Running head: HEALTH POLICY PROPOSAL FOR MIAMI 1

Health Policy Proposal for Miami-Dade County

Jeanne Zamith

University of South Florida

HEALTH POLICY PROPOSAL FOR MIAMI-DADE COUNTY 2

Health Policy Proposal for Miami-Dade County

Over the past several years, data has shown the resurgence of vaccine-preventable

diseases, which were once under control (Matt, 2017). Miami-Dade County provides an

excellent case study, demonstrating how the lower rate of compliance regarding childhood

vaccinations significantly impacts the prevalence of these diseases. Individual noncompliance

has an impact not only on the individual but also the community as a whole because these

individuals provide a vector for these diseases to spread and weaken herd immunity. This study

will analyze factors that contribute to Miami-Dade Countys rise in vaccine-preventable diseases,

discuss interventions that may be used, and propose a health policy that addresses this problem.

Overview of Miami-Dade County

Miami-Dade County is a large, mostly urbanized county located in Southeast Florida. Its

total land area of 1,898 square miles, makes it the third-largest county in Florida by land area

(U.S. Census Bureau, 2011). Its estimated population in 2016 was 2,712,945 (U.S. Census

Bureau , 2017b). Its population density of 1,315.5 people per square mile is significantly higher

than the states average of 350.6 (U.S. Census Bureau, 2017a, 2017b). Miami-Dade Public

schools, Miami-Dade County, and the Federal Government are the three largest employers in the

county, and the two major hospital systems are Baptist Health South Florida and Jackson Health

(The Beacon Council, 2015).

Comparison of Local vs. State Populations

Approximately 20.5% of the population in Miami-Dade County lives below the poverty

line, compared to the states 16.7% average. The rate of the population greater than five years

old who speaks English less than very well is 34.5%, which is significantly higher than Floridas

average of 11.7%. 20.4% of the countys population greater than 25 years old does not have a
HEALTH POLICY PROPOSAL FOR MIAMI-DADE COUNTY 3

high school diploma, which is approximately seven percentage points higher than the states

13.5% average. The total Florida Family Practice Physicians in Miami-Dade County is 13.7 per

100,000 population, which is lower than the state average of 19.6. The number of County Health

Department full-time employees is 28.9 per 100,00 population, which is about half of the state

average of 51.1, placing the county in the bottom quartile in the state of Florida (Florida

Department of Health [FDH], 2017a).

Analysis and Interpretation of Data

Identified Strengths

Considering that Miami-Dade County is a coastal county, an assumption could be made that

most of the population would be exposed to more sun and, therefore, a higher incidence of

melanoma would occur. However, at 1.2 per 100,000 population and 7.4 per 100,000

population, which are the countys melanoma death rates and incidence rates respectively,

Miami-Dade Countys averages are less than half of the states respective averages of 2.8 and 18

(FDH, 2017a). 64% of women aged 40 to 74 years old received a mammogram within the past

year. This exceeds the states 57.5% average by 6.5%. This could, potentially, explain the

countys lower breast cancer mortality rate of 18.5 per 100,000 population, compared to the

states 19.8 (FDH, 2017a).

At 8.6 per 100,000 population, the heart failure age-adjusted death rate in Miami-Dade

County is significantly lower than the states rate, which is 11.3, placing Miami-Dade in the

Florida Department of Healths most favorable county quartile for this specific statistic. This

is especially a significant strength considering the countys heart failure age-adjusted

hospitalization rate of 128.6 per 100,000 population, which is almost double the states 75.2.

Even though the rate of hospitalizations is significantly higher, placing the county in the bottom
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quartile, this data shows that the health care team is effective in treating this disease and

preventing death (FDH, 2017a).

Identified Weaknesses

Even though the heart failure age-adjusted death rate is managed relatively well

compared to the state, in Miami-Dade County, the diabetes age-adjusted death rate of 21.1 per

100,000 population is higher than the states 19.5 average. It is also pertinent to consider that

8.9% of people in the county have been told they have been diagnosed with diabetes, compared

to the states 11.2%; thus, the countys diabetes age-adjusted death rate is a significant weakness

considering fewer people have been clinically diagnosed (FDH, 2017a). In Miami-Dade County,

39.8% of adults are considered overweight, which is about 3% higher than the states 36.4%

average. This statistic could be due to multiple factors; however, one factor to consider is the

countys 55.8% average adult population who is considered inactive or insufficiently active,

compared to the states 52.9% average (FDH, 2017a).

Another weakness to consider is the countys above-state-average rates of infectious

diseases. For example, the prevalence of Hepatitis A, which is a vaccine-preventable disease,

per 100,000 population is 1.3, which is just over double the states average of 0.6. This could be

due to the fact that 92.2% of Kindergarten children in Miami-Dade County are considered fully

immunized; the state of Floridas average is 93.4% (FDH, 2017a). Even though this is only

about a 1% difference, the health outcomes regarding infectious disease rates are significant,

most likely due to the high population density, which facilitates the spread of these diseases, and

as a result, a weakened herd immunity within the population.

