Apache County Public Health Services District P.O. Box 697 St. Johns, AZ 85936 Fax (928) 337-7592 Phone (928) 337- 7532 APACHE COUNTY PUBLIC HEALTH SERVICES DISTRICT ANNUAL REPORT FY 2013/2014 This report is produced is response to the statutory requirement of Arizona Revised Statute Title 36 Chapter 1 Article 4 Section 186 which requires the Director of a county health department to “submit an annual report to the local board of health, the county board of supervisors, each city in the county and the director of the department of health services”. Assessing the condition of public health in Apache is always a difficult task. There are two distinct population groups and at least two distinct cultures in the county served by two distinct medical systems and three public health units. Disease information is generally reported for the county as whole making analysis of health status and vital statistics information for communities almost impossible. This report deals with Apache County as whole and does not try to segregate data. THE CONDITION OF PUBLIC HEALTH IN THE COUNTY Generally speaking, the health of the population in Apache County is good. However, there are issues that need to be worked on to improve the health of the citizens in the county. The County Health Rankings and Roadmaps published by Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute for the last five years has ranked Apache County #14 in Health Outcomes and #15 in Health Factors out of 15 counties in Arizona (see Appendix A). Health Outcome rankings are based on mortality and morbidity measures and Health Factors rankings are based on behavioral, clinical, social and economic, and environmental factors. ACTIVITIES OF THE DEPARTMENT   DIVISION OF CLINICAL SERVICES held clinics every Tuesday in Round Valley from 9:00-5:00 and every other Wednesday in St Johns from 1:00-4:00. Late clinics were held the second Tuesday of every month from 1:00-6:30 PM in Round Valley. 218 patients were evaluated under the Family Planning Program from 07/01/201306/30/2014 from 7/1/2013 -06/30/2014 The contract for the Well Woman (WW) Healthcheck program was not renewed for the fiscal year 2014. Instead North County Healthcare was awarded the contract for the WW program in Apache County. 1         Negotiated a contract with North County Healthcare for the WW program for Apache County. Patients living in Apache County were evaluated in clinics located in Round Valley and St. Johns for their annual cervical and breast screenings. North County was billed for those services at the previously negotiated reimbursement rate for the WW Healthcheck program. The TAPI “Hot Shot Award” from TAPI was received-- “Honoring the commitment to increase immunizations by going above and beyond the call of duty”. Insurance billing generated $54,806.67. 1534 recommended childhood vaccinations and 1355 adult vaccinations were administered. Flu shot clinics were held in all area schools, including Sanders. Adult Flu shot clinics were provided in all area Senior and Community Centers, drug stores and Assisted Living Facilities throughout Apache County. Employee flu shot clinics were held in Chinle, Sanders, Ganado, and Window Rock. “Catchup” immunizations were administered to students at Vernon, Concho, and Alpine Schools. DIVISION OF PUBLIC HEALTH EDUCATION administers the Bureau of Tobacco and Chronic Disease (BTCD) which encompasses: CDSMP (Chronic Disease SelfManagement Program), Tomando (CDSP in Spanish), Matter of Balance, Su Corazon Su Vida, Your Heart Your Life and English and Spanish Diabetes workshops. Public Health Education also includes WIC (Women, Infants, & Children), Snap-Ed Nutrition Program and the educational component of the Smoke-Free AZ Act. Public Health Education is active in the Apache County Youth Council, Apache County Drug-Free Alliance, and provides support for the Boys and Girls Club utilizing their skills and resources to promote alcohol, tobacco and drug awareness and reduce substance abuse in our communities.           Nine workshops completed with over 120 participants in FY13/14. Since we began this Chronic Disease Self-Management Program (CDSMP) program in 2010, we have held a total of 49 workshops for 1098 participants! Twelve lay Leaders were trained for Apache County including staff, Little Colorado Behavioral Health Center staff and community members Added 2 additional workshops including Matter of Balance and Diabetes SelfManagement program Eight locations served through our CDSMP program Six workshops now available through Bureau of Tobacco and Chronic Disease (BTCD) for our communities: Chronic Disease Self-Management, Diabetes Self-Management, Your Heart -Your Life, Matter of Balance, Tomando Control de Su Salud (Spanish version of CDSMP), and Su Corazon Su Vida Five Fidelity Checks conducted for CDSMP program New Staff received their Diabetes Program certification We hosted a School Health Index/School Health Advisory Council Training for 40 participants Eight staff attended the Attorney General’s Retailer Education Training One staff completed the FDA Compliance Program Training 2    Four Staff were trained for the Attorney General’s Compliance Checks Two staff completed the Substance Abuse Training, held at Show Low High School Staff began “at home” breast feeding counseling and assisted 8 mothers in the comfort of their own home.  