NEHA March 2023 Journal of Environmental Health

The March 2023 issue of the Journal of Environmental Health (Volume 85, Number 7), published by the National Environmental Health Association.

JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional

Volume 85, No. 7 March 2023

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JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 85, No. 7 March 2023

ADVANCEMENT OF THE SCIENCE Assessment of Chemical Exposures Investigation After Fire at an Industrial Chemical Facility in Winnebago County, Illinois........................................................................8 The COVID-19 Pandemic, Fukushima Nuclear Disaster, and Commonalities and Public Health Threat Complexities: A Public Health, Healthcare, and Emergency Management Command and Support Supersystem Model.....................................16 ADVANCEMENT OF THE PRACTICE Identifying Public Perceptions of Information on Harmful Algal Blooms to Guide Effective Risk Communication...................................................................................26 Direct From AEHAP: From Assessment to Action: A Road Map to Becoming an Environmental Health Science Professional ............................................................................. 32 Direct From CDC/Environmental Health Services: Community Resources for Contaminants of Concern in Private Wells .............................................................................. 36 Direct From ecoAmerica: The Climate World Is Changing, So Can We ....................................... 40 NEW Environmental Health Across the Globe: How an Australian Centre for Disease Control Can Reinforce Environmental Health Systems and Services ............................ 42 Programs Accredited by the National Environmental Health Science and Protection Accreditation Council.......................................................................................45 ADVANCEMENT OF THE PRACTITIONER Environmental Health Calendar................................................................................................46 Resource Corner........................................................................................................................47 JEH Quiz #5...............................................................................................................................48 YOUR ASSOCIATION President’s Message: Join the Fliers Who Soar to Great Heights . ............................................................. 6 NEHA Second Vice-Presidential Candidate Profile...................................................................49 Special Listing............................................................................................................................50 NEHA Regional Vice-Presidential Candidate Profiles................................................................52 NEHA News...............................................................................................................................54 NEHA 2023 AEC.......................................................................................................................60 NEHA Member Spotlight...........................................................................................................62

ABOUT THE COVER

Accurate, under- standable, and reli-

able information is crucial during and after a harm- ful algal bloom (HAB) event. This month’s cover article, “Identifying Public Percep- tions of Information on Harmful Algal Blooms to Guide Effective Risk Communication,” examined perceptions of residents near Lake Erie’s western basin about where they received HAB information, what information was most important, and which sources they found most credible. Results from the study highlight that effective risk communication should provide information about severe events in an under- standable and timely manner, convey unbiased facts, deliver information from sources seen as trustworthy, and use existing opportunities in the community to provide education. See page 26. Cover image © iStockphoto: ansonsaw, wichatsurin

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March 2023 • Journal of Environmental Health

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in the next Journal of Environmental Health don’t miss  Bacterial Contamination in Long Island Sound: Using Preemptive Beach Closure to Protect Public Health  Decreased Moderate to Vigorous Physical Activity Levels Are Associated With Increased Traffic-Related Air Pollutants in Children With Asthma  Effectively Communicating Results of Drinking Water Tests From Private Wells

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Published monthly (except bimonthly in January/February and July/ August) by the National Environmental Health Association, 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910. Phone: (303) 802- 2200; Fax: (303) 691-9490; Internet: www.neha.org. E-mail: kruby@ neha.org. Volume 85, Number 7. Yearly subscription rates in U.S.: $150 (electronic), $160 (print), and $185 (electronic and print). Yearly international subscription rates: $150 (electronic), $200 (print), and $225 (electronic and print). Single copies: $15, if available. Reprint and advertising rates available at www.neha.org/jeh. Claims must be filed within 30 days domestic, 90 days foreign, © Copyright 2023, National Environmental Health Association (no refunds). All rights reserved. Contents may be reproduced only with permission of the managing editor. Opinions and conclusions expressed in articles, columns, and other contributions are those of the authors only and do not reflect the policies or views of NEHA. NEHA and the Journal of Environmental Health are not liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein. NEHA and the Journal of Environmental Health reserve the right to reject any advertising copy. Advertisers and their agencies will assume liability for the content of all advertisements printed and also assume responsibility for any claims arising therefrom against the publisher. The Journal of Environmental Health is indexed by Clarivate, EBSCO (Applied Science & Technology Index), Elsevier (Current Awareness in Biological Sciences), Gale Cengage, and ProQuest. The Journal of Environmental Health is archived by JSTOR (www.jstor.org/journal/ jenviheal). All technical manuscripts submitted for publication are subject to peer review. Contact the managing editor for Instructions for Authors, or visit www.neha.org/jeh. To submit a manuscript, visit http://jeh.msubmit.net. Direct all questions to Kristen Ruby-Cisneros, managing editor, kruby@neha.org. Periodicals postage paid at Denver, Colorado, and additional mailing offices. POSTMASTER: Send address changes to Journal of Environmental Health , 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910.

