examination of the increased risk for falls amongst individuals with knee osteoarthritis. And our presenter today will be Jessica Wong. Sorry, Jessica Wilfong. Jessica is a research associate at the Schroeder Arthritis Institute with the Kremble Research Institute at the University Health Network. She is a member of the Arthritis Community Research and Epidemiology Unit, which partners with Arthritis Society Canada to disseminate information on the prevalence and impact of arthritis in Canada. Her research focuses on investigating the epidemiology of arthritis, primarily osteoarthritis, the most common type of arthritis and the impact and burden in the population. So I will now turn it over to Jessica. Welcome. Okay, perfect. Thank you so much for the introduction. So today I'll be presenting, as Jennifer mentioned, on the examination of the increased risk factor for falls among individuals with knee osteoarthritis. So the objective is to present findings from our published work by the same title, which was published in Arthritis Care and Research earlier this year. So a little bit of background. The burden of falls in the world, the Global Burden of Diseases Study in 2017 listed falls as the 18th leading cause of disability-adjusted life years. And the second, oh, and disability-adjusted life years are defined as the number of healthy years lost due to ill health disability or early death. And falls were also listed as the second leading cause of death due to unintentional injuries in the world. Specifically in Canada, falls are the leading cause of hospitalizations and emergency department visits for injury and trauma. In this report, they found that 72% of emergency department visits made for falls were made by patients under the age of 65, while 71% of hospitalizations for falls were made by patients older than 65 years. So really falls are a problem across adulthood, but you can see that it becomes a bit more severe of an issue in the older age groups. In 2018, they found that falls accounted for $10.3 billion or just over a third of the total cost of injury. So how common are falls? About 20 to 30% of Canadian seniors experience one or more falls per year, and 6% of Canadian seniors experience a serious injury resulting from a fall. And we know that the prevalence of falls is expected to rise with the aging of the Canadian population. So there are three major risk factors, major categories of risk factors for falls. They include behavioral or activity related factors, extrinsic or environment related factors, and intrinsic or person related factors. Now the cause of a fall or multiple falls may result from a complex interaction of risk factors, either between these different groups, even within these different groups. So identifying those most at risk is quite a difficult task. Just to go into some more details here, the some examples of behavioral factors or those external factors that may result in a fall are lack of physical activity, risk-taking behavior, poor nutrition or hydration, alcohol intake, especially excessive, and improper medication use. Some example of extrinsic or those environment related factors are falling on the stairs or steps, falling due to tripping hazards, having a lack of adaptations, inappropriate walking aids, footwear and clothing, poor lighting in your environment or unstable furniture. And finally, some examples of intrinsic or those person related factors are advanced age, having a history of falls, having previous fractures, especially in the lower limbs, having impaired balance or gait, poor vision, pain, being on certain medications, and having certain comorbidities or chronic conditions. One of which, for example, is Neosteoarthritis or OA, as I'll be referring to it throughout the presentation, which is of particular importance and interest in our group. So a little bit of background on NeoA, just very basically it's a generative joint disease of the knee. It results from the breakdown of cartilage in the knee. So as you can see on the left, we have an image of a healthy knee joint. At the top, you can see articular cartilage, which is a tough, rubbery tissue on the ends of the bones that allow you to bend and move your knee. And then below that, we have the meniscal cartilage, which absorbs shock from pressure and load on your knee. Now, OA has often been described as being caused by wear and tear of the joint associated with aging, which has led to the misbelief that OA is an inevitable result of use of a joint over time. It's now understood that OA is actually a result of a body's failed attempt to repair joint tissues that are damaged due to things like abnormal joint loading, joint injury, and inflammation. So in a healthy joint, our cartilage is being broken down and regenerated in harmony, and that's facilitated by healthy movement of the joint. But in OA, that occurs when there is more degeneration than regeneration, which we can see in the knee joint on the right side there. Now, when the cartilage breaks down, we lose some of the joint space between those two pieces of cartilage. And when the cartilage breaks down, the bones in the knee joint rub together, and this can cause friction, which results in pain, stiffness, and swelling. And importantly, in the context of fall risk, can cause knee instability and the feeling that the knee could buckle or give out. So how common is knee OA? There's an estimated 15% of Canadian adults age 20 plus are diagnosed with OA in general. Now, we don't have good estimates of knee OA specifically in Canada, but we do know that knee OA is the most common form of OA. And there was a study that came from residents in Alberta, which estimated the prevalence of knee OA to be about 11% for adults age 18 plus. So really, it's a very prevalent condition in the country. Here we have a graph, which is based on data from the Canadian Chronic Disease Surveillance System. It depicts the prevalence of OA and Canadians age 20 plus over time from 2007 to 2021. So here on the left Y axis, we have the percent of people with diagnosed OA in Canada. And on the X axis here, we have the fiscal year from 2007 to 2021. The males are represented by the lighter green triangles at the top there. And then males are the yellow squares. And we have both sexes together represented by the dark green circles. As you can see, the trends depict the increasing prevalence of OA over the years, regardless of sex. And this prevalence is predicted to continue increasing as the Canadian population ages, just as we predict that falls prevalence will increase as well for the same reason. So now putting everything together, knee OA is a known risk factor for falls. And we know that fall prevention is also an important clinical target among individuals with knee OA because falling can cause further damage to the joint and other injuries leading to decreased physical activity and social participation. Data from a representative national sample in the US showed that older adults with arthritis are at an increased risk of fall-related injuries and are more than twice as likely to have recurrent falls. That's defined usually as falling two or more times within a year. And this is all compared to people without any arthritis. This is important as recurrent fallers are known to experience worse health and negative outcomes than those who are not recurrent fallers. We also, there is also research that shows that older adults with knee OA are at an increased risk of recurrent falls regardless of the severity of their OA. Now, knowing all we know about the relationship between knee OA and falls, unfortunately the mechanisms and risk factors contributing to falls in individuals with knee OA is not yet fully understood. There was a recent review, systematic review of risk factors for falls in individuals with knee OA, but it only yielded very few articles that met their inclusion criteria. And just to quickly summarize, their inclusion criteria was simply studies involving individuals with knee OA that was confirmed either using standard classification criteria or self-reported doctor diagnosis among people who were older than age 18 and had to have a history of falls. So really not a very stringent inclusion criteria despite only finding a few articles that fit. After reviewing what few articles were available, the authors graded the risk factors for falls identified in the studies as having strong, moderate, limited or conflicting evidence supporting them. As you can see here, no risk factors were found to have strong evidence of being associated with falling among individuals with knee OA. Factors with moderate evidence were impaired balance, decreased knee muscle strength, increased number of symptomatic joints and comorbidities. Limited evidence was available for knee instability, the use of walking aids and impaired proprioception. And just quickly, proprioception is basically our ability to know where and how our body is oriented in our surroundings. And finally, with conflicting evidence, they found pain. So it's important to highlight here that the grading of a strong and moderate level of evidence for these risk factors was hampered primarily by the low number of studies available, not the quality of the studies themselves. On an individual basis, all but one study included in the review was rated as high quality. The main conclusions from this review were really that we need more evidence to be able to make stronger conclusions about what the risk factors were falling are among individuals with knee OA. And this is exactly what we set out to do. So the purpose of the current study was to better understand more about the nature of falls among individuals with knee OA using a Canadian population-based longitudinal study. So longitudinal study is just a study that looks at the same participants over a period of time. We broke this down into four main objectives. First was just to confirm knee OA as a risk factor for falling in our specific sample. Second, we wanted to characterize the profile of risk factors for falling separately among those with and those without knee OA. Our third objective was to examine the context surrounding a fall, including where and how the fall occurred, so getting some of that environmental context. And then fourth, because recurrent fallers are known to experience worse outcomes and those with knee OA are more likely to be recurrent fallers, we wanted to look specifically at those risk factors that contribute to an individual with knee OA experiencing two or more falls in our fourth objective. So heading into some methods. We used the baseline and three-year follow-up of the Canadian Longitudinal Study on Aging. Specifically, we used the comprehensive cohort, which includes just over 30,000 individuals, age 45 to 85 years