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Volume 131, Issue No. 4 July/August 2016
Current Issue
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ISSN 0033-3549
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NEPHC Abstracts

Emergencies 1

Public Health Emergency Medical Countermeasure Enterprise Chemical Event Data Gaps

  • S. Cibulsky , US Department of Health and Human Services

Background: Public health preparedness planning and response to chemical events depend on valid data on issues including: number, type, size, and impact of events; human toxicity estimates; medical countermeasure effectiveness; off-label use of medical countermeasures; and medical treatment gaps. Yet, in many cases such data are lacking. Issue: The Public Health Emergency Medical Countermeasure Enterprise (PHEMCE) is an interagency effort to provide end-to-end coordination of public health emergency response within the Department of Health and Human Services and with other departments, including Defense, Homeland Security, Veterans Affairs, and others. The PHEMCE defines requirements, coordinates research, early and late stage development, and procurement activities, and develops deployment and use strategies for medical countermeasures. This work relies upon medical consequence modeling and risk assessment, which in turn, use available data on past events, their impact on public health, and medical treatments administered. Chemical events, especially accidental releases, occur frequently. However, the United States does not currently have in place a comprehensive, nationwide system for data collection related to these events. Results: A comprehensive chemical event data collection program managed by the federal government but with full participation by state and local officials could be designed to fill existing knowledge gaps. Chemical accident probabilities could be estimated with a thorough accounting of the number and type of such events. In-depth analysis of a subset of events could provide data on public health impact, including human exposures, treatments administered, and outcomes. Implications: Such data would allow for enhanced assessment of chemical event risk and, therefore, strengthen the prioritization of funding decisions. Medical consequence modeling and requirements setting could be improved if new data on human toxicities and current countermeasure effectiveness were available.


Emergencies 1

Wisconsin Hazardous Substances Emergency Events Surveillance (HSEES) Data Over 15 Years; Partnerships, Frequencies, Adverse Health Outcomes, and Data Usage

  • J. Drew , Wisconsin Department of Health Services'
  • H. Anderson , Wisconsin Department of Health Services

Background: Prior to HSEES in 1990, there was no single source for comprehensive information on hazardous materials releases and their public health consequences. State HSEES programs have collected information from multiple local, state, and federal sources focusing on the adverse health outcomes associated with the “uncontrolled or illegal release of hazardous substances.” The HSEES database contains information about frequency of events and event location; other demographics; substance names and quantity; contributing causes; numbers of evacuees; and victim information, including medical treatment and disposition. The data are collected into a secure, Web-deployed, electronic data collection format, and shared with Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry on a real-time basis. Issue: In Wisconsin, for the period 1993–2007, there were 6,165 qualifying HSEES incidents, resulting in 1,529 victims, and 52,575 evacuees. There were 54 events that resulted in 144 emergency responder injuries. Ammonia releases (719) represented only 12% of total events, yet accounted for 19% of total victims; and ammonia evacuees (8,943) represented 17% of total evacuees. Approximately 60% of ammonia events occurred in private sector venues where ammonia was used as a refrigerant (food processing, dairy, cheese making, etc.), resulting in about 45% of total ammonia victims, and around 82% of total evacuees associated with ammonia exposures. Results: Based on this HSEES data WI implemented an outreach activity which became known as Ammonia Awareness Day. It was a data-driven, measureable educational interaction focused on ammonia refrigerant users. Lessons Learned: Without the HSEES program in WI, there would be no data or resources to target prevention activities. Effective surveillance at the state level is vital to the success of the newly proposed National Toxic Substance Incident Program.


Emergencies 1

Developing a National Toxic Substances Incident Program

  • M. Orr , Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • G. Williamson , Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry

Background: Nationwide, about 14,000 facilities store and use extremely hazardous substances that could kill or injure workers or residents of nearby communities if suddenly released. Approximately 700 of these facilities are near population centers with at least 100,000 people. The Hazardous Substances Emergency Events Surveillance (HSEES) system was established in 1990 by Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry as a cooperative agreement with state health departments to track hazardous substance releases and use that data to prevent future releases and reduce associated injuries and deaths, as well as for chemical terrorism preparedness and response. Issue: HSEES is the only federal public health tracking system that collects, analyzes, and interprets data on acute releases of hazardous substances and their potential public health impacts. The state cooperative agreement ends in FY 2009. An external peer review of the program suggested that, while HSEES collects very high quality and worthwhile data, the coverage and scope of the program need to be broadened to have more impact. Results: Through numerous stakeholder information-gathering sessions, we have developed a 3-part program to maximize impact and meet the identified needs.