WIC staff modified our Void report procedures to insure that there is consistency and accountability for their completion each week  WIC staff updated all of our outdated outreach materials, and began the distribution of the items to increase our outreach in the communities  WIC staff created a protocol for following up with the new breastfeeding moms, so that they feel supported in the first weeks of being home with baby Events and School Collaboration:  We hosted Walk To School each month which averaged 250 students per walk  Two Tobacco Sales Compliance Checks were completed which included a total of 30 businesses  Annual County Fair - We provided an education booth and gave out over 950 information bags to students from various school districts including: St John’s, Vernon, Alpine, Concho and Round Valley  Annual County Fair - Signed up 32 participants for CDSMP workshops  Community Food Bank - We assist community volunteers in preparation and distribution of more than 200 food boxes monthly  Completed 284 Smoke Free Business Visits with 351 participants  Attended the Head Start Resource Fair with over 200 parents and staff in attendance, and provided education materials on our BTCD programs  Red Ribbon Week - four schools participated total students with a total of 894 students  Recovery Walk – 45 Youth Coalition members, 8 Adult Leaders; 200 community participants  Kick Butts Day – Designed “Pledge Walls” in five schools (grades 4-8th) totaling 690 participants  Organized a Hygiene Fair for 90 students + adults at the Vernon School  Attended 4 School District Open Houses with 614 total-students/parents/staff DIVISION OF PUBLIC HEALTH PROMOTION consists of 2 Program Coordinators, and 6 Health Educators. The division administers the Community Health and Injury Prevention Program, Governor’s Office of Highway Safety Occupant Protection Program, Baby Sprouts- Health Start Home Visitation Program, and Teens Do CareTeen Pregnancy Prevention Program. All programs are grant-funded through Arizona Department of Health Services. Decreasing unintentional and intentional injuries and improving the health of women prior to pregnancy is the Community Health and Injury Prevention Programs focus. Since 2005, the program has provided services that include:  Provided 2 Northeastern Safe Kids Chapter meetings in Apache County and cofacilitated 2 meetings in Navajo County 3             Enrolled 5 new members into the Northeastern Safe Kids Chapter to decrease unintentional and intentional injury in southern and northern Apache and Navajo counties Attended Navajo Nation Safe Kids Coalition meetings for collaborative efforts to reduce injury in communities of northern Apache County Collaboration between agency staff at Nahat’a Dziil Clinic in Sanders and Navajo Nation Injury Prevention programs (Chinle, fort Defiance, Red Rock, Window Rock service areas) for distribution of car seats and educational classes to families they serve Providing pre-conception health-related educational materials for high school students Offering car seat educational classes, and car seat distribution for families Facilitating car seat educational lessons for agency staff that transport children and providing car seats for children they serve Facilitating certification and continuing education courses for participants enrolled in national child passenger safety courses and/or who are certified child passenger safety technicians Over 200 car seats distributed annually to families in southern and northern Apache County through attendance of individual classes or car seat check events in communities Facilitated car seat education lessons for CASA staff and volunteers and for Child Protective Services agency staff that transport children. Also provided an inventory of car seats for children they transport. Provided assistance to families who transport children with special health care needs for safe transport and correct car seat and wheelchair use Provide pre-conception health education and distribute health-related and injury prevention materials to families in the communities, and/or to agencies for use with their staff or families they serve Provided 10 health classes for youth at juvenile detention center in St. Johns Also through this program, Northeastern Arizona Safe Kids Chapter meetings are held and provided quarterly in the community. Members work together to help prevent unintentional childhood injuries in their respective communities for children 18 and under. Meetings are co-facilitated by Apache or Navajo County health district staff, and are held in either Apache or Navajo County locations so that members in both locations can attend.  Applied for and received funding from the Governor’s Office of Highway Safety (GOHS) to provide occupant protection equipment (car seats) and training and education, totaling $11,656. Goals of the program are to decrease injury and deaths related to motor vehicle crashes and to educate community members on proper installation and fit of car seats for children. Funding allowed for one hundred and one car seats to be purchased and provided to community residents in both northern and southern Apache County either through attendance at car seat check events provided in the communities, through car seat educational classes offered at health district offices or through enrollment in the Baby Sprouts/Health Start home visitation program. Safe Kids Worldwide child passenger safety technician certification courses will be offered and provided through a collaborative effort of individuals who work in injury prevention related fields at Apache and Navajo County health districts, Navajo Nation Highway Safety and Fort Defiance Indian Health Services, Environmental and 4 Engineering department. This team of instructors will work together to increase the number of certified child passenger safety technicians in the communities to assist parent and caregivers with car seat education and distribution. These services are provided through GOHS contracts: 2014-OP-023 and 2014-OP-014.  In May 2014, applied for funds from the Governor’s Office of Highway Safety for continuation of occupant protection services. In July 2014, the program had received notification by GOHS that funds will be awarded but amount of funds was not disclosed. The program looks forward to working with the Governor’s Office of Highway Safety to help decrease injury and deaths related to motor vehicle crashes.  