at baseline. Now, in our analytic sample, we included both those who responded yes and no to the question, has a doctor ever told you that you have osteoarthritis in the knee? But for those who responded no, we excluded any individuals who responded yes to any of the other questions about other types of arthritis in the CLSA, which includes OA in one or both hands, OA in the hip, rheumatoid arthritis, or the question on any other type of arthritis. This way we could create a clean no arthritis group. So this exclusion left us with a final analytic sample of nearly 22,000 individuals with and without knee OA. Our primary outcome, we defined an injurious fall within the past 12 months reported at follow-up one. So this was determined if a respondent answered yes to the question in the last 12 months, have you had any injuries that were serious enough to limit some of your normal activities? And also answering yes to the question, was this injury or were any of these injuries caused by a fall? Those who responded yes to both were then asked how many times they had fallen in the past 12 months, and we categorized the number of falls as none, zero, one, or multiple, which was defined as true or more. Participants were then asked, where did this fall happen? Now, this fall refers to the fall which occurred within the past 12 months that caused the most serious injury or problem to the participant. They were provided the response options of the fall happened inside of their home, outside of their home, but inside a building, or outdoors. Just for simplicity, we decided to combine those first two groups to have indoors and outdoors. Then participants were asked, how did your fall happen? For those who fell indoors or outdoors, they were provided response options in the middle there, standing or walking, fell well on the stairs or steps, fell well exercising, fell from a height or other. Specifically those who fell indoors were also provided the options that they fell from the furniture, they fell getting in and out of the bathtub, or they fell getting in or out of the shower. And for those who fell outdoors, specifically they were provided the option of if they fell on the snow or ice. So again, to simplify things, we recategorized a bit. We kept standing or walking as a lone category, on the stairs or steps as a lone category, and exercising as a lone category. But then the remaining reasons were then lumped into a general other category, specific to whether the fall occurred indoors or outdoors. We had many predictors of interest that we wanted to look at. These were all characteristics reported at baseline that we wanted to assess to see if they predicted a fall reported at follow-up. So some of the predictors of interest, of course, NEOA is one of the major ones. We wanted to see if reporting a baseline injurious fall was predictive of falling later, age at baseline, BMI, alcohol use, knee symptoms, which were defined as in the past four weeks, having knee pain on most days, having knee pain while climbing downstairs or walking down slopes, or experiencing knee swelling, a lower body fracture, which was defined as reporting ever having suffered a break or fracture of the hip, leg, knee, ankle, foot, or toes. We were also interested to see if self-rated vision predicted falling, and whether certain chronic conditions and impaired physical performance predicted falling. And we're gonna go into more detail about those final two points in the following slides. So chronic conditions we were interested in all have some form of research around them that have connected them with falls. As we were interested in respiratory conditions, cardiovascular disease, urinary incontinence, neurologic conditions, diabetes, high blood pressure and depression. And for those final three, diabetes, high blood pressure and depression, participants were also considered to have the condition. If they reported taking medication for the condition as well, as medications for these three conditions specifically have also been shown to be associated with falls. Now moving into the physical performance measures we were interested in. First, we looked at the standing balance test, which is the time and seconds for how long a participant is able to balance on one leg before their foot touches the ground or they lose their balance and touch the wall in front of them. Based on previous research done using CLSA data, we chose a cutoff of 4.5 seconds, such that if a participant balanced for 4.5 seconds or less, this was considered impaired balance. Next, we looked at the timed up and go test. This is the time and seconds for how long it takes a participant to stand up from an arm chair, walk three meters, turn around, walk back to the chair and sit down again at their normal pace. Again, we used the same study to choose a cutoff of 14.2 seconds, such that if a participant took 14.2 seconds or more to perform the task, this was considered impaired mobility. Finally, we looked at the chair rise test. This is the time and seconds. It takes for a participant to stand up from a chair and sit back down five times as quickly as possible with no rest in between. Using the same study, we identified a cutoff of 15.9 seconds, such that if a participant performed the task in 15.9 seconds or more, this was considered impaired balance and coordination. Now, moving on to the findings. Some general characteristics of the sample, we found that 19% of the sample reported NEOA. Now, this prevalence of NEOA is a bit higher than I reported in the background slides, but that's just because participants in the CLSA are a bit older. And as we mentioned, the prevalence of NEOA increases with age. Now, of those just over 4,000 individuals with NEOA, 10% reported having at least one injurious fall at follow up. This breaks down to 6% who reported one fall and 4% who reported two or more falls. Now we'll go objective by objective with our findings. Again, just a reminder, the first objective was to confirm NEOA as a risk factor for falling. So this is one of our figures in our published paper. On the y-axis here, we have the percent or proportion of people who report a fall. And on the x-axis, we have arthritis status and age group. So we can compare between those with and without NEOA within each age group. The black portion of the bar indicates the percent of people that reported having just one fall at follow up. And the lighter gray portion indicates the percent of people that reported having two or more falls at follow up. So together, the full bar indicates the percent of people that reported having one or more falls at follow up. The error bars there are the 95% confidence limits for that overall percent of people reporting one or more falls. So based on the confidence limits and the fact that they do not overlap, we can see that the proportion of people reporting one or more falls is significantly higher among those with NEOA compared to those without within each age group. This is our published table one. I will walk you through it. No need to get bogged down in all the numbers here. But just to orient you here on the left, we have those baseline characteristics or those variables we wanted to see if they predict falls that I listed out earlier. And up here, we are stratifying by those with NEOA and those without NEOA. And then within each of these groups, we're making comparison between fallers and non-fallers. And I'll just highlight here that the values in the table are percents. So the percent of people who report these baseline characteristics. And I will highlight the important findings here. We found that fallers are more likely to report at baseline and injurious fall, knee symptoms, lower body fracture, various chronic conditions, and impaired physical performance. And these differences are seen among both those with and without NEOA, with very little difference between the two groups. So first statistical analysis, we wanted to see which of these baseline characteristics would indeed predict reporting a fall at follow up compared to not. So therefore we use the logistic regression analysis, which is a common statistical tool for modeling the probability of a binary or two option outcomes such as we have here. Did someone fall? Yes or no. This is our table two, the results from our logistic regression. So just again to highlight on the left here, we have those same baseline characteristics we've been looking at. And this time we have three separate logistic regressions. Right now we're just focusing on model one in the first column, which includes the full analytic sample, both those with and without NEOA. The values in the table are odds ratios, which are very basically a numerical measure of the relationship between the baseline characteristics and the occurrence of a fall. So here we see, I'll highlight the main finding. So here we see that the odds ratio for the baseline characteristic of having diagnosed NEOA is greater than one and the confidence interval does not overlap one and is therefore statistically significant, which in summary means that the risk or odds of falling is indeed significantly higher for individuals with NEOA compared to those without. So we've confirmed objective one in our sample. Onto objective two, which was to characterize the profile of risk factors for falling among those with and without NEOA. So we're going back to that same table, only now we're focusing on these final two columns. Model two includes just those with NEOA and model three includes just those without NEOA. Highlighting the important findings here, we found that significant risk factors among both those with and without NEOA were having a baseline fall and having a lower body fracture. Now highlighting the findings that were unique among those with NEOA, we found that urinary incontinence and having a neurologic condition were significant risk factors for falling among those with NEOA. And finally highlighting those findings just for those without NEOA. We found that the significant risk factors for falling among those without NEOA were being female, having depression or taking medication for depression and having impaired balance. So we've really highlighted two different risk factor profiles, but there are quite a few similarities between the two groups as well. So onto our objective three, which was to examine the context surrounding a fall, including where and how the fall occurred. So here for this objective, we took only individual to experience the fall from the analytic sample because these would be the only people who answered the questions about where and how the fall occurred. So just looking simply at that indoors versus outdoors variable, we found that individuals with NEOA were significantly more likely to report falling indoors