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258085 OR161NAL TO CITY CLBRK 258 n�5 CITY OF ST. PAUL FIOENCIL NO. , OFFICE OF THE CITY CLERK ' COUNCIL RESOLUTION—GENERAL FORM f�i ENTED BY Dean Mered ith Apri 1 7, 1972 COMMISSIONE ATE WHEREAS, The Bureau of Health of the Department of Public Safety has been awarded a "Rheumatic Fever Prevention" Grant by Northlands Regional Medical Program, Inc. , covering the twelve month period April 1 , 1972 through March 31 , 1973; and WHEREAS, It is necessary for the success of the program that a qualified and experienced Project Coordinator be employed; and WHEREAS, The Regional Medica) Programs Service of the United States Department of Health, Education and Welfare has consented to grant a Leave Without Pay status for twelve months to one of its empioyees, Mr. Harry Kaphingst; and WHEREAS, Mr. Harry Kaphingst has been determined to be qualified as Project Coordinator through his previous experience in similar programs in the State of Minnesota and the State of Missouri ; now, therefore, be it RESOLVED, That the City of Saint Paul , through the Bureau of Health of the Department of Public Safety, be authorized to enter into contract negotiations with Mr. Harry Kaphingst for the furnishing of such personal services, said contract to include reimbursement for salary, fringe bene- fits, retirement ciwdits, etc. , in a total amount not to exceed �16,2�:fjII��. for one year from t`�e date of said contract; and be it FURTHER RESOLVED, That the proper city officers are hereby directed and authorized to execute on behalf of the City of Saint Paul a contract between the City of Saint Paul and Mr. Harry Kaphingst. APR 12 1972 COUNCILMEN Adopted by the Counci� 19— Yeas Nays Butler ve APR 12 19721s� b�iGL1CYQ� J Levine � Tn Favor Meredith � . Sprafka �V ��r A gainst Tedesco Mr. President, McCarty PUBLISHED ApR 151872 �� CITY OF SAINT PAUL DEAN MEREDITH Capital of Minnesota B. J. MEARS, M.D. Commissioner Health Officer R�I,PH G. MERRILL �L a'�tNLGK� 0 kvl��G �Jl� C� Deputy Commissioner p � �� L�uz�a.0 o f �Ea�E�i v� Health Cen[er — 555 Cedar Street St. Paul, Minnesota 55101 227-7741 April 6, 1972 Mr. Dean Meredith Commissioner Department of Public Safety Public Safety Building 101 East lOth Street Saint Paul , Minnesota 55101 Dear Commissioner Meredith: On April 3, 1972, we were awarded a "Rheumatic Fever Prevention" Grant by Northlands Regional Medical Program, Inc. , covering the twelve month period April 1 , 1972 through March 31 , 1973. In the development of this grant, we were assisted by Mr. Harry Kaphingst, an employee of HEW, stationed in Rockville, Maryland, in the office of Regional Medical Pro- grams Service. Mr. Kaphingst was formerly assigned to the Minnesota Department of Health, where he coordinated their Rheumatic Fever Prevention Program. He was then assigned to the Missouri Department of Health, where he engaged in similar activities on a state-wide basis. I am enclosing a copy of our grant proposal for your information. It is necessary for the success of this project (which we hope will be conducted for an additional two years) that we initially procure the services of an experienced Project Coordinator. The U.S. Department of Health, Education and Welfare is willing to grant Mr. Kaphingst Leave Without Pay for one year so that he may be employed on our project. In order to accomplish this, I have prepared a draft of a resolution, and request that you consider it for submission to the Council for approval . Please call me if you wish any additional information. Sincerely, .�� E. R. Eberhardt Deputy Health Officer ERE:bb Enclosures . � „ • RfIEUi�i111'IC fEVER P�;Ct�E�IT1�r�: � • � � � A DE�^.O�dSTftltTION /1�1D EDUCATIOP� PROGP,II��I . . � , . . ,��-�� s CQIYTRACT SUi�t�'ARY �� P.hec�ia�ic rever, a major cause of cardiovascular disease, is pre- . ventable; yet it still occurs at too great a frequency. Available m°thods for cr�m:�ry prevention ar•e available but not being applied. • Fai 1 ure to d��°ct Group ��, beta ne�aolyti c s ti�ep�ococcus resul ts with failure t� �reat adequately. The only reliable detQction - � me�ho� o` streotococcal pharyngitis is by throat culture. In Sain� Pau1 tf�e incidence o� rhe��atic fever is at least 140 each y°,�r, rr:o��ly among the 6 to 12 year olds. A prevention pro- , gram could b� ?cd by tnis health depar�:e�t, with participants to , include priv�ce pF:ys�c�ans, public health and school nurses, - school persornel , and program recipients. �o ed rrooram to be conducte� by tf�e Bureau} ti�rill be iim- � � The pro� s , , � ited `c� the 20,C00 children enrolled in parochial schools or � . served �y tne Cni 7 d fleal th C1 i ni cs and the 0.E.O, Corr�uni ty ! Clinic. Afi a later date the target population r�ould be expanded. � � � A seven-�oint sura��ary of objectives is the follo��ring: . • � . . : 'd nti- " � . 1. To lor�er thz incidence of rheumat�c fever by eariy � e � � fication of streptococcal ohar}�ngitis. � : . 2. To givz bacte:,iolog�cal support for diagnosis and treat- ! • � ment by priva�e pi�ysicians. . � 3. Yo �i:�e bact�riolo;ical support for iden�i`ying ottier � " s�trep�ococca? di se�ses to pri va te �h;/si ci ans. 4. To e�.�cate p�arents �r�� st�derts. � 5. 70 �ersua�� seeking .o� treatm��t under private physician�. ' 6. To support pri��ate physi ci ans wi tt-� referr�ls and per�i n-� � ent li��rature, . �7. To �erlons tra te the fe�si bi 1 i ty of thi s type of program. - Educati�nal ��zt�rial�a7d com�iunicatior� ti•rill be e`fected. Thirteen � (13j school r,�:rses and 3 public health clir+ic nurses at the already mention�d 3 si �es w;ll be a�railable to take throat cultures. The spec�^�?rs vriil be cultured for G�oup A at the Bureau's lab�ratory. i'he ja�.ra�cr� report will .be nailed to-the child's physician and . telep°�or.ed �o i;i s ef`i ce.