# Implementation of a Countywide Vector Control Program in Shelby County, Tennessee

# 2006 - 2007

# 

# Environmental Public Health Leadership Institute Fellow:

# Lorrie D. Clark, MSPH

*Assistant to Director, Memphis and Shelby County Health Department*

## 814 Jefferson Avenue Memphis, Tennessee 38105 (901) 544-7583

[*lclark@co.shelby.tn.us*](mailto:lclark@co.shelby.tn.us)

# Mentor:

### Daneen Farrow-Collier, MSPH

## Centers for Disease Control and Prevention

# (Acknowledgements):

### Yvonne S. Madlock, MAT 

#### Director, Memphis and Shelby County Health Department

**Norman LaChapelle, MSPH, RS, RPH**

## Administrator, Environmental Health Services, 

## Memphis and Shelby County Health Department 

### L C Garth, Manager

## Vector Control Services, Memphis and Shelby County Health Department

### Daniel Sprenger, PhD

## Entomologist - Vector Control Services, Memphis and Shelby County Health Department

> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

Vector control services are necessary on a continuous, routine and
area-wide basis to protect the public's health and enhance the economic
development, recreational use, and enjoyment of outdoor living. With the
emergence of new vector-borne diseases locally (e.g., lyme disease,
mosquito- borne encephalitis, West Nile virus) and nationwide (e.g.,
Dengue hemorrhagic fever in Texas, and the West Nile virus), the
surveillance of vectors and the implementation of control measures have
taken top priority within local health departments and communities
throughout the United States. Subsequently, reducing and controlling the
number of vectors that are able to spread and amplify these diseases or
inflict pain or injury, is the focus of local vector-borne communicable
disease programs. While impossible to eliminate all mosquitoes, numerous
methods (i.e., surveillance, larviciding, adulticiding, source
reduction, community education, etc.) are employed to keep their numbers
as low as possible. Through the years, Shelby County has experienced
serious bouts of mosquito--borne disease epidemics and outbreaks of
Yellow Fever, St. Louis Encephalitis and West Nile virus. West Nile
virus was first identified in Shelby County, the fall of 2001, since
that time the county has experienced a significant number of human cases
and fatalities. Faced with the termination of federal grants and a
reduction of local funds, Memphis and Shelby County Health Department
(MSCHD) was forced to direct its attention on select high-risk census
tracks where the majority of mosquito related diseases were identified.
In 2005, County Commission authorized MSCHD to contract with a local
utility agency to collect a fixed monthly vector control fee from Shelby
County residents to affect the cost of the mosquito and rodent control
program. With the funding barrier addressed, MSCHD began implementing
and coordinating vector control services. Implementation strategies were
divided into 3 distinct areas: *Interagency Service Delivery, Workforce
Development and Resource Enhancement, and Marketing*. During the
implementation phase several constraining actions were identified:
stakeholders lack of knowledge of the processes and timeline for
implementing vector control services, stakeholders buy-in and ownership
of the program, and the increase acreage combined with a shortage of
trained and certified personnel to implement services expeditiously and
effectively. During the next steps of the implementation process, MSCHD
plans to develop an evaluation tool and customer service satisfaction
survey to measure the program effectiveness as it relates to program
management, quality control, resource issues and workforce allocation.
In addition, MSCHD will continue to educate the community to increase
stakeholder knowledge of the vector control program and services
provided with the goal of reducing potential negative feedback.

# INTRODUCTION/BACKGROUND:

Memphis and Shelby County Health Department is a joint funded agency of
County and City governments. Shelby County contains seven incorporated
municipalities (e.g., Memphis, Arlington, Bartlett, Collierville,
Germantown, Lakeland, and Millington) and several unincorporated areas.
Shelby County is also the largest county in the State of Tennessee, both
geographically (approximately 783 square miles) and in population
(909,035).

Historically, Memphis and Shelby County has experienced serious
mosquito--borne disease epidemics and outbreaks of Yellow Fever, St.
Louis Encephalitis and West Nile virus resulting in a significant number
of human cases and fatalities. West Nile virus was first identified in
Shelby County, the fall of 2001. The first human cases occurred in 2002,
resulting in 40 human cases of severe illness and 7 deaths. Faced with
the termination of federal grants and a reduction of local funds, MSCHD
focused its efforts on select high-risk census tracts where the majority
of mosquito related diseases were identified. According to the World
Health Organization (WHO) "strategies to control vector-borne diseases
should combine curative and preventive measures, including anti-vector
interventions". For these reasons and to prevent future major human
threats, MSCHD sought to expand mosquito control services countywide,
instead of the previously selected high-risk census tracts within the
county.