compared to those without NEOA. So that's almost 47% of people with NEOA reporting falling indoors compared to just 39% of people without NEOA. We do see a difference in who fell outdoors with more people without NEOA reporting falling outdoors, though this difference was not statistically significant. Now just looking at those who fell indoors, we're looking at how the fall occurred. So for those who fell indoors, those with NEOA were significantly more likely to say they fell while standing or walking compared to those without NEOA. Those without NEOA were much more likely than those with NEOA to report that it occurred while on the stairs or steps or while exercising, though these differences were not statistically significantly different. We speculate that it's possible that individuals with NEOA, especially those experiencing knee pain or other symptoms may use more caution when walking down the stairs or steps or while exercising or potentially avoid these activities altogether, which may result in these differences. Next, just looking at falls that occurred outdoors. Again, we see that individuals with NEOA were significantly more likely to report falling while standing or walking compared to those without NEOA. And they were also slightly more likely to report falling on the stairs or steps. So again, this isn't significant. Those without NEOA on the other hand were most likely to report exercising or an other reason as the cause of their fall, which if you remember other for outdoors, including falling on the snow or ice. Again, we suggest that the latter two activities are potentially activities that someone with NEOA may exercise greater caution while attempting or avoid altogether. I also want to pause here to acknowledge that those with NEOA were only significantly more likely to report having an injurious fall while doing very basic physical activities such as standing or walking, which is truly the only unavoidable activity on the list here. And now on to our final objective, which was to identify risk factors that contribute to an individual with NEOA experiencing two or more falls. So we're gonna bring you back to the figure we showed you right at the beginning. And we see that although there are some differences in the number of people with NEOA who report having one fall, again that black part of the bar, the biggest differences between those with and without NEOA are in the percent of people reporting two or more falls or those recurrent fallers as we've been calling them. Just as summary, overall among those with NEOA, 6% reported one fall and 4% reported two or more falls, whereas in those without NEOA, only 4% reported one fall and just 1% reported two or more falls. So therefore for this final objective, we wanted to focus on just those individuals with NEOA and what predicts reporting zero, one or multiple falls. So here's our table with the values in here, the percents again, so the percent of people reporting the different baseline characteristics. But this time we're just looking at individuals with NEOA and we're stratifying them by whether they experienced zero falls, one fall or two or more falls. If you remember, and then highlighting the important findings, individuals with NEOA who reported two or more falls were more likely to report a previous injurious fall, knee symptoms, a lower body fracture and impaired physical performance compared to those reporting zero falls or those reporting one fall. So now if you remember before, our outcome had two categories. Did someone fall yes or no? Here we have three possible outcomes. Did someone fall no yes once or yes more than once? So therefore we have to use a different statistical tool because there is a clear ordering of the categories of the outcome. We started with an ordinal logistic regression. So this statistical tool assumes something called the proportional odds assumption, which is basically that for each of the baseline characteristics included in the model, the effect of the characteristic is consistent or proportional for each increase in the level of the outcome. In our case, this would mean the effect is the same whether we are comparing one or two or more falls to none. So comparing any number of falls to none or whether we are comparing multiple two or more falls to either zero or one falls. Using a score test, we found that the proportional odds assumption was violated and therefore we used a different statistical tool called a partial proportional odds model, which I will walk you through the results of in the following slides. But basically for the predictors where the assumption is not violated, we can present one cumulative odds ratio as we've been doing previously. And for the variables where the assumption is violated, we present two separate odds ratios for those two separate comparison groups we identified. So looking at that, this is our table with the results of the partial proportional odds model. Again, the values in the table are odds ratios. And just to highlight the significant findings here, we see similar findings to what we had before when we were looking at the risk factor profile among those with NEOA. We have baseline fall, lower fracture, urinary incontinence and neurologic conditions, which should all be familiar. But now we also have two novel risk factors that appear, having a respiratory condition and having impaired balance. So we're gonna go through groups of these bit by bit. So first highlighting those risk factors which did not violate the proportional odds assumption. So therefore we have one cumulative odds ratio to present. Here we find that having a lower body fracture and having urinary incontinence were both significant predictors of reporting any number of falls that follow up. And the effect was the same regardless of the comparison groups. Next, having had a fall at baseline and having a neurologic condition were also risk factors for having any number of falls that follow up. The difference here is that the proportional odds assumption was violated. So therefore the risk is different whether we are comparing any number of falls to none here or whether we are comparing multiple falls to having zero or one fall. As you can see here for both factors, the risk is higher for experiencing multiple falls than it is for experiencing any number of falls. So that was an interesting finding. Next, we'll highlight those two novel risk factors having a respiratory condition and having impaired balance. For both of these risk factors, the proportional odds assumption was also violated. But in this case, the odds ratio for experiencing any number of falls was not significant. So, but the odds ratio for experiencing multiple falls was significant. So having a respiratory condition or impaired balance are only risk factors for experiencing multiple falls. And the lack of association with experiencing any number of falls is why we did not see these risk factors emerge in our previous logistic regressions. So doing this method has really revealed other potential risk factors among people with NEOA. So that's the end of our published results. In response to our publication, we did receive a letter to the editor highlighting some concern about potential residual confounders we had not considered in our study that may, in their opinion, impact our study results and conclusions, namely our finding that NEOA is an independent risk factor for falls. So in the following slides, we'll highlight some of their concerns as well as our response. So first, they were concerned that we could, we did not consider the severity of chronic conditions that we included in our model and that it may affect the study results and conclusions. And we agree that this is a potential issue if the severity of chronic conditions differs between those with and without NEOA. Now, we unfortunately do not have the data to determine whether there is a difference. However, even if it is the case that co-occurring disease severities are greater among those with NEOA and this contributes to increased falls in this group, the fact remains that for those living with NEOA, there is an increased risk of falls. So we don't predict that including this would have any effect on our study results and conclusions. They were also concerned that we did not consider the severity of NEOA specifically. And again, we agree this is a potential issue if the risk of falling differed across different levels of NEOA severity. And again, this is unfortunately not something we have the data to look at. But as we cited in our background, both in this presentation and in our published study, there was a study conducted that found that while there was a small degree of elevated fall risk with increasing NEOA severity, the risk was still significant among those with mild disease. So as our population-based NEOA sample as we have here likely includes individuals with a full range of OA severities, we believe our findings still support that fall prevention efforts should focus on all stages and severities of NEOA and that NEOA is still an independent risk factor for falling regardless. And finally, there was some concern that we didn't include chronic kidney disease. Again, we agree this may be a potential issue if there are differences in the prevalence of chronic kidney disease between those with and without NEOA. And there is some evidence that has shown chronic kidney disease to be associated with fall risk and the variable is readily available in the CLSA. So we decided to reanalyze the data. And this was the table that we included with our response. You'll be familiar again with those baseline characteristics on the left. This model one here is the same model as we included in our original paper. And now model two here is the same exact model just adding chronic kidney disease into the model. So highlighting the important findings for chronic kidney disease and Neosurethritis, we found that chronic kidney disease is indeed a significant risk factor for falling. But the risk of falling remains significantly higher for individuals with NEOA compared to those without. So there's no impact on our conclusions based on including this extra variable. So moving into some strengths of our study were the use of a large longitudinal population-based sample, namely the CLSA. This allowed for the inclusion of adults with NEOA across a wide range of ages from middle-aged to elderly adults. And in fact, very few population-based studies ask about OA specifically as opposed to the general umbrella term of arthritis, which includes over a hundred different conditions. And even fewer studies ask about OA in specific joints. And it is a great benefit to our research that the CLSA does include this more specific information for a few select joints, specifically