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Volume 85 • Number 7

Do you know someone who is walking the walk? When your colleague or team steps up to create a more just, diverse, equitable, and inclusive environment, it matters! Let them know by nominating them today for the Dr. Bailus Walker, Jr. Diversity and Inclusion Awareness Award. Nomination Deadline: May 15, 2023 neha.org/awards Dr. Bailus Walker, Jr. Diversity and Inclusion Awareness Award

Recognize your colleague! Do you work with someone who is always coming up with creative ways to educate the public or colleagues? Is there someone on your team who has created tools or a practice that has really made a difference in improving environmental health? Nominate them for the Joe Beck Educational Contribution Award and show them how much you value their contribution. Nomination Deadline: May 15, 2023 neha.org/awards Joe Beck Educational Contribution Award

March 2023 • our5(l o- 5=0ro5me5;(l e(l;/

YOUR ASSOCIATION

 PRESIDENT’S MESSAGE

Join the Fliers Who Soar to Great Heights

D. Gary Brown, DrPH, CIH, RS, DAAS

T he quote by Marty Rubin, “The deep roots never doubt spring will come,” is a reminder even in the season of re- newal that the current season of bloom for the National Environmental Health Association (NEHA) is from the environmental health trail blazers who sowed the initial seeds. In this column I want to highlight two groups—the American Academy of Sanitarians (AAS) and the NEHA History Project Task Force—that many associate with the foundation or roots of environmental health. Being around these amazing people reminds me of what Pelé said, “Success is no accident. It is hard work, perse- verance, learning, studying, sacrifice, and most of all, love of what you are doing or learning to do.” I cannot begin to express my gratitude for all the work done by these distinguished groups whose energy is infectious. I have the pleasure and honor of being a member of both organizations where I have gained knowledge, fellowship, friendship, and joy. As Michelangelo said, “I am still learning.” Furthermore, Antoine de Saint- Exupéry stated, “The tree is more than first a seed, then a stem, then a living trunk, and then dead timber. The tree is a slow, endur- ing force straining to win the sky.” If our environmental health pioneers are the roots of the tree, mid-career professionals are the trunk and early career professionals are the leaves. A tree (e.g., NEHA) does not flourish unless all parts of the tree are working to- gether. The bursting petals of the new NEHA logo represent a new era and excitement for what is possible for NEHA and our profes- sion. NEHA shares the idea stated by Eleanor

courage improvement and stimulate public interest in food service sanitation. AAS has supported early career and stu- dent members since its inception. Through a partnership between NEHA and AAS, an- nual educational scholarships are awarded to exceptional undergraduate and graduate students pursuing a career in environmental health. AAS also helps to enhance student ex- periences at the NEHA Annual Educational Conference (AEC) & Exhibition. Becoming a diplomate in AAS denotes a high standard of professionalism with marked distinction and a record of accomplishment in environmental health. It denotes profes- sional status and gives prestige to the holders of the diplomate certification. AAS invites and encourages professionally credentialed envi- ronmental health practitioners with qualities of outstanding competence and leadership to become certified as diplomates. Currently, there are thousands of regis- tered environmental health specialist/reg- istered sanitarian (REHS/RS) professionals, but since the inception of AAS in 1966, only 611 environmental health professionals have been awarded diplomate status. Becoming a diplomate helps you stand out from the crowd, enhancing your career while promot- ing the profession. Join the dierence mak- ers! As Jane Goodall stated, “What you do makes a dierence and you have to decide what kind of dierence you want to make.” To become a member of this prestigious group you must hold an REHS or RS creden- tial, have three reference letters, have at least one published paper, and demonstrate to the

Roosevelt: “The future belongs to those who believe in the beauty of their dreams.” AAS is an organization that elevates stan- dards, improves the practice, advances pro- fessional proficiency, and promotes the high- est levels of ethical conduct in every field of environmental health. Many environmental health professionals do not realize that AAS sponsors the Davis Calvin Wagner Sanitar- ian Award, which is conferred for exceptional leadership ability, professional commitment, outstanding resourcefulness, dedication, and accomplishments in advancing the sanitar- ian profession and public health programs. In addition, AAS is one of the many cospon- sors of the Samuel J. Crumbine Consumer Protection Award (https://crumbineaward. com). The Crumbine Award is a prestigious national award given annually to local envi- ronmental health jurisdictions that demon- strate excellence and continual improvement in a comprehensive food protection program. The purpose of the Crumbine Award is to en- The current season of bloom for NEHA is from the environmental health trail blazers who sowed the initial seeds.

Volume 85 • Number 7

satisfaction of the AAS board your good moral character and high ethical and professional standing. For further information, please visit the AAS website at https://aaosi.wildapricot.org. In 2020, NEHA President Dr. Priscilla Oliver, the founder of the One NEHA theme, started the NEHA History Project Task Force, which is composed of a group of illustrious NEHA professionals who have made numer- ous contributions to our field. I have had the privilege and honor of being an ex-officio member of this task force. The NEHA History Project Task Force accomplishments include launching a web- page in 2021, led by Kristen Ruby-Cisneros, managing editor of the Journal of Environ- mental Health , to showcase its work and NEHA’s history (www.neha.org/history). The NEHA History Project webpage provides an overview of the project and a list of task force members and how to get involved. Other highlights from the NEHA History Project webpage include: • An electronic version of the NEHA Green Book: E nvironmental Health 1937–1987, Fifty Years of Professional Development With

