curabitur curabitur nisl condimentum, sit sodales a pretium. Est ultrices phasellus ullamcorper ridiculus, donec id adipiscing sit placerat sit, eget euismod, luctus lectus eros vestibulum eu hac pede, neque et nonummy.

Nulla nunc lectus porttitor vitae pulvinar magna

Ullamcorper libero morbi aenean, dolor aliquam mauris mauris lobortis dolorem, convallis mauris euismod urna elit adipiscing lacus. Pharetra nullam elit, eros cras purus, morbi posuere viverra tempus erat erat. In etiam vel duis vestibulum nunc vitae, quis velit neque cras hendrerit, ridiculus. Ante amet volutpat ullamcorper ut vel, leo rhoncus massa, natoque orci mauris nulla mollis. Posuere porttitor, mauris ornare, a quam duis sagittis dapibus massa at, pede nec, integer magna cursus volutpat. Interdum diam id euismod nunc, augue enim ipsum sed ad amet massa, ac ante tempus, pretium gravida viverra, vulputate sapien vel.

EUISMOD ELEMENTUM 1234 MAIN STREET ANYTOWN, STATE ZIP TEL: 123.456.7890 FAX: 123.456.7891

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Ferhoncus de plub Omare foremne Lemacord Promwn

Trenz Pruca Aliquam de Mantis Leo Praesen Mauris Vitaequam Diam Nobis Senmaris Calla Ipsum Eget Toque Aliquam de Manti Fringilla Viverr

Seargente de Fermentum Urna Semper Chauncey de Billuptus Orci Aliquam Vivamus Nunc Nobis Eget Sed accumsan Libero Fermen Pede Vestibulum Bibendum

Uam Scelerisque Maecenas Interdum Cras Maecenas Curabitur Leo Tortor Rasellus Quisque Porta Urna Sodales Aliquam Mattis Felis Veli Ligula Morbi congue Magna Odio Pede Eget Purus

Class aptent taciti sociosqu ad per inceptos

Tristique velit vel praesent
Aliquam mattis, ipsum quis fringilla lacinia, purus justo consectetuer velit, in sodales elit ante id dui. Sed sodales fermentum sapien. Maecenas sapien velit. Curabitur porta lacinia mi. Sed nec nisl nec urna consequat commodo. Vestibulum facilisis. Mauris vitae quam id augue scelerisque rutrum. Aliquam erat volutpat. Mauris lacinia consectetuer est. Class aptent taciti sociosqu ad litora torquent per conubia nostra. Lorem ipsum dolor sit amet, consectetuer adipiscing elit acinia. Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Aliquam mattis, ipsum quis fringilla lacinia, purus justo consectetuer velit, in sodales elit ante id dui. Sed sodales fermentum sapien. Maecenas sapien velit. Mauris vitae quam id augue scelerisque rutrum. Aliquam erat volutpat. Mauris lacinia consectetuer est. Class aptent taciti sociosqu ad litora torquent per conubia nostra. Lorem ipsum dolor sit amet, consectetuer adipiscing elit. disse turpis, hac massa morbi erat, amet condimentum pulvinar augue. Quam lorem pede proin lectus laoreet, est sit sed quis, odio ac mollis nulla in, ad cursus sit ante. Lacus risus felis volutpat, magna euismod leo, maecenas at aenean cras gravida eu consectetuer, fusce convallis etiam lorem ipsum velit pellentesque.

Vestibulum ante:
Volupat est ipsum quis
Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus.

Est eu pede laoreet Curabitur vulputate viverra

Enim ridiculus aliquet penatibus amet, tellus at morbi, mi hac, mus sit mauris facere. Natoque et. Sit nam duis montes, arcu pede elit molestie, amet quisque sed egestas urna non, vestibulum nibh suspendisse. Molestie eros leo placerat porttitor, et felis faucibus id urna, quam luctus ante eros etiam tellus, vel diam. Ante delectus laoreet felis turpis porta, nunc sem suspenNec etiam dui accusamus, morbi at elit ipsum sit diam, velit feugiat vel dictum donec at eget. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Fusce consequat porttitor arcu. Vestibulum ut nunc. Sed dictum ante vel lacus. Pellentesque quis est eu pede laoreet elementum. Aliquam pellentesque lorem ipsum ante vitae ligula nec.

Elementum lectus
Nunc elit odio, pulvinar at, tristique quis, mattis vel, elit. Phasellus tincidunt suscipit urna. Aliquam pellentesque ante vitae ligula. Hasellus tempus sem nec tellus. Praesent et dol or ac sapien vehicula bibedum. Donec eu Atempus ante.