In 2004, MSCHD drafted a state ordinance, supported by the County Mayor
to initiate a monthly vector control fee to fund and sustain a
countywide mosquito and rodent control program. May of 2005, the
Tennessee General Assembly authorized Shelby County to contract with a
local utility agency to collect the vector fee, and in August of that
year County Commission approved the contract. With the funding barrier
addressed, MSCHD began implementing vector control services countywide.
The vector control program incorporates a vast array of services (i.e.,
mosquito and rodent control, urban and rural sanitation); this project
however, will only focus on the implementation of the activities and
services involved with the mosquito control management aspects of the
program.

####### ***Problem Statement: Implementation of a comprehensive and integrated mosquito control program, which will provide year round services to Shelby County residents based on scientific driven methodologies.*** 

+------------------+---------------------------------------------------+
| **MEMPHIS AND    |                                                   |
| SHELBY COUNTY    |                                                   |
| VECTOR CONTROL   |                                                   |
| PROGRAM**        |                                                   |
+------------------+---------------------------------------------------+
| **Services       | **Services Provided Post-Countywide Vector        |
| Provided         | Control Program**                                 |
| Pre-Countywide   |                                                   |
| Vector**         |                                                   |
|                  |                                                   |
| **Control        |                                                   |
| Program**        |                                                   |
+------------------+---------------------------------------------------+
| Vector control   | -   Environmental Assessments                     |
|                  |                                                   |
| activities were  | ```{=html}                                        |
|                  | <!-- -->                                          |
| performed based  | ```                                               |
| on               | -   Surveillance                                  |
|                  |                                                   |
| select census    | -   Larviciding, and Adulticiding                 |
| tracts           |                                                   |
|                  | -   Source Reduction (i.e., clearing/cleaning     |
| where the        |     culverts and ditches, tire removal/disposal,  |
| majority of      |     and identifying man made breeding sources)    |
| mosquito         |                                                   |
| diseases were    | -   Complaint Investigations and enforcement of   |
| identified.      |     local and state health codes through          |
|                  |     Environmental Court                           |
|                  |                                                   |
|                  | -   Public Education and Outreach (i.e.,          |
|                  |     door-to-door inspections, distributing        |
|                  |     pamphlets/brochures, media, WNV hotline, and  |
|                  |     civic presentations                           |
+------------------+---------------------------------------------------+

The mosquito control program is designed to be preventive, proactive and
population-based in nature. Activities are primarily directed by
surveillance and are data and science-based driven. Implementation
required the participation of a wide range of stakeholders and
organizations with synergized efforts, interests and strategies.
Collaboration and communication among stakeholders were key factors to
establishing and building community ownership and support. To obtain a
high level of participation, stakeholders from the community were
identified: (1) residents and corporations within the Shelby County
jurisdiction, (2) City, County, and Municipal Mayor's, (3) City Council
and County Commission, (4) environmental and agricultural organizations,
(5) Public Work Directors and Supervisors, and (6) local pest control
operators. Integrated mosquito management techniques were developed to
control and minimize costs and provide the highest quality service
possible. These techniques included multiple forms of control and
targeted different life stages of disease and nuisance mosquitoes.
Efficiency and productivity in the program was gained as control
operations were separated into pest and vector control activities and
then, subsequently into smaller operations targeting specific groups of
mosquito species with shared characteristics.

**BEHAVIOR AND TRENDS OVER TIME GRAPH**

**Shelby County's Mosquito Control Program**

(Pre/Post Countywide Vector Control Program)

+---------------------------------+------------------------------------+
| 1.  Mosquito Control Activity   | 5.  Service Coordination Among     |
|                                 |     Municipalities                 |
| 2.  Workforce Allocation and    |                                    |
|     Staffing Needs              | 6.  Marketing of Vector Control    |
|                                 |     Program and Services           |
| 3.  Public Demand and Interest  |                                    |
|     Level                       |                                    |
|                                 |                                    |
| 4.  Funding for Vector Control  |                                    |
|     Program                     |                                    |
+---------------------------------+------------------------------------+

![](media/image2.wmf)

######### Ten (10) Essential Public Health Services

In 1988 the Institute Of Medicine report "The Future of Public Health",
proclaimed public health to be in disarray and prompted national
discussion about the status of public health. The report defined the
three (3) core functions of public health (*Assessment, Policy
Development, and Assurance)* and later expanded the core functions into
the ***10 Essential Public Health Services*** as depicted in Figure1.