the knee, hip, and the hand. So it would also be beneficial to have information about OA as a whole disease, which can occur in any joint in the body. And as this disease, which impacts such a large proportion of the population, especially among older adults. And OA is associated with the presence and management of other conditions, which affect the elderly, and therefore is really an important, it's really important to understand from a population-based perspective. Another huge strength due to the CLSA was the ability to stratify by the number of falls. So because we know from previous work and reiterated in our findings, there are important differences between recurrent and non-recurrent fallers, which we are able to dive deeper into. Some limitations of our research, the self-reported nature of the question about falls. So some researcher shows that individuals with poor cognitive function are less likely to recall falling in the previous 12 months. Up of participants in the CLSA were screened for mild cognitive impairment at baseline and follow-up. So this is likely not a significant issue. There's also the self-reported nature of the question about NEOA, which may introduce some recall bias, but self-reported OA has been found to be a valid measure of the prevalence in population-based surveillance studies. So again, likely not a significant issue. We were also unable to assess the contribution of many of the extrinsic or behavioral factors that were listed, and further research would benefit from being able to dive into those and examining the interaction between those and the intrinsic factors that we examined today. And we also used a very specific definition for falls. So with this, we just need to keep in mind that our findings are specific to injurious falls and may not be generalizable to falls which do not result in an injury. So in conclusion, a quick summary of our findings, we found that NEOA is indeed an independent risk factor for experiencing one or more injurious falls. We found that urinary incontinence and neurologic conditions were unique risk factors for falling among those with NEOA and potentially important clinical targets. For fall prevention, we also found it's important to consider environmental factors when assessing the risk of falling among those with NEOA. And really to acknowledge again, that those with NEOA were only significantly more likely to report having an injurious fall while doing very basic physical activities such as standing or walking. And that really reflects what a problem this is among that group. Finally, we found that the fall risk profile differs for those with NEOA who experienced multiple falls. We found that respiratory conditions and impaired balance were only risk factors for recurrent fallers. So our finding support that fall prevention is an important clinical target, especially among individuals with NEOA as falling can cause further damage to the joint and other injury. Our study provides important modifiable intrinsic risk factors and important target environments associated with falling among individuals with NEOA that may provide opportunities for clinical intervention and fall prevention strategies. So just a quick thank you slide. Special thank you to my co-authors on this project, Lisa Badly and Anthony Pruccio and the entire team at ACRU. I'd also like to thank Arthritis Society Canada with whom we have collaborated with on a number of arthritis projects. And of course, thank you to the CLSA for providing the data that made this project possible and for allowing me the opportunity to present her findings to all of you today. Great. Thank you very much, Jessica. I think lots of questions have come up already and I'm sure people have lots that are spinning around in their mind. I guess the first one, which is a great place to start is a definition of osteoarthritis. I don't think you put one at the beginning and normally sometimes that's a place to start, but what was your definition that you used? So I defined, sorry, I'll just scroll back, I defined NEOA in particular, but just to, OA can occur in any joint and is very similar in different joints. So it's just a degenerative joint disease and it results from the breakdown of cartilage in whatever joint that it's in. So whether it's injury or inflammation, there's too much breakdown of the cartilage and not enough regeneration of the cartilage. And as I said before too, it was often defined as a wear and tear disease, but we now know that it's actually OA in general as a result of the body's failed attempt to repair joint tissues. And so it's really a whole body disease that's likely incorporating systemic inflammation and other issues that really just break down the ability of the joint to function properly. Great. And in terms of specifically NEOA, the question is wondering how is NEOA diagnosed in the CLSA data and what criteria was used? Yep. So in the CLSA, Neosterearthritis was defined if a participant self-reported, doctor diagnosed NEOA. So there was one question that asked if a participant had been diagnosed with NEOA and if someone indicated that yes, they had been diagnosed by a doctor, then we considered that a diagnosis of NEOA. Great. Now we have a couple of questions from Denise. So the first one is, you showed respiratory conditions increase the risk for falls. Any thoughts on why this may be the case? Yeah, good question. So I had to do a little digging on that because we weren't sure why that showed up either. But it turns out that having a respiratory condition such as COPD or asthma can prevent blood from being properly oxygenated. So that means that the lungs and brain aren't receiving enough oxygen and this can lead to chronic dizziness. This is especially a problem when going to a standing position from laying or sitting. And generally lack of blood oxygenation can also cause weakness in the legs and balance issues, both of which can certainly contribute to the risk of falls as well. Yeah. And just to follow up because another condition that we had had some questions about why it might cause more falls was urinary incontinence. But like respiratory conditions, NEOA is associated with difficulty moving to a standing position from laying down or sitting just due to basic balance impairments and mobility limitations. And this may contribute to slowness which leads to an increased risk of falls in response to urgency to get to the bathroom in a timely manner. So I think you answered the second question as well which was other factors you were able to consider what else might be contributing to falls in people with knee OA? Great. Then I will go on to the next one from Shannon. Hi, Jessica. That was a great presentation. You presented in a very professional and relatable way. I'm wondering if you looked at any self-reported quality of life impact differences between knee OA, between the knee OA group and the non-OA group? That's a great question. That's not something that we looked at but definitely something that would be interesting to look at. Again, I think we do know that quality of life due to pain, activity limitations, all these symptoms and multiple joints, the quality of life is quite a bit lower in people with knee OA compared to people without knee OA. And I would imagine that we'd see the same thing among fallers in the two groups as well. Great. Well, those are all the questions we have. So if anybody has any last questions and wanted to pop them up, we do have a few more minutes. But maybe I'd like to just might as well move to thanking you now. And we really appreciate researchers like you coming to these webinars. We always have a good group of researchers and CLSA participants that attend. I'd like to remind everyone that the next deadline for data access is January 17th of 2024. You can visit the CLSA website under Data Access to review what data is available as well as additional details of the application process. I'd also like to remind everyone to complete their anonymous survey before you exit today. And before we move on to the final slide though, we do have time for a couple questions that did come in. So I'm gonna go back to questions now. So the question is, did you consider diseases like neurological problems like dizziness or migniers? I don't even know, mine ears. Maybe you know what that is. And the non-clinical me does not. Yep. So we did look at neurologic conditions, not that one specifically. But I believe this included multiple sclerosis, Parkinson's disease, and maybe dementia was the other one. And we did find that neurologic conditions did play a role in increasing the risk of falls among those with NEOA. This is likely due to the fact that these neurologic conditions really affect the brain and central nervous system, which are key to maintaining balance and our compensatory actions to avoid falls. So sort of a comment slash question. It's interesting that the function measures like impaired balance were not significantly related to the fall risk in NEOA patients in the multivariable model. Any speculation on why that relationship would be weaker in this group? Yeah, so we found it interesting as well that we didn't see this relationship come up among people with NEOA, as you can see on this slide, in the original analysis. But then when we looked at the risk factors for multi-joint, sorry, multiple falls, we did find that impaired balance did come up. So it's just a matter of the fact that impaired balance may not be a risk factor for just experiencing one fall among those with NEOA, but it certainly is a risk factor for being a recurrent faller among those people with NEOA. Okay.  Do you, oh, and Alham clarified that it was Meniere disease. That's what I thought it was when you typed it in. But so the question was, you commented on fall prevention strategies? Yeah. So we think that the results of this study are key indicators of some potential fall prevention strategies. So we've identified intrinsic and also modifiable risk factors. So we have things like urinary incontinence or a neurologic condition. If we can do things to treat those, maybe we'll reduce the fall risk within people with NEOA. Unfortunately, there's not much we can do except to prevent falls in the first place or preventing lower fractures in the first place to take care of those other risk factors. And again, treating respiratory conditions, even training balance because there's a lot of exercises that can be done to help people improve their balance that may also help prevent falls. And the next CLSA webinar is going to explore the topic, successful aging in Canada, findings from the Canadian longitudinal studies. And it will be presented on Tuesday, December 19th at noon Eastern time by Dr. Mabel Ho of the Factor Inventosh Faculty of Social Work at the University of Toronto. Registration details for the webinar as usual will be posted on our webinar. And they're also available in the chat box of the webinar today. And then finally, if there are any other additional questions, I'm sure Jessica would be able to, would be happy to answer them if you emailed her directly or you can email them to us at the CLSA. And I guess the last thing is just remember that the CLSA does promote the webinar series using the hashtag CLSA webinar. And we do invite you to follow us on Twitter as well at CLSA underscore ELCV. So thank you again and I wish everybody a wonderful day.