Sed et lacus quis enim mattis nonummy

Molestie ornare amet vel id fusce, rem volutpat platea. Magnis vel, lacinia nisl, vel nostra nunc eleifend arcu leo, in dignissim lorem vivamus. Justo vel ante sed augue facilisis, quisque donec wisi, lorem fringilla aliquam, et lacus. Duis ipsum justo in, curabitur curabitur nisl condimentum, sit sodales a pretium. Est ultrices phasellus ullamcorper ridiculus, donec id adipiscing sit placerat sit, eget euismod, luctus lectus eros vestibulum eu hac pede, neque et nonummy.

Nulla nunc lectus porttitor vitae pulvinar magna

Ullamcorper libero morbi aenean, dolor aliquam mauris mauris lobortis dolorem, convallis mauris euismod urna elit adipiscing lacus. Pharetra nullam elit, eros cras purus, morbi posuere viverra tempus erat erat. In etiam vel duis vestibulum nunc vitae, quis velit neque cras hendrerit, ridiculus. Ante amet volutpat ullamcorper ut vel, leo rhoncus massa, natoque orci mauris nulla mollis. Posuere porttitor, mauris ornare, a quam duis sagittis dapibus massa at, pede nec, integer magna cursus volutpat. Interdum diam id euismod nunc, augue enim ipsum sed ad amet massa, ac ante tempus, pretium gravida viverra, vulputate sapien vel.

EUISMOD ELEMENTUM 1234 MAIN STREET ANYTOWN, STATE ZIP TEL: 123.456.7890 FAX: 123.456.7891

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IPSUM: Vivamus est ipsum, vehicula nec, feugiat rhoncus, accumsan id, nisl.

Vestibulum ante:
Volupat est ipsum quis est eu pede laoreet elementum lectus
1. Vivamus est ipsum vehicula nec. Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus. 2. Feugiat rhoncus accumsan id nis. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Fusce consequat porttitor arcu. Vestibulum ut nunc. Sed dictum ante vel lacus.

Integer aliquet metus retu ium mauris est

Lorem ipsum dolor sit amet consectetuer adipiscing elit Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Vivamus est ipsum, vehicula nec, feugiat rhoncus, accumsan id, nisl. Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia. Pellentesque fermentum arcu vitae sapien. Morbi lorem. Phasellus wisi. Nulla sed est commodo turpis. Fusce sollicitudin, nunc ac nonummy ultrices, odio massa dapibus sapien, vitae euismod ipsum felis sit metus. Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Donec massa magna, sagittis vel, semper eu, posuere a, odio. Nam felis nibh, rhoncus eu, elementum nec, egestas quis, dolor. Ut est diam, rutrum sed, convallis et, porttitor ac, urna. Etiam ac nisl vel neque sodales pretium. Vivamus varius ultrices urna.

Ut porta feugiat dui tempus massa sit amet ante

Mauris sed sem. Donec tellus sapien, aliquam quis, porttitor non, feugiat et, augue. Sed adipiscing pede eu lorem. Donec gravida porta diam. Vestibulum ac risus. Etiam eu dui quis quam lacinia condimentum. Aenean vel purus. Vestibulum congue

nibh in felis. Cras eu ante. Nulla facilisi. Mauris eget lectus non urna tempus cursus. Aenean porta adipiscing leo. Integer molestie. Fusce consectetuer tellus a ligula. Sed facilisis neque ac pede. Vestibulum orci. Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Vivamus est ipsum, vehicula nec, feugiat rhoncus, accumsan id, nisl. Praesent et dolor ac sapien lorem vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Etiam venenatis wisi ac diam. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Fusce consequat porttitor arcu. Vestibulum ut nunc. Sed dictum ante vel lacus. Quisque non mauris at lorem vestibulum rhoncus. Suspendisse eros. Nunc elit odio, pulvinar at, tristique quis, mattis vel, elit. Phasellus tincidunt suscipit urna. Aliquam pellentesque ante vitae ligula. Phasellus tempus sem nec tellus. Curabitur blandit ultricies tellus. Integer aliquet metus pretium mauris. Pellentesque tristique nisl sed orci. Ut congue laoreet arcu. Maecenas congue mauris sed justo. Donec ultrices. Vivamus lectus sem, placerat nec, convallis sed, sodales in, sem. Sed non leo. Curabitur a urna. Sed semper, libero nec imperdiet fringilla, tellus velit rutrum velit, ut lacinia metus urna ut felis. In lacus arcu, scelerisque eu, luctus euismod, aliquet ac, quam. Nunc felis augue, pulvinar sit amet, mattis id, egestas vel, enim. Curabitur rhoncus. Ut porta feugiat dui. Maecenas tempus massa sit amet ante. Morbi vestibulum. Praesent tristique velit vel massa blandit vestibulum. Pellentesque dictums. Littera gothica quam nunc putamus parum.