> ![](media/image3.png){width="2.25in" height="1.7722222222222221in"}

Figure 1: Ten Essential Public Health Services

Source: Public Health Functions Steering Committee (July 1995)

This project addresses the following essential health services:

1.  **Monitor** the environment and health status of the community to
    identify environmental health problems such as West Nile virus and
    St. Louis Encephalitis.

2.  **Diagnose and investigate** environmental health problems and
    health hazards in the community.

3\. **Inform, educate, and empower** Shelby County residents about
environmental health (vector) issues in their community by attending
town hall meetings and making presentations to community groups to
increase public awareness of mosquito-borne disease and prevention
methods. Empower municipalities through collaborative efforts.

4\. **Mobilize** community partnerships to identify and solve
environmental health problems. Given today's West Nile virus concerns,
it is essential that MSCHD and municipalities work collaboratively to
identify and solve vector control problems. Mobilizing partnerships will
alleviate jurisdictional boundaries and establish a comprehensive and
countywide program.

5\. **Develop policies and plans** that support individual and community
environmental health efforts.

6.  **Enforce laws and regulations** to ensure the health and safety of
    residents, commuters and visitors of Memphis and Shelby County.

7.  **Link people to needed environmental health services** and assure
    the provision of environmental health services when otherwise
    unavailable.

8.  **Assure** a competent environmental health workforce by hiring and
    training internal and external staff.

9.  **Evaluate** the effectiveness, accessibility, and quality of
    personal and population based environmental health services.

####### **National Goals Supported** 

Shelby County's vector control program activities support and embrace
the objectives of Healthy People 2010 (HP 2010), the National Strategy
to Revitalize Environmental Public Health Services, and the Centers for
Disease Control (CDC) Health Protection Goal -- Healthy Communities. The
HP 2010, health objectives served as a roadmap for diagnosing, assessing
and improving the health of local residents, Tennessee and the United
States. Within HP 2010 there are "Leading Health Indicators" that
provide a snapshot of the health of the nation and serves to provide
guidance and focus for local health departments such as MSCHD.

The techniques used for this project was MAP-IT (Mobilize, Assess, Plan,
Implement, and Track). The first step in building a healthier community
is to mobilize and motivate key individuals and organizations to form a
community-wide coalition. Next, is to assess the areas of greatest need
in the community, as well as the resources and strengths that are at the
disposal of the local health department. Plan the programs
implementation approach by developing the vision and action steps
necessary to achieve the vision. Implement the countywide vector
(mosquito) control plan utilizing concrete action steps and finally
establishing an evaluation process for tracking vector control services
and resources.

This project also supports the goals and activities of the National
Strategy to Revitalize Environmental Public Health Services. The
overarching goal of the strategic plan is to enhance and revitalize the
system of environmental public health services by addressing a broad
range of issues facing states and communities. The following goals of
the National Strategy to Revitalize Environmental Public Health Services
also support aspects of this project:

**Goal I:** **Build Capacity** - improve and support environmental
public health services at the state and local level.

**Goal II:** **Support Research** -- enhance environmental public health
services by (1) defining effective approaches to address existing and
emerging needs, (2) identifying the environmental antecedents of disease
outbreaks, (3) engaging community involvement, and (4) encouraging
innovative environmental public health practices, and services that
emphasize prevention.

**Goal III:** **Foster Leadership** -- enhance environmental public
health services by developing strong working relationships among the
stakeholders in environmental public health services.

**Goal IV:** **Communicate and Market** -- improve communication and
information sharing among environmental public health agencies,
communities, policy makers and others and enhance the significance and
understanding of environmental public health.

**Goal V:** **Develop the Workforce** -- this goal is intended to
promote the development of a competent and effective environmental
public health workforce to deliver contemporary services and address
emerging needs.

**Goal VI:** **Create Strategic Partnerships** -- foster partnerships
among various agencies and entities that influence vector services and
practices. This goal also fosters communication and interaction among
stakeholders and policy makers.

#######  {#section-2 .unnumbered}

#  {#section-3 .unnumbered}

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

# Program Goal 

To implement and coordinate a countywide vector control program in seven
(7) incorporated cities and several unincorporated areas within Shelby
County, Tennessee.