� The phys�ci an has the resoonsi bi 1 i ty for treat��nt. P�rents �:ri 11 be no�i Ti ed al so. For �'�e 5w Yrf�� have no : pri va�e physi ci ans, the Qt�reau �•�i 11 ti�eat. . Eollo�r-!:p ard s��et•vision will be underta�en by the coordinator; routi;�� main�er��nce and updatinq of files, also con�unication, , under�a�:er 5y ��e c1e:�-typist. . � . Pri va�e phys i c�ans' ceonera�i o;� ti��i 1 Z b� sol i ci ted 5� provi di r�g . tnem �-t��h �reE� labora}ary services for� culturing sub;,iit�°d speci- ' mens at the 3ur2au. 0�her coaperation :�li 11 be sougi�t ��i th cor�- • muni Ly acenci es a7d organi zati o�s for an ever.�uai c;�y-��i de Rheu- • matic Fever °r�v°ntio� Frogran. • ' The eva i�atior, o` the program ti�ri 11 be on-g�i ng, bas�d on i ts ob- j�cti v?s , by qc�a.lti fyi na �•r�enever possi bl e. , � ' ; • � � . . . . � �� ,.; �, . F� � � l� RI!E.��t•�T?C FEYF2 PR.. 1EilTIO�a; � • A OEt•1Gi1S�':<:1�I'J°J r�:'!D EUUC�TIQI� Pf:O�R�`,�1 � .; .� � � FOR4lAP.D ' � ____— The Saint Paul Qur�au of Fl��al *h is gravely concerned ai�out the ef- �, fects of the insidiou� ;�•��u% �, beta ��:�olytic streptococcal infec- . � tions that prevai 1 to ;;°:,c:.�r•di z2 the heal th ar.d �•relfare of the com- muni ty. Since ri,e�;�a�i:' `ev��T- occurs as one of the sequelae, the � concern is ti•tell ju�tiri�•�. hn accepta��le esti,�iatio� is that 1 to : 3r of thosz �ritti u^p��' r�sp�r4 �.ary i^fec�ion fru-� this o1•ganism re- . sul t ►�ri th rheu�a�.i c f�v:r. S?nce r�ost a11 cases of rheur�,ati c fever t are preventable, it i�, �i:Q ur:��s�ior.,F�le resnonsi5ility of this � � heal tn bureau, :•ri t�zi n t�e j uri sd�cti oi� of con�r�11 i ng communi cable � � diseases, to tuk� a�ti��n. It :�roul d b2 remi ss , cn cur part, i f the ' � Bureau ar?re to i�nore a.�y �ut��r�.-a}cs or cor:munica�le upper respira- ; tory infectian ti•mer: :�e ca�asa;.ive ager�� is Group �, beta h�moly�ic streptococcus. � � • PP.OQLE<<1 � . for the State o;` �linnzso�a, 14,518 ca��s of rhe,!�atic fe��er have . been registered in th� o�st ie^. years for secon�ary prophyiaxis. t�lo doubt the ti-ue inci��nce is much higner beca�se of incornplete � repor.ting causec by t;;� lack �f �iagr.�sis confir�:ed by laboratory - � � • cultures. Consid.�r�r; :�n, �or��r �'istri�ution o� :�1ese cases through- out the State, ti>> Ciiy of S�int Paul should account for approx- imately 1 ,400 diag;�osr�.i a�d i•E_ported cases. • All a5e g'roups are sv�c:��YtiF ie *o rheuTa�ic �fev�r, but th� greatest . incidence occurs in c�:il�'r•�;� 5 to 12 yea"s , beir;; some��rha�' rare in chi 1 dren undc�r 5. Fro�n �x�s��n;, current d�,�a, =�° preval ence of rhEUmatic fever for ��e scrool-aged Fopulat�on is some;�rhat known, • du� to the con�pilation of a ":�andicap�ed P,epor�n by both the public and pa�cchial sc►.co1 s.�st�ms . f.ccordin� to the .vYo�,�, at least 81 � students are kr.o�r:� to have rnz�amatic �`ever out o= �pproxim�ately � 65,000 stuc+erits. ?n a�ia�ti�.i , a� least 80 stude.�}s nave some form of heart m�armur, Y!no�z �ciol�c;y is unkno�ln t� th:s agency; ho�aever, those Ytith kr�oti��n cor.c�r,i�31 h�ari dcr"ects hav� b«n eliminated. ' v ti' , 7'he fol l o•,�i r.g tabl°s gi ve di s tri buti ons by ag� gr.^.ups of those w�th _ rheumatic fever or h�art mur^ur in bo��f� the paro�:tial and public schaol systems: � � . Schoo� Year 1°�0-1971� � • Students �i±.� =heuc,a t�c Fever or He�rt `�urmur: ' - � • Dis:ribu�ion 5y Age ' � -� - . SAI"l i PAUL °:�.?OCNI�L SCH04LS , � � '. . ' ' 1��F � Di sease � T��al E-� .._ ` 9-T� 12-14 15-18 ' P.heur}ati c Fever 3C� 0 - . 3 13 -� klezrt tdurmur* �4 9 . . 13 18 4 � , '. , . • «2_ � ' , . . " . 1 . � � . ' 1 � ` School Year 1970-1971 i Students ��i th P,heumati c Fever or F{eart t•lurnur: ' j � Distribu�ion by Age � SAIt2T PF�UL PUELIC SCNOJLS , AGE . Disease 7ota1 62s � � 129�� 15338 euma�ic Fever �� 9 � Neart t�turinur* 36 7 1� 9 . � , �� - -. School Year 1970-1971 . � Stud�nts lrlith,Rheumatic Fever or Heart hturmur: Distribution by Age . . � SAINT PAllL PAF.GCttI,'�l A�yD PUBLIC SCHOOLS � . AGE . . Disease Total 6-8 9-1'�T+ 12-14 15-18 . R eur�ati c Fever 8f � � � � � . . Heart �turmur* 80 16 24. 27 13 � � . *Whenever possible congenital defects vrere not counted. . � � � Other Group �1 streptococcal infections include 101 repo.rted cases . of scarlet fever for t;�E city in 1970. Pio data are available on the nur�6er o` "sore throats" . Like all morbidity d�ta, these num- bers represent tt�e loti•rer range of an approximation of the true � magnitude. � F . , Within.the school systems, bo�h public and parochiai , the detection � of Group A, beta heroly�ic .streptococcal u�per respiratory infec- � � ti ons t•roul d be most produc�i ve •to prevent rheumati c feve�. The hi gh • risk �ge grou� to rheumatic fever, 6 to 12 years of age, is readily accessible to a mass screening program to detect the prevailing pre- cipitating agent. � � At the prese�� time there is no overall satisfactory method for �he epidemiological preventiarr;, detection, "con±rol , and treat^ent of Grou� A, beta h�molytic streptococcus in the scheols. 