Funded by the Arizona Department of Health Services, the Teen Pregnancy Prevention Program continues to offer services that promote responsible decision making and skill building by providing community-based education for youth and parents. Evidence-based curriculum approved by the Arizona Department of Education is used to facilitate lessons for students at high and middle school levels. Curricula and schools that were provided lessons include: Making Proud Choices – St. Johns Learning Center, Native Stand – Navajo Nation/Ganado High and Middle School, Wise Guys and Smart Girls – Concho Elementary School, Wyman Teen Outreach Program – St. Johns Learning Center. Three-hundred sixteen students were served in 2014. The program also hired and trained one new health educator for the Ganado office. This new health educator will help with expansion of services to other schools located in the Navajo Nation. A Memorandum of Agreement with Window Rock Unified School District was approved for implementation of Native STAND in all High School health classes beginning January 2015. Two Active Parenting workshops and one Teen Maze event was also provided in 2014. The program will continue to provide and offer services in 2015 for schools in both southern and northern Apache County. Trainings and meetings attended by Health Educators for Fiscal Year 2014:  Quarterly Contractor meetings  Active Parenting of Teens curriculum training  Mental Health First Aid training  First Aid / CPR training  Native STAND curriculum training  Youth Mental Health First Aid training  The Health Status of American Indian Youth  Helping Boys Thrive  ADHS Teen Pregnancy Prevention Summer training  Wyman Teen Outreach Program training  Embracing Diversity for Equality training  Since 2000, the Health Start Program has provided an at-home visitation program for pregnant women and their families in southern Apache County. Fourteen years later, Arizona Department of Health Services continues to provide funding so that health educators of the program can assist, advocate and offer support to these women who are enrolled in the program. Once the baby is born the mother and child is followed for 2 years. Health Educators continue to ensure families have a medical home, are offered education when needed, and are directed to resources in the community they may need; all in the comfort of their home. Due to the increase of home visits, the program has been awarded an increase in funds. The Program Coordinator is a certified lactation consultant and all staff of the program are certified child passenger safety technicians, 5 infant massage facilitators are CPR/First Aid certified. The program will continue to provide services in 2015. Services provided by Health Educators for fiscal year 2014 include:  119 families enrolled  219 Prenatal Visits provided  455 Family Follow-up Visits provided  16Classes provided  57lcohol Screenings provided  1 Enhanced alcohol screening Trainings and meetings attended by Health Educators for fiscal year 2014 include:  Annual contractors meeting  Breastfeeding Basics 1 & 2  Newborn Observation  LATCH AZ  Strong Family Alliance Home Visitation  Health @ Home Assessment  Infant Massage  6 CEU Workshop for Child Passenger Safety  Domestic Violence  Sexual violence  Infant Mental Health  Monthly Fetal Alcohol Syndrome Conference Calls Health Start Measures MEASURE Fiscal Year 2012-2013 2013-2014 % Increase /Decrease 97 119 # of prenatal visits 146 219 50.00 (+) # of family follow-up visits 453 455 0.44 (+) 7 15 114.28 ( +) # of families served # Classes 22.68 (+) DIVISION OF PUBLIC HEALTH EMERGENCY PREPAREDNESS training and exercise program is a vital area of preparedness activities for staff to better serve the communities within Apache County. Public Health Emergency Preparedness (PHEP) had set a goal for the past year to further educate its staff for emergency response focusing on the Emergency Management and Training and Exercise plans. Another key area of focus was training and exercising with our partners and continuing with outreach within our communities. PHEP also encouraged outside training for public health staff. The following training and exercise activities support the goals listed above: 6                Completed Continuity of Operations Plan Conducted Call Center Operations full scale exercise in April 2014 Opened, managed and staffed the Call Center during the San Juan Fire (6/26/147/05/14) Completed training for Pandemic Planning at the Center for Domestic Preparedness Feb. 17-22, 2014 Completed Public Information Officer Disaster Communications training April 16-17, 2014 The All Volunteer Emergency Response Team (AVERT) received 501.C.3 status AVERT members completed the 20 hour Community Emergency Response Team (CERT) training AVERT members received training in: Basic Search & Rescue, Sheltering Fundamentals, Strategic National Stockpile receiving and distribution, Volunteer Reception Center Management, Incident Command System, First Aid & CPR, and Traffic Control. The volunteer program received a $3,500.00 grant from the National Association of City and County Health Officers/Medical Reserve Corps AVERT recruitment activities resulted in the volunteer leadership reaching 18 core members and a total volunteer base of 80 residents AVERT members supported the San Juan Fire incident by managing and running the Volunteer Reception Center Public Health Emergency Preparedness staff attended Point of Dispensing training in Flagstaff Public Health staff participated in the mass power outage full scale exercise with the State of Arizona Seven public health staff members attended training at the Center for Domestic Preparedness Public Health staff have trained in Incident Command System role specific classes DIVISION OF ENVIRONMENTAL HEALTH employed one full time Environmental Health Specialist (6/13—2/14) who performed inspections of permitted facilities and septic tank systems. The Health Director is also the manager of the Environmental Health Division and the field inspector in addition to his other duties. In Apache County there are 204 food establishments, 2 public and semi-public pools, 3 children’s camps, and 24 public accommodations.         