Identification of a Priority Health Issue

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In Miami-Dade County, there has been a recent resurgence of infectious diseases, despite

the availability of vaccines, most likely caused by the below-average rate of kindergarten

children considered fully immunized and exacerbated by the countys high population density.

For example, in 2007, Miami-Dade County accounted for 55 of the states 1,683 cases (3.2%) of

chronic Hepatitis B. In 2015, 2,634 of the states 14,012 counts (18.8%) of chronic Hepatitis B

came from Miami-Dade County (FDH, 2017a). Furthermore, even though some vaccine-

preventable diseases overall incidences have decreased, Miami-Dade Countys decrease has

been relatively slow compared to the states. In 2007, for example, the countys number of

tuberculosis cases was 8.5 per 100,000 population, compared to the states 5.7. In 2015, the

countys number of tuberculosis cases was 5 per 100,000 population, which was about one and a

half times more prevalent than the states average of 3.1 (FDH, 2017a).

The risks associated with diseases, such as tuberculosis, hepatitis A and B, or influenza

are not only a decreased quality of life but also death. Since 1996, there have been a total 161

deaths from infectious disease, tuberculosis, alone in Miami-Dade County (FDH, 2017d).

Healthy People 2020 considers the reduction of vaccine-preventable diseases, through the means

of technological advancements and strong partnerships, one of its main goals because these

infectious diseases are now among the leading causes of illness and death in the United States.

(Office of Disease Prevention and Health Promotion, 2012).

Discussion and Application of Community Health Models

Community health models serve to analyze a given population, individually or as a

whole, working to understand the strengths and weaknesses within the population and creating

innovative interventions to either enhance the strengths or intervene on the weaknesses. The

Determinants of Health Model focuses on the understanding that, even though changing
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individual behavior may be successful at reducing risk, focusing on population behavioral

change and creating interventions that will help the general population is equally as important. It

works by analyzing personal, social, economic, and environmental factors and creating

interventions taking these factors into account (Savage, Kub, & Groves, 2015).

Personal factors that affect Miami-Dades increased incidences of communicable

diseases may be adherence to religions or philosophies that prohibit vaccinations or fear of the

potential harm (Harmsen et al., 2015). These factors themselves may even be reinforced by

social factors, such as the internet, social media, blogs, and the exchange of ideas with people

with similar beliefs. One study showed that parents who use the internet as a source of vaccine

information are 3.5 times more likely to refuse vaccinations for their children, 50% more likely

to see alternative health care providers as a reliable source of information, and 40% less likely to

see regular health care providers as a reliable source of information (Jones et al., 2012).

Considering Miami-Dades above state average poverty level, it may be possible that a

reason for higher prevalence of infectious diseases would be the inability for parents to take time

off of work to either take their children to get their vaccinations or stay at home with their

children when they do get sick. Within the first fifteen months from birth, a parent would need

to visit a clinic on at least five separate occasions in order to adhere to the proper immunization

schedule (U.S. Department of Human Services, 2006). The fact that clinics often have long

waits may make this a burden on parents who cannot afford to take the time off from work.

The weakened herd immunity caused by lower vaccination rates is an important

environmental factor that contributes to the increased prevalence of communicable diseases.

Miami being a major destination for travel and trade increases the populations exposure to
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infectious agents. This problem could be exacerbated by the high population density, facilitating

the spread of these diseases (Sumdani, Frickle, Le, Tran, & Zaleta 2014).

Population Diagnosis

The general population of Miami-Dade County is at risk for further increase in the

prevalence of vaccine-preventable infectious diseases due to below state average rate of

Kindergarten children considered fully immunized and its high population density as evidenced

by the previously discussed statistical data regarding increasing infectious disease rates.

Community/Population-based Interventions

Primary Level of Prevention

Considering its below-average rate of fully immunized Kindergarten children, one way to

intervene and promote health protection for Miami-Dades increased prevalence of infectious

diseases is by encouraging parents to vaccinate their children. While this type of risk

modification mainly focuses on the individual, it also protects the community as a whole. In

2011, only one state in the United States reached the 92-94% threshold required to maintain herd

immunity. This resulted in 42,000 new cases of pertussis, causing the biggest outbreak since the

1950s ("Vaccines ProCon.org," 2017).