7'r�e school . _ nurse, upon receiving the volurtary complaint of the stuc�ent with � a sore throat, t�:o.uld inspect that a�ea an� refer tt�e student to his - p h y s ician. Some instances a consent to re�urn to class r:ust be ob- - tained from the physician. I� all students vrith sore throats from ' upp°r respiratory infections ��ere to consult �heir physicians and _ receive treat�ent, tnere ti��ould be no need for this proposed program. � It is evident ti�at ir.any cases ofi undetected uoper respir��ory Uroup ' A herr.olytic streptococcus prevail , especially in the loti�rer socio- - econcni c s trati:i cati on ar.d �hose r;i th 1 arez fami 1 i es, t�lo dou5t many students tiri tn up�ei- resp>>�a�ury i nfecti ons do �ot consul t r�ri th • � the scltioo� nurse or tneir physician, and in r�any cases are not en- � courag°d by their parents. Th�y �•rould let tne. disease run its nat- ural course, not being ati�iare of a�y dire co�seq��ences , or if treated, . . � � ' e , • �� . , . � , •� � -3- • « . � ' :! • -� the duration of treatm�r,t tirould be inadequate in many cases. The _ •' fault lies ti��ith many oarents also - sor*z see�, telephone diagnoses from tf�� family physician, ti�rho certainly is placEd in an a�•�kward ; position in trying to ccr.�ply. Once treatment has begun and overt . t symptor.�s disappear, many tend to discontinue any prescribed cf�emo- �` .R thera�y. '; Clearly an educational program, an er.�pirical laboratory diagnostic , . procedure, and a fo11o��r-up of przscribed treat�ent course can serve a very cre�ible role in the prevention of rheumatic .fever just in - the school systens. . . JURISDICTIO"iAL LIPII7S � . . _ � P.ny ne�•� program should have a limited scope, at least in the pilot � . . and demonstrational phase. It is to the advantage of success for a , � new progra� to encompass only areas ti•rhere the op°rative agency has administrative control and in areas where a re�•� �rograri can anatomose � irrithin related, existing prograr3s. Administratively tt�e Saint Paul , Bureau of Heal�n, in pe►•tinent areas, :has co7trel over the Parochial � School Hea�th Program, providing sct�ool nurses , equipmznt and sup- pl i es, the ��iaternal Ch i i d Heal th Program, and the Corrmuni ty Eieal th • Clinic, a joint operation .or tnis bureau and the Of�ice of Economic Opportunity. The public schoel H�alth and tlursing Deoartment has � sho4�rn i nterests i n thi s pi•ograr� and ccu�d 5e i ncl ud?d as proce�ures becor�e es�ablis}�ed. In order to institute a successful endeavor, the 6ureau at the presert tin��, has decided to lir:�it the �r�oposed Rheumati c Fev::r Prevention Program to the reci pients o` tn.2 a�'ore-- mentioned thr2e areas. Draw�ng fron these t�ree sources , the nur.��er of individua? recipients in t��is pr�oposed program could potentialiy ' be 20,000 i ndi vi dual s betti�reen the ages of 4 to 18. Fro�r, an epi dem- � iological approacfi, clflse contacts, both sympto�atic and carriers , of the case in focus should be examined. Ncwever, this agency �ri11 not take an acti��e role in the examination of the forr:er, due to the. . limited scope of tf�is proposed prog�-am. "{everthel�ss , education in � the form of literature, telephone conversation, ard in some cases personal contact wiil be re�legated. -- � . ,r OBJECTIVES : � � � A. General � � The prir�ary objectiv� of the proposed program is to decrease the_ in- eidence of rh�u�atic fever ��ithin a linited pop��lation and secondar- . - ily _to reduc� ti;e incic±ences �of disease ar their co�plicatiors rrom , those caused by Group A, •beta hemolytic streptococci such as: scar- . let fever, cellulitis , lym�i�ademitis , nastorditis, otitis �edia, per- itonitis, septicer�ia, ir�o�tigo covitGgiosa, etc. . Since no upp°r respiratory norbidity data are available, one can only speculate that out of the prop�sed 20,000 targ�t population, at leust ' 20,000 cases of sore throats can be expec�.ed in a given year. Again � . , - -- _ ' , ' . . r • , w�� • . e � � • t . � , onl s eculation can approxir�ate the nun5er of Group A, beta hemo- � Y P lytic strent�cocct�s as ti�e cause of morbidity. S�nce available data ; sugr,est that 3`,� of uni:reated stre�tococcal infec�ions are follo,�red by � rheu^:atic ►�ver, a credible im�ac� could be felt in an endeavor as r follorrs: A proposed goal o� 10,�JOQ tt�ro�ct cul tures can be undertaken on a yearly o�se. If anly 1 ,000 b4cteriological support procedures (by throat cu?tur�) inJicate Group A, beta henolytic streptococcus , 30 cases or rneurratic fetier could be exp�cted if none, so indicated, had tr•eatn;�r�t. T��e propos�d progran exp°cts to perforr� 10,000 eom- . plete throaz cultures during this fiscal year. . , � 6. Educa�ion �� The a�reau er��ploys 13 public health nurses and one supervisor for the . , Parochial Scnool }�eal�:ti Program. Overall jurisdiction extends to 43 paroci��ial schools �r;it}i an enrollr�nt of approximately 18,000 students. In addition, under a federally spo,lsored f�'aternal Child Health Program, approximatQly 1 ,700 pr�-school chiidren are given som� r;,edical service � each year, The next program, Conmunity t(eaith Clinic, -jointly spon- - sored by O.