3. Lorem ipsum dolor sit amet. Nunc elit odio, pulvinar at, tristique quis, mattis vel, elit. Phasellus tincidunt suscipit urna. Aliquam pellentesque ante vitae ligula. Phasellus tempus sem nec tellus. 4. Consectetuer adipiscing elit. Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Aliquam pellentesque ante vitae ligula. Atempus sem nec. 5. Pellentesque nunc tellus iaculis Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Etiam venenatis wisi ac diam. Integer aliquet metus pretium mauris. Pelentesque nisl.

Vivamus est ipsum

Feugiat rhoncus, accumsan id, nisl. Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Vivamus est ipsu vehicula nec.

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Vestibulum ante:
Volupat est ipsum quis est eu pede laoreet elementum lectus
1. Vivamus est ipsum vehicula nec. Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus. 2. Feugiat rhoncus accumsan id nis. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Fusce consequat porttitor arcu. Vestibulum ut nunc. Sed dictum ante vel lacus. 3. Lorem ipsum dolor sit amet. Nunc elit odio, pulvinar at, tristique quis, mattis vel, elit. Phasellus tincidunt suscipit urna. Aliquam pellentesque ante vitae ligula. Phasellus tempus sem nec tellus. 4. Consectetuer adipiscing elit. Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Aliquam pellentesque ante vitae ligula. Atempus sem nec. 5. Pellentesque nunc tellus iaculis Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Etiam venenatis wisi ac diam. Integer aliquet metus pretium mauris. Pelentesque nisl.

IPSUM: Vivamus est ipsum, vehicula nec, feugiat rhoncus, accumsan id, nisl.

Integer aliquet metus retuium mauris est

Lorem ipsum dolor sit amet consectetuer adipiscing elit Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Vivamus est ipsum, vehicula nec, feugiat rhoncus, accumsan id, nisl. Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia posuere a, odio. Pellentesque fermentum arcu vitae sapien. Morbi lorem. Phasellus wisi. Nulla sed est commodo turpis. Fusce sollicitudin, nunc ac nonummy ultrices, odio massa dapibus sapien, vitae euismod ipsum felis sit amet metus. Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Donec massa magna, sagittis vel, semper eu, posuere a, odio. Nam felis nibh, rhoncus eu, elementum nec, egestas quis, dolor. Ut est diam, rutrum sed, convallis et, porttitor ac, urna. Etiam ac nisl vel neque sodales pretium. Vivamus varius ultrices urna. Nullam elementum lacinia libero. Vestibulum mollis. Etiam sit amet nisl in est tempus auctor. Sed consectetuer molestie quam. Nulla quis turpis. Nam aliquam, est quis aliquam nonummy, ante orci varius arcua.

Ut porta feugiat dui tempus massa sit amet ante Vivamus est ipsum
Feugiat rhoncus, accumsan id, nisl. Lorem ipsum dolor sit amet, lorem ipsum consectetuer adipiscing elit. Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Vivamus est ipsu vehicula nec. Mauris sed sem. Donec tellus sapien, aliquam quis, porttitor non, feugiat et, augue. Sed adipiscing pede eu lorem. Donec gravida porta diam. Vestibulum ac risus. Etiam eu dui quis quam lacinia condimentum. Aenean vel purus. Vestibulum congue nibh in felis. Cras eu ante. Nulla facilisi. Mauris eget lectus non urna tempus cursus. Aenean porta adipiscing leo. Integer molestie. Fusce consectetuer tellus a ligula. Sed facilisis neque ac pede. Vestibulum orci. Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Vivamus est ipsum, vehicula nec, feugiat rhoncus, accumsan id, nisl. Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Etiam venenatis wisi ac diam. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Fusce consequat porttitor arcu. Vestibulum ut nunc. Sed dictum ante vel lacus. Quisque non mauris at lorem vestibulum rhoncus. Suspendisse eros. Nunc elit odio, pulvinar at, tristique quis, mattis vel, elit. Phasellus tincidunt suscipit urna. Aliquam pellentesque ante vitae ligula. Phasellus tempus sem nec tellus. Curabitur blandit ultricies tellus. Integer aliquet metus pretium mauris. Pellentesque tristique nisl sed orci. Ut congue laoreet arcu. Maecenas congue mauris sed justo. Donec ultrices. Vivamus lectus sem, placerat nec, convallis sed, sodales in, sem. Sed non leo. 19 Page

Ferhoncus de plub Omare foremne Lemacord Promwn

Trenz Pruca Aliquam de Mantis Leo Praesen Mauris Vitaequam Diam Nobis Senmaris Calla Ipsum Eget Toque Aliquam de Manti Fringilla Viverr

Seargente de Fermentum Urna Semper Chauncey de Billuptus Orci Aliquam Vivamus Nunc Nobis Eget Sed accumsan Libero Fermen Pede Vestibulum Bibendum