Emergencies 2

Personal Protective Equipment Use and Respiratory Outcomes among 9/11 Rescue and Recovery Workers Enrolled in the World Trade Center Health Registry

  • V. Antao, Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease RegistryL. Pallos , Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • Y.Shim Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • J. Sapp, Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • M. Orr, Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • R. Brackbill, Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • M. Farfel, New York City Department of Health and Mental Hygiene
  • S. Stellman, New York City Department of Health and Mental Hygiene

Background: The World Trade Center Health Registry contains self-reported data on 71,437 people (Wave 1 Survey—baseline data) and 46,322 adults (Wave 2 Survey—follow-up data). The objective of this study was to characterize the use of personal protective equipment (PPE) and examine its association with respiratory outcomes among persons who participated in rescue and recovery work (RR workers) after the September 11, 2001, World Trade Center (WTC) terrorist attacks. Methods: We included RR workers or volunteers who worked for at least one shift on the pile of debris and answered both Wave 1 and Wave 2 surveys. Outcomes of interest were shortness of breath, wheezing, and cough, with onset or worsening after 9/11 and present during the 30 days prior to Wave 2 Survey. PPE use was dichotomized: those who worked on “the pile” with full- or half-face respirators or disposable masks with N95 or P100 rating (“protected”), and those who in at least one time period did not (“unprotected”). We conducted descriptive and multivariable analyses adjusting for sex, age, education, smoking, severity of dust cloud exposure on 9/11, and total number of days worked. Results: 9,296 RR workers were included in the analysis. Among 8,787 RR workers with available PPE data, 24.7% were “protected.” The likelihood of increased respiratory symptoms among “unprotected” compared with “protected” RR workers was as follows (odds ratio [95% confidence interval]): shortness of breath = 1.49 (1.31–1.69); wheezing = 1.45 (1.27–1.66); cough = 1.54 (1.28–1.85). Conclusions: The lack of PPE use or the use of nonrated disposable masks was associated with increased odds of respiratory symptoms among RR workers and volunteers at the WTC site, compared to the use of protective respirators.


Emergencies 2

Diagnosed Asthma Among Persons Exposed to September 11, 2001, Terrorist Attacks

  • R. Brackbill , Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • J. Hadler , New York City Department of Health and Mental Hygiene
  • C.Ekenga , New York City Department of Health and Mental Hygiene
  • M. Farfel , New York City Department of Health and Mental Hygiene
  • S. Stellman , New York City Department of Health and Mental Hygiene
  • L. Thorpe , New York City Department of Health and Mental Hygiene

Background: The objective of this study was to characterize and examine risk factors for new asthma diagnoses among highly exposed adults 5–6 years post-attack. Methods: The World Trade Center Health Registry (WTCHR) contains longitudinal data on a cohort with baseline enrollment of 71,437 individuals (September 2003–November 2004); 46,322 adults (68%) completed the adult follow-up survey (November 2006–December 2007). We conducted descriptive and multivariable analyses to assess the impact of exposures associated with 9/11 on self-reported diagnosed asthma post-9/11. Results: Of follow-up participants with no asthma history, 10.1% reported new asthma diagnoses post-9/11; highest rates were in the first 16 months. Intense dust cloud exposure on 9/11 was a major risk factor for newly reported asthma diagnoses for all eligibility groups (adjusted odds ratios [aORs], 1.4–1.5). Asthma risk was highest among rescue/recovery workers working on the WTC pile on 9/11 (aOR, 2.2, 95% confidence interval, 1.9–2.6). Prolonged risk exposures included working longer at the WTC site, not evacuating homes, and experiencing a heavy layer of dust in one's home or office. Conclusions: Both acute and prolonged exposures resulted in a large burden of asthma 5–6 years after 9/11. Continued surveillance, outreach, and treatment are needed to mitigate the burden and inform long-term disaster response planning.


Emergencies 2

Current Health Status of Persons Injured in the September 11, 2001, Terrorist Attacks

  • R. Brackbill , Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • Y. Shim , Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • S.Stellman , New York City Department of Health and Mental Hygiene

Background/Objectives: The September 11, 2001, terrorist attack on the World Trade Center (WTC) exposed hundreds of thousands of persons to potential injury resulting from evacuation from high-rise buildings, falling debris, and dust/debris cloud from collapsing towers. The objectives are to describe the current health status of persons injured on 9/11, and to identify exposures related to 9/11 and social and psychological factors related to impairment at follow-up. Methods: The World Trade Center Health Registry (WTCHR) contains data on a longitudinal cohort with baseline enrollment of 71,437 individuals (September 2003–November 2004); 46,322 adults (68%) completed the first follow-up survey (November 2006–December 2007). We conducted descriptive and multivariable analyses to assess the current health status of persons injured on 9/11. Results: Of the 71,437 individuals enrolled in the WTCHR, 9,177 (12.8%) responded that they were injured as a result of WTC attack on 9/11, including sprain/strain (57.5%), cuts/abrasions/puncture wounds (53.1%), fracture/dislocation (6.3%), and concussion (4.6%). The rescue/recovery/cleanup workers (15%), R/R/C who worked on the WTC pile on 9/11 (25%), and individuals exposed to the dust/debris cloud (19.3%) were most likely to report an injury. In the first follow-up, 66.6% (6,110) of the injured and 64.2% (39,940) of the uninjured participated. Among the injured, 37.2% screened positive for probable post-traumatic stress disorder (PTSD) versus 16.0% for the uninjured (p<0.001); disability and inability to work were more frequently reported among the injured (10.5% vs. 3.5%, p<0.001). Conclusions/Implications: Persons injured on 9/11 continue to report high levels of psychological and physical impairment 5 to 6 years after the disaster. Continued surveillance is needed to monitor the burden and inform long-term disaster response planning.