�.Q, a»d this a�e�cy, gives, services to approximately 3,400 unc�er-12 a;e group in a year. Tfie latter trro progt•ams share three pub- . lic health nurses fr�m tf�is bureau. Each public h�alth nurse is to be . equipped in her respective location to ta,ke a spzcir�°n for a throat culture, la�:er i.o �e corplet�d at �;fle laboratory at the �Bureau. .4 � trai ni ng sessi cn �•ri 11 5e establ i st�ed b2forenand for al l i nvol v2d per- . scnnel to learn the proper r��tho:lalogies. It is the d�sired g�a1 that i�ritn litet�ature to t}�e students and parents � and sp�cial lectu��s by a rr,ember of this stafj, a a��re se;�ious outlook wi 11 be, i ns ti i 1 ed, fol l o�.:`d by �redi�cal attenti on, c�nen a sore throat • prevails. Obvieusly, once Group A, beta her��olytic streptococcus is � identified frcm an indiv►dual , epidemiological n�t��ds is to be fol- lo��ed, ��ri�n that afflicted individual receiving tr�atnent from his � physiciar;. Folio�.r-up by a team of specially desi�nated personnel a�ill . make cert3in that the infected received a regim�n of cnemotherapy as przscribed. Emnl�asis in educatioi� to ��certain extent �•ril i be placed on prophylactic - me�sures to prevent �ny symptor�atic indication of str�ptococcal diseases. Each i ndi vi duGl t�r;11 be i nfor�r�e� tf�at the quanti t� of mi croorgani sms is directly proportio.n�d ta the ris� of ov�rt disease synptons. Nence an � individuul �•rill b� cautioned against b2ing in cl�se contact or being in � . � c1us� p►-oxi�r.ity ��ith the diseased person. Otner sanitary measures will also be ddvl5ed. - In conjunction ti•ritn infotining the parent(s) if streptococcus is identi- ' ' fied by ih� agency's laboratory, a refer;a� forr� �:tll be sent to the � � � priva�e physic�ar� of the case. A synopsis or l�t�rature from th° �mzri- can Hearz ,",ssocia�ien entitled "Pi•�vention of L�c�erial Endocarditis" will be se��t the sarr�� ti :r� but only a� t��e firs� T�iling. Aside fror� the i��ailin�, a telephor� call �•.i11 be rac� to th? physician's office • for the F�;�ysician to direct propzr disposition aL F�is dis�retion. . � , � . ; -�-,-�� : _5_ � : . ; ' ther areas of education, it is a goal of ��'�� a95inilaraprograme - In o near future the Publ i c Scho�l S�sten: ►�ri 11 cen..uc. as the propose�, for the 45,0�0 students enroll::d there. t�ence, a _ � a � �1ct, i�ere, is abso- ro ram to demonstrat� feasibilitf an�. i ,•�•' working p 9 _ lute. If there is a desire for activa1Paetco�r�r�,�s�n9ui.t'�zUe.at��t�ever the Publ i c School t�eal tt� Program, an . Prevention P7�ogram for the hi,n r'��`fever�irGti 2 Sain�SPaul+areaor - the future eradicatian of rheumat � � C. Nealth S�rvices • � From clinical grounds alone it is alm�st i�r.pos��ble to �dSnSten.GrBa�- A, beta herolytic streptococcus of the uppe, r._spiratory riolo ical support to t{�2 clinical impressio:�^?D�hra`�of throatbcul�f : te 9 not critical . The results of the laborato, y pr��- : ture is th� determinant ofr�n�ncoursetmay Tollos,olaBeo��healthrcare k ism so that a proper treat for the pr000sed populat�o� follo':�e��ishcorldec�edCe Plo�dout�t identifi- � follo�r-up by �hi s agency s personn ' cation is critical in establ�shing the:prer„ise. . � th�. educa�ian of studerits, The facets of the proposed prograr,� i ncl ude ^ ; • Parents, and health personnel to tl�e serious se��i�lae �hat may result from u�per respi ratory i nfecti on �ror�� Gr�uP `°�, b`��a `�`-'�'1°�y�i c s�reoto- coccus. Thrctigh litera�ure and l�ctures tn� �t+a�'�nts ��d �arents ��rill be made a�•iai•e of an encou��aged to ta�:e advan�:ac;�' ef vii� free, r��jt1is avail�b�e throat culture sequ��►ce at the sa��n��`1'��d`studzrtse�rill re- � the opinion of tnis agency that botn the p spond ti•�hen the occasion ar�ses to have a tt�r;,at culture ta�:en by tne school nurse or the attendi bgen�os��f cl�ienteli s�+:ponCreq�!°sty��ri thgthes� . � This servi ce v�i 11 be ava�1 a minimum of "red tape" or �•raiting, ti��ith the cons�ni of botii the parent and respective physician. - _ . Costs are minimized since the prop�sed s�rvices ofa�� a;+hanY th�1r�eXed sixteen (16) public healtn nurses ��ii11 be incoru� isting functions. Only a_a?tmo°s to�mainta�n�costs�a�aau�nininum�or�o personnel are necessary ad . perfoi•n� identification, isolation,ta nst`��h�nnt:�e�lar�get�p pulation�� beta hemolytic streptococcal �nfec D. i�tanpo�•rer . . Si nce the resul ts of the throat cul tures ti�l^�-�i d rL,� a�'c�1�5��Pa+thn� by24 hour period fron t}z� time ofbetat��enolytic�ss"='�'`^cocc•�l infection can . the p�ysi ci ans fo r Group 11, �� t�,,� ��;, b� b2t�er uti 1 i zed, ' begi n i f the cul t�.res so i ndi cat�. Ph� s1 ci a,.� � � what to tre�t at th� ��ry c'r�,°± of t1�e D3Lient's knot��ing so..cifically 4� � � latian�, by the visit. The o;�treach into the fie�d of t�,_ �',�..'•^re�t�y �ncrease the 6urcau, to prov�de lah�ratory cor,rirmaticns n.,.n?� performance of needed medical care in t',-:�s r_s;.....�• , . . � � .. - ' � _6- . � . � � , �In sumnation the follo�•�ing ord�red sequence of priorities lists the objective: ' , � � � 1 . To lower the incidence of rheuTatic fe��zr by the early � id�ntification of Group R, beta her�olytic streptococcal uoper respiratory infection. � 2. 1'o give bacteriological sup�ort for di4gnosis and treat- ment by pri��ate physicians. . � 3. To gi,ve bacteriolbgical suoport to diagnose other strepto- . eoccal diseases fram clinic�l grounds by private physicians. . 4. To educate parents and studen�fectionsrto avoidtserious treat�r:en� of hen:olyti c s treptococcal �n consequ°nces. � � ' � � de and uide �hose with morbidity to seek treat- � � 5. To p..rsua g _ . - �ment and to fo1la��r the full regimen of treatment. . : � � � � � 5. To su�port private physicians �ti�ith re�errals and pertin- � � _ent literature. . _ � � �� - 7. To demonstrate the feasibility of suc{1 a prosram to other �agencies for future caop°ration and participation. . 8. To minimize the unit cost for n�aximum e�fQcti��enzss. , ' � 9. 7o utilize ava�lable, existing medical services. .