In conjunction with Malena Bazurto, County Grants Manager, initiated work to demolish and remove the dilapidated Cabins at Canyon Cove in South Fork. Tree thinning was started and the cabins were tested for asbestos. 137 septic tank systems were inspected 11 well site locations were approved 35 food worker classes were presented 375 food workers participated in the classes 170 food workers took the food worker test in the office 386 inspections of food establishments 23 inspections of schools 7    21 inspections of hotels and motels 3 inspections of children camps 89 Smoke Free inspections of public establishments Assistant Health Director Report Staff Development In the fiscal year 2013/2014, the staff development and training program continued the priority of addressing the eighth Public Health Essential Service; ENSURE A SKILLED, COMPETENT PUBLIC HEALTH WORKFORCE and to ensure National Incident Management System (NIMS) training compliance for all staff. The Apache County Public Health Services District (ACPHSD) leaders believe that quality services can only be delivered by well trained, knowledgeable staff. The Staff Development and Training policy was rewritten in January 2014. All new employees are required to take the following training within the first 6 months of employment:  IS 100 (Introduction to Incident Command System)  IS 700 (National Incident Command System [NIMS])  Orientation to Public Health  HIPPA/Confidentiality All employees are required to take IS 200(Incident Command System for Single Resources and Initial Action Incidents) and IS 800 (National Response Framework, An Introduction). On an annual basis the following are required:  Apache County Emergency Plan (ACEMP) awareness training  Blood-borne Pathogens  HIPPA/Confidentiality  Emergency Response Role-Specific training  Participate in 2 state required (per Public Health Emergency Preparedness grant) exercises  COOP (Continuity of Operations Plan) exercise 2014 classes include:  Blood-borne Pathogens  Confidentiality  First Aid and CPR/IAD  County Food Handlers class  HIPAA Goals:  To address compliance with the Training Policy into annual staff performance evaluations.  To offer relevant training staff as they become available Vital Records: The St. Johns vital records office is the primary location offering services from 8 am to 4:00 pm, Monday through Thursday. Birth and death certificates are also issued on a part time basis in Springerville, Ganado and Chinle. Deaths: The office of Vital Records registers deaths and issues certified death certificates. 8 Dr. James Sielski has been the Alternate Medical Examiner (AME) in Apache County since 2009. The AME is responsible for the certifying violent, suspicious or unexpected deaths. The AME authorizes cremations and orders autopsies for deaths occurring in southern Apache County. Births: The office of Vital Records began processing birth certificates in August 2010. The Vital Records office processes corrections and amendments and prints certain birth certificates. Vital Records  Received training on new State (OVR) Office of Vital Records systems  Implemented new State OVR systems  Provided Vital Records services at 4 sites in Apache County; Springerville, St. Johns, Ganado and Chinle  Created a total of 1319 birth certificates  Created a total of 1188 death certificates  Created 830 birth or death certificates in Ganado and Chinle  Created 1158 birth and death certificates in St. Johns  Created 519 birth and death certificates in Springerville Alternate Medical Examiner  A full time Death Investigator was hired and started in November 2013, to assist the Alternate Medical Examiner  The Investigator and a Sheriff’s Deputy attended Medico-legal Death Investigator training in St. Louise, MO  After training, 36 deaths were investigated from January through June 2014  The Death Investigator assisted 5 local agencies; Apache County Sheriff’s Office, Springerville Police Department, Eagar Police Department, St. Johns Police Department and AZ Department of Public Safety with death investigations  11 autopsies were ordered for southern Apache County deaths Smoke-Free AZ Apache County Public Health Services District receives a grant from the Arizona Department of Health Services to provide education about the Smoke-Free AZ Act. Complaints under the Smoke-Free AZ Act are responded to by a delegation agreement.   Fourteen group educational presentations were completed reaching 50 people Education to individuals at local businesses and workplaces reaching 307 people CHARACTER AND EXTENT OF ALL DISEASES REPORTED The diseases listed in this section are reportable diseases and are above the Arizona rate. Information below was taken from the 2012 Arizona Health Status and Vital Statistics, 2013 Arizona Health Status and Vital Statistics and Control of Communicable Diseases Manual, 19 th Edition. 9 Pertussis (Whooping Cough) is a serious disease in infants and child 5 years old and younger. Medical literature indicates that parents and grandparents transmit this disease to infants. In adults Whooping Cough symptoms are manifested as coughing or similar to a cold. In 2012 the Arizona rate was 17.4 cases/100,000 population and Apache County rate is 38.7 cases/100,000 and 2013 the Arizona rate was 21.9 cases/100,000 and Apache County rate was 18.0 cases/100,000. Pertussis is a vaccine preventable disease. Campylobacteriosis in humans is causes diarrhea (frequently with bloody stools, abdominal pain, malaise, fever, nausea and/or vomiting. Poultry and cattle are the most frequent carriers of this disease. Other animals that may carry the bacteria are puppies, kittens, swine, sheep, rodents, and birds. The 2012 Arizona rate was 14.5 cases/100,000 population; Apache County rate was 48.4 cases/100,000 