# Health Problem

The first human cases of WNV occurred in 2002, resulting in 40 human
cases of severe illness and 7 deaths. In 2003, there were an additional
10 human cases with 1 death; 2004, 12 cases with no reported deaths;
2005, 13 cases with 1 reported death, and as of December 2006, Shelby
County has experienced 10 human cases with no reported deaths. Before
the implementation of a countywide program services were delivered in
varying degrees within Shelby County. Lack of coordination among these
agencies resulted in gaps in services, slow response time, and an
inefficient use of manpower and resources. In addition, the continued
advent of urban sprawl to surrounding municipalities, further
facilitated the need to implement countywide services to reduce the
number of human WNV cases and/or fatalities, and to address vector
control problems that may overlap and affect outlining municipalities.

# Outcome Objective 

Memphis and Shelby County Health Department worked with public work
officials to discuss and implement mosquito control services in Shelby
County to include: vector service timeline (e.g., answer complaints,
service calls, adulticiding and larviciding -- as area surveillance
dictates), guidelines, goals and objectives. The results lead to
coordinated efforts and an increase in response time.

# Determinant 

-   The number of vector control services performed (i.e., tire
    removal/disposal, Gambusia Affnis-larvae eating mosquito fish,
    surveillance, light traps, adulticiding, larviciding, inspections,
    etc.) countywide

-   The number of municipalities (i.e., officials, staff, or employees)
    who participate in education seminars and training activities

-   Increased resources (i.e., employee, equipment) and training
    opportunities for existing and new MSCHD staff and outlining
    municipalities

-   Cleaning and clearing ditches, culverts, tire removal/disposal, etc.

# Impact Objective 

By January 2007, MSCHD Vector Control will have coordinated and assigned
mosquito control work crews to each of the seven (7) municipalities.

# Contributing Factors 

-   Lack of knowledge of vector control (e.g., nuisance vs. disease
    outbreaks) processes by stakeholders

-   Increased acreage -- Shelby County 783 sq. miles, 7 municipalities
    spread over county

-   Lack of trained, certified personnel to implement vector control
    services in newly acquired service areas

-   Increased public demand and interest -- increased service
    expectations

-   Marketing and education of vector control program to community

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-   Lack of coordinated services among public works
    directors/supervisors, pest control operators and environmental
    health services --vector control management

# Process Objectives 

-   Establish dialogue with municipalities -- articulate services that
    vector control program will provide to service areas (i.e.,
    surveillance, adulticiding, resident adulticiding (spray)
    notification, larviciding, mapping, vector control hot
    line/complaint system)

    1.  Educational activities, and pamphlets geared toward specific
        stakeholders (i.e., residents, municipalities, council members)

-   Provide awareness of vector services to Shelby County residents
    through weekly media releases, and presentations conducted at town
    hall meetings to community organizations, and neighborhood
    associations

-   Development of GIS database system

-   Identify the services that municipalities are currently performing
    and their expectations

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-   Hire additional staff, purchase equipment

-   Draft cooperative vector control plan with input from municipalities

-   Training Opportunities (internal, external)

# 

# METHODOLOGY:

1.  **Event:** Interagency Partnership

> **Activities:**

-   Interagency Meeting (May 2005) - facility tour, overview of services
    and equipment, identification of key personnel and their functions.

-   Discuss strategies for interagency partnership(s)

-   Contact respective area public work directors/supervisors to
    schedule meetings and enlist support for the program

-   Develop a response plan and guidelines -- seek input from
    municipalities

2.  **Event:** Workforce Development & Enhancements -- to address
    personnel issues and the increase in acreage through workforce
    development and technology

> **Activities:**

-   Conduct and participate in on/off-site training sessions

-   Service delivery feedback survey

-   Purchase equipment (spray trucks, computer program/database)

-   Vector control call center/complaint system

-   GIS database and mapping system -- assigns adulticiding (spraying)
    and larviciding sites, assign specific chemical types based upon
    duration and the effect of control, etc.

3.  **Event:** Marketing Campaign -- develop an awareness of the health
    benefits and importance of a vector control fee for service program
    with Shelby County residents

> **Activities:**

1.  Presentations, educational activities, and pamphlets geared toward
    specific stakeholders (i.e., residents, municipalities, council
    members)

2.  Billboards, public service announcements, press releases

3.  Update City and County Elected Officials and Agency Officials (i.e.,
    weekly press releases, updates on hot topics and statistics --
    services provided per municipal area)

# Next Steps & project successES:

1.  Finalize and update countywide vector control interagency program

2.  Quarterly meetings between municipalities to discuss response plan,
    timelines, complaints, etc.

3.  Develop an interagency complaint and call center through Mayor's
    Assistance Center

4.  Conduct a pre/post needs assessment

5.  Customer Service Satisfaction Survey -- service delivery feedback

Countywide response plan (i.e., MOU with municipalities, short term,
long term goals and objectives) will serve as a beacon to guide the
vector control program and activities countywide. The program will
encompass objective measures that the vector control program and its
oversight bodies can look to as an evaluative tool for enhancing
mosquito control processes for the upcoming mosquito season.