Harry Grenawitzke, Dr. Priscilla Oliver, Dick Pantages, Vince Radke, Dr. Welford Roberts, and Dr. Chris Wiant. Retired RADM Webb Young represents the uniformed services and Drs. Robert Powitz and Leon Vinci represent the private sector. Rounding out the commit- tee in an ex-officio capacity (along with me) are NEHA Executive Director Dr. David Dy- jack and Kristen Ruby-Cisneros. The NEHA History Project Task Force states it best: “All forms of input, ideas, and history are welcomed, and we invite you to share that with the task force. The task force also encour- ages individuals to reach out if interested in joining our work in preserving and presenting the history of NEHA and our profession.” Please become involved with NEHA on a local, state, or national level by spreading the word that environmental health is public health. In doing so, it can be as Dr. Seuss said, “You’ll be on your way up! You’ll be seeing great sights! You’ll join the high fliers who soar to high heights.”

the National Association of Sanitarians/ National Environmental Health Association was published in 1987 by NEHA and pro- vides a brief history of the first 50 years of the association. The task force, led by Dr. Hermen Koren, is developing a new and updated publication on the history of NEHA and the profession. • NEHA Virtual Museum: We have posted images and descriptions of artifacts, instrumentation and tools, publications, and miscellaneous items related to envi- ronmental health and NEHA from the per- sonal collection of Dr. Robert Powitz. • A listing of past NEHA AECs: You can learn about where our past AECs have been held and peruse links to the reports published in the Journal of Environmental Health about each conference. Dr. Leon Vinci has been a great chairper- son keeping us on target. The task force has included distinguished individuals from aca- demia such as Dr. Jack Hatlen and Dr. Her- man Koren. Several NEHA past presidents have served on the task force, including Bob Custard, Diane Eastman, Dr. Amer El-Ahraf,

gary.brown@eku.edu

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March 2023 • Journal of Environmental Health

ADVANCEMENT OF THE SCIENCE

Assessment of Chemical Exposures Investigation After Fire at an Industrial Chemical Facility in Winnebago County, Illinois

Jasmine Y. Nakayama, PhD Krishna Surasi, MD

found for other analytes monitored, includ- ing volatile organic compounds, carbon monoxide, oxygen, and hydrogen sulfide (Illinois Environmental Protection Agency, 2022; U.S. EPA, n.d.). Because additional chemical exposures, such as exposures to heavy metals, were unknown, public health authorities considered how to determine the health eects of the chemicals released from the fire in nearby communities and among first responders, who could have had dierent exposure experiences than the general population. After a chemical exposure incident, ATSDR evaluates the need to conduct an Assessment of Chemical Exposures (ACE) investigation, which is an epidemiological assessment that can provide information to assess the health eects of the incident on individuals and communities, direct the public health response, focus outreach to prevent similar incidents, assess the need for modification of emergency response pro- cedures, and identify groups of people who might need long-term follow-up (Agency Epidemic Intelligence Service, Centers for Disease Control and Prevention Lance R. Owen, PhD Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry Mark Johnson, PhD Office of Community Health Hazard Assessment, Agency for Toxic Substances and Disease Registry Sandra Martell, DNP Abigail Kittler Peter Lopatin, MBA Winnebago County Health Department Sarah Patrick, PhD Illinois Department of Public Health Caitlin Mertzlufft, PhD Office of Community Health Hazard Assessment, Agency for Toxic Substances and Disease Registry D. Kevin Horton, DrPH Maureen Orr, MS Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry

b:;r(*; After a chemical fire, an investigation assessed health e ects by using syndromic surveillance to monitor emergency department (ED) visits, a general health survey to assess the general public, and a first responders health survey to assess first responders. A total of four separate multivariable logistic regression models were developed to examine associations between reported exposure to smoke, dust, debris, or odor with any reported symptom in the general public. Syndromic surveillance identified areas with increased ED visits. Among general health survey respondents, 45.1% (911 out of 2,020) reported at least one symptom. Respondents reporting exposure to smoke, dust, debris, or odor had 4.5 (95% confidence interval (CI) [3.7, 5.5]), 4.6 (95% CI [3.6, 5.8]), 2.0 (95% CI [1.7, 2.5]), or 5.8 (95% CI [4.7, 7.3]) times the odds of reporting any symptom compared with respondents not reporting exposure to smoke, dust, debris, or odor, respectively. First responders commonly reported contact with material and being within 1 mi of the fire ≥5 hr; 10 out of 31 of first responders reported at least one symptom. There was high symptom burden reported after the fire. Results from our investigation might assist the directing of public health resources to e ectively address immediate community needs and prepare for future incidents.

Introduction On the morning of June 14, 2021, a fire ignited and spread rapidly through an industrial chemical facility owned by the largest industrial grease manufacturer in the U.S. and located on the Beloit Corporation Superfund site (U.S. Environmental Pro- tection Agency [U.S. EPA], 2022a) in Win- nebago County, Illinois (2020 population: 285,350; U.S. Census Bureau, n.d.). The fire created a dark plume of smoke visible by sat- ellite imagery; required specialized firefight- ing services; and released smoke, dust, and debris for 4 days. Local authorities issued a 1-mi evacuation order and a 3-mi masking

advisory during this time to assist mitigation of potential negative health outcomes in the nearby communities. The available air sampling data from the U.S. Environmental Protection Agency demonstrated several 2.5 micron (PM 2.5 ) and 10 micron (PM 10 ) measurements above the World Health Organization pub- lic health screening levels (World Health Organization and Environmental Health Team, 2006); the Illinois Department of Public Health and the Agency for Toxic Substances and Disease Registry (ATSDR) determined that no measurements above the public health screening levels were