Uam Scelerisque Maecenas Interdum Cras Maecenas Curabitur Leo Tortor Rasellus Quisque Porta Urna Sodales Aliquam Mattis Felis Veli Ligula Morbi congue Magna Odio Pede Eget Purus

Class aptent taciti sociosqu ad per inceptos

Tristique velit vel praesent
Aliquam mattis, ipsum quis fringilla lacinia, purus justo consectetuer velit, in sodales elit ante id dui. Sed sodales fermentum sapien. Maecenas sapien velit. Curabitur porta lacinia mi. Sed nec nisl nec urna consequat commodo. Vestibulum facilisis. Mauris vitae quam id augue scelerisque rutrum. Aliquam erat volutpat. Mauris lacinia consectetuer est. Class aptent taciti sociosqu ad litora torquent per conubia nostra. Lorem ipsum dolor sit amet, consectetuer adipiscing elit acinia. Pellentesque nunc tellus, iaculis quis, volutpat eget, bibendum ac, lectus. Aliquam mattis, ipsum quis fringilla lacinia, purus justo consectetuer velit, in sodales elit ante id dui. Sed sodales fermentum sapien. Maecenas sapien velit. Mauris vitae quam id augue scelerisque rutrum. Aliquam erat volutpat. Mauris lacinia consectetuer est. Class aptent taciti sociosqu ad litora torquent per conubia nostra. Lorem ipsum dolor sit amet, consectetuer adipiscing elit. disse turpis, hac massa morbi erat, amet condimentum pulvinar augue. Quam lorem pede proin lectus laoreet, est sit sed quis, odio ac mollis nulla in, ad cursus sit ante. Lacus risus felis volutpat, magna euismod leo, maecenas at aenean cras gravida eu consectetuer, fusce convallis etiam lorem ipsum velit pellentesque.

Vestibulum ante:
Volupat est ipsum quis
Praesent et dolor ac sapien vehicula bibendum. Donec eu ante. Pellentesque quis est eu pede laoreet elementum. Vestibulum ante ipsum primis in faucibus.

Est eu pede laoreet Curabitur vulputate viverra

Enim ridiculus aliquet penatibus amet, tellus at morbi, mi hac, mus sit mauris facere. Natoque et. Sit nam duis montes, arcu pede elit molestie, amet quisque sed egestas urna non, vestibulum nibh suspendisse. Molestie eros leo placerat porttitor, et felis faucibus id urna, quam luctus ante eros etiam tellus, vel diam. Ante delectus laoreet felis turpis porta, nunc sem suspenNec etiam dui accusamus, morbi at elit ipsum sit diam, velit feugiat vel dictum donec at eget. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Fusce consequat porttitor arcu. Vestibulum ut nunc. Sed dictum ante vel lacus. Pellentesque quis est eu pede laoreet elementum. Aliquam pellentesque lorem ipsum ante vitae ligula nec.

Elementum lectus
Nunc elit odio, pulvinar at, tristique quis, mattis vel, elit. Phasellus tincidunt suscipit urna. Aliquam pellentesque ante vitae ligula. Hasellus tempus sem nec tellus. Praesent et dol or ac sapien vehicula bibedum. Donec eu Atempus ante.

Sed et lacus quis enim mattis nonummy

Molestie ornare amet vel id fusce, rem volutpat platea. Magnis vel, lacinia nisl, vel nostra nunc eleifend arcu leo, in dignissim lorem vivamus. Justo vel ante sed augue facilisis, quisque donec wisi, lorem fringilla aliquam, et lacus. Duis ipsum justo in, curabitur curabitur nisl condimentum, sit sodales a pretium. Est ultrices phasellus ullamcorper ridiculus, donec id adipiscing sit placerat sit, eget euismod, luctus lectus eros vestibulum eu hac pede, neque et nonummy.

Nulla nunc lectus porttitor vitae pulvinar magna

Ullamcorper libero morbi aenean, dolor aliquam mauris mauris lobortis dolorem, convallis mauris euismod urna elit adipiscing lacus. Pharetra nullam elit, eros cras purus, morbi posuere viverra tempus erat erat. In etiam vel duis vestibulum nunc vitae, quis velit neque cras hendrerit, ridiculus. Ante amet volutpat ullamcorper ut vel, leo rhoncus massa, natoque orci mauris nulla mollis. Posuere porttitor, mauris ornare, a quam duis sagittis dapibus massa at, pede nec, integer magna cursus volutpat. Interdum diam id euismod nunc, augue enim ipsum sed ad amet massa, ac ante tempus, pretium gravida viverra, vulputate sapien vel.

EUISMOD ELEMENTUM 1234 MAIN STREET ANYTOWN, STATE ZIP TEL: 123.456.7890 FAX: 123.456.7891

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