� ; 10. To facilitate ti�e private physician's scheduling and treat- � , �� ment of patients. . - ' . PROJECT D�SiGr1 Surnnary - At the be�inning o� the school year, a note to the students `' and pa�•2nts ��i 11 be di stri bu�ed by the teacher. It �•�i 11 i nform them of the potential serious sequela� of streptococcal sore throats. A . - throat culture is advised for those students ti�rho are synptomatic (Ex- � hibi t A) . The school nurse or cl i ni c nurse �•;i 11 ta�e a throat s��:ab to be cultured at the Sureau of Health. Tf�e nurse vrill us� the kit � containir.g a sterile dacron tinped apolicator; a;i�h throat specimen, it is inserted in a silica gel� pouch. All contents ti��ill be sealed in a poly-foil kraft envelope ti�rith the nar;e of tf�e participanti (Exnibit - (Exhibit g). A �orm �•lill b2 aartially compieted by the school nurs� dead- C). The specic^°n Yrill be delivered to thz eureau b� 3:00 p.n. ' line. It v�ill be cultured by blood agar and bac�tracin disc method � and gro�,�th observed ��ithin 2-^• hours. If c�ltu�� gr�,rs Group A, beta hemolytic streptococci , it vrill be recordcd in �he form (Exhibit C). � Copies of the partially co^��leted forr� �rill b� se�� 14o boti� th2 parent and r�specti v� pi�ys i ci an. A copy �ri 11 be kept i n our fi 1 e to be cc��- � pietzd later. 7he parents and pnysician's offic� ti�rill also be nc�tiri�d by tele�hone. An inquiry to the student/parent ti�;ill be ma�+e apprcxi- mately �'�� hours after identifica�ion, to r..al:e c�:tain that a treatment _ . • , • • . i i . � r ' . ' '„ � • � . � . � , i . : . � artici ant has no private physician or ' � course f�as begun. If the p p ,1 due to �xtenuating circunstances could not see iiis physician, the ¢ Bureau will provide trcat��nt rather than allo�.r the case to rer�ain ; untreated. Follo�;r-up ror a t��:o-�.r�ek eeriod ti�ri11 be mad� to conqlete ; �the parti ci pant's fi 1 e (Exni i�i t C) . T��e 1 aboi•atory servi ces �•�i 11 b� � p r o v i d�d, f r e e o f c h a i•��, t o ph ysi ci ans Vri�o furn�sh th�i r o��.n spcci- � ments fer diagnostic purpose to identify streptecoccal infections. i The �arious asnects of ti�e p~oposed project are so interdependEnt = in co�nptexity that to aive a coherent outline can peri�aps be accom- ' � plished by detailing the co�ponents of activi�ies by the categorizing ; �� of functions and events. �lh�never possib•le, the interaction of roles shall be related. Perh�ps b;/ this assignn�ent ti�e reader could folloti•� the proposed �vents tt�at conv.rg� to a project•design. . As previously nentioned the propose� project wrill encompass the Paro- chial School ti�alth Service, t�e ��aterna� a;�d Child Health Clinic, and the Co��:ml�nity Health Clinic. 7he rajority of participants to be - - sct^eened for streQtococcal throat infection ��rill be s�udents under - � the Parochial Sci�ool S,stem, �:here the eureau provid�s school nurses ' for its health s�rvices. Foi� the sar� of clarity the descriotion of the project �2sign s}�all be focused only on the sequence relative to the pt-o�osed program undertaS:en �•rith the parochial school students. - - � The reader is quite capable to oroject and modify in his o�.m mind th� seq�aence tl�at a;oul d take �l ace �� he t�•�o co�muni ty cl i ni cs , which �•;ould be, iiz principle, similar }o ti�e parochial school program. . A. P.ol es and E��ents = � �- . . � • l�lemorandum to Students and Parents - 7he teachErs or .assistants at the outset of the school year, or at som� later anpro�riate date, would givz euch student a copy of a r�,emorandur� (Exhibit A) , discGSSing • - th� potential dangers o` streptococcai u�per resp�ratary infections. It infor;ns ther� and their parents that a throat cu3ture to detect � Group A, beta her�olyti c streptococcus caii be i ni ti ated at the school nurse's office. . ' � Obviously�tnose that ti��lshrto have a throat culture taken at t:�eir . physician's office hav� free choice in the r�atter. In fact the 6ureau � kould gladly comnlete throat cultures for p;►ysicians free of charge ifi specir�ens are delivered ta the Bureau's laboratory. The ��r�oran�urn also ��arns th�at if tfle culture ind�cates streptococcus, � it is tlien imperative to seel: nedical treatn4nt ti�ith the ap�ropriate ' _ regiT�en of cf�er�othera�y. A �tuder,t ►�rill not be all��ed t� return to sch�ol ti�1i�h syrnto�:ia�i c streatococcal throat unl ess there i s evi d�nce • ' of treatn;ent and ��ith a physician's clearance. I�� the stud;.nt has no - private p!�ysici3n or is under so:�? extrern�, exten;�ating circumstances ��here treatment i s not �:i thi n hi s rezch, tne G�reau under ti�e }feal th Officer feels a responsibiii�y to tr�at �tiir,l. Cle�:rly ��hen t1�e case indicates fl�o;n in�or��ation frorS tne parent(s) andJor stud�nt that. n� means for treatr.;ent is avail�ble, it is only hur:ane, ��rithout qG�stions for the Burea�.� as a com.,uni t� hea�th agency to s tep i n - here �h� re- sponsibility lies in stemning a cur,�unicaUle disease. . , . ' _8 . . . 4 ! . , � � - t : , . � . � ' ctions - blhen sore throats prevail , the students . ` � Scliool t�urses Fun ' ��i 11 be di rected to tS�e sctlool nurse on th�i r o«n i ni ti a�h`eteac}�er t the part of the parent(s) because of tt�° r�'r,orandu.r�, b,/ ; Qr assistant, by the school nurse h�rself, oi• by the private pf�ysi- i The school nurse ti�,ill proceed t cian to initiat� a throat cultur�. � �{ to tele{�hone for permission frorr th� parent and the stu:lent's piiysi- cian or his office to take a throat swah for culturing. ! s Through her ad hoc training on techniqt�es, she ;�ill proceed ti•rith t permission to use a 6-incf� dacron tipped sterile applicato7�, tirith ; the tongue d�pressed, to s��rab bot'r��1toQ��in�a silicaagelpcontaining �� . pharynx. Then the appl�cator �s pp.