Volume 85 • Number 7

Syndromic Surveillance State health departments have access to the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE), a syndromic surveillance pro- gram that monitors counts of reasons for ED visits (i.e., chief complaints) (Burkom et al., 2021; Centers for Disease Control and Preven- tion, 2022). The ESSENCE program incorpo- rates statistical methods to detect anomalies in data and provides alerts and warnings that can guide eorts to determine if the trends require further attention or intervention. ESSENCE was used to monitor trends in ED visits during the month after the incident, map ZIP Code areas with the largest numbers of ED vis- its, and specify which chief complaints (e.g., respiratory, mental health) increased in these areas. As the facility was near the Wisconsin border, the Wisconsin Department of Health Services also queried ESSENCE using the same criteria for ED visits related to the fire during June 14–July 1, 2021. General Health Survey Using a general health survey to assess the general public, the investigation team exam- ined the association of residents’ reported con- tact with material (i.e., smoke, dust, debris) or report of smelling an odor with any reported new or worsening symptom within the 2 weeks prior to survey completion. The inves- tigation team designed an electronic survey that was adapted from survey forms available from ATSDR’s ACE Toolkit (ATSDR, 2014; Duncan & Orr, 2016) and Epi Contact Assess- ment Symptom Exposure (Epi CASE) Toolkit (ATSDR, 2020) to evaluate the human health eects of the fire in the nearby population. The survey asked about demographic characteris- tics, residential distance from the facility, con- tact with material, smelling an odor, healthcare use, and new or worsening symptoms within the 2 weeks prior to survey completion. Demographic characteristics included age, gender, race, and ethnicity. Age was calcu- lated from date of birth and categorized as 0–19, 20–44, 45–64, and ≥65. Respondents selected one option for gender: female, male, transgender, or other. Respondents self- reported race from a list of options (White, Black or African American, Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, Other) and were considered “Multiracial” if they selected more than one

TABLE 1

Characteristics of General Health Survey Respondents by Symptom Status and Overall and Characteristics of the General Population From 11 ZIP Codes, Winnebago County, Illinois, July 2021

Characteristic

Asymptomatic Respondents ( n = 1,109) # (%)

Symptomatic Respondents ( n = 911) # (%)

Respondents Overall ( N = 2,020) # (%)

General Population From 11 ZIP Codes ( N = 240,043) # (%) 61,626 (25.7) 72,678 (30.3) 64,305 (26.8) 41,434 (17.3)

Age (years) 0–19

17 (1.5)

11 (1.2)

28 (1.4)

20–44 45–64

370 (33.4) 492 (44.4) 225 (20.3)

363 (39.8) 400 (43.9) 135 (14.8)

733 (36.3) 892 (44.2) 360 (17.8)

≥65

Missing

5 (0.5)

2 (0.2)

7 (0.3)

–

Gender or Sex a Female

664 (59.9) 431 (38.9)

613 (67.3) 272 (29.9)

1,277 (63.2)

123,580 (51.5) 116,463 (48.5)

Male

703 (34.8)

Transgender

1 (0.1) 1 (0.1)

5 (0.5) 5 (0.5)

6 (0.3) 6 (0.3)

– – –

Other

Prefer not to answer

12 (1.1)

16 (1.8)

28 (1.4)

Race

White

967 (87.2)

777 (85.3)

1,744 (86.3)

188,983 (78.7) 30,516 (12.7)

Black or African American

25 (2.3)

40 (4.4)

65 (3.2)

Other Asian

21 (1.9) 31 (2.8) 15 (1.4)

21 (2.3)

42 (2.1) 40 (2.0) 27 (1.3)

4,396 (1.8) 7,291 (3.0) 8,075 (3.4)

9 (1.0)

Multiracial

12 (1.3)

American Indian or Alaska Native Native Hawaiian or Pacific Islander Prefer not to answer

2 (0.2)

6 (0.7)

8 (0.4)

757 (0.3)

0 (0)

25 (<0.1)

48 (4.3)

46 (5.0)

94 (4.7)

–

Hispanic or Latino No

1,064 (95.9)

855 (93.9)

1,919 (95.0)

209,996 b (87.5)

Yes

45 (4.1)

56 (6.1)

101 (5.0)

30,047 (12.5)

continued on page 10

for Toxic Substances and Disease Registry [ATSDR], 2016; Duncan, 2014). On June 25, 2021, the Illinois Department of Public Health invited ATSDR to conduct an ACE investigation (Surasi et al., 2021). This article presents findings from the ACE investigation of a chemical fire in Winnebago County, Illinois. The investigation included several public health tools to examine the magnitude, geography, and nature of the

health eects of the fire in nearby communi- ties and assessed exposures and health out- comes among first responders. Methods This ACE investigation used syndromic sur- veillance to monitor emergency department (ED) visits, a general health survey to assess the general public, and a first responders health survey to assess first responders.