Let me ask you about just Jay Prince.  How was it, you know, just your relationship with Jay? Oh man, Jay has been like an uncle and a brother. You know, we used to do concerts a long time ago. Okay. And that's how we met Jay Prince. Yeah, we on Boss Talk 101. Yeah. That's something to be proud of too. Most people don't even look at it in a way where they think it's tough because you get locked up. But really, I don't define it that way. You don't get no purpose for being locked up. That just means you got cold. That's right. That's correct. Let me ask you about just Jay Prince.  How was it, you know, just your relationship with Jay? Oh man, Jay has been like an uncle and a brother. You know, he, we used to do concerts a long time ago. Okay. And that's how we met Jay Prince. So back in the 90s when we were doing shows, but it wasn't, it wasn't people in the communities doing shows like the shows we were doing. So when they came and seeing some black people having shows in arenas and there was a bunch of people there and everything was peaceful and everything, you know, they was interested in seeing like, who was this that was doing it? And from there, we met and the relationship just grew over years.  You know how far back that is, that's the 90s. So we stayed in touch and, you know, the relationship got real from there. Yeah, he spoke, you live about your father, you know what I mean? In a good place, I think I even married him on some of the songs. And he meant to visit him and all that. That's right. You know what I mean? So he knows him compared to people just think that he's on supporting him or hopping on the bandwagon. He actually knows him. Yeah, yeah. And that's a real, that's a real situation. What is, does your, I'm gonna say, what is your, I'm gonna ask, what is, do you think that there is a solution to like, what's going on in the show right now? Like, what's the ultimate solution to try to, or is there one to kind of get people in another kind of mind frame, outside of the one hand up there, the youth? All right, that's a, I say that's a couple things that need to be done, you know what I mean? As far as a solution, right now, people go out to accept their losses and move forward with their life. Yeah. You know what I mean?   You know what I mean? That's one thing, then you have to have a different outlook on why is everybody shooting each other? Like, it's no reason to be trying to, you know what I mean? Kill each other over everything. You know what I mean? Every argument or disagreement is worth somebody pulling out a gun and shooting somebody. Then everybody is the stick up man. There's always been stick up man, but now everybody is robbing everybody. They're not just robbing people. They're killing people. You have what you wanted from them and they're still killing. Like, why is everybody just killing? Why is it no respect for life? Like, you're really not that hopeless. It's okay to live life a regular way, to work a job, to work your way to what you want. Everything don't just come right away. But we want everything now and right away. Does it seem like the city's doing something? Does it seem like they trying to do something? Does it seem like they just letting it happen? It's for the most part, it's a lot of just kind of letting it happen. You know, they try to pay organizations to curb the violence or try to go see what happened after it happened, but it's a lot of things that need to be preventative before it gets to that point. Like, the kids need to start learning how to relate and deal with each other before they even get to the age where they're ready to take each other's heads. And they need to learn how to do all that. Yeah, we on Boss Talk 101.


Okay, I'd like to call the order of the Sheboygan County Board of Supervisors meeting of Tuesday, September 17th. Certification of compliance with the open meeting law. The agenda was posted on the 13th of September at 3.30 p.m. Please join me in the Pledge of Allegiance. I pledge allegiance to the flag of the United States of America and to the Republic for which it stands, one nation, under God, indivisible, with liberty and justice for all. Thank you. Roll call. 23 Supervisors present. Can you hold it off a minute? Cheryl Ed is walking in as he walks up. He can push his button. That's okay. I hate the really out of order Supervisor Baumgart because that was so funny. That was unbelievable. That was good. That was good. 24 Supervisors not present. Thank you. Approval of the August 20th, 2019 Journal. Supervisor Glavin. Move to approve. Thank you. Supervisor Glavin. Supervisor Aten. I'll second that motion, Mr. Chairman. Thank you, Supervisor Aten. Any questions or discussion? Seeing no lights, please push your aye or nay button. Motion to approve unanimously. Thank you. Consideration of appointment by chairperson. To you, County Board, Jacqueline Bellman of Cascade. I think you received the information on this. I'm just going to briefly say she's a town chair person out in the town of Mitchell.  But as I said to people, you only need one really good applicant. I think she's an excellent candidate. I'll be perfectly honest. I think I speak for Vern when I say we both interviewed her. She impressed both of us with her knowledge and background. And I think she's committed to the County Board. So I'm very pleased to submit this for your approval, hopefully. Supervisor Gehring. Thank you, Mr. Chairman. I move to concur with the appointment of the chair. Thank you, Supervisor Gehring. Supervisor Abler. I support that motion. Thank you, Supervisor Abler. Are there any questions or discussion? Seeing no lights, please push your aye or nay button. Appointments approved unanimously. Thank you very much for that. Consideration of appointments by Executive Committee. To the Transportation Committee, Jacqueline Veldman, and to the Health Care Center Committee, Jacqueline Veldman. Just real briefly, I just wanted to point out, the executive committee supported me in this. And as with six months ago, frankly, I didn't want to play musical chairs and move a bunch of people around. I also happen to think Jackie's very qualified, not that there wouldn't be other people who are qualified. She's particularly qualified relative to transportation. She's done a whole lot of things out there. So I just thought to move her into Dick's two positions for the last six months would be better than doing a bunch of musical chairs. So that was my decision-making, if you want to. I always like to share that with you, so. Supervisor Gehring. Thank you, Mr. Chairman. I move to concur with the appointment of the chair. Thank you, Supervisor Gehring. Supervisor Glavin. Second. Thank you, Supervisor Glavin. Are there any questions or comments? Seeing no lights, please push your aye or nay button. Those appointments are approved. 23 ayes, one nay. Thank you very much. I did want to point out that Jackie is not here tonight. She had a previous, I think it was some sort of banquet that she's involved in running in that. And this came up, obviously, fairly quickly. So she's not here. She'll be sworn in tomorrow. And we'll assume her position beginning tomorrow. But I wanted to let you know otherwise you'd be able to meet her. But because of that, and I fully understood that it happens within a month and people have plans sometimes. So she felt bad about it, but those things do happen. So thank you. Consideration of appointment by county administrator. Aging and disability advisory committee. Reappointments. Joanne Van Horn-Wheeland. Jim Gilligan. David Williams. Derek Mench. Mary Newecke. And Teresa Gessler. Okay, if people are comfortable, we can take them all at once. Surveyser Obler. I'd move to approve the county administrator's appointments, Mr. Chair. Thank you, Surveyser Obler. Surveyser Procek. I will support that recommendation. Thank you, Surveyser Procek. Any questions or comments? If not, please push your iron A button. Those appointments are approving endlessly. Thank you. Consideration of appointments by the county administrator. And we'll take these all at once unless there is objection. Surveyser Tostrodi. Thank you. Mr. chair, I'll move for approval. Thank you. I'll second that motion. Thank you. I think we're moving too fast here, so we're going to give Cheryl a minute. in that motion. Thank you, Supervisor Zigabarra. I think we're moving too fast here, so we're going to give Cheryl a minute. Doot, doot, doot, no number. Who made the motion again? Do you have it, Cheryl? Okay, now we may vote. Disappointments are approving unanimously. Thank you. Presentation. Matt Stripmoder from Health and Human Services Director and Diane Leibenthal, Health and Human Service Division Manager of Public Health Importance and Immunizations. Welcome, Matt and Diane. So, good evening. My name is Matt Stripmoder. I'm the Health and Human Services Director. And on behalf of Diane and myself, it's our pleasure to be here tonight to talk briefly about the role and importance of immunizations. This is something that I'm sure you've been thinking about. I'm also pretty sure that nationally or in the state media, there is things that you've seen in the last weeks or months. This is something that's in the forefront. For example, a measles outbreak that has now reached 31 states in the country. And immunization is the primary mechanism for protection of the public. Wisconsin has legislation that's being contemplated related to personal convictions because personal convictions of choosing to not be vaccinated for a personal reason does seem to be affecting the overall protection of the public through vaccinations. And with that, I will turn it over to Diane Liebenthal to give you additional information related to the topic. So, the goal of vaccination, as Matt stated, is really to protect everybody against vaccination, preventable diseases. And everyone in our community can be impacted. As you can see on this slide, every age group needs certain vaccinations. As Matt mentioned, the measles outbreak is definitely something that brings us all to mind. And without a needed level of immunization in our community, there will be disease that will