- � envelope, and both are then sealed in an invoiced r,ani?a envelone also provided by the kit (Exhibit 6} . . . � She then suhr�its the enclosed specir��en and a par�ially cor�pleted t � • he Gureau's lahoratory. The �� file farm (Exhibit C) for d�l�very to t � delivery ti•►il1 be donz by the sanitarian aid� or the nurse herself on � � som� occasions before 3:00 p.m. each sctiool day. �i ' �_ Laboratory Functions - The project tecf�nician und�r the supervision ;: • .of the bacteriologist or technalogPst ��l��n��f�,ZGrau;� �1,lb�iang�m°- � material� and techniques to isolat.. an J ; lytic str�otococci : A commercially availzble bloo� ar,ar base from Ealtimor� Biological Lab�ratory is prepared and s��r�liz�d according to directions. 02fibrinated sheLp 51�od to a volu^� of 7 p°��cent is aclded to the agar at 45-50°C and nixed by gentle r�tation. The bload agar mixtur� is �oured ;n�°dP�aarlv,ouldrbe�about 6nmm�t�ick5-20 cc I . ar�ounts. The layer of bloo g : Tf�e labeled envelope from the sct�ool nurse �he�ae��acatore1�The swab � silica gel ir�bedded sp°cinen on •ti�e tip of t . pE • is im�diately rubbed and t<<:isted anto �i�e edge of �he r��ist sheep blood agar plate for the primary inocuculation,�failol1ed bYra stab is used for 10-20 stro�e secondar,� �no inoculation. A bacitracin-coinflvence�both ligt;t7y andc}iea�ily ine area of inoculation so as to , oculated zones. The plate=�s incubated overnigh� at 37°C. Strepto- cocci causing acute respirator�hencolonies,arF,pr�e�kg�a�e1,b20t�oursear zone of hemolysis surround�ng � after inoculation, if there G�o ac�tis�identifbe�31cnbt��rnconf�irmatory around but not to the disc, P - tests may be used. . Clerk-7ypist Functions - Ap�roxir�ately 2� hourl ��;o��ulturemvouldtbe throat sti��ab by tne school nurse, the resul �s o� ' kno�rn. The Clerk-Typist �•:ould further cor��plete t:�e file farm (Ex- � hibit C) , recording the organisr� identified and t�,z nur5er of cbetaies counted fror� the laboratory report. If the gi�oti•:�:� is Group �, � hemolyti c s�reptococci , a copy of the fi 1 e ?s sent to bo�h �f�e �arti- cipant's parents� an d his p��y s i c i an. In additian, tel�p+�one ca11s to both ti�ould be r�ade. Tt►e original copy ��ri 11 be !:e�� in suspense at the Eureau to a:�rait final co�npletion as tF�e 7rea_-�_nt and Fo11oY!-��p informa�ion is gathered. . , : ' � � . • � , , ^�- ' 1 - E . . , . ; , Coordinator Functions - The �oord3rator, ti��ho is a Public i�ealth P�urse, � : is responsibl� for t he fo l la�v-u p o f a l l t h o s e identified to have Group � , A throat infection. She will , t��reu,t� telephone conversations and hon;e : � visits to perstiadz, maE:P C�l�t�,in that mtidical tr•eai:rrent is sought and . ; a 10-day regin�en of che�ott�er•�py is follo;:ed. In other educatio►�al areas, : she �vill co:,d�ct sh�rt lec�ures at ti�� paroc'nial schools to encourage tne � . participation for a successTUl Ri�eu�!atic Fever Prevention Progj�m}d au�li- . judgn:�nt ��i 11 be considered as to ti•�fiich participants, if any, fy for treat�^�nt by tf�e Bureau. T}�� o��erall duties ��lould include the over- seein� that t'�e pro�ra�� is op�rati�g to its �expectation, that it is opera- �� ting efficier��ly, anc �hat� it serves a credible role in de�7onstration and :+ education. In additio�, t"e respo�sibility of official reporting, corre- � spondence, and public rzlations lies here. . . f . �. Health Officer Fur,ctions - Th� Nealth Officer, ti•;l�o is an internist, hasUp_ � the overall respo:;sibility of the Rheumatic Fever Prevention Prog�'am. � on th° recor��r�endatiens of the Coordinator fcr the selected fe�-1 �•rho could � not accor,:nc�ciate private.medical care, mostly from the loti��bused onCbiologi- � � stratum, prescri pti o�s for ci�e�,ot��erapy ��ri 11 b� ti•rri tten, cal support. A 10-day regir��n of either pe�icillin G (o�•Zl� ar erythro- � mycin �rill be dispens�d by t��z Bureau. In r;:ost cases the filled prescrip- t tion ti�till be picked-up by a far�ily r�ember of the case in focus. �� •� Anciliary Pcrsonnel Roles - Th� services of the F�ea�t� Statisti�ian and � Kealth Cducator ��rill be utilized for direction, evaluation, and inpact. � 6. Education, Coc,p°ration, and Participation . t A joint cooperativ� program is se°ked betti�;een the �ureau ai�d private physicians in �heur,�atic Fever Prevention. The availability of the free• laboratory services for streptococcal detection is a si�n of good:�;ill by the Qureau. The specimens could be delivered beTCre 3:00 p.m. to tiie Bureau's 1 aboratory, and ti�e resul ts ti�roul d he tel e;�honed to t��e physi- � eian's office �•rithin 24 hours. A joint venture sucF� as a cooperative screzning o:-ogram :�iith the Public Sbas�d }on�our d2ponstrationall be so- licited, arhose acczotance �•�ould be + BU�GET Ai�lD FEI'�SI6ILITY O�rPl:OJECT � The request from P�,°,+?P funds for the f;heuM�atic Fever Prevention Program is appraxir�a�ely $25,000. i�lost al l of the rec,uested fundi ng ��ri 11 be used for salari�s to suppo~V add�tional. oroject p°rsonnel . The ad�itional person- � nel includes onz full-timc Public Ihealth F;urse II to coordinate the program, a fu11-tin° Clerk-Typist II to kEep records �nd ex��dite com�unication, and a ha1 f-tii�z b:�ericl�y��t to ass i st i n the 1 auarato��y. A mi ni��um i s reques�ed . for office supolies. Tf�2 Bureau is sunplying th� services of sixteen . (16) public health r.urses on an average of 5� tir:? each, a 5% tiri�� lab- oratory teci�^ol ogi s t, bac'r.