March 2023 • our5(l o- 5=0ro5me5;(l e(l;/

ADVANCEMENT OF THE SCIENCE

race. Respondents indicated whether they were Hispanic or Latino. The distribution of age, gender or sex, race, and ethnicity was compared between survey respondents and the entire population of the 11 ZIP Codes of interest using estimates from the American Community Survey 5-Year Data 2019 (U.S. Census Bureau, 2021). Residential addresses of survey respon- dents were geocoded at the census tract level. Their residential distance from the facility was calculated using Esri’s ArcGIS Pro desk- top application, and respondents were cat- egorized as living <1, 1 to <3, 3 to <5, 5 to <10, 10 to <15, or ≥15 mi from the facility. Geospatial analyses used data from the Social Vulnerability Index (SVI), in which a higher quartile indicates higher social vulnerability (i.e., a community’s susceptibility to negative eects from disasters) than a lower quartile (ATSDR, 2022). The survey asked about contact with mate- rial and respondents chose all that applied: smoke, dust, debris, other, none, or unsure. Respondents also indicated if they smelled an odor. The survey then asked about the high- est level of healthcare received because of the incident: formal healthcare services (i.e., hos- pitalization; visit to an ED, urgent care center, or outpatient clinic; or telehealth consult), self-treatment, or no healthcare needed. The survey asked, “Over the past 2 weeks since the event have you experienced wors- ening of a preexisting or a new onset of any of the following symptoms?” and allowed respondents to select all that applied from a list of symptoms organized by category: ears, nose, and throat (ENT); neurological; ophthalmic; cardiopulmonary; psychiat- ric; and skin. Respondents reporting a new or worsening symptom within the 2 weeks prior to survey completion were categorized as symptomatic and all others as asymptom- atic. Among symptomatic respondents, it was determined which symptoms were reported, how many symptoms were reported, and how many symptom categories were involved. The survey was administered by lever- aging the Qualtrics XM Platform client engagement system, which is an existing system that was used for COVID-19 vac- cination registration. The survey was pub- licly available July 1–15, 2021, and residents could access it through a link shared via news outlets, social media, and the local

Characteristics of General Health Survey Respondents by Symptom Status and Overall and Characteristics of the General Population From 11 ZIP Codes, Winnebago County, Illinois, July 2021 TABLE 1 continued from page 9

Characteristic

Asymptomatic Respondents ( n = 1,109) # (%)

Symptomatic Respondents ( n = 911) # (%)

Respondents Overall ( N = 2,020) # (%)

General Population From 11 ZIP Codes ( N = 240,043) # (%)

Residential distance from the facility <1 mi

26 (2.3)

92 (10.1)

118 (5.8)

– – – – – – – – –

1–<3 mi 3–<5 mi 5–<10 mi 10–<15 mi

140 (12.6)

175 (19.2)

315 (15.6)

86 (7.8)

90 (9.9)

176 (8.7)

233 (21.0) 438 (39.5) 186 (16.8)

177 (19.4) 280 (30.7)

410 (20.3) 718 (35.5) 283 (14.0)

≥15 mi

97 (10.6)

Healthcare use

No healthcare needed

1,096 (98.8)

451 (49.5) 347 (38.1)

1,547 (76.6)

Self-treated

8 (0.7) 3 (0.3)

355 (17.6)

Consulted a healthcare professional via phone or video conferencing Visited an emergency department, urgent care, or outpatient clinic

45 (4.9)

48 (2.4)

0 (0)

57 (6.3)

57 (2.8)

–

Hospitalized

0 (0)

4 (0.4) 7 (0.8)

4 (0.2) 9 (0.4)

– –

Missing

2 (0.2)

Note. Data include survey respondents of the general health survey and exclude first responders. General population data were obtained from the American Community Survey 5-Year Data 2019. a Survey respondents self-identified their gender. The American Community Survey 5-Year Data 2019 presents proportions for sex. b The non-Hispanic or Latino proportion of the general population was calculated by subtracting the number of Hispanic or Latino proportion from the total population.

health department website. Additionally, on July 5, the Qualtrics system was used to send the survey link to 40,217 email addresses of registered residents from 11 ZIP Codes of interest (5 identified through surveillance data and 6 nearby ones) and it was noted whether a respondent accessed the survey through the email link. On July 12, the sur- vey link was emailed to registered residents of a neighboring Wisconsin county. Survey data were analyzed in R soft- ware (version 4.1.0) and a response was excluded if it was a duplicate entry, the residential addresses did not geocode, it was missing symptom data, or it was from

a first responder. Duplicate entries were determined by identifying duplicate unique identifiers created by the Qualtrics system; the earliest entry was included and subse- quent entries with the same unique identi- fier were excluded. Additionally, geospatial analysis was conducted to visualize the distribution of respondents reporting any symptom. Frequencies were calculated for reported demographic characteristics, resi- dential distance from the facility, health- care use, contact with material, smelling an odor, and symptoms for residents from the general public responding to the general health survey. Multivariable logistic regres-

Volume 85 • Number 7

through internal professional communica- tion channels. First responders who completed the first responders health survey and respondents who completed the general health survey (e.g., before the first responders health sur- vey was available) and self-identified as first responders were grouped together. Frequen- cies were calculated for reported demographic characteristics, use of personal protective equipment (PPE), contact with material, smelling an odor, symptoms, and healthcare use for first responders. No inferential statis- tical tests for first responders were performed because of small sample size. This activity was reviewed by the Centers for Disease Control and Prevention (CDC) and was conducted consistent with applica- ble federal law and CDC policy.