Emergencies 3

Clinical Characteristics of New Orleans Children With Asthma One and a Half Years Following Hurricane Katrina

  • J. El-Dahr , Tulane University
  • K. Paris , Children's Hospital, New Orleans, LA
  • M.M Sikora , Ochsner Clinic, New Orleans, LA
  • H. Mitchell , Rho, Inc, Chapel Hill, NC
  • M. Lichtveld , Tulane University
  • R. Cohn , SRA International

Background: Children with asthma have a high prevalence of sensitization to indoor allergens, but the relationships between allergen exposures—especially to molds—and asthma morbidity are unclear. Since flooding from Hurricane Katrina resulted in copious amounts of mold and other allergens immediately after the storm, post-Katrina New Orleans offers an unprecedented opportunity to study these relationships. Objectives: Examine asthma morbidity and skin sensitization in post-Katrina New Orleans children. Methods: Children (n = 182) with moderate-to-severe asthma from Head-off Environmental Asthma in Louisiana (HEAL) underwent comprehensive baseline clinical evaluations consisting of a medical history, pulmonary function testing (spirometry and/or peak flow), and skin prick sensitivity (indoor allergen panel and extended mold panel). Interviews with caregivers provided information on asthma symptoms, utilization, and medications. Results: Children's maximum symptom days and health care utilization are reported in an accompanying poster. For lung function, the children's average FEV1-% predicted was 93.44+1.64, but their average FEV1/FVC ratio was 79.35+0.96. The majority of children (72%) were sensitive to at least one mold and the average number of mold sensitivities per child was 5.33+0.38. Predominant sensitivities included dust mites (67%), cat (36%), cockroach (52%), and certain mold species ( Alternaria 53%, Penicillium 48%, and Cladosporium 29%). Conclusions: Baseline clinical data from children in the post-Katrina New Orleans area show that enrolled children have moderate to severe impairment in lung function and significant asthma morbidity with high health care utilization. While skin sensitivity results for common indoor allergens were comparable to children from other asthma studies, HEAL children have higher rates of sensitivity to mold and certain mold species. Mold sensitization (especially to Alternaria ) has been linked to the presence and severity of asthma, and might contribute to asthma morbidity in post-Katrina children.


Emergencies 3

Head-off Environmental Asthma in Louisiana (HEAL) Study—Study Objectives and Design

  • P. Chulada , National Institute of Environmental Health Sciences
  • R. Cohn , SRA International, LTD
  • J.El-Dahr , Tulane University
  • L. Grimsley , Tulane University
  • M. Mvula , New Orleans Department of Health
  • E. Thornton , Visionary Consulting Partners, LLC

Background: In New Orleans, many families were impacted by Hurricane Katrina, which disrupted health care and caused high home mold and allergen levels and high stress levels, all potential triggers for asthma. Objectives: Examine the relationships between environmental factors (physical and psychosocial) and asthma morbidity in children in the post-Katrina New Orleans area; and test a novel Asthma Counselor (AC) Program that provides both case management and home remediation. Methods: Families (n = 182) with moderate-to-severe asthmatic children (4–12 years old) were recruited from Orleans, St. Bernard, Saint Tammany, and Jefferson parishes. Baseline assessments included clinical and home environmental evaluations, with interval assessments at 6 and 12 months. Families also received asthma counseling with case management and tailored guidance on home remediation. Endpoints included maximum symptom days, medication use, and medical resource utilization. Results: HEAL children were 54% male, 71% African American, and 27% white. At enrollment, they lived in houses (84%), apartments (8%), Federal Emergency Management Agency (FEMA) trailers (5%), or other types of dwelling (3%). Dwellings were damaged from flooding (23%), rain (24%), or both (14%). Two weeks prior to enrollment, the children averaged 6.6+0.36 symptom days (5.34+0.34 days of wheeze, 3.22+0.29 days of slow play, 3.28+0.31 nights of sleep disruption). Three months prior to enrollment, 77% children had at least one unscheduled emergency department (ED) or clinic visit and 19% had at least one Prednisone burst. Conclusion: Asthma symptoms in HEAL children were frequent and severe, and resulted in multiple unscheduled ED and clinic visits. Flooding and rain damaged homes, which facilitated the growth of mold and other asthma triggers. In post-disaster situations like this, case management in combination with tailored guidance on home remediation might be more effective at reducing asthma morbidity compared with case management alone.