-u� P°�'sonnel , 1 aboratory and o�her suppl i es. � The curren� estir�ation is tnat at least 10,000 throat cul�ures could be eompleted in a yea�• and ��ith aoproxir,ately 2,OQ0 follorr-ups, the estir�:ated numh�r tha� �:{ould ir�dicate �roup 11, beta f�e,:�oly��c streptococcal in��ction. � In addition, cons�dering tne pro�ospd educatior�al b2r�efits to tne 20,000 . . . . t • -1Q- � ' • � , � � � � � o�ul a ti on and thei r i mmedi ate farni l members, the budget - � target p { Y justifi�s tfze effort. • Otf�er events frori th� prograr� �•roul d be the c1 ose i nteracti on bet.aeen � � this agency and private physicians for tf�e benefit of the patients. The participation of tf�e Public School Fiealth Deoartm�nt is anticipated � in the v�ry n�ar future, in order to establis� a city-s�f.ide P,neumatic Fever Prograr� to encor�pass all ages bet��reen 5 and 18 years of age as the t�,rget po�ulation. Si nce the program ti�ri 11 fi t i n a frameti�aork of cl osely rel ated operati ons , � tne additional proposed personnel are those expet•ienced in public healti�. � Elence grade II personnel are requ�sted to pe��form the necessary func- � � tions. 7he non-project �funded personnel are all experienced and coi�- petent in their respective field. Qeing designated a pilot and demonstration pro�ra�i, the proposed must be given a just firial period to perfect its overall efficiency, method- ( ologi2s, coordination, and relative effectiveness. A three-year fu��ding � � peri od i s not unreasor�abl e. At the ti me of phas i ng out P,R��P s uPport, i t s is t�oped that the local budget of th� city's health funds 4l1�1 supaort i it. Prediction is difr'icult, being dep�nderit on the judgment of poli- � . ' ticians. The other channels of possible suoport for continuation could � • � , perhaps cor� fror� state or federal funds. � , i �For the p�riod of the next three-years, this aqency feels that alony ��rith preject funding ard local contribution, the resources both in nersonn�l and costs are adequat� to operate the pr�posed program to . serve some credible function. ' ' EVALtIAi I�Ot{ . . � . � � Since the primary objective of the proposed pragram is to lo��rer the � � incidence ofi rneumatic fever in a selected pop;�lation, a morbidity . . i ndex i n compari ng rates ti�ri th thos e of the pas t ti�toitl d be i d2a1 . Ho�r- ever, mor5idity data are not available as of noti�r to any valid extent. Induction r��thods to r��asure r�orbidi�y must be relied upon ti��itn an- � cillary indeces . Nere the,-basic probiem is the follo��;i:�q: l�lithin a given population for a given� tir�� interva' , a given number of individ- uals develop Gro�o A, beta hemolytic str•eptococcal infections of ti�e ' upper respiratory system. 7he basic question is ho��•1 riany remai�l un- - � treated due to a lack of id�ntification of the organism or du� to the complete disregard in se�kin� treatr��nt. This question cannot be � � ansVlered. Clearly tnose that develop rheunatic fevet• are those from � this sub-pooulatian. As �entioned in another section, the underlying sche^�e is for the � � identirication of the oi•ganisn and broad-s�ec�rur� education. 7he ten- poi nt ob�ecti v�s �•ri 11 be quanti fipd ti��i thi n the 1 irni ts o` countabi 1 i ty. � Basically the uata 4J1�� present the number of cultures completed, the . r�umt,�er of Group �, beta he^�olyt�c sLreptococcal cc�ltures i�entified, the nu�!ber of individuals referrzd for treatr�ent, the number of cultures . , � ' � � . . , � � -��- . � , • . � � . . p2rformed for physicians, the number of educational materials given � out, and the number of confer�n�es held. A quarterly narra�ive re- . , port describing hi gi�l i ghts v�i 11 be submi tted along 1•�i th a statistical • report to �1P.t�;P. • An assur�otion must b� r�ade to compare "before" and "after" data. The • assunntion ti•�ouid bc t�,ro-fold: 5�°� of those 4�rit'n Group �, beta h�nolytic stre�tococc�l infection of tlje uppzr res�irator;/ remain u�itreated or inadequately t�•eated; 3ro of those un�reated or inadequat�ly treated develop ri�eur:atic fever, tience tne irjoact of ti-�e proposed program could be felt in prev�nting 1 .5� of all thos� infected �•;ith this organi sn frar� der,�el opi ng rneunati c feti�er �at thi s i nci dence, provi d-. ing medical follos�r-up is lOJ°� efficient. - Anotf�zr ind�x to measure the "befor�" and "after" effects of the pro- � posed prograr� is to gain participation of other agencies , oarticularly - � the Pu�I i c School fleal tt� and f��rsi^g Depart�;ent, the Pedi atri c 0?part- ment a� Sai nt Paul-Rar�s ey Hos pi tal , and pr�v�te r,:edi cal cl i ni cs. The active participation could give Saint Paul an extren�ly valid pf,eumatic Fever Prevention Program. � - . . - . Individuals records ��riil 6e kept on all participating clienteles. 7hose identified to have Group �,, bzta her,iolytic str•eotecoccal tnroat infec- tian arill have their records separated from the main body. Thi`s second fi le ��i l l contai n foi 1 o�,�-up dsta on each i ndi�ri dual . Quar terZy, a parti- � tioning c�f the ov2ra11 uata tirili be made availabtc. i�lo� only the magni- tu�e of t'ne prevail�rg streptococcal throat infec�ion can be aearbxi- mat�o but also the proportion or acequa�e treatr�n� ar!on�� .�e i�divid- . ua1s. The Bureau's Health Statistician wil�l prese�t the aata. As tf�e pilot program becom�s on-going, relative conparison t•rill become more r��aningful . A trend analysis could be establisfied. �loreover, the ' impact of ti�e educational facet could be exam�ned for a given ti�� in- terval, both in tl�e acceptance of tne onset throat culture to tt�e com- � pletion of treatment. Other measur�ments that co�.�ld be ana7yzed in- clude the effect of a cooperative dpt�ction and trzatr�2nt program be- t��een this agency and priva;e physicians. Tt�e efTects of this screen- ing nrogram ��;ould be fol iJ�;ed by patierit care UII�?1• the private physi- cian. The aralysis of such a joint effort could be determined by the . raport betti•reen thi s agericy and the r.