Health care providers, which are stakeholders in this issue, are obligated to stay up-to-

date with current research about the benefits versus risks of vaccinating children and educate the

parents accordingly. If education is ineffective and vaccination rates continue to decline, there

will be an increased risk of an outbreak of these infectious diseases. With an estimated twenty-

seven dollars saved per one dollar spent on the DTaP vaccine and thirteen dollars saved per one

dollar spent on MMR, it is in the best interest of state legislators and public officials to reanalyze

the amount of exemptions being provided in order to increase the vaccination rates state-wide,
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which would effectively raise vaccination rates in the county as well ("Vaccines ProCon.org,"

2017). In concept, this would decrease the prevalence of the communicable diseases and save its

constituents both time and money.

Community health nurses are responsible for advocating for their patients outside of the

acute care setting. As an essential part of the health care team, they have an obligation to stay

up-to-date on research and educate the patients they encounter in order to improve health

outcomes not only for that patient but also their surrounding community. Depending on the

availability within the setting of community health, the nurses should have access to their

patients vaccination records. If the patient is exempt, the nurse should educate about

alternatives, such as proper diet and exercise to maintain a healthy immune system.

Secondary Level of Prevention

Despite the availability of vaccines, proper education by health care providers to the local

population, and state mandates to raise vaccination rates, infectious diseases are still somewhat

inevitable. Because many of these diseases can lead to death if not treated properly and in a

timely manner, secondary interventions such as a proper diagnosis and treatment at the

individual level must be in place. As stakeholders, due to their ability to manage this issue,

healthcare providers are responsible for diagnosing and treating these diseases as quickly as

possible to prevent further complications. Diagnosing diseases early, especially before severe

symptoms have occurred, can reduce their severity (Caliendo et al., 2013).

Due to the similarity of symptoms between many viral and bacterial infections,

increasing the utilization of a system in which unvaccinated children can easily be identified,

such as Florida SHOTS, may help healthcare providers in forming differential diagnoses FDH,

2017c). This can lead to earlier diagnosis, and proper treatment, of infectious diseases, which
HEALTH POLICY PROPOSAL FOR MIAMI-DADE COUNTY 9

the majority of the population would be vaccinated against but which unvaccinated patients

would be more vulnerable to. This type of intervention has a potential drawback of requiring

parents to take their children to health care providers very shortly after the onset of symptoms,

which, for financial reasons, would be less likely because it would require parents to take time

off of work to seek treatment for symptoms that may initially appear benign.

In order to develop and carry out this intervention successfully, community health nurses

should have a strong foundation of the pathophysiology of infectious diseases, as well as the

ability to detect early signs and symptoms. If, and when, parents choose to opt out of vaccinating

their children, making them more susceptible to the diseases, community health nurses should

educate those parents about how to detect early signs and symptoms of the disease and the

importance of bringing their child to their provider if the symptoms do occur.

Tertiary Level of Prevention

Once secondary prevention has been implemented, a tertiary intervention, such as the

quarantine of infected individuals, can also be also be implemented. While an ideal goal would

be to eliminate, or even eradicate, these diseases, this might not be feasible in the near future;

therefore, this type of intervention should be put in place for when the infections do occur to

prevent further spread. This system-wide intervention could be achieved through policies both at

schools and work places requiring individuals with symptoms of potentially infectious diseases

to stay home.

Such a policy would have an impact on the community, which are the stakeholders,

including the school and work place, by lowering their possible exposure to these diseases, but

this policy would also have potential downfalls. In the workplace, for example, an immediate

concern would be decreased productivity for the employer and decreased income for the
HEALTH POLICY PROPOSAL FOR MIAMI-DADE COUNTY 10

employee. However, the short-term decrease in productivity would be outweighed by the

avoidance of having a greater drop in productivity if the disease were to spread.

For this level of prevention, it is imperative for community health nurses to take proper

precautions when dealing with the individuals with potential infectious diseases and to encourage

the patients to go to the hospital as soon as possible to get proper treatment. The community

health nurse should use evidence-based practices that have been shown to help reduce the spread

of infection, the primary worldwide focus being proper hand-washing (Royal College of

Nursing, 2015). They are the ones entering homes and communicating with the general public,

and even though they cannot require anyone with a potential illness to seek medical help, they

can educate their patients and their community about the importance of hand washing to prevent

the spread of the diseases. Community health nurses could easily become a vector of these

infectious diseases due to the nature of their job, so it is vital for them to do everything possible

to avoid spreading the diseases to the already sick people they encounter.

Development of Health Policy

As a core function of public health, health policy serves to implement solutions to health

care issues in the community (Savage et al., 2015). In Miami-Dade County, the numbers of

infectious diseases, compared to the states, are staggering, causing the county to be one of the

least favorable in terms of the number of vaccine-preventable diseases, potentially due to the

below-average amount of kindergarten children fully immunized or Miami-Dade Countys high

population density (FDH, 2017a). While attempting to fix its population density could result in a

decreased prevalence of infectious diseases, this is not feasible because of the countys

immigrant population being the second largest in the country along with its constant trade and
HEALTH POLICY PROPOSAL FOR MIAMI-DADE COUNTY 11

tourism (Migration Policy Institute, 2015). Thus, a more feasible option would be raising the

immunization rates within the county.