present. Currently, as Matt stated, 31 states and over 1,200 people have been impacted by the measles outbreak within the United States. In addition, there are costs associated with that outbreak. And that includes tracing all the contacts and administering vaccines. And that is costly. In Colorado, two cases of measles cost $68,192. And 283 people were impacted by that. The next concept we kind of like to go over is about herd or community immunity. And this is a really important concept. So what this means is that the more people that are vaccinated, the more protection we have. There are always people that cannot be vaccinated, babies before a certain age, for example, people with diseases and other things like that, such as cancer or HIV. An example of the amount of people who would need to be vaccinated in order to protect the community is found again in measles. So it's 93 to 95% of the community would need to be vaccinated to allow protection to most of the population. An example in Sheboygan County is that children by age two in Sheboygan County, only 83% of those children are vaccinated against measles. So going over this graph, and the first third of the graph, the people in blue are not vaccinated. And when a disease strikes their community, you can see on the right hand side that almost everyone is impacted by the disease. In the second or the center column, there are some people in yellow that are vaccinated. And so when disease hits their community, there are less people that are impacted, but still pretty high. And then the third example is when a lot of people, or like we're talking about with measles, 95% are vaccinated, then most of the community is protected. This is a chart that demonstrates one of the things that we monitor in public health is the vaccination rates of children in schools. And this data is from 2018 to 2019. And as you can see, Sheboygan County is doing better than the state of Wisconsin, but there is room for improvement. Again, going back to measles, we would need to be at 95% to protect the community. This is an example of the waivers that we do now have available. And there's three types. In July of 1975, waivers were put into place for medical and religious waivers. And then in May of 1980, personal conviction waivers became available to parents to use if they did not approve of vaccinations for their children. So this chart really looks at that data and you can see that health and religious waivers have remained fairly stable. However, the personal conviction waivers have continued to increase every year. So that's just a brief update on vaccinations. And thank you. Hi, my name's Tom Campion with the Kettle Trails Group working on the ATV routes in the area. I want to talk a little bit tonight about keeping it simple. We run into, as we go through our process, different counties and different concepts on how to do things. And what we run into is in some townships and counties where they've had trouble with clubs doing their own thing, they put very restrictive rules, for example, in the Fond du Lac County. By putting such restrictive rules on ATVs and making everyone go through a lot of committees, they've caused a whole bunch of problems for themselves. The highway committee is overwhelmed with requests where it actually consumes their meetings every month. And then more clubs are getting into it and more people are doing it. It's to the point now where Fond du Lac County has actually stopped taking requests for roads, taking requests for signs because they've made a very cumbersome. So I guess I'm here to ask that when considering the ATV proposition that you just keep it simple. We wanna do it easy, we wanna work with everybody, we wanna do it right. But we don't wanna create you guys a lot of work, cost you a lot of money, or cost the highway department a headache. We would like it to be easy, we're willing to work with everybody and do anything we can to make it as simple as possible. If we keep it easy, it's very simple to take a sign that we use now on the ends of towns, which says all town roads in the town of Scott are open to ATVs. And if it's a simple process here in the county, all I gotta do is change that sign to town and county roads in the town of Scott are open. It's a simple change of a sign and it's all done. If it's very cumbersome, I have to mark every single road that's open or closed, beginning and end, and it becomes a trouble and then I have to get road permits and stuff and bother Mr. Snell over there too much. So I just ask that you keep it simple. Thank you. Thank you. All right, then Timothy Rohrer, 6415 Glenn Court of West Bend. Good evening. I am also a representative of the Kettle Trails, but I'm also the president of the Kettle Marine ATV Association and we do a lot of interacting with Sheboygan County actually over the last couple of years. We have several members, many members, that belong to our club that live in Sheboygan County. As my address shows, I'm not a county resident, but as a representative of the club, I just wanna pass along from the club and obviously the members that live in Sheboygan County that we would like to see an ordinance passed to move this along. The other thing that I wanted to talk about really quick was the economic development here in Sheboygan County has been a great asset to us. They have put out press releases. They sent a letter endorsing the ATV trails and routes in Sheboygan County as a positive for Sheboygan County. So I would like to just thank them for all their support also. Thank you. Thank you. That is all we have. Thank you, John. Letters, communications and announcements. There are two items. The first is a letter from Roy Sellers of Sheboygan regarding traffic on the intersection of O and Y. That'll be referred to the Transportation Committee. The last item is the resignation letter from Supervisor Bemis. And I've had numerous conversations. I just wanted to add with Dick. And I mean he was here close to or right at 40 years and Dick is not a big fan of recognition as you probably know and tried at least three or four times to give him to come here. And we had very nice conversations. He's very grateful for what we've done for him and comments in the paper but he does not want to have recognition but we're working on something a little more private form just so you know, we'll let you know when that takes place. But he just, 40 years it should be recognized. It's unbelievable in my opinion to be that length of time on a county board and I can't let that go without mentioning something because that would be just I think heresy. And just so you know and Dick thought this was a kind of a neat idea. I asked Supervisor Distrudi as the senior member now of the county board to make the motion to adjourn. I said, Dick, otherwise we're never gonna adjourn. We're gonna be here all the time if you're not here. So Supervisor Distrudi as the senior member will now make that motion. So thank you. County Administrators Report. Thank you Mr. Chairman, good evening. Supervisor Beame has called me this afternoon and he already sounded relaxed. He continues to serve on the Rocky Knoll Foundation and Kayla and I spoke just prior to that and Kayla said, you know I saw Supervisor Beame is at the foundation and he just seemed so much more relaxed and when Dick called me this afternoon just to check in, not only was he complimentary of the county board chairman's appointment to fill his seat, I think he's feeling good about that but he just, he's in a good place. He says he's doing well, he's feeling good. His wife is home and doing better. So wanted to share that but he definitely was feeling good. So we're gonna miss him I know but I'm glad that he's in good spirits. I'm gonna briefly talk about the five year capital plan. I think that's probably one of the key decision items you have on the county board agenda this evening. As you know, we have a very extensive and successful five year capital planning process. The county board, the county as an organization has had it in play for a long time. It's a collaborative approach where department heads work with their respective liaison committees, myself, the finance director and ultimately get approval from the finance committee and the executive committee to come forward with the revised plan. And on your desks last month and you certainly had it as part of your mail out, your packet Friday, I wanna thank Cheryl for also sending out not only the high end summary but you had the whole report in there as well that the finance committee had the benefit of going through that detail. So I hope you had a chance to do that. I'm just gonna very briefly touch on some of the highlights of the plan in case you didn't get a chance to do that or you haven't looked at it in the last few days or weeks. The five year capital plan, the beauty of it is we often put things out two, three, four, five years out. We have more time to review that project and then ultimately it comes to the point where we need to either bond dollars or leverage dollars or generally a combination of both. As you know, planning and conservation has a number of good projects in play. One is continues to be Amsterdam dunes creating a wetland mitigation bank. Why? So we can enhance economic development as well as have less taxpayer expense if we're extending a road, widening a road, working on an airport runway or a company like Sargento wants to extend its headquarters and impact wetland. We now have a wetland mitigation bank in play that we can utilize here rather than buy expensive credits in Ashland County or some other area. Erin continues to work with the Department of Natural Resources on getting that wetland mitigation bank up and running. We're hoping to see most of the work that needs to now get done to finalize that happening this fall and winter and by next year we wanna have our credits available and of course the county board will ultimately determine what are we gonna sell those credits for, how much. So it's a win-win for the business community and local units of government. Greenbush, Old Plank Road Trail, the new construction from Greenbush to the Fonda-Lack County line. No doubt all of you are watching the Highway 23 expansion work go. My dad was just in town the other day and he's like, what is going on with Highway 23? Well, if you're here every day, you certainly know. And they're making good progress. As part of that project, they're gonna be putting in the foundation, the base work for that trail. We'll have to then come in with the pavement to maintain that but they're getting that site all ready for that and so that's gonna be a wonderful amenity that will continue on the Fonda-Lack. So that's in play. Courthouse Boiler Replacements. Not a real fascinating topic