population. In 2013 the Arizona rate was 12.9 cases /100,000 and the Apache County rate was 48.5 cases/100,000. The spread of Campylobacteriosis can be minimized by proper hand washing after handling or slaughtering animals and proper cooking of meat from poultry, cattle, swine and sheep. Salmonellosis in humans is characterized by acute inflammation of the small intestine and colon, with sudden onset of headache, abdominal pain, diarrhea, nausea and sometimes vomiting. Dehydration among infants and the elderly may be severe. Wild and domestic animals including poultry, swine, cattle, rodents, and pets such as iguanas, tortoises, turtles, chicks and other baby poultry, dogs, cats and hamsters. The 2012 Arizona rate was 13.2 cases/100,000 population and Apache County rate was 24.9 cases/100,000 population. In 2013 the Arizona rate was 15.3 cases/100,000 and the Apache County rate was 34.6 cases/100,000. Control of Salmonellosis can be achieved by through cooking of meat and eggs, pasteurization of milk, maintaining a sanitary kitchen, excluding rodents from the home and hand washing before preparing food, after handling meat and eggs, after handling animals and pets. Tuberculosis common signs and symptoms are cough, fatigue, fever, night sweats, weight loss and chest pain. Arizona rate in 2012 was 2.9 cases/100,000 population and Apache County rate was 8.3 cases/100,000 population. In 2013 the Arizona rate was 2.6 cases/100,000 and the Apache County rate was 8.3 cases /100,000. Best prevention is prompt diagnosis and treatment. Gonorrhea is a sexually transmitted disease. Females with a gonococcal infection are often asymptomatic while males have an acute purulent discharge. Conjunctivitis may occur in newborns with resultant blindness if not rapidly and adequately treated. In 2012 the Arizona rate was 89.4 cases/ 100,000 population and Apache County rate was 102.5 cases/100,000 population. In 2013 the Arizona rate was 98.2 cases/100,000 and the Apache County rate was 105.7 cases/100,000. Treatment is with antimicrobial agents. 10 Preventative measures include early detection and treatment, consistent and correct use of condoms with all partners not known to be infection-free, avoiding multiple sexual encounters or anonymous/casual sex, and mutual monogamy with a non-infected partner. Chlamydia is a sexually transmitted genital infection manifested in males primarily as urethritis, and in females as a cervical infection. Up to 70% of sexually active women with chlamydial infections are asymptomatic. Complications and abnormal conditions resulting from a chlamydial infection include inflammation of the fallopian tubes with subsequent risk of infertility, ectopic pregnancy, or chronic pelvic pain. Infection during pregnancy may result in premature rupture of membranes and preterm delivery, and eye infections and lung infections of the newborn. The 2012 Arizona rate was 466.5 cases/100,000 population and the Apache County rate was 930.4 cases/100,000 population. In 2013 the Arizona rate was 466.6 cases/100,000 and the Apache County was 870.2 cases/100,000. Treatment is with antibiotics. Prevention is through education emphasizing use of a condom during sexual intercourse. Annual screening of sexually active adolescent girls should be routine. Screening of adult women should also be considered if they are less than 25 years old or at increased risk. Streptococcal Group A (invasive) may cause any of several clinical syndromes including pneumonia, skin infections, deep soft tissue infection, meningitis, peritonitis, osteomyelitis, septic arthritis, postpartum sepsis, neonatal sepsis, and non-focal bacteremia (Case Definitions for Reportable Communicable Morbidities, Arizona Department of Health Services, August 2006). In 2012 the Arizona rate was 3.1 cases/100,000 population and the Apache County rate was 11.1 cases/100,000 population. For 2013 the Arizona rate was 3.5 cases/100,000 and the Apache County rate was 16.6 cases/100,000. Treatment is with antibiotics. Prevention is educating the public the modes of transmission, the importance of hand hygiene and the need for prompt diagnosis and completion of the full course of antibiotics prescribed by their physician. Streptococcus pneumonia (invasive) causes pneumonia, blood infection, ear infections and meningitis in infants. Infants who survive may have speech, hearing or visual problems, psychomotor retardation, or seizure disorders if there has been meningeal involvement. The Arizona 2012 rate was 3.1 cases/100,000 population and the Apache County rate was 11.1 cases/100,000 population. In 2013 the Arizona rate was 11.9 cases/100,000 and the Apache County rate was 42.9 cases/100,000. Intravenous penicillin treatment of women colonized with group B streptococci at the onset and during labor will interrupt transmission to the newborn. Prevention for the pediatric population is immunization with a pneumococcal vaccine. EXPENDITURES OF THE DEPARTMENT Expenditures of the Apache County Public Health Services District for FY 2013/2014 were $2,550,800.89. The revenue amount was $2,297,067.76. The discrepancy between the revenue and expenditures is due to the fact that the ACPHSD deals with grant budget years that start in July, October and January. We provide services in one fiscal year and are not paid for those services until the next fiscal year. 11 Another issue is the ACPHSD is tasked with paying for Restoration to Competency (RTC) and Title 36 Court ordered Evaluation holding time. Because the number of people who will be incarcerated in the RTC program and the number who are being held until in a behavioral health facility is unknown at the beginning of a fiscal year, budgeting for this item is extremely difficult. Expense for RTC and Title 36 Court ordered evaluations in FY 2013/2014 was $139,510.00. RECOMMENDATIONS OF THE DIRECTOR A relentless, consistent public health education campaign with an easily understandable message regarding