In general, research supports that childhood immunization is one of the most effective

ways of preventing the spread of disease and, therefore, reducing morbidity and mortality

(Ventola, 2016). Considering 92.2% of Kindergarten children in Miami-Dade County are

considered fully immunized, and the state of Floridas average is 93.4%, a goal of being at or

above state average is ideal. In 2004, only 6.3% of kindergarten children had exemptions for

either temporary medical, permanent medical, religious or unknown status reasons, compared

to the states 5.5% average. In 2011, 10.7 percent of kindergarten children were exempt from

immunizations, compared to the states 7.2% average (Veiga, Alcantara, & Dapena, 2017).

The purpose of any policy implemented should not be to infringe on the rights of those

with religious and philosophical reasons for not vaccinating, so, perhaps, a more appropriate

focus would be on targeting the bulk of the exemptions, temporary medical exemptions, which

were granted to 9.3% of kindergarten children in 2011 (Veiga et al., 2017). Temporary medical

exemptions can be given to allow children to be enrolled in school while still in the process of

completing their immunizations (Florida Department of Health, 2017b). At that stage, he or she

is not considered fully immunized and can still contract the disease and contribute to its spread.

Even though some of these exemptions may be necessary, great care must be taken to

ensure that those with temporary medical exemptions go onto complete their vaccinations.

Miami-Dade County currently does not have an effective system in place to follow up with

temporary exemptions (Veiga, 2017). Therefore, a health policy with the primary goal of

implementing such a system would increase the number of kindergarten considered fully

immunized and consequently decrease the prevalence of vaccine-preventable diseases. As

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stakeholders, school nurses and public officials would play an integral role in the implementation

and execution of this system. Community members would directly benefit from the

implementation of this system due to their own decreased exposure to these diseases; however,

they would also bear the financial burden of the possible tax increases required for funding.

In 2016, 282 out of 392 schools in Miami-Dade County were served by a school health

program, which provides health screenings and follow-ups to students of the school district

(Miami-Dade County Public Schools, 2017; The Children's Trust, 2017). In order to implement

a more effective follow-up system, more funding would need to be budgeted to expand this

program, so that it can serve all schools in the county. The need for increased funding may

generate pushback from community members and public officials.

Health care providers would likely be strong supporters of this policy since they are, in

general, already advocates for vaccinations. The providers could influence public officials, who

would be the ultimate deciding factor, by educating and convincing them of the importance of

this program. Even though public officials are the ultimate deciding factors of whether this plan

is budgeted and implemented, health care providers would be the better candidate to approach

first due to their status and respect within the community and their ability to influence public

officials more effectively.

Due to the fact that many Miami-Dade County students frequently switch schools within

the county, the expansion of the current program to all schools must be the first step in

implementing this policy in order to avoid losing track of students who relocate to schools

without access to the program (Veiga, 2017). Once the expansion is complete, strategies can be

discussed and implemented to effectively follow-up with those individuals who were granted

temporary medical exemptions.

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This type of system would not only benefit the general population by decreasing their

exposure to infectious diseases. It would also benefit the underserved population in Miami-Dade

County because it does not place any further financial burden on the underserved population by

requiring them to vaccinate their children. It is simply the creation of a more effective follow-up

system for temporary medical exemptions in the school system, which should, potentially,

decrease the prevalence of vaccine-preventable diseases in Miami-Dade County.

Conclusion

Despite Miami-Dade Countys many strengths involving the healthcare of its population,

there are still weaknesses that need to be addressed. One of these weaknesses, specifically the

high incidence of vaccine-preventable diseases, was identified as the priority health issue for the

county. This paper provided interventions that addressed this priority health issue, such as

increasing immunizations among kindergarten children, utilizing Florida SHOTS to aid in

diagnosing these diseases, and recommending the quarantine of infected individuals to prevent

the spread of the disease. A health policy recommendation was made to address the issue by

implementing a more efficient system of tracking and following up with students granted

temporary medical exemptions to ensure that they complete their vaccination schedule and

become fully immunized.

As a hopeful future pediatric nurse practitioner, I am going to be part of the healthcare

team involved in the prevention of the spread of infectious diseases. This research has helped

me to better understand the consequences of a lower-than-threshold rate of children who are fully

immunized and the importance of quickly treating the individuals who do contract the diseases.

It has also helped me to more fully appreciate the magnitude of the challenge that this issue

presents as well as the influence that my future career can have over such a large population.
HEALTH POLICY PROPOSAL FOR MIAMI-DADE COUNTY 14

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