address the exposed population size, type of exposure, severity of health outcomes, and special populations of interest. Investigators have modified medical chart abstraction forms, key informant interviews, responder-specific questionnaires, survey sections focused on mental health, and quali- tative questionnaires. ACE investigations fre- quently use mapping and analysis capacities from the Geospatial Research, Analysis, and Services Program (GRASP) within ATSDR for planning, evaluation, and presentation of the findings (ATSDR, 2023). In 2021, the ACE team conducted the first community-level, post-acute-disaster follow-up investigation at the request of the Winnebago County Health Department and Illinois Department of Public Health (Sekka- rie et al., 2023). Since the initial request, the ACE team has conducted two additional fol- low-up investigations at the community level. These follow-up investigations included the collection of qualitative data from residents and key informants, which resulted in data about lingering concerns and broad eects on community resources that were not available elsewhere. ACE follow-up investigations after an acute disaster have given public health authorities a distinct opportunity to gauge recommendation implementation and iden- tify any continuing needs in the community. Discussion ATSDR created the ACE Toolkit in 2010 to help public health authorities conduct epi- demiologic public health responses after chemical incidents. Since the development of the original toolkit, the ACE team has dil- igently incorporated innovative techniques and implemented key takeaways from inves- tigations into the ACE tools. These modifi- cations have enhanced user experience and enabled rapid initiation of acute chemical exposure investigations. The ACE Toolkit facilitates both rapid needs assessments and long-term health monitoring that capture the experiences of participating respondents and help guide public health action in a timely manner. The ACE and Epi CASE Toolkits are designed to be easily modified. They are well suited for various exposure scenarios and for assessing health impacts to both first responders and the general public. Recent improvements to the toolkits provide the
FIGURE 1
Epi CASE Decision Support Tool
Pre-Incident 1. Did an incident occur? It could be chemical, biological, radiological, nuclear,explosion, natural disaster.
Practice primary prevention . Train and drill on the Epi CASE T oolkit and other disaster epi tools andmethods.
2 . Have you noticed or been notified of an unusual number of people reporting or having similar symptoms with no known cause?
No
No
Incident
Yes Yes 3. Did an incident result in at least one of the following (check all that apply): Confirmed exposure, and short-term or long-term outcomes are possible or unknown? Confirmed disease and/or environmental cause is plausible or possible?
No No need to assess people at this time . Maintain situational awareness using existing tools and methods.
Significant public health outcome or rare exposure? Significant political/public pressures to collect data? Potential for significant public health knowledge gains?
Yes 4. Consider immediately assessing people using the Epi CASE 7 oolkit to better evaluate the situation and not lose the exposed to follow up. Communicate your current actions and future findings to partners and stakeholders ( eg , exposed persons, healthcare workers, responders, elected officials). Post-Incident 5. , sit possible/practicalto assesspopulation status post-incident using the following methods? $ Assessment of Environmental Exposures (ACE) 3rograP : 4 uick environmental epi assessment https://www.atsdr.cdc.gov/ntsip/ace.html
Yes Use appropriate method to collect data . Use assessment from Step 4 as necessary. Report findings. Proceed to Step 6
% Community Assessment for Public Health Emergency Response (CASPER) : T ype of rapid needs assessment https://www.cdc.gov/nceh/hsb/disaster/casper/default.htm & Emergency Responder Health Monitoring and Surveillance (ERHMS) : : orker exposure and disease monitoring https://www.cdc.gov/niosh/erhms/default.html ' Surveillance : 6 yndromic aberration detection, health outcome, and mortality data collection from various sources No 6. Do yo X need a method to evaluate long-term health outcomes that might take significant time to develop? Yes 7. Will the method have a defined purpose, such as the following: Potential to reduce disease or death among the exposed? Potential to improve the delivery of health services to the affected population? Potential to justify an intervention? Ability to better identify population at risk? Yes 8. Could ALL the following conditions be met (i.e., Yes to all VeYeQ questions below)?
Do not create a registry at this time. Retain assessment data and maintain situational awareness. Consider other methods as needed . Do not create a registry at this time. Retain assessment data and maintain situational awareness. Consider other methods as needed . Do not create a registry at this time. Con sider a health study to answer the more immediate public health questions. If the exposure happened years in the pastand thereis no assessment of the exposed,consider doing a health statistics review to identify further investigation needs.
No
No
Is there adequate data to assess exposure? Can data be collected in a reasonable period? Will the sample size be sufficient to produce meaningful results? Is there sufficient long-term funding, considering that a registry might span many years? Is there sufficient staffing to complete data collection, entry, analysis, and long-term maintenance? Are there adequate communication channels to relay information and results to the registrants? Is there political or popular support (or at least no opposition)? No
Yes Establish a 5 egistry
Note. Epi CASE = Epidemiologic Contact Assessment Symptom Exposure.
Recent Investigations The ACE program has completed 16 inves- tigations in 10 states since 2010 (Figure 2). From 2010 to 2014, the program developed the original ACE Toolkit and completed five investigations (Duncan & Orr, 2016). Since 2015, 11 ACE investigations have been com- pleted and acute chemical exposure-related data have been collected on more than 8,200 participants (Table 1). Each ACE investiga-
tion is unique—the exposure, the response, the community, and the needs. Most inves- tigations begin with the ACE general survey. Investigators can easily modify the ACE and Epi CASE Toolkit features to produce final survey tool(s) specific to the exposure event. The ready-made tools make it easy to modify survey questions, distribute surveys, and manage databases in the field in real time. This feature allows investigators to rapidly
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November 2023 • Journal of Environmental Health
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