-   Measure the effectiveness of surveillance activities, source
    reduction, larvae control, adulticiding, public education and
    outreach in targeted areas.

-   Evaluation component -- data will be collected from all phases of
    the program for the purpose of management, quality assistance and
    accountability:

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-   The number of services implemented based on science driven data

-   The number of services per municipality (by zip code, zones)

-   Adulticide areas by zip code (municipality) and zone in comparison
    to the reported WNV cases

# 

# 

# 

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### **Lorrie D. Clark**

The Environmental Public Health Leadership Institute (EPHLI) has
provided me with a new insight into my leadership style through various
self-assessment tools (e.g., Individual Development Plan, Myers-Briggs
Type Indicator, Change Style Indicator, and Skillscope) utilized
throughout the program. The forementioned self-assessment tools helped
me to closely examine my personality, strengths, weaknessess, how I
perceive information, how my perception differs from others, and how I
should interpet others perceptions and thought process into my daily
work plan.

With new tools i.e., logic models, systems thinking, and communication
strategies available for use, I am now better adapt to systematically
assess, address, and communicate the foundational cause of a problem and
develop long term solutions and strategies insead of quick fixes and
temporary remedies. My broader perspective to problem solving has
assisted me in my decision making process and collaborative efforts with
both internal and external collegues. The institute helped me to gain a
fuller understanding of system dynamics, how things fit and can affect
other things and how these relationships can be used to enhance a wide
variety of circumstances. With the tools I now have, I am better
equipped both personally and professionally.

# ABOUT THE EPHLI FELLOW

Lorrie Clark grew up in Memphis, Tennessee the older of two (2)
children. Ms. Clark was appointed Assistant to the Director, in June of
2005. She is responsible for representing the Division Director in
divisional or community based meetings; implementing special projects
and initiatives, coordinating the budget within the Director's office as
well as monitoring the health department's forty-two (42) grant funded
programs.

Prior to that appointment, she was the Senior Compensation Specialist
for Shelby County Government from 2001 through 2005. Before joining
Shelby County Government, Ms. Clark was previously employed by Memphis
Regional Planned Parenthood as a Health Educator, The United Way of
Mid-South as the Regional HIV Coordinator, Latino Memphis (Hablemos
Espanol Coordinator), and Meharry Medical Foundation.

A graduate of Meharry Medical College, Ms. Clark holds a Masters of
Science degree in Public Health and is currently a Doctoral candidate in
Business Management with a concentration in Healthcare Administration.
Ms. Clark has also sought additional certifications during her tenure at
Memphis Shelby County Health Department: Community Emergency Response
Team Training (CERT), Community Bioterrorism Emergency Response (CBER),
and several National Incident Management System (NIMS) certifications.

She has also been active in many local and civic organizations (e.g.,
NEXUS Leadership Program, Americorps-VISTA, and the Tennessee Minority
Health Summit -- staff member). She currently serves on the Board of the
Exchange Club of Memphis, and is an active member of various
organizations: American Public Health Association, Tennessee Public
Health Association, Mpact Memphis, Tennessee Coalition on Cancer --
Surveillance Committee, American College of Health Care Executives, and
the National Association of Health Services Executives.

**REFERENCES**

1.  U.S. Census Bureau and ACCRA demographics NOW, 2005.

2.  CDC. West Nile Virus Activity -- United States, 2001. MMWR 2002; S1:
    497-501.

3.  CDC. A National Strategy to Revitalize Environmental Public Health
    Services. Atlanta, GA: Department of Health and Human Services. (US)
    CDC: September 2003.

4.  Carl, Osaki, RS, MSPH, Northwest Center for Public Health Practice,
    10 Essential Environmental Health Services.
    ([www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf](http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf))

5.  CDC Health Protection Goals
    ([www.cdc.gov/about/goals/default.htm](http://www.cdc.gov/about/goals/default.htm))

6.  Goodman, M., Karash, R., Lannon, C., O'Reily., W., and Seville, D.
    (1997).

Designing Systems Thinking Intervention. Waltham, MA. Pegasus
Communications, Inc.

7.  Senge, P. (1990). The Fifth Discipline. The Art and Practice of the
    Learning Organization. New York: Doubleday Currency.