�edi cal cor,�muni ty. Periodic evaivation of the project ��rill be cond�c�ed by the Elealth Statistician, Project Coordi;;ator, Flealth Educat�r, and a repres�nta- tiv� of tne Public Health School nurses. The evaluation L:ould include the ov�rall effectiveness of �the program, the n�acnitude o` ti;� problem, the relevanL and "riglit" indeces , the raport and c�op�ration a��g this � ' agency, clie��eles, and private on}�sicians , and t;e impact of education. . ��iodi`icatio�is ti•rould be sought to'improve the program Yriien occasions � Vlarrant. -�� 7/30/�1 . . ; . � , . . . � .. , a . � . ' Qureau of Health • 555 Ce�Jar St. ' • � . � St. Paul , �-linnesota � . ` fioute throuc�h: Sci�ool Ffealth� Pnone: 227-7141 Community Clinics Dear Parents and S1;udents: _ 7he season is i�car to becom� a►�rare of uppet- respiratory in`�c�iens. 7fie particu�ar concern is streptococcal sore throat. It �ould lead to . rheur�atic fever �ritn per,c;ar�ent heart damage, kidn�y disea�e, an� joint damage i�` ui��reated, Rneumai:ic fever and ot��er d;;�ca,e ca� be prevented. If sore throat is present, do not take it l�ig'r��ly. S�e t��e school cr clinic nurse for a throai: culture. The results of t��e cuir.:ure will be kno►��r� to you and your physician ��rithin 24 hours. If tile cul ture i ndi cates streptococci , consul t yo�ir p:ty51 C i o� l��r,�zcii ately for n��dica�ions. A coi�sent to return to school is necessary. If yoci have no family physician or cou�ld find no o:�er way for treatment, un;�er these circwl�si:.��.nces, t��e Eureau of Health �vil3 cor.sent to �reat you with prescribzd r;;edications. � . . • . � ' • _ B. J. hl�ars, t1.D. . . Nealth Offic2r . . _ � _ � . . . � , •� —• . . . �r _ - ' • r ._ ,.:i• - �• - . �! j'`:, .. •7• , . ._ ..._� ...'I.�.l:..�.��.�_�:_•-y,.�.�...... . .. .._"'�' .. .. __'_ , •. t.. �� J. ��r'� :l� .. . .'�!;� • . '�51:,' . � • �'� .� t ' �: ��I. .,1�, ` '�. �'�'� . � . . . .:.i .::•.�1 . -.. • •� t�.l . , __��. � . ..• . " . ��.�•�(. _ . ��l�� , _ �` ..��t. - . .. ... ..._ -.. .. ' _ .. ','�,i; _ • \ � ~- � - ' � '- - - lTr .... . . . .. . ' i,�i� - - - - -- ... . .... ....• .. . 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'--_»—'..... �e�:ure to p:o_^ suFSic�cr.! �os:o9e will . . - ' ~._.•.�..___$�rder': As�r^cs�. crlay in the e:.e^i�erion eF apecir,.:n. - ' . . • � . � •.� : y. . �• ."i. � �• �L� .:� �/ �..w.J�.��v�N .. . . .�.V.��• - - ��w: . . . . . : � CITI�' OF S:'�l�T P�t�L . � - . . Tp, Capit�! of�tinnesot: , � ' � ' / � - � - U ' # � , �' � , ,..�� c� 1)�cCcc a-��fc' � � � � . � ; �.J:��.z�::,:��, � o � . 47 � . ,[ . 1 - �• . t�: � , [ ; . . : �{f�CE� � u ; . �ic��au o f �_1 p t . < . � � ' ' � . �'-�, G � �'�j:�lth Cer.t.r - 55� Ce�_•r Strect � � '� . , . St. P�t�l, �t�RI1zSUI� S��IU1 �_7 C� . � � 0. C�` � � � � . 237•7741 r. _ . I � . ;.t,�._....,-�>�-r--, .•�---�^''_"';...''" . . ( -..�._ --.-.-_-.-�:- _ . . . . i:.r !'•ac. ,,.loa�tol ,' �..��,�:t:c�. T 3�5 • . • ' , . . � '`�_•�-�L^�Ci ?i_ DI:;i� 11��..i ��" _t��Tich :l,::1.-� ' � . . .. . _ . . . ,: . � . � � Saint Paul , �-iinnesota 55101 8ureau of� Health Phone: 227-7141' ;55 Cedar Street FILE: RNEU(U1TIC FEVEP, PREVENTIO�J � � Agent: Group A, l3eta Her:�olytic •Streptococci + Name Birthdate Age Address - ' Phone Sex ____,_ [�ame of School ' . S;fmptor�s " N�.m� of Physician . Address Phone Date of Cu1 ture __ P.esul ts of Cul ture 7rea�rrent Fol i o�•�-up . ---' � - • , � ATTE��'FI0�1 t•1.d. : A�throat culture v�as taFen. Your patient above ti•ras found to hav� Gra.�E� fi, beta hemolytic streptococcal infectian of the upp�r respira�ory system, �•rhich could lead tG rheu�natic fever if untreated. . � . ATTE^1TI0:�1 PAP,Et1TS: Your child has an infectious strep throat. If untreated it co«1d lead to rheumatic fe�►er, �•rhich could damage the heart; kidneys , or joints. Consult the child's physician immediately for credications. 7he Sureau of Heal th �•ri 11 provi de �meu�i�cati ons by tne Heal th Offi cer i f your chi 1 d t��as no physician oi• if und�r emergency conditions. � - ._ - ► . . . � � �1 �.� . • `� � • APPEPIDI X - CtJRRI CULU'rl VI7AE � , r . � . s ' � r ' . � a Burti s J. Plears , t1.D. (Pro ject Di rector} . btedical Education: Bachelor� of Science and Bach�lor of Giedicine Degree, University of ttinnesota, 1931 . ' � htedical Degr-ee, Unive��sity of Ptinnesota, 1932. Certified by Board of Intet-nal Medicine, 1949. _ �� Experience: General Practice of ��tedicin2, St. Paul , 1932-1943. . Captain, U. S. Army tfedical Corp. , •1943-19��6, - ' � assi gned to P�tanha t�an Engi np�ri ng Ui s tri ct for the control of nedicai and radia�ion haz��;ds receiving . the Arr�y Cor�n,e��dati cn P.i bbon for "Oui;standi ng Service" in conrec�ion �ritn the developmen� of the atom borib. Practice limited to Inter�al hiedicine, 1946. � � . . Associa�e Clinical Prcfessor of liedicine, University . . � . of Minnesota, 1962. � Teaching appointr��nt, St. Paul Ramsey fiospital , 195J. , � AFpai nted Heal th Offi cer, Ci ty of St. Paui , h1a�y 1 , : � . � 1968. � - � Nospital Staff P1en;oership: Senio'r attending staff ` � member: Charles T. �ti l ler Nospi tal - St. Paul � . St. Joseph's Haspital St. Paul �` � St. Luke's tiospi tal •� ,,;,�. St. Paul . St. Paul Ramsey Hospital � ' St. Pau1 • . �Societies: A�r;erican t•1ed�cal Association � . � American College ol Physicians � - • (�iem5ershi p, t�ti rinesota Academy of t�tedi ci ne and . � � hlinnesota Society of Internal �1�dicine) • t•tinnesota Public Healtn Asso.ciation � � American Public Nealtn Association � . . . . � , . � -_ti . , � .