FIGURE 1

Kernel Density Map of General Health Survey Respondents Reporting a New or Worsening Symptom Within the 2 Weeks Prior to Survey Completion, Winnebago County, Illinois, July 2021

Results

Syndromic Surveillance ESSENCE syndromic surveillance data identified 15% more ED visits than baseline on the day of the incident in the county, and the number declined within the week. Mapping the area around the facility, the team identified 6 ZIP Code areas down- wind of the facility with the largest num- ber of ED visits. Among residents in those 6 ZIP Code areas, ESSENCE data showed alerts and warnings for specific chief com- plaints compared with the previous 90-day baseline. Chief complaints for respira- tory symptoms increased on June 14, and chief complaints for asthma increased on June 17. Chief complaints for disaster- related mental health increased on June 15, and chief complaints related to self-harm increased on multiple days. Continued trends in ESSENCE 1 month after the inci- dent were not identified. The ESSENCE query conducted by the Wisconsin Department of Health Services resulted in 17 unique results for individuals visiting the ED from June 15–24; further, 6 of the results had a direct reference to the chemical fire for the chief complaint. None of the individuals was admitted for a higher level of care. General Health Survey From an initial 2,053 responses, 2 dupli- cate entries, 17 responses with residential

Note. Data include survey respondents of the general health survey and exclude first responders. CDC/ATSDR = Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry.

First Responders Health Survey Although the general health survey was avail- able to the general public, a separate health survey was later developed specifically for first responders that had nearly identical questions. Because it was suspected that first responders did not want to be identified on the general health survey because of fear of professional consequences, the first respond- ers survey did not require them to enter identifying information to complete it. Local police and fire chiefs shared the survey link

sion was applied to assess the association of contact with material or smelling an odor with the outcome of symptom status (symp- tomatic versus asymptomatic) among resi- dents from the general public. Four sepa- rate models were developed with symptom status as the dependent variable and con- tact with smoke, contact with dust, contact with debris, or smelling an odor as the main exposure variable—and were adjusted for age, gender, race, ethnicity, and residential distance from the facility.

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addresses that did not geocode, 4 responses that were missing symptom data, and 10 responses from first responders were excluded, resulting in an analytic sample of 2,020. Overall, 911 (45.1%) of respon- dents reported experiencing at least one new or worsening symptom within the 2 weeks prior to survey completion. Char- acteristics of respondents by symptom status and respondents overall, along with demographic characteristics of the general population from 11 ZIP Codes, are shown in Table 1. Figure 1 presents a map of the distribution of symptomatic respondents using a magnitude-per-unit-area visu- alization. Only 91 responses were com- pleted between July 1–5; on July 6 and 7, an additional 860 and 630 responses were completed, respectively. Among symptom- atic respondents, 80.6% (734 out of 911) accessed the survey through the email link, and among asymptomatic respondents, 96.1% (1,066 out of 1,109) used the email link to access the survey. Analysis indicated fewer survey responses and fewer reports of using formal healthcare services in census tracts with the highest SVI quartile com- pared with census tracts with lower SVI quartiles in a nearby city. A total of 1,225 (60.6%) respondents reported contact with any material, with 965 (78.8%), 498 (40.7%), 690 (56.3%), and 47 (3.8%) of them reporting contact with smoke, dust, debris, and other mate- rial, respectively. A total of 1,047 (51.8%) respondents reported smelling an odor. Table 2 presents adjusted odds ratios for four separate models with reported symptom status as the outcome variable and dierent exposure variables (i.e., contact with smoke, contact with dust, contact with debris, or smelling an odor), adjusting for age, gender, race, ethnicity, and residential distance from the facility. Among the 911 symptomatic respondents, 635 (69.7%) reported any ENT symptom, 477 (52.4%) reported any neurological symp- tom, 380 (41.7%) reported any ophthalmic symptom, 302 (33.2%) reported any cardio- pulmonary symptom, 237 (26.0%) reported any psychiatric symptom, and 99 (10.9%) reported any skin symptom. Among symp- tomatic respondents, the median number of symptoms was 4 (interquartile range: 2–6) and the median number of symptom cat-

TABLE 2

Adjusted Odds Ratio Associated With General Health Survey Respondents Reporting a New or Worsening Symptom Within the 2 Weeks Prior to Survey Completion for Four Separate Models With Different Exposure Variables, Winnebago County, Illinois, July 2021

Exposure Group

Adjusted OR

95% CI

Contact with smoke versus no contact with smoke

4.5

[3.7, 5.5]

Contact with dust versus no contact with dust

4.6

[3.6, 5.8]

Contact with debris versus no contact with debris

2.0

[1.7, 2.5]

Smelling an odor versus not smelling an odor

5.8

[4.7, 7.3]

Note. Data include survey respondents of the general health survey and exclude first responders. The four separate models are adjusted for age, gender, race, ethnicity, and residential distance from the facility. A total of six respondents with missing age data were removed from all four models. Furthermore, a total of 252 respondents were unsure about smelling an odor and were removed from the model with smelling an odor as the exposure variable. CI = confidence interval.

TABLE 3

General Health Survey Respondents Reporting a New or Worsening Symptom Within the 2 Weeks Prior to Survey Completion for Commonly Reported Symptoms, Winnebago County, Illinois, July 2021

Symptom

Symptom Category

Respondents Reporting Symptom ( N = 2,020) # (%)

Headache

Neurological

449 (22.2)

Stuffy nose or sinus congestion

ENT

384 (19.0)

Increased congestion or phlegm (mucus)

ENT

309 (15.3)

Irritation, pain, or burning in eyes

Ophthalmic

280 (13.9)

Burning nose or throat

ENT

267 (13.2)

Runny nose

ENT

250 (12.4)

Anxiety

Psychiatric

208 (10.3)

Coughing

Cardiopulmonary

207 (10.2)

Increased watering or tearing

Ophthalmic

199 (9.9)

Hoarseness

ENT

198 (9.8)

Dizziness or lightheadedness

Neurological

181 (9.0)

Difficulty breathing or feeling out-of-breath

Cardiopulmonary

139 (6.9)

Tension or nervousness

Psychiatric

129 (6.4)

Asthma

Cardiopulmonary

105 (5.2)

Fatigue or tiredness

Psychiatric

104 (5.1)

Difficulty sleeping (e.g., falling asleep, staying asleep)

Psychiatric

100 (5.0)

Note. Data include survey respondents of the general health survey and exclude first responders. The table includes only symptoms reported by ≥100 respondents. Respondents were able to report more than one symptom. ENT = ears, nose, and throat.