the above diseases needs to developed, funded and promoted throughout all Apache County. Additionally, the Apache County Public Health Services District will continue to work collaboratively with partners and reach out to counterparts in the Navajo Department of Public Health to improve concerns listed below which adversely affect individuals, families and society in Apache County. In Apache County the Teen (15 years old to 19 years old) Birth Rate is 38.2 births/1,000 females and the Arizona rate is 31.3 births/1,000 females. The highest rate in Apache County is for 18-19 year old females 68.5 births/1,000 females and the Arizona rate is 53.6 births/1,000 females. Teen pregnancy has a host of problems for the individual and society. Finishing an education becomes a big challenge; babies born to teenage mothers are more likely to have problems or complications than those born to those mothers who are not teenagers. Care and nurturing of the baby may be a problem due to the immaturity of the mother. A mother with little education may have a difficult time obtaining employment that is sufficient to support herself and her baby and the list goes on. An area that claims many lives in Apache County is Accident (unintentional injury) with a State rate of 46.3deaths/100,000 and an Apache County 2013 rate of 1108.7deaths/100,000. Motor vehicle accidents have a State rate of 11.4 deaths/100,000 while Apache County is at 43.1 deaths/100,000. Alcohol related deaths are 15.7/100,000 for the State and 45.5/100,000 for Apache County. Intentional self-harm (suicide) has a rate of 17.0 /100,000 for Arizona State and 36.0 /100,000 for Apache County. Finding solutions to reduce the above rates will take a coalition of individuals, government agencies and departments, behavioral health professionals, schools, family advocacy agencies and others north to south and east to west in Apache County working together regardless of political boundaries. The County and incorporated areas should be proactive in attracting businesses and industry to locate in Apache County. As gainful employment increases, families are better able to provide for themselves, their healthcare improves, their outlook on life improves and the health of the population improves. Having good paying jobs with good fringe benefits improves public health. Respectfully submitted, Chris G. Sexton, Health Director Apache County Public Health Services District 12 TABLE 5A-5 BIRTHS AND BIRTH RATES, FEMALES 19 OR YOUNGER BY COUNTY OF RESIDENCE, ARIZONA, 2013 NUMBER OF BIRTHS County of residence 15-19 years All 19 years or younger 10-14 years Total 1519 15-17 18-19 Apache 120† * 114 38 76 Cochise 139 0 139 37 102 160† * 155 46 109 Gila 90† * 84 24 60 Graham 70† * 69 20 49 Greenlee 13 0 10† * 9 La Paz 32 0 32 8 24 Maricopa 4,231 41 4,190 1,169 3,021 Mohave 180† * 174 35 139 Navajo 190† * 184 44 140 Pima 1,007 12 995 283 712 Pinal 390† * 390 98 292 80† * 76 23 53 Yavapai 160† * 158 39 119 Yuma 380† * 378 117 261 TOTAL STATE 7,222 70† 7,151 1,990† 5,166 Coconino Santa Cruz BIRTH RATES County of residence All 19 years or younger a 15-19 years 10-14 years Total 1519 15-17 18-19 Apache 19.0 ** 38.2 20.3 68.5 Cochise 17.2 0.0 32.9 14.5 61.0 Coconino 14.5 ** 23.7 18.4 26.9 Gila 27.8 ** 55.7 24.7 112.3 Graham 24.9 ** 51.5 23.9 97.3 Greenlee 16.3 0.0 33.2 ** 61.2 La Paz 33.4 0.0 68.6 27.7 134.9 Maricopa 15.2 0.3 30.3 14.3 53.1 Mohave 15.3 ** 30.0 10.3 58.1 Navajo 21.9 ** 43.5 16.9 86.7 Pima 15.4 0.4 28.8 15.5 43.7 Pinal 14.7 ** 31.5 12.9 61.2 Santa Cruz 19.6 ** 40.1 17.8 87.4 Yavapai 14.0 ** 27.1 10.9 52.5 Yuma 23.9 ** 46.3 23.9 80.0 TOTAL STATE 15.9 0.3 31.3 15.0 53.6 Notes: * Cell suppressed due to non-zero count less than 6; ** Cell suppressed due to rate/ratio/percent based on non-zero count less than a 6; † Sum rounded to nearest tens unit due to non-zero addend less than 6; The number of births per 1,000 females in specified group. -ADJUSTEDa MORTALITY RATES FOR SELECTED LEADING CAUSES OF DEATH BY GENDER AND AVERAGE AGE AT DEATH FROM ALL CAUSES BY COUNTY OF RESIDENCE, ARIZONA, 2013 Pima Pinal Santa Cruz Yavapai Yuma 869.0 786.5 421.8 693.1 667.9 845.8 901.6 696.6 636.2 550.5 760.4 551.9 Cardiovascular disease 187.7 178.7 243.4 152.0 221.1 184.9 115.5 209.2 181.4 264.0 202.0 198.4 178.2 173.6 177.5 139.8 Diseases of heart 143.0 127.6 185.5 123.8 170.6 142.7 82.8 182.5 135.9 237.6 139.1 148.2 138.1 119.5 137.7 109.2 110.0 90.4 126.8 82.9 104.2 82.2 53.4 154.7 107.0 183.7 98.0 116.3 103.0 89.3 97.2 80.8 149.6 144.4 161.5 125.5 148.3 175.6 108.4 130.1 147.3 192.2 155.7 151.8 146.2 122.3 162.5 116.9 Lung cancer 36.4 22.7 41.0 28.3 44.3 31.7 23.9 30.9 36.5 59.2 33.6 34.6 32.9 15.5 34.5 25.4 Colorectal cancer 13.6 14.5 19.6 9.4 9.9 12.4 0.0 11.9 13.3 19.6 13.4 13.3 13.4 11.3 15.4 8.1 Breast cancer 11.3 2.0 5.1 13.8 8.8 18.5 8.5 10.0 11.9 10.4 11.7 10.9 9.2 12.2 13.2 11.2 Prostate cancer 7.7 17.1 8.5 9.1 6.3 6.4 18.5 11.5 6.7 12.3 12.0 8.6 6.4 9.3 11.3 4.4 Malignant melanoma of skin 3.0 0.0 3.8 2.6 5.1 2.9 0.0 4.8 2.9 4.3 5.8 2.2 3.4 5.7 4.1 3.8 Cervical cancer 1.2 1.7 4.0 1.2 1.0 3.2 0.0 0.0 1.3 1.8 1.1 0.8 0.0 0.0 2.4 1.7 Navajo 671.5 Mohave Gila 759.8 Maricopa Coconino 905.6 La Paz Cochise 687.8 Greenlee Apache Total, all causes Graham ARIZONA AGE PER 100,000 TOTAL POPULATION (BOTH GENDERS): Coronary heart disease Malignant neoplasms Accident (unintentional injury) 46.3 108.7 33.2 78.8 84.0 52.3 35.4 61.7 40.7 52.9 106.1 50.8 37.4 32.2 74.7 35.0 Accidental poisoning 15.0 9.5 6.3 29.5 27.1 20.4 0.0 18.5 12.6 21.7 51.0 20.0 9.5 7.3 23.1 10.8 Accidental falls 12.1 11.0 10.3 14.4 7.1 5.8 0.0 2.9 12.8 7.9 6.3 12.7 9.1 2.1 18.2 5.7 Motor vehicle accident 11.4 43.1 12.5 23.3 31.5 5.4 26.9 25.4 9.4 12.9 30.1 10.4 12.4 14.4 12.6 11.1 Accidental drowning Chronic lower respiratory diseases Alzheimer's disease 1.1 1.7 0.0 0.5 6.8 3.2 0.0 10.3 1.1 0.7 0.0 1.0 2.0 0.0 1.4 1.4 44.5 19.2 44.7 34.1 65.7 50.6 27.8 37.4 43.6 71.5 33.9 41.2 45.2 15.4 58.2 35.2 33.2 