perhaps for most of you but they haven't been replaced since 1968. There's asbestos in the ceilings and thank goodness we have folks like Jim to Beast who plans accordingly for that and make sure that we're replacing them as needed. That goes for the roof replacement too. Number of years ago Jim worked with the property committee to put a roof replacement plan together. So rather than us knee jerk reaction to a leak or a severe situation, he's thoughtfully, prudently going through the roofs as needed. So that's part of the plan as well. Rocky Know will have some work done. The Courthouse Second Floor Ledge will have some work done and the Aging and Disability Resource Center garage will have some work done and that's just in 2020. Obviously there's work after that as well. Health and Human Services. If you've parked there recently, you know doggone well that that parking lot is in sorry need of enhancements. In fact, we purchased that building in 1987 and the parking lot has not been upgraded. In fact, when we reach out to vendors now to do a seal coat, they won't do it anymore and the reason they won't do it anymore is because there's sinkholes, there's ponding. Obviously there's icing situations in the winter. They don't want to touch it. And so again, thanks to Jim to Beast and his crew we're gonna line up the work to get that upgraded and it's been since 1987 just so you know. So it's time. The Sheriff's Department is gonna finally see a shooting range that actually has some up-to-date technology with scenarios and as you can imagine we want our law enforcement to have the tools they need to do the difficult work that they do. The target system has not been functioning for the last few years and in fact has not been replaced since the law enforcement center was built in 1981. So it's time. And then a couple others. On-site childcare at Rocky Knoll. Certainly the health care centers committee has been following that. As I said, the finance committee and the executive committee have reviewed and approved or is recommending approval for all of these but why would we add childcare at Rocky Knoll? One of the reasons is we're paying more and over time than we care to and that's because we have over 20 CNA positions filled. We're struggling to find nurses and LPNs and you think about the people that work there. There's a lot of young people with young families and if we could have childcare on-site we really think that could help us with recruiting and retaining employees. We also have the transportation complex just down the road and that presents an opportunity as well to provide a benefit for our employees and also open it up to the public as capacity provides. So we have a space identified. We have plans in play and of course we'd have to contract with someone to operate it. It's not our plans to operate the facility just to provide the space for it. And speaking of that, I'll end with the customs facility. As you know, we've had discussions about the customs facility for a number of years. We've had in the five year capital plan the board's voted on a number of times. The cost has actually come down and that's a credit to everyone involved but what I'm pleased to report tonight is we now have a signed operational agreement with the Kohler company that did test folks' patience involved but it is a wonderful example of collaboration between the largest employer in the county. Kohler company as you recall, asked us to establish the US customs facility. They wanna have a staff person there obviously and they have agreed for the next three years to fully fund it. After that we would implement user fees and depending on the user fees that might offset some of their costs associated with it. So if Bemis or Johnsonville or other companies start utilizing that as well or as we get people flying into Sheboygan County to golf some of the nicest golf courses in the country that will present some revenue as well. So it is not the county's plan to get involved with the operational cost that's gonna be covered by the Kohler company or user fees going forward but we are pleased that this facility is proceeding. Lot of work's been going on behind the scenes by Greg Schnell and our team to get this designed. We're hoping to break ground in November and it's our expectation that it will be built and operational in August of 2020 because the Ryder Cup as you know is in September of 2020. So that's a little snapshot of the five year capital plan and many of the good projects that are in play. Thank you, Mr. Chairman. Thank you, Adam. Consideration of committee reports, Executive Committee resolution number eight. Regarding the 2025 year capital plan recommendation to adopt. Survisor Gehring. Thank you, Mr. Chairman. I move for adoption of resolution number eight. Thank you, Survisor Gehring. Survisor Obler. Support that motion. Thank you, Survisor Obler. Any questions or comments? Seeing no lights, please push your aye or nay button. That's a preview unanimously. Thank you. Committee reports, Executive Committee resolution number nine. Regarding requesting the Wisconsin legislature to end use of personal conviction waivers for school and daycare center immunizations, recommendation to adopt. Survisor Hoffman. I move we approve. Thank you, Survisor Hoffman. Survisor Gehring. Thank you, Mr. Chairman. Sorry, I hit your light twice. Thank you, Survisor Gehring. Okay, any questions or comments? Survisor Otten. Aye. Use your mic. That's okay. I want everybody to realize that this is a very important request because what's happening is many parents are coming when school starts and they say I didn't have my kids vaccinated so I'm going to ask for a abstaining from doing that and for personal reasons. And many times it's just neglect of not having it done. So I think this is very important because it puts everybody else at risk so we should be concerned about passing this. Thank you. Thank you, Survisor Otten. Supervisor Bruhler. Thank you, Mr. Chairman. As elected officials, it is our duty to take action on items that are in the best interest of our community as a whole. With this in mind, I understand first by removing the personal conviction waiver option, a loophole still exists. That would be the religious conviction waiver so that a parent, legal guardian, et cetera, who does not want their child vaccinated may still be able to refuse the vaccinations while the child continues to attend school, therefore negating the removal of the personal conviction waiver. Second, by allowing the religious conviction waiver to remain, we are, in my opinion, showing preferential treatment to one group of citizens over another. Therefore, if we support removing the personal conviction waiver, should we not also support removing the religious conviction waiver? Thereby removing any chance of parents, legal guardians, et cetera, to use a loophole and the possibility of preferential treatment. As removal of these waivers would greatly lessen the ability of children to get the communicable diseases for which they would be vaccinated against, I believe that doing so would be removing a parent's right to decide what is best for his or her child. Instead, I believe we should educate the parents on the benefits of vaccination and the consequences of not vaccinating via a series of required classes of verifiable data by knowledgeable professionals, for example, before a parent legal guardian, et cetera, would be able to sign a waiver of any kind. I have faith in parents as a whole and think that given accurate information, they then have the ability to make an informed decision. I believe this issue requires closer scrutiny before we, as a board, put our support behind this particular resolution. Therefore, I, for one, will be voting against showing our support for this resolution. Thank you, Mr. Chairman. Thank you, Supervisor Bruehle. Supervisor Epping. Thank you, Chairman Wigner. I can't very much top Supervisor Bruehle's a description on some of my attitudes about this. I also feel that if there is something that tells them that they have to vaccinate, what happens if they still refuse? Are there any consequences for that? And I don't see that built into the situation right now. Plus, it's a personal choice, so I will be joining Supervisor Bruehle in voting against this. And in addition to that, this is just a request to the Wisconsin legislature to end this, so it's not necessarily, as I see it, a lot that we're putting into place. Thank you. Thank you, Supervisor Epping. Supervisor Oje. Thank you, Mr. Chairman. With all due respect to my fellow supervisors, it's if you choose to get vaccinated and someone else's one and a half year old child gets measles because they weren't old enough to get vaccinated yet. And the argument that you should do nothing rather than going half away with what's being proposed to me is nonsensical. We have an opportunity to do something that doesn't involve religious freedoms, which would be the big hold up with trying to do away with the religious refusal. To me, it's a start because the people who are most at risk are the ones who probably aren't able to get vaccinated. So to say it's a victimless crime and it's personal choice, it's not. I guess I just don't follow that line of reasoning and I'm sorry that I don't, but I will be voting for this because I believe that you need to protect the people who are unable to get vaccinated from the people who choose not to get vaccinated. Thank you, Supervisor Oje. Supervisor Hoffman, do you wanna speak? I got a feeling you're trying to push your button. We discussed this thoroughly in the Board of Health and I agree there's probably some reason on both sides, but I'm gonna err on the side of safety. Also, I think we should have a personal exemption to the income tax. I don't like paying that. So let's get rid of that and those that wanna pay it can pay it and those that don't don't. What do you think of that idea? Well, this is much the same thing, I think. I mean, you're always gonna have people that say, well, I don't wanna and I don't think personal exemption is a strong enough reason to say I don't wanna. So I'm gonna be voting for this and as much protection as we can get for the rest of the public, we have to be considerate of each other and that's why I'm gonna vote for this. Thank you. Thank you, Supervisor Hoffman. Anyone else? Okay, seeing no lights. Please push your aye or nay button. Motions approved, 22 ayes and two nays. Thank you. Consideration of committee reports, Transportation Committee, ordinance number four. Regarding designating all-terrain vehicle routes and regulating the operation of all-terrain vehicles, committee recommendation, amend per the committee report and an act as amended. Supervisor Tostridi. I move to enact resolution, ordinance