Emergencies 3

Psychosocial Impact of Hurricane Katrina on New Orleans Families With Asthmatic Children

  • M. Lichtveld , Tulane University
  • J. El-Dahr , Tulane University
  • E.Thornton , Visionary Consulting Partners, LLC
  • Y. Sterling , Louisiana State University
  • M. Mvula , City of New Orleans, Department of Health
  • H. Mitchell , Rho Federal Systems Division, Inc

Previous research has demonstrated that significant relationships exist between psychosocial factors and asthma morbidity in children. In post-Karina New Orleans, families were exposed to inordinate amounts of stress from loss of homes, neighborhoods, and jobs and disrupted health care, family, and social networks. Objectives: Examine psychosocial issues facing families with moderate-to-severe asthmatic children in the post-Katrina New Orleans area. Methods: Questionnaires were administered to caregivers to collect data concerning their specific needs (needs assessment) as related to social and health care services. Other data were collected on asthma symptoms, attitudes and beliefs, health care utilization, mobility, quality of life, life events, social support, and other potential asthma stressors. Potential associations between stressors and clinical and morbidity endpoints were examined. Results: On average, Head-off Environmental Asthma in Louisiana (HEAL) families moved 3.3+0.15 times since Katrina. The number of moves correlated to living at the time of enrollment in a home with no leaking roof (p = 0.001) but that had flooded (p = 0.029), and a higher FEV1/FVC ratio in the child with asthma (p = 0.003). Perceived stress scores for caregivers averaged 5.42+0.23, and stress correlated with lower income (p = 0.042), not having a high school education (p = 0.002), and the child living with a caretaker other than the mother (p = 0.013). Behavior Check List scores for children averaged 49.47+0.84. Conclusions: Social environment influences the development and morbidity of asthma and may contribute to asthma risk either by stress or by exposure to increased levels of allergens and pollutants. This was clearly evident in post-Katrina New Orleans, where rain and flooding damage from Katrina forced families to move often, and the multiple stressors of the post-flood environment contributed to the asthma morbidity present in study children.


Emergencies 4

Laboratory Preparedness for Radiological Emergencies: Federal Perspectives

  • K. Caldwell , Centers for Disease Control and Prevention
  • R. Jones , Centers for Disease Control and Prevention

Background: In the case of radiological or nuclear event, significant numbers of the population may be exposed to radionuclides, resulting in internal contamination and radiation exposure. Valuable information could be obtained from rapid radiochemical measurements of urine from individuals known or suspected to be contaminated. These rapid analytical methods can help in the speedy identification of people who have been exposed to these radionuclides above a level of concern. The Centers for Disease Control and Prevention (CDC) is currently developing the Urine Radionuclide Screen (URS) to assess exposure of large populations to 20+ priority radionuclides. Issue: CDC's URS will utilize analytical methods to determine radiation exposure using gamma, beta, and alpha counting as well as mass spectrometry techniques, and will likely include 12–15 CLIA ( Clinical Laboratory Improvement Amendments )-certified analytic methods that will provide for rapid “screening” and prioritization as well as the identification and quantification of priority radionuclides in human samples. In the URS, radionuclide exposure is identified first by a rapid screening method followed by a confirmatory method that also quantifies the amount of the radionuclide. Once valid methods are developed, the technology can be transferred to public health laboratories. However, CDC has not yet established a Laboratory Response Network–Radiology (LRN-R) but hopes to be able to develop this capacity if resources become available in the future. Results: To date, CDC has developed and validated 6 radioanalytical methods for 7 priority radionuclides.


Emergencies 4

EPA Environmental Response Laboratory Network (ERLN)

  • T. Smith , US Environmental Protection Agency

In response to presidential directives to protect the nation from the potential threats posed by terrorism or catastrophic events, the Environmental Protection Agency (EPA) has implemented the Environmental Response Laboratory Network (ERLN). The ERLN is a network of laboratories designed to support environmental responses by providing known analytical capabilities, capacities, and quality data in a scalable, systematic, and coordinated manner. The ERLN is faced with many unique challenges. It must be able to provide the following: (a) analytical capabilities for a variety of environmental matrices, (b) analytical capabilities to support a broad spectrum of capacity needs, such as individual short-term responses involving a few dozen samples to multiple long-term responses that require the analysis of tens of thousands of samples, and (c) analytical capabilities to support a wide variety of data. The ERLN has been designed to provide reliable, high-quality analytical data to federal, state, and local decision makers to identify chemical, biological, and radiological contaminants in environmental samples collected in support of response and remediation activities


Emergencies 5

Adaptive Strategies to Prevent Heat-Related Mortality: Lessons Learned From New York City, 2008–2009

  • N. Graber , New York City Department of Health and Mental Hygiene
  • A. Tantri , New York City Department of Health and Mental Hygiene
  • A.Paykin , New York City Department of Health and Mental Hygiene
  • N. Clark , New York City Department of Health and Mental Hygiene

Background: A total of 40 heat stroke deaths and 100 excess deaths occurred in New York City (NYC) during a 10-day heat wave in 2006. Risk factors identified from the investigation included age >65 years, having multiple medical conditions or a psychiatric disorder, and no home air conditioner. Although some victims lived alone, many did not and almost all had family in the metropolitan area. It is possible that limited awareness of risk factors, preventive actions, and inability to recognize symptoms of heat illness can reduce the protective effect of living with someone. Methods/Results: In 2008–2009, the NYC Department of Health and Mental Hygiene participated in a multiagency adaptive strategy to prevent heat-related mortality among low-income adults ages >65 years. Strategy components included (1) disseminating educational materials to heighten awareness and perceived risk, (2) disseminating alerts to health care providers concerning key risk factors via a health alert network and public health detailing, (3) encouraging community and faith-based leaders to conduct community outreach during heat waves, (4) issuing media messages in conjunction with National Weather Service heat advisories at recently lowered threshold Heat Index, (5) providing and promoting neighborhood “cooling centers,” and (6) promoting a free air conditioner program, resulting in >5,000 installations. Discussion: A successful adaptive strategy includes surveillance and opening of cooling centers during heat waves as well as measures to address the home environment and provide heightened awareness and “keep cool” tips.