13.2 19.0 22.9 29.0 12.1 9.3 0.0 39.2 13.4 18.5 36.7 26.7 32.2 19.7 9.1 Cerebrovascular disease 28.2 34.1 42.1 17.8 35.6 23.7 32.7 22.5 28.1 16.8 41.1 31.1 25.1 33.1 28.9 20.0 Diabetes 23.6 44.3 24.7 19.9 35.8 44.2 9.3 8.8 22.8 24.2 42.3 22.4 22.5 25.9 15.5 44.1 Intentional self-harm (suicide) Chronic liver disease and cirrhosis Influenza and pneumonia Essential (primary) hypertension and hypertensive renal disease Parkinson's disease 17.0 38.1 20.4 17.7 33.7 19.9 9.8 20.4 15.2 29.5 23.2 17.9 13.6 13.5 30.3 7.9 14.5 31.3 15.4 17.1 28.4 24.9 9.5 27.2 12.0 25.4 41.3 15.9 17.6 12.0 16.2 10.5 10.0 26.4 15.9 13.2 18.3 8.9 10.9 8.1 8.0 11.6 20.1 10.2 12.0 16.7 15.0 17.8 9.7 6.2 9.0 4.9 5.4 16.3 0.0 2.7 11.1 5.7 13.5 9.7 8.9 9.7 5.6 5.2 8.0 3.5 9.3 6.4 6.5 8.4 0.0 1.9 8.2 4.8 9.1 8.5 6.5 6.2 12.3 4.3 Assault (homicide) 5.9 21.1 4.1 5.2 12.9 6.8 0.0 26.1 5.4 5.1 15.2 7.2 5.0 0.0 3.5 4.5 Nephritis 5.3 11.0 10.9 12.2 11.9 8.4 0.0 13.6 3.4 11.5 10.8 4.6 9.2 5.7 11.4 5.1 Septicemia 4.8 6.6 10.4 4.0 4.4 3.2 0.0 0.0 3.6 4.2 9.7 5.6 5.8 11.9 6.6 10.8 HIV disease 1.4 0.0 0.0 2.4 5.2 0.0 0.0 0.0 1.3 3.7 0.6 1.4 0.9 0.0 0.5 1.1 Injury by firearms 14.1 20.7 16.0 10.0 20.9 12.6 0.0 10.2 13.5 19.7 15.1 15.9 8.8 9.1 21.3 11.4 Drug-induced deaths 16.9 1.4 8.1 16.1 27.1 20.4 0.0 20.0 15.5 29.5 25.1 22.2 11.8 5.3 27.2 11.9 Alcohol-induced deaths 15.7 45.5 10.9 37.8 24.3 19.8 0.0 8.7 13.0 20.8 77.5 17.2 16.4 12.0 12.0 5.5 AVERAGE AGE AT DEATH 72.7 64.2 73.6 67.2 72.7 69.4 66.4 70.1 73.0 73.3 67.2 73.8 69.8 74.3 75.3 72.9 MEDIAN AGE AT DEATH 76.9 69.6 76.7 71.3 76.6 73.3 70.5 72.1 77.6 75.2 71.7 78.2 73.0 78.3 78.8 77.1 TABLE 5E-11 (continued) AGE-ADJUSTEDa MORTALITY RATES FOR SELECTED LEADING CAUSES OF DEATH BY GENDER AND AVERAGE AGE AT DEATH Navajo Pima Pinal Santa Cruz Yavapai Yuma 784.0 #### 861.9 528.4 794.8 782.8 997.5 #### 818.3 749.0 682.6 896.1 629.3 288.9 163.1 269.2 228.3 192.9 262.5 223.9 317.1 225.0 244.3 199.4 233.3 223.3 165.6 Diseases of heart 183.6 167.1 231.0 136.1 212.8 164.0 117.6 241.9 177.4 290.9 164.1 192.6 160.6 170.9 181.7 135.2 145.6 134.2 159.5 103.0 126.3 113.8 97.3 216.4 143.4 234.0 124.4 153.7 123.9 143.7 136.7 104.6 175.0 157.0 195.1 150.8 165.3 188.9 80.3 124.5 172.6 223.4 181.0 176.8 185.6 135.5 180.3 126.0 Lung cancer 42.9 37.6 55.5 32.7 53.2 33.6 11.2 33.2 43.7 58.4 32.3 38.5 45.5 16.3 44.0 28.3 Prostate cancer 18.2 0.3 0.5 0.3 0.2 0.1 0.1 0.2 8.6 1.3 0.4 3.5 0.7 0.2 1.4 0.4 Colorectal cancer La Paz 888.0 214.9 Graham #### 229.0 Gila 805.8 Cardiovascular disease Cochise Total, all causes Apache Mohave Maricopa Greenlee Coconino ARIZONA FROM ALL CAUSES BY COUNTY OF RESIDENCE, ARIZONA, 2013 PER 100,000 MALES: Coronary heart disease Malignant neoplasms 15.3 8.1 18.5 11.4 12.7 14.6 0.0 9.7 15.8 22.4 15.8 13.4 14.5 4.6 15.0 9.9 Malignant melanoma of skin 4.1 0.0 4.2 6.6 4.3 6.3 0.0 2.9 4.0 5.5 7.0 3.3 4.0 12.3 4.4 4.3 Breast cancer 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Accident (unintentional injury) 60.1 161.2 30.4 89.7 119.6 52.4 31.1 93.9 54.1 64.0 144.4 62.9 45.4 52.4 103.4 43.9 Accidental poisoning 19.1 19.2 2.8 37.3 43.4 20.7 0.0 20.3 16.9 25.4 75.3 23.2 9.7 3.8 30.4 12.9 Motor vehicle accident 16.3 64.6 13.4 30.1 40.3 10.2 31.1 44.2 14.2 16.3 31.6 14.0 18.9 28.1 20.0 12.1 Accidental falls 13.2 11.4 9.9 3.9 8.8 0.0 0.0 5.8 14.4 6.8 10.9 13.8 8.7 5.8 20.0 7.2 Accidental drowning Chronic lower respiratory diseases Diabetes 1.6 3.3 0.0 1.1 13.9 5.8 0.0 20.3 1.5 1.3 0.0 1.4 2.6 0.0 0.9 1.7 48.1 26.0 52.9 44.3 83.7 87.6 16.5 27.4 46.8 74.4 26.0 41.8 53.3 13.6 67.2 37.0 29.1 59.3 27.5 15.9 46.2 26.2 0.0 14.3 28.3 38.4 46.7 27.8 22.5 24.4 23.1 52.3 Cerebrovascular disease 27.2 24.2 43.1 19.5 40.8 39.0 75.2 20.6 27.1 14.5 39.3 29.9 23.9 35.4 25.4 20.4 Alzheimer's disease 27.2 21.8 16.6 22.4 20.2 6.3 20.3 0.0 32.6 6.3 12.0 30.7 23.6 20.1 17.8 8.2 Intentional self-harm (suicide) Chronic liver disease and cirrhosis Parkinson's disease 26.6 61.5 29.0 29.6 64.9 29.4 19.5 28.9 24.0 39.2 33.4 28.7 22.3 26.4 44.3 9.9 18.2 27.3 25.3 23.7 28.1 22.3 17.2 41.5 14.9 33.4 40.7 18.4 25.3 17.3 21.6 16.1 12.0 0.0 12.3 7.9 7.1 11.7 0.0 3.4 12.5 8.9 13.4 12.9 7.8 16.1 19.3 4.0 Influenza and pneumonia Essential (primary) hypertension Assault (homicide) 11.6 23.5 20.8 16.2 11.0 0.0 37.6 12.4 8.9 15.9 21.6 11.2 18.7 32.2 14.3 24.1 10.4 0.0 0.2 0.1 0.1 0.1 0.0 0.0 6.5 0.2 0.2 1.8 0.5 0.1 0.5 0.1 9.2 25.7 7.9 7.2 17.7 5.8 0.0 50.2 8.5 8.5 28.1 12.0 5.9 0.0 5.4 5.9 Nephritis 6.1 12.3 11.8 19.0 21.8 0.0 0.0 0.0 3.7 16.8 12.3 4.9 9.9 5.8 13.1 2.8 Septicemia 5.6 10.5 9.3 3.7 5.5 5.8 0.0 0.0 4.1 6.4 15.0 6.6 6.7 9.0 5.0 13.4 HIV disease 2.5 0.0 0.0 3.3 10.7 0.0 0.0 0.0 2.4 6.8 1.3 2.6 1.6 0.0 1.0 2.1 Injury by firearms 24.1 28.5 28.7 18.6 38.4 20.9 0.0 8.6 23.3 31.0 26.3 28.3 13.3 20.5 36.1 16.0 Drug-induced deaths 20.3 0.0 4.0 13.4 43.4 20.7 0.0 23.2 19.9 29.4 26.9 25.2 13.7 0.0 34.2 13.8 Alcohol-induced deaths 21.9 65.6 18.8 55.1 20.1 22.3 0.0 5.7 18.4 28.6 108.6 22.2 22.4 25.9 18.1 9.1 AVERAGE AGE AT DEATH 69.8 59.5 71.8 64.0 70.3 68.9 59.9 68.0 69.7 71.3 63.8 70.9 68.4 71.0 72.6 71.3 MEDIAN AGE AT DEATH 73.5 63.0 74.7 67.2 73.7 74.1 63.8 70.4 73.7 73.4 68.0 74.7 72.0 73.7 75.8 75.5 TABLE 5E-11 (continued) a AGE-ADJUSTED MORTALITY RATES FOR SELECTED LEADING CAUSES OF DEATH BY GENDER AND AVERAGE AGE AT DEATH Pima Pinal Santa Cruz Yavapai Yuma 719.1 730.2 330.7 593.2 570.1 694.0 796.9 592.5 531.3 448.5 632.7 479.6 142.1 178.4 154.0 63.1 160.4 147.0 208.2 179.7 158.7 158.4 128.8 137.2 115.9 Diseases of heart 109.2 97.5 143.9 112.5 135.2 128.6 47.8 126.4 102.9 183.6 116.7 110.6 118.2 79.1 99.3 85.7 80.2 57.7 98.3 66.5 84.1 57.0 15.4 96.5 77.8 133.9 76.0 84.4 84.4 47.9 62.8 59.1 Mohave 568.6 201.6 La Paz 647.2 148.6 Graham 732.9 152.4 Gila 583.8 Cardiovascular disease Cochise Total, all causes Apache Navajo Maricopa Greenlee Coconino ARIZONA FROM ALL CAUSES BY COUNTY OF RESIDENCE, ARIZONA, 2013 PER 100,000 FEMALES: Coronary heart disease Malignant neoplasms 129.9 138.9 132.4 105.5 132.8 164.4 