number four. Thank you, Supervisor Tostridi. Supervisor Glavin. Second that motion. Thank you, Supervisor Glavin. Any questions or comments? Supervisor Ojai. Thank you, Mr. Chairman. I have a question. Who approves the right-of-way permit application? Is that a committee function or is that a transportation director function? Right, I'll turn that over to Greg Schnell, our commissioner. The director does, you do. Okay, then I have a second question. We're charging these guys a fee so that they can take in, put up the signage, do all the footwork to get the route so that I as a citizen can ride on it. I hope this is a really small fee because they're doing an awful lot of work for people other than themselves. I understand, I don't know if there's a, and Greg, anything else? Yeah, I would move to, I'm not pro-probable, I won't get support, but I would move to eliminate the application fee. Okay, there's an amendment then to eliminate the fees. Is there a second to that amendment? I need to clear the board, otherwise I can't see who's seconding it. Okay, is there a second to Surveyser OJ's motion to eliminate the fee? Is there a second to eliminate the fee? Is there a second to eliminate the fee? Surveyser Epping, did you push your button? I saw your hand. Yeah, your knee. Pardon? There's blood. Yeah, I got you. So are you seconding it? Oh, I will make you second to that one. Okay, there's a second then. Is that debatable, or do we just vote, I believe? An amendment, no, amendment? Amendment is debatable. It is debatable. Okay. Okay, Surveyser OJ, would you give Cheryl the language? No, I gotta find it. I would just in line 66 and 67 eliminate and the associated fee. Yeah, it was just striking out and the associated fee. No, this is just the fee for the right-of-way application to the county. Everything for the county. It doesn't affect the signage or anything else. It's just them not having to pay money for me to use their trip. 66 and 67. Yeah, not fees. It's just fee because it's only one fact. I don't want to confuse you into thinking. I want to make this so that they're not paying the township. They're not paying for signage. I just don't feel they should have to pay a fee for them to get a trail approved for everyone else to use. You got it, Cheryl. Is that it? Surveyser OJ, you see it up on the top? Yes. Okay. So we have a motion and a second on an amendment and it's right at the top. Is there any discussion on the amendment? You don't think that's it? If I may, Mr. Chair. Sure, go ahead. You said to strike on line 66 and the associated fee. Correct. So you said strike. That says up there to eliminate any associated fee. Yeah, that would be incorrect. Yeah, I just wanted so that the people, they would not have to pay a fee to the colony for the right-of-way application. So they would still have to do the application. They just wouldn't be paying a fee for it. We gotcha. Okay. Line 66 under G, it says a right-of-way permit application that you strike the words and the associated fee, just strike those four words. Oh, an MDA session. A and D. Surveyser OJ. Correct. The associated fee. A and D. It's really just line 66. Okay. Got it. I think we have it. All right. There's an amendment on the floor. Any discussion on that amendment? Hearing none, let's vote on the amendment as written at the top. That motion does not approve. Six ayes, 18 nays. Okay, thank you. Now we go back to the original ordinance which is on the floor. Is there any other discussion on the original ordinance? Surveyser Hoffman. Thank you, Mr. Chair. One of the speakers that was up here just a little bit ago said, keep it simple. Doing all roads open is not a good idea. Some roads should not be open. So you can't really go ahead and say, keep it simple. Secondly, I'm gonna vote against this whole thing because we are more or less an urban county and especially Talna Wilson. I think we're opening up a can of worms and for safety reasons, I'm gonna vote against this ordinance in its totality. Thank you. Thank you, Surveyser Hoffman. Surveyser Nelson. Just one clarification, please. Sure. Previous to the amendment that didn't pass. I thought I heard the resolution was to approve it, not the amended resolution. And I think it should be the amended resolution. Yeah, and you're right. The first time I said it, I think the second time I didn't. Thank you. You're right. Anything else? Surveyser Epping. I'm Wigner. In, I went to the last transportation meeting where they discussed this issue. I'm fully in favor of opening all county roads to ATV traffic. I feel ATV drivers are reasonable, sensible, and safe. We have opened county roads up for bicyclists, walkers, and who knows what else. And we feel free to do that. And if there's anything more dangerous on the roads, and I counter this all the time, people bicycling and walking on county roads with and against traffic. However, it should be. ATV traffic should be regulated to a certain extent, just like regular traffic. And I think that's part of the amendment. So I'm fully prepared to support this motion or this ordinance as a way to allow ATV riders the ability to use county roads to get wherever they want to or even just use it at their pleasure. This would also include workers on farms. And this is a, like a supervisor often said, this is a real community. And ATVs working on farms in the rural area could be a needed necessity. But yet, I don't see why we should restrict ATVs when we don't restrict bicycles and pedestrians from being on the roads. Thank you very much. Thank you, Supervisor Epping. Supervisor Bosman. Yes, I started out with wanting to speak to Supervisor Huffman's comment that the first stage of this approval is that the ATV club comes to the township and gets the approval of the township. So that needs to happen before anything else occurs. So as a township, you may make a decision that you don't want to have ATV routes in your township. This ordinance simply allows the connection between two town roads by utilizing a county road. And there are maps that are drawn to designate which roads will then be the connector between the two town roads. And as I have gone through this and worked with this, this is my understanding of what's happening. So first of all, the township has to approve of it. And then we make the connections on roads that are approved to connect those town roads. So no, we are not opening up every road in the county. We are simply providing in those situations where a township has already agreed with the ATV group to designate routes that we can then connect those town roads by a county road. Thank you, Surveyser Bosman. Surveyser to Sturdy. Thank you, Mr. Chairman, to the point of opening up all of the county roads that may sound good, but there are several county roads that go right through cities, like TA, the extension of Taylor Drive, and in Falls and Plymouth, they also have county roads. And again, I don't think that would be wise to open all of the roads up. The idea is to have each municipality approach the county if they do want some links linking some of the spots and some of the town roads so that there's a continuous trail, but to open them all up, that would be very unsafe to say and open that point up. Thank you, Surveyser to Sturdy. Any other comments or questions? Surveyser Hoffman. Thank you, Mr. Chair. Yeah, Al, I did understand that and I've got this and I understand that it wouldn't be, how it was going to be done, but I'm still against it. So, and speaking to Mr. Epping, who I greatly regard and respect, just because one thing is legal, that doesn't mean another thing should be legal. So that's just this opinion of mine. Surveyser Hoffman, I just want, you can answer the, I have no problem, but remember to direct your to the chair. All right, thank you, Mr. Chair. I've said my piece. Thank you. You're welcome. Anybody else? Okay. Seeing no lights, we'll vote on ordinance number four, which is for the committee recommended as amended. That motion's approved. 20 ayes, four nays. Thank you. I will turn the gavel over to the vice chair. Resolution's introduced. Resolution number 10 from the executive committee. Regarding affirming the right of all Wisconsin citizens to fair and equal representation and requesting the adoption of a nonpartisan process for the preparation of legislative and congressional redistricting plans. Pursuant to rule 13, it is anticipated that a motion to withdraw this proposed resolution will be made if by majority vote, the board votes to pull a resolution, it will be subject to immediate action. Supervisor Gehring. Thank you, Mr. Vice Chairman. I move to pull for immediate action. Thank you, Supervisor Gehring. Supervisor Obler. I support that motion. Thank you, Supervisor Obler. This issue is holding a resolution is non-debitable, so if you'd please vote. Motion to pull is approved 22 to two. We will be voting on resolution number 10. We need a motion. Is there a motion, please? Supervisor Sugabar. I would like to make a motion. Thank you, Supervisor Zipalbalas. Supervisor Obler. Support. Thank you, Supervisor Obler. Is there any discussion? Supervisor Palmgard. I've just been clarification. Which one are we on? I've just lost track. Resolution number 10. Thank you. No further discussion. Please vote. That motion is approved. 24 ayes, four nays. Resolution number 11 from the Law Committee. Regarding authorizing application for fiscal year 2019, justice assistance grant program award. Resolution number 11 will be referred to the finance committee. Resolution number 12 from Planning Resources, Agriculture and Extension Committee. Regarding approving revisions to the Farmland Preservation Plan. Resolution number 12 will be referred to the executive committee. Resolution number 13 from Planning Resources, Agriculture and Extension Committee. Regarding approving, he's meant for a village of Kohler Sewage Interceptor at Erie Avenue, Old Plank Road Trailhead. Resolution number 13 will be referred to the executive committee. Resolution number 14 from the Transportation Committee. Regarding authorizing county aid for a bridge culvert construction in the towns of Herman Plymouth, Sheboygan Falls, Sherman and Wilson. Resolution number 14 will be sent to the Finance Committee. There were no ordinances introduced. So we're up for adjournment. Supervisor Tisferuti. I would like to move to adjourn, but just for clarification, I may be the longest serving, but I don't think I'm the oldest one of the group. I'll let the record show I stand corrected. Thank you, Supervisor. It happens at home a lot, so I'm used to it. Thank you, Supervisor Tisferuti, Supervisor Epping. Supervisor Epping, did you second the motion? Did you second the motion to adjourn? Thank you, Supervisor Epping. Please all vote on adjournment.