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rologic symptoms, 3 reported ophthalmic symptoms, and 5 reported cardiopulmonary symptoms (Table 4). Furthermore, 1 of the 10 symptomatic first responders sought care in an ED, urgent care, or outpatient clinic; 2 first responders self-treated; and the remain- ing 28 did not need healthcare. Discussion Nearly one half of the general health survey respondents reported a new or worsening symptom within the 2 weeks prior to survey completion. Moreover, reported contact with smoke, dust, or debris or report of smelling an odor was strongly associated with being symptomatic. This association suggests that the increase in reported symptoms could be related to reported exposure to the fire and its resulting material. Reported symptoms are consistent with previous reports of exposure to elevated PM 2.5 and PM 10 (An Han et al., 2020; Bazyar et al., 2019). While the long-term health eects of this incident are unknown, other reports have identified adverse health outcomes reported many years after acute exposure to a chemical fire (Degher & Hard- ing, 2004; Granslo et al., 2017; Greven et al., 2009). Given the high level of reported symp- tom burden in this sample, support for the community’s access to appropriate healthcare resources and ongoing monitoring for changes in health, such as via syndromic surveillance, should be prioritized. Findings from this investigation can also inform leaders to prepare for future emer- gency responses. Industrial companies can consider discussions to prevent and miti- gate incidents with chemical exposures by having safety measures and emergency response resources to limit impact on the surrounding population and environment. Robust participation in Local Emergency Planning Committees can contribute to emergency response planning (U.S. EPA, 2022b). Careful attention to first respond- ers’ working conditions and PPE, especially during chemical exposures, is important in protecting the health of this group (Mel- nikova et al., 2018). More attention to gen- der, racial, and ethnic minority groups and residents from areas with higher social vul- nerability—who might be at higher risk for negative eects from disasters—could con- tribute to a better understanding of if and how specific groups are disproportionately

TABLE 4

First Responders Reporting a New or Worsening Symptom Within the 2 Weeks Prior to Survey Completion, Winnebago County, Illinois, July 2021

Symptom

Symptom Category

First Responders Reporting ( N = 31) # (%)

Headache

Neurological Ophthalmic

4 (12.9)

Irritation, pain, or burning in eyes

3 (9.7) 3 (9.7) 2 (6.5) 2 (6.5) 2 (6.5) 2 (6.5) 1 (3.2) 1 (3.2) 1 (3.2) 1 (3.2) 1 (3.2) 1 (3.2) 1 (3.2) 1 (3.2)

Coughing

Cardiopulmonary

Hoarseness

ENT ENT ENT

Stuffy nose or sinus congestion

Increased congestion or phlegm (mucus)

Asthma

Cardiopulmonary

Runny nose

ENT ENT ENT ENT

Burning nose or throat

Odor on breath

Sensation in throat

Dizziness or lightheadedness

Neurological Ophthalmic

Blurred or double vision

Difficulty breathing or feeling out-of-breath

Cardiopulmonary Cardiopulmonary

Wheezing in chest

Note. Data include respondents of the first responders health survey and respondents of the general health survey who self-identified as first responders. Data exclude respondents of the general health survey who did not self-identify as first responders. Respondents were able to report more than one symptom. ENT = ears, nose, and throat.

egories involved was 2 (interquartile range: 1–3). Symptoms reported by ≥100 respon- dents are listed in Table 3. Among symptom- atic respondents, 106 (11.6%) used formal healthcare services and 347 (38.1%) self- treated. Four respondents who used formal healthcare services were hospitalized and the reported indications for admission were asthma ( n = 2), epistaxis ( n = 1), and one unknown indication. First Responders Health Survey Representing 14 dierent organizations, 31 first responders completed the surveys (10 from the general health survey and 21 from the first responders health survey). One first responder self-identified as female and the rest self-identified as male. Further, 28 first responders self-identified as White, 1 self- identified as Black or African American, 1 self-identified as Other for race, and 1 first responder was missing race data. Further- more, 2 first responders self-identified as His-

panic or Latino, 1 was missing ethnicity data, and the remaining self-identified as non-His- panic or Latino. Moreover, 19 first responders reported wearing standard fire protection gear (i.e., fire helmet, turnout pants and jacket, leather gloves, and boots); 3 first responders reported wearing a mask; and 7 first responders reported not wearing a mask, gloves, goggles, hazmat suit coveralls, or standard fire protec- tion gear. Further, 7 first responders reported spending ≤4 hr, 17 reported spending 5–23 hr, 5 reported spending ≥24 hr, and 2 were missing data on time spent within 1 mi of the facility. Only 2 first responders reported not contacting any material; 26, 19, 19, and 5 reported contact with smoke, dust, debris, and other material, respectively. And lastly, 26 first responders reported smelling an odor, 4 were unsure whether they smelled an odor, and 1 reported not smelling an odor. Of the 10 symptomatic first responders, 6 reported ENT symptoms, 4 reported neu-