129.1 136.7 128.6 164.4 136.4 132.4 112.7 112.1 148.4 108.3 Lung cancer 31.0 11.3 28.0 25.4 35.9 31.1 34.5 28.0 30.6 60.7 34.5 31.6 22.0 14.0 26.8 22.6 Breast cancer 20.7 0.0 0.2 0.4 0.2 0.2 0.0 0.1 12.2 0.8 0.3 3.3 0.9 0.2 1.1 0.6 Colorectal cancer 12.3 19.7 20.2 6.6 7.2 9.4 0.0 13.4 11.5 16.3 11.0 13.4 12.2 16.2 15.9 6.4 Cervical cancer 2.4 0.0 0.2 0.0 0.0 0.0 0.0 0.0 1.5 0.1 0.0 0.2 0.0 0.0 0.2 0.1 Malignant melanoma of skin 2.2 0.0 3.0 0.0 5.9 0.0 0.0 6.7 2.1 3.1 5.4 1.3 3.5 0.0 3.8 3.2 Chronic lower respiratory diseases 41.8 13.4 39.1 26.3 51.9 20.4 32.8 46.5 41.2 69.8 41.3 41.2 38.9 16.8 50.2 33.5 Alzheimer's disease 37.2 6.1 20.9 24.8 36.1 15.7 0.0 0.0 43.2 18.8 23.5 40.8 29.1 37.6 21.1 10.1 Accident (unintentional injury) 32.8 57.8 35.7 64.9 49.4 51.2 38.8 28.0 27.8 40.7 67.7 39.7 29.3 15.2 46.2 26.3 Accidental falls 11.0 10.3 9.7 20.7 5.7 10.8 0.0 0.0 11.2 8.6 3.1 11.9 9.3 0.0 16.5 4.5 Accidental poisoning 10.8 0.0 10.1 21.4 10.6 18.7 0.0 17.7 8.4 17.7 26.4 16.9 9.2 10.0 15.8 8.7 Motor vehicle accident 6.6 20.9 11.9 16.7 22.8 0.0 21.0 5.2 5.0 9.6 27.7 7.0 5.4 2.6 5.7 9.9 Accidental drowning 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.6 0.0 0.0 0.6 1.7 0.0 1.9 1.1 Cerebrovascular disease 28.5 39.8 40.6 16.7 29.3 11.0 15.4 25.9 28.5 17.3 41.2 31.2 25.5 32.9 31.7 19.4 Diabetes 18.8 31.5 21.2 21.9 27.3 63.6 17.0 4.2 18.3 10.5 37.7 17.8 22.7 26.5 8.8 36.4 11.1 35.5 5.9 10.5 28.7 25.7 0.0 11.6 9.2 17.7 41.9 13.6 10.7 7.7 10.9 5.3 9.1 0.1 0.2 0.1 0.1 0.0 0.0 0.0 5.7 0.3 0.2 1.6 0.4 0.1 0.1 0.2 Influenza and pneumonia 8.8 27.2 12.5 10.7 24.6 15.8 0.0 4.2 7.2 7.8 18.4 9.2 6.2 7.1 14.9 12.2 Intentional self-harm (suicide) 7.7 13.9 11.6 6.0 1.9 14.9 0.0 11.6 6.9 20.2 12.9 7.7 4.1 4.1 17.0 5.9 Parkinson's disease 5.1 6.1 7.5 4.0 6.1 5.4 0.0 0.0 5.3 1.1 5.5 5.4 5.2 0.0 6.3 4.6 Nephritis 4.8 10.3 10.6 7.5 6.1 15.6 0.0 27.5 3.2 7.0 8.7 4.5 8.3 6.7 9.8 7.1 Septicemia 4.3 3.0 11.4 3.6 3.6 0.0 0.0 0.0 3.3 2.4 5.0 5.1 4.9 14.2 7.9 8.6 Assault (homicide) 2.5 16.6 0.0 3.3 8.0 8.7 0.0 0.0 2.2 1.5 1.9 2.3 3.9 0.0 1.6 3.0 HIV disease 0.3 0.0 0.0 1.5 0.0 0.0 0.0 0.0 0.3 0.5 0.0 0.3 0.0 0.0 0.0 0.0 Chronic liver disease and cirrhosis Essential (primary) hypertension Injury by firearms 4.4 13.1 2.7 1.4 3.5 8.7 0.0 11.6 4.1 8.1 3.8 4.0 4.0 0.0 6.8 6.8 13.5 2.8 12.6 18.5 10.6 18.7 0.0 17.7 11.4 29.6 23.4 19.3 9.8 10.0 20.2 10.1 9.9 26.3 3.5 20.6 28.8 16.0 0.0 11.6 8.1 13.3 46.6 12.9 10.9 0.0 6.4 2.2 AVERAGE AGE AT DEATH 76.0 70.5 75.8 71.0 75.4 69.9 74.9 72.8 76.4 75.9 70.8 76.8 71.7 78.0 78.4 74.8 MEDIAN AGE AT DEATH 80.6 75.8 79.3 76.7 79.6 72.2 79.2 75.1 81.3 78.4 74.7 81.7 74.4 81.5 82.1 78.9 Drug-induced deaths Alcohol-induced deaths Notes: a Adjusted to the 2000 standard U.S. population; All rates are per 100,000 resident population; The rates based on fewer than 10 deaths (see Table 5E-12) are not statistically reliable. ARIZONA Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma TABLE 5E-13 RATESa FOR SELECTED LEADING CAUSES OF DEATH STATEWIDE AND BY COUNTY OF RESIDENCE, ARIZONA, 2013 Total, all causes 758.7 841.0 967.1 517.3 1296.8 726.1 421.5 1177.4 682.1 1319.3 897.9 862.6 623.9 581.1 1277.1 630.6 Cardiovascular disease 208.9 166.3 310.1 105.4 352.2 163.7 110.0 419.5 185.2 426.3 197.8 254.0 166.1 184.9 326.3 161.5 Diseases of heart 159.5 117.8 235.3 86.2 273.9 124.1 82.5 362.3 139.1 383.1 136.2 189.9 130.0 128.0 253.2 125.6 123.1 83.1 165.8 59.0 167.7 71.3 55.0 305.1 109.6 300.1 96.6 149.7 98.5 97.5 177.2 93.6 170.1 139.9 216.9 101.0 268.3 169.0 119.1 271.7 152.4 333.0 169.3 191.3 158.7 136.1 292.6 134.7 Lung cancer 42.0 22.2 55.0 22.1 80.1 29.0 27.5 81.0 38.0 109.0 38.6 44.4 37.6 18.3 66.6 31.1 Colorectal cancer 15.1 12.5 26.0 8.1 18.6 13.2 0.0 23.8 13.6 31.4 13.8 16.5 14.5 12.2 27.2 9.1 Coronary heart disease Malignant neoplasms 3.4 0.0 5.3 1.5 7.5 2.6 0.0 9.5 3.0 6.4 6.4 2.7 3.3 6.1 7.0 4.3 Chronic lower respiratory diseases Malignant melanoma of skin 50.1 19.4 59.6 23.6 113.7 47.5 27.5 85.8 44.4 122.3 35.9 52.7 46.0 16.3 105.0 41.6 Accident (unintentional injury) 47.7 98.4 37.4 68.5 87.6 47.5 36.7 62.0 40.9 55.5 100.3 55.5 34.3 30.5 87.7 35.4 Accidental poisoning 14.7 8.3 6.1 27.3 20.5 18.5 0.0 9.5 12.5 20.1 46.0 19.5 8.9 6.1 19.2 10.0 Falls 13.2 9.7 13.0 8.1 13.0 5.3 0.0 9.5 13.1 11.3 6.4 16.0 7.6 2.0 34.7 6.7 Motor vehicle accident 11.7 38.8 13.8 23.6 33.5 5.3 27.5 28.6 9.5 12.8 28.5 11.1 11.7 12.2 13.6 11.0 1.1 1.4 0.0 0.7 3.7 2.6 0.0 4.8 1.0 0.5 0.0 1.0 1.8 0.0 1.9 1.4 Alzheimer's disease Accidental drowning 36.2 11.1 23.7 13.3 46.6 10.6 9.2 0.0 39.4 20.6 17.5 47.9 21.6 32.5 37.5 10.5 Cerebrovascular disease 31.1 31.9 54.2 11.1 55.9 21.1 27.5 47.7 28.5 27.0 39.6 39.5 22.6 34.5 53.4 23.4 Diabetes 26.5 41.6 32.8 16.2 46.6 42.2 9.2 19.1 23.7 35.9 45.1 27.9 23.4 28.4 25.3 51.6 Intentional self-harm (suicide) 17.0 36.0 19.1 19.2 31.7 18.5 9.2 19.1 15.0 33.4 22.1 18.1 13.2 14.2 29.1 8.1 Chronic liver disease and cirrhosis 15.8 30.5 19.1 16.2 31.7 23.8 9.2 19.1 12.4 34.4 40.5 18.1 18.8 12.2 23.9 11.9 Influenza and pneumonia 11.0 22.2 19.9 8.8 22.4 7.9 9.2 19.1 8.0 16.7 19.3 13.1 10.7 16.3 24.4 21.0 Essential (primary) hypertension 10.8 5.5 11.5 3.7 9.3 15.8 0.0 4.8 11.3 9.3 14.7 12.7 7.6 10.2 10.3 6.2 Parkinson's disease 8.8 2.8 12.2 3.7 11.2 7.9 0.0 4.8 8.2 8.4 8.3 10.9 5.8 6.1 23.0 5.3 Nephritis 5.9 9.7 13.8 8.1 18.6 7.9 0.0 9.5 3.4 20.1 10.1 5.7 8.9 6.1 21.6 5.7 Assault (homicide) 5.8 18.0 4.6 5.2 11.2 5.3 0.0 14.3 5.4 4.9 12.9 7.1 4.8 0.0 2.8 4.3 Septicemia 5.4 6.9 13.8 2.9 7.5 2.6 0.0 0.0 3.6 6.9 10.1 7.0 5.6 12.2 13.1 12.9 HIV disease 1.4 0.0 0.0 2.2 5.6 0.0 0.0 0.0 1.3 3.4 0.9 1.5 0.8 0.0 0.5 1.0 INJURY BY FIREARMS 14.1 19.4 16.0 10.3 22.4 10.6 0.0 14.3 13.3 22.6 13.8 16.4 8.9 10.2 19.7 11.5 DRUG-INDUCED DEATHS 16.7 1.4 7.6 15.5 20.5 18.5 0.0 14.3 15.5 28.5 23.0 21.6 10.9 4.1 23.4 11.5 ALCOHOL-INDUCED DEATHS 16.7 41.6 12.2 33.9 26.1 18.5 0.0 9.5 13.5 27.0 69.9 19.4 17.0 12.2 17.8 6.2 Notes: a These are crude mortality rates (the number of deaths per 100,000 population).