Emergencies 5

The Heat Is On

  • L. Harris-Franklin , Missouri Department of Health and Senior Services

Background: Missouri is the only state that includes hyperthermia (heat-related illness) as a reportable condition. Hyperthermia became reportable by state law on April 8, 1993. This surveillance program began as a result of the 1980 heat wave, which claimed 295 Missouri lives. Issue: The Department of Health and Senior Services (DHSS) Hyperthermia Surveillance Program determines the weather-related morbidity and mortality attributed to extreme heat conditions. Temperature, relative humidity, and heat index levels for 5 locations in the state are received from the National Weather Service (NWS) on a daily basis from late May through mid-September. Illnesses are reported by local public health agencies, hospitals, through the Bioterrorism Syndromic Surveillance System, and by the media. Death data are received and verified through the Department of Health and Senior Services Vital Records system. Results: DHSS uses the data collected to educate the public on the health hazards associated with weather temperature. Data are analyzed based upon geographic location, sex, race, ethnicity, age of patient, and other factors. Lessons Learned: The addition of syndromic surveillance has verified the underreporting of hyperthermia cases. Extreme heat health and safety information is issued to the public in conjunction with the NWS. Heat affects everyone, so educational efforts do make a difference. New partnerships and ways to reach at risk populations are being made each year.


Emergencies 5

The 2008 California Wildfires: Emergency Response Strategies to Lessen the Public Health Impact of Smoke

  • S. DuTeaux , CA Air Resources Board
  • J. Cook , CA Air Resources Board

From May to July 2008, there were an unprecedented number of wildfires burning in northern and central portions of California, many sparked by lightning strikes. Officials estimate that as many as 2,000 fires were simultaneously burning over 1 million acres. The California Air Resources Board (ARB) Emergency Response Team deployed at the request of local air districts and the California Emergency Management Agency (CalEMA) to monitor smoke in impacted communities. The number and extent of fires coupled with fire suppression and changing meteorological conditions resulted in sustained unhealthy air quality for weeks. For the first time in state history, the governor based an emergency proclamation on air quality decrements from a wildfire. Additional local, tribal, and presidential declarations allowed for the deployment of more resources to mitigate the impact of wildfire smoke. These resources included a combination of reference and portable air monitoring equipment that provided real-time particulate concentration data to the public and media through US Environmental Protection Agency's (EPA's) AIRNow Web site ( Local health officers and air district officials used the air quality data combined with the Air Quality Index (AQI) to inform health-based decision making. Additional public health actions included door-to-door visits on tribal land, distributing portable HEPA HVAC units and N95 masks with proper instructions for use, opening clean air shelters, and cancelling certain public events. However, advice concerning protective actions was not always consistent across jurisdictions, leading in some cases to confusion at the community level as to the most appropriate action to take. Cooperation during the fires was largely a success. Further training and preplanning will help build consensus among federal, state, and local partners prior to the next air quality emergency.


Emergencies 5

Community Assessment for Public Health Emergency Response Following the Winter Ice Storms in Kentucky—February, 2009

  • S. Vagi , Centers for Disease Control and Prevention
  • Y. Redwood , Centers for Disease Control and Prevention
  • T.Bayleyegn , Centers for Disease Control and Prevention
  • A. Wolkin , Centers for Disease Control and Prevention
  • M. Riggs , Kentucky Department of Public Health

Background: Kentucky was declared a major disaster area after a severe ice storm struck January 27, 2009, causing 36 deaths and leaving 770,000 residents without power. February 2, 2009, the Kentucky Department for Public Health (KYDPH) requested assistance in rapidly assessing the health and safety of persons residing in rural and remote counties in western Kentucky. In response, a Centers for Disease Control and Prevention (CDC) team deployed to conduct a Community Assessment for Public Health Emergency Response (CASPER). Methods: CASPER was conducted in 4 areas; each area was composed of 1–4 counties. The team used multistage probability sampling and weighted analyses to provide census-based population estimates of needs for each of the 4 sampled areas. A standardized data collection instrument was administered to households and included questions regarding storm related injuries and illnesses, generator use, availability of basic necessities, barriers to shelter use, and special needs. Results: Between February 6 and February 9, teams completed 735 interviews across the 4 areas. Almost 2 weeks after the storm, up to 25% of households were still without electricity, up to 56% had used generators, and 5–7% did not have a working telephone. In some areas, 20% claimed that pet ownership prevented them from seeking alternative shelter. Up to 23% reported illness, up to 10% reported an injury, and up to 16% reported mental health problems. Among those reporting special needs (10% of total), 44–67% were oxygen dependent. Conclusions: In response to CASPER results and recommendations, KYDPH distributed radio announcements and flyers about how to safely use generators. Further, KYDPH's planning for future disaster response includes pet-friendly shelters, alternative communication mechanisms, and ways to better address special needs of oxygen-dependent individuals.