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aected by chemical exposures. Addition- ally, future investigations and survey meth- ods (e.g., oversampling) could be beneficial in addressing this issue. Our findings are subject to limitations of the survey that was rapidly modified from an in-person, interviewer-administrated survey to an electronic, self-administrated survey with limited time for validation. The general health survey might not be representative of the entire exposed cohort because it used a convenience sample. Fur- ther, the general health survey was primar- ily accessed through a direct link emailed to registrants who signed up for COVID-19 vaccine updates and required respondents to provide contact information and demo- graphic information. This sampled popu- lation might be more comfortable with electronic communications, interested in public health activities, and agreeable to providing identifying information in sur- veys than the general public (Tripepi et al., 2010). The general health survey used an adapted Epi CASE survey—a brief survey

designed to capture information soon after a disaster—but it did not capture detailed information on behaviors that might have increased or decreased exposure, factors aecting health status, or the nature of contact with material. Moreover, the gen- eral health survey did not collect detailed information, such as duration or intensity, about the characteristics of symptoms. Fur- thermore, the survey question about use of healthcare did not provide an option for respondents to indicate that they needed healthcare but lacked access, which could potentially mask the needs and experiences of dierent groups of people. Additionally, the 1-mi evacuation order and 3-mi mask- ing advisory might have aected respon- dents’ exposure, perception of risks, and responses to survey questions. Conclusion An epidemiological assessment was per- formed after a large chemical fire at a facil- ity to identify potentially aected areas and assess the health eects of the fire in nearby

communities and among first responders. This investigation was successful in using several public health tools after a fire at an industrial chemical facility in Winnebago County, Illinois. High levels of reported symptom burden were identified among surveyed residents. There were associations between respondents’ reported contact with material or report of smelling an odor with any reported new or worsening symptom. Results from this investigation might assist the directing of public health resources to eectively address immediate community needs and prepare for future incidents. Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the ocial position of CDC or ATSDR. Corresponding Author: Jasmine Y. Nakayama, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-5, Chamblee, GA 30341. Email: qdt2@cdc.gov.

References

Agency for Toxic Substances and Disease Registry. (2014). ACE Tool- Kit . https://www.atsdr.cdc.gov/ntsip/ace_toolkit.html Agency for Toxic Substances and Disease Registry. (2016). Assess- ment of Chemical Exposures (ACE) Program . https://www.atsdr.cdc. gov/ntsip/ACE_ToolKit/docs/ACE_Fact%20Sheet_053014.pdf Agency for Toxic Substances and Disease Registry. (2020). Epi CASE Toolkit. https://www.atsdr.cdc.gov/epitoolkit/index.html Agency for Toxic Substances and Disease Registry. (2022). CDC/ ATSDR Social Vulnerability Index. https://www.atsdr.cdc.gov/place andhealth/svi/index.html An Han, H., Han, I., McCurdy, S., Whitworth, K., Delclos, G., Ram- mah, A., & Symanski, E. (2020). The Intercontinental Terminals Chemical Fire Study: A rapid response to an industrial disaster to address resident concerns in Deer Park, Texas. International Journal of Environmental Research and Public Health , 17 (3), Article 986. https://doi.org/10.3390/ijerph17030986 Bazyar, J., Pourvakhshoori, N., Khankeh, H., Farrokhi, M., Delshad, V., & Rajabi, E. (2019). A comprehensive evaluation of the associ- ation between ambient air pollution and adverse health outcomes of major organ systems: A systematic review with a worldwide approach. Environmental Science and Pollution Research , 26 (13), 12648–12661. https://doi.org/10.1007/s11356-019-04874-z Burkom, H., Loschen, W., Wojcik, R., Holtry, R., Punjabi, M., Siwek, M., & Lewis, S. (2021). Electronic Surveillance Sys-

tem for the Early Notification of Community-Based Epidemics (ESSENCE): Overview, components, and public health applica- tions. JMIR Public Health and Surveillance , 7 (6), e26303. https:// doi.org/10.2196/26303 Centers for Disease Control and Prevention. (2022). National Syn- dromic Surveillance Program (NSSP). https://www.cdc.gov/nssp/ index.html Degher, A., & Harding, A.K. (2004). Case study of a chemical fire in an urban neighborhood: A wakeup call for the emergency response system. Journal of Emergency Management , 2 (3), 33–42. https://doi.org/10.5055/jem.2004.0031 Duncan, M.A. (2014). Assessment of chemical exposures: Epidemi- ologic investigations after large-scale chemical releases. Journal of Environmental Health , 77 (2), 36–38. Duncan, M.A., & Orr, M.F. (2016). Toolkit for epidemiologic response to an acute chemical release. Disaster Medicine and Pub- lic Health Preparedness , 10 (4), 631–632. https://doi.org/10.1017/ dmp.2015.187 Granslo, J.T., Bråtveit, M., Hollund, B.E., Lygre, S.H., Svanes, C., & Moen, B.E. (2017). A follow-up study of airway symptoms and lung function among residents and workers 5.5 years after an oil tank explosion. BMC Pulmonary Medicine, 17 (1), Article 18. https://doi.org/10.1186/s12890-016-0357-3

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