Emergencies 6

Post-Disaster Carbon Monoxide Poisoning Surveillance Workgroup: Lessons From Three Recent Storms

  • J. Clower , Contractor, Centers for Disease Control and Prevention
  • S. Iqbal , Centers for Disease Control and Prevention
  • F. C.Yip , Centers for Disease Control and Prevention
  • E. Lutterloh , Centers for Disease Control and Prevention
  • P. Garbe , Centers for Disease Control and Prevention

Background: Carbon monoxide (CO) poisoning is preventable, yet poses a substantial public health problem when storms cause large-scale power outages. In such settings, there is often a high risk for CO poisoning from improper generator use. Issue: The Centers for Disease Control and Prevention (CDC) partnered with state health agencies in Iowa (2008 floods), Texas (Hurricane Ike, 2008), and Kentucky (2009 ice storm) during widespread power outages to conduct CO surveillance. We used several data sources to assess morbidity and mortality, including the National Poison Data System and the Undersea and Hyperbaric Medical Society's hyperbaric oxygen treatment (HBOT) database. In Iowa, we conducted a household survey to assess health behavior. Results: In Texas there were 13 CO-related deaths, 34 persons received HBOT, and there were 80 CO-related poison centers calls. Similarly, in Kentucky there were 10 deaths, 28 HBOTs, and 115 poison center calls. Over 75% of all reported exposures in Texas and 80% of CO fatalities in Kentucky were due to improper generator use. In Iowa, 59% of respondents reported placing a generator within 10 feet of the home. Conclusion: Our findings illustrate that CO-related morbidity and mortality are an ongoing public health issue in disaster settings, largely due to improper generator use. A continuing effort to inform the public about CO sources, including generators, is vital. The data sources used were not designed to comprehensively assess CO poisoning and are not part of a post-storm CO surveillance framework that includes systematic data collection and communication channels. These gaps may result in incomplete data reporting and delay public health action. An improved framework can assist in understanding the impact of improper generator use and other CO-related risk factors. The newly formed Post-disaster CO Poisoning Surveillance Workgroup is composed of data stewards from concerned agencies and institutions that will work to improve the understanding of CO exposure and develop better targeted messaging and policy to reduce storm-related CO poisonings.


Emergencies 6

Emergency Post-Hurricane Debris Landfills in New Orleans: More Superfund Sites?

  • C. Hu , Louisiana State University
  • J. Diaz , Louisiana State University
  • Y.Chiu , Louisiana State University
  • D. Harrington , Louisiana State University Health Sciences Center, School of Nursing
  • Y. Chiu , Jin Wen University of Science & Technology (Taiwan)

Background: In 1965, the closed Agriculture Street Sanitary Landfill in New Orleans was reopened in an emergency to receive Hurricane Betsy debris. Later, a residential community was built over the site. In 1994, the landfill site was designated an Environmental Protection Agency (EPA) superfund site after arsenic, lead, and other toxicants were discovered in the soil. Cleanup costs exceeded $20 million. Issue: In 2005, Hurricanes Katrina and Rita devastated coastal Louisiana. Reacting to community needs for urgent disposal of mounting solid wastes, the Louisiana Department of Environmental Quality (LDEQ) exercised its statutory powers to authorize the City of New Orleans to reopen 2 closed landfills for disposal of hurricane debris and related wastes. Although LDEQ classified the hurricane debris as nonhazardous construction and demolition debris, hazardous materials were disposed of in unlined landfills. These landfills encircled a minority community of commercial fishermen and truck farmers and were surrounded by nature preserves and wetlands. Results: For the past 3 years, the minority community has expressed mounting concerns over potential toxic food and waterborne exposures from the landfills. Although LDEQ announced that there were no adverse health impacts posed by the landfills, nongovernmental environmental groups labeled the now-closed landfills as future environmental catastrophes. The disparity between government and community understanding about any hazards posed by the landfills continues. In addition, there is no site-monitoring program for potential toxicant migration. Lessons Learned: If future environmental risk assessments document the recurrence of temporary hurricane landfills posing community or ecosystem health hazards, then federal and state environmental agencies should reconsider the balance between fast, short-term cleanup strategies and long-term environmental health impacts to avoid more Superfund sites.


Emergencies 6

Environmental Disaster: Coal Ash Release—the Tennessee Department of Health Story

  • D. Borowski , Tennessee Department of Health

Background: On December 22, 2008, a retaining wall failed at the Tennessee Valley Authority's (TVA's) Kingston Fossil Plant in Roane County, Tennessee. An estimated 1.1 billion gallons of coal ash were released. The spill covered about 300 acres of river, sloughs, and waterfront land. While there were no immediate injuries, the physical and natural environment was dramatically changed. The spill affected hundreds of residents living nearby. Citizens have been stressed by the spill, worried about the health of their families and pets, property value, and overall quality of life. Issue: The Tennessee Department of Health (TDH) performed several important roles during the initial emergency response. Our goal was to protect the public from touching, eating, drinking, or breathing coal ash. The environmental response included the Tennessee Department of Environment and Conservation, local emergency medical services, the Environmental Protection Agency, Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry, and TVA. In addition, nongovernmental groups including motivated citizens, environmental groups, celebrity legal counsel, and salespersons were involved. Results: A tremendous amount of environmental sampling and risk communication was necessary to protect the health and safety of the public. Testing for heavy metals, airborne particulates, radioactivity, and wildlife bioaccumulation was performed. Additional testing of soil, air, water, and groundwater will be required in the future. An Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry–certified public health assessment is being prepared by TDH to document the public health response. Lessons Learned: An environmental emergency provides many learning opportunities. TDH integrated into a multiagency Incident Command structure while maintaining our independent authority. TDH learned the importance of good risk communication within our agency, amongst other agencies, the media, and the general public. Overall, our program learned how to adapt our small staff to respond to overwhelming public health concerns for an environmental site of national importance.


Emergencies 6

Integrating Informal Drills to Improve Environmental Emergency Response—Experiences From New York City

  • A. Tantri , Centers for Disease Control and Prevention
  • A. Almiroudis , New York City Department of Health and Mental Hygiene
  • A.Paykin , New York City Department of Health and Mental Hygiene
  • N. Clark , New York City Department of Health and Mental Hygiene

Background: Following the events of September 11, 2001, the New York City Department of Health and Mental Hygiene (DOHMH) coordinated public health response activities, including environmental risk assessment, data management, and risk communication. In recent years, DOHMH further developed emergency response protocols, trained staff, and conducted formal drills and tabletop exercises to improve public health preparedness. DOHMH recently implemented informal, regularly scheduled drills to further refine protocols and improve environmental emergency response skills. Methods: In 2008, DOHMH conducted 4 informal risk communication drills. Each involved a scenario-based design, observers and evaluators, and participants (researchers, writers, and editors). Drill scenarios were based on actual incidents or priority contaminants of concern. Participants were asked to identify key audiences and develop fact sheets and talking points. Participants conducted drills at their desks without additional resources. Each drill and debrief took approximately 2–3 hours to complete. Results: Through these drills DOHMH successfully built capacity in environmental risk communication, learned about priority contaminants, refined protocols and templates, and reduced the time required to develop materials. Lessons Learned: Observers are essential to identify strengths and gaps in staff capacity and protocols, drills must involve experts for effective knowledge transfer, and multiple drills are required to reinforce lessons learned and effectively address gaps. Implications: Large-scale drills and tabletop exercises require tremendous coordination, preparation, and resources. Short drills can be conducted frequently with minimal coordination and preparation, fit into daily work schedules, require few resources, and ensure successful capacity building.


Emergencies 6

Investigation of Community Health Status Following a Release of Coal Ash Sludge in TN

  • J. Roth, Jr. , Centers for Disease Control and Prevention
  • A. Green , Tennessee Department of Health
  • I.Ribeiro , Centers for Disease Control and Prevention
  • D. Kirschke , Tennessee Department of Health
  • T. Jones , Tennessee Department of Health

Background: On December 22, 2008, 1.1 billion gallons of coal ash sludge was released from a Tennessee Valley Authority (TVA) facility near Kingston, Tennessee, following the collapse of an earthen wall of a facility retention pond. Ensuing community health concerns prompted a community health survey conducted by the Tennessee Department of Health (TDH), in collaboration with the Centers for Disease Control and Prevention (CDC). Methods: Dwellings within a 1.5 mile radius of the coal ash release were identified using satellite imagery. Residents within this geographic area were invited to participate with the verbally administered, standardized questionnaire. Results: January 8–15, 2009, assessment teams of 2 to 3 public health staff visited 324 residences within a 1.5 mile radius of the release. Investigators interviewed 368 participants representing 170 households. Among participants 24% were ages <18 years, 59% ages 18–64 years, and 17% ages =65 years. A third of participants (33%) reported that their shoes or clothing had been in contact with the fly ash, and a smaller number (13%) reported direct skin contact. Most respondents (62%) reported no change in physical health status after the release, although 33% reported worsening of one or more symptoms. Among the most common symptoms reported by residents were worsening of cough (27%), headache (25%), wheezing (14%), and shortness of breath (14%). Symptoms of stress and anxiety were reported by 52% of the participants. Conclusions: Most of the respondents did not report any change in physical health status. Anxiety and stress were prominent findings, however. About a third of persons reported that they perceived worsening of upper respiratory symptoms. While it is not possible to link individual symptoms to particular exposures, the perception of worsened health status by some residents since the release will need to be addressed in an ongoing way during the recovery period.


Emergencies 7

Internet-Based Systems for Operationalizing Public Health Workforce Management During a Disaster or Pandemic

  • M. Kosnett , University of Colorado–Denver and Axion Health, Inc.

Background: A disaster or pandemic has the potential to undermine the readiness of the public health and safety workforce at the same time that demands on that workforce rise. Issue: Compared to extensive efforts to assist the public in the event of a disaster or pandemic, practical ways of operationalizing plans for maintaining health and readiness of critical sector workforces has received less attention. For example, a 2009 survey of unionized health care institutions ( concluded that one-third were “either not ready or only slightly ready to address the health and safety needs necessary to protect healthcare workers during a pandemic.” Result: Internet-based continuity of operations tools have addressed the need for enhanced workforce communication and management before, during, and after an event. For pre-event pandemic influenza planning, a secure Internet program successfully evaluated, prescribed, and dispensed >30,000 courses of antiviral medication to employees and dependents of a multistate energy utility. An Internet/telephonic system under deployment by a metropolitan hospital system will provide management with real-time updates on the health and work status of key personnel, facilitate rapid prioritization and disbursement of medications and other countermeasures, allow “doorway screening” of entrants to critical work areas, streamline screening of volunteers and new hires, and allow tailored, secure communications to targeted personnel via password-controlled Web portal, e-mail, or automated voice messaging. Lessons Learned: An Internet-based continuity of operations system represents an advance in workforce management for disasters and pandemics.


Emergencies 7

Innovative Tools for EH Emergency Preparedness

  • B. Golob , Hennepin County

Background: All Americans face hazards posed by natural and human-made disasters. We knowingly accept this fact and live in areas routinely subjected to natural disasters such as hurricanes, tornados, floods, and earthquakes. In addition to these hazards,human-made or technological ones such as bridge failures, chemical releases, terrorist acts, and hazardous material incidents can also pose risks to public health. Issue: In the event that a disaster strikes a community, there is uncertainty and confusion among many environmental health (EH) professionals regarding how they will respond to an incident and what roles they would have during response and recovery phases. Many working professionals do not believe they have received adequate training or emergency equipment to respond to an incident. Some local health departments do not have a written environmental health emergency response plan. The prevailing “climate of uncertainty” must be addressed to build staff capacity and instill confidence in the individuals who comprise the environmental health profession. Results: Environmental health, public health, and other professionals will benefit from the session by learning about a variety of useful resources, developed by the Twin Cities Metro Advanced Practice Center (APC), that are available to help them prepare for and respond to natural and human-made disasters. APC staff have developed and used many practical products focusing on 3 broad areas related to environmental health emergency preparedness: training, planning, and food protection emergency readiness. These resources collectively strengthen the ability of environmental and public health professionals to plan for and respond to an incident, and to effectively partner on behalf of the public's health. The presentation will summarize and highlight these materials. Lessons Learned: Many working professionals across the country will save time and effort by being aware of these products that can immediately benefit their preparedness efforts. There is no point in local or state health departments reinventing the environmental health emergency preparedness response wheel when effective resources are readily available.


Emergencies 7

Development of Epidemiologic Tools for Radiological Emergency Preparedness and Response Through Partnerships

  • C. Martin , Centers for Disease Control and Prevention
  • A. Chang , Emory University
  • A.Wolkin , Centers for Disease Control and Prevention
  • J. Tropper , Centers for Disease Control and Prevention
  • A. Ansari , Centers for Disease Control and Prevention
  • J. Nemhauser , Centers for Disease Control and Prevention

Background: Epidemiologists have a key role in preparing for and responding to radiological public health emergencies, including characterizing population health impact, using epidemiologic data to assist in prioritization of biological specimens for laboratory analysis, and identifying individuals needing medical treatment and long-term monitoring. These topics have received increased attention following the Top Officials 2 and 4 radiological exercises. Objective: This abstract describes the recent work of the Centers for Disease Control and Prevention (CDC) National Center for Environmental Health (NCEH) Health Studies Branch (HSB) to address the need to develop epidemiologic tools to prepare for and respond to a radiological emergency in collaboration with public health partners. Response: HSB will develop epidemiologic tools for collecting data following a radiological event with the assistance of NCEH Radiation Studies Branch, Conference of Radiation Control Program Directors, and state and local health departments. HSB is working with the American Association for Poison Control Centers' National Poison Data System to develop surveillance definitions to monitor human health impact of an event. In cooperation with CDC's National Center for Public Health Informatics, HSB is identifying ways to enhance the Countermeasure and Response Administration system to track radiological countermeasure administration. In order to prioritize biological specimens sent to CDC for testing, HSB is working with the NCEH Division of Laboratory Sciences to develop prioritization algorithms based on individuals' exposure and other epidemiologic data. Next Steps: HSB plans to collaborate with both internal and external partners to develop new tools and enhance existing systems for surveillance and epidemiologic data collection, analysis, and integration to assist states during a radiological public health emergency. Next steps include testing these tools during a radiation exercise and identifying gaps.


Emergencies 7

Gimme Shelter: An Environmental Sanitation Response to Sheltering Operations During Hurricane Gustav

  • T. Zerwekh , Memphis and Shelby County Health Department

Hurricane Gustav was a Category 4 hurricane that slammed into the coast of Louisiana and New Orleans on August 31, 2008. Through Federal Emergency Management Agency mandate, approximately 3,000 New Orleans citizens were preemptively evacuated to the state of Tennessee; of which 2,000 were sheltered in Memphis and Shelby County. The 10-day sheltering operation required full Emergency Operations Center activation and coordination with myriad local, state, and federal agencies. This presentation will focus specifically on the Memphis and Shelby County Health Department environmental sanitation response to sheltering operations, including environmentalist activities and frequency of inspections, mitigation of different organizational shelter activations, common environmental problems and issues encountered at shelters, inspection result data, and demobilization of environmental sanitation sheltering activities.






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